Tell Me I Didn't Put it There

E

ven after forty-five years, memories of Simon continue to haunt me.  He was a simple man, so it seemed from the initial medical history.  A high school graduate, he opted out of college for earning a living as a salesman in one clothing store after another.  In an era of few working wives the family income was supplemented by his wife’s clerical job. 

Simon had no special interests or skills.  He was not a joiner. Having had no ritual training, he even avoided synagogue life, which further alienated him from potential friends.  He lumbered through his ten-hour workday, arriving home with no more energy than to eat supper, read a newspaper, and listen to the radio news.  (Television had yet to be commonplace.)  Conversation with his wife was sparse and usually concerned money.  He had little to say to his three children.   

 Yet, Simon was a likable soul.  Customers appreciated his gentlemanly behavior: he offered advice without pushing to make a sale.  In my office he was genuinely courteous.  He was embarrassed to admit that he had agreed to come to me only after a mutual friend had reassured him that I would charge a minimum fee.

He a big man who overflowed the sides of my office chair.  His clothes were crumpled, his thinning gray hair was combed but unruly.  Hesitatingly, he offered his reason for coming to me.  “I’ve been bleeding when I go to the toilet. It happens when I move my bowels … for three weeks.” 

He was pale; otherwise his physical examination was normal.  I hoped I would find bleeding hemorrhoids; no such luck.  The next day I performed a proctoscopy, which showed no abnormalities.  Had I missed something?            

At that point Simon asked if he might have cancer.  “What makes you think so?” I asked.

“Well, my father died of it at forty-seven (Simon was sixty-one). My brother died at fifty-five; we never knew his diagnosis but he lost a lot of weight and was in pain for months before he died.  I don’t think I could go through that.”

As he spoke each word I could sense my training being challenged.  My medical mentors, always peering over my shoulder, waited for me to stumble.  If Simon had cancer, would I be able to lie to him?  Of course I must for that was what I was taught only ten years before (in 1946).  Simon wasn’t one of the exceptions listed on the blackboard such as a wealthy corporation executive with an estate to protect.  I temporized.  “It could be colitis or polyps.  Maybe tomorrow’s X-ray of your colon will give the answer.”  He was not cheered but then again, I don’t think I ever saw him smile.

I gave Simon instructions for “cleaning” his bowel in preparation for the X-ray.  I called his wife, Rose to tell her that “the diagnosis might be cancer and if so …”.

Rose interrupted me.  “You mustn’t tell him.  It would kill him.  He’s been talking about nothing else since he finally admitted to me why he was seeing you.  He says he knows he’s going to die like his father and his brother.”  She began to cry. 

“Okay.  We’ll see.  Maybe you should come in with him.  We can talk after I finish the barium enema.”

What I didn’t tell either of them was that, as a resident though I had performed over a hundred X-ray examinations of the bowel, Simon’s would be the first in my new office. I saw no reason to mention my apprehension about the technical aspects of the procedure.  I didn't want to disturb my image as an infallible Harvard specialist.

The next morning my nurse, Pauline, had everything ready.  Simon lay on the X-ray table. A two-liter bag of chalky barium suspended three feet above the table was connected via a tube inserted into Simon's rectum.  I motioned to Pauline.  “Let’s begin.”

  Pauline released the tubing clamp.  As I turned on the fluoroscope to watch the barium enter the rectum, I was chagrined to see barium spreading on the table.  “Stop,” I said to Pauline.  She snapped on the lights. 

“Oops.  The enema tip came out.  Simon, I’ll reinsert it deeper.  Sorry.”  I  couldn’t be sure but I think Pauline was blushing. 

With the lights out again, we resumed.  Barium was entering freely.  All was normal in the rectum and deeper into the sigmoid until “Oh my God!” resounded in my head.  “Look here,” I whispered to Pauline.  The X-ray motor drowned out my voice.  There was a huge mass, which allowed only trickles of barium to advance beyond it.  I took a few X-rays to show to a surgeon.  “Finished,” I said to Pauline and Simon. 

  I returned to my consultation room and sat in my expensive, high-backed chair.  “Look at me.  What a great doctor I am!”  But almost simultaneously I thought, “Oh, my God!  Poor Simon.  Until I found the tumor, it didn’t exist.  Tell me I didn’t put it there!”  Irrational?  I don’t even have to ask.  I guess it was a form of denial; I didn’t want Simon to have cancer and I dreaded handling all that was bound to follow. 

After Simon had dressed, I invited him and Rose into my consultation room.  They could tell from my expression that the news was not good.  “Bad and good,” I started.  “Good in the sense that we’ve localized the problem and good in the sense that there is a large polyp inside the sigmoid."  I drew them a picture to show its location.  "That’s where the bleeding is coming from.  Bad in the sense that you need to have it removed, Simon, to stop the bleeding.”  I didn’t think it was necessary to add the threat of bowel obstruction if he were to procrastinate. 

“Then, it’s not cancer.”  Rose made it a positive statement.

I lied.  “It doesn’t look like cancer but to be honest, only the pathologist will be able to tell us for sure.  If it turns out to be cancer, I'm sure that the surgeon will be able to remove it all.  You’re not your father, Simon.”  He fought back tears.  “You have reason to cry, Simon, but more reason to be optimistic.”  (See the chapter “Down with doubletalk to cancer patients” in my memoir, “By All Means, Resuscitate.”)

