Emma Goldberg - Life on the Line: Young Doctors Come of Age in a Pandemic

For my mom, Shifra

This book is a work of narrative nonfiction, in that all events described are real and based on extensive interviews with six doctors: Sam, Gabriela, Iris, Elana, Jay, and Ben. But this is not a work of live reporting, in that the author did not observe these events firsthand; the dialogue was reconstructed from the memories shared. Jay is referred to by her nickname and her family members names have been changed to protect their privacy. The names of her medical school and hospital have not been identified to protect the privacy of patients described in detail.

The names of all patients have been changed to protect their privacy, though the hospital convention of referring to them by their last names has been maintained. Patient ages and dates of hospital admission have not been identified. Any resemblance to persons living or dead resulting from these changes is coincidental and unintentional.

Next upSamuel.

The applause sounded like it was coming from some parallel universe. One where he would have crossed a graduation stage and seen the faces of his mom and his boyfriend hollering from somewhere in the sea of seats in Alice Tully Hall in Lincoln Center. One where he could have waved his graduation cap in the air, grinned, and shuffled forward in the regal purple robe of New York University.

But instead here he was, hearing his name called and his friends cheer at 7:30 on a rainy April morning in Bellevue Hospital as he and his classmates received their staff badges. It was a full three months before any of them had thought theyd be starting work. They stood a couple of feet from one another, whoops muffled by masks. Their group seemed impossibly small in that cavernous space, normally bustling with throngs of patients, nurses, visitors, and homeless New Yorkers.

Sam came forward and took the ID out of the outstretched hand of a hospital administrator. There was his name, printed alongside the block letters MD.

Woo-hoo! His classmates clapped as Sam rejoined their ranks.

Deprived by their weeks of quarantine of any real graduation ceremony except for a short event on video, some of Sams classmates were approaching their first day on the job, in Bellevues coronavirus wards, as a pseudo-celebration. This was the day theyd looked forward to for yearsthe day they would finally feel useful, no longer underfoot.

Every minute that morning held a sense of anticipation, of the strange stillness preceding a storm. There was Sams commute from Greenwich Village on an empty M23 bus. There was the ghostly quiet of the block around Bellevue. Then there was the line of doctors in scrubs getting their temperatures taken with a temporal artery thermometer as they entered the building, the familiar faces tougher to pick out behind their masks. Someone in a face shield took Sams temperature and pronounced it normal.

With their badges in hand, the new doctors lined up to take Bellevues notoriously slow elevator upstairs, where theyd be fitted for protective equipment. They traded tips and grievances about the endless preparations for their actual residencies, set to start in July after this temporary Covid-19 assignment. After three hours of paperwork, their orientation was complete and they were free to head home. It was a straightforward affair. The next morning at 7:00 they would report for their first handoff, which meant reviewing the list of patients that they were responsible for.

As Sam headed toward the exit, the rain outside was falling in sheets. The city streets sat limp, like laundry waiting to be wrung out.

It was April 13. New York State would lose 778 more patients to coronavirus before the start of Sams first hospital shift the next morning.

There are few relationships more intimate than the one between a patient and doctor. The stakes are not just the heart but the living self, and the dependence can be absolute. It is an act of total trust to submit ones body to anothers hands.

Its often said that doctors play God, that they determine life or death through the medical orders they issue. But of course they arent all-powerful or particularly mysterious. They are humans, pressing through a long shift, rolling their ankles to relieve the tension of a day on their feet, mulling over the takeout theyll order for dinner, hoping their supervisor caught their deft insertion of an IV needle. They are normal people with an outsize influence on how we live or die.

Yet their impact on our lives is powerful. It is no wonder that they are granted an unusual degree of societal statuswhile the median income for an American adult is roughly $50,000 a year, for a physician it is four times that amount. But medicine distinguishes itself from other high-paying fields by its alchemy of conscience, merit, and money. It is one of the last remaining affluent professions that stakes a claim to earning its pay fairly: in raw talent, unflagging exertion, and a clear-eyed commitment to public good.

In its devotion to elitism masked as meritocracy, the story of Americas doctors mirrors the story of this country. The medical profession has rendered itself exclusive by design. In the late nineteenth and early twentieth centuries, medical organizations surveyed the field and decided it wasnt quite restrictive enough, so they undertook an effort to close medical schools, shrink the number of annual graduates, and ensure that those that remained met a standard of rigorous performance. The effect was also to make those school populations more affluent, more male, and overall more homogeneous. A century later, American medical schools are still predominantly white and wealthy. This is partly because doctors are predominantly white and wealthy, and doctors tend to beget doctors.

In recent decades, many medical schools have made a concerted effort to draw their student bodies from a wider range of racial and socioeconomic backgrounds. Some have come to realize that such diversity is integral to the work. Quite simply, it improves the health of patients. Recent studiesthe type that might not have been funded just a few decades agoshow that Black patients have better outcomes when treated by Black doctors; they are more likely to bond with these doctors emotionally and agree to important preventive care measures like cholesterol tests and diabetes screenings. Its likely, too, that theyre less apt to face racial bias.

In other words: in the exam room, identity matters, both the doctors and the patients.

And so the fields exclusive bounds have begun to crack. As the medical profession has started to look more like its patients, a shift has emerged, not just in the culture surrounding the work but also in the outcomes of that work. When patients and doctors see themselves in one another, they forge stronger bonds and have more candid conversations. They talk more openly about preventive care screenings, medications, and which invasive measures to forgo at the end of life. They build the type of trust that has long been absent from clinical examination rooms.

Gradually, the face of American medicine has been changing. It has been growing less homogeneous. It has also been becoming more open, less distant from patients, and more focused on communication and connection. And then, on top of these two slow shifts, there came a once-in-a-lifetime crisis.

In March 2020, a virus far smaller than a grain of sand upended Americas medical institutions. With hospitals under siege, a handful of medical schools fast-tracked graduation and sent their fourth-year students to the front lines. These newly minted doctors immediately saw their fields inequities laid bare. The people most likely to get sick and die from Covid-19 were the countrys most vulnerable: nonwhite and working-class people. African American and Hispanic people were hospitalized at four times the rate of white Americans. They were also more likely to have essential jobs that didnt allow them to socially isolate. The countrys deep-rooted inequalities, made manifest in its health disparities, became crystalline to the new doctors as they saw Black bodies filling their hospital beds.