CHAPTER TWO
phase transition
Not like the brazen giant of Greek fame
With conquering limbs astride from land to land;
Here at our sea-washed, sunset gates shall stand
A mighty woman with a torch, whose flame
Is the imprisoned lightning, and her name
Mother of Exiles.
—EMMA LAZARUS, “THE NEW COLOSSUS,” 1883
O rientation week passed rather quickly. I spent much of Tuesday in a subterranean classroom near the hospital being trained in advanced cardiac life support. I sat next to a new intern whose biggest worry seemed to be the upcoming urine drug test. In the morning we learned the protocol for treating ventricular fibrillation: “Shock, shock, shock . . . epinephrine, shock . . . lidocaine, shock . . .” In the afternoon I practiced CPR on an inflatable doll, placing the oxygen mask over her mouth and extending her neck slightly to get an adequate seal. I learned how to put a laryngoscope together—straight blade, curved blade—and then use it to insert an endotracheal tube. “Visualize the vocal cords,” the instructor commanded. “They look like pieces of cauliflower.” I rotated and cocked my wrist to get a better view. “Okay, you just broke your patient’s teeth,” the instructor barked. Using the heel of both hands, I compressed the mannequin’s chest approximately two inches, hearing it click loudly. “Faster, harder, deeper!” the instructor bellowed. “You’re not getting enough blood to her brain!” It was embarrassing, acting out like that around a roomful of strangers, most of whom were breezily nonchalant about the whole exercise, but I knew that soon enough I was going to be called upon to do the real thing.
I met a fellow intern waiting in line to get a hospital ID card. Vijay was a lanky Indian fellow who had spent his junior year of college at Oxford, studying biochemistry and “British bitter.” He had gone on to study at Cornell, the medical school affiliated with New York Hospital, so he already knew the place well. He had a placid, diffident manner I found instantly likable.
“They say the only mistake you can make is not asking for help,” he said skeptically, “but do you think any doctor really wants to be called in the middle of the night?”
I nodded. I had no problem asking for help, I replied. But some things people couldn’t help you with.
“It’s strange that all week they’ve hardly mentioned the patients,” he went on. “These are the people we’re going to be learning on. It’s like they’re already invisible.”
The usual anxiety among incoming interns was compounded in my case by the fact that I had skipped my fourth year of medical school. In my first year in St. Louis, I was told I had the option of “short-tracking,” finishing medical school in three years instead of four. The fourth year was mostly electives, and many students spent a considerable portion of it learning how to do scientific research, which I had already done in graduate school. Whether much clinical development took place during the fourth year was a matter of some debate. One of the deans, a jovial pediatrician, told me he viewed it as a year of consolidation: becoming comfortable with what you knew and, more important, what you did not. He said that any “clinical deficiencies” would disappear by the end of internship, and that in any case, none of the Ph.D.’s he knew who short-tracked felt disadvantaged after five years. But this did little to allay my worries. I was eager to get on with my career, but five years seemed like a long time to wait to feel competent.
That week, when I wasn’t in class, I ambled around the city by myself. I went to a street fair on the Upper East Side, where peddlers were pushing cheap trinkets and fresh-squeezed lemonade. In a crowd on the sidewalk, I tried to spot disease. That old man sitting on the bench, eyes closed, T-shirt creeping up on a distended abdomen, legs like tree trunks, capillary tangles all over his shins, dried blood at the corner of his mouth. What did he have? Must be alcoholic cirrhosis!
There had never been any doubt in my mind that I was going to come to New York for residency. People had warned me that the city, with its Darwinian pace, was a hard place to be a doctor, but I didn’t care. Somehow I knew even in medical school that in my journey out of the ivory tower, New York City, with its grit, its urbanity, its swirl of humanity, was where I had to be. New York bred ambition, short fuses, a kind of go-to mind-set. Even the on-ramps to the freeways were impossibly short. Amid the litter and dirty brick and rusted embankments and peeling paint was a sturdiness no other city possessed. It was a strength I desperately wanted to acquire.
