Synopsis
Uncommon Wisdom In light of the escalating costs of healthcare in the U.S. and the on-going debate about appropriate health insurance reform, it's easy to forget about the human side of medicine and the importance of the doctor-patient relationship. In "Uncommon Wisdom," neurologists John Castaldo and Lawrence Levitt share what they have learned in their many years as doctors, not just from tests and labs, but fr... Full description
Extrait
Encountering Leonard
"Mrs . Pool ?" I spoke softly to the frail, gray-haired woman lying motionless on the bed. There was no response. "Mrs. Pool?" I ventured again. "Can you tell me how you're feeling?"
The sheets stirred slightly. "Very weak," she finally whispered. She reached out to touch my hand, mumbled something unintelligible, and drifted off to sleep again, ending my interview before it really got started.
I was a first-year resident at Memorial Sloan-Kettering Cancer Center in New York City, and feeling frankly overwhelmed. I knew that Dorothy Pool had been recently diagnosed with lung cancer and had traveled to our hospital from her home in Allentown, Pennsylvania, after becoming suddenly and unaccountably weaker. Her doctors in Allentown couldn't figure out the source of her precipitous decline, which is why her husband, Leonard, had been advised to bring her to Sloan-Kettering. We were their last hope. Mr. Pool was sitting on a chair across from his wife's bed, looking up at me with a mixture of sadness and stoicism. I could imagine him thinking: "Too young, too inexperienced. Wasting our time."
If Mr. Pool was thinking that, I said to myself, he was probably right. I was twenty-seven years old and green to the gills, stuffed with textbook knowledge but not much experience with actual patients, much less their families. My first impulse was to flee the room, just to get away from the sadness in his eyes. "Dr. Levitt?" I heard him say. "Could we talk a moment?"
Apprehensively, I sat down in the green vinyl chair opposite him. I expected him to start peppering me with questions. Exactly what do you plan to do to get to the bottom of my wife's sudden deterioration? What treatments will you try? What are her chances? But Leonard Pool just looked at me and smiled. "It's good of you to help us," he said simply. A lean, fit man with alert hazel eyes, he appeared to be in his early sixties, several years younger than his wife. He was dressed in corduroys and a plaid flannel shirt, and had the look of someone who'd worked outdoors his whole life.
"We will certainly try," I said, with more confidence than I felt. "Perhaps you could tell me a bit more about your wife's condition." Nodding, he told me that Dorothy had been diagnosed with lung cancer earlier that year, after three decades of chain smoking. "I tried to get her to stop, but ..." He trailed off, shaking his head. But after she'd undergone a round of radiation, he continued, she'd recovered some of her energy. She'd been going out with friends, taking walks in the countryside, even traveling to visit her sister in Detroit. Then, two weeks ago, she became suddenly and overpoweringly exhausted, "as if all the energy had been just scooped out of her," Mr. Pool said. "She got so weak she could barely stand."
As he said this, he let out a deep sigh and stared out the window into the hospital parking lot. His hands, ropy with veins, gripped the sides of the chair. Somehow, I got the distinct sense that he was picturing his wife's death.
For the second time in ten minutes, I wanted to run out of the room. It all felt like too much responsibility, not just to diagnose and treat this woman's strange symptoms but to know that so much feeling--a lifetime of love and protectiveness, I guessed--hung in the balance. What if we couldn't help her? "Well," I said awkwardly, "try not to worry." Brilliant, Levitt, I thought. Why shouldn't this man worry? "We'll do our best to help Mrs. Pool," I added lamely. I couldn't take this anymore. I got up from my chair, made some feeble excuse, and escaped out into the hall.
Over the next two days, I worked with my attending physician, Dr. William Geller, to try to figure out the cause of Dorothy Pool's mysterious weakness. We ordered up blood tests, a routine step following a hospital admission, but one that often elicits nothing worthwhile. But as we analyzed the results of Mrs. Pool's sample, our first clue emerged: a key blood salt known as serum sodium had fallen to a critically low value. The salt had plunged low enough to cause excess fluid to flood delicate brain tissues, which would produce exactly the kind of progressive weakness and lethargy that Dorothy Pool was experiencing. Dr. Geller and I both knew that if the cause of this plummeting blood salt was not promptly uncovered and treated, Mrs. Pool would quickly die.
