CHAPTER 1
Unprepared
In July 1975, I entered my fourth and final year of medical school at Columbia University in New York City. I had completed all my required courses except surgery and was eager to engage in its drama.
Surgeons acted boldly and decisively. They achieved cures, opening an intestinal blockage, repairing a torn artery, draining a deep abscess, and made the patient whole again. Their art required extraordinary precision and self-control, a discipline of body and mind that was most evident in the operating room, because even minor mistakes--too much pressure on a scalpel, too little tension on a suture, too deep probing of a tissue--could spell disaster. In the hospital, surgeons were viewed as the emperors of the clinical staff, their every command obeyed. We students were their foot soldiers. I was intoxicated with the idea of being part of their world.
The surgical team I joined was headed by Dr. William Foster. Foster was a tall, imposing man with sharp features like cut timber. His rounds began at dawn, followed by two or three surgeries that lasted until late afternoon. As is typical in a teaching hospital, all of Dr. Foster's patients were assigned to medical students who learned the basics of diagnosis and treatment by following cases. Not long after I began the course, I was designated as the student to help care for Esther Weinberg, a young woman who had a mass in her left breast.
Esther Weinberg was twenty-nine years old, full-bodied, with almond-brown eyes. She was a member of the Orthodox Jewish community in Washington Heights, the neighborhood adjoining Columbia's medical school. When I entered her room, Esther was lying on the bed, reading from a small prayer book. Her head was covered by a blue kerchief in the typical sign of modesty among married Orthodox women, whose hair, as a manifestation of their beauty, is not to be seen by men other than their husbands.
"I'm Jerry Groopman, Dr. Foster's student," I said by way of introduction. I wore the uniform of the medical student, a short, starched white jacket with my name on a badge over the right breast pocket. The badge conspicuously lacked the initials "M.D." Esther quickly took my measure, her eyes lingering over my name badge.
I did not reach out to shake her hand. Men do not touch strictly Orthodox women, even in a casual way.
Esther's eyes returned to my name badge, then to my face. I guessed at what was crossing her mind: whether my not shaking her hand indicated that I was Jewish and knowledgeable of the Orthodox prohibition, or simply an impolite student. "Groopman" was Dutch in origin, not a giveaway. Dr. Foster had described Esther as anxious, and I felt that disclosing our shared heritage would put her at ease.
"Shalom aleichem," I said, the traditional greeting of "Peace be with you."
Instead of offering a welcoming smile, her face drew tight.
Following protocol, I began the clinical interview, which includes taking a family and social history. Esther Weinberg, nee Siegman, was born in Europe in 1946. Her family was from Leipzig, Germany, and of its more than one hundred members, only her parents had survived the Nazi camps. The Siegmans immigrated to America in the early 1950s. Esther married at the age of nineteen, had her first child--a girl--a year after the wedding, and then twin girls eighteen months later. Her father died of a stroke not long after. Over the last year, she had worked as the personal secretary for the owner of a cleaning service in midtown Manhattan; her job was strictly clerical, without exposure to toxic solvents that can be carcinogenic.
One of the primary risk factors for breast cancer is a family history of the disease. Esther had limited knowledge of those who had perished in the war, but she recalled no afflicted relatives. Another major risk is prolonged and uninterrupted exposure to estrogen, which occurs when menarche, the onset of menses, happens at a very young age, or when pregnancy occurs later in life or not at all. But Esther had entered puberty at thirteen, a typical time, and carried and nursed three children in her twenties. This early motherhood would, if anything, lower her risk for breast cancer.
I conducted the physical examination that I was taught to perform specifically on women, to convey a sense of propriety and respect for their body. I covered each breast in turn as I palpated for irregularities. I was taken aback by what I found. The mass in her left breast was very large, about the size of a golf ball, easily felt above the nipple. There were many lymph nodes in the left armpit, also large and rock-hard.
For a cancer to grow to this size, and to spread into the adjoining lymph nodes, takes many months, if not years. Its prognosis, dictated by the dimensions of the tumor and the numbers of lymph nodes containing metastatic deposits, was very poor. How could a seemingly attentive young woman have waited so long to consult a doctor?
