By Emma Goldberg
Ms. Goldberg is an editorial assistant at The Times and the author of the forthcoming “Life on the Line: Young Doctors Come of Age in a Pandemic,” from which this essay is adapted.
Iris had been a doctor for all of six days. Her long white coat still felt almost like a costume. Her patient had a severe case of Covid-19. She wanted to put him on the phone with his family, but first she had to ask him the essential question: Did he know how he wanted to die?
In the hospital lexicon, this became: Did he want to get chest compressions if his heart stopped? Or a tube down his throat if he was struggling for breath?
There was an eerie intimacy to the exchange. The surrounding blare of alarms and monitors fell away. It was just the two of them, this middle-aged man and Iris, with her sleek dark hair and honey-sweet voice, skin flushed beneath the protective layers of her N95 and surgical masks. He told her, in a voice tinged with certainty and fear, that he would do anything to survive.
Outside the Montefiore Medical Center’s Moses campus, which includes a 700-bed hospital affiliated with Albert Einstein College of Medicine in the Norwood section of the Bronx, the city streets were blanketed in a hush broken only by the sound of sirens. It was mid-April 2020. It was, as would be clear in retrospect, the height of New York City’s first coronavirus wave. The hospital was brimming with coughing patients, fading patients, patients struggling for breath — so many that even its lecture hall had been filled with beds.
In the final stretch of Iris’s last semester of medical school, she and her classmates were drawn into the riptide of a historic crisis. She’d planned to spend her spring celebrating the end of medical school and preparing for the start of her career in internal medicine. Instead, she joined the front lines of the fight against a plague. (Iris asked to be referred to by only her first name because of the sensitivity of information she shared with me.)
At the end of Iris’s first week, she woke up early thinking about her patient. Would he need to be intubated that day? When she got to the hospital, the night team told her the news was worse: He had died overnight.
Standing by the nurses’ station, grief sitting heavy on her chest, Iris questioned whether she’d made a mistake in volunteering to work in the Covid wards. She wondered whether she’d agreed, implicitly, to all the trauma that entailed. “Let’s take 30 seconds of silence,” one of the residents said.
In the ensuing stillness, Iris tried to take in the reality of this new casualty. One more tally on the death count. One more body wrapped up for transport to the overflowing morgues. And with that, Iris had been a doctor for seven days.
On March 24, 2020, the Grossman School of Medicine at New York University became the first medical school in the country to tell its students they had the option to graduate early to fight the coronavirus surge. Other schools across the city followed: Einstein, Mount Sinai, Columbia. The students took the Hippocratic oath on WebEx, ensconced in their bedrooms and their last moments of safety. At Montefiore, Iris and her classmates were known around the hospital as the “Coalition Forces”; downtown at N.Y.U., their counterparts were called the “Covid Army.”
Most doctors don’t spend their first training days on a front line, for good reason. Modern medicine isn’t meant to be like warfare. The normal transition from medical school to residency involves months of emotional preparation and celebration; some students jokingly refer to their final semester as “the most expensive vacation you’ll ever pay for.”
As the virus spread, Iris and her classmates were told that they were signing up for the battle of their lifetimes. But when soldiers enlist, they are prepared for offensive strikes, to do harm and put themselves in harm’s way. That’s not meant to be a doctor’s role. Doctors mitigate danger; their aim is to comfort and to heal. And most of the time, they’re not asked to put their lives on the line. Underneath words like “coalition” and “army” was a reality of young and idealistic people just setting out in their careers.
In April 2020, I began speaking with a group of doctors who graduated early from medical school at the height of the pandemic. I wanted to know what was underneath the lofty wartime terms, how people my age, in their mid-20s, were confronting this unwanted test. I called them early in the morning and late at night, while they were grocery shopping or headed home from 10-hour shifts. I also spoke to dozens of their colleagues. And as I asked them about their workdays, about the patients they saw and the treatments they gave, we tiptoed around deeper questions: What does it do to you when the first-ever medical note you sign is a certificate of death? How do you keep working when your care feels futile? What does it mean to become a doctor on the front lines?
