God, Doctor, and Patient: The Uncomfortable Hospital Triad

I would never pray with a patient at the bedside. What doctor has time to talk about God? And who knows whether a patient will find the suggestion of prayer offensive, helpful, or rapport-building? Most of us doctors, when we think about prayer at all, keep it as far from our work as possible. I am an observant Jew, yarmulke wearing and Sabbath observing, and I pray three times a day. But never would I mention to my colleagues a word about my daily spiritual practice. We are practitioners of our own esoteric art, which we like to pretend is uncontaminated by outside influence, and our white coats are not cassocks. Even when an appreciation of religion might be of some use, we make an extra effort to keep it at a distance. When patients are about to die, or when our care is serving only to prolong suffering, we delegate the hard questions to highly trained ethicists sharing our worldview. When there's nothing left but to commend a patient's soul to its maker, we murmur something about "medical futility."

Thus the small but growing scientific literature linking prayer to health is discussed by nobody in my circles. It's in the same category as "alternative" medicine (acupuncture, Chinese therapies, ayurvedic medicine, and the like) or, for that matter, most of psychology - areas worth dabbling in but never imagined by orthodox practitioners as primary to the profession. Once organic causes have been thoroughly "worked up" (through appropriate technologies and laboratory tests), then we are free to speculate about the psychological and spiritual realms, usually with a cocked eyebrow or an eye on the clock.

What would it mean for prayer to help the sick? It's a question linked to others great philosophers have plumbed and foundered on: the existence of evil, God's relationship to prayer, the necessity of any belief in God at all when one prays. One might think that the scientific literature shouldn't find the problem as difficult as the philosophers - just find an objective measure of "prayer" and "help." But objective measures of prayer are precisely what are lacking, as psychologists Kevin Masters and Glen Spielmans explained in a review published in the Journal of Behavioral Medicine in 2007: what the field needs are "experimental studies based on conceptual models that include precise operationally defined constructs [and] longitudinal investigations with proper measure of control variables." In other words, we're back to the same issues: what is prayer? And how do we tell what is the effect of prayer, and not merely the nonspecific warmth of human companionship?

God is most relevant to me at work for different reasons. I'm a medical resident in his final year whose routine usually involves others' tragedy. Religion in my practice is usually evident only as a wedge between what I want and what patients - and, more often, patients' families - want. Enveloped by a medical culture which is difficult to step outside, I often catch myself assuming with an unquestioning certainty exactly what should happen in a given case: this person over here is worth treating (from a "medical" perspective - that is, from the perspective of my guild), there is progress to be made here, and we should try to convince the patient and family of this; or, conversely, there is "nothing to treat here," and any protestations to the contrary are due to delusion, illusion, or "cultural differences," a common euphemism which includes religion. Often it happens that religious patients and their families want more care than we doctors want. This is frustrating for me as a religious person: what's the point of all the spiritualism if it only blocks lines of communication between doctor and patient?

As in the case of prayer and health, the issue of end-of-life care for religious patients (and their families) can be illuminated through empirical research where otherwise we might get lost in philosophical byways. In a recent issue of the Journal of the American Medical Association, Holly Prigerson at the Harvard Medical School Center for Palliative Care, together with her colleagues, published a rigorous study of patients who use religious faith to cope with a diagnosis of advanced cancer. Even after controlling for other variables, these patients with "positive religious coping" request and receive more intensive life-prolonging care at the end of life.

In an on-line interview, the authors declined to make recommendations to clinicians based on this conclusion. In the article, however, they observe "because aggressive end-of-life cancer care has been associated with poor quality of death and caregiver bereavement adjustment, intensive end-of-life care might represent a negative outcome for religious copers." This would certainlly justify doctors' bewilderment when dealing with religiously intransigent families. Such families are arguing their loved ones into more days in the ICU and a death entangled in wires and tubes.
Thinking it about it in another way, though - trying as hard as I can to think like the spiritual person I occasionally manage to be outside of work - a scrabbling after every scrap of life, even as it seems to slip inexorably away, is a perfectly religious path. For many religious people, sick or well, the question is not "Does prayer help?" but "How can I manage to pray?" Prayer has no point; its existence is enough. Similarly, I would not be surprised if many religious families viewed the question of "negative outcomes" as just another barrier thrown up to the achievement of transcendence. Life is life. Clinging on to it has no point; the clinging is enough. These days our art of medicine is always accompanied by debates about the evidence, what it is and how one introduces it into practice. While God and God's adherents frustrate me no end while I am trying to get work done in the hospital, I am vivified by those whose attachment to life is circumscribed by something other than evidence.

Distress and disease: inextricable

The important lesson to be drawn from studies of medical-psychiatric comorbidity is that distress and disease both produce physical symptoms. It is not productive to dichotomize symptoms as "somatogenic" and "psychogenic" because physiologic and psychological processes are involved in all symptom production and perception. "Rule out" diagnostic strategies that search for either a medical or a psychiatric cause of a physical symptom are not supported by epidemiologic findings of high rates of medical and psychiatric comorbidity.

-from Katon W, Sullivan M, Walker E. Medical symptoms without identified pathology. Ann Intern Med 2001;134:917.

I remember last year when I started the night float rotation; the interns passed around a handout, compiled a few years ago by some previous interns who were now attendings, about how to diagnose common inpatient complaints. Anxiety languished far at the bottom of the list for diagnoses explaining chest pain. "This is a diagnosis of exclusion!!" said the handout - the implication being that no one should ever diagnose anxiety (or other psychological complaints) on the hospital floors. The cultural supposition is that chest pain is either a heart attack, or an aortic dissection - or else it's "bullshit." (No one would write this, of course . . . it's understood.)

Trauma in the slot
Notes in and out of the ER.

Oh hell.

I put down whatever I'm doing, sometimes spilling it/surprising the patient/abandoning my computer orders uncompleted, and quick lope across the hall to the Trauma Slot (it's a room with space for several trauma victims), where I put on a disposable gown. Then I am supposed to shear off the victim's clothes and stick an IV in their arm. He (they're generally hes) is lowing, often drunk or otherwise substance-addled, but definitely in pain. I don't move fast during this ritual, nor in general, so a few minutes into the slot I'm standing uselessly at the side of the room, waiting for some signal from a superior to go get more work done inside the ER.

Back in the ER desperation on all sides: patients ask when you're going to see them, families wonder what's going on, why hasn't the X-ray been read/glass of water brought/IV taken out of arm/broken bone been set. Nurses are busy doing something else. Senior residents drift from corner to corner of the ER, occasionally assuming a stance ten feet or so away from the patient board on your end, with a look of quizzical impatience: why aren't things moving faster? Why hasn't N, with the abdominal pain, been seen yet?

Rounds punctuate. Someone is admitted - off our hands. Someone is waiting for dispo - a test, for example, to decide whether they'll stay or go. Attendings talk about patients right in front of them, in the third person.

But nevertheless (despite all these initiation rituals that I thought I left behind with intern year, but now as a second year resident I am submerged in again, on this my ER rotation) I am seeing pathologies I never laid eyes on before: the dinner-plate eyes of cocaine, the writhing appendicitis, the horrible pain of a cancer patient that knows (or doesn't yet) that it will never go away completely.

Always the crush of patients to muddle through (primary care medicine in the Bush era), always the disappointed person who hoped that their months-long back pain would be cured by a 4 am visit to the ER. And always, in the middle of all this, the cursed interruption: Trauma in the slot!

Presenting the second-year resident
Now in a magically supervisory capacity.

Said the cattle thief: it's time to take stock.

The intern is a snake devouring its own tail. The second-year resident ("R2" is the quasi-robotic nickname) is still chewing at her tail but is also keeping an eye on the tail-devouring of other snakes, with helpful comments all the while. "Open the maw a little wider! Fangs into the tail like you mean it!" And the hot sand all around, with the Georgia O'Keefe-ish carcasses. And the whistling of passing trains.

The meaning of the allegory: I still sometimes don't feel like I know what I'm doing, even with years and years - I mean, fourteen months - of medical experience under my belt. I know for a fact, more abstract than concrete and more intuitive than learned, that it is better to say "I don't know" than to invent a probably-misleading principle on the basis of limited information. But the latter is what I see people doing all the time around me, and whenever I say "I don't know," I still feel guilty and weak.

Some of this is due to lack of confidence, which will be repleted steadily until my graduation, at the end of my third year of residency. Some of this is due to epistemological uncertainty. I don't know what it means to know about medicine, and at times I'm not sure that everyone else does either.

