Since we were already at 115th Street, we cut through the Columbia campus. Mohan sprinted in front of me. On the main plaza he dunked his hands into the brackish fountain, breaking through the muck of feathers and cigarette butts floating on the surface. I asked him if he wanted to climb to the top of the stairs and watch people—my favorite pastime at Berkeley—but he wanted to run. So we ran around on the grass in front of the math library, trying to scare squirrels.
I’d been promising to take him to the dinosaur playground, so we walked down to the subway to catch a train going downtown. When we got out at Ninety-sixth Street, throngs were out on the sidewalk. I carried Mohan through the crowd. Music was blaring, and street vendors were peddling their wares. “So many scooters and bicycles and motorcycles,” Mohan cried. “It’s such a beautiful day!”
On the way to the playground, we walked by his school. “Mr. Tabakin doesn’t like James,” he said.
“Why?” I asked.
“Because James eats candy. Ms. Morrison and Mr. Tabakin said you can’t bring candy to school. Not because everybody wants some—that’s not the problem—but because it will get disappeared. That means it’s gone. That’s the problem.”
I chuckled. “Mama said James pushed you the other day.”
“Yes, he pushed me.”
“What did you say to him?”
“I said, ‘Don’t push me.’”
“And what did he say?”
“He said, ‘Okay, I won’t push you.’” He smiled, obviously proud of this victory.
By the time we got to the river, he was tired, so I carried him for a ways. Off in the distance, the George Washington Bridge unfurled over the Hudson like a steel bracelet. When we reached the playground, he wiggled out of my arms. “Let’s run!” he commanded. I followed him. Almost immediately he was running up the steps of a slide. He glided down the corkscrew and then quickly followed a kid back up to the top to maximize the chance of barreling into him at the bottom.
“Be careful, I don’t want you to get hurt,” I called out.
“We can fix the hurt, Dadda,” he said, before quickly climbing up the steps to give it another go. “We can fix the hurt.”
At the other side of the playground we found a girl, about twelve years old, playing with her little brother. At first the little boy and Mohan regarded each other warily, like dogs sniffing out danger. Mohan started doing a sort of dance, his arms moving back and forth in stiff karate-like movements, as if he were weaving a spell. It was an invitation to play. The boy looked on silently, a bit enticed, perhaps even a bit fearful. I quietly watched this act of charm and seduction. Soon they were playing like old friends.
I often think of my own childhood growing up in New Delhi and then California. My playmates and I used to compete in marbles. Those purple alleys and red opals: Hold them up to the light and they’d shimmer. Flick one with your thumb and hit your friend’s and you could keep it. Sometimes the marble would lightly graze in the collision. Other times you’d get a clean hit and your marble, imparting its entire momentum, would stop in its tracks, taking the place of the other.
We used to play tops, too. You’d spin your top in the dirt and drag it with a string to try to hit your opponent’s top. Whoever’s top twirled the longest got a chance to gouge his opponent’s with the metal nail at the apex of his own. Nothing was more satisfying than splintering your opponent’s top with a short, clean stab.
As boys, we loved measured violence. In California, where my family moved when I was ten, we played pencils. Your opponent would hold his pencil firmly at both ends, and then you’d whack it with the metal tip of your own, bending your pencil with your thumb to get maximal force. If you snapped quick and hard, the other pencil would crack.
Once, I snapped Tony Hernandez’s brand-new Ticonderoga. Tony played tackle football. He was the biggest kid in sixth grade. Insulted, he challenged me to a fight after school. It took place on an elevated patch of grass next to the playground. Every boy in the class showed up. I’m not sure why I did. Perhaps out of fear of further offending Tony.
So there was Tony, towering over me, the scrawny immigrant kid with spectacles. I could smell his warm milk breath on my face. Everyone was watching, waiting for someone to make the first move. He circled me silently for what seemed like minutes. Finally, emboldened by the gallery’s calls for some action, I cried, “Get off!” and pushed Tony hard in the chest. I don’t know why I did it. I was petrified. He could have kicked my ass with one hand tied behind his back, but he backed down. He warned me not to cheat at pencils again and walked away. The other kids left, too, disappointed, I’m sure. I remained at the playground, sobbing out of relief—and perhaps remorse, too, for making Tony lose face.