Simon wasn’t convinced nor was he wrong.  Within the week he was operated on.  The bowel cancer had spread to his liver.  The huge mass was removed but only to prevent the hideous complication of obstruction.  Since I had nothing good to offer Simon (those were the days before chemotherapy), I told him that he had a "benign (noncancerous) adenoma" and that it had been totally removed.  (With Rose I was truthful.)  Simon felt better after receiving two units of blood but this didn't last long.  His condition rapidly deteriorated as the flesh fell away from his body. 

Simon never returned to work and he never asked questions even as his skin became yellow from progressive liver failure.  He had very little pain.  Oddly, though he had no medical insurance he never expressed concern for the hospital bills that Rose would have to contend with after he was gone.  Two months following surgery and after a three-day coma, Simon died at home.

  So I didn’t kill him, but in my mind he didn’t have cancer till I found it.  That's an ironic way of looking at what happened in Simon's medical story. I was proud of myself for having suspected and proven his true diagnosis but, then again, how could I feel gratified if I was the one who brought out a verdict of death?

Better than Money

One of the delightful aspects of adopting a new life in Israel was the move from a fee-for-service payment system to a fixed salaried one, delightful even though entailing a drastic reduction in my income. It was like returning to the days of my medical training when hospitals paid minimal salaries while providing years filled with rich doctor-patient encounters, unencumbered by that ugly word, money.

Whatever the reasons, I was uncomfortable having a patient put money directly into my hands or even discussing fees. I avoided these whenever I could by referring the patient to my secretary. Did I feel guilty thinking I was rewarded enough just by being allowed to provide my services? Or was it my worry that maybe my fee was too high or maybe that I had misjudged the patient’s ability to pay. Or maybe I was tapping into the ill-conceived notion that just talking with a patient didn’t merit a fee. One surgical colleague didn’t charge a patient for his consultation unless it was followed by an operation. He rationalized, obviously incorrectly in my opinion, “If I didn’t operate, I didn’t do anything for the patient.” Matters were greatly alleviated for both the patient and me, when insurance carriers, Blue Shield and Medicare, began paying most of my fees. The following patient put me to the test.

Roland Jasper at age 53 had an attractive, debonair flair as he offered a firm handshake across my desk. “A born salesman,” I thought. In answer to my opening question, “What can I do for you,” he replied, “Not much. It’s just that I’m going across the country to promote and sell encyclopedias to families and schools. It’s very profitable but also very exhausting work. Though I’m feeling fine, I wanted a general checkup to make sure.” At the conclusion of my study, which included routine lab work, a chest x-ray, and an electrocardiogram, I suggested that because of borderline high blood pressure he should lose ten pounds, go easy on salt, and, by all means, quit cigarettes. The multitude of oral medications now popular for hypertension was not in vogue at that time. He agreed to try to comply – he didn’t display much enthusiasm – and said, “See you when I get back in a couple of months.”

On the way out, he stopped at my secretary’s desk and gave her ten dollars as the initial payment on his $110 bill. For the remainder he gave her a post-dated check, cashable two weeks later.

At the appropriate interval the check was deposited. Lo and behold, the following day the bank manager called to inform me that the check had bounced “for insufficient funds.” He continued, “Let me tell you, David, this Jasper guy is a con artist. He’s passed bad checks all over town. I even lent him a few hundred dollars on the basis of his previous year’s tax return, which I later discovered was a fake. Welcome to the club.”

Approximately six months later Roland, without an appointment, popped his head past my office door saying he had palpitations and a severe headache. “Please, can you help me?” The patient I was examining was startled by this rude intrusion. I excused myself to her and went into the waiting room.

“Yes, but on condition that you pay up your old bill and put down another fifty dollars toward your next bill.” I didn’t like myself, sounding so mercenary, but I wasn’t going to let him take advantage of me a second time.

“I can give you fifty dollars now and another fifty tomorrow. The rest, I really can’t say.” That bit of honesty was a step forward.

Something about his expression told me “Con man or not, I believe him and besides, this time he looks sick.” I said, “OK. Hold on for about ten minutes until I finish up with my last patient.” As I turned around I noticed him handing a fifty-dollar bill to my secretary. I mused, “I bet it’s counterfeit.”

As Roland sat on my examining table, I was tempted to begin by discussing his morals. His fearful facial expression dissuaded me from that. Instead I took his blood pressure. 230/130! I checked it repeatedly, in the other arm as well, without noting any significant difference. Among other findings were warm, moist skin and a heart rate of 125/minute. I said to myself, “So what if I’m conned out of a couple hundred dollars! This case is my meat.”

I immediately thought of a severely overactive thyroid, causing “thyroid storm.” Untreated, this can be quickly fatal. Against this was the absence of either a goiter or protruding eyes.

My second choice was an adrenal tumor called “pheochromocytoma.” (The adrenal glands sit on top of the kidneys.) I listened with my stethoscope over his kidney regions and sure enough, there it was: a murmur suggesting the tumor’s increased blood flow. I didn’t have time to congratulate myself for in the next few moments Roland began gasping for breath. Liquid in his lungs was audible without a stethoscope. Sitting him up helped somewhat as did an oxygen mask. I gave him an intravenous injection of a strong, rapidly acting diuretic. Roland was considerably improved by the time the ambulance came to take him to the hospital.

