Years ago, Charlie, a highly respected orthopedist and a mentor of mine, found a lump in his stomach. He had a surgeon explore the area, and the diagnosis was pancreatic cancer. This surgeon was one of the best in the country. He had even invented a new procedure for this exact cancer that could triple a patient’s five-year-survival odds—from 5 percent to 15 percent—albeit with a poor quality of life. Charlie was uninterested. He went home the next day, closed his practice, and never set foot in a hospital again. He focused on spending time with family and feeling as good as possible. Several months later, he died at home. He got no chemotherapy, radiation, or surgical treatment. Medicare didn’t spend much on him.
It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.
Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen—that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).
News organizations used Dr. Judah Folkman’s death to report on his decades-long cancer research career. Given his status as a distant, non-celebrity, non-Nobel surgeon, you may be asking yourself why you, personally, should care about his death. Here’s why.
We were in our second year of medical school, feeling the growing pressure of clinical years just around the corner, when we would be thrown into the hospital system. For now, we had lectures in a large hall with 130 students sitting in chairs that sloped down to a stage. Professors came with presentations and handouts and complex diagrams. The immunology lectures were continuous strings of letters and numbers, with only the occasional verb, impossible to decode as human speech without months of training. Every tissue, every disease, every human physiologic function was discussed, down to the sub-molecular level. After hours of these lectures, the air would get stale and backs would ache and the squeak of weight shifting in chairs would become a metronomic beat marking out time that seemed to pass endlessly.
Then, one day, Dr. Folkman walked on stage. He asked us to put down our pens. He said he was going to teach us something that no one else would ever discuss, much less teach. I can’t imagine what he was thinking as he looked out on the sea of our faces. Give or take a few years, almost all of us were twenty-four years old. Almost all of us were single, ambitious, untouched by any of the major human experiences—no children, tragedies, severe illnesses or grief. The youth, the arrogance, the lack of world experience, all of it had to be a daunting, uninspiring sight. Dr. Folkman knew that in mere months, we would be keepers of information that would profoundly change lives. Pathology reports, cancer diagnoses, even the death of a loved one, those were all things we would be telling vulnerable people. Our actions and our words would be often unsupervised, particularly when disaster struck in the middle of the night.
I have a split medical personality. On one hand, I am a pediatrician; I light up around babies and love to mess around with little kids. On the other hand, I am an Internist; I love complex problems and love talking to the elderly. But the one part of internal medicine which gives me perhaps the most joy is the opportunity to solve medical puzzles. Yes, pediatrics has puzzles in it too, but they are far more common in adults.
The term used for a medical puzzle-solver is diagnostician. It is always a great compliment to a physician to be called a great diagnostician. It means you are a good thinker, have a good store of facts, know how to organize your thoughts properly, and can see patterns in things you otherwise would never have found. It is the Sherlock Holmes, Lord Peter Whimsey, or Harry Dresden side of medicine. The diagnostician searches for clues, but especially searches where they are most often missed: right out in the open.
I am not sure anyone has called me a good diagnostician, but there are few things that give as much satisfaction in my job. It calls on my creativity, my memory, my mental organization, my ability to ask questions, my power of observation, and my ability to put all the disparate pieces together to form a cohesive whole. It’s not just coming up with an answer; it’s coming up with a plan.Continue reading…
A few weeks ago I called a neurosurgeon to discuss a patient’s recent headaches. My patient had been seen in the emergency room several days prior with the worst headache of his life. A complete work-up had not revealed a cause for the headache. Although he was found to have a small aneurysm on CT angiogram, there was no evidence of bleeding by lumbar puncture. The story, however, was slightly more complex than this. There had been several other findings that remained unexplained. One of the findings led me to discuss the patient’s case with a cardiologist. My patient had also undergone cervical spine decompression surgery several months prior to treat cervical myelopathy. I wanted to engage the neurosurgeon and get his professional opinion about my patient’s headache, which had now recurred several days after his ER visit.
The surgeon was cordial, but about 5 seconds into my story he seemed inpatient and interrupted me. “I heard about this guy,” he said, “What he needs is to be seen by one of our neurovascular specialists.” I had more I wanted to say, but the doctor did not seem to want to listen. I raised my voice slightly, interrupted him before he had a chance to end the conversation, and bulldozed through, telling the rest of the story in about two minutes. “Now we’re talking,” he said, as I explained further about a family history of clotting and my concern about a dural thrombus as a potential etiology. Together we formulated a plan that I was satisfied with–though the interaction left me with a feeling of unease.
I saw a gentleman in my office recently. He was having severe pain radiating from his lower back, down to his calf.
I was about to describe my plan to him when he interrupted me saying, “I know, Doc, I am overweight. I know that this would just get better if I lost the weight.” He hung his head down as he spoke and fought off tears.
He was clearly morbidly obese, so in one sense he was right on; his health would be much better if he would lose the pounds. On the other hand, I don’t know of any studies that say obesity is a risk factor to ruptured vertebral discs. Besides, he was in significant pain, and a lecture about his weight was not in my agenda. I wanted to make sure he did not need surgery, and make him stop hurting.
This whole episode really bothered me. He was so used to being lectured about his obesity that he wanted to get to the guilt trip before I brought it to him. He was living in shame. Everything was due to his obesity, and his obesity was due to his lack of self-control and poor character. After all, losing weight is as simple as exercise and dietary restraint, right?
Perhaps I am too easy on people, but I don’t like to lecture people on things they already know. I don’t like to say the obvious: “You need to lose weight.” Obese people are rarely under the impression that it is perfectly fine that they are overweight. They rarely are surprised to hear a person saying that their weight is at the root of many of their problems. Obese people are the new pariahs in our culture; it used to be smokers, but now it is the overweight.