At the water fountain, Mohan and his new playmate took mouthfuls of water and spit them at each other. Pretty soon we were all running through the sprinklers. After a while we all took some rest on a bench. “How old are you?” the boy asked Mohan.
“I’m five,” Mohan replied.
“I’m five, too,” the boy said. “My sister is twelve.” He asked Mohan how old I was.
“Forty,” I replied.
“Forty!” Mohan cried. “Come on, Dadda. That’s not a number!”
“Forty is too a number!”
He looked at me sadly. “Oh, that’s too bad, Dadda.”
There was a thunderclap. I quickly turned. A huge branch of a Dutch elm had come crashing down onto the gray asphalt a few feet from where the children had been standing. It was ten feet long, about a foot in circumference. It would have crushed anyone standing under it. The boys ran over excitedly to inspect the splintery mess. I stared at it in shock. A woman said she was calling 311.
I quickly gathered up our things, and we boarded a bus going back uptown. It sped up Riverside Drive, past busy playgrounds and Parisian-style apartment houses garnished with metal scaffolding. Back in our neighborhood, I picked Mohan up again. The sidewalks were buzzing with the usual Saturday-afternoon mercantile swarm. I asked him if he wanted to go to the diner for lunch. He nodded yes.
A man was playing the trumpet on the sidewalk in front of the restaurant. We went inside and got seated in a booth. I ordered chicken fingers and a strawberry milk shake for Mohan and a cheeseburger and French fries for myself. When the food came, we dug in. Licking his fingers, Mohan said, “This is fun, Dadda. Let’s do this every week.”
A sad feeling washed over me, as I knew our outings to Riverside Park were coming to an end. We ate in silence. I finally broached the dreaded subject. “Do you want to live in a house with a backyard?”
“Yes,” he said, munching on a French fry.
“But it means we have to leave New York.”
“Will there be chicken fingers there?”
“Yes, of course, but they’ll be from a different place.” He looked at me carefully but didn’t say anything. “We can still come back and visit James,” I said. He remained quiet. A minute passed.
“You’ll go to a great new school with a big playground. You’ll make new friends.”
He nodded, seeming uninterested. I started to say something, but he interrupted me. “I don’t want to talk about this anymore,” he said.
“Why?” I asked.
“Because I’m tired,” he said.
NINETEEN
A Country Husband
One by one, as they march, our comrades vanish from our sight. Be it ours to shed sunshine on their path, to lighten their sorrows by the balm of sympathy, to give them the pure joy of a never-tiring affection.
—Bertrand Russell
The old man was lying on a double bed, on gray sheets that looked as if they needed washing. The sparsely furnished room was permeated with the stuffy smell of sickness and sleep. A tray of food sat untouched on a bedside table. His cheeks were sunken; his skin was the color of stone. His bare legs had a bluish tinge.
We’d been taking care of Hyman Gesselman for almost two years, but because of progressiv
e heart failure, he was no longer able to come to the office to see us. A few weeks back we had started him on a continuous infusion of dobutamine at home to support his failing heart, just as I had done for Joseph Cimino in the hospital three years prior. Gesselman lived on a quiet street about a mile from the hospital. It was fall. The ground was damp, and the tiny lawn in front of the house was already brown and bare. His wife, Elsa, met John and me at the front door and showed us to their bedroom. She was in her early sixties, about fifteen years younger than he was, with cellophane gray hair and masculine worker hands. An émigré from Russia, she had been a health aide to Gesselman’s first wife, who had died two years before. He had married Elsa to secure her a green card and permanent residency. Theirs was a fraught relationship. At office visits she would constantly interrupt him, disputing almost everything he said: whether he had slept, whether he had eaten, whether he had tripped or fainted before falling. Vexed, he’d glare at her and say, “I thought we discussed you weren’t going to say anything,” but there was little he could do to prevent her from speaking her mind.
