On Being a Doctor

Caring for Strangers - Essay

The quiet young girl with thick eyebrows arching over blue eyes sat quietly, waiting for her chin to be sewn, and took it all in. The room was nearly full. Most of the people waiting with her were familiar to her, seemed to know her, glanced from her to her mother and formed the unspoken gossip with their eyes. This was life in a small town. She avoided their stares much as she suppressed the pain of her chin. Looking through the door, she saw the starched white nurses waiting on the doctor. She didn't ever want to wait on anybody. She wanted to be waited on. The doctor had something in his right hand, brought it down to a bare leg, then away, then down and away again. The girl caught the pungency of iodine, the steel-sharp scent of alcohol. There were old magazines she didn't want to read and a chart of fruits and vegetables on the wall. She was bored. She was tired. She was hurting.

"Next," said the skinny nurse, and the young girl followed her mother into the next room. She sat on the table, tried to cover the rip in the knee of her jeans with a hand, and looked around.

"How old are you, honey?" asked the older nurse with the glasses on a chain. "Has she had her shots?" she asked the girl's mother.

"Nine," said the girl.

"Yes," said her mother. "They're up to date."

"Dee-Pee-Tee?"

"Just last year, in school," answered her mother.

Laughter shot from the adjacent examining room, then shuffling, a clinking of metal on glass, and the doctor breezed in. He was tall, young, happy-looking. He probably had kids of his own.

"My God," he said, "what beautiful eyes! And your eyebrows, young lady...."

"She takes after her father," said the girl's mother. "Those are his bushy black eyebrows." Privately, the girl loathed her eyebrows. She would pluck them as soon as she got home to her room. "Yes," said the surgeon, "oh yes, I see...."

He knows about the divorce, thought the young girl. Everybody in town knows about the divorce.

"It's down to bone," said the surgeon to no one in particular. "Pretty bad cut, actually. It'll take some time . . . three layers. June," he said, lifting his head to the older nurse and nodding toward the waiting room, "see if Bob can come down and help with them."

The shot stung severely, and then her chin went numb. Stitching the wound took more than an hour - she was a pretty girl, after all, and the surgeon, skilled enough in plastics, took his time with her. Through the drape covering her face, the young girl answered with staccato yeses and noes the surgeon's questions about school, about play, about friends and pets and brothers and sisters. But with the mind of a discontented, troubled 9-year-old, she heard more than questions and felt far more than her simple answers. The surgeon's voice was not the harsh, abusive, slurred male voice to which she had been accustomed. This voice was kind and deep, holding gentleness rather. She felt touched by it and its caress, allowed herself to be soothed by it, permitted herself a small bit of hope and a fleeting arousal of what she would later call love.

"It's like Cassiopeia," said the surgeon. "You know, the constellation Cassiopeia. Your laceration, it's a sort of lazy W, like Cassiopeia." And it was in this way that his pet name for her came to be.

For the next 4 years, until puberty struck her like a hot shower, the young girl cherished that moment with the surgeon, frequented the hospital through any excuse to volunteer or visit, so she might hap- pen upon him, to hear him call her Cass, to feel him touch the lazy W on her chin, and to bask in the attention of her secret, very part-time surrogate father.

But together with Chance's shifts and realignments, with Progress' seeming advance and sorry decline, 14 years more passed by. For the young girl, now a handsome young woman in hip-length white coat, stethoscope slung around neck, pockets jammed with note-cards, black book, pins, percussion hammer, and tuning fork, these were years of frenetic pace and postponement - years of endless study and ceaseless competition, of anatomy and melancholia, of friends who never were, of slices of nephrons stared at through exhausted eyes rather than slices of life consumed through eager lips. These were years of quick sex for its own sake rather than relationships for the hope of intimacy, and, for the young woman particularly, these were years of searching for other surrogate fathers. In the dust of memory mingled with tragedy of another kind, she had long since forgotten her surgeon of childhood. He had moved on to the City himself, a casualty of circumstance and life, and she had sup - planted him with others - for one, with the cardiologist who had taught her physical diagnosis and who had taught her as well that a patient was merely a good case, demonstrated great clinical findings and little else, and that there were other great cases to be found rather than any story to be listened to. From this man she moved on to the senior resident who taught her how to take the history while examining the patient at the same time and, by so doing, minimize time spent with each hit. She slept with this resident as though it were part of the rotation, and while he worried about keeping it from his wife, she worried about The Match. It was all part of the hardening-up process, a part of this training of the physician of today. Legacy and tradition were never to tread upon her character.

