Doctored (37 page)

We never did make it back to see Mr. Gesselman. For the next couple of weeks we were too busy in the hospital, and he died not long afterward. That house call was our first since I'd started working at LIJ. In 1930, 40 percent of all doctor-patient visits were house calls. Today the proportion has dwindled to less than 1 percent. The major reason, not surprisingly, is money. Traveling to patients' homes is inefficient and almost never profitable. But it felt good to finally do something that didn't have a price tag on it.

After all the wasted time of the past two years, I was eager to focus once again on my heart failure job. I still wanted to create a comprehensive disease management program, implementing best practices into treatment algorithms in the emergency room, on the wards, and in transitional and postdischarge care. Applying such algorithms, I believed, would offer the best chance to reduce hospital costs, readmissions, and mortality. I'd just written a ten-page document summarizing evidence-based practices for heart failure diagnosis and management, which we disseminated to residents and attending physicians. Once I got started, I moved quickly: I audited charts of patients with rapid readmission, hired a case manager to help streamline the transition to outpatient care, began attending multidisciplinary rounds, created a special unit to cluster patients with heart failure diagnoses, partnered with the palliative care service to increase the use of hospice care for my end-stage patients, and took the initial steps to begin an outpatient infusion clinic so that patients who required intravenous medications would not necessarily have to be hospitalized. The lessons I'd learned over five years were with me, and now, finally, I had the time and energy to implement them in practice.

*   *   *

Homeostasis is the ability of a biological system to maintain a condition of equilibrium or stability in the face of external stresses. It is closely related to resilience, the power to return to the original form after being bent, compressed, or stretched. In many ways medicine is the study of human resilience—biological, physiological, and emotional—and not just in patients. Perhaps more than any other profession, medicine demands adaptability of its providers.

We start to get bent early on in medicine. In medical school there's the fear factor: Do I know enough to move on to the next stage? The stresses don't end there. In internship and residency there are other pressures, more physical—sleep deprivation, exhaustion—but also existential. And of course, even in full-fledged practice, one is constantly being stretched and bent by factors beyond one's control. There are always new challenges to be faced, no matter which stage you are in on your journey as a doctor, demanding patience and resilience.

How to prevent the burnout that is so widespread in the profession? There are many measures of success in medicine: income, of course, but also creating attachments with patients, making a difference in their lives, providing good care while responsibly managing limited resources. It is whether you find that meaning in your work that determines whether you feel successful or not. The challenge in dealing with physician burnout on a practical level is to create new incentive schemes to foster that meaning: publicizing clinical excellence, for example (of course, we need to better define exactly what that is), or rewarding for patient satisfaction. It won't be easy, but the predominant financial scheme today has created a lot of misery.

In the end, it's a problem of resilience. American doctors need an internal compass to cope with the changing landscape of our profession. For most doctors this compass begins and ends with their patients. In surveys, most physicians—even the dissatisfied ones—say the best part of their jobs is taking care of people. I believe this is the key to coping with the stresses of contemporary medicine: identifying what is important to you, what you believe in, and what you will fight for. For me, I've learned, it's the human moments, such as the house call with Hyman Gesselman. The human moments are what others—the lawyers, the bankers—envy about our profession, and no company, no agency, no entity can take those away.

*   *   *

We moved to Long Island on Christmas Eve, a few days before an ice storm. The sunlight that day was blinding, fluorescing off the white world. The moving men showed up early and rapidly disassembled, bundled, packed, and loaded eleven years' worth of our stuff. Standing on the wet sidewalk, I watched the silver Harley from apartment 4E roar out of the garage for the last time. By the time we got on the Long Island Expressway, it was already early afternoon. Dirty spray from the speeding haul truck spattered on my salt-stained windshield. Inside the car, everyone was unusually quiet. I stole furtive glances at Sonia and the children; they were exhausted. I could hardly believe we were finally making our move. It had been a huge decision to uproot my family. I still had no idea if it had been the right one. At our street, tree branches reached out in embrace over the roadway. A sign at the corner said
DEAD END
.

