This transcript has been edited for clarity.
Abraham Verghese, MD: Hello, everyone, and welcome to this episode of Medicine and the Machine. This is Abraham Verghese and I'm with my co-host, Eric Topol. We're delighted today to have two guests on our show. First is the writer Emma Goldberg. She has a new book, Life on the Line: Young Doctors Come of Age in a Pandemic. She's also a reporter at The New York Times, writing on health and science, gender, and culture, among other topics. This book is the tale of the COVID epidemic in New York City, told through the characters of six medical students who are now interns. We're privileged to have one of them, Sam Dubin, with us. This is a wonderful story and it's good to have both of you here.
Emma Goldberg: Thank you for having us on. Sam is the real expert so I'll defer to him, but I am grateful to both of you for having us on the show. This is a real honor.
A Glimmer of Hope
Verghese: I'm going to start by reading a passage from the book that blew me away because it was so uplifting. This has to do with medical student Ben:
The brightest moments in Ben's week came when the hospital halls rang with Jay-Z's "Empire State of Mind," which meant a COVID patient was being extubated or discharged. Each hospital had its own soundtrack. Lenox Hill played the Beatles' "Here Comes the Sun" with nurses calling "Code Sun"! Hackensack University Medical Center played Bill Withers' "Lean On Me." Maimonides in Brooklyn rotated hits like U2's "Beautiful Day" and the theme from Rocky. New York City's Metropolitan East Harlem chose the Journey classic "Don't Stop Believin'."
This was a tale of such tragedy, with an overwhelming onslaught of very, very sick patients. To me, that moment stood out.
But I want to begin by asking you, how did you meet the medical students? How did you arrive at the structure for telling the story?
Goldberg: The reason I was so drawn to the story of the medical students who graduated early was that it felt like a bright spot and a glimmer of hope in the midst of the crisis in New York. The medical students–turned-doctors gave me inspiration and hope in the early weeks of the pandemic. April in New York last year was a dark time. The streets were empty, the hospitals were full, and all you could hear all day was the sound of sirens. For journalists, it was a moment of paralysis because we're used to being able to go out and about and report and be in the thick of things. Instead, newspaper offices emptied out, and everyone was at home reading headlines about the war zone–like atmosphere in the city.
Speaking to medical students who were mobilizing and doing something extremely constructive and valuable in the moment was a real bright spot for me. I was fortunate to be connected to doctors like Sam through medical schools such as NYU and Albert Einstein, that reached out to students and connected me with some people who were willing and generous enough to share their experiences as they were working these long shifts in the hospital.
Eager to Dive In
Verghese: The book begins and ends with you, Sam. It must have been quite a shock to be a final-year medical student watching this happen. Tell us a bit about how you wound up volunteering to work in the hospital.
Sam Dubin, MD: The fourth year of medical school has a reputation of being like an expensive vacation, when the pressure cooker of the earlier years is released somewhat, especially post-match. But this one didn't follow the textbook. Many of us were ready and waiting, in a mindset that we have these skills, we've matched, and we're just waiting to start. For those of us who had the time and privilege of being able to step forward and offer ourselves in this way, while it was a very surreal circumstance, it fit with the narrative that otherwise, we're going to be quarantined in our homes, figuring out a way to volunteer. In less than 2 months anyway, these are the same skills we are supposed to start developing, although in a very different context. We were happy to do it.
Verghese: Emma, you could have told the story in many different ways. I'm glad you told it the way you did. But did you wrestle with that or did you arrive at it by accident? How did you get the idea to use six characters to tell the story?
Goldberg: I was following more doctors in the beginning, and over time I winnowed that number down, partly based on who was willing to continue updating me and providing me with real information and as much detail as they could about what they were seeing and experiencing. And I wanted to include doctors who had different interests, had come from different communities, and had different perspectives. And so the doctors I followed in the book all represent new aspects of what it means to be drawn to medicine.
There was a young Orthodox Jewish woman who wrestled with questions about her faith. There was a first-generation American who had grown up with a family that was skeptical of Western medicine and the US healthcare system in particular.
I wanted to follow doctors who brought surprising, unexpected, or diverse viewpoints in terms of their interest in medicine. The decision to bring in some of the history of the US medical education system came about because it felt that it was becoming a broader story about the changing face of medicine, and the changing norms and perspectives of younger doctors. I wanted to contextualize that by looking at the histories that inform how we actually got to the current state of US medical education. That led me to the Flexner Report and the history of paternalism in the system. I knew that I wanted to bring in different threads that would inform lay readers who aren't as familiar with the history of US medical education.
