Intern (7 page)

One night at the beginning of my first internal medicine clerkship of third year, a resident, a stocky, cocksure man, admitted a patient from the emergency room. “See if you can figure him out,” he said to me on his way out of the hospital the next morning.

The patient couldn't tell me what was wrong, and neither could his eighty-year-old mother. “He's been lying on the sofa for weeks,” she complained when I went to see him. “He just won't get up.” Sloth was a sin, but was it a reason to be admitted to the hospital?

They had been living together in a house in East St. Louis. He was fifty-six and single, working mostly odd jobs until recently, when he started spending his days on the couch, watching television. According to his mother, he seemed sleepy most of the time. He forgot appointments and left chores unfinished. When confronted, he became irritable and withdrawn.

She suspected he was using drugs, but he never left the house long enough to buy any. Sometimes he seemed to be responding to visual hallucinations. She begged him to see a doctor, but he wouldn't go. When he stopped bathing, she called 911.

Though it was my first third year clinical rotation, even I could tell that this wasn't the usual midsummer lethargy. He was lying in bed, almost expressionless. His movements were slow and listless. When he spoke, he slurred his words.

He denied using drugs and said he didn't have any previous medical problems. He vaguely recalled taking a medication, but given his current state, he couldn't remember what it was. I asked his mother to bring in the bottle.

Meanwhile, I asked him a few standard questions. He knew where he was and the year, but not the month or the president. I asked him to count backwards from one hundred by seven, a test of attentiveness, but he stopped at ninety-three. I asked him to spell “world” backwards, but he started and stopped at “w.” The mental status tests I had learned in class were useless on a patient with such poor mental status.

The differential diagnosis of his delirium was almost impossibly long. Some of the usual suspects had already been ruled out. He wasn't intoxicated or hypoglycemic. A CAT scan of his brain revealed no stroke, tumor, or bleeding. Seizures could explain the lethargy and confusion, but his mother had never seen him shake.

Of all the diagnostic possibilities, infections were probably the
most serious. AIDS could cause a kind of premature dementia, but he didn't have the usual risk factors. Lyme disease was unlikely;
Ixodes
ticks weren't endemic to St. Louis. What about meningitis, I thought, or, worse, syphilis? Untreated syphilis could infect the spinal cord and brain, causing severe nerve damage and dementia. Syphilis was one of the “great masqueraders,” along with tuberculosis and lupus, diseases with such protean manifestations that they could almost never be excluded with certainty. In fact, syphilis was enjoying a resurgence in urban areas like St. Louis. The only way to rule it out was to do a spinal tap.

With help from another resident, I had the man sit on the side of his bed, leaning forward onto a table. I scrubbed his lower back with antiseptic soap and then injected local anesthetic into the tissue between the third and fourth vertebrae. It was my first spinal tap, and I gingerly pushed the needle and trocar through the soft tissue, worrying that I was going to pierce the spinal cord. My hands shook in a fine tremor; beads of perspiration wet my brow. I advanced the needle in micron-size increments. It must have taken ten minutes to go an inch. When the needle finally perforated the sac around the spinal column, clear fluid bubbled back through the hub. The resident congratulated me on a “champagne tap,” free of blood. We sent the fluid off to the laboratory.

Later that evening, test results started coming back. Blood tests for kidney and liver disease were negative. The spinal fluid was clean, ruling out an infection. But when the level of thyroid-stimulating hormone came back, it was off the scale. My patient had the worst case of hypothyroidism the doctors had ever seen.

The next day, his mother brought in a brown bag. Inside it was an empty prescription bottle. Sure enough, it was for thyroid hormone; he had been taking the medicine at home but had stopped six months earlier after it ran out, slowly sinking into an amnesiac delirium that made him forget he needed it, a lapse that almost cost him his life. Hypothyroid coma has a 20 percent mortality rate even if diagnosed and treated appropriately.

As in physics, everything fit together nicely. His condition had been a puzzle, but through logic and judicious testing, I had solved it. I felt proud of myself.

The next morning I ran into my resident and told him I had made the diagnosis. “Let me guess,” he said.

