On the first day of my first clinical rotation at the end of my second year of medical school I stood at the doorway of Mary’s room in the old Baltimore City Hospital clutching my clipboard and watching her breathe. Her eyes were closed, her face as white as the sheet tucked neatly across her chest. My careful reading of her chart told me that Mary was sixty-two years old and single, that she lived alone and was a secretary for an insurance company. But the swollen body lying in the bed seemed to me as ageless and genderless as the cadaver I’d dissected in anatomy class a year earlier.
The senior resident on my team assigned me Mary, who, he informed me, was a “great medical student case.” He grabbed a piece of progress note paper, and drew out Mary’s dilemma for me: she had a metastatic ovarian cancer which had studded her internal organs. Her cancer had taken away her appetite, so she was poorly nourished and didn’t have much protein in her blood—a condition that let fluid out of her blood vessels and into the interstitial tissues, causing the limbs and abdomen to swell. Mary, the resident said, looked like the Pillsbury Dough Boy, so swollen that you could stick a finger in her belly and leave a dent.
I was assigned Mary for a reason other than the medical interest of her case: the residents didn’t like her. The nurse said Mary snarled at the staff, no matter how much they did for her. Mary also had a Do Not Resuscitate order on her chart. Looking back, I now recognize that the hopelessness of Mary’s condition contributed to her unpopularity. Doctors don’t like feeling inadequate and often unconsciously blame patients with conditions that are hard to diagnose or treat for making them feel that way. Then, though, I simply accepted that my role as a novice medical student—perhaps the only role I felt competent to fulfill—was to spend time at the bedside of a patient my superiors would just as soon avoid.
As I stepped into the room, Mary’s eyes were still closed. In a low, gravelly voice at once forceful and barely audible, she said, “Come here.” I approached slowly and stopped a few feet away. “I’m the medical student on the team,” I announced. Her eyes still shut and her voice barely above a whisper, Mary commanded, “Come here.” I obeyed and stood an inch from the side of her bed, waiting for my next instruction. Mary withdrew her left arm from the tightly tucked sheet and said, “Sit down.” I sat. “Hold my hand,” she said, and I did.
Then something happened. At first I wasn’t sure what. I watched Mary open her mouth, her breath coming out in small bubbles which inflated and deflated, more and more slowly, until the bubbles formed and remained. I stared at them. I gripped Mary’s cool, damp fingers in my own. And then I understood what had happened. Mary had died.
* * *
Growing up Jewish, I’d never attended a wake with an open casket and so had never viewed a corpse. Death hovered in the background of my childhood like a rumor. I didn’t know anyone who had died except for Debbie Weissman, a girl in my third grade class who wore plaid jumpers, formed her capital Ds like billowing sails and, mysteriously, didn’t return to school at the start of fourth grade. Some older kids said that she’d shot herself by accident, playing with a relative’s gun. Our teachers never mentioned her again. At home, death was tied to the Nazis: my father had fought in the war, as everyone’s father had, and he made it clear that vigilance would be required if we were to avoid sharing the fate of six million murdered Jews. “Vigilance,” for our family, consisted of boycotting products made in Germany and swearing never to set foot on German soil.
Death remained vague until early one winter morning in my senior year of high school when we took a field trip to witness the autopsy of a nursing student who’d been stabbed to death the night before by her boyfriend. As a mother and doctor it seems preposterous to me now that any adult thought such a trip advisable for our Advanced Placement Biology class. But my classmate’s father, a coroner, had offered to host us, so off we went.
I remember that the walk from the subway was cold, sunny, and windy. In fact, I remember everything about the autopsy except the dead woman’s name—though I do recollect that of the handsome young man who lay on the gurney next to hers in the morgue, naked with a single bullet hole in the center of his forehead: James Narducci. He was, I read a few days later in the New York Times, a pre-med at City College who had tried to intervene in the robbery of a hardware store.
What I remember most, though, is my refusal to flinch or look away as many of my classmates did. I felt it would be girly, un-doctorly, though I had not yet clearly articulated an ambition to be a doctor. Flinching or looking away would acknowledge the reality that this young woman, barely two years older than me, with long straight hair parted in the middle such as I had always wanted for myself and wearing a rust-colored suede jacket similar to one I’d seen in Glamour and coveted, was like me and that I was like her, just a knife and a jealous boyfriend away from the autopsy table., She was, in a way, my first patient.
My second body was the cadaver I dissected in my first year of medical school. During anatomy class, students learn the name, location, and structure of all 206 bones in the human body—as well as every muscle, tendon, nerve, and organ. Besides being more or less necessary to practice medicine, this knowledge admits you to that exclusive society of people who possess it. You are initiated into the “hidden curriculum of medical school,” a doctrine which comfortingly asserts that practitioners do not belong to the same species as our patients. We are less vulnerable—more likely to wield the knife than to lie beneath it.
