Poor Role Models

He was cocky and arrogant. The kind of attending every medical student feared. I heard the rumors before his arrival. But I was hoping that reality was less harsh then word of mouth. I had only one week left in my Internal Medicine rotation. So far, I received glowing reviews from my residents and attendings. Seven more days and I would clinch the sacred "honors" grade that I needed to be eligible for the top residency programs. A "pass" would just about eliminate all the highly competitive options.

It was the beginning of my third year of medical school and I had chosen general medicine as my first rotation. I was already signed up for the early subinterniship like many of the other students who were entering the field.

As he walked into the resident's room for the first time, I waited cautiously. He scanned our faces briefly before flopping in a chair beside us. There was no formal introduction. No exchanging of names or titles. He nodded at the third year resident and spoke to no one particular.

So what do you got for me?

*

The rest of the week went similarly. He spoke only to the residents and barely looked in the direction of the students. His condescending demeanor dripped with sarcasm and contempt.

Occasionally he accompanied the team to the bedside. He rarely asked the patient questions or spoke to them directly. His statements were curse and robotic.

Unfortunately, he was brilliant. He was able to pick apart a patient presentation and pull out the relevant facts with ease. His skills were adroit. There was no doubt his presence was highly valued by the university. He spent ninety percent of his time in the lab. Likely some administrator relegated his minute clinical duties to the VA to minimize his ability to do harm.

*

On the last day of the rotation he walked into the lounge with a smirk on his face. He would return in the afternoon to watch each student perform a blind history and physical.

My resident scrambled to find an appropriate patient. He looked for someone who could tell a good story, and had a problem befitting a third year medical students fund of knowledge and abilities.

The attending returned later that day and we walked quietly to the patients room. To our surprise, when we entered, the room was empty. She had gone for a stress test.

Looking mildly annoyed, he asked the head nurse for another suitable patient to examine. She, of course, not realizing the purpose of the interview chose a complex medical patient with a rare disease. She thought it would be a good learning experience.

*


The interview was a disaster. The patient was demented and confused. His self described pneumonia was, in reality, a pulmonary embolism. He also had empty sella syndrome.

I absolutely flopped. And to add injury to insult, after I finished the attending performed a superb history and physical and elicited everything I missed.

He later sat me down and berated me for half an hour. He was disappointed in my abilities. That morning he had been ready to give me honors, but now...
*

My final grade for internal medicine was "pass".

Although I aced many other rotations as well as my subinternship, I would not be offered interviews at many of the top residency programs that I applied for.

Years later, as I look back on the experience, I realize that that hour changed my life.

I would never have been motivated to become the teacher that I am today

if I hadn't started with such a poor role model.

Mortally Wounded

I remember it.

As the call room door closed behind me, all semblance of light disappeared. I felt no guilt about missing rounds. I stumbled to the bed and sat down. Cradling my head in my hands, I waited for the gush of tears. They never came. Neither did the gut wrenching nausea or the searing pain in the chest. Nothing.

I felt absolutely nothing.

And that's when I knew I was lost.

*

I was overwhelmed within the first few minutes of internship. I clutched my stethoscope with sweaty hands as I followed the chief resident from ward to ward. He chattered incessantly listing a series of do's and dont's. I was barely listening.

The nurses bustled to and fro as I loitered by the chart rack. Eventually the chief returned with another resident in tow.

This is Jim. It's his last day of residency. He can't be hurt anymore!

My mind reeled. What did that mean..."can't be hurt anymore". Hurt by whom?

My question never made it to my lips. Jim quickly sputtered off a list of patients for me to follow. He handed me his pager and placed his arm around my shoulder.

Good Luck!

Sometimes, in the lonely moments over the next few years, I would wonder how Jim became invincible.

*

It's not like patients never died before. As a second year resident, I manned the ICU on my own. But this one was different.

Maybe I was a little to cavalier when I decided to intubate. Maybe not. But the damn tube wouldn't go down. And then Anaesthesia never showed up. We kept on paging and paging.

I finally got the tube in and within moments, he coded. We worked on him for thirty minutes.

When I called his wife, she seemed strangely distant. She came at 2am to sign the papers and make funeral arrangements. She didn't ask any questions.

With a heavy heart I worked through the rest of the night. There were too many sick patients to stop and mourn. To process. It was only later that it hit my like a ton of bricks.

*

The first daughter phoned from out of state. She explained that she didn't talk to her stepmother and was wondering how her father was doing. Moments later she was screaming at me. No...no...no.

