Excerpts from Musings of a Medical Dinosaur
On my sixth birthday I became very annoying. You know how most six-year-olds continue to ask “Why?” no matter how many successive answers you give them? Well, I did that to an extreme. I always wanted to dig deeper.
I am now nearing my sixtieth birthday, and things haven’t improved. In fact, they may have gotten worse. I don’t want to be annoying just for the sake of being annoying (well, maybe once in a while). It just turns out that getting to the bottom of things can make people irritable.
I used to feel badly about this until I read that all great truths contain paradox, and I think this is what makes people feel unsettled.
For example, as most people know, a great truth of life is that it involves pain. Pain is nature’s way of warning an organism that its survival is in question, and living things are programmed for survival. So, all living things work to avoid pain. On the other hand, we humans come to realize that in situations involving pain (physical or emotional), we often grow the most. Losing weight to improve our health is painful; breaking up with someone when we are in an unsatisfying relationship hurts. So the paradox is that although we are programmed to avoid pain, we accept that this thing we are supposed to avoid can help us. Weird, eh?
So, you see, in writing this book, I want to make you feel uncomfortable. Because when we feel uncomfortable, we know that we are dealing with stuff that both matters to us and challenges us. We are delving into the great truths, into the heart of paradox. And that discomfort and challenge tells us that we are attempting to grow.
On the surface, this book is about the practice of medicine from the perspective of a family doctor who has been doing his shtick for about thirty-five years. In this day of such rapid changes, thirty-five years makes me a dinosaur. Personality-wise and physique-wise, I see myself more as a brontosaurus than a tyrannosaurus or velociraptor, hence the book cover. I am large and plodding and am working on becoming a vegetarian.
I have been, more through good luck than management, fairly healthy, so I can speak more from one side of the stethoscope than the other. This is most fortunate for me because I am quite a wimp. However, at times I have been a patient, and I will share that experience as well.
On a deeper level, this is a simple man’s struggle to make sense of nearly sixty years of life and thirty-five years of sharing patients’ journeys. Something along the lines of Søren Kierkegaard’s words that ”Life can only be understood backwards; but it must be lived forwards.”
But be warned, as a family doctor I am an expert in nothing, and I like it that way. In fact, I never want to be an expert. I am a generalist, and that is both my greatest strength and greatest weakness. Paradox, you say?
That is why I called this book “musings,” not ”treatise.” I will be thinking out loud, not offering a definitive tome. When I offer answers, they invariably will lead to more questions. Annoying, yes; blame the six-year-old still inside of me. But those questions will be at a higher level than the answers, so I trust it will be worthwhile.
So what am I going to muse about?
One of the many things I wanted to understand when I was six years old was how I “worked.” What was going on inside of me? That’s probably what drew me to medicine. I enjoyed medical school for that very reason—I was finally learning about the human organism, and it was fascinating.
In 1985, I completed a three-year residency in family medicine that included extra obstetrical training, six months of anaesthesia, and three months of work in an intensive care unit (ICU). My first years of medical practice were filled with interactions with patients in which I could apply my training, and much of it was technical in nature, such as giving anaesthetics and caring for patients in a small ICU.
I assisted at hundreds of births, witnessed the deaths of a number of patients, and shared everything in between. It was busy and stressful, and I loved it!
But slowly over time I realized that my career felt incomplete. Like a scientist studying lab subjects, I had come to understand the human organism pretty well. I felt comfortable with all aspects of the human body, even ones that made most people feel uncomfortable or squeamish. But I wasn’t sure that I understood human beings nearly so well. I was confused; we appeared to be living paradoxes.
Each of us, myself included, seemed regularly to plumb both the heights of altruism and the depths of narcissism, inspire with stunning insights amid surprising naïveté, and occasionally make leaps of maturity in a setting of nearly unrelenting stubbornness.
So, after years of thinking that I was done studying “us,” I started over again and explored the human species from a different perspective, this time trying to figure out what made us tick.
I have shared with thousands of patients the births and deaths, joys and tragedies, and hope and despair that define our lives. In doing so, I have both observed and wondered, and my musings revolve around three questions:
1) If we understood ourselves better, could our lives be better?
2) If we understood ourselves better, could our world be better?
3) If we understood better how we got to where we are now, might it provide insight as to where we go from here?
In seeking answers, I have read from a wide variety of sources. When sharing this wisdom with you in this book, I often forget where I heard or read it. If I remember, I tell you; I don’t want to take credit for someone else’s work or ideas. My sincerest apologies to those I don’t identify; I can assure you that memory, not malice, is the culprit (I am, after all, an old brontosaurus).
Also note that I have changed the names and some characteristics of the people featured in the stories I tell, in order to maintain confidentiality, without compromising the essence of their teachings.
One of the important themes in this book is the concept of “having enough.” In keeping with this theme, since I have enough money, all profits from this book are being donated. Because addictions are conditions in which an individual can’t seem to get enough, I am offering the profits to addiction centres to assist individuals in obtaining treatment.