In anatomy my feet hurt from hours of standing, and I was bored. Spatial orientation is not my strong suit. Acquiring the necessary habit of thinking diagonally—the patient’s right is the doctor’s left as they face each other—gave me a headache. I didn’t associate the bloated, smelly log over which we labored with my own mortality or anyone else’s. Nor did I deflect, consciously or unconsciously, the idea of such an association. At the end of anatomy in medical schools today, there’s often a memorial service. But we had no candles, no songs, and no prayers of gratitude to honor the people our bodies once had been.
The summer between my second and third years, after the medicine rotation at City where I’d briefly met Mary, I signed up for inpatient oncology at Johns Hopkins Hospital. The resident was a self-possessed woman named Patricia, and the oncology fellow was a linebacker of a man named Joe, who had finished his residency and was now doing subspecialty training
The dean at Hopkins when I studied there, Henry, was a dear mentor. In 2010 he told me a story from his own residency at Hopkins in the late 1940s, when he was rounding with the legendary pediatric cardiologist Helen Taussig. Dr. Taussig, one of the few women doctors then on staff, had invented a novel corrective surgical procedure for infants with congenital heart defects. Her male colleague Alfred Blalock took top billing, so the procedure became known as the Blalock-Taussig shunt. Blalock’s lab assistant Vivien Thomas played a key role in designing the operation. Yet he was Black, the grandson of a slave, and attempts to rename it the Blalock-Thomas-Taussig shunt didn’t stick.
At Hopkins until the 1950s the blood bank, hospital wards, bathrooms, cafeteria, and even the morgue were segregated. A Black person could receive a white person’s blood in an emergency but never vice versa. As Dr. Taussig and Henry passed the blood bank, she asked, “Doesn’t this strike you as very wrong?” Henry had grown up in racially and ethnically diverse Passaic, New Jersey. His family was not unlike the many immigrant families Henry’s pediatrician, William Carlos Williams, described in his writings.
His story made me think about the de facto segregation in place at Hopkins during my residency in the 1980s, an encoded institutional racism that still exists at many teaching hospitals today. We were practically incentivized to remain silent—the unofficial segregation of Black patients on the public wards reinforced the reassuring message of the “hidden curriculum”: that we (mostly white) residents were fundamentally unlike our Black patients. We would never suffer from “their” diseases: AIDS and bacterial endocarditis from intravenous drug injection, amputations and blindness from poorly controlled diabetes, emphysema and asthma from smoking and air pollution. Public health experts now recognize that poverty, not race, predisposes people to these conditions. But back then we were taught to identify patients according to their color—This is a fifty-year-old Black man with diabetes—as if Blackness alone were a risk factor for disease. This racist assumption validated what we white trainees told ourselves, consciously or not: that our difference kept us safe.
The few residents of color in our program experienced things very differently. But I learned this only years later when I finally thought to ask. At Henry’s memorial service I reconnected with Edward, one of the few Black students in my medical school class and residency. He’s now an infectious diseases specialist. I told him that I’d been thinking about my failure to recognize the hospital’s segregation of patients during our training, even though it had been hiding in plain sight. But it had always been clear to Edward. He told me that he’d forged bonds with many of our Black patients that he was certain surpassed those made by white residents. He also told me that several white patients on the private service had refused to be treated by him.
* * *
Deaths were common during my month on oncology. One woman, younger than I, with a platelet count so low that her blood didn’t clot, hemorrhaged from a stomach ulcer, spewing red across the beige linoleum floor as we watched in horror. Even Patricia, the resident whose calmness I admired and had decided to emulate, placed her hand over her mouth at the sight of so much blood.
My first oncology patient’s name was Colette. She was Black, a life-long resident of East Baltimore, twenty-seven years old, and twenty-seven weeks pregnant. Her pregnancy had been uneventful other than a nagging cough in her second trimester. She’d had a positive skin test for tuberculosis, a disease with a high incidence in her neighborhood. Though doctors are reluctant to expose pregnant women to X-ray radiation, it was important to know if Colette had active TB—it could affect her unborn baby if left untreated. During the X-ray her protruding midsection was draped with a lead lined cloth. The image did not show tuberculosis. Instead, it showed a large lung mass which, when biopsied, proved to be adenocarcinoma, the most common lung cancer among nonsmokers like Colette. Now our team had to find a solution for a most challenging problem: we had to kill the rapidly dividing cells of Colette’s tumor without harming the rapidly dividing cells of her growing fetus.
I entered Colette’s room early that evening expecting to find an emotionally devastated but physically stable young woman. I’d rehearsed my introduction. We were exactly the same age; I’d never been pregnant but hoped to be soon. I could imagine being pregnant like Colette, but I couldn’t imagine being pregnant and having lung cancer. I planned to sound sympathetic but not too personally revealing—that while I couldn’t pretend to know exactly how she felt, I would do everything I could to help her.
I never had a chance to deliver my speech. I found Colette sitting straight up in bed, gripping the bedrails, sweat streaming down her face as she gasped for breath. I ran for Patricia and Joe, the oncology fellow. Within moments, the room was full. An X-ray technician appeared with a portable machine to take another chest X-ray, this time without a lead drape since there wasn’t one readily available. I stationed myself on the right side of Colette’s bed to hold her hand and feel her pulse. Her heartbeat was irregular, but in a curiously regular way—it stopped when she inhaled and started up again when she exhaled. I looked at the veins in her neck. They bulged when she breathed in, flattened when she breathed out.
