Heart Failure - Shortness of Breath

by Michael Greger, MD and United Progressive Alumni

[ Medical School Resources | Appendices | Discussion ]


V. INTERNAL MEDICINE - March 30-June 19

Shortness of Breath

The double edge of wind-in-the-hair warm Spring breeze weather. Deep breath before entering the (not so) sterile halls. I think I can I think I can.

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A first day briefing from the hospital infectious disease control officer. Her advice? Don't eat the tuna in the cafeteria.

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I meet person after person, resident after resident, doctor after doctor, and all they ever see is my outside.

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I'm impressed with Falkner Hospital hearing "Nutrition Rounds starting now" broadcast overhead throughout the week. Then I find out it's a code phrase they tell the operator to announce when there's a drug lunch.

Drug lunches are meals (and propaganda) provided by drug companies to residents as "gifts." See Appendix 66.

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Last night at an animal rights lecture reception I saw real smiles. I introduced myself as a Boston-area inactivist. Nine months ago my life ceased to be important. I miss doing things that I'm good at.

Other people graduate from schools and have skills. The summer before medschool I volunteered for seven social justice organizations. The coordinator at Bread and Jams asked what my skills were. Carpentry? Spanish? Anything? We arrived at "Can drive a car." Give me a #2, though, and I can bubble like nobody's business.

"He who doesn't know a trade becomes a doctor." - Italian Proverb.

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Night. A classmate sits down with head in hands. He looks up to ask and answer why he chose to go to medical school. "I was fucking out of my mind." Later in the halls he motions a gun in his mouth.

Why do people go into medicine? Appendix 67.

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The chairman of medicine talks about the upcoming hospital buyout. He talks of revenue streams and off-loading case material.

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"Boston, where value is measured in degrees." - Advertisement on the T.

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New junior resident on the service. "The only thing worse than a patient is a patient's family," he says. "And the only thing worse than that is a 3rd year medical student that follows you into the bathroom."

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Those precious phone-robot words every night. "Page status: Out of hospital, not available." But in the morning it's, "In hospital, on page" (or "on pain," my intern prefers). In one article, "One woman [resident] described her 'beeper' as being like a leash that was periodically yanked."[160]

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A weekend in the hospital ends. I climb in my car to Metallica's Fade to Black on the radio. "Growing darkness taking dawn. I was me, but now me is gone."

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Susan is lonely. I can hear her sobbing in the other room. I thought I could I thought I could.

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It's cold and rainy and the streets are empty. But the leaves are back and it's green again. As I walk I stop for every squirrel, every flower - the trees are filled with both, awash in the heady sweet scent of lilac. I never saw that flower before (hydrangea). This is my first day and it's beautiful. I come home to incredibly red tulips.

Late spring rain -
again I must become
just me.
- Hekigodo

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Morning rounds. A patient named Jim asks us for all our addresses. He says he'd like to have us all out to his place - and have us shot. "Nothing personal, but you must know that most doctors are monsters."

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If you tell the truth, make them laugh or they will kill you.
- George Bernard Shaw

The House of God, written almost two decades ago about internship at Beth Israel, is as poignant now as it ever was. One commentator writes: "Probably the major reason that The House of God has been so embraced is that its humor and language capture the stress, anger and frustration of hospitals so well."[161] It, "has the sort of humor that keeps you going. If you can't laugh at it you'll cry. And if you cry, you won't make it."[162] My favorite line from the book: "Suspicious and angry I felt the world too depleted to wash away my bitterness. A child's rocking horse was rotting in the snow."[163]

"Medical school is made up of a thousand minor crises occasionally interrupted by truly epochal upheavals" - Robin Cook. Appendix 68a.

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Drug breakfasts now too. Fresh squeezed OJ compliments of Eli Lilly.

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I want to get slowly out of bed, stretch and greet the day. I want to take stacks of books - lives experienced - and touch it all. I want to be here now.

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Patriot's Day. I remember the marathon last year. It's been a whole year.

The years like great black oxen tread the world,
And I am broken by their passing feet
- William Butler Yeats

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Even after I offer my name, the Other's perfunctory squint at the name badge. Everyone is treated differently.

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A resident introduces herself. I fumble what I'm holding in reflex. "You don't have to shake my hand," she says.

