Friday, June 8, 2012

Why I Chose Family Medicine: Part 1

     It was my fourth year of medical school.  I had to imagine myself as a particular kind of doctor.  I was being exposed to a lot of different specialties but now I had to choose one in order to enter the lottery for a residency position.  It was obvious that this decision would frame my entire future just as the house I built one day would frame my living space and thereby become a template for my inner world.  The specialty I selected would determine my geography, the kind of building where I unveiled myself through daily work, and the people with whom I associated.  It would also decide my income bracket and my lifetime loneliness quotient.
     There wasn’t a rotation that hadn’t mesmerized me. This was clue number one.  “If you loved every elective you’re probably meant to be a family doctor,” said my solo doc preceptor who “did everything” with inspired fervor in the ramshackle space of his resplendently overflowing office.
     I hated the hospital.  My abhorrence was peculiar among medical students, most of whom got so used to the cold echoing corridors at night, slate-blue tint of fluorescent lighting, and know-it-all quirkiness of veteran charge nurses (whose mien could shift on a dime from mother hen to scorpion) that they felt at home on the hospital wards.  Medical students seemed to accept that one day they too would take their place in the pecking order, basking at long last in the sycophantic adoration of  these same nurses, who perpetually dusted and polished the pedestal of the Attending Physician.  This is how it seemed to us lowly medical students, anyway.  
     But my reason for hating the hospital had to do with a four-week rotation in Pediatrics during my third year of medical school.  This is the year in which a student is blasted out of a cannon from the classroom into the clinical wards, abruptly faced with real, suffering human beings, hoards of them, all requiring urgent, lifesaving care, all thrusting themselves onto the timid medical student with a litany of symptoms and queries, unburdening the horrifying facts of their messy, piled-up lives--lives such as we could never have imagined from memorization of our textbooks!--and we were supposed to diagnose them, understand them, fix them, send them home, or send them back to the streets.  
     Temple Medical School is in North Philadelphia, an impoverished, depressing neighborhood where every night violent crime produced gunshot and stab wounds that gave us an opportunity to practice our skills--if we were lucky enough to be supervised by residents who “let” us assist--at placing chest tubes and draining blood from the abdominal cavities of victims.
     It was 1988 and Temple was on the forefront of the AIDS epidemic.  My job as a student on a Pediatrics rotation was to do spinal taps on infants with AIDS.  But I made a mistake.  I wanted to know, every day:  Who are these babies?  Where are their parents?  Why do they have AIDS?   I had a baby of my own and was pregnant with a second.  These were my own little ones who during medical school were brought pink-faced and baby-powderish to the hospital every four hours for me to breastfeed during stolen bathroom breaks.
     My attending physicians told me to stop asking these questions.  The spinal taps were done with no anesthesia and the babies screamed throughout.  The procedure required an infant to be held on its side in the fetal position while I inserted a long needle through the skin into the spinal cavity, avoiding if possible the spinal cord. Then a sample of cerebrospinal fluid was extracted into a syringe, the needle was removed, and the child sent away.  Holding or comforting the child was a sign that I was too attached, too emotional.  I was supposed to be grateful to be given experience at these procedures.  We were doing spinal taps on the same babies day after day.  In most cases the babies had been born to IV-drug using mothers who were dying of AIDS, or to mothers who had been exposed unknowingly to AIDS through their partners, and to fathers who were dead or whose whereabouts was unknown. Was there some way the spinal fluid would guide treatment?  Could the suffering we inflicted be justified in any way?  It seemed not, at least not from the standpoint of the babies’ experience, not as far as I was concerned.  Very soon I understood that the specimens were being used for research and the babies, whose next of kin were neither present nor sophisticated enough to understand what was happening, were at the mercy of the doctors. 
     I cried after these procedures, often unable to conceal my anger and grief behind the veneer of objectivity expected of good physicians-in-training.  What if these were my babies?  What about their pain?  Wasn’t I supposed to take an oath to “first do no harm”?  Was there no room for caring? The response I heard, whether it was spoken directly or not, was that I didn’t know enough to question what was happening.  I was a neophyte.  Why couldn’t I appreciate the privilege of this training, the opportunity to learn procedures, and the judgment of the attending physicians?
     I passed my Pediatrics rotation but received terrible evaluations from the preceptors.  “Too sensitive.”  “Not enough self-control.”  “Lets personal feelings interfere with medical care.” (Notice that my name was not used in the incomplete sentences of the write-ups, nor were pronouns which might indicate that I was a real person who could be affected by and could affect others. The message:  Real doctors don’t let themselves get involved.)  This experience caused aftershocks and questions about medicine and morality which continue to inform my care of patients today.
     The hospital is a place where a person stands a good chance of being harmed.  This is what I thought then and what I believe today.  There is now much corroboration for this idea, of course, in statistics which show the rate of iatrogenic ("caused by doctors") disease, medical errors, and deadly MRSA and C. dificile infections suffered by patients because they spend time in the hospital.  And back then old-timers in the clinic used to refuse hospitalization because they perceived it as a place you go to die. I was always on their side. 
     Deciding never to work in a hospital meant that I couldn’t be any brand of surgeon, nor could I be a sub-specialist in Internal Medicine--a neurologist, cardiologist, oncologist, or infectious disease specialist.  I couldn’t go into Radiology. I couldn't be an Emergency Room doctor.  In fact my options for a specialty were limited by my bias against ending up in a hospital-requiring practice to Dermatology, Psychiatry or Family Practice.
     Family Practice is a specialty.  It is no longer being a “GP."  The three-year residency training can be extended several years longer if a physician wishes to secure even more education in geriatrics or sports medicine.  I liked the idea of having a patient all to myself, seeing him or her first, and spreading the confusing facts of symptoms and findings in front of me like landmarks on a huge map across which I would need to help the patient find a way home.  “Home” would be a place where sickness has been transformed into understanding, and healing would be when that understanding becomes a part of the matrix of a person’s being.  As a family physician I would be a guide through the wilderness of fear,   pain and suffering, a guide home to relative wellness and to a person changed by illness, even by small illness.  I thought I could do that.

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