Intern (38 page)

There was that time in the early evening when patients were settling into bed, watching television, when I felt the most comfortable; that was when I felt the hospital was a village, and I most enjoyed making my rounds. The lights were on; patients were fed, getting ready to turn in for the night. It was the best time to visit, the time in the day when you were least likely to encounter rancor or resistance. Patients had accepted their stay in the hospital—and so had I.

At the same time, I felt more relaxed with my resident colleagues, chatting with them in the corridors or commiserating with them over bagels and coffee at morning report. “Six-hitter last night,” someone might say, and I would grin and empathize, proud to be a member of a clique that knew exactly what those words meant. (Admitting six patients in one night was quite a feat.) The struggles of ward life forged bonds—not friendships always, but a kind of intimacy that was accelerated
by the daily grind. Finally, after so many years, I was beginning to feel connected—to the same people from whom I had previously felt so estranged.

I was also beginning to participate more in the social life of the hospital. Something as simple as running to the coffee stand with my interns after rounds became an activity I looked forward to intensely. One morning, Lane, a stocky Australian intern with long sideburns and a Captain America haircut, said to me: “This is the first time I've worked with people that I like. You're the first person above me that I haven't feared.” Some nights I'd lay awake, smiling at a joke someone had made on rounds or recounting to Sonia the antics of a member of my team, like the medical student who did a great impersonation of a fat man with abdominal pain. At first I disapproved, but he was hilarious, and in the end I succumbed to the humor like everyone else. Doctors make fun of patients for many reasons. Sometimes as a defense mechanism, and sometimes just because they can. Though I was lapsing into some of the same behaviors I had once found objectionable, I rationalized it by telling myself that the job would suck if you didn't have fun with the people you work with.

One week, I was assigned to work the night shift in an emergency room in the South Bronx. The hospital, affiliated with New York Hospital, was in a neighborhood not far from where Son of Sam, the serial killer, started his murderous spree in 1976. Some nights when I was sipping coffee in the ambulance bay during my break, I could hear the rat-a-tat-tat of gunshots. In the emergency room, it was not uncommon to encounter drunks swinging at nurses, drug addicts shouting, and handcuffed prisoners under armed escort.

It was my job to try to drain excess fluid from the belly of a young woman with alcoholic cirrhosis. I hadn't done an abdominal paracentesis in over a year; the last time was on 10-North, when the catheter had fallen out of the patient with AIDS and I had almost stuck myself. This time, I set up my instruments carefully: catheter-tipped needle, rubber tubing, plastic buckets. When I was ready, I cleaned the woman's belly
with iodine soap. She shivered; it was cold. Then I pierced her abdominal wall with the catheter and started filling the buckets. Midway through the third bucket, I got paged. “Whatever you do, don't move,” I said to my patient, whose breath still smelled of alcohol. “I'll be right back.” If the catheter comes out, I told her, I wasn't going to put it back in. She nodded. I left the room and stopped by the nursing station. “Just keep an eye on her while I'm gone,” I told a nurse.

I was away for only a couple of minutes. When I returned, the buckets were upturned and puddles of liquid were all over the floor. The catheter was out, and the drain tube was coiled uselessly on the tiles. “I told you not to move,” I said angrily, tiptoeing across the mess.

“I didn't,” my patient replied unconvincingly. “A man came in here and had a seizure on the buckets.”

Exasperated, I stalked out to the nursing station. “I thought I asked you to keep an eye on her,” I said to the nurse.

“I did,” she replied, “but then a man wandered into the room and had a grand mal seizure on the buckets.”

Another night I was assigned to the midnight–4:00 a.m. shift in the “salon de asthma,” a treatment room in the back of the ER. The hospital opened it in response to the mysterious rise in asthma in the Bronx, where the prevalence once was eight times as high as the national average. (Today it has declined, probably because of more vigilant monitoring and treatment.) Patients could walk in right off the street and get treated without unnecessary delay. The largest influx occurred at dusk when teenagers started filing out of neighborhood playgrounds and basketball courts and sought help for asthma attacks brought on by exercise.