Medicine has been described as "ruthlessly pyramidal."[164] Appendix 69.

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"The problem is the family knows too much [medicine]," said the junior resident, "uneducated people are so much easier to take care of."

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Our attending saw As Good As It Gets. When actress Helen Hunt rants about HMOs, evidently audiences across the country are cheering. "That's when you slouch down in your seat," he tells us.

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I glance at today's New York Times. Congress killed a 30 cent increase in cigarette taxes, even though we have among the lowest cigarette taxes in the world. In Canada, for example, it's $3.64 per pack in taxes alone.[165]

One MD/MBA classmate is torn. (My year is the first graduating class of Tufts' new MD/MBA dual degree program - just the existence of which is telling.) "Yes it would cut smoking rates," he reasoned to me, "but it will just cost more money in the long run, because people would live longer."

The AMA in bed with big tobacco - Appendix 70a.

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A classmate needs to return to his native country for obligatory military service. He's looking forward to the break. You know when you're looking forward to boot camp....

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Playing the Transformation Game I draw the perfect card. "Looking for the worst in people, expecting the worst situations, no wonder I live in a hostile and painful world."

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I ask the clerkship director why only 2 out of the 12 weeks are spent in outpatient settings, with the other 10 spent in the hospital. Because, "Time is money," I am told. And, "Teaching takes time."

From Ruth Sidel's A Healthy State: "In most medical schools, well over 50 percent of the teaching is done on 'horizontal' rather than 'vertical' patients.... It's like teaching forestry in a lumber yard."[166]

More on medical teaching in Appendix 71.

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I used to be disappointed with the social distance on the T. But I look up and people are talking, holding hands, reading, thinking. It's all relative.

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A friend tells me of her time on medicine. An old woman came in deathly ill, nearly comatose, but was revived the next day enough to say that she wanted to go home. "No," my friend tells her, "you can't, you're too sick." "But I must," she said, "my flowers are not being watered."

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I've been reduced to instrumental service - caring or even hoping that people will see me doing good. Recognition even.

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"I see with my mind," he said.

Today was my first good day all year. It only took about three hundred days. First of all, it was a half day - specialty clinic. Today with infectious disease. I broke away from the 5 minute per patient doctors and just sat on a bed with a man named Randell. Blind, he was riddled with acronyms like CMV, MAC, HIV. We talked about real things. "It's so simple," he said, "damn the white/black issue. There are the haves and the have-nots. Why doesn't anyone ask the questions? They buy new bombers with urgency. Doesn't poverty bother them? What are we telling these kids? You can't expect people to obey."

He asks for his bag and hands me a copy of the Marianne Williamson quote:

Our deepest fear is not that we are inadequate. Our deepest fear is that we are powerful beyond measure. It is our light, not our darkness, that most frightens us. We ask ourselves, who am I to be brilliant, gorgeous, talented, and fabulous? Actually, who are you not to be?

You are a child of God. Your playing small doesn't serve the world. There is nothing enlightened about shrinking so that other people won't feel insecure around you. We are born to make manifest the Glory of God that is within us. It's not just in some of us, it's in everyone and, as we let out own light shine, we consciously give other people permission to do the same. As we are liberated from our own fear, our presence automatically liberates others.

As I walk out of the clinic, I find myself blurting, "fuck you" to the nearest stethoscoped portrait on the wall.

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An anesthesiologist explains the ABCs of managing medical students. "Accuse, Blame, Criticize."

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It's been a long day, but it's only 11 a.m. And I wish I wanted them long.

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I start my two weeks of outpatient. One of the doctors describes to me the patient population at the second of two sites. "It's a walk-in clinic; patients are unsophisticated." But here? "White upper middle class, so they're intelligent."

A classmate recommends the other site. "There are a lot of good looking girls that go there."

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CHIEF COMPLAINT

The office looks like a sporting goods store. Corporate drug logos everywhere, from pens and mugs to clocks and tissue boxes. There are inscribed bars of soap - even brand name antibiotic microwave popcorn bags. One study found that medical practices - between their store room shelves, their waiting and consulting rooms - have an average of over 1000 promotional items from drug companies."[167]

"It is amazing how dull-witted some of my colleagues can be," one doctor writes in the New England Journal of Medicine:

One division chief went around for weeks with a shirt pocket protector holding his collection of pens and displaying an advertisement for a drug. These plastic pouches cost about 50 cents... yet this man was willing to be a walking bulletin board for this meager reward.... If the Pennzoil people were to offer him 50 cents to wear a sticker advertising Pennzoil for a few weeks, he would think they were off their rockers.[168]

Drug pushing - Appendix 72a.

