Excerpted from Dr. Moskowitz’s book: Plain Doctoring
My fundamental beliefs and attitudes about doctoring grew out of my experiences as a medical student in the 1960’s, when practical dilemmas encountered on the wards of a large city hospital led me to question the values I was being taught, and to study philosophy before going into practice, bad habits that have shaped my career ever since, throughout internship and more than fifty years of clinical work.
Medical school was a real turning point in my life, a time of inner turmoil that shook my optimistic temperament to the core and radically changed my idealistic world-view forever. The first two years I found more tolerable on the whole, and even engaging and interesting at times, being largely devoted to book-learning, and above all to memorizing enormous quantities of material in anatomy, histology, physiology, biochemistry, pathology, microbiology, pharmacology, and embryology, tasks I was thoroughly familiar with and reasonably proficient at.
In September of my first year, as our very first assignment, we were divided up into teams of four, presented with the mortal remains of what had been until quite recently a human being just like ourselves, and instructed to dissect, dismember, and eviscerate them as carefully and systematically as possible, with nothing more than an atlas for reference, and rare, perfunctory visits from a preceptor for supervision and guidance.
While I’ve long since forgotten the names of my teammates, and felt awkward and clumsy in the dissecting room, we all got along reasonably well, and the whole exercise proceeded without hindrance, despite the hot, humid weather and the reek of our sweaty bodies commingling with the formalinized corpses we were taking apart, which often drove us to the water fountain or outside for long stretches of the afternoon.
For the most part, we endured it patiently enough, as the rite of initiation it had long since become, at least subliminally aware that the grave-robbing dissections of the Renaissance painters and anatomists had pioneered and come to epitomize that mighty revolution in human thought into which we were about to be indoctrinated.
But inasmuch as my primary goal in studying medicine was clinical practice rather than academic research, my objections and antipathies didn’t really take shape until the hospital clerkships of the last two years, and continued to percolate inside me for many more years after that, until I could understand and articulate them in a way that made sense to me.
At the start of our clinical rotations in the fall of our third year, the entire class of a hundred and twenty or so gathered in the main auditorium for the Chief of Surgery’s formal speech of welcome. Although I’ve drawn a blank on everything else he said, I’ve never forgotten his very first words, solemnly declaimed in a loud voice, only half in jest, like a watchword for us to live by, if not a mantra for the profession as a whole: “Never say ‘Whoops!’ ”
Most of our clinical work was performed at Bellevue, the antiquated but still venerable city hospital for the Borough of Manhattan, which provided the latest diagnostic and treatment facilities gratis to anyone who needed them, along with substantial quotas of neglect and abuse from overworked interns and residents, and attentions both welcome and unwelcome from the students as we rotated through each service.
In those days, third-year students on the Medical wards were initiated into the mysteries of patient care by “drawing the bloods” for the day. In charity hospitals maintained at public expense, indigent patients were routinely taken advantage of by the students, interns, and residents in exchange for their care, and were duly expected to surrender themselves and their body fluids for any tests that any of us were even remotely interested in or curious about.
Even today, sixty years later, I can still almost hear the low, mournful wail that greeted us every morning as the patients saw us coming with our implements down the hall.
After days and weeks of clumsy experimentation on veins often weak and traumatized to begin with, I was regularly at a loss to find one that was serviceable, and often needed to be rescued by Dr. Randolph Chase III, our Chief Resident in Medicine, a handsome, powerfully-built, and very black former Captain of Marines in the Korean War, whom I idolized intensely.
Materializing suddenly, as if out of nowhere, he would always offer to help in a soft, kindly voice, with a can-do attitude that radiated confidence in the face of any challenge. On those rare occasions when even he came up short, our last resort was the dreaded femoral puncture, which took only seconds to execute, but left perpetrator, witness, and victim alike holding our breaths until the huge syringes were filled at last.
On the medical wards, we were responsible for admitting all the lobar pneumonia patients, typically alcoholics from the Bowery, for whom a high fever, productive cough, pleuritic pain, or some equally serious ailment was often the only ticket to a warm bed and regular food on cold winter nights. In most cases, the sputum was loaded with Streptococcus pneumoniæ, an organism easily detectable by microscopic examination and wholly curable in those days with minute doses of penicillin.