Eric J. Topol, MD: It's an extraordinary book and a phenomenal contribution about medical education in a historic time. What is fascinating is that internship is like going into the deep end of the pool and learning how to swim. It couldn't be more of a contrast — learning how to swim in the worst pandemic in Bellevue Hospital, what had been ground zero for HIV, and now with COVID. Didn't you have a lot of trepidation, even though you were eager to get started on your medical career?
Dubin: Admittedly, I should have had more trepidation than I did. It wasn't out of bravery but perhaps out of cabin fever from the pandemic and eagerness to start at NYU. The early graduates were put where their sub-internships had been, so we had some familiarity with the system. What helped somewhat with the trepidation was not going crazy from being in my apartment for a month or two, and knowing the system and who I would be working with. People from my pediatric clerkship were now with me on the medicine service, like an endocrinology fellow who had finished residency the year before and was now my attending. It was a sort of bizarre community.
Bellevue Then and Now
Verghese: Bellevue could have been the centerpiece of the whole book; it's such a storied hospital. We've had Danielle Ofri on our show. Her writing is centered on Bellevue which, since it opened in 1816, has always been at the forefront of immigrant health, new diseases, and new epidemics, especially in the HIV era. In the spring last year, Bellevue became overwhelmed with COVID. Could you talk a little bit about Bellevue — what you saw, how they handled the pandemic?
Goldberg: One of the most fascinating moments for me was picking up David Oshinsky's Bellevue last spring. I was reading that as I was speaking with some of the doctors around New York who were going in and out of the COVID wards. Dr Oshinsky's account of the history of Bellevue includes journal entries from interns who were working at Bellevue during the HIV crisis, and the experiences of people who saw other epidemics hitting New York over the decades, such as typhus and other diseases. It felt like I was reading modern-day accounts of those who were witnessing COVID.
One intern talked about seeing wealthy New Yorkers fleeing the city in the 1860s. It was like the chariots flowing out of the city, carrying people escaping Pompeii while the lava was flowing. There were visceral moments that mapped precisely to what we were witnessing with COVID. This was when we were seeing people leaving New York City in droves and these eerily empty streets. In the book, I was reading the accounts of doctors who were in the AIDS wards at Bellevue, talking about the kind of simultaneous fear and pride and the real grief of seeing patients there who didn't have visitors or family members with them. It was an intense experience to read these accounts from doctors at Bellevue over the centuries that felt so in tune with what people were experiencing in the COVID wards. It felt like history was coming alive. People were walking in the footsteps of that history and honoring what Bellevue has always stood for, which is being at the forefront of New York City's response to epidemics, and the courageous role that doctors played then as well as now.
Verghese: It probably won't surprise many of our listeners, but it must have been a surprise to you to find how much of your work revolved around social issues — things that were bigger than COVID. People were coming from Rikers Island prison, and COVID was only a small part of it. Could you speak to that a little bit?
Dubin: COVID disrupted all systems, not just healthcare delivery. Bellevue is one of 12 or 13 hospitals in New York's public city hospital system. It's a flagship and as such has one of the highest levels of resources. Folks from all over the city are transferred to Bellevue if they need cardiac catheterization or a neurosurgical intervention. So although geographically we're on the far East Side without subway access, we get patients from all over the city. We were not spared any part of what the city saw.
Graduating early and seeing Bellevue as an epicenter of HIV and AIDS is something I'm still processing. Coming into my interest in LGBTQ health in college, I was following the opioid epidemic as a modern-day parallel. Then all of a sudden I'm the one responsible for bringing in a food tray because the ancillary staff aren't vaccinated and don't have enough masks, or I'm standing there sweating in my PPE, holding up the phone because a loved one can't come in the room to have a discussion about the end of life.
Emma tells the story of my experience with a patient who was incarcerated at Rikers Island. Because of the pandemic, that incarceration ended in the midst of his hospitalization. We're used to trying to navigate the system as best we can as healthcare providers at Bellevue. But it was just one more disruptive thing that COVID took the curtain off of. And we got to see that system even more so for what it was and how it impacted our patients.
The COVID Effect on Med School Applications
Topol: A surprise that came out of this intense, nightmarish situation is that medical student applications have soared tremendously like we've never seen. I'm not sure they know what they're getting into, but I wonder if you would comment on the reigniting of enthusiasm and excitement about being a doctor, which we haven't seen in a long time.
Goldberg: There's been about an 18% jump in applications and a parallel jump in applications to nursing schools as well, which is fascinating. It wasn't all that surprising after having talked with people like Sam who decided to graduate early and go right into the hospital. What I heard from them was a sense of obligation, that there is value in being able to put the skills that you've been trained in to work. You've done the hard work and you want to be able to help. And there's never been a moment where we've seen how much we rely on healthcare providers.
