August 18, 2023
Dear Interested Readers,
A Continuing Story
I am continuing “my story” this week although I am very tempted to discuss “issues.” It has been a week that should make us a little nervous as we begin to realize that we may have miscalculated how long we have until we pass the point of no return with global warming. At a minimum, the summers just keep getting warmer and the weather just keeps getting more violent.
My wife worked as a nurse in Hawaii in 1969, but I first visited Oahu, the big island, and Maui, in 2007 and we returned to the islands in 2019 to spend some time on Kauai followed by a delightful week in an “Air B and B near the beach with our grandsons, son, and daughter-in-law in November of 2019 just before the pandemic. We can’t reproduce that week because the house we rented was near the beach in Lahaina. I still enjoy swimming in a shirt that blocks UV light that I bought in a shop on Front Street. That shop is surely gone. We enjoyed ice cream near the amazing banyan tree in the center of town. In those moments who would have ever imagined that most of it would be lost forever except from memory and old photographs? There have been many reports from Lahina, but the report that best described the emotions of loss for me was the interview on the “Daily” podcast with the woman who is the pastor of the oldest church in Maui. She describes the combination of loss and hopes for the future. Looking to our collective future in a continuously warming world, will we experience more and more Lahinas?
Also this week, we endured yet another milestone in the continuing legal saga of our former liar-in-chief. I won’t add to your information overload by referencing all the redundant legal analyses of former President Trump’s Georgia indictment. I doubt that there is anything that I could say that would enhance your knowledge, but I would suggest that if you have not read David French’s column in the New York Times that sets this indictment apart from the previous three, I would recommend it to you. It may take a long time to get all of Mr. Trump’s cases before multiple juries, but history has already been made. We live in strange times. Could it be possible that the next president will conduct the business of the nation from a Georgia penitentiary rather than the White House?
In a typical week, I would have given you my take on the third installment of Nicholas Kristof’s assessment of our healthcare system which provides substandard care for increasing numbers of people and is not a system. Kristof’s latest piece has the challenging title “How Do We Fix The Scandal That Is American Healthcare.” Unfortunately, we may have a better shot at curbing global warming or putting the conspirators that Fani Willis has indicted behind bars than we do of fixing our healthcare system. Effective enthusiasm for healthcare reform may have ended with the passage of the ACA and its survival of congressional and court challenges just as the enthusiasm for the civil rights movement ended with the passage of the Voting Rights Act of 1965 and the assassination of Dr. Martin Luther King. Jr. in 1968. It is sad to look at how the Supreme Court has continued to unwind the progress that Dr. King and the civil rights movement made in the 50s and 60s. Will we someday look back on the stagnation of progress toward healthcare equity, The Triple Aim, and the desire to improve the social determinants of health and realize that our progress toward being a healthier nation began to slow down after 2010? This brings me back to where I started my autobiographical diversion a few weeks ago.
I began my attempt at writing a short version of my medical autobiography as a way of connecting with the concept of moral injury in healthcare. I had the feeling that most of the people that I had met in training had become physicians or nurses because they were committed to compassionate care. That desire to be of service was further developed and matured by multiple experiences and exposure to remarkable mentors in our long years of training. I believe that my own story is rather typical and that I, like most physicians and nurses, was imprinted during my training with an image of the care that I hoped to be able to provide throughout my career. Moral injury exists for many physicians on a daily basis because they are trying to work in a system that continually violates the principles they absorbed in training. Whether my story adds anything to that concept is for you to decide.
Last week, I described two events that I well remember from my four years in medical school. The first was the accidental discovery of iron lungs in storage at Children’s Hospital sometime in the first month of medical school. That event triggered memories from my childhood when I was afraid of becoming a polio victim after several of my classmates were unfortunate enough to become infected. I remembered the relief I experienced when we were given the Salk vaccine. The second story was a brief description of my two-year longitudinal experience in the Children’s Hospital Family Healthcare Program. There were many other memorable experiences between those two events that warrant brief comments.