I appreciate you reading this book. Thank you. I hope some day we can share our thoughts and grow together.
Incontinence: (noun) the inability to maintain control; (medically) the inability to contain bodily waste; involuntary urination or defecation
Incontinence may seem a pretty odd title for the opening chapter of a book, and you are right. But there is a method to my madness, so hang in there.
In the first months of life, we are all incontinent, and in the absence of disease or illness, we gradually mature to continence and maintain a measure of control over our urine and bowels for the rest of our lives. Unfortunately, a wide array of illnesses and conditions can sometimes play havoc with this desired state of affairs, even if only transiently.
Now, it’s time for us to be honest with each other, okay? Tell me, since childhood, have you ever been incontinent? I am a doctor, sworn to confidentiality, so I promise I won’t tell a living soul. Well?
Specifically, have you ever been incontinent of stool? You know, had a poop at a time or place when you are not supposed to have a poop, all without expecting it? Maybe you picked up some bug while holidaying in Mexico and then rolled over in bed or strained to pick up your luggage and, oops, stuff happened?
Or maybe you have just had a really scary experience where you pooped yourself?
If you are too embarrassed to admit to it, I understand. Well, I had an episode at work where I came as close to incontinence as you can get without actually being incontinent.
I know I am not alone in this regard. I am sure many of you have had these near misses, even though you may not care to remember or share your story with me.
Most of us practising any acute-care medicine have had at least one of these experiences. In pseudotechnical jargon, we refer to what bails us out from experiencing the humiliation of a full-blown, five-alarm loss of bowel control as “sphincter tetany.” That is, the muscles that constitute the “last line of defence” in our anus go into hyperdrive and save us from impending disaster.
So if you won’t tell me about your brush with the unmentionable, I will.
As I mentioned in my preface, in my early career I was very interested in the biomechanical aspects of the human body and disease, which is why I was attracted to doing general practitioner (GP) anaesthesia. As a family doctor (a.k.a. GP), I had taken nine months of extra training—six of anaesthesia and three of the intensive care unit (ICU)—in order to be pronounced competent to provide anaesthetics for people undergoing surgeries. So I worked part time as a family doctor seeing patients in my office and part time as a GP anaesthetist.
I was trained to give basic anaesthetics to low-risk patients undergoing low-risk surgery. Full-time anaesthetists are board-certified as specialists who train for five years or more and are capable of providing anaesthesia to more complex patients having more complicated surgeries. I do the low-risk work, and the big shots do the high-risk cases, or at least that’s the theory.
The problem is, high-risk situations sometimes pop up suddenly and unexpectedly, and it may simply be impossible to have a full-fledged anaesthetist available. So, occasionally, we GP anaesthetists have to do our best in situations beyond our control and at the limit of, or beyond, our comfort or expertise. There is a certain adrenaline rush involved in that, and perhaps that is what draws us to it. Adrenaline, of course, cuts two ways.
Many years ago I was on call when a cute six-year-old boy was brought by his parents to the emergency department of our rural hospital. He was suffering from a sore throat and had trouble breathing. There is a long list of causes (referred to as the “differential diagnosis”) of a child at this age having trouble breathing, and some can be quite serious. The emerg (emergency) doctor had called in our local otolaryngologist (ear, nose and throat specialist), a good friend of mine, and he in turn called me in to help out.
It was obvious that this child needed to have some help with his airway because he was struggling to breathe and was not improving. Based on the story his parents had provided and the examination of the young lad, the differential diagnosis included two serious possibilities: epiglottitis and bacterial tracheitis. Both are serious infections that cause swelling and secretions to block the airway, either at the level of the epiglottis, just above the larynx (or voice box), or at the level of the trachea, the large cartilaginous tube below the larynx leading directly to the lungs.
It is important in these situations, when the child is quite sick and scared, to proceed very cautiously because upsetting the child can suddenly make his breathing much worse, to the point of complete obstruction, and that is bad news. Needless to say, time did not permit us the luxury of transferring the child in an ambulance hurdling down a bumpy highway to an urban hospital where specialist anaesthetists were available. In this particular circumstance, as one of a handful of GP anaesthetists at our hospital, I was part of a small cadre of people who were the best our hospital could offer to this child and his family.
As a resident, I had seen one case of epiglottitis and had been hand-held through the process of securing the child’s airway in the safest haven of the hospital for performing such a feat—the operating room. That particular case, five years earlier, had gone well. In my second year of practice, I saw my second epiglottitis and managed it as an independent physician, not as a resident with a staff person overseeing my work, prepared to bail me out if I screwed up. That case, too, went well.
So I was feeling scared but confident that I could handle the challenge, particularly because my good friend, the otolaryngologist, would be there to perform an emergency tracheotomy if I could not intubate (place a plastic tube through the mouth into the trachea) the child to secure his airway.
