While Dr. Jaiswal was less than forgiving of careless intern error, I had to admit that she was probably on point with her criticisms of Helen and Craig: Their presentations had been weak. And in her defense, she could tell you everything about her patients. For example, Dr. Jaiswal knew that Mr. Jones, who had been brought to the hospital in multi-organ failure, had suffered a botched knee replacement five years earlier. Fearing another bad hospital experience, he waited at home for three weeks with increasing knee pain and swelling before he allowed his family to call EMS to transport him to the ER for his septic joint. Also, she was a good diagnostician, and had even spotted in one patient acute intermittent porphyria, a disease rarely ever considered outside Discovery Health Channel’s Mystery Diagnosis or the movie The Madness of King George. And though she was brusque, if you could absorb her example, you had every chance of becoming a phenomenal clinician. Tenderness would have to be learned elsewhere.
On that uncomfortable summer morning in my first month of intern year, it was my turn. As our medical team headed to my patient’s room, I felt myself getting light-headed from a mix of sleep deprivation and fear. The walk from the fifth floor felt like a sprint. We were already on the seventh floor as if by time travel. Had we gotten on an elevator? I shuffled my papers, willing myself to remember everything I had learned about the patient the night before. (Dr. Jaiswal berated us if we glanced down at our notes during a presentation. Her logic: If we couldn’t retain the information on a couple of patients at a time, then we had chosen the wrong field.) Nervously, I reminded myself of what I knew: The patient had a history of high cholesterol and hypertension. He was on no medications other than Crestor, for his cholesterol.
“So, Michele,” Dr. Jaiswal said to me as we made our way to his room. “I hear you enjoyed a quiet evening. How lucky for you! Only one admission for us this morning? Well, we’ll make the most of it!” She smiled, baring even, white teeth behind matte crimson lips. (She always wore red lipstick, and the hue seemed to amplify her every word.)
Quiet? Had she just used the word quiet? When I’d walked into the hospital last night, it was as if I were walking the plank. Just three other interns and I were covering the ward, and I felt the usual dread of holding other people’s lives in my not-yet-capable hands. Two of my patients spiked fevers, one became hypoxic, one had chest pain, and another went into a rapid heart rate, which made me go into an even faster arrhythmia. There was nothing about the evening that had felt quiet, and now I didn’t feel “lucky,” either.
We reached the door to the patient’s room and gathered around. I cleared my throat and began to present. “Mr. Frame is—”
“Oh, no, no, no,” Dr. Jaiswal said. “Let’s go in. Let us see the patient. Very important to actually go to the bedside and see the patient you are caring for. Assessment starts at first glance.”
She couldn’t be serious. Not only did I have to present to Dr. Jaiswal after I had been up all night, but I had to do so in front of the patient? As Dr. Jaiswal ushered the team inside the room, there was no time for me to anticipate the myriad ways this could all go terribly wrong. With a swiping motion of her finger, she indicated where each of us, obedient sheep that we were, should stand around the bed.
“Good morning, Mr. Frame,” she said to the patient. “I’m Dr. Jaiswal, the head of the medicine team who will be taking care of you. I hope you don’t mind that we will be discussing your care right here with you.”
“Not at all. Nice to meet you all,” Mr. Frame responded. He was a nondescript, middle-aged white man with dark hair and a medium build. The spotlight of my having to discuss him to my supervising physician at his bedside gave him a new level of distinction.
“Hello, again,” I said, nodding to the patient.
Then I began anew: “Mr. Frame is a fifty-nine-year-old male with a history of hypertension and high cholesterol with a chief complaint of worsening fevers, chills, cough, and nausea who was admitted with a liver abscess. He had been treated for this with two courses of antibiotics before coming to us. He completed a ten-day course of Augmentin, and then his primary care provider changed him to a course of Clindamycin. He was on day seven of ten when he presented last night.”
