PLEASE DON'T SHOOT THE INTERN

After graduating from medical school, I completed my medical training in a city hospital. I thought it would give me the best opportunity to see a wide variety of patients and the freedom to learn medicine without tagging along behind private practitioners. Many of them afraid to allow interns or residents to care for their patients. Obtaining training in a city hospital wasn't a free for all and provided more freedom to get hands-on experience. One of my most memorable experiences was my rotation in the emergency room. The emergency department was enormous and divided into several sections that included surgical cases, acute medical patients, female and male walk-in or stretcher cases, and an obstetrics section.

One evening I was assigned to the male medical section. As usual, it was full of the sick, the not so ill, and those with imagined illnesses. The patients were minimally screened for the severity of ailment by the admitting personnel consisting of a receptionist, and orderly, who was busy transporting patients. The service was overrun with patients 24/7. My dull gray room was packed that night with patients who sat on uncomfortable metal chairs lined up against the far wall awaiting an examination. The examining area on the opposite wall consisted of a stretcher, sink, and desk, separated by a drawn curtain separating me from the waiting patients. When a patient is called to be examined, everyone moves to the next vacated seat. It was musical chairs without the music.

After examining a patient, I'd pull the curtain open and look around the room before calling for the next victim. I quickly noticed an elderly gentleman who, by comparison, appeared relatively well dressed, with a shirt, tie, and clean, pressed pants. He was seated at least 10 chairs away from the launching chair and sat there quietly with his eyeglasses fogged up and forehead covered with beads of sweat. I walked over and, without saying a word, placed my hand on his forehead. He was burning with fever, and I helped him walk to the examining area. I shut the curtain and asked him to undress. While questioning him about his illness, the curtain was yanked open. A not-so-well-dressed man appeared demanding an examination.

I explained that the sick old guy sitting on the exam table had looked like he was ready to pass out and required my attention before of all the other patients. The not so well -dressed man said he was there before the older gentleman and I should have examined him first. I told him to wait until I finished with the elderly man, and I would then be happy to see him. At that point, he put his hand in his pocket and pulled out a small revolver, pointing it at me. He coldly stated that he would kill me if I didn't do what he said. In my panicked state, I thought about the time and energy it took to arrive at that point in my brief medical career that would be wasted if soon over. Collecting my senses and all the courage I could muster, I coolly told him if he killed me, I wouldn't be able to examine him and make him feel better. Looking at me with an anguished stare, soaked with perspiration, he said that there were people in the room threatening his life. His visions advised him that I had to examine him before they killed him. It was clear that I was dealing with a psychiatric patient and pleaded with him to put the weapon away. After a long pause, he reconsidered his options and slowly handed me the revolver.

I instructed him to wait on the other side of the room and quickly drew the curtain. With trembling hands, reaching for the phone on the desk, I quietly called security for help. During the episode, the patient sitting on the stretcher sat there peaceful and unruffled with a frozen facial expression. Surprised, I concluded he hadn't passed out because of an adrenaline surge he likely experienced from observing the whole event. I then described the intruder to security so they could identify him and take him to the psychiatric unit. I handed the gun over to them, finished administering to the patient with the fever, and called for the next patient.

Happily, I haven't had any more experiences like that.

BUG CURES STROKE

During medical school, I had a clinical rotation at the old Veterans Hospital in Washington, DC, in the 1960s. It was initially a private girl's school built-in 1930 that had been converted to a Veterans Hospital after World War Two. Its structural design didn't change very much when it became a hospital. The dormitory rooms became patient rooms with minimal changes. There was no air conditioning, and in the summer, it was hot and sticky. On Friday nights, many of the week's patients were discharged, and many vacated hospital beds were available. One evening on a sweltering summer night, I was assigned a newly admitted patient to evaluate. During summer, weekends usually presented with a surge of homeless veterans in the emergency room, recovering from a week of inadequate nutrition and the overconsumption of cheap alcohol.