Everything went very well, initially. We took the child to the operating room and very gingerly began to anaesthetize him in order to insert the airway-preserving endotracheal tube. When the child was sufficiently “deep,” in other words, well anaesthetized, I looked down his throat with a laryngoscope, and the diagnosis was clear: bacterial tracheitis. After aspirating the copious secretions that had been making his breathing so laborious, I inserted the endotracheal tube relatively easily and stabilized it so that it would not become dislodged. With the diagnosis confirmed and airway secure, we could now safely transfer him to a specialized children’s hospital, which would continue the treatment and assure complete recovery. The worst was over, or so I thought.
The plan was for me to fly down with the patient by helicopter to that facility, but of course, it takes time to make all of the arrangements and have the chopper come to our hospital. We had an adult ICU, but no paediatric ICU. We simply did not have the volume of patients nor staff at a small rural hospital to maintain one. No problem. The helicopter team would be there within an hour, and we could certainly manage to take care of the little lad until they arrived as he was now safe and stable.
Unfortunately, at six years of age, a child’s airway is not that large, nor is the endotracheal tube we put into the trachea. The young boy continued to produce copious secretions, and eventually it became more difficult for him to breathe again. He became restless and was “bucking the tube,” clearly struggling. I used an Ambu bag (a compressible bag attached to a tube or mask to blow air into the lungs) to help him breathe, but it was necessary to frequently suction the secretions to keep the tube patent. Eventually, though, the thick secretions began to take their toll, and it became very difficult to maintain his breathing comfortably.
I knew that I would need to replace the tube. He was still asleep from the anaesthetic, but not enough to change the tube because that is very irritating for the patient. Our airways have some of the most sensitive nerves in our body; it’s nature’s way of keeping our airways open, by getting very upset if anything gets in the way. If we don’t keep them open, we can die very quickly. Even the smallest bit of unwanted material will make us cough and hack uncontrollably for that reason, as any of us who have had a postnasal drip will testify.
It is said that the art of anaesthesia is 95 percent boredom and 5 percent panic. That may be a bit of an exaggeration, but it hammers home the point that bad things can happen in a hurry when you are dealing with airways, so preparation is critical. You learn to have a carefully crafted routine that provides the tools to deal with whatever is thrown at you. You always do it the same way, and you check and double check. You leave yourself margin, and you make sure that you have extra amounts of everything, just in case. Your routine gives you confidence and comfort. Naturally, losing that routine can throw you off.
I had already brought lots of equipment with me when we moved from the operating room to the ICU, in case something went wrong during the transport. So I was well prepared to change the tube in the ICU; everything I had had in the operating room was with me still, including a large selection of different-sized endotracheal tubes (you never know exactly what size tube you will need until you get in there).
I set up as I usually did and proceeded to give the child intravenous medications, both to paralyze him and keep him unconscious enough to intubate him and keep him comfortable until the helicopter team arrived. I would then breathe for him with his new secured airway using the Ambu bag.
As he drifted into a deeper sleep, breathing for him with the Ambu bag became a little easier, but I knew I still had to replace the tube. So I calmly placed the laryngoscope in his mouth with my left hand, and with my right hand removed the mucous-filled tube, suctioned the remaining secretions in his throat, and then reached for one of the new endotracheal tubes I had placed on my right side two minutes earlier.
But when I reached for one of the tubes, there was nothing there. The child was incapable of breathing for himself, given the drugs I had administered, and all of my tubes had vanished!
Even as I type the details of this story twenty-five years later, I can feel twinges of the terror I felt. It was horrible. My safe, dependable routine was disrupted, and I wanted to run and hide or just disappear into thin air. I wanted to be anywhere but there. I experienced an intense nausea and a nearly overwhelming sense of foreboding. That’s as close as I ever came to incontinence (and believe me, it was close), and I never want to get that close again.
Fortunately for me, my friend the otolaryngologist, himself shaken, pulled me back from the brink, reminding me that I could probably use the Ambu bag and just a mask, without the tube, at least long enough until someone could find some paediatric endotracheal tubes (there were none normally in the adult ICU, and the operating room was two floors down). After all, I had cleared the secretions, and the swollen airway would not collapse down immediately, having been stented by the first tube during the previous hour.
Fortunately, the boy’s airway retained its patency. I used the Ambu bag and mask until some new tubes magically reappeared. Then I successfully reintubated the still-paralyzed and unconscious little boy.
As I taped that new endotracheal tube solidly in place, my thoughts and fears, including my sphincter tone, gradually returned to a more tolerable, near-normal level. The team arrived, and we transferred over to the chopper and had an uneventful flight to the paediatric hospital and its ICU. By the time I made it back to home base, it was around two in the morning.
So, what had happened to the original extra tubes I had brought up to the ICU, the ones with which I was going to do the second intubation? Was I not as well prepared as I thought I was?
Well, in fact, I had done my usual preparation, but it turns out that before I realized that I would have to change the original tube, the staff had suggested that we have the parents come up and see their son. We had already told them that the initial operating room proceedings had gone well, so we thought it important for them to see their son now that things were stable.