She was always there, always on the wards, always to be seen, noticed, appreciated. When she wasn't on call, she'd read about the other students' admissions, deftly one-upping them the next morning on teaching rounds. This was how you got ahead. She quickly learned that the professors were human, most of them every bit male, and so learned to dress and comport herself with just the proper degree of seductiveness. In this huge new world of Medicine as Business, of patients as clients, and of doctors as providers, she too was a commodity, after all. And the bottom line for her, while not yet money, was clearly the top of the ladder.

The first years of residency she merely endured. There was little else one could do. When not serving up caths for the cardiologists, she was sorting through the stroked-out gomers, trash bags, and drunks in the emergency room. She had long since forgotten the quiet calm of the community hospital whose halls she had walked as a child. Now, this waiting room held druggies poised to infect her with HIV, alcoholics ready to vomit on her, and the swinging, lurching wildness of the crazed dirtballs whom she would punish in return with Foley and large-bore Levine.

The last residency year was better. She could glimpse the light at the end of the tunnel: the fellowship that would rescue her from this dark- alley existence and deliver her to the high-tech, pristine calm of the consultant. There was odd re- lief, too, in helping those poor bastards beneath her in training contend with what she had only too recently had to stomach herself, assisting them with last night's hits and today's drooling dispositions. She knew the ropes now, could teach them the short cuts, the quick paths around the crap of patient care. The attendings sympathized, of course. This was the medicine of today, the business of having to earn all of one's salary through patient care, make money for the department, and please the chief so he could be away. This was the mythical time of universal coverage in which indigents' costs were covered by seeing ever more patients faster and more efficiently. This was the time of the in- and-out, touch-the-shoulder race of bedside teaching rounds. It was the era of case presentation, with films on the viewing box, data on the blackboard, bagels and coffee on the conference table.

As a fellow, the young woman began again to be excited about medicine. Now one of the boys, she began to be treated like the men, except on that occasion when allowing herself to be treated like a woman might further her own career, all the while learning from the men of medicine how one gets by in a man's world. Medicine as a discipline became more focused, narrowed, manageable, her hours more reasonable, sleep coming more predictably and in greater quantities. "Cases" now were consults. Now she could be insulated by intern, resident, and attending from the dirtball and his obligatory rectal exam. Now she could think in terms of pre-excitation rather than palpitation, plaque formation rather than chest pain, and wires and devices, forgetting the tedium of a tiresome patient's fainting spells.

Oh, still the occasional consult might bring her too close to the patient and that hell of early residency. Even now she might be compelled to linger at the bedside while some goddamn student with whom she had been saddled to teach and who wouldn't take "it doesn't matter" for an answer searched for the diastolic sound. That there might ever be in these encounters with patient and student the chance of missed occasion never occurred to this young woman who had been once long ago a constellation of infinite possibility.

So it was this night. Once more she had been summoned to the maelstrom of the emergency ward. Yet again she leaned over this patient "found down," careful not to touch him, placed the bell of her stethoscope over precisely the right spot and handed the earpieces to the student to get this "teaching moment" done with, while this patient, swimming frantically to consciousness and blue with cyanosis, gasping from dyspnea, soaked wet with the work of breathing, stared at her even as she felt his stare and loathed and avoided it, peered at her disbelieving and caught the thick, black eyebrows that had become her signature, caught the cobalt blue of her eyes, hurried his gaze frantically to the lazy W of her chin, recalled his own surgical precision, and eased within himself, thinking, "Cassiopeia ... Thank God. I am in good hands."

Michael A. LaCombe, MD
Bridgton, ME 04009

Requests for Reprints: Michael A. LaCombe, MD, 103 South High Street, Bridgton, ME 04009.

Ann Intern Med. 1997;127:329-330