A Quiet Departure
Volume 62/63, P. 157
We were a distinguished group. At least, surely, we looked distinguished: five medical students in starched white jackets, alert and bright-eyed, sporting four beards and a ponytail. The ponytail was Mike Keane, a tall, spare figure with muttonchop sideburns. On special occasions he trimmed the ends of his straw-colored hair and tied it up in a ribbon or a bone clip, but on weekday rounds he made do with a rubber band. My beard was red and curly, the bushiest of the four, since trimming exposed a mangy scattering of bare spots. During that era I was so well-fed my poker buddies nicknamed me the Fat Man, and the beard gave my rounded face what I hoped was a professional mien.
In my day job they addressed me as Doctor Gamel. I was at the top of my form. A year-long effort to measure the effects of scurvy on guinea pig livers had come to a close, my first scientific article was wending its way toward publication, and now I was enrolled in an exclusive tutorial while the boneheads in my class endured the tedium of standard rotations – percussing chests, auscultating rales and rhonchi, reading Harrison’s Textbook of Medicine. A shabby business. We five were the lucky ones, selected by Jim Goode for his prestigious Clinical Tutorial. Our goal was to examine the scientific underpinnings of medicine without getting bogged down in the details of day-to-day care. Forget textbooks, for us only original articles would do. We plumbed the depths of the medical literature: Monographs in Allergy, Recent Results in Cancer Research, Parasitology, The International Review of Thoracic Diseases. Simon Rosenthal – the wunderkind of our group, a fidgety myope with a sleek beard and wire-rimmed glasses – earned a murmur of approval at morning rounds when he translated an abstract in Acta Clinica Belgica from the original Dutch.
Of course we had patients, too, the most fascinating cases in Northern California, gleaned from every wing of the Palo Alto Veterans Hospital. They suffered from the rarest diseases, offered the most bizarre clinical presentations, yielded lab values that ran off the chart. James Goode was our cheerful and garrulous Chief Resident, assigned to the VA by Stanford during his final year of internal medicine. If the man ever stopped smiling or talking we never caught him at it. He hovered like a mother hen, treating us with undeserved respect, but he also made certain that we never laid a hand on a patient except under his cautions eye.
“Read the literature,” he said. “You’ll never get another chance like this.”
Read we did. And write. Our write-ups on new patients spanned twenty, sometimes thirty pages, with a page or two of citations at the end. A daily progress note shorter than five pages was considered negligent. Our patients’ charts soon bulged with nascent wisdom, but the most exciting opportunity to strut our stuff came during morning rounds as we stood at each patient’s bedside. First, the student assigned to that patient waxed eloquent for ten minutes, following the recently adopted formula known as SOAP:
Subjective – “Mr. Rackham reports that his burning peri-rectal pain remains unabated.”
Objective – “My examination disclosed a hard, fixed, three-centimeter mass on his right buttock; his crit is 27, his sodium 137, his white count seven hundred, his bilirubin . . . ”
Assessment – “The endothelioma originating in his right kidney has metastasized to a lymph node in his buttock.”
Plan – “We should increased his dose of methotrexate by twenty milligrams, as suggested in a study published by Niedercorn and his coworkers at Hopkins.”
For an ideal performance, the patient’s chart was kept closed, held against the presenter’s chest to emphasize that all this minutiae had been committed to memory. Photocopies of relevant articles won extra points. When the student finished his spiel, his four colleagues offered their opinions, and then, at last, ever so gently, Doctor Goode pointed out our errors: there are no lymph nodes in the buttocks; the lump was an abscess, not a matastisis; the patient’s white count had dropped alarmingly during the last week, and thus an increased dose of methotrexate would kill the poor man surely as a bullet. After rounds, abashed by the gaps in our knowledge, we rushed to the library to pour over yet more journals, while Doctor Goode wrote the orders and performed the procedures needed to keep our patients alive.
* * *
It would be hard to exaggerate our naiveté. At that time, Stanford Medical School was a naïve place, not withstanding its worldwide reputation and a faculty that included five Nobel Prize winners. The problem had started in 1959, seven years before my arrival, when some administrative genius decided to move the medical school from its original site in San Francisco – where the indigent and unhealthy abounded, providing essential teaching material – to the trendy city of Palo Alto, the tofu capital of California. Most of the clinical faculty stayed in San Francisco, so the relocated school had started out with few seasoned instructors and a patient base of almost zero. This latter problem was soon but imperfectly remedied by recruiting patients with rare diseases from all over the world. Lupus, Hodgkin’s Disease, childhood cancers – the victims flooded into the elegant new hospital designed by Edward Durell Stone on a Spanish theme of open courtyards.