However, after many of these challenging cases, things often get a little messy with tape and sheets and other stuff strewn all over. The staff had simply thought that a little tidying up would be in order before the parents came into the room, and that included getting rid of my extra endotracheal tubes just before I was forced to do the second intubation. Oops!
No one ever admitted to taking them from where I had placed them. And I have no idea how long it was before they were returned to me; it seemed like years but was likely only a minute or two. The child was unaware of it and suffered no ill effects. My nerves seemed to have been the only casualty.
It would be easy to blame the staff for what happened, but this was a rare situation for them—an intubated child in an adult ICU.
But more than that, the hard lesson was that, ultimately, it was my responsibility. I had made the decision to change the tube, I had given the medications, and I had taken the tube out. The buck had to stop with me, the doctor, as terrifying as that may be.
I never told the parents what had transpired during that second intubation. In part, I felt that they had had enough worry for one night. Their child was going to be fine (and he was), and the miscue, although it could have been lethal, caused no harm to anyone but me. But of course, in part, I didn’t tell them because I really didn’t know how to articulate to them that I had almost killed their child!
After I had arrived back at our hospital around one in the morning, I returned all of the equipment I had taken with me for the flight. I was physically tired and mentally drained. I prayed that there would be no more pager calls for me for the rest of the night. As I walked out to my car in the emerg parking lot, something very strange happened.
Initially, I felt a sense of contentment. I had ultimately done a good job, rebounding, with the help of my friend, from a near catastrophe. A “that which does not destroy you makes you stronger” kind of moment.
But then I felt a profound weakness. There was a deep fatigue, of course, but it was more than that. Reviewing the case, as I usually did after a challenging one, I wondered what I would have done if the tubes had not been found in time. What if his airway had become blocked? The otolaryngologist would have had to do an emergency tracheotomy, a challenge at any time, but particularly on such a small airway in an adult ICU with staff who likely had never seen one (nor had I!).
That’s when it really struck me: the child could have died, and I would have had to explain to his shocked and grieving parents that it was my fault.
I knew that if it had happened, I would have manned up; that wasn’t the problem. The problem was, I was now heading home to see my two children and pregnant wife. How, had I killed this couple’s only child, could I simply have gone home, kissed my children snuggled asleep in their beds, nuzzled up beside my wife, and carried on with my usual life?
That’s when the profound weakness hit me. I staggered toward my car, collapsing onto the concrete curb before getting there. Sitting there, heart pounding and nauseated, I realized that had that child died because of me—if it had been my fault—I wouldn’t have been able to live with myself. Had the little boy not been allowed to see his family again, I would have made sure that I would not allow myself to see my family again either.
Despite the drama of the story I related to you in the first chapter, there really was nothing unduly complicated about what I did. Anyone with reasonable dexterity and enough training can learn to intubate; I did!
After all, a laryngoscope is a pretty simple device. It has a handle with an articulated flange, in which is embedded a light source to allow for visibility in the back part of the throat, the laryngopharynx. There aren’t a lot of buttons or switches; it has only one function.
There are times when other factors involved in preparing a patient for intubation, in terms of the status of their heart and lungs, as well as head and neck issues, can make it significantly more challenging and, hence, nerve-racking. But the process of intubation itself is usually not tremendously difficult. When you look down with a laryngoscope, there are only two holes to put the tube in: the larynx leading to the trachea, where you want the tube to go, and the esophagus, the tube our food goes down, where you don’t want the tube to go.
Occasionally, someone’s anatomy can make intubation very difficult. There was one patient I simply could not intubate. I could not see his larynx leading to his trachea, and all attempts to intubate him blindly failed. For the elective surgery he was undergoing, I had the option of simply using a bag and mask for the anaesthetic delivery, which I did without incident.
But when you must get a tube down to obtain or secure an airway and can’t, it is a terrifying experience. As with the little boy in the last chapter, the only option remaining to prevent asphyxiation is a tracheotomy: making an artificial opening through the front part of the neck into the trachea directly and inserting an artificial airway into it. This procedure is technically challenging at the best of times. But when done as an unexpected emergency, where the time constraint is mere minutes before brain damage begins, less than perfection can be catastrophic for the patient.
This brings me to an important insight: a lot of medicine is in our mind. It is all about how we perceive reality. By that I mean, what makes medicine very different from a lot of things we do in our lives is what hangs in the balance: someone else’s life. It’s not so much that it is complicated but that the stakes are high.
We like to think that what we do is incredibly complex, requiring a phenomenal IQ and extraordinary technical skills. It seldom requires either. I am quite sure that any seamstress or experienced knitter could technically do very well in the operating room. I suspect that excellent mechanics would also make excellent orthopedic surgeons. A wise and thoughtful hairdresser, who often listens to people’s sad stories supportively, with the right training, could become a reasonable psychiatrist. The crucial differences, of course, are that you are sewing the flesh of another living human being, not cloth; or operating on a machine that is always living and you can’t turn off while you manufacture new parts; or the person you are counselling may commit suicide, and you will be held accountable.
