Writer, M.D.

by Leah Kaminsky

  “Dead. Dead. Dead,” he pronounced, moving swiftly past the Alzheimer’s patient with three strokes in Bed 10, the woman with metastatic lung cancer in Bed 9, and the demented bilateral amputee with renal failure and liver failure in Bed 8. On the days when our other attending, Dr. Marks, rounded with us, we spent a full ten minutes at each bedside reviewing the labs, the X-rays, and the medications. The poor prognosis would be acknowledged in an oblique way, but the entire treatment plan would be discussed and debated as with any other patient. Only Dr. Sitkin had the honesty—or the chutzpah, depending on your viewpoint—to call it like it was. “Dead. Dead. Dead. Why are we wasting our time even talking?” The team would shuffle along uncomfortably, knowing that he was right in a way—all these patients were going to die in the near future no matter what we did—but it didn’t seem proper, somehow, to say that right out in the open.

  Bed 11—“Dead.” Bed 10—“Dead.” Bed 9—“Dead.” Bed 8—“Dead.” Bed 7. This was where Dr. Sitkin would stop. Stop walking and stop joking. Li-Feng Chen was thirty-two years old. Her leukemia had been in remission for two years, but six months into her pregnancy it flared up with a “blast crisis.” Determined to keep her baby, she avoided chemotherapy until she was so sick that she required an emergency Caesarean section. The baby was downstairs in the neonatal ICU; Ms. Chen was upstairs in the adult ICU. Her bone marrow had been devastated by the leukemia and her body was now a veritable petri dish for infection.

  “This is a patient who deserves our ICU,” Dr. Sitkin said. “This is a patient who might be able to benefit from our intensive monitoring.” On the days we rounded with Dr. Sitkin, we spent 98 percent of our time in front of Ms. Chen’s bed. He demanded to know every lab value, the exact dose of every medication, the specific chemotherapy regimen. He’d perch on the edge of the chart rack and grill us on the minutiae of her care. And then he’d scrunch up his face and think. Minutes of silence would follow as the whole team watched him cogitate. He’d rub his nonexistent beard or twirl the wedding ring around his finger. Then he’d say, “I’m not satisfied with her antibiotic coverage. She’s at risk both from typical infections seen in oncology patients as well as those from a gynecological source. Let’s start from scratch.” He’d have us draw more blood cultures, repeat a spinal tap, change all of her IV lines, and then start her on new antibiotics.

  On the railing of Ms. Chen’s bed was a Polaroid picture of her baby. It was a scrawny thing with a full head of wet black hair, sporting nearly as many tubes and catheters as her mother. As we left Bed 7, I always thought I caught Dr. Sitkin stealing a glance at that photo.

  Dr. Sitkin was not shy about sharing with us the latest exploits of Andrea, his eight-month-old. “Yesterday, she discovered her toes,” he announced during a conference. “Don’t ask me how she did it, but she managed to get all five of her toes in her mouth at once. The kid’s a genius. My wife and I attempted the same thing, and I warn you … don’t try this at home without the proper safety mechanisms.”

  One day, I had to choose which antibiotics to give to my patient with metastatic esophageal cancer after he had spiked a new fever. I debated which combination of drugs I should use, and then I thought, Gee, we have a specialist in infectious diseases this month, let me give him a call. I left a message at Dr. Sitkin’s private-practice office, and he called back promptly. I described the situation and asked his advice.

  “My advice is that you grow up and make your own decisions. Don’t page me to choose some designer assortment of antibiotics. I don’t care which ones you use, the patient’s dead anyway.” He hung up the phone and I felt ashamed of my juvenile question.

  Every Wednesday, we had “ICU Touchy-Feely Rounds.” One of the psychiatrists met with the residents over a pizza lunch to discuss any feelings we had about our time in the ICU. Our attendings were deliberately not present, so we could feel free to talk. Frequently, we bitched about the long hours.

  Occasionally, someone talked about a difficult patient. But mostly we complained about Dr. Sitkin. About how inappropriate he could be. About his constant jokes at the expense of patients. About how we were made to be “colluders” in his humor. About how he had no patience for 95 percent of the staff and 95 percent of the patients. About how we were nervous presenting cases in front of him because he always had cutting criticism to offer.

