Blog | 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.