The house was a white-shingled colonial built in 1955 on a potato farm. In the front yard black locust trees were dusted with white powder, like Christmas cookies. I stepped out of the car. Fresh snow crunched under my feet as we started to unload. On the front porch, icy spears dripped. Inside, the house was empty. We started to sort through our belongings as the kids gingerly explored their new surroundings. I could hear the pitter-patter of Pia's little feet on the bare hardwood floors. As dusk settled, the house got cold and drafty. I convinced the movers to stay for a while; so much work remained to be done. They didn't leave till 10:00 p.m., extorting a huge tip.

I took two weeks off from work to help us get settled. It was a strange and confusing time. We all felt a sense of dislocation, but at times mine seemed overwhelming. (Change always precipitates a measure of fear, whether in the personal or professional realm.) Whenever the kids would cry, I'd feel guilty, as if it were my fault for bringing them there. I imagined Pia missing her stroller ride around our old neighborhood, waving to all the sidewalk fruit vendors. Mohan would call me whenever I went out to run errands after dark, crying, “Dadda, where are you? When are you coming?” Simple tasks like troubleshooting the oven controls or prying open the frozen cover of the trash receptacle left me in a state of panicky frustration. Rajiv, who lived about ten miles away, had his usual no-nonsense take on my gloominess. “How can you compare this house to that apartment in Manhattan?” he demanded. “There is no comparison.”

At night the silence was unsettling. I'd sometimes sneak out and gaze up at an owl in the backyard. It was a haunting apparition at the top of a tree, a hooting hole in the fabric of the blue-gray sky. Raccoons scurried off into the bushes, their beady eyes glinting at me through the leafless brush. For months, Mohan would wake up in the middle of the night and call for me. I'd get into bed with him, palming his cranium, pressing it softly. I craved the warmth of his body on those chilly nights, his knee settling comfortably into the small of my back, his sweaty palm tightly clasping my elbow. I slept in his bed as much for me as for him.

One night, while I was lying in his bed, staring up at the fluorescent stars on the ceiling, he asked me, “What if somebody tries to rob a bank in the middle of the night?”

I thought for a moment. “An alarm would go off and the police would come,” I said.

“No, they wouldn't. You're just saying that. They couldn't hear it.”

Sensing he needed reassurance, I said, “If the alarm goes off, the police get a phone call.”

“What if they're sleeping?”

“There's always somebody awake.”

“Always?”

“Always.”

He sighed, obviously relieved. “Oh, that's good,” he said.

Gradually, as the weeks wore on, the pieces of our new lives started to fall into place. We built our first snowman, a grotesque, haphazard sculpture at the base of the driveway. We joined the aquatics program at the Jewish Community Center in Roslyn and started going for family swims on Saturday afternoons. I even restarted my evening runs, sprinting through air crisp and heavy with the fragrance of burning wood. Before long we were shopping for bathroom fixtures at Target on Saturday night. The white fluorescent lights and the immigrant families pushing metal carts transported me back to that time in my life when my parents would pile us all into their beat-up old Buick and take us to Kroger's or Food Town. Buzzed on the scent of fresh-roasted chicken, Rajiv and I would race up and down the aisles with the grocery cart, grabbing boxes of frozen pizzas or TV dinners, tormenting my mother. I missed my parents. Despite all the obstacles they'd faced, they'd succeeded in creating stable and secure lives for their three children. There was a measure of comfort in knowing that I had come full circle, returning to what were more or less my roots.

We were reluctant travelers. We moved to the suburbs because we could no longer afford a certain life in the city. But against all my expectations, it has provided peace of mind, respite from the stresses of urban living, which quelled much of the anxiety I'd been living with. I quickly learned to savor the predictability, the fewer choices, the circumscribed nature of the experience. Just as cells integrate into the matrix in which they land, obeying signals that we can barely fathom, so, too, did we integrate ourselves into our new environment. In fact, I was probably a suburban guy all along. I just hadn't known it.

