Medicine For People!

March 2008: Evolution of a Doctor

"In the measure to which I think and speak not from my own individual conviction but simply repeating what 'is said' and 'is thought' my life ceases to be mine, I cease to be the supremely individual person that I am, and I act on society's account." Joes Ortega y Gasset (in my twenties, my favorite quotation)

Evolution of a Doctor

"We Loved Him Just the Way He Was"

I am a young medical student at Duke University observing a team of pediatric cardiologists in the cath lab. A small, frightened child bawls. Beside him the pediatric cardiologist sits patiently with his stethoscope on the tiny chest. In the silence between the child's cries, he calmly describes the sounds made by this diseased heart. "A systolic murmur, loudest at the base, probably from the aortic valve. A constant murmur left back, probably a patent ductus arteriosus. Some stenosis of the pulmonic valve."

I admire these pediatric cardiologists immensely, knowing I'll never attain their degree of skill. In the middle of a hurricane, these guys could hear a clock ticking in the house next door.

To pinpoint the defect, the doctors insert a catheter into the child's groin and thread it up to the heart, inject dye and take a very rapid succession of X-rays. The procession of film cassettes, each one a heavy metal frame holding a piece of X-ray film, rapidly rattles down two sets of metal tracks to the exposure points behind and beside the small patient. The complicated loud chattering noise reminds me of a machine gun or early experimental aircraft.

With the clattering beating around us, all eyes focus on the various monitors. Suddenly one monitor shows the heart rate dropping frighteningly, from 120 down to 80, to 60, then to nothing. Pushing the equipment out of the way, six doctors bend over the tiny body, calling for medication, pressing on the little chest, and glancing at the line staggering across the monitor. They work frantically to no avail. Finally they give up. The child is dead.

I walk out in the hall with the cardiology fellow, a woman, whose job it is to take the terrible news to the parents. The mother is grief stricken. She sobs in the hallway.

"I'm sorry, Mrs. Ashton, but we did everything we could."

"Why did you do it? There was nothing wrong with him when you started." She is wailing, her sobs echoing down the hall.

"Please, Mrs. Ashton, not so loud. His heart was diseased. He couldn't play, or run. Unless we discovered what was wrong and repaired his heart, he would never have grown up at all."

"We loved him just the way he was, why did you have to do it? There was nothing wrong with him, he was good the way he was!"

I was used to seeing patients stoically and without question accept the doctor's wisdom; all this noise in the hallway surprised me and the cardiology fellow. All that I admired in the cath lab – the impressive X-ray apparatus, the high tech skills – meant nothing to this mother. As far as she was concerned, we'd killed her child.

In the past 30 years since I stood in the hall listening to the mother's loud sobbing and sensing dimly that the balance between technology and humanity was out of whack, medicine has changed and I have changed. Sometimes people ask me how I came to be the independent-minded doctor that I am. In this month's newsletter, I tell about my medical evolution, starting with my beginnings as a young, wide-eyed idealistic newly-minted doc.

Regrets and Objections

For some time after I graduated, I regretted having attended medical school. True, the professors were usually dedicated and kind, but the system as a whole seemed lacking.

How it seemed to me in the early 1970's was this:

Doctor-centered medicine: For all my professors' curiosity and attention to detail, they did not always listen to what the patient was saying or appreciate what the patient was going through. Some people call this "medico-centrism," the idea that sick people eagerly await the doctor's next pronouncement and have nothing they'd rather do than agree and be grateful, regardless of any ill effects.

Over-emphasis on technology: Here's an example. I could tell from a physical exam when a patient had pneumonia, but I was supposed to order a chest X-ray and blood tests anyway. Those tests can be lifesaving if a case is grave or complicated. They are not necessary in many cases I saw and still see on a regular basis. With my thrifty Dutch background, this lack of concern about patient cost bothered me.

Inaccessibility and arrogance: My partner in Milwaukee made every patient who telephoned him at the office wait on the phone at least twenty minutes. We had five lines; all five buttons on the phone were usually flashing with patients on hold waiting to talk to him. Once on the phone, he spoke as if he had just come out of a burning building and had to go right back in again to save another life. About once a week he felt like chatting, so he'd come into my office, sit down and, despite the flashing lights on the phone, the full exam rooms, the full waiting room, talk as if we were on the golf course and he had all the time in the world. Whatever the reasons, doctors were in a hurry with patients, the result being an occasional missed diagnosis or ill considered treatment. All the expensive tests could not make up for this.

Bias towards intervention: Although the physiology classes in medical school touched on the body's natural healing systems, these were often ignored when it came to treatment. In the delivery suites, for example, the process of birth was attacked as if the baby were an enemy who wasn't coming out without us going in after it.

