by Robin Cook
The waves added to the atmosphere with their impetuosity and rhythm; one minute an organized vibration of harmonic motion, the next a swirling mass of senseless confusion. I caught one of the waves. I felt its power, the wind and the sound. Twisting as the board responded, I made my body work against the force to fall; speed and crucial milliseconds. Down the wave and then a twist of my torso, running my hand along the sheer wall of water and the crash and swirl, yet still standing, my feet on the board lost beneath a swirl of white foam. Finally the sudden kickout, with a violent but controlled backward twist, made me want to shout with the joy of being alive.
Darkness erased the scene slowly and drove us back to shore. Hastings went his way and I mine, to the hospital for a shower. Back in the geometric, sanitized world of clean floors, utilitarian showers, and fluorescent lights, I dressed and left the grounds again. Driving up Mount Tantalus, I pleasantly anticipated the night to come.
Her name was Nancy Shepard, and I had met her—how else?—through the hospital. Her father had been a gall-bladder patient whose progress I followed closely after assisting a private M.D. in the operation. Every time I changed his dressing, he had mentioned that he wanted me to meet his daughter, retelling how she had gone to Smith and spent a year at Boston University working on a master's degree in African history. In truth, I grew a little tired of hearing the stories, although I remained interested in meeting her. Finally, the day before her father left the hospital, she had appeared, and she was nice—very. In fact, she looked a little like another girl from Smith I had dated while I was in college. Anyway, we went to the beach a few times, which we both enjoyed. She could talk about almost anything; it was fun to be with someone educated and intelligent. A political-science major, she was fond of arguing heatedly over small points of government, especially about Africa. Despite a number of successful dates and my admiration for her, I stopped asking her out very often, mostly because of lethargy and lack of time. In fact, that night’s invitation to dinner had come out of the blue. Not that I didn't want to see Nancy. I just never got around to it—and by then Joyce had become pretty convenient.
The dinner was fine. Nancy's parents and two brothers were also there, all of them lively talkers. After coffee, Nancy and I wandered out into the large, verdant yard and began an argument about Jomo Kenyatta and Tanzania. Why had Africa failed to produce more Kenyattas? She was emotional on the subject; it was good to see her color rise as she warmed to the argument, making her even prettier.
But then she started asking me questions about medicine. Because she was really interested, not just passing the time, like so many, I worked hard to make her understand, answering as well as I could. Inevitably, she asked why I had gone into medicine. To this question an intern develops many answers. Most of them are evasive half-truths. But with her I decided to try for the whole truth.
"Well, Nancy, I don't think I'll ever know exactly. In the beginning I suppose I had some vague notion about helping people by entering a noble profession. But now that I have a lot of medicine behind me, I think I was attracted just as much by the idea that being a doctor would give me a sort of power that other people don't have—a power over people as well as disease. Few things mean more to Americans than good health, and those who have that to give, or claim to have it, are automatically authority figures in our society."
"What do you mean by power and authority?"
"Just that, I suppose. It's something like the power a medicine man holds in a primitive tribal society. He holds a high position only so far as he's able to play on the fears of his fellow tribesmen and make them think he can control nature. If s a kind of legitimate hoax—legitimate because he performs a more or less useful function, and a hoax because he doesn't really control anything but the tribal psychology. I think modern medicine is the lucky heir to that kind of psychological misconception. My patients don't fall prostrate before lightning and thunder, but they're sure as hell terrified by cancer and lots of other diseases they don't understand. When they come to the hospital, they are looking for a medicine man in more ways than one. Before I went into medical training, I was like any guy in the street. I mean I believed in the power of medicine to do almost anything, and I wanted that power, wanted to be looked up to as the agent of that power."
"But surely you mean the power to help people?" She still didn't understand.
"Sure, I can help people. Not as much as I'd like, and nowhere near what they hope for, but some. But that kind of power is severely limited. Medicine is still fairly primitive. We just don't know enough. It's the other kind of power, the more abstract kind, that I'm talking about. That's nearly unlimited. For example—I played a little football in high school, and one time a fellow broke his leg in practice. I was right next to him in the pileup, and I found myself there looking straight at him, wanting to do something, but totally helpless. When I thought about it later, what I remembered was the envy I felt toward the doctor. I know now that he didn't do much except say a few soothing words, administer a painkiller, and haul the guy away. But to me, to all of us, he was a kind of god. The more I thought about it, the more I wanted a piece of that power."
"But what about the idea you started with, of medicine as a noble profession, of just helping the boy with the broken leg. What happened to that?"
