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A Patient's Desire: A Doctor of The Mind and The Soul
Presentation at theWhite Coat CeremonyUniversity of IowaRoy J. and Lucille A. Carver College of Medicine
Friday August 23, 2013
byPeter Densen, M.D.Professor, Department of Internal Medicine
Dateline: Baltimore, Maryland. 9:00 AM Friday September 9, 1966 Setting: W. Barry Wood Jr. Basic Science BuildingEvent: Orientation to the first year of medical schoolDean “Tommie” Thompson began orientation with a warm welcome but soon shifted gears … in a deep voice he commanded us, as I now command you, “look at the student on your left … now at the student on your right … a year from now … all of you will be starting your second year.” He went on to say that the school did not admit the top 0.01% of college graduates to fail them.So began the story of my life in medicine.Today, I will be sharing parts of that story with you, but first a disclaimer. My wife of 45 years, an English literature major who has had the “privilege” of sitting through many, many speeches, and who is here today, declares there is little that is worse in a talk than the liberal use of the pronoun "I." But because this is a personal story, I trust that she - and you - will overlook the frighteningly large number of “I”s as I proceed to break her rule.For now I want to impress upon you that each of us has a story. We use our narratives to help make sense of our individual lives and as such they are central to who we are. What Dean Thompson said to us 47 years ago is as valid today as it was back then. So today, the first line on the first page in the first chapter of the story of your life in medicine reads similarly to mine: “the Carver College of Medicine did not admit you – a top college graduate – to fail. Of course, most of us didn’t believe it and neither do you. Why then did we, and why do you, greet the college’s statement with skepticism? Well, for one, our experiences – our shared story about the difficult and narrowing path to medical school – suggest otherwise.Then there is the very personal element of comparing yourself to others in the class – in my case wondering whether a graduate from a small coed college in Maine really, truly belonged with the other 99 first year students, all of who seemed to have attended Ivy League schools and seemed so much more poised and knowledgeable. In addition, academia, medicine in particular, places a very high premium on thinking and it typically uses mastery of facts as a proxy for the former. Each chapter of the story of your path to medical school has ended with a test, mainly factual, the outcome of which determined your next chapter. And, in each successive chapter you have been the cream rising to the top. The single best predictor of entry into medical school is the total MCAT score – and as a result, here you are today turning the page on your yesterday while simultaneously inscribing the first page of a new chapter of your life. Dateline: Iowa City, Iowa. 4:00 PM November 3, 2003. Setting: the midst of a hectic dayEvent: an emergency room visitA concerned older colleague called and urgently described the abrupt onset of fever and chills. I quickly met him in the Emergency Room. Lying down his blood pressure was normal, but he had a very fast and bounding pulse as well as a wide pulse pressure. He was breathing at twice the normal rate and his temperature was 103°F. Based on just these facts, I estimated his APACHE II score – a severity of illness score - to be between 15 and 20, in other words he was headed for the ICU. Therapy for septic shock was instituted within minutes of his setting foot in the emergency room, he was admitted, a stormy course ensued, and fortunately he survived. He continues to be an active member of our faculty. Knowledge is academia’s currency: we take great pride in new discoveries, in using this new knowledge to treat disease and in sharing that knowledge with students … students like yourselves. We use stories like this one to justify the emphasis placed on knowledge and facts in medical education, so that when the day comes – and it will – you will have the ability to apply that knowledge to save someone’s life. Good medicine is life saving and sustaining.Yet as personally pleased as I am by my colleague’s wonderful outcome and its confirmation of my knowledge, and my ability to apply it, when I reflect on the patients who have taught me the most about the good that medicine can do, those patients turn out to be the ones for whom I have cared at the end of their lives. As you sit here today about to enter a culture steeped in saving lives and denying death, the sense of fulfillment that I derive from the care of these dying patients may seem counterintuitive. Perhaps the following stories will help to clarify my perspective.Dateline: Baltimore, Maryland. November 1970, internship yearSetting: Adolescent ward in the Children’s Medical and Surgical CenterEvent: Admitting a patientThis particular afternoon, a family appeared for admission with a 12-year-old boy with shortness of breath and low blood pressure due to end stage viral cardiomyopathy. I say a family appeared for admission because it was as if the parents, two daughters and the patient were one. A year earlier, at the time the diagnosis was made, the father left his job, took the girls out of school, and set the entire family off on a journey around the country enjoying what life had in store for them. They visited the Grand Canyon, Alaska, Disneyland – you name it. In those days there was no ICU, no invasive monitoring and no heart transplant service. The boy was admitted to a 4-bed unit equipped with EKG monitors, given oxygen and morphine, and digoxin to coax the last bit of strength from his tired and failing heart. Magically, he perked up. Yet within a few days the EKG monitor faithfully resumed its grim record of shrinking complexes – the outcome was beyond doubt. And so it was at 2:00 AM, with medicine having nothing left to offer, that this 12 year old innocent died while being held lovingly in his father’s arms, with his family gathered round and me, the interloper, lingering close by.Until that overwhelming moment I had not fully understood what Philip Tumulty, a medical school mentor, meant when he said: “ …Sickness rarely affects only the patient …the entire family is inevitably affected, to greater or lesser degrees. … Hence in a peculiar and special sense, all clinicians have family practices …” (1)Dateline: March 2000 Setting: Iowa City, VA Medical CenterEvent: Making inpatient rounds Our ward team came to a patient’s room at the end of the hall, farthest from the nurses and physicians stations … the door was closed. The senior resident whispered that the patient didn’t like to be bothered