Within two more days urine chemical testing and computerized tomography confirmed the diagnosis. Conservative medical treatment resolved Roland’s symptoms but cure would come only from surgical removal of the tumor. For that I wanted him to be in a medical center for the operation requires a team of experienced, highly qualified surgeons, anesthesiologists, and specialists in hypertension. I had already learned that Roland had hospital insurance but like me, his doctors would have to enjoy the medical experience for monetary remuneration would exist on paper only.

The surgery was successfully performed in a Pittsburgh hospital. Other than the discharge letter from the operating surgeon I lost all track of Roland. Statements of money owed to me were returned, “addressee unknown.” We gave up. Seeking the aid of a collection agency long ago in other trials had lost its appeal for me; it was an angry, fruitless gesture. Satisfaction from a quick diagnosis and cure of a rare disease were to be my reward.

It was five years later that the man with an attractive, debonair flair walked into the office. Roland told my secretary that he just wanted to say, “Hello.” She escorted him into my office. We shook hands and, without any greeting, he handed me a brown paper heavy bag. “Look inside,” he ordered. To my chagrin there were a several handfuls of silver dollar coins. “This is a first payment,” he said. “Believe me (I didn’t) there will be more.” Then, departing, he called back over his shoulder, “And thanks, Doc.”

After the door had closed, I took one of the coins and bit it. Though it stood the test – I wouldn’t have been surprised if it had been chocolate – I thought I should do the same for the whole collection. In today’s competition of “one upmanship” both Roland and I were “one-up,” he for recovering his health at a bargain price and I for having a story to tell my grandchildren.

Sicker Than I Thought

It never occurred to me when I sat at Rose’s bedside that she would be any different than the scores of patients I had treated with radioactive iodine for an overactive thyroid.  And as with the others, it wasn’t long before her tremulousness, typical of the disease, also infected me; I felt my body trembling in rhythm with hers. 

It was 1950.  I had accepted a fellowship in radioactive iodine research at the Beth Israel Hospital in Boston without even knowing what radioactive iodine was.  Few academicians anticipated that this isotope would herald the field of nuclear medicine.  That it would play such a significant role in my life was hardly in my mind; I initially thought of the job merely as a stepping-stone to an appointment as a Resident in Internal Medicine.  In fact it was to lead me to my wife and to a successful move to Israel.  But that’s another story.

Rose K., age thirty-five, looking fifty-five, was a mother of three children; the youngest was five years old.  Her husband, age forty, hadn’t been employed for several years because of unexplained bleeding in his extremities – more on this in a moment.  They lived in a three-room apartment in a public housing project, subsisting on welfare checks and food stamps.  One child had a seizure disorder, another, asthma.  Rose had little reason to smile.  On the contrary, she was haggard, appearing malnourished with cracked lips and a vitamin-deficient, smooth, red tongue.  Her gaunt cheeks sagged, as did the skin of her arms, indications of a recent twenty-pound weight loss.  Her skin was warm and her pulse, fast.  All of these signs were typical of patients with hyperthyroidism, an overactive thyroid.  But why didn’t she have protuberant eyes and an enlarged thyroid gland, other findings typical of this disease?  I would soon learn the answer.

At this point it was obvious that I would have another candidate to add to my growing research study dealing with the use of radioactive iodine in the treatment of hyperthyroidism.  A few more and a pioneer publication could be expected, maybe even a presentation at a national medical meeting.  This sequence didn’t unfold quite as I imagined it would.

I explained to Rose the nature of the radioactive iodine test to be performed the next morning.  It would measure the function of her thyroid gland, information essential for arriving at a proper treatment dose of radioactive iodine.  I even anticipated this treatment by explaining that radiation from the dose I would give her would gradually shrink her gland over six to twelve weeks and, thereby, reduce its function.  Most patients would be cured by the end of that period.

The following morning Rose was brought to my lab in a wheel chair – her muscles too weakened to permit walking.  I gave her a drink of a small dose of radioactive iodine.  The following morning she returned for measurement of the amount of radioactive iodine collected by her thyroid gland.  In normal patients the answer would be 15-30%.  In a patient with an overactive gland it would be 35-80%.  Imagine my dismay when Rose’s measurement was 1%.  First I blamed my technique.  Had I given her water instead of radioactive iodine?  The presence of a significant amount of radioactive iodine in a urine sample discounted that possibility.  Next I blamed the equipment.  I checked the electrical connections on our homemade, primitive set-up.  Finally a successful check of a known quantity of radioactive material proved that I had to look elsewhere for the answer.

After Rose returned to her room, someone suggested that she might have been taking diet pills and just neglected to tell us.  In that era diet pills contained thyroid extract in quantities sufficient not only to block thyroid function (and reduce the entrance of iodine into the gland) but also to cause adverse effects on the body, which simulate the findings of an overactive thyroid. We called the unit and had the intern ask the patient if she was taking diet pills.  The intern spoke with me.  “Rose appeared irate and emphatically denied this.” 

I thereupon requested the nurse to send Rose back to the lab for “retesting.”  During the time that she was with me – I feigned a change in technique for measuring her thyroid activity – the nurses inspected Rose’s bedside table and locker.  Lo and behold, two bottles filled with thyroid pills were found!  The nurse phoned with this startling finding.  The mystery of hyperthyroidism associated with low iodine uptake was solved, as was the absence of protruding eyes and an enlarged thyroid gland.  A dose as little as four tablets a day would mimic hyperthyroidism.