Narrow-mindedness: Mainstream medicine seemed arrogant. My professors expressed the opinion that no other medical methods were worthwhile, yet as far as I could see they knew nothing about botanical medicine, Native American medicine, Chinese medicine or anything outside their own narrow sphere.

Ignoring Self-Care: In mainstream medicine little attention was paid to the health of the physician. How, I wondered, could physicians help their patients with their mental and physical well-being when they paid so little attention to their own? And patients asked in vain for advice on how to take care of themselves. Unless they were happy to pay to hear the doctor say "a healthy diet and more exercise," they were likely to be disappointed.

Finding Dr Welby (Where You Wouldn't Expect)

I came out of med school in the late 1960s, a time of reexamination of the previous generation's values and I was very much swept up in that rebellion. The disillusionment outlined above led me away from medicine for a time. I didn't want to use the cookbook given me in medical school. If I couldn't be Dr Kildare, Ben Casey, or Marcus Welby, I'd sail off into the sunset instead. You can read more about "The Long and Winding Road" in a previous newsletter.

By the time I came back to medicine, I had learned to meditate and found it valuable. As Rabindranath Tagore writes, "The mind all logic is like the knife all blade. It cuts the hand that holds it." For me, meditation was a wonderful handle. Too, during my time off I'd done some reading about herbal medicine. I took some courses in polarity therapy, an early combination of Ayurvedic medicine and touch therapy. To my amazement, much of this had some beneficial effect, even for serious problems such as asthma. My friend Fritz Smith, MD, who practiced acupuncture, collaborated with me. He had developed his own technique of bodywork called Zero Balancing and taught that to me. One evening in the hospital, a nurse complained about a severe back-ache. In a treatment room I gave her a five minute treatment that totally relieved her back pain. I was as surprised as she was.

At the same time, I discovered a joy in using the skills I had learned in my training. I might not be Dr Welby, but I could do what was possible and bring comfort. I was drunk, both on conventional medicine and on all the new things I was learning. Rejuvenated, I recognized the rough jewel I had been given at Duke Medical School.

The Kiss of the Spider Bite

There was one major problem. The docs who hired me to join their practice were not similarly enthused. While one seemed interested in acupuncture and meditation, he thought I went overboard to recommend it to patients instead of anti-depressants or Valium. When I gave patients unconventional advice, they weren't happy.

I remember one woman who came in with a red spot on her forearm. I questioned her, examined it, and told her that she had a spider bite. No worries, there was nothing we needed to do. It would go away on its own. She got angry and said "You mean I came in here and paid for your office call, and you're not going to give me any treatment?" I looked at her, I looked the bite, and I lifted her arm up and kissed the bite. Now, in this day of HIV and gloves on all the time, I know that sounds homicidal or suicidal. Back in those days, however, while we wore gloves for surgery, we didn't have all the infection control practices we have now. Anyway, as I recall the patient laughed and seemed content.

Another time, a woman had a mild vaginitis. There was no evidence of infection, so I recommended a comfrey douche, something I'd seen work most of the time. She didn't have any access to comfrey, so I gave her my address and suggested she stop by and ask my wife to give her some from our garden.

A day later the senior doc in the group called me into his office and fired me. He'd heard about me kissing the spider-bite, he was unhappy with my practice in general, and he was incensed that I had some teenager out at my house practicing gynecologic medicine without a license.

Now, there was a simple explanation, but it took me a day or two to piece together what had happened. My wife and I were quite taken with meditation, so much so that we occasionally provided room and board for the local teachers and let them use our house as a meditation center. They had helpers to check the meditation practice of those who had learned. Having no study or other private rooms in our house, they employed an unused bedroom to teach and to check meditation. One of those young helpers was checking meditation on the day my patient stopped by for her comfrey. She arrived to find the front door open and some people sitting on the couch, so she sat down too. The helper finished checking one meditator's meditation, walked her out from the bedroom, then beckoned to my patient, saying "come in, let me check you." The patient, by now probably wondering if a simple medical consultation had run seriously off the tracks, concluded the young man wanted to give her a pelvic exam in the bedroom. He looked about 18 years old, and she'd already had one today, thank you very much, and what the hell was going on here. She drove back to the office to explode about all this to the senior doc.

Hence my getting fired.

As it happened, the next week my very stressed senior colleague had a heart attack; they called me up and asked if I'd come back to work. Within days I was back to practicing medicine.

This newsletter has already exceeded our usual length, so let's leave our story in Watsonville, California in 1975. Next month I'll share some more about my voyage though the jungles of alternative medicine, and how I came to the views and practices I use today.

story: Evolution of a Doctor, March 1968


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