My patient, a middle-aged male, admitted from the ER with a stroke diagnosis, was unresponsive to verbal and physical stimuli. He lay in bed with his eyes shut, unable to give a history of his illness. He was breathing comfortably, and vital signs were normal, but his extremities were flaccid. They fell to his side when lifted and released; however, all his reflexes were brisk and healthy when checked with a reflex hammer. Writing in his chart, next to the bed adjacent to an opened window, a sudden strange fluttering sound was occurring behind me. As I stepped away, a giant brown cockroach about the size of a baseball landed on his bare abdomen. His eyes immediately opened wide. His back arched upward off the bed, seeming to levitate as he rose upwards to jump out of bed, running out the room. I ran after him shouting for him to stop so I could finish my examination, but he escaped down a stairwell, and I lost sight of him. Embarrassed, I had to report that the exam was incomplete because a roach seemed to have cured a stroke, and I lost the patient. Later that evening, the intern informed me that security had found him and instructed me to finish my examination. He hadn't had a stroke, but he remained a guest of the hospital over the weekend. Admitting the homeless on weekends to feed, bathe, and dry them out (detox) was a service to the community and a way to keep medical students on their toes. I doubt that there are any therapeutic roaches curing strokes these days in our modern VA system.

Lucy in the Sky without Diamonds

At the time of my medical residency training in the 1960s, a tumultuous period in America, "Make Love, not War" was the mantra permeating the "Flower Children" culture. Like the beat generation before them, they desperately tried to break away from the conservative standards that this country sanctioned. I had minimal exposure to the Flower Children's period since I was studying medicine. The exceptional music of that era of Bob Dylan, The Beatles, Jim Hendrix and others captured that period's ethos for everyone's enjoyment, including mine.

I remember attending a medical meeting in San Francisco near a park occupied by the Flower Children. They dressed colorfully in various outfits in loud and dazzling colors. Disorganized and non-intrusive, making no loud noises or booming music and generally no hoopla, they appeared peaceful and non-threatening. Their generation preferred to demonstrate their independence with colorful clothing, hairstyles of different colors, music, and drugs. Devotees of powerful drugs producing psychedelic effects and hallucinations transported them away from the chaos created by their elders. 

This story is about their premier drug, LSD, lysergic acid diethylamide. Unlike heroin that dulled the prior generation's senses, it produced a heightened feeling of being alive with the ability to communicate with an imaginary world of visions, almost spiritual. The familiar anti-anxiety drugs used by the general population had evolved from Miltown in the 1950s, followed by Librium in the 1960s, then Valium, and the current flavor of the decade, Xanax. The Flower Children were not the only disciples of psychic altering drugs.

One memorable day during medical rounds, I learned a medical student was a patient on our medical service admitted the previous evening. Rumor had it that he had achieved the highest or one of the best scores on the MCAT (medical college admission test). He had graduated from Harvard and was a follower of Timothy Leary, the infamous proponent of the wonderous drug LSD that claimed to produce many beneficial psychological effects. That evening, the emergency unit admitted him with labyrinthitis, a diagnosis of an imbalance of the middle ear causing dizziness or vertigo. Neither Jim nor I had seen him when admitted to the unit since we were not on duty that night. The new patient was in the first bed of a large open ward of male patients on the hospital's seventh floor. The bed was close to the nurse's station so they could carefully observe him. Jim had examined him earlier that morning before rounds and was puzzled by the admission diagnosis. Admitting a patient with that disorder to a hospital dealing with life-threatening illnesses is unusual. The emergency room discharges a patient home with this diagnosis and usually treats them with a handful of seasickness tablets.

Another thing that confounded Jim was that his physical examination was negative. There were no physical signs to suggest the diagnosis of a middle ear imbalance. Jim also remarked that his patient, who I will call Jack for this story, presented with a strange affect. He did not speak or answer questions and required restrains to keep him in bed. Restraints should not have been necessary for someone with the diagnosis unless the patient was confused, which does not usually occur with middle ear imbalances in young patients. The constraints allowed some movement while keeping him in bed and were needed to prevent a confused, dizzy medical student from falling out of bed. 

After completing rounds, I usually examined new patients to allow more time to take a history and perform a physical examination.

Jim and I were examining the fourth or fifth patient in the ward when we heard a loud commotion from the first bed. Jack had taken off the restraints, jumped over the bed rails, and headed to the nearest stairwell. I told Jim to take the fastest route to the ground floor and block Jack's exit from the hospital. Jim was a muscular fellow with a physique resembling that of a football tackle. Our patient was a tall, gaunt guy who did not appear menacing. I followed my patient, who had had a head start to the stairway, where I could see him on the fourth-floor landing looking down at Jim, who amazingly had reached the ground floor. I yelled at Jack to return to bed and reassured him that we would not harm him. There was no answer as he moved out of sight. All I heard were clanking noises sounding like metal pots banging together, produced by empty green oxygen tanks stored on the stairwell landing. It soon became apparent that Jack was dragging an empty tank along the railing. The metal tanks were about 4 to 5 feet in height and heavy even when empty. Jack was attempting to lift a green tank over the stairwell railing and hurl it down at Jim. I yelled to Jim to get away from the stairway and call security.

