“Oh, no,” I imagined all sorts of draconian punitive assignments I might be forced to undertake, “what penance will be required for forgiveness of my sins?”
“He’s going to take you to dinner.”
“What?” I replied. “He’s going to punish me by taking me to dinner?”
“Well remember he likes you, Vega. So this particular retribution will be more subtle. We have come to know it by another name—‘torture by sushi’”.
“You’re talking about raw fish?”
“I ain’t talking about no New York Strip Steak. He will order for you and expect you to love every bit of it. And don’t even think about calling at the last minute and saying you’re sick. He’ll just courteously reschedule.”
“I’m dead. I hate fish and the thought of raw fish makes me want to jump off a pier.”
“You should’ve thought of that when you took two days off of this sub-internship without a properly completed death certificate—yours. Your only saving grace is that I told Royce that you’ve always wanted to try the sushi in this area and you would be looking forward to having dinner with him at Kiku Sushi restaurant.”
“I don’t know a thing about sushi except that I’d rather eat spent nuclear fuel rods.”
“Then you’d better start studying up on that little delicacy or your career in trauma surgery could be over before it starts.”
* * *
Royce and I met at the restaurant at around 8 PM after evening rounds. He seemed relaxed rather than angry and I thought maybe this would be a low-key evening after all.
“Welcome to Kiku Sushi, Vega,” he gestured grandly around us as if he was the proud owner rather than just another diner. “I hope you’re ready to appreciate one of life’s greatest culinary experiences.”
I was, but I knew I was going to be subjected to uncooked seafood instead.
“I am absolutely prepared,” I replied, “although I have always wondered why the modern dish is still called ‘sushi’. Sushi, as I’m sure you know, literally means ‘sour-tasting’, which harkens back to the days when it was prepared in fermented rice. Modern sushi is not prepared that way and yet we still call it ‘sushi’.
Royce’s eyes flashed with recognition. “Vega, I see I underestimated you again. Not all Midcentral U students are complete hayseeds, after all. You do indeed have an appreciation for fine food.”
He turned his attention to the menu. “I was going to order some simple ‘beginner’ stuff for you, seeing that it might be your first time eating this exotic cuisine. But now that I see that you are a fellow connoisseur, I think we need to really do things up right, don’t you?”
He motioned to the waiter and my heart sank as I realized my little bit of research had gotten me in even worse trouble. Maybe I would get lucky and have a severe allergic reaction to one of the first courses.
“Waiter,” Royce began with nauseating enthusiasm, “We’ll have two orders of the seaweed salad, then one order of unagi, one order of ika…hmmm..oh, yes how about an order of the tako and an order of the ikura. We’ll also have some green tea. Also some shoyu, wasabi and gari.”
My senior resident had just ordered eel, squid, octopus and salmon eggs with some delicious sauces to accompany them. And there was no way out.
“Dr. Cunningham, those are some of my favorites. I don’t know how you could have known.”
“I’m pretty perceptive that way. You know, Vega, some students and residents come onto my team and think I’m sadistic or that I don’t care about people. Nothing could be further from the truth. Actually, I test everyone pretty hard because I’m afraid that if I don’t, they’ll fail at the next level. If one of my students or interns didn’t succeed because I was too easy on them, I would feel responsible, you know what I mean? So if I ride someone’s ass really hard, it’s because I want them to make it.”
I couldn’t believe it. In some small way, Royce Cunningham felt like he had to justify his methods to a fourth year medical student.
He went on, “The truth is, Vega, you have the technical tools and the rapid decision-making ability to be a surgeon. Your patients also genuinely like you and bond with you, even in the short time they spend on the trauma service. Most physicians are not gifted both technically and humanistically to the degree that you are.”
Our food arrived and Royce attacked it with his characteristic zeal—it reminded me of one of those old National Geographic films we watched in high school where the lions munched down on a wildebeest.
I took a sip of my tea and tasted each of the rolled slimy morsels of raw fish flesh in front of me. Waves of nausea broke through the effects of the anti-nausea pill that I had gotten one of the residents to prescribe for me.
Royce came up for air and looked at me with a penetrating gaze.
“Well, what do you think, Vega? Does it come up to the standards of sushi you’ve had in the past?”
I thought very hard. There was no way I was going to be able to finish my meal. I had come to a crossroads with Royce Cunningham. I could work my butt off in his rotation but I had to stop kissing his. There was a risk, but I was going to have to tell him what I really thought.
“Dr. Cunningham, the truth is…well…I have never really cared for fish and sushi doesn’t do anything for me.” I waited for the storm from Royce that would end any hope of my becoming a trauma surgeon.
He stood up and threw down his napkin.
Here it comes.
“Son of a bitch, Vega, you do have a backbone. You’re the first sub-intern I took out for sushi that had the gonads to tell me straight up that they didn’t like what I liked. I don’t impress easy, Vega, but being willing to take chances when you feel strongly about something is what sets great trauma surgeons apart from merely good ones. You let me know when you need a recommendation, even if it’s for a candy-ass family practice residency, alright?”
