Things I Didn't Learn in Medical School: Tough Lessons from a Lifetime of Practice

Things I Didn’t Learn

In Medical School

Tough Lessons from a Lifetime of Practice

Gary L. Fanning, MD

Copyright © 2012 by Gary L. Fanning, MD.

Library of Congress Control Number:       2011963264

ISBN:         Hardcover                               978-1-4691-4249-4

                   Softcover                                 978-1-4691-4248-7

                   Ebook                                      978-1-4691-4250-0

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Contents

Chapter 1 Introduction

Chapter 2 Reality Check

Chapter 3 Who Am I?

Chapter 4 Wash Your Hands

Chapter 5 Respect Your Fellow Human Beings

Chapter 6 Communication

Chapter 7 Medical Economics

Chapter 8 Know the Rules and Obey Them

Chapter 9 Medical-Legal Issues

Chapter 10 Ignore Your Gonads

Chapter 11 There’s More to Life than Medicine

Chapter 12 Take Care of Yourself

Chapter 13 Final Thoughts

Chapter 14 Acknowledgments

To my grandchildren

Evelyn

Alex

John

And my children

Michael

Mary Ellen

Sarah

And my sons-in-law

Ted

Steve

But most of all, to my dear wife

Arline

Before beginning, prepare carefully.

—Marcus Tullius Cicero

To acquire knowledge, one must study; but to acquire wisdom,

one must observe.

—Marilyn Vos Savant

Chapter 1

Introduction

I have always wanted to be a physician and cannot explain why. My mother said that when I was quite young, I had a boil on my thumb that was exquisitely painful. So she took me to the doctor, who lanced it. Evidently, I had a relieved and grateful look on my face after he did the deed, and Mom counted that moment as the beginning of my desire to be a physician. Neither she nor my father pushed me in that direction, so any movement toward becoming a doctor must have come from within—until I entered fifth grade.

At the Springdale Elementary School in Tulsa, Oklahoma, my fifth-grade teacher, Mr. Garrett, had wanted to be a physician when he was a boy. As a young man, he fell from a tree and seriously injured his hip, which left him with a pronounced limp. This resulted in his being advised not to become a doctor, because the rigors of medical education and practice were thought to be too onerous for someone with his disability. This was unfortunate because he was vigorous despite his physical limitations and, judging by his intelligence and kindness, might have been an excellent physician.

Fifth grade is traditionally the year when children are first exposed to matters of human health in any depth in the school curriculum. When Mr. Garrett learned of my interest in medicine, he took care to see that I had extra reading material and encouraged me at every turn. An affable man and a superb teacher, he transformed a glowing coal within me into a roaring blaze. By the time I finished fifth grade, my desire to become a doctor had turned into a passion.

Having gone through high school and college taking all the appropriate courses and attaining acceptable grades, I was ready to apply to medical school. Nothing discouraged me from my goal, and I was eager to begin my career. My first interview was at Albany Medical College in Albany, New York, and the interviewer was a pathologist named Dr. Alexander. He was a tall gray-haired elderly gentleman wearing a spotless starched white lab coat over his shirt and tie. He had a serious, almost-grim demeanor.

I listened carefully to his first question: Fanning, why do you want to be a doctor? As the sweat began to bead and my pulse began to race, I told him the truth: my wanting to be a doctor was something that preceded my memory, and I could not recall ever wanting to do anything else.

His reply: In other words, Fanning, your desire to become a physician is a childish whim to which you have never given a moment of rational thought.

Those were his exact words, undoubtedly remembered after all these years because they are branded somewhere on one of my cerebral hemispheres and because there was at least a modicum of truth in what he said. I went on to explain how I had prepared myself for medical school by studying hard and majoring in biology, a science that greatly interested me. I fumbled on for a while and was most relieved when this trial ended. The second interviewer (whose name I do not remember) was benign by comparison, and he pleasantly tried to convince me to attend that school instead of any other. I think back on it as a bad cop, good cop experience. I did get accepted there, but I chose to attend the State University of New York Upstate Medical Center in Syracuse.

