On a sultry June morning in 1976, wearing a starched white coat and tightly knotted tie, I entered the Massachusetts General Hospital. It was my first day of internship, the moment when I would become a real doctor after four years of medical school. I had been a driven student, intent on learning every fact and detail. In the lecture hall, I sat in the front row, furiously scribbling notes. During my clinical courses in pediatrics, surgery, internal medicine, neurology, and obstetrics and gynecology, I tried to gather all the information I could, recording the highlights of cases on index cards. Each night, I reviewed the cards, and worked to commit the salient points to memory. I believed I was creating a compendium in my mind of necessary medical knowledge, so that I would be prepared for the day when I assumed responsibility for another person’s life.
I made my way through the hospital’s labyrinthine halls to a conference room in the Bulfinch building. Dr. Alexander Leaf, the department chairman at the time, greeted us with brief remarks: as interns, we had the privilege to both learn and serve. Not stated but clearly implicit was that the internship program at Mass General was highly selective, the beginning of a career in which each of us would achieve important positions in academia and make notable contributions. After Dr. Leaf finished, the chief resident gave each intern his schedule.
I began on the wards with a fellow intern and a junior resident. The on-call schedule was every third night, shared equally among us. That first night was mine. Like all interns, I would be on-call alone, expected to care for all of the patients on the floor as well as admit new patients from the emergency room. Early the next morning, the resident and two interns would convene to review what had happened the night before.
As that first day edged into evening, my resident prepared to depart for home. He looked at me squarely and said, “Remember, be an ironman and hold the fort.” Only in the most dire circumstances was I to contact him for help in managing a case.
After the resident left, I reviewed the charts of the patients on the floor, and then went to introduce myself to a man I’ll call Mr. Morgan. He was in his sixties, African-American, with high blood pressure that was not well controlled with medications. Two days before, he had come to the emergency room with chest pain. The encyclopedia in my mind rapidly offered the fact that African-Americans have a high incidence of hypertension, which can lead to both heart disease and renal failure. The cause of his chest pain was still obscure: his initial evaluation did not suggest a blockage of a coronary artery.
Mr. Morgan was warm and outgoing, shaking my hand firmly and noting, “First day, ha?” We chatted, and I informed Mr. Morgan that the X-rays done earlier in the day showed no abnormality in his esophagus or stomach that might account for his chest pains.
As I was about to depart, Mr. Morgan bolted upright in bed. His eyes widened, his jaw fell slack, and his torso heaved violently.
I asked him what was wrong, but he was unable to speak, struggling for air. I tried desperately to think, but couldn’t. My mind was blank. The compendium of clinical facts memorized over four years seemed to have been erased. I stood frozen.
All of a sudden, I heard a voice behind me. “This man seems to be in distress.” A middle-aged man with black hair and a handlebar mustache was standing behind me. “I’m Dr. Burnside,” he said. “I trained here a number of years ago and was by to see some old friends. I’m a cardiologist in Virginia.”
All I could summon in my mind was that Burnside was the name of a famous general in the Civil War. Dr. Burnside took the stethoscope from my pocket, listened to Mr. Morgan’s chest, and then told me to listen. It sounded as if a faucet had been opened full blast, then closed, then opened again, over and over. “This gentleman just tore through his aortic valve,” Dr. Burnside explained. A cardiac surgeon was needed—immediately.
Dr. Burnside stayed with Mr. Morgan while I ran and found a nurse. She paged the cardiac surgery team and then came rushing back with a resuscitation cart. Dr. Burnside rapidly inserted an airway in Mr. Morgan’s mouth and the nurse began to pump oxygen into his lungs via an Ambu bag. The cardiac surgery resident soon arrived and rushed Mr. Morgan to the operating room. Dr. Burnside said good-bye. I thanked him.