We enrolled Mohan in a wonderful little school not far from our house. Most mornings I'd drop him off at class, and some afternoons I was even there to greet him at the bus stop. A few weeks after he joined, I ran into one of the school moms at drop-off. “How's it going?” she asked pleasantly.

“Oh, you know, the same,” I replied with faux weariness.

She laughed. “Yes, I know. Same thing every day.” But I wasn't bothered by the routine, and I suspect neither was she. The routine offered calm and security.

Though we had both grown up in suburbs, Sonia made the move out of the city more gracefully than I did, pulling me along whenever I faltered or lost heart. Perhaps she had been more ready to leave than I'd realized. By springtime she was saying stuff like “It feels like these trees are our friends, even though we cut their limbs off.” She made the frequent trips to Home Depot or Britton Hardware to make the house into a home, rushing home to take Mohan to soccer practice, stopping by Whole Foods to pick up groceries or dinner, multitasking constantly.

She also quickly got credentialed at LIJ and started seeing patients. I'd assured her that I would send her referrals, and so would Rajiv and his friends. By then I had learned to accept the referral game. At one time I'd viewed it as a racket to be avoided; now I saw it simply as realpolitik. Insurers can make doctors jump through hoops to get paid. They can tell patients which doctors they can see. They can restrict medications and tests. But they still cannot tell doctors whom or when we can ask for help.

One wine-soaked evening when we were relaxing in front of the fireplace after the kids had gone to bed, Sonia said to me: “Even our bad times have had some good in them. Remember when Mohan was Babydeep?” Her eyes watered, and mine probably did, too. “I've already forgotten. He is so much his own person now.”

Later she wrote me this note: “I just wanted to tell you how much I love and adore you. You are EVERYTHING to me: my light, my hope, my best friend in this funny journey. I think what I've always loved about you is how you always have long pieces of black curly hair falling over your prominent and shiny forehead. Little Mohan isn't there … yet.” Relaxing that night amid bookshelves in the armchair in my tiny den, my kids in their animal pajamas asleep in their beds, I felt a contentment that had been missing for too long.

*   *   *

Rajiv invited me to join his tennis group. They hit every Sunday morning at an indoor tennis complex in Huntington, a community of steeple churches and conservancies about ten miles from where I lived. The first time I played with them was a few weeks after we moved. I left the house at 7:00 a.m. and nearly slipped on the front steps. The frigid air burned my bare legs. The wipers on my car were stuck, so I turned on the defroster and waited for the ice to melt. (Be patient, you cannot rush it. Things don't happen immediately.) Gradually the car warmed up, and the frozen sheet on the windshield shattered into countless pieces.

Joggers in polychromatic Gore-Tex were out on the slushy road. I sped up Northern Boulevard, past the docks in Cold Spring Harbor, past the golf courses and plant nurseries and estates sequestered by iron gates and pointy yew hedges. Walking trails branched out from the roadway, ducking into the snow-shrouded woods. When I arrived at the court, Matt, a stent salesman at Medtronic and a former college player, was feeding balls to Rajiv and three of his doctor friends: Chaudhry, Gupta, and Goldner. “Nice shot, Confucius,” Rajiv called out to Gupta, a cardiologist in private practice, who was growing a beard. Gupta reached to hit a low backhand volley, which he dumped into the middle of the net. “For a man, you bend over well,” Rajiv taunted. Then he hit a passing shot. “There you go, baby. Can't touch this!”

Matt was lobbing balls to Chaudhry. “No overheads,” Chaudhry protested. “My back is too stiff.” He was an enthusiastic, if stodgy, player, with the slightly awkward strokes of someone who had picked up the game as an adult. He turned his shoulders to protect his back, ironically just the right move to allow him to line up the shot perfectly. “Do that every time and you'll be fine,” Matt told him.

Already drenched in sweat, Gupta came over to rest on the bench where I was stretching. Rajiv held up his hand to stop play. “Let up on him, Matt,” he said, grinning wickedly. “I'm on interventional call. If he has a heart attack, I'm going to have to leave.”