Now one day Pooh and Piglet and Rabbit and Roo were all playing
Poohsticks together. They had dropped their sticks in when Rabbit
said "Go!" and then they had hurried across to the other
side of the bridge, and now they were all leaning over the edge,
waiting to see whose stick would come out first. But it was a
long time coming, because the river was very lazy that day, and
hardly seemed to mind if it didn't ever get there at all ....
And out floated Eeyore.
"Eeyore!" cried everybody.
Looking very calm, very dignified, with his legs in the air, came Eeyore from beneath the bridge ....
"Eeyore, what are you doing there?" said Rabbit.
"I'll give you three guesses, Rabbit. Digging holes in the ground? Wrong. Leaping from branch to branch of a young oak-tree? Wrong. Waiting for somebody to help me out of the river? Right. Give Rabbit time, and he'll always get the answer."
"But, Eeyore," said Pooh in distress, "what can we -- I mean, how shall we -- do you think if we --"
"Yes," said Eeyore. "One of those would be just the thing. Thank you, Pooh."
There was a moment's silence while everybody thought.
"I've got a sort of idea," said Pooh at last, "but I don't suppose it's a very good one."
"I don't suppose it is either," said Eeyore.
"Go on, Pooh," said Rabbit. "Let's have it."
"Well, if we all threw stones and things into the river on one side of Eeyore, the stones would make waves, and the waves would wash him to the other side."
"That's a very good idea," said Rabbit, and Pooh looked happy again.
"Very," said Eeyore. "When I want to be washed, Pooh, I'll let you know."
"Supposing we hit him by mistake?" said Piglet anxiously"
"Or supposing you missed him by mistake," said Eeyore. "Think of all the possibilities, Piglet, before you settle down to enjoy yourselves."
From The House at Pooh Corner by A. A. Milne, Dutton 1956
I got to know Dr. Ed Friendly on the internal medicine service
during my family practice internship (1977-78). We spent a month
together making rounds, admitting and discharging patients, doing
consults in the Emergency Room, and sharing ideas, concerns, and
complaints. During that time, I not only gathered bits of Ed's
personal philosophy but I also came away with a goodly share of
the wit and wisdom of Winnie the Pooh. Dr. Friendly was quite
taken by the 'Bear of little brain,' who paradoxically spoke profound
aphorisms on occasion. Almost every day as we walked the halls
and rode the elevators of Martin Army Hospital, Ed passed on a
story which highlighted the times and truths of Pooh and his pals.
For some reason, I had missed Pooh in my childhood years. I knew his name and little more. Thanks to Ed, I became knowledgeable about him and his friends who populated the Hundred Acre Wood and brought joy to millions over the generations. For my thirtieth birthday, Ed presented me with two "Pooh packages." I received two Pooh paperback books, which I subsequently read and reread, as well as the cover painting of the Bear and friends created by his devotee, Dr. Ed. The latter present remains one of the most unique and cherished one I have ever received. The unsigned original has hung prominently on my office wall, wherever that has been, from my thirtieth birthday to the present.
To consider all the possibilities, according to Eeyore and A.A. Milne, you will have to spend time in the World of Pooh. It might be as pleasant and productive a diversion for you as it was for Ed Friendly and me. For Dr. Friendly, to "consider all the possibilities" meant to be an acute and thorough physician. Thoroughness was the mark of a 'good doctor' seventeen years ago and probably still is today. I have heard numerous patients over the years praise their physicians because, "He left no stone unturned," "She ordered every test in the book," "They considered every possibility, I'm sure."
It is easy for a physician to give the impression of having 'covered all the bases.' There are so many tests and procedures that can be performed and so many specialists who can be consulted. With enough time, patience, and money, all the possibilities can be considered, at least in a pro forma manner. According to Dr. Friendly and most orthodox physicians, each patient's complaint should be examined acutely and astutely. The expanses of medical knowledge and capability should be plumbed to discover the correct diagnosis. "Diagnosis is key!" to the practice of modern medicine.
Dr. Ed related this story quite directly to one of the consensus ideals of medical practice. But, I connected with the story in an entirely different way. I had begun to consider a wider range of possibilities in medicine and in life some years before I met Ed Friendly and heard the tale of Eeyore and Pooh. The opening came when I discovered the readings of Edgar Cayce. The Cayce teachings came to me at a prominent turning point in my life just as I entered medical school and set my sights on becoming "a doctor, a physician, an M.D." My call to the profession and selection for training from among large numbers of qualified applicants gave me pause to consider the possibilities of such a career.
Prior to being admitted to the University of Texas Medical School at Houston, I had worked in various areas of allied health for seven years. I had been a medical corpsman (medic) in VietNam and in a stateside Army hospital. Going through college, I worked as a technician's assistant in xray and as a vocational nurse in a hospital emergency room. I earned a bachelor's degree in medical technology, but survived only two months attending microbes in the catacombs of a hospital laboratory. I then returned to working with living human beings in the emergency room of a county hospital.
I had almost been "raised" in the system. I found orthodox medicine relatively simple and picked up most necessary skills easily. It was as if I had done most of the work before and was taking a refresher course. The medical field, especially the ER, was often exciting, even glamorous. But, the laboratory definitely wasn't for me, although the training I received there helped alot in my later studies. The lab was cold and dry and removed from human beings. "People" people didn't generally work there. Although I was a bit of an intellectual and bookworm myself, I knew real people were more interesting and important than testtubes and Coulter counters. Going to medical school, I felt comfortable saying I wanted to become an emergency room physician. My desire to "help people," which prompted me to become a medic on entering the U.S. Army in 1967, still held firm. The Emergency Room was an active place in which I imagined people were quickly, dramatically, and permanently helped.
Yet along the way, I developed reservations about medicine, its single-mindedness and roteness, its sterility and distance from patients, and its reliance on pills and scalpels. The only time I ever contacted a patient as a med tech was when I went on rounds to draw blood. What a strange way to "touch" and relate to another human being. As an xray tech's assistant, one of my main jobs was to take portable chest films after placing a cold, hard plate behind an ailing patient's back. As a nurse, my chief duties were to give meds and injections, start IVs, set up procedures, and do charting. The human element was fitted in as time and interest permitted. Fortunately for me and my patients, I had some of that interest.
I suppose that my aptitude and consciousness fostered my "encounter" with Edgar Cayce just prior to entering medical school. I simply read Joseph Millard's The Mystery Man of Miracles and was hooked from the "get-go." It didn't take much of an introduction to make me a committed follower. Cayce's words, given in hypnotic trance to hundreds of different individuals and groups over a period of 40 years, seemed to speak straight at me. I quickly joined the Cayce organization, A. R. E. (Association for Research and Enlightenment). I read just about everything written on Cayce in biographies, journals, and books. I studied literally hundreds of the medical readings. My appetite for reading and learning, for once in my life, found a fitting menu. Cayce, though distant through space and time, became a real friend and teacher.
I have not had the fortune to have an esteemed, living teacher in this lifetime. But, my relationship with Edgar Cayce and his work certainly made up for that lack. I consider my time with Cayce to have been on the level of "A Meeting with a Remarkable Man." I date the beginning of my real life circa 1974. The rest is BC and AC: Before Cayce and After Cayce. At age twenty-five, I was reborn from the mundane into a realm of possibilities, I was awakened into a space of expanding light, I was offered opportunities and tools to begin the building of a whole life. Of course, it was just a beginning - another beginning - but, it was a powerful and exciting one. Even today, I am not fully aware of all the challenges, happy as well as painful ones, which were precipitated by my discovery of and commitment to the Cayce paradigm. Yet, there were obvious ones to be faced as I studied medicine during the day and Cayce at night. Over the years, to those who might understand, I have often said that I learned more from my Cayce studies than from the medical school curriculum.
My earliest challenge as a result of my Cayce studies was to take another look at the whole of medicine. I realized rather quickly that if I was really going to embrace the Cayce concept, I would have to develop an interest in preventive medicine. Having worked in the fast-paced arena of emergency medicine for several years, I worried, "Oh, I'll be bored by the dull, lackluster field of prevention." Nonetheless, I dug deeply into preventive and holistic concepts because of their integrity and the strength of their witness to life. I eventually recognized the wonder, value, and opportunity offered in the true preventive approach to health care. Prevention, like any day-to-day process or operation, is not glamorous, but it is necessary and eventuates in valuable change. It required a reorientation from the quick fix to the long effort and a widened perspective.
The Cayce philosophy gave me insights into the breadth and depth of bodily life - the human constitution, the nature of healing, and the vital relationship between God and man. It offered me an alternate reality with which to view the world. It was a mystical, optimistic, and idealistic one which had a potent effect on a naive medical student. At the same time, the Cayce view was couched in scientific terms and holistic perspectives. I grasped the paradigm firmly and ran with it for a long distance. Yet, the Cayce ideal was not simple to apply. It demanded work and change, self-searching and discovery.
There was more to my "Cayce period" than just reading and thinking. Opportunities arose regularly to "put Cayce to the test." I, the physician-in-training, found plenty of occasions in which to practice the "Cayce method" during my medical school days. Along the way, I tried most every common Cayce remedy on myself or my wife. Both of us became guinea pigs for a wide variety of Cayce products, devices, and suggestions. I was most often the willing experimenter. My former wife, Kelly, was not always so keen on my projects. Still, experimentation is a great way to learn.
