Confessions of an M.D.
If You Can't Save Your Patient's Life, Find Someone Who Can
It's the young deaths that kill you. If you can save one person from dying young in your entire career, you can feel triumphant when you pull off your stethoscope for the last time. In 1968, one of the coldest fish who ever entered the mainstream of medicine was a 63-year-old hematologist, now dead, who practiced down the hall from me. His dour personality defeated the spirits of hundreds of people who came to him for help. One of these people was a gorgeous 24-year-old woman; she had returned deathly ill to the States after a stint in Central America with the Peace Corps.
It was I, the World's Best Doctor, who referred this dying woman to the cold fish. She had consulted me at the insistence of her parents; a thorough workup at a famous medical center had left her with a diagnosis of aleukemic leukemia. The parents refused to accept that death warrant; the patient was too sick to care.
When I examined her, I despaired. Her lymph nodes were the size of golf balls; her liver and spleen, soccer balls. I reviewed the results of her previous diagnostic tests in detail. I finally concluded I didn't know what the hell was wrong with her. At that point, I called in the cold fish.
Dr. Carp (as I will call him) was the brightest physician I'd ever known. He subscribed to, and devoured, 60 medical journals--no issue of which he ever threw away; his consultation room resembled a Times Square magazine stand. I warned the patient and her parents that Dr. Carp would not bowl them over with his personality, but if anyone could put an accurate label on her illness, he could.
After he had examined her, Dr. Carp called me on the phone. I was startled to detect a hint of animation in his voice as he invited me to look at the patient's bone marrow slide with him. Leave it to Dr. Carp to repeat a painful bone marrow aspiration on the patient after she had already had two at the medical center. I told my secretary I'd be down the hall for a few minutes and to hold the fort.
Dr. Carp was seated at his $8,000 dual microscope as I was ushered into his small office laboratory. Without taking his eyes off the microscope, he beckoned me to sit down opposite him and peer into the second pair of eyepieces on the scope.
The bone marrow smear looked to me like myeloid suppression.
"Look at the red cell in the very center of the field,' he said. "What do you see next to its left border?'
I looked, feeling like a first-year medical student about to be tossed on the economy.
"A platelet?' I guessed.
"Uh-uh,' said Dr. Carp, switching the lens to a much higher magnification. "Take another look.'
And there it was. A tiny one-eyed monster that was killing the patient. "What the heck kind of parasite is that?' I asked. The hair on the back of my neck stood up like exclamation points.
"The amastigote of Leishmania donovani,' he said, savoring each syllable.
"You S.O.B.,' I said, kicking him hard on the shins under the table. "You saved her life.'
To soften the blow, I leaned forward and bestowed a loud kiss on the epicenter of his balding pate.
Dr. Carp looked up for the first time from his scope. "Why, Oscar,' he said, "that was very sweet of you.'
The merest trace of a smile was imprinted on his bloodless lips. That smile remained there for the last ten years of his life. The patient's response to high doses of Pentostam was a wonder to behold. She is now in her 40s, a successful author, and an ecstatic mother of three.
Did this case wrest from me the title of World's Best Doctor? Not at all. A clear understanding of how much I don't know about medicine is one of my great strengths.
After practicing medicine intensely for a few decades, what you ultimately learn is the phone number of a cold fish, or a warm heart, who can save your patient's life when you can't.
Tell an Addict to Take a Walk
I will agree to treat just about anyone who appears at my office door--but never an addict. My policy on accepting new patients is taken from the poem on the Statue of Liberty: "Give me your tired, your poor, your huddled masses yearning to breathe free.' Huddled masses yearning to breathe free--that's my waiting room on a Friday afternoon. The Statue of Liberty, as far as I can tell, is not carrying a torch for an addict, and neither am I.
The day I started practice, I resigned from the first case I saw. An angelic, middle-aged man limped piteously into my office. For a half hour I listened to his convoluted story about a severe, chronic pain in the first three toes of his right foot. At the conclusion of his heartbreaking narrative, he looked down at his open-toed tennis shoe and wondered if I'd write him a prescription for aspirin with codeine. I promptly asked him to take a walk, his limp notwithstanding, and find another doctor. Any patient who requests a narcotic prescription on his first visit is out my door before you can say Hydroconone.