Before initiating treatment, we were instructed to inoculate the sputum into the peritoneal cavity of two mice, yielding an almost pure culture of the pneumococci when we sacrificed them two days later. Since the test was purely academic, I merely pretended to do it, being still too timid to raise the issue of animal testing, but unwilling to inflict or witness the torture myself.
Having grown up to think of illness as a particular episode that we come down with, work through, and recover or perhaps die from, I was wholly unprepared for the existential shock I experienced daily on the wards of Bellevue, where chronic disease was the definitive, omnipresent reality, and a vast nexus of goods and services had been created to manipulate and exploit it.
I have never wholly recovered from my dystopian fantasy that everyone there — doctors, patients, students, nurses, employees, and policemen alike — must have somehow imbibed, inhaled, or osmotically acquired and assimilated a full complement of dysfunctions, diseases, and abnormalities that we would never be entirely free of.
Even on those rare occasions when the wards were deserted and the beds were empty, I could still almost smell the faint but ineradicable miasma of sickness and disease that lingered over the place, like the accumulated residuum of all ills past and present.
Enlisting us to perform their dirty work, the interns and residents would try to win our co-operation by pointing out that we could similarly lord it over our own crop of students in the future. In that fraternal spirit, one of the interns hit on me to pass a Rehfuss tube into the duodenum of a diminutive Puerto Rican woman whom he was working up for possible pancreatic disease.
Like a stomach tube, but with a weighted metal ball at the tip to carry it through the pylorus into the small intestine, this little devil was practically impossible for an unanæsthetized person to swallow without gagging.
After three failed attempts, I handed it back to the intern, wishing that doctors be given a taste of their own medicine before being allowed to administer it to others. Faring no better himself, my de facto rôle model for the day took to blaming the victim, unleashing a torrent of racist slurs and scornful invectives like “stupid” and “animal” that are almost identical in Spanish, in a contemptuous tone of voice that also required no translation.
Pulling herself up in bed to face him, this quiet, little lady suddenly rose to an impressive stature with dignity, poise, and bearing, rebuking his insolence and vowing retribution for having molested her. A few days later, noticing two burly, mustachioed young Latinos lurking about the ward, I made myself scarce, but secretly wished them success.
In like manner, the hospital dramatized the need for patient empowerment through the gnarled and twisted shapes it often assumed there, like the middle-aged black man with a chip on his shoulder who lived on the street but knew more about emphysema and chronic lung disease than most of the doctors treating him for it, and could usually be found in the hospital library boning up for our discussion of him on rounds the next morning.
Many years were required for me to fully grasp that the inequality in rank and power that allowed us to do whatever we wanted and obliged our patients to obey and even thank us for it regularly culminates in the actual propagation of disease, both indirectly, by spreading fear and doubt, and directly, through excessive use of diagnostic and treatment procedures with obvious power to harm.
One senior Professor of Surgery never tired of promoting his pet theory that chronic pancreatitis arose from spasm of the sphincter of Oddi, causing reflux of bile into the pancreatic duct, and resulting in chemical inflammation of the gland.
After successfully reproducing a facsimile of the disease in animals by applying electrical stimulation to the sphincter and clamping off the common bile duct above it, he devised a protocol for human subjects that blithely crossed the frontier of ethical restraint into a gray zone where the only law was whatever the traffic would bear and whatever a tenured Professor could get away with.
Under his tutelage, interns and residents at the GI Clinic would select indigent patients for “pancreatic studies” who were not yet diagnosed or claimed for other projects, like the woman described above. Those surviving the ordeal of the Rehfuss tube might then be earmarked for surgical insertion of a T-shaped catheter into the common bile duct, from which samples of bile and pancreatic juice could be taken out for analysis, and into which radio-opaque dyes injected, permitting X-ray close-ups of the biliary and pancreatic system.
Although I was slow to put it all together, it should not have been a surprise to anyone that traumatizing such delicate structures tended to irritate and inflame them, thus provoking spasm of the sphincter and eventually chronic pancreatitis as well.
