I could not wait to leave. On a salary that equated to eight dollars per hour, I worked over ninety hours a week at a program that did not enforce the eighty-hour work week rule. I endured thirty-six-hour shifts every four days. My next day often began even though the previous one never ended. Twenty years ago, as a Black woman intern in a program of primarily White males, I needed to show everyone I was just as tough despite having reached my physical and emotional limit. After six months of working as a medical intern at an underfunded public hospital, I fled to Spain.

This rotation abroad was a four-week elective I created at a Spanish language school in Madrid to improve my medical Spanish. My program director approved it with a raised eyebrow and called it the most unusual elective request he’d received.

I made friends at the Spanish school—most of them American, all of them my age—who had saved up money, quit their jobs, and moved to Madrid. I’d never been so jealous. The polite and neatly dressed locals, the social culture, the fresh-tasting tapas, the affordable leather shoes, and the dazzling Sephora (before it became big in America) made me love my time there. My friends and I went clubbing and hot Spanish men would be drawn to us like magnets. With weekends free, I visited Paris, Rome, Barcelona, the quaint Spanish towns of Toledo and Segovia, and the breathtaking cities of Seville and Grenada. My friends lived off savings, but some worked odd jobs that paid in cash. They hoped to stay a year, maybe more, and then go back home.

For four weeks, I lived my friends’ life of freedom, exploring, partying, traveling. In control of my own time. Enjoying being alive. As my independence, self-reliance, and Spanish strengthened, I longed to stay. I wanted to quit my suffocating internship and see what else I could become.

Throughout my first six months as a medical intern, I often thought about quitting. But leaving medicine scared me. I’d dreamed of being a doctor for most of my life.

When I was ten, I watched as an elderly Black man holding a cane and fedora was turned away from our health clinic. I stood in line with my mother to check out while the receptionist kept yelling, “You haven’t paid your bill. The doctor cannot see you!” The man, obviously hard of hearing, leaned in every time she spoke.

Then, after several moments, as if hearing her for the first time, he answered, “I’m gonna pay it,” with a voice that came out soft and shaky.

“I’m sorry, but until your account is paid, you can’t be seen.” The receptionist, a White woman with shoulder-length brown hair and pointy red nails, spoke to him with sympathy but didn’t change her position.

I felt a responsibility to do something, but I was a child, and my parents taught me that children should not challenge authority. Surely one of the grown-ups here would stand up for this man, or at least make an effort. My throat swelled with shame as my mother and the waiting area around us remained still and quiet.

The elderly man released the counter’s edge and I watched in disbelief as he turned and tottered toward the exit without a single person stopping to help.

“Next!” the receptionist called out.

I knew in that moment that I’d become a doctor. I wanted to take care of an at-need population, especially those who couldn’t afford treatment. As my mother and I approached the receptionist’s desk, I smiled at the idea of helping someone in a similar situation one day in the future. The dream of becoming a doctor made my entire family proud, an identity that made me proud. After years working to attain this goal, how could I quit? What was I if I wasn’t a doctor?

And so, I said goodbye to my friends, left Spain, and went back home. When I returned to Chicago, radio stations played Christmas music, the Salvation Army bell rang in the subway stations, and baked goodies appeared in the nurses’ stations. I’d left for Madrid a month ago, after working on Thanksgiving, and returned to find I’d been placed on call for Christmas. My complaints of unfair scheduling were answered with a shrugged shoulder and “That’s just the way the schedule turned out.”

Christmas arrived with a blizzard. Snowfall danced across the hospital windows as I carried out the tasks on the to-do list for the patients on our inpatient medicine service:

• Parrino: Check chest X-ray for proper central line placement, replace if necessary
• Walkers: Write pre-procedure orders for barium study tomorrow
• Jackson: Taper down Ativan
• Cultler, Ramirez, and Jones: Draw labs—all have bad veins
• Peterson: Check labs and switch antibiotics if white count is still high
• Hanley: Examine and mark out thigh erythema and compare to 6 a.m. markings
• Salvador: Check platelet count for abdominal paracentesis tomorrow and give platelet transfusion orders if <20,000

By late afternoon, phone calls for admissions mounted, but the real question was how many would arrive.

In the on-call room, I ate dinner at the small desk while watching the television broadcast whiteout conditions, stranded cars on the highway, and snowplows that couldn’t keep up. Newscasters branded this blizzard “the worst in a decade.”