In the large room, patients were sitting on purple chairs of cracking vinyl, inhaling a mist of albuterol, a drug to open airways, from plastic pipes connected to oxygen outlets in the wall. A nurse was there, administering medications and checking vital signs. “In the asthma room, the patients don't fight,” she told me during a lull in the activity. “The tough guys are outside, the drunks. They always want to bite us, to cut us. Here it's different. Here everybody gets along.”

The atmosphere actually was more like a party. At 3:00 a.m., two middle-aged men—one having his first asthma attack in twelve years, the other a “frequent flyer”—were in rapt conversation. A young woman—not wheezing, just “a little tight”—was walking in and out of the room, talking on her cell phone. Near the entrance, one of the patients, a fifty-two-year-old man, started doing a stand-up routine.

Dressed in jeans, a plaid shirt, and white sneakers, he delivered his lines in Spanish with Seinfeldian exasperation. His audience wheezed its approval. Between laughs, the patients translated for me. He was telling them about the time he was riding on the train, chewing gum. When he tried to spit the gum out the window, out flew his false teeth.

A sixty-four-year-old homemaker from the Bronx, a regular visitor to the asthma room, gasped for breath. “I can't believe it, he makes me laugh,” she said, pausing to inhale after every few syllables. She tried to explain the story to me but the laughter overcame her. “I'm not used to it,” she said, before putting the pipe back in her mouth. “I'm a serious person. I never joke.”

Two seats away, a sixty-year-old man from Venezuela leaned forward in his chair and wiped away a tear. “When he got home, he covered his mouth,” he translated. “When his wife finally noticed, she asked him, ‘What happened to your teeth?' ” Then the whole group laughed and coughed in unison.

I watched in quiet amazement. The ways people cope with illness always produce gentle surprises.

IN THE FALL
I rotated through the geriatrics ward. One of the attending physicians was an irritating woman whose idea of the Socratic method was pimping you with really vague questions, then acting like she had already thought of whatever answers you gave and that you were only telling her what she already knew. The other attending was a throwback to “the days of the giants,” when pneumococcal pneumonia was diagnosed by injecting sputum into mice and antibiotics for urinary tract infections were tested on agar plates. One morning, one
of my interns presented a case to him of an elderly man who had been hospitalized with fever and a cough producing green sputum. “He has pneumonia,” she proclaimed confidently. “Take a look at this chest X-ray.” She pulled up a digital image on a computer screen showing a distinct pneumonic streak. The senior physician waved it off. “First tell me about your lung exam,” he said.

It was a common scenario on the wards: young doctor ignoring physical examination to the chagrin of an older and wiser counterpart. At one time, keen observation and the judicious laying on of hands were virtually the only diagnostic tools available to a doctor. Now, on the wards, they seemed almost obsolete. Technology—ultrafast CAT scans, nuclear imaging studies, and the like—ruled the day, permitting diagnosis at a distance. Some doctors didn't even carry a stethoscope.

There was a growing disconnect between the older and younger generations of physicians on this issue. While residents were apt to regard physical examination as an arcane curiosity, like an old aunt you've been told to respect, a few physicians proselytized on its behalf, claiming for it a power it probably no longer has. These anachronisms wanted to hear about whispered pectoriloquy or some such esoteric finding of the lung exam before letting you describe the results of a chest X-ray. Our apathy seemed to fuel their fervor, increasing their fear that exam skills would atrophy and die.

“Medical students don't know how to listen for breath sounds,” our attending complained. “It's not that they're bad students; it's just that no one is teaching them. When I was a resident, you had to know physical diagnosis because we didn't have any other tools. CAT scans were just coming out. You had to cut someone open to figure out what was wrong with them.”

One morning I shared one of my favorite medical stories with my team. We had just finished examining an elderly woman with a cardiac rhythm disturbance when I mentioned that Karel Wenckebach, a Dutch physician at the turn of the twentieth century, discovered the arrhythmia later named after him by timing a patient's arterial and venous
pulsations. Wenckebach's discovery preceded the advent of the EKG and still stands as one of the most astute clinical observations in the history of medicine. Isn't it amazing, I asked my team, what doctors were once able to do?

“Today we'd get an EKG,” an intern shrugged. “It's more accurate anyway.”

“Who has the time to stare at a patient's neck?” another said. “They'd think you were crazy!”