In this seamless fashion, so obvious and out front as to be quite hidden in plain sight, his careful methodology not only corroborated the hypothesis that had inspired it, but also generated a continuous supply of experimental material to prove it, since once scarring occurred it tended to be more or less irreversible.
During those same years, a noted Professor of Pediatrics proved for the first time what many had long suspected, that viral hepatitis, the disease now known as Hepatitis A, is transmitted through the ingestion of contaminated feces, just like polio and other intestinal viruses.
He too succeeded by his willingness to conduct dangerous experiments on individuals without their consent, informed or otherwise, in this case mentally-handicapped children at Willowbrook State School, who couldn’t speak for themselves and often lacked parents or guardians who were able or willing to speak for them.
Feeding stool samples from inmates with known infection to others not yet sick, this doubtless sincere and dedicated physician soon had irrefutable data regarding the portal of entry, incubation period, clinical course, liver enzymes, and every other known parameter of this major infectious disease.
Some years later, when a citizens’ group tried to blow the whistle on his research, which was being conducted almost entirely at taxpayer expense, he correctly pointed out that because of overcrowding and poor sanitation the disease was rampant at the school in any case, and was allowed to continue his work with impunity.
Neither man was gratuitously cruel or malicious in the manner of serial killers who defy social norms, or war criminals who carry out atrocities under orders in extreme circumstances. What they did was evil and indeed monstrous for precisely the opposite reason, that they were successful and even illustrious in a system which prizes their work so highly and rewards its achievements so extravagantly that even making the distinction between valid science and immoral or criminal behavior tends to be overlooked, dismissed or kicked down the road, and the legal and ethical standards regulating such behavior, if they exist at all, are easily if not routinely ignored.
For all of its shortcomings, Bellevue nevertheless continued to honor its historic mission of providing quality health care to the poor and disadvantaged; and in spite of everything there were many occasions when I felt proud to be a part of it, and to serve in whatever way I could.
I still vividly remember the legions of small children brought into the Emergency Ward with ear infections in the wee hours of the night, screaming their heads off with high fevers and violent earaches, until more often than not their eardrums would burst, discharging large quantities of pus and blood even before we could get the penicillin into them.
Although well aware that the pain and infection would subside dramatically once the pressure was relieved, we obediently followed instructions and gave them the injection anyway.
My favorite assignment in those days was night call on the maternity service, where the miracle of birth often squirted out before anybody had the chance to step in and do anything about it. Listening to the women in labor from my cot in the adjoining room, I soon learned to distinguish the excruciatingly difficult yoga of passively allowing the cervix to dilate, with its typically high-pitched screams, from the more exuberant grunting and bellowing as the uterine muscle then mightily propelled the baby through the va-gina and into the light.
At such times I would often reflect on our Latinate word “obstetrics,” derived from the prefix ob-, meaning “against” or “in the way of,” as in ‘obnoxious’ or ‘opposed,’ and the root stet-, meaning “stand” or “standing,” as in ‘station’ or ‘status.’ Just as I was witnessing on a regular basis, “obstetricians” lived up to their name as physicians trained and even celebrated for standing in the way of the birth process, manipulating and controlling it for presumably worthy ulterior motives of their own.
With only a smattering of women students in our class, sexist and misogynist attitudes were still rampant everywhere in the medical profession back then, perhaps nowhere more blatantly than in obstetrics and gynecology, as in the photo appearing in our yearbook of a prominent member of the OB/Gyn faculty immortalized for posterity for posing rakishly between two women lying flat on their backs on adjoining examining tables in gowns and stirrups, with his gloved hands feeling up both of them simultaneously.
With no hint of disapproval or reprimand, the exploit was dismissed as an amusing, boyish caper, not unlike its counterpart in the hallowed tradition of freshman anatomy, where once a year, when everyone else had gone home for the night, someone of either sex could be counted on to remove the penis from a male cadaver and insert it into the va-gina of a nearby female, such that, when everyone returned the next morning, we were sure to be greeted with the inevitable punch line, “One o’ you guys left in a hurry last night!”
On our clinical rotations, we were again divided up into groups of four, both for seeing patients and consulting with our attending supervisors, which often carried over from service to service, so that long-term friendships easily developed. Two of the guys I stayed with through most of these were Al Lipton and Herb Lifschutz, both genial six-footers who were amiable, easy to be with, and towered above me to an extent that was inherently comical and brought grins and guffaws to nearly everyone we met.
