Intern (2 page)

Thankfully, I am finished with my apprenticeship, and I can say with pride that I made it. I now work as a cardiologist at a large teaching hospital on Long Island. Some days it feels strange being an attending physician, and other days so perfectly reasonable, like it was preordained. For the most part, I am happy. I enjoy my job, taking care of critically ill patients with heart failure. But so much about medicine still troubles me; sometimes I still want to muddle through things; sometimes I'm still not sure cardiology was the right choice. At one
time I didn't know how to read a chest X-ray. I worried about being a code leader. I wasn't sure if I even believed in critical care. Now I make my living practicing it. It isn't something I ever expected I'd be able to do, and yet now I am doing it. I have made the leap. But I will never forget the journey.

There is no short cut, nor “royal road,” to the attainment of medical knowledge. The path which we have to pursue is long, difficult, and unsafe.

—
JOHN ABERNETHY, ENGLISH SURGEON, HUNTERIAN ORATION
, 1819

 

I
had been an intern less than an hour, and already I was running late. The sloping footpath leading up to the hospital was paved with gray cobblestones. My feet ached as my oversize leather sandals slipped on the rounded irregular rocks. The hospital was an old building browned by the passage of two centuries, with spidery cracks in its façade. Founded in 1771, New York Hospital is the second-oldest hospital in the United States, a mecca for doctors and patients from all over the world. I had been in the building once before, six months ago, for a residency interview. I spun through a revolving brass door, nearly running into the burly security guard reading the
New York Post.
He looked up from the tabloid just long enough to point me in the direction of the elevator.

The tiled corridors were dark and dull, mixing shadow and light. I darted past the chapel, past the café, around the information desk, which sat in the middle of the huge atrium like a fort, and entered a bank of elevators. Hanging on a wall was a portrait of a gray-haired lady in a blue dress sitting in dignified repose before an open book. She was a graduate of the medical school, class of 1899, ninety-nine years ago, who built a medical college for women in Northern India, on the
banks of the Ganges, near where my father had his early college education. Nearby was a metal tablet in bas-relief: “She cared for all in need. For each, she made time to guide, to teach, and to heal.”

When I arrived on the fourth floor, other interns were still filing into the auditorium. A woman handed me a manila folder, and I went inside and sat down. The orientation packet contained several essential documents: a house-staff phone card, directions for obtaining autopsies, instructions on how to use the hospital dictation system, and the residency contract. I leafed through it quickly. My salary was going to be $37,000 a year, about eight dollars an hour, I calculated, given the number of hours I was going to be working, but I didn't mind. Though I was a year shy of thirty, it was more than double what I had ever made.

My classmates, though younger than I, appeared older than I expected, casually dressed, all thirty-five of them, in khakis and polo shirts, faded jeans and sequined tops. Some of them evidently knew each other, because they were already chatting in small, insulated groups. They were from some of the best medical schools in the country: Harvard, Yale, Cornell, Columbia. Though I too had gone to a top school—Washington University in St. Louis—I had been feeling insecure about the prospect of working with them. For months I had feverishly been reading Harrison's tome on internal medicine and review articles in
The New England Journal of Medicine
to prepare for this day.

Someone in the front row stood up and turned to face us. It was Shelby Wood, the hospital's residency director. He was a serious-looking man of medium build, with straight brown hair and a long, aquiline nose. He was wearing a white coat and a fat blue tie that might have been in fashion twenty years earlier. My elder brother, Rajiv, a cardiology fellow at the hospital, six years ahead of me in his medical training (though only two and a half years older), had warned me that Dr. Wood was a bit of a grouch, but had added that he was also fair and decent and a strong advocate for his house staff. Wood, I was to learn, hailed from the old school, where you were expected to live and breathe medicine, stay late in the hospital, neglect your family for
the sake of your patients, and emerge on the other side a seasoned physician.

He cleared his throat and began to speak. His voice was deep but incongruously soft, and because I was sitting in the back of the sixty-seat auditorium, I only managed to catch snippets of his remarks. It was going to be a busy year, he said, as thirty-five heads stared motionlessly back at him. We were expected to devote ourselves fully to medicine. “You don't learn French by taking classes at Hunter College. You learn it by going to Paris, sitting in the cafés, talking to people.” Likewise medicine: we would learn it by living it. “You are now ambassadors for the profession,” he said gravely. “So don't let the students hear you complain. It sets a bad example.” If everything went as planned, he added, by next June we'd be ready to supervise the next batch of interns.

I glanced over at the pretty brunette sitting next to me. She looked back at me, rolled her eyes, and opened her mouth in mock panic.

Then Wood dropped the bomb. Every intern starting on the wards or in the intensive care units was required to come to the hospital every single day, including weekends, for the first six weeks. The only exceptions were interns starting in the outpatient clinic, which was only open from nine to six; they would have no evening call and weekends off for the first month. I later learned that this regimen was a longstanding tradition at the hospital, the most efficient way to get everyone up to speed. To me it seemed brutal, like a kind of hazing, not to mention a violation of residency work-hour limits set forth by the Bell Commission in New York in the mid-1980s. Uneasy murmurings reverberated through the auditorium as new interns rustled through their packets. I scanned the master schedule before breathing a sigh of relief. Along with six classmates, I was slated to start in the clinic.

“We are here to help you,” Wood said, raising his voice over the light chatter. “You should feel free to call on us anytime, day or night. The only mistake you can make is not asking for help.”