“Hypothyroidism.”

“How did you know?” I asked in disbelief.

“I tapped on his knee,” he replied; the tap had elicited the slow reflex that is a classic sign of the disease. I had been taught this clinical pearl in class, but as with most of what I learned during the first two years of medical school, I had forgotten it. The lapse had caused my patient to undergo a painful procedure he probably didn't need.

I often felt intimidated by the clinical acumen of my internal medicine superiors. On morning rounds, their eyes would turn to me and my throat would tighten and my mind seize, like an engine low on oil. I admired their snappy, confident style. I wasn't sure how much I had in common with them, but fundamentally I knew I wanted to be like them. One afternoon, I watched a resident struggle to reinsert a breathing tube into a morbidly obese man with severe emphysema who, in a fit of delirium, had yanked it out. The patient was choking, grabbing his neck with one hand as he fought off the resident with the other. A pulmonologist suddenly appeared. He strode up to the bedside, pulled out a metal laryngoscope from his coat pocket, violently pulled the man's head back and inserted a new breathing tube in one seemingly continuous motion. The whole thing took less than thirty seconds. “Carry on,” he said, strutting out of the room in a theatrical flourish. I must have looked awestruck. “That's Hoffman,” the resident said. “He likes to intubate people.” I remembered him from a lecture he had given on respiratory physiology. In the lecture hall he seemed pedantic and disorganized, his handouts poorly written and pedagogically unsound, but in the hospital he was
the man
, powerful and in command. I envied his confidence, his swaggering style. It was what I yearned for in my new profession.

So, in the end, I decided on internal medicine. In internal medicine, there was more to know, more to do, more potential to help people,
and more potential to impress. It was, it seemed, doctoring in its essence.

Medical school graduation fell on my parents' thirty-third wedding anniversary, an unplanned but perfect gift. They beamed with pride as I strode into the auditorium in my cap and flowing blue gown. The commencement address was delivered by Dean Dowton, a pediatrician who spoke eloquently about his early dreams of becoming a doctor while growing up in the outback of Australia. “From that limited horizon,” he said, “I knew nothing of the world at large, let alone the world of medicine.” His words resonated with me. Not so long ago, ensconced in academia in a college town overloaded with knowledge and ambition, I had felt the same way.

“Here today,” he went on, “we watch the best and brightest transit from an environment which is familiar to one which is new and exciting, even if a little anxiety-provoking. The world these new physicians enter will be one of contrasts: savoring success on the one hand, demanding duty on the other; exalted expectation, followed by endless effort. Are you, new medical graduates, entering a world beyond reach, away from the rest of society?”

He went on to talk about what could be done to bridge the gap between the world of medicine and the world at large. “There are tangible things we all can do to make certain medicine is not a world beyond. You, parents and partners, will be a window through which these new doctors will look into the real world. You will serve this role many times over. We need those who care about us to provide a mirror for our actions as we step out into the brave new world.” To me, his comments seemed ironic at the very least. From the ivory tower of the university, the world of medicine and the real world had seemed one and the same. That was why I had decided to become a doctor in the first place. But evidently for someone who had spent enough time in the world of medicine, it was its own ivory tower, removed from the world at large.

He directed his final remarks to us graduates. “Don't be afraid to say ‘I don't know.' It gets easier every time you do it. Never be afraid
to admit you don't know something, most especially to your patients, but in doing so make a commitment to do your best to find out. No matter the tongue-lashing you might take from a Socratic superior, don't be tempted to hide your ignorance—it is an addiction far too rampant in medicine of all ilks today.”

In closing, he offered this thought: “Keep a simple value system. Work out what things in life you care about, the beliefs you hold near and dear, and stick to them. You are about to go through a most tumultuous time. What are you willing to accept? What are you willing to fight for?” I wrote it down in my Palm Pilot:
Figure out a value system.
Arriving in New York a month later, I still didn't have a system down, but I did have some vague ideas about the kind of doctor I hoped to become.

Buy a long stethoscope.

