My friend reassured him on that point, and the lawyer fell back at ease.
A month later, ten professors and thirty residents from the obstetrics
and anesthesiology departments met to discuss the case. I had expected
the residents to complain about the obstetrics attending’s absence after
midnight. Instead, the majority of them angled for less frequent night call duty. They argued that the obstetrics resident had made a bad decision
because he was tired. This was around the time of the Libby Zion case in
New York, where a young woman had died in an emergency room after
receiving a drug to control her shaking, which interacted with another
drug (an antidepressant) already in her system to cause cardiac arrest. 1
The plaintiffs argued that the residents prescribing the drug were over-
worked and overtired. This was not the case in the catastrophe I was
involved in—and I was there—but the issue was on everyone’s mind.
An anesthesiology professor, Dr. T, opened the floor to discussion. He
sat calmly on a chair with his legs crossed, his long white coat falling
around his sides, looking like a gentleman’s cape, even a royal one. He
was an eloquent man, almost artificially so, in the way he avoided
contractions in his speech and policed the residents’ speech. For example, if a resident during a presentation said he had “tubed a patient,” Dr. T
would sternly correct him and say, “You mean you intubated the patient’s
trachea.” His habits were cultivated, often at the expense of comfort,
including the residents’ comfort, as when he expected everyone attending
a drug company–catered lunch to listen to the lecture before grabbing the free food. I found him pretentious, and yet in the midst of it all I was
conscious that he made good on his claim to superiority. What is a gentleman doctor, let him be ever so eloquent and have so many long white
coats? And yet, even with such a self-satisfied creature as Dr. T, I myself felt his gentlemanliness.
The audience hesitated. Then a beeper went off. As the resident being
paged walked toward the door, he declared, “How about changing call
from every third night to every fourth?” Before anyone could respond, he
was out of the room. But the most difficult thing had been done: someone
had spoken.
Dr. T kept his dignified bearing and said, “We can consider the pos-
sibility.”
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7
“Consider”—what could be more ineffectual than that absurd and
pitiful word? we thought. “Why just ‘consider’?” a resident shot back.
“We’re overworked. That’s why people are making mistakes.”
In a quiet, measured tone of voice, Dr. T replied, “More night call
means more clinical experience.”
A collective moan rose up from some of the residents. They saw that
excuse as a residency program’s highhanded way of justifying hundred-
hour workweeks.
A complex mixture of emotions played across the professors’ faces.
Anger, agitation, astonishment—that was what one could read on their
features at one and the same time.
Curiously, another resident defended the current system. A young man
with glasses said, “Let’s just do our jobs and take care of patients.”
“We can’t if we’re overworked,” another resident replied.
“You can if you really want to,” the man with glasses said straightfor-
wardly. He seemed to understand the other resident’s simple secret
thought, that she just wanted more time off, and his comprehension gave
him confidence. It was almost as if he expected from the other resident an honest acknowledgment of her guilt.
“I do want to do it,” the resident said defensively. “But every third
night call is dangerous.”
“Quit whining,” interjected another obstetrics resident. He was a mus-
cular young man who habitually sucked on a toothpick.
“I’m not whining!” the resident shouted back.
“Yeah, you are,” said the man with the toothpick. Then he smiled and
boasted, “I don’t care about night call. Give me more. I want to see how
much I can take.”
Some of the residents cursed in disbelief. One resident whispered,
“Macho bullshit.” But one of the anesthesiology department leaders, Dr.
S, agreed with the young man. “He’s right. You want to learn medicine?
Then you do cases,” he announced. He spoke as if everything were prede-
termined and also quite clear to him—that the residents had no hope of
getting what they wanted and should have no hope. Indeed, he seemed
less angry about what the residents were asking for than at who was doing the asking.
Dr. S was a resolute and ruthless man. Such a personality was once
necessary in medicine. Since most doctors a generation ago were by
nature independent, great force was needed to weld them into a unity;
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sometimes the sole criterion for the job of department chairman was
being the biggest bully. Dr. S was especially hard on the residents, al-
though his teaching methods were partly calculated. With excessive
praise, inexperienced residents sometimes remain stunted in their growth, thinking that they don’t have any further to go; it lulls their minds to
sleep; it makes them proud and hinders a critical attitude toward their
own work. Dr. S’s constant carping actually helped them become better
doctors. But it would be years before I understood this.