In the bedroom, he extended his hand to me weakly. I held it for a few seconds. Spidery blue veins zigzagged under the paper-thin, almost translucent skin. I asked him how he was feeling. He nodded vacantly. I checked his pulse, weak but regular, and his jugular veins, which were reedy and congested. I listened to his chest with my stethoscope. He was wheezing, front and back. I checked on the drug infusion settings: 2.5 micrograms per kilogram per minute, as ordered. I surveyed the room: no obvious tripping hazards. I opened the window blinds. As I was getting ready to leave, he stopped me. “My life was travel, Dr. Jauhar,” he mumbled. “Arizona, Bar Harbor—will I ever be able to do that again?”
I didn’t know how to respond. I knew he would likely never make it out of his house again, let alone travel by plane, but I didn’t want to take away all hope. “I don’t know, Hyman,” I said softly. “Let’s see how things go.”
Glassy-eyed, he rasped, “I just want to be able to walk. It’s so depressing lying here.” I told him I’d come back to see him soon. He nodded appreciatively. “Just hearing your voice makes me feel better,” he said. “I don’t feel so scared.” He motioned to John, who was standing beside me, as he had dutifully for the past five years. “You are good men,” he said. “I have faith in you. I have faith in what you tell me.”
John and I went to the kitchen to speak to his wife. She was sitting silently at the dining table. In the white porcelain sink was a mess of dirty dishes. “He is going to need more Lasix,” a diuretic, I told her. She nodded silently, appearing exhausted. I looked in the fridge. It was nearly empty. On the counter there were canned soups, all loaded with sodium, precisely what he should not have been consuming. I told her that I was going to continue the dobutamine, but I didn’t want to increase the infusion rate. He was dying, and we all knew it, including him. A visiting nurse was supposed to come by later that day. I left instructions for her to draw blood and fax me the results. Then we bade Elsa goodbye.
We never did make it back to see Mr. Gesselman. For the next couple of weeks we were too busy in the hospital, and he died not long afterward. That house call was our first since I’d started working at LIJ. In 1930, 40 percent of all doctor-patient visits were house calls. Today the proportion has dwindled to less than 1 percent. The major reason, not surprisingly, is money. Traveling to patients’ homes is inefficient and almost never profitable. But it felt good to finally do something that didn’t have a price tag on it.
After all the wasted time of the past two years, I was eager to focus once again on my heart failure job. I still wanted to create a comprehensive disease management program, implementing best practices into treatment algorithms in the emergency room, on the wards, and in transitional and postdischarge care. Applying such algorithms, I believed, would offer the best chance to reduce hospital costs, readmissions, and mortality. I’d just written a ten-page document summarizing evidence-based practices for heart failure diagnosis and management, which we disseminated to residents and attending physicians. Once I got started, I moved quickly: I audited charts of patients with rapid readmission, hired a case manager to help streamline the transition to outpatient care, began attending multidisciplinary rounds, created a special unit to cluster patients with heart failure diagnoses, partnered with the palliative care service to increase the use of hospice care for my end-stage patients, and took the initial steps to begin an outpatient infusion clinic so that patients who required intravenous medications would not necessarily have to be hospitalized. The lessons I’d learned over five years were with me, and now, finally, I had the time and energy to implement them in practice.
* * *
Homeostasis is the ability of a biological system to maintain a condition of equilibrium or stability in the face of external stresses. It is closely related to resilience, the power to return to the original form after being bent, compressed, or stretched. In many ways medicine is the study of human resilience—biological, physiological, and emotional—and not just in patients. Perhaps more than any other profession, medicine demands adaptability of its providers.
We start to get bent early on in medicine. In medical school there’s the fear factor: Do I know enough to move on to the next stage? The stresses don’t end there. In internship and residency there are other pressures, more physical—sleep deprivation, exhaustion—but also existential. And of course, even in full-fledged practice, one is constantly being stretched and bent by factors beyond one’s control. There are always new challenges to be faced, no matter which stage you are in on your journey as a doctor, demanding patience and resilience.
