Saturday, July 1, 4:45 a.m.

The smartphone alarm went off at 4:45 a.m. in Noah Rothauser’s small and sparse third-floor one-bedroom apartment on Revere Street in Boston’s Beacon Hill neighborhood. As a surgical resident at the Boston Memorial Hospital, it was the time Noah had been waking up just about every day except Sunday for five years. In the winter, it was pitch black and cold, since the building’s heat didn’t kick on until seven. At least now, in the summer, it was a bit easier to climb out of the bed because it was light in the room and a pleasant temperature, thanks to a noisy air conditioner in one of the rear-facing windows.

Stretching his sleepy muscles, Noah padded into the tiny bathroom buck naked. There had been a time when he wore pajamas as he had done as a child. But the habit had been abandoned when he came to appreciate that pajamas were just another piece of apparel he had to launder, and he wasn’t fond of taking the time to do laundry, as it required walking a block up the street to a Laundromat and then waiting around. It was the waiting he couldn’t abide. As a totally dedicated surgical resident, Noah chose to have little time for anything else, even personal necessities.

He eyed himself in the mirror, recognizing that he looked a little worse for wear. The evening before, he’d had a couple drinks, which was rare for him. He ran his fingers up the sides of his face to decide if he could get away without shaving until after his first surgical case. Often he shaved in the surgical locker room to allow him to get to the hospital that much earlier. But then he remembered today wasn’t a usual day, so there was no reason to hurry. Not only was it Saturday, with its usually light surgery schedule, but it was also July 1, the first day of the hospital year, called the Change Day, meaning a whole new batch of residents were beginning their training and the existing residents were advancing up the training ladder to the next level. For fifth-year residents, also considered chief residents, it was a different story. They were finished their training and were off to begin the next stage of their respective careers—everybody except Noah. By a vote of the surgical faculty, Noah had been proud to be selected to do a final year as the super chief resident who would run the Boston Memorial Hospital surgical department on a daily basis like a traffic cop at a very busy intersection. In most other surgical residency programs, a super chief status rotated among the fifth-year chief residents. BMH was different. The super chief was an added year. With the help of a full-time residency program manager, Marjorie O’Connor, and two coordinators under her, it was now Noah’s job to schedule all the residents’ rotations in the various surgical specialties, their operating room responsibilities, their simulation center sessions, and their on-call duties. On top of that, he was responsible for work rounds, chief-of-­service rounds, and all the various weekly, biweekly, and monthly conferences, meetings, and academic lectures that made up the academic part of the surgical department’s program. As a kind of mother hen, he also had to make sure that all the residents were appropriately fulfilling their clinical responsibilities, dutifully attending all the teaching venues, and handling the pressures of the job.

Without the usual need to rush to the hospital, Noah opened the medicine cabinet over the sink and took out shaving cream and a razor. While he lathered his face, he found himself smiling. His new job sounded like an enormous amount of work and effort, especially since he would have his own patients and be doing his own surgery at the same time, but he knew he was going to love the year. The hospital was his world, his universe, and as super chief he was to be the alpha-male surgical resident. It was an honor and a privilege to have been selected for the position, especially since on its completion, he was assured by precedent that he would be offered a full-time faculty position. This was huge. For Noah, the opportunity to be a full-time attending surgeon at one of the world’s premier academic medical centers associated with one of the world’s premier universities was the pot of gold at the end of the rainbow. It had been his goal for as long as he could remember. Finally, all the work, effort, sacrifice, and struggles in college, medical school, and now as a resident were going to pay off.

With quick strokes of the razor Noah made short work of his overnight stubble, then climbed into the tiny shower. A moment later he was out and vigorously drying himself. There was no doubt that it was going to be a very busy year, but on the positive side he would not have any official night call, even though, knowing himself, he’d be spending most evenings in the hospital anyway. The difference was that he would be doing what he wanted to do with interesting cases that he’d get to choose. And equally important, he would not be bogged down with busy work, the typical bane of house officers or hospital residents, particularly surgical residents, since there was always some menial task that had to be done, such as changing a dressing, advancing a drain, or debriding a gangrenous wound. Noah would be able to designate others to do all that stuff. For him, the learning opportunities were going to be off the charts.

The only fly in the ointment, and it was a big fly and a nagging, persistent worry for Noah, was the responsibility he now had for the damn bimonthly surgical Morbidity and Mortality, or M&M, Conference. This conference was different from all the others, since Noah would not have the option of farming out any aspect of the responsibility to other residents. It was going to fall to him and him alone to investigate and then present all adverse-outcome cases, particularly those resulting in death.

Noah’s fear of the M&M Conference was not some irrational concern. Since the conference was specifically about cases that didn’t turn out well, often involving mistakes and individual shortcomings, blame and finger- pointing in an emotionally charged environment with dirty laundry hung out for everyone to see was the norm and not the exception. Considering the egotistical mind-set of many of the surgeons, the atmosphere could be explosive and a breeding ground for hard feelings, with the potential of creating enemies unless an underling scapegoat could be found. Noah had seen it happen over the last five years, and the scapegoat often was the messenger: the presenting super chief resident. Noah worried that the same could happen to him now that he was super chief, especially considering the Bruce Vincent fiasco. The case had trouble written all over it for many reasons, not least of which was that Noah had been involved. Although Noah had never second-guessed his decision to put the man on emergency bypass, he knew others might.

