Although my training, in both internal medicine and nephrology, was excellent, I was lamentably green for some time when it came to the practical aspects of medicine. I did, however, learn one lesson early on.
One day, I rose from my office chair to greet a new patient who walked in slowly, supported by a cane and holding the arm of a much younger man, who helped her into her seat before taking his. To me, she appeared to be "old," because in those long-ago days I thought of anyone over sixty-five in such terms.
He is dying, and they will not have visitors. He is my closest sibling in age and my closest emotional connection. He's my big brother who had my back on numerous occasions. Okay, I had his, but less often and less serious, like the time I put him to bed when he came home drunk, after a few beers in high school.
“Excuse me? I’m lying right here, ya know. C’mon!”
The voice came from behind the cloth curtain of the test bay, in a tone of defensive disbelief. It belonged to a patient who had Brugada Syndrome and an implanted defibrillator awaiting her stress test.
I had been discussing Brugada, the potentially lethal and heritable “sleeping sickness” marked by unheralded syncope (loss of consciousness) and sudden death. My colleague and I were enthusiastically running through the electrocardiographic characteristics, diagnostic uncertainties, defibrillator firings and death rates when the conversation turned to the patient.
“If she were to drop dead during exercise…” I had started to say.
It was 1962. I was in my third year of medical residency at Philadelphia General Hospital, the only charity hospital in the city.
I was in the outpatient clinic, seeing an African-American patient for the first time. I noted that he was on an anticoagulant, Dicoumaral (similar to Coumadin).
His prothrombin time (a test that indicates the level of blood thinning) was very low—in fact, outside of the therapeutic range. When the range is too low (meaning the blood is too thick) or too high (the blood is too thin), the patient is at risk for serious complications such as clotting or hemorraghing.
Without thinking, I said, “You must not be taking your medicine.”
Always occupied with the needs of others, medical students often put their needs and wants aside. Sometimes for an unhealthily long time.
Although the consequences of such self-inhibition are not readily apparent, they can have an insidious impact on academic and clinical performance. But the story I am about to tell is something far worse.
I ambled with squirrels and rabbits on an urban trail overflowing with chaparral and mossy oak. Early morning bird chatter, drone of bugs in rays of sun, and the crackle of underbrush beneath my feet kept me company. My thoughts wandered brisk as the sound of river water on rock.
A man wearing a holey T-shirt and sweatpants approached me, accompanied by a large German Shepherd. The dog was off leash but seemed friendly. The man had a vacant stare, and as I passed him I gave a perfunctory smile and “Good morning.”
He didn’t even note my existence nor change his faraway gaze, and I immediately snickered at his lack of basic human decency. Shaking my head, I glanced back at him. He had stopped, looking up at the cloud-threshed sky, and suddenly emitted an unearthly wail.
The movie, One Flew Over the Cuckoo's Nest, became popular the year I was working on my hospital's med/surg psych ward as a nursing student. While this cult classic raised awareness about injustices in mental institutions, the public assumed all administrative nurses were cut from the same cloth as the film's RN whose name rhymed with wretched. On more than one occasion, I had to restrain myself when someone said, "Bet you're Nurse Ratched, ha, ha, ha. Only kidding."
When Joan was in last week and told me she had just completed chemotherapy for breast cancer, I assumed congratulations were in order. When I smiled and offered them, she suddenly became forlorn and began to cry. And these were not tears of joy.
Ella was a surprise sent to me by a geriatrician for osteopathic manipulation (OMT). With knees and back stiffened by osteoarthritis, Ella had found that chiropractic care and her walker kept her mobile enough to get out to family events and church activities. Now she could no longer afford chiropractic care, but visits with me--her family physician--would be covered.
At thirty-six, I had my first child. Up until then, my focus was on my career to become an ob/gyn physician.
During my pregnancy, I chose a doctor and hospital that were not affliated with my hospital. I wanted to be a patient, not a doctor who happened to be pregnant. I ended up having a scheduled C-section; my child was breech, and no amount of encouragement would change that.
As soon as my OB walked into the operating room, he loudly announced, “She is an OB too!” And, in an instant, the cat was out of the bag. No longer could I be anonymous.
I was called to the NICU to see a baby who had just born with hydrocephalus. The CT scan showed he had Dandy-Walker syndrome. His teenage parents were told he would be severely handicapped, so they refused permission for a shunt and wanted him to die. The NICU staff was horrified and asked me (the neurologist), "They can't really do that, can they?" I said no they can't, and immediately called the hospital lawyer. She brought a judge into the NICU who agreed, obtained legal custody and assigned guardianship to a local advocacy agency. The new guardian authorized the shunt which worked well. The boy was discharged into foster care and eventually adopted.
But then it got really interesting. Yes, he had Dandy-Walker syndrome and hydrocephalus, but he was developing normally!
When I first met my future sister-in-law—I was fifteen, she was seventeen—I assumed that her life was perfect. She was pretty, perky and popular—everything I was not. She was dating my brother, a medical school student, while I had never been on a date. I just knew her life would be a fairy tale with a happily-ever-after ending.
I had breast cancer twice. My first time I made an educated choice not to start aromatase inhibitors (AIs). With early stage premenopausal cancer, overall survival rates were the same, on or off AIs. (There is 13% increased chance of reoccurrence off AIs). I chose survival rates and lifestyle. I am very active and wanted to avoid muscle and joint aches, osteoporosis and possible diabetes.
I felt like I was in Vegas, spinning in Russian Roulette. I chose the wrong number and lost. Two years later, I grew another breast cancer on the same side, in breast tissue remaining after my mastectomy. Now there were two metastases in axillary lymph nodes. My survival rates markedly declined. I had difficult choices to try to improve my odds.
As a physician, I make assumptions all the time.
As a pre-med student, I volunteered in the emergency department of a local hospital, and I also worked as a personal trainer for MacWheelers, an exercise program for adults with spinal cord injury. Looking back, I now realize how often I made wrong assumptions about elderly patients I cared for. I assumed they were too weak and fragile for simple tasks. As a personal trainer, I was overly restrictive on which equipment they could use and the types of movements they could safely perform.