I tried Cayce-suggested chiropractic, diet, eye exercises, and colored lights for my myopia (near-sightedness). I never achieved much success on that one. I played with potato poultices and herbal mixtures, the violet ray machine and the radioactive appliance, Atomidine and Glyco-Thymoline for various and sundry reasons.
I used the Cayce method on sinusitis early in medical school. I vividly remember slogging through first year Gross Anatomy with a drippy nose. I recall the pungent and pervasive smell of formaldehyde which emanated from the "pickling fluid" used to preserve the cadavers we dissected. The aroma percolated everywhere. It seemed to invade my whole being. It "gave" me headaches and a wet, runny nose. I initially tried the conventional method to combat the problem: first decongestants and later antibiotics. These got me nowhere. Then, I dug into the Cayce materials and found an inhalant suggested as useful for such a condition.
The concoction was composed of a few drops of aromatic oils, like pine, eucalyptus, and tolu, in a grain alcohol base. I visited an old-time pharmacy and gathered together as many of the ingredients as were available there. I went to a liquor store to purchase Everclear (180 proof grain alcohol). For a few moments, I played the role of apothecary using an eyedropper to measure out the proper amounts of oils for the solution. Then, I simply agitated the bottle and whiffed the fumes.
I seemed to have real success with the remedy. It took some effort to put it together, but it was my own "concoction" -- based on a Cayce recipe. It was novel and unique. I inhaled the fumes several times a day. I snorted them up high into my sinuses, the tenacious, yellow phlegm liquefied and poured out through my nose in a relatively short time, and I was back in action. I resorted to the aromatic inhalant on a few other occasions of colds or flu.
At one point, imagining that my hairline was beginning to recede, I tried the Cayce method for baldness. Now, that was a real ordeal and only a devotee or a fool would put himself through the process Cayce outlined. The program called for regular treatment of the scalp with crude oil, along with some dietary recommendations and a course of Atomidine (iodine trichloride) taken in small doses in water. On the evening of this monthly experiment, I got into the shower, washed, and rinsed my hair. Then, I rubbed my scalp thoroughly with crude oil - straight from the well, or almost. Next, I rinsed off the majority of the oil with some grain alcohol left over from the "sinusitis experiment." Finally, I applied a thin layer of petroleum jelly to my scalp and covered my head with a turban made from a towel. In the morning, I washed out the greasy remains of the experiment with olive oil shampoo.
You might visualize this as a "messy" and involved procedure. Like a number of Cayce suggestions, a large part of the value of the crude oil treatment may have been produced by all the energy expended in its research, development, and production. It did indeed create a MESS. The bathtub required a lot of scrubbing to erase the black, greasy ring. Towels were sacrificed for the procedure and bedding had to be specially protected during the experiment.
The success of the venture is really hard to evaluate. Today, I have lots of hair and curls: "A full head of hair." My barber often comments on my "thick hair" and elderly ladies rave about it and wish they could "borrow some of those locks of yours." Actually, the crude oil scalp treatment may have been for naught, but it would have made a great home video!
I can, however, make testimonials for the castor oil pack, Cayce's most popular remedy. While the mechanism by which it works is not clear (physicians still don't know how aspirin does what it does), The Pack has been "proven" by me and to me as much as any remedy can be. Cayce suggested that the application of a warm castor oil pack to the abdomen particularly benefited the function of the intestinal and digestive organs. The castor oil, like most oils, is absorbed through the skin and seems to be picked up eventually by the intestinal lymphatic system. The pack may also have effects on the nervous system through the solar plexus center. Through its apparent cleansing and stimulating effects, the pack seems to have remarkable effects on numerous conditions.
While the pack is another relatively messy treatment, it is fairly simple to apply and often worth the trouble! The "experimenter" needs two or three layers of cotton or wool flannel. In a pinch most any cloth will suffice. A generous supply of castor oil required.
One saturates - wet, but not runny - the layers of cloth with castor oil. Then, places them squarely over the belly - from the pubic bones to the rib cage and covers with a warm heating pad. The heating pad is not absolutely necessary, for simple body heat will "coax" the oil through the skin and into the lymphatic system. A once-folded bath towel placed over the heating pad and the whole pack fitted under the pajamas stabilizes the arrangement.
In my various experiences, I have used or recommended the castor oil pack for such conditions as cancer, migraine, allergies, depression, and all manner of gastrointestinal disturbances. During the latter days of my internship, I found acute value for the pack in my own life. I was a few days into a bout with hepatitis. My body was colored raw ocher from the inside out. I was tired and nauseous and felt like I weighed a thousand pounds - maybe only 800.
But, my worst symptom was restlessness, especially at bedtime. Despite the oppressive heaviness, I felt like my insides were constantly moving - like the blue meanies were active and excited in every inch of my body. I went through a couple of agonizing and seemingly sleepless night. Fortunately, Kelly reminded me of the good ol' castor oil pack. We put one together immediately and I found relief and comforting sleep until I was no longer OD green. I became a true blue believer, too.
The castor oil pack became a part of Kelly's own therapy as she endeavored to deal with what her psychiatrist called "endogenous depression." Kelly had a history of psychological turmoil, mood swings, and phobias as well as low self-esteem. Kelly"s behavior was a bit of paradox. One of her therapists had diagnosed her as manic-depressive and prescribed lithium carbonate which she took for some time. On the spur of the moment, Kelly had the nerve to walk up to a celebrity in a crowded restaurant to beg for an autograph. At another time, she was afraid to ask the apartment house neighbor to loan her a cup of sugar. The "public" Kelly was bright, smiling, and gregarious, while the "private" Kelly was bogged down in fears and guilts and self-condemnation.
Along with counseling and varying prescriptions for tranquilizers and antidepressants, Kelly temporarily followed a plan designed by a "Cayce physician" at the A.R.E. Clinic. The regime included the application of the castor oil pack, oil rubs by me, dietary changes, use of the Wet Cell Appliance, and chiropractic manipulations. Looking back, I have to say that while the physical approach may have been warranted and somewhat helpful for Kelly, her real needs were left untouched by her physicians and counselors, by the Cayce remedies, and particularly by me.
I, the naive potential physician-healer, was attracted to and married a woman who I perceived needed HELP. I thought I could help Kelly. I was very wrong. Kelly's problems, as yours and mine, were multi-dimensional and probably beyond the capability of a REAL healer's to set in simple order. It was certainly far beyond the capacity of such a one as myself -- a fledgling medical student, a Cayce proselyte, an optimistic experimenter -- one who should have been a husband or friend rather than a therapist. For the longest time, almost ten years, I was one of Kelly's major problems.
I knew not how to be a reassuring husband, a supportive confidant, or a sympathetic friend. We never learned to communicate in the same language. I could not (and generally did not want to) penetrate the fogs and clouds of emotions which so often surrounded her. Kelly could not accept or relate to the aloof mind which I often displayed around her. Nor could she compete intellectually with the bright young medical student, although she tried in a number of ways. K. experienced life chiefly through feelings - deeply, dramatically, and dysfunctionally. My life was lived mainly through ideas.
The challenge of marital friction and imbalance was apparent, at least momentarily, from the very beginning. I distinctly, and embarrassedly, remember walking across the campus of the Texas Medical Center eighteen months before I began my professional training there. It was the day after our wedding and we were traveling through Houston en route to college. For a moment, Kelly walked a few paces ahead of me. In a flash, I was struck by the question-exclamation: "Can I live with this woman for the rest of life?!" I can recall an instant of near-panic, then an oppressed feeling, and, finally, an "Oh, well. Let's get on with it."
The Cayce philosophy and system offered a wealth of information, a fount from which to experiment, and a treasury of wisdom. Yet, we each have to live our own lives and circumstances, challenges and problems. We meet the people and events which are necessary to stimulate our growth. "That which doesn't kill me makes me stronger," some sage has said. Disease and discord are part of the wonderful opportunities of life which we so unconsciously and unknowingly confront.
The direct possibilities for healing between Kelly and me in this lifetime have more than likely been spent. Yet, who knows for sure! Regardless, we are bound to meet again in the face and force of many others who mimic the others' attitudes, thoughts, and feelings. And, likely there will be distant meetings in other times and places.
I imagine that Mr. Cayce would be pleased and proud if Kelly and I met the challenge to heal our bond through the relationships we develop with any and all people we touch in the days ahead. Those interactions, although generally appearing as one-dimensional, are always multi-faceted. Even the simplest contact, remedy, or therapy has vastly more to it than meets the naked eye. Cayce would happily suggest that we ponder the many hidden possibilities for our health and disease in our coming in and our going out, our living and dying and living again.
Cayce pointed me toward an expanding horizon. While I was frequently unable to grasp the deeper vision in my personal world, I took full advantage of his perspective within as well as without the walls of my orthodox medical school. On my own time, I studied widely in alternate healing methods, spiritual disciplines, and self-development. I read the writings of the few physicians, such as Norm Shealy and Carl Simonton, who were championing the ideals of holistic medicine at the time. I attended various workshops and programs which came through Houston. I dabbled in this area and tasted that one. I tried a Muktananda intensive, but was deterred from further investigation by the apparent worship of the guru by several participants. I attended Unity's Golden Pyramid Church on occasion, but never felt quite at home there. I tried Cayce Search For God Study Groups. Although the material was excellent, few of the groups which I visited over the years seemed to ever advance beyond the first chapter, literally or figuratively. (That chapter is entitled Cooperation.) For some months, I went to evening classes on Sound, Vibration, Color, and Breath taught by Andrew Richards at the Esoteric Philosophy Center. The content of his message is lost to me, but the subjective impression he made upon me in the span of a relatively few class periods was most positive and supportive.
