The Year of the Intern

Day 365

The appendix lay to one side in a steel dish, where I had put it a moment earlier before turning back to the operating table. The surgeon was finishing sewing up the stump where the appendix had been. Our concentration was so intense that neither of us saw the hand until it crept into the operative field and began groping aimlessly around, palpating the fleshy, moist intestines. The hand was ungloved — most definitely out of place in our previously sterile operative field. It seemed to be a foreign thing from the twilight zone beneath the surgical drapes. The surgeon and I looked up at each other in alarm, and then at Straus, the newly arrived intern, but Straus couldn't take his eyes off the hand. The next few seconds whirled in mental confusion as the three of us strove to connect the intruder with one of the operating team. Just as I dropped my needle and thread and was reaching to pull the hand away from the incision, the surgeon figured it out. "For Christ's sake, George, the guy's got his hand in his belly!"

Awakened from his reverie, George, the anesthesiologist, poked his nose over the ether screen and commented, "Well, I'll be damned," in a noncommittal sort of way, before dropping back on his stool. With a deftness that belied his apparent torpor, he injected a potent muscle-paralyzing drug, succinylcholine, into the IV tubing. Only then did the patient's hand relax and fall back onto the surgical drapes.

"When you said you'd keep the patient light, I never thought I'd be wrestling with him," said the surgeon.

Instead of answering, George eased off on the succinylcholine IV with his right hand while his left opened the tank of nitrous oxide a few more turns. After several forceful compressions of the ventilation bag, to speed the nitrous oxide into the patient's lungs, George looked up to join the fray.

"You know, George, this epidural anesthesia of yours is good fun. Puts the challenge back in surgery. In fact, this case is exactly like a sixteenth-century appendectomy."

"Oh, I don't know," George retorted. "Back then the patients not only attacked with their hands; they kicked, too. Have you noticed how quiet his feet have been? We're making a lot of progress in anesthesia."

As such sallies went, this was a pretty heavy barrage, and the surgeon decided not to return fire. Instead, he directed his attention toward salvaging what he could of the operative field. While he kept a precautionary hold on the patient's troublesome hand, I covered the incision with a sterile towel soaked in saline. Straus and the scrub nurse and I were still sterile, as the OR terminology put it.

Breaking the sterility of the operative field was a serious problem, because it greatly increased the probability of post-operative infection with something like a staph. Some surgeons are quite maniacal about sterility — but never, it seems, in a consistently rational way. For instance, one professor in medical school required interns, residents, and students to scrub for exactly ten minutes by the clock. Anyone trying to get into the OR after a scrub of less than ten minutes had to start over from the beginning. These strictures did not extend, however, to his own scrub, which lasted, by generous estimate, no more than three or four minutes. Apparently the others' were more contaminated, or his bacteria less tenacious.

His fastidiousness about sterility had been responsible for one memorable episode. The case was an interesting one, involving a bullet wound of the right lung, and residents and interns were three deep around the OR table. One resourceful medical student a rather short fellow, was intent on seeing every detail. He piled several footstools on top of each other, stood on them, and by holding on to the overhead light for support, could lean over and gaze directly down into the operative field. This ingenious vantage point worked well until his glasses slid off and fell with an innocent plop directly into the incision. This had so unnerved the professor that he directed the resident to continue the case.

Luckily, Gallagher, the surgeon for the appendectomy, had a firmer grip on his emotions than the medical-school professor had. Though obviously upset, he was still functioning.

"George, see if you can pull this arm out from under the drapes and hold it securely," Gallagher said, looking over at me and rolling his eyes at the absurdity of it all as the anesthesiologist burrowed headfirst under the sheets.

"And, Straus, you just back away from the table," I said. Poor Straus was obviously confused. His eyes moved back and forth from the surgeon, still grasping the patient's hand, to the trembling mass of drapes that indicated the anesthesiologist's progress, or lack of it." "Just fold your hands, Straus, and keep them about chest level." Straus backed away, grateful for the instruction.

With some difficulty, the anesthesiologist worked the patient's hand back into its proper position and attempted to secure it flat on the operating table. Then the surgeon stepped back and allowed the circulating nurse to remove his gown and gloves, while the scrub nurse descended from her footstool with a new, and sterile, replacement set.

What a way to end my internship, I thought. This was my last scheduled scrub as an intern — perhaps my last time in the OR as an intern, although I was scheduled to be on call that night and could get some after-hours surgery. Anyway, this case had been a circus right from the start. For one thing, the patient had been given breakfast because I had forgotten to write "nothing by mouth" in the chart, and the nurses, who should have known better, what with all his other preoperative orders, had missed it, too.

"Straus, help me with the sterile drapes." I leaned across the patient and held one end of a fresh sterile drape toward the new intern. We were overlapping by one day — his first and my last. I was still officially an intern, although I suppose I had been acting more like a resident since all the new interns arrived. They seemed a good group, as eager and green as we had been. Strauss and I had been scheduled together so I could help him get acquainted. In fact, we were on joint call that night.

"Hold it up high," I directed, raising my end of the drape to about eye level and letting the edge cover the old drape. "Good. Now let the upper portion fall over the ether screen." He seemed to catch on easily, and I gave him the lower drape. But the surgeon, now freshly gowned and gloved, was impatient, and he took the drape from Straus, helping me to complete the redraping rapidly and without another word.

It was two-fifteen by the large clock with its familiar institutional face. I could not comprehend that within twenty-four hours I would be leaving my internship behind. How rapidly the year had passed. Yet some memories seemed older than a year. Roso, for instance. Hadn't he always been a part of me? And…

"How about a little help, Peters?" Gallagher was already brandishing a needle holder that trailed a fine filament of thread from the tip. But he couldn't begin because the sterile towel I had draped over the incision was still in place.

"Large clamp and a basin." I reached toward the scrub nurse, and she crashed a clamp into the palm of my hand. She was a demon when it came to OR procedure. Apparently she had been watching a lot of television, because she cracked the instruments into your hand almost to the point of pain, and when she gloved you it was as though she was attempting to stretch the glove all the way to your armpit. Using the clamp, I removed the sterile towel without otherwise touching it and plopped it into the basin. The concept of OR sterility baffled me to the point that I always erred on the safe side. I didn't know if Gallagher thought the towel was contaminated, but, to be sure, I didn't touch it. Of course, with the patient rummaging around in the wound with his bare hand, all this procedure was nonsense.

The towel out of the way, Gallagher returned to the appendix stump. Luckily, the patient had chosen a good time for his antics; not only had the appendix been removed, but the stump had also been inverted. Gallagher had been nearly ready to put in his second-layer closure over the area when the mysterious hand appeared.

