Heart Failure - Epilogue

by Michael Greger, MD and United Progressive Alumni

[ Medical School Resources | Appendices | Discussion ]


Epilogue

The life of every man is a diary in which he means to write one story, and writes another; and his humblest hour is when he compares the volume as it is with what he vowed to make it.

- J. M. Barrie

I look back at a year's diary entries. Just a night, I read. But that night was 15 hours long. Even I am beginning to forget.

Many summations of feelings expressed in the medical literature resonate with me. See Appendix 79.

"The fourth year is one of gradual withdrawal."[194]

I did some public health, Boston Healthcare for the Homeless. I saw my first in-hospital hug thanks to Dr. Z - it only took four years. Tufts gave me credit for herbalism. Margi was the first professor that ever told me I was loved. As Phillip Reilly wrote in To Do No Harm, "Everyone thinks that medical school is a four-year program, but in fact it is virtually over at the end of the third-year clinical clerkships."[195]

I packed all my electives to the end, squeezing time off before graduation. It feels good to strut around school in dirty inside-out pajamas after a sweaty morning with Food Not Bombs. Grinning at deans, smiling at everyone else.

Sue and I picked up another stray - Noam. Mites, FIV, diabetes. A cute kitty to an acute kitty. We moved again. I saw the Patch movie - depoliticized goofy doctor schmaltz, but now they have the money. I took my white coat out and burned it.

I look around. Where do I have to be today? I ask myself. Nowhere. Where do I have to be tomorrow? Nowhere. And that is enough. After 1300 days, medical school is over. I'm going home.

UNSUITABLE

Interviewing for internship was the same old garbage. I have memories of walking around in conservative gray, schmoozing with other applicants. Touring one hospital, I see Baghdad bombed on every TV screen. I am thinking I should be somewhere else.

"This place is great," I was told in a rural Pennsylvania hospital, "Very conservative."

I did meet a few spectacular folks. Well, one. An intern in Reading, PA. We swapped stories. "Why didn't you quit," she asked.

The last day of the last interview, I looked down. This may be the last time I ever wear a suit.

The worst pain a man can have is to know much and be impotent to act.
- Herodotus

Coming in third in the most-painful-memories-of-third-year contest is the abuse. Second place goes to seeing patients mistreated. The grand prize, though, is the self-betrayal - choosing to remain powerless, standing passive while the patients were treated that way. One doctor writes, "the question is why I was not driven to protest or to object in some way.... [This] is something I have to live with today. Why did I not speak up? What was wrong with me?"[196]

Cowardice asks the question, 'Is it safe?'
Expediency asks the question, 'Is it polite?'
Vanity asks the question, 'Is it popular?'
But conscience asks the question, 'Is it right?'
And there comes a point when one must take a position that is neither safe, nor polite, nor popular, but he must take it because his conscience tells him that it is right...
- Martin Luther King, Jr.

An unrectified case of injustice has a terrible way of lingering, restlessly, in the social atmosphere like an unfinished question.
- Mary McCarthy

Polite and safe too long, I break the silence. Done with school, I figure it's about time to air Tufts' little secrets - the abuse, the lying, the pelvic exams without consent. In a flurry, I fired off letters to the deans, the clerkship directors, the faculty. They were the kind of letters one writes for catharsis and throws away, but I mailed them. Knowing that I could bring the world down on top of them, I demanded action. As one of the articles about the pelvic exams under anesthesia asserts, "Teaching practices that are outmoded, legally dubious or morally unacceptable should not be allowed to continue...."

Our lives end the day we become silent about things that matter.
- Martin Luther King, Jr.

A few days later the dean of student affairs calls me into her office. It is not the first time I have been brought before the deans. The first time was during first year. In the middle of a lecture on the patient-doctor relationship, I left to get a cup of tea for a sore throat. Sitting on a bench in the lobby was a man, huddled onto himself, staring at the floor. I got the tea. On my way back I sat next to him. I introduced myself. We talked. He told me of his estrangement from his daughter. He cried. And midsentence, my arms around him, a Tufts security officer grabbed him and started dragging him towards the door.

"What the Hell are you doing?" I exclaimed. I was told he didn't belong here. I continued to protest. The Judge, as I learned he liked to be called, explained that he didn't want to get me in trouble and so he left - outside to the bitter cold. Already that year two people had frozen on the streets. I started in on the officer. "How dare you?"

"Do you want to go see the Dean?" He threatened, like in an elementary school flashback. They never expect you to say yes. So we went into the dean's office, my elbow in his hand. He instructed the dean, "Deal with him."

I explained how we were in mid-conversation.

