The Soul of a Doctor

by Gordon Harper

  I have come to believe that my ideal field will somehow combine children, oncology, surgery, and long-term relationships. Fortunately, it is possible to combine these in a variety of fields. I don’t know where this will lead me, but I do know that it won’t lead to obstetrics and gynecology.

  Raincoat

  Anonymous

  IT’S 7:00 A.M. and I’m on my way out the door. Keys, check. Phone, check. Palm, check. As I guzzle down my vitamins, supplements, and an antidepressant with some water, I try to remember something I forgot. Right, the morning pep talk. As I begin my daily migration to the hospital, I also commence the daily ritual of tying down all of my insecurities beneath a thick covering of inspiration and self-motivation. It begins to sound a little like a Stuart Smalley skit from Saturday Night Live: “I’m good enough, I’m smart enough, and gosh darn it, people like me.” You may laugh, but it helps me to get through morning rounds until the next break in the day, when I will repeat this ritual. Pep talk, five minutes three times a day, as needed for insecurity.

  At the beginning of third year, one thoughtful physician told us to bring a raincoat to work to shield ourselves against the regular onslaught of pimping, fair and unfair criticisms, and outright disrespect that we would be subject to on the wards. I took his advice in stride at first, but I have become acutely aware of its importance in the past five months. I’ve been yelled at, cursed at, told to stand in a corner, had my input degraded, and had my clinical skills openly criticized for all to see. Interns have played mind games with me. Residents have smiled to my face and given me lukewarm evaluations behind my back. Fellows have belittled me during rounds. Attendings have pimped me to tears. I take an antidepressant and see a therapist every two weeks.

  The nice voice that peps me up in the morning tells me that this is the system of medical education at a large academic center and that I had better hold on to that raincoat for dear life because this process will make me a better doctor. Meanwhile the nasty, self-critical voice points out all of my mistakes, errors in judgment, and wrong answers and tells me I’d better quit while I’m ahead because I’m never going to be the surgeon I dream of being in the future. That voice rarely shuts up. It goads me into comparing every aspect of my performance with that of other medical students. Am I carrying as many patients as they are? Are my notes as good as theirs? Am I learning as much as they are? Are they getting better evaluations than I am? The noise of self-doubt, self-criticism, and insecurity can be unbearable at times. But somehow it is quiet when I am with the patient, when I am standing face-to-face with someone whose only concern is whether I can help them.

  The same interns who seem to take pleasure in insulting my intelligence are as meek as lambs in the presence of an attending physician. Sometimes I imagine that I have joined some fraternity, only the hazing never stops; the individual spirit has to be broken in order to forge group identity and rebuild character according to the ideals of the fraternity. In its place is a sadistic, nonproductive cycle of competition between equals and nonequals alike.

  Maybe there is a method to the madness: how could I be responsible for a patient’s life if I cannot survive and thrive in this stressful environment? In the future I suppose that during an operation, no matter the extent of my experience, the mind games and slights I see now will pale in comparison to the questions I will ask myself with each new movement of the scalpel.

  My mother always taught me that what doesn’t kill us will make us stronger. I remember running to the bathroom in a fit of crocodile tears when she was teaching me long division and I was having trouble. Giving no mercy, she told me to dry my eyes and get back to the worksheet. And that’s the day I learned long division. In many ways, third year is the same. It is difficult. There is a steep learning curve. It must be done. And no one is going to hold your hand while you cry in the locker room. Although I have the support of family and friends, I am on my own during morning rounds. So I will continue to pack my raincoat.

  Physicians or Escape Artists?

  Sachin H. Jain

  WORKING AT A MAJOR academic center, I was assigned to the care of Benny, a nineteen-year-old with lupus. He had come to the emergency room after having a seizure outside his grandmother’s house. Two weeks before, Benny had stopped taking his medications.

  When he arrived on the floor, it was clear to everyone that he had no desire to be there. In the first three days of his hospitalization, Benny had tried to escape so many times that we posted security to keep him in his room. When I asked him if I could do anything for him, he always said the same thing: “Get me out of here. I want to go home. I’m not sick.”

  The truth, of course, was that Benny was very sick. A lumbar puncture, an MRI, a CT scan, and blood cultures had ruled out the possibility of a bacterial infection; the lupus had started affecting his brain. His short-term memory was shot, and his gait was unsteady. Nearly every joint in his body hurt. Benny’s aunt had had lupus too and had died from it when she twenty-two.

  In medicine, we use the term chief complaint to describe a patient’s primary illness. While Benny’s lupus was his major disease process, it wasn’t his chief complaint. Denial was far more likely to kill him than the lupus itself. While he was defiant and cold in the daytime, those of us who attended Benny at night learned of a different person: a boy who cried shamelessly, stayed up for fear of dying in his sleep, and spoke of taking his own life. In short bursts, he would tell us that he felt abandoned by his birth father. His dream was to become a fashion designer in New York. “Look at my jeans,” he said. ”I designed them.” Together, as a team, we were beginning to unlock the mystery that was Benny. Maybe we were building the trust that would be necessary to transform his view of himself and his disease.

