|Publisher:||Big Eye Books|
|Product dimensions:||5.40(w) x 8.20(h) x 0.50(d)|
About the Author
Read an Excerpt
"Mr. Spock: Doctor, if I were able to show emotion, your new infatuation with that term would begin to annoy me.
Dr. McCoy: What term? "Logic?" Medical men are trained in logic, Mr. Spock.
Mr. Spock: Really, Doctor? I had no idea they were trained. Watching you, I assumed it was trial and error."
–Leonard Nimoy and DeForest Kelley: Star Trek
The nausea was so overwhelming it nearly sent me to the ground. I'd spent 31 years in training if you count preschool preparing for this day, my first day as an attending physician running my own neonatal intensive care unit (NICU) service.
By that point, I'd been a doctor for six years and had made thousands of in-the-moment decisions that were only later validated by my supervising attending physician. The time had come, however, for me to take to the trapeze without a net. I no longer had a supervisor looking over my shoulder — I was the attending, and the final call on each decision was entirely my own. Just like a trapeze artist swinging without a net for the first time, the magnitude of that responsibility hit me hard, and sent my stomach reeling. After all, that responsibility was why I went into medicine in the first place, and its full weight now finally rested on my shoulders.
Truth be told, the arc of my life had bent toward medicine since I was in Underoos. When I was 5, my family lived in a small Long Island town about an hour outside of New York City. My father had torn the place down to the studs and rebuilt it into a bustling home, replete with backyard swing-set, batting tee, Slip-N-Slide, and a variety of enormous-looking bushes. I remember playing outside near those bushes with my sister one day in the middle of summer. It was her second birthday party, and the bushes were covered from top to bottom with small red berries. The kind that look just like candy to 2-year-olds.
As a firstborn genetically incapable of not serving as guardian and protector of all within my keep, I watched her walk toward the back stoop then suddenly lurch for the berries and shove a handful in her mouth. They must have been bitter, because I remember her making a terrible face, spitting them out, and then toddling off toward the Slip-N- Slide.
I took off into the house, heart pounding and hands spinning over my head like the lights on an old police car while screaming "EMERGENCY! EMERGENCY!" I relayed the story, crushed that I failed to stop her from eating the berries and convinced I would lose my first patient to backyard berry poisoning before I'd even been to kindergarten. A quick (and reassuring) call to poison control and all was returned to normal. Except for the helpless bushes, as my father slipped silently away from the party and promptly turned them into wood chips.
My mother practiced nursing before my siblings and I were born, and I grew up marveling at how much she knew about healing. She always had an answer, a treatment, a reassurance for whatever was ailing anyone in the family, and I wanted to know just as much about caring for people as she did. By the time I hit elementary school, other kids were coming to me routinely for medical advice about bug bites and scrapes. I remember one day on the playground in first grade, a boy bloodied his knee playing kickball and a flotilla of children came running my way. He had a small cut just under his kneecap that was indeed bleeding but would clearly stop on its own. I vividly remember thinking to myself, "Well, touching blood with my bare hands is risky, but I really need to treat my patient." I wiped away his blood, told everyone he'd be fine, and the group went back to playing.
Recess ended and I walked to the school nurse's office, ready to face whatever horrors awaited me for touching blood without wearing the appropriate personal protective equipment. Pale and trembling, I told the nurse what happened, and said that I was ready now for the gigantic needle I was convinced she needed to use to test me for all manner and variety of infectious diseases. She instead gave me a popsicle, reminded me that I didn't have a license to practice either nursing or medicine in the state of New York, and sent me back to class.
While I didn't know it yet, even at 8 years old, the strains of the American Medical Association's 1847 Code of Ethics rang true in my heart, which says a physician must be "ever ready to obey the calls of the sick ... because there is no tribunal other than his own conscience, to adjudge penalties for carelessness or neglect."
While I spent years in my childhood dreaming about medicine, it turns out that the actual practice of medicine is rather different from what most people think. Centuries of folklore have given us a gilded picture of the good doctor, sitting in a dark, wood-paneled library surrounded by stack upon stack of medical textbooks. The air is heavy, and you can practically feel the weight of ancient wisdom as the ghosts of Osler, Galen, Hippocrates, and other famous physicians from history hover over his shoulders. His white coat is rumpled, reading glasses askew, and you can just make out his furrowed brow beneath the amber light of his table lamp as he desperately tries to connect the dots.
