“Code” will always hold mingled meanings for me—horror and bewilderment, fear and sadness, helplessness and hope. It still amazes me to this day what faith his family had in us that we could accomplish the impossible; and however unfounded those prayers were, or from whatever desperation they sprouted, I nevertheless felt enormously privileged to have been allowed to share in their despair and pain, in their search for truth, for divine guidance, and for God. We were as bewildered as they; our reasons were only ostensibly different. In looking back, every moment of that conversation was a precious glance through a window opened momentarily only to the privileged few. To be allowed to share in another’s anguish is to be permitted the opportunity to see and understand, and to soothe and comfort. What my mysterious patient taught me, about life and death, and what his family taught me, about hope and faith, I shall never forget.
The Heart of Medicine
Annemarie Stroustrup Smith
I FIRST MET JAN BROWN on her return trip to the hospital. It was her first admission since her surgery one year ago. At that time, one of the attending surgeons on the colorectal surgery service had attempted to remove the tumor that was blocking her small intestine. Unfortunately, as the operation progressed it became increasingly clear that Jan’s tumor was not simply plugging her intestine, but was completely investing it: gluing it down to her spine, plastering one loop of bowel to another, and creating a twisted, complicated mass made up of both tumor and vital organs. So one year ago, Jan woke up from what she hoped would be her last trip to the operating room and was told that although some tumor had been resected, much was left behind. The remaining tumor would inevitably grow back.
When she was told shortly thereafter that she had twelve to twenty-four months to live, she said, “I’ll prove you wrong.”
Jan is fifty-two years old. She has two teenage sons. The weekend before coming back to the hospital, Jan and her husband had taken their older son to college. It was a difficult separation, not least of all because Jan began feeling increasingly bloated and nauseated as the weekend progressed. By Monday night, she had begun to vomit every few hours. Tuesday she stopped eating and drinking as she felt too unwell, but the vomiting continued. On Wednesday, she went to a scheduled office visit with her oncologist. He sent her straight to the hospital. That is how, at approximately six o’clock on a rainy Wednesday night in early September, Jan Brown came into my care.
Of course, she was not ever truly in my care. She was admitted to Dr. Smith’s team. I, as the third-year medical student, was the most junior member of that team. My responsibilities were rarely more glamorous than wound checks and paperwork, but on that night I was asked to do the admitting history and physical, as Jan had bypassed these steps by entering the hospital without stopping in the emergency room.
I spent much of that night making Jan comfortable. Initially that meant putting a tube up one nostril and down her throat into her stomach to drain the fluid she would otherwise vomit. As the night went on, though, I realized that what Jan needed most was emotional support. She had fought her illness since her initial diagnosis more than a year before and still hadn’t accepted that she was a very, very ill woman. We talked about how she was too young to have an unresectable tumor (she wasn’t ready to say out loud that she was dying, although she clearly knew she was) and how she was scared for herself and even more so for her family. We talked about how she desperately wanted more chemotherapy, but how that might not be the best choice, as she’d already failed the two most promising regimens for her cancer. We talked about how she needed to talk to her husband, her high school sweetheart, and how he would be strong enough to take it. And we talked about her younger son, who was struggling too much as a teenager to be left without a mother.
The next morning, I called the palliative care psychiatrist at the Dana-Farber for a consult, as Jan certainly needed someone to talk things through with on a long-term basis. I spent much of the next week following Jan to and from the operating room. I had the terrible task of telling her that our last surgical attempt had been unsuccessful. I sat with her husband as the attending surgeon told him that his wife had, at most, only a few more months to live.
The day Jan left the hospital, she was more comfortable physically but in significantly more psychological pain. Despite having lived with her cancer and dismal prognosis for more than a year, this week had been the turning point in which she realized that her death was truly coming.
Amazingly, instead of hating those of us who brought her to this realization, she left me with a big hug and a bouquet of flowers as she was discharged. I like to think that this ability to heal the soul, even when nothing can be done to heal the body, is the heart of medicine.
IV.
Finding a Better Way
Education must not simply teach work—it must teach Life.
W.W.B. DUBOIS
Black Bags
Kurt Smith
I REMEMBER A STUDENT asking a medical-instruments sales representative about purchasing a black bag.
“Oh, nobody buys those anymore,” she responded offhandedly. “Carrying one of those these days sort of makes you a marked man, you know what I mean?”
I’m not sure I know what she meant: either old fashioned or presumptuous, but certainly not dignified or genuine. Nobody advertises house calls anymore either, unless they’re some concierge care group that charges an additional two thousand dollars a year for their congeniality. I’m sure that good docs still do make house calls, but nobody’s going to go around advertising it. Is it because we really are too busy, or is it because we fear litigation, since you can’t take a chest X-ray or an abdominal CT when the patient is still at home? Or is it because everybody’s so damned specialized: Can you imagine an interventional radiologist making a house call? Or what about a nephrologist? What’s he going to do, taste the urine?
