Doctored (32 page)

I stormed back to my office. I didn't know what to think. Was my judgment being blinded by sentiment? Was I trying too hard to save Lily, or was Muller not trying hard enough?

The following day I went to speak to Dr. Lerner, the chairman of the department of medicine. “It's unfortunate,” he told me in his spacious office after I had delivered my complaint.

I said that it showed a certain—I fumbled for the right word—“I don't know, arrogance, insecurity…”

“It's not arrogance,” Lerner said. He told me how when he was in the ICU as a patient, his primary care physician had come by, but no one had followed his recommendations either. “I found it kind of strange, but I've seen this attitude in many ICU doctors. Muller doesn't like to be questioned. I've seen him go down a certain path and be very reluctant to change. Maybe it is insecurity.” He suggested that I transfer my patient to the cardiac unit and take care of her myself.

The next morning, as transfer preparations were being made, I went to see Lily. Muller and his team were at her bedside. All I caught was “and I think it's inappropriate,” and then they went on to the next patient.

When I walked into Lily's room, she was on her side, being cleaned. A tube was in her rectum, draining liquid stool. I told the nurse that I was going to take her to the CCU. The nurse appeared relieved.

Predictably, Lily's sojourn in the CCU was a disaster. She was unable to be weaned from the ventilator. Her liver failure worsened. Even as it became clear to me that she was going to die and that my aggressive interventions had been for no good purpose, I became very reluctant to change course, too. We checked blood tests several times per day. I inserted a pressure catheter in her pulmonary artery to monitor her hemodynamics. I started her on continuous veno-venous hemodialysis, but the dialysis catheter repeatedly got clotted because of her low blood pressure. The breathing tube remained in her throat till the end. Eventually she succumbed to multisystem organ failure and sepsis, nearly a week after I'd transferred her to my care. She was eighty-nine.

At their core, my actions were also a kind of deception: convincing myself, despite all the evidence, that I could save her, stay the inexorable course of her disease. Perhaps I was afraid of failure or embarrassed by my impotence, or maybe I was unwilling to face the grief over a dear patient's dying; I don't know. Those last few days of her life, she almost ceased to be a person for me. She became an experiment, a puzzle, one that I desperately wanted to solve. Of course, I thought of James Irey, the Trinidadian man whom I'd convinced to undergo a cardiac catheterization against his better judgment and who died from complications of the procedure. How much—and how little—had changed in the past four years.

In the end, we all practice a certain amount of deception to make it through our lives. We erect defenses to cope with our deepest fears: of powerlessness, loss, and death. Ernest Becker writes about the “vital lie” that keeps us from facing the true reality of our existence. “We don't want to admit that we do not stand alone, that we always rely on something that transcends us, some system of ideas and powers in which we are embedded.” And when that system, personal or professional, fails us, and the anxiety of our existence rushes in, sometimes the best we can do is to simply absorb ourselves in our everyday pursuits. Perhaps this is the solution to medicine's midlife crisis, too: doctors focusing on their noble craft, their relationships with patients, the stuff over which we have some control. Ultimately, this may be the best hope for our professional salvation.

 

FIFTEEN

Ticktock

Death is not an event in life.

—Ludwig Wittgenstein

That summer, Mohan and I went to Fargo, North Dakota, to celebrate my father's seventieth birthday. (Sonia, understandably nervous given the complications of the last pregnancy, stayed behind in New York.) “Don't fly first-class,” my father said when I told him we were coming, though such an extravagance hadn't even occurred to me. “I want my grandson to be strong, learn how to struggle.”

“Dad, he's four years old!”

“Still, you don't want to spoil him. It's never too early to teach him right from wrong.”

Descending into Fargo on a small commuter jet, I peered out the window at the flat landscape. The fields were barren, dotted with lonely lights. My parents picked us up at the airport. My mother was dressed in an overcoat, though the weather was temperate. My father, insisting on carrying my luggage, struggled with the heavy suitcase. The cuffs on his pants were threadbare. His hair was whiter and more flyaway than I remembered from the last time I'd seen him. He offered me the car keys. On the way home, he was in an inexplicably foul mood.