Adding to Noah’s concern, the death of the popular parking czar had the entire medical center in an uproar and gossip was rife. Prior to the event, Noah hadn’t even known the man, because Noah didn’t have a car and never had any reason to visit any of the hospital’s three garages. Noah walked to work, and when the weather was bad, he merely stayed in the on-call facilities, which were expansive and more inviting than his own apartment. He’d seen the kids’ photos on the cafeteria bulletin board but had never known whose children they were. Yet now he knew and understood he had been in a distinct minority of not being a Bruce Vincent fan, all of which was going to make the M&M Conference a standing-room-only affair.

The main reason Noah was fearful was that the Vincent case involved Dr. Mason, who Noah knew to be egotistical, quick to export blame, and outspokenly critical of Noah. Over the previous year and a half, Noah had made an effort to stay out of the man’s way as much as possible, yet now, with this next M&M coming in less than two weeks, they were on a ­definite collision course like a certain cruise ship and a giant wayward iceberg. Whatever Noah was going to find in his investigation of the case, he knew it was going to be a diplomatic nightmare. From the little the anesthesiologist had said at the time, it seemed to Noah that a considerable amount of responsibility had to be directed at Dr. Mason, who had been running two other concurrent surgeries. The concurrent-surgery issue alone was an emotionally charged hot-button issue within the department.

Noah ducked back into the bedroom and went to the bureau for underwear and socks. There were only three pieces of furniture in the room: the bureau, a queen-size bed, and a single bedside table that supported a lamp and a stack of medical journals. There were no pictures on the walls or any draperies over the two windows facing out into a rear courtyard. There were no rugs on the hardwood floor. If someone had asked Noah about the decor, he would have described it as spartan. But no one asked him. He didn’t have visitors and wasn’t there much himself, which was probably the reason he’d experienced a few break-ins since Leslie had left. At first such episodes had bothered him as a personal violation, but since he had almost nothing to lose, he came to accept it as part of city living with lots of impecunious students visiting the tenants above him. Mostly, however, he didn’t want to take the time or effort of finding a new apartment. In lots of ways he didn’t even consider it a home. It was more a place to crash a few times a week for five or six hours.

There had been a time several years ago when he’d felt differently, and the apartment had been warm and cozy with things such as throw rugs, framed prints of famous paintings on the wall, and curtains over the windows. There had also been a small writing desk covered with framed photos, and a second bedside table. But all that homey stuff had belonged to Leslie Brooks, Noah’s long-term girlfriend, who had come with Noah from New York to go to Harvard Business School after she graduated from Columbia in economics and he in medicine. She had lived with Noah until she finished her graduate degree two years ago, but after graduation had moved back to New York with all her stuff to a great job in finance.

Leslie’s departure had taken Noah by surprise, until she’d explained that she had come to the realization over the three years that his professional commitment was such that there was little room for her. Most surgical residents got progressively more time with their families as they advanced up the residency ladder. Not so with Noah. Each year his hours got longer by choice. There had been no rancor on either of their parts when they went their separate ways, even though Noah had been initially crushed, as he had come to assume they would marry at some point. Yet he quickly realized that she was right and he had been selfish with his time and attention. At least until he finished his graduate training, which he thought of as a 24/7 activity, he was metaphorically married to medicine and had spent very little time in her company and in the apartment.

On occasion Noah missed Leslie and looked forward to their monthly FaceTime phone calls, which she made the effort to continue. Each considered the other to be a true friend. Noah was aware she was now engaged, which tugged at his heartstrings when he thought about it. At the same time, he was thankful that she had been forthright about her needs, and he was relieved that her contentment was no longer his responsibility. At least until his residency was over, medicine was his overly demanding mistress. Ultimately, he truly wished the best for her.

From the closet Noah got a white shirt and a tie and went back into the bathroom to put them on. Once he was satisfied with the knot, which often took several attempts, he dealt with his rather thick, closely cropped dirty-blond hair by parting it on the left and brushing most of the rest to the right and off his face. Back when he had been a typical teenager, Noah had been vain and worried about his looks. He had spent a lot of time wanting to believe he was a stud, as a couple girls had referred to him. Although he wasn’t exactly sure what they had meant, he had taken it as a great compliment. Now he was not concerned about his appearance other than to look appropriately doctorlike, which he interpreted as being reasonably manicured, with clean, pressed clothes. He despised those residents who thought it a badge of honor to wear wrinkled, bloodstained outfits, especially scrubs, to advertise how hard they were working.

Noah was a bit more than six feet in height and still appeared athletic, even though he’d not had time for athletics since he’d graduated from college. Still weighing in at 165 pounds, he had never gained weight like some of his high school friends, despite not getting much aerobic exercise. He attributed his good luck to rarely taking the time to eat and to having decent genes, thanks to his father, which might have been the only positive thing he got from him. In the looks category, what made him the proudest was his chiseled nose separating emerald-green eyes. The eyes were a gift from his redheaded mother.

The final act of dressing before heading off to the hospital involved his white pants and white jacket, both of which he was known to change several times in the same day, taking advantage that they were cleaned and pressed by the hospital laundry. When he was fully ready, with his computer tablet in his side pocket, he checked himself in the mirror that hung in the living room. The mirror had belonged to Leslie, and why she had left it she had never explained, nor had he asked. Otherwise, the living room was almost as stark as the bedroom. The furniture consisted of a small threadbare couch, a coffee table, a floor lamp, a folding card table with two folding chairs, and a small bookcase. An elderly laptop sat on the card table as the sole remnant of his teenage love of computer gaming. The only wall decorations in the room were a simple brick mantel painted white and the mirror. Like the bedroom windows, the living room windows were bare. They looked out onto Revere Street and the typical Beacon Hill brick buildings opposite.