Let me qualify: there are many models of what it means for a doctor to know something, but none of them covers all the situations that we encounter. "Evidence-based medicine" (one model) is a misnomer, because the "evidence" is population based, while much medicine is done person by person. There are many other jerry-rigged epistemologies, lizards skittering up and down the hospital hallways between the feet of housestaff. "See one, do one, teach one" - sure, but what is "seen" and "done" depend very much on how one is taught. Diagnostics is an epistemological minefield: take into account all your probabilities (Bayesian and otherwise), but you must still walk into a patient's room with at least two or three layers of information and attempted diagnoses made by other people in the hospital who have seen the patient first. Seasoned diagnosticians often cannot explain how they arrive at the correct diagnosis; on the other hand, autopsies (of a previous generation; these days they're rarely done) indicate that diagnoses are wrong about a quarter of the time.

The epistemologic dissonance par excellence is between doctor and patient. The doctor knows the patient's sick, and the patient doesn't believe this at all - or vice versa. The patient knows what's going on in her body, but the doctor needs to do another test to find out - because he says he doesn't know yet. You can say that this is because doctor and patient subscribe to different epistemologies (biomedical vs. traditional, quantitative vs. narrative, or what-have-you), or you can say that neither doctor or patient knows how they know things, or thinks about it much at all. (Meta-epistemology? You came to the right place.)

Now I'm a second-year resident, with more time to think about how I (don't) know what I (don't) know. This is precisely the time when I am supposed to start conveying my knowledge to those one step below me: the interns. (Many of whom, in terms of raw medical facts and figures, know more than I do anyway.) It's appropriate that I don't feel like I know how to do this.

Perhaps I'm thinking about this all wrong. Medicine (or, to term it more appropriately, health/sickness/wellbeing) is based not on knowledge but faith. Induction is a leap. The sun will rise tomorrow because we've seen it done so for our entire lives and heard stories about its constancy. Doctors and patients alike put themselves in the hands of their combined trust: standing at the foot of the mountain or at the door of the hospital.

Dr. Zauberberg
Or: How I learned to stop worrying and believe in the (d)(5) hold.

I'm now rotating. (Of course, we're all rotating together, being on the Earth and all.) I'm currently working on the Chest Service of Bellevue Hospital. "Chest" means "lung" which means (at least for most of our patients) tuberculosis. There are lots of lung diseases, but the most common ones (pneumonia, asthma, COPD [emphysema and bronchitis]) get thrown in the same big barrel as all the other medical conditions, spread out among all the other medicine teams on the regular wards. This particular ward I'm on now is limited to the tubercular.

It is a Manhattan version of the Magic Mountain. There are New Yorkers of unexotic ethnicity (Puerto Rican, say) who have AIDS; there are Asian immigrants who have had the misfortune to contract drug-resistant TB; there are the elderly and demented from Coler-Goldwater, who are exiled from their residence until their cultures come back negative, no acid-fast bacilli swimming redly past the eyepiece.

And then there are those who are under arrest, under Article 11.47(d)(5) of the New York City Health Code. In other words: they have TB, and they can't or won't either take their medications or modify their behavior so as not to pose a risk of contagion; they have been warned, and now they are shut in. They are under (d)(5) hold.

This is justified by public health necessity, which is defined by the New York City Department of Health. On a case by case basis, the DOH balances the danger of contagion, the necessity of treatment, and the contingency of private circumstances.

I wish I had something wise to say here, something which would precisely trace this intersection so we could see it as clearly as pathologists see the offending acid-stained bacilli. All I can do - as usual - is ask myself questions while I immerse myself in the work the system requires of me in the name of the patients.

I've been thinking all day of the word "misprision," but I'm sure it's not as foreboding or relevant here as it seems.

What it's like to be an intern
A week before I unbecome one.

Resident: Says "Let's get a quick [arterial blood] gas."

Intern:
1. Sighs inwardly.

2. Goes and finds
a. a little syringe with some heparin in it so that the blood doesn't clot
b. some alcohol swabs
c. a Ziploc bag
d. another little syringe for a second try
e. needles to stick with

3. Goes into the patient room, lays supplies at bedside. Says: "I'm sorry, I need to get some blood from you."

4. Realizes that he has forgotten
a. Gauze
b. Some ice in the bag

5. Raises up the bed so he doesn't break his back.

6. Finds the pulse.

7. Gives the patient a considerate and well-meaning count-of-three.

8. Sticks the patient.

9. Doesn't get it on the first try [return to step 5], or the second, or the . . . ha! Gets it on the third try.

10. Holds gauze on the sticking point till the bleeding stops.

11. Takes the bag up to the lab.

12. Knocks on the door. Shouts "Hello?" Hears an echo.

13. Pages the person he's looking for.

14. Hands in the blood.

15. Waits by the computer, refershing the lab results page about twenty times till the results come back.

16. Hustles back to the resident with slip of paper in hand. "The gas [huff, puff] is seven point [whew] two three . . ."

Resident [absentmindedly]: "Hey, thanks! Yeah, I thought that's what it would be. Listen, can you just get some quick cultures off this guy -- and then guaiac him?"

An Intern's Lexicon
Version 1.0
Descriptive only. Not prescriptive, endorsed, or reflective of these terms' actual scholarly or humanistic meanings.

A-stick (v.) to draw blood through puncturing the radial artery.

Baseline: at baseline (adj.) Describing a usual or healthy state before arrival in the hospital or before some insult or incident. "His baseline mental status is poor."

Code: 1. (v.t.) To attempt to resuscitate a patient. (n.) An attempted resuscitation. 2. (v.i.) To undergo an attempted resuscitation. 3. (v.i.) To die after an unsuccessful attempted resuscitation. 4. full code (adj.): Someone who is to be resuscitated in case of cardiopulmonary arrest. Opposite of DNR.

Cute: (adj.) Possessed of some attractive or positive attribute. Used of older patients. "That patient of mine in the step-down is so cute! He sits there with his blanket, reads the paper, and asks me how I am when I pre-round on him in the morning."

Dispo: (Short for "disposition.") (n.) Plans for discharge, or a patient's destination upon being discharge. "She's hanging out, waiting for dispo."

DNR: Short for Do Not Resuscitate.

Fail: (v.) (paradoxical reverse construction) To be unsuccessfully treated by a medication. "That gomer failed Vanc[omycin], so we put him on Imi[penem]."

Female: (n.) Woman.

Fix: (often jocular) (v.) To treat, especially acutely. "Your list is so small!" "I fixed everybody."

Gome: Short for "get out of my emergency room." Originally used in House of God, now generally used. n. An older, chronically ill, demented patient. -- Gomey (adj.)

Hang out: (v.) To stay in the hospital while no longer acutely ill. "Anything going on with Mr. Smith?" "He's just hanging out."

Ins-and-outs: Measurements of intake and output on the part of the patient.

Jeopardy: (n.) A backup system whereby certain residents are called in when others become sick or otherwise unavailable.

Male: (n.) Man.

Mental status: (n.) Cognition.

Psych issue: (n.) Psychiatric, psychological, or emotional complication. More generally, any expression of feeling.

Resp (v.) : Short for "respire." To breathe at a certain rate. "The patient is resping at 36."

With it: (adj.) Able to converse; interactive. "He was with it when he came into the hospital

Insensitive introjection

I don't know if any of you remember my Medicine Mensch column way back in April, when I described a "code" on the ICU - that is, the death of a patient despite attempted resuscitation. I just now noticed a letter to the Forward written in response later that month, which I point out now as an instance of a common phenomenon: the tendency to ascribe to me, the columnist, an attitude in agreement with the attitudes described in the column. Thus:

In his April 14 Fast Forward column (“Springing Into Action”), Zackary Sholem Berger captures the unquestioning introjection of emotional insensitivity into the psyches of our physicians in training. As such, he seems unaware of the recurrent abhorrence to those outside his insider’s narrative: the initial “frown” by the resident whose chat was interrupted by a nurse’s concern over a dying patient; the “workplace banter” while the life of a husband, father, brother, friend… hung in the balance; the incompetent obscene specialist whom Berger feels compelled to shield, and finally, the reassurance of “the attending… that we should not beat ourselves up about the patient’s dying, that everything had been done the right way.”

Perhaps reflecting his own indoctrination, Berger attempts to anesthetize the reader’s pain with a reminder that those outside the code are the “uninitiated,” that the complete absence of any feelings whatsoever over a man’s death is sanctioned by a review and validation of the emergency protocol, as well as by the hollow reassurance of one’s superiors and peers.

