Робин Кук - The Year of the Intern

Now I was hurrying on to surgery, already late. There was a lot of activity on the medical floor. I passed interns, residents, and doctors standing around beds talking, as they always were — unless they were sitting around talking in the lounge. Most discussions centered on treatment, on which drugs to use. As a point of agreement would near on some medication, one of the participants would bring up a side effect, whereupon a drug would be suggested to counter the side effect, which drug could, in turn, have its own side effect. Which was worse, the question now became, the second side effect or the original condition? Would the second drug make the original symptoms worse than they were before the first drug made them better? On and on it went, around and around, until usually the discussion got so complicated it seemed best to start again, on the next patient. Or that’s what the medical wards looked like to me. Talk, talk, talk. At least, in surgery we did something. But the medical guys pointed out, with some truth, that we just cut it out when we couldn’t cure it. We countered that cutting it out did, in fact, often cure it. The argument went inconclusively back and forth, always conducted in an entirely friendly, even jovial, style, but its roots sank deep.

Climbing into another clean scrub suit was a compounded dėjà vu. I was beginning to live in those things. Since no medium sizes were left, I had to wear a large, and the strings of the pants went around me twice. Through the swinging doors into the OR area. While I was putting on my canvas shoes, I glanced at the board to see who was doing the operation. Zap! It was none other than El Almighty Cardiac Surgeon. But what was he doing here? The procedure was listed as “Abdominal abscess, dirty,” and obviously El Almighty usually worked in the chest. Strange things had ceased to surprise me, however. As I looked up, he saw me and greeted me by name, being very friendly, but I knew better than to lower my guard. It was just the first move, a condescending act early in the show — especially since he had to shout the greeting from halfway down the corridor to make sure everyone noted his good cheer and camaraderie.

I remembered wryly one time when a resident and I were assigned to a cardiac case with not one, but two such surgeons. These men, completely alike in manner and hidden behind masks, could be distinguished only by their girth, one being much fatter than the other. That case had begun smoothly enough, with affability and backslapping all around. Suddenly, with no warning whatever, one of the surgeons began to harangue the resident for giving blood to a patient dying of lung cancer. True, the decision was debatable, but not serious enough to warrant such a tirade in front of all assembled. He was just puffing himself up, improving his self-image. So it went throughout the operation, praise and then blame, each overdone, until we reached a kind of frantic crescendo of invective that gradually ebbed away, back into good humor. It had been like a madhouse.

There is something of this in many surgeons — a kind of unpredictable passive-aggressive approach to life. One minute you are a close and valued friend; the next, who knows? It was almost as if they lay waiting in ambush for you to cross some invisible line, and when you did — wham! — you got a fireworks of verbal abuse.

Perhaps this is a natural effect of the system, the final result of too much intensity and repression through too many years of training. I had begun to feel it in myself. If he wants to get ahead, an intern learns to keep his mouth shut. Later, as a resident, he learns the lesson so well that it becomes internalized. Underneath, however, he is angry much of the time. No matter how cleansing it might have been to tell some guy to stuff it, I never did, and neither did anybody else. Being at the bottom of the totem pole, we naturally aspired to rise higher, and that meant playing the game.

In this game, fear was symbiotic with anger. If anything, the fear portion of it was more complicated. As an intern, you were scared most of the time; at least, I was. At first, like any good little humanist, you were afraid to make a mistake, because it might harm a patient, even take his life. About six months along, however, the patient began to recede, becoming less important as your career went forward. You had by then come to believe that no intern was likely to suffer a setback because of official disapproval of his practice of medicine, however sloppy or incompetent. What would not be tolerated was criticism of the system. No matter that you were exhausted, or were learning at a snail’s pace, if at all, and being exploited in the meantime. If you wanted a good residency — and I wanted one desperately — you just took it without a murmur. Plenty of hopefuls were lined up to take your place back there in the big leagues. So I held feet and retractors, and took the other shit. And all the time the anger ate at me.

Most of us didn’t believe in the devil theory of history, or in an extreme notion of original sin, and so we knew that these older men we hated so much must have once been like us. At first idealistic, then angry, and then resigned, they had finally come to be mean as hell. At last the anger and frustration, held in so long, were gushing out in a gorgeous display of self-indulgence. And at whose expense? Who else? The sins of the fathers and grandfathers were visited on us, the sons of the system. Would it happen to me? I thought it would. Indeed, it had already started, because I had advanced beyond my period of medical-school idealism. I was no longer surprised that there were so few gentlemen among surgeons; in fact, the wonder of it to me was that any doctors at all came out as whole human beings. Apparently, few did. Not among them was El Almighty, whom I was about to face.

He slapped me on the back, wanting to know how every little thing was. It was as if he were going to give me candy or kiss my baby like a corrupt big-city politician gathering votes. Actually, he was gathering ego points. I was so tired I didn’t care what he said or did. I kept my head down, scrubbing away, taking one step at a time. I put on the gown, and then the gloves. The scene around me was unreal. The surgeon’s voice boomed on about nothing and everything, several decibels above everyone else. The anesthesiologist seemed to have either a special immunity or effective earplugs; oblivious to the surgeon, he went quietly about his business. Even the nurse ignored El Almighty. Whether he asked politely for a clamp or thundered for one, she would hand it to him in the same reserved efficient way and go on adjusting the instruments. I hoped he was listening closely to himself, because he apparently was his only audience.

The case turned out to be a reoperation for inflammation of the little pockets older people sometimes get in the lower colon. This unlucky patient had been operated on for his diverticulitis, as the condition is called, about a month before. Normally, a three-stage operation is recommended, but the first surgeon to operate on the fellow had tried to do it all at once. The result was a large abscess, which we were about to drain, and a fecal fistula, leading through the previous incision down into the colon, that was draining pus and feces.

Mercifully, the procedure was short. I tied a few knots, all unsatisfactory to the surgeon. Otherwise, I remained silent and immobile as he went on about the vicissitudes of his life when he was an intern. “Really tough in those days... do histories and physicals... every patient... through the door... and besides... quarter of the salary... and you crooks get...” I hardly heard it. My exhaustion really made me immune, bouncing all his comments off my brain.

At the end I wandered out and changed into my regular clothes. It was almost four. A little afternoon sun had dodged the thick clouds and was sneaking in the window. The rays refracted and sparkled off the raindrops clinging to the window. It made me think of going surfing. But afternoon rounds were still to come; I wasn’t free yet.