DOCTOR IVAN THE TERRIBLE

One of my first clinical tours of duty was in the internal medicine ward at the University Hospital. I was nervous about displaying my ignorance of clinical medicine to the icons of medicine, the full-time academic staff.  The intern I was assigned to was Ivan. He was a tall fellow with chiseled facial features and thick black eyebrows giving him a menacing appearance. His greenish-brown eyes, however, suggested a gentler and mellower person. What impressed me about Ivan was the energetic and confident way he examined patients and how focused his diagnoses were. Whereas most interns would write a laundry list of diagnoses after examining a patient, Ivan limited his differential diagnosis to two or three disorders at best. They would be listed in the order of their likelihood with the most likely first. Because of his ability to give patients a thorough examination and produce relevant diagnoses, the private physicians frequently requested him rather than the other interns to evaluate their newly admitted patients. As a rule, interns were chosen on a rotating basis and not selected individually. He was also the pride of the director of medicine as the intern who produced the most autopsy cases. Autopsies were very important in academic teaching programs at the time since the number of autopsies performed was listed in directories that evaluated the teaching programs. It was a way for prospective interns and residents to judge programs with the most autopsies since they provided the most significant teaching experience and attracted the best and brightest interns and residents. It may seem counter-intuitive that the higher the number of autopsies, the better the medical program, but the number of autopsies only reflected the number of deaths in which autopsies were obtained. One program with fewer deaths could have performed more autopsies than another with more deaths. The autopsy, also known as the postmortem examination, is the gold standard for determining the patient's underlying disease, the effect of any treatment, and the cause of death. It is vital for confirming that the chosen diagnosis and treatment were correct and why the patient died. Each week the interns and residents were required to attend the mortality conference where the autopsied cases were reviewed and discussed. CT, MRI, and PET scans weren't invented or used for this purpose until much later. Today the autopsy continues to remain the most objective way to obtain this critical information.

I was Ivan's gofer and followed him around like a groupie followed his rock star, hoping that some of his light would shine on me. One day after arriving on the ward, I found him in an empty patient's room, pacing back and forth alone and mumbling to himself. The patient's bed had been made, but there was no patient in the room since he had died during the night. I thought Ivan was upset about the patient's death, and I went over to console him. I told him that after everything that was done, there was nothing more that could have saved the patient. The patient was terminal and expected to die. He looked at me as though I was crazy. He said he wasn't grieving the death but was upset that the family had refused to consent to an autopsy. He had tried every maneuver he used to persuade them except one. I asked him which one he hadn't used, and he didn't answer. I asked him again without a response, and finally, after several more attempts, he relented. He threatened that he could only tell me if I agreed to keep it a secret and not tell anyone else about his method. Without a thought about what I was agreeing to, I gave him my word. He reluctantly explained for patients who died following surgery, the families were told that as a last resort, the doctors had used a special treatment requiring gold during the surgery to save the patient's life. He further responded that there was an alternate method using the gold for patients who hadn't had surgery, but I'll spare you the unpleasant details. I couldn't believe what I was hearing. He continued that without an autopsy the gold remained in the body and the family would have to pay for it. I was speechless and dumbstruck. Now it was apparent why they called him Ivan the terrible, and I had naively thought the other interns were just jealous of his ability to obtain the most autopsies.

A few years later, when I was an intern, I had difficulty persuading a family to consent to an autopsy on a family member. The patient died following a complicated hospital course, and I really wasn't sure why. The family adamantly refused on religious grounds. I tried to explain that the results of the autopsy would help us understand more about the disease and could help other people with the same problem. I thought about Ivan and his crazy method but didn't dare to use it. During a snowstorm on a bitterly cold winter night in the dark and shabby lobby of a city hospital, I clearly remember the second meeting that day with the family who accompanied by an elderly rabbi stressed that the rabbi agreed, not to consent on religious ground. The misgiving I had that night was only tempered by the strength of their religious conviction requiring an old rabbi shivering from the cold of winter to dissuade me. Obtaining consent for an autopsy has never been easy, but none has been as memorable or challenging.