LESSONS FROM A MEDICAL LIFE

My blog is 7 years old this month, a fact that is difficult for me to comprehend.  How can that be?  I just started it a few years ago....didn't I?  I thought I would celebrate the occasion by re-visiting some of the very early posts, either in their original form, or with some revisions.

Today's post first appeared in November, 2007, and has had a few minor revisions an additions.

During my years of medical training, which consisted almost entirely of managing patients with acute or chronic illnesses in a hospital setting, it was easy to imagine that life was over run with disease and illness. It was only after entering private practice did I appreciate that most people are not sick, and do not have low blood counts, abnormal renal studies, or abnormal chest X-rays’.  Abnormal laboratory results that were commonplace in the hospital would “stick out like a sore thumb” in my office practice.

I began to see the randomness of disease and illness. Yes, there are habits and behaviors that may promote well-being, but there are no guarantees; we are all vulnerable to the vagaries of genetics, circumstances, and chance.  With some exceptions, there is little reason to take credit for good health or blame for poor health. Thus I have learned to appreciate my own good health, and that of my family, and not take it for granted.

I have also seen the amazing resilience of the human machine and its ability to compensate and/or overcome a variety of physical and emotional assaults.  The symptoms of many illnesses are a direct result of our bodies attempt to overcome the offending insult. This has led me to believe that good health is more than the absence of disease and illness.  A healthy body is one that can withstand an illness and effectively compensate for the insults of disease.

The patients that I found difficult to deal with were those who could not understand why they were ill because they lived a “healthy lifestyle”, ate the right foods, and exercised.  They demanded to be treated and cured immediately.  (Yes, there are people like that.)

A GENTLE MAN AM I

Reviewing old files I came across this post from 2007 (written in 2003), and decided to re-post it, adding the illustration.

At least that is how I think of myself, and I believe those who know me would agree with this humble assessment.  I abhor violence of any kind and would never think of striking someone, well, OK, maybe I would think of it, but would never do so!  (When I was 9 years old I did punch Eddie and his cousin in their noses, but that was only because they provoked me.)  Except in very rare circumstances I do not yell and scream at others.  In fact, my life in general has been focused on making other people feel better about themselves, both physically and emotionally.  So the incident I am about to describe is totally out of character for me, in fact looking back I cannot believe it really happened, but it did.

Emergency medicine in a busy city hospital can be challenging and stressful, especially late on Friday and Saturday nights when there is no telling who and what will walk through the door.  The experience can drive an otherwise sane and gentle person to uncharacteristic behavior.  THAT is my excuse, and I’m sticking to it!

Shortly after the ”last call” in the local pubs we could count on several patients scattered about the ER on gurneys in various states of acute intoxication.  Most of the time they were understandably subdued and quiet, but there was always the occasional obnoxious drunk who could not resist articulating his (they were almost always men.) alcohol-tainted feelings about his current life’s circumstances.

It had been an especially busy night and I was near the end of my shift in the acute care unit.  I was tired and depleted, struggling to cope with all that was required of me, and this one very noisy and obscene drunk was beginning to get on my nerves.  A constant stream of obscenities flowed from his mouth, loud enough to be heard by the other patients in the area.  I politely asked him to be quiet, repeatedly, to no avail.  I tried pleading, coxing, and even bribing, but nothing worked.  Finally in desperation I threatened him!  I told him that if he did not cease his yelling I would remove his filthy socks from his equally filthy feet and stuff them in his mouth!!  Actually I believe I yelled something like, “if you don’t shout your goddamn filthy mouth I’ll’....well, you get the idea.  He told me to F___ off, and continued to yell and swear. So I did it!  To the shock of the nurses and staff, and to the patient, I pulled off one of his socks, balled it up, and shoved it into his mouth.

 

I don’t know how many of you readers have had the occasion to remove socks from the feet of some one who hasn’t bathed in who knows how long; the skin of the lower legs and feet is dry, flaky, and dirty, and when a sock is pulled of the foot it is invariably accompanied by dry flakes of dirty skin.