All of the young doctors I followed were drawn to medicine by the same desire to connect with their patients. They were raised in a generation that rejected the old-school images of doctors as cold figures of authority, who simply instructed the patients on what was best. They wanted to relate to the people they cared for, cultivating trust.
But the coronavirus removed the part of medicine that makes it most fulfilling to many: the relationships. It emotionally depleted most doctors, but few more than the newest recruits. As they started their jobs, with the virus raging, they couldn’t spend any more time with their patients than was clinically necessary. They couldn’t meet their patients’ families. Instead, they spent much of their time helping their patients determine how they wanted to die. And the grief felt all the sharper for those in the newest cohort of doctors who didn’t look like their predecessors — working-class people and people of color who’d gone into medicine only to see Covid-19 ravaging the very communities they’d set out to serve.
“It was like they came into this postapocalyptic world where everyone was bitter and exhausted,” said Dr. Lakshman Swamy, a critical care physician in Boston, of his trainees. “We were totally burned out, and we had no empathy left. And you need a lot of empathy for junior learners, because they have a lot of knowledge, but they don’t know how to be doctors.”
On Gabriela Ulloa’s first day as a physician at N.Y.U. Langone’s Tisch Hospital on the east side of Manhattan, New York State lost 481 people to Covid-19. Already it was becoming clear that Hispanic people like her were among the hardest hit: They were dying at twice the rate of white New York City residents.
For her first day, Dr. Ulloa, who had a bold-brow and long-lash natural glamour and the buoyant tone of a camp counselor, wore a pink mask dotted with cartoon characters. “Can you tell I’m going into pediatrics?” she joked to one of the patients.
What Dr. Ulloa noticed right away was the facelessness of her patients. Masks concealed any pursed lips or nervous smiles. Typically, during her training, she’d sit at her patients’ bedsides and ask them about the children and doting partners waiting for them back at home. But senior physicians had warned her not to spend too long in the Covid-19 patients’ rooms. Every extra minute meant more exposure to the virus.
Dr. Ulloa could still get the data she needed: blood pressure, respiration rate, heart rate. But so many of the real measures of the people she cared for were gone — how tightly their fingers laced around her palm, how long their eyes locked onto hers when she asked, “How are you really feeling?”
One of Dr. Ulloa’s first patients was an older Black woman who had just recovered from Covid-19 and was preparing for discharge. Technically this was good news, but the woman was petrified to leave the hospital. For many Covid-19 patients, the initial symptoms came on abruptly, a cough morphing into shortness of breath, and they worried about deteriorating again just as rapidly. The patient turned a set of pleading eyes on Dr. Ulloa, asking what she should do if her oxygen levels dipped. Dr. Ulloa wanted to sit at her bedside, making her laugh until the woman’s anxieties waned. Instead, she had to keep the exchange as brief as she could. “We wouldn’t let you go if we didn’t think you were ready to leave,” she assured the patient.
Dr. Ulloa had been confident that she wanted to train in medicine since she was a teenager, working as a shampoo girl at her mother’s salon in Millis, Mass. She’d spent long afternoons lathering her hands in floral-scented pink liquid and massaging it into the clients’ hair. She liked the intimacy of it. The women tilted their heads into her hands, asking her questions while she rinsed: What did she want to do when she was grown up? The answer came easily. She wanted to be a doctor, which seemed to have qualities in common with being a shampoo girl. It was about earning someone’s trust, fostering a certain kind of openness while you ran through your set of tasks.
But all she could do on that first day in the Covid wards was move quickly among her patients, willing herself not to linger. She grasped for the right words of comfort before going on to the next bed.
With the invention of the stethoscope in 1816, the gap between doctors and their patients grew profound. Using that instrument, physicians could extract information from their patients without even pressing ear to chest. That tool helped turn medicine from a trade into a profession. When people fell sick, they no longer turned to a neighbor or local healer; they knew they would get authoritative care by seeking out a physician.
