Faculty Bibliography

THE patient has AIDS. Therefore, in obedience to the signs posted on his door, we are putting on gloves and masks. Finally we troop into his room and stand around his bed, our faces obscured by surgical masks, our hands encased in plastic skins. The resident looks down at the sick man in the bed, and suddenly sounds a little bit abashed. ''Um, this is hospital policy,'' he says. ''We're all wearing these masks because that's the policy when anyone has a serious infection.'' So the patient is questioned through masks and responds to the faceless doctors gathered around him, and then he is touched through thin plastic. Then we troop out of the room, strip off our masks and gloves and, one after another, solemnly wash our hands. Medical people are sometimes unwilling to accept that deadly infections persist. It does not seem right to us. Throughout history there have been deadly infectious diseases, epidemics and plagues, microbes that disrupted whole civilizations, germs that killed children. Nowadays, in most of the world, this is still true. It was true when my parents were growing up in New York City; polio epidemics left empty seats in the classroom. When I was little and my parents talked about those times, they seemed very remote to me, at least as remote as Beth's death in ''Little Women.'' I asked my parents, ''Are there still sicknesses I can catch which could kill me?'' No, I was assured, because now medicines can cure all those sicknesses, and vaccines can keep you from catching them. I talked with a medical student who watched a good friend die of AIDS this year. The student, whose perspective lay somewhere between nondoctor and doctor, viewed the precautions partly in terms of the delicate politics of the hospital. When the policy was masks he wore a mask, specifically not to antagonize the people taking care of his friend. He also felt strongly that the precautions were the doctors' way of creating distance between themselves and the patient: ''It's a way of saying, you have AIDS and I don't, you're gay and I'm not, you're going to die and I'm not, and I'm not gonna get attached to you.''

''YOU want to help sick people?'' asks my friend rhetorically. ''You want to care for people in pain? Become a nurse.'' We are both medical students. We are both in the middle of a clinical clerkship on the medical wards of the hospital. What she means is, the nurses spend time with the patients. They get to know them, they meet their families, they tend to their immediate and sometimes desperate needs. They offer comfort, encouragement, explanations. The doctors, with the medical students in tow, show up briefly on morning rounds, returning only if the patient is seriously ill, or in need of some procedure or other. When patients leave the hospital, it is the nurses to whom they send thank-you notes, or chocolates, or flowers. This can at times be very irritating to those who are insecure about their own status, and as a medical student I was certainly a bit insecure about mine. After all, the medical student's role in the hospital is a little unclear, especially from the patient's point of view. Doctors often introduce medical students as ''student doctors,'' or just as ''doctors'' - this is contrary to all rules of proper behavior, but is done all the time, on the pretext that patients feel more comfortable if they think they are being examined by doctors, no matter how obviously inexperienced. So medical students may feel like frauds. Although experienced nurses know a great deal, and although they are keen judges of budding young doctors and medical students, they are not formally expected to teach us. My first week in the hospital, I asked who was responsible for evaluating my performance. ''Oh, everybody,'' I was told. ''Everybody? You mean, interns, residents and nurses?'' The reply was, ''Well not nurses, of course.'' Of course

''Macho'' can refer to your willingness to get tough with your patients, to keep them from pushing you around. It can refer to your eagerness to do invasive procedures - ''The hell with radiology. I wanna go for the biopsy.'' Talk like that and they'll call you a cowboy and generally mean it as a compliment. ''Macho'' can mean territoriality: certain doctors resent calling in expert consultations and, when they finally have to, await the recommendations with truculent eagerness to disregard them. ''These are our patients and we make all the decisions,'' I heard over and over from a resident I worked under. The essence of macho, after all, any kind of macho, is that life is a perpetual contest. You must not let others intrude on your stamping ground. You must not let anyone tell you what to do. And, of course, the most basic macho fear is the fear of being laughed at; whatever you do you must not let anyone mock you or your team. Life in the hospital is full of opportunities to prove yourself if you want to look at it that way. ''I want you guys to be able to get blood from a stone,'' announced our new resident on his first day as our leader. The ''guys,'' the other female medical student and I, must have looked a little dubious because he continued, ''O.K., it may mean the patient gets stuck a few extra times, but I don't want you giving up just because of that.'' Sure enough, when I came to tell him that I had stuck a woman six times without success, and could he please come show me where he thought a decent vein might be, he sent me back to try her ankles. ''Blood from a stone!'' he called after me; when I finally got a tube of this unfortunate woman's blood, he patted me on the back and said, ''Strong work!'' We don't say or think, ''Mrs. Hawthorne's cancer is making her sicker.'' We say, ''Mrs. Hawthorne's crumping on me,'' so Mrs. Hawthorne represents the challenge we cannot meet, the disease we cannot cure. Instead of hating her cancer, it's not hard to start hating Mrs. Hawthorne, especially if she has an irritating personality and most especially if she somehow seems to be blaming us - that is, if every day the doctor sees the challenge again in the patient's eye, hears it in the patient's voice: ''You can't do anything for me, can you, despite all the tests and all the medicines?''