The second daughter called from the road and would be arriving in a few hours. Her crying horrified me. It never stopped. After a few minutes the line went dead.

I told the last daughter in person.

She collapsed into my arms.

*

I would never hear from any of these women again. But they changed me.

Their grief left an indelible mark on my soul that would last long after residency.

By the time I handed my pager to a brand new intern I was mortally wounded. I was dead.

I guess I couldn't be hurt anymore either.

I Was Still The Apprentice

Dr. G was like the Jedi master of our residency program. He was board certified in multiple specialities. But it wasn't the training that set him apart. He was just brilliant. An educator at heart. No nonsense. He told you how it was and he was right most of the time.

The residents actively searched for cases to stump Dr. G. We connived to present to him at case conference, something he had never seen before. But mostly we sat back and enjoyed watching the mind of a master clinician at work.

He taught us lessons about being a physician. He hammered us on deductive reasoning. I can still here his raspy voice scolding me in the exam room when I'm struggling to put the pieces together:

Be the detective.

*

While Dr. G could expound on almost any topic, he was known as an expert in one disease in particular: Hereditary Hemorrhagic Telangectasia (HHT). An autosomal dominant disease, HHT was widely recognized among our residents. Patients came from far and wide to see Dr. G in his clinic. By the time I finished training, I treated at least ten patients with this rare problem.

Although years later my mind is fuzzy on the details, every time I see a person with chronic nose bleeds I think of HHT. Often when I hear hoof beats I think of this zebra.

*

I watched in the ER as my patient rolled back from xray. She was thirty five years old and plagued by anemia. She had been admitted to the hospital five times over the last decade for transfusions. She showed up at our door when fatigue and shortness of breath had become unbearable.

The laboratory values confirmed it. She lost quite a bit of blood. Given her good pressure and pulse rate it was likely that this occurred over several months. I introduced myself and started to question her.

As the details unfolded I became excited. Apparently she had nose bleeds since childhood. There was no other cause of blood loss. I examined her. When she opened her mouth I saw a few small red dots on her tongue. Telangectasias! The hallmark of HHT.

As I explained the diagnosis, I informed her that I knew one of the world's experts on this disease. We would transfuse her blood. Have her see an ENT to help with the nose bleeds. If she was willing to travel the few hours to St. Louis, she could even see Dr. G. himself.

*

As the phone rang I felt like I was in residency again. I was calling Dr. G to tell him about another patient. Could I stump him?

After exchanging pleasantries, I informed him that this was not a social call. I had a patient to discuss. I was about to begin with the details when he interrupted me.

What's the patients name?

I stammered. Epi...Mrs Epi Staxis

He laughed a deep belly laugh. I felt small. Like I was a student again.

Another HHT case!

I was taken by surprise.

How...how did you know?

He paused. Well I take care of at least ten different people from the Staxis family! Didn't she tell you she comes from St. Louis?

I felt a growing sense of embarrassment. Dr. G. made the diagnosis without even hearing a single detail of the patient presentation. He was still the Jedi Master. I was still the apprentice.

Didn't we teach you anything hear in St. Louis?

You gotta take a thorough Family History!

What The Undertaker Said

I bolted upright with the sound of the alarm. The first thing I noticed was intense jaw and head pain. My wife sleepily looked up at me.

You were grinding your teeth again last night.

Thirty minutes later I was in the car half way to the hospital. I rubbed my jaw with one hand as I steered with the other. Damn TMJ. It had come back recently as my stress levels increased. One of the physicians left our practice, and my partner and I had to pick up the slack.

I was on call every other day. Every other weekend. The nursing homes were packed and the phone kept ringing. Not to mention that I had taken on other administrative responsibilities and a few speaking engagements.

And of course my son and daughter were getting older. Each day filled with a new activity for me to supervise. Violin practice, homework, dance class. For the first time I felt truly overloaded.

*

I'm not afraid of death.

The gentleman sat on my exam table with a jovial smile. He was strangely at ease in the doctor's office. I suspect this was due to his fifty years as a funeral director. When you spend so much time among the recently deceased, the specter of illness is less a demon and more an old friend.

He liked to take the last appointment before lunch. Countless times he watched as I raced out of the office to go to the nursing home. He would show up early to give me a little extra time. He was all to aware of my tight schedule.

As I finished my exam, I typed the last few sentences into the emr. I would have just enough time to avoid construction and breeze into my noon lecture. After that, I would visit nursing home patients and then rush home to make dinner, feed the kids, and take my son to violin.