The rest of my trauma surgery rotation went really well. Maybe even extraordinarily well. I saw and assisted with just about every type of procedure associated with trauma that I could hope to experience. Burns, penetrating trauma, blunt trauma, gunshots, inhalational injuries, reconstructive surgeries and wound care/rehabilitation were all thoroughly covered on my curriculum. I came away with newly acquired knowledge of and even greater respect for the men and women who practiced this branch of medicine. The only thing that was missing in this highly sophisticated field of practice was an ongoing month to month or year to year relationship with patients and their families. The encounter with a trauma patient was a very brief and intense one compared with other specialties of medicine. There was much opportunity to save lives and make a difference but not much chance to forge a lasting relationship or even communicate beyond very short snippets. I came away from Metro still unsure as to where my professional future lay.
And so I found myself once again at the poker table with my old friends Courtney, Gomey and Tyler. It was now November and in two short months we would be submitting our preferences for the National Residency Matching Program. The NRMP is a system by which graduating medical students are matched with training programs where they will further develop their skills for a particular medical specialty. The student specifies a list of programs in rank order that he or she wants to attend and the programs rank the students that they want to accept. The result is referred to by both parties as “the match”.
Tyler dealt the cards while everyone waited to see who would be the first to state what they wanted to do and where they wanted to do it. But before that moment came, Gomey blurted out a little news:
“I have an announcement, everyone. I’m getting married.”
“Congrats, Gomey,” Tyler said from behind his cards, “who is she and when the hell did you have time to actually date during the killer rotations you’ve done so far this year?”
“The answer to both your questions is that she is a pharmaceutical representative named Chloe that I met at my general surgery sub-internship in New York
so she was making sales calls to the hospital. Take a look at these pictures,” he said as he passed around his smart phone.
I made some impressed noises as I looked through the pictures of a woman who was clearly wasting her time hawking medications to doctors when she could be on the cover of Vogue.
“Okay Gomey,” I said as I remembered his comments about Jilllian, “these pictures make it clear that there is only one more question to ask. How many Land Rovers and how many elephants did you have to offer her father?”
Gomey answered in the most serious tone imaginable, “My friend, we are not in Africa. Her father asked for a much greater price.”
Courtney was now on the edge of her seat, “What was that?”
“He demanded that I do everything in my power to make her happy.”
Tyler was highly indignant, “The nerve of that bastard!”
Gomey nodded solemnly, “That is not the worst of it.”
I looked incredulously at him, “You mean, that wasn’t all?”
Gomey shook his head, “In fact, he made it clear that if I hurt her, he would cause me to part with my testicles without anesthesia and outside of an operating room. This caused me to question the American legal system, the American health care delivery system and American marriage customs all at the same time.”
The poker table dissolved into peals of laughter at poor Gomey’s expense although the twinkle in his eye told me that he knew all along that his fiancee’s father would not carry out the threat. I also knew the guy was so smitten with his lady love that he had nothing to worry about—he would do everything possible for her happiness.
A few hands later, we knew it was time to discuss the inevitable. Tyler began the discussion.
“We all know that why we’re really here tonight, aside from our pathologic need to play a game which is really nothing more than a ritualized manner of donating to the Gomey Honeymoon Fund. It’s time to lay our REAL cards on the table, so I will start. You all know that I intended to become a neurosurgeon, but I changed my mind. My neurosurgery rotation was just not what I hoped for—a lot of egos and not much opportunity for me to learn and get involved. My next rotation was vascular surgery and during that time I got involved with interventional cardiology and vascular procedures—like opening up narrow blood vessels and sticking stents in and stuff. Now you guys know that next to poker, my favorite thing is video games. Well, endovascular procedures are just like video games! You make a little incision, you thread in a little catheter, you look up on the screen and move the thing around. Then you open an artery up and stick in something to keep it open—all essentially by remote control. You can stop a heart attack while it is happening! And best of all they pay you big bucks to do it. I figured, THIS is what I was made to do. So, I am going for a general surgery residency at Duke University and later I will do a fellowship in vascular surgery followed by an endovascular fellowship. I’ll be 34 years old when I finish but it will all be worth it.”
The whole table applauded and whooped. When the ovation died down, Courtney spoke. “Well, my story isn’t as entertaining as Dr. Video Game over there but I’m just as committed. My ambitions haven’t changed one bit. I want to do Orthopedics plain and simple. It’s a surgically challenging specialty and there’s limited interruption for a bunch of silly documentation. You know what they say about an orthopedic surgeon’s note in the medical record: ‘Bone broke. Me fix.’ There’s really no need for anything more than that.”
“Wait a minute,” I challenged her, “Now with electronic health records, won’t even orthopedic specialists be expected to write longer more comprehensive notes?”
“Oh, well you’ve got a good point, Vega. In the future, the note will say ‘Bone Broke. Me Fix. Then Me Buy Mercedes-Benz.’”
“That sounds so much better,” I said with a sarcastic sigh. I turned to Gomey, “Please tell me a more heartwarming story of the journey to your chosen medical specialty.”
Gomey looked pensive. “I must tell you there has always been a little voice inside me saying, ‘Gomey, your little village in Africa is poor and underserved. The people need you. Go back there and heal those who cannot afford the care that you have learned to provide.’”