  At our urging, he agreed to meet the hospital’s pediatric psychiatrist. The psychiatrist put to rest our fears that he was suicidal. Frustration, they called it, a natural response to his illness. But they also added that he needed mental-health care on a regular basis. “He keeps too much inside,” they said. “His mother”—who was at his bedside much of the time—“doesn’t know how to deal with him.” Benny’s rejection of his disease had led to conflict between them. Twice in my presence, they nearly came to blows.

  Benny’s condition and attitude improved, albeit slowly. By the end of his hospital visit, he was less anxious about being there and far less resistant to receiving care. Our greatest breakthrough came just as we discharged him. Benny had vehemently refused to see a psychiatrist on an outpatient basis, but as he prepared to leave, I asked him one last time whether he would consider seeing a psychiatrist on a more regular basis.

  “Make an appointment,” he said finally. ”I’ll see how I like it.”

  The day after he left the hospital, I started making arrangements for Benny to see a psychiatrist at a health center near his home. I called his mother to see how he was doing.

  “He’s vomiting, but he’s keeping most of what he drinks down. The thing I’m most worried about is his sleep. He’s not sleeping. I told him if he doesn’t sleep, I’m just going to bring him back to the hospital.” What about the sleeping pills (zolpidem) we had prescribed? I asked.

  “I couldn’t get them because they’re not covered by his insurance. They need some kind of waiver form. Can you help us with that?”

  Of course I could. I told her I would call her in a short while and let her know when I would fax the form to her pharmacy.

  I approached the first-year resident with whom I was working and told him Benny hadn’t been sleeping and asked her if we could help Benny’s family with the form or, at the very least, prescribe an alternate medicine.

  RESIDENT: Why did you call him?

  ME: I just wanted to see how he was doing and tell him about what I was doing to set up an appointment with a psychiatrist.

  RESIDENT: We’re not supposed to do that. Once they leave the hospital, their primary doctors are in charge of their care.

  ME: I don’t ge
t it.

  TESIDENT: I know you want to help them, but if we change the prescription or fax the form, we’ll have no record of doing it and won’t be able to follow up with him about it. Besides, their primary care doctor should handle all that. That’s the difference between hospitalists and primaries. We can’t be chasing after every person we discharge.

  ME (increasingly frustrated): But we prescribed the medication. This is part of our plan for him. Besides, he hasn’t seen his primary care doctor in the two years since he was diagnosed with lupus. He doesn’t know a thing about Benny right now. And I wanted to set up the psych appointment while he is still willing to go.

  RESIDENT: This will help him reestablish that relationship. Anyway, he should be seeing his primary care doctor, and the primary can suggest a psychiatrist. I know you want to take good care of him. But you have to learn to let go. He’s not our patient anymore. You shouldn’t call him anymore.

  I felt as if the very values that had drawn me to medicine—the sanctity and transformational power of the relationship between a patient and his caregiver—had been devalued in that single, short conversation. I left the room and asked another member of our team if there were any alternatives.

  “Seeing the primary sounds right to me,” he said.

  I asked the pharmacist that worked with our service.

  “Next time, try prescribing the medications a day before they leave and asking the mom to get them filled, and try to find out what is and isn’t covered.”

  But we didn’t know that we’d be prescribing the zolpidem until the day he was discharged.

  “I know. It’s hard. Sorry.”

  Another doctor told me that the hospital couldn’t bill the patient once he is discharged.

  Tail between my legs, unable to offer anything useful to her, I called Benny’s mom back and told what I had been told, that she should make an appointment with Benny’s primary doctor. Like me, she didn’t understand. She didn’t think Benny’s pediatrician knew anything about Benny anymore. Hadn’t we just been taking care of Benny in the hospital? I repeated the same twisted logic the resident had given to me to justify our inertia. She bought it, or more likely, she accepted it. I went home that night knowing the bottom line of all of this: Benny wouldn’t be sleeping that night. It became clear to me that in the eyes of our team, Benny had been our patient, but now he’d been tossed to the next player and was no longer our concern. A simple thing like a discharge order form had transformed us from care providers to escape artists.

  That night I called my father. He told me what I had seen him tell his students: always be good to the patient. So I remained in contact with Benny and his mother. I called her daily for a while to set up the psychiatry appointment and see how he was doing. But he didn’t get to see his primary doctor for two days and didn’t get the prescription filled (or sleep) until a week later. Benny’s mom remained worried that she’d have to bring him back to the emergency room with a seizure—or worse.

  The promise of hospital medicine is that doctors who practice primarily in that setting are more likely to provide “clinically appropriate” care in cases of acute illness. This logic works if our metric for clinical appropriateness is limited to matching diagnoses with treatment. But what about patients like Benny, who are suffering from chronic diseases? For these patients, the prognosis depends more on working relationships than on adherence to protocols. To be sure, all hospitals, hospitalists, or care teams might not have reacted to Benny’s situation in the way mine did. They might have faxed the form without hesitation. But what would become of the deeper knowledge of Benny that had been unearthed in the course of his eight-day stay? Or the trust that had begun to enable him to accept his disease? Were they merely squandered artifacts of his hospitalization?

