A Heart to Serve

by Bill Frist

  Med school demanded that students learn massive amounts of material, while perpetually reminding us that if we didn’t learn it all, someone could die. It was motivating to learn, but I felt the pressure to learn it all.

  I WAS IN MY SECOND YEAR OF MEDICAL SCHOOL, IN THE MIDDLE OF my first clinical rotation—that time when a med student finally gets to see patients—when I received the call from Nashville. Dad had suffered a heart attack and had undergone emergency coronary artery bypass surgery. This was a relatively routine operation even in the mid-1970s, but no surgery is ordinary when it is performed on one of your family members. I flew home from Boston immediately and went to visit Dad in the hospital. He was recovering well and encouraged me to get back to school. “I’ll be fine; don’t worry about me,” he told me. “Just attend to your studies.” I spent the night in Nashville, and then dutifully returned to Boston.

  Five days later, my brother Bobby, a heart surgeon, called from Nashville and delivered the devastating news: “Billy, Dad has had a stroke.” I flew back to Nashville, fatigued from the loss of sleep, and even more weary than merely physically tired. Despite my medical training, I was unprepared for what I saw and heard that first morning after Dad’s stroke. Feeble-looking and drawn, my always strong father, his six-foot-three-inch frame filling the hospital bed, struggled to speak. When he finally formed some words, he spoke in a strained whisper and he could not raise his left arm. It was a sound that would haunt me and woo me back home over the years, but it was a sound I would never forget. I was distraught; I could tell that he was scared. I stayed with him in the hospital, holding his hand through the night. My own accident had caused me to face my mortality, but Dad’s stroke caused me to face the potential loss of the foundation of family—from which I had drawn all strength and security.

  Dad slowly recovered and over time regained function of his arm and pretty well returned to life as normal, but his voice never fully came back. He resumed work, but began slowing down his busy medical practice. A warm and charismatic speaker before the stroke, Dad’s mind was still sharp; even much later in life he continued to put in ten-hour days as the cultural voice of HCA. But he was always noticeably frustrated by his impaired speech. Despite the hoarse whisper, and a slight stutter and sometimes slurred speech, he was constantly asked to speak at HCA gatherings and hospitals around the country. The whisper, however, betrayed him—and reminded me that he was not Superman, but a human being. On the other hand, the whisper worked well for him as a public speaker, as adoring audiences clung to his every word, leaning forward, straining to hear what he had to say. And he always had something good to say. It was always something simple, personal, optimistic, and patriotic. They loved it. Dad had turned his disability into a useful communication tool!

  Dad soon realized that he would no longer be able to continue his work with the same intensity and devotion as in the past. To whom would he turn over his best friends, his patients, for their future care? He heard about a remarkable young physician who had developed a reputation for spending quality time with patients, who was available seven days a week. This internist, like Dad, treated each patient with respect and dignity. And he had a degree from divinity school, and before medical school had spent two years in Africa. Dad became the mentor to this young doctor, Dr. Karl VanDevender, and confidently turned his patients over to him, one by one.

  Karl likes to remind people that before accepting him as a partner, Dad insisted that Karl submit to a physical exam, an exam that Dad conducted himself! Dad’s real purpose in doing so was to make sure that the young physician learned how to make even the most humiliating and personally invasive procedure of a physical examination a caring, respectful, and dignified experience for the patient. (“Always warm up the stethoscope before placing it on the patient’s chest.” “Don’t jot down notes during the exam; keep your focus 100 percent on the patient.”) Dad and Karl not only became partners, they became great friends. Karl earned the full confidence of Dad; he became like a fourth son.

  I SPENT FOUR YEARS AT HARVARD. MY SOCIAL LIFE REVOLVED around my girlfriend, whom I had started dating in high school and who was now in Boston at dental school. Between going to Princeton for board meetings on weekends, my studies (where I felt I had to work twice as hard to keep up), and my relationship, I made little time to socialize with my fellow medical students. The first two years were principally academic and in the classroom, which I tolerated but didn’t love. But the last two were clinical, and I was finally experiencing what I really wanted to do, care for patients. That’s what I’d seen as a little boy on rounds with Dad. You never forget the first time you are introduced as a “student-doctor.” The first time you examine a patient. The first time a patient dies and there is nothing you can do about it.

  Even back in med school, I found myself gravitating toward a different path—a path that led to the unknown, the creative, the innovative. Although few students at that time deviated from the normal course sequence, at the beginning of my third year I asked and received permission to conduct a six-month independent research project in the laboratory of William John Powell, a cardiologist who had one of the busiest research labs at Massachusetts General Hospital (MGH), rather than do the customary coursework. I guess my experience of independent study at Princeton was still in my mind, as was Professor Alyea’s advice to take the road less traveled.

  During that half-year period of intensive laboratory experience in the basement of the MGH, I designed an experiment to figure out how the heart relaxes under conditions of low oxygen environment—the same conditions that occur when a person is having a heart attack. No one had ever addressed this question, which could potentially lead to therapies for the millions of people who die of heart attacks each year. Since I don’t have an artistic bone in my body, I’d never felt the joy of creativity that I imagine an artist lives for. But now I did.