"I walked by you; you were talking for two hours."
"How long am I allowed to talk to him?" I replied.
"He's a streetperson; he's not allowed in the building."

God forbid - especially in a school of medicine.

"Friends and family are allowed in the building without ID," I reminded her, "and he was my friend."
"He was not your friend."
"What?"
"How long have you known him?" She demanded.
"How long do I have had to known him for him to be my friend?" And so on...

What is done, is done: Spend not the time in tears, but seek for justice.
- John Ford

This time, I prepared for the deanfrontation. The day came. After accusing me (falsely) of being late, she took me to her office and handed me a letter - it was not one of mine. It was written by a residency director requesting that I be disciplined for canceling an interview at the last moment. I looked up at her. What about the issues I had brought up? She refused to talk about them. How anticlimactic. She accused me of making Tufts look bad.

I had canceled an internship interview after talking to the residents there the night before. Realizing that there was no chance I would go there, I called to cancel, not wanting to waste their time or mine. I should have gone anyway, she told me. I should have just pretended that I was still interested. From the article "Teaching Medical Students to Lie," "Lying and deception have become standard practices within medicine's resident-selection process.... Students feel coerced into lying...."

The article continues, "It is disconcerting that medical students openly resort to the use of deception, dishonesty and outright lies in the resident-application process.... It is ironic that our profession advocates honesty but has institutionalized dishonesty."[197]

It's a matter of taking the side of the weak against the strong, something the best people have always done.
- Harriet Beecher Stowe

I continued to see the Dean in the following weeks; she continued to stall. She was still "looking into it." As a fourth year student, I was able to interview premed applicants to the school. One week, upon telling an applicant how disappointed I was in the school administration, the dean walked in the elevator. "Have you had a chance to look into any of the letters?" I asked. She ignored me. I asked again. When she got off, the applicant turned to me, mouth agape. "I would never have believed it if I didn't see it for myself."

Never Whisper in the Presence of Wrong - title of a book on nuclear disarmament

Focusing on the pelvic exam issue, I decided to get the American Medical Women's Association and the Boston Women's Healthbook Collective involved. I schemed for graduation. If still by then no progress, I planned on cap, gown and a big sign. The sign would read, "Tufts Medical Student's Should Not be Practicing Pelvic Exams on Anesthetized Women Without their Consent."

In the weeks to follow - despite the added pressure - the dean continued to stonewall. I got resolute. My plans changed from standing on stage with the sign to standing on the stage with the sign refusing to move. Then maybe go limp as I was arrested in front of faculty, families, and friends. My mom - I love her - volunteered to bring bail.

I just want to do what has to be done so much. I'll never understand why everyone else doesn't feel this way.
- Abbie Hoffman

When word gets out about my plans, classmates are pissed - they seem more threatened than the administration. "If you do that I'll kill you," one says. "I won't have to kill you, my mother will kill you," says another. "What about women's rights?" I ask. "Then think of the mothers," they reply.

One medical student activist writes:

Support from the rest of the student body, when present, often had to be obtained anonymously. One student told me, 'I agree with you, just not in public.' 'In public' meant in front of faculty or administrators. 'In public' meant in front of other students. The worry was that a student who spoke up about issues of conscience would have narrower career choices because of poor evaluations doled out by disapproving faculty.[198]

But all the evaluations were in; it seemed more like patriotism. It doesn't matter what Tufts did to us, or does to others, it's our Big Day. Another activist from an article called "Singin' the Med School Blues":

It often seems to me that medical students are not well exposed to regular life; most of them have basically only gone to school, and that with a single-minded goal - to beat out twenty other people at the med school of one's choice. But this lack of experience makes students quite uncritical of the process they are undergoing. I have a fantasy of the entire freshman class chanting in unison 'everything is for the best, in this best of all possible worlds.'[199]

"Always hold firmly to the thought that each one of us can do something to bring some portion of misery to an end." [200]

But I won. Two months after I sent those first letters, the administration capitulated, citing as delay changing department chairs. Departmental policy will evidently soon include a stipulation that doctors should ask permission from patients - what a concept - to have students practice pelvic exams on them while they're under.

It feels like such a hollow victory; they shouldn't have been doing it in the first place. And will the dean keep her word? Will the doctors care? I did involve some of the preclinical students, though. At least if one of them complains, she or he may at least be able to point to a piece of paper.

It is not because things are difficult that we do not dare; is because we do not dare that things are difficult.
- Seneca

Not to pass on a 10,000 person audience opportunity, I decide to make some other sign for graduation - if nothing else than for tradition's sake. In high school I picketed Reagan; at Cornell's graduation I hoisted "47,000 Kids Under the Age of 5 Were Killed in the Persian Gulf War."

