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  Sonia felt like many of the doctors I spoke with. “I would never feel comfortable with a lawyer or a Wall Streeter,” she said on that languid summer evening. “For me it’s about finding yet another place of common ground. I love that we are in the same field. We can help each other. We can even go into practice together!” Inside, I groaned. I never wanted her to see me practicing medicine. In the hospital I felt constricted, anxious, racked with doubts. I didn’t want her to see that side of me.

  “So are we going to get married?” Sonia asked me again, as we waited to cross the street.

  “Let’s see how things go,” I replied.

  “So I guess in the coming months you’ll be deciding whether to rule me in or out,” she said with a mischievous glint. It was a reference to my time in the CCU, where we were always ruling out myocardial infarction. It was the kind of comment Sonia was always making: pithy, honest, funny, without a hint of animus. I burst out laughing.

  CHAPTER NINE

  customer service

  Medicine, as a general technique of health even more than as a service to the sick or an art of cures, assumes an increasingly important place in the administrative system and the machinery of power.

  —MICHEL FOUCAULT, POWER/KNOWLEDGE: SELECTED INTERVIEWS &

  OTHER WRITINGS, 1972—1977

  The clock-radio alarm sounded at 5:45. It was still dark outside. Even though Sonia had been in Washington for several weeks now, I still kept to what was now my side of the bed, as if transgressing into her space would mar a sweet memory. I lay in bed for a while, swathed in the covers, drifting in and out of sleep. The month in the CCU had left me with a touch of insomnia, and I had tossed and turned most of the night. So this must be what Rajiv had meant, I thought. In medical school, when I confessed to him that I worried about whether I’d be able to wake up in the morning during internship, he replied rhetorically: “Do you wake up for finals? Then you’ll wake up for internship. It’s like having a final every single day of your life.”

  A Neil Young song came on the radio, and for a few minutes I was transported back to parties in the Berkeley Hills, where beer and joints were passed around liberally from one friendship-braceleted hand to the next. Those days held so much promise: living among the giant redwoods, the rooftops peeking out over the dense clouds, everything green and fresh. Now I was living in a concrete jungle, and the thought of going to the hospital across the street and standing on my feet for twelve hours and rounding on patients I hardly knew, and drawing blood and inserting IVs and doing all the other things that were expected of me, filled me with dread. It felt like I was in a boat being pulled along by a powerful current, not knowing where I was heading, only that I was being propelled toward some discovery I might not want to make, but that I needed to confront.

  I forced myself out of bed, put on my shorts and sneakers, and went downstairs for a jog. A morning run to relieve stress had become an indispensable part of my day; I knew I’d be useless in the hospital without it. Outside, the air was hazy, as the rising sun diffracted through the early morning fog. The sidewalk in front of the building was the usual minefield of dog turds. People were buying coffee from the cart at the corner. A few green-scrubbed figures were already scurrying toward the hospital. Must be surgical residents, I thought, always the first to get to the wards.

  I sprinted down the bike lanes of the promenade. The East River reflected the sunlight like a mirror. Roosevelt Island glittered like a shiny brooch as cargo boats floated by. I was crossing over a peeling overpass when I ran into Alphonse, a fellow intern, who was heading into the hospital in slacks, a button-down Oxford shirt, and tie. I had first met Alphonse during the outpatient month in July. Tall and muscular, intense and soft-spoken, he had a strong Caribbean accent and an elusive, tranquil island air about him. His hair was thick and curly, and his short mustache looked like it had been painted on. “Just coming back from your run?” he said, grinning impishly. I nodded, trying to hide my embarrassment. Most mornings Alphonse arrived on the 10-North ward, our current assignment, nearly an hour before I did.

