The day I learned how to be a doctor

March 8, 2002

A terrifying incident in the office proved to this young FP that strong clinical skills aren't everything.

 

Winner of our 2001 writing contest

The day I learned how to be a doctor

A terrifying incident in the office proved to this young FP that strong clinical skills aren't everything.

By Brent Greenberg, MD
Family Physician/Escondido, CA

About five years ago, fresh out of a chief residency at a large Chicago tertiary care system, I applied for my first job with a well-established group of 10 family physicians in southern California. I arrived at my interview with all sorts of ideas to improve the practice, thinking I could expand my "chiefdom" here.

"Where do you see yourself in five years?" the interviewer asked.

"Running this group," I replied.

They hired me despite my arrogance.

Young doctors experience a steep and invigorating learning curve, and I was no exception. But not all the learning comes from books and journals. I discovered early on—through an episode I'll never forget—that there are dimensions to the practice of medicine that I could learn only with the help of someone special.

During my first months on the job, I began to notice differences in my colleagues' practice styles. They worked at various paces, and some were friendlier than others with patients and staff.

I became increasingly concerned, however, with the practice's senior partner, an old-timer I'll call John Smith. Admittedly, I'd never seen a doctor who had better rapport with his patients. They practically worshipped him! But his charts were disorganized and unreadable! Worse, he seemed to feel it wasn't necessary to take patients' vital signs or address preventive measures with them at all.

Trained to be paranoid about documentation and to cover all the bases, I voiced my concerns to our medical director. He said he was well aware of the "issues" surrounding Smith, but that the other physicians had learned to tolerate his weaknesses. The medical director mentioned something about how you can't teach old dogs new tricks, and that essentially ended our discussion.

A month later, another partner asked me for a favor. A longtime patient of his had been having intermittent abdominal pain. An ultrasound had revealed distressing findings; results of a CT scan were pending. He feared the worst, but the CT results wouldn't be back before he left for vacation. So he asked me to convey the results to her. Although I wasn't looking forward to it, I felt strangely honored that he had entrusted me with such a morbid task.

Lois Simpson was 60, gruff and fiercely independent. She had been running a successful collections business out of her home for several decades; her husband, Tom, was a laborer. (I'm not using real names.) Her thick chart described years of smoking, drinking, and other self-abuses. My colleague's notes breathed disconcerting sighs of failed attempts to get her to alter her lifestyle.

I received Mrs. Simpson's report about an hour before I was scheduled to meet with her and her husband. Phrases such as "indicative of," "metastatic appearance," and "involving the liver and pancreas" leaped from the page.

A small lump formed in my throat, but I reminded myself that I'd delivered bad news before. I'd get through this.

The couple arrived 10 minutes early. I told my nurse not to interrupt me for any reason short of an emergency.

I introduced myself with the warmest smile I could muster. The crow's-feet around Mrs. Simpson's eyes and mouth reflected years of hard work and even harder decisions. I knew that she wasn't going to accept any sugarcoated descriptions of her condition.

I asked her how much my colleague had explained to her, so that we'd be on the same page. She was aware of an abnormality on the ultrasound, and had been told that the CT scan would provide better pictures.

"Mrs. Simpson," I began, "the CT scan showed that something is happening in your liver and pancreas. We can't be certain what until we do a biopsy, but—"

"It's cancer, isn't it!" she interjected, her eyes burning holes through mine. "Tell me the truth!" Her husband sat motionless, staring into space.

"It appears to be cancer," I said. "But we won't be certain until we—"

"I knew it!" she blurted. "The damn cigarettes, the drinking . . . I knew this would happen!"

I let her vent, while Mr. Simpson continued to stare, too frightened or worried to say anything. She echoed my colleague's past warnings and her refusal to heed them. I looked back at the problem list, witlessly muttering assurances that she was otherwise healthy. "Let's take one step at a time, Mrs. Simpson, before making any assump—"

I glanced up to make eye contact but found her eyes rolling back. Her face had become ashen, and perspiration dotted her forehead. Her body appeared tremulous, like she was seizing. Mr. Simpson was still, seemingly in shock.

I cushioned her fall as she slid off her chair and onto the tiled floor.

"Has she fainted?" her husband asked.

"The news was too much for her," I replied. "Why don't you go to the waiting area while I take care of her. I'll call you back when she feels a little better." He did as I told him.

I turned back to his wife. The shaking had stopped, but her lips were blue and she was unresponsive. I couldn't feel a pulse or detect respiration. "Oh, God, please," I whispered. Reflexes from my residency training kicked in, and I struck her over the sternum. No response.

I swung the door open and yelled for help. "Call 911," I told my nurse. "And find me a crash cart!"