“Your mother killed herself all week,” he groused. “I mean, chicken, fish, gulab jamun, ras malai. It was a bit ridiculous.”

“She hasn't seen me in almost a year, Dad.”

“Drive with two hands,” he ordered. I grudgingly placed my right hand on the steering wheel. My father looked back at my mother. “He still acts like a kid,” he said. “He still drives like it's a game.”

At the house, I noticed there was rust on the garage girders. Lightbulbs needed to be replaced. One of the kitchen tiles was cracked, and soap dispensers were empty. The house, like my parents, was in a state of subtle decay.

I unpacked my suitcase in the guest room. On the bedside table were some pictures of me from high school, along with a couple of old tennis trophies and my tattered copy of
Zen and the Art of Motorcycle Maintenance.
Inside the closet I noticed the world globe I had used in middle school, as well as my dad's old Petri camera. Each object was heavily laden with memories: the lemon drops my father offered whenever he drove me to school board meetings; the tennis racket I played with when my father forced me to give up my spot on the local team going to the California Interscholastic Federation tennis tournament because Rajiv, whom I had beaten in the qualifying match, was a senior and it was his last opportunity to play CIF. Despite the ambivalent remembrances, the room had a cobbled-together quality, as if it were being used for storage.

Downstairs, my father was sitting at the dining table, sorting through bills. He seemed blank, anxious, worked up. We quietly ate the meal my mother had prepared. My father asked how my work with Chaudhry was going. I hadn't told him much about what had transpired, other than that Chaudhry had cut back on some of my hours. “Sometimes he doesn't give me work, and then I'm short paying my bills,” I said offhandedly.

“Does he pay you on time?”

“Yes, he pays,” I said, trying to squelch the conversation. “He's not that bad, just a bit stingy with the work.”

After dinner we lit candles and cut a small cake. Mohan belted out “Happy Birthday,” trying to infuse some celebration into the proceedings. While I went upstairs to put him to bed, my parents cleaned up. Coming back downstairs, I spied my father fishing a birthday envelope out of the trash bin. It was covered in grease and cream. He passed it to my mother. “Keep it,” he said. “For a memory.”

My sister and her kids arrived the following day. The cousins played hide-and-seek in the backyard. We went go-karting at an amusement park. Every evening after dinner we'd go for ice cream. One evening we went to my father's lab to check out his new microscope. Afterward, in the greenhouse where he grew his wheat hybrids, he tried to explain genetics to Mohan. “What's inside cells?” my father asked him.

“Genes,” Mohan replied proudly, as I'd taught him.

“No, chromosomes,” my father said sharply. Mohan looked at me, deflated. “You have forty-six chromosomes,” my father said.

“Chromosomes have genes in them,” I gently explained to Mohan.

“A cell doesn't have genes?” Mohan asked.

“No!” my father barked. “Well, it does, but you can't see them.”

Now Mohan was really confused. “The genes are inside chromosomes,” I explained. I picked him up. “Do you have to make it so difficult?” I snapped at my father. Turning to Mohan, I said, “Every cell in the body has forty-six chromosomes. Nana has forty-six, Mama has forty-six, you have forty-six, I have forty-six—”

“If you have more or less—forty-five or forty-seven—you will be abnormal!” my father boomed.

My father got increasingly testy as the week wore on. “I don't know what will happen to us,” he said in one especially malevolent altercation at the kitchen table. “When you get old, you lose your importance.”

“That's the way of the world, Dad,” I said evenly, refusing to be emotionally manipulated. “What makes you think our family is any different?”

“I took care of my mother. She died in my arms.”

“She died in a nursing home!”

“We visited her three times a day!”

I laughed mirthlessly. I didn't want to continue the argument, but I couldn't stop it either.