A SPOONFUL OF SUGAR

One doc says that he's uncomfortable taking gifts from drug companies. He tells me how he's been wined and dined in all the finest Boston restaurants. Every Wednesday, his whole office continues to be treated to lunch. I guess not that uncomfortable.

He tells me of Oroflex, a pain-killing "wonder drug" - actually shown to be no better than aspirin - which Eli Lilly spent $12 million in promoting. Interesting historically, Oroflex was the first time a drug company had marketed a product directly to patients.[169] The rest of the millions of dollars went for the doctors.

"Me and my wife were given an all expenses paid trip to New Orleans," he confides. "And I love to spend money." Doctors were brought - bought - from all over the country to hear "experts" croon on about the drug. He's reimbursed by Eli Lilly for the $250 dinners, a $1200 check in all. "I felt cheated though," he tells me. "There were docs there that were getting trips to the Bahamas."

As described in a British expose, "In many cases, [American] physicians were paid 'honoraria' ranging as high as $1000 [in addition to the all expenses paid plush resort vacations for physician and guests] merely for being willing to attend [such company-sponsored symposia]."[170]

From the journal New Physician:

To say that the medical profession is involved in a 'conflict of interest' is merely a wishful idealistic phrase.... Medicine's alliance with the drug industry is neither unusual nor unexpected - just another example of the profession's general policy of maintaining its own material self-interest and privilege above all else.[171]

The Oroflex experts in New Orleans evidently forgot to mention anything about the hepatic necrosis, though. People were dying of liver failure within a month of release of the drug. Federal investigators later discovered that Eli Lilly knew of the drug's deadly potential all along. For the 50 people killed by Oroflex before it was banned, Eli Lilly was charged with a misdemeanor and fined $25,000.[173]

Prescription drugs kill more people than pneumonia and twice as many people as diabetes.[172] Appendix 73a.

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M&Ms

Mortality and Morbidity conference, described as, "kind of a confessional for physicians."[174] It provides a legally protected forum where doctors discuss their mistakes without fear of malpractice suits. This protection is provided in hopes of maximal disclosure so that other doctors won't repeat their mistakes. The implication, though, seems to be that physicians will only talk about mistreatment if they are guaranteed to get away with it. Dead men tell no tales. The blood melts in their mouth - not on your hands.

"Young doctors make humpy cemeteries" - French Proverb. Appendix 74a.

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A patient breaks down crying; her husband just died. She's embarrassed of the emotion. The doctor pretends not to notice and goes onto the next question. He's more embarrassed.

The doctors I've known have been awkward social misfits. Or as one commentator notes, "technologically proficient but societally challenged...."[175]

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Doctor versus patient even in the office. One doctor describes a patient as an anchor around his neck. I ask what's so bad about her. "Whatever I recommend," he tells me, "she always has to put her two cents in. She's always trying to feel in control."

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TOO MANY PATIENTS, NOT ENOUGH PATIENCE

I ask how many patients doctors have. How many consider one doctor their doctor? Referred to in the industry as the "panel size," two to three thousand people! My doc of the day notes, "They all start looking the same after awhile." Faces in a crowd.

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Advice du jour: "Never disagree with another doctor in front of a patient."

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I think people go to "alternative" practitioners because they are treated like human beings, listened to as person not patient. The doctor saw seven patients this morning and didn't really do anything for any of them. Who's the quack?

The art of medicine consists of amusing the patient while nature cures the disease.
- Voltaire

Medical science has little theoretical basis.[176] Many medical decisions have been described as, "spun arbitrarily out of flimsy strands of evidence."[177] Ninety percent of the visits by patients to doctors are caused by conditions that are either self-limited or beyond the capabilities of medicine in the first place.[178] Or as Eugene Stead, Jr. - called one of the most important physicians to bestride American academic medicine - states, "In... 90 percent of your practice, you will be practicing like a quack."[179]

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One woman in a local nursing home crocheted a pillow, "The golden years suck." Another patient tells me the golden years are all tarnish. "I want to die with the sun, sky, and wind," she tells me.