George, the anesthesiologist, had made a fantastic recovery. Things were already back to normal over his way — the sound level of his portable Panasonic was competing with the automatic breather that had been brought in after the succinylcholine. This was not a mere precaution. Succinylcholine is so powerful that the patient was totally paralyzed now, and the machine was breathing for him. As Gallagher took the first stitch after his arm wrestle, the general atmosphere returned to precrisis level. We even paused to listen when the surf report drifted out of George's radio over the ether screen—"Ala Moana three-four and smooth." But my board had already been sold. Gallagher was one of a couple of the younger attending surgeons who occasionally surfed. I had seen him a few times at "number 3's" off Waikiki, and he was definitely a better surgeon than surfer, being rather dainty at heart. He had a telltale habit of picking up surgical instruments with his little finger stuck out, the way a flower-club lady holds a teacup.

That was the way he took the next stitch— extending his pinky as far as possible from the rest of his fingers and deftly trailing the silk out of the needle holder into my waiting hand. Since I was the first assisting, it was up to me to tie. Straus was holding the retractors. The first throw was formed and run down extremely rapidly, as happens when an act has become reflexive. The opposing walls of the large intestine came together over the inverted appendiceal stump. As I tightened the suture, Gallagher pretended not to watch, but I was sure he had an eye cocked. Since he didn't say anything, I guess he approved the degree of tightness I placed on the first throw. Then he took the freshly loaded needle holder from the scrub nurse as I started the second throw.

"Hey, Straus, how about lifting up a little on those retractors so I can see my knot?" It bugged me that Straus was staring off into space just then. I held up running down the second throw while he looked into the wound and lifted with his right hand, opening the wound wider. That made it possible for my right index finger to carry the fold of thread down until it matted with the first throw, where I tightened it with a precision that seemed to me exactly right. Another throw, but with my other hand leading, so the knot was sure to be a square knot, not a slippery granny.

Five such sutures completely covered the appendicial-stump area, and we were ready to close.

"Straus, you did a fantastic job," said Gallagher, winking at me, as he took the retractors from the new intern. "Couldn't have done without you." Not really knowing if Gallagher was putting him on, Straus wisely elected to remain silent. "Where'd you learn to retract like that, Straus?"

"I scrubbed a few times in medical school," he said quietly.

"I was sure of it," returned Gallagher, a supercilious smile creeping from the sides of his mask.

"Peter, can you and our young surgeon here close the wound?"

"Yes, I think so, Dr. Gallagher."

Gallagher hesitated, looking at the incision. "On second thought, maybe I'd better stay. If the patient gets a postop infection, I want as few people to blame as possible — just George. George, you hear that?"

"What’s that?" George looked up from his anesthesia record, but Gallagher ignored him and stepped back to rinse his hands in the basin.

"Straus, how are you at tying knots?"

"Not too good, I'm afraid."

"Well, ready to try a few?"

"I think so."

"Okay, when we get to the skin, you tie."

The fascial sutures went in quickly. My tying now was nearly as rapid as the surgeon's suturing, and the scrub nurse had to hustle to keep up with us. The smiling wound came together as the subcutaneous sutures were placed and tied.

"Okay, Straus, let's see what you can do," said Gallagher, after placing the first skin suture in the center of the wound and trailing the silk thread out over the patient's abdomen. The first skin suture, in the center of a wound, is the hardest, because until the adjacent sutures are placed it bears a lot of stress, and the stress makes it hard to tie with the correct tension. Gallagher winked at me again as Straus picked up the two ends of the thread. Straus didn't even have his gloves on tightly, and there were wrinkled bunches of rubber at the tips of his fingers. He didn't look up, though — which was a good thing, because I knew what was coming and my face was contorted in a broad smile of anticipation.

Poor Straus. By the time he got the second throw down, he was perspiring, and the skin edges were still almost half an inch apart. Moreover, he had gotten his fingers all bunched up in the suture in a fashion that suggested he was going through a comic routine. But he still didn't look up, a good sign. He would be all right.

"Straus, you've got the theory right. Skin sutures should not be too tight." Gallagher chuckled. "But half an inch is pushing a good thing too far."

"You guys can take all the time you want. The patient is going to be paralyzed for quite a while with that succinylcholine," added George.

I cut the gaping suture, pulled it out, and dropped it on the floor. Gallagher flipped in another in its place, detaching the thread from the needle with an almost imperceptible twist of his hand. Straus silently picked up the ends and started fumbling again.

"This isn't the first time I've seen a bare hand in a stomach wound," I said, looking over at Gallagher. "Once in medical school about eight of us students were in the OR trying to see a case, and the surgeon said, 'Feel this mass. Tell me what you think.' The residents all took a feel, nodding in agreement, and then an ungloved hand sneaked between two residents and felt around, too."

"Was it one of the medical students?" asked the anesthesiologist.

"Probably. We never knew for a fact, because we were all thrown out by the chief resident, who was trying to calm the surgeon."

Straus was still fussing with the second suture, dropping the ends, getting his fingers caught, and leaning this way and that in a kind of hopeful body English. I'm not sure how he expected body English to help, but I recognized the same tendency in myself.

"Did the patient get a postop infection?" asked Gallagher.

"Nope. Sailed through without a complication," I said.

"Let’s hope we're traveling the same path."

Without saying anything, I untangled the silk from Straus's hands and rapidly placed a knot, pulling it over to the side so that it was away from the incision. Straus doggedly kept his head down while Gallagher whipped in another suture.

"How about that one, promising surgeon?" said Gallagher, stretching his arms out with his hands inverted and his fingers intertwined. One or two knuckles cracked.

This Straus certainly was a silent fellow; not a sound came out of him as he concentrated on the skin suture. Actually, I was already tired of the game, of watching him fumble around. It was getting pretty close to three, and I had a lot to do, last-minute packing and other details. After a reassuring glance at Gallagher, I again untangled the suture from Straus and laid a rapid square knot, bringing the skin edges together without any tension.

"Well, I think you two can finish this up. Remember, I want only a piece of paper tape for a dressing." With that, Gallagher swaggered over to the door, snapped off his gloves, and disappeared. Straus looked up for the first time since starting the skin sutures.

"Do you want to tie or stitch?" I asked, looking at his drawn, sweating face. Actually, I couldn't decide which would be worse, his tying or his stitching. I wanted to get out of there.

"I'll stitch," he returned, reaching toward the nurse, who, true to form, slammed the needle holder into his palm. The sharp sound of metal on tense rubber glove surged and echoed around the blank walls of the OR. Straus literally jumped, startled by the impact. Then he winced and, after pulling himself together with another quick glance at me, bent over the wound and tried to dig the needle into the skin on the upper side of the incision.