  I could barely contain the exhilaration I felt each day at the thought that I, as a mere medical student, and an average one at that, could possibly contribute to an evolving body of knowledge that might literally change the lives of millions of others for the better. The possibilities energized me, stimulated my mind with big thoughts; they ignited a fire in me as nothing else ever had.

  That research—not a standard part of the curriculum then—taught me a lot. Research can change the world. It introduced to me the excitement and passion for exploring the unknown. It allowed me to recognize that one individual willing to pursue the possibilities can make an enormous difference in the world. And it became the basis of the belief that whatever we do with health-care reform, we cannot sacrifice the innovation that makes American health care so unique and powerful.

  ABOUT HALFWAY THROUGH THE FOURTH YEAR OF MEDICAL SCHOOL, you have to choose a field in medicine for your residency, the three- to six-year period of specialization after med school. I was uncertain what field of medicine I might enter. My dad had chosen internal medicine and had a special interest in the heart; he became a cardiologist. That intrigued me. But surgery held a special allure. Even Dad had said that if he’d had the money to stay in school, he would have been a surgeon. My brothers were both surgeons, and my personality seemed to fit that sort of practice. Surgeons tend to be solution-oriented; direct, cool performers under pressure, with a “let’s fix things” attitude. By contrast, the general practitioner or internist is usually more of a thinker, producing a deliberate, thoughtful, and thorough diagnosis—more a thinker than a doer. These are probably unfair generalizations, but they get the point across.

  I’d had the luxury of seeing both options, medicine and surgery, up close in my immediate family. During med school, I took various rotations, each for a month at a time—a month in surgery, a month in pediatrics, a month in orthopedic surgery, and others—and eventually I began to get a feel for what I really liked doing. In that fourth year, I became especially enamored with the field of heart surgery, a field that my brother Bobby had chosen. It was still a relativel
y young field, with the first bypass operations done in the mid-1960s. It was the dramatic field of medicine; the whole idea of starting and stopping the human heart, the seat of human life, to repair it attracted me.

  So when it came time for me to make my decision, I applied for a surgical residency, leaning toward an eventual specialization (which does not occur until after five years of general surgery) in the heart. I put as my first choice the Harvard–affiliated MGH. I was admitted. I reasoned, I had come this far going to what was considered the best, so why not continue on that track if I had the opportunity? And I knew I’d get back home someday.

  The Massachusetts General Hospital is facetiously referred to as “Man’s Greatest Hospital.” It is the origin of many marvelous discoveries in modern medicine. The list of great surgeons educated at MGH seemed endless, and our Harvard professors reminded us frequently that we walked in the hallowed halls of greatness, and it was our responsibility to carry on the rich healing traditions of our forefathers.

  The walking-a-tightrope mentality that med school students learn is emphasized even more during residency, especially in surgery. Surgical residency is sometimes compared to a sort of doctors’ boot camp, and rightly so. It is constant, intensive training, designed to produce supreme competence. But like boot camp, residency is also a totally consuming indoctrination period and a cutting off from the outside world. At the time, even getting married during residency was frowned upon, because there was simply no time for outside interests.

  The surgical program at MGH certainly stretched my comfort zone like nothing I’d experienced previously, and in the process led to the death of many of my illusions about medical practice. The schedule at Mass General was more grueling than that in med school. We were on call in the hospital every day and every other night, often working around the clock, forty-eight-hour shifts. You develop an intense camaraderie with your fellow residents, who are all going through the same experience. MGH prided itself on a strong ward service, where the surgical residents had complete control over the patients, with the attending doctors acting only as consultants. There was some truth in the old mantra “see one, do one, teach one.” The training tended to be hierarchical, with the sixth-year chief residents running the service, with the fifth-year residents supervising the fourth, the fourth the third, and so on. The years of residency were exhilarating.

  Mass General’s surgical residency insisted on perfection. A small error in surgery can cause someone’s life to end. Therefore no mistakes are tolerated.

  One of the biggest surprises for me later in life when I went to Washington was to find a much greater tolerance for error. Such mediocrity was not accepted in surgical residency; in government it was accepted as unavoidable. Moreover, in medical practice, a higher level of accountability day-in and day-out is demanded. In politics you are held accountable by elections every six, four, or two years. In surgery you are held accountable for someone’s life every minute. What’s more, in a political campaign, rhetoric can trump fact; in surgery, there is no rhetoric—just 100 percent accountability. When I compare the frustration of Washington’s tacit acceptance of imperfection and error, I appreciate all the more the high standards of professional excellence and accountability I learned on those wards working with patients every day and night, year after year, at Mass General. I came to expect those high standards of others and, most important, of myself. They spilled over from medicine to politics and from politics to business.

  In recent years, surgical residency has been sensationalized and glamorized on TV. I’m now out of the business of doing surgery every day, but I appreciate more than ever the sacrifices these medical students and residents and young doctors make every day. Few people understand the number of hours it takes to learn to diagnose an uncommon disease, to choose the specific correct surgical procedure for an individual patient, and to develop the practiced operative skills to achieve the excellent outcome that every patient deserves. It takes the every-other-night call, or its equivalent, for years in formal surgical residency to allow one to master the latest life-saving technology and advances (which change almost daily) and to manage every single complication Mother Nature will throw your way after even the most routine operative procedures.