When I sent my mother a picture postcard showing the fountains that lined the entrance to Stanford Hospital, she thought it was my new apartment building. To my brief note, “Here’s where I’ll be for the next few years,” she responded, “How the hell can you afford a ritzy place like that?” Palm trees and hanging planters, together with the sunshine of Northern California, gave a cheerful lift to some of the sickest patients on earth. But where were the indigent patients, with their common diseases and their dependence on student doctors for primary care?
Stanford Medical School had made a decision at the highest level: it would no longer encumber itself with training “ordinary” physicians. No, Stanford graduates would become the professors of the future, academic physicians taught by the greatest scientific minds on earth. Arthur Kornburg and Joshua Lederberg, recent Nobel laureates, were recruited to chair the Departments of Biochemistry and Microbiology. Within the next few years, three of their underlings also won Nobel Prizes. Research – publish or perish – became the catchword among junior faculty.
From that time forth, no bedside “grunt,” no devotee of hands-on medicine would ever earn tenure at Stanford. Clinical rounds on some services began at five a. m., rousing patients from a sound sleep during the pre-dawn darkness so the team could get an early start on the laboratory research that followed. Medical students were given blocks of free time to immerse themselves in Petri dishes, cell cultures, cages filled with white mice. Generous grants from the National Institutes of Health allowed even the most junior faculty to hire these students as budding scientists. During freshman orientation, the Dean assured us our class would become the vanguard of American medicine, an ambition that no doubt made the crusty old mandarins at Harvard glance anxiously over their shoulders.
* * *
So there stood the five of us, bursting with information, eager to boost our egos by one-upping each other at every opportunity. We had read piles of textbooks and journals. We knew how to palpate and percuss and auscultate. Our learned ears could detect the splitting of the second heart sound, the opening snap of mitral stenosis, the three components of a pericardial rub. No enlarged spleen or rock-hard liver could hide its secrets from our probing fingers. We knew our patients inside-out – vital signs, physical findings, laboratory reports. But alas, our keen young minds harbored an unsuspected void.
And one sunny morning, there amidst our ignorance lay Nathan Newborn, an emaciated gentleman whose skin shone with a glossy tightness. Systemic sclerosis, a rare disease that suffocates the tissues into layers of useless scar, had given his body the color and consistency of polished mahogany. Carcinoid, an equally rare disease that metastasizes to the liver and seizes the bowels with cramps and explosive diarrhea, gave him violent mood swings by releasing bursts of serotonin into his bloodstream. A nightmarish combination: whatever agonies one affliction spared him, the other was sure to cause. His only payoff was a six-month stay at Stanford Hospital, where the rarity of his two-disease combo had earned him the royal treatment, but now, his medical insurance long since exhausted, he had come to the Veteran’s Hospital so our team could attend his wooden body while the diseases ran their dreadful course.
It was a fine Saturday morning. The East Wing, an open ward with ten beds, had once served as a TB sanitarium, and the tall windows designed to let in the healing light were doing an excellent job. The blue California sky shone so bright it hurt our eyes. Since Doctor Goode had taken off to attend his wife’s third delivery, rounds were to be supervised by his friend Jerry Peggotty, a rheumatology fellow destined for a faculty appointment in the Department of Medicine.
None of us had ever met Doctor Peggotty. In all his years at Stanford he had never set foot in the VA Hospital, and the first thing he did upon entering the front door was to get lost. We had been waiting for twenty minutes when a scruffy-looking fellow stormed up to the nursing station and – or so it seemed from a distance – got into an argument with the clerk behind the ward desk. The two of them raised their voices and waved their arms about, until at last the clerk pointed in our direction. The new arrival headed toward us with an impatient stride. He was short and square, leaned a bit forward as he walked. Surely this was a doctor; his white coat suggested as much, but everything else – tennis shoes, faded jeans, an ill-knotted tie hanging down the front of a wrinkled shirt – left the issue open to question. His long brown hair was badly combed.
Peggotty introduced himself, then explained that he had been up all night doing a skin-graft experiment on salamanders. His hoarse, brusque voice suggested the final throes of exhaustion. His eyes were moist, almost glazed. Sleep dust matted his lashes. The man looked as if he were on drugs, and the excitement had yet to begin.
The tableau of that sunlit ward remains vivid in my mind. The ten beds were lined up in two rows, the polished floor between shining bright as a mirror. As we approached the first patient, Mike Keane launched into his routine.
“Mister Oberon is a forty-seven year old white male with interstitial pneumonitis of unknown etiology. He entered our hospital six days ago complaining of . . . ”
The first four patients went smoothly, though we were disappointed by Peggotty’s lack of enthusiasm. How could he not gaze in wonder at such rare afflictions? When Mike handed him a reprint from The International Journal of Autoimmune Diseases, he read the title aloud – “A Survey of Interstitial Pneumonitis at Guy’s Hospital” – then gave the article back to Mike. “Very interesting,” he said. “Now, someone tell me about the next patient.”