One such assignment took us to St. Vincent’s, a friendly neighborhood hospital in the West Village, where I remember gathering around the bed of an elderly Jewish woman to take her history. Looking us up and down with a quizzical air, she finally jerked her thumb in my direction, saying “He’s a daactah, too?!?!”, not seeing fit to address me directly, with a final lilt in her voice at the end of the sentence that lay somewhere between a question and its answer, thus accurately mirroring my own lingering doubts on the subject.
The rotation I remember best was Medicine, where many of the nurses in charge of each floor were unmarried women of middle age or older who knew vastly more about our patients and how to care for them than most of the House Staff, and showed no mercy for the genuine ignorance and moral shortcomings of us male students, interns, and residents in particular.
Our Faculty Preceptor was Robert Eisinger, M. D., a thoughtful, unassuming, and scholarly man of forty-five or so, whose knowledge of clinical medicine was encyclopedic, and whose unfailing respect for patients was truly inspiring to me.
Quizzing us about signs and symptoms, he taught us first of all not to jump to the obvious conclusion or settle on a diagnosis before ruling out all other possibilities. On the other hand, he was equally fond of the old adage, “Look for the horses, before you look for the zebras,” meaning, consider the obvious, ordinary causes before bothering about the more exotic ones, a precept more often honored in the breach than the observance in a teaching hospital like Bellevue, where the most recent discoveries tended to be the most fashionable, and the “local MD” was a stock figure of comedy, liberally seasoned with ridicule for failing to keep up with the latest advances.
In his quiet way, he taught us to respect the wisdom and acumen of the master clinicians from long ago, who, both because and in spite of lacking the most modern information and technology, consistently located the heart of the problem using mainly their common sense, careful observation, and the causal reasoning of daily life.
Among my most distasteful memories was having to witness a man with aortic insufficiency die a miserable, agonizing death, with IV’s, breathing tubes, catheters, and other appliances pouring medicine and nutrients into and siphoning excrements and other body fluids out from almost every available orifice, all in the name of treating this or that disease, relieving this or that symptom, and thus of prolonging his life as long as possible, rather than simply allowing him the dignity and respect of dying in peace with his loved ones.
As before with the mice and the pneumococci, my default response to all these aggressive interventions and procedures was not objecting or protesting, but just leaving the room, absenting myself from the further duty of participating in what I couldn’t bring myself to perform or accept.
Now, in retrospect, I can draw an intellectual distinction between scruples of conscience and feelings of moral outrage, such as would tend to rule me now, and the largely æsthetic repulsion from the sheer ugliness and indignity of the experience that mainly overcame me at the time; but I’ve long since come to regard these perceptions as overlapping if not synonymous, and to trust and pay heed to whichever one is uppermost, since they’re inextricably bound up together in any case.
In much the same vein, I remember a heart-to-heart with Meir Yoeli, Ph.D., an Israeli microbiologist who had become a sort of mentor to me, an unenviable rôle that entailed having to listen to my growing catalogue of ethical problems and moral scruples.
Shaking his head sadly, he replied, with all due solemnity, “Compassion is not enough!” by which he meant that practicing in the best interest of patients demands rigorous scientific knowledge, strict, logical reasoning, and sometimes even a willingness to act on their behalf without their approval or consent, a sermon that encapsulated more than a little of what I was rebelling against.
By early spring of my last year, as Matching Day for internships and residencies drew near, and my classmates were busy applying, I felt completely up in the air, without any clear direction or purpose to my immediate future, or indeed the rest of my life. I knew that I couldn’t bring myself to practice medicine in the way I’d been trained, but hadn’t the slightest idea what to do or where to go next.
One day, while visiting my brother David in the Village, he floated the idea quite out of the blue that I should study philosophy, a thought that had never once occurred to me; and it felt instantly and completely right, exactly what I needed to do at that juncture.
With only one college course in the subject under my belt, and in formal logic at that, I’m forever grateful to him for discerning in that one throwaway line who I really was, still am, and indeed have always been, much more clearly than I did myself.