Chapter 7
RESIDENCY: A NARCOTIC ADDICT’S NEW CAREER
Scenario
I walked into the waiting room to find my new patient. I knew what he looked like, having scanned the emergency department (ED) residency list and seen Dr. Asim Chofan’s image and biography beforehand. In the photo, my new patient was a rather young-looking Asian man with buzz-cut black hair. He was clean shaven, with a round face, and seemed somewhat overweight. In the photo he had worn a white shirt, a lavender tie, and a white lab coat that proudly showed his name. I was looking forward to meeting Dr. Chofan after my fascinating discussion with his training director. She had finished our conversation by saying that when he had started residency, he was the last person she would have expected to be referring for psychiatric assistance, but she now couldn’t see him succeeding without substantial help, whatever was wrong with him.
I looked around the busy waiting room, where more than a dozen patients were waiting to be seen. I saw no one who looked similar to the photo, presumably taken 3 years ago when he started residency. The only young Asian male in the room was standing nervously by the front door, almost as though he were ready to escape. He was thin, with greasy black hair, and dressed in worn-out jeans, a faded tee shirt, and a black leather jacket despite the heat of the day. I had to take a second look before I realized it was Asim. I called his name to be sure it was him, and when he replied in the affirmative, I asked him to follow me to my clinic room.
My room, like those used by many psychiatrists in major medical centers, is very conventional. In and out boxes had papers sticking out here and there. Three computer screens, which I use for all of my writing and editing as well as for seeing patients via telemedicine, are equally spaced across the back of the large desk. About half of my patients prefer to be seen at home or their workplace by video to avoid traveling to my clinic, especially my physician patients. I invited Asim to sit in one of my leather chairs while I took the other. I noticed him taking his time to check the various picture frames around the room that held a combination of degree documents, prints, and paintings collected over many years of practice.
I began the session. “Thanks for coming to see me, Dr. Chofan. I understand that your training director, Dr. Brucer, has talked to you about coming to see me and is very concerned about you.” To this Asim slumped into his chair, looking downward toward his feet and saying nothing. Finally, he nodded his head.
“I don’t know why she insists I see you. Everyone knows that I have chronic pain in my back from ankylosing spondylitis and that I need to take pain medication. I just took one tablet too many the other night by mistake, and that’s why I seemed a bit off at work. I have no reason to see you. You just need to talk to my primary care doc to have him confirm my situation. I have no idea why I’m seeing a psychiatrist.”
“Well, given that you’re uncertain why you’re here, perhaps I should tell you what Dr. Brucer has told me. Incidentally, I’ve already looked at your medical record and have seen all the notes and X rays confirming your back problems. It does seem clear that you have longstanding chronic pain, which is rotten. I am so sorry,” I said.
“Exactly,” he responded. “That’s why this is a waste of time. But yes, please tell me what Dr. Brucer said. I’m very interested to hear what her accusations are. She’s not interested in my health, just in making sure that we residents cover all our shifts and that patients get seen quickly.”
“I’ll summarize our discussion,” I told him. “She told me that you’ve missed three shifts altogether in the past month and been late on four other occasions, and you haven’t been able to give a good explanation for any of these events. This is apparently on top of longstanding tardiness and your deteriorating academic performance on the internal residency quizzes, which she said has led to you receiving two letters of expectation in the past year. Dr. Brucer also told me that she and other attendings have been observing you carefully at work and are concerned that you might be taking too many painkillers for your back pain, concluding on several occasions that you seemed to be either excessively sedated or possibly somewhat high. On top of this, she told me you’ve lost a lot of weight in the past year, about 30 pounds by her estimate, and she wondered if you were not eating properly. I’m sure you can understand her concerns about your health. She decided that I should see you before you go back to work as planned next week.”
“All of that is explained, as I said, by my back pain,” replied Dr. Chofan, rather irritably. “Why do none of you listen?”
“Let’s start with your back pain, then,” I answered. “Tell me about it, and what you do to cope.”
“What I do depends on where I am. If I’m at work, I take very little Oxycontin and try to just grin and bear the pain. But I find that difficult, so in the past few months I’ve been trying to take the Oxycontin regularly, every 2 hours, whether I’m working or not.”
“That means you must be taking a minimum of 12 tablets every day, by your counting,” I said. I had logged into the state’s controlled-substances database earlier that morning to review all the prescriptions Asim had picked up in the past year, so I knew he was taking a lot more Oxycontin than he was telling me. He had prescriptions not only from his own primary care physician but also from three other doctors at urgent care centers whom he seemed to visit fairly regularly.
I continued the discussion. “Are you sure that’s all you’ve been taking, Dr. Chofan? The story from Dr. Brucer suggests more, and when I checked the state controlled-substances database, what I found indicates you’re getting several times that amount from four separate doctors. Can you explain that?” Asim just looked down. No response. No eye contact. Only his right leg shaking and trembling suggested any impact of my words. I waited for a short while before deciding to continue. “It seems to me that you may have a much more serious drug problem than you’ve been admitting and are likely addicted to narcotics. Do you think that might explain your behavior recently? Would you like to tell me more about what’s been going on?”