Plus, I was hoping that in a city of eight million people, I’d be lucky enough to meet someone to fall in love with.
At the end of orientation week, all of the new interns were invited to a cocktail reception at the faculty club, a wood-paneled place with festive green carpeting under a massive, ornate chandelier. Hanging on the walls were distinguished portraits of white-coated titans from the medical school’s past. Most of the class was there, the men dressed in navy blue blazers and the women in fashionable summer dresses, milling around, displaying an attitude of tremendous earnestness. I was wearing khaki pants and a spotted yellow tie I had just purchased at Brooks Brothers. Some of the orientation speakers, mostly stiff, gray-haired senior physicians, were there, too. I spied Dr. Wood, the residency director. At orientation he had come off a bit uptight, but now, drink in hand, he looked much more relaxed. Standing in a corner, it felt like there was a padlock on the tip of my tongue. I downed a glass of Chardonnay, then another, then another. Pretty soon I was feeling warm and comfortable.
Someone tapped me on the shoulder. It was Rashmi, an Indian woman who had been a student in a physics-for-premeds class I had taught at Berkeley. Rashmi had luxuriant black hair, a sweet, soulful voice, and an almost regal bearing. She hugged me and told me she had seen my name on the list of new interns but couldn’t believe it was really me. Somehow we had managed to miss each other all week. “What are you doing here?” she asked, incredulous.
“I’m not sure,” I replied uneasily. We both laughed.
As we were chatting, two members of the current class of interns, a year ahead of us, walked in and stood off in a corner, nibbling on appetizers. They had on surgical scrubs; their hair was greasy, matted down. Black stethoscopes cradled their necks. It looked like they were coming off a night on call and had crashed the party for the free food before going home to collapse.
In twelve months, I was going to be one of them. I searched their faces, looking for some clue about the journey I was about to embark on. All week, dutifully completing the tasks of orientation, I had hardly reflected on what was coming up. Now my thoughts started racing. This place was about as far away as I could imagine from graduate school in Berkeley, hiking on Mount Tamalpais, playing basketball in Codornices Park, riding my scooter through the fog-shrouded hills, roaming aimlessly through cafés, smoking pot with my best friend, Farhad, and then getting onto his Yamaha motorcycle and zipping into town for a late night meal at Fat Slice or Top Dog. My life had been slow and leisurely. Lab time had been my own time; I rarely got to work before 11:00 a.m. I had come and gone as I pleased.
You don’t know these people, I thought. You can never know them; they will never know you. They are basically the driven premeds you disdained at Berkeley. They’re not curious about you, about things. They want to be here! I wish there were one person I could point to and say, he’s like me, she’s like me, she feels the way I do, he has the same misgivings.
Loosened up by the alcohol, I turned to Rashmi. “Do you ever have any regrets about going into medicine?” I immediately rued the question, which was met with silence.
“No,” Rashmi replied. “It’s pretty much all I ever wanted to do.”
Evidently, motivation for a career in medicine was assumed if you were standing in that room. It made me feel even more alone.
After the reception, I walked up First Avenue. Though the neighborhood had a reputation for being gentrified, it was funky by St. Louis standards, with a vibrant bar scene. Alrea
dy I had a favorite: the Hi-Life, a kind of old-style speakeasy with a brightly lit two-foot-tall neon martini glass on its Prohibition-era storefront. Inside, it was decorated with dark wood paneling, spacious booths with vinyl seats that stuck to your legs, antique lamps, slow-moving ceiling fans, and waitresses with attitude. It was like the bar where I imagined C. C. Baxter had spent New Year’s Eve in Billy Wilder’s movie The Apartment.
Tiny candles were flickering on the faded wooden bar. I sat down and Shannon, the bartender, poured me a martini. If the Hi-Life was the perfect Manhattan bar, Shannon was the perfect bartender: sassy, sexy, with a ribald sense of humor. Over the past week, she had become something of a muse.
I told her about the hospital mixer. “I really have to stop questioning my commitment to a medical career in public,” I said.
