The Patient Was…

Quotations are useful communication tools in many circumstances. Usually succinct, often eloquent, these words and phrases can convey ideas, information, emotion. Quotations can set the tone for something to come and sum up what has already been. They can move people in ways that other things cannot.

Who can forget President John F. Kennedy’s, “Ask not what your country can do for you…..”? Or Winston Churchill’s WWII paean to the Royal Air Force, “Never was so much owed by so many to so few.”

Medicine has its own collection of quotations. Sometimes, a quotation is so impactful, it is better remembered than its source.

Primum non nocere, a Latin phrase that translates to “First, do no harm,” is a basic ethical principle that guides medical care. It is a compelling idea that emphasizes the duty owed by physicians to their patients. It is alluded to, but not actually stated as such, in the original Hippocratic Oath, but it stands as a bedrock principle in clinical healthcare.

Other oft-quoted medical aphorisms include Sir William Osler’s observation that medicine combines both art and science. And one of my favorites, from Dr. William Peabody: The secret of the care of the patient is in caring for the patient.

Quotations, by their very definition, are words or phrases repeated by someone other than their original author or speaker, in order to influence or in some way affect yet others. But there is another kind of statement that I think about in the context of influencing someone else. It’s a statement made to me personally that influenced not only my feelings or beliefs or emotions but impacted the very trajectory of my life.

The physicians I knew as I was growing up were all practicing doctors who took care of patients. They didn’t have “side jobs” and didn’t do other things within medicine. They had their own offices, they set their own hours, and they established their own working conditions. And once I knew for sure that I was going to be a doctor  —  there was a brief period of uncertainty (called “rebellion” by my family)  —  I assumed that all I would do is take care of patients.

During my years of medical education and training, I realized that there were other pathways in medicine. There were physicians who were full-time researchers. There were physicians who were full-time administrators. There were corporate doctors. There were even some entrepreneurs. But still, nobody did more than one thing.  They chose a single path and stayed with it.

Early in my actual medical career, after finishing all my training, when my practice was still small and growing, before I was fully committed to clinical practice, and when my wife and I were still young, we contemplated the notion of living abroad. It sounded romantic and adventurous. And when I saw a notice in a leading medical journal about a position in Geneva with the WHO (World Health Organization), I thought, “Why Not?”

The notice listed ten qualifications for the position. I had one! I was a physician. The other criteria involved mostly public health education and experience. Nevertheless, I applied, and to my surprise was granted an interview by a locally based recruiter.

His first words to me, after the briefest introduction, were, “You know you’re completely unqualified for this position.”

I responded, “I know, but I’m a quick learner. And by the way, why did you grant me an interview?”

“Because I wanted to meet a guy who would apply for a job for which he was completely unqualified,” he said.

We then talked for a while, and it was a relaxed and enjoyable conversation, at the end of which he said, “You would be bored silly by this job. But let me tell you something. My job is to understand people, and you’re going to have three or four different careers in medicine, some even at the same time. You won’t be satisfied just doing one thing.“

This was the first time I really considered the possibility of multiple careers within medicine, even while one aspect, like patient care, played a main role. I thought of Robert Frost’s choice of “’the road less traveled” and the notion that a single decision can transform a life. (Later I laughed at Yogi Berra’s suggestion that when you come to a fork in the road “take it.”)

At the time, I didn’t fully understand the implications of multiple aspects to a career, but as mine evolved it came to embody a number of very different choices. I served as Medical Director of an advertising agency, an education company, and a public relations agency. I wrote a column for a large newspaper chain, edited and published medical newsletters, and wrote a book translated into several languages and sold in many countries.(It made the best-seller list in Australia.) I served as Medical Director for two large multinational pharmaceutical companies. Finally, I was the first Chief Medical Officer of the American College of Cardiology, and continue to serve as a global advisor to that premier medical specialty society.

That statement made to me, that I would have multiple careers in medicine, opened my mind to the enormous possibilities before me, and really did set the tone for a very fulfilling life.

Before I completed my general medical residency training and cardiology specialty fellowship, I was inducted as a Captain into the United States Air Force. I was assigned to a very active military base where a SAC (Strategic Air Command) wing was stationed. At the time, the base also housed what I was told was the only Navigator and Electronic Warfare Officer School. I was in charge of the Air Force Clinic, which was actually the family medicine clinic serving the dependents of active duty servicemen.

