Intern Read online

  I nodded nervously; that was what I was going to suggest, too. “Good pickup,” she said, perhaps sensing my unease. “You caught it early. He can probably be cured.”

  Testicular cancer is the most common solid tumor in men fifteen to thirty-four years of age. Like most malignancies, it used to be a death sentence; today, with advances in chemotherapy, it has a cure rate of over 90 percent. Even patients whose cancer has metastasized can usually be cured. Standard chemotherapy will successfully treat the vast majority of these patients. Of the remainder, approximately a quarter will be cured with second-line chemotherapy, and approximately a quarter of the remaining few will be cured with newer regimens involving high-dose chemotherapy with stem-cell transplantation.

  When I got back to the exam room, Jonah was even more on edge. “What do I have?” he demanded. I decided not to burden him with unconfirmed suspicions. “I don’t know,” I said. “Can you come in tomorrow for an ultrasound?” A wave of alarm washed over him. “Do I have cancer?” he whispered.

  I didn’t want to be the one to break the bad news. “I just don’t know at this point,” I lied. “We need more information.”

  The next morning I called a urology resident and told him that Jonah needed an ultrasound. “No problem,” he replied. “We’ll do him this afternoon.” Around five o’clock, he paged me. “It’s cancer,” he said. The test showed a round, well-defined mass, about five-eighths of an inch in diameter, on top of the right testicle. “Have you told him yet?” I asked. “I’m about to,” he replied.

  Jonah later told me how he got the news. “The resident just walked right in with his team and told me,” he said, still shocked. “He was very take-charge and matter-of-fact. His attitude was, ‘This is what you have, and this is what we need to do about it.’ But it was sort of like—boom!—I wasn’t expecting it. The scariest thing is how you can be just fine one minute, and the next have someone tell you that you have cancer and need to have your testicle removed.”

  I wondered whether my being more honest with him that first evening might have lessened the blow.

  A short while later, a stream of residents and medical students flowed in to examine him. “I understand why they had to do it,” Jonah said. “It’s sort of rare, and they have to learn. But at that point I just wanted to be left alone.”

  Three days later, Jonah had an orchiectomy, in which the urologist removed the testicle by pushing it up through an incision on Jonah’s upper groin. He was out of the hospital later the same day. After the operation, a cancer specialist told him that his kind of testicular cancer had about a 30 percent chance of recurrence and that he had two options: dissection of the lymph nodes in his groin and abdomen for evidence of residual disease, or “watchful waiting,” in which he would have blood tests and X-rays every month, as well as CAT scans every three months. Jonah decided to wait.

  “Sometimes, late at night, I lie awake thinking,” he told me several months later. “Like, if I don’t stir, it won’t emerge again. Like if I move around too much, I might awaken it. Like it’s this beast.”

  A beast, I agreed: asleep and scary, but one that can be killed.

  There were days when it felt like I was grappling with my own slumbering beast. Though my overall mood was much better than it had been six months earlier in the winter, my motivation for medicine still seemed weak, ill formed, a bit suspect. At times I was feeling low again, uncertain of the path I was on. My classmates were already talking about subspecialty fellowships, moving on, getting further training. Earlier that spring, in a sort of post-depression euphoria, I had considered applying for a cardiology fellowship. I devised a reading schedule, reviewing a new topic—electrocardiograms, antiarrhythmic drugs, atrial fibrillation—nearly every day. I knew that I was going to have to perform well second year to garner strong letters of recommendation and have a chance of securing a spot the following spring. But by the start of the new academic year in July, I could no longer imagine pursuing further training. I still felt overwhelmed by the responsibilities that I already had.

  ONE AFTERNOON IN EARLY JULY, I was summoned to the chief residents’ office. Stuart Barton, who had been my resident on the nephrology ward, and Clarence Riley, another third-year, met me there. They were both assistant chief residents now, an honor reserved for the most brownnosing seniors. Riley, who had thin brown hair and a disproportionately wide mouth, was sitting behind a large wooden desk. I remembered him from the welcoming party at the faculty club during internship orientation. He was one of the two residents who had walked into the party in scrubs, which had seemed awfully brazen at the time, but in the intervening months I had found him to actually be quite smarmy. Barton had been a supportive junior resident, but now he was standing pompously grim-faced at Riley’s side. It was sad to see how easily he had been corrupted by power.