In the mid-1900s, that dynamic began to change, as it became clear that patients needed to have some rights, too. The shift was accelerated by the 1947 trial and judgment of 23 Nazi doctors and bureaucrats. They were indicted, facing charges related to torturous experimentation on their victims that included mass sterilizations, bone-grafting and forced exposure to drugs. The physicians claimed that they had no medical code of ethics limiting their behavior. The Nuremberg Code that emerged called for the “voluntary consent” of subjects in human research — in other words, for the first time, patients had to know what was being done to their bodies.
In the decades that followed, other physicians began to take the idea further. Dr. Jay Katz, an ethicist at Yale, argued that patients should be involved in their own medical choices. His landmark book “The Silent World of Doctor and Patient,” published in 1984, challenged the paternalistic assumption that patients should quietly accept all their doctor’s ideas.
By 1996, Dr. Bernard Lown, a cardiologist, was arguing that the biggest problem in America’s broken health care system wasn’t about money but compassion: “Healing is replaced with treating,” he wrote. “Caring is supplanted by managing.” Instead of tending to full humans, doctors were treating distinct organs like a car mechanic examining malfunctioning parts.
Medical schools began to teach these once-radical ideas to their students. Faculties put a new emphasis on notions like informed consent, training would-be doctors to build relationships with their patients and not just expect compliance. This seemed all the more important for the most sensitive hospital conversations: If you are going to ask patients at what point they’d want to forgo life-sustaining measures, for example, then you’d better have earned their trust first. You’d better sit with them and get to know their families.
Today, medical students have access to a wealth of new research on what it takes for doctors to cultivate their patients’ trust. They also know about the growing evidence that some patients have better health outcomes when treated by doctors who look like them; Black patients, for instance, are more likely to agree to elective procedures like cholesterol tests and diabetes screenings when seen by Black doctors. There’s an expanded understanding of what it means to be a good doctor, of the skills and sensibilities that go beyond medical textbook terms.
But when the pandemic erupted, there was little time for deep conversations and relationship building. Physicians were rushing to try to save lives. Patients weren’t just patients; they were masses of contagion. It was almost enough to make some doctors forget why they wanted to do this work in the first place.
In mid-May last year, Iris was assigned one Covid-19 patient whom she visited daily but couldn’t get to know. He was a large man who had been given a tracheostomy, a hole cut through his neck into his windpipe for easier connection to a ventilator.
Each time Iris went to check on him, she was met by silence and hollow eyes. He couldn’t respond to her voice or give any indication of whether he understood her words. The machines around him beeped and whirred, like a conversation in which he couldn’t partake. Still, it was important to Iris to speak with him. She wanted him to know that she saw him as a full person, not just a body in the bed. “I’m always around, if there’s anything you need,” she liked to tell him.
The patient’s family had decided that he should be marked “full code,” which meant that if his heart or lungs failed, he would get any intervention that could save his life. His chances of a meaningful recovery seemed slim, but they wanted him to keep fighting.
One day, Iris’s team decided that it was time to wean him off the sedatives he was being given to keep him from ripping out the breathing tube. Opioids suppress the respiratory drive — the body’s compulsory fight for oxygen — and they wanted to see if he could start to breathe on his own.
He was taken off the medication on a Thursday morning. He was Iris’s first patient on prerounds, and she touched his shoulder gently to wake him up. “Your family is praying for you,” she told him.
Then, for the first time since he came into her care, she saw his eyes well up. A tear spilled over onto his cheek. She wished, more than anything, she could know what he was thinking.
Soon Iris had to leave to check on her other patients. Outside, in the hallway, she texted her partner: “If I’m ever vented, please just let me go.” Iris could manage pain and discomfort. But there was a certain kind of voicelessness, a loss of self, that scared her more.
Before the pandemic, a patient’s death in the hospital might include family members packed into the room with music and prayers. During Covid-19, it was more likely to involve a nurse holding up an iPhone. Even the sickest patients, who were deciding whether they were ready for palliative or hospice care, had to do so without their family members present.
