Reflections in a Head Mirror

"The whole art of teaching is only the art of awakening the natural curiosity of young minds for the purpose of satisfying it afterwards."
-Anatole France      


On Aug. 15, I will have the opportunity to speak to the incoming medical school class at the Medical College of Wisconsin. Two hundred men and women will be starting their first-year classes and I will have a few minutes to talk to them as part of the ceremony where they will receive their first white coat.        

The “White Coat Ceremony” has been alternately praised and criticized in academic circles. It is praised because it emphasizes the role of compassion and an appreciation for the Humanities in Medicine. The ceremony reminds the students that they have a responsibility of "caring" in addition to "curing." The ceremonies have been criticized, though, because they sometimes seem self-congratulatory. Worse, some worry that the coat gives some students an irreversible sense of entitlement. Medical student bloggers tend to find the quality of the ceremonies inconsistent.

I have spoken to several medical students about their recollections of the White Coat Ceremony. By and large, the students are so animated about the entire process of starting medical school that any specifics about the speakers or the speeches quickly fade away. Maybe that’s a good thing.        

Personally, I remember waiting with my classmates to be called up onto the stage where the University President helped us on with our coats and then the Dean shook our hands. If anyone made a speech, I certainly do not remember.      

So, if you were in my position, what would you tell a roomful of first-year medical students? What do they need to hear just as they set out on their journey to become physicians? I look forward to your input. (Please select the Feedback link below.)

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The following is feedback received for this blog: Just tell stories. Tell the kind of things you write about. Don't tell them how to interpret them, just tell the stories. Usually the interpretation is plain enough. - Rob Lamberts http://distractible.org Make mental health something you address with every patient. Please join consumers (those with mental illness that pay for doctors, couselors, day care centers, community support systems and medicines) in their quest to have ample insurance coverage to help them with their diseases of the brain. - Anne Feyen Why not encourage them all to start a blog? Explain to them that blogging is a valuable way to influence health policy and improve the healthcare system. Everyone has a voice - and even Secretary Leavitt is listening. Counsel them not to divulge private patient information, but to chronicle their growth as doctors, so that people can understand what medicine is all about (the good, the bad, and the ugly). And if any of them are particularly good writers - tell them Dr. Val would like to recruit them to post to (and maybe even host) Grand Rounds! :) My two cents... - Val Jones www.revolutionhealth.com/blogs/valjonesmd When my mother came to Froedtert as a patient I thought this was the best hospital for her to be in. I don't know if I was right or wrong in my thinking. I have some mixed emotions on this while I waited for answers to questions and rarely got to see a faculty doctor. As a teaching hospital I know that having residents on call is how business is done. But I lament over the fact that faculty physicians are not visible. I think that being a good mentor means to be an example, and you need to be accessible and on hand to guide those students and residents. I know at an academic institution it is overwhelming for faculty physicians to teach, conduct research, practice, and sit on committees. As my mother's daughter my expectation is that the doctor, nurse and any other medical staff treat my loved one as they would their own mother, father, sister, brother or child. - Gail Please remind them to treat the whole patient and not just the symptoms. I live with a chronic illness and I ask my doctors often "what else can I do to be well?" The doctors seem dumbfounded at times by the question. Bruce, tell them that they are part of the healthcare team, the center of which is the patient and the family. Encourage them to always keep an interdisciplinary approach to caring for the whole person. But tell them in your own style, which embodies all of that. Good luck and enjoy the ceremony! - Susan Please tell them that there is a human being they are treating who has a disease. Treat each patient as you would want to be treated, with care and compassion. - Mary Fiegel There is only one thing I would tell young doctors: ALWAYS LISTEN. Do not only hear, but LISTEN. ! - Priscilla Paliwoda

"Two things are infinite: the universe and human stupidity; and I'm not certain about the universe."
- Albert Einstein


Several years ago, with alarms sounding in the background, I answered an urgent page. “Dr. Campbell, please come to Mr. Pearson’s hospital room immediately.” I dropped what I had been working on and headed to the floor.    

