PROFESSION

Finding one's place (book excerpt: Intern: A Doctor's Initiation)

New York cardiologist Sandeep Jauhar, MD, PhD, revisits his hectic days as a resident and details the inner workings of medicine.

By Sandeep Jauhar, MD, PhD, AMNews contributor. Feb. 25, 2008.

Book Excerpt
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Dr. Jauhar's book details the dilemmas of a young doctor's experience. This first excerpt looks at the clash between young and old physicians and differing views on diagnosing patients.

In the fall I rotated through the geriatrics ward. One of the attending physicians was an irritating woman whose idea of the Socratic method was pimping you with really vague questions, then acting like she had already thought of whatever answers you gave and that you were only telling her what she already knew. The other attending was a throwback to "the days of the giants," when pneumococcal pneumonia was diagnosed by injecting sputum into mice and antibiotics for urinary tract infections were tested on agar plates. One morning, one of my interns presented a case to him of an elderly man who had been hospitalized with fever and a cough producing green sputum. "He has pneumonia," she proclaimed confidently. "Take a look at this chest X-ray." She pulled up a digital image on a computer screen showing a distinct pneumonic streak. The senior physician waved it off. "First tell me about your lung exam," he said.

It was a common scenario on the wards: young doctor ignoring physical examination to the chagrin of an older and wiser counterpart. At one time, keen observation and the judicious laying on of hands were virtually the only diagnostic tools available to a doctor. Now, on the wards, they seemed almost obsolete. Technology -- ultrafast CAT scans, nuclear imaging studies, and the like -- ruled the day, permitting diagnosis at a distance. Some doctors didn't even carry a stethoscope.

There was a growing disconnect between the older and younger generations of physicians on this issue. While residents were apt to regard physical examination as an arcane curiosity, like an old aunt you've been told to respect, a few physicians proselytized on its behalf, claiming for it a power it probably no longer has. These anachronisms wanted to hear about whispered pectoriloquy or some such esoteric finding of the lung exam before letting you describe the results of a chest X-ray. Our apathy seemed to fuel their fervor, increasing their fear that exam skills would atrophy and die.

"Medical students don't know how to listen for breath sounds," our attending complained. "It's not that they're bad students; it's just that no one is teaching them. When I was a resident, you had to know physical diagnosis because we didn't have any other tools. CAT scans were just coming out. You had to cut someone open to figure out what was wrong with them."

One morning I shared one of my favorite medical stories with my team. We had just finished examining an elderly woman with a cardiac rhythm disturbance when I mentioned that Karel Wenckebach, a Dutch physician at the turn of the twentieth century, discovered the arrhythmia later named after him by timing a patient's arterial and venous pulsations. Wenckebach's discovery preceded the advent of the EKG and still stands as one of the most astute clinical observations in the history of medicine. Isn't it amazing, I asked my team, what doctors were once able to do?

"Today we'd get an EKG," an intern shrugged. "It's more accurate anyway."

"Who has the time to stare at a patient's neck?" another said. "They'd think you were crazy!"

It is true that teaching hospitals are busier than ever, and residents probably have less time to spend examining patients. And it is true that physical examination is often inaccurate. But these facts only partly explain its apparent demise.

The major reason for it, I have come to believe, is that doctors today are uncomfortable with uncertainty. If a physical exam can diagnose a slipped spinal disk with only 90 percent probability, then there is an almost irresistible urge to get a thousand-dollar MRI to close the gap. Fear of lawsuits is partly to blame, but the major culprit, I think, is fear of subjective observation. Doctors today shy away from making educated guesses on the basis of what they see and hear. So much more is known and knowable than ever before that doctors and patients alike seem to view medicine as an absolute science, final and comprehensible. If postmodernism teaches that there are many truths, or perhaps no truths at all, postmodern medicine teaches quite the opposite: that there is an objective truth that will explain a patient's symptoms, discoverable provided we look for it with the right tools.

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This excerpt discusses bias in care and the struggles of doing what's best for the patient.

The disparities were not limited to race. Women with heart disease got fewer cardiac angiograms and catheter procedures than men, and they were more likely to die from heart attacks and unstable angina. A recent study had shown that women with chest pain waited longer than men did for emergency room examinations. Perhaps, influenced by behavior stereotypes, doctors were more likely to minimize symptoms in women and attribute them to emotions.

The list went on, encompassing gays, the elderly, and other groups. These and other studies suggested systemic discrimination in medicine, though it was hard to draw any firm conclusions from them. Why did it take longer for doctors to put black patients on the kidney transplant list? Was it racism, or was it because blacks have a higher rate of transplant rejection? Why were doctors more likely to withhold artificial ventilation, dialysis, and surgery from seriously ill elderly patients than from their younger, equally ill counterparts, even after preferences regarding aggressive treatment were accounted for? Was it ageism, or rational, merciful medicine? Bias, unconscious or not, might account for these disparities, but it was camouflaged, which was perhaps why it was so hard to root out.

I couldn't help but wonder: Had our own bias toward Ira Schneider been camouflaged, too?