She was standing on rubber grating at the middle of the bar, wearing black pants and a denim blue oxford shirt, polishing a glass. “If they can’t handle it, too bad for them,” she said. “You don’t have to be like everyone else.”
“Yes I do,” I said. “I really have to make this work.” I did not want to hobble myself with doubt once again. I told her about a recent conversation I had had with my father, in which I admitted to ambivalence about starting internship. “Well begun is half done,” my father had admonished. He told me about a recent experiment conducted by his plant geneticist colleagues. They had created a cross between a tomato and a potato: a “potomato.” Shannon giggled expectantly, waiting for the punch line. “They thought it would make tomatoes on top and tubers on the bottom,” my father said sadly, “but it took too much energy and did nothing.”
Drunk now, I went for a walk on the East River esplanade. A storm was threatening. Lonely silhouetted figures traipsed across the bridge over the roadway, where the vehicles were emitting a cacophony of horns and beeps. On the footpath, the Victorian street lanterns glowed ominously. A cargo boat was tied to a pier; the wooden dock was creaking as the boat rolled in the waves. Off in the distance, the Queensboro Bridge unfurled over the river like a steel bracelet. I looked up at the hospital, which was mounted on concrete stilts above the FDR Drive. It was eerily lit in the moonlight, the Gothic spire of one of its buildings jutting straight into the sky. With its massive array of windows, it looked like a house of cards. What dramas were unfolding up there? I wondered. I imagined a group of doctors conferring about issues of life and death. How was I ever going to operate in that world?
I felt like an actor about to take on a role he was unequipped to play. My parents had invested so much hope in my brother and me, all their dreams of success, so any failure of mine would be theirs, too, a failure of many layers, slowly accreting over twenty-nine years. They had always regarded me as their brilliant son, but I had never been put to the test—at least not a test like the one I was about to take. There was so much to be afraid of: running a code; being on call; encountering my own spotty knowledge over and over again. I didn’t have what my brother had to pull him through: a jovial, laissez-faire manner, a hail-fellow-well-met good cheer that won him friends and support. I’d probably appear defensive and humorless by comparison.
I feared I was about to lose something, but I couldn’t pinpoint what it was. Freedom? Contemplativeness? Innocence about the workings of the human body? Was I going to start feeling less sexual, seeing disrobed bodies day in, day out? “I don’t know any doctors who stop wanting to get laid,” Rajiv had assured me.
In physics, the grandest of transformations is called a phase transition, as when ice melts into water. The physical properties of the transition are novel, not a simple superposition of the starting and ending states. This was the condition in which I now found myself. Part of me wanted to complete the transition, to flow like water, but mostly I wanted to return to being a square and solid ice cube, where I was secure, where I knew the rules.
I had been preparing for this moment since that visit to San Diego. I had steeled myself for it, running up hills to the point of nausea, braving the freezing cold without adequate clothing, anything to toughen me physically for the challenges that lay ahead. And here I was, about to begin but still unsure of what I sought. I gazed southward. In the distance I saw the lights of Alphabet City and the smokestacks of Brooklyn, and beyond that, Ellis Island and New York Harbor, where immigrants had sailed through the centuries. New York had always embraced people trying to reinvent themselves. Why not me?
CHAPTER THREE
medical school
Secure a hand saw and open the chest wall.
—GROSS ANATOMY DISSECTION MANUAL, PAGE ONE
By the time I completed the three-day drive from Berkeley to St. Louis, zipping through vast, hilly vistas browned by the intense heat, past signs that read BE PREPARED TO STOP and EMERGENCY PULL-OFF (were the warnings directed at me?), all the while blasting Dylan and the Dead till I had memorized every lyric, every guitar riff, I had missed all of medical school orientation, including the white-coat ceremony. My classmates must have thought me a freak wandering into the auditorium during closing remarks on Friday afternoon wearing shorts and a T-shirt, black as coal after baking for three days in the Great Plains sun.
