Intern is Sandeep Jauhar's story of his days and nights in residency at a busy hospital in New York City, a trial that led him to question our every assumption about medical care today. Residency—and especially the first year, called internship—is legendary for its brutality. Working eighty hours or more per week, most new doctors spend their first year asking themselves why they wanted to be doctors in the first place.
Jauhar's internship was even more harrowing than most: he switched from physics to medicine in order to follow a more humane calling—only to find that medicine put patients' concerns last. He struggled to find a place among squadrons of cocky residents and doctors. He challenged the practices of the internship in The New York Times, attracting the suspicions of the medical bureaucracy. Then, suddenly stricken, he became a patient himself—and came to see that today's high-tech, high-pressure medicine can be a humane science after all.
Now a thriving cardiologist, Jauhar has all the qualities you'd want in your own doctor: expertise, insight, a feel for the human factor, a sense of humor, and a keen awareness of the worries that we all have in common. His beautifully written memoir explains the inner workings of modern medicine with rare candor and insight.
|Publisher:||Farrar, Straus and Giroux|
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About the Author
Sandeep Jauhar, MD, PhD, is the director of the Heart Failure Program at Long Island Jewish Medical Center. He writes regularly for The New York Times and The New England Journal of Medicine. He lives with his wife and their son in New York City.
Sandeep Jauhar, MD, PhD, is the director of the Heart Failure Program at Long Island Jewish Medical Center. He is the bestselling author of Doctored and Intern and a New York Times Contributing Opinion Writer. He lives with his wife and their son and daughter on Long Island.
Read an Excerpt
A Doctor's Initiation
By Sandeep Jauhar
Farrar, Straus and GirouxCopyright © 2008 Sandeep Jauhar
All rights reserved.
There is no short cut, nor "royal road," to the attainment of medical knowledge. The path which we have to pursue is long, difficult, and unsafe.
— JOHN ABERNETHY, ENGLISH SURGEON, HUNTERIAN ORATION, 1819
I had been an intern less than an hour, and already I was running late. The sloping footpath leading up to the hospital was paved with gray cobblestones. My feet ached as my oversize leather sandals slipped on the rounded irregular rocks. The hospital was an old building browned by the passage of two centuries, with spidery cracks in its façade. Founded in 1771, New York Hospital is the second-oldest hospital in the United States, a mecca for doctors and patients from all over the world. I had been in the building once before, six months ago, for a residency interview. I spun through a revolving brass door, nearly running into the burly security guard reading the New York Post. He looked up from the tabloid just long enough to point me in the direction of the elevator.
The tiled corridors were dark and dull, mixing shadow and light. I darted past the chapel, past the café, around the information desk, which sat in the middle of the huge atrium like a fort, and entered a bank of elevators. Hanging on a wall was a portrait of a gray-haired lady in a blue dress sitting in dignified repose before an open book. She was a graduate of the medical school, class of 1899, ninety-nine years ago, who built a medical college for women in Northern India, on the banks of the Ganges, near where my father had his early college education. Nearby was a metal tablet in bas-relief: "She cared for all in need. For each, she made time to guide, to teach, and to heal."
When I arrived on the fourth floor, other interns were still filing into the auditorium. A woman handed me a manila folder, and I went inside and sat down. The orientation packet contained several essential documents: a house-staff phone card, directions for obtaining autopsies, instructions on how to use the hospital dictation system, and the residency contract. I leafed through it quickly. My salary was going to be $37,000 a year, about eight dollars an hour, I calculated, given the number of hours I was going to be working, but I didn't mind. Though I was a year shy of thirty, it was more than double what I had ever made.
My classmates, though younger than I, appeared older than I expected, casually dressed, all thirty-five of them, in khakis and polo shirts, faded jeans and sequined tops. Some of them evidently knew each other, because they were already chatting in small, insulated groups. They were from some of the best medical schools in the country: Harvard, Yale, Cornell, Columbia. Though I too had gone to a top school — Washington University in St. Louis — I had been feeling insecure about the prospect of working with them. For months I had feverishly been reading Harrison's tome on internal medicine and review articles in The New England Journal of Medicine to prepare for this day.