The letter-writer, it seems, equates the depiction of emotional insensitivity with emotional insensitivity on the part of me, the writer. This is certainly possible but I think untrue in this case. Indeed, I share his concerns about the emotional insensitivity of many doctors; on the contrary, a careful reading of the article would not find a "complete absence of any feelings whatsoever" over the patient's death. In short: depiction of the status quo does not connote satisfaction with it.

Tales of a Twenty-Sixth Grade Nothing
Not a student anymore. Can I handle it?

MEDICINE MENSCH: Bidding the Classroom Adieu

For some people, 12 years of school is enough. Add four years of college and 10 years of a long M.D.-Ph.D. program. Finally, at the end of all that, I can say that I'm no longer a student. I'm ready to enjoy the benefits of my new station in life: sleeping late, meals at my leisure, freedom from subordination to institutional requirements.

Just now, though, medical residency stands in the way. I will be working the hours I am told; my schedule of rotations includes more than a few lectures. During my three-year program, I'll have to pass several challenging exams, including the feared American Board of Internal Medicine certification. I'll have to make presentations, turn in written reports, be deferential to my instructors, and remember everything I'm told in case I have to repeat it at a moment's notice. I'll have a locker and eat in the cafeteria. The cool kids will wear better clothes. Sundays will be for laundry and homework.

Suddenly residency seems a lot like the past 26 years of schooling.

I could leap to the cliché that we are all life-long learners, and that my transition from student to residency is merely an example of the transitions we all undergo. More accurately, we are all both teachers and students, with the two roles assuming various proportions during different stages of our lives.

Becoming a resident doesn't mean that I quit being a student; it just means that the teachers, modes of evaluation and goals are different. It also means that I have become a teacher myself, counseling and tolerating medical students who are just like I was two weeks ago. Someone will throw themselves to the floor in a patient's room, trying to find the cover of a ballpoint pen, and I'll have to strike the teacher's balance between friendly sympathy and calibrated advice. ("Maybe you should get one of those clicker pens?" I'll suggest, and the student will nod dutifully.)

I'll have to teach each patient as I give treatment, not knowing if my words are making a dent — or if the patient is just smiling and agreeing with me in order to get the heck out of my examining room (or so that I can leave him at peace in his hospital bed). In return, every patient teaches the doctor, though it's often not immediately obvious what is to be learned from the umpteenth sick person you've just met.

Something else came to mind during my graduation from medical school, a carefully arranged, flowers-and-champagne event with more popping flashes than pomp and circumstance. The commencement address was the customary sort, reminding us that now is an extraordinary time in medicine: Unimagined advances in science and technology can be brought to bear in the struggle against disease, but, on the other hand, premiums for malpractice insurance are high, and the wolves of overregulation are at the door. (Because the acoustics weren't so great, I might have missed a metaphor or two.)

But there are many times when nothing is being taught or learned and no death-defying struggles are being waged, long stretches of workaday medicine where no high-tech progress is made. It's just doctor and patient waiting for the most recently agreed on medical strategy to take effect, saying hello to each other yet again — like co-workers who keep passing each other by the water cooler in the hall, wondering whether they have to say "Good morning" every single time.

There will be times over the next three years when I'll be neither teacher nor student, just an average guy doing a job day in and day out. But if I'm to keep a proper balance, this ordinariness carries with it its own sort of responsibility: to remember that my job is not, in the final analysis, an average one. This means, among other things — and with every bit of my well-earned humility, sense of insignificance in the larger scheme of things and healthy respect for my own fallibility — that what I do is important. Thus, even as I trip over myself countless times during the first year of residency, I still have value, and my patients need me. I want to remember this during the first night on call, when my first bonehead move makes a nurse slap herself in the forehead once I've turned my back. And since this is my final column, I hope I'll still have the opportunity to write about my mistakes — and have readers to point them out to me.

If you'd like to follow the Medicine Mensch through his residency, you can read his blog, http://zackarysholemberger.blogspot.com. Bye for now!

A code on the unit
The resuscitative dance.

MEDICINE MENSCH: Springing Into Action
By Zackary Sholem Berger
April 14, 2006

In the hospital where I spent my critical care rotation, the patients in the intensive care unit ("the unit," for short) weren't as sick as those in some other hospitals. They were all more or less aware and oriented to their surroundings. You could have a conversation with them.

On one not particularly busy day, a team of doctors was standing in a patient's room, chatting. The full-length windows (a common feature of ICU architecture) showed a sunny day. We were talking both to and about the patient, shifting easily between including him in the conversation and cutting him out of it. A nurse popped into the room occasionally, to take care of something or to confer with one of the interns. The other students and I hung out in the back of the room, talking about what residency programs we matched with and about our upcoming vacations. It was strangely peaceful.

Once again, a nurse again came into the room; she whispered to an intern. The intern's face assumed an expression of practiced frustration, and he left the room with a sigh. Purely out of curiosity, we three students followed him into an adjoining patient room. There the electronic monitor showed a grossly irregular heartbeat, and the elderly man in the bed said he felt uncomfortable and couldn't breathe. We couldn't breathe for a second, either — we knew that the heart irregularity we were looking at was deadly, more often than not.

Then everything started to happen at once. Someone called out, "Let's bag him!" and a mask was placed over the man's nose and mouth to help him breathe. He was still conscious and could state his name clearly through the mask, even though the beat on the monitor was still irregular. "He won't be conscious for long with that rhythm," someone said.

Someone else called a code, or a signal over the loudspeaker connoting a medical emergency. More generally, a "code" is the high drama of resuscitation made mundane by repetition. It's a combination of shared concentration, workplace banter and choreography that no one ever should have to witness as a bystander. This was the last code I saw as a medical student, which means it was the last code I could spend flattened against a wall, hoping no one would run into me, and occasionally running tubes to the laboratory or trying to page someone on the phone. I couldn't see the patient from the corner where I was standing, but the elderly man was now lying quietly on the bed as the team maneuvered around him. I hoped for his sake that he was already unconscious.

To the uninitiated, a code is chaos. I'm definitely not fully initiated yet, but I know enough to say that the chaos is only apparent. People participating in a well-run code, like any other piece of complicated teamwork, have their well-defined roles.

But even in this lifesaving drama, people can demonstrate their flaws. One doctor — whose specialty I won't reveal — wasn't able to do what he was supposed to do. And when the senior resident, who was running the code ( i.e., giving orders and directing the choreography), told him to take a minute and do what he should have done, he responded with an expletive.

To everyone's great credit, no one paid any attention. There were smirks and raised eyebrows, but people kept on doing what they were supposed to do. This was the first remarkable phenomenon of the code: Conflicts that ordinarily might have disrupted the choreography only served to emphasize how smooth it was.

One other thing happened, which is horrible to relate. Despite everyone's best efforts, the patient died. Half an hour after the 20 or more people in the not-so-large room had begun their unsuccessful struggle, only a few people remained with the deceased, and it was time for our team to resume rounds. We went back out into the hall and talked about the other patients. Then, finally, we retreated to the on-call room.

But even then, when we were safely out of view of everyone else on the unit, it was not a time to cry or to mourn. We kept talking. The attending physician who was rounding with us said that we should not beat ourselves up about the patient's dying, that everything had been done the right way. He made a few observations about the code, we shared our impressions, and that was that.

In the cold summary of hospital jargon, the patient had "coded." A hospital doesn't allow much deliberation during the aftermath. Perhaps the only lesson to be learned is that best expressed by Robert Frost in his poem "Out, Out," about a horrible accident:

They listened at his heart.
Little-less-nothing! and that ended it.
No more to build on there. And they, since they
Were not the one dead, turned to their affairs.

Except there is a saving grace. The affairs we turn to in the hospital are the saving of other lives. For good or ill, this is the only ritual observed in every hospital on the death of a patient: going back to work.

Zackary Sholem Berger is a frequent contributor to the Forward. He will start his primary care residency at New York University in July.

Why Johnny still smokes
Unhealthy behaviors and why we can't stop.

MEDICINE MENSCH: Nobody's Perfect
March 3, 2006

When it comes to our health, we can all be careless. Why do some of us keep smoking when we have relatives who died young from lung cancer and heart disease? Why do we eat like it's going out of style when New York is chock-full of obese diabetics? Why are so many Sabbath tables heavily laden with cholent and challah with nary a fruit or vegetable?

All these behaviors are hard to change; some are even addictive. There's also ample scientific proof that some of them are partially society's fault. It is attractive to smoke when cigarettes are made to seem glamorous. It is hard to eat a healthy diet when the nearest store with fresh fruits and vegetables is 25 blocks away, in the rich people's neighborhood. To take a more familiar example, more and more of us are sedentary and overweight — with the rest of society forced to pick up the slack.