I called my boyfriend, Ian, who held up the phone for his family to say “Merry Christmas!” His sister asked, “Does she get paid time and a half for working on Christmas?” Ian answered no. I called home next. My mother, who heard the sadness in my voice, gave me a pep talk, saying “You can get through anything” before passing the phone to my younger siblings, who spoke over the Christmas movie in the background to say my present was in the mail. My pager ended the call.

BEEP! BEEP! BEEP!

“This is Doctor Williams. I was paged?” I said, calling the number I recognized as the psychiatric ward.

“Yes, I paged you because we need help with Melissa.”

I blew out an exhale at the familiar name. Melissa Clemente, who always wore pounds of Mardi Gras beads, was a known patient to our medicine team. “What’s going on with her?”

“She pulled out her IV and won’t let us put in another one.”

“How did she pull it out? Didn’t you have her in restraints?”

“We did have her in restraints, but she was being cooperative, so we released one leg. Then she was still cooperating, so we released the non-IV arm. That’s when she pulled it out.”

“Geez,” I gasped.

“She needs antibiotics for a dialysis catheter infection. We’re already behind her scheduled dose.” The nurse’s breathy words had a tone of exasperation, maybe desperation. “I need help with her.”

I didn’t like getting involved with these refusals of treatment. I imagined a doctor’s duty was to provide high-quality clinical care to patients. I did not anticipate or enjoy taking on the expected role of enforcer. If an informed patient didn’t want to do something, it wasn’t my place to coerce and try to convince them.

“Can’t it wait until the morning, when her team comes in?”

“She’s mentally and legally incompetent. We have to get this IV finished. And I need a doctor’s written order for chemical restraints if she doesn’t comply.”

As soon as I passed the buzzing of the State Mental Health security door, I heard yelling.

“Don’t touch me! Don’t you fuckin’ touch me!”

Melissa, a six-foot-tall obese White woman in her mid-forties, had a reputation. She’d been admitted to psychiatric hospitals for decades with schizoaffective disorder, a condition with symptoms of both schizophrenia, such as hallucinations, and bipolar disorder, such as mania and depression. Her condition impaired her decision-making, which is probably the reason she accosted the nurses and doctors who took care of her. She’d been a resident of the hospital for a few years because it had a medical psychiatric ward that could manage her advanced medical problems.

“Thank you for coming,” the nurse said, meeting me in the hallway. “We tried everything. Doughnuts and extra smoke breaks usually work, but she just swung at one of my nurse assistants. Luckily, she missed.”

I took a moment to consider what I faced. I had to negotiate with Melissa, emotionally volatile and sometimes-scary Melissa, to let me put a needle in her arm so that we could treat an infection caused by a medical intervention that she didn’t want in the first place—dialysis. Her kidney failure stemmed from years of psychiatric medication. She hated dialysis and everyone who forced her to have it. But without dialysis, she’d die.

“I’ll go talk to her,” I said.

Melissa quieted as soon as I stepped into the doorway. I took this as a good sign. The nurses’ aides in the room relaxed their shoulders, knowing her attention would be on me for a while. Melissa didn’t look like her usual self. On an average day, she dressed up with shimmering plastic beads around her neck, a splattering of red lipstick across her mouth, and too much rouge on her cheeks. Those added to her larger-than-life presence. Without them now, after lights out, she seemed reduced, like a character unmasked. She’d propped herself on her elbows. Long saggy arms extended out of a white sleeveless T-shirt, the restrained hand clutching the edge of the bed. Images of Mickey Mouse danced on her red pajama pants and pink fuzzy slippers rested on her feet. She squinted to study me and the wrinkles that emerged aged her by twenty years. Scant locks of brown hair hung at the level of her ears and neck.

“Hi Melissa. It’s Doctor Williams.”

“Get lost, bitch.” She spoke with a lisp because she had already taken her dentures out for the night.

I spoke calmly. “Melissa, you pulled out your IV. But you need it so you can get medicine for the infection. I’m here to put it back.”

She didn’t take a moment to consider. “Fuck you! You doctors only cause me pain. You just wanna cut into me like a slab of meat. Get the fuck outta here.”

The stuffed animals and dolls that lined her shelves as decoration peered at me. Black bears, brown bears, pink bears, Cabbage Patch Kids, and dogs, lots of dogs, all sat with their eyes fixed, waiting for my next move. Holding onto my cool and taking a slow step forward into the room, I said, “Melissa, you have an infection and you need medicine to cure it.” As I enunciated every word, she pulled her chin down, looking at me from underneath hooded eyelids. “If I don’t put your IV back in, you will get really, really sick.”