True, there is a lot to learn about the human organism, and for that you need a reasonable intellect and memory. Like any field of study, a passion for the work is important too. But I seriously don’t think you need to be a genius or a sleight-of-hand artist, or anything close to it, to train as a medical practitioner.
Certainly, the admissions process to medical school requires stellar academic performance, proof through references that you are a reasonably functioning and civil person, some evidence that you have at least a modicum of social and nonacademic skills and are not just an accomplished bookworm, and life experience that indicates interest in aiding humanity.
But it may come as quite a shock to most of you that when we are screened for entry into medical school, or residency, we are not screened at all for any physical aptitudes. Our hearing is not evaluated to determine that we can differentiate the midsystolic murmur of aortic stenosis from the pansystolic murmur of a ventricular septal defect. Our vision is not assessed to confirm that we can distinguish a benign from a malignant mole. Our touch sensation is not tested to assure that we can detect a worrisome nodule on a prostate. Like everyone else, it is simply assumed that if we do something often enough, we’ll get better at it.
Nor is our ability to handle stress screened. I am not even sure if or how one could be screened for stress-management capability since the stress of dealing with someone else’s life is hard to approximate, and few life experiences a twenty-two-year-old would have had can provide much insight in this regard.
However, once you are in medical school, the mystique begins. You are now part of the tribe, that valiant group of very special people who devote their lives unwaveringly to the enhancement of human life. You can deal with misery and misfortune, blood and guts, and do it all on little sleep and still keep smiling. Well, at least that’s the persona we are encouraged to adopt as members of the medical tribe.
I once led a hands-on seminar for some first-year medical students dealing with injections, suturing, and other minor technical procedures. They were excited but also very nervous. I began by showing them a photo on a large screen of a narrow, winding road going up the side of a mountain. There were no guardrails on this road, which meant that a moment of inattention might result in one toppling over the edge to a near-certain death hundreds of metres below. Oohs and aahs filled the room.
I then asked them why they should feel any different driving on a road at ninety kilometres per hour, where all that separated them from the people going in the opposite direction at the same speed was a single yellow line. Surely, a very similar moment of inattention, crossing the yellow line and colliding at essentially 180 km/hour with an eighteen-wheeler, would leave you as dead as the fall off the cliff?
The light went on for them. It’s all how your mind interprets it. The same is true of the practice of medicine. Injecting a human with a syringe and injecting an orange are different, not so much in the technical or intellectual aspects but in the psychological aspect. The same holds true for the seamstress and the surgeon, the mechanic and the orthopod (orthopaedic surgeon), and the hairdresser and the psychiatrist.
I frequently think back to a most amazing man I met during medical school. His name was Harry Whittaker, and when I knew him, he was in his sixties and had been working as a laboratory technician for almost fifty years. In his teens, he had begun his career by taking care of the microscopes in the histology laboratory (histology is microscopic anatomy, as opposed to gross anatomy, which is the anatomy we can see with the unaided eye). I doubt that he even had a grade ten education; people in those days seldom did.
Over the years, as part of his job, he attended all of the histology lectures that all of the medical students attended. Despite his lack of formal education, he was quite a clever fellow, so, not surprisingly, he learned a lot about histology.
He was perhaps the most humble man I have ever met. He was always smiling as he shuffled around the classroom in his white lab coat, offering assistance and gentle encouragement to us like a mother hen tending to her chicks.
During medical school, at the end of each formal histology lecture, our learned professor would leave the room. Then the real teaching began—by Harry. In a simple and folksy style, he explained to us what was going on in the slides, how to recognize what we were looking at (stacks of Big Macs were red blood cells, for example), and how to make sense of it all. If it weren’t for Harry, many of us would have had a much harder time passing the histology exam.
The first thing to learn from this is that anybody, in my opinion, given enough interest, time, and support, can learn to do most things to some degree. Do something often enough with a little coaching and you will get better at it, perhaps even quite proficient. Maybe not to the point of being well paid for it, but enough to enjoy it and be helpful to others.
The second thing learned from Harry is what he used to say to us around exam time. He would profess his perpetual amusement that nearly every medical student ran around frantically at exam time, moaning like Chicken Little that they would never pass and become a doctor one day. Perhaps to reassure us, but I suspect more likely in an attempt to keep us humble, he would remind us that despite our angst, the day would arrive when we would receive our diplomas and be called “doctor.” And on that day, everything would change. Magically, not only would we be doctors, but now we would also know how to fix fridges, invest wisely, have great political insights, and more. People would seek our counsel on no end of topics, because, after all, we were doctors.
I got his tongue-in-cheek message, and have retained it ever since. I am not sure that all of my colleagues did. So it turns out that Dr. “Bones” McCoy on Star Trek had it right, after all: “Damn it, Jim, I’m a doctor not a _______” (I’ll let you fill in the blank).