"Straus."

"Yeah?" His face tilted up from his hunched position.

"Hold the needle so that the point is perpendicular to the skin, and then roll your wrist — in other words, follow the curve of the needle."

He tried, but when he rolled his wrist he pivoted the needle holder without taking account of the distance from the end of the needle holder to the tip of the curved needle. The result was a faint metallic snap as the needle broke off right at the skin. His hand froze, while his eyes, filled with disbelief and anxiety, darted from the broken needle point back to me.

Screw, I thought. "Okay, Straus, don't touch anything." "Big Ben" said five after three. Needle points — in fact, whole needles — were almost impossible to find once you lost them. Luckily, I could see the upper part of this one flush with the surface of the skin. "Mosquito clamp." Without taking my eyes off the almost invisible needle point, I reached toward the scrub nurse. Wham. The force of the delicate instrument sent a shock wave up my arm, vibrating my field of vision. The broken needle vanished. I scowled at the scrub nurse. She was a hulk, practically spherical, who surely outweighed me by a good twenty pounds, and her glare at that moment held such unexpected malice that I declined the opportunity of saying anything.

Instead, I concentrated on the delicate mosquito clamp, which was, at any rate, still in one piece in my tingling hand. By placing my left index finger in the incision and pulling up slightly under the broken needle, I was able to get some resistance before I attempted to grasp the embedded piece of steel. Still, the first attempt only succeeded in pushing the damn thing a little farther in. That was when I decided to finish both the suturing and the tying myself. The second attempt was more successful; withdrawing the clamp, I was relieved to see the gleaming needle point firmly caught on the end of it, and with a watchmaker's care I deposited the broken point on the corner of the instrument tray, matching the piece with its base to be absolutely sure there were no missing segments. Satisfied, I asked for a suture, avoiding a look at Straus.

The skin indented under the perpendicular needle as I raised the pressure until, with a pop, the needle broke through the skin. Rolling my wrist in an arc whose center shifted to eliminate torque on the needle point — the force Straus had ignored — I brought the needle point to the undersurface of the skin on the opposite side of the incision. Against the counterpressure exerted by the index and middle fingers of my left hand, I gave a decisive, crisp final twist of my right hand, and the needle point burst forth. Plucking the needle out with the needle holder completed the stitch. I detached the thread by lifting the needle holder so that the eye of the needle pointed upward; the drag on the end of the thread looping through the skin pulled the thread from the instrument.

Following the accepted routine, I dropped the empty needle holder into the draped area between the patient's legs. The scrub nurse would automatically retrieve the instrument and rethread it. Meanwhile, I snatched up the end of the thread, laid four throws of a square knot, and finished with the two ends on a stretch. Only then did I look at Straus.

"How about cutting, Straus?" I said.

He moved without answering, cut the thread, and continued looking at the incision. Ten more sutures were placed in like manner, rapidly and without conversation. After cutting a piece of paper tape and placing it over the closed incision, I turned to Straus. "Why don't you write the postoperative orders? You've got to start sometime. I'll look them over after I change. Then I'll introduce you to your patients. Okay?"

"Okay," he said finally, in a flat tone.

"Also," I continued, "I'll show you what I know about suturing and tying if you want." Straus didn't say another word.

What a drag, I thought. If he's tired already, he'll have a long, long year. But that was his problem, and his attitude didn't bother me for long; I had too much to do. Dropping my gloves in the bag by the door, I left the OR for the last time as an intern without the slightest feeling of nostalgia. In fact, I was euphoric. I felt I had done my time and was ready to be a resident — very ready. Medical practice was at last within sight. As I walked down the OR corridor, I wondered whether to buy a Mercedes or a Porsche. I'd always wanted a Porsche, but they were, after all, a little impractical. A Cadillac? I'd never own a Cadillac. What an obscene automobile! — although it was a favorite with surgeons. Hercules had one, and Supercharger, too. Anyway, a Mercedes sounded better to me.

The menu called them veal croquettes, but to us they were mystery mounds; ketchup was the antidote. Like that of most hospital cafeterias, the food here required a vivid and willing imagination on the part of the diner. If the menu said veal, it was best to cling tenaciously to the notion of veal, despite evidence to the contrary in taste, texture, and appearance. It was also helpful to suppress any knowledge of slaughterhouse malpractices, to be very hungry, and to be blessed with good conversation.

In fairness, I suppose the cafeteria cuisine in Hawaii was cordon bleu compared to hospital cafeterias I had seen during medical school in New York. Yet even in Hawaii the food service occasionally resorted to mysterious patties of ground meat, and, as if helping me celebrate, they picked this night to serve the veal one of my favorite conversation pieces. Also, I was still on call. Even so, the meal was like a banquet. It was my last night as an intern, and yet I was already a step removed from the battleground. Straus would undoubtedly be the first line of defense if and when trouble started.

The climate in the dining room was pleasant. Crisp, thin shafts of sunlight cut through cracks in and around the blinds on the windows facing the southwest. Specks of dust danced in and out of the golden beams of light, like bacteria under a microscope. Leave it to a doctor to think of such a comparison. One of the drawbacks of concentrated technical training, such as medicine, is that your mind eventually reduces everything to a technical experience. The dust could just as easily have looked like fish in the ocean or birds in the sky. But to me it looked like bacteria in a urinalysis sample.

A group of us were sprawled around one of the large round tables near the window. Straus was on my left, just beyond Jan, who sat next to me. In a social context, away from the terrors of the OR, Straus was anything but quiet and withdrawn, as I had typed him. In fact, he was extremely animated, vocal, and you'd have to say, contentious. He seemed to disagree with every point I made, whether it concerned automobiles, the drug scene, or medicine.

As frequently happened, the conversation had drifted inexorably toward the subject of medical care in the United States. There were six or seven others at the table, besides Straus, Jan, and me, but for one reason or another they had elected early in the meal to listen, rather than participate, and they ate their food and drank their coffee silently, leaving us to jabber on. Their only input involved an occasional incredulous laugh, accompanied by much eye rolling and headshaking, to demonstrate the ridiculousness of what had just been said. Obviously, they weren't going to add anything concrete or relevant. I began to tune them out, concentrating on Straus, who was plunging volubly onward.

"The only way medical care can be equitably distributed so that everybody enjoys the benefits is to restructure the whole delivery system," Straus was saying, alternately lifting his opened palm from the table and lowering it in time with the points he wanted to stress.

"You mean just junk the present system of doctors, hospitals, et cetera, and try something new?" I asked.