I vaguely listened as he started to tell a story. At the funeral home he had an employee who was always bugging him for a promotion. The employee did a good job but was exceedingly slow. So slow, in fact, that he usually had to stay late into the night to finish his daily responsibilities.

That guy just needs to speed up!

I listened to his exclamation as I tried to nonchalantly look at the clock on the wall behind him. If I left immediately, I could make it in time.

He noticed my glance. Unexpectedly he placed his hand on my shoulder and looked me dead in the eyes.

And you, you kid have to slow down!

I paused. It's not everyday that the undertaker offers unsolicited advice.

But even now, as I quickly put the final flourishes on this blog post before facing the onslaught of patients in my waiting room, I wonder.

Will I listen?

Why I Moved To Private Practice

Chief of Medicine
Evanston Hospital
October 23, 2005


To whom it may concern,

I would like to take a moment to express my deep displeasure with one of the interactions I had with a physician in the Church Street location. I use the term "interaction" loosely since the doctor in question, Dr. Jordan, never actually saw me. Apparently he was too busy.

Last Thursday I was shopping in downtown Evanston when I felt the sudden onset of severe abdominal cramps. I ran into the nearest restaurant and spent the next thirty minutes on the toilet. After finishing I felt much better and packed up to leave. As I exited the restaurant, I noticed your clinic across the street.

Thinking that this was my lucky day, I entered the waiting room and asked for an appointment. Since this was my first time in the office, I was asked to fill out numerous forms. A few minutes later a nurse brought me back to an exam room.

She asked a lot of questions about my diarrhea and abdominal pain and then examined me. She then left the room for a few minutes. When she returned she explained that Dr. Jordan was the only doctor in the office and currently seeing other patients. The nurse made up some excuse about another doctor calling in sick. He could see me but it would have to be at the end of the day.

My jaw dropped. That would be like four hours later. Why couldn't I see him immediately? The nurse explained that she had evaluated me and my vitals signs were stable. She said my abdominal exam was normal. She then tried to shoo me away by saying that most diarrhea is self limited.

By now I was quite angry. I demanded that the nurse at least give me an antibiotic before I left. I could be dead by the the end of the day. The nurse left the room yet again and returned a few minutes later. Apparently Dr. Jordan felt that antibiotics are not usually indicated for most forms of diarrhea and he would prefer to examine me himself before he made that decision.

I stormed out of the clinic with my mind made up never to return to one of your facilities again. When I got home I took some amoxicillin which was left over from my root canal. I felt better within minutes.

I am lucky I had the antibiotic in the cabinet or I could have become very sick. I believe Dr. Jordan is a horrible physician and he brings down the quality of care that you are trying to provide. I hope you work to correct his attitude!

Sincerely,

Disappointed Customer


Written in neat cursive on the side of the letter was a note from an administrator:

Dr. Grumet. Can you please call this patient and apologize. We definitely handled this one wrong.

My First Patient

It didn't really happen in the beginning. The atmosphere of awe and mystery was too great. In fact we barely spoke a word those first few sessions. Half the class was buried behind their books while a few students clutched at their scalpels wildly. I made a point of being the first to place blade against cold leathery skin.

As time passed, however, familiarity cut through the tension much like our scalpels. The air of humility was replaced by the buzz of students busily working through their lessons. The quietness was interrupted by voices: some laughing, some arguing, and others carrying on everyday conversations.

*

The inappropriateness was subtle. One day it would be a classmate holding a dismembered limb up to his own body. Or occasionally a group of students would gather around a tank to stare or snicker at a particular body part.

although, on the outside, we each had come to terms with the gruesome act of dissecting the human body, a process of internal hardening had begun.

I disdained my classmates for their lack of taste. I cowered in the corner with the dissector pretending not to notice. Ever dour, I was building my own walls of protectionism but I chose a slightly less infantile route. I abandoned the scalpel and retreated behind the anatomy primer. I would direct the dissection from afar. My hands would not get dirty.

*

There were days in the anatomy lab that seemed to last forever. The students developed back and shoulder pain as they huddled over their tanks. Their were a number of finger sticks. We all carried our scars.

The physical discomfort paled in comparison to the emotional. We didn't like to talk about it. But sometimes, in the middle of a session, the whole mood of the room would change. We sat helplessly as the whirr of the bone saw cut into our cadavers pelvis. The fetid smell of singed bone filled our nostrils and we wanted to vomit.