The consultation continued in this vein. It was like pulling teeth; he remained very defensive and elusive, difficult to tie down to hard facts. The story, as he told it to me initially, was approximately as follows.
Asim Chofan came from a high-achieving Asian family where educational success was key. His father was also a doctor, a successful surgeon, and his mother ran a public relations company and was quite a high-profile member of the local community, involved with numerous charities and community development projects and often in the media. He was the second of two sons; his elder brother was a corporate lawyer on a fast track to senior management. Asim had always loved arts and music, with real talent as a painter and a love of playing the violin, but his father in particular had discouraged these interests, and both parents had strongly encouraged him into a career in medicine. Painting and music had become a sideline. While he was in college, he had drifted unthinkingly into medical school without really even considering what a life in medicine might be like. He flew through medical school; his almost photographic memory meant passing exams was a breeze. It was only when he hit residency and began working shifts in the ED that he suddenly realized he had made a poor career choice.
Although Asim had started his residency in a positive way, enthusiastic and engaged, he soon became disaffected, especially when he started having severe back pain that led to the diagnosis of ankylosing spondylitis, a painful arthritic back condition with no real cure. His back pain progressively became worse during his first year of residency, exacerbated by the inevitable physical maneuvers, sudden weight bearing, and changes of position that an ED doctor has to withstand in such a physically strenuous environment. To keep working effectively, he started taking narcotics to control the pain—in small doses initially, but rapidly increasing.
He found that, to make sure he could feed his habit, he had to make lifestyle changes. He had never had many girlfriends, but now he lost interest in females completely. He also lost interest in spending time with his residency colleagues at the hospital and had drifted to the outside of their social circle, with increasingly little involvement in residency activities. He quickly realized that if he volunteered to do elective rotations at other hospitals, he had more peace and less likelihood of being challenged by his colleagues or his training director. He started taking all of the away rotations he could, which of course only marginalized him further during his second year of residency.
At the end of this first consultation, because of his constant evasion and my impression that he was minimizing his drug use, I decided to insist on a drug screen being done immediately to see what exactly was in his body at that time. He became upset at this suggestion, accusing me of not believing him and saying that I was acting more like a police officer than a physician. Nevertheless, I insisted, and having phoned the pathology lab and informed the chief medical officer, I walked with him to ensure that he had the observed screening done immediately. Fortunately, as the chair of the hospital well-being committee, the medical staff bylaws gave me the authority to require a “for-cause” drug or alcohol screen on any physician suspected of being intoxicated at work.
As we walked over, we had a fascinating follow-up conversation.
“What drugs are you going to screen me for?” Asim asked diffidently. “Is this a screen for more than Oxycontin?”
“Yes, it certainly is,” I responded. “The screens that I’ve ordered for you, and which will be done routinely, will pick up a wide range of both legal controlled substances, such as Oxycontin, and street drugs, such as meth, cocaine, and weed.”
“Why are you doing that?” he replied. “After all, I’ve only taken Oxycontin.”
“That’s good, then,” I said. “But you seem a bit worried about this drug screen, so if you’ve taken any other drugs, please tell me now so we can both know what the screen will show. The tests are very sensitive and will pick up an amazing range of drugs, remember.”
“What about heroin?” he asked, to my almost complete surprise. I hadn’t been expecting him to be taking an illegal narcotic when, as a doctor, getting hold of prescribed narcotics, especially in an ED, is relatively easy. “Will the test pick up heroin?”
“It certainly will, although as I’m sure you know, many people who think they’ve taken heroin end up taking other drugs that have been cut into whatever they bought. It sounds to me like you’re saying that you think you’ve taken heroin. That’s serious, as you know. How recently, and how has this happened?”
After completing the drug tests, Asim finally shared more of the story. It seemed that he had minimized his distress and drug usage dramatically. He now admitted to taking marijuana quite regularly at medical school as well as drinking excessively from college onward, with blackouts ending in a drunken stupor several times per year. He had managed to keep most of these events away from his parents because he was not living at home but was sharing an apartment with his elder brother, Samir, in whom he confided. Samir knew about Asim’s drinking and drug use and was aware that he really wanted to study music and art rather than science; he had been trying to persuade Asim to see a counselor for several years. In Asim’s final year of medical school, Samir had moved out of state to pursue his own career, leaving Asim without his primary support as he started residency.