and would it be ok if she and I were to come back later. She told me the story of an irascible veteran with end-stage esophageal cancer, who didn’t like physicians and whose family, led by an interfering nurse-daughter, were upset by their perception of sub-standard care. I sent the resident off to noon conference and proceeded to knock on the door, enter, introduce myself to him, and to talk with him and to complete a thorough examination. He was as described: irascible, tired, monosyllabic not wishing to be bothered by yet another physician. He deteriorated briefly the next morning and we intervened to stabilize his condition. In the office that afternoon I received a call from his daughter that rapidly escalated in intensity. I set up a family – staff meeting to air differences and develop a plan to which all could agree. This meeting included the patient. Hard words and accusations emerged. In the end, the family, the staff and the team reached agreement that going forward I would be the point person for communication, that I would work as the family desired to transfer his care to the Mayo Clinic and, that in return, the team would come to see him everyday on rounds or as often as appropriate. I made it a point to visit with him at the end of each morning and again on my way home at night. I learned about his career in the CIA, Gary Powers, Afghanistan, Chess and Bridge. We both came to look forward to our conversations. I updated his daughter regularly and in the process learned of her role as an ICU nurse in the quad cities and of her sometimes-difficult relationship with her father. Together we worked to arrange his discharge … he never did go to the Mayo Clinic. And even though it was now April and I was off service, I arrived in time to help get him in the van and say goodbye. A month later his daughter called to tell me that he had passed away peacefully at home. Not too long afterwards, I received a grateful letter from her that also contained a note from her father. Each time I think about this patient, I inevitably hear Dr. Tumulty saying:Despite outward appearances, patients, well or ill are frequently frightened by what their illness may mean, … “sickness very rarely brings to flower the very best of human characteristics”. (1)Humanism in medicine describes relationships between physicians and their patients that are respectful and compassionate. It is reflected in attitudes and behaviors that are sensitive to the values, autonomy, and the cultural and ethnic backgrounds of others. The defining feature of being human is our need to, and our ability to, connect with others and to have compassion for their suffering just because they suffer, not because their sufffering is attached to something else.Shortly, your name will be called; one by one each of you will come up on the stage, will be congratulated, will don a short white coat and will – as a group – recite a version of the Hippocratic Oath. As with any of life’s major transitions, your focus will likely be inward: What will classes be like? What about that first test? Am I good enough?One of the things you will do early on is to see “real” patients and for this you will wear your white coat. You will likely feel awkward and ill prepared for this first encounter. How could I possibly know enough medicine to talk to “my” patient? How could I possibly listen to a heart and make sense of what I am hearing? Your focus will be on yourself, not the patient.When you walk into that patient’s room, she will not see your uncertainty. Instead, she will see a person in a white coat; that coat will make all the difference. It will provide the credibility that you fear you lack. It will make it acceptable for you to ask patients things about their health, habits and relationships that none of us would ever think about sharing with a complete stranger. It will make it acceptable for you to probe patients’ bellies and to listen to their chests. To paraphrase Dr. Tumulty, “most laymen will assume your knowledge and take your clinical abilities for granted, which they assume you possess merely because …” [you were worthy of admission to the Carver College of Medicine and because you wear a white coat.] “Instead, you will be judged, and then trusted accordingly, solely in terms of the genuineness of your interest; the thoroughness of your approach; your personal warmth, understanding and compassion; and the skill with which you communicate”. (1)After donning your white coat, you will recite the version of the Hippocratic Oath that is on the last page of your program. In this version, the line:“That I will lead my life and practice my art in uprightness and honor”replaces the following lines in earlier versions of the oath: “I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.I will remember that I do not treat a fever chart, or a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems if I am to care adequately for the sick.”It has become common for physicians to write about patients’ stories. These writings typically describe a specific condition and medicine’s advances in that context. In my opinion, these writers often miss a central point articulated by Robert Coles, a Pediatric Psychiatrist, in his book “The Call of Stories: teaching and the moral imagination”. (2)“The people who come to see us bring us their stories. They hope they tell them well enough so that we understand the truth of their lives. They hope we know how to interpret their stories correctly. We have to remember that what we hear is their story … Remember, what you are hearing [from the patient] is to some considerable extent a function of you, hearing.” (2)I’ve shared some of my story with you. What I hope you’ve heard is that facts and reasoning are necessary and important in medicine, but in and of themselves they are insufficient if you are to become an effective and complete clinician. Becoming a complete physician requires attention to soul – the patient’s and yours. In the best of all worlds your patients will benefit from both your knowledge and your soul but they will experience them as one. Today we have turned a shared page in our stories. The time has come for you to begin your next chapter. Neither you nor I can yet make out its details, but the College is certain they will be memorable and we look forward to celebrating that chapter with you at graduation.Thank you.References:1. Tumulty, P. A. “What Is A Clinician And What Does He Do?” New England Journal Of Medicine. 1970;283:20-24. (c.f., also: “The Effective Clinician” P. A. Tumulty. W.B. Saunders Company. 1973.)2. “The Call of Stories: teaching and the moral imagination” R. Coles. Houghton Mifflin Company, Boston, 1989; chapter 1: ‘Stories and Theories’ pp. 1-30.
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