For years I tried to rehabilitate a wealthy married couple who were hooked on vodka. At breakfast they tinged their vodka with orange juice; at lunch, they pinkened their vodka with tomato juice; at dinner, they sweetened their vodka with vodka. Each year at Christmas they were found sprawled face down in the snow outside their front door. They consistently won the yuletide lawn-decoration award in their neighborhood, and they were a nightmare to care for.
I finally resigned from their case. They understood completely and even drank to my health. That New Year's Eve they spent under the care of their new doctor, in the hospital.
Show me a young, beautiful cocaine addict and I will show her the door. As she stands out in the cold with the wind whistling through her nose, I point over her shoulder and say, "Get out of town and find someplace where you can't buy the stuff.'
The codeine junkie, the alcoholic, the slave to cocaine all need doctors, all right--but not in private practice.
I instruct my receptionist to screen them out when they call for their first appointment. I have her on the alert for slurred speech, the sound of gunfire in the background, a faint whistle in the foreground. If a junkie escapes her net and I find myself face to face or nose to nose with one of these Doctor Destroyers, I politely suggest, "I'm afraid I'm not the kind of doctor who can help you. Let me give you the names of some clinics that might be able to treat you.'
If the addict still won't budge from the office, I have no choice but to press the button that activates the trap door beneath the patient's chair.
Execute Insurance Forms at Dawn
Insurance forms, the cockroaches of a medical office, should be dispatched at once, before they take over the premises. If allowed to multiply, insurance forms (and their prolific cousins, disability forms and work-injury forms) can sorely tempt the physician to commit arson or suicide.
I have a family in my practice whose members have lifted themselves out of poverty and plunged me into depression by mastering the art of self-inflicted personal injury in public places. The combined efforts of the Bustamontes have generated the nastiest forms I've ever wept over. Their modus operandi is to slip on fallen fruit in supermarkets, trip over footstools in shoe stores, fall into holes dug by sewer districts, step in front of small foreign cars moving slowly through intersections, climb over hospital bed side rails and dive headfirst for the floor. On a quiet afternoon, I can stand on any downtown street corner and hear the distant thud of a Bustamonte. In homage to the Flying Wallendas, I have named them the Diving Bustamontes. I have often thought of resigning from their care, but I haven't the heart to inflict the Bustamontes or their forms on a beloved colleague-- or even a hated one. The only way I can keep pace is to examine the stricken Bustamonte in a hurry and fill out the form before he or she can fall off my examining table.
Don't Plant Time Bombs in Your Office
I may always be late, but I never waste time. Like a blackjack pro counting cards, I watch every move my patients make. I can look at a patient's fingernails for one second and make the diagnosis of chronic arsenic poisoning that another doctor missed during 30 half-hour visits over five years. If I lose my concentration, then I become the bimbo some hot-shot internist one-ups five years later.
In my practice, I've got to move fast but not so fast that I empty my office of problems that come back to haunt me. I don't want to send a malignant melanoma out my door because I'm too rushed to have my patient fully disrobe during a checkup. That melanoma is a time bomb that will explode two years later when I finally detect it--far-advanced--on the back of my patient's thigh. If I had taken a few moments to check the patient's skin two years before, he would now be cured instead of imminently dead.
I have to be ruthless with my time. I can effectively deal with the sore throat of an established patient in 3 minutes. I then have 25 minutes to examine, at some leisure, a new patient with chronic back pain who has brought in a 35-pound stack of old X-rays. I know at a glance that his back pain is caused by hauling that load of films to numberless consultants, but I'll need 25 minutes to get up the courage to tell him.
Make a House Call and Become a Legend in Your Own Time
If the patient can withstand the shock, I offer to make a house call. Once I get there, I never regret it. A house call is such a novelty these days that the patient's family can't do enough to express their gratitude.
