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Unless you like being unpopular, never mention that saving a life is a “for now” sort of thing.

Most of the patients I learned from as a medical student and then as an intern and resident would never be admitted to a hospital today because they are not sick enough. Because inpatient stays cost insurance companies money and insurers control the vast majority of a hospital’s income, the push to get a patient home starts as soon as the patient hits the door. Leukemia, heart attacks, major infections, et cetera, have all become outpatient diseases. If you’re not sick enough to be in an ICU, you can probably be treated as an outpatient. As soon as you’re out of the ICU, you’re discharged to rehab or chronic care. Medical students, interns, and residents don’t get to know their patients or see how things turn out; much of what they do any given day is transfer and move people around. It’s all about placement.

My first patient in internal medicine was a cheerful seventy-five-year-old Italian. He was admitted for something else, but because he drank a quart of wine a day, I put him on Librium to prevent the DTs like the resident told me to. We turned our only bright spot on the ward into an unresponsive, openmouthed-snoring, bedridden lump. “Well, at least he didn’t seize,” said the resident.

Being six years older than most of my fellow students had some advantages. After being up all night I looked more like an attending. I was the only one in my class to have a baby at home. During some clinical rotations you were supposed to sleep over at the hospital. Ninety-nine times out of a hundred there wasn’t anything for us to do, so I sometimes went home, where I had real responsibilities, to sleep in my own bed and get up with my own fussy baby. I told them to call me if they needed me.

With the exception of one or two people who were there to please their parents, everyone at medical school was there because they wanted to be and had worked hard to get there. We all expected to do important things. We all expected to be part of something like what medicine had accomplished between 1950 and 1975. We expected medical care to transform society. The idea that we would ever be told what we could and couldn’t do by insurance companies would have seemed far-fetched and bizarre.

There are a million lives going by at a million miles an hour, and all I could take in was the briefest narrative account of how they came to be in the hospital. There was the passion and energy of a twenty-year-old girl, holding down a job and taking care of her seven-year-old brother who was going to die of a horrible rare cancer; a thirty-two-year-old grandmother whose sixteen-year-old daughter had just had a baby; the father who wanted us to operate on his daughter’s inoperable brain-stem tumor and put it in his head instead of hers … I didn’t have time to give any of these stories anything like the attention they deserved. I wrote orders and discharge plans and tucked people in for the night.

My first clinical rotation was obstetrics. My first patient was in labor, and what she said to me after I introduced myself was “Cut me. Take out the baby.”

“You’re making good progress,” I assured her, and she had a beautiful baby about ten minutes later. This doctoring stuff wasn’t so hard.

I watched other doctors like a hawk. I worked very hard at learning how to examine babies and children. I still carry in my brain high-resolution images of how the doctors I admired listened to hearts and felt bellies. I kept accounts of what worked and what didn’t, when I was right and when I was wrong. Everybody who loved medicine wanted it to be better than it was, and that meant wanting to be a better doctor than you were.

Even most so-called accidents could be studied like diseases with various risk factors: teen gun violence required a gun, a grudge, alcohol, and impoverished future prospects. Take away the preconditions and the harm stops. Figure out what goes wrong and fix it. Goodness emanated from Harvard and a few other