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April 4, 2005
A fireside chat
william waters is a 1958 alumnus of the school of medicine
There are some advantages to being an M-50.
1. You can impress the house staff (temporarily) by making some instant diagnoses. After a half-century, knowing that the abdominal pain is merely early shingles is just recognizing an old, old friend.
2. You have finally stumbled upon the magic shortcut to clinical evaluation: Forget the MRI and take another history from the patient.
3. You can ski free at many Colorado resorts.
4. But the most fun about having a half-century of memories is just that: You can project them around in your brain at will, no admission charge.
Take, for example, the euphoria of senior medical students. First of all, they know everything. And when they’ve gotten their match for a graduate program around March of the year, they can hardly bring themselves to speak to ordinary mortals. If you’re so unfortunate as to have a member of this species in your office for a month (as I did for some 30 years), you’ll get no work out of them—if you can even find them. I found one, Larry, in March, asleep in the library. I found another, William, in April, asleep in our receptionist’s office. They had not been studying late. They had been celebrating.
When I was one of these creatures myself, I had boldly asked my dad, a physician since 1924, if he knew anything about hypoglycemia. Without a word, he dug out a yellowing reprint of an article in the Annals of Internal Medicine, vintage 1931. It was the first report on treatment of low blood sugar with a high-protein diet. There was a single author. It was my father.
Fortunately, this psychotic exhilaration of seniorship has its own built-in cure. It’s the instant effect of the first day on the ward as an intern. I remember it well. I had eight patients on the Grady medical unit, all my own, and I was suddenly responsible for all of them. As I made rounds, the gut-wrenching realization descended like a shroud:
I didn’t know diddly-squat.
I devised endless clever maneuvers to pry advice out of residents and attending physicians: “Suppose you had a patient who keeps running a fever but the white count is normal... ”
By far the worst was Minnie. Some 65 years old and living alone, she had come in very sick, indeed. I knew she had severe sepsis, probably from an infected kidney. I knew she was in shock. I figured I had her on the right treatment. But why this heavy breathing? This severe acidosis? Despite all our efforts, including staying up all night, she died.
I carried Minnie around from then on, part of my permanent educational baggage. And then, during my fellowship in Boston three years later, my brilliant mentor discovered lactic acidosis, previously unknown. Helping him write a couple of papers on this strange condition, I had a double realization: First, we were breaking new ground; second, I was beginning to understand Minnie.
As I surf the memory bank, the images roll. Riding the ambulance as an intern ... diving into icy Piedmont Lake vainly trying to save the man trapped in a submerged car, then learning he had left a suicide note …prying a man out of a car wrapped hopelessly around a telephone pole some 20 feet in the air (they estimated 115 miles per hour) and being amazed that he only had a few bruises. What is that about sparrows? And what is that about spiritu frumenti?
The rewards keep coming back ... storming into the administrator’s office at Grady complaining about the nurses and orderlies. He, between puffs on his cigar, told me: “You know my hardest problem, Waters? Getting orderlies and nurses. You know my easiest problem? Getting interns.” But then on the ward the next day, I noted a vast change in attitude of the staff. I learned that the whole crowd had been called on
the carpet the night before—by the administrator.
As a faculty member at Emory, being referred a man with a weird array of recurring abdominal pains and nerve damage. Then noting to my horror the horizontal bands (“Mee’s lines”) in his fingernail beds, indicating multiple doses of arsenic. (No arrest followed, but a divorce did.)
Or the student rushing up to tell me that my new patient had Wilson’s disease (!), a rare disorder causing copper to deposit throughout tissues of the body and producing liver trouble and mental disorders. “First of all,” sayeth the experienced clinician, “compose yourself, son, and tell me what Wilson’s disease is all about.” He did, it was, the patient was treated, he responded, and I’ve followed him for 40 years. The student, who acquired instant fame in internal medicine circles, went into psychiatry.
The pictures keep streaming. Telling the family, in 1965, that we couldn’t do much for Tom, sick in the nearby hospital room, because he had end-stage kidney failure. Then turning and seeing who? Tom himself standing there? No—his identical twin! Then arranging the trip to Boston, the only place where kidney transplants were then being done––and only between identical twins.
Having the young new ICU nurse ask if I was Dr. Waters’ father. (Dr. Waters IV (my son)––on hospital staff 2 days; Dr. Waters III (me)––on staff 25 years.) “Yes, my dear.”
Despite all the hassles of modern medicine, I still tell the new medical students about my fantasy: I could step down from the podium, walk up the aisle, find an empty seat...
And start all over again.
P.S. All the names have been changed to protect the guilty.
This essay first appeared in the summer 2004 issue of Emory Medicine and is reprinted with permission.