Memorizing a pile of big textbooks about how the human body functions (and hopefully understanding them) is a wonderful achievement. But all it means is that you have memorized and understood a pile of big textbooks about how the human body works. That’s it. It doesn’t give you better fine motor skills. It doesn’t necessarily make you a morally better person, or a more mature and wiser person either. And it doesn’t necessarily mean that you understand how human beings work, including yourself.
As my first chapter illustrates, it doesn’t mean that you know how to handle real-life stress, especially life-and-death-type stress, even though you may know how to intubate. Despite the fact that everything turned out all right in the end, does my thinking process at the end of the last chapter, about what I would have done if things had not turned out all right with the little boy, mean that I shouldn’t have become a physician? That I didn’t have the right stuff?
From a purely intellectual perspective, I think medicine was a good choice for me. I have always enjoyed learning, and the sciences were a passion for me. I wanted a job that was interesting and contributed something useful to the world, made it a better place. To be honest, I am not sure what else I am suited for. Perhaps teaching. But from a nonintellectual perspective, I am not sure I am cut out to be a physician. It’s not that I doubt myself so much as I doubt whether I know what qualities one should have for being a physician. And it’s not clear to me whether anyone else knows either.
Since there seems to be no universally agreed upon, dependable screening process for determining what makes a good doctor, we often resort to using surrogate markers. In other words, we examine and measure identifiable markers in the hope that they will give us some insight into the things we really want to know about. They are, at best, just approximations.
For example, if someone can do well under the stress of exams, maybe that means they’ll be wonderful at telling a patient that they have terminal cancer?
Maybe if someone is a really good musician or athlete and has done so competitively, that means they have exceptional manual dexterity and the mental toughness to handle a difficult intubation?
Perhaps if they have a really pleasant personality, they will not succumb to the lure of greed in a profession that earns more money than most people make?
There was a time when people had little formal education, which meant that becoming a doctor was exceptional, primarily in its rarity. Today, lots of people have multiple years of postgraduate education, as physicians do. We are no longer exceptional. Many people have stressful jobs and work long hours, including blue-collar workers. Many times in winter, I have looked out from my comfortable office to see a crane operator climb ten or more floors to operate a large crane carrying many tons of materials. In her line of work, a moment of inattention could cost lives, and I have secretly hoped that she was getting paid at least as well as I am. How do they determine if crane operators have the right stuff?
I must admit that I have never been comfortable being called “doctor.” I am not entirely sure why. I think it’s because I feel that it puts a wall between the person for whom I am caring and me; that somehow I’m special and deserve a special appellation.
During residency, I struggled with this physician persona. Wearing a tie and a white lab coat and introducing myself as doctor just didn’t feel right. I was blessed to have Ernie Haynes as my staff supervisor at the time. He was a wise sage who recognized my struggle and quite literally changed my life with three simple words. He took me aside one day and said, “Barry, be yourself.”
It amazes me how compassionate interactions change us; how much we need one another. How three such simple words, offered lovingly to me, changed for the better not just how I looked at the world but, more importantly, how I looked at myself. I never got a chance to thank Ernie for saving my career. I suspect he knew, nonetheless, because he saw me grow so much afterward. I think it was then that I got my first few insights into how we humans tick.
I understand that the profession likes to be called “doctor” as a sign of respect for the hard work, knowledge, and sacrifice that comes with the career. Fair enough. But I suspect the real motivation is that it helps us put a protective wall between our patients and us. Let me explain.
Patients quite rightly want us to be kind and compassionate and sensitive to feelings, but often only to their feelings or feelings that help them. In other words, patients want us to be very sensitive and kind when dealing with them, but when our endotracheal tubes go missing and we are just about to fill our diaper, they want us to be as cold as ice. “Doctor, tell the previous patient you saw that they have terminal cancer in the most compassionate way you can, but then come into my exam room like nothing happened, and focus all of your attention on my problems, no matter how trivial by comparison.”
In other words, have a huge reservoir of compassion, but be able to turn it off and on instantly and effortlessly. Don’t let it get to you on a personal level because that might adversely affect your treatment of me. And while you are at it, don’t let your personal struggles or your own medical conditions compromise your care of me either.
I know that I am sounding, perhaps, somewhat harsh here. Many patients do care about their doctor’s feelings, and I am always very moved by that. And the truth is, when you are scared, in pain, or suffering, it’s hard to care about what the doctor is feeling at the moment, and I get that. It’s perfectly reasonable to expect your doctor’s undivided attention when you see her or him; it’s just from this side of the stethoscope, it can be very difficult.
So the paradox is, we want a sensitive and an ice-cold doctor, all in the same nicely wrapped package.
In all of my years of practice, I have never been given any time or assistance in dealing with any of the numerous stresses I have faced. I have had to resuscitate, unsuccessfully, a young man involved in a severe motor vehicle accident, share the horrible news with his family that he had died, and then go right next door to deal with someone upset because they have had to wait four hours to be seen for a sore throat.