Why am I telling you all this? Sitting here at seventy-one years of age, I have practiced medicine for more than forty-five years and still cannot tell you with any certainty why I wanted to become a doctor. From my perspective, it feels like my profession chose me instead of the other way around, so I consider it a calling instead of a choice. Mind you, this does not make me any better or any worse than other members of my profession; it is simply that, like all of us, my life’s experiences will color everything I believe and write. I have a passion for medicine bordering on religion, another facet of my being that influences my outlook. You would be wise to remember that as you read. Because of my pride in my calling, I have expectations for the members of the medical profession that others may not share. I find it difficult to accept behavior in a physician or any other health care professional that is anything less than honest, moral, legal, and selfless. To many, that makes me a stuffed shirt or worse. I can live with that.

This book is written primarily for those in the health care professions, especially those about to enter their training; however, people already in training or recently graduated might find it interesting as well. Laypersons not associated with medicine but with a general interest in the field might enjoy some of the stories, philosophy, morality, politics, and controversies contained in the work, because much of what I have to say is equally applicable to people working in other fields. The tone of the book will be conversational, because I want you to feel that I am speaking directly to you. Try to imagine our sitting together, having a cup of coffee and discussing the issues I raise. I love to talk, argue, and reminisce. So just consider this reading as a one-sided conversation. Grab a nice cappuccino to enjoy as I give you words of advice, a memoir, a guide to practice and life, and a compilation of strongly held beliefs and homespun philosophies. There will also be criticism of situations and behaviors I find unacceptable. You will read a number of stories from my life, which I hope you will find interesting. They all happened as I describe them to the best of my recollection.

I am not afraid to say what is on my mind, and if anyone with a critical eye ever reads this book, my opinions will suffer the majority of the artillery shots. So be it. I am not ashamed of them, most of which have been formed after careful thought, study, observation, experience (including both failures and triumphs), debates, and consultation. I am willing to change my attitudes based on new facts or changing circumstances; however, my principles are immutable, forged over a lifetime and battle tested. I am well aware that if a man can find agreement with his opinions 50.001 percent of the time, he is lucky indeed, and I have many friends who disagree with some of mine. I love to spout off, and I will sound preachy some of the time (another sure target of criticism), but not in a truly religious sense. Any morality discussed will be mostly in social or secular terms, even though secular mores and religious mores are often inseparable. I will even quote a religious source or two; nevertheless, I am quite content with your finding your own religion and will not proselytize. You will learn that I am a practicing Episcopalian and am quite serious about my faith, another factor that greatly influences how I view life and how I react to others.

I hope you read the preceding paragraph carefully. I do not wish you to become angry with me if you disagree with my opinions. You have every right to opinions of your own, and if yours don’t always jibe with mine, that’s OK. It will make me supremely happy if in reading what I write, you are motivated to examine your own views concerning a variety of issues. I have never met anyone who has all the right answers about everything, not even that guy I see in the mirror every morning when I shave. So feel free to disagree, but let’s remain friends.

Why have I written this book? I wanted to share some of my life’s experiences and strong feelings with friends and family, and it occurred to me that these might be of interest to people entering medical fields. I also thought about many of my encounters in recent years with young physicians just out of training, some of whom are terrific—skilled, dedicated, and ethical. Others, quite honestly, have a view of life that is so far from mine as to be upsetting, especially in the areas of morality, professionalism, work ethic, greed, and compassion (primarily a lack thereof). I wondered, therefore, if medical school training is perhaps lax in exploring these subjects and if it might be worthwhile to add my voice to those attempting to insert some humanitarian issues into the curriculum.