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"Do you work?" the doctor asked. "No," the patient replied. "I've got no bosses - best part of being a widow."

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I was impressed today with a doctor who asked me if I think they care about fungal toenails in Sarejevo.

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My elaboration of future plans - more interest in social change than in clinical practice - elicits interesting reactions from the doctors. One responded today, "[Us] practicing physicians would like to be doing those things, but we're too busy."

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Twenty-five year old man comes frequently to the office for his asthma. "What a wuss," the doctor explains.

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A doctor remarked in clinic today, "I want to blow my head off."

GENERALIZED MALAISE

Among American physicians, "Overt and vocal dissatisfaction with their lot is quite common and almost routine"[180] Quoting from the New England Journal, "There has been an undercurrent of unhappiness among physicians for many years, but the complaints seem more widespread and more strident now."[181]

From the New Statesman:

Medicine is a queer business. Doctors, as a trade, stand high in the ranks of those who go mad, top themselves, filch pills, sniff gas, run from their spouses, weep in the night, live chronically disjuncted lives.[182]

"At present," writes one commentator, "there seems to be very little joy at any level [of medicine]."[183]

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A patient wants to tell the doctor something but doesn't want it to get into her chart. The doctor reassures her it will be strictly off the record. Afterwards - as scribe - I am instructed to include it all. He snickers, "There's no such thing as off the record."

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The patients wait as the three-doc discussion moves from which market sells the best meat to a study and contrast of Bahamas' beaches.

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A woman with no home walks in, having just been beaten by her boyfriend. The physician rolls his eyes. "That's Mary. She's always here for handouts. Tampons, toothpaste. I always just tell her we don't have any."

Bruised and dirty she's curled up on the table crying. Each tear has more feeling than my whole white coat clad body. We give her the equivalent of aspirin and kick her back out on the streets. "She likes being homeless," he says.

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A METAPHOR FOR OUR TIMES.

I ask the nurse for her most memorable story from the clinic. She laughed as she told it. It was summers ago, a "streetperson" brought in a pigeon with a broken wing. And he refused to leave until they took care of the injured bird. So they called the police.

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Angry, pained and bitter. And you?

A friend with whom I shared my account of third year joked to an acquaintance to remember my name. "Because some day, some day... he's going to be in a tower picking off people with an assault rifle."

Anger in medical training, Appendix 75.

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I wish I had made a medschool time capsule, to be opened when I finish. I think I would have written,

Hi, this is who I am. Don't change, OK?
You were light. And you smiled.
Don't let them in.
We'll be together again soon.
Love,
You.

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The best of doctors will go to hell - The Talmud (Kiddushin, IV.82a)

At first, I found doctors all too human - petty, insecure, narrow-minded. But now, they're not human enough. All with a little splash of self-hatred.

I feel safe enough just physically being out of the hospital, that when asked by my outpatient doc-of-the-day why I'm not interested in practicing clinical medicine, I replied, "I hate doctors."

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It's a private hospital - two-ply toilet paper, single rooms with picture windows to trees. I touch my fingertips to the glass. I wonder how much nicer I would be if I hadn't done surgery.

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I attend the annual Physicians for a National Health Program conference. Social justice at the Hyatt Regency? Also the nonunion Hyatt Regency. Rich people talking about poor people.

I am surrounded, however, by the hundred most like-minded radical docs in the country, yet I sit alone - not talking to people, not learning from people, interacting, experiencing, realizing anything. Just dead and watchful. I am losing buoyancy. Am I shy? Am I afraid?

I feel distant, pushing people away. I'm miserable to be around. I'm embarrassed of who I've become - I don't want to meet people who didn't know me Before. Or maybe, I try to tell myself, I just schmooze with docs too much as it is.

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Happy to meet people I'm not happy to meet. Being a waitress must be like being a medical student - transparent busy grins and forced laughter. I'm a habit of empty smiles and fraudulent living.

C. Wright Mills asked,

What must the consequences be of being fake all day? When white-collar people get jobs, they sell not only their time and energy, but their personalities as well. They sell by the week, or month, their smiles and their kindly gestures, and they must practice that prompt repression of resentment and aggression.