Among these conflicting opinions and voices I distinguished five par-
ties, separated by what each believed was most important about being a
doctor.
The first party consisted of the resident with glasses and three other
adherents. They were earnest toilers with self-abnegating natures who
went into medicine to help people. Yet there was something both attrac-
tive and repulsive in their benevolence. They expressed real kindness
toward patients. They demonstrated a passionate love for children, espe-
cially sick ones, and were sorry for them all. But they exuded the aroma
of sympathy for patients in the same way that men who have just been to
the barber reek of cheap scent. It was too obvious. And their sympathy
never bent; it sometimes stuck out and pricked like a needle from a
cactus. They reproached those residents who wanted more time off to
enjoy their lives.
The second party consisted of physicians who saw themselves primar-
ily as scientists. Although the residents in this faction were still immersed in clinical training, the professors had eagerly left this dimension of medicine and now understood little of clinical practice, which partly embar-
rassed them, and even partly scared them, but which they also saw as a
noble inability, of which they were secretly proud. Usually they were able to fix it so that someone helped them or covered for them in the operating rooms. The residents in this group wanted less frequent night call to
spend more time in the lab. When they became professors that desire
would merge seamlessly with a desire to stay out of the operating room
altogether.
The third (and second-largest) party consisted of most of the profes-
sors and some residents, including Dr. S and
the young man with the
toothpick. All the members of this faction were men. They saw the doctor
as a practitioner of discrete tasks, especially technical procedures, that one had to master. The more a doctor practiced them, the better he got,
T H E P O L I T I C S O F A C A T A S T R O P H E
9
and so the more night call, the better. They looked upon the scientists
with a secret sense of superiority and a certain pity, as if they were
hopeless cases who would never get the needle in the right place. They
didn’t know their respective fields inside and out the way the scientists did, but they knew what was necessary to know.
Perhaps they were right. The real value in medicine is often in the
administration of drugs or the performance of procedures. Once, in a
lecture on anaphylaxis, Dr. S had told the residents, “All you have to
remember is the number ‘0.3,’” as that was the dose of adrenalin needed
to treat the condition. The arcane research controversies surrounding the subject were unimportant, he declared. In truth, when a patient is wheezing and the blood pressure is dropping from an allergic reaction, they are unimportant.
The doctors in this group were cocky because they were accomplished
in something practical, giving them the gung-ho quality of the college
fraternity. The professors saw every third night call as a doctor’s rite of passage. “We did it, so why can’t the young doctors?” they insisted. The
residents in this faction agreed, viewing night call as a glorified form
of hazing, and a welcome opportunity for real men to knock down walls
with their foreheads. They saw themselves as heroes—military-style
heroes.
The fourth party consisted of Dr. T and one of the obstetrics profes-
sors. They sympathized with the residents’ desire for an easier call schedule but thought it imprudent. They saw every third night as a sad neces-
sity. Doctors needed experience; it was as if God had intended the injus-
tice of every third night call to be permanent. No residents were in this group; indeed, no resident really even understood this group. The two
men exhibited a statesmanlike grandeur but also a glossy impenetrability; they seemed to want to live up to certain principles of character, but
doing so made for a different reality about them. That they were privi-
leged white men who had gone to elite schools made them antagonistic to
progress and altogether unconscious of the demand for equality—includ-
ing the admission of more women and minorities into medicine. Indeed,
they seemed to believe that God had arranged the medical profession to
be the way it was, and that they were God’s emissaries on earth. But they did their work with an easy grace, and with such kind voices and pleasant manners that one almost thought they were.
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The fifth, and largest, faction consisted of the vast majority of resi-
dents, including many of the female residents. Compared to the other
doctors, they were of a different breed—those “who know how to live.”
By securing an easier call schedule for themselves, they believed they
were joining in that normal, truly human condition that people should
always be in. They wanted to do a good job for their patients while also
taking pleasure in their own lives. There was an absence of all effort at self-glorification among them. No fussy amplification of white coats, no
made-up sense of gravitas, no feigned seriousness, no attempt in their gait or speech to show superiority. As doctors in training, they were simply
doing a job while occasionally thinking about what they might have for
supper that evening or where they might go for the weekend.
