I met him when I was a 4th year medical student. My military scholarship allowed me to do an elective each year at a military hospital. I had chosen to do pulmonary medicine at the Naval Medical Center Portsmouth, VA.
I met him on my first day in the pulmonary medicine clinic. Dr. C was a Captain in the U.S. Navy. He was a specialist in pulmonary medicine. He was a southerner, complete with the soft, lazy sounding accent. I was a young medical student. We both wore the working uniform of the day which were Navy Khakis made of CNT (Certified Navy Twill). He was a Captain. I wore the single bar of an Ensign.
We went to see a patient with asthma. Perhaps it was the pollen or the flowers in the Virginia area that were causing her problems. They always had such beautiful Azaleas each year in Virginia Beach. Regardless of the cause she had been having multiple flares of her asthma. Each episode brought her to sick call or to the medical urgent care clinic. With the flares she would get a brief course of prednisone and would improve. She had accumulated enough of these that she was in danger of being pushed out of the military.
In order to serve in the United States Navy, everyone had to have a physical examination each year. The primary reason for the physical examination is to determine if you are, “fit for all duty at sea and on foreign shores.” That is the standard for the Navy. Unlike some of the other branches of the military, the Navy feels that based on their mission, if you cannot be fit to do everything, then you are not fit for service. If you are not fit for service then you receive a “medical board”. A medical board removes you from the military.
Our asthma patient was being sent to us to see if she should have a medical board. She was 16 years into her Navy career. She could retire in 4 years. With the 20 years, she would have lifelong medical benefits and a lifelong pension. A medical board before that time might give her some disability payment or not depending on whether the board determined if her condition “existed prior to enlistment (EPTE).” Either way she would lose her pension.
Captain C listened to her and examined her. He asked her if she wanted to remain in the Navy. She shook her head yes vigorously. She had committed 16 years of her life to her career. She really wanted to at least get to the 20 years to get her pension.
Captain C took me out to the charting area. We looked through her record. Charts were paper then. They travelled with every sailor from duty station to duty station. We could see every medical interaction she had ever had. We could see her initial entry into the military, every physical examination, and every clinic visit. He pointed out that she did not have any hospitalizations. Each of her asthma flares had improved with outpatient treatment.
“Do you know what she needs?” he asked me.
“What does she need sir?” I replied.
“She needs a big jar of prednisone and to be taught how to stay away from us.”
I can still hear his southern drawl as he said it and that expression, “a big jar…”
Captain C took a blank consult sheet and started writing on it. His writing wasn’t neat or pretty but it was legible. On one side of the paper, he drew a picture of her chest x-ray. That was his trademark. He always did that. When he was finished writing, we went back into our patient’s room.
“I am going to try to help you finish your career. But you need to promise me that you will work with me.” He then went through a process of teaching her how to use occasional courses of prednisone to counter her asthma flares. He made her promise to not use them too frequently and to call him if the flares became too frequent. He then wrote a prescription for a “big jar of prednisone” and gave it to her. He set her up for a follow up visit to monitor her progress.
I learned a lot in that first hour in clinic. I don’t know whether he realized it but he was teaching me in ways that went far beyond just lung disease.
You could always recognize one of Captain C’s notes. On every note he would draw a picture of the chest x-ray. A picture is worth a thousand words. From Captain C I learned that there is a lot more that you can communicate than just the words you write. You should create a full picture of who the patient is and what you thought was going on. For a chest physician looking at the chest x-ray is key. It often means so much more than just reading a sentence about what someone thought the x-ray showed.
In future years I found myself looking in the charts for Captain C’s notes. I would flip through the pages looking for the rough drawing of the patient’s chest x-ray. A quick look at his note would tell me a lot. The sketch was always valuable, but I looked for his notes for reasons that went beyond the sketch.
Captain C’s words themselves were about creating a picture of who the patient was and what was going on. His words were honest and plain and to the point. They were important. When you finished reading his note, you could see in your mind and really understand what was going on. Reading his notes, I could always hear his southern accent in my mind. He wrote exactly like he spoke which was exactly like he thought. He would even put, “I think” in the notes.