  By the time I went in, it was almost six-thirty. In medical school, I had strolled proudly into the hospital in my short white coat. Now, I marched in at an anxious clip, head down, as though to duck the long day that stretched before me. I thought of how my father used to walk me to the school bus stop in New Delhi when I was a boy. We usually left home at dawn. My fingers would ache as his warm, sweaty palm tightly squeezed them as we crossed the busy road, trying to avoid the slow traffic and bullock carts and roaming white Sindhi cows. At the bus stop, or sometimes in the park on the way there, he’d force-feed me an overripe banana. On this morning, nostalgia for that time, for my father, came flooding back. It was on mornings like these, when I yearned for the day to have ended already, that I missed having someone there to hold my hand, to force-feed me breakfast, to pull me forward, to watch my back.

  I hurried past the dour security guard, past the library and the café, which were closed, and into a marble lobby. This was the Greenberg Pavilion of New York Hospital. For all the drama I always imagined going on in here, right now it was placid, almost like a museum, displaying gilt-framed portraits of hospital benefactors instead of masterpieces. In a corner was a small piano, and hanging nearby was a notice addressed to hospital employees:

  Welcome all customers in a friendly manner. Make eye contact and smile. Create positive first impressions. Treat everyone with respect. If possible, exceed your patient’s expectations.

  Next to the notice was a typed testimonial from a patient:

  “You take the time to listen, answer questions, and make patients feel, no matter what, that they are your number one priority.”

  I shook my head, as if to block a thought, and rode the elevator to the tenth floor. Ward 10-North was one of only three general medical wards in a hospital sectioned mostly into subspecialty units. Here, the patients, often underinsured, some homeless or with criminal backgrounds, were treated for bread-and-butter disorders: AIDS, pneumonia, congestive heart failure, and the like. 10-North was the place in the hospital where you were most likely to find security guards carrying revolvers or orderlies conducting 1:1 surveillance watches (while sitting in the hallway outside the wayward patient’s room reading People magazine). It was ward medicine in all its unfiltered mess.

  The physical plant, however, like the rest of the pavilion, was gleaming and new. At the end of a long, brightly lit corridor were tall windows looking out onto the sloping steel girders of the Triborough Bridge. The staff workstation had a fax machine, a copier, a chart rack, several desktop computers, a shelf with about thirty different requisition forms, and a whiteboard with the names of the forty-odd patients, color-coded by intern/resident team. It was here that doctors, nurses, and social workers took refuge, writing orders, checking labs, pressing on their eyeballs while on hold on the phone. Sometimes a patient or family member would lean over to ask a question, but even that was frowned upon.

  The routine on 10-North was call every fourth night, with a cap of six admissions per night per intern (the overflow went to more senior residents), except on Saturdays, when you were expected to admit patients all night long. At 10:00 p.m., chief residents came around for “cookie rounds” to discuss the day’s admissions over a box of Entenmann’s. (They always brought an assortment of goodies but never the thing you desired most after sixteen hours on your feet: fluid.) Overnight, you were responsible for your own patients (those you’d admitted in previous days), plus the patients you admitted that night, plus all the other patients who had been signed out to you for the evening. “Cross-coverage” was definitely the hardest part of being on call. You had to make critical decisions about patients you barely knew. Sign-outs were often inadequate (sometimes just names and lists of medical problems) as interns and residents rushed to get out of the hospital after their own long shifts. The nurses could call you for anything, and they often did: fever spikes requiring blood cul
tures, respiratory distress requiring an arterial blood gas, insomnia requiring sedatives. It helped to have a short “differential,” a list of diagnostic possibilities, for the cardinal symptoms—chest pain, abdominal pain, shortness of breath—committed to memory. The next day, post-call, you could go home after your notes were done and you had taken care of any unfinished business from the night before—including signing out all your patients to other doctors. It was supposed to be done by midmorning, but it almost never was. Around noon, other residents would start offering their help. “What’re you still doing here?” they’d say, as if they had just noticed you. “What can I do to get you out?” The key was to finish your work quickly, or you could easily stay past three o’clock. The longer you stayed, the less efficient you became, the more time it took to write notes or call consultants, and once you hit the wall, any chance of getting out in a timely fashion was pretty much shot.

  I arrived on the floor at six forty-five to find Rohit, a second-year resident, sitting at the nursing station. He was a short Indian man with a bright, open face and a broad, insincere smile. He looked like someone I might have avoided at my parents’ kirtans (prayer meetings) when I was growing up.

