"What Can I Do for You?"

Benjamin C. Sturgill, M.D.

Dean Carey, Class of 2002, colleagues and guests, I am deeply honored to have been asked to address this most important convocation wherein we shall dedicate or rededicate ourselves to the high calling of medicine.

My remarks are addressed primarily to the Class of 2002, but others are invited to listen. You have chosen to enter a distinguished profession. In fact, Hippocrates said that medicine is the most distinguished of the professions.¹ But medicine is first and foremost a profession with obligations to society. It is not primarily a business or industry, though some aspects of this have been forced upon us in recent years. Listen to these words from our vision statement: "Serving patients is our highest calling.... In all that we do, we strive to act in the best interest, not of ourselves, but of others." ²

This evening I want to talk with you about my experience in medicine, not as a medical student or as a pathologist, interesting as that has been. Rather, I want to talk with you about my experience as a patient. I do this neither to solicit your sympathy nor to teach you about my particular illness but to show you what a marvelous profession you have joined and to call your attention to some things with which you will or should be concerned.

About thirteen years ago I donated a sample of blood to a colleague who needed a normal control for some studies he was doing. A few days later he came to my office to tell me that the blood was not normal, that I had a monoclonal population of lymphocytes indicative of chronic lymphocvtic leukemia (CLL). My first reaction was disbelief. I felt perfectly well. Although I knew that many patients with this disease are asymptomatic when it is discovered, I was sure that in my case there had been some mix-up in the samples. So I requested a repeat test, which, of course, confirmed the diagnosis. Denial is a common reaction in patients. It is not irrational. It is an act of self-defense. I received this devastating news on the eve of my daughter's wedding, so I did not feel that I could share it with anyone in the family for fear of ruining this happy occasion. Even after the wedding, I found it difficult to inform my family. Patients will sometimes go to great lengths to protect those whom they love by withholding information about themselves. You must be prepared to deal with this phenomenon.

But how does the patient deal with this once the obstacle of denial is over come? As a pathologist, I knew quite a lot about chronic lymphocytic leukemia, perhaps too much for my own good. One thing I knew was that, while the average life expectancy is four-to-six years, many patients have no shortening of their life. I immediately placed myself in this category. Patients will latch on to the thinnest thread of hope. You will always want to inform your patients of the nature of their disease and your expectations, but you should never deny your patients that thin thread of hope.

I received no treatment for my condition. Doing nothing is one of the hardest things for a physician to do and one of the hardest things to explain to a patient and for the patient to accept. But there are times when doing nothing is the best thing to do. This was one of those times. There is no evidence that treating asymptomatic patients with CLL improves their quality of life or life expectancy. There is a saying in medicine that we should treat the patient, not the disease; and the cardinal rule of medicine is: First do no harm. Never lose sight of that aphorism. If the risk of treatment exceeds the expected benefit, don't do it.

In 1988 I suffered the first of three small heart attacks. These came at about three-year intervals and were associated with normal coronary arteries by angiography. Moreover, I had no risk factors for coronary artery disease. I did not smoke; I did not have hypertension; and my blood lipids, by the standards at that time, were within normal limits. I should not have had a heart attack, but I did. After three events with normal coronary angiography, the attacks were attributed to coronary vasospasm, an uncommon cause. The lesson here is that, while on average an event or condition is unlikely, every patient is an individual and will not always conform to the average. My physicians understood that, and appropriate therapy was prescribed.

Following my third heart attack I was discovered to have intermittent atrial fibrillation, a condition in which the atria of the heart merely quiver instead of contracting rhythmically. This pattern causes stasis, and blood tends to coagulate in the atria, creating a risk for embolization of coagulated blood to other parts of the body, including the brain. To prevent this, anticoagulants were prescribed.

You will come to recognize and call what I have just iterated the past medical history (PMH). The PMH can provide clues to the present illness, but it can also mislead, as you will see.