I took Rose into a private office and confronted her.  “Rose, tell me about the bottles of thyroid pills in your belongings.”

At first she looked at me with scorn.  I suppose it was when she realized that I cared about her, that she broke down, sobbing, “I want to die.”  In the ensuing hour her tale unfolded.  More than depressed, she was angry – angry at life but more specifically, at her husband.  “He’s never held down a job.  He just sits around all day listening to the radio or studying a racing form.  Of course, that is, when he’s not in the hospital.”

“Why,” I asked, “does he need to be in the hospital?”

“‘Need to be in the hospital?’  That’s funny.  He’ll kill me if I tell you.  Oh, what the hell!  I told you that he has bleeding in his arms and legs.  Your blood department has been struggling to diagnose a rare bleeding disease.  Well, there is none.  He just bangs his legs against the toilet bowl and his arms against the sink until they are black and blue.  He loves being fussed over by the doctors and nurses.”

“But, Rose, what’s this got to do with your taking thyroid pills?”  She had admitted to taking fifteen to twenty a day, a dose that, if continued, would eventually kill her.  She knew it.  I suggested that, “there are faster ways of killing yourself.”

“That’s the point.  I wanted to make my husband suffer as he watched me dying, not that he could care much once I’m gone.”  I was now getting over my head into psychiatric waters that called for the involvement of a psychiatrist; this I arranged for both Rose and her husband.  (The latter’s hematologists on first hearing of the self-inflicted lesions wanted to kill him for wasting their precious time and resources.)

Putting a name thyrotoxicosis factitia on Rose’s condition didn’t help except as the title of her case report that was published in a medical journal a year after our first encounter.  Rose was checked in the thyroid clinic ten months after stopping thyroid pills; her gland function was normal. 

It is a sad commentary that neither my memory nor the article gives any indication of the family’s psychiatric follow-up.  It’s not conceivable that I cared only about getting my name in the medical literature.  Or is it?

A Doctor in the Family

This chapter could be titled mea culpa or the Hebrew parallel, “al het,” asking forgiveness “for the sin ... .”   Though not sealed in any oath equivalent to that of Hippocrates, an admonition not to treat one’s own family is nearly as binding.  And yet, many times there were extenuating circumstances, which placed me in a compromising role I could not avoid.

Take for example my treating my wife, Marcia, for “the flu.”  In the fall of 1954, we were living in Boston while I began a two-year fellowship in internal medicine at Lahey Clinic. Marcia developed symptoms typical of an upper respiratory infection: low-grade fever, sore throat, coryza, and a non-productive cough.  I listened to her lungs with a stethoscope and heard no abnormal sounds.

The following day when her temperature rose and her cough became productive, I threw in the towel and called a seasoned internist-colleague.  Within a couple of hours he examined Marcia and heard moist crackles – rales – in one of her lungs.  “I believe Marcia has pneumonia, Dave.  Let’s take her to the hospital for a chest x-ray.”  And, of course, the diagnosis was confirmed; Marcia was hospitalized and quickly recovered on penicillin therapy.

It is possible that the “rales” may have developed between the time of my exam and my friend’s.  More likely, thinking wishfully, I tuned them out.  And therein lies the inescapable truism: as physician to one’s family, the doctor’s judgment is faulty.  He will go to the extremes of denial, wishing away any abnormal findings. Accordingly this relationship is to be avoided whenever possible as will be re-enforced by other examples that follow.

I was one of three internists who treated heart patients in Aliquippa.  The other two are now dead so I can freely claim that I was the most experienced and up-to-date with newly developed techniques.  It therefore seemed logical to me to be my mother’s doctor when she developed heart trouble.  The relationship worked well for several years until one day in 1971 when my mother was 84 years old.  Over the telephone I could hear that she was in severe congestive heart failure.  I called an ambulance; we arrived at Mom’s house almost simultaneously.  We sat her up in the ambulance stretcher; this gave some relief.  As soon as she was in a hospital bed, I began the then state-of-the-art therapy.  First order of treatment was to put an oxygen mask on her.  I then applied tourniquets to her legs and arms, which lowered the work of her heart by reducing the circulating blood volume (not to worry, the tourniquets were removed at set intervals so that no extremity went without circulation for too long). This should have worked.  A nurse administered an injection of morphine to try to relax my mother’s frantic breathing efforts.  I then gave an intra-muscular injection of a mercurial diuretic again to reduce the fluid, which was backed up in her lungs.  Lastly, I injected intravenous aminophylline to relieve bronchospasm.  I won’t say I was proud of myself but I was self-consciously aware of the nurses watching me take control of the situation with such dispatch.

The only problem was that nothing I did seemed to improve my mother’s dire condition.  I was at a loss for something more to do for my mother who would soon die.  A “code blue” announcement went forth over the loudspeaker system, which would bring more help.  I don’t know who was inspired to initiate the call but within minutes in rushed Dr. Horto, our Turkish anesthesiologist.  He assessed the situation in less than a minute and within another, without asking my permission, inserted a tube through my mother’s mouth into her trachea.  Immediately he began pumping oxygen under considerable pressure.  This would force fluid from the breathing spaces in her lungs into the blood stream, making room for exchange of oxygen and carbon dioxide.  Within two to three minutes my mother’s breathing was easier and much less bubbly.  Her previously blue nail beds began to pink up, indicating improved oxygenation of her tissues.  (If my mother had been fully aware, removing her meticulously applied fingernail polish to expose the underlying innate color would have angered her.)  Within five minutes of Dr. Horto’s treatment, Mom opened her eyes and smiled at me.  Because of the tube, she couldn’t talk but it was evident that she was out of trouble.  Within ten days she was fully mobile and was discharged home.

