As the hands of the clock on the cafeteria wall close in on 7 p.m., the hashers, oozing fatigue, make the first threatening motions toward cleaning up and leaving for the night. The final batch of interns and residents bounds in and lunges to the counter to be dished out gummy Salisbury steak, overcooked green beans, and jello, standard hospital fare. Once seated, the topic of general interest is: Where does the faculty eat?
“Maybe they brownbag it in their office.”
“Naw, they go to fancy restaurants.”
“Perhaps they go home for something edible.”
“Well, with their higher salaries, possibly the hospital won’t allot them meal tickets.”
“They could get tickets if they wanted them.”
San Diego’s University Hospital cafeteria is in many ways similar to an army mess hall. Costumes point up rank. Nurses are all in white—either pant suits or dresses—while female physicians wear the same coats as their male colleagues. Interns’ uniforms consist of white pants and jacket. Residents wear only the jacket; the faculty sports knee-length coats. Ancillary employees are garbed in various distinguishing ensembles. Lest any confusion arise, name and rank are clearly imprinted on plastic name tags: So-and-so, RN, Clinical Nurse III; So-and-so, LVN; So-and-so, M.D., Dept, of Surgery.
Older doctors, those who went through internships and residencies in the 1930s or 40s, tend to look back on the experience with bittersweet nostalgia, similar to the way in which most men, after allowing that “war is hell,” reminisce about their army days. Veterans of medical service frequently vie to outdo one another in swapping stories about the rigors and deprivations of an intern’s life. Suggestions that life today is still difficult for members of a hospital housestaff are usually scorned and dismissed.
My father trained at N.Y. City’s Bellevue Hospital during the late 1930s. In his day, interns and residents were required to live in the hospital—mainly because they weren’t paid enough to afford room and board elsewhere. Marriage was postponed until they were in their early thirties. Our family is familiar with exciting tales of riding on ambulances (something that doctors no longer do), careening through the Bowery, and administering first-aid to drunks in the throes of cardiac arrest.
According to my father, today’s housestaffs have it soft: salaries are higher, about $10,000-$15,000, enabling them to live out. Many are married. But other conditions are relatively unchanged. Interns often put in more than a 100-hour work week, which comes to approximately $2.30 an hour. Surgery interns are scheduled for 24-hour duty every other day, or, if they’re lucky, every third day. Hospitals definitely save money on the housestaff, which performs the scut work of doctoring in return for a small salary and the set-up in which to learn their trade.
The surgery housestaff lingers a moment over coffee. A resident with a slow Texas drawl regales the group with gossip about DeBakey, the famous Houston cardiac surgeon. “He is such an autocrat, a bastard, he makes the chief of this surgery department look like a pussycat. He’d sack anyone, even his chief resident, if the guy looked at him crosseyed. And he’d always pick a time when there’d be a big audience. I remember one time in the hospital cafeteria—DeBakey was behind this resident in line and the guy was taking too long, or slopping his food on the wrong way, or something. DeBakey looked him right in the eye and yelled: ‘You’re fired!’ ”
Young doctors enjoy exchanging stories about the bigwigs in their field. They nod knowingly and cynically when told of a prominent San Diego surgeon who has “mitten hands” and often makes serious mistakes during routine operations. This surgeon wields enough power to prevent any underling from confronting him with his errors. The assisting surgeons just quietly rectify the errors and store the tale away for upcoming social gatherings.
Brian Kopeki is the typical intern in general surgery at University Hospital. He wakes groggily at 6 a.m. to the blast of the alarm. He stumbled into bed only six hours ago and dreamed fitfully all night of taking out and putting in an endless row of sutures. As he fights to unglue his eyes, he strains to recall what his wife looks like. One hour later, clothed reassuringly in crisp white, feigning brisk efficiency, he begins rounds, tagging after the attending physicians, the resident, and his fellow intern. They confer in low voices outside each patient’s door. Two operations are scheduled for that morning, and there is only half an hour until starting time. This month Brian is on neurosurgery and with this service’s chief, the knife falls promptly at 8 a.m. He checks his work-up of the pre-op in Room 13, experiencing relief to find all the necessary lab results duly noted. He remembers the disaster during his first month of internship, when the lab screwed up and failed to report the results of a patient’s tests in time for the morning rounds. His explanation had been met with an overwrought resident’s harsh rebuke: “When I tell you to get something done, I want it to get done. And I don’t want to hear anymore about it.” At the time Brian had wondered if he’d missed a turn somewhere and mistakenly found his way into the medical corps of the French Foreign Legion.
It is 2 p.m. They are halfway through the second operation. A four-year-old girl has accidentally been shot by a dropped pistol. Her brain has swelled, and the surgeon is removing a portion of the cranium to relieve pressure. The intern is assisting, which means that he primarily holds open the aperture, swabs blood, and sutures when needed.
There is an old medical joke that goes: Did you hear about the longest operation on record? It took sixty hours and used ten surgeons, twenty nurses, five residents, and only one intern. Surgeons are immobile on their feet so much that many resort to wearing support stockings to forestall varicose veins.
Released finally from the operating theatre, Brian grabs a late lunch before checking on patients, writing orders for medication, and issuing instructions to the ward nurses. He is on-call that night and must stay in the hospital for the next 36 hours, attending to new admissions and any crises that may arise. If anything serious develops, he must contact the resident and chief. He dawdles a few moments over a glass of milk, hoping that no one will get sick or hurt in the city that evening and that the nurses will have no reason to interrupt his sleep.