 Security did rescue Jack and placed him in a locked psychiatric ward on the hospital grounds. The following day, a mental hospital in the city, not affiliated with our hospital or medical school, accepted him as a patient. A few days later, I heard that they had discharged him after three days of observation. I wasn't expecting to hear more about Jack. A few days following his release from the psychiatric hospital, I found the staff huddled together, looking down at something on an empty bed. As I approached, I asked what was happening, and they held up a newspaper with the first-page headline reading in large bold print, LSD killer. Following his discharge from the other hospital, Jack returned home and killed his mother in law. From what I recall, it was a gruesome murder in which he stabbed her more than one hundred times. 

 Following the murder, the news buzz was that he was a chronic LSD user and continued using it up to the day of his hospitalization. Was it all a bad trip (a term used to describe the opposite of a high) that made him kill his mother-in-law? This "Flower Child" drug could make you do terrible things and not just make love. For several months, there were various theories bandied about by a generally uninformed public. The final verdict was a brilliant young man with a paranoid psychosis could get high grades on tests while high from drugs. However, a twisted psyche prevented him from becoming a doctor.

 Unfortunately, there were no tests at the time screening for severe psychiatric disorders in medical school applicants. Passing the MCAT test provides essential information about one's intellect but nothing about their personality or psyche. The problem is that there is no simple window into a person's mind or soul to determine the required mental stability to become a doctor. That said, how can we predict a physician's bedside manner?

 

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.

Medicine in Black and White with shades of Grey

While in medical school, I sat next to a student named Frank during histology class. He became one of my closest friends. Histology is the study of the microscopic appearance of healthy human tissues. Each student had a microscope and a histology text with color illustrations of the tissue sections that he or she used as a referenced to identify the slides under the microscopic. One day the professor was explaining in great detail, a description of microscopic cells on a page from the text that had softer color tones than those appearing on the slide viewed with the microscope. Frank leaned to me and asked me to point out the color that was being described. I thought this was strange since it was apparent from the picture in the book. I looked at the slide in his microscope to see if he was comparing the correct slide to the one described in the book. Everything looked right, and I asked him what his problem was. He told me in a hushed voice that he was color blind and had to learn the different colors in shades of grey. As a 2nd year medical student without clinical experience, I didn't give it a second thought and was totally oblivious of potential problems, if any, for a color-blind doctor.

Many years went by, and I had lost contact with Frank while we completed our internships, residencies, and military service in different locations. While I was in practice in Florida, I learned he was practicing in Los Angeles, and we resumed our friendship. I then discovered he had become an up and coming plastic surgeon who catered to a Hollywood clientele. I was flabbergasted. When I had the opportunity to see him in person during a car trip to LA with my wife and kids, I questioned him about his color blindness. Specifically, how he was able to perform surgery without being able to see the color of tissues he operated on, like the arteries, veins, and nerves. He calmly told me it was no different than driving a car and being able to tell a red from a green or yellow traffic light. He became a very successful plastic surgeon despite his color blindness and was a great surgeon and friend.

I guess the lesson I learned was that we need to look beyond color to be successful in life and what others consider impediments can be overcome successfully. I received an email that quotes a Ben Herbster, which sums it up better than I can. He stated, "The greatest waste in the world is the difference between what we are and what we could become."

Introduction

Patients often discuss the accomplishments of their doctors. A critical qualification always includes the physician's "Bedside Manner". When selecting a doctor it is often a deal maker or breaker. Medical schools have more recently implemented training for providing a caring demeanor when attending to patients. Molding a physician's character, however, may take years of experience. The incidents that a doctor responds can be light or severe, humorous or life changing. This blog chronicles some of the early experiences in the life of this physician as a medical student and practitioner. If these stories spark some interest, provide a comment on a visit you've had with a physician that revealed an exceptionally good or bad beside manner. The true name or title of an individual or health care facility cannot be printed if used in a comment and the comment will not be printed