Where had I failed?  It was obvious that I couldn’t bring myself to carry out the most significant therapeutic measure on my own mother; it was just too invasive.  Mom lived reasonably active another three years until her heart failure returned, that time not to be reversed.  Within hours she was dead.  As she was dying I spoke with my brother, Jerry, a superb physician, who asked, “Are you ready to let go?”

I replied with a choked, “Yes.”  I would not have been three years earlier.

The issues are clear.  With my wife, wishful thinking blunted my diagnostic acumen.  With my mother aggressive action on my part was unthinkable, too disrespectful, too unfilial.  My role as a physician was subverted.

At least I did act appropriately, albeit harshly, when Mom at age 82 caused a traffic accident in which her car was nearly totaled; she got out of the car and, adjusting her hairpiece, asked a passerby to call her son.  It was painful for me to take the driver’s license away from my mother but I gritted my teeth and did it. (Ff turnabout is fair play, my children did this to me last month!) She was less accepting when two years later, I took control of her checkbook.

My daughter Amy was not always easy to read.  As I look back on her short life, I have to admit that I, we – Marcia and I – more than once questioned her judgment as when at age six, she shouted that a suitcase had just fallen off our car luggage rack; 100 miles later she was vindicated.  So when she rather casually claimed a broken leg from what I witnessed as a rather gentle fall while skiing, I had her sit while the rest of the family finished our ski afternoon.  To placate her when we arrived home, I took her into the x-ray room of my office and x-rayed her leg.  I couldn’t believe the result: a long spiral fracture of the tibia.  I was in no way exonerated when both the ER nurse and, subsequently, the orthopedic surgeon asked, “Which leg?”  Fortunately no harm came to Amy by the several hour delay in my making the diagnosis, not even significant pain.  Both of these incidents did give her leverage in subsequent disagreements with me.

A judgment error for which I probably will never forgive myself also concerned Amy.  It was the morning after we had retrieved her from Hampshire College in Amherst, Massachusetts.  Afflicted with manic depression, Amy had made superficial cuts on her wrists.  She called us from the infirmary to say that she felt like jumping out of a window.  Marcia was at her bedside within hours while I arrived some time later by car.  Immediately on our return home we made an appointment for the following morning with a psychiatrist in Pittsburgh, thirty miles away.  That morning Amy was acting strangely; that was the only description I could apply.  As we got into the car, she was acting somnolent and “acting” was what we thought was the explanation.  I wavered between going directly to my hospital one minute away and proceeding on to Pittsburgh, an hour away.  I elected the latter.

By the time we got to the psychiatrist, Amy was in a deep slumber.  He ordered us to proceed directly to a nearby hospital where remnants of sleeping capsules were aspirated from her stomach.  Amy lay in a coma for two days during which time I didn’t budge from her unit; I had to be there when she awoke or if further complications were to develop.  She did eventually recover; I didn’t.  It is obvious that my judgment was terribly impaired.  How could I think it was just another of Amy’s tricks?  Or was I afraid to confront the staff of my hospital  – where I was "infallible" – with the reality of my mentally sick daughter? 

The most recent incident of questionable professional conduct occurred in reference to Marcia’s resolve to donate a kidney to her niece.  The final decision regarding her acceptability and ultimately the surgery were in the hands of a team in New York.  She received instructions for arranging a preliminary battery of tests here in Israel.  In addition, forms for a complete history and physical examination were to be completed by a doctor. Marcia had no family doctor and certainly no one could document as complete a history and as expeditiously as I.  I therefore undertook the responsibility.  I assiduously performed each examination as objectively as possible. It took concerted effort to fight the desire not to find any abnormality. Certainly I could not overlook any finding that might jeopardize Marcia’s life should she undergo the nephrectomy.  The only important finding was borderline high blood pressure. I was not concerned but reported it accurately.

When the surgeon who was responsible for Marcia approached her, it was obvious that he was riled up over something. Immediately Marcia saw him as an adversary who would prevent her from saving her niece’s life.  “We never use a sixty-six-year-old donor unless it’s for her own child. And does your husband not know how unethical it was for him to do your history and physical?” Marcia listed my professional qualifications, all irrelevant.

By the time the surgeon took Marcia’s blood pressure, she was in a rage and her blood pressure proved it. “Your husband lied! Your blood pressure is not 160/80.  It’s 200/100!”

 “Do you think my husband wants me to die?  Let someone else take my blood pressure in another hour.” She was terrified of further antagonizing him, lest he disqualify her as a donor.

Well, the surgeon was not entirely wrong about my completing Marcia’s examination.  But not only did he not seek an explanation, he didn’t suggest having a colleague redo the exam.  Eventually she went through the surgery and with no untoward effects, her niece was restored to good health, and a year later the surgeon was looking for a new job.