—ADVICE FROM A MEDICAL SCHOOL PROFESSOR

 

I
spent the first morning of internship running errands. I picked up a pager from the telecommunications office and a stack of light brown scrubs and short white coats from the hospital laundry. Unlike other teaching hospitals in Manhattan, at New York Hospital only attending physicians and clinical fellows were allowed to wear long coats. This had provoked some grousing during orientation, as my classmates seemed eager to show off their new status as physicians, but it didn't bother me. I didn't feel like much of a doctor yet.

Back in my apartment, I tried one on. In medical school I had always felt proud of my short white coat, walking home through the Central West End with my stethoscope jutting out of the waist pocket. Now, as I put on a white coat for the first time as a doctor, a sense of pride washed over me once again. Despite any misgivings I had about medicine, the uniform conferred authority, cachet, membership in an exclusive guild. I stuffed the pockets with useful paraphernalia: a
Pocket Pharmacopeia
, a
Sanford Guide to Antimicrobial Therapy
, a
Facts and Formulas
, a
Washington Manual of Medical Therapeutics
, a small notebook, my Palm Pilot, a few pens, a stethoscope, a reflex hammer, a tuning fork, a penlight, a small ruler, a pair of EKG calipers, and a handful of alcohol swabs. I could have added more, but my shoulders were starting to sag.

I checked myself out in the mirror. I still looked like a medical student, not a resident, much less a doctor. I poked a Washington University School of Medicine pin through a lapel. I clipped my photo ID onto the chest pocket. Someone had once told me that when you become an intern, nurses treat you better because now you can write orders. But I certainly didn't feel any different.

Earlier that morning, at 9:00 a.m. in the wood-paneled clinic conference room, Dr. John Bele, a short man with a penchant for pink shirts, yellow ties, and loafers, had distributed orientation packets and quickly gone over the broad outlines of the rotation. As Dr. Wood had promised, there was to be no call. Unlike our colleagues in the main hospital building across the street, we were going to have weekends off because the clinic was closed. Most days we'd be finished by five or six o'clock, he said, except Tuesdays, when there was evening practice. Teaching conferences were held every day at noon in the main hospital. Lunch was usually provided. Grand Rounds were on Thursday mornings; attendance was mandatory.

He had passed out an exam testing our knowledge of primary care. When we were done with it, we could leave; none of us had patients scheduled that first morning. The test questions were straightforward, having more to do with ethics and doctor-patient relations than management of specific clinical conditions. Even as I was taking the test, I wondered how I was doing in comparison to the others. Some habits from medical school die hard.

After lunch, I walked back to the clinic. The air was thick and still. On the sidewalk, blooming tulips rose out of the gated tree plots like hands coming out of a grave. I took off my coat and swung it over my shoulder. Its contents spilled all over the sidewalk.

The clinic was divided into color-coded sections, though the carpet was one long, continuous gray. For the afternoon, I had been assigned to the Red Area. My room was a crowded space with a computer, a small desk, two chairs, and a sink. In the bookcase were a few outdated textbooks. Next to the sink was a box for used needles. From the orientation packet I fished out the temporary password I had been given—
“bogus doctor”—and typed it into the computer. Four patients were scheduled to see me that afternoon. One, Jimmie Washington, had already checked in. According to her chart, she was a seventy-one-year-old resident of Harlem who had had a radical mastectomy for a breast tumor that turned out to be benign. Over the years, she had suffered from various intestinal ailments, including chronic diarrhea, but an extensive workup had revealed nothing abnormal. Before going out to the waiting area, I phoned her gastroenterologist to inquire about the results of her most recent colonoscopy. “She's fine,” he declared, sounding amused. But what did her colonoscopy show? “She's fine!” he repeated.

In the waiting room, patients were buzzing around the front desk, which, with its tall mahogany counter flanked by tall ferns, resembled a fortress. Washington was supposed to be an elderly black woman, but there were several out there. Which one was she? I felt shy about calling out her name. I made a first pass, pretending to be going somewhere, and then doubled back after identifying two potential candidates. I tapped one of them on the shoulder. “Ms. Washington?” I said, the words catching in my throat.