Someone in the front row stood up and turned to face us. It was Shelby Wood, the hospital's residency director. He was a serious-looking man of medium build, with straight brown hair and a long, aquiline nose. He was wearing a white coat and a fat blue tie that might have been in fashion twenty years earlier. My elder brother, Rajiv, a cardiology fellow at the hospital, six years ahead of me in his medical training (though only two and a half years older), had warned me that Dr. Wood was a bit of a grouch, but had added that he was also fair and decent and a strong advocate for his house staff. Wood, I was to learn, hailed from the old school, where you were expected to live and breathe medicine, stay late in the hospital, neglect your family for the sake of your patients, and emerge on the other side a seasoned physician.
He cleared his throat and began to speak. His voice was deep but incongruously soft, and because I was sitting in the back of the sixty-seat auditorium, I only managed to catch snippets of his remarks. It was going to be a busy year, he said, as thirty-five heads stared motionlessly back at him. We were expected to devote ourselves fully to medicine. "You don't learn French by taking classes at Hunter College. You learn it by going to Paris, sitting in the cafés, talking to people." Likewise medicine: we would learn it by living it. "You are now ambassadors for the profession," he said gravely. "So don't let the students hear you complain. It sets a bad example." If everything went as planned, he added, by next June we'd be ready to supervise the next batch of interns.
I glanced over at the pretty brunette sitting next to me. She looked back at me, rolled her eyes, and opened her mouth in mock panic.
Then Wood dropped the bomb. Every intern starting on the wards or in the intensive care units was required to come to the hospital every single day, including weekends, for the first six weeks. The only exceptions were interns starting in the outpatient clinic, which was only open from nine to six; they would have no evening call and weekends off for the first month. I later learned that this regimen was a longstanding tradition at the hospital, the most efficient way to get everyone up to speed. To me it seemed brutal, like a kind of hazing, not to mention a violation of residency work-hour limits set forth by the Bell Commission in New York in the mid-1980s. Uneasy murmurings reverberated through the auditorium as new interns rustled through their packets. I scanned the master schedule before breathing a sigh of relief. Along with six classmates, I was slated to start in the clinic.
"We are here to help you," Wood said, raising his voice over the light chatter. "You should feel free to call on us anytime, day or night. The only mistake you can make is not asking for help."
I was reminded of a residency interview in Chicago a few months earlier. The interviewer, a portly senior physician with an abundance of facial hair, had posed the following scenario: A nurse pages me in the middle of the night to tell me that a patient who just had hip surgery is short of breath. What would I do? "Go see the patient," I said. I had enough sense to know that there was only one right answer to that question. Walking to the room, what would I be thinking about? "Pulmonary embolism," I replied. Blood clots in the lung are a feared complication after hip surgery. When I arrive in the room, the patient is in distress. His heart is beating 130 times per minute and the oxygen tension in his blood is low. Now what? I went over the treatment options in my head — blood thinner, supplemental oxygen, arterial blood gas — but it seemed the examiner wanted me to say something else. I'd heard about the notorious "July phenomenon," in which hospital mortality supposedly increases every summer with the entry of new and inexperienced hospital staff. "I'd call a senior resident," I finally answered. Why? "Because I could be missing something." My interviewer nodded; I had passed the test. Like all residency directors, he was looking for a soldier, not a cowboy.
Now it was late June, and we were the new hospital staff. For the rest of that first morning, we sat through a series of tag-team lectures. A woman from the blood bank talked about blood transfusions. A pathologist talked about the importance of autopsies. A psychologist spoke about work-related stress and told us that confidential counseling was available. A lawyer from risk management, the department that defended the hospital against lawsuits, informed us that at some point in our careers every one of us was likely to be sued, and that we could even be sued during residency. She offered some advice: Document your decision-making; document when a patient refuses treatment; never admit wrongdoing; never talk to an opposing attorney; and, finally, be nice to your patients. Doctors who were nice to their patients were rarely sued, even in cases of egregious malpractice. I looked around the room, trying to gauge the reaction of my classmates, frankly surprised that such a cynical thing was being taught on the first day of residency. No one's eyes met mine.