I am reminded of a parable Irene shared with me: There is a person on a street corner holding a sign with some social justice-type message on it. The person is approached by someone who asks, "Why are you holding that sign? Do you think you're going to change the world by holding some sign?" "No," the gentle sign holder replies. "With this sign I'm not trying to change the world; I'm trying to keep the world from changing me."

Sentient beings are numberless, and I vow to save them - Buddhist saying

So in our stray wonder-hamster Golda's honor, I chose antivivisection, carrying a placard stating "TUFTS TORTURES. Stop Klaus Miczek's Cruel Animal Experiments." I hand out explanatory pamphlets I xeroxed on the school's copier. The commencement speaker warns everyone, "Don't shave your conscience."

On stage - gripping my sign overhead - the dean is not surprised. Sydney J. Harris: "The most fatiguing activity in the world is the drive to seem other than what you are; it is finally less exhausting to become what you want to be than to maintain a facade."

MATCH MADE IN HELL

There was something weird about match day - the day in which all the nation's medical students get their residency assignments - something plastic. I already really knew where I was going for internship - Lemuel Shattuck, the public health hospital here in Boston. I was curious, though, about the fabled event. People were dressed up; there was lots of drinking. I watched as they opened their letters. Families broken up - congratulations! Another four years away from home - congratulations! Fear. Congratulations! Ambivalent smiles and small talk about big matters.

Rain beats a leopard's skin, but it does not wash out the spots.
- Ashanti Proverb

I wish it were over. That One Day will come, but not before internship. With graduation over I have four weeks until internship starts - my countdown to extinction. I'm afraid this month to reawaken parts of me shuddering in some corner of my self, because the winter isn't over yet.

Internship brings up the same fears, the same pledges and promises to myself, the same self-delusion that I will be able to help. Before third year, I swore I would never change. The week before my first interview for medical school - about a half-decade ago - I cut off six years of hair. I wasn't selling out, I told myself, it was camouflage. It didn't work. I watched as much of the rest of me got cut off as well.

Glimmers of some of the harder stuff is still there. Nearly a vegan decade makes it easier for me to refuse complicity in ethics versus food tensions - four years and not a single drug lunch. Odd and unsociable me.

But I did lose my way. As one student wrote in an article "Struggling to Stay Human in Medicine," "I had walked away from more than one cry for help. I had gone into medicine to help other people, but seemed to be fleeing more and more from human contact. I began to wonder if the change was irreversible."[201]

More on the fear of permanent harm in the last Appendix, number 80.

The most difficult battle you will ever face is the battle within yourself.
- Zen

Internship starts next week. I'm finding it hard to tell the difference between the feelings I share about internship, what I really feel, and what I tell myself I really feel. How will it really be for me? How will it really be?

The worst time during third year was the three weeks on general surgery. Three weeks and I was a mess - and there weren't even any overnights. Now I stand before thirty-five hour shifts every fourth night for months*. I will leave the human race.

* Before this year - maybe because I complained - it was every third night.

Will it be different because I know more now? Will I be able to stay above it, beside it, a step beyond it? Or will it take me in a week? Maybe a few months? Maybe I'll be gone in a day.

Shattuck is the flagship hospital of the Massachusetts public health department. The only acute-care public hospital left, actually, after a few Republican gubernatorial terms. It has the prisoners, the homeless, the AIDS, TB. I fantasize managing a "good morning," a pillow, water, anything anywhere - the patients there have traditionally been so worn down that whatever I can do will go further, I suppose.

I want to quit before I even start. I could walk away right now. I could take a year off, but I'd never come back. And what does that say?

Is there someone in my future I will help in a way I only could have with a medical license?** Maybe I should subject myself to internship. But then I think about the things I could do this year - for others, for myself. Will my self be the same after internship? Maybe I shouldn't. This week I am all fear. I am here on the edge.

** In most states one only needs a year of clinical medicine - the internship - to be a licensed physician.

 


 

[194] Reilly, PR. To Do No Harm: A Journey Through Medical School Westport: Greenwood Publishing Group, Incorporated, 1987:210.

[195] Ibid.

[196] Brody, H. The Healer's Power Danbury: Yale University, 1992.

[197] Young, TA. "Teaching Medical Students to Lie." Canadian Medical Association Journal 156(1997):219-222.

[198] Silver-Isenstadt, AD. "Times of a Medical Student Activist." Journal of the American Medical Association 276(1996):1435.

[199] Fugh-Berman, A. "Singin' the Med School Blues." Off Our Backs 15(1985):10.

[200] From a Syracuse Cultural Workers poster.

[201] DE. "Struggling to Stay Human in Medicine." New Physician 1973(May):295-299.

 


 

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