  Riley motioned for me to sit down. I didn’t know what was going on, but the atmosphere in the room told me that some sort of reprimand was forthcoming. Leaning back in his chair, fingers steepled, his eyes focused on a point on the wall behind me, Riley said: “So can you tell us how you came to write the article about the ICU?”

  He was referring to an essay that had just been published in the Times. “People were pretty upset about what you wrote,” he said. “Suzanne Mendes”—one of the ICU attendings—“was especially unhappy. She came to us and complained that you shouldn’t be writing this stuff in The New York Times.” In the essay, I had discussed the case of a seventy-two-year-old woman who walked into the emergency room one day carrying a report from another hospital stating that she had fluid in the sac around her heart. While lying on a stretcher in the ER, she had briefly stopped breathing. Physicians in the ER had inserted a breathing tube in her windpipe and transferred her to the ICU. I wrote:

  There things rapidly fell apart. A needle, inserted in an effort to drain the fluid around her heart and examine it for clues to her underlying disease, was inadvertently pushed too far, piercing her heart. She lost several liters of blood. Because she was a Jehovah’s Witness, she refused to accept blood transfusions. Debilitated and anemic, she became dependent on her ventilator. But she found the breathing tube painful and uncomfortable, and she periodically tried to yank it out, which raised her blood pressure to dangerous levels. One morning, I walked into her room to find her unable to move the right side of her body. A CAT scan confirmed that she had suffered a large stroke.

  Now she was lying in bed, heavily sedated, her wrists restrained, receiving sustenance through a tube. The attending physician looked at the woman sadly. She would have been much better off, he said, if she had never come to the ICU. “Bad things happen here. You see it all the time. It’s probably a combination of patients already being sick and the terrible things we do to them.”

  Iatrogenic, or hospital-acquired, complications, the essay went on, had reached epidemic proportions.

  ICU care, provided to the most frail and sick patients, often results in the worst iatrogenic injuries. Catheters placed in various organs and invasive procedures, like spinal and lung taps, can cause complications like bleeding and infection. Frequent blood drawing and round-the-clock monitoring often result in fatigue and depression among patients. Heavy use of medicine sometimes results in drug reactions. “Most of our patients would do better on auto pilot,” a doctor completing a senior fellowship in the ICU at my hospital recently told me. “They’d be better off if we brought them in here and just left them alone.”

  Of course, this is an exaggeration. Many patients will do fine if they can be supported through an acute medical crisis. But even for these patients, the level of care that is safe and necessary has not been clearly defined.

  In 1980, Dr. Arnold Relman, then editor of The New England Journal of Medicine, wrote: “The cost and psychological stress of ICU treatment would be justifiable if such units were known to reduce mortality and morbidity from levels achievable with less costly and intensive modes of hospital care. [But] there have been
no prospective, randomized, controlled trials to supply such data.” Almost two decades later, such studies are still lacking.

  I told the story of an elderly woman in the ICU who was in a coma for a month.

  She developed a blood infection, and kidney, heart and respiratory failure, but lingered for weeks with antibiotics and drugs to elevate her blood pressure. We all knew she was going to die and that our efforts were futile. Still, no one in her family was willing to give up, and so we persisted in aggressively treating her, causing her obvious pain every time we poked her with a new catheter or pushed on her belly to examine her. What finally caused her death was a catheter placed through a hole in her abdomen, which probably resulted in yet another infection. She did not live any longer because of what we had done, just ended her life more miserably.

  One day, I walked into the residents’ work room and saw scribbled in red ink on the eraser board: Primum non nocere. First do no harm.

  The essay concluded:

  More is not always better, especially in medicine. Less aggressive treatment may sometimes reduce the risk of injury, particularly in patients who have a good chance of getting well again. Though it runs counter to most medical training, only when doctors learn to do less, and not always more, will they stop causing inadvertent harm to patients in the ICU.