But every year there are many people who stop smoking, and there are others who manage to lose weight, even when all outside factors are stacked against them. Conversely, many of us who keep smoking, drink to excess or eat unwisely aren't doing so under duress. No one is holding a gun to our heads.

What's the cause of our errors in judgment? I don't know. But there are some potential answers.

We don't know any better. Why would someone knowingly behave in a way that has negative consequences? By nature, people strive for the good, one could say, and self-damage is only committed out of ignorance. But after years of intensive health education financed by everyone from the feds to Philip Morris, it's hard to find the untroubled soul who still believes that Marlboros are the doctor's best friend or that obesity is not damaging. Our response to being (re-)informed about the harms of this or that consumption is not a surprised "Oh, really?" but a guilty headshake and a sorrowful "I know, I know! I should stop!" There are those cases — such as in the early years of the AIDS epidemic — in which education makes, or would have made, all the difference, but not when an unhealthful behavior like smoking, poor diet or lack of exercise is already deeply ingrained.

We don't like to think about risks. Many people ride their bikes without a helmet — not because they don't know that helmets prevent injury, and not because they're foolhardy, but because they don't think about it. No one likes to think about car accidents, least of all on a beautiful spring day with the wind in your hair as you fly through Central Park.

That's an oversimplification. We do think about some risks quite a bit: The press has been preoccupied with recent disclosures about the ineffectiveness of the low-fat diet and with the pandemic of influenza among birds. But to use an unpoetic word, we misprioritize. It's not bird flu or fatty foods that are to blame for some of the world's worst and most frequent health problems — it's unwise, widespread behaviors, the consequences of which are easily predictable.

We can't be helped. Somewhere between the naiveté I started with as a medical student (just smile and be friendly, and people will cooperate to make themselves healthy) and the desperation of the cynics ("If there's a problem, it must be the patient's fault") is a disquieting truth. There are some of us who make decisions that doctors would call the wrong ones. Then, when we are involved in a conversation about our own health, given all the information and opportunities we need and provided with dedicated staff, experts in their fields who want nothing more than to help us over the rough patches — then, finally . . . we make exactly the same unwise health decision we made in the first place. Given all the necessary data, we make a different decision than public-health workers would make on our behalf.

Maybe that's because of the reasons I already mentioned: We don't know about the scientific evidence, or we can't appreciate technical discussions of statistical risk. But maybe, in the final analysis, we just don't want to. In other words:

It's out of our hands. We would change, but we can't. Quit bothering us. I don't like to exercise. I enjoy my cigarette. No one likes to be nagged. The more we're talked down to about what we should and shouldn't do, the more difficult it is for someone well meaning to broach the topic — and the more unpleasant it is for us to think about our unwise behaviors in the privacy of our own room. We avoid the issues.

Information is not the cure-all. Educating us to understand the complexities of health risks requires a shift in thinking that could take a couple of generations to take hold. Sometimes our frustrations and defensiveness seem insurmountable. So two choices are left: give up or keep trying.

Not coincidentally, these are the same choices every health-care worker has when trying to help a patient. Obviously there's only one right choice that helps both parties. To keep trying doesn't mean success; it means that patient and doctor show up at least semi-regularly — with ears open and with the hope that, equidistant from their frustrations, lies an understanding of why the other behaves the way he does. If we listen to each other in the doctor's office, maybe we'll all make fewer mistakes. Or at least we'll better understand the mistakes we keep making.

In the next few installments of Medicine Mensch, Zack will complete his last rotation as a medical student, travel to China, and get his M.D. Ask him about anything, or tell him how he's wrong, by writing to doctor@forward.com.

How to talk to people

Sick people, I mean.

MEDICINE MENSCH: So...? How Are Things?
By Zackary Sholem Berger
February 3, 2006

Do you like to talk to other people? Sometimes I do; it depends how many there are. If I'm at a party, I slink toward the chips and-salsa or talk only to my wife. (Wallflowers don't blossom; they just climb farther up the wall.) If I'm talking to a friend of mine, it can take me some time to shut up. But if I'm face to face with a person who's providing a paid service — a checkup, a haircut, a repair — I have to remind myself to use the pleasantries that keep ordinary conversation going. I clam up.

Now that I'm almost a doctor, and, more to the point, now that I'm starting a rotation called Ambulatory Care (outpatient medicine, where patients are seen in clinic), I'll get to see the entire range of patient-conversationalists. But I have to figure out how to talk just enough.

This is both easier and harder than it sounds. Easier because the person you're talking to gives signals; following those signals is a well-marked route to conversing in a non-annoying fashion. (If the patient is checking her watch, rolling her eyes, or — as in the movie "Airplane" — tying a noose round her own neck, it's a good sign that her patience is wearing thin.) Talking less is generally good advice in any situation. No one likes a bore, least of all a bore whose favorite topic is your illnesses. Even though patients would like to be fully informed, most of them would like their information in a few concise paragraphs, not in a long-winded discourse.

On the other hand, a doctor needs to talk to get his work done. A silent doctor, like a silent lawyer, invites suspicion. But so does talking: Like lawyer and client, doctor and patient never can have a normal conversation; each of them is waiting for the other word to drop. The patient dreads the openings "There's something you need to know" or "We need to take a look at that" in the same way that the doctor never can escape the "doorknob questions" that the patient remembers just when she's about to leave: "Oh, I've been meaning to ask you something"; "Just one more thing."

If the conversation starts off on the right foot, it won't be so fraught for the parties involved. The accepted pedagogy in medical school is that one must begin in an "open-ended" way, and only later "cone in" to more specific, useful questions. Translated from jargon, this means that ideally the physician would welcome the patient into the office, invite him to sit and then wait silently, like an oracle. If necessary, at the very most one can utter a single word: "Well?" or "So?" Thus encouraged, a patient will spill the whole story without undue interference from the doctor.

If this oracular opening actually were to be adopted in most doctors' offices, patients would get confused and think they wandered into the psychotherapy suite by mistake. I've tried it myself a couple of times, and it spooks the patient. Of course, there's a compromise available: You can start off without a torrent of detailed questions, but your intro can be friendly and personable.

I've tried to see which opener works best for me. There's "What brings you here today?" An old favorite, but I can never say it without thinking of the old, jokey answer: "A taxi, doctor." I could ask, "What seems to be the problem?" Fine, I suppose, but it's nothing I actually would say in the course of a normal conversation. "How are things?" I used that once, and the patient said "Fine, thanks" — and stopped talking right there. I had to restart the conversation from a standstill.

There's a difference between what's supposed to happen (according to the theory of the clinic visit) and what actually happens. According to theory, I open up in a general vein and then become more specific as the patient reveals her problems. But the truth is that our conversation only traces the surface of the problems affecting the patient. What people say to their doctors often doesn't point to the true nature of their ailment. An office visit that the doctor considers notably successful (a problem correctly diagnosed, inroads made into diabetes control or reduction of cardiovascular risk) can appear completely useless to the patient: Her annoying cough hasn't gone away, and her back still hurts.

This is the conundrum of outpatient medicine. Since the patients seen in hospitals (where young doctors get their start) are sicker on average than they were decades ago, the bulk of today's training is focused on keeping them alive, or, in rare instances, on curing them. But day-to-day clinic medicine (and the role of doctors throughout much of history) has been not to save lives but to improve them, to make the acute problem less acute and the chronic one easier to bear.

When residents talk, they often say that clinic patients are hard to deal with. Do they mean that hospitalized patients, with their long lists of potentially fatal medical problems, are easy to treat? Maybe it's that patients in clinic, with their multiple medium-sized problems, come with the same considerable challenges and small-scale opportunities that are present in any interaction. The aim is to make incremental improvements while keeping an eye out for those brief openings that allow a significant change for the good. For the average clinic visit of 10 minutes or so, that's plenty to talk about.

That's all we have time for today, I'm afraid. Same time next month?

Zackary Sholem Berger has another patient waiting, but he cares about you personally. Write to him at doctor@forward.com.

The resident at rest?
Saving lives: the Sabbath as a normal workday.

MEDICINE MENSCH: Good Shabbos, I'm Off to Work
By Zackary Sholem Berger

People outside the medical field don't understand the process by which beginning doctors are trained. Were I to start this column right off and say, "I'm interviewing for residencies now" (which happens to be true), many reading this would scratch their heads, wondering when, if ever, I'll finally finish my schooling. Let me explain.

