Friday Reflection 1: My First Patient
By Adam Cifu, MD
The patient is a 55-year-old-woman with a 10-year history of rheumatoid arthritis. She initially presented with pain and stiffness in both hands, worse on wakening. Her symptoms would improve over the first hour of the day and with a dose of aspirin. Recently her symptoms have been well controlled with daily prednisone. She presents for routine follow-up.
Let’s start with a patient I never met, saw for only a few seconds and wouldn’t have been able to “care for her” for another two decades.
She was a woman in her 50’s, dressed smartly in a dark, knee-length skirt. I would not have registered her existence – I was 10-years-old at the time – had she not been pointed out to me.
I was sitting with my grandmother, Marie, in the lobby of the NYU medical center. Scratch that. We were years before hospitals became medical centers (and then became medical centers named after “Masters of the Universe”). I was in sixth grade and had broken my wrist. My grandmother took me the doctor to have the cast removed. After arriving in the busy waiting room of an orthopedist, Marie sat me down and went to talk to the nurse, a young woman wearing a white dress and white shoes.
Marie, in her sixties and always professionally dressed, talked with this nurse like they were old friends. In my limited experience, doctors’ waiting rooms were not a place that adults had conversations like the ones my parents and their friends had at dinner parties.
My grandmother came to me, took me by my (un-casted) hand and led me out of the waiting room.
Let’s go to the lobby, it’ll be more interesting there. We need to come back up in 20 minutes.
Did you know her?
No, we’re just both nurses.
You’re not a nurse.
Once a nurse, always a nurse
In the lobby she suggested that to pass the time we guess why people were at the hospital. The first person I saw I guessed was coming in for open heart surgery.
Why do you think that?
I don’t know.
Come on, you can tell a lot if you really look at people.
She proceeded to point out the pathology of patients who came and went. She offered diagnoses, prognoses, and even suggested what therapy they might be receiving. It was the first time I heard phrases like emphysema, hemiplegia, movement disorder, cachexia. To my 10-year-old brain, this was magic.
See that woman, what do you notice about her.
I don’t know, she looks like she is having trouble walking, she’s going super slow.
Good, an antalgic gait. Anything else? What about her face?
She was just passing us at this point
She’s a little fat, I whispered.
She is not! Look at her legs, she has beautiful thin legs. But you’re right, her face is puffy. Puffy and red. And now, look at her back, doesn’t it look like a buffalo hump?
I squirmed with discomfort. I was shy and sensitive to slights visited on others. I wouldn't think of shushing my own grandmother but in the years to come I’d frequently feel the need to shush her daughter in similar situations.
I looked carefully. Though embarrassed, I was kind of transfixed.
It does, what does she have?
Rheumatoid arthritis, I’ll bet. That’s why she is in pain. The moon facies, plethoric face and buffalo hump are probably all due to the cortisone she is being treated with. The medication makes her feel better but it is leaving its mark.
When my parents got home from work that night, they asked me about having the cast sawed off. All I could talk about was what I had learned from my grandmother. Her ability to read diagnoses from people’s appearances. Years later, in medical school, it was this ability that sold me on internal medicine as a specialty. Sure, opening someone’s chest, stopping their heart, replacing arteries and then bringing them back to life is all well and good but, for me, it doesn’t compare to watching someone on the bus, looking at someone in a locker room shower, or talking to someone for 15 minutes in the office and figuring out what is wrong with them.
My morning with my grandmother, so impactful at the time, was kind of lost to me for years. The sense of wonder that I felt, and still feel, during the diagnostic process was probably just too abstract when asked that painful question, “Why do you want to be a doctor?” -- the inevitable follow up to, “What do want to be when you grow up?”
I have hated the “Why do you want to be a doctor?” question since I was first asked it in about 8th grade, about the time that doctor replaced astronaut, fireman, or Tom Seaver as my answer. I went on detesting it when asked it during my application to medical school, when it was asked as “why medicine?” I continued to abhor it when it morphed into “why internal medicine?” or “why academic general medicine?” as I rose through the ranks. I even reviled it as I graduated from the interviewed to the interviewer.