I have been at the deaths of hundreds of patients, been sued a few times (doing high-risk work like anaesthesia and emerg makes it unavoidable), and worked for twenty-four hours straight (or more), and there has never been any acknowledgement of the emotional toll it takes nor any assistance for that. No critical incident counselling. We patients want sensitive physicians, empathetic and compassionate physicians, but on our terms.
This is why we medical people build these walls—like being called “doctor.” Benign enough, but some of the behaviours we adopt to cope with this emotional residue are not so benign. We get sidetracked by alcohol, drugs, or affairs, or by the money, the prestige, or the mystique. It’s not because doctors are bad people. It’s because doctors are people. We are not special; we are not exempt, no matter how many textbooks we memorize.
The profession tries to pretend that we are exempt, of course, by having very strict admission criteria, but none of those criteria really have much to do with the really important issue: that medicine is not so much an intellectual game or a talent game but a mind game.
I suspect that if I were to apply to medical school today, I would not be granted admission. The standards are so much higher in the sense that the profession wants to give the impression that those admitted are Übermensch—superwomen and supermen. They want to brag that they accept only individuals who have not just great academic gifts but are also exceptionally talented and successful in multitudinous ways. They have excelled in athletics or music or the arts, for example. And they have demonstrated a profound ability for caring for others by becoming involved in some humanitarian effort, often in a remote and underprivileged part of the world.
All of this sounds wonderful, except it means by definition that medicine is becoming a profession of the elite. Perhaps it always has been, to some degree, but with such expensive tuition, and the need to demonstrate proficiency in so many other aspects of life, one has to be very well off financially to develop the resume needed to prove that you have the right stuff, that you are an Übermensch.
I came from a middle-class family. We did not have the money to nurture any other talents, if I had had any. I had to find a job every summer to pay for university, any job I could get my hands on. I could not afford to travel to exotic lands and do volunteer work, as much as I might have wanted to.
But this admission process brings me back to one of my original questions. What surrogate markers are we using to identify the people we think will make the best physicians? Will such wildly talented people be able to handle the stress of life and death better? More importantly, can they relate better to their patients, most of whom are mere mortals? Do they have the compassion to care for people who are much less accomplished? Are they any less prone to the psychological foibles we are all subject to? Are they better balanced people, able to avoid the pitfalls that prestige and wealth expose us to?
As my career unfolded, I reflected upon my training and how incomplete it seemed in terms of understanding how human beings really worked—how I worked. Sure, I had gained the technical and intellectual skills to do my job, but was my mind ready for it? Had it matured enough to deal with all the stuff that lay beyond the technical and intellectual?
So I read more about philosophy and psychology; I wanted to understand better how my patients and I function at a deeper level. And I read about evolutionary neuropsychology because I needed to know more about our evolution to the pinnacle of nature’s cognitive pyramid as the species with the fullest consciousness and sentience.
The Phone Call
During the time that I was reading more about philosophy and psychology, I interacted with many patients in many different circumstances, and each time I learned a little more about our minds. Let me share with you a story about a good friend and patient of mine, Joe. His mind surprised me one day in a way I never expected, from which I learned a great deal.
I had known Joe as a patient for about eight years. He was in his midsixties. He had a great sense of humour and was very down-to-earth. He kept abreast of how my kids were doing. I considered him a good friend.
Joe’s life had not been an easy one. In the 1950s, when psychiatry was not as sophisticated as it is today, he had been admitted to psychiatric institutions several times for anxiety and depression. Back then, there were not as many effective drugs, so he had received electroconvulsive therapy (ECT). This is a brief procedure performed under general anaesthesia, during which electrical currents are passed through the skull and, hence, to the brain to trigger a brief seizure. In doing so, brain chemistry is changed, resulting in improvement in some mental illnesses such as severe depression. Joe had received at least one full course of ECT, with good results according to him.
But his journey, naturally, had left some scars. He functioned at a reasonably good level but knew that he would never be free of his anxiety completely. There was a strong history of mental illness in his family, and some traumatic life events as a youth contributed to his fragile emotional state. There would be times of relative psychic stability, but he and I both knew that he would likely never be cured.
I always looked forward to seeing Joe, but don’t get me wrong, he could frustrate me as well. Like many anxious people, he worried about his health in particular, sometimes to excess. It might not be an exaggeration to say that he was a little hypochondriacal. But the beautiful thing about Joe, which made me so fond of him, was that he recognized this in himself. This meant we could have a very honest dialogue about his health. He knew that he had a tendency to blow minor symptoms out of proportion (termed “catastrophic thinking”), so he learned over time to trust my judgment with respect to when to simply watch and wait and when to investigate further. Well, most of the time.
Every once in a while, he would get himself so worked up that no amount of rational thought on my part could settle his angst. I would be forced to relent and order some test to prove to him that nothing serious was going on.
