Medicine For People!

February 2011

Duke University Hospital

The Making of a Doctor

The Interview

Thirty-five years ago, I found myself outside a room on the second floor of the medical school building, a naïve young man hoping to make a good impression at my interview for medical school admission. Not only had Duke University made me no promises for the future, they had gathered all us "pre-med" students in the auditorium on the second day of orientation to describe the challenges ahead. Then the professor asked each of us to look at the person on the left, which we dutifully did. "Look now at the person or your right." Several hundred heads swiveled to the right. Then came the punch-line: "Only one of you is going to make it into medical school."

So I waited in that hallway with some considerable apprehension. I'd been working towards this day since the age of eight, and wanted so much to get on with the anatomy, the microscopes, the community of doctors, the patients with all their subtleties, the hard work. I was hooked.

The Short Life of a Cheap Suit

Low on cash but desperate to make a good impression, I had bought the cheapest suit I could find. Wearing my new purchase, which hung on me like a scarecrow's clothes, I entered and sat at one end of a table facing six medical school professors. The profs quizzed me about my qualifications. I was unaware that the deck was already stacked in my favor. I had a night job in a research laboratory with an assistant professor, important in my young mind only as my boss and chief source of income, but who pretty certainly avowed I had the work ethic of a bulldog along with an obsessive nature, both assets to a medical student.

As the professors quizzed me, I began to sweat profusely. I had forgotten my handkerchief, so I wiped a generous palm full of perspiration from my forehead, and not wanting to lean down to wipe it on my sock, I dried my hand on my pant leg under the table. Later dry-cleaning of the suit never removed that stain.

The final question was, "Well, if we let you in, you are going to need financial assistance. Would you rather we give you a loan or a scholarship?"

"Whichever it is, I'll pay you back." (Which I did, but you gotta love the military kid upbringing; the correct answer was built in.)

To my surprise, they asked if I had any questions for them. Unprepared, I blurted out the only thing on my mind. "Are you going to take me?" At the other end of the table, Jerome Markee, our chain-smoking anatomy professor, smiled kindly and said, "Well, I can't say. I'm only the chairman of the committee. But I don't think you have much to worry about." Later the letter came, admission and a full-tuition scholarship, so the sweat-stained suit could retire with honor.

Anatomy Class

The first hurdle in med school was facing the cadaver. Dr Markee gave us what I'm sure he thought was an unforgettable speech, perhaps about how we were about to embark upon our career of saving lives by learning from the dead. After all these years I've forgotten what he said. At the time, the only thought in my mind was, can I do this without fainting or otherwise embarrassing myself. Can I do it at all? The way we all got by was to distance ourselves, and this was easier because our aged human body marinated in preservative didn't really remind me of anyone I had ever known. Most of the bodies were African-American, a few white, but after a certain amount of dissection the difference wasn't apparent.

We spent much time taking these bodies apart, bit by bit, and spent our breaks by the lecturer's blackboard, co-opting it for a game of "guess that quote." Someone would write "Mistah Kurtz, he dead." And several voices would cry "Heart of Darkness, Joseph Conrad." And before the phrase "Tis a far, far better…" could be finished, a general chorus of "Tale of Two Cities." After several weeks the quotes got pretty abstruse and the answers slower. At least this game got our minds far away from what we were doing in that room.

The final months at Duke Medical School were shadowed by my realization that I was starting my residency on July first. I'd add up the months, and think "Four months ‘til July, and I don't know anything." Then "twelve weeks ‘til July, and Duke medical school is making an awful mistake." I didn't dare tell anyone, wanting to take the next step, but fearful.

Internship

Soon enough I'd gotten to and through the first months of my internship without harming anyone and I found myself part of the emergency room night shift in a tough Oakland neighborhood. As an intern, I was expected to care for most patients without help. Once in the fray, the sense of inadequacy disappeared. I was buried under endless hours examining people who had been shot or stabbed; sewing up all kinds of lacerations; stopping the bleeding; and giving mouth-to-mouth respiration. In the ER we brought a few people back, but not nearly the percentage you see on television.

In those days before AIDS, while we protected patients from infection, we didn't pay much attention to ourselves. Somewhere in there I picked up a silent case of hepatitis B, probably through exposure to vomit, blood, or some other bodily fluid doing CPR in the ER. I discovered this only years later when a blood test revealed the disease had come and gone uneventfully.

Real World Learning

How much sleep we got at night I couldn't tell you. Every third night I slept in the hospital and was awakened many times each night for some emergency great or small. I relied not just on what I learned in medical school, but what I discovered outside the hospital walls. For example, when we learned CPR in school, the first step was (and still is), to open the airway. One rare weekend off, we were skiing in the Smoky Mountains, the day just after a thaw and a freeze, so the slopes were hard as iron. I was heading down the slope when a man ahead of me crashed to the surface and skidded down the hill in circles until he came to a stop, motionless. My heart pounded as I reviewed the protocol. I skidded to a stop beside him. His eyes were closed, he was completely motionless. Step one, I thought, open his airway. I kneeled down and put two fingers into his mouth. Immediately he spit them out, opened his eyes, and sputtered "What the hell are you doing?" I don't think I made any kind of coherent explanation, just got up, skied down the slope and tried to avoid him the rest of the day.

So as an intern, I didn't assume that first appearances were correct. Once I was called at 2 am by a new nurse, reporting a female patient who appeared to be in cardiopulmonary arrest. I rushed down to the room, yelled into the patient's ear, shook her shoulder, and was gratified to see her eyes very slowly open. She had some problems, yes, but didn't require CPR.

Becoming a Doctor

One thing I learned along the way is that becoming a doctor was not about being a hero or developing superhuman capacities. It only required getting up every day to go in to training. It meant paying the best attention I could, even when I was tired, studying as long at night as I could force myself to, and accepting whatever task or critique I was given. Of our eighty entering students, about 10 percent left, usually from emotional complications.

Becoming a doctor isn't a run at being Einstein. You want a doctor who can remember things, solve problems, not give up when challenges come, remain emotionally stable in sometimes trying circumstances, and make judgments, usually based on incomplete information some of which may well be incorrect. Medical training as I experienced it in the 1960's and early '70s did come close to accomplishing that. From that first sweaty interview until now, I've never regretted taking it on. Thinking back to that interview, at one point one of the professors asked why I wanted to do it. Why did I want to become a doctor, which for me at that time was like asking the Wright brothers why they wanted to fly. I stumbled through several answers, only to be asked the same question again. Finally I stammered that I thought it would be a worthwhile challenge. Half a dozen older heads swiveled as one and looked at me. Today I'd still have trouble telling you why that is the correct answer. But it is.

story: Medical Training Back in the Day, September 1965

Medicine for People! is published by Douwe Rienstra, MD at Port Townsend, Washington.