Medicine For People!

April 2014: Good Doctoring - A Mission in Life

The Doctor Luke Fildes

Five Lessons

  1. It Takes More than Training
  2. They have got to Love the Job
  3. Beware the Zealot
  4. Where there is Wheat, there is Chaff
  5. Human Beings Are Complex

When as a child I had a worrisome fever, our doctor stopped by our apartment to examine me. When I cut my eyebrow on the coffee table, my mother and I met him at his office after supper for stitches. He was calm, competent, and completely reassuring to five year old me. So at an early age I decided this was what I wanted to be. A two or three month stint in the hospital at the age of 11, including three surgeries, only strengthened that conviction.

Throughout my 40 year journey through medicine, I've learned a few lessons that I think could be useful to you as a patient. So here are my five lessons for excellence in medical care.

1. It Takes More than Training

After a rigorous three years of pre-med classes during the day and lab work during the night, I entered Duke Medical School. I focused so hard on learning medicine that I little recognized what a robust education I was getting. Now I can look back and see that most of my professors were truly erudite men and women who stopped at nothing to make a diagnosis or to treat some rare and unusual illness. They really did devote every ounce of energy and intelligence to relieving suffering. They exercised real creativity in their work, not seeing it as a 9-to-5 job but as a mission in life.

So that's lesson one. Medicine is not just book knowledge and training; it's built from the attitude, attention, presence, and focused performance I saw in the best of my professors.

2. They've got to Love the Job

After med school, I took a year of general medical and surgical internship and another of pediatrics in the San Francisco Bay area. All that time, I couldn't stop thinking about a patient I had met near the end of my training at Duke. He was about 55 years old and had just discovered he had pancreatic cancer. One day, as I stood at his bedside, he mused sadly how he had worked so hard and looked forward so long to the enjoyments of retirement, now so cruelly snatched away. I was only 24 year old when I earned my medical degree, young and idealistic enough to be disillusioned with how things were going. I was still felt fatigued from the stress of med school and internship. That dying man's regrets echoed in my mind.

So I worked in an emergency room long enough to fortify my bank account and bought a 30 foot trimaran sailboat. I spent two years sailing all over Puget Sound, up around Vancouver Island, and eventually down to Monterey Bay in California. At that point, my bank account empty, I went to work substituting for doctors who were ill and needed help with their practice. After about three months of that, and it was hard work, the realization struck me that I was happier practicing medicine I had been sailing around on the sailboat.

So that's lesson two of my long journey. Any profession or occupation can truly bring a person happiness depending upon the inner state of the individual. And the advice I give to you as patients is this: if you are being cared for by someone, be they doctor, nurse or candlestick maker, it is rational and reasonable to expect that they will be content to care for you. If they show unwarranted impatience or disrespect, or appear disinterested, don't mistake this for professionalism or high intellect.

Once my brother traveled to Houston for heart surgery at a world-famous hospital. He called me that night to tell me what a disappointing experience he had had. He had seen physicians, nurses and technicians, was scheduled for surgery the following day, and felt everyone was just going through the motions. After we talked, he did something very difficult-he dressed and walked out of that hospital, leaving them with an empty surgery suite the next morning.

3. Beware the Zealot

Now back to the end of my sail to California. At that time, I made friends with a talented chiropractor. He had excellent hands-on skills, and the same dedication to his patients I'd seen in my professors at Duke. I took classes from a touch for health practitioner with a world reputation. I have taken many courses over the decades, and frequently come back with a new toolbox chock-full of new healthcare tools. Then I try out these tools in the context of my existing methods. Sometimes they are an improvement. Sometimes the new tools turn out to cost too much, are inefficient, or are not really better than what I already do. This is true of courses in surgery, psychology, and alternative and natural medicine.

I have run into healthcare practitioners who have one or two of these toolboxes and mistake it for a whole workshop. You can identify them by their zeal for their methods. They have not discovered that each of us is so individual that there is no one toolbox or school of medicine or worldview that works for everyone.

And this is lesson three. Beware the zealot. Beware the person who can measure every problem with one ruler. Beware the healthcare provider who fits every question into one system, who never says "I don't know." The very best physical therapists I ever ran up against were Sven Solvik and Sarah Grossman. They were both curious problem solvers. I remember Sven finishing his diagnostic tests, sitting silently with a puzzled and faraway look on his face, and then relaxing as he reached an understanding and began to tell me what to do.

4. Where there is Wheat, there is Chaff

Early in my career I learned to ignore the propaganda-laced free pharmaceutical company educational meetings. Developing my personal educational track, I took courses in nutrition, naturopathic medicine, AyurVedic medicine from India and many more. I learned much, but also discovered that alternative practitioners and methods carried shortcomings and warts as did western medicine. I became very discriminating about where I sought continued education, and found particular benefit from courses at the Mayo Clinic and from the top naturopathic doctors in the Puget Sound area. I learned to cherry pick from the best of both worlds. Each time I gained prospective tools for my workshop and as the months passed after each course, I learned how to integrate the best of those into my work. The true pearls of medical knowledge came from my colleagues in the various specialties, from the medical journals, from the latest editions of medical textbooks, and from my experiences with my patients. But nobody was right all the time.

So, lesson four. There is wheat and there is chaff everywhere in medicine as there is in every other part of the human world.

If you were to ask me what kind of doctor I am, I would say "cherry picker". I would say, "One who knows how to avoid the thorns."

5. Human Beings Are Complex

You may know about the hookworm, a parasite that was prevalent in the southern United States. These worms mature, mate and lay eggs in the human intestine. Before people had good plumbing or outhouses, they would defecate in out-of-the-way places allowing the eggs to enter the soil and hatch into larvae. When a barefoot person walked by later, the larvae would pass through the skin of their feet and enter the bloodstream. The larvae would leave the bloodstream and enter the lungs, there to be coughed up and swallowed to live their adult life in the intestine and start the cycle over again.

This scourge has largely been ended by modern plumbing and shoes. So the hookworm is an unadulterated menace to human health, yes? Not so fast. Recent years have brought the recognition that some people do not tolerate well the absence of parasites from their gut. After all, during our evolution most of us carried various parasites. Unlike other animals, we have gotten rid of most of ours. Our intestinal lining, which has evolved to carry on a continuous minor skirmish with these parasites, in some people develops an imbalance and begins to attack itself. The results are horrible diseases which result in bloody stools, difficulty controlling bowel movements, loss of energy and weight. We've not had unparalleled success with pharmaceuticals. In the past decade or so, enterprising doctors have discovered that when they introduce a limited number of hookworms into the intestines of these sufferers, their symptoms often go away.

Here's the last lesson I'm going to give you today. Long ago the genetic material from your mother and your father recombined in a unique and individual way that gave rise to the unique and individual person you are. You are not unique just in the way you look or the way you think or the way you feel. Your very metabolism is like no one else's. Just as hookworm might be harmful to one person or beneficial to the next, any medicine or surgical technique you undergo needs to be chosen with care to match your unique and individual needs.

The doctor who cared for five year old me embodied that customized and human approach to medical care. I feel very lucky to be able to follow in his footsteps.



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