We watch for a moment as he moves from book to book, the gears in his mind spinning faster and faster until something finally catches his eye. It's a line from the 19th century Latin translation of the Ancient Egyptian Ebers Papyrus and it sends him headlong again into the stacks. Thousand-page tomes by Sabiston and Harrison crash thunderously to the floor until he finally emerges with a copy of Nelson's Textbook of Pediatrics. Rifling through the pages, he stops on page 1,754, scans the minuscule print, pounds his fist against the heavy wooden desk so hard it startles the medical students hunched in their nearby cubbies, and exclaims, "Of course!"
He grabs the book and streaks down the Gothic library corridors, his white coat a blur as he bursts through the hospital's main doors and re-enters its cold, sterile embrace. Taking the stairs two at a time, he climbs five flights up to the pediatric ward. Stopping only briefly at the pharmacy, he sprints to his patient's room, locks eyes with the young girl's parents, and with both relief and triumph in his face says, "We've got it."
He starts an intravenous line in her tiny arm, spikes the clear glass bottle of medication, opens the clamp and the mysterious drug begins flowing into her bloodstream. Within a matter of seconds, her eyelids flutter, she begins to stir, the corners of her mouth curl into a weak smile and she opens her eyes for the first time in days. Her parents rejoice while the good doctor slumps into an uncomfortable rocking chair, the weight of one life lifted from his shoulders.
Medicine is practiced like this in exactly two places: 19th century British paintings and prime-time television dramas.
My real life as a physician has never been so simple. While like any doctor I've had a handful of "eureka" moments, I can't count the number of times I've fallen asleep on hard call-room mattresses thinking about a particularly challenging patient and woken up still thinking, struggling to find the one unifying diagnosis that would perfectly connect all the dots.
Real medicine is messier than it looks in paintings or on television, diagnoses are rarely perfectly cut and dried, and with the possible exception of doctors old enough to have actually used glass bottles and metal IV catheters, you should almost never allow a doctor to start your IV. We're just not as good at it as nurses are, a fact my wife (an oncology nurse) finds reason to remind me of nearly every day.
My first chance to experience the complex choreography of real medicine came as a teenager living in a bucolic Massachusetts town about 45 minutes west of Boston. I was incredibly fortunate to have Dr. Mary-Ellen Taplin as a neighbor, a world-class cancer doctor who introduced me to the wonders of science and medicine through her oncology research. She took me into her lab one summer and showed me what cancer looks like under the microscope. She explained how she was trying to isolate specific genes responsible for changing normal prostate cells into the rapidly dividing monsters that grow into tumors. While all of the then state-of-the-art pipetting, polymerase chain reaction, and DNA blotting experiments we ran in her lab were fascinating, what I found most exciting were our trips to the tumor board.
Tumor boards are clinical meetings where all of the cancer-treating experts in the hospital — surgeons, oncologists, radiologists, pathologists, research scientists, and more — collect to weigh in on the most challenging cancer patients' cases. These weren't teaching cases or research cases — these were real patients, real people with real doctors all working together to make really hard decisions about how best to treat them. The complexity was titanic. The teamwork was inspiring. The mantle was daunting. I decided then and there in our last tumor board of the summer that I would go to medical school.
I went to college just outside of Boston, and during my freshman year I wanted to get as close as I could to really treating patients. I took an emergency medical technician (EMT) course offered by the campus EMT squad and passed the exam in the spring of 2000. I spent the next three years volunteering as a campus EMT, responding to calls for everything from seizures to car wrecks to drunks. Lots, and lots, and lots of drunks.
In my junior year, I remember getting a 911 call for a kid who was convinced his tongue was alive. He was flailing around in the middle of the lawn between two large dormitories, terrified that his tongue was literally going to crawl out of his mouth. I channeled both my mother and the school nurse from first grade while trying my best to reassure him that, no matter how much tequila one drinks, tongues cannot independently detach from a human's mouth.
I had a fantastic time working as an EMT, both for the university squad and for a local 911 and non-emergency ambulance service. I also supplemented my time on ambulances with a job in our local hospital's emergency department as a technician during summers back home. Really connecting with patients one-on-one for the first time fueled me through the countless hours of organic chemistry, physics, and biochemistry required to pass the medical school entrance exam. It also gave me an abundance of stories to tell medical school admissions deans, who read thousands of such stories every year in the application essays of aspiring medical students. My essay about performing CPR wound up being intriguing enough to land interviews around the country. Having fallen head over heels for North Carolina's warm spring and ready to finally escape New England winters, in June of 2003 I found myself driving 12 hours south to Durham, North Carolina to begin my career as a doctor at the Duke University School of Medicine.