There is always a risk involved in doing tests, in looking further. In general, in medicine, you ought to order a test very carefully, understanding the purpose of the test before you do it. In other words, you have to have some idea what you are searching for; otherwise, you’ll end up ordering the wrong test that can’t possibly answer your question. For example, an ultrasound is not the best test to look at a bone, and a plain X-ray is not the best to look at nonbony structures.
Then you have to ask yourself if there is any point in doing this test if you are not going to do anything about a legitimate result, either because you can’t or you won’t? It’s true, there are times when you won’t do anything directly about the test result, but it is still worthwhile doing. For example, if you find out that you have terminal cancer, you might not want to have a hip replacement since the recovery from such surgery might steal what little precious time you have left. But in general, it is common wisdom that you don’t do a test just for curiosity’s sake because tests can be expensive, uncomfortable, and risky.
People often forget about the risks of tests, and some tests carry more risk than others. Any time a test is invasive—that is, it involves entering into your body (e.g., scopes, X-rays, needles)—there are risks.
There is always the risk that a test result comes back and you are not sure of its significance. There is something abnormal, but does it mean anything? Does it really relate to the patient’s symptoms, or is it a red herring, an “incidentaloma” as we like to call it?
There is also the risk of the false-positive result. In other words, because no test is ever 100 percent accurate, sometimes a test says that you have something wrong, and it turns out on final analysis that you don’t. That means that you have taken the risk of the initial test for no benefit; but worse still, in order to prove that the test was a false positive, you have to undergo further tests, all of which may be painful, anxiety-provoking, and risky as well.
Now getting back to Joe, he had been having some vague abdominal discomfort, and on the first visit, I reassured him that there appeared to be nothing seriously wrong and that the best thing to do was to monitor the situation for a little while. I explained to him that there were no red flags, worrisome signs, or symptoms, but if such arose, then to come back to see me.
None arose, but Joe worried nonetheless. He was noticeably more anxious on the second visit, and although nothing clinically had changed, I realized that he would only be reassured if I ran some appropriate blood tests.
The tests, of course, came back normal, but on the follow-up visit, his third visit about the discomfort, Joe was not reassured. I have always made it a rule not to take a patient’s intuition lightly, so even though I was convinced that there was nothing wrong, I relented and ordered an abdominal ultrasound. Just like everybody else, I can make mistakes, and it’s easy to be dismissive of someone’s symptoms just because they have worried excessively in the past for no justifiable reason. The truth is that even the most hypochondriacal patient eventually dies.
The result, unfortunately, came back abnormal. The difficulty was that the radiologist, understandably, could not be sure what the exact problem was or if there was one at all. What the radiologist had seen was a mass somewhere around the head of the pancreas. The pancreas, which is the organ deep in the abdomen responsible for producing both digestive enzymes and insulin, is so far back in the abdomen that it can be hard to see in detail, particularly if the patient is at all chubby, which Joe was. (Radiologists euphemistically state that the accuracy of the report is limited by the patient’s body habitus—“yellow muscle” the surgeons call it.)
The worry was that this could be pancreatic cancer—a disease that often has no symptoms until it is quite far advanced. The position of the pancreas deep in the abdomen is part of the problem. But my reading of the ultrasound was that the mass did not seem to be part of the pancreas but in front of it, although it was hard to be sure. I was concerned, but Joe was near panic. I arranged for an urgent CT scan, which would elucidate the truth for us. The scan was scheduled in two days, on a Friday, and I would hopefully have the result by Monday. I did my best to allay Joe’s fears and urged him not to get ahead of himself, as difficult as I knew that would be for him.
He told me he would hang tight over the weekend, and I promised that I would call as soon as I knew the result.
I received a call about Joe Monday morning before I started to see patients. But it wasn’t the call I was expecting from the radiologist.
It was a call from the coroner.
The previous evening, Sunday night, Joe had been sitting with his spouse watching their favourite TV program. During a commercial break, shortly before the end of the show, Joe got up and went to the bathroom. He returned in time to see the end of the show. As was usually their routine, his spouse went to bed ahead of him, kissing him good night beforehand.
The next morning, his partner awoke to find that Joe was not in bed. Entering the living room, his partner found him sitting as he had the night before, lifeless. Joe had taken an overdose of his psychiatric meds and various over-the-counter medications during that bathroom break and had died during the night.
The phone call from the coroner was devastating for me. The news of a patient committing suicide is one of the most gut-wrenching experiences I think a physician can have, second only to the death of a child in their practice.
I had lost a good friend, and I hadn’t seen it coming. I thought I had allayed Joe’s anxiety sufficiently for him to get through the weekend, and that together we would deal with whatever the CT scan revealed on Monday.
But the saddest part of the story came thirty minutes later. The radiologist called and was completely convinced that the mass was a benign lipoma—a collection of fat in front of the pancreas. The autopsy later that week confirmed the diagnosis.