“Now see everyone, there is the heartwarming story we have been longing to hear,” I beamed with pride.
Gomey then continued, “And then there is a much louder voice saying, ‘You know you want a two story stone colonial in Greenwich Connecticut and a summer house in the Hamptons and your children to go to the best prep schools money can buy so who are you kidding about going back to Africa?’ I then realize how much I want to do transplant surgery and I let the louder voice drown out the little voice.”
Another round of laughter seized the table and I joined in too even though I wish Gomey hadn’t given up on the little voice quite so easily. Then I realized it was my turn and I took center stage.
“You all know that I am one of the few senior medical students who is actually trying to choose between family medicine and trauma surgery. In many ways, the two specialties couldn’t be more different. Each offers unique challenges and rewards but both have potential limitations. The truth is that I still can’t decide. I may wind up making the decision the day I send off my preferences to the NRMP.”
Courtney was the first to chime in with a less-than-supportive reply, “Vega, that is so LAME. You are never going to be a surgeon if you can’t be more definitive than that. You know what they say about surgeons, ‘often wrong, never in doubt’”.
Had she been a man, I might have displayed the central finger of ultimate respect at that moment. As it was, I just shrugged and dealt another hand of cards. I wasn’t sure how long it would be until we would play again.
Chapter 37
The rotation that would lead to the winter holidays was Orthopedics back at Midcentral which had a pretty nice referral hospital even if it was in a rural area. It was also near my hometown which was a plus. The best thing about ortho was that there were some awesome physical therapists who taught me how to diagnose everything from anterior cruciate ligament tears to tennis elbow. The surgeons were more interested in having me take out skin staples or evaluate post-operative fevers so they could catch up on sleep uninterrupted.
Things were going swimmingly until I got an unexpected call from my Dad telling me Abuela had been admitted to Midcentral. This threw me for a loop since I hadn’t known her to be sick since I was little. Abuela didn’t believe in sickness. Unfortunately, illness found her anyway. She got a bladder infection like many elderly women do and tried to ignore it until it turned into a kidney infection. The kidney infection spread into her blood and she was very sick in a hurry. She wound up in the ICU on intravenous antibiotics and despite the best preventive efforts developed a blood clot in her leg and bleeding from her stomach (ICU patients often get stress ulcers). To top it all off, she never told me she’d been treated for high blood pressure and diabetes for years and wasn’t very cooperative with medications and follow up visits with her doctor prior to this hospitalization.
By the time I came to her room in the ICU, she was on the aforementioned IV antibiotics, was getting a blood transfusion, intravenous acid blockers, oxygen and insulin among many other medications. I approached her bed with trepidation.
“Now I see what it takes to get you to visit me,” she said with the slightest hint of a smile.
“Don’t joke like that Abuela, you know I would have come even if you had just been in a regular hospital room. Going to the ICU was going over the top, don’t you think?”
“Okay, next time, I do it differently. Carlito, you must explain things. No one here is telling me anything. They just poke and prod and give me medication. There must be 10 different doctors that have seen me. What is going on? When can I go home?”
I carefully explained everything I had read in her chart-which the ICU resident was kind enough to let me read. I concluded with a procedure that was planned.
“Abuela, you have a blood clot in your leg because you didn’t move around much for a few days. Normally, they would give you blood thinning medication. But they can’t do that, because you are having bleeding in your stomach. So instead, they are going to put a filter in the big vein in your abdomen to make sure the clot in your leg doesn’t go to your lungs. This is necessary because a blood clot in the lungs could be fatal.”
“Okay,” she agreed, “If you say it is the right thing to do, I do it.” We then got one of the nurses to bring the consent form and she signed. Then, I gave her a quick kiss on the forehead and they pulled the curtain and brought in a special table and equipment to do the procedure right there in the ICU.
I went out to the waiting room of the ICU and greeted my parents with a hug. They both looked pretty exhausted. I wrote down each of Abuela’s problems, the medicine that was used to treat it and what I thought might need to happen before she could be sent to a regular hospital room or eventually home. My dad was appreciative.
“Carlos,” he said fighting off a yawn, “the doctors here actually seem pretty nice, but when they talk, they speak a different language. They use words we don’t understand and Abuela actually got angry at one point. I know they are trying to help. But we can’t even tell which specialist takes care of which part of her body.”
It occurred to me that he was absolutely right. Doctors, nurses and hospitals had moved into the 21st century with digital lightning fast communication. But patient communication was still confined to a few words on 6AM rounds. The average patient was elderly, in pain, frightened and sleep-deprived and there was no way he or she could access information about care at times when a nurse or doctor was not present. Furthermore, we as medical students and doctors were given little or no training in the art of communicating with patients. I was amazed that no-one seemed to have developed a software application for this purpose—especially since a large percentage patients were now coming into the hospital with their own tablets or laptop computers.
I promised Mom and Dad that I would keep them updated each day and returned to my duties on the Orthopedics rotation. But Abuela’s experience as a patient left an impression on me as I decided how I would conduct myself as a doctor over the course of my career.
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