I was the only doctor in the office who had been recently trained in advanced cardiac life support, but I began to feel like a helpless intern all over again.

Smith rushed down the hall and offered his assistance, asking me to direct him. We did CPR for what felt like a lifetime, but thankfully the paramedics arrived quickly.

We dragged Mrs. Simpson into the hallway and continued doing CPR while setting up chest leads and an IV. A young paramedic, who was probably still in training, tried to intubate her, but his clumsy attempt served only to infuriate me.

"We don't have time for this!" I shrieked. I grabbed the tube and laryngoscope and shoved him aside. Mrs. Simpson's neck was thick, but I managed to get the tube in.

A large crowd had assembled around us. One of my colleagues directed our employees to keep everyone out of the area. The entire practice came to a standstill.

Paddles were placed on Mrs. Simpson's chest. The monitor read asystole.

"Fix the gain!" I demanded. My head swam with shock, guilt, and disbelief. How could this have happened? Could my words have been this damaging?

Even with all my training, my confidence had bottomed out. I struggled to maintain my composure, but inside I was unraveling. Over the chaos, I heard a voice say, "In 15 years of practice, I've never seen anything like this."

Thirty minutes passed. Then 40. "Do you want to call it?" the paramedics repeatedly asked.

"I'll call it when I'm ready!" I shouted. But I knew the truth they were trying to help me face. It was over. This poor woman had come to me alive, feeling fine. Somehow, my words had killed her.

The phrase "do no harm" tortured my conscience. I had never felt so much guilt. I shunned my colleagues' sympathetic cliches: "It wasn't your fault." "Who could have seen this coming?" "She's probably been saved from a lot of suffering anyway." On and on it came, but nothing could distract me from the tragedy.

I spoke with the coroner's office. No formal inquiry, they said; probably an arrhythmia or an MI. Still, I felt as if I'd stabbed Lois Simpson to death with my own bloodied hands.

We lifted her lifeless body onto an exam table. And, as if this weren't awful enough, her husband was still in the waiting room.

He was nervously pacing, smoking a cigarette. He said he knew that the paramedics had arrived to attend to his wife. There was a cantaloupe lodged in my throat and a pool of blazing lava in my belly. What was I going to say to this man? I couldn't rid myself of the looping image of him seeing his wife slump to the floor, lifeless.

Smith put his hand on my shoulder. "Brent, it's going to be okay," he said. "We'll bring him into my office, and the three of us will get through this together."

Two staffers escorted Mr. Simpson to Smith's office. He shuffled forward like a man approaching the electric chair. Employees in the hallway couldn't even look at him.

My palms were sweating as I prepared to respond to his questions. I thought he'd begin by asking me if she was okay, but he didn't.

"She's dead, isn't she?" he said.

I sat motionless, stared at his ruddy face, and choked out my reply: "Yes, she is."

We looked at each other silently, until the eye contact was too painful to bear.

Smith observed all of this. Then, slowly, methodically, and gracefully, he began to talk with Mr. Simpson. I listened as he began to unwind the confusion of events. His words were heartfelt and honest. I marveled at the intonation and the comfort they held. The emotion cascaded out with the words.

Here was the man I had wanted to oust from the practice. His charting and clinical methods made me think he'd been nothing but lucky that the whole town didn't suffer from what I had perceived as his incompetence.

But as I listened to him, I recognized a genuine healer whose emotional connection to this despondent man was able to soften a terrible blow. It was clear to me, as he spoke to Mr. Simpson, that fears of lawsuits, oversight boards, license revocation, and all of the insolent humiliations doctors have to endure never even occurred to this physician. He lived only in that specific moment, when a person was suffering and needed support.

I was awestruck. Smith was the true town physician; I was the village idiot.

Mr. Simpson's response was even more incredible. "I'm just so relieved that if this was going to happen, it happened at a wonderful place like this," he said through his tears. "If even great doctors such as yourselves couldn't save her, no one could have."

Smith's retirement party had all the grandeur a man of his stature deserved. Three generations of patients he'd cared for came to wish him well. There were lots of hugs, laughter, and tears.

Some doctors in our community snickered that it was about time he hung it up. Others knew better. I still have a hard time deciphering his charts when they cross my desk, but in a way, he was a mentor for me. In the untenable distractions of HMO medicine, written and rewritten "standards of care," and policies and procedures, Smith taught me that practicing good medicine starts with a soft voice, a resigned ear, and a supportive touch.

Connecting emotionally to our patients is the ultimate method of providing quality care. Nothing in my perspective now could be clearer.

 

Brent Greenberg. The day I learned how to be a doctor. Medical Economics 2002;5:93.