Every once in awhile when I’m berating myself, I wander back in my mind to 1967 to our family trip to Israel.  We were at a swimming pool in Eilat when Danny, age four, cut his forehead.  The cut was about one centimeter wide but deep.  We rushed him to a local clinic where the nurse indicated that no doctor would be available for another hour.  Hearing that I was a doctor, without checking my credentials, she handed me a sterile suturing kit.  With the help of a local anesthetic I deftly applied two sutures.  I was pleased with my handy work but much more so when Danny said, “Gee, Dad, you’re a great doctor.”

Don't Put Off Till Tomorrow...

Those were exciting weeks as I anticipated the opening day of my medical office.  It was to be August 1, 1956, eleven years and ten months from the day I entered Harvard Medical School and approximately ten years since I first laid a hand on a patient.  So much preparation in those years, acquiring knowledge, developing skills, molding attitudes toward patient care, and drawing up schematics of the form my medical practice would assume.

Taking a cue from my brother Jerry’s General Practice before he went off to fight in WW II, I rented office space above my Aunt Sarah’s jewelry store on the main street in Aliquippa.  Adapting it to my physical needs required no structural changes.  At the entrance was a combination secretarial office-waiting room, which led into both a consultation-examining room and a room accommodating an x-ray machine.  A closet became an x-ray developing room and a bathroom. Sharing the waiting room with an adjoining lawyer's office reduced my costs.

I had spent the month of July ordering office furniture and medical and secretarial supplies including calling cards and personalized stationary.  One dilemma arose when it came to deciding on a desk chair.  The corporation president’s chair was too ostentatious and expensive; I settled for the vice-president’s model, also too expensive.  (I remembered the advice of a highly successful accountant who was under my care at Lahey Clinic.  We were discussing my bleak financial situation as I approached entering private practice.  “Don’t borrow a small amount of money from the bank; you’ll just stay awake at night worrying how to pay it back.  Borrow a large sum.  You’ll sleep better knowing that you’ll have to pace yourself over a long haul rather than repaying the loan quickly.”  To wit, the lavish chair.)

The most costly item was the x-ray machine.  Though I was a specialist in Internal Medicine, my training included one year of gastroenterology during which I became proficient in performing x-ray examinations of the gastro-intestinal (GI) tract.  One of my favorite teachers, the chief of radiology at the Beth Israel Hospital in Boston, showed his disapproval by ordering me out of his fluoroscopy room when he realized that I, as an Internist, would be performing GI x-ray procedures.  I rationalized my plans on the basis of the absence at that time of a hospital and a radiologist in my town.  At the outset of my practice a few physicians became acquainted with me by sending patients just for an x-ray.  The fact that Blue Cross Medical Insurance paid handsomely for x-ray procedures years before compensating a doctor for his consultation was of more than subliminal importance in those early hungry days. Oh, yes, my in-laws paid for the x-ray machine -- my request as a substitute for their furnishing our home.

Lastly was the need to find an office assistant I could afford, a woman who could be a nurse, a lab and x-ray technician, and a secretary.  A newspaper ad produced several candidates, one of whom, Pauline, stood out above the rest.  A licensed practical nurse, she had done office work for her husband.  She also had a pleasant personality.

For several days prior to the announced opening date as printed by our local newspaper Pauline and I organized schedules of painters and plumbers, electricians, and instrument technicians.  Pauline practiced drawing blood from me and together we performed the basic blood counts and screening chemical tests.  I also taught Pauline urine tests; this time it was her specimen.  She also performed an electrocardiogram on me and on the lawyer in the adjoining office.  All that was lacking was a special switch to activate the x-ray machine, which was promised for the 31^st of July.

It was Pauline who answered the phone on the morning of the 31^st.  “Good morning.  Dr. Chamovitz’s office.”  It was a woman calling.

“I would appreciate it if the doctor could see me today.”

“Just a moment.”  Placing her palm over the phone’s mouthpiece, Pauline relayed the request.

 I picked up the phone.  “This is Dr. Chamovitz.  Can I help you?”

“Why, yes.  Yesterday morning I awoke with one side of my face flat and I believe it’s paralyzed.” 

“How has your health been otherwise?”

“Fine. But I’m really worried.  Can you see me today?”

“Truthfully, we need today to make last minute preparations but I’ll see you first thing in the morning.  I’m sure you’ll be okay.”  I assumed she had Bell’s palsy for which there was no treatment anyway.  (As I write forty-five years later my attitude appears lackadaisical; were it today, she would have had an immediate Computerized Tomogram of her brain to rule out a stroke.)

I could hear the disappointment in her voice as I turned her back to Pauline.  I gave it no more thought except to whisper a “Eureka!  My first patient.”

The following morning Pauline and I donned our new, dazzling white professional garb, I, a long lab coat, she, a nurse’s uniform.  At the appointed hour Pauline ushered in Mrs. Georgia Lewis, a thirty-nine-year-old housewife dressed in “church-going” clothes.

I noted the faint sagging of the right side of her face as she sat in one of the two salmon-colored leather office chairs opposite my desk.  A faint smile further exaggerated an asymmetry of her face.  I posed my opening question.  “Why are you smiling?”  I anticipated compliments for my office décor or comments regarding my being so young to be a specialist.  (After a few years I no longer heard that latter compliment.)

“Doctor, you won’t believe it but when I looked into the mirror this morning, I could see that my face was much improved.  What do you think of that?”

