Somehow, some way, the insightful, providentially wise admissions committee of the day offered me a place in the Harvard Medical School class of ’79. I was three years off of Thorazine. It had been almost four years exactly since I was hospitalized. Getting into medical school tied up my having been mentally ill with a big red bow.
He went crazy. He’s the son of Godzilla.
Yeah, but he went to medical school.
Which one?
Harvard Medical School is five white-marble buildings surrounding a quadrangle of grass and walks. When the building in the Back Bay down near Mass General became too small, Harvard sent a delegation with plans to talk with Cornelius Vanderbilt, who looked the plans over and reportedly wrote out a $13 million check on the spot, saying, “Good meeting you, gentlemen. I believe that should cover it.” So they named the dorm, which is also built out of white marble, after him. Vanderbilt Hall.
Seen from Longwood Avenue, Building A looks a lot like the Parthenon. There aren’t any other buildings in the neighborhood that look like the Parthenon. There’s a tree off to the side that was grown from a cutting from the tree on the island of Kos under which Hippocrates taught his students. Hippocrates gave us the famous oath that contains the admonition “First, do no harm.”
The quadrangle was built in 1906. There were no antibiotics then. Surgery had to be very quick and was as likely to kill you as cure you. Keeping germs out of the surgical field was a novel idea. There were 155 medical schools in the United States, most of which were run for profit by one or two doctors, like trade schools. There were no admission requirements. If your family could pay, you could be a doctor. Doctors were taught and trained without being exposed to patients or science. The chances of any given patient being helped by any given doctor were slim. Most were peddling snake oil of one sort or another. The Flexner report, published in 1910, sought to improve medical care by making sure medical schools had reasonable admission requirements and were associated with universities and that medical education stressed the scientific method and empirical observation of patients. One of the things that stressing science and empiricism did was to democratize medical care and make innovation possible. In European medicine, medical students didn’t have any exposure to patients; things were done a certain way because they had always been done that way, and all the various committees and academies and practice guidelines said they should be done that way. So the forces of innovation won, and American medicine became the best in the world, and all that white marble was trying to get us to be the best we could be.
After you’ve promised to “do no harm” and to honestly do your best to ascertain what is true, the rest is just details.
Science was the only way we could avoid fooling ourselves about what helped and what didn’t. Doctors were supposed to act like battlefield medics, identifying and addressing pain, suffering, and disability. I believed that once you had a medical school education, especially a Harvard Medical School education, doing good was just a matter of showing up.
I liked all the white marble, but it can be hard to live with. The five buildings facing the quad appear to be not quite part of this world. They have wings that stretch and branch out into labs and foundations and institutes and hospitals and on and on into the so-called real world, but it’s all connected to the white-marble hole.
My Harvard Medical School advisor had a recurring nightmare. He’d wake up in a cold sweat saying to himself, “This really is the best place.”
There was and always will be a million miles between what my classmates and I wanted to do and what we would end up doing. We at Harvard and Harvard’s teaching hospitals were the light and the way. All you had to do was ask us. It has always amazed me how much quackery and bad medicine goes on. The temptation of being worshipped and pushing snake oil and making a ton of money at it turns out to be more than most people can withstand.
After being rejected by fourteen publishers, my book The Eden Express was published the same year I started medical school. My favorite rejection comment was “This book is good but with your last name it would have to be better.”
I took the paperback advance and bought a substantial serious adult-type Victorian house a ten-minute walk from the medical school. When a classmate came over for something, he said that it was the kind of house we weren’t supposed to have until we were older.
“I am older,” I pointed out. Right before getting the book published and right after getting into medical school, I got married.
The book ended up doing well enough to pay most of my way through medical school—no Slaughterhouse-Five, but not bad for a beginner.
Harvard took some flack for admitting me, which probably had something to do with why I shut up and didn’t write much for thirty years. There were letters from outraged alumni who knew deserving applicants. With so many earnest wholesome applicants, why was Harvard out dredging for bottom-feeders like me?
My mother, my cousins, and my sisters weren’t doing so great. We had eating disorders, co-dependency, outstanding warrants, drug and alcohol problems, dating and employment problems, and other “issues.” At least now number one son was married and had a fixed-up Victorian house where everyone could have Thanksgiving and Christmas dinner. What chip on what shoulder? Maybe a man with a compass, a machete, and a strong right arm could lead his people out of the wilderness. If I, as a sick person, had been dragging a dozen or more people down, maybe as a healthy one I could lift up that many or more.
I saw myself as somewhat of a placement problem, and getting into medical school was a huge help. Later, when I was interviewing applicants to HMS and they all had such high aspirations, I wondered if less might not be more. Maybe one of them might say, “I’m just looking for an interesting way to hang out and stay out of trouble.” Something like that.