The ultimate goal, of course, is to produce health care providers who are not only scientifically and technically competent, but also humane, sympathetic, and moral, because the true measure of a physician is not only how he or she treats diseases, but also how he or she treats patients. I do not remember hearing a lot of thou shalt and thou shalt not statements from my professors in medical school. That’s OK in many respects, because medical schools and institutions training other health care professionals are not seminaries. Nonetheless, in the practice of our various disciplines within medicine, some behaviors are acceptable and some are not; and that applies to the perspectives of one’s colleagues, one’s patients, and society in general. The way in which we conduct ourselves reflects on us and on our profession. The old saw about a rotten apple spoiling the barrel is appropriate, and I do not wish the barrel of medicine spoiled by the behaviors of a few rotten apples.

Those difficult individuals that I have encountered in medicine over the years have left an exceedingly bad impression on my memory. A few years ago, a college friend and I sat in a restaurant after having not seen each other in over twenty years. He is a gynecologist. After the cocktails had been delivered, I said to him, We worked hard to prepare ourselves to become physicians and have practiced a good long time now. What is your biggest disappointment in medicine?

He replied almost immediately, My fellow physicians.

He was right. Even though I have loved and respected most of the physicians with whom I have worked, there are those few who have been the sources of considerable consternation. I have had many occasions to observe both acceptable and unacceptable behaviors, and I have been disturbed that too many people do not recognize the latter. Believe me, I am neither a scholarly philosopher nor an ordained clergyman nor a credentialed medical ethicist. I am a practicing physician, husband, father, and grandfather who has lived a long time and observed a tremendous amount of human activity, which qualifies me to recognize unacceptable professional behavior as much as any person I have ever met. Although I am not blameless in exhibiting unacceptable behavior from time to time, I do not believe that I am guilty of the egregious examples I shall cite.

I wish to leave behind some of the things I have observed and lived and some of the simple values that have made my life easier, more pleasant, and hopefully more appreciated by those whom I have encountered, worked beside, treated, and loved. Those principles have come from many directions and numerous individuals over the course of my life and practice. My few serious regrets have arisen largely from the times I ignored or forgot my core values. Those new age types who disagree with my philosophies and reject my principles will have a field day tossing mud in my direction. That doesn’t bother me in the least.

It has been said that it is better to judge a man by his enemies than his friends, and I feel much more comfortable with those who basically adhere to the ideologies I hold dear, ones that I view as mainstream morality. I fully recognize that others will view them as old-fashioned, immature, and naïve; however, I am comfortable with the life I have lived and the moral standards that have guided me.

The title of the book is slightly misleading, because I will include many things that I did learn in medical school, but not just in class or from reading texts. For those just beginning health care training and for those already there, I hope you will benefit from the observations of a seasoned veteran. They say that experience is the best teacher; but it is also the cruelest, least forgiving, and most ruthless. The ability to benefit from both the good and bad experiences of both others and ourselves is one of the huge advantages of being human. As a species, however, we tend to forget or ignore that capability; thus, we keep repeating the same old mistakes. For intelligent individuals who read history and make keen observations of the present, this failing of our kind is a source of madness. No one has adequately answered this simple question: Why can’t we learn from the past? Actually, we can learn from the past if we so choose. One might define an act of stupidity as doing that which we know we should not do, and our knowing what not to do often comes from observing the acts of others. Unfortunately, some people are incapable of learning from their own or others’ mistakes and continue to make bad choices throughout life. Always try to benefit from your own experiences and those of others. It will save you a lot of pain in the future.

For laypersons who read this book, I hope you will gain some insights into the practice of medicine and the mind-set of one practitioner. Being a doctor, nurse, or other medical professional is not as easy as it seems from the layperson’s perspective. So perhaps reading this will help you understand and respect your own caregivers a bit more. I am distressed over the stories in the media about doctors and other health care professionals who allegedly do bad things. Without question, there are people in medicine who do bad things, often horrible things; nevertheless, I believe that the overwhelming majority of my fellow practitioners work harder for your benefit than for their own. Mistakes are most often the result of good human beings trying to do their best in difficult circumstances and not the result of bad people being malevolent and malicious. After reading this, despite some of the horror stories I will relate, I hope you will agree.