“Dr. Harper, this already sounds very strange. Who was treating him?” Dr. Jaiswal asked.
“His primary care provider.”
“Just his primary care provider? Huh. And what was he being treated for?”
“As I understand it, it was for a liver abscess, until his doctor sent him into the hospital last night.” In my mind I scrolled through my notes, but I feared they wouldn’t help. I didn’t know. I hadn’t adequately reasoned through the case. “Um, yes, I seem to remember that it was only his primary care provider who had been treating him before he came in last evening.”
“Does that strike you as odd? Why would his primary care provider take this course of action to treat him, as a sole provider, with only oral antibiotics for a liver abscess? There’s something missing here, something missing in the history. It simply doesn’t make sense.” Dr. Jaiswal paused as if to give me space for an impossible redemption.
I could hear each intern’s bated breath and the rustle of Mr. Frame’s crisp white hospital sheets as he shifted in bed. The air was humid and stale with the smell of half-eaten toast from the breakfast tray at the foot of his roommate’s bed. In the hallway, nurses opened and closed cabinet drawers for the morning medication administration. The housekeeping staff knocked on doors asking permission to clear trash. Against the backdrop of this din, I stood in the cramped room in front of a ring of interns and our resident, floundering for answers I didn’t have.
Finally, I spoke. “Well, the patient had a fever with his infection and continued to have fevers through the Augmentin, so the physician changed him to Clindamycin.”
“Huh? What testing had been done prior to his presentation?” she asked.
“As I gathered from his history, lab, and radiology results the patient brought with him, his primary care doctor had completed blood work consisting of a CBC [complete blood count], basic metabolic panel, blood cultures, and also a chest X-ray. There was a persistent elevation in his white count and a small pleural effusion on the chest X-ray.”
Dr. Jaiswal grimaced. “Uh-huh. Dr. Harper, you are clearly missing some critical information as well as basic medical knowledge, which has degraded your presentation and assessment here. Proceed for now, and we will get back to it,” she directed.
I shook off my terror and continued. “Chest CT in the ER last night demonstrated a pleural effusion as well as a collection in the liver. A dedicated CT of his abdomen and pelvis was pursued to further evaluate this finding, which revealed his hepatic abscess.”
“Yes, now it’s making more sense,” Dr. Jaiswal stated. “Sounds like there was no diagnosis apart from fever of unknown or at least unclear etiology and some nonspecific small pleural effusion found on a chest X-ray as the PCP worked up the patient. Due to Mr. Frame’s worsening clinical status on antibiotics, his physician appropriately referred him to the ER for advanced evaluation and treatment that could not be offered in an outpatient setting. Upon arrival to the ER, they completed a series of CAT scans that revealed Mr. Frame’s final diagnosis of hepatic abscess. In keeping with the guidelines for the management of this type of hepatic abscess, it will require drainage in addition to antibiotics to ensure proper treatment,” she said, giving me a curt nod signaling that because I obviously lacked the proper medical deductive reasoning, she would make the patient presentation herself.
Then, turning to the patient, she said, “Nice to meet you, Mr. Frame. We will be speaking with interventional radiology today to coordinate the drainage of your infection. Of course, there is more testing we will need to do as well while we continue your treatment. There will be many more people by to see you—providers from the departments of radiology, infectious disease, gastroenterology,
and, of course, the general internal medicine team.” She smiled at Mr. Frame the way a person who has everything under her control would, as if to say that nothing could go wrong because a benevolent captain was in command of this ship.
She turned back to me. “Thank you, Dr. Harper. You can go home to rest up for tonight. Make sure to read about how to take a history, the workup of fever of unknown origin, as well as the presentation, evaluation, and treatment of hepatic abscess. Ideally, these are things you would do before rounds. Thank you again. I’m sure we all learned a great deal from your presentation.”
“Yes, of course, Dr. Jaiswal.”
