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,
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
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
"Nine," said the girl.
"Yes," said her mother. "They're up to date."
"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
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
more than questions and felt far more than her
simple answers. The surgeon's voice was not the harsh, abusive, slurred
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,
the hospital through any excuse to volunteer or
visit, so she might hap- pen upon him, to hear him call her Cass, to
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
- years of endless study and ceaseless competition,
of anatomy and melancholia, of friends who never were, of slices of
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
her surgeon of childhood. He had moved on to the
City himself, a casualty of circumstance and life, and she had sup -
him with others - for one, with the cardiologist
who had taught her physical diagnosis and who had taught her as well
a patient was merely a good case, demonstrated
great clinical findings and little else, and that there were other great
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.
and tradition were never to tread upon her
She was always there, always on the wards, always
to be seen, noticed, appreciated. When she wasn't on call, she'd read
the other students' admissions, deftly one-upping
them the next morning on teaching rounds. This was how you got ahead.
quickly learned that the professors were human,
most of them every bit male, and so learned to dress and comport herself
just the proper degree of seductiveness. In this
huge new world of Medicine as Business, of patients as clients, and of
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 first years of residency she merely endured.
There was little else one could do. When not serving up caths for the
she was sorting through the stroked-out gomers,
trash bags, and drunks in the emergency room. She had long since
the quiet calm of the community hospital whose
halls she had walked as a child. Now, this waiting room held druggies
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
The last residency year was better. She could
glimpse the light at the end of the tunnel: the fellowship that would
her from this dark- alley existence and deliver her
to the high-tech, pristine calm of the consultant. There was odd re-
too, in helping those poor bastards beneath her in
training contend with what she had only too recently had to stomach
assisting them with last night's hits and today's
drooling dispositions. She knew the ropes now, could teach them the
cuts, the quick paths around the crap of patient
care. The attendings sympathized, of course. This was the medicine of
the business of having to earn all of one's salary
through patient care, make money for the department, and please the
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
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
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,
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
think in terms of pre-excitation rather than
palpitation, plaque formation rather than chest pain, and wires and
forgetting the tedium of a tiresome patient's
Oh, still the occasional consult might bring her
too close to the patient and that hell of early residency. Even now she
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
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
patient "found down," careful not to touch him,
placed the bell of her stethoscope over precisely the right spot and
the earpieces to the student to get this "teaching
moment" done with, while this patient, swimming frantically to
and blue with cyanosis, gasping from dyspnea,
soaked wet with the work of breathing, stared at her even as she felt
and loathed and avoided it, peered at her
disbelieving and caught the thick, black eyebrows that had become her
caught the cobalt blue of her eyes, hurried his
gaze frantically to the lazy W of her chin, recalled his own surgical
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