  “You’re late,” he said, checking his digital watch. “We have to pick up night-float admissions at seven o’clock.”

  “Yes, I know,” I said, hovering in the corridor.

  “All right, hurry up and see your patients,” he snapped, turning back to the computer. “You’ve got fifteen minutes.”

  I went down the hall to the first room, which was filled with the stale effluvium of sleep. Michael Harrison was a typical patient on 10-North, an emaciated black man of about seventy who was on dialysis for end-stage kidney and heart failure. His neck was sinewy, his arms pencil-thin. His temples were bony, yet full at the forehead, imparting an intellectual look. Short wispy hairs were growing out of his chin. His skin looked like it was frosted with ice, probably a sign of kidney failure. It was obvious that he had once been handsome.

  I said good morning. He opened his eyes slowly, nodded, and then closed them again. It was early; he wanted to sleep.

  I asked him how he was feeling. “Okay,” he mumbled. I pulled down the blanket that was covering his body. A catheter filled with dark, reddish brown urine the color of beer passed through the end of his shriveled penis. I pressed gently on his edematous legs, leaving tiny craters with my fingertips. “You’re going to get more dialysis today,” I said. He opened his eyes. “Not today, I ain’t goin’,” he said, shaking his head. “They took me upstairs yesterday and they left me on the machine two hours longer. They said three hours and then they did five. They said I be back in three hours but I ain’t come back.”

  “Well, maybe they needed to take out more fluid,” I said.

  “No, that ain’t what it was,” he replied, shaking his head. “They was just foolin’ around. In that dialysis room, all they do is drink beer.”

  “I find that hard to believe.” Mr. Harrison was always making such claims.

  “Yeah they do. I think so, at least. Probably smoke pot, too. I told one of the aides there, ‘I’m goin’ to speak to your manager.’ He didn’t care. He just laughed.”

  He coughed, and then cleared his throat loudly. His head moved searchingly from side to side. I picked up a box of tissues and offered him one, but he had already raised the bedsheet to his lips and wiped his tongue of the phlegm. It was thick and green and coagulated, with a pinkish tinge, and it stuck to the sheet like a thick gob of glue. I swiped a handful of tissues and wiped the sputum off the bedspread, trying to avoid looking at it.

  “Nobody cares,” he continued philosophically. “Nobody wants to bother with you when you’re like this. They go on past you, they don’t care. They say, ‘I’ll be back,’ but no one come back. I need pills, but they don’t care. Yesterday they gave me nothing to eat.”

  “Why? Did you have a test?”

  “No.”

  “So why didn’t they bring you a tray?”

  “I don’t know,” he replied, exasperated. “They overlooked it.”

  I glanced at my watch. It was ten minutes to seven. “I’ll come by to see you later,” I said.

  “Can you turn me over?”

  “I can’t do it right now,” I replied automatically. “I’ll tell the nurse to come in.”

  “You can’t just turn me over? The nurse said she couldn’t do it; she didn’t have the time.” I looked over my list. Rohit was surely going to give me a hard time if I didn’t at least get my patients’ vital signs before rounds.

  “All right,” I said, putting down my sheet. “I’ll turn you over.” I lowered the bed rail. His body lay crumpled on the bedsheets. I reached around him, wedging my hand under his moist armpit, and scooted him up in the bed so that his head reached the pillow. Then, with my other arm, I reached under him and spun him onto his side.

  “That’s better,” he said. “If you ain’t been through this, you don’t know what it’s like. The nurses tell me I ain’t allowed to sleep on my stomach. It’s the regulations, somepin’ about it’s against the law. But I can sleep on my stomach if I want to. It’s my body.”

  I nodded impatiently.

  “All peoples are human,” he continued, like a man who had seen his share in the world. “It don’t matter if you white or black or a foreigner like you. It don’t matter. We all human. Everybody deserve to be treated right. Not like this. You ask them, ‘Can you turn me over?’ and they say, ‘Go to sleep; just go to sleep.’ I say, ‘I can’t go to sleep. My butt be hurtin’, how am I supposed to sleep?’ ”

  I shifted on my feet. I had to get out of the room.