Medical school is only the first step. A medical school graduate (which I will be this May, God and registrar willing) will get an M.D., but at that point the degree is only good for hanging on a wall, getting a nonclinical job or applying for further training. Any physician who wants to practice with a state license needs to undergo such training — in other words, a residency.

Residents are apprentices in the guild system that medicine still preserves: uniforms, vocabulary and work hours all set the doctor apart. To what extent these vestiges can be shed, without disrupting the core of the physician's identity, is a discussion that has lasted the past few decades. Uniforms (the white coats) haven't been abandoned, and medicalese is a thriving dialect. But my work hours as a resident will not be the same as the chain-gang days of old, when young doctors would stagger to and from the hospital — uphill both ways — at either end of a 36-hour shift. New York's "405 regulations," passed in the 1980s, placed restrictions on residents' total work hours and required minimum rest periods. These guidelines have now been adopted nationally, so that hospitals must now keep closer tabs on how long their residents work.

Work hours of a different sort will play a role in my decision of where to spend residency. (I'm in the middle of applying to residency programs in the subspecialty known as primary care, but I haven't yet come close to deciding where I want to be. What follows are just general principles, not pros or cons of any specific program.) The issue is this: Should I work on the Sabbath?

Most people's first response is: "But I thought doctors could work on the Sabbath." Without getting pedantic about the halachic or exegetical details of the principle, it's true that "saving a life sets aside the Sabbath," as does (broadly speaking) the treatment of a dangerously ill patient. But does doctors' work always entail saving lives? And are there Jewish reasons outside of Jewish law that might make it preferable for Jewish doctors to work on the Sabbath?

A resident doctor working in the hospital on the Sabbath does not spend all 25 hours, from Friday night to Saturday night, nimbly plucking the gravely ill from the mouth of death. Some of the time is spent dealing with busywork ("Sign this!" "Send that!" "Answer that intrusive page!"), while much of the rest is spent talking to patients, other caregivers and family members about matters that, while necessary, do not mean the difference between life and death. Not everything that a doctor does during a shift is lifesaving. This is a message reinforced by the changing work hours of medicine: If doctoring is a job like any other — with shifts, overtime and holiday bonuses — why shouldn't doctors get a regular weekend, or at least one day out of seven predictably free? In other words, the Jewish legal realities of the practice of medicine (the Sabbath "work" of the doctor is more often than not something less than lifesaving), coupled with the economic and family desiderata of the young doctor (it's nice to have some regular time off), has encouraged the development of the Sabbath-observant residency program in which residents work the same number of hours as their peers, but switch off their Friday-Saturday calls to others.

This development might be taken as a sign of the salutary tolerance that American institutions demonstrate for traditional Jewish observance, something that wasn't true in our grandparents' or even our parents' generation. I don't exactly disagree with this assessment; I find these programs to be quite attractive, and I'm applying to several of them.

But there's a downside here: Gaining your soul — not having to work on the Sabbath — might mean losing the world. Part of being a doctor is the relative cushiness of the profession itself, with its good salary and societal esteem. But part of being a Jewish doctor is something different: striking a balance between God's law and human law; between death, which might strike at any time, and the call to a life of rest and contemplation, which must be obeyed one day in every seven, lest it be snowed under by the detritus of the everyday. It's like being a religious Jew: Part of keeping the commandments is knowing when not to keep them, seeing where the boundaries are and when they might (or must not) be overstepped. How can you know what it means not to eat nonkosher food if you've never seen it on a menu? Spiritual concentration requires the rigorous exercise of contact with the nonspiritual; isolation can encourage a religiosity that does not allow itself contact with the outside world.

In short, being a Sabbath-observant resident might be the best of both worlds. But I'm not sure if a Jew is supposed to allow himself that.

Chicken soup and gefilte fish, preferably in vacuum-packed containers suitable for opening in trayf, unsanitary call rooms, may be sent, general delivery, to doctor@forward.com.

No longer confused, not yet overwhelmed
After a year of my medical-student ramblings, what have I learned?

MEDICINE MENSCH: Taking Stock
By Zackary Sholem Berger
December 2, 2005

There's a joke about travel writers turning experiences abroad into publishable material. Spend two months in China, say, and you can write a book; spend two years, and you can write an article. But spend 20 years, and you find you can't write anything at all. I feel the same way about the past year of being a medical student. Every day is packed with thousands of stories. Every patient is an epic unto herself. The first few months of being a medical student were an encounter with the world of the hospital. In such a first encounter (with a new book, a new person, a new language), you can ignore the occasional troubling aside and focus on the big picture. But as you get used to things, you can't avoid the episodes that are harder to talk about.

As a beginning medical student, I was mostly confused. As a fourth-year student who's just completed his sub-internship (a sort of pre-residency), I've become less confused and more intimately involved in the contradictions of the hospital. Once I become a resident, I might become too overwhelmed by life and death to write at all. Now, at the end of this column's first year, I thought I should take stock of my reactions to what I've seen. "Love" and "hate" are the first words that come to mind for many things I've encountered this past year. Sometimes I hate and love the same thing in succession.

I hate going into rooms of people who are very sick. They lie in their beds, staring at the wall. What's the right thing to say to them? Most of the time, as little as possible: I already know this from visiting the sick as a layperson. But as a doctor-in-the-making, I'm no longer someone who visits the sick. I now intrude on them for their own good, asking them questions they would rather not answer and viewing their bodies in ways that they never would countenance when healthy. While I try to build rapport, strengthening the doctor-patient relationship through our basic human connection, more often than not our conversation doesn't exceed the bare minimum. I need to get my work done; they need to get their rest. So I leave the room feeling guilty, while they lie there feeling no healthier than before.

At the same time, there are patients I come to love even though I know them only slightly. An older, frum woman was admitted with pneumonia. The admitting team described her as demented. According to the technical meaning of the term, this was correct: She suffers from a constant, progressive decline in cognitive function. But too many assume that the demented patient is childlike, not deserving of the respect we would give anyone outside the hospital. I've seen more than one demented old woman called "sweetie," more than one writhing figure in the step-down unit called "nonverbal" while he's screaming in Yiddish for people to leave him alone. It takes extra effort to listen.

I walked into this woman's room last Tuesday and asked her how she was. She said something incomprehensible, and I bent closer to hear. "What's that?" I said, a trifle impatiently. "Ki tov," she said. "It's the day of ki tov." It was Tuesday, the third day, the day that God called good twice. I cried at that — not so anyone would see, of course. I loved that patient even though I didn't know her at all, because she had said something heartening.

I dislike walking the halls in a long white coat, hearing people call me "Doctor," running into relatives and families hungry for information that I don't have or can't give them. I am the "doctor figure" in whom they find comfort, even though there might be nothing I can do at the moment. At the same time, I try to tell them what I can — even if it's only the simplest details of the imaging study that's about to be performed or the tests that are about to be drawn.

There are other reactions that cannot be stopped and break into my best intentions like a freight train. At 5:30 in the evening on the last day of my sub-internship, half an hour before I was due to sign out to the night intern, I was called by a nurse who told me that over the past few hours a patient had become short of breath and incoherent. My first thought, you'll understand, was not, "Let's see what we can do to help this poor man." It was, "Why couldn't he have waited half an hour?"

But I drew the tests, asked the nurse for an EKG and took the man down for a CAT scan. We tried to figure out what the matter was, piece by piece. Maybe I've begun to acquire the everyday discipline that is more important than the drive to do good. Even if it's half an hour before you're due to go home, you go do what you're supposed to. (With your resident, or whoever your boss might be, providing a little push.)

I got into the elevator to go home, and a religious Jewish couple, seeing my yarmulke, gave me a smile. "What a Kiddush HaShem," they said, using the term for an act or person that shows Jews in a favorable light. I didn't feel like I had been sanctifying God's name — I was just learning how to do my job. Do the two overlap? We'll see.

Zackary Sholem Berger isn't a doctor yet. Complaints about how long it's taking should be sent to doctor@forward.com.

Para-rabbis and PAs
"Totem pole": descriptive, not prescriptive.

MEDICINE MENSCH: What Little I Know About Medicine
By Zackary Sholem Berger
November 11, 2005

I thought I would title this month's column "What I Don't Know About Medicine," but my editors want 800 words, not an encyclopedia. What I do know about medicine should fit nicely into the space allotted.

The rotation I'm starting this week is known in hospital jargon as the sub-internship; the registrar's office calls it "advanced medicine." In this rotation the medical student plays the role of an intern, a first-year resident. He can write orders on the computer, decide on a course of treatment and prescribe medications — all with the co-signature of a supervisor, of course. The main thing is that the student manages his own list of patients. In other words, I won't be following a resident around anymore; I will be a resident.