In the hospital, Schneider continued to have severe chest pains -- small heart attacks, really -- that were inadequately relieved by medications. One morning, he nearly doubled over while washing up. The surgeons, reconsulted, turned him down again. Rajiv told me it was because agencies monitoring surgical outcomes were putting tremendous pressure on cardiac surgeons to produce good results. Over the past decade, while surgeons with higher-than-expected mortality statistics had lost operating privileges, others with lower-than-predicted rates had taken to advertising on the radio. Because surgeons who had been aggressive about treating very sick patients like Schneider had incurred higher mortality rates, they had been penalized. Apparently this was an insult many surgeons could no longer countenance.

I didn't know what to do, but I knew I had to do something. I thought of Dean Dowton in St. Louis and his commencement address. "Believe in something," I remembered him saying. "What are you willing to compromise? Where are you going to take a stand?" If there was one ethic I was sworn to uphold, it was to do whatever I could to prolong life.

I knew I couldn't go talk to the surgeons -- they would have no patience with my second-guessing -- so I decided to talk to Schneider himself, in the hope that I could spur him into getting a second opinion. In Dr. Klein's world, there were private patients and service patients. Fortunately for Schneider, he was a private patient with good insurance. He would have no problem finding another doctor.

I went to his room one afternoon. When he saw me, he tried sitting up, transferring his weight this way and that, as if trying to fall upward. With a heave that almost pulled me off my feet, I helped him up.

"I wanted to talk to you about something," I said. He leaned forward on the bedside table, pushing his lunch tray aside. I hesitated. "I should have talked to you about this before, but -- " I stopped.

"What is it, Doc?" he said, sounding worried.

"It's nothing, really. It's just, I wanted to make sure -- do you know that you can go somewhere else for a second opinion?" He stared at me with the same puzzled look he had had when I tried to bring up the subject on the night he was admitted.

"You can go somewhere else to have surgery," I went on in a hushed, conspiratorial tone. "You can see another doctor. You're the one in charge. You can do what you have to do to protect yourself."

He continued to stare at me silently.

"It's just one surgeon's opinion, see," I said, feeling treacherous. "You can go to another hospital. For another opinion." I wasn't sure he was getting it. "Maybe another doctor will agree to operate. Do you understand what I'm saying?"

"Yes, I understand," Schneider replied testily. "You're telling me that I can go to a surgeon who is willing to operate on me." He paused. "Listen, I'm just grateful to God for being alive. Look at me! I would never survive an operation!"

From Intern: A Doctor's Initiation by Sandeep Jauhar, published by Farrar, Straus and Giroux, LLC. Copyright © 2008 by Sandeep Jauhar. All rights reserved. $25. (www.fsgbooks.com) Note that the work appearing herein is protected under copyright laws, and reproduction of the text in any form for distribution is strictly prohibited. The right to reproduce or transfer the work via any medium must be secured with the copyright owner.

ADDITIONAL INFORMATION:

Author Q&A

Did you have any concerns about how your colleagues and patients would react to your doubts about medical practice expressed in the book?

Not really. I wrote the book from the perspective that I had 10 years ago. Obviously, I've made it through, and I'm happy that I completed my training, and I feel reasonably well-fulfilled in my medical career. The gnawing doubts and sort of existential crisis that I went through is not relevant to my life today. But it was a decade ago. I'd say that it's also something that a lot of doctors, interns especially, share.

I can't tell you how many colleagues have said, "This book expresses what I want to say about my own internship." Or they've read something in the book and say, "That's exactly how I felt. The book is right on the money." I think a lot of doctors experience doubts and ambivalence. They may not always want to admit it, but I think it's there. The other issue is when I point to incompetence in the book, it's almost always my own incompetence as an intern. So I think that colleagues understand that I'm not out to point the finger at anyone. If I point the finger at anyone, it's at myself.

What do you hope physicians gain from your experience?

What I really wanted to do was record a history of my own apprenticeship for incoming doctors, so they know what the profession is about. We shouldn't be afraid of being honest about our profession and what it's about. It's not the way it's portrayed on "ER" or "Grey's Anatomy." It's very different. There's a lot of uncertainty. There's a lot of fallibility. There are mistakes. The training is not completely humane. There are reforms that still need to be put into place, so I really wanted to present medicine as it is, not the fantasy world that you see on television.

What do you think of limiting resident work hours?

It's a good thing, but we can't stop at just cutting down the hours. When you cut down hours, you need to find cross coverage, and that's the problem. That covering physician often doesn't have adequate information. So we need to have a better information system, perhaps electronic, that gives covering physicians adequate information about the patients they're taking care of. It's clear that when you're exhausted, and you've been working 24 hours straight without any sleep, that's a potentially dangerous situation. I don't think we should go back to the old days where you had very fatigued residents taking care of patients without adequate cross coverage. We have to ensure that there's appropriate patient handoffs and information handoffs to covering physicians.

Do you see much of yourself in the interns you encounter today?

I love dealing with interns, because the interactions with them force you to revisit some of the questions you had early on in your training. Over time, those questions start to fade, and you sort of accept the culture of medicine, but when you're an intern, everything is fresh and new, and you start asking questions. At the same time, you're extremely fatigued, and that sort of breaks down some of the etiquette that develops in medical school about not asking too many questions or rocking the boat. They bring me back to a time when I was a little more naïve about medicine.

Interview by Damon Adams