I joined the largest faction after a quick process of elimination. I had
run afoul of the resident with glasses earlier in my career. One day, as I rushed to sign out my patients to him to meet friends for dinner, he
grumbled, “It seems like the whole point of medical training for you is to get out by 6 PM.” I replied honestly, “Well, yes.” He looked at me with a scowl. Yet I had also run afoul of the resident with the toothpick for being too attentive. Once, I had noticed that a patient scheduled for surgery had an EKG suggestive of a recent myocardial infarction. I told the team
during rounds, including the resident with the toothpick, who was my
senior at the time. The attending groused about having to postpone the
operation until further evaluation; the resident took the toothpick out of his mouth, glared at me, and whispered, “You fucked up.” By being
thorough, I had thrown a monkey wrench into the surgical schedule.
Henceforth, I was called “scientist” and “pointy head.” And yet the scientists left me cold. An anesthesiology researcher had once berated me for
giving a narcotic to a patient in pain, thereby ruining his research project by contaminating the control group. The gentleman doctors grated against
my democratic instincts. The only party left to me was the largest one,
clamoring for every fourth night call, which also seemed to me the most
sensible.
The different parties argued back and forth. Finally, a resident asked,
“Can the hospital even pay for extra residents?”
Dr. Z, the obstetrics attending who had been on call the night of the
catastrophe, rose up to speak, grabbing everyone’s attention. He was an
elderly man, his face gray and unfriendly.
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1 1
“The hospital doesn’t care about your call schedule,” he grumbled.
“They value doctors cheap these days, at no more than the cost of a
body.” His spleen welled up, bringing with it all the hatred and contempt for human beings raging in the depths of his heart at that moment. “They
search our bags. They treat us like dirt,” he groused.
The “searches” he referred to had started several months before. Em-
ployees had been caught stealing bread and peanut butter from the
lounges and toilet paper from the restrooms, and so the hospital posted
security guards at each exit to check people’s bags as they left. Some of the employees laughed as the guards rummaged through their miserable
belongings. Others were alarmed. I was irked. When I told a guard I was
a doctor, he said, “Sorry, I have to check everyone’s bags.” When I
insisted I was a doctor, the guard smugly asked, “How do I know you’re a
doctor? A tie’s not enough anymore. Where’s your badge?” So I let him
search my bag. But the older doctors were livid and refused to be
searched, including Dr. Z. They felt they were being treated like common
criminals. Eventually the hospital heard their protests and excluded the
doctors from the searches. But the damage had been done.
“They treat doctors like dirt when they’re not clinically involved,” Dr.
S said to his colleague. “Remember the radiology department? They
didn’t want to come in at 7 AM and read chest X-rays for the OR cases.
So the hospital said, ‘God damn it! You get out of here and we’ll build
our own department of radiology!’ And they did.”
One of the scientist doctors made a last-ditch push for every fourth
night call. “I think residents should submit a peer-reviewed journal article before graduation—as a condition of graduation. A lighter call schedule
would facilitate that.”
“No one reads those
journals,” replied Dr. S, with a dismissive wave
of his hand. “A good doctor practices clinical medicine. That’s why I
make sure nothing happens in the operating rooms without my signature.
My department is in charge of the intensive care unit. We stock the
emergency carts. We place IVs on the floor. We do lumbar punctures in
the emergency room. I’d control the parking lot if I could. And that’s how you want it. No one in the hospital even goes to the bathroom unless they ask you, because you have the key.”
“What has that got to do with every fourth night call?” the female
resident asked.
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“Because I don’t want to ask the hospital to pay for extra residents!”
he barked.
Dr. S’s harangue was enough to convince those residents angling for
easier night call duty that they weren’t going to get it. But privately I saw that I had misjudged Dr. Z. He wasn’t angry about his salary. His feeling of resentment was more subtle, as during a conversation, when it is not
the words spoken that offend a person but the intonation, because the
intonation reveals another meaning—the hidden real meaning. Dr. Z felt
disrespected as a physician. He thought he was being treated without the
respect due to a doctor. And yet how much respect should a doctor expect
if no one knows what a doctor is? Even we doctors didn’t know. That’s
why we were fighting among ourselves.
Night call remained every third night as before. But across the country
residents in all fields demanded better hours. They got them by the turn of the century. Residency programs that kept the old system lost applicants.
Finally, in 2003, the accrediting agency for the nation’s residencies
capped a resident’s workweek at eighty hours. The next generation of
doctors wanted more time off for private life. No gentleman doctor or
abusive professor could restrain so elemental a movement.
During the next month, I pondered the matter of what a doctor is. As
an anesthesiologist, I had time to do so.
Medical Catastrophe Page 2