It is true that teaching hospitals are busier than ever, and residents probably have less time to spend examining patients. And it is true that physical examination is often inaccurate. But these facts only partly explain its apparent demise.

The major reason for it, I have come to believe, is that doctors today are uncomfortable with uncertainty. If a physical exam can diagnose a slipped spinal disk with only 90 percent probability, then there is an almost irresistible urge to get a thousand-dollar MRI to close the gap. Fear of lawsuits is partly to blame, but the major culprit, I think, is fear of subjective observation. Doctors today shy away from making educated guesses on the basis of what they see and hear. So much more is known and knowable than ever before that doctors and patients alike seem to view medicine as an absolute science, final and comprehensible. If postmodernism teaches that there are many truths, or perhaps no truths at all, postmodern medicine teaches quite the opposite: that there is an objective truth that will explain a patient's symptoms, discoverable provided we look for it with the right tools.

Of course, technology itself can be inaccurate, its results irreproducible. In the ICU, our catheters could often produce spurious data because of poor positioning. It wasn't uncommon for us to discard the information, pull out our stethoscopes, and make a clinical decision based upon what we saw and heard, not the numbers on the screen. Moreover, the readings always had to filter through our eyes and minds, where, inevitably, they were contaminated by the very subjectivity from which we were trying to escape.

Perhaps, then, this is the new role of the physical exam: helping doctors decide when to go beyond it.

IN DECEMBER,
Dr. Wood invited me to his office for my semiannual evaluation. Sitting behind a large wooden desk, he handed me a manila folder. As residents, we were judged in seven categories: clinical judgment, medical knowledge, clinical skills, humanistic qualities, professional attitudes and behavior, medical care, and overall clinical competence. The ratings were on a scale from one to nine, with written descriptions for each scale, like “indecisive in difficult management situations” or “reasons well in ambiguous situations,” “pedestrian diagnostic ability” or “establishes sensible differential diagnoses.”

My evaluations were excellent, mostly sevens, eights, and nines across the board. I was credited with being a good manager and getting along well with my colleagues. One attending commended me for “not giving in to the urge to put down [my] patients.” It was faint praise, and not entirely accurate, but from what I had seen over the past year and a half, I took it as a compliment.

Dr. Wood asked me about my plans after residency. Some of my classmates were already filling out applications for subspecialty fellowships. I told him I had been thinking about applying for a fellowship in cardiology, but that I hadn't yet made up my mind. “Why cardiology?” he asked, surprised. Judging from his tone, he didn't think it was a good fit. I muttered something about how cardiology had powerful therapies, a solid evidence base, a good mix of inpatient and outpatient work, etc., etc., but Wood appeared unconvinced. Those were personal-statement reasons, he said, reasons to give in a fellowship interview.

The real reasons were a bit more complicated. Part of it was family pressure. I had married into a family of doctors where one's standing was measured in part by one's degree of specialization, and cardiology was at the top of the list because of its prestige and high earning potential. In my own family, my mother wanted me to become a cardiologist
so that I could work with my brother. She wanted us to be equal, to have the same capacity to enjoy things, which in her view meant having comparable salaries. Unwittingly, she had encouraged us to think about cardiology since we were boys. My brother and I had grown up with her dire warnings that my father would develop “heart failure” if we were too rowdy or didn't do our chores. We grew up with a fear of the heart as the executioner of men in the prime of their lives.

But a bigger reason for my interest in cardiology, which I didn't want to admit to Dr. Wood, a general internist, was that I had become disillusioned with primary care. In the outpatient clinic I was arranging colonoscopies, checking prostate-specific antigen levels, giving pneumonia vaccinations, and counseling smoking cessation—all important activities, to be sure, but not how I wanted to spend my professional life. There was so much to do in the clinic: disability forms, insurance letters, home-care orders, depression screens, cholesterol testing, mammograms, Pap smears. The physicians there seemed harried, overworked, and ours was an academic clinic with interns and residents, social workers and nurse practitioners, good clerical staff, and computerized medical charts. What to say of the real world, where ten- or fifteen-minute office visits were the norm? With decreasing reimbursement and increasing medical liability costs, the thought among my classmates, which I shared, was: Who needs the hassle?