My present illness began in September of 1997. After a lapse of several months, I resumed an exercise program that included stationary bike, treadmill, and rowing. Shortly thereafter I began to have pain in my lower back. I attributed this to being out of shape and continued my exercise with increased vigor. Over a period of several days the pain not only did not diminish but progressed, so that on a Friday afternoon I called my primary care physician for consultation and advice. Be aware that symptoms that have been present for days or weeks will often reach a crisis stage at the least convenient time. My symptoms suggested to my physician that I had begun to herniate an intervertebral disc. Bed rest with analgesics and muscle relaxants was recommended. This regimen led to some improvement after a week, and so I resumed my duties. But the improvement was short-lived. X rays of my spine were ordered. They showed diffuse osteoporosis and partial collapse of one of my lumbar vertebrae. What now?

As a member of this faculty, I have informal access to a lot of experts. So, I telephoned a colleague who is expert in osteoporosis. Why, I asked, should I, a sixty-three-year-old man, have osteoporosis, a disease primarily of older women? He was appropriately circumspect but suggested that it might have something to do with my anticoagulant therapy. I should not have put my friend and colleague on the spot. He was not caring for me and did not have complete information. You will be asked from time to time even while you are still a medical student to answer medical questions for relatives or friends. You will want to be helpful but you will also want to be circumspect, because you will not have complete information. The person best qualified to answer their questions is almost always the physician who is caring for them.

The presence of osteoporosis with a partially collapsed lumbar vertebra and continuing symptoms despite bed rest suggested to my wise primary care physician that something other than or in addition to disc disease was going on. An MRI of my spine was ordered, and arrangements were made for my hospitalization and further study. The MRI, which was performed on the day of and just prior to my admission, showed no evidence of disc disease but did show several abnormalities in my vertebrae.

By now it was early October. I had called on my colleagues in pathology and in admissions for assistance during my periods of bed rest at home. They were more than willing to help, but it is frustrating not to be able to carry your load, and there is a natural reluctance to ask for help. You must learn to overcome that reluctance, because we all need help from time to time. One of the unexpected dividends of an illness for the patient is the discovery that there is an enormous amount of support just waiting to be called upon.

So here I was in the hospital, reasonably comfortable with mild analgesia and antispasmodics, and feeling guilty that I was not doing my job. I felt a bit of a wimp. The first physician I saw after being admitted was one of our recent graduates, a resident in family medicine. On entering, she greeted me warmly, took my hand, and asked simply: "What can I do for you, Dr. Sturgill?" We strive hard to admit to medical school those students who are not only well qualified academically but who also have the personal qualities to become compassionate physicians. We sometimes have to wait several years to learn if we have chosen wisely. There was no doubt in my mind that in this individual we had chosen wisely. I would encourage all of you to develop this attitude:

"What can I do for you?"

Laboratory work performed upon my admission confirmed the diagnosis of chronic lymphocytic leukemia, but this was nothing new. A few days later, a blood study called a serum protein electrophoresis showed an abnormal protein in the gamma globulin region. It had the characteristics of what is known as a monoclonal spike and is usually indicative of the presence of abnormal plasma cells, the cells in the body responsible for the production of antibodies. This finding, plus the Osteoporosis and partially collapsed vertebra, made the diagnosis of multiple myeloma, a malignancy of plasma cells, almost a certainty. The hematologist-oncologist who had been following my course for the CLL was consulted. A sample of bone marrow was obtained, which showed an increased number of plasma cells, some of which were abnormal in appearance.

As a pathologist I knew quite a lot about multiple myeloma, mostly all the bad things. As my physician outlined the course of action to be taken, he was well aware that I might be focusing on these bad things, so he was quick to tell me that he had patients who had been in remission for years after the therapy he had outlined for me.

Remember, always give the patient a thread of hope.

In contrast to my reaction of denial when confronted with the diagnosis of CLL, on this occasion I was accepting and even relieved. I believe the explanation for this reaction is that this time I knew something was wrong, and uncertainty had been replaced with certainty and a course of action outlined.

So, I embarked on another journey, that of chemotherapy. In most patients' minds and especially in the minds of friends and relatives, chemotherapy conjures up the image of hopelessness. That this outlook is not always justified cannot be overemphasized. At the same time, chemotherapy, like most therapy, is a two-edged sword. In the case of chemotherapy, the sword can be quite indiscriminate, killing not only the targeted cells in the bone marrow but also the rapidly dividing cells lining the alimentary canal. In other words, the treatment can be as bad as or worse than the disease, at least while the therapy is in progress. My therapy consisted of three drugs: melphalan, an alkylating agent not unlike systemic radiation in its effect; decadron, a powerful steroid; and intravenous pamidronate disodium, a relatively new drug that blocks the action of osteoclasts responsible for the bone destruction in multiple myeloma. I was to receive multiple courses of this therapy at two-to-six-week intervals for the next several months. I received my first course of all three drugs while in the hospital and then was discharged home.

