The last time I started a new job was 14 years ago. Just out of residency, I accepted a faculty position in a community hospital because I thought it would be fun to teach, because I liked the idea of varied responsibilities, and because I wanted time at home with our brand-new baby girl. I was nervous about seeing patients on my own and about supervising residents, who I was sure would see right through my inexperience. What seems like a lifetime later, I’m now jumping to an academic center where I’ll take on new responsibilities. What’s changed since my last transition? Well, my family for one thing. Our month-old daughter, who screamed into the wee hours, is now 14; she is no longer screaming but is still peevish about the service around here. We also have a second daughter, who is now 12. My wife has advanced her writing career and returned to her first love, the piano; and I’ve been building muscles and calluses, as it were, through the practice of medicine and teaching, and through writing. One of my assignments at Montefiore will be to spearhead the launch of a new magazine; the working title is Progress Notes: dispatches from medicine’s front lines. In making this change, I feel familiar trepidations. At the same time, I’m genuinely excited about the road that lies ahead.
My first Montefiore Family Health Center patient arrives, and it’s like déjàvu. Once again, I’m working in an underserved community, caring for decent people who struggle with challenging circumstances. Because I struggle in my own ways, I enjoy the opportunities for emotional connection and repair. Evelyn is a 47-year-old woman with type 2 diabetes who is worried about left breast pain. The breast doesn’t worry me much because I can reproduce her pain by compressing her ribs. What worries me is that she has nocturia twice a night, she doesn’t check her blood glucose levels, she has no money or insurance to buy a glucose meter or test strips, she’s taking insulin but doesn’t know the type or dose, her blood sugar and blood pressure are elevated, and her last doctor is “back home” across a stretch of Caribbean water. “Welcome to your new job—and please help me,” Evelyn’s searching expression seems to say. Fortunately, our health center is blessed with resources that can make a difference. For the moment, I suggest that we order a mammogram, draw blood, and check her urine for microalbumin. “Come back in two weeks with your insulin, and we’ll go from there.” Evelyn looks relieved, and I’m pleased that my new journey has begun with a familiar first step.
Although the pharmacologic treatment of erectile dysfunction (ED) has been a god-send to many men, it may also have created unrealistic expectations about sexual performance and some inappropriate requests for ED medications. During a routine visit, 45-year-old Jerome expresses concerns about his sex life: specifically, that he sometimes has trouble sustaining erections. Fair enough. More history reveals, however, that he generally sustains himself through 20 to 30 minutes of intercourse seven days a week, and that he has sex twice in one night if he misses a day. Is this man suffering from ED? Not to this physician, who is admittedly less Herculean. But something else grabs my attention: Jerome, whose business takes him out of town a lot, has a wife and a girlfriend, and he doesn’t use a condom with either partner. When I ask if he’s worried about HIV infection, he says, “I’ve asked my girlfriend to tell me if this isn’t working for her.” I let his words hang in the air before offering him a carefully worded caution, after which he concludes, “Maybe this problem is just my age.” I’d have to agree, and I’m glad he doesn’t push for medications to enhance his sex life. From a public health perspective, the last thing Jerome needs is more sex.
With Thomas Wolfe’s famous warning about going home again echoing in my brain, I cautiously start out to do teaching rounds in a Bronx hospital, a place that was my home as a medical student 20 years ago. The halls jangle with memories, and I recall my anxiety about examining patients for the first time. I also remember those early days of the AIDS epidemic, when we admitted patient after patient with pneumonia, diarrhea, meningitis, encephalitis, or bacteremia, all careening toward death. I remember their misery and the hospital’s dysfunction in the face of such need—supplies that ran out, specimens that never made it to the laboratory, and basic chores (like transporting patients) for which there was no staff. For many residents at that time, the long, unregulated work hours meant emotional frustration and physical exhaustion. Today, I blink at residents calmly placing orders and pulling up lab results on computer screens, and mutter to myself, “What happened to the chaos?” When a plumbing crisis strikes (e.g., a stopped-up toilet), someone places a quick call and within minutes a man in a forest green maintenance outfit arrives carrying a toolbox. I’m dumbfounded. Can a repair be that simple? Is this the same hospital that lives in memory? Wolfe was right: you can’t go home again. And in this case, thank goodness.
Today, I observe Harold, a somewhat humorless neurology fellow, interviewing Matthew, our 28-year-old patient who presented to the hospital three weeks ago with seizures and mental status changes caused by viral encephalitis. Matthew is alert, pleasant, and cooperative, yet his affect is childlike and otherworldly. He can’t remember what he had for breakfast, doesn’t know his phone number, and can’t recall who the president is. He’s able to repeat the phrase “No ifs, ands, or buts,” but only after several tries and with the facial effort worthy of differential calculus. Harold then offers him a business proposition: “Let’s say you bought some bananas for 75 cents and gave the clerk a dollar. How much change would you get?” Matthew furrows his brow. “The bananas are 75 cents? Each?” He pauses. “How many bananas? Three? For just one dollar?” Harold shakes his head, irritated. “Forget that problem. Let’s say you buy one banana …” I wonder, is this a medical interview or a comedy skit? At the same time, I reflect that Matthew was functioning normally three weeks ago, that we haven’t a pill or potion to make him better, and that we don’t really know his prognosis. What anguish would I feel if this young man were my son?
I’ve been informed that the Diary From a Week in Practice column will be ending its long run in December. These entries are to be my last; the other diarists will have one more column each. I feel sad to lose this space that I’ve occupied since May 2003. I’ve enjoyed the opportunity of recording my experiences with patients and family, and as a writer I’ve appreciated the sense of legitimacy afforded by a regular column. I’ve delighted in the sense of connection that comes with e-mails from readers, appreciated working with American Family Physician’s capable and professional editorial staff, and felt honored to be a part of a Diary lineage that I trace back to Walter L. Larimore, M.D., and John R. Hartman, M.D. I’m told that AFP is at work on a new format to provide some of the perspective offered by the Diary. I’m glad. Just as I believe in the rigorous application of scientific medicine, it’s also my experience that much of what transpires in the examination room falls outside the scope of available evidence. Although it’s critical that we use our heads while caring for patients, I believe it’s equally important that we pay attention to our hearts, where we accumulate the rich essence of what we do. It is this essence that sustains and nourishes us all when we share our stories.