I stayed a few days in the medical school dormitory, then transferred to a studio apartment in a high-rise about half a mile from campus in the Central West End, a quaint neighborhood with coffee shops and eclectic restaurants, the closest thing to Berkeley in St. Louis. My first night there, miserably camped on the carpet in virtual darkness trying to memorize the cranial nerves with the aid of a tiny lamp I had brought with me, I phoned Rajiv in New York and told him that I wanted to quit. He laughed hysterically and told me to stick with it. “A lot can change in a few months,” he said.
My thoughts were already dominated by the towering hospital off the highway, not by the medical school building half a block away. In my lowest moments that first year, when information was being sprayed at me as if through a fire hose, the hospital came to represent my emancipation from the classroom. My classmates embraced the curriculum, discussing it excitedly in the cafeteria or at parties on the weekends, which only deepened my sense of alienation. Their attitude seemed immature to me. I prided myself on having seen more of the world—even though it had been a rarefied sphere I had wanted to escape. In the formaldehyde-ridden anatomy lab, the humor was dark. When we were dissecting the heart, my partner took the organ, rested it precariously on our embalmed cadaver’s forearm, and said, “This guy really likes to wear his heart on his sleeve.” But despite the occasional light moments and the protection from any real responsibility that the classroom afforded, I almost immediately grew impatient with the coursework. I had been a student all my life; it was all I had ever been. The lecture hall didn’t present any fundamentally new challenges. The hospital, on the other hand, represented the real world, the world I had lost touch with during my years in academia. To succeed there was going to require skills I wasn’t sure I even possessed: communication, observation, empathy. What if I went blank interviewing a patient? What if I broke out in nervous laughter? It seemed there were so many opportunities for disaster.
As first-year medical students, we were required to take a course called Introduction to Clinical Medicine. Once a week, we attended a desultory lecture on history-taking and physical diagnosis—where we learned, among other things, the oft-quoted clinical aphorism that about 80 percent of medical diagnoses are made (correctly) on the basis of a patient’s history. Afterward, we headed off to the wards of the hospital to practice on patients. I was in a group with four other students. Our instructor was a gangly, awkwardly mannered hematology fellow in his early thirties who, like many doctors I would encounter in the coming years, was clearly ambivalent about the value of the skills he was teaching. Of course, he dutifully taught us the mechanics of medical interviewing and physical examination—palpating for lymphadenopathy, performing a comprehensive neurological exam, and the like—and he uttered homilies about their importance. But the e
mphasis at our weekly sessions was on normal findings—the “soft-nontender-nondistended-abdomen-with-no-organomegaly” shorthand we would become accustomed to scribbling in patients’ charts in the coming years. To the fellow, it seemed, the course was a platform for teaching a new language, not a tool of discovery. Once, in response to a question, he scoffed that it would take two days to perform the physical exam described in our textbook. Even as he taught physical diagnosis, he seemed to be dismissing it as a waste of time.
My first encounter with a patient that year did not go well. There I was in my stiff khakis and bulging white coat, standing at the bedside of an elderly man who was watching television. His gray, curly hair ended at the base of a protuberant forehead, and he had deep creases around his eyes. I asked him if he would be willing to talk with me for a few minutes. Without turning away from the TV, he readily agreed, even offering me a chair. He seemed glad for my company.
Aside from his unwillingness to look me in the eye, he was pleasant and cooperative. I glanced at my note cards detailing the “review of systems.” Any depression or anxiety? I asked. No, he replied. Any problems with hearing? “What?” he said, and I laughed politely. Any ringing in the ears? No. Any problems with smell or taste? No. Any vision problems? “What do you mean?”
“Flashing lights, double vision, that sort of thing,” I replied. “Not since I went blind,” he said. Again I laughed, but this time it was no joke. He was totally blind; I hadn’t noticed.
Second year was busier than the first, with exams covering entire textbooks of material. The daily routine was stultifying: study, eat, study, eat, sleep. The tests were long and depleting; you wanted to put your heart and soul into them, but there was only so much you could do before feeling sick. In graduate school I had never learned to memorize. You could always look things up; even final exams were often open-book. But now I couldn’t rely on logic and reasoning; I had to commit huge swaths of material to memory.
Intern Page 4