I investigated chiropractic and osteopathy in my spare moments. I frequented the local chiropractic college and made regular visits for a time to the office of a Houston osteopath whose practice centered around manipulative therapy. I arranged my senior year in medical school to be eclectic as well as elective. Most every month of that school year offered me insights and opportunities beyond the orthodox medical scheme. I spent a month in family practice at the A.R.E. Clinic in Phoenix, a month with a downtown, oldtimer orthopedic surgeon, and another month with a laidback suburban obstetrician from cajun country Louisiana.
The dean of the med school allowed me to do a month at Kirksville College of Osteopathic Medicine to study Osteopathic Theory and Methods - a high point of my medical school career. During another month, I worked with a Canadian anesthesiologist in his Pain Management program. I also took a month of Diagnostic Radiology, which turned out to be more break than work. We looked over the radiologists' shoulders during the mornings and were generally given our leave in the afternoons. I used most of that time for personal sleuthing in the Harris County Medical Library.
I researched a variety of odd medical topics and found lots of curious information in the allopathic library over which to pore. One of the subjects which particularly intrigued me at the time was colonics - high enemas - a common therapeutic suggestion in the Cayce medical readings. The library had slim pickings with direct reference to colonic therapy which was in vogue around the turn of the century. But, there was a sizable number of journal articles on colectomy, the surgical removal of the colon (large intestine). At that same time, Sir Arbuthnot Lane, a British surgeon, was making a name for himself by excising the colons of great numbers of patients for a wide variety of conditions supposed to be caused by disease of the large bowel. As I read those old journal entries, it occurred to me that colonic irrigations, although not quite so dramatic, might well have been a reasonable substitute for such a monstrous procedure as Lane practiced.
My investigations at the Harris County Medical Library brought me to a solid conclusion which I hold to this day: With the tremendous numbers of books, periodicals, and papers catalogued in diverse libraries (medical and otherwise) and the mounting accumulation of information in the world, a determined researcher can find support for most any idea, method, or argument.
Learning and knowledge are precious commodities for the student of any age, in any discipline, and with any viewpoint. Discrimination and wisdom - the abilities to use knowledge rightly - are of significantly higher merit. Schools generally teach knowledge. It is the student's responsibility, whether he/she knows it, to discriminate amongst data, information, and possibilities, to determine meaningful values, to cultivate conscious awareness - here and now, and to develop wisdom in action. Following the guidelines of the current or popular system of formal education hardly accomplishes the ideal. Yet, there do remain vital opportunities to learn and to discriminate within a school system, and even a medical school system.
The medical school I attended was both typical and atypical. Like all professional schools, it was mandated to meet certain requirements. The University of Texas Medical School at Houston followed general guidelines for accreditation purposes, to keep up with sister institutions, to compete nationally for faculty and funds, and to train physicians-to-be to pass boards and be admitted to postgraduate training programs. The medical school was different from many others because it was quite new (a few years old when I entered) and just beginning to build a permanent home. It was building relationships with hospitals in the medical complex and around metropolitan Houston. The school was still hiring staff who came from all over the world to work in the famed Texas Medical Center.
The program to which I was admitted was experimental. The typical four-year physician training was compacted into three years. At that time, the experiment was being tried by several other schools around the country. It was brought to a halt shortly after I graduated and subsequent students have spent four full calendar years training to become medical doctors.
The class of 1977 was composed of 52 hopeful souls. All but two were Texans by legal residence, but few of us had Texas accents. A handful of women and a few minorities were represented. There were at least a couple students who "sported" gray hair. Our average age was several years older than that of most classes entering medical school. We had a goodly share - half dozen or so - of military or former military, I among them. In some ways, we had a fairly good mix. Yet, we were like most med school classes stuffed with "scientific" types. We were quite lacking in students with artistic or social orientations. We had been taught the verbal/mathematical system and done at least reasonably well, else we would not have been chosen to enter such a select group.
Yet, many of us were fortunate to be there. Not all of us had the most sterling credentials for matriculating at an august institution mandated with the "sacred secular" duty to create physicians.
I had an excellent MCAT (Medical College Admissions Test) score and a respectable GPA which got me as far as the interview stage at all five schools to which I applied. The ostensible deciding factors in my acceptance to UTMSH were the two-page autobiography which I submitted as part of the application procedure and a very favorable personal interview.
I have never regretted the decision to accept, to train, to become a physician - even though I had numerous struggles along the way and gave up medical practice several years ago. But, I have often wondered about the deeper circumstances, the fortune, the karma, the synchronicity which brought about my positive interview. I freely admit that I could have been passed over for medical school and my position been filled by any one of dozens, if not hundreds, of comparable applicants. I am thankful for the many opportunities of discovery which I experienced at and since UTMSH. I give credit to the school's progressive, liberal application procedure, to the openness of my interviewer, and to the hidden forces of life which bring people and places together in a wonderful, mysterious order.
The first two years of medical school classes were spent almost entirely on the twelfth floor of Center Pavilion Hospital. While the permanent med school facilities were being built a few blocks away in the middle of the Texas Medical Center, we preclinical students were closeted (almost literally) atop CP Hospital. For first and second-year students, UTMSH basically existed as one-room schoolhouses. For 40 hours each week, half a hundred of us were cramped into a makeshift classroom within the walls of the aging hospital on the edge of the TMC.
Our "escapes" from CP confinement were relatively rare moments in which we took courses which could not be crammed into our 12th floor penthouse. We joined the dental students in the basement of the Dental Branch to study Gross Anatomy which was taught by visiting instructors chiefly imported from the British Commonwealth. The Pakistanis, Indians, Scots, and Irish added a peculiar flavor to our otherwise smelly anatomical studies. We spent a few hours each week during one term in the first year in a clinical preceptorship with a cooperating physician. In lieu of a laboratory course in Physiology (the medical school did not have adequate lab facilities at the time), we were farmed out to various basic scientists to pursue some form of laboratory research during the second year. We also had a short course in history taking and physical examination at the M.D. Anderson Hospital and Cancer during the second preclinical year.
Looking back, I don't know how we - or I - managed to sit through hours upon hours upon hours of dry, cold, dusty lectures on the minutiae of systems biology, pathology, neurosciences, histology, genetics, embryology, etc. But, we did - with a couple exceptions. I have been led to believe that most medical lectures and lecturers are rather boring regardless of the school. Our situation was probably not much worse than that of students at other institutions except for our cramped and tedious environment.
Fortunately, there were a few high spots in the teaching program. A couple of impressive physician-teachers come to mind. Dr. Guillardo Bottlebohm was considered to be a crackerjack nephrologist. He was a fiery speaker and enthralled with his work. He thought nephrology was terribly important and, like many of our professors, believed his field deserved more space in the medical curriculum than it was allotted. Still, most of the profs just lectured, gave multiple-choice quizzes, and got back to their real work. Not Dr. Bottlebohm. The Argentine firecracker was one of the few professors who aggressively questioned students in the classroom. He wouldn't take any excuse for students not answering his questions accurately. When irritated at a student's failure to respond rapidly and properly, he would speak forcefully with a strident Latin accent: "Study more, put more time into your books and less into your beds. It has never been proven that a young, healthy medical student requires sleep."
Dr. Ralph Conrad taught a short and dull course in Virology. He openly and frequently lamented the fact that the curriculum only gave him a dozen hours to cover his most critical subject. He claimed that the school at which he had previously taught gave over 100 hours to the teaching of his "vital" discipline. Conrad was memorable for his receding hairline, curly auburn pate, smoldering cigar, and blustery manner. Dr. Conrad remains planted in my memory particularly because he offered the medical staff the most enjoyable Grand Rounds I ever attended. He gave a slide show and talk upon his previous profession: orcology. Conrad had worked for some years as a whale pathologist. His slides were magnificent, his stories were poignant, and his presentation was bright, cheery, and very funny. Thanks, Dr. C.
Two major departments in Basic Sciences did excellent work in team-teaching their material. It seemed to me that the professors from Biochemistry and Reproductive Biology went beyond the accepted norm to share their special interests with us. Interestingly, the Biochem and Repro Biology tests were the only essay exams which we took during the whole of medical school training.
Examinations, objective or essay, brought on moments of high stress and late night cram sessions for many of my fellow students. Some chose to manipulate the system or "shake the trees" for exams given to students in previous years. No doubt, several of them spent more time worrying about test scores or chasing down those old exams than I ever did in simply keeping current with my studies.
On a few occasions - only a few - classmates would ask to borrow my notes for this day or that class. They didn't get much information when they did and were either amazed or disappointed. Usually, I wrote down only a few sentences to a page or so of notes per lecture - not much help for someone who missed an instructor's whole talk. I decided to put to paper only the 'bare bones' of the daily drones. If I knew lecture material from a previous course or experience, I had no need to transcribe notes to paper. If the information was simple trivia or medical minutiae, why waste effort and paper. If the material was not testable, I let it pass by, too.
I picked up the essentials from most lectures. I kept up with my textbook reading and regularly culled my notes of concepts and data which had subsequently been stored in the "computer" between my ears. By the time a test came up, I was ready. I went over my notes a couple more times and culled them again down to a few pages of critical or complicated items. Like a Boy Scout, I tried always to "Be Prepared."