With that, she pivoted on her kitten heels and walked out of the room. One by one, the interns followed, a trail of white coats shuffling behind trying to keep up. One intern tripped on the feet of the one in front of her.
I slinked out of the room, wishing desperately that I could vaporize. That morning, I went home and napped away the day.
I never forgot that encounter. For the entire intern year, I made sure to ask too many questions of my patients. After all, it was the clinician’s job to get the history. Sure, the patient had to answer questions honestly in order for this to work, but I was the detective, so I needed to know what I was looking for and where to look for it. To the best of my ability, I not only read about the topics I didn’t understand, I also read around them. I reviewed the history in my head and practiced my assessment and plan, making sure the reasoning led to a logical conclusion. And if I felt that I didn’t have all the information from a patient, I went back as many times as required to make sure I got it. Each case was a story, and the story had to make sense.
That was the last time I was unprepared for Dr. Jaiswal’s rounds. What’s important was that in that very long year, she helped me become a better doctor because I saw the good in her, in the value she placed on meticulous preparation and critical thinking. The other parts, the parts that were derogatory and cruel? I made up my mind to ignore. All of it, the rough and the smooth, was crucial for my development as a doctor. I later realized that even with its excruciating challenges, this intern year prepared me best for the transition from my former life to my life after residency and my divorce.
* * *
—
“Doctor Michele Harper.”
My residency program director had called my name, breaking my trance. My final graduation.
I don’t remember what I wore to the ceremony, or who spoke, but I vividly remember how eternally grateful I was for the power to compose myself in the seven seconds it took me to stand and walk to the podium. I claimed my diploma and took the obligatory photos before dissolving into tears. I knew how to compartmentalize—my family dysfunction and my stint in medical school had given me a lot of practice. I didn’t have time to grieve for my marriage or for the future my ex-husband and I would never share. I had to pack, move, unpack, coordinate a divorce and the sale of our co-op, and start a new job in a new city, alone. I hadn’t even considered the new life part. Thank goodness for that convenient oversight. If I had stopped to consider that for even one moment, I don’t know how I would have gotten into the Ford Explorer Dan and I shared—it would be returned to him, as it had been a gift from his family—to make the drive to Philly.
I don’t remember much else about my residency graduation because I was striving so hard to let go of that future and struggling to understand that another was already under way. I’d signed a lease for an apartment in one of the upscale buildings in Center City, within walking distance of the hospital where I was to work. The doormen called you by name and asked how your day was going. The elevators ascended silently at warp speed. My thirty-fifth-floor unit was absolutely tranquil, and I had floor-to-ceiling windows that let in waterfalls of light. I hoped these fancy things might fill the void inside me currently inhabited by pain.
For my first night there, I had an air mattress, six boxes of clothing, two boxes of kitchenware, and my computer. I possessed little else materially. The one item I had taken from our co-op in the South Bronx was a large mirror. I asked Dan to send two items that had been gifts to us: a woven basket from Kenya and a framed photograph of a woman standing at a bus stop in front of the Shepard Fairey Barack Obama HOPE poster. He agreed, but I knew he wouldn’t send them, and I couldn’t muster the energy to mount any significant protest. They would be just two more parts of a past I had lost.
On one of my first days in the new apartment, I sat for hours on the living room carpet staring out the windows. I could see the signs and façades of neighboring businesses, many of which were owned by my new employer. Unfortunately, the neon sign announcing “Andrew Johnson Hospital” was the biggest during the day and shone brightest during the night. It wasn’t reassuring then, and as it turned out, that wouldn’t change. Still, I could just make out a corner of the Schuylkill River snaking along the horizon, which offered a calming contrast to the cityscape.