  “What day is it?” he asked.

  “September 8,” I replied.

  His eyes glimmered. “It’s my birthday.”

  “Oh,” I said, pleasantly surprised. “How old are you?”

  “Six . . . nine.”

  “Sixty-nine?”

  “No, six . . . plus . . . nine.” He smiled devilishly. “I’m fifteen years old.”

  Outside, I jotted down a few notes. The encounter had taken almost fifteen minutes. At the rate I was going, I’d have to start coming in at five o’clock to preround. I immediately dismissed the thought. Why ever go home?

  At the nursing station, Alphonse and Rohit were waiting for me. “Did you know that it’s Mr. Harrison’s birthday?” I said. “Nice,” Rohit replied, turning away. “Tell the nurses to give him something.”

  We walked down the long hallway to the stairs. Up ahead were the resident call rooms. Through a window, off in the distance, I could see a smokestack, a few skyscrapers, and the Triborough Bridge. Every morning I would spend a few moments staring out at the bridge, watching real life go on. It reminded me of the Bay Bridge in San Francisco, and looking at it reminded me of my old life. The view was both sad and something that I relished.

  We headed downstairs to the conference room to pick up our admissions. Rohit took the scuffed gray steps two at a time as Alphonse and I followed. We exited the stairwell on the fifth floor and took a shortcut through the oncology unit. The atmosphere here was quieter, more sedate. The ward smelled of disinfectant, unlike 10-North, which always had a musty odor. We marched through double doors, entering a carpeted back hallway where a fax machine had printed out the admission list by ward and resident team. We picked up a sheet.

  In the conference room, the night-float residents were presenting cases as the ward teams, arranged in small groups, took notes. “This is a lady that’s a soft admit because she’s a VIP,” said a resident. “This guy’s a two-pack-per-day smoker for thirty-five years and we’re putting him up in a two-thousand-dollars-a-night hotel room,” said another. In one group, a team giggled as a resident explained how he was trying to arrange a CAT scan for a morbidly obese patient by transferring him to the Bronx Zoo, where they had a scanner for elephants and other large animals. Cynthia, a classmate, came over to say hello. “Rumor has it you don’t p
reround,” she whispered. I was stunned; who had been talking? “I preround,” I protested. “Just not on every patient.”

  After picking up our admissions, we hurried back to the floor. Precariously resting our coffee cups on the wooden banister outside each room, we made rounds. Since Alphonse had managed to preround on all his patients, he had a lot more to say than me.

  One of his patients was Peter DiGeorge, whose room had the rank odor of morning breath. “He has that HIV look,” Rohit said out of earshot. When I asked him what that meant, he just looked at me and shrugged, as if it required no further explanation. At the bedside was a wooden table with drawers, and on the far side of the room were light pink curtains framing windows overlooking the central atrium. Di-George had been admitted to the hospital because of tiny blood clots that were seeding his skin. He had a broad nose, a high, arched forehead, and a beard that looked like a patch of ragweed. In deportment and appearance, he resembled a boxer dog. Two gold teeth jutted out of his mouth like fangs. His goatee, complemented by his arch eyebrows, gave him a sinister look. He was wearing large aviator glasses that partially obscured crusted lesions around his eyes. When he opened his mouth, I could see it was coated with large white plaques of Candida fungus, an opportunistic infection often seen in AIDS patients. Rohit exposed his legs, which looked like the surface of a blueberry muffin. The bluish spots culminated in a large round one above the right ankle, which was about a centimeter wide, with red and black crust, exuding pus. With his bare hands, Rohit pushed on the sides of it, and DiGeorge winced. Rohit had taken a Polaroid of the lesion yesterday to present at morning report with Dr. Wood. When DiGeorge had asked for a copy, Rohit had promised to make him one, but we never did. “We’re going to continue your antibiotics,” Rohit told him. “Nothing new today.”