Mr. Pearson was in his mid-50s but he looked much, much older. Like many patients with cancer of the throat, he had started smoking as a teenager. His first cancer had been treated several years before and, despite strong admonitions, he had continued to smoke and drink. When the second cancer appeared, we made a last-ditch effort to remove it surgically. Now, a few days after that procedure, he was languishing in a hospital bed, attached to tubes, and too weak to move around.    

I got to the room. “What’s wrong?” I asked. “Is he all right?”    

The staff alternated between anger and relief as they told me the story.

One of the nurses had been walking past his room and smelled something burning just as the alarms began. She pushed open the door to investigate and, sure enough, there was Mr. Pearson trying to put out a fire that had started in his bed. Apparently, he had decided to have a cigarette and had accidentally ignited the sheets. She quickly moved him into a chair and doused the blaze. The room smelled of smoke, burnt cloth, and ash as staff and firefighters slowly finished cleaning up and went back to work. Fortunately, my patient was unharmed. I was amazed by the entire scene.

“What were you thinking? You set your room on fire! Why didn’t you call for help?” I asked.      

He shrugged. Gesturing towards the nurses, "I knew they would be mad," he said. "By the way, is there is a smoking area nearby?” he asked.      

Duh, I thought. “No, there isn’t.”      

“Didn’t think so.” He slumped deeper into the chair.    

A couple of days later, an administrator contacted me because they were thinking of filing criminal charges against my patient. As Mr. Pearson's health deteriorated, they reconsidered. 

What an incredible addiction is nicotine! We were fortunate that there was no catastrophe. It was a memorable day.

“Difficulties increase the nearer we get to the goal.”
-Goethe    



Have you ever noticed this, as well?  

When the kids were little and we were driving cross-country, they would play and bicker pleasantly all day long in the back seat. Things were not exactly peaceful, but there was an acceptable level of uproar that allowed for happiness in the back of the car and conversation in the front. However, it never failed that when it was time to find a gas station, locate a campground, or figure out how to find an address in some unfamiliar city, the noise level always seemed to reach deafening and distracting proportions.  

“How come you always get out of control just before it is time to stop?” I would yell. They would look at me blankly and sulk the rest of the way to our destination. "Bad Daddy," I would think later.  

Interestingly, I was reminded of our car trips one day while working in the operating room. The bilateral neck dissections were proceeding smoothly. Our goal was to remove all of the cancer-containing lymph nodes in the neck, especially adjacent to both jugular veins.   

The dissection on the right side went well although the cancer had grown directly through the wall of that jugular vein. In order to clear the cancer, we removed the vein, a maneuver that has no long-term side effects. I reminded the residents that we would have to save the jugular vein on the left because removing both veins almost always leads to complications.  

As we lifted the nodes off of the left jugular vein, my heart sank. Once again, the cancer had invaded the vein. My mind flashed back to images of a patient for whom I had cared during my own residency who had lost both jugular veins — his head had swollen up dramatically, his eyes swollen shut and his lips massively enlarged. The swelling took weeks to resolve. I never wanted to see that problem again.  

Suddenly, the radio was too loud and the normal operating room chatter became oppressive. The distractions in the room became overwhelming.  

“Could you please turn down the music?!”  

The operating room stilled while I continued to attempt to free up the vein. I dissected the mass from every angle, working to see if I could discover a hidden plane between the cancer and the vein. It proved impossible. Finally, I conceded that the vein needed to be removed.  

I had not encountered this exact situation in the past. Just to see what options might exist, I asked a colleague from Vascular Surgery to take a look at the vein. The surgeon scrubbed in and grafted a leg vein into the neck to replace the portion of the jugular that I had removed. The graft went in perfectly and flow through the vein was re-established. I was relieved.  

The case suddenly became routine once again. As we closed the wound, I noticed that things were very quiet in the room.   “You can turn the radio up again.”  The chatter resumed. Things were back to normal.  


Who would have thought that a day in the operating room could have the same long, routine stretches and brief moments of intense concentration as a driving trip with the kids? And that my reaction would be exactly the same?

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The following is feedback received for this blog: Great post. OF course, I am reading this right before a 8 hour driving trip to Chicago with two year old twins. At least I can think I am not in the OR in any capacity! - Christian Sinclair www.pallimed.org Interesting parallels... :) - Val Jones www.revolutionhealth.com/blogs/valjonesmd