"I think every doctor ought to be sick early in his career. I'd like to see every young doctor feel pain."
A compassionate surgeon said that to me once. He was the late Dr. Charles H. Mayo, a son of one of the Mayo brothers who founded the Mayo Clinic. He himself was one of the clinic's outstanding doctors, one who would put his hand on a frightened patient's shoulder and say, "You'll be all right," and be believed.
As a sophomore medical student, he sometimes explained, he got rheumatic fever and was out of school a year as a patient. "If I had to repeat anything," he would say, "I think I'd repeat that, much as I hated it."
Doctors who become patients often teach themselves some of medicine's most important lessons. They are lessons, too, for fellow doctors and for all of us who may become patients.
The late Dr. Franz Ingelfinger, from 1967 to 1977 the keen and forceful editor of The New England Journal of Medicine, learned in 1975 that he had cancer. It was, he said in a talk in mid-1977, a "particularly grave" glandular cancer at the bottom of the esophagus, an area "to which I had paid much attention as a physician . Therefore I can hardly imagine a more informed patient."
He underwent surgery, but then faced other decisions. "Should I have prophylactic chemotherapy with all its side effects? And if chemotherapy, what kind? And should I have radiotherapy? . . . I received from physician friends a barrage of well-intentioned but conflicting advice . . . Not only I but my wife, my son and daughter-in-law, both doctors . . . became increasingly confused and emotionally distraught."
Finally, when "the pangs of indecision had become nearly intolerable, one wise physician said, 'What you need is a doctor.' "
Ingelfinger found one, took his advice and lived nearly three final productive years.
Dr. William Nolen is the Boston-trained surgeon who chose a small-town practice -- in Litchfield, Minn. -- and became a well-known author as well as his area's surgical stalwart. At 50, he wrote in "Crisis Time" (Dodd Mead, 1984), he suffered a mid-life crisis, with doubts about his job and his life. He turned to alcohol, Valium and Quaaludes.
Finally, he told Marian Christy of the Boston Globe recently, he "got very scared" and said "I have a menopause problem. I'm going to do something about it . . . I went to an internist. I said: 'I need help.' "
He had learned, he said, that a doctor is not omnipotent, but rather "ordinary, vulnerable, imperfect." And: "My life is in order now, because I faced up to the situation in which I found myself."
Dr. Allen Bassler, now of Fort Washakie, Wyo., was a third-year resident, a doctor nearly ready to practice his specialty, when he broke his jaw. A piece of bone had to be grafted from his hip to his jaw. His jaw bones had to be wired together to heal and his tissues sewn back into place.
"I realize now why patients love their surgeons," he wrote in the New Physician after his hospital stay. "If I felt as awful as I did after the surgery, imagine how much worse I would have felt if things had not gone so well."
He also recalled his hospital mood: "I listen attentively, gratefully, to the nurse's explanations of what to expect and how to take care of myself after the surgery. I begin to understand why patients regard nurses so highly. Here is a person talking to me, with me." About disease processes? "No, about coping and helping me to cope."
Physician-author Oliver Sacks of Albert Einstein Medical College in New York tells in "A Leg to Stand On" (Summit, 1984) how he fell and tore a thigh tendon and underwent surgery. He learned that his surgeon could not "hear" the feelings that he was trying to convey. He also tells how finally music helped him move his dead-seeming leg once more.
Dr. David Rabin of Vanderbilt University wrote in The New England Journal of Medicine of developing amyotropic lateral sclerosis -- Lou Gehrig's Disease -- and how hard it was for many of his fellow doctors, even his close friends, to face debilitating illness in a colleague and friend.
"Perhaps," he said, "it is because we, as physicians, are the healers . . . To the fraternity of healers, becoming ill is tantamount to treachery."
Still other doctors helped him face his ordeal, however. And he learned "how much can and should be done for the patient, even when one is confronted with a so-called incurable illness."