Doctors are not immune to the convenience of stereotyping. But while laypeople assign collective characteristics to physicians as a whole, within the profession differences are detected according to specialization. Anesthesiologists are easy-going and like to have a lot of free time; internists are book worms; obstetricians don’t like sick people; psychiatrists are screwed up; pediatricians are affable and masochistic; and pathologists are intellectual and food-oriented. Surgeons are targets for the most malevolent generalities: they are thought to be arrogant; jocks and technicians, who would rather cut than treat. They spend so much time learning and practicing surgical procedures that they not only forget what medicine they studied in school, but have no opportunity to add to their store of basic medical knowledge. I know one resident in dermatology who avoids visiting the surgery wards because, he says, “Even the nurses jump down your throat every time you open your mouth.”
Other departments lag only half a century behind non-medical institutions in political and social organization, but surgery harkens back to feudalism. The chairman is lord and master, the teaching staff, lesser noblemen; and the housestaff, serfs with different degrees of seniority. The other day 1 overheard someone from anesthesiology advising a surgery intern to switch to anesthesiology “where at least they treat you like a human being.”
Each surgery department is virtually an autonomous state, presided over by an appointed autocrat with near dictatorial powers. Although they may be adept at flattering their superiors, fraternizing with equals, and pouring on the bedside manner for influential patients, not many chiefs are known for benevolence toward subordinates.
There is a “horror” story currently circulating about a resident in the UCSD surgery department who, having completed the residency program in surgery, was attending the traditional ceremony when certificates are awarded. After dinner, to his surprise, the chairman informed him that his work had been judged unsatisfactory and that he wouldn’t be receiving certification. Without such certification a physician is ineligible to take the state examination for licensing as a qualified surgeon and is relegated to a practice in the boondocks where accreditation isn’t so strictly observed. Those acquainted with the situation generally felt that allowing the man to continue for four years was cruel, when it should have been apparent after the second year whether he was going to make the grade or not.
In our system, a great deal more goes into educating a doctor than merely imparting medical skills. There is a complex socialization process that originates when a student makes that decision to enter medical school. If doctors are not to the manner born, they are to the manner made.
Undergraduates often dread being in the same classes as pre-meds, who are avid “A” chasers. It is rumored they pop pills, steal exam questions, or bribe professors to earn those high grades necessary to gain admission to medical school. So many apply; so few are chosen. By the time students reach medical school, the pattern for compulsive work and achievement is set.
If God made man in his own image, the same^ principle holds for medical school admission policy: doctors choose students in their own image. They prefer young people who will develop placidly into the mold prescribed by the AMA. Radicals, iconoclasts, long hairs, and others thought prone to eccentric or disruptive behavior are weeded out.
I have a friend who, during her first year of medical school at UCLA, sat on the admissions committee responsible for selecting the incoming class. She told of one qualified applicant who was passed over because be sported Byronic locks and listed writing poetry as his outside interest. The consensus among committee members had been that he would have found it difficult to “fit in.”
During the fourth year of medical school, students apply and interview for internships and, via a computer matching service, are fixed up with a program where some mutual interest has been expressed. Competition for “good” appointments, usually those in large university-affiliated hospitals, is fierce. Many programs, such as surgery at UCSD, are pyramidical, which means that out of twenty-five interns, five are selected for chief residencies, five or six more for an additional year, and the remainder are dismissed to seek positions elsewhere. Decisions are made by the department chairman and are frequently unpopular and controversial.
The housestaff avoids possible avenues of appeal, fearing reprisals in the future. No one wants to risk being blacklisted. Doctors are a close-knit pack; career advancement, it seems, is contingent to a great extent on contracts.
Recently the courts, called on to determine the status of interns and residents, ruled that they were students rather than hospital employees and were thus legally ineligible to strike or to join the hospital’s collective bargaining unit. This leaves the housestaff in a bind. Excluded from the benefits and rights of being employees, they are also barred from many of the advantages of being a student, such as low-cost housing and low-interest loans.
Few housestaff members are politically active in protesting their position. They consider their ordeal to be temporary and resign themselves to present suffering, while anticipating future recompense. There is, among them, a widespread sentiment of having “paid their dues.”—Eight years of intensive schooling, followed by five or six more of an apprenticeship during which they are exploited as well as trained, oppressed by their superiors, and often maligned by patients who want “real doctors” to treat them. Having paid dues enables them to justify and, indeed, covet the rewards—large income, prestige, power—that await them. And adjusting to each new privilege that accompanies every rung of the hierarchical ladder, they regard their juniors with a combination of condescension and indulgence.
When Brian graduated from medical school to hospital, he left a comfortable world of theory, example, and conjecture, and entered one where he was called on to actively grapple with illness and death. He became intimate with tragedy and suffering and came face-to-face with moral and ethical questions that most of us are free to speculate about idly. The junkie who was barely saved by a long and tedious operation— he’ll be back soon after another overdose. A family, recent immigrants from Thailand, severely burned when a gas heater exploded in their temporary home— the baby dead; the older brother condemned to a life of horrible deformity. Wouldn’t it be an act of mercy to let some people die?
Brian and other doctors develop protective layers of callouses. Defense against their closeness with the underside of the human condition. Some seek solace in disparaging the nurses. Others make up private nicknames, not for public ears. Chronically ill patients, whose bodies and minds are pretty-well used up, are referred to as “gomers.” Sometimes nurses and residents will laugh nervously about burn victims and call them “bacon chips” or “crispy critters.”
This doesn’t mean they don’t care or they lack compassion. Tasteless jokes seem to ease their own bewilderment and horror. An intern at Mercy Hospital told me that he didn’t think he was going to be able to sleep that night. He had been treating a boy who had fallen off a horse and had told the parents that their son would recover. The boy’s condition, however, had taken a sudden turn for the worse. He would die. The intern didn’t know how he could face the family.