"It got all mixed up with the god idea. Anyway, I went on to college planning to become a doctor. Although a lot of new avenues opened up after that, no pressing alternative appeared. So I finally just drifted into medical school, not really having anything else in mind, wanting both kinds of power, and realizing I could have them in the medical profession, plus the social status and a reasonable income. Now mat I've more or less made it, all those abstract notions have fallen apart on me. I don't have much social status, no money at all, the god-power thing seems utterly empty, and as for the power over disease itself—I hope to heaven I never have to undergo any surgery. I know too much about the limitations of medicine."
I should have been sharp enough to notice the slight chill Nancy was giving off, but I didn't. She had been waiting for the "ever since I was a little boy" story so dear to television and other fictionalized accounts of medicine. But she had made me reach down into myself, searching for answers, and the little boy wasn't there.
"Then you don't feel you have any special quality that made you go into medicine? No vocation, so to speak?" She was still looking for Ben Casey.
"No, this is definitely not like the priesthood for me. The closest I can come to medicine being a vocation is that I did well in both science and the humanities in college, and medicine is a logical combination of the two."
"Well, you don't sound like you have the same motivations as the doctors I know." She was flaring up. And so was I.
"Just how many doctors do you know, Nancy? My whole world is made up of them. I live with them— interns, residents, attendings, the medical-school crowd—and I can tell you that, in general, what happened to me happened to them, and what I feel is pretty much what they feel, if you can get them to admit it."
"Well, I think it stinks."
"What stinks?"
"That our society has let you get this far. You're the wrong person to train as a doctor, because you don't care enough about helping other people."
"I just told you that I want to help people, and I do, but the whole thing is more complicated than that. Hell, I'm just like everybody else. I don't have one consuming goal that shuts everything else out. I want to live, too. Besides, a lot of the idealism I had was smothered in medical school. It's just not oriented that way."
"Don't you like being an intern?" she interjected.
"No, not really."
She was again surprised. "Why not?"
"Basically I feel so tired, really exhausted, all the time. And yet I lack any sense of real usefulness. I realize most of the things I do could be done by someone without the training I've had. Plus I'm constantly scared, thinking I'll screw something up and look
like a fool. You see, medical school didn't seem to prepare me very well at all." By now, the resolution of that afternoon to keep my mouth shut had dissolved in the intensity of the moment.
"Well, I think that's understandable. Medical school can't do everything," she said.
"It might be understandable from a distance, but when you're right in the middle of it, you don't understand what’s happening to you. And when I do stop to think, and realize that the four years at medical school were mostly wasted as far as taking care of the patients is concerned, and that I'm being exploited under the guise of learning, the psychological burden is too heavy. I just get furious at the system— the way medical school and internship and medical practice are interconnected—and at the society that supports it."
"Being furious is hardly the best attitude for a doctor to have," she added with coolness.
"I couldn't agree with you more, and I wish the establishment realized that, too. Eventually, you reach a point where you don't give a damn. Sometimes, after getting called on a cardiac arrest in the middle of the night, I suddenly realize that I wish the guy would die so I could go back to bed. I mean that’s how tired and pissed off I get. In a sense, I've stopped thinking about patients as people, and of course that only adds to the guilt."
Looking over at her, I could see her ethics creaking under the strain of my words. But I went on blindly.
"I suppose this business of not thinking about patients as people is the hardest to explain. Maybe a few doctors can empathize indefinitely. But not me. I can't take it. To survive now, I want to know my patients only as gall bladders or hernias or ulcers. Of course, I include in that anything about them that directly affects their basic disease process, and I believe I am becoming a good doctor technically, but beyond that I don't want to get involved. My system is not geared for it. I had this one patient named Roso, and I got so tied up with him that when he was discharged I was more relieved he was gone than I was happy he was alive."
The silence was icy. I stared into the sky, purposely looking away from her. Then I went on.
"Another thing. Very important. As an intern, I'm exploited the same as an underdeveloped country operating under mercantilistic relations with a colonial power. For instance, all I do in the operating room ninety-nine per cent of the time is hold retractors, often for the sloppiest G.P., who shouldn't be doing surgery, anyway. I'm there to be used. Anything I learn is in spite of the system, not because of it. And if I don't do what I'm told, or make too many complaints about the medieval system—pouf!—out goes my chance to specialize in a good hospital. So when I say I'm scared about making a mistake, I'm worried not so much for the patient—although that's partly it—but because I might get the boot and end up in some hick town giving typhoid shots. That's medicine's equivalent of the living death.