My mind detached from Colette’s panicked struggle to breathe and I nearly smiled. I had read about this. Suddenly Colette’s suffering became clear to me: her lung cancer had filled her pericardium with bloody, tumorous fluid, which increasingly pressed upon her heart each time she inhaled. What was it called? Kussmaul’s sign! A young woman, seven months pregnant lay before me acutely short of breath, and my mind wandered from her distress as I pictured exactly what was happening at that moment in her heart and lungs.
Colette’s X-ray confirmed the diagnosis. When I ran back to the ward to report this finding, my colleague Joe had arrived at Colette’s bedside. He whispered something low but audible to everyone in the room, something that revealed the emotion we’d been advised never to show and of which our superiors would certainly have disapproved. Joe whispered: “Jesus fucking Christ.”
* * *
Amir, the cardiologist who drained Colette’s pericardial sac later that evening, was known as one of the smartest residents at our hospital in recent memory. He’d supervised my husband when he was an intern. When Amir heard that I had made the diagnosis he smiled. “So, two stars in your family,” he said. Again, my mind strayed from Colette, lying on the table with a fluid collection bag hanging by a slender tube from her heart, to my own swelling pride.
The next day, Colette’s baby girl Kayla was delivered by C-section. In the 1980s the prospects for a twenty-seven-week preemie weren’t great, but Colette couldn’t survive her cancer without immediate and aggressive treatment that would kill her unborn fetus. Now she lay in her bed on the oncology ward with staples in her flattened midsection while Kayla lay in the NICU connected to a ventilator. I’d been awake for more than twenty-four hours when the oncology attending asked me if Colette had seen her baby yet. I stammered something about how that didn’t really seem possible under the circumstances and he said, “Make it happen.”
An hour later a nurse and I wheeled Colette and all of her tubes and bags up to the NICU, where presumably she was able to touch her daughter with a gloved hand through the incubator’s porthole. “Presumably” because I have no memory of this poignant scene.
Sunlight filled Colette’s room when I arrived the next morning, as did the wails of her mother and boyfriend who had hurled themselves across her still, silent body. Her mother screamed at me, “Get him some Tylenol! Do something for him!” By “him” she meant Colette’s boyfriend, Kayla’s father, whose grief had thrown him from the bed to the floor, sobbing.
A few years later I was sitting in the doctors’ charting area of the emergency room with one of the senior pediatric residents. He told me he planned to specialize in childhood leukemia and, stupidly and predictably, I asked him if that wouldn’t be awfully depressing. He answered, “Would it be less depressing if kids have leukemia and I don’t take care of them?” Embarrassed, I changed the subject. Had he ever heard of a baby named Kayla, a preemie who’d be about two now, if she’d survived, born to a mother with lung cancer who had died the next day? “Oh sure,” he said. Everyone knew that story. He told me that Kayla had indeed survived. She had some disabilities but was being raised by her grandmother and was doing okay.
Amir, the brilliant cardiologist, died of AIDS in 1993. As a resident he’d stuck his hand while drawing blood from a patient who’d had multiple transfusions. He had a fever and rash shortly after the incident and then forgot about it for a couple of years, until he began getting the opportunistic infections to which people with immune deficiencies are susceptible. Rumors started among the residents that Amir had acquired AIDS while visiting prostitutes. That he could have contracted AIDS doing something that all of us did all the time was too frightening to contemplate.
During the last years of his life Amir became an activist for improved occupational safety protections for healthcare workers. There’s a clip of him on YouTube testifying before Congress. He was survived by his wife, also a physician, and a baby daughter.
Patricia, the resident, is dead, too. She was killed in a car accident in 1990, three months pregnant with her first child. By coincidence, Patricia’s family lived in the same suburb of Washington, D.C., as my in-laws, and though we had moved to Boston from Baltimore earlier that summer, we happened to be visiting them when Patricia died. I left my husband and our baby daughter at my in-laws’ house and drove to the wake. I arrived feeling self-conscious, wearing the flowery sundress that was the only remotely suitable clothing I had with me. The first person I saw as I entered the funeral home was a woman I recognized as a former resident from Patricia’s year. Her husband would die young too, just a couple of years later, from a rare cancer. I burst into tears when I saw her and, though we barely knew each another, she took me in his arms and patted my back. “I know,” she said. “I know.” I wouldn’t be comforted. I pulled back from her embrace and asked, “But how could such a thing have happened?”
Suzanne Koven is a primary care physician and the inaugural writer-in-residence at Massachusetts General Hospital. She is also a member of the faculty at Harvard Medical School. Her writing has appeared in The New England Journal of Medicine, The Boston Globe, The Lancet, and other publications. Her memoir Letter to a Young Female Physician: Notes from a Medical Life, from which this essay is excerpted, is forthcoming next week.
Image: Kimmo Räisänen / Creative Commons