After spending the first year and a half mostly in classes except for our occasional “clinics,” I was eager to begin the course called “Introduction to the Clinic” which occurred during the second semester of the second year. Eli Lilly had provided us all with “black bags” and stethoscopes. Even in 1968, there were progressive members of my class who felt that the drug company was trying to “buy” us and compromise us into a future of being knee-jerk participants in the “medical industrial complex.” We were not having it. As a class, we dramatically returned all of the swag that Eli Lilly tried to offer us. By the time the course started, most of us had purchased our own stethoscopes, black bags, reflex hammers, tuning forks, otoscopes, ophthalmoscopes, and blood pressure cuffs and were annoying our spouses and friends with attempts to try out our new equipment.
The course began by donning white jackets with name tags that identified us as medical students and then meeting with faculty members who would take us to the bedsides of patients who had agreed to be demonstration subjects. While we stood in a hallway outside a patient’s room our mentor would briefly tell us about the patient’s problem or problems and the physical findings of significance that we might appreciate when examining the patient. After our hallway discussion, we would all enter the room and surround the patient’s bed while our teacher would demonstrate the findings, and then each of us, there were usually four of us, would try to hear or feel the finding of significance. As we took turns we would whisper to one another things like, “Did you hear it?” Our pockets contained leather-bound manuals describing physical signs and a little red paper-backed book that described how to approach the patient and record a history and physical. Later as we actually began to rotate through the various specialties on the wards of the Harvard hospitals we would replace the manuals of physical diagnosis and history taking with the latest edition of The Washington Manual of Medical Therapeutics which has been published since 1942 and is now in its 36th edition. I think my edition was around the tenth. The Washington Manuel is the best-selling medical book in the world. We referred to this book which bulged in our pockets as our “peripheral brain.”
Finally, after theoretically learning how to talk to and examine a patient, we were given a patient to see and examine alone. My very first patient was a gentleman in his late 50s named Mr. Hart. He had been brought to the Boston City Hospital by ambulance with crushing chest pain which occurred while losing at poker. His cardiogram in the emergency room had revealed ST elevation in the inferior and lateral leads which suggested a large inferolateral myocardial infarction in progress. If he were to present in a similar fashion today, he would probably be whisked to a cath lab for an acute intervention with the hope of preserving the inferior wall of the heart that was in the process of dying probably because of an acute blockage of the right coronary artery, or in ten percent of patients the far end of a very long and dominant left coronary artery. In 1968, he was taken to a cardiac unit where he was monitored and given morphine for his pain. All this had occurred almost two weeks before I saw him. In those days it was standard practice for patients with his sort of injury to spend about three weeks in the hospital with their activity for most of that time limited to bed rest or sitting by their bed in a chair. Now it is possible to be home in a few days. Sitting in a chair by his bed was where I found Mr. Hart. The experience was entirely the story. His physical exam except for being overweight was normal. I was thrilled by the opportunity to see him and examine him “on my own.” He was quite gracious in his toleration of all my questions and my fumbling rookie exam.
My second encounter with a patient did not go so well. It was in the outpatient clinic of the Mass General. My instructor was an endocrinologist who would several years later be my colleague at Harvard Community Health Plan. The patient was a woman in her early seventies who had come to the clinic complaining of joint pain. Her physical exam was quite normal. There was no physical or laboratory evidence of an acute or chronic inflammatory disease. I talked with her for over an hour. I learned about all of her family problems and disappointments in life and developed the idea that she was isolated, lonely, and depressed. After I had finished the conversation and examined her, I stepped into the hallway and “presented her” to my instructor. He suggested that we give her Darvon Compound for use as needed for her pain. She seemed happy and left without complaint about the two-hour process. The next step was where I failed. I had to “write her up.” My write-up was a disaster. I tried to record everything she had told me. My instructor was kind. He invited me to come to his apartment in the evening so that he could tutor me on how to do an effective write-up of a history and physical. I had never been in the position of needing “extra help” from a teacher, but felt so lost that I was delighted to accept his invitation although it seemed unusual to be going to his apartment at night. The visit was a positive experience for me, but I feel like it was a ruined evening for his wife who busied herself in the kitchen while I consumed more than an hour of his time in the living room. In retrospect, being invited to my instructor’s apartment was perhaps the kindest thing that ever happened to me in medical school. Your head may be full of facts, but organizing the information in a way that is a useful document for others to read is a separate skill that is fundamental to the care of the patient.