Nathan waited for us at the end of the row with his eyes half closed and his arms lying at his sides. Two nurses stood in the light of the tall windows, smiling and gossiping as they changed his sheets – a tricky job when done with the patient lying motionless in the middle of the bed. Nathan seemed relaxed, unperturbed by their gyrations, even when they rolled his hard, smooth body from side to side. His dusky face, a contrast to the plaid pajamas he wore that day, was peaceful as a mummy’s. His chest was also still except for a gasping breath every few seconds. I remember thinking how fortunate it was that the agitation brought on by his serotonin storms had finally abated.
“Oh, please go right ahead,” said one of the nurses, smiling at the circle of doctors gathered around the bed. “We’re almost through.”
As soon as the nurses had bundled up the dirty sheets and moved on to the next bed, Simon Rosenthal, Nathan’s assigned student, clutched the chart to his chest and launched his presentation.
“Mr. Nathan Newborn is a 64 year old Caucasian male who suffers from systemic sclerosis and carcinoid. His case was reported in the March, 1969, issue of Recent Results in Cancer Research. During the six weeks Mr. Newborn has been on our service . . . ”
Simon was good. Very good. His voice had gravitas, with a care and cadence to his diction that said, I’m one hell of a smart guy. He always wore a freshly-ironed white coat. His hair was short, his thick beard trim and glossy. His encyclopedic memory left me feeling like a clod. Only one defect, a tiny flaw: his nails were bitten to the quick. For days I had watched him out the corner of my eye – on rounds, in the cafeteria, in the library – but never saw his fingers come near his mouth. A secret vice, like masturbation. The thought lifted my spirits. And there was that wonderful morning when Simon had shown up for rounds with a brown shoe on one foot and a black shoe on the other. The rest of us laughed raucously, rocking back and forth and slapping our thighs, the pleasure of the moment enhanced by the dark, sullen blush that ascended from Simon’s collar to the roots of his jet-black hair.
As we stood in the sunshine, gathered in a semicircle around Nathan’s bed and gazing at his peaceful face, Simon’s voice gave a soothing basso continuo to the debacle that was about to unfold. Nathan lay still, his arms at his sides atop the fresh sheet.
“ . . . Mr. Newborn’s last UA showed four plus white cells and a trace of hematuria, so we’re working him up for a UTI, but so far . . . ”
It was Peggotty, our temporary attending. His shout was explosive – so loud and abrupt it shocked the whole ward. Everyone gawked at him. The man had gone mad. His eyes, staring at Nathan, seemed ready to pop out of his head. The silence that followed his outburst was broken by a rattling gasp from Nathan’s throat.
“What . . . ,” Peggotty said, “what . . . what’s going on here?” He staggered toward Nathan’s bed, turned to look wildly about at the circle of puzzled faces. We squirmed with embarrassment and looked down at our feet. His eyes bulged, his hair seemed to stand on end – a psychotic break, perhaps from an overdose of some recreational drug. Amphetamine? Mescaline? LSD? There was a lot of that going around the San Francisco Bay Area, especially among physicians. “Tell me . . . is he . . . is he a no code?” As Peggotty spoke this last sentence, a rising note of panic in his voice, he lurched forward and pressed his fingers against Nathan’s stringy neck. We had no idea what he was talking about. I was beginning to consider what could be done to help Peggotty through his crisis.
“My god!” he shouted at last, snatching open Nathan’s pajama top so abruptly the buttons flew off, exposing a sallow, bony chest. Not until he pounded on that chest and forced air into Nathan’s gaping mouth with his own lips did the five of us begin to understand. The clerk rushed across the ward to pull Peggotty away and let the poor man die in peace. Nathan was indeed a no code.
We had never seen anyone die, and the medical literature had not prepared us for death in the flesh. Death, one might say, was our blind spot. Of course Nathan’s gasps were Cheyne-Stokes respirations, the classic mark of final agony that we had all read about in textbooks, but not one of us connected the words on those pages to the patient who lay before us.
Peggotty glared at us as though we were a pack of idiots. We stood abashed, feeling ourselves children whose hands had been smacked by a ruler, longing for Doctor Goode’s forgiving presence. We had been misled, just like the nurses who tucked clean sheets under Nathan’s expiring body. And there was the sunshine, the blue sky, the light-filled windows – a conspiracy of ambience. Who but a battle-scarred veteran, a real doctor, could imagine that death might visit on a day as fresh and bright as life itself?