More precisely, I'll be pretending to be a resident. That's the catch of this rotation — it's the adolescence of medical education, in which one is something more than a senior student but something less than an intern. How much like an intern will I be? If one reasons by similarity of activity (lack of sleep; independent decision-making on behalf of actual patients), I could very well call myself the intern. Could I walk into my patient's room and say, "I'm Dr. Berger, and I'll be taking care of you during your stay in the hospital?" The second half of this statement is definitely true, but the first part (with "Dr.") isn't quite. I won't have my medical degree until my graduation in May 2006, and I won't have a license to practice medicine until I finish my boards, which stretch from now (while I'm still a medical student) until the end of my residency.

On this rotation, I don't plan to introduce myself as "Doctor" (that would be quite a stretch), but I understand why some of my colleagues would. While many patients don't understand the difference between senior medical students, interns, residents, fellows and attending physicians, they come to appreciate something of the hierarchy during their hospital stay. One thing soon becomes clear to them: Medical students are at the bottom of the totem pole of health care providers. (Or almost at the bottom —more on that subject, below.) If a sub-intern walks into a patient's room and starts out by saying, "My name's Joseph Brighteyes, I'm a medical student, and I'm here to take care of you," the patient is likely to respond, "That's great, Joe, but who's going to be my doctor?"

Is qualification defined more by knowledge or by capability? This larger question comes up when talking about the thousands of people whose elbow grease makes a big hospital run as smoothly as it can. Even lower on the pole than the medical student is the physician assistant. P.A.s train for fewer years than medical students, so they often get less respect from folks in medical academia. But in every rotation where, as a medical student, I've worked together with P.A.s or P.A. students, they have seemed more on the ball than the medical students — not as over-theoretically concerned with fascinating disease entities and more knowledgeable about what might immediately help the patient. Part of the reason is that the P.A. student spends more time in her early training (most P.A.s I've met are women) familiarizing herself with the way things actually are in the uncompromisingly practical universe of the hospital or clinic. Perhaps P.A.s can't name 12 different kinds of small-vessel disease. (I'm making up that number; I certainly can't name them, either — not off the top of my head.) But such encyclopedic knowledge is sometimes transcended, or rendered irrelevant, by practical considerations. On the other hand, you don't want to miss the rare diseases when they do pop up. So both kinds of training (practical and theoretical encyclopedic) are essential, even complementary. The trick is to appreciate both kinds of thinking at the same time, even though most people find one of them more congenial than the other.

A similar divide is evident in the Jewish tradition, especially with regard to Torah study. In previous generations — and even today in some circles — memorizing vast tracts of the Talmud is a prized skill. On the other hand, if you've dipped into any of the Talmud, you know that it takes considerable exegetical ingenuity to derive laws applicable to everyday life from the rich stew of magic, folklore, intellectual speculation, casual yeshiva talk and campfire tales about the destroyed Temple. (Even the strict constructionists, those who actually bury their fingernail clippings according to the magical practice of the rabbis, still have to exercise creativity in deriving everyday religious practice from Babylonian-Jewish digression.) The two skills — encyclopedic knowledge of the Talmud and the ability to apply the Talmud to everyday religious life — are complementary, but rarely are found in the same person. Many of the greatest talmudic scholars have famously refused to adjudicate Jewish law, protesting that they could see all sides of any issue.

Today's Jewish communities rely very much on what some people call "para-rabbis" — people who aren't religious scholars but are reliable, even expert, in the details of daily practice. You might have met some of them: the guy who knows everything about building a sukkah; the woman who is obsessed with reading Torah; the member of the local synagogue who knows exactly how to help a recently bereaved family.

In other words, Jews (at least religious Jews) depend on "rabbis' assistants." In the same way, a hospital must cobble together a vast number of people who have different abilities. Some sit in offices and absorb themselves in the study of disorders affecting 10 people in the entire world, while others, down amid the gore in the E.R., can contradict those same scholars with absolute certainty if they see in front of them a practical problem they know how to solve quickly and effectively.

Bit by bit, I hope to amass both kinds of knowledge till I can be considered a doctor (a learned person, according to the word's historical meaning) in at least one of these categories. But no matter what, there always will be plenty of material for my upcoming masterwork, "What Zack Berger Doesn't Know." I look forward to doing the research.

Zackary Sholem Berger is becoming a doctor, hour by sleepless hour. Feel free to write him about it at doctor@forward.com.

Get up!
Stand up for your rites.

MEDICINE MENSCH: Resetting the Spiritual Clock
By Zackary Sholem Berger
October 7, 2005

I've been getting up at five in the morning for the past two months. It would be nice if this new schedule granted me some insight into the human condition or the plight of the sick, but my observations are on a smaller scale.

A lot more people than you might think are up that early. On the way from my apartment building on the Lower East Side to my bus stop there's an unsavory-looking building that is shuttered during the day. When I stumble by at 5:45 in the morning, there's an improbably well-organized fruit stand out front, tables of oranges, apples and bananas under the streetlamps. The fruit seller is always wearing a T-shirt and shorts, no matter the weather. I say good morning to him, and to the MTA bus driver, but maybe it's the wrong thing to say — these people have been up for hours already and probably are ready to go to bed after their shift switch. "Sleep well" might be more appropriate. ("Sleep well" is something you never say to a medical resident, unless you're trying to taunt him.)

All the people getting to work at this hour can be divided into different subgroups, the most obvious being the 6 a.m. cell-phone talkers. (Who are they talking to? Other 6 a.m. cell-phone talkers, I guess.) There are those plugged into their iPods, the nurses chatting and joking away in friendly groups, and solidly built men in leather jackets carefully avoiding eye contact. Then there's the group of eccentrics you always find in the city: people mumbling to themselves.

I'm among the mumblers. According to Jewish law, there are times in the very early morning when it's just too early to daven. I can say certain prayers when I'm at home, certain prayers on the bus (when it's already slightly later, and the sun is scrambling into place) and certain other prayers in the chapel tucked away in one of the corners of the cavernous Long Island hospital where I'm now stationed. My davening is fragmented, and my morning feels that way too — something I start assembling at 5 a.m. and piece together, hour by hour, until I arrive at my destination and start my work day more or less a whole person.

The best way to describe davening, or, more universally, prayer, to those who don't generally engage in it is to say that it's a systematic stock-taking. Residents do this every day, when they visit their patients before they're expected to present them to the entire team. They pre-round, or round before rounding, making sure they're informed about what happened to their patients overnight and what these patients need during the new day.

More often than not, my mind drifts during davening, like someone walking down the street on the way to a familiar destination. I think about my day's responsibilities, what I'm going to eat for lunch, what I need to study. I manage to reduce thousands of years of stirring liturgical yearnings to a shopping list.

Then once in a while — or, more precisely, once a year — I start trying to pay attention to davening again, in the religious equivalent of getting up at five in the morning to go to work. A week or so before the High Holy Days, Jews begin to gather at ungodly hours to recite Selichot, impassioned vows of contrition and pleas for mercy on the part of the Almighty. The irony is that this liturgy is based on the piyyut, a medieval poetic form distinguished by its labyrinthine syntax and obscure biblical references. What happens, then, is this: A dozen or so half-asleep Jews mumble incomprehensible prayers with less than notable fervor, though in every minyan there's always the exception who makes a point of clenching his fists, staring at the ceiling and making other signs of overt piety. So what's the point of the poems? There might be one Jew in 50 who understands their content (English translations like Artscroll try their best, but end up sounding like a Brooklyn-accented imitation of "Masterpiece Theater").

But in this area (as in a number of others), it's not the content but the form that's important. Getting up early shocks the internal clock into a new and unfamiliar time zone. For the medical student, it takes this shock to move from everyday pursuits into the uncomfortable, cold and early-rising world of the hospital. You have to learn to pay attention to both your patients and the clock. For the Jew entering into a new year, getting up early can help realize the famous challenge of the shofar (as Maimonides understands it): "Wake up from your sleep!" Get up early to shock yourself into the new year. Get up early, or you might miss the shofar. And if you mumble your first prayers while you're still half asleep, you'll be perfectly understood not only by God, but by any medical student.

Zackary Sholem Berger hopes that in 5766 you never have to see the inside of a hospital — unless you work in one.

Medicine Monster
Time to find myself.

Medicine Mensch 9, in which I specialize, specialize, specialize.