I really don’t know how long it remained in his mouth, far less than a minute.  But it was effective.  He knew I was not some one to be antagonized; in his alcohol-saturated mind I was mean and evil, and certainly not a compassionate healer.  I suspected that even the ER staff looked at me a little differently after that.

There is no telling what a Friday night shift in the ER will do to a person

Walter from the dumpster. (From the ER journals)

The usual routine when patients were brought into the treatment rooms was for the nurses to get vital signs, and asses the problem so they could set up the room with equipment or supplies as needed.   When ever possible, I would like to see the patient for a quick “greeting” and assessment of my own, before the nurse arrived.

 

I had no idea who was in the treatment room, or why. I pushed the curtains aside, stepped into room and was immediately overwhelmed by an oppressive, sickening odor coming from the crumpled dirty figure lying on the gurney.  I am ashamed to say that my first reaction was to think, “I’m glad I’m not the nurse who has this room”.

Like so many of our homeless patients, Walter was brought to the ER by the local police.   He apparently sought relief from the severe weather by crawling into a dumpster to sleep, only to be rudely awakened when the garbage truck began lifting the unit to collect the trash.  He had enough presence of mind to know what was happening and quickly scrambled up and out of his now moving abode.  Unfortunately he was a good 10 feet above ground when he exited, and thus he became our guest.

The next time I parted the curtains and looked into the room, Walter was standing by the gurney sporting the one size fits all hospital gown washing himself with the help of one of the many angels working in the ER as registered nurses.  The odor was now tolerable and his clothing was nowhere to be seen.

Walter had a head full of wild looking hair that did not fit with the chagrined, embarrassed look on his face.  Clearly he was ashamed of his situation.  He appeared to be in no distress or pain and we were surprised when his x-rays revealed non-displaced radial fractures of both fibula.  It was our turn to be chagrined for having him stand and wash himself.

Like most of the homeless that we saw in the ER, Walter was humble, polite, and very appreciative of all that was done.  I will never forget the image of him standing there dripping wet from his sponge bath.  Nor will I forget the smell the first time I walked into that exam room.

THE FIRST PATIENT

While revising some of my files I came across this post from 2011, made a few minor changes and decided to re-post it. 

It was an experience not to be forgotten.  We were in our third year and our small group was in a general medical clinic; we were to see patients, examine as necessary, and then report our findings and treatment plan to the medical resident or staff physician.  After all these years the specifics of the clinic are rather vague, but two things are still very clear to me.

It was hot and humid early September, and we were dressed per school requirements, shirt and tie plus the short white jacket that identified us as lowly students, recognized not only throughout the hospital but in the surrounding neighborhood.  I entered a small exam room (no air conditioning) and introduced myself to my patient, and elderly, rather wrinkled woman whose problem has been long gone from my memory.  What is not gone is the absolute, awful, knock you down, odor of her breath, enhanced no doubt by the heat and closeness of our quarters.  Unfortunately It was necessary for me to examine her throat, and when I approached her with tongue blade and flash light (trying hard to overcome basic physiology by only breathing out) she signaled me to pause for a moment while she removed a huge clove of garlic from her mouth which I swear was the size of a tangerine…Ok, maybe a walnut, but I can tell you this, even the most Italian of all Italians would have been done in by the dear ladies breath.  As for me, I did not get near a piece of garlic for days…Ok, maybe hours.

WHY MEDICINE?

I have tried to recall the thought processes that led me to decide to become a doctor and can only come up with a rather embarrassing few. I was an 18 year old freshman at the Philadelphia College of Pharmacy & Science when, at some point during the spring semester I remember deciding that I would rather be writing prescriptions than filling them. Acting in a manner that would come to be rather common place for me, I very quickly notified the proper people of my decision (my parents, the Dean of the college, and my best friends, Carmen and Desi) and the following fall I found myself at Lebanon Valley College with a pre-med major.

And that’s it! No dreams about serving others or saving lives, no aspirations to be on the forefront of the medical frontier, either in research or teaching. In fact I cannot remember ever having any concrete ideas about what my life's work would entail. All I knew was that I was going to be a physician...that it was the right thing for me to do, and that was all I needed to know at that time.