In retrospect, I believe I could have done as well academically (that wouldn't have been too hard: we were on a pass-fail system) and learned lots more by skipping preclinical classes entirely. I might have gotten the assignments and read the necessary texts as well as advanced ones with all the freed up classtime. Then, I could have searched for real life situations in the Texas Medical Center in which to directly reinforce those studies. However, I am quite sure that the system would not have accepted the novelty of such a plan. As it was, I plodded on with the docile deck of 52.
We studied and sat, worked and worried at the CP "penthouse" for two whole school years. We (I) dragged through the classes and days anticipating the "clinical" years ahead. About the only respite we had during the long school days was found at breaks between class periods. We talked and bantered back and forth in groups and pairs, complaining about the present and planning for the future. Most of the time, we kept the game room going. I squeezed many minutes in at the foosball table and developed a wicked left-hand goalie shot. Ah! A pre-clinical high point!
When we did escape for a few hours from the CP classroom during those years, we came back with stories and anecdotes of our experiences to share with other classmates. My first step out into the Houston medical establishment was very disillusioning. It may have been predictive of my future in medicine.
As with all first-year students, I was assigned to a primary care physician preceptor for one term. Each of us spent one half-day weekly in a clinic office chiefly viewing a physician in practice. Occasionally, we were allowed to participate in some minor way in the office activity. But, mostly we just sat or stood (medical students do a lot of both) in our short white jackets, watching the flow of the things as unobtrusively as possible. We all hoped to learn something of lasting value during those moments, whether by eye, ear, or simple osmosis. It didn't matter.
The preceptorship experience was one of my earliest in learning how to discriminate. I have had many since, succeeding at some and failing at others. My assigned preceptor was Dr. Grey Stocking, a family practitioner, whose office was located on the far northside of Houston. It seemed like the trip took hours to drive the 30 or so miles there. I imagined the trip getting longer and longer each time I went to Dr. Stocking's office.
By all outward appearances, Dr. Stocking had a credible and successful practice. I suppose "the good doctor" may have given a similar amount of time to his patients as most physicians do. The exams he performed were, in medical jargon, cursory, and the histories he took seemed even briefer. His manner was neither abrupt nor caring, just rather businesslike and matter-of-fact. He followed a rote pattern and went through the motions, conducting a practice and making medical decisions. I tolerated his manner for some time and just expected that I would have to sit patiently, much as I sat through the long hours at the CP classrooms.
But after a few weeks, I picked up on extraneous conversations, not meant for my idealistic ears. I heard the doctor gloating over the number of patients he was seeing in a day - 60 and more. I imagined him banking the day's receipts and putting them in his investments which he did discuss over the telephone between patients. I overheard comments regarding a male patient who came in for a simple physical examination. The doctor had done the briefest history and exam on this young person who had no apparent or elicited health problems. "Just thought I ought to have a checkup." Dr. Stocking then proceeded to order an expensive battery of tests. The man balked at the cost of the tests and told the nurse he could not afford them. Stocking told the nurse: "Negotiate with him."
The doctor seemed to write copious prescriptions for the most minor complaints. He ordered gamma globulin shots a number of times during the course of an afternoon. I never gathered his justification, nor dared to ask for it. All I could surmise was that the injections were moneymakers.
If these things weren't enough, the kicker stood right in front of me in the person of Dr. Stocking. While I was and am in no position to judge another human being, I can and did make useful observations based on the picture which Dr. Stocking projected to me and the world. I remember him relatively well. He stood about 6' 2" tall and usually wore a shiny, dark brown polyester suit. He didn't look much like a physician (nor did I ever, for that matter), but more like an insurance executive - someone who sat behind a desk most of the time. In his late 30's, Stocking had brown hair and eyes and a big, round face with sagging jowls. He reminded me a bit of the actor, Victor Buono. According to the office nurse, he weighed well over 300 pounds, having dropped over 100 since a recent stomach-stapling surgery. All in all, Dr. Stocking offered little in the way of a positive example for either an anxious patient or an idealistic medical student.
I became more and more uncomfortable with my preceptor - his person, his manner, and his practice - and thus resolved to do something about it. I made an appointment with the Dean of the Medical School, Dr. Ron Biddle. When we met, I told him what I had observed and felt about the situation - about my discomfort with having to endure viewing Dr. Stocking's brand of medical practice. I gladly volunteered to transfer to another preceptor. Dr. Biddle listened attentively as seemed to be his habit. He made no comment on Dr. Stocking, but thanked me for sharing my story and concerns. He simply ended the interview by saying that I would not be required to continue the primary care preceptorship program. "Oh, what a relief it was!"
I had another meeting with Dr. Biddle just before entering the third-year clinical rotations. I was apprehensive about how I was going to fit my irregular beliefs into the medical orthodoxy in which I was about to be surrounded. My nighttime studies in the Cayce materials and other holistic paradigms were very important to me. My beliefs and understandings were growing, yet delicate and hardly formed. On the other hand, my faith in allopathic medicine was flagging. I foresaw problems, but knew not in what manner they would appear. I even had dreams which suggested conflict ahead.
I was frank and direct with Dr. Biddle. At the same time, I didn't tell him the whole story. I am quite sure it wouldn't have helped and might rather have confused things. Again, he listened carefully and responded with genuine sensitivity as well as a dose of realism.
Dr. Biddle spoke, "It's your responsibility to learn medicine as it's taught to you. You must learn, know, and practice standard medicine while you are in this institution. When you've completed your training and are on your own, you'll be free to experiment and investigate and even teach about a new brand of healing. But, that is some time off, you know. Be a student and a good one. Be attentive to the interns, residents, and staff who have more experience than you. They have much to teach and they need your support."
I was somewhat reassured, but only somewhat. I was reassured mainly that the reins of the medical school were in good hands. But, I was not clear about what I would meet in the coming days nor did I know how much my inquisitive and idealistic nature might stand out on the wards. Questions can irritate as well as intimidate. Mine certainly have on numerous occasions.
One of the first things a medical student notes on hospital rounds is the way staff physicians and particularly chief residents question their underlings. It is often called "pimping the med students." It seems that a student can be allowed to have part of an answer, but never a complete one. The resident may, for example, ask a student in group formation, "What are the major causes of jaundice?" The student could literally recite a dozen different responses which cover fully 99% of the known causes of human jaundice. Yet, the resident needs to stay on top. He will either dispute one of the student's answers or dredge up another from the great wellspring of his experience. Too often, the job of the chief resident is to intimidate and "keep the novices in line." The student has to parrot information, maintain a student reserve, and follow orders, but not think or act creatively. On the other hand, questions from students are often unappreciated unless the teacher has ready answers or can use queries to his/her advantage.
There is little room in orthodox medicine for debating fine points - intellectual or emotional, ethical or esthetic, humanistic or spiritual. That became obvious on my very first hospital rotation. I was assigned to an oncology floor - a cancer ward - on the internal medicine service. The medical team included an authoritative medical resident, Dr. Book, an intern who intended to become an orthopedic surgeon, and two medical students.
In some ways, oncology was a rough place to start. I remember my first patients: Peter Schmidt and Eula Roberts. Peter had a malignant brain tumor and Eula was diagnosed with lymphoma. Both died during my few short weeks on the service. I recall the latter days of Mrs. Roberts, in particular. Within a few days of her hospital admission, Mrs. R. was placed on heavy - probably too heavy - doses of chemotherapy. Her blood counts rapidly soured. She developed oral thrush, could not eat, and slipped away quickly. Mrs. R. died early one morning to the consternation of the medical resident. Apparently not wanting to accept such a rapid demise of one of his patients, Dr. Book tried to find someone to blame. He claimed that the night nurse had suctioned Mrs. R. too vigorously and had precipitated her arrest. I don't think anyone bought the excuse. Some of us - at least one, anyway - surmised that the resident felt guilty for overmedicating Mrs. Roberts and letting complications of treatment overtake her disease and her life.
Dr. Book was bright and medically shrewd. He was dedicated to the orthodox model and didn't take well to my questions about some of the interventions made in the lives of the patients on the cancer ward. Whenever a patient improved, it was because of a medication or therapy. When another worsened or died, it was due to an underling's error, a failure in the protocol, or "just too little, too late."
From my inferior standpoint, one cause of a number of patient problems and even deaths may have been "Too much, too soon." I suppose even at that time in my medical career, I had a commitment to the Hippocratic injunction: "First, do no harm." It seemed that many medical/surgical interventions performed on our cancer patients were just "adding insult to injury." Dr. Book accused me of being a therapeutic nihilist on one occasion. His observation may not have been far off base. I really felt for the suffering patients on the ward and imagined that much of their pain and discomfort, anxiety and trauma were unnecessarily produced by hospital "care."
I remember going on rounds to other cancer ward and seeing a pretty young woman who was being treated for an acute leukemia. (I viewed her from the midst of our medical entourage on several occasions, but I never got to meet her, talk with her, or find out what was important in her life. I wonder if any of the doctors or students ever did.) Mary was bombarded with chemotherapy and taken through the latest protocol in hopes of reaching a remission. Each time I saw her, she changed. In a few short days, she metamorphosed before my very eyes. First, Mary lost her hair and had to wear a cap or scarf. On occasion, I saw her naked head except for a wisp or two of fine, babylike hair. I was reminded of photos of the emaciated, baldheaded victims of the Nazi concentration camps.