"You're damn right. Scrap it. Let’s face it. Medicine is behind the times in the way it organizes and distributes care. Think how much technology has changed over the last fifteen or twenty years. And has medicine changed? No. Sure, we know more science, but that doesn't help the man in the street. The fat cats get the benefit of the newly developed isoenzyme test, round-the-clock handholding, everything and anything new. What about the poor guy in the ghetto? He gets nothing. Did you know that forty million Americans have never even seen a doctor?"

Straus didn't wait for an answer, but kept up his attack, moving closer to the table. It was a good thing he didn't pause, because forty million seemed like a hell of a lot of people, and I wanted to question the figure. Besides, what did the figure mean, anyway, since it was common knowledge that plenty of Americans were literally starving for food? What good was sophisticated medical care when people didn't get enough to eat? But the statistic got lost in the conversation as Straus continued.

"What we have is a bunch of street-vending doctors pushing around handcarts in the space age. And it's the doctors' fault!"

"Now, wait a second," I said. I couldn't let that generality go by. "Things might not be in the best possible shape, but there are a lot of fingers in the pie.

"Right, a lot of rich, greedy fingers. I mean when health care, as lousy as it is, takes seven per cent of your gross national product — that’s about seventy billion dollars a year — there are bound to be a lot of interested parties. But the fact remains that in the United States doctors have made the system, and they run it. They run the hospitals, the med schools, and most of the research. Most important, doctors control the supply of doctors."

"What about the medical-insurance companies and drug firms?"

"Insurance companies? Well, their hands are not so clean, but, at any rate, they haven't interfered in the doctor-patient relationship — I suppose out of fear of the AMA. I mean if one company pushed too hard, the AMA could conceivably refuse to honor and treat that company's patients."

"Oh, be reasonable, Straus." I looked for support and got no commitment except from Jan, who nodded her head vigorously.

"So you don't think the AMA would do such a thing?" asked Straus.

"I can't imagine it."

"Ho-ho, my friend. Are you aware of the glorious history of the AMA?"

"What do you have in mind? I know some things about the organization." Actually, I was far from being an authority on the subject, both because it had been ignored in medical school and because — well, I just hadn't been very interested in it.

"What do you mean, some things about the AMA? Are you a member?"

"Well, sort of. You know interns and residents can join at a reduced rate. So I did. But I haven't done anything. I mean I haven't gone to any meetings, or voted, or participated in any way."

"There, that's one of the problems. You are a member. You're one of their statistics. They like to think that everybody is a member, only some are more active than others. The AMA claims it represents some two hundred thousand M.D.'s in the country, but do you know what?"

"What?" Straus definitely gave the impression of knowing what he was talking about.

'Their figures are out of whack. In lots of states, it's rigged that in order to get hospital privileges a doctor must join the local medical society, and with it comes automatic and compulsory membership in the AMA. And do you think most of those doctors care or even think about what's going on in the AMA? Well, dream on, because they don't. They say to themselves, I'm too busy; I don't have time. Or perhaps they have a feeling, although they don't examine it very carefully, that the AMA is dirty politics. In that they are correct. But through their apathy the sweet old AMA stands up in Washington and says that it speaks for some two hundred thousand M.D.'s, who never contradict the allegation. To make matters worse, it not only speaks for them, but throws their money around as well. Do you realize the AMA budget is over twenty-five million dollars a year, paid in dues by the doctors who say they haven't the time to find out what’s going on?"

"Okay, okay." I had to interrupt him; he was getting too excited. Two of the residents on the other side of the table stood up and left, dropping their napkins onto their trays. It was after six, and I had to get to my packing. Yet I couldn't ignore Straus. By now he was leaning toward me, literally in front of Jan, who had to sit bolt upright to accommodate him. I could see his eyes. He was a skinny, intense guy, anyway, and his eyes were burning.

"Straus, I'm not going to defend the AMA, but it is common knowledge that they've lifted the art of medicine out of the chaos it was in the nineteenth century. Before the Flexner report, around 1910, medical training was a joke, and it was the AMA that took on the burden of altering that."

"Yeah, sure they did. But let me ask you, for what end?"

"What do you mean, what end? To rectify a sorry situation."

"Perhaps, but also for their own ends."

"What do you mean by that?"

"Just that they cut the number of medical schools and made them better — that I'll agree to. But at the same time they locked up their control over the accreditation of medical schools. Translated, that means they have control over the supply of MD.'s and control over the curriculum. In other words, they have determined the social path through which potential doctors must pass, and they make damn sure that the students are nicely molded into the system."

"Straus, you are a romantic. Are you sure you want to start an internship?"

"I want to be a doctor, and if there were any other way of getting there, I'd do it. But to change the subject, tell me, Peters, are you aware of the burden of history you're assuming in entering the medical profession in America?"

"What are you driving at?" The last two doctors who had been sitting silently opposite us scraped back their chairs and departed. Only Straus, Jan, and I remained, leaning on a table littered with dirty dishes and soiled trays.

Undaunted, Straus continued. "The AMA has an almost unblemished record of failure in supporting, much less initiating, progressive social changes. For instance, the AMA was against the Public Health Service giving diphtheria shots and setting up V.D. clinics. And against Social Security, voluntary health insurance, and group practice. In fact, in the thirties the AMA labeled medical groups as Soviets!"

I sputtered, trying to say something, but I couldn't get it out.

"A couple more points. Did you know the AMA fought against full-time salaried hospital chiefs, and, closer to home, even against federal low-interest loans to medical students?"

"What was that?" I had started tuning Straus out when he lapsed into his list of grievances, until the words "loans" and "students" connected in my head. I still owed quite a bit of money from my medical-school days. "They were against loans to medical students?"

"You better believe it."

"Why?" That really did surprise me.

"Lord only knows! I guess it opened medicine up to the nonrich. But one of the most pathetic aspects of this scene is that after such reforms have been accepted by society and forced on the AMA, the AMA later tries to take credit for them. Makes you think of Orwell's newspeak in 1984. I mean the whole crummy scene has got to change. I think the government has to do it."

"Okay, Straus. Are you trying to tell me that after going all through those years of study, and all the years you still face, you're going to be willing to work for the federal government? That’s what you seem to be suggesting."

"Not necessarily. All I'm saying is that doctors have had the control, and they've screwed it up. Their responsibility is a lot broader than their solitary practices, treating a succession of individual patients. They've got to consider the totality of health care, including the treatment of the man in Harlem and the family in Appalachia — they're as important as treating a chairman of the board in Harkness Pavilion. If doctors fail again, the government will have to take control and order the medical profession to accomplish what is needed. After all, adequate health care is the right of every citizen."