Why did I do that? How did I know it was right for me? What information did I sift through, consciously or unconsciously to arrive at that decision? When I think about it now I am amazed. At that time in my life I was totally unconscious of what might be considered my aptitude, gifts, or of anything remotely resembling an awareness of my inner life, drives, needs, etc. And yet that choice...to practice medicine...was to tap into what I have since recognized as a deeply seated gift, as well as a need, to care, and to be present to others. This has been one of the defining characteristics of my life.

Was there more...has time blunted my memory of the events of that defining time? If so, maybe in my terminal years, when we somehow find old memories, in place of the short term ones, I’ll have the answer.

I made that choice, and in spite of another calling years later, I have zero regrets. Medicine helped me define who and what I am, and has given me the unbelievable privilege of serving others. I am forever grateful for that opportunity.

(from my journal...2002)

Note...the image at the beginning of this post has nothing to do with anything. I felt that any post would not be complete without at least one painting...in this case, an oil pastel.

And further more...I hope to be posting a series of these journal entries over the next few weeks focusing on the interplay between medicine and art.

THIS IS MEDICINE?

Yesterday my wife showed me a flyer she picked up at her recent visit to her gynecologist’s office. It was a standard sheet of paper with multicolored flowers and butterflies listing all of the “specials” available from a “health specialist” in the office. These included, among other things, botox injections, laser hair removal, and a variety of treatments for wrinkles, sagging chins, and cellulite. What bullshit!!

When did wrinkles and sagging chins become a health issue? And who is the “health specialist” that administers this ....whatever. I can’t bring myself to call it treatment. (How about cutaneous intervention?)

I refuse to relinquish my belief in what the practice of medicine should be...a noble profession providing the physician with the privilege to serve. The flyer my wife showed me was not about service, it was about exploitation. Sadly, I have come to expect this from the plastic surgeons, but now it appears even the Ob-Gyn folks have climbed on the money express. Far too many physicians today are more concerned about maintaining their inflated incomes than about the service they provide.

posted 6-1-08

Lessons from life....Medicine

Intensely Orange Oil Pastel aprox 15x30

This morning I awoke with this single thought in my head: what have I learned in my 68 years of living that is worth noting? I have pondered this question before, but this morning it insinuated itself in my mind and could not be dismissed. So, I have tried to address the issue, and plan to do so in a series of small posts over time, starting with my experiences in medicine.

During my years of training, which consisted almost entirely of inpatient medicine, it was easy to imagine that life was over run with disease and illness. Only after going into private practice did I appreciate that most people are not sick, and do not have low blood counts, abnormal renal studies, or abnormal electrocardiograms.

In the years that followed I began to see the randomness of disease and illness. Yes, there are habits and behaviors that we can adopt to maximize our well being, but still there are no guarantees; we are all vulnerable to the vagaries of genetics, circumstances, and chance. Thus I have learned to appreciate my good health, and that of my family, and not take it for granted.

I have also seen the amazing resilience of the human machine and its ability to compensate and/or overcome a variety of physical and emotional assaults. This has led me to believe that good health is more than the absence of disease and illness, but also includes the ability to heal and or compensate in the presence of either.

A LIFE IN MEDICINE -8- “KG"

The Mother of all years

Dr. Kenneth Goodner, the chair of the Microbiology Department, was affectionately referred to as KG (NEVER to his face!) As freshmen all we heard from the sophomores in the fraternity house was KG did this, KG did that, KG said this: KG stories were notorious. He was totally off the wall and unpredictable, every medical students worse nightmare. So, it was with tense anticipation that we entered Dr. Goodner"s world of microbiology to learn all about the life and habits of “germs”, and how to identify them by looking and by testing.

A KG classic: We are given a slide hosting an unknown microbe. The slide is treated with a “fixative” that is dropped on the unknown (marked with a check on the end of the slide), heated briefly over a flame, and examined under a microscope. On more than one occasion the slide is marked on the wrong side, so the unsuspecting student fixes nothing and then proceeded to char the unknown specimen with the flame. The lesson? Do not take anything for granted!