MEDICINE MENSCH
Job Hunt: Choosing the Right White Coat
By Zackary Sholem Berger
September 2, 2005

I am 32 years old, and it's time to decide what I want to be when I grow up.

I do have things narrowed down somewhat: I want to be a doctor. But what kind? I don't have the luxury of thinking it over much longer. The time has come to apply to residency programs (the four-or-so-year stints of hospital-based indentured servitude marking the start of a doctor's career), and I need to decide on a specialty.

There are many different kinds of physicians. A Web site run by the American Medical Association lists more than 50 specialties, ranging from aerospace medicine to colon and rectal surgery. Each has its partisans and its detractors, but finally the decision is my own.

Many medical students ask themselves whether they should apply to one of the "lifestyle residencies" — specialties chosen because of desirable salaries or fewer demanding hours. There is a whiff of snobbery in this label. Medicine is, after all, still an attractive profession for many, precisely because it offers a comfortable living. Even those specialties that are not the highest paying certainly are no road to self-denial. By most definitions, doctors are still rich. Isn't lifestyle a reasonable criterion for choosing a career?

I won't even say which specialties are considered "lifestyle residencies," because the definition changes every five years. Each specialty, no matter how unpopular or looked down on at one time, is redeemed eventually through market forces. Take, for example, circus medicine (not a real specialty, as far as I know). It used to be that no one wanted to be a circus doctor, dodging screaming children all day and putting casts on unlucky trapeze artists. But the wheel of fortune turned, and some students discovered the attractions of the specialty. The pay is not bad, and the hours are reasonable: The shows are at regular times, and in between you can hang out with the Siberian tigers or do whatever else you want. Plus the popcorn's free. Suddenly it's a buyer's market, and circus showmen have more applicants than they can handle. How did circus medicine get more popular? The specialty didn't change at all, but more medical students discovered that they'd rather do something else during their residency than work 18-hour days.

Ideally, our passions and our needs would coincide. What we want to do would be precisely what we're trained to do, and a good bit of money would be made doing it. Sometimes, though, it works the other way: Money (and livable hours) point out a career to us that we wouldn't have thought of before. To go even further, there's nothing wrong with moneymaking as the chief criterion for one's choice of medical specialty or any other profession. The rabbis of the Talmud tell us to teach our children a trade, not a career. If our child can make a good living in something legal, nine to five, and completely dull, there is no reason (according to this strain of Jewish thought) for her employment to have a larger redeeming social value. Her redeeming value should come from her spiritual life, not her professional one.

But of course, work is more than work. It shapes our life. The stereotypes that medical students attach to various specialties are only partially untrue. Certain specialties are known to be impatient with abstractions, abrupt and unfriendly, while others are known for indulgent book-learning and a tendency toward long-windedness. Even if a doctor doesn't conform to these stereotypes when he enters these specialties, he might be brought more into line with them, both by working with his colleagues and by the particular kind of medicine for which these personalities make sense.

So instead of choosing a specialty (or a job) that makes possible the rest of your life, you can choose one that becomes your life. The rabbis were experts in choosing a "clean and simple trade," a profession that provided both sustenance and space for what they held to be life's most important pursuit: the study of Torah. But they didn't have as much to say about choosing careers that provide professional satisfaction, possibly because this wasn't relevant either to their historical moment or to their economic class. (The same rabbis also said, "The best of doctors are bound for hell." But that's a discussion for another time.) Later Jewish thought does see a place for intellectual and professional absorption in things other than Torah — a career for career's sake — as a worthwhile way to spend one's time.

The answer to all this is the punch line of an old joke: You're right, you're right and you're right, too. Someone who chooses a career (or a medical specialty) for the sake of personal satisfaction might find out years later, when it's too late, that his personal satisfaction depends not only on intellectual and spiritual sustenance but also on having time to spend with one's family as well as money to buy what one needs. But one who chooses a job that leaves time for the rest of life might discover that the rest of life feels boring without the stimulation of a demanding profession.

I'm still not sure what I'll be. Maybe I'll run off and join the circus to cure the age-old medical syndrome of big red noses and oversized feet.

Zackary Sholem Berger, a fourth-year medical student, accepts all well-meaning job advice at doctor@forward.com.

Hospital Food
It's always lunchtime somewhere.

Here's Medicine Mensch 8. Dig in!

MEDICINE MENSCH: Doctor's Orders: Fruit Salad and a Cheese Sandwich
By Zackary Sholem Berger
August 5, 2005

Despite the superpowers previously described in this space, medical students are normal people. They need places to lay their heads, white medical coats to keep out the rain, and three meals a day. Since their time for breakfast and dinner is sacrificed to sleep, three meals often means only one: lunch.

What's for lunch, and where do I eat it? On the ground floor of the hospital I'm working in, there's a diner with the same wishful-thinking menu of other diners — many things can be ordered and some of them are even available. I eat there occasionally. That is, I go with some other medical students, order an iced tea and a fruit salad, and eat my kosher bread and cheese from a bag I hide under the table. No one throws me out, and the iced tea is good.

The fruit salad, in a securely-fastened plastic box easily opened by surgeons or other coordinated people, is the same that's available just next door, over the partition at the hospital's coffee shop. But there, rules are different, and the hospital's stern hierarchy is topsy-turvied. Attending physicians and patients' cousins alike wait in line to grab the attention of the blue-shirted guys who take orders, man the cash registers and bag coffees and tuna wraps with frightening speed, calling women mi amor and discussing soccer with each other in Spanish. A sign over the cash register explains enigmatically: "All Kitchen Items Cannot Be Ordered Express." In practical terms, this means that the blue shirts have complete control over what they pack up quickly and what they prepare in their own good time. I'm not sure how long it takes to become a regular in their eyes, but if I go there often enough and order a homemade iced tea, no sugar, I hope eventually they'll start to recognize me.

As you move upstairs, the options change. There are vending machines with sweet and salty snacks, from a company that either has a dark sense of humor or doesn't realize how many patients here are suffering from diabetes or heart failure. On the 12th floor there's a dining room with a cafeteria that I've never seen open, a phalanx of vending machines, and a row of microwave ovens; at lunchtime the place is packed with nurses speaking Tagalog, Chinese and Spanish. Outside, above the door, there's an inviting Dante-esque sign: "Patients Not Permitted."

This is because patients are expected to stay in their rooms, awaiting care. Their care, like everything else in this hospital, is dependent on the combined efforts of thousands. And when something goes wrong, such mistakes are discussed exhaustively over lunch. At morbidity and mortality conferences, mishaps are analyzed over bagels and coffee. In line at the coffee shop, people whisper about the surgeon who operated on the wrong leg. These days, hospital administrators are terrified of the survey commission that's about to come through town, flashing remorseless, efficient smiles and catching careless errors in every chart. Some mistakes don't cost anyone's life or limb — they merely make the patient's dinner late. But even this can be a serious blow. As one resident told us students, "The best way to piss a patient off is not to feed them."

A couple of nights ago I was in the E.R. A patient had been sent there with an unexpected heart problem after what he had assumed would be an uneventful checkup. I took his history, did a thorough physical, and then thought: What more can I possibly do for this person before the resident has time to come see him? I had already done his EKG, and I'd already apologized to him for the confusion in the E.R., which, to the untrained eye, is the natural state of the big-city emergency rooms. (That particular night, the air conditioning wasn't working, a dozen or so cops were guarding their charges and the guy in the stretcher next to my patient was screaming, more out of churlishness than pain.) I asked, "Is there anything I can do for you?" The man looked at me, thought a bit, and said tentatively (in Spanish), "Well, I'm awfully hungry."

It was a rare privilege to lay down a hot meal in front of this sick man. I didn't stick around to see whether he liked the spaghetti, or, after he finished, how he managed to get his tray off the stretcher while staying attached to his heart monitor. I was too busy getting up to the 17th floor, where I would tuck into a saag paneer and drink some mango lassi. It was 9:15 p.m., finally time for lunch.

Zackary Sholem Berger looks forward to breakfast and dinner, too. Medical-student recipes and tales of past mistakes are available at doctor@forward.com.

Medicine Mensch goes (Poly)Glatt
Number seven in a series.

Visiting Patients, With Dictionary In Hand
By Zackary Sholem Berger
July 1, 2005

Before I became a medical student, I thought I spoke Spanish pretty well. I spent six months after college researching minority languages in Spain and, after moving to New York, I've had many a friendly conversation with miscellaneous Spanish speakers I've accosted: random passersby from Puerto Rico, law students from Colombia, grocery packers from the Dominican Republic.