“Why don’t you people just let me die already?” She yelled with a face bordering on rage and anguish.

When I first met Melissa for a separate and less severe dialysis-related complication months ago, she called me pretty and offered one of her beads to me—a purple one to match my blouse. That was her sometimes-sweet side.

“I’m sorry you feel like that,” I said. “When your psychiatrist comes back tomorrow, you can talk to him about that. I’m just here to help you get your medicine.” I stepped toward her and she kicked at me with her one free leg. The nurse screamed, and I stumbled backward. With Melissa’s altered sense of coordination and her still being partially restrained, she didn’t make contact, but seeing the flash of the underside of her slipper switched me out of patience.

Why am I taking the risk of being assaulted? I wondered.

I left the room feeling aghast and angry about being put in this situation. “We’ll have to sedate her,” I said to the nurse.

“What would you like to use, doctor?” she asked.

“Haldol and Ativan. Four-point restraints. And get some people up here who can hold her down so nobody gets hurt.”

The nurse rushed off as I explained the medical necessity for these actions into Melissa’s record. She had become a danger to herself and others, and based on her mental illness, she was already deemed legally incompetent.

When the syringe was ready, the nurse followed four big guys into Melissa’s room. I trailed behind.

“Don’t you fuckin’ touch me!” Melissa yelled. Holding onto the bed for leverage, she kicked wildly. It helped that she got winded quickly. One of the big guys pushed Melissa down onto the bed while the others held her legs and torso long enough for the nurse to give her a shot in the meaty portion of her thigh.

Melissa screamed, bucked, and spat at us until the nurse covered her mouth with an oxygen mask. I felt the eyes of her stuffed animals on me, shaming me. But they should’ve seen that she gave me no choice.

The men held her down as she continued to yell, “I’ve had it. I don’t want any more dialysis. Just let me die.”

“You can’t die tonight,” I said. “Not on my watch.”

Ten minutes went by, and her breathing settled down. Another five minutes and she was out. One by one, the men peeled off her, hesitant and ready to constrict again. She failed to give a single flinch.

They replaced the other two restraints and the rest of us in the room blew out a sigh of relief, or maybe regret. I didn’t like what I’d just had to do. Melissa always seemed informed about her condition and the consequences of refusing treatment. But, even though it scraped against the grain of my core self to force my will onto someone else, it wasn’t my role, nor did I have the power to decide that Melissa was competent enough to make her own decisions. My stomach burned with thoughts that made me feel guilty. In three months, I’d learn that my worsening abdominal pain was the result of a smoldering stress ulcer.

The nurse checked Melissa’s vital signs. A nurse’s aide held her hand in hers, searching for an entry site. She inserted a needle, attached the tubing, and ran a small bag of antibiotics into Melissa’s veins to fight the infection. She would stay sedated and restrained until the morning, when her regular team returned from the holiday.

In the elevator bay, snow hurled itself sideways past the windows while some caught in the corners of the frame. Memories from Spain teased me as I stood in a hospital feeling trapped by a system that exploited me. In Spain, I had a nice life. I had control over my circumstances. I wanted that freedom, but I also wanted to live out my dream of practicing medicine one day. Plus, I owed $150,000 in medical school loans. I couldn’t pay that off teaching English in Barcelona. If I wanted to survive this internship, I had to keep treading water.

But I needed some hint of freedom to make it through. It wouldn’t be in the form of walking on Barcelona’s Las Ramblas in the middle of the day or reading a leisure book on a Saturday afternoon. The only freedom I had was in the form of detachment. Detachment to protect my emotions, but also to disconnect myself from the work and people so that I could be free within the rigid boundaries set around me. As an intern with a lot of responsibility but little power, this seemed to be the only way to cope with the drudgery and stress of my daily life.

I was unaware that this path would come at the expense of my patients. I was able to handle their medical problems, but I had lost the ability to see the individuals within.

*

Two decades later, after my internship, after therapy helped me survive it, after five years of training at different hospitals in the field of ophthalmology and oculoplastic surgery, after my sensitivity and humanity for patients returned as my work hours and working conditions improved, after I left medicine, after I returned when the ache in my chest spoke like Daddy’s once-imploring words to give back to the community, after I got a part-time position at a New York City public hospital living out my childhood aspirations to help those who can’t always afford to pay, I wanted to share my story. There weren’t many books showing how hard medical training is (and even fewer by women of color). I wanted to help current and future trainees cope, and I decided to write a book.