Dr. Geller immediately dispatched me to research Mrs. Pool's cancer type, known as small cell carcinoma. This was 1967, long before the Internet would make medical research a matter of a few mouse clicks. Back then, we went down three floors to the hospital medical library, where we first looked up our subject in a series of ten-£d reference tomes known as Index Medicus. This process, in turn, directed us to specific issues of medical journals that featured articles on the subject we were hunting down. Then we combed the cavernous library stacks until we found those journals. Finally, we sat down to read the relevant articles therein.
As I hunkered down into a library carrel with a stack of journals piled high in front of me, I again thought of Mr. Pool's face as he stared out onto the parking lot--his mixture of sadness, forbearance, and undisguised pain. I realized how much I wanted to make a difference to his wife--and to him. Still, given her clearly critical condition, what were the chances? As I was thinking this, I was paging through a study on small cell carcinoma in a little-known medical journal. Suddenly, I sat up straight. The small cell tumor, I read, was distinctive in its ability to secrete a potentially deadly substance called antidiuretic hormone. I knew that in healthy people, this hormone was secreted in very small amounts by the pituitary gland. But in some cancer patients, the article went on, this hormone can be released in toxic quantities by the tumor itself and wreak havoc on the body's ability to regulate salt and water.
My heart racing, I read on. The most effective treatment for the disorder, called Syndrome of Inappropriate Antidiuretic Hormone (SIADH), was to restrict water intake, because it caused the sodium to rise back to normal levels. Quickly, I photocopied the study and ran back upstairs to intercept Dr. Geller. He scanned the article, quickly nodding his head several times as he read. Then he looked up at me, smiling.
"Let's get started."
Together, we went to Dorothy Pool's room to explain our recommended treatment to her husband. We explained that while "water restriction" might sound a bit draconian, in fact we were advising that Mrs. Pool limit herself to the equivalent of three glasses of water a day--less than half the amount most people ingested but more than enough to prevent thirst. As we stood at her bedside outlining our plan, I watched Mr. Pool's face brighten with hope. "We think this is a very promising approach," Dr. Geller told him. "But of course, we can't guarantee that it will reverse Mrs. Pool's symptoms." At his words, I found myself filled with anxiety. It had to work!
Later that evening, shortly after starting Mrs. Pool's treatment, I entered her hospital room feeling bad that I had left too soon earlier that day, and found her husband sleeping on a cot next to her bed. I'd noticed the cot there before and realized, with a start, that Mr. Pool probably couldn't afford a hotel room. Though he'd never mentioned what he did for a living, he'd told me that the Allentown, Pennsylvania, area was a farming and industrial community, so I gathered he was a laborer of some sort. The next morning, over breakfast, I told my wife, Eva, what I'd seen. "You must invite him to dinner!" she said. "He probably hasn't had a decent meal or sat in a comfortable chair in a week." I nodded, ashamed that I hadn't thought of this myself. "Bring him here tonight," Eva said firmly.
And so that evening, I brought Leonard Pool back to our small apartment on Fourteenth Street near First Avenue, in the Union Square neighborhood of New York City. As we walked through the door to the aroma of roast chicken, Mr. Pool seemed to almost palpably relax. "Well now," he said, after I'd made introductions, "this is just what the doctor ordered!" Then he asked that we call him Leonard. As he grinned broadly at the two of us, I saw that Eva had been right. His wife might have been the patient, but this man badly needed a little TLC.
I can't remember everything we talked about that evening, but I'm sure that we discussed Dorothy, who already seemed to be responding, ever so slowly, to treatment--her blood pressure had risen slightly and she was now able to speak a few sentences at a time. Leonard talked about what an amazing woman she was, an accomplished pianist and painter who lived every day to the hilt and had "the best laugh in the world." I could tell that Leonard was still very worried about her, and I wanted to reassure him, to say something heartening like "I'm sure she'll be fine," but I managed to swallow it. I wasn't at all sure she'd be fine. I knew I had no right to give Leonard, or anyone, false hope.
As we sat around our Formica-topped kitchen table eating Eva's delicious chicken and roasted carrots, Leonard also asked me a number of questions about my work and our future plans. What kind of doctoring most interested me? In what area of the country would we most like to settle? He seemed genuinely interested in both of us. When I asked him what he did, he just murmured "this and that" and asked us what it was like to live in Manhattan. At the end of the evening, he said he hoped that when his wife had recovered her energy, we'd come and visit them in "our wonderful city of Allentown." When Eva responded, "Alan who?" we all laughed, and she admitted that she'd never heard of Leonard's hometown. I didn't add that I'd never heard of it, either.