"May the outward and inward man be at one" - Socrates.

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I look at my life. I am not a part of anything; I'm not a whole of anything either. I know what giving up and selling out would feel like.

If I from before
The real me, the core
Were to see me now
He'd ask, why? And, how?

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I sing to myself. "Keep your eyes on the prize; oh Lord, you've got to hold on." But what is my prize after all this? Illegitimate authority like the rest.

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I made an impact in surgery! Now, evidently, the surgeons are preempting self-expression by telling the new students they are not to wear buttons of a political nature. As a classmate is telling me this I scan the room. All the residents' coats brandish the same little gold pins advertising the HMO that bought the hospital. Drug logos jut out of every pocket.

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Woman with shingles. "I've got such a pain God can't even handle it."

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"Think about me," a patient cried out on rounds this morning. "Pray for me. I hope God doesn't give up on me at eighty-seven." We just left as usual, no nothing. The intern shares his secret to the resident, "I just keep changing the subject so she doesn't cry."

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Another patient is sobbing. She has months to live with a brain tumor resistant to all our poisons. "I want to make 2000," she says. "I want to be normal. I want to go home and see my dog."

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Suharto is gone. The world changes under my feet.

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Another patient wants God to bless me for spending a whole ten minutes with her today.

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My friendships are mostly memories. "Friendship requires more time than poor busy men can usually command" - Emerson

"Others can be seen as consumers of time - the scarcest of commodities."

Ned Cassem, the director of psychiatric residency training at Mass General Hospital, gave a commencement speech at Harvard Medical School on how to survive life in the hospital. He spoke of the attending physician's "infantile tantrums, neuroses, unbridled narcissism, petty jealousies, delusions of academic achievement [and] disastrous doctor-patient relationships." He named the number one terror in all doctors' lives - "that someone will waste their time."

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Driving with the windows up I sit shielded, unshaken as everything whizzes by, whizzes past. Everything's moving but me, no sound, no smells, no wind - breathing my own air. And if I blink, close my eyes, look back, glance to the right - even think too hard, I might crash.

There is always oncoming traffic, so both hands on the wheel. I slip into autopilot and just nod and listen and nod - wasted time until my destination. When I get there though, I'll come around to her side (she's been home all along) and slam the door behind me.

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I jot down some of my favorite quotes from rounds:

"The family can't just show up any time and expect to talk to me."

An attending spends five minutes with the patient stressing the importance of compliance. I tell the attending that I don't think he understood. Shoulder shrug. "Did my best."

"He's inappropriately happy."

"That really pisses me off," the resident growled this morning as the nurse asked us to return after she was finished bathing the patient, "the doctor's role is primary."

"Squeamishness has no place in the neurological exam."

One of the residents got a chance to practice on prisoners at Kings County:

"Lots of great pathology."

"HIV is cool! So complicated, good teaching material."

"There's a lot of cardiac disease [here]; which is great for us,"

"That button's going to get you into a lot of trouble."

Resident tells a deaf guy behind his back to take deep breaths.

Resident advises the woman going in for a mastectomy to, "tough it out."

Chairman refers to geriatric ward as a "toilet."

"Of all the things you don't want to see in a patient, mother's an MD...."

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Shattuck - the public health hospital - is not air-conditioned. The prisoners lay prone, miserable. The windows are locked to only open a crack. It's bad PR for inmates to die in prison, so when they're close to death - AIDS usually - they come here to bake for their last few hours.

I am reminded of an account of ante-bellum cruelty recorded in the medical literature. Reportedly, Georgia physician Dr. Thomas Hamilton conducted a series of brutal experiments on a slave to test remedies for heatstroke, the purpose of which was to, "make it possible for masters to force slaves to work still longer hours on the hottest of days."[184]

Out in the hallways, the guards have fans. And the doctors? Well, the doctors have air conditioning. At the nurses station, behind glass, cool, we view the prisoners - Black mostly - shining with sweat. And they look back at us. I am reminded of a poem by an angry Black poet that contained a line, an intention, to "Icepick out their air-conditioned eyeballs."