I sat stunned for many minutes at the nurse’s station, the sweat pouring down my neck. The entire event seemed a morbid fantasy. Engaged in a pleasant conversation with one of my first patients, and then a sudden upheaval, like an earthquake. Deus ex machina, Dr. Burnside appeared. All those furiously scribbled details on index cards. All that memorizing. All of the high grades I achieved as a student. Selection to a highly competitive internship program. Then, my first test in the real world, abject failure.
The rest of the night passed uneventfully. I admitted several patients from the ER, none of them terribly sick. In the wee hours of the morning, I called the operating room and learned that Mr. Morgan had successfully undergone open heart surgery, and that a prosthetic aortic valve was now firmly in place. A wave of relief swept over me. I had survived my night on call, but more importantly, so had my patient.
As dawn broke, I was filled with the sense that this was only the beginning. Indeed, there would be other “firsts”—the first time I acted decisively to save the life of a patient, and the first time that a patient was lost under my care. The first instance when I made an astute diagnosis, and the first when I failed to discern what was wrong, so that the patient suffered for it, his disease worsening because of my ignorance. The first time I made a serious technical error, inserting a catheter into a large vein and missing, puncturing the patient’s lung. And the first time I walked slowly from the ICU to meet with a family waiting to hear news about a patient and then had to tell them that despite all the measures of modern medicine, she was worsening, and it was time to withdraw support.
The intensity and burden of such experiences prompt physicians to share them, whether privately with other doctors or when, unable to fall asleep, the events of the day racing through the mind, they come out in fragments with a mate in bed. And then there are writings, in which experiences and emotions are not only recorded, but made comprehensible to a larger world outside.
Terrence Holt, an internist in North Carolina, writes about such “firsts” during his internship and residency training in Internal Medicine. His stories, though, do not recount recollections of exact events. Rather, Holt offers what he terms “parables.” The patients are not really individuals whom he cared for, but rather composites. He states with great passion his rationale for not simply disguising the identity of the actual patient by altering a few details, as I did by calling my patient “Mr. Morgan”:
That’s not enough to respect the patient. As long as there’s an actual, unique individual beneath that disguise, you’re making a spectacle of somebody’s suffering, and that’s a line no one should cross. It’s bad for the patient. It’s not good for the writer, either.
This poses a challenge to a writer trying to offer a factual account of residency. Medicine without patients isn’t a very useful story. This is why the patients in this book aren’t based on specific individuals, no matter how disguised. They aren’t “facts.” They are at most assemblages drawn from a variety of sources, compiled from multiple cases, transformed according to the logic not of journalism but of parable, seeking to capture the essence of something too complex to be understood any other way.
I was inspired to write by the work of Oliver Sacks. His profound narratives of patients explored both science and the soul. In these portrayals of people with neurological disorders, Sacks shows great sensitivity; the contention that the subjects are being exposed in a freak show, “spectacles” for voyeurs, is simply wrong. Moreover, Sacks maintains that while patients may share a diagnosis, each is unique as a person in how that malady affects his or her life. For example, describing Tourette’s syndrome, he writes that it is seen “in every race, every culture, every stratum of society,” but with a great diversity of manifestations, concluding, “no two patients were ever quite the same.”*
A similar individuality is apparent in Sacks’s accounts of how each of us adapts to a certain condition. To that end, he never depicts patients as mere “cases,” or “diseases,” or, in Holt’s term, “facts”; rather they are presented in the full breadth of their humanity. This humanistic depiction would be diluted if they were amalgamated into composites. Furthermore, some of the people Sacks described, such as Temple Grandin, used his portrayal as a springboard to launch their careers as writers, contributing in their own voices to a deeper understanding of their maladies and lives.
When I began to write patients’ stories, both in books and for periodicals, I confronted the issue that vexes Holt. There is a sacred bond between me and the people who seek my care as their doctor. So if I consider writing a story, I obtain permission from each patient. I emphasize to them that I am a doctor first and foremost, a writer second. Alert to the power imbalance between physician and patient, I make it clear that there is no quid pro quo, that the answer will not alter our relationship—it is their choice.