  On Wednesday afternoons, he’d catch my eye with a wink and say, “Did you all have a good time kvetching about me?” I would smile sheepishly, and he’d say, “That’s okay. All of your complaints are probably justified—I’m a boor, I’m insensitive, I’m condescending.”

  I’d nod cautiously. “Well, a few things like that were mentioned.”

  “Good, good,” he’d smile. “It’s heartening to know that I’m not losing my touch.”

  I decided to take some risk and push a little bit. “Well, some people feel a little uncomfortable with all the jokes, Dr. Sitkin.”

  “Jokes? Every goddamn person here is dying. What else can you do but joke? You guys take everything so seriously. Relax a little.”

  “Some people are a little uncomfortable during the case presentations because you can come down so hard on them.”

  He shook his head in disbelief. “Listen, I’m never going to lie to anyone. You can trust me on that. Whaddya guys want, a goddamn kindergarten ice-cream party?”

  I shrugged. “That wouldn’t be so bad.”

  The next day, during conference, Dr. Sitkin hauled in twelve pints of Ben & Jerry’s ice cream. “Ofri thinks I’m being too harsh on you,” he announced, plunking them on the table one by one, their lids glistening with frost. “She thinks I should get you some ice cream to make you feel better.” The room was silent for a moment. But residents are residents, and free food is free food, even if it was ice cream for breakfast. Everyone dove in with plastic spoons, competing for the good flavors like Chocolate Chip Cookie Dough and Super Fudge Chunk.

  Dr. Sitkin licked a spoonful of vanilla. “How am I doing, Ofri?” he asked dryly. “Better?”

  During our case conference the following week, Lauren was presenting one of the admissions from the previous night. Lauren could have passed for twelve years old. Everything about her—her wispy voice, her four-foot-ten height, her shyness, her wide, innocent eyes—appeared childlike. Dr. Sitkin’s raucous sarcasm made her visibly nervous. Even though she’d grown up on the same side of the Mason-Dixon Line as he, she’d inherited the more genteel aspects of Southernism, while Dr. Sitkin was more of a Brooklynite cloaked in a Tennessee drawl.

  Lauren read from her admission note. The note was long and overly detailed. Lauren’s nervousness kept her from even once looking up from the printed page. She labored over word after word, too tense to include any inflection or pause. Even I couldn’t deny that it was boring as she plodded along. We all were feeling the somnolent effects of her dry presentation, and struggled to stay focused. Dr. Sitkin rolled his eyes. Then he rolled his neck, loudly cracking a joint. Then he plunked his head on the table and left it there, curled up in his arms.

  We sat in stunned silence. Slowly, we looked from one to the other. We’d never seen an attending do that before; nobody knew what to do. Lauren resumed reading from her admission note in a tentative voice, but Dr. Sitkin didn’t stir. Eventually her voice petered out and we sat riveted to our seats.

  No one said or did anything to break the silence. Finally I took a deep breath. “Should we call a code?” I asked.

  Smiles bubbled up on people’s faces, but no one wanted to laugh out loud. Dr. Sitkin snapped his head upward and the team giggled, then burst out laughing. He looked at me, and I wasn’t sure if it was a look of anger or humor. He nodded slowly. “Good one, Ofri. Touché.”

  Ms. Chen grew sicker. Her leukemia had spun out of control, taking her immune system with it; the infections were getting the best of her. Every morning on rounds, we sped through the ICU until Dr. Sitkin parked us at Bed 7. We ploughed through the data exhaustively, hunting
for a chink in the relentless progression of her pathology through which we could intervene. “Leukemia can be a curable disease,” Dr. Sitkin insisted. “If we can pull her through this crisis, she still might achieve a remission, if not a permanent cure. Forget all the corpses in the other beds; this is where our attention should be.”

  The nurses from the neonatal ICU paid visits frequently to update Ms. Chen on her daughter’s condition. Ms. Chen had not seen her daughter since the birth, four weeks ago. She’d had a few minutes to meet her baby in the delivery room before each was whisked to her respective ICU. The Polaroids on the railing were updated weekly.

  When Ms. Chen began to bleed from her gut, we transfused her. When she began to have seizures, we hauled her and all of her machinery downstairs for a head CT. When her lungs weakened, we intubated her and gave her a breathing tube.