These notes had immense value. They were not some generic worthless writing of the same stuff over and over again. The notes gave you a valuable opinion, insights and a plan for each patient. They contained the thoughts of an expert.
We get lost today in the world of electronic notes. It is easy to use the computer to generate enormous and lengthy notes that say nothing. I get so frustrated when I see notes that require several minutes to scroll through only to find no expression of human thought anywhere in the note. I would rather have only 1 sentence that showed what the physician thought than 20 pages of computer-generated meaningless data.
We get lost in our communication with each other also. Whenever I blog I find that I write too many words. I have to go back and simplify. I delete words. I shorten sentences. I delete entire sentences or paragraphs that do not add value. The goal is to communicate. If we do that well we create a picture that others can see and understand.
Often I fill my interactions with others with a flurry of words but only narrowly communicate. Oddly, I am worse at this when it is really important. It feels safer to bury what is really important under too many unimportant words. I think I fear being blunt, open and honest.
But from Captain C I learned to say what I think. In medicine, and in life, when someone is able to do that, as humans we hungrily gravitate toward it. It is like digging through the chart looking for the rough sketch of the chest x-ray that will indicate a Captain C note. We seek it out because there we find reality and truth.
That afternoon we went to the lung cancer tumor board. This is where a group of experts get together to review cases of patients diagnosed with or suspected of having lung cancer. We talk about options and what would be the best care of the patient.
One patient’s case was presented. He had advanced lung cancer. Captain C spoke up,
“Do you know what this man needs?” He paused for effect and looked around the room. “He needs a big jar of morphine and a fishing pole.” It truly was the best option for that patient. At that time there was really no effective treatment for him. Any attempts to treat him would just make him feel worse and were not going to help to improve his survival.
I hear people talk about their mentors. Sometimes I feel left out.
When I hear about a mentor I imagine someone selecting me and then investing hours and hours of focused attention on me. I can’t say that I have ever really had that.
If I am honest, however, I realize that while I haven’t had one specific mentor, I have had dozens. I cherish all of them and what I learned from them. Most of them never realized how they were teaching and molding me. They likely had no idea what a dramatic impact they would have on my life and who I am.
To this day I can still hear Captain C’s voice in my head. Late at night when I am sitting at my computer trying to finish my day’s notes it comes back to me. What should we do for this patient? Should we put in an LVAD? Should we try to push to get him to transplant? Is there anything else? I read the written interpretations of the echocardiograms and the heart catheterizations. The words are empty and lack enough substance to guide my decision making.
I open up the software and start viewing all of the images myself. As I do I start to get a feeling for what I really think is best. I could have just typed the quick note. Press F2 and select the standard language. Maybe type, “Continue current inotropes. Evaluation in progress.”
Instead, my memory of Captain C pushes me. I push myself to put a real opinion. I hope that I can be the expert that guides the care to the best options. I start writing what I really think. I hope that will help me the next time I see the patient. Maybe it will help others who also will see the patient?
I saw another patient in the office. He was elderly and frail. He was failing. His heart failure was causing more and more problems for him. The easy path would be to put him in the hospital. I worried that if I did so he would never go home. Being in the hospital is hard on people. We do all sorts of tests on them. With each test we make them “npo” (not able to eat). They come back from the tests exhausted. As hard as we try to keep the wards quiet, there are noises in the night. They never sleep well in the hospital. I have seen so many patients get admitted and then not go home or go home just a shadow of who they were before.
“Do you know what you need? You need to not let me hurt you by putting you in the hospital.” The patient doesn’t know but in the back of my head I can hear a familiar voice complete with his southern accent, “Let’s come up with a plan to keep you away from the emergency room and the hospital.”
After we come out the exam room, I explain to the student who is with me that there is some data showing improved survival duration with hospice. “What this patient needs is a big jar of torsemide (a diuretic) and to be home with their family!”
I try not to say it with an accent, but in my head is Captain C’s voice, southern accent and all.
I hope he would be proud of me.