I should have been delighted.  “You fool,” I said to myself.  “Look at what a hero you would have been if you had seen Georgia yesterday!”  Still I tried to reap some glory out of the situation.  “Over the phone I suspected that your diagnosis would be Bell’s palsy, most often a self-limiting disease that requires no treatment. That’s why I had no qualms about delaying your examination one day and why I tried to reassure you that you would be okay.”

Georgia took the bait.  “It’s true that I felt more relaxed after I spoke with you.  Could it be that’s why I improved?”

I wasn’t a total scoundrel.  “The truth is that we don’t know everything about this illness except that it’s probably caused by a virus but why it subsides quickly in some and very slowly in others, we have no idea.”  With tongue in cheek I added, “Who knows what a positive attitude will do?”  I was shameless.

Without much enthusiasm I proceeded with a history and physical examination and had Pauline perform the screening lab work.  I asked Georgia to report to me in a week and with that phone call our relationship came to an end. 

Well, not quite.  I called her on our “first anniversary” to note the occasion and to inquire as to her health.  “I’m fine and you’re such a marvelous doctor!”  Again, shame on me.

You’ve Got 3 Months To Live

I had always been skeptical of stories about patients who were cured of cancer by eating a certain root or drinking an extract of elderberries, or such.  I would feign interest while to myself I would say, “idiocy.”  Life subsequently made me less of a scoffer.  In Love, Medicine and Miracles Bernie Siegel states that every doctor has a cancer patient who experienced an unexplained cure.  In fifty years of practice I encountered two; each was puzzling and humbling.

The first was Nick, a retired steelworker, who came to my office because of abdominal pain.  Reluctantly he consented to being hospitalized.  When routine tests failed to turn up any cause for his pain, I performed a nuclear scan of his pancreas. This was my first attempt at such a scan, as I had just returned from three days of studying the procedure in Cleveland.  To my unabashed and disgraceful joy the scan showed a tumor.  How proud of myself I was with my newly discovered talent.  A subsequent biopsy demonstrated malignant cells, confirming a diagnosis of cancer of the pancreas, a death sentence since almost all such patients at that time died within one year.  Nick refused to undergo surgery, which seldom helped anyway).  I told Beth, Nick’s wife, that there was no other treatment (these were the days before chemotherapy, fortunately for Nick as it turned out) and that his days were numbered in months, not years.

To my surprise and chagrin Nick never returned to my office.  Periodically I kept in touch by phone, hearing only that he was well.  I remember one particular phone conversation with Beth.  “Can I speak with Nick?”

“He’s out in the garden.”

“How’s he feeling?”

“Fine.”

“How much weight has he lost?”

“None.”

“How’s his pain?”

“He doesn’t have any.”

Desperately seeking to elicit one little symptom, I pleaded, “Does he burp?”

“No. He’s just fine.”

In disbelief I had eminent pathologists review the microscopic samples taken from Nick’s pancreas.  Always the same answer: “cancer.”  And my Cleveland mentor confirmed my interpretation of the nuclear scan. My isotope scan of Nick’s pancreas was even published in a textbook of nuclear medicine as a proven case of cancer of the pancreas!

Five years after my prediction of an inevitably early demise, an ambulance brought Nick to my office parking lot for the formality of my pronouncing him dead.  At my urging Beth agreed to an autopsy.  Knowing what the pathologist had to find, I prevailed upon him to be more meticulous than usual.  Lo and behold the cause of death was an acute myocardial infarction, a common heart attack; there was no cancer to be found.

With no other hypothesis to fall back on, I’m left with believing that perhaps Siegel’s thesis is correct, that a proper attitude on the part of the patient can positively influence the course of his cancer.  I now, at least, recommend gardening.

Helen, my second miracle case, was a nurse at my hospital and a personal friend.  How proud I was of myself, and yet wretched (in that order), when I diagnosed colon cancer from a barium enema I performed in my office.  I had to remind myself that I hadn’t put the cancer there.  On Thanksgiving Day that a cancer surgeon operated on Helen.  I watched as he deftly removed the cancer and one cancerous lymph node. 

Three months later while I was out of town, Helen experienced renewed pain in her abdomen. I received a phone call from a surgical colleague.  “Dave, I just opened Helen’s belly.  It was sprinkled with tiny metastases everywhere.  Oh, yes, I did splash in some nitrogen mustard (the only chemotherapy drug at that time) before I closed her but you know that can’t do much good.”  The surgeon told Helen’s husband that she had three to six months to live.  I concurred.

Against all odds, Helen continued to live in good health defying my prediction, just as Nick had.  Questioing my initial diagnosis, I sent tissue samples from both of her surgeries to two university pathologists who confirmed the diagnosis of metastatic cancer.  Not one of the many oncologists I consulted would credit the nitrogen mustard for her remission.

In the ensuing years Helen remained symptom-free with occasional checkups disclosing absolutely no abnormal findings.  Her husband would ask, “Doctor David, how do you explain our good fortune?” 

At a loss for words on each occasion once I did offer, “Well, you know that the night before Helen’s first operation, I attended a Brotherhood meeting with Bishop John Wright (later Cardinal Wright) and he agreed to offer a special prayer for her.”

 Helen lived thirteen years, after the second surgery, continued nursing (not gardening), until death came from a massive stroke.  It was not surprising to me at that point that the autopsy showed no evidence of cancer. 

