Ivan the Great

When I was a medical student on the University Hospital medical ward, an intern, Ivan, was my mentor. Following him around from patient to patient, I was impressed by his enthusiastic care of patients. His commitment to each patient was so palpable that the patients were believed they were receiving the best care possible. His bedside manner and intellect made him appear to be an exceptional doctor, and his patients called him Ivan the Great. Some doctors, including his fellow interns and residents, considered his performance one-upmanship, but the patients loved him.
 A particular patient encounter illustrated the conflict between an intern who matches his wits with a senior staff physician. An elderly female patient,  Grand Matron of High Society celebrated and featured frequently in the local newspaper for her galas that raised enormous amounts of money for charity was admitted to his service. The private physician caring for her was primarily known for a practice that catered to the social set and had a priggish and overbearing manner. Ivan, the admitting intern evaluated his patient that day. I've forgotten the name of the attending physician, but I'll call him the Prince for the sake of the story. In many ways, he was the complete opposite of Ivan, but both had comparable huge egos. The patient had difficulty walking, falling several times as though experiencing multiple small strokes due to the hardening of the brain's arteries. Ivan did his usual thorough evaluation and entered his findings in the hospital chart along with a concise differential diagnosis listing three possible disorders. He ordered the laboratory work and some X-ray examinations that evening.

 The Prince came in during the evening to check on his patient and review her hospital chart. He quickly excused himself from the patient's room and ran to the doctor's conference room, searching for Ivan. Ivan was not on call that night and wasn't in the hospital. The Prince became ballistic, ripping out Ivan's examination report from the chart, and immediately phoned the medical director who was in his office. With the written findings in his hand, he rushed into the director's office to show him what Ivan had written. The director carefully reviewed the two-page report and asked the Prince if there was a problem. The physician flustered stammered,  "Do you see what the first diagnosis is!" The director's answered yes, adding that Ivan's examination was consistent with the diagnosis. In an imperious tone, the physician exclaimed that it was impossible since the patient was a pillar of society and a spinster who had never married. The diagnosis, which hadn't been confirmed as yet by any tests, would ruin her if it became known, he shouted. The director telephoned Ivan and told him to come in and rewrite his examination and list his initial diagnosis as the last one in his list of probable diseases. He warned Ivan that with suspicion of a sensitive diagnosis, he had to notify the admitting physician of the findings before writing his report for hospital rounds in the morning.

 The following morning everyone was waiting for the fireworks to start when rounds began as Ivan and the Prince met to examine the patient. Ivan had stopped by the lab to obtain results of the blood work drawn the night before. The confrontation began with a brawl in the hallway before they examined the patient. Both were quickly escorted to the conference room to avoid the battle overflowing into the patient's rooms. The Prince told Ivan that his insensitive diagnosis of a dreaded social disease was inappropriate for this sweet old lady whose only problem consisted of trouble walking. He added that only an arrogant moron who enjoyed grandstanding would use an outlandish diagnosis before knowing the test results. At that point, Ivan quietly withdrew the lab reports from his pocket and showed him the positive screening test for syphilis. The Prince raised his eyebrows in shock, stating the test was wrong, a false-positive. It was unbelievable to him that his elderly patient had an advanced stage of syphilis; neurosyphilis. Follow-up tests confirmed the diagnosis, and a further history revealed that she had been sexually active in her youth. Neurosyphilis usually develops decades after the initial exposure. It can result from a failure to diagnose syphilis at an early stage or from receiving inadequate treatment for syphilis during its early stages.

I often wonder what kind of physician Ivan became. He had the temperament of a surgeon but would have been a brilliant internist. Had he maintained the skills he developed when dealing with patients and his incredible bedside manner?