The physician should look upon the patient as a besieged city

and try to rescue him with every means that art and

science place at his command.

—Alexander of Tralles

Chapter 2

Reality Check

Is This What You Had in Mind?

Unless you have grown up in a medical family or have already worked in the medical field in some capacity, you have no realistic image of what it means to be a doctor or health care professional; therefore, I thought I might begin by giving you a look at what it is like to be a practicing physician. Forget about what you see on TV. No matter how graphic they make it seem on that screen, it can never compare to the real thing. If you harbor any degree of humanity, some of the cases you experience will brutally challenge your ability to act appropriately and effectively under conditions that would compel most human beings to scream and run. It will be your duty to function at full capacity under such circumstances. Medical training is a good introduction to what you will see in practice, but in the short time of your formal medical education, you cannot see everything. In this chapter, you will read the details of several cases that I dealt with during my career, ones that significantly affected me. Think about them carefully, because they are relatively tame compared with the challenges faced by many of my colleagues as I have heard them described at medical meetings and read about in journals. If you are a medical student or soon will be one, perhaps this chapter will help you focus on your studies and give more meaning to what you are learning. If you are studying to become a nurse, paramedic, or other health care provider, it will underscore how important you are in helping physicians do their duty. If you are a layperson, you are about to read some vivid descriptions of actual situations I have faced. Some of it will not be for the faint of heart, to say the least. It all happened as I describe it to the best of my memory.

As an intern in surgery, I began my rotation in the emergency department at Strong Memorial Hospital in Rochester, New York, on a Saturday morning. Emergency medicine was quite different in those days. There were no paramedics and no meaningful communication between an ambulance and the hospital. Surprisingly, many ambulance drivers and attendants did not even have basic first aid training. In many communities, ambulances were owned and operated by funeral homes, a situation morbidly described by some wags of the era as a classic conflict of interest. There were no cellular phones, and two-way radios were largely confined to the police and fire departments. As a result, ambulance crews simply picked up patients, took them to the hospital, and dropped them there, so-called load and go.

On that first morning of my rotation, ambulance attendants, without any prior notification, brought in a four-year-old boy on a stretcher and dumped him onto an examination table. The child was stiff and unmoving, and his skin was beet red. He was quite obviously dead. The ambulance driver told us that the child’s mother found him in a clothes dryer that was turned on and running. In those days, when one opened the door of a dryer during the cycle, the machine automatically stopped but resumed functioning when the door was closed again. Thankfully, this is no longer the case; and now when one interrupts the cycle by opening the door, a button well away from the door has to be pushed to resume the operation. This child had opened the dryer door, climbed inside, and shut the door behind him, thereby restarting the heating and spinning cycles. In precious little time, his lungs were burned by the hot air in the dryer, and he succumbed. His skin was beet red from the heat of the dryer and the abrasive effect of the clothing lashing around him as he tumbled lifelessly inside the machine until discovered by his mother. I feel certain that his stiffness resulted from his muscles being essentially cooked. The vision of that child lying there dead on the examination table has stayed with me all these years. He was sandy haired and handsome, and I wanted him to leap off that examination table and start running around the room. Most people would have burst into tears and run. I could do neither. I was horrified by the mechanism of this boy’s needless and most unfortunate death, by the fact that there was absolutely nothing I could do about it, and by the knowledge that I had to go and talk with his distraught parents.

It is heartrending to tell someone that a loved one has died, an emotion magnified many times when you deliver that news to parents. You cannot avoid sharing their grief, and then you begin to think of the guilt and remorse they will likely suffer for the rest of their lives. In addition to offering condolences, you must try to help them in any way you can, such as notifying clergy, family members, and their family physician. Nothing will test your compassion as much as dealing with loved ones at the time of death, especially an untimely, accidental one. Your teachers can do little to prepare you adequately for this in medical or nursing school. While you may be exposed to death and dying many times during your training, it would be hard to train you for every tragic situation you might face in your career. I have concluded that dealing with the reality of death is a duty one must learn