Mary began to bloat. Her bright and attractive face became aged and pained and round like a balloon. Her skin turned a mottled, pale yellow - a little sun might have done her and many such patients some real good. Mary's platelet count took a nosedive and she developed ecchymoses (oozing of blood under the skin). She required frequent blood and platelet transfusions. But, her IV's backed up and had to be restarted repeatedly, making her arms and feet all the more marred and blotched. At one point, she went through a nervous, agitated state which bordered on a psychotic breakdown.
Despite Mary's tenuous physical and emotional state, there was no relenting on the aggressive treatment of her leukemia. The battle had to be waged. Then, a weekend passed. When we returned for Monday rounds, Mary's room was empty and she was gone. Not a word was said on rounds. I got the news of her death from the nursing staff. Another unspeakable loss to the nemeses - Cancer and Death.
When the treatment is worse than the disease, as is often the case with cancer, I was and am quite skeptical. I was more vocal then or, at least, I showed little appreciation for the orthodox approach of "poison, burn, and cut" - chemotherapy, radiation, and surgery - used on cancer patients. Methods in oncology, then and now, are reminiscent of military combat! I wonder what kind of karma patients and doctors and the society deal with in this thing called cancer.
My questions and questionings, ideals and feelings were not overlooked by Dr. James when he wrote my evaluation. Suddenly, I had an appointment with Dr. Waldo Kirkpatrick, the school's Chief of the Department of Medicine. His manner was reserved, yet not unpleasant when we met. Still, he was certainly less than pleased to see me. His basic message was, "Your performance has not been totally satisfactory on your first medicine rotation. You'll have to do better on the next for us to pass you on. I am told that you lack common sense and enthusiasm. Let's see if you can do better next go-round, okay?"
I am not sure how Dr. K. expected me to move from a state of deficient common sense and enthusiasm to one replete with those supposedly universal medical student traits. But, at least he let me have another go at it. Actually, he probably didn't like to be troubled with student or personnel problems. His easiest option was to pass me and my shortcomings on to the next department.
Dr. K.'s evaluation and pep talk were less than a "shot in the arm." But, while Dr. Biddle's gentle admonitions didn't give me much impetus to "lie low and keep my mouth shut," Dr. K.'s did. At least for a while.
My next rotation was on another medical ward in a different institution, St. Joseph's Hospital. The ward team consisted of a low-key resident, Dr. Patterson, two interns from obstetrics who were going through the motions while keeping a decided sense of humor, another medical student, Tom Mix, and myself. While I did not generate enthusiasm over that six-week rotation, I did become reasonably comfortable working with a spectrum of non-cancer patients. I kept my mouth shut for the most part and played the game.
As I write this story, I am, at times, a bit amazed that the orthodoxy tolerated me at all and that I survived as long as I did. For, I did confront its values and articles of faith too often. During one formal but small medical rounds moderated by Dr. Chauncey Smuts, former Dean of the Medical School, I stood up to a medical resident from another team. Dr. Duane Barth was an effective, but arrogant resident, much different than our own Dr. Patterson. He had been gloating over his recent success at "running a code" and "saving a life." During rounds, he was belaboring the importance of technical medical skills. I rose to the defense of the human touch in medicine and in life. I suggested that we had plenty of technicians and know-how in medicine, "What we need is more physicians who can sit with their patients, relate to their suffering, and offer them human compassion as well as technical wonders."
Fortunately, Dr. S.'s presence soothed the tense interlude in the rounds. While he did not support either side of the debate, he did give me a little help and hope by sharing some "common sense" views on one of the arts of medicine. The eminent value of history and exam (face-to-face and hands-on) has long been touted by foremost medical educators, past and present. But, modern practice and actions speak to the contrary. I like to think that Dr. Smuts' practice may have fit his preaching.
Dr. S. offered a perspective in which to consider tests in respect to history and examination of a patient. He said something to this effect: "Before you order a laboratory test or xray, you should consider your real need for ordering it and its potential diagnostic value. Through your past experience, careful history taking, and competent examination, you should pretty much be able to predict the result of that test. And, if you already know what the result of any diagnostic procedure will be, you might well dispense with the test and decide not to put the patient through the expense, discomfort, and ill effects of it. You should always ask yourself, 'Will the result of the tests that you order change your treatment or in any way lead to the enhancement of the patient's health?'"
Those words and suggestions were spoken by either a consummate diagnostician, an astute communicator, or just a man much "in touch" with his patients. Unfortunately, I believe that there are relatively few medical men like him today, in terms of acumen, sensitivity, and philosophy. Our medical system makes it difficult to marry the values of the competent and caring "country doctor" with those of the talented technical practitioner. Almost the whole of modern medicine and of modern society militates against a "real common sense" and "hands-on" approach to health issues. Fortunately, everything, even medicine, is subject to change.
My memories of the days on Dr. Patterson's medical team are few probably because there was little confrontation, not much learning, and a bit more "common sense" on my part. As the latter days of the rotation arrived, I felt fairly confident that the Medicine Service would pass me on. I had "behaved like a good boy" for all but a few moments of those few weeks. Yet at a critical moment, I started up a conversation with Tom Mix about treating gallstones with castor oil packs. Dr. Patterson appeared unexpectedly and overheard bits of the conversation. Within a few moments, he asked the two of us to come to the conference room to "have a chat." I was immediately suspicious and fearful. I thought, "Oh, Oh! My goose is cooked!"
Tom and I had just enough time to sit down, when Dr. Patterson was called away. He didn't return and the meeting was never reconvened. We proceeded on to our next rotations. I didn't have to meet with Dr. K. again, fortunately for both of us - probably more fortunate for me than for him. I was told some weeks later via the grapevine that the evaluations for Tom and me on that rotation had been lost. A bit of grace, maybe. I presume that Dr. K. passed me on through "the benefit of the doubt."
The next three rotations - pediatrics, psychiatry, and obstetrics - lie rather quietly and nondescriptly in my mind. During that time, I took a breather. I ruffled few feathers and moved along neither impressing nor depressing my mentors. Those rotations were spent chiefly in teaching hospital wards with occasional moments spent in clinic settings. Curiously, medical school is highly prejudiced toward ward work and that in the midst of large urban medical centers. Yet, most medical care is delivered in clinics and the vast majority of human illness is played out in the world of daily living.
Memories of pediatrics (internal medicine for children):
Nursery - Newborns, fresh from the womb and from God - no wrinkles and no worries. Soft, warm, precious infants - delightful to watch and to touch.
Neonatal Intensive Care Unit - Unnerving clangs and beeps and blips from innumerable electronic devices. Tiny, tiny premature infants connected to IV's, monitors, and life support systems.
Pediatric Ward - Needles inserted into tiny veins and arteries. Needles and tubing taped and draped on little heads. Needles missing their targets again and again. "Important" tests canceled for lack of blood specimens.
Crying, hurting, and also - thank goodness - smiling children. Anxious parents and relieved parents - and bereaved parents.
Pediatric Clinic - Little people and little doctors. Scabetic children. Children with croup. Children with coughs. Children with ear infections. Children with ear infections. Children with ear infections! Endless examinations of ears, noses, and throats. Equally endless prescriptions for Ampicillin - stinky sweet and looking like big people's Pepto Bismol.
Memories of obstetrics (institutionalized birthing) and gynecology:
Generalities - Hollywood staff physicians and bumbling residents. Chuck Barris and The Gong Show at noontime breaks.
Obstetrics - Fears of dropping the first wet, slippery infant I would deliver. Smiles and joy at seeing a soul enter a new body and new world. Happy feelings on watching men support their mates through labor and delivery.
Obstetrical Surgery - The technical wizardry of an obstetrician with a sharp scalpel and a mission to deliver a fetus in near record time by Caesarean Section.
Gynecology - Apprehensions on doing my first - and subsequent - pelvic examinations. How does a physician - a man or a woman - ever become comfortable putting two fingers in a strange woman's vagina - and another into her rectum?
Memories of psychiatry (medicine for the head):
The Psychiatric Ward - CP Hospital again! A ward of the living dead or, at best, living sleepwalkers. A mass of darkened and disturbed minds. Pills for psychoses, pills to counteract side-effects, pills to counteract counteractions. Apparently bright physicians theorizing and rationalizing about reasonable therapy for the unreasonable behavior of irrational beings.
The Psychiatric Clinic - Bearded and guarded psychiatrists. Hostile therapists. One-dimensional therapy for minds, like the one-dimensional therapy for bodies offered in the other medical center institutions. And, they suggest that holistic ideas are farfetched!
Throughout the third year, we were required to spend an afternoon each week in the Family Practice department of the downtown Houston Memorial Hospital. For the most part, it turned out to be a break from the regular rotation routines and/or stresses. But, the experiences and learning opportunities in FP were hit-or-miss, at best. The FP professors and residents were more caring in general than most of the other clinical faculty - the pediatricians were very solicitous of patients and parents - but they were unimpressive from the angle of knowledge and clinical acumen. So, it goes. It's not easy to be well-rounded enough to even approximate wholeness.
In one of our family practice assignments, each of us was assigned a new patient to interview before a videotaping camera. The interview was then discussed in the presence of other students and a supervising family practitioner. Each student was further expected to follow his/her patient over the course of the year.
Joyce was selected as my patient. I first met her only moments before the video interview. We sat rather uncomfortably before the camera as I conducted one of my first clinic interviews. Joyce and I had a wide-ranging conversation that allowed me to bring out things about her which had not been previously discovered.