"That’s easy enough to say, but I'm not so sure. After all, when someone is bothered by a headache at 4:30 a.m., and he gets a doctor out of bed because health care is his right, what about the rights of that doctor? I mean how much can you impose on one person for the rights of another? Surely the doctor has rights, too.

"And besides, if somebody's kidneys give out, but all the artificial-kidney machines are in use, whom does the patient sue? Society can't have an artificial-kidney machine sitting in the corner for every citizen. The fact of the matter is, health care is a service industry provided by highly trained people and sophisticated equipment, both of which are always in short supply. You can't promise health care to all when you have limited resources."

"I'm not going to argue that point, Peters. The federal government has clearly defined health care as a right of its citizens by passage of the Medicare and Medicaid laws."

"Well, Straus, I'd like to talk to you again after you finish your internship. Up until now you've been a student, and let’s face it, if things got too bad you could just walk out and leave somebody else with the responsibility. I wonder if you'll feel the same after this year is over."

Jan had been listening quietly, more, or less on my side, I thought. Now she chimed in. "There might be some problems with health-care distribution, but we do have the best medicine in the world, Straus. Everybody knows that."

"Nonsense," retorted Straus. 'Take infant mortality. The United States ranks fourteenth in prevention of infant mortality, eighteenth in projected male life span, and twelfth—"

"Hold on a minute, Straus," I said, refusing to listen to another statistic.

"Only fourteenth in infant mortality?" asked Jan. Straus had really gotten to her.

"Jan, dear, don't be misled by statistics. You can prove almost anything with statistics if you deal with different sample populations. It can be a kind of mathematical gerrymandering. Straus, being fourteenth or whatever we are in infant mortality probably has more to do with the fact that we keep such accurate records in this country. Lots of countries record only the births in hospitals. All others go unrecorded."

"They're pretty good at record keeping in Sweden," returned Straus with a smile.

"Well, then, there are differences in records according to what time during the pregnancy the kid came out — whether it was a stillbirth, dead in utero, or whether it was a case where the kid died when it was really a viable being. It makes a big difference where a country draws the line in amassing statistics on infant mortality."

Straus put up his hands, palms toward me, and slowly lowered them as he continued. "Again, I won't argue about the technical details of the statistics. But the fact remains that the United States is not at the top. And fourteenth is a pretty low position when you consider where we are in most other technological and service fields. Frankly, Sweden makes us look pretty sick."

"Sweden doesn't have our problems," I said sharply. "They deal with a relatively small, homogeneous population, whereas the United States is a pluralistic society. Do you mean to say you feel that a socialistic welfare state like Sweden is the answer to all social ills, and the solution for us?"

"It seems to be better for infant mortality, and children's dental care, and longevity. But I'm not saying that the United States should adopt the Swedish system of government or health care. All I'm trying to say is that there are places where health care in general is better than here. That, translated, means that better health care is possible, and we have to make it happen."

"Well, you can't create a service industry like medicine out of a vacuum, nor can you abruptly legislate it. Changes in social structure occur only through changes in the attitudes of people. These changes are slow, and related to the educational forces organized to deal with them. People are used to the current doctor-patient relationship. I don't think they want it to change."

"For Christ's sake, Peters, forty million people have never even seen a doctor! How can they develop an attitude? Man, that's a vacuous excuse. Yet it's typical, too. You and your buddies can think of a million little irrelevant reasons why the present system should stand without change. That's why the whole structure has to be scrapped. Otherwise, we'll water down the problem by compromises like Medicare and Medicaid."

"So even Medicare and Medicaid are bad. Straus, you're a real bomb thrower. Everything is black from where you sit. I think Medicare and Medicaid are pretty good laws. The only problem I can see with them is that they screw up the graduate teaching system by making it possible for many of the patients we'd been handling to go to private M.D.'s, who don't let the interns and residents in on the case. As a result, we have effectively lost a large population of patients for learning."

"Well, that’s pretty important," said Straus. "And if s indicative of the Band-Aid solution to gigantic social ills. Yet the biggest problem of Medicare and Medicaid is that they have just thrown more money into the hopper, creating more demand. If the demand goes up and the supply stays the same, prices soar."

"Sure, sure." I was getting a little angry now. "What you want is another monolithic government bureaucracy, with millions of file cabinets and typewriters. But this is going to cost a lot of money. Health-care cost would probably go up, not down, with such a bureaucracy. And I suppose you envision all doctors on government salary. That would be interesting! Society is going to be in for a little shock when it finds out how much money it needs to pay those doctors. Financial return would have to go up, as the doctor rapidly learned to compare himself to someone like a unionized airline pilot, who can get about fifty thousand dollars a year for a sixty-five-hour month. How many doctors would it take to man the healthcare system if each one worked sixty-five hours a month? Plus they'll want retirement benefits—"

"That is a—"

"Just let me finish, Straus. Putting all the doctors on salary would have other, more subtle effects. If you are on salary, no matter what you do, it has an effect on your motivation in marginal situations. Look, Straus, when you drag yourself out of bed at 4:00 a.m., you want something for it, something more than the satisfaction it gives you. Lots of times it doesn't give you any satisfaction at all. Quite the reverse.

"After all, the garbage man, the airline pilot, everybody else gets overtime. Well, the doctor is going to want that, too, or he won't crawl out of bed. Let me put it another way. When you work for a salary, you have specific hours. Come five o'clock, and the salaried doctor washes his hands and goes home. I happen to know that, stripped of a lot of mythology, a doctor is a pretty ordinary human being."

"Can I talk now?" asked Straus.

"Please."

"Several things. Number one: a national health service is not the only answer. You're jumping to conclusions. Private prepaid health plans, for instance, work well, plus improving the productivity of individual doctors for a number of reasons. The government's role could be merely to guarantee that everyone is covered, one way or another, with at least a good-quality, basic health-care package. And number two: I don't agree with your views about the sleeping doctor. At the same time, I do believe the doctor will have to be paid in relation to some rational scale that compares favorably with airline pilots, or plumbers, or anybody else, keeping in mind the duration and investment of his training, as well as the long hours he must work. But, on top of that, I believe that the professional pleasure of practicing medicine will carry the doctor over the bumps in his day — especially if he is relieved of the burden of paper work and other piddling tasks that absorb twenty-five per cent of the solo practitioner's time. Besides—"

"Dr. Peters, Dr. Peters." My name suddenly shot out of the page speakers near the ceiling and echoed around the room. Straus went on talking as I moved toward the phone in the corner.

"Besides, in group practice," continued Straus, "there is more chance for peer review. The doctors can keep a good eye on each other and offer advice and criticism when needed. And records. Patients' records would be far better, because they'd be organized and complete whether the patient saw the G.P. or a specialist." Straus was literally shouting by the time I got to the phone and dialed the operator. Then, thank God, he finally shut up.

