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Friday, December 7, 2012

A Hippocratic Oath for the holidays

Part of the well-known oath we swear upon receiving the degree of Doctor of Medicine is that we will honor those who taught us this art. It occurred to me as I was preparing for Thanksgiving how many thanks I owe to those who have taught me to be the doctor I am. Some of them were physicians and some were patients. Some meant to teach and others did so without realizing it. I meant to post this on Thanksgiving Day, but as usually happens, I was on call and things got busy, but I still think the topic is apropos for the entire holiday season. So today I want to thank some of the people I have learned from in so many different ways.
First there were my schoolteachers going as far back as elementary school. I owe my early interest in anatomy to my fourth grade teacher Mrs. Raynor who undertook to dissect a cow's heart in front of the gathered class, demonstrating the valves and chordae that tethered down the mitral valve leaflets. Mrs. Veigel, my sixth grade teacher, wherever you are, thank you for inspiring confidence in my ability to help others and supplying me with the first contributions to my collection of adages, aphorisms, and old saws, which have served me well in speaking with my patients colloquially and to which I have added an abundance and even made up a few of my own.
My first medical experience other than as a patient was when I volunteered to be a phlebotomist at a community hospital in Rockaway, Queens in order to polish my extra-curricular credentials as I pursued my pre-med studies. In that small, squat and squalid hospital I was welcomed eagerly by the phlebotomy team without any qualifications, to help the overtaxed LPNs and technicians, if only for a couple of months.
The woman who taught me was head of the team and I believe she was an LPN. Somehow she was able to get me past my initial reaction to the sight of blood and my flinching from inflicting pain on anyone. She patiently taught me the skill of drawing blood with the newly invented vacutainers and then with "butterfly" needles, first from slam-dunk antecubital veins to smaller ones on the back of the hand. In those days the oral anticoagulant Coumadin was in wide use for conditions we now treat with injected Heparain, and it required daily monitoring of blood clotting, so there were many people who needed their blood drawn.
She herself was tough, caring, always full of good cheer, and constantly on the lookout for ways to instruct. She even sneaked me into the pathology department to stand behind the residents, all foreign medical graduates, to observe an autopsy. I must also thank the many patients who gladly suffered my early practice on them just because it even gave them some pleasure to have a young, handsome man (in their eyes), be their "vampire," as so many of them called us.
I search my memory but I cannot summon up her name. What I do recall is learning at the end of my stay that she was very ill and had been hospitalized at Kings County Hospital in Brooklyn. One of the other phlebotomists took me along to visit. To my questions during our ride about the nature of her illness, my companion would only divulge that it was due to a habit she was unable to break. I wish I could say my final words with my teacher were an unforgettable valedictory, but all I can remember was her telling me I would be a great doctor someday. A week later she was dead.
As a third-year medical student on the wards at Hopkins, my best teachers were for the most part the patients. We were charged with "following" the patients, which I didn't at first understand, because I couldn't see how I could learn to treat people if no one would teach me how to do things to them and how to order others to do so. So follow them I did, to the radiology department and back to their rooms, doing histories and physicals that occasionally someone took the time to critique. At that early stage in my career, my efforts at constructing a narrative at the expense of hitting every element cost me points. Perhaps our system of bullet points for billing codes was already in its infancy.
I got to follow the interns and residents on rounds, mostly to be ignored. But I learned a great deal from the patients in spite of what seemed to me to be abysmal clinical teaching. One man with small cell carcinoma of the lung liked to call me his doctor, though he well knew my role, because I was the one who stopped to explain things to him. Another young woman said, "Dr. Sack, you had best keep that stethoscope of yours in your pocket if you want to put it on me, because that thing is COLD!" I carried my stethoscope in my pants pocket for the remainder of medical school, internship and residency.
There was one resident at Hopkins who did make a big impression. His name is Lou Frees (sp?), and he probably doesn't even remember me. He sat in the day room of Osler 4 with the interns, smoking his pipe, an affectation that at the time looked to me as natural as if he had been born with it in his mouth, and made pronouncements and gave orders. He must have been all of 29 years old, but he looked to be the eyes of age. Unconsciously, I think I perceived him as a Mark Twain-like figure. He spoke in a colloquial manner that I quickly came to admire and then adopt. I could see how he immediately put patients at ease with how he spoke to them regardless of what he had to say.
To this day, I remember him saying things like, "I'm going to look you over" as he picked up his stethoscope, or "Let's take a gander at you." This began my study of how to use words to put people at ease in the exam room. I have since learned to adopt whatever the patois might be of those I see as patients, whether it be a machinist from Maine or a PhD from Philly.
I owe a debt to the interns and residents on the wards at Baltimore City Hospital for teaching by example, but this was much more literal example. It was the first time, and not the last, that I heard the words, "see one, do one, teach one." I'm still not quite sure what gave them the trust in me to allow me to do thoracentesis, paracenteses , pleural biopsies and lumbar punctures with only the most brief and casual of instruction , but I assume that it was simply a matter of too many patients and too little time. I can only thank God that these procedures all came off at least apparently without mishap.
I remain indebted to Dr. Ira Morris, who was then leading up one of the first HMOs in the nation in the slums of East Baltimore. I was at a low ebb in my clinical confidence and one of my advisors suggested doing a rotation with him. That experience gave me the assurance I needed to look after people without another physician in the room.
But perhaps the greatest debt that I owe in medical school is to one of my teachers who never actually taught me anything directly other than to have that confidence in myself. My student advisor, Dr. Philip Tumulty, was a revered member of the faculty and was known for being a consummate clinician. He wrote a textbook on how to be an effective clinician, which I have read and reread when I was in school and many times since. He repeatedly assured me that I would make a great doctor, although I felt at the time he hardly knew me and that he was only saying so out of kindness. In retrospect, I can be sure that he would have been kind, regardless of whether I merited such praise.
The doctor who most of all deserves my thanks and gratitude was Dr. Ezjel Lederman, worked for 40 years in southern Brooklyn as a family doctor and who became my father-in-law. He was nothing short of a giant of a man in every respect. He was trained in post-war Germany in an era when clinical diagnosis relied upon physical examination and he finished his career in the era of genetic engineering and magnetic resonance imaging. Every week he read the New England Journal of Medicine religiously and studied the CPC as if it were the Sunday crossword puzzle. There were many dinners at the Lederman household when the conversation was one of spirited dispute between him, his two physician sons and me about the difficult cases that he had seen that week and how they should be treated. What I learned from him as a physician cannot be summarized in the remainder of this post, so my thanks to him here are merely a promissory note for a fuller account that I hope to render sometime soon.
In an age when electronic charts and ever more burdensome regulations threaten to remove all meaning from our profession, let us remember what a privilege it is to be entrusted with the lives of others. Even when we know there is little we can really do to alter the course of events, we must remember that our patients don't always know that, and we are all they've got.
David M. Sack, MD, is a Fellow of the American College of Physicians. He attended Harvard and Johns Hopkins Medical School. He completed his residency at Lenox Hill Hospital in New York City and a gastroenterology fellowship at Beth Israel-Deaconess, which he completed in 1983. Since then he has practiced general gastroenterology at a small community hospital in Connecticut. This post originally appeared at his blog, Prescriptions, a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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