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"He says he's in pain," I report. Prisoner with pancreatitis, albumin through the roof*. The attending won't listen so I go to the director. He also refuses to give pain-killers. Can we get the pain management team to see him? "No, they'll just give him pain meds."

* Levels of albumin, a protein in the blood, have traditionally been used to follow the severity of pancreatitis attacks.

"For over 20 years the medical literature has carefully documented the under-treatment of all types of pain by physicians."[185] Appendix 76.

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A friend today experienced the epitome of scut. From Academic Questions: Medical students, "regard the rather humble, unpaid tasks they are called upon to perform (clerk and dresser have been clinical students' titles time out of mind) as somehow unfair (scut work)...."[186]

"I could either walk or take my bike," he tells me. Three miles to get tampons for his resident.

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One doctor on the floor noticed my Ad Hoc Committee to Defend Healthcare (Patients not Profits) button today. "I'd join but I'm scared," he whispered to me, "You'll be blackballed. The HMOs control everything. They own the patients; they can pull the rug right out from under you. If I were you I'd take off the pin and keep your mouth shut."

A flyer on the wall. A Tufts Managed Care Institute sponsored lecture for the medical students entitled "Why Physicians Should Be Clamoring For Managed Care."

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A doctor conferring with a medical student in Shadow of a Great Rock, a novel by Murrell Edmunds:

'I was like that in the beginning. There was so much suffering and pain and neglect in the world, and I was going to sally forth on my white charger and set things right.' His voice was more serious, and he leaned forward. 'You'll learn, my boy, that a doctor is never as pure again in his professional life as he is on the day he... starts out to make over a sorry world. Never again!' his voice was positive and dogmatic. 'He is the one who is made over.... The world is just lying out yonder in the gap waiting to pounce on him and buy him off.'

Protest dawned in Langdon's eyes. Dr. Travers promptly forestalled it. 'Oh, he can be bought,' he declared. 'None out of ten can't be bought with one coin or another. And that's because there are more words than there are honest doctors - eloquent words, noble words, slick, tricky, damnable words - for us to hide behind. We talk about physician-patient relations, when what we mean is physician-cash relations; we oppose something we label socialized medicine, when what we really mean is: Keep your cotton-pickin' fingers out of this and leave us doctors alone in our racket; we brag about the unexcelled quality of American medicine with our high priced public relations hucksters, when what we mean is if you are a millionaire and will pay us through the nose, you may enjoy the benefits of modern science.'

The inequities of American healthcare, Appendix 77a.

GAG CLAUSE

My favorite piece of medical satire was published last year in the New England Journal. It conjures an account of what Hippocrates would say at an HMO job interview.[187] It drew many letters of support. This one from a British colleague:

To the Editor: At last, a physician willing to suggest that the American medical profession is a spineless, avaricious, and directionless cartel unworthy of being called caring. The fact that this sentiment had to be couched in irony of almost Brechtian density to be published in a respected journal heightens the effect.

I have often been asked whether I would like to work in the United States. 'Hey man,' I'm told, 'the money's really good.' I have always replied that I would rather sell my soul to the devil (he may be harsh but at least you know where you stand).

Your country, which spends 10 percent of its gross national product on 'healthcare' and yet has one of the highest infant and perinatal mortality rates in the developed world, is so steeped in the specious 'deserving poor' argument that the rest of the world can only gag in astonishment.

We poor Britons may seem financially strapped by exercising some social conscience, but as physicians we sleep well at night, knowing that our job is to treat the sick.[188]

The author of the piece responds. "I appreciate Dr. Brown's comments greatly. Unfortunately, I have some bad news for him. We actually spend 14 percent of our gross national product on healthcare. He may have mistaken us for one of the relatively efficient systems of Western Europe or Canada that spend 10 percent. Or perhaps he could not actually believe that a nation that spends this much ($1 trillion) would still have significant gaps in access and quality."[189]

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I confront a classmate who is considering a military scholarship. She stresses that she'd just be playing a healing role. I share with her an article I find in the New Physician. "The physician is a necessary part of the war machine.... The stated mission of the U.S. Army Medical Corps... is, 'to conserve the fighting strength.'"[190]

U.S. Army Field Manual 8-10: "The Army Medical Service is a supporting service of the combat elements of the Army primarily concerned with the maintenance of the health and fighting efficiency of the troops...." Its mission is to "conserve manpower [for] early return to duty."[191] For example, "the military physician would be expected to let a seriously wounded soldier die in order to save the life of one less seriously wounded who was able to return more quickly to battle."