  The model of hospital medicine that’s being advanced by the profession, supported by industry organizations such as the Leapfrog Group, and reinforced by models of insurance compensation works well for most patients, but does not account for people like Benny and his mom. They don’t have the same neat understanding of the separation between “inpatient” and “outpatient.” They only have the basic human expectation that their doctors will do their best to care for them. The presence of the distinction between hospital medicine and primary care can create an artificial boundary that encourages physicians, in discharging patients, to discharge themselves of their responsibility to their patients.

  In 1926, Francis Weld Peabody famously told an assembly of medical students that “the secret of the care of the patient is in caring for the patient.” I wonder what Dr. Peabody would have thought of the increasingly commonplace notion that “caring” is a neatly divisible property of the physician-patient relationship.

  The Healing Circle

  Chelsea Flanagan Elander Bodnar

  I SOMETIMES TRY TO GO to the church on St. Paul Street near Coolidge Corner, but more often than not I am an hour late or early because I can never keep straight whether the services are at nine and eleven or eight and ten. Whenever they actually are, more than once I have ended up spiritualizing with the Sunday Times and a double-tall latte at Starbucks rather than in that stone-on-the-outside, seventies-decor-on-the-inside Episcopal church. But on the Sunday after my first month of inpatient medicine, finding time for church seemed more important than ever. Even though I arrived an hour early, I returned after my latte to a pew in the back.

  In addition to the usual readings, Gospel, and sermon, the members of St. Paul’s were also celebrating the thirtieth anniversary of the Episcopal church’s decision to allow women to be clergy. Coffee hour was also going to be especially fancy this week in celebration of the lesbian minister’s recent marriage; the members of the hospitality committee had really outdone themselves on cake, cookies, and the postservice punch. And this Sunday, like most, they were offering individual prayers for healing after communion. I had heard the scheme explained before, usually while I was doodling a note to my family or boyfriend about that day’s reading or making a to-do list for myself of that week’s tasks. After communion—which these Episcopalians do in a perpetually forming and dissolving circle around the front of the sanctuary—if you stay standing, the special healing-prayer crew will come to you ready to lay on hands and rapidly anoint you with oil. I had never even considered remaining up there for a second longer than I had to. I preferred to be more of an observer and to stay in the back of the church; I didn’t even make a practice of staying for coffee hour (no matter how fancy), let alone awaiting the prayer ladies with their hands and oil to spot me in front of everyone.

  But today, the thought crossed my mind. For some reason that oh-so-public standing for a little extra healing seemed, for a moment, not such a bad idea. As the front of the room rose to start the winding and unwinding communion circle, I wondered why I heard the offer for healing so differently this week. I wasn’t sick. No one around me was sick. I was elated to be starting a much calmer month. I had just read the paper while drinking coffee for the first time in weeks.

  Then they came clearly into my mind: Ms. Huntington, Ms. Mission, Roseann, the first people with whom I had sat as each heard terrible news or waited in the terror of not knowing or gasped for final breaths before dying alone in that huge hospital. As my turn to rise and circle for communion got closer, tears came to my eyes, and I knew that despite all of the latte drinking, I was still in need of help in bringing this month to a peaceful close. Perhaps, I thought, I was suddenly drawn to standing in front of that whole congregation with the prayer-for-healing team now because I knew real patients for whom I could pray for healing. But in as much time as it took for the row in front of my own to rise and begin their ambling journey to communion, I knew the need for healing was also, and most immediately, my own.

  So I stood up there with the communion circle dissolving around me. It took only a few moments of my standing there alone for them to see me. Maybe they knew I sat in the back and rarely went to coffee hour, but the tw
o women—one young, with a dyed white streak in her dark hair, and the other older, larger, in an orange scarf—came close. The young one put her hand on my head; the older one came with the oil. They asked for whom the prayer was to be prayed. I smiled as I found myself stumbling to say that it was for me, and for the whole team really—probably meaning everyone from the team that listens to me at night, to the team that really had the responsibility for the patients that I’d seen this month. The healing-prayer crew was thrown only for a second before they proceeded with earnest prayers for me and this mysterious whole team. I returned to my seat in the back pew. I felt silly. I felt better.

  Strong Work

  Walter Anthony Bethune

  IT WAS THE LAST DAY of my emergency-department rotation. I was physically drained from the grueling schedule, which had had me working twenty-four hours on, twenty-four hours off, for the past three weeks. I was emotionally drained from the constant stream of crises that make up a typical day in the emergency department. I was even mentally drained, from trying—and usually failing—to anticipate my senior resident’s next move and what I could do to help him deal with these crises and avoid, as much as possible, “taking the beats,” which was what he called it whenever the surgical attendings or chief resident decided to unleash their fury on their underlings because things hadn’t been managed just so.