  It’s just plain hard stuff. And it takes a long time—in my own case, twelve continuous years of exhausting formal training after college before I was even allowed to do my first heart transplant on my own. Twelve years. And, in part because of the time required and the dedication it demands, it requires extraordinary personal sacrifices the public never sees, but sacrifices that take their toll on relationships with others, most notably one’s spouse and children.

  So why do it? What are the genuine privileges of putting up with such a regimen? A central one, at least for the surgeon, is the trust you earn to care for patients whose lives have taken a turn for the worse. You enter their lives for a moment, you focus all your resources and energies on them, and you leave them better, healthier, and happier. Dad was so right when he said there is no greater profession than that of a doctor. I began to see it during these residency years. You learn what is important in life by touching intimately the lives of others in exceptional ways—and in return your own life is made richer by the shared moments.

  I didn’t fully realize all this until I stopped doing it every day. My political friends would later ask what the most difficult part of surgical training was. For me, it was the missed special moments with my wife Karyn and our boys. It was missing our babies’ first steps, cutting short most family birthday celebrations to rush back to do emergency surgery, spending Christmas Eve not at home but in the hospital doing a transplant, and having to miss the funeral of a close, personal friend.

  Dealing with death is never easy, not even for a doctor, and is perhaps especially difficult for a young doctor in training. One of my first patients to die was a little girl who had suffered severe burns and was suffering from lack of oxygen in her blood as a result. She was admitted right after the burn, and the nature of this kind of injury is that the patient gets increasingly worse over the next forty-eight hours. She came in badly injured but not disfigured. I watched her die before my eyes in spite of doing everything humanly possible to reverse the downhill course. I remember going outside the hospital by myself an hour later, sitting on the ground, just hurting and crying and feeling helpless. I even questioned seriously whether I wanted to live the remainder of my life in constant battles with death—and worse yet, in not always winning those battles.

  I was dejected and discouraged, and I went back to Nashville that weekend where my entire interest in medicine was so firmly grounded. I talked with my dad and my surgeon brother Bobby. Dad and Bobby consoled me, and then Bobby gently but firmly reminded me, “Sometimes even when you do all you can, life and death are not in your hands. We are just human.” I returned to Boston, determined to become an even better surgeon, understanding that our purpose was not to alter destiny, just to shape it toward a better end.

  Adding to my emotional turmoil, I sensed the approaching end of a long-term relationship with my girlfriend. We had been dating since high school, remained together through college and graduate school, and it seemed a natural progression for us to get engaged. Although we both may have had misgivings about our future together, we were so wrapped up in developing our careers, we never really addressed our differences. Our relationship remained on autopilot, two Nashville kids who grew up together, loved each other, both from well-respected families; now two young adults heading steadily, inexorably, toward a wedding.

  Then I met Karyn.

  5

  Karyn

  On a crisp, spring morning in 1979, I pulled out of bed, climbed into my obligatory surgical intern’s garb of white pants, white shirt, and short white coat (the outfit affectionately called “toad skins” by the MGH surgical staff—because of the “toad” work interns were required to do for the senior surgeons). Half awake, I stumbled down Boston’
s famous Beacon Hill to Mass General—my daily trek. It was still dark, about five in the morning, and though we were right on the cusp of summer, the air still had a slight New England chill.

  At the time, I lived in a one-bedroom apartment on the second floor of an old, recently renovated brownstone at the top of Mt. Vernon Street, only a few blocks from the Massachusetts State House. I’d vary the route of my walk to the hospital each day, sometimes going straight down the dilapidated backside of Beacon Hill, at other times walking the uneven, red brick sidewalks of Mt. Vernon to pass the more charming antique shops and markets of Charles Street—but always leaving before the sun rose and returning long after it set. One thing was consistent: Each day the route ended on Fruit Street, the final stretch of about two blocks leading directly to the prominent grand entrance of my workplace, the White Building of the Massachusetts General Hospital.

  Entering the modest front lobby of the hospital, I headed straight around the corner to meet my surgical team in the X-ray department to begin our early morning prerounds in preparation for what I assumed would be just another routine day. But little did I know that this day would lead to a radical turn off a long-anticipated road in my personal life. Indeed, my life was forever changed by the events that would unfold on this day.

  Normally we began the day with a review of X-rays and an intern’s presentation of the overnight admissions from the emergency room, before making patient rounds. Gulping a cup of coffee on the run would follow rounds, and then on to the third-floor operating rooms. By 7:00 A.M. we would be in the OR, well ahead of the attending surgeon, prepping and draping the patients, making sure all was in order for a “cut time” of seven-thirty sharp. All aspects of surgery are precise. But the routine was broken on Thursdays, when part of the team separated off to man the Surgical Clinic, treating patients for nonemergency care, evaluating for potential surgery, or conducting routine postoperative exams.