There were many other memorable moments in medical school and many more that have been forgotten, but I will briefly share two other stories that occurred during elective rotations at the Mass General. I entered medical school with the idea that I might want to be a surgeon. During the summer between my first and second years in medical school, I secured a position in the lab of Dr. Gerald Austin who was then the chief of cardiac surgery at the MGH. During the summer of 1969 between my second and third years in medical school while Neil Armstrong was walking on the moon and Ted Kennedy was driving off the Chappaquiddick Bridge, I was in London working in the lab of a surgeon at the University College Hospital.
My core surgical rotation was at the Boston City Hospital, and it was my first rotation after “Introduction to the Clinic.” Surgery at the BCH was an excellent experience, but then I really enjoyed my medical rotation at the Peter Bent Brigham Hospital and my pediatric experience at Children’s Hospital. After my psychiatric rotation at McClean Hospital, I was really confused about what I wanted to do. To test my enthusiasm to be a surgeon, I decided to take a couple of surgical electives. I signed up for an orthopedic elective at the Massachusetts General Hospital followed by a general surgical elective with the famous MGH surgeon, Dr. Claude Welch.
I really enjoyed the orthopedic experience primarily because I was tagging along behind an excellent resident, Dr. Lyle Micheli, who was later to become well-known as an authority in Sports Medicine and is still a professor at Children’s Hospital. Late one evening, Dr. Micheli was called to the EW to see a woman who had presented to the emergency room with leg pain which was revealed by x-ray to be a pathological fracture likely secondary to a metastasis from a tumor to the tibial plateau of her left leg. Dr. Micheli examined her leg and then left to attend to some other patients while I did her admission history and physical.
She was a very shy unmarried woman in her mid-fifties. During my conversation with her about her symptoms and her social history, I developed the sense that she was a socially isolated woman who led a very cloistered life. She had worked for years in a clerical position in a small company and lived alone in a small apartment in a “triple-decker” in one of Boston’s lower-income neighborhoods. Things went well until I began to do the physical exam. She was sitting on a gurney in a hospital gown with her arms crossed over her chest and breasts. She refused to let me listen to her heart. After some time she finally agreed to let me lower her “johnny” enough to complete my exam. The moment that the johnny came down far enough for me to put my stethoscope on her left chest I encountered a rock-hard raw mass that was firmly fixed to her chest wall where her left breast should have been. There was a remnant of recognizable breast tissue that could still be seen. She said, “I didn’t want you to see my problem.” I stepped back to catch my breath as the conversation continued. She told me that she had first noticed a “lump” a few years earlier, but she was too embarrassed to show it to a doctor. As the mass grew, she had been increasingly concerned that she would be castigated for waiting to get care, so she continued to avoid getting help. She had tried to keep the area clean and would not have come for care except for the pain in her leg that made it almost impossible to walk. I excused myself from the room to search for Lyle to tell him what I had discovered. I remember him coming in and gently examining her breast while telling her that he was very glad that she had had the courage to come for help. It was a moment that revealed to me just how complicated and challenging it was to care for people. What was her primary problem? What personal history had made her so afraid to get help when she first discovered the lump? I never had my questions answered, and I never saw her again because her admission was quickly switched to the medical service. But, I have never forgotten my surprise and my sense of inadequacy, and what appeared to be her sense of shame when she slowly lowered her johnny. What passes between a patient and a caregiver can be more confusing and difficult for both parties than the search for the answer to obscure symptoms.
Not long after the orthopedic rotation, I had my month with Dr. Claude Welch. He was a very dedicated old-time doctor who was also an important contributor to the New England Journal of Medicine and a national leader in surgical circles. Someone has written an incredible review of Dr. Welch’s life and work in his Wikipedia bio. You should take a look at it, but in case you don’t I have lifted some lines which provide a good description of who he was.