  “I only give up when there’s no hope,” Dr. Sitkin said. “And there’s still hope.” He still made “whale blubber” remarks about the obese demented lady in Bed 2. He still had no patience for the end-stage AIDS patient in Bed 3, even though a large portion of his private practice consisted of AIDS patients. “I have nothing against dying—it’s a noble process—but it should be done at home or in a regular medical bed. Not in the ICU. This is the place to give intensive care when there is a possibility of meaningful recovery. We’re not a hospice here.”

  On that Tuesday morning, when we told him that Ms. Chen had died overnight, Dr. Sitkin was quiet and only nodded. He asked us to tell him in detail what had happened. We described the incessant hemorrhaging and intractable fevers. We described the bottoming blood pressure that refused to respond to any intervention. We told him how her lungs flooded despite the forced air of the ventilator. We told him that her seizures continued unabated. We told him how we pronounced her dead at 4:53 a.m. and then called her family. He nodded throughout. “Good job,” he said at the end, his voice uncharacteristically soft. “You guys did a good job.”

  On the last day of our month in the ICU, we sat with Dr. Sitkin in the conference room. “Okay, guys, here’s your chance to tell me what you think of me. We’re going around the room in ascending order of seniority—interns first. Be brutally honest, because that’s how I’d be with you. And don’t worry—anything you say today has probably been said before about me.”

  He pointed to Lauren. “You first.”

  Lauren immediately reddened.

  “C’mon, Lauren. Lay it on the line. I ain’t made of glass,” he drawled.

  Lauren cleared her throat. “Well, I appreciated all the stuff you taught us about infectious disease.”

  “Don’t worry, you don’t have to make me feel good.”

  “Well, sometimes you made me feel shy. You made me feel like I couldn’t do anything good.”

  Dr. Sitkin nodded and twirled his wedding ring. “Good, good, now we’re getting somewhere. Keep it coming.”

  “But I can do things good,” she said.

  “Tell me, Lauren. What can you do good?”

  She paused. “I can sing.”

  “Sing?”

  “Yes, I sing every Sunday in church.”

  Dr. Sitkin smiled and leaned back in his chair. “By all means, Lauren. Sing us a song.”

  Lauren looked at him, confused.

  “I’m serious,” Dr. Sitkin said. “Sing us a song.”

  Lauren adjusted her lab coat, then stood up slowly. She focused on a spot over our heads and opened her mouth. Out came the loudest, clearest soprano that I’d ever heard. All of her diffidence and “childlikeness” suddenly melted away. It was as though when she stood up those robes slipped away onto the chair behind her. She belted out a church hymn that was almost too powerful for our little conference room. We were jolted awake and mesmerized by this stunning, compelling woman before us. When she finished, she sat down abruptly.

  Dr. Sitkin was visibly moved. “Thank you, Lauren. I’ll have to say that’s never happened to me before.” Back in her seat, Lauren was as physically diminutive as she’d always been, but she never again appeared childlike to me.

  Dr. Sitkin went around the room, pointing at each intern and then each resident, who gave him some feedback. When he got to me, he went out of order and skipped to the pulmonary fellow who was actually above me in seniority. “You’re last, Ofri. I’m saving the best for last.”

  When it was finally my turn, the room quieted. Everyone seemed to expect a face-off, because they knew I had criticized him heavily both in person and in “Touchy-Feely Rounds.”

  “Well, Sitkin,” I said. “This month has been nothing if not interesting. You have been a unique attending in all my time at Bellevue. I appreciate your honesty and I know that you really do care about the patients and us, even if you won’t always admit to it.” I took a deep breath. “But at times you are entirely inappropriate, juvenile, insulting, and downright nasty. I sometimes can’t believe that the department lets you run free like this, entrusting the education of impressionable young interns to you. And I hate the way you make fun of sick patients who are dying. I think that’s despicable.”

  “Whew,” Dr. Sitkin said. “I was worried for a moment that you were actually going to say something bad about me.”

  “The worst thing is,” I continued, “is that I find your disgusting humor incredibly funny and I’ve actually enjoyed this month in the ICU.”

  “Praise the Lord,” he said, looking upward. “She likes me. Ofri actually likes me.”