"You're a saint to come all the way out here to see Grandpa!'
"Can I take your coat?'
"Would you like a cup of coffee?'
"How about a 64-piece set of sterling silver? Sheldon, carry the silver to the doctor's car.'
Of course, if the patient had received this much loving care, he wouldn't have needed a house call in the first place.
The fact remains that sometimes a patient is too sick to get out of bed to see the doctor. Rather than punish him for his infirmity by having an ambulance drag race him to the nearest emergency room, the doctor can jolly well hitch up the horse and buggy and go out in the snowstorm to the patient's bedside. Although the horse and buggy have been replaced by the Mustang and Volkswagen, the only modern way to cope with a snowstorm is to practice in Palm Springs.
Despite the time and trouble, I have almost always found the house call a vivid experience. Last year I paid a visit to the bedside of a dying cellist. The elderly veteran of the symphony lay propped up on one half of a double bed, staring straight ahead. His cancer of the liver had spread widely since my last visit. His thin, jaundiced body with its distended abdomen was a grotesque caricature of the very instrument he played. His silver-haired wife was a blur of activity in contrast to his stillness. She took my coat, plumped up his pilllows, pulled over a chair for me, and turned on the bedside lamp.
After I examined him, I was hard put to say anything that would comfort him or his wife. I followed his gaze and noticed his gorgeous cello-- as silent and delicate as the patient --standing against the wall. The old, deeply polished instrument lay inside a new padded vinyl case that stood open.
"I bought Herman a new case for his cello, just before he got sick,' said his wife, her eyes brimming.
My God, I thought, he's staring at his own funeral!
"The cello and the case are beautiful,' I said, looking up at the wife. "But let me suggest you carry them out to the hall.'
With a slightly hurt look, she obeyed. While she was out of the room, the patient's face relaxed. He smiled at me and said, "Thank you, doctor; I didn't want to hurt Gerda's feelings.'
When she returned to the room, the patient had drifted into the first peaceful sleep he had had in days. He never woke up.
Don't Try to Feel a Breast Lump over the Telephone
The moment a woman calls to say she's discovered a breast lump, I tell her to come over at once. Until I see her, she's in a frenzy of suspense.
I usher her into the exam room as soon as she arrives--no New Yorkers for her. If the lump feels suspicious, I explain right off that I'd like to have a surgeon biopsy it. She's expecting the worst anyway, so there's no use telling her, "Don't worry-- there's always a chance it's benign,' or "Don't worry--let's get mammograms,' or "Don't worry--lots of lumps go away by themselves, blah, blah, blah.' Get her to the best surgeon in town, who will cut out the blah, blah, blah--and the lump.
When she goes into the hospital, I visit her every day and don't, for God's sake, charge her. (This article is not subtitled How to Be the World's Richest Doctor.) If the lump is benign, I celebrate with her; if it's malignant, I tell her every happy story I know about 20-year survivals. Indeed, I've stuck around long enough to have patients thank me 20 years after the mastectomies just for having been there.
Don't Be the Last Doc on the Block to Own a Plastic Gall Bladder; See a Detail Rep
I'm a pushover for pharmaceutical salespeople. I've tried to analyze why I allow myself to be propagandized by these well-groomed supplicants of the Corporate Drug Structure. Is it because my father was a struggling shirt salesman? Do I invite a detail rep into my office to keep a drug pusher off the streets? Am I so intellectually starved that my mind hungers for the advertising pap of the caplet cartels? Am I trying to amass the world's largest collection of antihistamine samples? Am I afraid to say no?
No. None of the above. The reason I see detail reps is their bountiful gifts. I refer to the one-fourth-scale, three-dimensional plastic colon--so glistening, pink, and upright on its fragile stand! Through a window in its splenic flexure, one can see the lurid red and yellowness of amoebic dysentery. My plastic colon makes a perfect centerpiece for our dining room table when we entertain guests who profess to be on diets.
And how I treasure my dozen hollow plastic kidneys! They make ideal bathtub toys for doctors and their children. You've never heard of floating kidneys?