Primary care docs could make house calls. But they’re too busy. There simply aren’t enough people in primary care to handle the patient load, given that everybody and his dog has to see the primary care doc in order to get a referral to the specialist. And primary care docs have to fill out mounds of paperwork to get paid by the insurance/management industry so they can see even more people on their way to the specialist. Besides that, no insurance company would ever pay for a house call: How could they be sure that the doc is accurately billing his time? Who pays for the time and expense of travel to and from the house? Is there any validated data that show that house calls impart any actual benefit? If so, has this been modeled and tested to show cost-effectiveness? These are the “important” questions that would need to be answered for the powers that be to allow doctors to bill for house calls. And if you can’t bill for a house call, why the heck would you make one? And if the rest of your patients found out that you were making free house calls, wouldn’t we all be demanding house calls?
I’m not even sure people would want house calls. I can guarantee you that people aren’t going to accept that they have an upper respiratory infection without an X-ray, and certainly not without being given a script for antibiotics. Who’s going to believe they have a lobar pneumonia without an upright and PA radiographs? Honestly, if you visit people at their house these days, all they want to know is whether your four-year, $150,000 education thinks they should go to the hospital to see a “real” doctor or whether they should just wait it out. And chances are, if you don’t tell them to go to the hospital, they’re going to go anyway.
At some point, and probably rightfully so, somebody decided that we just know a little too much about medicine these days for any individual to know it all. Ask hospital specialists if they feel that primary care docs know anything about the fundamentals of their specialty, and they’ll give you a five-minute sermon on the ineptitude of the primary care practitioner. So we all go into specialties so that we can know it all in our particular field, because that’s important. We should know all the details that man has accrued over the past thousand yea
rs in order to provide the best diagnosis and treatment. But I wonder how much more we cure people with our specialized medicine. It seems to me that the twentieth century, aside from the development of antibiotics and vaccines, was the century of diagnosis, not real curing. And whether you see a patient in his home with left-sided weakness and dementia and call it apoplexy, or see the MRI and perfusion study at the general and call it a right middle cerebral artery infarct and subsequent stroke, the guy in the bed stays the same, every time. Just because you can call it autosomal dominant polycystic kidney disease doesn’t improve that patient’s life—it just alters the element of intangible fear.
But we’re so confident of our ability to pin the tail on the donkey, we don’t even bother to do autopsies anymore. The autopsy rate is down to about 10 percent at most teaching institutions, and most autopsies done nowadays are mandated by the medical examiner. The major reason for this is that physicians don’t ask the families of the deceased for permission to perform a postmortem. When physicians are asked why, they usually feel that the diagnosis was certain from radiological and laboratory tests, and the gruesome process of dismembering the loved one won’t add to medical knowledge, won’t add insight into the cause of death, and will only add to the trauma for those still living. Yet over the past fifty years, the rate of misdiagnosis at autopsy has remained the same (about 20 to 30 percent for major mistakes) despite the advent of the CT, MRI, ELISA, and every other financial treasure chest of a test that modern medicine has cooked up since the dark ages. Granted, we’re getting better with our diagnostics, but we’re also realizing that the human body is more complex at every level. I’m not convinced that understanding and diagnosis have been translated into care just yet.
Sir William Henry Osler, that renowned physician of Johns Hopkins fame and literary celebration, died in England at the hands of his family physician. Osler, in addition to writing, teaching, and being a physician to thousands, had always taken meticulous notes on symptoms for each patient, in addition to noting his diagnosis and treatment. At the end of each case, whether the patient was healed or deceased, Osler then sorted his cards based on correct or incorrect diagnosis in order to learn from his personal mistakes. No one would dream of doing that now—what if your “incorrect” pile were found by a less-than-moral lawyer? Few physicians would be able to make those piles, take a long, hard look at the size of that for the incorrectly diagnosed (more succinctly called the “misdiagnosed,” or even the “missed-diagnosis”), and not feel an enormous wave of guilt and responsibility. My guess is that Osler probably felt that same guilt, but somewhere in between his time and ours, mankind bought into the fantasy that physicians always cure and only miss the cure when they fall short of their potential. In the face of striking evidence to the contrary, we still believe (and worse yet, our patients still hold on to) the fallacy that we can cheat death, avert disease, and prevent grief, suffering, and tragedy.
Osler, as he lay on his deathbed, had already informed his family physician that upon his demise, he wanted an autopsy to be performed not only to confirm the cause of death, but to serve as a final lesson in diagnosis to pass on to those who followed his teachings. Furthermore, in the tradition of the time, he demanded that his autopsy be performed by the physician who had cared for him. His family physician later recalled his apprehension at performing the autopsy on such a famous personage, lest he discover something amiss in his treatment or diagnosis. To his credit, his diagnosis was borne out by the duly performed autopsy: Osler died of bronchopneumonia. Today most of us would cringe under some legal “conflict of interest” defense to avoid the harsh possibility of misdiagnosis. When did we stop learning from our mistakes and instead relegate that learning to the pathologists in the basement?