Then I lied. I told the intern that I was crying for the young woman who had died, whose parent were sitting by her bed, dazed and saddened by the ending of a long and terrible ordeal. I said I was crying for the patient and for her parents, but I knew that in large part I was crying for myself. I was crying because I hadn't slept much, and because I had a long day in front of me in which I would be put on the spot and have my ignorance revealed again and again, a day throughout which I would feel tired and sick and heavy-headed and inadequate. And also, of course, because a young woman had died. It was embarrassing enough to be crying in front of the intern; the least I could do was pretend my motives were purely sympathetic and altruistic, rather than substantially mixed with self-pity. I cried for the patients. I cried after a man talked to me for 15 minutes about what a vigorous lively intelligent person his wife had been before her stroke, and then took my hand, called me ''doctor,'' and begged me to hold out some hope that she would be that way again. I have come to realize that I was not the only one crying. A friend told me about crying because a patient was dying and she could do nothing to help and everyone kept saying it was a ''fascinating case.'' An intern told me about crying because one night when she was swamped she asked a more senior doctor for help, only to be told off the next day because asking for help was a confession of weakness. Perhaps we cry because we are in a harsh environment that offers us little comfort, and in which we frequently find ourselves unable to offer comfort to others.

If I learned nothing else during my first three months of working in the hospital as a medical student, I learned endless jargon and abbreviations. I started out in a state of primeval innocence, in which I didn't even know that ''s C.P., S.O.B., N/ V'' meant ''without chest pain, shortness of breath, or nausea and vomiting.'' By the end I took the abbreviations so for granted that I would complain to my mother the English Professor, ''And can you believe I had to put down I picked up not only the specific expressions but also the patterns of speech and the grammatical conventions; for example, you never say that a patient's blood pressure fell or that his cardiac enzymes rose. Instead, the patient is always the subject of the verb: ''He dropped his pressure.'' ''He bumped his enzymes.'' This sort of construction probably reflects the profound irritation of the intern when the nurses come in the middle of the night to say that Mr. Dickinson has disturbingly low blood pressure. ''Oh, he's gonna hurt me bad tonight,'' the intern may say, inevitably angry at Mr. Dickinson for dropping his pressure and creating a problem. The resident was describing a man with devastating terminal pancreatic cancer. ''Basically he's C.T.D.,'' the resident concluded. I reminded myself that I had resolved not to be shy about asking when I didn't understand things. ''C.T.D.?'' I asked timidly

''With blood gases, for me it's more like see three, try four, miss them all,'' said a friend. Drawing blood gases means getting blood from the artery instead of the vein. The artery is harder to find than the vein, and the process can be excruciating for the patient - especially if you miss the artery the first couple of times. A patient on the ward where I worked for my first few weeks this summer finally rebelled. We marched in one morning on rounds, the whole crowd of us, one resident, two interns, two medical students. The resident asked her how she was doing, listened to her chest, said to me, ''[Perri Klass], let's get another blood gas on her.'' ''Oh no he's not!'' said the patient. ''He tried too the other day. I'm not letting either of them near me.'' She pointed to one of the interns. ''You do it, you have a light touch.'' In the end, perhaps that is the lesson that comes with experience in the things I do that cause patients pain: as I become a little more experienced, a little more sure of myself, I become less anxious to retreat behind the barrier of professionalism. Even with drawing blood - the first few times I did it, I was terrified the patient would see how nervous I was and would guess why. ''You'll just feel a little stick,'' I would say cheerfully, trying desperately to find the vein. By now, reasonably sure that I can find the vein if it's there to be found, I am much less afraid to let the patient see if I am puzzled or unsure. ''This will hurt a little, but I'll do it as quickly as I can,'' I say. Perhaps there is an implicit apology in my attitude, and that does not seem such a bad thing, because surely there ought to be some acknowledgment in such a situation that however necessary the pain may be, I am not the one who has to bear it.

''WHO'S taking care of your baby?'' ''Larry. His father.'' Over the course of my summer in the hospital I perfected a rather pugnacious intonation for that answer, designed to suggest that I would brook no congratulations and no commiseration. I mean, you wouldn't think people would actually imply that you were doing your baby a great disservice by leaving him with his father, would you? And yet some do just that. ''Can he take care of such a What Larry got was gushing praise for being such a perfect new-age father, along with all sorts of unappetizing jargon such as ''primary parent'' and ''role reversal.'' But frequently there was an undertone there too, and it was, you miserable wimp, how did you ever let yourself get backed into this? What he also received was a constant stream of anxious inquiries: how was he managing, was he able to get through the long days with the baby, could he handle it? Buried in this solicitousness was the constant insulting suggestion that he didn't really know how to take care of a baby. The summer went on. [Benjamin] cut his fourth tooth and was weaned. I became more aggressive about showing pictures of him in the hospital. I tried hard to take care of him when he woke on the nights I was home, and I became very good at snatching one-hour naps in hospital lectures. I worked out rejoinders to remarks about how lucky I was. ''Yes,'' I would say, ''and I'm especially lucky to have so much practice getting up at night. The only problem is, the patient spikes a fever, the nurses wake me up and without a moment's hesitation I diaper the patient.'' Well, it seemed funny at the time.