Popular shows like Gray’s Anatomy, ER, and House, MD have given the television watching public a good eyeful when it comes to the inner workings of medicine, hospitals, and emergency rooms. They have also shown us how the personalities of those who take up the stethoscope and reflex hammer run the gamut from the sweet, demure, tentative types to the sons of bitches who cut first and ask questions later.
I can look back and remember a few attending physicians who trained me and shaped me and sometimes scared the hell (and a good night’s sleep) out of me.
The first one who always comes to mind was Dr. B, who served as my attending on a medicine service at the Veterans Administration hospital when I was a junior medical student. For those of you unfamiliar with the medical hierarchy, a JMS is one step up from a one-celled organism in the pecking order in any hospital. As a JMS, you did all the grunt work, drew blood cultures in the middle of the night on febrile patients, wrote up admission histories and orders by hand, and always had a well-worn copy of Harrison’s Principles of Internal Medicine close by.
The medical services at the VA were always busy. The patients were interesting but very sick, and you were very lucky to get less than a half dozen admissions in a night. Before rounds first thing in the morning, a JMS needed to have his ducks in a row for Dr. B. That meant doing an exhaustive history, gathering collateral information from old charts and family, doing a thorough physical exam, writing up the H&P (history and physical) by hand, writing admission orders, collecting lab samples if needed, running down x-ray films and lab results once they were completed, reading all you could find about the illnesses your patient had, and then gathering all this information in your hand and head to present it to the resident, chief resident and attending in rounds.
Dr. B might pick you to formally present your case, or he might pick someone else. One of his eyes lazily rolled outward and never quite focused on anything, so you never knew if he was looking at you or the pitiful creature next to you, even when he was gazing your way. This was unnerving and terrifying. Plus, he had a very deep voice that was controlled fury. Sometimes it rose to thunder pitch, but usually, it was soft, low, growling and oddly soothing. Sort of like the low growl a rabid dog makes as it looks at you with rheumy eyes, just before it bites you.
You’d better have everything that a good physician would need to treat your patient by 6 a.m. the morning of rounds. You’d also better have the esoteric stuff like viral titers and preliminary results from toenail fungus cultures and ionized calcium values. (I’m only partially kidding.) You’d also better know why you had and knew these things. Simply spouting off the numbers didn’t cut it with this man. He knew when you were blowing smoke, and he would blow it right back in your face, with more fire to boot. When you were finished, and he had grilled you to a nice char on the outside (still rare and tender on the inside — we were still medical babies at that stage, after all), you were lucky to get a thank you, much less any other feedback. He left that to the house staff. The thing you were sure of was that you had presented a case to Dr. B, maybe your first, maybe your thirty-first, and you had another t-shirt that said “I Survived Rounds on Medicine at the VA” on it.
The second physician attending who will always hold a place in my mentor hall of fame was my boss on a GI surgery rotation, also in my third year of medical school. By that time, I was already well aware that there were no gall bladder surgeries or trauma calls in my professional future. My personality did not match with the surgical workflow or lifestyle at all. I was (and am still) more introverted, introspective, quiet, and analytically oriented, and the smell of cauterized flesh and the shrill sounds of a Stryker saw going through bone still only occupy archival gyri in my brain.
At any rate, this man, short, fire-pluggish and prone to wearing the loudest colored jackets he could find when off duty shepherded me through the surgical learning process. I learned exactly how to scrub in, I got pretty good at gowning and gloving, I could hold a mean retractor, and I even learned to throw a few sutures and tie a few knots by feel alone. I got a chance to put that first year of anatomy to practical use in an OR.
The thing I remember most about that rotation was the final. It was oral. With Dr. B. (Yes, another Dr. B.) He asked the expected questions about cases and procedures and techniques and surgical materials and pathology reports and labs. I knew what I knew, and it was enough. He then offered me the chance to take a stab at a bonus case for extra credit. What the hell, I thought. It turns out it was something about a patient who had diabetes and developed a post-surgical infection and other complications, something I could talk knowledgeably about. I passed the final and the rotation. He was not nearly as intimidating in the end as I had feared.
My third mentor was my department head. Dr. P was a disheveled, oddly dressed, greasy-haired cigarette puffing bear of a man who could walk into a room of a hundred people own it. He was crazy smart, had more books on his built-in bookcases at home that one human could possibly read in a lifetime (he and his chosen faculty had written several of them), and ran the department of psychiatry and health behavior out of his head.
Dr. P also demanded presentations of us. If you were tapped to do chairman’s rounds you knew you were in for a ride. You had to pick a case, know it thoroughly, present it cogently and succinctly per a rigid outline, come up with a diagnostic formulation, defend a diagnosis, and then intelligently expound on a reasonable treatment plan. There were no shortcuts. This man knew it all and had most likely written the book or was drinking buddies with the guy who had. It was a terrifying rite of passage for all residents in my program, and once you got over that hurdle, you were on your way.
These three men were harsh, belittling, brutal, demanding, keenly intelligent, exacting, and expected nothing short of perfection. I know now that they knew that was not possible, especially from a junior medical student, but I didn’t know it then, and that’s what mattered. When you presented a case or explained a diagnosis to them, you had to know what you knew, but also why you knew it, why you needed to know it, and then show that you could present that information to others in an easily understandable way. No easy task for a greenhorn in medicine.
Doctors can be imposing, blustering, narcissistic people. They can be hard to approach.
But you know what? Most of them, even the Dr. Bs and Dr. Ps of the world, are worth getting to know.
Years later, I was sending consult reports from my private work with patients, and I came across some office notes of Dr. B’s that I needed to review before making my recommendations. He had left out a couple of pieces of critical information that I needed to complete my work. Imagine that. It made me smile.
I was leaving the house after meeting with some church friends for a planning meeting and dinner. My mother had recently been diagnosed with breast cancer and was going to have diagnostic testing and treatment soon. I was upset, fearful, anxious. One of my friends followed me out onto the porch. He could tell that I was struggling.
“I’m not sure what to call you. Father, Joe, Dr. B …” I trailed off.
“Any of those will be fine,” he said softly. “Would you pray with me, for my mother,” I asked him, tears already forming in my eyes. The GI surgeon, now an Episcopal priest, took my hands in his and prayed for my mother, and for me.
I had been at the residency training program during a time of sweet harmony, everyone working on what they loved, a good strong faculty full of energetic people who loved to treat and teach and write and study. Dr. P was at the head of it all, doing deals and running things seemingly from his own head, remembering everyone’s name and a what they wanted and needed.
One bright sunny morning, as he was cresting a hill in his little Volkswagon, he turned against traffic, blinded by the morning sun. He was not wearing a seatbelt, and the impact ejected him from the car. He did not die right away, but the larger than life man that we all knew, the quirky, smoking, pompous, wonderful man who had trained us all to love even those who could never love us back, was gone.
I sat in my car and cried like a baby when I heard the news.
Greg Smith is a psychiatrist who blogs at gregsmithmd.
Image credit: Shutterstock.com