A child ready to learn how to read represents an enormous amount of luck, work, time, and patience. Imagine the astounding luck and work involved in making a medical school applicant. Doctors are like baby oysters on a very deep reef of forefathers and mothers and aunts and uncles hundreds of feet deep with a million important details buried beyond recall. What I asked myself about applicants was whether talking to them made me more or less lonely.
Zachary, my first son, was born when I was two years into medical school. First son had first son so there could be an orderly succession, like the House of Windsor.
Having a famous parent is a leg up to nowhere. It made sense to people that Kurt Vonnegut’s son would have mental health problems. It made sense that I would not do well.
“You’re Kurt Vonnegut’s son? I heard that you had hung yourself in a barn in New Jersey.”
“No. Actually I’m in med school.”
My mother glossed over the chaos we had come from. “You all turned out so well.”
To me it looked like one close call after another and like the woman had been just plain lucky. She could just as easily have a child or two in prison or not getting better from their various disorders and maybe having me hang myself in New Jersey rather than go to medical school.
In general people don’t wish the children of famous people well. It’s somehow fitting or instructive that we screw up or come to tragic ends. It helped me a lot that I didn’t grow up the son of a famous man. It was like watching from afar when the money hit. I’ll always remember my father as the world’s worst car salesman who couldn’t get a job teaching English at Cape Cod Community College.
At Harvard, the courses were pass-fail, but I wanted to get as much right on the tests as possible. I wanted there to be a margin of safety. There were a few of us who would race to see who could finish the tests first. I won more than once. Doing well seemed well within my power.
I loved that we had accumulated and organized so much information. I was standing on the shoulders of giants and was possibly the flower of Western civilization. Self-will was running riot, but it was for a really good cause.
Sooner or later in
medical school you end up across the table from a senior surgeon with a pair of scissors in your hand. The surgeon ties and holds the suture and says, “Cut.”
You cut. He says, “Too long.”
You cut the next one a little shorter.
“Too short,” he says.
And so forth.
After thirty or forty cuts that are all too long or too short, you ask him if he wants the next one too long or too short, and that’s how you pass the test.
I practiced surgical knots until I could do them in the dark. Learning anatomy, microbiology, pathology, pathophysiology, pharmacology, et cetera, was like being on vacation. It was interesting in its own right and I was in love with being able to do it. The questions on the tests had right answers, and because I had read what I was supposed to read and studied what I was supposed to have studied, I knew what they were.
My publisher gave me a copy of Scott Turow’s One L, an excellent account of his first year at Harvard Law School, but I either wasn’t interested in writing anymore just then or couldn’t get an angle on medical school that made me want to write about it. If I really loved writing all that much, I wouldn’t have gone to medical school. Maybe it wasn’t so good for a guy like me to spend too much time alone with a typewriter.
It amazed me how angry some of my teachers and much of the psychiatric profession was that I had been treated with megavitamin therapy. There were two instances in large lectures where I was all but mentioned by name as promoting quackery. I felt like I had been kicked in the chest by a horse and would have thrown up except it would have drawn attention. I was just a guy still in his twenties glad to no longer be in and out of psychosis. I didn’t think the vitamins had much to do with my recovery, and I did nothing to promote vitamin therapy. It just happened to be what they were doing at the hospital I was hauled off to.
The megavitamin docs and their critics all seemed like self-absorbed babies whose interest in helping patients was outweighed by the joys of self-righteous vehemence. Their primary interest was in yelling at one another.
A pox on both their houses. Where are the adults when you need them?
Gradually and carefully I’d stopped taking most of the vitamins. It didn’t seem to make any difference. So when I discovered my own enlarged thyroid in anatomy class and the doctors at Harvard’s Health Services suggested I stop taking the lithium, I didn’t think much about it. It was increasingly clear that there wasn’t really much wrong with me anyway. I had been started on lithium by one of the “vitamin doctors.” He didn’t change my diagnosis but said, “You’re the kind of schizophrenic who gets better on lithium.” This was all pre–DSM III, the modern way to slice and dice mental illness. The only thing I really had come to believe in, more than any specific therapy, was the medical model itself, which got rid of shame, blame, and other hurtful voodoo. That was worth doing.
The basic science and the preclinical courses were easy. I was looking forward to learning how to use a stethoscope and those cool little lights and how to draw blood. We practiced on one another and ourselves until we were ready to be unleashed on the world.
After a year and a half of amphitheater/classroom learning, we put on white coats and learned medicine by pretending to be doctors with people who really were patients with the whole show being overseen by people who really were doctors in real hospitals.
If you’re not sure what to say to a patient or the patient pauses for a while in his story, what you say is, “That must be hard for you.”