When I first started to be asked “the question,” I found it intrusive. When I became the one asking it, I found it unrevealing. Why does anyone choose any field? The answer is always complicated: some combination of what you enjoy, what you have experienced, the role models to whom you’ve been exposed, where your interests and talents lie, what your family expects and what will pay the bills. As an interviewer I began to think that to get to the real answer you would need to give the applicant six months, a therapist and, usually, a ghost writer.
However, the question, “Why do you want to be a doctor?” is the question that brought back the memory of my afternoon with my grandmother.
I had a college student shadowing me in my general internal medicine practice. As we wrapped up for the day I asked if she had any questions, thinking she would ask me about the how to break bad news or how to choose from among all the new diabetes drugs. Probably thinking, “I know I’ll be asked ‘why medicine’ and I want something better than, ‘I have always done well in science. I want to help people. Medicine will allow me to combine my skill and my passion,’ she hit me with, “how did you decide to become a doctor?”
Instead of launching into an exposition of why I hate the question I answered it, for the first time in years, and what came out was that the story of that 1970’s afternoon at NYU.
Interesting. That is not how I had ever answered the question before. When I was a child I attributed my destiny to my father and grandfather, doctors both. It wasn’t long, maybe middle school, that I dropped the, “I want to be a doctor because my father was a doctor.” Not only did this answer begin to seem childish but I realized that my forerunners had pretty complicated, and not terribly inspiring, reasons for becoming doctors.
My grandfather was the sixth of seven children; the first born in New York, rather than Palermo. He was smart and driven but was forced to drop out of the undergraduate program at Columbia University because his family could no longer pay the tuition – I think I’ve read somewhere that times were pretty tough in the early 1930’s. He jumped at the chance to continue his education, even without a bachelor's degree, when he was offered a scholarship to The Long Island College of Medicine.
My father, born 20 years later, to parents who had immigrated from a town in southern Italy that made turn of the century Palermo look like modern-day Dubai, also found his way into medicine without much planning. After an uninspiring stint at Fordham University, he found himself adrift but the focus of great expectations – he was the one son n his family and those were the biases of the time. When some college buddies pitched the low costs of postgraduate education in postwar Europe, he joined them and enrolled in medical school in Rome.
Maybe because of how they chose the field, both these men saw medicine as an honorable profession but not some higher calling. Neither extolled the satisfaction their careers brought them. Neither encouraged me to enter the field. I have pretty clear memories of my father, not completely joking, telling me not to make the mistake he made by choosing something he found interesting rather than something that promised riches.
My grandmother, however, was an inspiration. She came from an Irish family, Americans for generations. She was nurse, but freely admitted that she went into nursing in order to marry a doctor. She never practiced, having met my grandfather during her training – mission accomplished. She was a writer who penned an advice column under the moniker “Nurse Craig” for the Brooklyn Eagle. She combined the reverence for doctors (that I associate with nurses of old) with the practical and clinical excellence of nurses of any era. It was her, rather than my father or grandfather, who explained to me the importance and value of their work. It was her who gave me a book of essays on medicine with the inscription, “I see a lot of you in the writing of this great physician.”1 (I was a senior in high school at the time!)
I expect that there was more complexity to my father’s and grandfather’s career choice than “Italy sounded like fun” and “we could no longer afford college.” Those in medicine seldom refer to their career as a calling -- unless they are writing as book -- as the day-to-day slog would make such a statement slightly absurd. “I am so happy I followed my heart because there is no higher calling than waiting on hold to argue with an insurer that my patient really does need a CT scan.”
Medicine served both my father and grandfather well. My grandfather had a successful ophthalmology practice in Brooklyn. Family lore has it that he was the eye doctor for the Dodgers in the 40’s and 50’s. My father thrived in private practice and maintained an academic appointment at NYU. He practiced psychoanalysis, focusing on adolescents -- certainly a specialty that could only be sustained in 1970’s and 80’s Manhattan. A good portion of his practice involved caring for teens who attended New York’s private schools. More than a few of these kids were my schoolmates, whose parents, indirectly, were paying my tuition. I was never one who needed any training about the importance of patient confidentiality -- I lived it at the dinner table.
My father saw me deep into my career. My grandfather died during my first year of medical school. Marie never knew, though seemed to expect, that I would end up in medicine. She died during my first year of college. Her final years were painful ones, suffering the effects of years of prednisone use for psoriatic arthritis and asthma.
A previous version of this essay appeared here.