My steps echoed in the hallway of the 17th floor of Bellevue Hospital as my head remained buried in the H&P my resident handed me only a few seconds earlier. Mr. W was a 64 year-old African American male with an extensive medical history including CAD with CABG, CHF with an EF of 30%, COPD, stage 4 squamous cell carcinoma of the lung (status-post chemotherapy and radiation), who was in his usual stage of chronically ill health until 3 days prior to admission when he began noticing shortness of breath and subjective fevers. Chest x-ray on admission revealed a right middle lobe pneumonia with an associated pleural effusion. He was given antibiotics without significant clinical improvement and repeat imaging revealed a near total collapse of his left lung. He went on to complete the antibiotic course for pneumonia without resolution of his lung collapse.
Tucking the H&P into my white coat pocket and entering his room, I was met by a warm, tell-it-like-it-is kind of man who immediately took to calling me “Dr. Doogie Howser” as a play on my last name and short stature. Although he was struggling to breathe, he managed to carry on a conversation as I got to know him and his story in more detail. He had recently found out about his left lung collapse and was awaiting a bronchoscopy, which he hoped would improve his breathing and “clear out the junk,” and after spending the morning with him, I was just as hopeful.
A few days later, as I sat behind the computer screen in the resident workroom, an inbox notification appeared for Mr. W. It was the procedure note from the bronchoscopy the day prior, and in clear black and white text it denoted findings consistent only with disease progression. At that point the realization slowly dawned upon me that his fate was inevitable. He was going to die from lung cancer. Whether it be in a few months or a year, the line in the sand had been drawn.
Each morning leading up to that day I had sat behind a computer, trending Mr. W’s lab results, reviewing notes, and learning other services’ perspectives on his progress, all in preparation to present his case on rounds. A large percentage of my time was spent staring at a screen, tracking Mr. W from afar. But on that morning as I walked into his room, I took the seat next to his bed for the first time, finally taking a minute to consider the world from his perspective. As he reached for my hand, the tears began to cascade down his cheeks.
Too often in the morning I breezed into his room, standing next to his bed asking about overnight events, the regularity of his bowel movements, and performing a review of systems and physical exam all within the span of several minutes. Day in and day out I was failing to ask about and address the most important component of his health – the condition of his spirit. Sitting down next to his bed that morning, I witnessed him facing the imminence of his own mortality for the first time. Suddenly the importance of tracking machines and lab values disappeared, and the true meaning of doctoring sat right before my eyes.
The philosophy of medicine, the art of deeply understanding what it means to be a doctor and a healer struck me as I sat with Mr. W that morning. In modern medical education, often the acquisition of knowledge and medical facts is the central focus, not necessarily the development of wisdom and insight into the complexity that defines man. I am reminded of Michel de Montaigne who profoundly wrote, “We work merely to fill the memory, leaving the understanding and the sense of right and wrong empty,” with education striving to make us learned, but not teaching us to seek virtue and embrace wisdom. Each day on the floor our minds are filled with knowledge, the latest-evidence, and principles of management. We derive benefit from the experience of our residents and attendings. And although our patients are our greatest teachers regarding the scientific aspect of disease, one often forgets that they are also our greatest teachers on the subject of the human spirit. An apt quote from Weatherall perfectly embodies this phenomenon: “The principal problem for those who educate our doctors in the future is how on the one hand, to encourage a lifelong attitude of critical, scientific thinking to the management of illness and, on the other, to recognize that moment when the scientific approach, because of ignorance, has reached its limits and must be replaced by sympathetic empiricism.” On that morning with Mr. W, the scientific approach had exhausted its limit, warranting replacement by one of sympathy and compassion. In this way, although the pursuit of knowledge remains a lofty goal, the pursuit of a deep understanding of the human spirit and the philosophy behind the practice of medicine remains similarly weighted.
The philosophy behind being a physician consists of the accumulation of a not only knowledge itself, but of reality and existence—a learning curve that begins with the first patient interaction. Mr. W was not simply defined by his three or four letter disease abbreviations, by his CAD, CHF, COPD, and SCLC. He was a fellow creature experiencing great suffering now faced with the reality of his own mortality. Doctoring involves the deep understanding of the mechanism of disease, but also the mechanism of the human mind and spirit. And all it takes to begin that study is a dose of perspective.
Kaitlyn Dugan is a 3rd year student at NYU Medical School
Image courtesy of Google images.
1. Screech MA, ed. Michel de Montaigne: The Complete Essays. Middlesex: Penguin, 1993. http://www.amazon.com/Michel-Montaigne-Complete-Penguin-Classics/dp/0140446044
2. Weatherall D. Science And The Quiet Art: The Role of Medical Research in Health Care. New York: Norton and Company;1995. http://www.abebooks.com/servlet/BookDetailsPL?bi=11838055744&searchurl=an%3DWEATHERALL%252C%2BD%2BJ