I did not ask. Dr. Foster strictly defined boundaries for students on his surgical team. Our role was to observe and learn, to do only what he told us to do.
"We will be making rounds with Dr. Foster later in the day," I said. "I wish you the best with the surgery."
"God willing" was her reply.
I started to leave.
Esther called after me, "Can I talk to you?"
"Of course," I said. A patient choosing to talk to us students made us feel very much like the doctors we wanted to be.
"Maybe later," she said uncertainly.
That afternoon, William Foster stood at the foot of Esther Weinberg's bed, flanked on his left by his three students, and on his right by the team's two residents. The waning July daylight cast long shadows across the room. I summarized the reason for admission, the physical findings, and the planned procedure, directing my words to Dr. Foster. The mass was almost certainly malignant, and it appeared to be quite advanced; it would first be treated by surgery, followed by chemotherapy. I went on with my charge as a student, reviewing for the team what Mrs. Weinberg had been told by Dr. Foster in his office about the impending operation. After she was anesthetized in the operating room, a biopsy would be taken of the mass, and if it proved to be malignant, as expected, a radical mastectomy would be performed right away. This was the approach handed down from William Halsted, an eminent surgeon who practiced in the early 1900s at Johns Hopkins.
Dr. Foster nodded and walked deliberately to the left side of the bed. He held Esther Weinberg's hand in his. He asked if she had any questions about the impending operation.
"Will Dr. Groopman be with me when I wake up after the surgery? I'd like him there."
Dr. Foster shot me a brief, quizzical look.
I was unsure why Esther wanted me at her side when she regained consciousness. I studied her face for a clue, but it revealed none.
"Mr. Groopman, like every student, follows his patients from the time of admission into the operating room and then through postoperative care. Be assured that I will discuss fully with you what we found at surgery and what next steps need to be taken."
Esther Weinberg's case was the first on the day's schedule. I scrubbed next to Dr. Foster and the senior resident. There was no idle chatter before surgery. We marched single file into the OR, Dr. Foster leading, the senior resident behind him, and I last, befitting my status. The anesthesiologist had already put Esther under. Foster nodded to me, and I swabbed an iodinelike antiseptic in concentric circles over the skin of her left chest. Then I laid sterile drapes around the painted breast.
Since beginning the surgery course on the first of the month, I had assisted in several operations and seen how the operative field was treated, as if it were a domain distinct from a larger living human being. The surgeon initially identified the relevant anatomical landmarks, like a surveyor delineating his planes. This promoted psychic detachment, lowering the emotional temperature and facilitating the intense concentration the cutting required. A stylized sequence reinforced this mind-set. Each set of incisions was followed by a formal appraisal of the newly exposed anatomy and a resetting of landmarks. The aim was to fully encompass the diseased region with minimum destruction to surrounding healthy tissues and maximum preservation of normal structures. But today's operation was different. In the event of a radical mastectomy, total destruction of the normal anatomy was planned. The mammary tissues of the breast would be removed, along with the muscles overlaying the chest wall, including the pectoralis and all the lymph nodes of the armpit. What would remain were scar and ribs. This draconian approach was rooted in Halsted's contention that cancer cells migrated stepwise from the primary tumor into the surrounding tissues and then, much later, through the bloodstream to distant sites like liver and bone. Only by extirpating a complete block of flesh on the chest could the surgeon remove the cancer cells hiding beneath the breast. Dr. Foster had lectured at length on how Halsted's insight had advanced the treatment of breast cancer from a plethora of haphazard operations to a uniform and highly scientific surgery.
Dr. Foster delineated the margins of the breast mass above Esther's left nipple and then instructed the resident to biopsy it. He made an incision and retrieved a wedge of gritty, glistening tissue. A pathologist was called to perform a "frozen section." He would flash-freeze part of the mass and immediately examine it under the microscope to determine whether malignant cells were present. If he saw them, the mastectomy would proceed.
Our wait in the OR was a short and silent one. Dr. Foster seemed deeply absorbed in his thoughts, and neither the resident nor I dared disturb him. The...