Joyce was a thinnish, black woman in her mid-thirties who came to the Hospital Clinic in downtown Houston that day because of left-sided chest and arm pain. She had, just moments before, consulted with a Family Practice resident. That physician, who was previously trained in psychiatry, had conducted a history and examination of the patient. He then ordered blood tests and an electrocardiogram. The procedures revealed "no significant abnormality." All that was and is quite standard procedure, but didn't do Joyce much good. It likely cost her more money than she could reasonably afford.
During our interview, I learned that Joyce had grown up in Louisiana and had moved to Houston some years ago with her husband. She was recently separated from him and didn't know his whereabouts. Her only daughter, aged seven years, was staying with Joyce's mother in Louisiana, partly for financial reasons. I never determined the other part. Joyce was quite alone and missed her daughter "too much." Still, she seemed to have some ambivalence about the situation.
Joyce thought her general health was "pretty good." She had, however, undergone a total hysterectomy some months previously for reasons which are now quite forgotten by me. Joyce showed little emotion during the interview, tearing but once when speaking of her daughter. She did admit to occasional moments of loneliness and depression. Joyce took no medication routinely and had not been offered estrogen replacement when her ovaries were removed during her recent operation.
Joyce generally worked as a store clerk, but had recently moved to a new job. There it was. The obvious, outer cause of her chest pain. It had been entirely overlooked by the psychiatrist-turned-family practitioner in his undoubtedly brief and hurried moments with Joyce. You see, Joyce had only a few days previously taken on new work as an elevator operator in an old downtown office building. Joyce's job was relatively easy, taking people up and down the building levels. "Oh, I don't mind it. I kind of like it." Joyce merely had to conduct people, push buttons, and manually open and close the elevator door using her left arm. Open and close. Open and close. Open and close.
The obvious, but superficial, cause of Joyce's chest pain was missed because the physician was concerned about and looking for a heart attack: rather unlikely though it is in a woman in her thirties. But, as the adage goes, doctors too often, "Look for Zebras not horses, when they hear hoofbeats." In Joyce's situation, a heart attack was rather like a Zebra, a muscle strain and pain due to relative overexertion was more like a plain, old horse. Joyce was not unusual, nor was her problem. Yet, she was a unique person who deserved more than a simple cookbook approach to a significant incident in her life.
There were deeper dimensions to her story which I certainly didn't fully realize at the time. One dimension related to her hysterectomy and inability to bear more children. Joyce had suffered the loss of ovarian hormones and the disruption of function in her whole reproductive and endocrine system due to her surgery. More importantly, she was trying to deal her separation from child and husband. All those factors were no doubt affecting her and must have contributed to her chest pain and "heart ache."
My contribution to Joyce's wellbeing was limited. I did help her get started on an estrogen compound. I saw her in the clinic and spoke to her over the telephone from time to time. I should have visited Joyce in her home surroundings. I did listen to her and encourage her attempts to improve communication with her daughter. I shared her life in a small way and for only a short time. But, hopefully, I did so in a humanistic and caring manner.
Each specialty in medicine seems to have its own stereotyped personality and the practitioners within that specialty reflect that personality - or is it the other way around. There is an aphorism which passes around the medical community in different forms and puts some of the specialties in a funny, but revealing perspective. It goes something like this: "Family physicians know nothing and do nothing. Neurologists (and internists) know everything and do nothing. Surgeons know nothing and do everything."
Surgeons are generally aggressive and in a hurry. Internists like to think and play with protocols, numbers, and statistics. Pediatricians are internists in miniature. Psychiatrists, pathologists, and radiologists stand on the fringe of medicine and, it seems, at an even greater distance from people. None of them ever really touches patients - other physicians rarely do either. Radiologists study x-rays, pathologist read tissue slides, psychiatrists study behaviors. All are generally rather aloof from real patient involvement.
The long white medical frock seems to symbolize the separation between physician and patient. These days, physicians are clean and sterile (interesting word - sterile), patients are unclean, infectious, and needy. Physicians too often use their titles, dress, and equipment to maintain distance from the very people whom they claim to aid. Psychiatrists have their own unique ways of establishing separation and maintaining distance. They often use big desks, diploma-covered walls, and stuffed couches, heavy beards and long hair, white coats and thick cardigan sweaters, and malodorous pipe fumes to help outline their own territories. Pathologists and radiologists have even less worry about getting close to people. Pathologists always wear gloves when they touch their dead patients or they simply look through microscopes at former bits of human beings. Radiologists mostly just view x-rays. When they do touch patients, as in fluoroscopy, they are gloved, aproned, and shielded - and not just from x-radiations.
Of course, more and more these days, all physicians and even nurses protect themselves with latex gloves. Hospital housekeepers wear the less stylish rubber ones. It used to be the stethoscope which chiefly intervened between patient and practitioner. Now we have paperwork and gloves, tests and technology acting as additional obstacles. How and when will the profession overcome this growing and seemingly impassable chasm?
I must say that surgeons do not fully follow this particular pattern of avoidance of touching patients. While they may distance themselves from many kinds of intimate communication with patients they are definitely not afraid to touch them. After all, they are the mechanics of the medical arts. They are the first to intervene in urgent situations. Saving lives is the surgeon's business.
The touch of a surgeon is different than that of any other specialist. It is quick and deliberate, probing and penetrating. He/she "gets in and gets out." Whenever I scrubbed for the OR and got close to the operative field, I was fascinated by the surgeons' pride in how small they could make abdominal incisions and yet fully excavate for internal pathology. On the other hand, obstetricians, at least when doing Caesarean sections, made great wide surgical swaths horizontally across the brims of pregnant pelves to allow lots of room to remove endangered fetuses. They then gingerly repaired their invasions to make tidy, almost invisible "bikini scars."
My surgical rotation was an entirely different kind of test for me than all of the others. I think most everyone has some significant conflict to deal with when he/she spends time on a surgical service, whether as a med student or intern, resident or certified surgeon, nurse or technician, patient or family member. Maybe the confrontation was a little more traumatic for me than others. Sure seemed like it.
For as long as I can remember, I have found it most difficult to relate to Scorpio personalities. And, surgery and surgeons are most definitely ruled by the piercing and cutting power of Scorpio. Even the best of surgeons have a simplistic "cut to cure" mentality as part of their makeup. They are mechanistic in their view of the human being, which is all right if paired with a subtle human touch and a woeful shortcoming if not. Several in the field reminded me of the bloody-handed barber-surgeons of the 18th and 19th centuries. We do often reincarnate into personas and professions similar to those of our previous lives.
I was uncomfortable from the first moment I appeared on the surgery service and joined the team staffed by Dr. Red Dock. Dock was just then taking charge of the Hermann Hospital Emergency/Trauma Team. An air ambulance system was beginning to boost activity at our financially drained hospital, to increase surgical/trauma admissions, and to cause the addition of numerous intensive care beds. A few years later, Dock became nationally famous by doing short takes on medical topics over PBS television. A short-lived TV series was even produced using our trauma surgeon as its model.
Red Dock was a short and lean Texan who sported wire-rim specs and a thick handle-bar moustache, a whiny drawl and a quick wit. I must say that he stood a cut or so above most surgeons I have met. He touched his patients, not just as a surgeon but also as a friend. He sat on their beds and related to them as fellow human beings. He talked and listened and counseled. He invested himself in work and people as well. Dock captured my admiration when I saw him enter a room, sit at the bedside, and ask a patient, "Have you got time to talk?" I respected him for his dedication and commitment. I was intimidated by his brusque and impetuous manner in the OR, his volatility, and his apparently hasty and ruthless decisions.
A couple of interrelated stories may give you a picture of my turn on the wheel of surgery with Dr. Dock's team. A typical entourage of chief resident, a junior resident, two interns, and two med students met in the Surgical Intensive Care Unit early the first morning of my rotation. Upcoming surgeries, duties, and general expectations were discussed by the head resident. Then we made brief rounds on the critical patients, saving the ward patients for later. The first surgical patient I met was an elderly black man named Abraham Johnson. He had been in the unit for a few days and was being readied for skin grafting. Abraham had suffered severe burns to large areas of both of his legs as the result of a freak accident. One evening, Abraham was sitting peacefully in his easy chair watching his favorite television program when the TV exploded before his eyes. Unfortunately, Mr. Johnson had some neurological deficit which prevented him from responding rapidly to this emergency. What should have been a minor mishap became a major physical trauma.
Later that day, the newbies were introduced to the real oddity of the whole surgical wing, Jeremy Christian. Jeremy was a twenty-five years old man who had been injured in a motor vehicle accident several years previously which left him quadriplegic. Jeremy reacted not atypically to his grievous injury by acting out his anger against everyone who came into his aura. He eventually landed in a nursing home. His care deteriorated over time as the aides and nursed "burnt out" trying to deal with both his devastated body and his hostile attitude.
Jeremy had been admitted to the University Hospital because of huge gaping, oozing, stinking bed sores over both hips. He had been treated with the gamut of surgical debridement, continuous dressing changes, and a host of antibiotics with no apparent benefit. The surgical staff was at that time making the decision to do a radical operative procedure to "fix" his problem.