  “They passed it around at morning report,” Barton said gravely as Riley continued to stare at me from behind the desk. I envisioned the scene: junior and senior residents and a few medical students sitting around a long conference table with Dr. Wood and a senior physician, munching on Tal bagels, mumbling among themselves as the essay went around. “Rob Lerner”—another ICU physician—“was the attending that week,” Barton added.

  “What did he say?” I asked. Lerner was the head of the ventilator management team and one of the senior physicians I admired most.

  “Not much,” Barton replied tersely. “He sort of scanned it, but he didn’t look happy. Someone asked if you were still serious about applying for a cardiology fellowship.”

  I shifted uncomfortably in my seat. Was I being threatened?

  “Maybe you should write a letter of explanation,” Barton suggested. “To Suzanne. To help her understand your point of view.”

  “I don’t see why I need to apologize,” I said defensively.

  “We’re not asking you to apologize,” Riley said quickly. “Just explain yourself.”

  Since when, I wondered, did I have to answer to a junior ICU attending, let alone residents only one year ahead of me?

  “The essay is pretty self-evident,” I said in a measured tone. “Complications occur in the ICU. Why should it bother anyone that I pointed it out?” Of course I knew why, but I had decided to adopt a disarmingly—if disingenuously—naive approach.

  “They’re going to keep a close eye on you,” Riley said. I wasn’t sure whom he was referring to, but I assumed it was higher-ups in the Department of Medicine. For a moment I considered just writing the letter, but then I thought, Screw it; I don’t owe them anything. In graduate school I had always been taught to think independently. Even my father had encouraged dissent, even if he hadn’t always tolerated it. Giving in to their demand would make me think twice about writing more essays. My writing was too important to me to allow it to get corrupted like that.

  “They’re not going to give you any more slack,” Riley warned. I said I’d take my chances.

  When I got home, a bit shaken, I called Rajiv. Cardiology fellowships were hard to come by, and though I doubted I was going to apply for one, I wanted to keep my options open.

  “Fuck ’em,” Rajiv said definitively. “There are other fellowship programs in New York. Some of them might even be impressed that you wrote something for The New York Times.

  “You know what your problem is?” he went on quickly. “And I’m shocked because it should have happened by now; you did a Ph.D. in physics for God’s sake. You don’t have a thick skin. You care too much about what people think. That’s going to be a major problem for you, especially if you keep writing these articles.”

  THE MONTHLONG ROTATION in the outpatient clinic passed rather uneventfully, until one morning when a sullen young woman walked into my exam room and plopped herself into a cracking vinyl chair. “I want a referral to a chiropractor,” she announced. Judging from her face, she was in no mood for small talk.

  Earlier that morning, she had clashed with the doctor answering the phones at the clinic. She had requested the referral but had gotten upset when he started asking questions about her back pain. When he insisted that she come to the clinic to be examined, she told him he was wasting her time and hung up. But about an hour later, she walked into the clinic, where, after an angry exchange of words with the front desk clerk, she was quickly ushered into my room. Her regular doctor was away.

  She was tall, frumpily dressed, with wavy auburn hair and narrow-set eyes. “How long have you had back pain?” I asked.

  “It started this morning,” she replied. “I heard a pop between my shoulders.”

  “Has this happened before?”

  “Yes, several months ago.” She had gone to a chiropractor, which helped.

  “What did the chiropractor do?”

  “I don’t know,” she replied, her voice rising. “He manipulated my spine and I felt better.”

  “Are you experiencing any weakness or numbness in your legs?” Nerve root compression from a slipped disk (like the one I had had in my cervical spine) was a common and potentially serious cause of back pain.

  “No.”

  “What about shooting pains?”

  “No.”

  “Pins-and-needles sensations?”

  “No!” she shouted. “How is this important? I just want a referral.”