Whatever the reason for these miracle patients, it is incumbent on me, and all physicians, to be truthful and humble; that includes not setting rigid limits on the projected life span of any patient.  I only wish that when I used to estimate the amount of time “left,” I could have been wrong an additional time or two or three ….

(Abstracted from my memoir, By All Means, Resuscitate)

The Cookie Jar

“Doctor, why are you staring at my breast?  Is something wrong?” Darlene spoke free of embarrassment or admonishment.

Her questions interrupted my concentration as I listened intently to her heart murmur.  As a fledgling doctor for the first time away from the protective network of a teaching hospital, it was difficult to quell my excitement.  I was so thrilled to be diagnosing rheumatic heart disease that I gave no thought to the person or the body that lay before me.  Let me put the event in context to allay any doubts the reader may be entertaining.

During my final year of internal medicine training in Boston, my wife and I were living on a tight budget.  Having trouble making ends meet, I responded to a request sent to all members of the Massachusetts Medical Society for volunteers to make house calls on indigent residents of Boston.  Actually “volunteer” wasn’t quite the correct word for each patient would be required to pay the sum of seven dollars.  Nominal or not, the payment would feed us for two days.  I signed up.

Actually I faced the potential new responsibility with trepidation.  From the moment of my first involvement with a patient eight years before as a second-year medical student in 1946, I had always the security of a backup of a huge cadre of teachers and more highly placed residents, and indeed, the vast support system of one medical school or another.  Now for the first time I would be out in the cold unforgiving world on my own.  I and I alone would be prescribing for a patient with no one looking over my shoulder to monitor my decisions.  It was scary.

Lo and behold on the following Saturday afternoon came a call from the dispatch center asking about my availability.  Receiving a positive reply, they gave me the address and directions to a run-down section of Back Bay, Boston.  I remember that my heart was pounding as I contemplated my mission.

Twenty minutes later I arrived at a two-story clapboard house.  Four warped steps led to the front porch.  Faded yellow paint was peeling around the door.  The doorbell made no sound so I knocked.  A six-year old girl answered and led me up one flight of stairs.  The sparse furniture was shabby.  The mother, who was obviously the patient, reclined listlessly in a cotton nightgown on a couch.  I gestured to her not to get up; she appeared grateful.  I shook her moist, flaccid hand.  She forced a near-motionless smile.

My first dilemma was where to sit.  I pulled a metal chair from the kitchen and sat opposite my patient, a comfortable and yet not unfriendly distance away and began my history taking.  Her daughter sat at a nearby table with a coloring book.

The patient, Darlene, was an attractive twenty-three-year-old, a single parent.  She worked in a laundry; her hands were red presumably from contact with strong soaps.  She had called “the service” because of a severe sore throat and fever.  Aspirin had done little for her.  Inquiring further I learned that twelve years before, she had been hospitalized for rheumatic fever.  She was unaware of any after effects and had no cardiac symptoms.  I spent another quarter of an hour compulsively documenting a complete history.  Her family had rejected her when she had become pregnant out of wedlock.

My next problem was where to examine her.  I could have done so as she sat on the couch but this was in front of a bare window.  Instead I helped her into a disheveled bedroom.  She sat on a double bed and started to take off her nightgown; I indicated that this wasn’t necessary.  I placed my medical bag next to her and started the physical examination.  The first abnormal finding was an inflamed throat with patches of pus on her tonsils, an obvious “strep” throat.  So far so good.  My training was paying off.  As I took out my stethoscope, again she started to raise her nightgown.  “Oh my!” I thought.  “This is far different from a hospital setting with a nurse in attendance or at least nearby.”   I began listening to her heart sounds.  Within a couple of minutes Darlene interrupted my routine with the question that started her story.

If I was embarrassed, this was not the explanation of my excitement for I had heard a loud heart murmur indicative of rheumatic mitral insufficiency, in lay terms, a leaking valve.  Such a great teaching case!  I wanted only to demonstrate my findings to the medical students working in the ward but, of course, this wasn’t a ward and there was no one around to teach.

I compulsively performed a fairly complete physical examination, but certainly no pelvic exam.  I couldn’t help wondering if Darlene pondered what a breast exam had to do with a sore throat or even a heart murmur.  I was relieved to return to the living room.  

“You have a strep throat,” I said.  I doubt if I weighed the impact of my medical jargon as I continued, “You have rheumatic heart disease.  We have to treat your streptococcal infection especially so to prevent the streptococci from spreading to your heart valves.  You must take penicillin pills four times a day for ten full days in order to do that.  Don’t interrupt the medicine even though you ought to be feeling normal within thirty-six hours.”  I was in high gear as though I were confidently completing the last question of a medical school exam.   I wrote out a prescription for forty penicillin tablets, which she could obtain for a minimal fee.

As I rose to leave, Darlene went to the kitchen where she took a cookie jar from a closet.  She reached in and extracted its contents, seven, crumpled dollar bills.  So many thoughts flashed through my mind.  “Was this all the money she had?”  “Could I take three?  Would that humiliate her?”  And finally, “Had I already not been amply rewarded by the validation of my years of training? Wouldn’t taking money from her tarnish our relationship”?  Never before having received a fee from a patient, I was at a loss for an answer.

I put the seven dollars in my pocket, and after an approving glance at the stick-figure drawings by the little girl, I departed.

I’ll never know if Darlene followed my instructions or whether in later years she had her valve successfully replaced or whether her daughter went on to become a famous artist.