The operator connected me to the private surgical floor, and then I had to wait while they looked for a particular nurse.

"Dr. Peters."

"Yes."

"We have a patient of Dr. Moda's who's having some breathing difficulty. He wants the intern to see her. Also, I need an order for a laxative on one of Dr. Henry's patients."

"How bad is the breathing problem?"

"Not too bad. She feels okay when she's sitting up."

"Dr. Straus will be up right away."

"Thank you."

Turning around and retracing my steps, I noticed the whole cafeteria was empty except for us. The sun had disappeared, and the illumination in the room had changed from sharp, contrasting light and shadow to a soft, suffused glow. It was a peaceful scene, made more so by my inner joy at knowing that I could send Straus to see the lady with the breathing problem and to handle the constipation case.

"Peters."

"Yeah?" The voice on the other end of the line was familiar.

'This is Straus."

T couldn't have guessed. You certainly do seem to be busy."

"I can't help it. Everybody's going sour," he said. I glanced at my watch. Ten-thirty.

"Well, what’s the current crisis?" I asked.

"An old lady died. About eighty-five years old. A private patient on Ward F, second floor."

There was a pause. I didn't say anything, expecting to be told more about the problem. Straus's breathing could be heard on the other end of the line, but he apparently had nothing to add. Eventually I spoke.

"Okay, so an old lady died. What’s the problem?"

"No problem, really. But would you mind coming over and taking a look?"

"Look, Straus, she's dead, right?"

"Right."

"Well, what do you expect me to do? Perform a miracle?"

There was another brief silence. "I just thought you'd want to see her."

"Thanks a million, old boy. But I think I'll pass it up."

"Peters?"

I'm still here."

"What do I do about the family and the paper work?"

"Just ask the nurses. They're old hands at this stuff. All you have to do is sign some papers, notify the family, and get an autopsy."

"An autopsy?" He was genuinely surprised.

"Sure, an autopsy."

"Do you think the private doctor wants an autopsy?"

"Well, he ought to, that's for sure. If he doesn't, he can turn it down. But we should get autopsies on everybody who dies here. It might not be easy, but get the family to agree."

"All right, I'll try, but I'm not guaranteeing anything. I'm not sure I'll be able to communicate much enthusiasm for an autopsy."

"I'm sure you can handle it. Ciao."

"Ciao."

He hung up and so did I, thinking once again about the yellow woman in the autopsy room in medical school. Jan interrupted me.

"Something wrong?" she asked.

"No. Someone died, and Straus wants to know what to do."

"Are you going over to the hospital?"

"Are you kidding?"

Jan was helping me pack. Actually, she was just there. We certainly didn't need any excuse to be together; we'd been spending a lot of time with each other. So much, in fact, that my imminent departure cast a shadow over the evening, although we had stopped discussing it.

The point at issue was whether I loved her enoughs— her wording — to ask her to follow me to my residency. I had implied as much many times, yet something kept me from asking straight out. What I had tried to tell her was that I wanted her to make the decision, without my direct interference. I didn't want the responsibility of forcing her to come with me. That was how I viewed it. I mean what if we didn't make it after we got to my residency? If I had forced her to leave Hawaii, then I'd undoubtedly feel bound by some sort of guarantee, and I just couldn't do that. I wanted her to come, all right, but on her own.

Jan and I had had a ball. It had been a relief to build a significant relationship with her after the debacle with Karen Christie and her screwed-up fiance. Although I had gone over to Karen's a few times after the confrontation with her boyfriend, I eventually realized that I couldn't keep seeing her. So I stopped.

The phone rang again. "City morgue," I answered, in a loud and cheerful voice.

"Peters, is that you?"

"At your cervix, Straus, old boy."

"You really threw me for a second. Don't do that," said Straus.

"All right, I'll try to be more civil. What’s up?"

"I got a call from the ICU, and there's a patient having difficulty breathing. The nurse said it was probably pulmonary edema. Apparently the private doctor is worried about heart failure."

"Pretty good nurses in there, huh, Straus? Diagnosis and all. That’s real service. Do you agree with them?"

"I haven't seen the patient yet. I'm just on my way up there. I wanted to call you in case you care to be in on the action from the start."

"Straus, your courtesy warms my heart. But why don't you hustle up there, check it out, and then give me a buzz, okay?"

"Okay. I'll call you right back."

"Fine."

Jan was absorbed in trying to fit my medical library into several trunks. It was obviously a problem of Gordian complexity requiring an equally drastic solution. I had to decide which books to leave behind — a terrible tragedy to a doctor. A lot of people appreciate books, but doctors worship them and communicate with them almost sensuously. If a doctor is at all realistic, he quickly grasps the fact that he can never match wits with his library. Consequently, he surrounds himself with books, greedily searching for reasons to buy a new text, whether he will ever read it or not. Books are a doctor's security blanket, and they were mine.

The mere thought of discarding any of my texts smacked of sacrilege — even that psychiatry text, or the one on urology. Urology wasn't my favorite specialty, by any means. I frequently wondered how anyone could spend the rest of his life fooling around with the waterworks — although the field couldn't be too bad, because urologists seemed a pretty happy group, on the average. Undoubtedly they had the best repertoire of dirty jokes.

"You're never going to get all these books in here," said Jan.

"Will, let’s take them all out and start over. In fact, let’s try to stand them up rather than lay them flat." I showed her by propping up approximately forty-eight pounds of Comprehensive Textbook of Psychiatry in the corner of the trunk. Then the phone rang again. It was Straus; his voice carried a sense of urgency.

"Peters?"

"What’s wrong now, Straus?"

"You know the patient I told you about before, the one the nurses thought had pulmonary edema?"

"What about him?" "Well, I think he does have pulmonary edema. I can hear bubbling rales with my stethoscope up both lung fields almost to the apices."

"Okay, Straus. Calm down. Did you telephone the resident on call?"

"Yeah."

"What’d he say?"

"He said to call you."

"Oh, fine." I hesitated, collecting my thoughts. "Is it a private patient?"

"Yes, Dr. Narru, or something like that."

"Is it a teaching case?"

"I don't know."

"Well, check, Straus." I played with the bell of my stethoscope while Straus left the line. Jan was making good headway with the books; it began to appear that she would get them all in.

"Yeah, if s a teaching case, Peters," said Straus.

"Did you call Dr. Narru?"

"Sure. I did that first."

"What’d he say?"

"He said to go ahead and do whatever was necessary, that he'd stop by later and check on things when he made his evening rounds."

