by George Stetten, M.D., Ph.D.
from "Resident Forum" JAMA, vol. 273, no. 14, pp. 1076f
Edited by Charlene Breedlove, Associate Editor, JAMA


He was dying anyway. His liver had been biopsied, a liver that was past hope, and the procedure had caused some bleeding. It was my first week as an intern. I had clipped my "M.D." name tag onto my short white coat, and draped my stethoscope around my neck. My pockets bulged with doctor things. And now I was responsible. The attending was telling me what to watch for, and I could not remember anything he said, because I was on the brink of tears. My father had died a few months earlier.

As in any veterans hospital, the old soldiers were bedded down four to a room, fighting this time against disease. As in war, their hours passed mostly waiting. I could imagine them singing "Tenting Tonight on the Old Camp Ground." Desert Storm was on every television, stirring up tales of glory from World War II. Saddam Hussen --- now there was an enemy, like Hitler.

The expected flood of casualties never arrived, but as we shelved the handouts about nerve gas and posttraumatic stress disorder and returned to the routine suffering and dying of peacetime medicine, I realized that our war was not over. Disease had not surrendered, and we were still on duty patrolling the hospital halls.

The staff surgeons were the marines fighting hand-to-hand, scalpels flashing. They found glory by advancing through the blood and guts. The anesthesiologists were the air force scrambling to fly into the theater of operations, remaining glued to their instruments just in case the patient crashed. The radiologists were reconnaissance, pinpointing pathology, surveying the terrain before invasive procedures. The psychiatrists were diplomats negotiating with the enemy on a savage battleground all their own.

And I was not really a soldier at all. I should have been a research scientist. I told myself that scientists were valuable too, spies unraveling secrets that could save a million lives. Instead, I found myself in this smelly forgotten war zone of a hospital defending one patient against an unbeatable foe. He knew he was dying, that old veteran. He looked out the hospital window and said he understood that none of us could help him.

We interns like to imagine that, fighting by our side, Mother Nature will provide her defenses, and Father Time will heal all wounds. We like to believe the medical industrial complex will always be happy to spare no expense. We blame the insidious conspirators, the patients themselves, who aid and abet the enemy with cigarettes, alcohol, cheeseburgers, and unprotected sex. We blame the lawyers, who like snipers watching for any mistake, sift through our acronyms and unintelligible scribble, our secret code of Latin and Greek. We say iatrogenic when we mean friendly fire.

Those old soldiers seemed to find it all so familiar, the uniforms and titles, the chain of command, the life-and-death decisions based on insufficient information. Pass the buck, kiss-up, kick-down, from the gnarly old generals to the strutting sergeants: If I had to do it, then so do you. This was my first tour of duty; I learned to live without sleep and to do everything by the book.

Whether we are heroes or mercenaries, each of us must earn a certain red badge of courage and suffer some of what real soldiers bring home from the front. We teach our patients there is no shame in posttraumatic stress disorder. Over the years we have had other, more forgiving names for the reactions due to the stress of war, such as battle fatigue and shell shock. My favorite comes from the Civil War --- soldier's heart.. We should not be surprised or ashamed to find such reactions in ourselves.

George Stetten's home page