The class would break down into small groups for conferences and oral testing. My first question from KG was, “who has the most influence on public opinion? This is in a microbiology class!!! I answered, “the press”, and was told no, it was Arthur Godfrey, as he made a mark in his little book. Or, he would as a true or false question, and if the first student’s answer was wrong, he would as the next student the same question.

But I must admit, KG provided some much needed levity in a demanding semester. And he did leave us with one bit of wisdom that I have never forgotten. He advised that everyone should become an authority on at least one subject, no matter how trivial, and as the years passed I came to appreciate that more and more. (To support this admonition KG invited every student to participate in the annual microbiology hobby show, where we all displayed the objects of our passionate interests, and you can be sure that we all had one.)

A LIFE IN MEDICINE -5- the second year

I'm gonna be a doctor!

Seasoned by the first year, my classmates and I were prepared for the avalanche of material we were expected to assimilate during this overwhelming year. This was undoubtedly the most demanding of the four years because of the voluminous amount of material which included: pathology, hematology, pharmacology, laboratory medicine, and microbiology. Like the first year, we were kept busy all day every day with labs and lectures. All of this was rendered palatable by one small course inserted in the midst of everything else, we were taught the fundamentals of the physical examination where we were to use, for the first time, the symbol of our trade, the stethoscope.

There is a lot to remember about this most memorable of the four years at Jefferson, the first of which is the apartment I shared with Gene Doo. We decided to move out of the fraternity house and found the apartment at the end of year one. While Gene returned to his home in Honolulu for the summer, I moved into the apartment and made it a “home” for us. I spent the summer working in one of the ENT labs being paid for doing basically nothing. As I recall I wasn’t paid much. Our apartment was about two blocks from the fraternity house so we could easily continue to get our meals there. It wason E. Pine St. in what was to become a very fashionable neighborhood in Philadelphia’s Society Hill. But in 1962 Society Hill existed only in the minds of the city planners, and rents were still affordable. It was on the second floor, and consisted of a kitchen, bath living room and 2 small bedrooms. Now, almost 50 years later, I remember little of our day to day life in that dusty abode, but certain memories persist, fodder for my next post.

ART & MEDICINE

In the 27 years since I began dividing my time between medicine and art, this is the first time I have attempted to write about how these 2 endeavors effect one another. And as unbelievable as it may sound, the first time I’ve really thought about it with any seriousness.

I left private practice for part-time work in an emergency room. For 4 years I alternated 3 months of full time ER work with 3 months in my studio. During that time I was acutely aware of the conflicting demands on my psyche. In the emergency room it became necessary to mentally and emotionally “close down” in order to deal with all that a busy city ER required of its staff. In contrast, during the 3 months in my studio I felt the need to open myself to all of the sensory and visual delights that were feeding my creative needs. The conflicting impact of medicine and art during those 4 years was easy to identify. Beyond that, the relationship between the two becomes more compatible.

I have never been aware of any conflict between my art and the practice of medicine (other than a desire for more time to paint). I applied myself to both in the only way I knew how, without any conscious effort to be anything other than myself. The ER experience did not repeat itself when I worked in an urgent care facility or when I returned to private practice 8 years later.

The difference, especially in my practice, was the relationship with the patients. In the practice there was an established, emotional bond between the patient and me that would often become a long term relationship. I encouraged and nurtured that relationship by being open and receptive to their needs and fears, and being present to them, honestly, without hiding behind my role as a physician. And this is the way I see myself functioning as an artist, openly and honestly responding to my encounters with the world around me, finding creative inspiration from these encounters. In a similar fashion, the most gratifying part of medicine has always been my encounters with the patients, easing their fears and concerns, providing hope and comfort, or simply gaining their trust. Art and medicine both require openness, sensitivity, and compassion.

A dear patient and artist once told me, “the doctor is not an artist, the artist is a doctor”.