Dr. Robert Mack, a surgeon at Swedish Hospital Medical Center in Seattle, told in The New England Journal last December how he was stricken with lung cancer in 1979, how he "recuperated quickly" from surgery and resumed his practice, only to face recurrences in 1981 and 1983.
"I was devastated, bewildered and very frightened," he wrote. He had chemotherapy and, later, radiotherapy. For the past three years he has taken an oral dose of an anticancer chemical every five days. The tumor progression seems arrested, though "I am surviving with a state of disease with which, statistically, there is no chance of survival."
He has had to stop doing major surgery. "I sometimes feel like giving up . . . My energy reserves are easily depleted and I need to rest frequently."
Yet "those negative feelings do not predominate . . . I am up and functioning each day, and most days I work six to eight hours" -- as chief of his hospital's medical staff, as an assistant sometimes at the operating table, as a hospital planner and a designer now of new home-care and hospice services.
"I have faced the imminence of death," he wrote. "I have ceased to feel that death is a dreadful something that I need to fear.
"I . . . focus on choosing to do things every day that promote laughter, joy and satisfaction. I decide on things like spending time in my garden, watching a basketball game, reading an interesting book or article, taking a slow and gentle walk at dusk with my partner, enjoying the Earth and its beauty.
". . . I have been permitted to share wondrous moments with friends and loved ones . . . I need to live in the present each day, yet plan for the future and try to balance the needs of today with the uncertainties of tomorrow. I choose to work, play, laugh and cry, and I know without question that this is a good time in my life . . . When my days are no longer nourishing and good, I hope that I can simply go and allow myself to rest in peace."
So this doctor, like Drs. Mayo, Ingelfinger, Nolen, Bassler, Sacks and Rabin, found, as he reports, that "one of the really ironic things about the human experience is that many of us have to face pain or injury or even the possibility of death" in order to learn about living.
Struck by experiences like these and his own brushes with illness, another author-physician, the eminent Dr. Lewis Thomas, echoes Dr. Mayo. He wrote in "The Youngest Science: Notes of a Medicine Watcher" (Viking Press, 1983): "Every young doctor should know exactly what it is like to have things go catastrophically wrong, and what it is like to be personally mortal."
Perhaps, he mused, there might be some way to create "electronic models" of coping with illness for medical students and interns, something like the way pilot trainees come in for crash landings on aircraft simulators.
Dr. DeWitt Stetten Jr., retired deputy director for science at the National Institutes of Health in Bethesda, still a senior scientific adviser there, had his own hell -- blindness, compounded by the failure of his eye doctors to give him any help in learning to live as a blind man. He did learn. That is a story in itself.
But he has suggested that "each young ophthalmologist be required to spend a few days either totally blindfolded or wearing heavily frosted glasses while trying to carry out all his normal activities, such as making rounds and getting his own lunch in the cafeteria -- an interesting experience for the visually handicapped."
Perhaps, he suggests, "the orthopedic surgeon should spend some time in a plaster boot and on crutches," and the otolaryngologist with deafness simulated by ear plugs.
Providing such realistic experiences might be hard for some kinds of doctors. "Fortunately," Stetten adds, there is another possible way to sharpen the young physician's sensitivity to patients' problems -- simply admitting some handicapped persons to every medical class.
Stetten realized this when he gave a commencement address to the medical graduating class at the State University of New York in Buffalo:
"In the graduating class was a young man who had become blind during his medical school years . . . His classmates apparently organized themselves to provide him with readers and . . . verbal descriptions of what had transpired in the lectures and clinics . . . There is no doubt in my mind that the daily exposure to a blind fellow student had a deep effect upon the rest of the class . . . I like to think they will all be better physicians for having had the blind classmate."
For "it was a proud moment for him and for the school when he walked across the platform, guided by his recently acquired seeing-eye dog, to pick up his diploma, which he earned with distinction in psychiatry."
Next Week: Dr. Stetten's own story.