While there is no doubt about his skill with a scalpel, he set himself apart from other surgeons by establishing and maintaining a superb rapport with his patients – something he considered essential to good patient care. Beyond the operating room, Welch fought for racial equality at the American Medical Association (AMA) and to establish standards for American Medical Practice. Welch considered these items among some of the most important things he did.
“His intelligence, diligence, attention to detail, restraint leavened with generosity, caring and a touch of humor brought him the trust of his peers and a succession of assignments, the summation of which truly characterizes him as one of the great surgical statesmen America has produced.”
Dr. Welch was an imposing figure who attracted patients from far and wide. Every time I saw him he was in heavily starched and tailored surgical scrubs with a short jacket that had something like a “Nehru Collar.” There was a lot to learn from going on rounds with Dr. Welch. He began his rounds at 6 AM and was in the operating room by 7 on most mornings. His resident was expected to be able to present all the recent data on every patient that Dr. Welch would see on his early rounds which meant that the resident and I had to begin the “pre-rounds rounds” no later than 4 AM. After a couple of weeks, the novelty wore off for me, and I began to question whether or not I really wanted to be a surgeon. The idea of spending several years climbing a very regimented hierarchical ladder balanced against the joy I had experienced in medicine and pediatrics got me thinking about whether being a surgeon was what I really wanted to do with my life. I am so happy that there are those who are willing to put in the years necessary to become skilled surgeons. They deserve our respect for the great skills they develop during those long years. I am very happy about my experience on Dr. Welch’s team because it helped me find my “true calling.” The experience was timely because not long after my time with Dr. Welch it was time to begin thinking about my internship.
The Best Time of the Year For Sunsets
My favorite time of the year is summer, and my favorite time of a great summer day is the evening. My favorite part of a summer evening is the sunset. There have been few spectacular sunsets this summer, and that has been disappointing. For a great sunset, you need a scattering of clouds to reflect the dying light. The problem this summer is that there has been a heavy cloud cover on many of our evenings even when it is not raining.
My deck faces East across the lake. My wife often wakes up early enough to see the sunrise. After fifty-plus years of rising early enough to get to the hospital before office hours at 8:30 or a 7 AM management meeting, I am not going to apologize about the reality that these days I am often still in dreamland at nine in the morning which means that I seldom take advantage of our sunrise view. Since the sun sets behind us, I need to be on the water in my kayak to see the orb drop below the horizon, but witnessing the sun itself is not what I like most. My pleasure lies in the spectacular colors that occur just as the sun sinks out of view. That view just requires that I look up toward a sprinkling of clouds that are reflecting the last rays of the sun.
I can count on the fingers of one hand the number of perfect sunsets that I have seen during this very unusual summer of global warming. One of the most spectacular sunsets I have seen this summer was in Boston as our plane landed on our return from Europe in June. It was just six in the evening but it was dark. That evening the sky was an eerie and hazy red from the smoke produced by Canadian wildfires that were hundreds of miles to the north and west. It was pretty, but the origin of the beauty was a man-made mess attributable to global warming.
Early this week we had an evening with just the right partial cloud cover to set up a picture-perfect sky which you can see in today’s header. Unfortunately, the next three evenings the sky has been obscured by a thick blanket of low-hanging clouds. Almost every day, as I look at the weather forecast on my i-Watch, I see nothing but the little emoji for rain for days on end. As I said earlier, if your favorite part of summer is its gorgeous evenings this summer has been disappointing. What worries me is what is yet to come. I would like to think that this summer of disappointing evenings is an aberration, but I fear that it may be the beginning of a new reality. Maybe next summer it will be even hotter which translates into more clouds and rain where I live. My response to such a gloomy possibility is to enjoy the few nice evenings that do come along from time to time.
I hope that you have some spectacular evenings this weekend. The sixth extinction may include the elimination of great summer evenings so catch one while you still can.
Be well.
Gene
