INTERN: A Doctor's Initiation by Sandeep Jauhar (Farrar, Straus, Giroux, Jan, 2008) Review by Nancy Yanes-Hoffman, www.writingdoctor.typepad.com, www.nyhwriter.com, nywriter@rochester.rr.com, 585-385-1515, NYH Communication Group, 16 San Rafael Drive, Rochester, New York 14618
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By what magic alchemy is an ambivalent, doubting, overworked, overwhelmed , guilt-ridden, exhausted, experimental physicist--complete with a doctorate in physics-- transformed into another sort of a doctor--a practicing physician? How do we who will all be patients someday, no matter how much we try to escape our fate, define a doctor? What do we expect from him or her? How do they live up to our expectations? How do they fail us? How can doctors and patients break down the wall between them?
What does the boot camp known as “internship”-- or more recently as “residency”-- do to change fourth-year medical students into thinking, practicing, deciding, questioning, questing doctors? How can we ascertain which doctors will be there when we need them to do the best they can for us?
In 21 chapters pairing medical anecdotes with crucial questions about his own medical journey, Dr. Sandeep Jauhar’s INTERN: A DOCTOR'S INITIATION (Farrar Straus Giroux, 2008) traces the brier-strewn path of his painful initiation into medicine’s rigors. In these 21 chapters, he achieves a medical adulthood, characteristic of 21 years of growing up into a man and a doctor.
The book divides into three sections. ”Switching Horses” incorporates Jauhar’s leap from quantum physics, a “hard” science, to medicine, not always a science, but still much harder to serve than physics' research. “Cracking Up” depicts his near-drowning in the slough of his own physical disease and psychological despair. Finally, “Reconciliation” records the tormented young doctor, Lazarus-like, somehow learning to compromise and cope with the demands and vicissitudes of the medical “culture.”
Dr. Jauhar covers a lot of bases that most medical students, interns, and yes, attending physicians might be unwilling to recognize, admit, or try to change. As an example, he talks about “informed consent,” that myth governing our decisions no matter what the choices, healthy or sick. For how can we ever be adequately informed about consequences of our decisions—especially when we’re sick?
In some ways, medicine, but particularly internship as Dr Jauhar depicts it, is a crap game where the dice are always loaded against the players. For patients differ. Age, sex, desire for life, yearning for surcease all play a role. Doctors differ in their ability, willingness, or unwillingness?—to understand, to communicate, to care. The Jauhar brothers differ in their attitudes toward medicine and patients. Time is the eternal enemy. Its winged chariot always ready to abandon a telling detail, hurry by a last word that might push the hapless patient into a waiting grave.
For whom did Dr Jauhar write this book? “My hope," he writes, “is that readers, on their own journeys—many of them in the medical profession—will draw lessons and perhaps even inspiration from my experiences (which) will be especially relevant to medical students preparing to make their own forays into the hospital.” Perhaps. But Dr Jauhar’s strengths and weaknesses differ markedly from those of many other green residents. Struggling with his own limitations, his sharp-eyed observations, and the fierce strictures “of the strange new culture I found myself in,” he feels “buried in a waking hell of my own (and others?) expectations.”
What about patients? How will they react to Dr Jauhar’s stories? The chaos and indifference he depicts is frightening. Early on, another intern remarks of their teachers: “It’s strange that all week they’ve hardly mentioned the patients….These are the people we’re going to be learning on. It’s like they’re already invisible.” Looking back, Dr Jauhar comments “I don't think the tales should frighten patients--just make them more aware of doctors' fallibility and the importance of advocating for themselves.” But his memoir of a young doctor coming to terms with his own inadequacies and those of his profession does not show patients how to find an advocate somewhere in the greyly echoing, antiseptic corridors of a hospital.
INTERN focuses on the growth process of an individual intern. Occasionally it touches too lightly on points that deserve far more attention. The discussion of the "Night Float” notes that “errors due to faulty transfer of information are at least as frequent as those due to fatigue from being on call overnight." True. But it's worth examining that argument in the light of the current trend in staffing with "hospitalists." The myth of Informed Consent deserves more details on Jauhar's concept of "soft" vs. "hard" paternalism.
The second edition deserves a glossary, showing the nuances of such ugly, house officers’ slang as "gomer." One of my least favorite words in the language, “gomer” means “get out of my emergency room,” but it is never defined in terms of the barriers between patients and doctors. Even a word such as DNR isn’t defined for the non-conoscenti.
Dr. Jauhar has taken many controversial stances in his articles for the NY TIMES, many of which are chapters in his book. Medicine should be all the better for it. Interestingly, the book—and the man--change in the middle when he becomes sick and learn how a patient feels. Something happens. It's as though the doubting Thomas (or Sandeep) begins to compromise his high ethical standards with the exigencies of day-to-day medical pressures.
His mentors grade his development. “Residents were judged in seven categories: clinical judgment, medical knowledge, clinical skills, humanistic qualities, professional attitudes and behavior, medical care, and overall clinical competence. The ratings were on a scale from one to nine plus written descriptions for each scale like “indecisive in difficult management situations” or “reasons well in ambiguous situations,” ”pedestrian diagnostic ability,” “establishes sensible differential diagnoses””not giving into the urge to put down patients.” Scoring sevens, eights, and nines, he is pleased even though most patients would want a solid nine-point scorer.
INTERN stops short after the internship. It doesn’t include Jauhar’s specialty training in heart disease at Bellevue or what’s happening now that he is in practice specializing in heart failure. It doesn’t compare doctors’ personalities. The differences between Sandeep, the thinker, who treats heart disease medically and his brother, Rajiv, the activist doer, an invasive cardiologist at the same hospital are worthy of Sandeep's analysis.
A missing last chapter should have reflected on the man he became as a doctor. It needs to expand on his introductory assertion that “so much about medicine still troubles me; sometimes I still want to muddle through things; sometimes I’m still not sure cardiology was the right choice.” In other words, where is he now?
Caveats aside, having experienced Sandeep Jauhar’s baptism under fire during his internship, wondering medical students, worried doctors of all ages, and strong-stomached patients can only hope that Sandeep Jauhar is saving this material for another book. With all his energy and his sharp-eyed perspectives, he ought to be hitting his computer soon.