My favorite part of the day last spring was that 7:00 PM applause. I would go out into the street and hear it ringing out. It was the loudest moment of the day on my street, aside from the sirens. That tribute was being made because everyone in the city was aware that while so many people were locked in their homes, the people doing the real work out there were the healthcare providers. Without those people making those sacrifices, we would have been in far greater trouble than we were. What I heard from talking with the doctors I followed was that their trepidation was not so much about putting themselves at risk because they knew that was what they'd been trained for and what they prepared to do. It was more from a concern about not being able to do all they wanted for patients.
I followed a young woman named Iris. When one of her first patients died shortly after being admitted, Iris had a moment of realization knowing that she'd made the right decision to graduate early and work in the hospital. Her regret was just that she couldn't actually do all the lifesaving work she wanted to do; it was less from putting her own health on the line.
We saw a real sense of duty, obligation, and courage reflected in healthcare providers over the past year. Medical school applications speak to that and shine a spotlight on the absolutely invaluable work of healthcare providers.
Illuminating Race and Medicine
Verghese: A significant part of your book is about the phenomenon of race and medicine. A disproportionate number of people of color and those who were disadvantaged by the healthcare system suffered from COVID and died in numbers greater than other groups. We just published in JAMA Network Open a study on the number of physicians who died. We used public databases like Medscape and The Guardian, which were keeping track of COVID deaths among physicians. Of 132 US physicians who died, a disproportionate number were foreign medical graduates. About 25% of the nation's physicians are foreign medical graduates, but the percentage who died was disproportionately higher in places like New York City and New Jersey, where many foreign graduates practice.
I'd like both of you to reflect on race and COVID as you saw it at ground zero there in New York City.
Dubin: A unique aspect of working at Bellevue is that it's both a city hospital and a hospital for the world. People come from all over. Emma asked me about witnessing health disparities in these early numbers, these sort of harrowing numbers showing which communities were being disproportionately impacted. Without being glib, my answer was that we already knew about this. Unfortunately, the topic is making headlines now for the wrong reasons. It takes a tragedy for the spotlight to shine, and my experiences with early healthcare disparities and inequities during the pandemic were consistent with what I'd already been exposed to clinically as a student at NYU and in New York.
And unfortunately, you saw when the families weren't in the room, or when other family members were in some other hospital room somewhere else and couldn't pick up the phone, you saw what resilience and resources those communities have and you saw them become even more impacted. I keep saying that COVID took a curtain off things and that was one area where it shined a light, at least for me. How do I not only provide competent care to everyone but make sure I'm acknowledging what my patients arrive with?
It's one thing to have your own politics and view of things, but to see what investment of energy, empathy, and time is needed to address these issues and bridge the gaps for patients was certainly one of those early walls for me. You think, I know these things; this is something I want to do. But showing up, and especially in a pandemic, you are reminded that it's, of course, easier said than done. As I said, though, health disparities was one of the many things the pandemic exposed. There were some people — patients, healthcare consumers, and providers — who already saw and knew this. It was not a new experience but a new story that the media started telling.
Goldberg: I do think that there is an extent to which the past year shows the life-and-death consequences of representation in medicine. I remember in the early weeks of the pandemic, there was a report from the city of New York showing that Black and Hispanic New Yorkers were dying at around twice the rate of White New Yorkers from COVID. Then you look at those statistics in conjunction with the evidence showing that Black and Hispanic patients often have better health outcomes when they're seen by doctors who look like them. And it speaks to the real stakes of representation in medicine and the real urgency around widening the pipeline and boosting the number of Black and Hispanic physicians represented in the workforce, which is under 6% for both groups.
We are fortunate to have access to evidence that shows empirically that Black patients have better health outcomes when seen by Black doctors, because that can boost and amplify calls for more representation in medicine.
I was floored when I saw a study from Dr Owen Garrick and Dr Marcella Alsan [and Grant C. Graziani] documenting that Black patients are more likely to agree to diabetes screenings and cholesterol tests when they're seen by Black providers.
The real work involves thinking about what it would look like to actualize those calls for representation, and not just pay lip service to it. Who has access to the pipeline, and how are we eliminating the invisible costs of medical training, whether it's pricey study banks, flashcard bank exams, or applying to interviews? There are all these hidden costs of becoming a doctor.
We need to start looking at the real stakes of representation and all the steps that it'll take to boost who is represented in the field. That's some of the work coming out of the pandemic. And as Sam said, many people have known this for a long time. Now it's thinking about how we can sustain the energy in these conversations and not allow them to just fizzle out as we're coming into the new stages of reopening.