At the midmorning break, I went outside. Stepping through the humid air was like sweeping away static. The sidewalk was buzzing in a kind of Brownian motion, with pedestrians sidestepping me as though I were a moving obstacle. A long line snaked from an aromatic hot dog stand. Buses and taxicabs were letting people off in front of the hospital. An ambulance whizzed by on the main thoroughfare, sirens blaring, lights flashing. The noise fed my sense of wonder. I had grown up in a quiet Southern California suburb, craving the excitement of a big city. Berkeley and St. Louis had their pockets of vitality, but nothing like this. Even the smell of the neighborhood — a mix of pizza, garbage, cigarette smoke, and fragrant fruit — was rich and seasoned, like wisdom wafting through the air.
I had only arrived in Manhattan a few days earlier, moving into a one- bedroom apartment about a block away from the hospital. On the plane flight in from St. Louis, the pilot took a detour because of airspace congestion, he told us, flying into LaGuardia from the south, not the usual flight pattern. As we passed over the World Trade Center and then soared low over the city, I craned my neck to look down at the broad swath of Central Park. The brown buildings on its outskirts were arrayed like divers ready to jump into a pool. Down there, I had imagined, all of the metropolis's unique charms were waiting for me: the old, stained sidewalks; the stealthy characters playing junkyard instruments on subway platforms; the deliverymen hurtling through traffic lights on their rickety ten-speeds, I [??] NY plastic bags swinging from the handlebars. The first time I had been to New York was the summer before medical school, when I spent a couple of weeks with my brother and his wife in their tiny one-bedroom apartment across the street from the hospital, where he had just begun his fellowship. I wandered around the city, going on walking tours of Harlem, joyriding on the subway, chatting with bartenders late into the night. Like many visitors to Manhattan, I was swept away. The delicatessens, the dry cleaners, the corner convenience stores and smoke shops. Unlike in Berkeley, people weren't just milling around, enjoying the sun. There was magic in the movement on the streets. So much was happening, and I could watch it all and remain a shadow. That was the wonderful paradox of Manhattan: you could be surrounded by people and yet be anonymous at the same time. "The United Nations is just down the street," I wrote a friend. "The building they use to broker world disputes, just down the street from me!" New York cast a spell on me that summer that I could neither explain nor resist.
Back on the sidewalk, I felt a light spray from air-conditioning units outside the apartment windows above me. Heavy construction was going on in a lot nearby; large bulldozers were exhuming a deep hole, as if for a tomb, their blades ravenously picking up mouthfuls of yellowish dirt. I passed by an old church and stopped at a fruit stand to buy a nectarine. Then I ambled back to orientation munching on it. A plane flew overhead. Looking up at it streaking across the clear blue sky, sweet juice trickling down my chin and fingers, I couldn't help but think that the abnormal flight path that had brought me here last week was an apt metaphor for my own twisting journey into medicine.
I STOOD ON THE BALCONY in Berkeley and lit a cigarette. My bags were packed, the bills paid, the car loaded. Most of my possessions had been sold, save for some clothes and a few boxes of books, which I forced into the trunk and backseat. After a week of sleepless nights, I had turned in my Ph.D. thesis on quantum dots that morning. I had even found someone to take over my apartment. Now all I had to do was leave.
It was late in the afternoon on Tuesday — August 1995 — and the sky over the shimmering San Francisco Bay had turned a smoky orange. Medical school orientation was starting tomorrow. I would be in a Honda Civic somewhere in the Rocky Mountains. After explaining to the dean that I was delayed finishing my physics thesis, she had urged me to at least try to make it to St. Louis by Friday morning for the white-coat ceremony and the recitation of the Hippocratic oath. After speaking with her, I looked it up: "... To please no one will I prescribe a deadly drug, nor give advice which may cause his death. Nor will I give a woman a pessary to procure abortion ..." Arcane stuff. Perhaps, I wondered, she'd let me write my own oath. Perhaps that could be my first contribution to my medical education.
The air was warm, still, vaguely welcoming. The fraying eucalyptus trees in the backyard gave off a pungent fragrance. Taking a long drag, I felt buzzed, even a bit dizzy. For the first time in months, I was in the moment. But the carefree feeling quickly dissipated as the thought — the same thought that had plagued me for months — reentered my mind, even as I tried hard to resist it: What the hell are you doing?