How to prevent the burnout that is so widespread in the profession? There are many measures of success in medicine: income, of course, but also creating attachments with patients, making a difference in their lives, providing good care while responsibly managing limited resources. It is whether you find that meaning in your work that determines whether you feel successful or not. The challenge in dealing with physician burnout on a practical level is to create new incentive schemes to foster that meaning: publicizing clinical excellence, for example (of course, we need to better define exactly what that is), or rewarding for patient satisfaction. It won’t be easy, but the predominant financial scheme today has created a lot of misery.
In the end, it’s a problem of resilience. American doctors need an internal compass to cope with the changing landscape of our profession. For most doctors this compass begins and ends with their patients. In surveys, most physicians—even the dissatisfied ones—say the best part of their jobs is taking care of people. I believe this is the key to coping with the stresses of contemporary medicine: identifying what is important to you, what you believe in, and what you will fight for. For me, I’ve learned, it’s the human moments, such as the house call with Hyman Gesselman. The human moments are what others—the lawyers, the bankers—envy about our profession, and no company, no agency, no entity can take those away.
* * *
We moved to Long Island on Christmas Eve, a few days before an ice storm. The sunlight that day was blinding, fluorescing off the white world. The moving men showed up early and rapidly disassembled, bundled, packed, and loaded eleven years’ worth of our stuff. Standing on the wet sidewalk, I watched the silver Harley from apartment 4E roar out of the garage for the last time. By the time we got on the Long Island Expressway, it was already early afternoon. Dirty spray from the speeding haul truck spattered on my salt-stained windshield. Inside the car, everyone was unusually quiet. I stole furtive glances at Sonia and the children; they were exhausted. I could hardly believe we were finally making our move. It had been a huge decision to uproot my family. I still had no idea if it had been the right one. At our street, tree branches reached out in embrace over the roadway. A sign at the corner said DEAD END.
The house was a white-shingled colonial built in 1955 on a potato farm. In the front yard black locust trees were dusted
with white powder, like Christmas cookies. I stepped out of the car. Fresh snow crunched under my feet as we started to unload. On the front porch, icy spears dripped. Inside, the house was empty. We started to sort through our belongings as the kids gingerly explored their new surroundings. I could hear the pitter-patter of Pia’s little feet on the bare hardwood floors. As dusk settled, the house got cold and drafty. I convinced the movers to stay for a while; so much work remained to be done. They didn’t leave till 10:00 p.m., extorting a huge tip.
I took two weeks off from work to help us get settled. It was a strange and confusing time. We all felt a sense of dislocation, but at times mine seemed overwhelming. (Change always precipitates a measure of fear, whether in the personal or professional realm.) Whenever the kids would cry, I’d feel guilty, as if it were my fault for bringing them there. I imagined Pia missing her stroller ride around our old neighborhood, waving to all the sidewalk fruit vendors. Mohan would call me whenever I went out to run errands after dark, crying, “Dadda, where are you? When are you coming?” Simple tasks like troubleshooting the oven controls or prying open the frozen cover of the trash receptacle left me in a state of panicky frustration. Rajiv, who lived about ten miles away, had his usual no-nonsense take on my gloominess. “How can you compare this house to that apartment in Manhattan?” he demanded. “There is no comparison.”
At night the silence was unsettling. I’d sometimes sneak out and gaze up at an owl in the backyard. It was a haunting apparition at the top of a tree, a hooting hole in the fabric of the blue-gray sky. Raccoons scurried off into the bushes, their beady eyes glinting at me through the leafless brush. For months, Mohan would wake up in the middle of the night and call for me. I’d get into bed with him, palming his cranium, pressing it softly. I craved the warmth of his body on those chilly nights, his knee settling comfortably into the small of my back, his sweaty palm tightly clasping my elbow. I slept in his bed as much for me as for him.
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