Verghese: What is the take-home message from the book? For me, it was a very hopeful one. I was inspired to know that medicine is in the hands of people like Sam and Iris and all the other wonderful students who are now residents. Sam, Emma chose to end the book with the Pride March — a great metaphor for hopefulness. What does the march symbolize at this point in time?
Dubin: Something I take away from my understanding of LGBTQ history is that right after Stonewall, although there had been activist movements before, the new trajectory was the all-encompassing idea that the people and systems that oppress us are not separate from other things. It's something I learned in my history class that I always found compelling, and I certainly see it in healthcare. I appreciate and understand Emma's choice to end with that, because for me, what was actually the 50th anniversary of the first Pride March (not Stonewall itself) had no parade permit and was the unofficial one, and there was violence and police intervention.
To be there on a day off from my rotation in the COVID ward was to have a lot of things collide for me. It was just another Sunday, but in reflecting on it and having the privilege of reading about it in Emma's writing is to say that the identity I bring in my experience, I bring to healthcare as these reminders of it. It's not learning about it in class anymore. It's about doing it and living it. It's been a privilege to have these conversations with Emma and hear her articulate these stories, including my own.
Storytelling in Medicine
Goldberg: All three of you do such powerful medical storytelling. That's something I'm very interested in as a nonphysician — thinking about how to tell the stories of people on all sides of the medical system, whether it's patients or doctors or nurses or others. Also thinking about how to humanize the field, because sometimes people who are outside of the medical field don't know about their entry point in the system, or ways of communicating and understanding the stories that show why doctors do the work they do.
One thing that I found striking about the past year from talking with doctors at different levels of the medical field was hearing about some of the ways in which COVID shook up clinical norms and almost bent hierarchies. There were people from very high levels of hospitals who were changing bedpans. And there were people who were stepping into more senior roles than they normally would. And there was a real all-hands-on-deck atmosphere and a sense that people were stepping up and stepping together and lifting up one another's work.
Something that I came away with is that there are people at all levels of the medical system with such powerful, urgent perspectives on medical care, patient-doctor relationships, and the shifting norms of medicine. As a person who comes at this from a storytelling — not a clinical — perspective, I want to continue to look for opportunities to put a microphone in front of them, particularly those who are less senior in the field and have fresh perspectives, and people who are veterans and have been doing this work for decades. The urgency of medical storytelling — not just in moments of crisis like this one, but always — is something that I'm coming away from the past year appreciating.
Topol: Such an important point. There's so little medical storytelling overall. It's not something we learn in medical school. Sam, would you say that's still the case now?
Dubin: Yes. Emma has been my first mentor in making a medical narrative and turning experience into a story.
Topol: This is phenomenal, and to think that we're recording this shortly after the grand opening of New York back toward COVID-free life. Hopefully it will stick. We can't thank you enough for the contribution that you made to stitch this all together as a masterful storyteller.
Goldberg: I'm thankful to all of you. Sam was so generous with his time and his insight. And it was a privilege to learn from him as he was in Bellevue doing such critical work.
Topol: We know Sam's got an incredible career going forward. And he's probably compressed 1 year equal to 5 years or more, maybe 10. It's an incredible experience that you were immersed in.
Verghese: This is just a remarkable book, especially if you know a young person who is interested in medicine, one of the many people applying to medical school. This is a real entry into what it is like — inspiring, but also realistic and beautifully told.
We've come to the end of another episode of Medicine on the Machine, with my co-host, Eric Topol. The book is Life on the Line by Emma Goldberg. Emma, we want to thank you and Sam Dubin for being with us today. A remarkable achievement, both of you. Thank you.
Eric J. Topol, MD, is one of the top 10 most cited researchers in medicine and frequently writes about technology in healthcare, including in his latest book, Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again.
Abraham Verghese, MD, is a critically acclaimed best-selling author and a physician with an international reputation for his focus on healing in an era when technology often overwhelms the human side of medicine.
Emma Goldberg is a reporter at The New York Times, covering health and science, gender issues, and culture. She has been recognized for her journalism with the Newswomen's Club of New York Best New Journalist Award and the Sidney Hillman Foundation's Sidney Award. She earned her BA at Yale and MPhil at Cambridge University.
Sam Dubin, MD, is a primary care–internal medicine resident at NYU Langone Health and currently works as the founder and lead writer for Queer Health Podcast. He served on the Advisory Committee on LGBTQ Issues to the Board of the American Medical Association and was a board member of GLMA: Health Professionals Advancing LGBTQ Health Equality.
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Cite this: The Medical Students Who Shunned Fear and Dove Into COVID Care - Medscape - Jun 25, 2021.