Thanks to the munificence of detail reps, I have a different ball-point pen for every day of the year. I could retire from medicine tomorrow and live for a decade on the sales of my promotional pens, flashlights, tranquilizers, and plastic viscera. ("Good morning. I'm "Doc' London. Please accept this complimentary Valium tablet. Can I interest you in a plastic pancreas today?')
In recent years, women have entered the ranks of medical sales reps. The first time a female detail rep handed a doctor a ball-point pen was an occasion no less auspicious than the day Prosciutto married into the Melon family.
So I am now in the some-would-say enviable position of having intelligent, well-dressed women dying to shower me with gifts. How I love to sit down and listen to them rhapsodize about the half-life of their latest tranquilizer. How I love to fantasize about leaning over my desk and asking one of them if she'd be willing to spend a half-life of tranquility with a middle-aged internist. I can imagine her look of genuine outrage--which would certainly be an improvement on her ersatz gall bladder.
Take Up a Hobby and Become a Multifaceted Bore Instead of a Simple One
At the turn of the century, Sir William Osler, the Best Internist in the Solar System, urged his students to practice medicine as humanitarians, scientists, and artists. In their spare time, he advised, they should take up a hobby. Sir William, that charismatic overachiever, has driven many a lesser physician to an early grave in an effort to emulate him. Here was a Victorian giant who wrote the definitive medical textbook of his age, who was No. 1 physician and teacher wherever he settled (Canada, the United States, and England), who had diseases he defined named after him--prescribing recreational therapy for us schleppers who are still on the phone with a character disorder at 8 p.m. With all due respect to Sir William, I submit that the only rewarding hobby a modern physician can take up is sleep.
I collect odd hours of sleep like a numismatist collects Indian-head nickels. My most treasured sleep takes place during the 20 minutes that follow the departure of my last patient. I sit alone in my consultation room and recite my mantra three times ("Osler, Os-ler, O-o-ss-ler') and fall into a dreamless sleep. I awake rejuvenated and for a few moments contemplate the joys of not having taken up an ordinary hobby.
I cannot end this disquisition on the physician as hobbyist without a few words on photography. Show me a physician with a single-lens reflex camera around his neck, and I will show you a menace to polite society. He comes home from Europe with 2,000 transparencies, of which he discards 7 as being below his standards. He has his wife invite 12 unsuspecting guests for dinner. After dessert, he announces, "Would anyone care to see my slides of Rome, Florence, and Venice?'
The guests scan the doors and windows; they are locked; there's no escape. Four hours later the ambulances begin to arrive. The comatose guests are rushed to the nearest emergency room, where huge doses of adrenalin are injected and a pastafree diet is prescribed for one month.
I know a urologist who had the effrontery to conclude a two-hour meal of pot roast, gravy, potatoes, and wine by saying, "I have a few slides of Yugoslavia I'd like to show you.'
Halfway through the presentation, a portly internist rose through a Burgundy stupor and stood before the screen. Lit by an overexposed harbor view, the internist drew a .38-caliber revolver (one of the few weapons more lethal than a 35-millimeter camera) and aimed it at the projectionist.
"Open the front door, Seymour, and let us out!' the internist shouted. "If you say the word Dubrovnik one more time, you're a dead man.'
Good night, Sir William, wherever you are.
Photo: For a half hour I listened to his convoluted story about a severe, chronic pain in the first three toes of his right foot.
Photo: One family in my practice lifted themselves out of poverty by mastering the art of self-inflicted personal injury in public places.
Photo: A doctor making a house call is greeted like a long-lost husband carrying a Tiffany shopping bag.
Photo: The salespeople's gifts of hollow plastic kidneys make ideal bathtub toys.
|Printer friendly Cite/link Email Feedback|
|Title Annotation:||medical doctor|
|Publication:||Saturday Evening Post|
|Date:||Oct 1, 1987|
|Previous Article:||Johnny Pye and the fool-killer.|
|Next Article:||To sleep, perchance.|
|Egypt presses Saudi Arabia for release of accused doctors.|