With my index finger, I tipped my watch over so I could see the dial. Five after eleven. Either Narru was putting Straus on or he really did make late-evening rounds — very late. Somehow I couldn't imagine that.

"Jan, why don't you put Christopher's surgical text in before those little books? Just a minute, Straus. Christopher's is that big red one. That’s it." It was going to be close. "All right, Straus, what kind of surgery did this fellow have?"

"I'm not sure. Some sort of abdominal surgery. He has an abdominal dressing."

"Does he have a fever?"

"A fever? I don't know."

"Is he on digitalis?"

"I don't know. Look, all I've done is listen to his chest."

"Did you listen to his heart?"

"Sort of."

"Was there a gallop rhythm?"

I'm not sure," he said evasively.

Good God, this guy is really eager, I thought sarcastically. "Straus," I said, "I want you to examine the patient, keeping in mind three possible diagnoses — pulmonary edema, which he probably has, pulmonary embolism, and pneumonia. Read the chart and find out about his cardiac history. Meanwhile, get a chest film, a complete blood count, a urinalysis, an EKG, and anything else you think you want. Is he very stuporous?"

"No, he's quite alert."

"Okay, then give him 10 mg. of morphine and put him on oxygen with a mask. But be sure to watch him carefully when you first give the oxygen. Then, when you get everything organized, call me back."

I was about to hang up when I thought of something else. "One other thing. If he's never had digitalis — at least, not during the last two weeks— give him 1 mg. of digitoxin IV. But do it slowly. Straus, are you still there?"

"I'm here," he said.

"We probably should give him some diuretic as well, to get rid of some of his excess fluid. Try about 25 mg. of ethacrynic acid." I knew that stuff was so powerful it would wring pee from a stone. Powerful — my inner fear of diuretics made me think twice, and I changed my mind.

"On second thought, hold the diuretic until we're sure of the diagnosis of pulmonary edema. If he has pneumonia, it wouldn't help too much." The old lady with cancer whom I had killed with the diuretic haunted me for a moment; she had died of pneumonia. Finally I hung up the phone.

"Hey, Jan, that’s great." She'd been able to squeeze in all but one small book. The remaining volume was what we called a throwaway — one given out by a drug firm hoping to convince somebody that one of its drugs was the answer to all pathological evil. I'd never read it, nor did I intend to. Nevertheless, I jammed it into one of my already full suitcases.

Except for my shaving equipment and other toilet articles, the clothes I was going to wear in the morning, and the dirty set of whites I was now wearing, all my junk was packed. The shippers were scheduled to take my trunks in the morning; the suitcases were going with me, along with an array of hand luggage that included a large piece of coral. Finally all was ready. I could relax and enjoy what remained of my year in Hawaii.

Jan chose that moment to drop her bomb by abruptly informing me she was going home. Just when we could forget all the packing and be together, she decided she was leaving. Obviously, it came as a complete surprise, since I had blithely assumed we would sleep together, as usual.

"Jan, why in heaven's name do you have to leave? Please stay. If s my last night."

"You need a good night's sleep before your trip," she said evasively.

"Well, how about that!" I gazed into her tanned face. She looked at me with her head tilted slightly forward and to one side, flirting expertly and suggesting that her sudden coyness was based on complicated female reasons. Yet I wasn't sure. I could understand her desire to leave if it sprang from a disdain for the artificial last-night routine, from not wanting to reduce our love-making to a sort of ritual to celebrate a passing era. The closeness we normally enjoyed probably wouldn't have been there, anyhow, since we were both preoccupied with other thoughts.

She kissed me lightly, said she'd see me in the morning, and noiselessly floated out the door. It all happened too rapidly for mental digestion.

Fleetingly, I thought of going to the ICU, even though I didn't really want to, but ultimately I shrugged off the thought with the rationalization that Straus needed to stand on his own two feet.

So I decided to take a shower — and no sooner had I stepped in than the jangle of the telephone sounded. The only way I could drown out the ring was by putting my head directly under the nozzle. I shouldn't have left the bathroom door ajar. But habit won out. On the fourth ring I sprinted back to my room and picked up the phone, while a puddle at my feet rapidly expanded its periphery.

"Peters, this is Straus."

"What a surprise!"

"Guess what? Good news!"

"I'm certainly ready for a little of that."

"The pulmonary-edema patient I talked to you about turns out to be on the medical service, not surgical, and the medical intern has assumed control.

"What about his surgery?" I asked, quite surprised.

"He hasn't had any surgery. At least, nothing recent. The dressing was covering a colostomy he'd had put in years ago."

"Congratulations, Straus. Your first clinical success as an intern. But why don't you hang in there just the same? Unless, of course, you have something else cooking."

"Sorry, can't stay. I got a call from surgery. They've scheduled a kneecap removal. Automobile accident, I think. Unless you want to go, I'll head up there."

A patellectomy, an orthopedic case! It was becoming very clear to me how much I would treasure being a resident rather than an intern. Imagine being able to send someone else on a midnight patellectomy! That was true happiness.

"I wouldn't deprive you of the pleasure, Straus. You go ahead and scrub."

Orthopedic surgery really freaked me. Before med school, I had labored under the delusion that surgery was an accurate and delicate science. Then had come the holocaust of my first orthopedic scrub, where I witnessed the grossest nail pounding, drilling, and bone crunching I could possibly have imagined. Not only that — the mayhem had also been accompanied by comments like "Get X-ray in here so I can see where the hell that nail went"; then, after looking at the X ray, "Damn, missed the hip fragment completely. Let's pound in another one, but this time aim at the belly button instead."

Such experiences had quickly eliminated orthopedic surgery as a specialty for me. Neurosurgery had fallen away soon after, when I saw the best neurosurgeon in New York pause during a case and peer into the hole he'd dug in a patient's brain to ask, "What is that light gray thing?" No one answered — after all, he was only talking to himself — but that was the end of neurosurgery for me. If he didn't know where he was after twenty years, there was no hope that I'd ever learn.

With all my medical books packed, I didn't have anything to read to put me to sleep. Then I remembered the drug-firm throwaway I'd crammed into my suitcase. I pulled it out and settled back into the cool white pillow. Appropriately enough, it was titled The Anatomy of Sleep. Flipping to the back of the book, I learned it was a hard sell for a sleeping pill. I cracked open the volume haphazardly and began reading. With so much on my mind, I managed to finish a whole page before my eyes began to droop.

The harsh ring of the phone came at me even before I had a chance to start a decent dream. In customary panic, I snatched up the receiver as if my life depended on it. By the time the operator connected me to the nurse who had paged me, I was well oriented as to time, place, and person.

"Dr. Peters, this is Nurse Cranston of F-2. Sorry to wake you, but Mrs. Kimble has fallen out of bed. Would you come over and check her, please?"