Radical repairs or even routine operations were never (at least in this lifetime) high on my list of favorite medical interests. Oh, there is a genuine mystique about the Operating Room, but not one powerful enough to hold my attention long. I tried watching surgeries from the operating theater gallery, looking over the shoulders of physicians, nurses, and students in the OR suite, and even peering into the operative field while holding retractors. But, I never obtained much of a view through the surgical incisions or developed more than a passing curiosity in the surgeons' prowess.
I was occasionally called upon to hold retractors and considered that task engrossingly boring. (How do you like that oxymoron?) It was terrible to stand utterly immobile for hours on end doing the job of a very dumb machine - holding a hooked metal bar or two ever so steadily and with the right amount of tension. It seemed that all too often the surgeon decided that, "You're not holding the retractor firmly enough" or "Damn it, loosen up. You'll tear the guy's flesh." It didn't take long for my feet, back, and eyes to begin to ache. I would selfishly, but unashamedly pray that the surgeon would work rapidly and efficiently. Fortunately, I was never delegated the job of retracting for one of their marathon procedures. In fact, my retracting days were relatively few as a student as well as an intern. Thank God for small favors. As far as I was concerned, they could take those darn retractors and ....
Some days along the way, Mr. Johnson was taken to the OR. His legs were grafted with split thicknesses of pig skin in hopes of stimulating recovery from his burns. He was then returned to the ICU for observation. At about the same time, Jeremy's festering wounds had received maximum medical management and his op day also arrived. When the procedure began, there were more techs, students, nurses, and interns in the OR than I could count. Jeremy was wheeled into the suite on a stretcher and moved to the operating table. The crew not so dexterously propped him on his left side, anesthetized, surgically scrubbed, and draped him. His wounds were still so wet and pussy that the antiseptic scrub didn't seem to make much sense.
The surgeons and helpers proceeded to flay his right leg, disarticulate the femur at the hip joint, and create a large pad over the hip with a generous portion of thigh tissue. Bluntly put, they cut his damn leg off!!
I managed to watch the spectacle for a half-hour or so, but could take only so much. The operation was so revolting to me and my sensibilities. I was equally disturbed by the surgeons simplistic assumption that cutting his leg off would be a quick and effective way to get rid of his infected bed sore. Even before he went into surgery, they were making plans to eventually amputate the other limb. Despite his terrible physical disability, his emaciated frame, and depressed mental state, Jeremy must have had some powerful will to live. For, he was soon out of intensive care and on a regular surgical floor. We made regular rounds to dress his surgical wound and other bed sore. I always joined in on rounds, but from that surgery on, I made myself as scarce as possible in the OR. Apparently, I was not greatly missed. No one ever questioned my whereabouts.
Mr. Johnson didn't fare quite so well as Jeremy. Actually, his life was soon in danger for the second time. Mere hours after his grafting, he was spiking a fever, his blood pressure was drifting south, and he was in deep trouble. Johnson was in a state of shock, source undetermined. The surgeons started doing blood cultures, pumping shotgun antibiotics, and pouring in IV meds to prop up his blood pressure. Yet, they scratched their heads in wonderment about the cause of the episode. It took several hours of fighting a battle with septic shock before the chief resident had the sense to take a look at the obvious source of the problem -- the recent porcine skin grafts. A grisly, oozing mess appeared when Abraham's dressings were removed. The tissue combination had become a culture medium and the graft was rejected - or was it the other way around. With the removal of the dressings and grafts, the cleansing of the slimy debris, and the administration of lots of IV fluids, Abraham came around rapidly. But, the dangers to his recovery were not yet dismissed.
A few days further along, Jeremy was making an amazing recovery. His surgical wound was closing and drainage decreasing. While he still had the gaping sore on the opposite hip, improvement on the surgical side was easily recognizable. The surgeons seemed to take that observation as some sort of universal sign. One morning, we rounded the SICU and passed beyond Mr. Johnson's bed. The chief resident commented on Jeremy's speedy recovery and added, "Maybe we could do Mr. Johnson a favor and get him well quicker by cutting his legs off, too."
I could hardly believe my ears! What a morbid, insensitive, grotesque statement! My stomach turned and my heart sank. I couldn't wait to be out of that environment and on to the next - whatever it might have been.
In fairness, I must tell "the rest of the story." Jeremy did have his other leg amputated. I heard that he did as well with the second operation as with the first. I am still amazed. He could then be propped up in a wheelchair and be pushed around the hospital corridors. I think he began to talk and open up, even make some acquaintances and friends. Somehow, the trauma of his surgery must have been insignificant to him while the procedures were strangely therapeutic and gave him a new start. A few weeks after the second surgery, I saw him from a distance in a hospital lounge in the midst of conversation with two or three other people. He seemed to be a changed person.
Strangely and sadly, I lost track of Mr. Johnson. I liked the old fellow even though he talked very little. I really don't know what happened to him. I just hope they didn't cut his legs off.
My OR and surgical experiences did not end when I completed the required surgery rotation. During my senior elective year, I mostly wandered outside the Texas Medical Center where my encounters with surgery were neither so dramatic nor so grizzly as in my third year experience. I scrubbed on a few cases with my Orthopedics and Ob-Gyn preceptors. The crowds were smaller, the pace slower, and much of the pressure was off - thankfully.
I did find myself frequently back in the Hermann Hospital OR during an elective in Pain Management, but the circumstances were quite a bit different from earlier days. A resident in Maxillofacial Surgery and I spent a month working under Dr. Jacques Epee, an anesthesiologist turned pain specialist. Dr. Epee treated patients with intransigent pain by using various types of anesthetic procedures. When common methods for pain relief were found lacking, patient failures were sent on to Dr. Epee. For the most part, Epee used paraspinal blocks in attempts to deaden or quiet irritated, inflamed, or uncooperative nerves. The blocks were intended to break the pain cycle of patients suffering from sympathetic pain syndromes. A large group of his patients had had failed herniated disk surgeries. There were some obvious defects in Epee's theory, but patients kept being referred and Dr. Epee was only too pleased to keep treating them.
I remember one particular patient, George Willing, who had been operated five times for low back pain and a herniated disk. He had had a laminectomy, two spinal fusions, and two other repairs to his lower back. George was a spunky and affable little fellow despite all his misfortune. I think the surgeries had cut him down an inch or two in size. He listed to one side, had a foot drop, and could only walk short distances without great difficulty. Willing spent most of his time in bed or in a wheelchair. We treated George on several occasions with paraspinal blocks to try to shortcircuit his pain syndrome.
Performing a paraspinal block was a good way to keep three or four medical personnel busy for a couple hours. The procedure was posted on the OR schedule and we set up a tiny OR suite with the necessary materials. Dr. Epee supervised the whole procedure, yet was able to circulate through the department looking in on other cases.
Placed in a prone position (face down) on an OR table, the sedated patient only received light anesthetic gas while we plunged six large bore 12-inch long needle into his paraspinal muscles. The objective was to place the ends of the needles (three on each side of the spine) close to the paraspinal sympathetic ganglia. To "eyeball" our rather blind efforts, we shot portable x-rays. Dr. Epee reviewed the films and made judgments about needle placement. He frequently had us extract a needle or two for reinsertion. I never figured out Dr. Epee's criteria for determining the accuracy of placement. When the needles were acceptably lined up, we slowly injected 50cc of a Novocaine-like solution through each needle into the paraspinal muscle mass.
Whenever we took George through this procedure, he had almost immediate pain relief lasting for 24 to 48 hours. He would be nearly ready to leave the hospital, when he developed an abnormal heart rhythm. George was then transferred to the coronary care unit for observation for several hours. The internists wisely did not undertake any major intervention during those interludes. Soon, he was back on the ward with a normal heart rate and rhythm, but his pain returned as well. The cycle was complete, but a new one would be initiated with another round of short-lived, symptomatic pain relief. Somewhere along the line, George took the hint and quietly slipped out of the hands of the Pain Management team. We never saw him again.
Another memorable patient admitted to the Pain Service was Ben Davis. Ben, his wife, Emily, and I developed a comfortable rapport, almost a friendship, and maintained a communication for many months. Davis was a semi-retired oil and gas leasing agent who had prided himself on his fitness and activity. He was referred to Dr. Epee because of chronic, excruciating pain in his right groin. The pain was originally thought to be caused by an inguinal hernia which was routinely repaired several months before he appeared at the Hermann Hospital. By the time Ben reached the Pain Service, he had been through quite a medical ordeal already and his travails were only just beginning.
Ben had submitted to a number of operative procedures following on the heels of his hernia repair in hopes that the cause of his pain might be discovered and some relief afforded. His first operative site was explored and a synthetic patch was implanted there - for what purpose I could never determine. On another occasion, his abdomen was explored and, finding nothing of great consequence, the surgeon excised Ben's appendix so as not to return from his expedition empty-handed. On a further visit to the OR, the patch was removed and the original incision reapproximated. Shortly before coming to the University Hospital, Ben had consulted a neurosurgeon who was reticent to intervene in his complicated and perplexing case. That physician did no more than suggest the use of a TNS (Transcutaneous Neuro Stimulator) and recommend a visit with Dr. Epee. Epee readily took on his case and intimated to Ben the potential for real benefit from a series of paraspinal blocks.
I was delegated the task of doing Ben's admitting history and physical examination. He and I went over the usual medical territory and then settled down to a good visit and got to know each other a bit. Only as his hospitalization progressed did I get know Mrs. Davis. Eventually, it was Emily who corresponded with me and kept me abreast of her husband's tortuous and torturous medical travels.