Having a conversation on the street or a chat in a café about politics or literature is one thing. If you don't understand a word, you can smile or nod and pick up from context what's going on. But say you've been called down to the E.R. to take a history and do a physical, and you find a drunk, toothless man in handcuffs gesturing frantically at something underneath his bed. If you could understand drunken, toothless Spanish a little bit better, it might not take you 15 minutes of sympathetic listening to understand that the man wants his cell phone (which the cops sitting nearby are not about to let him have).

The difficulty isn't simply a matter of decoding the speaker's register (someone from a different socioeconomic class can be hard to understand, even in one's native tongue), nor is it the fact that various dialects of the language are represented at any urban hospital. It's often the words themselves that make things hard. Like every other medical student, I have a command of several different kinds of medical terminology: the mind-numbing jargon of the scientific literature, the half-macho talk of rounds and last but certainly not least important, the normal words people use to talk in English about whatever's the matter with them.

It's this last kind of vocabulary that I lack in Spanish. I can talk a blue streak about genetic predispositions and infectious agents, about endoscopies and anesthesia — these are international terms, much the same in Spanish, English and many other languages. But lay language is different. I've already experienced a certain kind of linguistic blockage more than once. I've started a conversation with a Spanish-speaking patient, we've built up something of a rapport, she's complimented my Spanish, I've figured out why she's come to the hospital. Then, all of a sudden, I need to ask a specific question to narrow down the field of possible diagnoses. I use what I think is the right word, and one of two expressions appears on the patient's face: either outright incomprehension, or a polite glazed-over look that means, "I'm going to keep my mouth shut until I can figure out what the heck this nice doctor is saying." It's then that I have to search my dusty old neurons for a Spanish word I learned once, many years ago, or for a synonym that's used in the home country of this particular patient. During one memorable conversation, a patient and I sat through a long, awkward pause before she figured out that I was asking about her period.

Those familiar with the overscheduled life of the medical professional might wonder what's the point of trying to achieve "medical fluency" in Spanish or another foreign language. For most doctors it might be enough to master a minimal vocabulary, and the extra minutes spent figuring out the Colombian word for "tampon" or "leg splint" can more profitably be devoted to a more extensive history or exam of the other dozen patients that have to be seen today. It's also true that a translator is (usually) available. That's if one wants to take the legal route. Many doctors use the Spanish-speaking janitor, or the patient's sister who's waiting in the lobby; neither alternative would be applauded by medical ethicists.

It all depends on how the doctor sees her practice. If her task is to see clients who are visiting for necessary medical services, they probably can be more efficiently served (not to say "processed") with minimal communication. Many common complaints can be divined from the patient's presentation and demographic with only the bare outlines of a conversation. If this approach isn't warm and personal, it's certainly necessary when there are hundreds of patients to see in a week.

But since I'm still a medical student, I can still afford to let my personal tendencies influence the way I see medicine. I'm a person who doesn't mind sacrificing a little efficiency (or even a lot) to get a good conversation going with the person sitting in front of me. Will that make me a better doctor? Beats me, but I know I'll have more fun this way.

"You can't learn every language," a medical student friend of mine pointed out when she heard about my linguistic ambitions, i.e., trying to learn some Chinese. Many people at Bellevue know some stock Chinese phrases, but if I can avoid it I'd rather not storm into the hospital room of an 80-year old man and blurt out the Chinese version of "Did you piss today?" Most medical students wouldn't be caught dead asking an older person that question in English; clearly there must be another way to do it in Chinese. And I'm still trying to find the Yiddish speaker who doesn't assume that accented English will impress me more than mameloshn.

If you happen to speak English, I will make every effort to accommodate you once I'm a physician. Please realize, though, that since I'll be a doctor, my handwriting will be illegible — in any language.

Still a medical student, Zackary Sholem Berger has a bunch of dictionaries at home, but he never can seem to remember the word he needs. When he's a physician himself, he can have a medical student look everything up for him. Send him questions in the language of your choice at doctor@forward.com.

MEDICINE MENSCH
Making Rounds: A Hospital Drama
By Zackary Sholem Berger

There is a drama performed in hospitals that is as essential and unchanging as davening, or eating breakfast. It's the doctors' twice-daily bedside perambulation, known to everyone as "rounds."

Whenever a medical student walks into a patient's room, it's an act for both concerned. Perhaps the metaphor is inexact. Each actually wants to tell the other something that is necessary to know; real life is going on here, not just a staged meeting. But performance anxiety is also a crucial element of the interaction. The student wants to demonstrate confidence in front of the patient, in the hope of hitting on a juicy finding to feed the intern; then the intern, thus fortified, might look good in front of the resident, who would be nice to the intern — who would then, in turn, the student devoutly hopes, be nicer to her.

The patient has his role, too. There are as many different sorts of patients as there are people in general, but many would like to be the "good patient," the one whom resident and attending alike mention with a smile or, at least, without an eye roll and a barely suppressed groan.
Patient and doctor meet on this sort of medical date thousands of times a day in hospitals everywhere, each hoping that, for the other's sake, the two of them will hit it off.

But what is it like to go on rounds? It's a performance with its own special set of characters, among them the Patient (lying in bed, trying to sleep), the Medical Student (short white coat, bleary eyes, clipboard), the Intern (long white coat, even blearier eyes, folded sheaf of paper, look of a hunted woodland creature) and the Attending (long white coat, very little paraphernalia, confident and well rested). Morning rounds are executed in two acts. The first, featuring the Medical Student and the Patient, is transcribed below. (The Patient's responses are omitted — because, among other reasons, he's tired, talking through a sheet pulled over his head and wishing the Student would go away.)

ACT I
The place: A raucous urban hospital.
The time: 6:45 a.m.
Enter Medical Student.

Medical Student (to Patient): Good morning! Did you make a bowel movement last night? ...
I realize it's a quarter to seven in the morning. I need to ask you a number of questions about how you're feeling. Someone else asked you a bunch of questions this morning when she took your temperature? That was the nurse. And another person asked you questions earlier this morning? That was the intern. Sometimes he likes to get here early to get a jump on things without me. I'm a medical student, and I have my own questions to ask you. ...

Why can't we all coordinate the questions we ask? That's a good question. I wish I knew the answer to that. I'll get back to you on that one. ...

I'm glad you're answering my questions, sir, but please don't say that I can "practice" on you. My resident tells me I'm a vital part of the team. ...

So, about those bowel movements. Made any? Great! That's good to hear. What about gas? Urinating? How's your pain? Where would you rank your pain on a scale of zero to 10? Any other complaints? Okay — I'll speak to someone about the food here. And, what's that? Too many people asking questions? Your sense of humor is very healthy, sir. ...

Now I'm going to examine you briefly. First your abdomen. Where does it hurt? All right. Let me just look. I'm sorry! I know it hurts. I know, but I wanted to see for myself. After I'm done examining you, I'll just check your incision. Let me listen to your heart and lungs now. Breathe deep, please. ...

Okay, thanks a lot! Any other questions for me? ...

Normal food? I think you'll be eating normal food by tomorrow, but I'm not 100% sure. I have to ask the doctors, who are coming by a little bit later. Have a good day.

END OF ACT I

* * *

The second and final act of Morning Rounds happens a little bit later, with the Attending presiding. The curtain rises:

ACT II

The place: The same.
The time: 7:30 a.m.
Enter Attending, Intern and Medical Student. The Intern and Medical Student are silent, attentive, almost worshipful.

Attending (to Patient, while moving very fast): Good morning! How's the belly?

(Attending performs a thorough examination of the patient's abdomen in 25 seconds, during which time the Medical Student drops his pen cap, which rolls under the bed; makes a split-second decision to go after the cap, without success, and finally resolves to use only ballpoints like everyone else has, which click in and out. During this same period the Intern makes notes on 10 patients, tries to guess what time he's going home tonight and wonders what the hell his student is doing under the bed.)

Attending: Great! Okay, I'll see you later. Keep on feeling better. (Directs a stream of instructions to intern.)

(Attending, Intern and Medical Student leave the room and head down the corridor.)

Patient (shouting after them): Can I eat tomorrow?

(Medical Student does not answer. He will ask Intern later in the day, after rounds. The answer will be furnished by the time they all round again in the evening.)

Patient: Hello?
(Tries to go back to sleep.)

END OF ACT II

CURTAIN

If you missed the first performance, don't worry. The cast will be waiting by the elevators at 5 p.m. for a return engagement. Bring your clipboard.

Zackary Sholem Berger plays the part of the Medical Student. He's lost many pen caps on morning rounds while much of the city is still sleeping.