Dr. Ulloa learned that when she was assigned an older patient with end-stage metastatic colon cancer, in early May last year. The patient was slender and under five feet tall, a quiet woman who almost never complained. Dr. Ulloa knew she must have been feeling constant discomfort, especially an ache in all her bones.
The medical team finally determined there wasn’t much more they could do for her. It was time to have a conversation on her goals of care, whether she wanted to be resuscitated or intubated if her heart or lungs failed. Normally that discussion would involve her relatives sitting at her side to squeeze her tiny hands. But the hospital didn’t allow visitors, so her children joined by phone. The patient spoke Cantonese, so she needed an interpreter, who also dialed in remotely.
For a moment, Dr. Ulloa was dazed by the tangle of sounds: the children’s voices rising and tumbling over one another, the interpreter scrambling to make sense of everyone’s words.
The attending physician had to surmise, first of all, whether the patient knew what the word “hospice” meant. The term didn’t have a direct translation into Cantonese; it meant something roughly like “deathbed care.” There were thornier differences, too. The children seemed to think this was a family decision, as it so often was in Chinese culture, but the doctors had been trained to defer to the patient.
Dr. Ulloa thought about how much easier this conversation would be if they were all physically together. They could read one another’s facial expressions. The children could see their mom’s stoic nods. Instead, the family members’ voices were distant and disembodied, while the woman sat alone in her hospital bed, agreeing with the doctors that she was nearing her time to die.
As the weeks in the Covid wards wore on, the medical students-turned-providers began to emanate a quiet confidence. They didn’t freeze up so much when they introduced themselves as doctors. They accepted, somewhat bashfully, that the city’s applause at 7 p.m. was also meant for them. Even the vocabulary and protocols of Covid care — like pausing to put on full protective gear before responding to a code — began to feel less foreign.
And as the days grew longer and spring chill turned to summer heat, there were glimmers of hope in the city: New York’s daily death tolls declined. The incessant wail of sirens faded. Patients with non-Covid ailments started to trickle back into the hospital halls.
Slowly, the newest doctors also realized that they hadn’t been remade by the crisis. Their work hadn’t turned them brittle or extinguished their wide-eyed ideals. Instead, their frontline weeks had reinforced the values and traits that drew them to medicine in the first place.
For Iris, that meant committing to talk with the patients who couldn’t respond, sitting at their bedside and sharing words of comfort even when she wasn’t sure they could hear her speak.
For Dr. Ulloa, that meant finding a way back to giving clinical care that felt human, even in the Covid wards. In May last year, she was assigned an older patient with a variety of pains and problems, including an infection whose source wasn’t clear. The patient’s hemoglobin dropped low one evening, and the nurse came to do a blood transfusion. She pressed her fingers along the woman’s arm looking for a vein, then slipped in the needle. The patient winced. She grabbed Dr. Ulloa’s hand and gripped it like a lifeline.
“I know it’s hard getting this thrown at you,” Dr. Ulloa told her.
“I wish I could have my family here,” the patient said, her voice so quiet that Dr. Ulloa had to strain to make it out.
“It’s hard doing this without your friends and family,” Dr. Ulloa agreed.
For a moment, Dr. Ulloa felt as if she were in a pediatric unit back before the pandemic. Alone at the hospital, without family, the Covid patients were all like kids — bodies craving touch, craving certainty. As though they were learning to swim, letting go of the pool’s wall and kicking, kicking their legs as they looked for some familiar arm to hold.
The woman sat there with her eyes closed, trying to steady her breath: Inhale, exhale. Dr. Ulloa clutched her hand. The blood kept flowing, and all around them the hospital floors continued their steady hum.
Emma Goldberg (@emmabgo) is an editorial assistant at The Times and the author of the forthcoming “Life on the Line: Young Doctors Come of Age in a Pandemic,” from which this essay is adapted.
Photographs by Sasha Arutyunova for The New York Times.
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