Asking permission has elicited a diversity of responses. Several declined, and that was the end of the matter. It never was raised again, as I served as their physician. But in most instances, patients were delighted to have their stories told. Some asked me to use their real names, others requested pseudonyms. All expressed the hope that an authentic account of their experience would help others facing fraught choices about treatment and navigating complex relationships with family and medical professionals. For those no longer living, as with “Mr. Morgan,” I changed names to protect confidentiality.
Still, I appreciate the tension around the issue. The clinical world is messy: mistakes are made, misunderstandings arise, outcomes can be unexpected, and physicians and patients sometimes find themselves at loggerheads. Further, character may change during the course of illness, the character of the patient and of the doctor, and not always for the better. None of this should be glossed over or omitted.
But after several books and more than sixty articles, not once has a patient expressed regret about giving permission. (And my patients are encouraged not to be shy or reluctant to speak their minds to me about problems.) For some with cancer or AIDS who later died, their portrayal was welcomed by family and friends as a memorial.
I was taken aback by Holt’s assertion that only the form of parable can “capture the essence of something too complex to be understood any other way.” Tolstoy’s “The Death of Ivan Ilych” is an illuminating parable, as are the medical tales of Chekhov, Turgenev, and Kafka. But the nonfiction stories of Oliver Sacks, Robert Coles, Richard Selzer, and Sherwin Nuland, as well as potent new voices of young doctors like Danielle Ofri, Leah Kaminsky, and Christine Montross, certainly capture the essence and complexity of the clinical world.
In Internal Medicine, Holt names the physician-narrator “Harper.” I imagine it is one more signal to the reader that these stories are not literally true. Yet this is confusing, since Holt states that the parables are drawn from his own experience. Because the patients are amalgamations of many different people, the reader might ask, is Harper an amalgamation of many different interns? Or is he Holt, and the book a reflection of his own growth as a new doctor?
Once we overcome these stumbling blocks, we discover a writer of considerable talent. Holt brings into focus stark moments of success and failure, pride and shame, courage and cowardice, self-reflection and obtuse blindness that mark the years of clinical training. His tales are convincing, his style rich in description. The opening chapter, “A Sign of Weakness,” recounts that initial rite of passage, “first call”:
My first call night as an intern, I ran into Dr. M, one of the senior attendings, whom I had known for several years. “How’s it going?” he asked me. I told him I was on call. “First call?” He smiled. “I remember my first call. About ten o’clock that night, my resident said to me, ‘I’m going to be just behind that door. Call me if you need me. But remember—it’s a sign of weakness.’”
Harper is paged to evaluate a woman with scleroderma. This is an awful disease of the connective tissue that affects the skin and internal organs, particularly the lungs.
The patient was alone in a double room. The light in the room was golden, the late sun of the July evening slanting through the high window. The face that turned to me as I knelt at the bedside was curiously unwrinkled. Her skin had a stretched and polished look, her features strangely immobile, the entire effect disturbingly like a doll’s face. Her chest rose and fell, but her nostrils did not flare. Her mouth was a tight puncture in the center of her face. Only her eyes were mobile, following me as I moved.
There is no cure for scleroderma; treatment is palliative. Harper encourages her to take oxygen from a face mask to relieve her respiratory distress:
The eyes were open again, looking out through the plastic skin. She was holding the face mask in her left hand, about a foot away from her face, as if restraining something that had tried to attack her. Her chest was still rising and falling too fast.
I went to the bedside and crouched beside her. The eyes slanted down with me, the head immobile on the bed. “I won’t,” she said, and pushed the mask into my hands.
She shook her head. “Can’t.”
“Is it uncomfortable?”
After a short respite, Harper is paged to return to her bedside:
The room was different now. Light was striking in through the window, a dozen rising suns reflected off the opposite tower. The room was bright and still.