I was reminded of a residency interview in Chicago a few months earlier. The interviewer, a portly senior physician with an abundance
of facial hair, had posed the following scenario: A nurse pages me in the middle of the night to tell me that a patient who just had hip surgery is short of breath. What would I do? “Go see the patient,” I said. I had enough sense to know that there was only one right answer to that question. Walking to the room, what would I be thinking about? “Pulmonary embolism,” I replied. Blood clots in the lung are a feared complication after hip surgery. When I arrive in the room, the patient is in distress. His heart is beating 130 times per minute and the oxygen tension in his blood is low. Now what? I went over the treatment options in my head—blood thinner, supplemental oxygen, arterial blood gas—but it seemed the examiner wanted me to say something else. I'd heard about the notorious “July phenomenon,” in which hospital mortality supposedly increases every summer with the entry of new and inexperienced hospital staff. “I'd call a senior resident,” I finally answered. Why? “Because I could be missing something.” My interviewer nodded; I had passed the test. Like all residency directors, he was looking for a soldier, not a cowboy.

Now it was late June, and we were the new hospital staff. For the rest of that first morning, we sat through a series of tag-team lectures. A woman from the blood bank talked about blood transfusions. A pathologist talked about the importance of autopsies. A psychologist spoke about work-related stress and told us that confidential counseling was available. A lawyer from risk management, the department that defended the hospital against lawsuits, informed us that at some point in our careers every one of us was likely to be sued, and that we could even be sued during residency. She offered some advice: Document your decision-making; document when a patient refuses treatment; never admit wrongdoing; never talk to an opposing attorney; and, finally, be nice to your patients. Doctors who were nice to their patients were rarely sued, even in cases of egregious malpractice. I looked around the room, trying to gauge the reaction of my classmates, frankly surprised that such a cynical thing was being taught on the first day of residency. No one's eyes met mine.

At the midmorning break, I went outside. Stepping through the
humid air was like sweeping away static. The sidewalk was buzzing in a kind of Brownian motion, with pedestrians sidestepping me as though I were a moving obstacle. A long line snaked from an aromatic hot dog stand. Buses and taxicabs were letting people off in front of the hospital. An ambulance whizzed by on the main thoroughfare, sirens blaring, lights flashing. The noise fed my sense of wonder. I had grown up in a quiet Southern California suburb, craving the excitement of a big city. Berkeley and St. Louis had their pockets of vitality, but nothing like this. Even the smell of the neighborhood—a mix of pizza, garbage, cigarette smoke, and fragrant fruit—was rich and seasoned, like wisdom wafting through the air.

I had only arrived in Manhattan a few days earlier, moving into a one-bedroom apartment about a block away from the hospital. On the plane flight in from St. Louis, the pilot took a detour because of airspace congestion, he told us, flying into LaGuardia from the south, not the usual flight pattern. As we passed over the World Trade Center and then soared low over the city, I craned my neck to look down at the broad swath of Central Park. The brown buildings on its outskirts were arrayed like divers ready to jump into a pool. Down there, I had imagined, all of the metropolis's unique charms were waiting for me: the old, stained sidewalks; the stealthy characters playing junkyard instruments on subway platforms; the deliverymen hurtling through traffic lights on their rickety ten-speeds,
I
NY
plastic bags swinging from the handlebars. The first time I had been to New York was the summer before medical school, when I spent a couple of weeks with my brother and his wife in their tiny one-bedroom apartment across the street from the hospital, where he had just begun his fellowship. I wandered around the city, going on walking tours of Harlem, joyriding on the subway, chatting with bartenders late into the night. Like many visitors to Manhattan, I was swept away. The delicatessens, the dry cleaners, the corner convenience stores and smoke shops. Unlike in Berkeley, people weren't just milling around, enjoying the sun. There was magic in the movement on the streets. So much was happening, and I could watch it all and remain a shadow. That was the wonderful
paradox of Manhattan: you could be surrounded by people and yet be anonymous at the same time. “The United Nations is just down the street,” I wrote a friend. “The building they use to broker world disputes, just down the street from me!” New York cast a spell on me that summer that I could neither explain nor resist.

Back on the sidewalk, I felt a light spray from air-conditioning units outside the apartment windows above me. Heavy construction was going on in a lot nearby; large bulldozers were exhuming a deep hole, as if for a tomb, their blades ravenously picking up mouthfuls of yellowish dirt. I passed by an old church and stopped at a fruit stand to buy a nectarine. Then I ambled back to orientation munching on it. A plane flew overhead. Looking up at it streaking across the clear blue sky, sweet juice trickling down my chin and fingers, I couldn't help but think that the abnormal flight path that had brought me here last week was an apt metaphor for my own twisting journey into medicine.

I STOOD ON THE BALCONY
in Berkeley and lit a cigarette. My bags were packed, the bills paid, the car loaded. Most of my possessions had been sold, save for some clothes and a few boxes of books, which I forced into the trunk and backseat. After a week of sleepless nights, I had turned in my Ph.D. thesis on quantum dots that morning. I had even found someone to take over my apartment. Now all I had to do was leave.

It was late in the afternoon on Tuesday—August 1995—and the sky over the shimmering San Francisco Bay had turned a smoky orange. Medical school orientation was starting tomorrow. I would be in a Honda Civic somewhere in the Rocky Mountains. After explaining to the dean that I was delayed finishing my physics thesis, she had urged me to at least try to make it to St. Louis by Friday morning for the white-coat ceremony and the recitation of the Hippocratic oath. After speaking with her, I looked it up: “. . . To please no one will I prescribe a deadly drug, nor give advice which may cause his death. Nor will I give a woman a pessary to procure abortion . . .” Arcane stuff. Perhaps,
I wondered, she'd let me write my own oath. Perhaps that could be my first contribution to my medical education.