A social medicine doctor asks, "And if there were enemy wounded who were more urgently in need of care, when would their turn be?"[192]

I doubt the Army seriously concerns itself with anyone's health. See Appendix 78a.

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Another killing spree dream, this time shooting members of some cult. One woman pleaded that she has just as much a right to her opinions as I have to mine. I shot her in the face.

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I want to row slowly on a cold lake in the morning. I want to create something every day.

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Another needle stick and a headache. I am bleeding, thumb burrowed in temple. I don't smile like a kid anymore.

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You know you're grown up when summer is just a season. "When childhood dies, its corpses are called adults" - Brian Aldiss.

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From JAMA, "Students need not be ashamed of the fact that they are learning what they do not already know...."[193] Tell that to our senior resident who advised us, "Don't ask a question you don't already know the answer to."

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My Ob/Gyn grades came back. "Michael never appeared to connect with the rotation. His effort was adequate but was not accompanied by a significant level of commitment. He did not display a strong ability to connect with patients or to find ways to communicate that were beneficial to them. He also did not establish any significant level of chemistry with his team.... [He did good on the test] but he needs to apply these talents to his interpersonal clinical skills and not only to the acquisition of factual knowledge." I don't even laugh this time.

Four-pointed star

I got an Email last night. The first nine words out of my mouth were Oh my God; oh my God. Oh my God. What a way to end the year. Dr. S - . Surgeon Dr. S - ! I had written pages about him on my evaluation form - how he should be removed from faculty, a rant bordering on restraining-order/you'll-hear-from-my-attorney. And I signed it. Then five months later...

Michael-

I have had a chance to review student comments. Since you took the trouble to list your Email, it indicated to me that you wanted feedback.

I am sorry you had such a bad experience at NEMC because of me. Throughout our careers there will be times when these experiences have a poignant effect. I myself can remember the exact individual who caused me to avoid internal medicine as a career choice.

Your comments made me realize that you don't me very well. [sic]

My sincere apology

- S -

Yes, rumor has it that the dean came down hard on the department and him in particular - in essence forcing the apology. What's important, though, is that I hear he was much better to the next round of students.

Four-pointed star

at the Ending of this road,
a candle in a shrine:
- E.E. Cummings

Today, outside is for me too. And I walk the streets like it's the first time. I come home and hang up my white coat. I feel robbed - weeks, months, a year. But hugging Susan I see the faces on my wall, pictures of all those close. Smiling faces. I finish unpacking - 8 months after we moved in. It's time to call friends, time to start answering the phone again. Am I ready to live? Yes.

A year ago, dreading to start pediatrics, I was shopping for dress shirts and bunny ties. Who was I then? Who am I now? I read that the Yurok Indians have one and only law - be true to yourself. "For the sake of a family an individual may be sacrificed; for the sake of a village a family may be sacrificed; for the sake of a nation a village may be sacrificed; for the sake of one's self the world may be sacrificed" - Panchatantra.

Star by Star.
World by world,
System by system
Shall be crushed
But I shall live.
- Ralph Waldo Emerson

I sit down on our bed and rub my feet, toenail clipper in hand. It is said that tectonic plates - whole continents - move as fast as nails grow. I pause, and squeeze off the last chipped crescent of that lovely purple-brown.

 


 

[160] Ford, CV and DK Wentz. "Internship." Southern Medical Journal 79(1986):595-599.

[161] Kerridge, IH, M Lowe and KR Mitchell. "Surviving in the House of God." Medical Journal of Australia 162(1995):560.

[162] Rovner, S. "Doctor with a Shot of Humor." Washington Post 22 March 1985:C1.

[163] Shem, S. The House of God New York : Dell Publishing, Dec. 1980.

[164] "Stress in Junior Doctors." British Medical Journal 301(1990):75.

[165] Worldwatch 5:9.

[166] Sidel, R. A Healthy State: An International Perspective on the Crisis in U.S. Health Care New York: Pantheon Books, 1983.