  I had been visiting a friend at the beach on Long Island one weekend in early August, and biked over to the Amagansett Farmers Market to pick up some bagels. Sitting on one of the wooden benches by a bin of freshly harvested corn were Dr. Sitkin and his wife. A racing bike leaned against the back of the bench. When he saw me, he smiled and beckoned me over.

  “Julie,” he said to his wife, “this is Danielle Ofri, one of the best residents from Bellevue.”

  A compliment from Sitkin? An honest-to-goodness compliment? It took me a moment to absorb what he’d just said, and then I could feel a goofy grin spread from ear to ear, but I couldn’t help it. A compliment from Sitkin. When I recovered from my shock, I reached out and shook hands with his wife. “It’s a pleasure to meet you. Your husband is a one-of-a-kind attending.”

  Julie smiled. “He certainly is a one-of-a-kind guy. And you must be a one-of-a-kind resident if you managed to survive with him and still come out smiling.”

  “We actually had a lot of fun in the ICU,” I said. “Do you come out here often?”

  “We have a house here, in East Hampton,” Julie said. “Most weekends we’re here, though, Joseph spends more time on his bike than in the house.”

  “That’s not true,” Dr. Sitkin said in mock protest. “Just once a day, I take a spin to Sag Harbor to stretch my legs.” East Hampton to Sag Harbor was twenty miles round-trip, and it wasn’t all flat.

  “Hey, Ofri,” Dr. Sitkin said, “you haven’t met the most important members of the family.” He lifted a baby out of the stroller that was parked next to the bench. “This little sweetheart is Andrea.” He cradled her in his arms and tickled her chin so she would smile at me.

  “Ah, yes, the one who can get all her toes in her mouth.”

  “Precisely. And the real genius of the family is Ellen. Ellen? Where are you hiding?”

  A doe-eyed four-year-old came bounding out of the nearby wooden dollhouse and leaped onto the bench next to him. “This is Ellen,” Dr. Sitkin said. “She’s going to be a nephrologist when she grows up.”

  “I like kidneys,” Ellen announced.

  “I like kidneys, too,” I said, “and it’s a pleasure to meet you.”

  We chatted for ten minutes about my upcoming board exams, the new deck they were building on their home, and the receding dunes on the beach. When I’d finished my coffee, I bid them goodbye and hopped on my bike. I didn’t often have a chance to socialize with my attendings. It felt nice. It felt like I was actually growing up.


  Eighteen months later, I was returning home from a two-week vacation in Israel. It was a chilly January morning, and I was walking down Broadway on the Upper West Side. I had arrived only yesterday and I was still jet-lagged, but not jet-lagged enough to pass up a quarter-pound of Zabar’s best lox. My mind was tired, and it wandered from the British Airways billboard to the posters advertising upcoming rock concerts at Madison Square Garden. I saw a Missing Person flyer posted on a streetlamp for a young college student who had disappeared from a New Year’s Eve party. Probably overdosed on drugs, I thought, and walked past it. Then the thought suddenly struck me—that flyer represented a person. And not only a person, it represented a family in emotional panic. That kid was somebody’s son, somebody’s baby. How could I just walk by? A block away was another lamppost with another flyer posted on it, and I walked deliberately over to it. I was going to pay these poor souls their due. The white photocopied paper was affixed with tape on the top and bottom, but the corners flew loose in the wind. Suddenly I found myself staring at the face of Joseph Sitkin. “Missing,” it said, “since Monday. Last seen wearing blue jeans and yellow parka.” The photo showed his trademark curly hair spilling over the edges of his wire-rimmed glasses.

  I felt my legs grow weak as I grabbed the lamppost for support. I was sure my vision had been mistaken. These Missing Person flyers were always filled with distorted photos of strangers whose presence or absence could not affect my life. There must have been some mistake.

  I pulled myself back up and forced my eyes to gaze upon the flyer again. The photocopied version of the picture blurred the details and one couldn’t make out the sharp wit and ample intelligence that I knew permeated the lean features of his face, but it was Dr. Sitkin, or at least a representation of Dr. Sitkin. It was a disembodied reflection of the man I knew, not just because of the warped physical details of the picture, but because of his very presence on such a poster. I felt like I was looking through a photographic negative, and there was something discomfortingly unbalanced about seeing the opposite of presence. I was staring at his absence. How could Dr. Sitkin be missing?