From the very first day in medical school, medical students are taught that there are only two diagnoses we'll never make in our careers: the diagnosis we don't know about and the diagnosis we don't think about. This experience is made manifest in a medical student's introductory visit to the medical school bookstore getting ready for Day 1 of the "basic science" lectures.
I'd bought a lot of textbooks in college, but that first day in the Medical School Bookstore convinced me that the authors of medical textbooks must be paid by the word. I brought home at least five multi-volume sets, each with pages numbering well into the thousands. I was in fairly good shape at the time for a 22-year-old, but I needed reinforced cardboard boxes and a thick-wheeled hand-truck to get the bloated corpus into my apartment.
Once you really get down to it, the most daunting part of medical school isn't the ingestion of tens of thousands of pages of medical knowledge. In those first few months, we had hundreds of pages of reading each week across different textbooks interspersed with hour after hour of PowerPoint lectures and microscope time looking at pre-prepared slides. We also had the occasional exam that required you to regurgitate back reams of information in order to prove that you had really ingested it. This is where medical school differs most from college.
In college, finals week for me involved many, many hours of memorization, followed by one final and a massive explosion of knowledge aimed into the pages of a wide-ruled exam book, followed inevitably by the immediate liberation from my brain of everything I'd just memorized to make room for the next exam's batch. The cycle repeated itself, binging and purging course after course of knowledge, one exam so different from the next that there was rarely a need to remember the content after passing the final exam.
Medicine doesn't work that way. In order to practice medicine, you need to deeply understand pathophysiology, which is the science of all the ways in which the functions of the human body can go terribly wrong. Once you truly understand pathophysiology, you can then systematically work through all the ways you can try to fix the things that can go wrong, pick the best, and treat your patient. However, in order to understand pathophysiology, you have to understand physiology, microbiology, immunology, and pharmacology, and in order to understand those, you have to know anatomy, biochemistry, molecular biology, and cell biology. Each step builds upon the last, and like a teetering Jenga tower, you can't skimp on the base without endangering the penthouse. Figuring this out was, by far, the most overwhelming part of my first year in medical school — knowing that if I ever fell behind there would be no chance to catch back up.
In order to survive the year, I had to completely break down and build back up my approach to learning, which I suppose is in fact the point. Doctors must be lifelong learners, and medical school prepares our brains to continually add new Jenga blocks over the course of our careers while replacing old ones to keep pace with the exponentially expanding universe of medical information. This gets easier when each new bit of knowledge is connected to a real person, a story in which you have personally played a role. That's what practicing clinical medicine is like, but you don't get there until you've run the first-year basic science gauntlet.
If the basic science courses in medical school retaught me how to learn, the rest of medical school re-taught me how to think. Learning the language of clinical medicine restructures the way your brain thinks about the world and fundamentally shapes how a doctor approaches treating patients. In the clinical years of medical school, I was taught how to take a history, how to perform a physical exam, and how to integrate the signs and symptoms of one with the other to construct a logically consistent story of a patient's state of health.
Once we learn how to extract every bit of information we can from a patient through conversation, observation, and examination, medical school teaches doctors to progress through a phase called "the differential diagnosis." As medical students, we were expected to actually write out this thought experiment, the post-graduate equivalent of a fourth-grade math student asked to show her work when performing double-digit multiplication. Having weighed all the possible causes for a patient's constellation of signs, symptoms, laboratory findings, and radiology findings, it is then time to put down your chips and make a call. You write a statement known as your "assessment"— e.g., this is a 2-year-old boy with fever, right ear pain, and pus behind his ear drum, who most likely has an acute bacterial otitis media (an ear infection). Finally, you commit to your "plan," which in this case would include some combination of antibiotics, acetaminophen, ibuprofen, and advice that his parents sleep while they can because they're in for a few days of total misery.
We practiced writing these observations over and over again in student "History and Physical" notes, documents that never became part of the medical record and instead were submitted to our attending physicians for review. They read them with gusto and an active red pen, grading us as much on our thinking as on our writing and watching with pride as the expansive and disconnected H&P of a second-year medical student slowly but surely transitions into the tight, well- reasoned narrative of a fourth-year.(Continues…)
Excerpted from "Tiny Medicine"
Copyright © 2019 Dr. Chris DeRienzo.
Excerpted by permission of Big Eye Books.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.
Table of Contents
1 Getting There 27
2 Tiny Medicine 51
3 Stand Tall on the Quarterdeck 73
4 Alpha and Omega 97
5 The Bottom of the Well 123
6 Humanity, Technology, and the Future of Medicine 149
7 Never Give Up 177