A few years ago, on a sunny January day, while my young children were under the care of their grandparents so I could work on my writing, I sat in the back of a local coffee shop with my laptop, trying to resist the distraction of social media, when an email notification flashed across my screen: “Another Mount Sinai Doctor Jumps to Her Death.” I opened the email to read about a young doctor who wore her white coat as she stepped off the roof of the same thirty-three-story Mount Sinai residential building where two other women doctors had jumped to their deaths only months before. Her body remained at the front entrance for hours, covered with a tarp, before finally being removed.

This death and the ones that followed in the same year reinforced why I wanted to share my story. As I continued writing chapters to shed light on the pressures that doctors face, two doctors-in-training hung themselves within five days of each other that May at NYU Langone. And in October, I learned through the medical grapevine that my friend Byron, an always-smiling doctor with a southern drawl whom I trained with, killed himself eight months prior, in February. During those eight months, the regular email blasts from the institution where we both trained touted research achievements, generous gifts made by donors, and openings of newly built suites. No mention of Byron.

When I started writing about my year as an intern, memories, along with the emotions surrounding them, flowed onto the page, but I kept getting stuck in the same spots. I thought I’d overcome the experience of that year, but the patients still haunted me. No, I couldn’t blame the patients. Rather, my regrettably harsh reaction to them still haunted me.

One day, while doing research on healthcare in underserved settings, I stumbled across essays online by a writer who, like Melissa and many of my patients from internship year, had spent time in institutional settings. His writing, rich with compassion and deep reflection, inspired me to reach out and ask him for help understanding the “why” behind my patients’ actions. He agreed. My new writing partner showed me that the key to seeing my patients was to honor, imagine, and tell their stories. This process helped restore my compassion and rethink how I perceived people—patients from my internship as well as in my current practice.

When a patient of mine last summer missed every single appointment given to him for weeks before finally showing up one late afternoon just before clinic ended with severe worsening of his eye condition that could have been prevented if he’d come in when directed, jumping to the conclusion that he didn’t take his health seriously would’ve been easy.

But, when I took a few moments to ask questions and learn his story with the help of a Spanish interpreter, I found out that he worked as a lunch-service busboy at an iconic upscale restaurant on the other side of the city that didn’t offer him any benefits, let alone time off, and that the earliest he could ever get to clinic was 4:00 p.m. after work ended. I concluded that, for him, keeping his job took priority over the growing tumor on the surface of his eye. Thereafter, I told him to come at 4:00 p.m. even though the official last appointment was at 3:00 p.m.

In these moments, I feel the fulfillment and joy of medicine I’d dreamed of since childhood. Having the control and power I lacked as an intern makes this type of interaction possible.

When I felt trapped and hopeless during training, I escaped to Spain. Detaching myself from those I committed to help took a toll that lingered for decades. Too many doctors-in-training feel forced to escape in other ways, including taking their own lives. And even though I wouldn’t trade my time in Spain for anything, feeling desperate enough to flee and disconnect should not have been a necessity to endure medical internship.

As medical-training reforms continue to evolve, I hope that residents, even when justifiably triggered by patients, will be given the time, the support of leadership, and the emotional capacity to ask, listen and learn what is driving their patients’ behavior. Furthermore, graduate medical education must include and meaningfully embrace all aspects of wellness for young physicians—perhaps most importantly, their psychological safety.

Zinaria Williams is an ophthalmic plastic surgeon, author, and 2020 Queens Arts Fund New Work award recipient. After decades of being published in textbooks and peer-reviewed journals within the field of ophthalmology, dermatology, and ophthalmic plastic surgery, her writing shifted from scientific to narrative. Her opinion pieces have appeared in US News and World Report’s “Healthiest Communities” column and a forthcoming essay will appear in the anthology Nonwhite and Woman from Woodhall Press in 2022. Her literary work focuses on themes illustrating the harmful consequences medical training and medical culture have on doctors, juxtaposed against the struggles of patients, who suffer the downstream effects. This essay is an excerpt from her forthcoming memoir. She cares for patients at a public hospital in Queens, New York, and lives outside of New York City with her husband, two young children, an Amazon parrot, and an elderly cat.