My wife and I lived just off the base in a house we thought was heaven, since prior to this I had been a civilian intern in a major medical center, earning only ninety dollars per month and living in a fifth-floor tenement walk-up apartment. The salary in the Air Force seemed enormous and our home seemed grand. I loved my work and felt proud to serve. Life was good, and my wife and I contemplated a life in the military, which I still consider a noble profession.

I knew that I wanted to complete my medical training and my cardiology training, and the military provided that possibility. (When you train medically in the service you owe a year of service for each year of training. By the end of specialty training and payback of training time, you have already served almost a full career.) There were major teaching hospitals within the service where accredited training was offered. One such institution was, in fact, in Europe so the idea of living abroad was alive and well. When I expressed my interest to my Hospital Commander, a full Colonel, he was delighted. It is known that retention of medical officers in the military is difficult; too many more appealing opportunities lie in civilian life. It would be a feather in the Commander’s cap if one of his young officers re-upped (re-enlisted).

My wife and I were genuinely excited. My wife’s family had extensive military experience, mine very limited. As the Colonel ended his discussion with me, he said, “I promise this will happen.”

I said, “I’m so excited and happy. Of course, I will need that promise in writing from the appropriate authority.”

The Colonel said, “I can‘t give that promise in writing,”

“I don’t understand,” I said. “Why not?”

“The needs of the service come first.”

What a powerful sentence!

I thought about it for a long time. It was the 1960s. The situation in Viet Nam was heating up. “Boots on the ground” were replacing “advisors.” One career medical officer from our hospital had already been dispatched to Southeast Asia. I felt I couldn’t rely on a verbal assurance to allow me to go to Europe for training when a war was escalating in another theater. I declined to re-up, fulfilled my two-year obligation where I was, and returned to New York to complete my medical residency and cardiology fellowship.

A simple sentence, “The needs of the service come first,” changed the direction of my life. As I write this, it’s still personally a powerful quotation.

During my Cardiology Fellowship, I was in charge of a clinic at our hospital. The patients who came to the clinic did not have private physicians. They were mostly members of what were designated “underserved populations,” and were treated either by people still in training or by so-called Attending Physicians on the hospital staff who donated some of their time to the clinic as the price for hospital privileges.

One of my patients, about whom I’ve written in an earlier blog posting called “Regrets,” was a young mother of two, who had a diseased heart valve. On examination she had objective evidence of severe valve damage, but she had no symptoms whatever and had a busy life caring for her children and maintaining a household. I saw her in clinic regularly, alert to any report or evidence of difficulty in functioning. The disparity between the severity of objective evidence of disease and the total lack of any symptoms was puzzling, and I sought help from a panel of cardiology and cardiac surgery experts at the hospital. They interviewed the patient, reviewed the objective findings, and concluded that she needed surgery to replace the diseased heart valve.

I knew her as a person better than they did. I knew she functioned well at home. I knew she had responsibility for raising two young children and did it well. I knew she maintained her household for the family, including a hard-working and devoted husband.

But the experts presumably knew more cardiology than I did. And they said she needed surgery.

When she asked me what she should do, I told her that the experts said she needed an operation.

“But you are my doctor,” she said. “What do you think I should do?”

“I think you should continue as you are now,” I said.

And so for the next year I followed her in clinic, always alert to any deterioration in her condition. Despite a bad heart valve, she continued to function well. But I continued to worry that I was doing her a disservice by not following the experts’ advice. So l again presented her to the expert panel. Several members remembered her; they reaffirmed their recommendation and criticized me for not following it a year earlier.

When the patient asked me what she should do, I reiterated that the experts said she needed surgery. Calmly, she addressed me as she had a year ago.

“You are my doctor. What do you think I should do?”

Afraid I was continuing to offer her bad advice by avoiding an operation, I said I thought they were right and she should have surgery. In truth, I did not believe that, but felt overwhelming pressure to accede to their opinion.

On my advice she underwent surgery, and died on the operating table.

Her words remain with me to this day: You are my doctor. What do you think?

That experience colored my entire professional life. I made sure I knew everything I could about my patients, all the nuances that made them who they were and made their lives what they were. And if I knew them better than anyone else and I knew all the science I could about their conditions, then I would trust in my knowledge and my judgements in the face of other opinions.

 I violated this principle only one other time in my years of practice and it ended in the same way. I live with that regret.

Communication between and among individuals and groups is essential in our lives. There are moments when something is said directly to you that has a lasting influence on your life. Sometimes you don’t immediately recognize its importance, but in time its impact is revealed.

Those are the quotations I can never forget.