I remember staring and watching carefully as our Introduction to Clinical Medicine instructor easily took a patient’s hand and gently stroked his arm. I wanted to be able to do that. I was moving from a world where I couldn’t touch people I didn’t know to one where I could.
It was an advantage for me, over most of my classmates, to know that I was in medical school, at least partly, to save my own life.
We knew some things in amazing detail, right down to the microscopic and molecular level, like how cholera kills people. And over the years cholera has killed a ton of people; there were accounts of cholera epidemics where dehydrated corpses were stacked like cordwood. And now, because we understood it, we could prevent it and/or treat it. All those people who would have died from cholera and been stacked like cordwood got to do something else, like maybe have a son or daughter who went to Harvard Medical School.
There were no stains whatsoever on my coat, which was so white it glowed. I was an HMS II—Harvard Medical student, second year—doing Introduction to Clinical Medicine hoping I might stumble into doing something right or good or at least not humiliate myself too badly.
“Excuse me, but I’m one of the new HMS IIs, and the monitor and the guy next to the nursing station right back there both look really bad.”
“Thank you,” the nurse said kindly as she walked me back to the room. She looked briefly at the monitor and pulled the door closed.
The patient had had a heart attack at home and his family had gotten the heart going again but hadn’t done the breathing part of CPR, so his brain had been deprived of oxygen too long for there to be any hope of recovery. We were just watching him till he died, which was what he was in the process of doing. The nurse told me that the family came in every evening and that this would be a relief to them.
The breathing stopped after a few gasps. The monitor showed a flat line. The nurse unclipped his leads, looked at the clock, and noted on his chart the official time of death. We sat there quietly for a bit. Then we both had lots we had to do. I had gotten to be thirty years old without being in the same room when someone died.
Unless you like being unpopular, never mention that saving a life is a “for now” sort of thing.
Most of the patients I learned from as a medical student and then as an intern and resident would never be admitted to a hospital today because they are not sick enough. Because inpatient stays cost insurance companies money and insurers control the vast majority of a hospital’s income, the push to get a patient home starts as soon as the patient hits the door. Leukemia, heart attacks, major infections, et cetera, have all become outpatient diseases. If you’re not sick enough to be in an ICU, you can probably be treated as an outpatient. As soon as you’re out of the ICU, you’re discharged to rehab or chronic care. Medical students, interns, and residents don’t get to know their patients or see how things turn out; much of what they do any given day is transfer and move people around. It’s all about placement.
My first patient in internal medicine was a cheerful seventy-five-year-old Italian. He was admitted for something else, but because he drank a quart of wine a day, I put him on Librium to prevent the DTs like the resident told me to. We turned our only bright spot on the ward into an unresponsive, openmouthed-snoring, bedridden lump. “Well, at least he didn’t seize,” said the resident.
Being six years older than most of my fellow students had some advantages. After being up all night I looked more like an attending. I was the only one in my class to have a baby at home. During some clinical rotations you were supposed to sleep over at the hospital. Ninety-nine times out of a hundred there wasn’t anything for us to do, so I sometimes went home, where I had real responsibilities, to sleep in my own bed and get up with my own fussy baby. I told them to call me if they needed me.
With the exception of one or two people who were there to please their parents, everyone at medical school was there because they wanted to be and had worked hard to get there. We all expected to do important things. We all expected to be part of something like what medicine had accomplished between 1950 and 1975. We expected medical care to transform society. The idea that we would ever be told what we could and couldn’t do by insurance companies would have seemed far-fetched and bizarre.
There are a million lives going by at a million miles an hour, and all I could take in was the briefest narrative account of how they came to be in the hospital. There was the passion and energy of a twenty-year-old girl, holding d
own a job and taking care of her seven-year-old brother who was going to die of a horrible rare cancer; a thirty-two-year-old grandmother whose sixteen-year-old daughter had just had a baby; the father who wanted us to operate on his daughter’s inoperable brain-stem tumor and put it in his head instead of hers … I didn’t have time to give any of these stories anything like the attention they deserved. I wrote orders and discharge plans and tucked people in for the night.
My first clinical rotation was obstetrics. My first patient was in labor, and what she said to me after I introduced myself was “Cut me. Take out the baby.”
“You’re making good progress,” I assured her, and she had a beautiful baby about ten minutes later. This doctoring stuff wasn’t so hard.
I watched other doctors like a hawk. I worked very hard at learning how to examine babies and children. I still carry in my brain high-resolution images of how the doctors I admired listened to hearts and felt bellies. I kept accounts of what worked and what didn’t, when I was right and when I was wrong. Everybody who loved medicine wanted it to be better than it was, and that meant wanting to be a better doctor than you were.
Just Like Someone Without Mental Illness Only More So Page 6