Confidence seems to be a big deal in medicine. I once had a man tell me, “If you can’t be good, you can at least look good!” I used to think that my pediatrician and family doctors saw something when they used the ophthalmoscope to look in my eyes. After a few months of emergency medicine and general surgery, I am fully confident that any doctor who looks into your eyes for less than ten seconds hasn’t seen squat, and that when my pediatrician looks into my two-year-old’s pupils—while my son shakes his head, squints his eyes, and thrashes his arms—and then determines after a half-second gaze that my son is “fine,” my pediatrician is, if nothing else, confident. Nobody wants a doc who doesn’t seem to be sure about the diagnosis. I bet Osler pronounced his diagnoses to his ward patients with a grandeur and eloquence that let them know that this, this, was a doctor who had weighed the scales of his intellect with their afflictions and come to a conclusion that would dictate their course, treatment, and prognosis. But he was wrong sometimes too! So how do we trade off confidence with an admission of our fallibility? Granted, I don’t think too much of my pediatrician’s pronouncement regarding my progeny’s pupils, but I’d be downright distraught if she simply admitted that she usually doesn’t see much in the eyes. There’s safety and comfort in ritual and confidence, regardless of how useful that ritualistic confidence is.
So I’ve tried that suit on, with fantastic results. A confident medical student is infinitely more trusted than one who admits he knows only slightly more about disease than the patients themselves. It’s troublesome when I don’t have answers—feigning confidence when I’m not sure that confidence is warranted. But boldly I go on, in the tradition of those before me, attempting a stoic, knowledgeable demeanor while I try to learn everything as fast as I can, attempting to merge the mask with the flesh, until at some point I become my own Oslerian oracle, oozing enough confidence to fill a full-length white coat.
But how is anyone supposed to be that confident when we daily reaffirm that there’s far too much out there for any one man to know—while family practitioners are ridiculed for trying to treat all disease, and the rest of us hide behind the finite wall of knowledge that can be mastered in a lifetime, choosing to treat specific diseases rather than patients? I wonder who’s going to hold my hand when I die. I don’t trust my family practitioner enough to see him for more than five minutes, the endocrinologist doesn’t do hands, the orthopedist doesn’t work with soft tissue, and the dermatologist doesn’t hold hours convenient for dying. Ultimately, maybe the only one who will hold that hand is the pathologist, long after I care whether it is held or not.
Meanwhile I’m checking the antique stores for black bags.
A Murmur in the ICU
Joe Wright
THE FIRST TIME I visited an ICU was as part of a physiology course. Learning how mechanical ventilation works helps medical students understand the physiology of breathing. So we went over to a nearby hospital, and a doctor took us to the unit. In the rooms of the ICU, there were patients lying unconscious or nearly so, each with tubes in their mouths and noses, the whole unit quiet except for the whooshes and beeps of machines and alarms.
We went into one of the rooms, and the doctor leaned down to the patient and said hello to her, using her name, and then said, “I’m here with a group of students, and we’re going to talk a little bit while we’re here.” He laid his hand on her shoulder as he explained to us that although the patient was sedated, sometimes patients could hear or understand some or all of what was going on around them, and so a small introduction was in order.
And then he talked about respiration, about the physiology of the ventilators, and about the monitors on and inside of her. He pointed to the monitor screen, which clearly showed what he was telling us. I could barely register it. A friend of mine, standing next to me, was in even worse shape. She felt faint and had to walk out of the room to get some air for a couple of minutes. Pulmonary capillary wedge pressure? We weren’t thinking about that; we were looking at the family pictures around the room and wondering what it would be like for this woman’s kids to visit her here, to see her like this.
More than a year later, I was in another ICU. As an optional part of one of my classes, small groups of us
traipse around the hospital, following a young resident who takes us to see patients with good findings, meaning things you wouldn’t want to miss if you saw them. So we all trundle into a room and say hello to the patient and then feel his swollen liver, or look at his clubbed fingernails, or listen to her heart.
And so we went to an ICU to hear a heart murmur. The heart murmur was inside a man, a man who was deeply unconscious, who was plugged into machines. There were pictures of him and his family in the room. Did the resident say hello to the man when we came in? I hope so, but I’m not sure; I came in a bit after everyone else. I know I didn’t say hello as we put our stethoscopes on his chest.
I couldn’t hear his heartbeat at first, because of the sound of the air being pushed into his lungs by a machine. Eventually another student told me to look at the monitor. To hear the heartbeat under the noise of the air, we had to see it on the machine. We looked at a little valentine heart that flashed on the monitor with each beat, and then listened for a sound that happened every time the valentine flashed. Then suddenly, because we could see the beat on the screen, we heard the heart murmur in our ears, as clear as anything, whoosh, whoosh, whoosh. I showed another classmate how to hear it, and she put her stethoscope down on his chest and then looked pleased—now she heard it too.
As we were walking out, one of my classmates looked at the man and said, “Thank you, sir.” I berated myself for not saying something too, but hearing her, I also realized that the ICU didn’t bother me anymore or fill me with grand spiritual and moral questions. It was a place where sick people were hooked up to machines, and that was that. I was ready to plunk my stethoscope down on the chest of an unconscious man with no preamble, no introducing myself, no ritual of human connection, as if it were perfectly normal for him to be there, and for me to be there too. It was a murmur I was seeking; looking away from the man and toward the monitor, it was a murmur that I heard.
The Soul of a Doctor Page 12