"And besides, a lot of very real and serious problems come up, which no one tells us about or even offers any advice. Like the emergency-room question of when you should try to revive a patient and when you should just let him alone. As interns with no experience, we're totally vulnerable about such things. And this is not entirely a medical problem. What about the ethics involved? If the person is revived and becomes a brain-stem preparation—and that means he is taking up a sorely needed bed in the ICU—then you've deprived somebody else of the ICU bed, someone else who might have a better chance. That's a godlike decision. Medical school never taught me to play God. And then all—"
I had been rambling on, looking out through the dark trees, putting these thoughts together for the first time. In some ways I was talking only to myself, and when I turned and looked at Nancy she exploded, stopping me in the middle of a sentence.
"You're an unbelievable egotist!" she said.
"I don't think so. I just live in the real world."
'To me you're an egotist—cold, inhuman, unethical, immoral, and without empathy. And those are not traits I look for in a doctor." She could really lay it on when she wanted to.
"Look here, Nancy, what I've told you is the truth, and it's not just my truth. I'm a composite of most of the interns I know."
"Then the whole bunch of you ought to be thrown out."
"Right on, baby! If you feel so strongly about it, why don't you organize a sit-in at the ER? Compassion's a cheap commodity when you get eight hours of sleep a night. Most nights I get less than half that much. The rest of the time I spend checking Mrs. Pushbotton's itchy hemorrhoids. Don't you moralize at me from your easy chair."
And so it went, ending with both of us steaming with anger. I left after a halfhearted promise to call her sometime.
Back in my geometric, all-white room, I lay fuming, all keyed up, with less than nine hours before the ER holocaust was to begin again. Sleep was clearly out of the question. I called the lab, and Joyce answered. Could she come by at eleven? She said she would, and I felt better.
DAY 307
General Surgery:
Private Teaching Service
To an intern in medical practice during the latter half of the twentieth century, Alexander Graham Bell is the arch villain of all time. The blame, of course, must be spread a bit wider, to include not only the man who invented the telephone, but also the sadist who designed the ring. And then all those fellows working for Ma Bell who perpetuate the jangle— they're in it, too. How did hospitals function before the invention of the telephone? I often thought of myself, nowadays, as a mere extension of that little piece of black plastic. It was every bit as terrifying as the ambulance, and a good bit more sudden—always somehow expected in the back of my mind, and yet at the same time coming on me unawares. In all the world, there is no sound like it for disturbing the peace.
My peace just then consisted of falling gently asleep beside Karen Christie in her apartment after, I trust, a mutually satisfying encounter. When the telephone rang at 2:00 A.M., we both reached. I let her have it—not because it was probably for her. Since I was on call, it would more likely be the hospital night operator extending me an invitation to return to those corridors. But it might have been Karen's so-called boyfriend.
Indeed it was the hospital operator, who put me through to a nurse. "Doctor, would you come immediately? One of Dr. Jarvis's private patients is having trouble breathing, and Dr. Jarvis wants you to handle it."
Rolling over on my back, I stared at the ceiling and cursed inwardly, holding the telephone away from my ear. Dr. Jarvis I knew all too well. He was none other than our old friend the Supercharger, famous for his OR butchery, especially on breast biopsies. "Are you still there, Doctor?" the nurse intoned.
"Yes, Nurse, I'm still here. Does Dr. Jarvis plan to come in?"
"I don't know, Doctor."
Typical. Not only of the Supercharger, but of most private doctors affiliated with the hospital. The intern would go to see the patient, work up a recommendation, and phone the private doctor, who, of course, would tell the intern to do what he thought best. On most such occasions these guys didn't even bother with the amenities. One time I had spent about an hour going over one of the Supercharger's cases. When I called in my report. Supercharger had stepped out of his office and I had to leave a message with his secretary for him to ring me back. He rang back, all right, but to the floor nurse, not me. When she told him I wanted urgently to speak with him, he said he didn't have time to talk to every intern in the hospital. Rush, rush, for a few more bucks—that was the Supercharger's game.
Supercharger had another endearing habit. He admitted almost all his patients on the so-called teaching program. One might naturally think that a teaching program would in fact teach, at least a little. God knows, we interns were in need of it. In practice, the teaching program was a grim joke. It meant only that I or one of the other interns did the patient's whole admission history and physical—the "scut" work. As a reward, we might be allowed to do the discharge note as well. But in between we weren't allowed to fool with the orders, and in the operating room our contribution consisted of holding retr
actors, removing warts, and perhaps tying a few knots, if the doctor was in a condescending mood.
The ultimate in Supercharger's gall had occurred earlier, on that breast biopsy, the one he mauled so badly. On the admitting chart, giving the particulars of the case, he had written a little note saying that when the house staff—meaning the intern—worked the case up, he was not to examine the breasts. Now, how was I supposed to do an adequate history and physical on a breast-biopsy case without examining the breasts? Farcical. And now he wanted me to pop over at two in the morning to straighten out another of his messes.