Asim had chosen emergency medicine as his residency mainly because he felt it was the one specialty where, as a physician, you could turn up to do a shift of work, see your patients, and then go home. He hated the idea of worrying about any continuity of care and thought that this would not happen in the ED because others were always there to follow up behind you. As a medical student, he told me he had heard the term “lifestyle” specialties and thought that working in the ED, where he believed his work would be less consuming, would give him more of a chance to eventually get back to his art and music. He had not, however, realized just how difficult and personally traumatic working in an ED could be. Within a few months of starting residency, Asim was unable to sleep properly, was having nightmares of disturbed or dying patients, and could not rid his mind of the horrors that he witnessed. The final straw for him was having to try to save the life of a 22-year-old Indian woman who had set herself on fire in a bath of gasoline after her brand-new husband had been killed in a motor vehicle accident, in an ultimately successful attempt to join him in the afterlife. She had had 90% of her body covered in burns, and he had spent several minutes desperately trying to get a deep intravenous line going via her neck, one of the only unburned parts of her body. In the end he was successful, but all he could do was relieve her pain with morphine. She died within a few hours in the ED. He could not get the smell of burned flesh out of his brain, and for months afterward, whenever he smelled meat, he felt like vomiting. At work, when he saw sick individuals whom he was meant to save, he just wanted to run away and go home, sure he would fail. It was so unlike the rather naive and unrealistic perspective of the ED he had gained as a medical student, when he had been primarily an observer. By the end of his first year of residency, he had realized that he had made a mistake and should never have attempted to train in emergency medicine. He had phoned his brother to discuss his situation, feeling unable to talk to anyone else. The conversation had gone thus:
Asim: “I need to talk to you about what I should do with myself, Samir. I have no one else I trust like you, and I wish you were here, even though I know you’re doing what you want in your new job. I just wish you hadn’t moved away. Perhaps I’ll come out and spend a week with you when I get holidays in a few months. It would be good to get away from here.”
Samir: “I’m so sorry to hear that, Asim. I’d hoped things would get better for you over time and that you would settle into your work.”
Asim: “That’s what I assumed, but it’s not happening. We have to work so hard as residents, with usually just 1 day off per week and long shifts. We never finish on time, because it takes a couple of hours to finish our notes at the end of each shift. We have no time to recover, and all I want to do is to sleep when I’m not at work. I never really enjoyed the work, as you know, but now I literally dread going in to the hospital. You wouldn’t believe how some of the patients treat us, how hard it is to deal with them, and how much pressure is put on us by the senior medical staff and the nurses. We’re just everyone’s slaves, or so it feels like. “
Samir: “That sounds bad, indeed. Tell me more, I have lots of time.”
Asim: “Well, two sets of issues worry me. First, I know I’m very burned out. I have all the classic features, and the degree of burnout we have seems to be the only thing my fellow residents want to talk about. But they’re almost proud of it, as though they’re surviving on the front line of a battle, whereas I hate it and feel hopeless and useless. I no longer see the point in trying to help patients; I just work them up as rapidly as possible so I can get home on time at the end of a shift. I keep thinking of walking out part way through a shift and just going home and spending a few hours painting. It sounds so good. But I can’t do it.”
Samir: “What’s the second problem?”
Asim: “Well, that concerns one particular patient that I just cannot get out of my mind. I am constantly reminded of her. Whenever I smell burning, especially burned meat, I think of her and am taken back to what happened when she died. She seems to be all around me. Anything Indian or to do with the Hindu religion reminds me of her. If I pray, she’s there. When I sleep, she’s there. When I see anything violent on TV, she’s there. The other day, I was walking down the street on my day off, and suddenly I went past a shop selling baths, with several in the window, and I thought I could see her sitting in one. I had a flashback to her being in the hospital, dying. It’s so horrible. What can I do? The only thing that seems to help is drinking or taking a sedative to give myself some artificial sleep, so I’ve started to do that, but it worries me sometimes that I will be unable to get to work if I knock myself out too much. What should I do, Samir?”
Samir: “I am so sorry, Asim. I remember you mentioning this patient before, but I didn’t realize you were so upset. What actually happened?”
Asim: “It wasn’t just the horror of the situation. What upset me was the sort of person I think she was. She was beautiful and reminded me of an Indian version of our mom, from those pictures when she married Dad. She was wearing the remains of her wedding sari, a beautiful gown, now all burned and destroyed, and despite the massive pain of her burns, she still somehow looked at peace. She was only semiconscious, and when I tried to put a line into her neck to give her fluids and painkillers, she resisted, like she didn’t want me to do it. She muttered something to me, and I had the impression she didn’t want me to do anything to try to save her. I ended up looking her in her eyes, upside down, as I eventually put the line in her neck, and she seemed to be staring right through me. I know she was looking at me as she finally became unconscious and died. I was the last person she saw. I think she was pleased to see me, because she seemed to whisper something. I’m not sure what it was, but I wonder if she was asking me to pray for her. It was me pushing the morphine that ultimately killed her, even though I know rationally that she could not possibly have survived and that I was doing what my attending had told me to do. But I did finally kill her, even though I took away her pain.”
Samir: “I’m so sorry. I didn’t realize you were having so much trouble. Isn’t there someone you can go and speak to about this?”
Asim: “Yes, there is, but it’s too embarrassing, and I should be able to manage this myself. All the other residents do. There’s nothing special about me; we all go through the same experiences, and we all know we’re doing a tough residency. The issue for me is how best to cope and, perhaps more importantly, whether I should continue on or pull out and do something else. But what would Mom and Dad say if I did that?”
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