“You people don't respect your parents. When we are old…” His voice trailed off. “I don't want to see it.” He looked sharply at my mother. “I can't believe these kids. I never yelled at my father.”

“That's because he died when you were thirteen years old,” I said viciously.

Though seventy years old now, he was still the same: inflexible, restless, a victim of his own expectations. There was no question in my mind that he'd wanted us to come for his birthday, and he was probably touched by the gesture, too—even if he couldn't show it—but I couldn't help but think that for him it was more about the ritual of the visit than the sentiment. We were following the same old script from when I was growing up, unable to modify it to cope with the changing times.

“Things are never perfect,” I said to my sister when we took a walk around the neighborhood one evening. The air was warm and stale; the sidewalks were empty. Fireflies were starting to light up in the dusky haze. “I was so looking forward to this trip, but things are never perfect.”

She strolled beside me but didn't say anything.

“I get so irritated,” I said. “I know I shouldn't. I hate myself for it. But if I don't react, it's like I've given up.”

“Our parents are probably only going to be around for a few more years,” she said softly. “We keep forgetting that.”

“I know,” I said. I remembered what a doctor friend had told me at the funeral of a colleague's mother. “It's really something to lose your parents,” he'd said. “You grow up after you lose your parents.” I shook my head to banish the thought. Then I said defiantly to my sister: “I know he's never going to change. But neither am I.”

*   *   *

Back in New York, I was feeling increasingly weighed down by my bland responsibilities. Everything I was doing—as a doctor, husband, or father—seemed a crude and subpar approximation of what was good and ideal. I kept telling myself to be a witness and observe it all. But experiences refract aberrantly through the haze of gloom. A stick underwater gives the illusion of being bent.

In the fall I impulsively wrote an essay for
The New York Times
about the problem of overtesting in medicine that predictably created a backlash. After the article was published, a group of private cardiologists wrote a letter to my division chief saying they were “outraged … We take great offense to the portrayal of medicine on Long Island … as being driven solely by money,” they wrote. “Although you can argue that there are a few bad apples in the bunch, nevertheless the great majority of physicians that we associate with put the care, safety and concerns of our patients first and monetary issues second.” They said the article was “disingenuous and counterproductive … It would be impossible for our group to support any physician who spouts such self-destructive, one-sided opinions. If this is the opinion of the Department of Cardiology, support of such a department would also become more problematic.”

Though I believed in what I had written, I was still nervous. One can never underestimate how hard people will fight to protect their turf. And although my chief was generally supportive of my journalism, I couldn't help thinking of what Santo Russo, my Columbia mentor, had told me in my first year as an attending: “If you mess up relations with a referrer, you can get fired.”

One morning, several days after the article was published, Rajiv found me in my office. He closed the door. “No one loves you more than I do,” he said, sitting down, “so I have to tell you that you are fucking up.” I stared at him but didn't say anything. “You sit in this office all day. You keep the fellows and your patients waiting. I know how smart you are, but you are just so … disengaged. And then you write these goddamned articles for the paper! Get it together. People are watching. Don't wait for a crisis to change.”

No question, I was in a rut. The strain at home and at work had taken its toll. “You always look so pensive,” a colleague told me, and undoubtedly I had, for months. I had accomplished few of the goals I'd set for myself when I started my heart failure program four years earlier. Though I'd helped reduce length of stay and readmissions and had written an admission order set that was being used throughout the hospital, most of my good intentions remained unfulfilled. I knew I couldn't go on like this for much longer. I'd experienced periods of depression before—most recently during internship, when I was exhausted and sleep-deprived for the better part of a year—but this was different, a murkier feeling, as if there were something I was supposed to be worried about but I didn't know what it was, as if I were waiting for something to happen that wasn't happening, so I kept waiting and waiting, sort of hoping it would happen—whatever it was—and be done with.

One day I received an unexpected phone call. Chester Thomas, a young patient of mine, had died suddenly.