Ben was a wiry, feisty Texan with a dose of vinegar in his belly and a sparkle in his eye. His was in his early-sixties, but by no means ready to kick back. He had "too much life to live." Ben also had high hopes - too high - that Dr. Epee's method would give him real relief. So did Dr. Epee. By that time, I was getting pretty skeptical of the whole process on the Pain Service. I had seen nothing to suggest to me that any of the procedures performed did more than cover up pain for a few hours to a few days.
Ben's turn arrived and we went through the paraspinal block routine with the six giant needles, the portable x-ray check for needle placement, and the anesthetic injections. As expected, there was a rapid and dramatic decrease in pain. Ben had none - for a short time - and he was pleased, almost excited. He got out of bed at the first chance, walked and smiled while anticipating the best.
Alas! The relief was transient. Within forty-eight hours, Ben's pain was back with a vengeance. Davis experienced both mental and physical agony. He told me, "I must get back to my life. I'm going to beat this damn pain - or - die in the attempt. I can't live with this pain."
We repeated the procedure two more times. Dr. Epee and Mr. Davis still hoped for some lasting results. They were not forthcoming. After the third round, Ben went home, a small town a couple hours northeast of Houston, to consider his options. He left with his pain masked only slightly by the TNS, but no regrets for his fruitless experiences at the Texas Medical Center. His hopes were dampened, but not drowned.
Some weeks later, I was walking nonchalantly through the hospital Surgery Clinic when I encountered Ben and Emily waiting to see Dr. Epee on a routine followup appointment. Both were pleased to see me, but perplexed and burdened with Ben's unremitting pain. We chatted for a few moments before one of them pulled from a manila envelope a newspaper article on "Acupuncture." They asked me to look at it and wanted to know if I knew anything about acupuncture. "Do you know any acupuncturists?"
Without even considering my options, I truthfully said, "Yes. My friend, Dr. Frank, does acupuncture at his office a few blocks up the street."
Ben and Emily wanted to see him right away and I naively consented to take them to Frank's office. We left the hospital clinic, Ben missed his appointment with my former supervisor, and we drove a few blocks to see Roger Frank, D. O. Dr. Frank spent a generous amount of time with Ben on that and several succeeding days, using every modality and approach at his disposal. The Davis' stayed in a motel close at hand and visited Dr. Frank once or twice daily. Roger gave Ben gentle osteopathic adjustments and acupuncture treatments as well as potent analgesics. Again, Ben gained only temporary relief from Dr. Frank's ministrations. He genuinely appreciated Roger's sympathetic hands-on efforts. But . . . But, no cigar. His pain was recalcitrant.
It is so hard to understand what another person's pain is like, but Ben's must have been considerable. It must have been penetrating and all-consuming so as to keep him treading the medical mill of diagnosis and treatment. I followed Ben's situation - I hate to say case - from that time onward via letters from his wife, Emily. While Ben's pain persisted, so did he in seeking relief from it. Ben was nearly as tough as his pain.
Ben went back to the neurosurgeon who had previously refused to operate on him. I suppose Ben convinced him that he must operate, all else having failed. The surgeon first performed a neurectomy, severing the nerves to his right groin. He had no benefit from the surgery and was returned some time later to the OR for a cordotomy. The spinal cord was transected above the level at which the sensory nerves departed the cord to the pelvis. Again, Ben gained nothing from the surgery.
While Ben was recuperating from the unsuccessful cordotomy and the surgeons were contemplating performing a thalamotomy (the thalamus is a great waystation in the brain), Davis developed a bowel obstruction. The complication was likely secondary to the effects of the cordotomy. Nerves which had some influence on bowel function were disrupted or irritated as a result of the cordotomy. Ben must have been put through another round of torture with nasogastric tubes and intestinal suction.
Some time during that episode, Mr. Davis was hit with a blood clot to the lungs. The nightmare continued, but not for long. For, Ben next "threw another embolus," as the medics say, to his brain and he was soon dead. The story is sad and depressing. No one understood Ben and his pain. No one sought to understand his "case," probably not even Mr. Davis. All attention was focused on Ben's body and making it work again like it used to. But, without understanding the source of Ben's pain, wasn't the surgeon just guessing - "shooting in the dark?" Maybe he shot, missed the pain, and killed the patient.
But, Mr. Davis' death was ultimately of his own doing. Blame we not the messenger - the surgeon! Ben, or some part of him, made the decision long before to "shoot craps" and to "go for broke." He lost, but died trying, through his blindness and lack of understanding. "I am going to beat this damn pain - or - die in the attempt," he said. Ben was true to his word. Hopefully, future Ben's will find in themselves and in their physicians ways and means to explore not just the surface of problems but the substance which lies within them.
When I last saw Mr. Davis, I was in the final few days of medical school. The clock was ticking and I was eager to get my sheepskin, be proclaimed a physician, and start doing the work, albeit in a military internship. During the last month, I was assigned to Surgical Selectives - one week each of Ophthalmology, Neurosurgery, Orthopedics, and Urology. The Surgical Selective rotation was an attempt by the Surgery Department to get a bigger piece of the medical school pie as well as give students a taste of the surgical subspecialties. The month dragged and was a non-event for most students.
But, it became an EVENT for me during the final week and hours of school when I was on the Urology Service. I was assigned to perform an admitting history and physical exam on a private patient of Dr. Potts. The patient had progressive, metastatic cancer of the prostate. The gentleman who was in his 70's had had his prostate removed some months previously. He was on the next day's OR schedule to have a bilateral orchiectomy - in laymen's terms, castration - in street language, the surgeon was going to cut his balls off. The rationale was that surgical removal of the male gonads would decrease or stop the supposed adverse influence of testicular hormones on the progress of his prostate cancer.
The history and physical exam went rapidly and uneventfully in the patient's room until . . . As I was concluding my task and putting my instruments back into my black bag, the patient and I began to talk about his scheduled surgery. In retrospect, I imagine that it was my state of mind as much as the patient's which generated the conversation and most certainly the fallout from it. The patient seemed uncertain about another surgery and opened the door for a comment by me, who always had an opinion on things medical. I felt like saying, "I sure wouldn't let anyone cut my balls off." But, my words were slightly tempered and came out as, "I understand that this procedure is somewhat controversial, but . . . " After a pause, I concluded, "Your physician surely has good reasons for performing the operation." Ah, how gauche! How large my mouth must have been to fit a foot covered with a size 10 shoe into it!
I was immediately afraid that I had committed pre-graduation suicide. What was I doing, thinking, feeling to say such a thing - truthful and honest, but lacking in any tact and discretion? It didn't take long for the repercussions to hit, minimal though they turned out to be. I received a telephone call a day or two before graduation from Dr. Carter, Chairman of the Urology Department. He said that Dr. Potts had spoken to him and was irate about a lowly medical student questioning his practice and disturbing his patient prior to surgery. He wouldn't have any more of it or else. Dr. Carter hardly listened to my side of the story. Dr. Potts and he must have had other areas of friction prior to the episode. Carter seemed content to give me some advice about talking with private patients and said he would deal with Dr. Potts. Whew!!! I scraped by that one and at the eleventh hour. I hadn't had such a close call since my early rotations on the Medical Service.
Graduation day for the Class of '77 finally arrived. Forty-seven medical students received diplomas. I was one of them. A few of the original 52 had to repeat a course, one or two were dropped from the rolls. There were two graduation ceremonies - one for the whole Health Science Center and a private one for the medical students. A reception was held at the new medical school building for the fresh grads, our families, and the faculty.
My own family came for the festivities. So did Kelly's. My parents were beaming. My in-laws were ecstatic: "A doctor in the family." They already had a lawyer. What luck! My brother took photos of the events. And, I . . . I took stock.
The celebrations and speeches were typical except for, to me, an obvious and significant deletion: The Physician's Oath. We took none. What happened to the long-standing tradition which challenged young physicians to follow in the footsteps of Hippocrates and Maimonides? I wanted a challenge, but was I really ready for it?
I had experienced a lot, learned some and survived. I had been exposed to a wide range of orthodox medicine as well as quite a spectrum of alternatives. But, was I any wiser than the rest of my comrades? I had knowledge and experience from two paradigms. Still, my ability to combine both worlds in a practical way was quite lacking. I had discovered many possibilities, probably too many for the times and the limited talents I then displayed.
The days ahead in post-graduate medical training and in independent medical practice would offer me and my cohorts many opportunities to heal and be healed, to consider great and varied possibilities, and to learn to blend science with art. Oh, how we would need those opportunities. We were just beginning.
I suppose many of us thought we were now authorities and captains of our own ships. In fact, on graduation, I was promoted to the rank of captain in the United States Army. But, I would have to face the mundane truth. Captain or not, I was again low man on the totem pole. Kelly and I moved to Fort Benning, Georgia, where I entered my first year of residency in Family Practice.
Some days before departing Houston, I treated myself to a "Reading" by Andrew Richards. I was hoping to put some of my life - past, present, and future - into perspective. I remember asking several important questions of Mr. Richards, one of which went something like, "How can I fit my Cayce interests into the military? How can I use them in that institution?" Maybe it didn't take much wisdom to come up with the response. But, it would take more wisdom than I then had to live up to it. Richards said, "You can do it, just don't talk about it. Be careful and go easy."
Now, what possibilities did that statement imply? How could I proceed carefully and quietly yet express my thoroughly idealistic commitment to whole human beings and genuine healing?