By Barron H. Lerner,
a physician and author, most recently of "When Illness Goes Public: Celebrity Patients and How We Look at Medicine"
Wednesday, February 27, 2008

INTERN

A Doctor's Initiation

By Sandeep Jauhar

Farrar Straus Giroux. 299 pp. $25

Autobiographical accounts of medical internships have become quite fashionable.

The trajectory of these works is predictable: Idealistic and naive medical school graduates encounter inhumane conditions, leading them to become angry and resentful interns. Yet somehow, at the end of the internship, they emerge well trained and more human.

The latest contributor to this genre is Sandeep Jauhar, who recounts his internship at New York Hospital. Jauhar's year was surely eventful, full of dramatically ill patients, great saves and tragic outcomes.

On one occasion, he took a woman for a middle-of-the-night CAT scan. All was well -- until she clutched her chest and Jauhar realized she was having a heart attack. Abandoned by the technician, unable to wait for an aide, he rushed her into a freight elevator and to the intensive care unit himself, hoping not to get lost. "Please," Jauhar prayed to God, "just let me get through this night."

Poignant? Yes. Shocking? Well, not anymore.

Tales of internships were once full of genuine revelations. When the anonymous "Doctor X" (later identified as Alan E. Nourse) published "Intern" in 1965, he was outing practices that had previously remained secret among doctors -- in particular, the way physicians sometimes committed errors when caring for patients and then tried to conceal the damage.

Although fictional, "The House of God," published in 1978 by psychiatrist Stephen Bergman under the pen name Samuel Shem, revealed other transgressions. Young male doctors were more concerned about having sex with female colleagues than about saving lives; they ridiculed their patients with derisive names; and they liked nothing more than to "turf" away annoying and time-consuming patients, a phenomenon corroborated by the social worker Terry Mizrahi in her 1986 book, "Getting Rid of Patients."

Modern memoirs have continued this tradition of whistle-blowing, and Jauhar's is no exception. He describes being in charge of 80 unfamiliar cancer patients at night, a situation that practically ensured he was endangering lives. During the winter of his internship, Jauhar became clinically depressed. "A nugget of anger was always wedged deep in my brain," he writes, "ready to explode at the slightest provocation." When examining a challenging patient with severe back pain, he displayed no empathy, instead acting "automatic, hyperrational, and detached."

Although little is new here, Jauhar writes well, and aspects of his saga are interesting. He was not a traditional "straight arrow" who shot directly from college into medical school; he opted for graduate study in physics first. Stories about Jauhar's parents and his courting of a medical student who shared his Indian heritage are deftly woven into his narrative.

Perhaps the most revealing interaction in the book is between Jauhar and his older brother, Rajiv, an interventional cardiologist. If Jauhar is the soul-searching humanist, his brother is a bit of a cowboy, more interested in saving lives than contemplating them. In one intense scene, when Jauhar pages his brother for emergency help, Rajiv curses him out for overreacting, even as Rajiv attends to the patient. Now that is something I have never seen!

Jauhar also writes quite frankly and critically about several former colleagues. One intern is "a young punk with pointy eyebrows," while an "overbearing, arrogant" attending cardiologist is quoted as calling a patient a "scumbag."

Although "Intern" is billed as a chronicle of Jauhar's internship, it actually begins in medical school and ends with the author interviewing for a fellowship in cardiology, the specialty he eventually chose. In the course of this mini-autobiography, Jauhar discusses a series of ethical dilemmas: Is lying to patients ever permissible? Should doctors override the wishes of patients who appear to be making bad choices? Is informed consent as practiced in hospitals essentially meaningless?

But the extended time frame also raises another issue. Jauhar completed his internship a decade ago. In the meantime, many changes have occurred in the training of doctors, most notably limitations on the number of consecutive and total hours that interns may work. For the first time, some interns now complain about being sent home, not about being forced to stay at work.

This situation brings new questions. After years of expecting interns essentially to live in the hospital, what does it mean to train young physicians using a model that is closer to shift work? Will such doctors be as competent as their predecessors? Like other memoirists before him, Jauhar ultimately concludes that his internship, while harrowing, was the best way to learn medicine. "Internship is a classic apprenticeship of immersion," he writes.

Even if the old-fashioned model of internship is becoming obsolete, some of Jauhar's stories are timeless. In one case, after a man died from heart failure and seizures, the staff was unwilling or unable to express appropriate regret to the new widow. Jauhar admits that he, too, was guilty: "I wanted to stay, commiserate, maybe even grieve . . . but I was on call again that night."

You simply cannot remind the medical profession enough that it needs to do a better job in such circumstances.