We carefully dissected the genitals in pure silence. For some, it was the idea of physical discomfort that made them wince. For others, it was the total obliteration of all semblance of privacy. There is a certain amount of human dignity that we expect, even for the dead.

*

My hardest day in the lab came towards the end. As we entered the room, we were confronted with the most human of body parts...the face. I found myself handing the dissector to my tank mate and grabbing a scalpel. It was my first foray into cutting since early in the semester.

As I started to peal layers of skin, I thought about the lady whose body laid below my fingers. I knew so few details. Just some demographics.

As I came to the cheek muscles I wondered how they contracted to form a smile when her grandchild walk into the room. Or how here eyes, now dead and distant, would shine when she was happy. How her tear ducts would create moisture when she was sad.

As the hours passed my neck grew stiff. My joints grew tired. A tank mate had offered to take over but I resisted. I couldn't bare the idea of someone else doing such a horrific and personal task. Certainly not one of those who had previously made fun of the cadavers.

As I finished the dissection my nose began to run underneath my mask. My eyes were tearing. I excused my self and ran to the bathroom

By the time I returned the tanks were closed and the room was empty.

*

She was my first patient.

I tried to give her in death that which I couldn't provide in life. I attended to her with the sanctity and dignity necessary for such an intimate task. To me she was a person, not just a bundle of bones and tissue.

I left the gross anatomy lab that day with a promise.

I protected my patient in death.

For each person who walked through my exam room doors in the future, I would work equally hard...

to protect them in life.

Are You Listening?

I did what all good interns would do in the same situation. I rolled my eyes in the direction of the ER resident and waited for his response.

You have to be the sieve....the sieve.

We all did it. Stonewalled the ER in hopes that they would send our new admission packing. It rarely happened though. Somehow each admission always made it up to the floor. There was no turning back once the papers were filed and the bed was assigned.

Scottie was no different. His twenty year old body was fit and lean. His chest moved up and down in a rapid rhythm. I took my time examining him. As we talked his respiratory rate slowed. I placed my stethoscope on his chest. Maybe a few wheezing sounds but I had my suspicions that they came from his neck and not his lungs.

The paperwork classified him as an admission for asthma and bronchitis. My resident and I were doubtful. Scottie wanted, not needed, to be in the hospital. We just couldn't figure out why.

*

I spent the next three days trying to convince Scottie to go home. By day I would find him sleeping in bed with the covers pulled over his head. At night he awoke. His cell phone dangling from his tattooed arms. He teased the doctors and nurses. He convinced the dietary staff to bring him extra portions. He was king of the ward.

His charm was his greatest weapon. He smiled. He cajoled. He begged. But as another call day was approaching, my resident and I became more stern. We had to clear our census for the next onslaught of patients.

As I wrote the discharge prescriptions, Scottie tried again.

If I leave today I'll die out there. I just need more time!

By now I was immune to his pleas. His lungs sounded great and he was ready to be discharged. He pulled his hat over his eyes and his pants fell low on his waste. A few of the nurses gathered to wish him well. They whistled and catcalled as he disappeared through the hospital doors.

*

A few days later I was paged to the ER at three in the morning. As I yawned and rubbed the sleep from my eyes, A man dressed in sports coat approached from the door. He wore a cowboy hat and boots and I could see the outline of a gun tucked behind his coat.

He introduced himself as a detective from the St. Louis police department. He reached deep into one of his pockets and produced a tattered piece of paper. He held it up in front of my face. I squinted to read the writing. It was a set of discharge instructions with my signature at the bottom.

We found this in Scottie Pearson's back pocket. He was shot in the head and dumped in a field.

*

Scottie's story quickly spread among the physicians in our program. Everyone had a different idea of why he was hiding out in the hospital. Was it drugs? Gangs? Organized crime? A love triangle?

For many, Scottie became another memorable book mark in a series of odd and difficult experiences that marked our years in training. But as I get older, I think more about what he really had to teach me.

As so often happens in our lives, Scottie was trying to tell me exactly what he needed. Although I heard his words, I kept trying to interpret them based on my own point of view. Clearing my patient census for my next call rotation was more important to me then keeping him in the hospital. Sure I justified my actions by saying that he was healthy. But I never took the time to step outside of my own space to understand his.

Whether professionally or personally we all express our deepest needs to the people around us. Years ago, Scottie was trying to tell me his.

I just wasn't listening.