I pulled out of the driveway and headed south toward the Berkeley campus one last time. I passed the International House, Sorority Row, and the dormitory where I had lived freshman year. Ice plant still lined the side of the road, and the landscaping was still immaculate, just as it had been a decade ago. Freshman year, I remembered, I had planned to major in history or political science, but Victor, my randy Russian roommate, had deterred me. He was a double major in math and physics. (And "love," as he liked to put it. He put a mattress in our walk-in closet. Every night, moans from one of his girlfriends titillated me as I fell asleep.) Victor's enthusiasm for his chosen subjects was infectious. He lent me books on abstract algebra. He explained to me the wonderfully nonintuitive ideas of Kurt Gödel, an Austrian logician who proved that all mathematical systems are necessarily incomplete. He told me about Ramanujan, the Indian mathematical prodigy who claimed that the Hindu goddess Namakkal whispered theorems about prime numbers to him in dreams. In freshman chemistry, when I had to memorize the rules for how electrons occupy atomic orbitals, Victor taught me where those rules came from, in a quantum-mechanical language that was both beautiful and inscrutable. The exactness, the inaccessibility, of quantitative science intoxicated me. In the social group I eventually joined, math and physics had prestige, a sort of intellectual exclusivity that was deeply appealing. The spectrum of talent in these subjects was so broad, much broader than in the social sciences or humanities or even the biological sciences, where it seemed that with enough study even the grade-conscious premeds could master the concepts. What separated me from the rest of the pack was what separated Victor from me, and what separated my friend Mike from Victor, and what separated the genius student David Moulton from Mike, and what separated the weird, stinky math professor who ambled around campus mumbling to himself from David Moulton, and probably what separated Einstein from the weird, stinky math professor. The brain function required was so specialized that math and physics seemed to me the truest tests of intelligence. So, by the end of my freshman year, my major had changed to physics, and my intellectual heroes had changed from Churchill and Gandhi to Einstein, Heisenberg, and Feynman, men who changed the world through the power of mathematics.
But by senior year it had become clear to me that theoretical physics, at least at the level I wanted to pursue it, was beyond my capabilities. So, like many of my friends who didn't know what to do with themselves, I took the LSAT and applied to law schools. Trial law had always interested me; in high school I often fantasized about leading a courtroom charge like Atticus Finch in To Kill a Mockingbird. Law school, I hoped, would allow me to broach the big questions of ethics, philosophy, and politics that had always interested me. My father, a plant geneticist with a disdain for vagueness and imprecision ("Nonscience is nonsense," he often said), thought it was a bad idea. He didn't need to remind me of his opinion of lawyers. I got into the top schools and even deferred my admission for a year, but in the end I decided to stay at Berkeley for the graduate program in physics. I didn't know what else to do. Though I thought I might like law school, somehow I knew I didn't want to be a lawyer.
One thing I never thought seriously about was becoming a doctor. In fact, for most of my life, medicine was the last thing I wanted to do. My maternal grandfather had been an army doctor in India before he went into private practice. As a boy in India, before we moved to America, I used to watch him at work in his iodine-stained clinic on the ground floor of his palatial flat in an upper-crusty neighborhood of New Delhi. Pitaji's clinic always smelled pungently of medicine, as did he. Through the drawing room window I'd spy him examining patients with boils or sepsis on the mosquito-netted veranda while lizards clung motionlessly to the limestone walls. It was fine, noble work — or so I was told — but it never caught my fancy. To me, even as a boy, medicine was a cookbook craft, with little room for creativity.
Excerpted from Intern by Sandeep Jauhar. Copyright © 2008 Sandeep Jauhar. Excerpted by permission of Farrar, Straus and Giroux.
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Table of Contents
Internship: An Introduction,
I. SWITCHING HORSES,
2. Phase Transition,
3. Medical School,
4. Bogus Doctor,
5. On Call,
6. Road Trip,
7. First Death,
8. Heart Rhythms,
9. Customer Service,
10. Falling Down,
II. CRACKING UP,
12. Night Float,
14. Winter Blues,
15. Difficult Patients,
16. Pride and Prejudice,
17. Informed Consent,
18. Bloody Penguins,
19. Code Leader,
20. Gentle Surprises,