[167] Hedley, J. "It's Time We Doctors Took a New, Fresh Look at Our Ethics." Pharmacology and Therapeutic Advisory Committee. www.pharmac.govt.nz/drugscene/ethics.htm

[168] Waud, DR. "Pharmaceutical Promotions." New England Journal of Medicine 327(1992):351-353.

[169] Franklin, Karen. "The Pharmaceutical Tango." New Physician 39(1989):24-28.

[170] Greenberg, DS. "All Expenses Paid, Doctor." The Lancet 336(1990):1568-1569.

[171] New Physician 20(1971):164.

[172] Lazarou, BH Pomeranz and PN Corey. "Incidence of Adverse Drug Reactions in Hospitalized Patients." JAMA 279(1998):1200.

[173] Sherrill, R. "Medicine and the Madness of the Market." Nation 9 January 1995:44-71.

[174] Pekkanen, J. MD: Doctors Talk about Themselves New York: Delacorte Press, \1988:94.

[175] Owen, JA. "Doctors and Dollars." The Pharos 1994(Winter):2-5.

[176] Weeks, JA. The Artful Science of Medicine White Knight Publishing. http://www.wkpub.com/artful1.html.

[177] Ingelfinger, FJ. "Arrogance," New England Journal of Medicine 303(1980):1507-1511.

[178] Ibid.

[179] Hughes, SG, GS Wagner and MW Swain. "Dr. Stead on Doctoring." The Pharos 1998(Winter):20-22.

[180] Kassirer, JP. "Doctor Discontent." New England Journal of Medicine 339(1998):1543-1544.

[181] Ibid.

[182] Bywater, M. "The Doctors We Deserve?" New Statesman 127(1998):15.

[183] Lee, A. Letter. Medical Journal of Australia 169(1998):339.

[184] Gamble, VN. "Legacy of Distrust." American Journal of Preventive Medicine 9(1993):35S-38S.

[185] Rich, BA. "A Legacy of Silence." Journal of Medical Humanities 18(1997):233-259.

[186] Braverman, AS and B Anziska. "Challenges to Science and Authority in Contemporary Medical Education." Academic Questions 7(1994):11.

[187] Pruchnicki, A. "First Do No Harm (Pending Prior Approval)." New England Journal of Medicine 337(1997):1627-1628.

[188] Brown, DJ. Letter. New England Journal of Medicine 338(1998):1318.

[189] Pruchnicki, A. Letter. New England Journal of Medicine 338(1998):1319.

[190] Livingston, GS. "Warning: Experience has Demonstrated that Believing these Ads May be Detrimental to your Ethical Health." New Physician 1973(November):726-727.

[191] Ibid.

[192] Sidel VW and GA Silver. "Social Medicine: A 1990's Perspective from the United States." Scandinavian Journal of Social Medicine. 23(1995):145-149.

[193] Sukol, RB. "Teaching Ethical Thinking and Behavior to Medical Students." Journal of the American Medical Association 273(1995):1388-1389.

 


 

Reader's Comments

Your page is very well written as well as researched. However, I have become extremely disillusioned by your perception of the medical profession. I am a premed student who has recently gained admission to a prestigious School of Medicine. I am, rather, I was very enthusiastic about entering the field of "true" medicine (as opposed to premed). I have spoken with many surgeons and physicians, as well as medstudents who have recently completed the third year. I believe we may practice medicine completely different in the South, because although these doctors have reported instances of mild criticism by attending physicians, none has been a victim of the blatant abuse you have very vividly described in your article. I have no doubt in my mind that this treatment does exist, but I have never heard of the extremes you have described. I have not even embarked on the long journey to achieve the status you have, but I have considered every possible aspect of the clinical years of medicine, and no scenario I have imagined on my own has even come close to your description. I must say, I am scared as hell, and it's too late to turn back now. My peers have criticized my "lack of committment" to the medical profession, but they have not read your personal account. My only fear is to lose sight of the motivation behind my career decision, and that is to actually help people. My plans are to practice free of charge in third world countries. Perhaps my "Patch Adamsism" is idealistic and juvenile, but I would rather die than to succumb to the insurance companies, drug reps, and bitter, self-hating doctors who have lost sight of what the motivation of the medical profession is supposed to be-to save lives. May God help all the residents, attendants, and other personell you have described.



-- mary caroline barr barr, August 24, 2001

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