The particulate matter of memory, heavy and unrefined, filled the room. I inhaled it, letting it abrade the back of my throat and sting my eyes. I lifted my chin into peak June sunlight. Closing my eyes, I leaned into the gold, orange, and red behind my eyelids. I was drawn to it, like a plant. I felt my skin baking. I felt the crackle of the heat, but I didn’t flinch: I was finally feeling something. I didn’t know what existed beyond the window, beyond the door to my apartment. I didn’t know myself in this place. I didn’t know what I would be. I fancied that all things happened for a reason, so there had to be a reason I had been stripped to my core and was sitting here on a warm carpet, in the blazing reflected light of an unknown city. In a couple of days, I would unpack these boxes, don crisp green scrubs, and go to work. Sometime soon, I’d figure out the rest, but now, I just had to be broken. There wasn’t energy for much else.
A cloud breezed by, offering a moment’s respite from the heat. Thank the goddess for those windows. For the light. For the silence. Thank the goddess for the view from thirty-five stories up: I didn’t yet recognize anything I saw from that height, but it offered a critical distance, a life-saving perspective.
THREE
Baby Doe: Born Perfect
Night shifts are always inconvenient and much like hangovers: The older you get, the harder they are to recover from. For some, they are a badge of honor; those types sprint them like marathons, race after race, year after year, with the stamina of a long-distance runner. The nocturnists, the hospital-based physicians who are scheduled to work the night shift exclusively, are the strong and brave among us. The goddess forever blesses them because they allow the rest of us to dwell largely in the light.
While night shifts are a brutal subjugation of my natural diurnal instinct—yes, I prefer to conduct my life during the day and sleep at night—I have to admit that sometimes they’re a refuge. Sometimes it’s nice to leave the distractions of the daytime and let myself be swallowed whole by the night. I don’t have to respond to emails, or make phone calls, or schedule meetings, or do much of anything else when I’m working in the emergency room at night. In this way, it’s a nice break from my administrative work.
Don’t get me wrong, I signed up for admin. It was my habit, my well-worn groove. I wasn’t comfortable if I wasn’t in a leadership role. It was a routine I leaned into. After all, back in the early 1990s I had started a club I called Future Doctors of America at my high school (although, at the time, I wasn’t entirely sure I wouldn’t be an architect or an attorney instead), I was student government president my senior year, co-chaired our local branch of the American Medical Women’s Association while in medical school, and was a chief resident my final year in residency. Naturally, I thought I wanted to continue in leadership roles in the hospital while I worked as an attending ER physician.
So, here I was, at Philadelphia’s Andrew Johnson Hospital, a large teaching institution where I would have to prove myself. I started small, as the director of performance improvemen
t in the emergency department. It was fascinating reviewing cases to investigate potential clinical errors, cases where, for example, a doctor or nurse practitioner (each called a “provider” in health care lingo) had made an inaccurate diagnosis or prescribed suboptimal treatment. These cases were typically referred to me based on grievances about patient care in the emergency department made by physicians in other hospital departments, by the hospital legal department, or by patients. Initially, I enjoyed the detective work involved in uncovering subtle system failures. It quickly became clear to me, however, that no matter how deferentially I approached my colleagues on these matters, they were not thrilled to hear from me. A physician who has made a mistake (a misdiagnosis, a procedural misstep) never wants to hear the doctor in charge of case review ask him, “Remember the case . . . ?” While I had gotten over the need to be liked or feel externally validated sometime before, it was still unpleasant to be received like the in-law you are obligated to speak to at Thanksgiving dinner despite not really wanting to.
But while working nights in the ED, I found all of that melting away. In preparation for those shifts, I take off my administrative hat, close my laptop, and silence my phone. During night tours, I am able to budget time for one morning activity, plus sleep, before heading back to work again. I choose carefully what will occupy this prized morning slot. On a beautiful morning in late summer, I might have my pick of the most succulent blueberries and the most verdant kale at the farmers’ market, but I usually head straight to the gym. All the nine-to-fivers are on their way to the office by the time I get there, and anybody who isn’t working is still making their first cup of coffee, so I can enjoy the gym in peace—just me and the eighty-year-old man who seems never to leave.
The Beauty in Breaking Page 4