Fast asleep, even comatose, a living body moves. The chest expands, the nostrils flare, the eyelids twitch; pulses stir the skin, and over all of these there hovers an inarticulate hum of life. But a dead body is only that: dead, a body, given over to gravity and decay. The muscle tone that lends expression to the face is gone; the face is slack; the skin gone gray-green with the absence of blood (underneath, if you turn it over, you will find pooled at the backside a livid bruise).
The lesson offered in this story is a kind one about sharing the burden of futility, as opposed to the militaristic imperative I was given (“be an iron-man and hold the fort”) or the “sign of weakness” communicated by the attending doctor. When Harper’s resident listens to the events of the night, he shakes his head.
“You should have called me.”
Harper flinches and asks, “What would you have done?”
“Nothing,” he said. “Just like you. There was nothing to do. But at least we could have done it together.”
Another tale with an unanticipated twist is “Giving Bad News.” Mr. Jenkins has terminal cancer of the esophagus. Harper, as his intern, is the one to give the “bad news.” He struggles to communicate the diagnosis, fearful of shattering the patient. But as Harper failed at first to understand, the man is so cognitively impaired that he has no recent memory:
Two days later. Mr. Jenkins, his cancer thoroughly staged and determined beyond any hope of cure, sits peacefully in the recliner in his room. He is dressed in street clothes. Sunlight is streaming in over his shoulder, he’s breathing comfortably, and the television set is tuned to one of the two hospital channels, which is showing a locally produced documentary about dialysis. When I go in to see him one last time, Mr. Jenkins is watching, rapt. I realize I’m almost looking forward to introducing myself again, if only to say goodbye. And for a moment I watch him, and find myself equally rapt at the sight of him: sick, dying, and eternally unaware. For a moment I am almost envious.
The feeling passes, replaced by a kind of nostalgia. He’ll forget me again as soon as I’m gone. I’ll never learn from his account of me what kind of doctor I am. But that’s not it: I am tantalized by the sense that I’ve missed something here. I thought I was giving him bad news. The bad news wasn’t his, but mine.
The other stories in Internal Medicine follow a similar pattern, with self-reflections following unexpected outcomes. The concluding chapter tells a tale handed down from doctor to doctor, likely, Harper says, to be apocryphal, but one that “bears repeating.” Here, the “first” is witnessing an apparent ethical transgression. A German oncologist, trained at elite institutions in Europe and America, is treating children with leukemia and other cancers with highly toxic chemotherapy in a community hospital. A fellow doctor accuses him of prescribing these debilitating drugs with no clinical justification:
“Tortured” was what it was. I had never seen it before, for all the agony I had witnessed in my brief career, but I knew it when I saw it. And as that word occurred to me something else flashed through the haze still dimming my vision, cracking it into an appalling clarity. I knew what I was looking at.
“My God,” I remember saying. “It’s the Grand Inquisitor.”
It is a bold step for an author to invoke this Russian masterpiece and the theological conundrum of the suffering of innocents. Holt writes that the oncologist is driven to repay a “debt” incurred when he treated his own child, stricken with cancer, with highly toxic drugs, and achieved a cure:
There was something illicit about it, and that first, miraculous success could only have confirmed, perversely, its essential wrongness. The only way to right the balance was to find someone for whom the cure might be an act of grace freely given, and not of selfish need.
Holt goes astray here. The ethical dilemma posed in The Brothers Karamazov involves brutalizing blameless children to usher in eternal harmony and justice. The German oncologist, like all parents, rightly desires his child to be saved; selfishness is not sinful here or disruptive of some moral equilibrium. The narrator also errs by presenting the toxic drug regimen as useless; but it includes vincristine and prednisone, both highly active agents against childhood leukemia. Nonetheless, Holt’s last point rings true: clinical narratives often serve as a venue for doctors to confess their transgressions. Fiction and nonfiction alike can offer insight and solace, if not absolution.