  “Okay,” I replied, but first I had to examine her. I explained that if she had a pinched nerve, a chiropractor might do more harm than good. Reluctantly, she got up onto the examination table. I pressed on her back with my fingers, trying to see if I could localize any tenderness. Back pain was usually benign, but in rare cases it could be caused by an infection or tumor, and I wanted to make sure I wasn’t missing anything. After finding the testicular tumor in Jonah, I had become meticulous about physical examination. I raised her straightened legs one at a time, trying to elicit pain, a telltale sign of sciatica.

  “You’re wasting my time!” she erupted. “Call your supervisor.”

  Now my supervisor that day happened to be a calm, soft-spoken doctor who had a nice way with his patients. I called him to my exam room, explained what was going on, and excused myself. In the hall-way, I listened as my patient inveighed against the clinic and the doctors who had mistreated her. My preceptor’s quiet manner and attention appeared to mollify her, because she allowed him to examine her. Then, calmly, they discussed her options. She was not interested in Motrin or rest as therapy. She insisted on a chiropractor.

  About fifteen minutes later, he emerged from the room and asked me to please write the referral. I did, and the woman left, looking satisfied.

  Afterward, in his office, he shrugged and weakly smiled. “She was a difficult patient,” he said. “In such cases you listen and try to do the best you can. Sometimes patients just need to vent.”

  The encounter left me to wonder: Who had been more difficult, the young woman or me? After all, she was the one in pain, and I had presented an obstacle to her relief. Chiropracty was unlikely to do any harm; she told me it had already helped her. Still, for reasons I could not pinpoint, I had created hoops for her to jump through, asking irritating questions more for my own purposes than for hers. The situation demanded empathy, but instead I had been automatic, hyper-rational, and detached. It certainly wasn’t the way I had imagined I would be as a doctor. The right thing probably would have been to give her an unfettered referral without asking too many questions, but somehow I had not obeyed this instinct. Part of the reason was to assert my authority. Part of the reason, no doubt, wa
s that I was wearing a white coat. It wasn’t the first or last time that I felt my uniform was somehow suppressing my better instincts.

  Later that month, the clinic chiefs asked me to present a case at morning report, so I decided to present the case of the young woman. Snickers could be heard in the wood-paneled conference room when I put up my title slide: Difficult Patients. I started off talking about a landmark 1978 article in The New England Journal of Medicine by Dr. James Groves, then a professor of psychiatry at Harvard Medical School, called “Taking Care of the Hateful Patient.” In it, Groves described certain personality traits that kindle aversion, fear, despair, or even downright malice in doctors. He described such patients as “dependent clingers,” “entitled demanders,” “manipulative help-rejecters,” and “self-destructive deniers.” Emotional reactions to patients, he wrote, cannot simply be wished away, nor is it good medicine to pretend that they do not exist. Freud called such reactions countertransference—how doctors react to patients, not the other way around—and said these reactions could be used to explore the unconscious conflicts of doctor and patient.

  Aversive reactions, I told the audience, are common in any enterprise involving intimacy: marriage, psychotherapy, the battlefield, and so it is with medicine. The difference is that doctors cannot divorce their patients, at least not easily, and for good reason. Entrusted as we are with a fiduciary duty to preserve health, we cannot dismiss patients willy-nilly. But the question demanded asking: If patients can choose their own doctors, why can’t doctors choose their own patients?

  There are guidelines for when a doctor can dismiss a difficult patient, and usually only the most egregious misbehavior qualifies, including threats, violence, and noncompliance. For example, courts have ruled that kidney specialists do not have to provide dialysis to violent or disruptive patients, even those who need it to remain alive. In 1987, Dr. John Bower, a kidney specialist at the University of Mississippi, was sued after dismissing from his practice a patient who regularly missed dialysis appointments, verbally abused nurses, and even threatened to kill Bower and a hospital administrator. Bower cited medical noncompliance and violent threats as grounds for terminating care. The Fifth Circuit Court of Appeals, in New Orleans, agreed with him, ruling that doctors can refuse to treat violent or intransigent patients as long as they give proper notice so that the patient can find alternative care. Forcing doctors to treat such patients, the court said, would violate the Thirteenth Amendment, which prohibits involuntary servitude.