The luminous radium dial of my alarm clock told me I'd been asleep for about an hour.

"Miss Cranston, we have a new intern tonight. Name's Straus. How about giving him a call on this problem?"

"The operator already tried," she said. "But Dr. Straus is scrubbed in surgery."

"Piss."

"What did you say, Doctor?"

"Is the patient all right?" I was stalling.

"Yes, she seems to be. Are you coming, Doctor?"

I growled something implying the affirmative and hung up. Clearly, I hadn't graduated from internship yet. Until I actually hauled my body out of range, there would always be one more patient to fall out of bed. Lying there thinking about it was a mistake. I drifted back to sleep.

When the phone rang again, I responded with the usual panic, wondering how long I'd been asleep. The operator enlightened me — twenty minutes, she said — and canny as she was, saved me the effort of making an excuse by suggesting I might have fallen back to sleep. After all, it happened to everyone, even on emergencies. If I didn't put my feet out on the cold floor immediately, my chances of getting up fell precipitously. For a while, my trick had been to place the phone several yards from the bed, out of reach, so that I had to climb out of the warm nest just to answer it. However, with so many laxative calls that I could handle while horizontal, I eventually abolished that ploy and returned the phone next to the bed.

After the second call, I hauled myself out straightaway and dressed rapidly. With luck, I could be back in bed in twenty minutes. My record was still seventeen.

The fluorescent lights in the hall, the elevator doors, the stars in the sky — in fact, the whole trip over to Ward F escaped record in my brain. I functioned as an aware creature only when I found myself face to face with Mrs. Kimble.

"How are you, Mrs. Kimble?" I asked, trying to judge her age by the meager light of the lamp on the night table. I guessed about fifty-five. She was neat and tidy, and gave the impression of being a particularly meticulous individual. Her hair was drawn back in a tight bun that had streaks of gray.

"I feel terrible, Doctor, just terrible," she said.

"Where did you hurt yourself? Did you hit your head when you fell?"

"Heavens, no. I didn't hurt myself at all. I didn't even fall, really. I sat down."

"You didn't fall out of bed?"

"No, not at all. I came back from the bathroom, and I was squatting down right there." She pointed to the floor by my feet. "I was trying to get my notebook out of my night table when I lost my balance."

"Well, now try to get some sleep, Mrs. Kimble."

"Doctor?"

"Yes?" I looked back over my shoulder, having already turned toward the door.

"Could you please give me something for my bowels? I haven't had a decent movement in five days. Here, let me show you."

With great effort, she reached over and pulled out the night-table drawer, withdrawing a four-inch black notebook. She had to reach so far for the book that I was sure she would topple over, after all. I moved closer to the bed and held my arms under her extended torso.

"Look here, Doctor." She opened the notebook and ran her finger down a neatly written list of days. Each day was followed by a graphic and complete description of her bowel activity — form, color, and effort expended. Abruptly her finger halted at one of the days.

"There, five days ago was the last normal movement I had. Even that wasn't completely normal, because it wasn't brown. It was olive-green, and only this big around." She held up her left hand, with the thumb and index finger defining a circle about a half inch in diameter.

What could I say to her that would indicate competence and concern, and, most important, would extricate me immediately? I looked from the notebook to her face, groping for a reply and finding none. I passed the buck.

"I'm sure your private doctor would know far better than I what would be best for you, Mrs. Kimble. Just try to get some sleep for now."

Back at the nurses' station, I wrote something in her chart about the alleged fall; an entry in the chart was required after all such "falls." Then I set out on my return journey to my waiting bed.

"Well, Straus," I ruminated. "What would that little episode be worth under your new system? Professional pleasure, bull!"

My faith in airplanes is not unlimited. In fact, I don't truly believe- in the aeronautical principle. But I had to admit that the Pratt and Whitney engines sounded sturdy and reliable. I could hear them smoothly whining as they did their thing, and the huge, ungainly hulk of the 747 lifted off the ground, leaving Hawaii and my internship behind. I had a window seat on the left side of the aircraft, next to a middle-aged couple dressed in matching flower-print Hawaiian shirts. My carry-on luggage had been a bit of a problem — where to put it all — and I sat now holding my piece of coral, which was not designed by nature to fit neatly into a modern public conveyance.

The final good-byes had been rather subdued, after all. At the airport, Jan had "leied" me four times, as Hawaiian terminology puts it. Two of the leis were made of pekaki, and their delicate aroma floated in the air around me. There had been no more talk of Jan and me and the future. We would write.

I had mixed emotions about leaving Hawaii, but no ambivalence about the termination of my internship. Already, though, I was noticing a curious tendency in myself to remember and magnify the high spots, the fun of the year, and to forget the hassle and the hurt that actually had been dominant at the time. The body has a short memory.

As the plane banked to the left, I looked out the window at the island of Oahu for the last time. Its beauty was undeniable. Rugged ribbed mountains jutted toward the sky, covered by velvetlike vegetation and surrounded by a shining dark blue sea. By pressing my nose against the glass, I could see straight down to where the waves were breaking on the outer reef of Waikiki, forming long ripples of white foam. I would miss those.

I thought of Straus just starting his internship, with the whole year ahead of him. Right now, he was having one of the experiences I had had. Life was repeating itself. Straus and Hercules — that would be quite a confrontation. I imagined that the sharp edges of Straus's idealism would round off soon enough, after four or five cholecystectomies with Hercules.

Like a big bird in slow motion, the plane rolled back to a level position on its path toward California. The only evidence that we were moving was an almost imperceptible vibration. The island was gone now, replaced by an indistinct horizon where the broad expanse of ocean merged with the sky. I thought of Mrs. Takura, the baby born in the VW, Roso, and then Straus again. I didn't agree with everything Straus had said, but he had made me realize how little I knew, how little I cared about the system, except, of course, when it affected me directly. Imagine the AMA trying to block my federal low-interest loan for medical school! Impulsively, I rolled slightly to my right, clutching the coral, and extracted my wallet from my pocket. Settling back into the seat, I sorted through my cards and licenses until I came to it. "The physician whose name and signature appear on this card is a member in good standing of the American Medical Association." The words were impressive. They suggested an allegiance with a powerful institution. I had worked for five long years, and now I was there.

Just then I felt the first jolt, and then another one, sharper, more forceful, as the sign flashed on. "Ladies and gentlemen, please fasten your seat belts. We are expecting some local turbulence," the stewardess droned reassuringly.

I sat there next to the couple in the flowered shirts, holding my piece of coral and folding the AMA card nervously back and forth, back and forth, until the ragged fold parted and the card tore in half.