When I returned to the hospital the next morning, I checked in on Dorothy Pool to find her sitting up in bed, eating breakfast. Leonard, sitting next to her, was positively beaming at me. "Would you look at this?" he said, proud as a father showing off his child's first steps. By the following day, Dorothy was up and moving about the room, chatting with visitors. "It's a miracle!" Leonard said exuberantly, and though I didn't say so out loud, I thoroughly agreed with him.
When I'd first seen this woman, gray-faced and still, she looked as close to death as a person could be. Now she was walking around, cracking jokes and laughing--she did have a wonderfully infectious laugh--and planning all of the things she and Leonard would do when they returned home. When she was discharged a few days later, both of them hugged me. I found myself saying: "I'll miss you both."
And I reflected on the awesome power of medicine to make a difference--even when, at first glance, things look hopeless. Mrs. Pool was the kind of patient that doctors tend to easily give up on. She was elderly and already had advanced cancer. But I learned from her that if you can figure a case out early enough and if a particular symptom is treatable, you can improve the quality of someone's life even if he or she has a serious, fatal illness. It's vital to focus on what can change--an infection that can be quashed with antibiotics, an out-of-whack electrolyte balance that can be restored with IV fluids, a nutritional deficiency that can be reversed with a dietary adjustment. Small victories. From that day, I followed an unspoken motto: "Treat the treatable."
A few weeks later, I was on rounds when the hospital's loudspeaker suddenly crackled to life. "Dr. Lawrence Levitt," a disembodied voice intoned, "please report to Mr. Van der Walker's office immediately." My heart froze. Mr. Van der Walker was the president of Memorial Hospital. Being summoned to the head office was, by definition, bad news: It nearly always meant that a resident had done something terribly wrong, either medically or ethically. In the few cases I knew of, this kind of summons had been followed by suspension, or even discharge from the program. Once booted from an institution as outstanding as Sloan-Kettering, what other residency program would touch me? I saw myself giving up my dream of doctoring to join my father's fur business, where I would live out my days peddling fox stoles to rich matrons. I felt physically ill.
As I buzzed the elevator to take me to the top floor, I racked my brain for what I might have done wrong. I was pretty sure I hadn't made any major medical errors; if I had, my attending physician, Dr. Geller, would have already called me on the carpet. But I knew that fraternizing with patients' families was considered, if not unethical, at least highly unprofessional. Had someone seen me leaving the hospital with Leonard? Had somebody on the staff reported that I'd hugged a patient? I'd already been told by my superiors that at times I was "inappropriately expressive." Had I crossed some final, forbidden line that I hadn't even known was there?
As I entered the corner office of Mr. Van der Walker, I saw a blur of Persian rugs, heavy furniture, and great swags of silk drapery. Behind a massive mahogany desk sat Mr. Van der Walker himself. He was a tall, wiry man, impeccably dressed in a navy three-piece suit, red tie, and crisp white shirt. His pale blue eyes were cold.
"Are you Dr. Levitt?" he demanded.
"Yes, sir," I mumbled, trying hard to not drop my eyes.
"Do you remember the Pool case?" To my ears, the question sounded like a bark.
"Of course," I responded, my heart sinking. Here it comes.
"Well, your patient's husband, Leonard Pool, just came to see me," Mr. Van der Walker said. Confused, I watched the corners of the CEO's mouth turn up, ever so slightly. "He wanted to express his appreciation to you and Dr. Geller for the kindness and care you extended to him and his wife."
I closed my eyes, almost dizzy with gratitude and relief.
"Thank you for letting me know, sir," I managed to reply.
But Mr. Van der Walker wasn't finished. "You may not be aware," he said, "that Leonard Pool is the founder of a major chemical company, Air Products and Chemicals, in Allentown, Pennsylvania."
"Mr. Pool?" I said incredulously. I flashed on his plaid work shirts, the hospital cot.
"Yes, a highly successful gas and chemical company," Mr. Van der Walker continued. "And in appreciation of your care, he's just pledged one million dollars to Sloan-Kettering."
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