A few days after discharge, my back pain and muscle spasms became much worse and I was unable to get out of bed. Telephone consultation led to the prescription of a back brace. A team of technicians came to my home, took my measurements, and returned the next day with a "clam shell" brace that permitted me, with some difficulty, to get out of bed, but I was unable to support myself. On the heels of this, I developed fever. I needed to go to the hospital for evaluation, but there was no way I could get to or sit in a car for even a brief period of time. Less than a month before, I had walked from my car to the hospital with no assistance, and now I had to be carried on a stretcher. What kind of progress was this?

Sometimes things have to get worse before they get better, even when appropriate therapy has been initiated. This is especially true in the case of chemotherapy for malignancy. When a patient on chemotherapy develops fever, there is a strong probability that the patient has infection because of bone marrow suppression. Laboratory analysis showed that my polymorphonuclear white cells had pretty much disappeared. After my blood and other fluids were cultured, I was begun on IV antibiotics and also given a new agent called "colony-stimulating factor" to stimulate my bone marrow to make more white cells. So, everything was under control.

Well, not quite. I still could not support myself well enough to walk, even with the brace. And I was having heavy night sweats, which were so severe that I was awakened every night around 3 a.m. To address the problem of walking, physical therapy was consulted. I had never thought much about physical therapy. I had never needed it myself nor had anyone I knew required physical therapy. Let me tell you that physical therapy, in the hands of the right therapist, can be a lifesaver. Few things are more dangerous than lying day after day in a hospital bed. While I was getting antibiotics for suspected infection, and colony-stimulating factor for my low white count, a physical therapist spent an hour twice a day getting me out of bed, on my feet, and walking. By the time I left the hospital ten days after admission, I was walking up stairs!

Over a period of weeks at home, I went from using a walker to a cane to nothing. The lesson here: Remember to ask for consultation in those areas where special expertise is required. I might have recovered function without a back brace and without physical therapy, but it would have taken much longer and would have been very frustrating.

It is often said that it is the little things that count. This is especially true in a hospital. At the University of Virginia one can almost always count on getting the best and most up-to-date care from physicians and nurses, but it is easy for the physician or nurse to overlook the little things. Take, for example, night sweats. In and of themselves they are of no great concern, since they are expected in patients with fever. But unless you have awakened in a cold sweat you cannot appreciate how uncomfortable this is. And it takes a certain amount of courage to ring the bell and ask for assistance at 3 o'clock in the morning when, you suspect, nurses are busy taking care of patients with more serious problems. But ring I did, and in each instance someone, a nurse or a nurse's assistant, came, changed my sheets and gown, and made me very happy. I can tell you there are few experiences to compare with going from cold and wet to warm and dry in the context of a hospital.

Never underestimate the importance of small things when caring for your patients.

I would now like to relate to you one of the few unpleasant experiences I had, in hopes that it will make you sensitive to the small things. On the morning before I was to be discharged from this second hospitalization, I had just settled to sleep after having been rescued from a particularly heavy night sweat. I was suddenly awakened by a bright overhead light. I was temporarily disoriented and blinded but soon was made aware that some blood was needed from my arm for analysis. It was an early morning phlebotomist. To make conversation and to attempt some instruction in the fine art of phlebotomy (I had been a phlebotomist before coming to medical school), I asked, "Do you enjoy your work?" She said that she did; that she enjoyed mechanical things. Mechanical! Certainly there are mechanical aspects to phlebotomy, but is that the essence of this intimate procedure? I continued, "Are you planning to continue in this line of work?"

"I am one of your medical students," she replied.

My heart sank. I had not yet recovered my sight, and so I did not recognize the student until she told me who she was. She had not identified herself. I began to wonder if we had made a mistake with this admission. She and I subsequently had a lengthy conversation about the need for sensitivity in dealing with patients. This trait is something we hope and expect all of our students to have or to acquire, but it is left pretty much up to chance and the individual.

Be sensitive.

Over the next several weeks I made steady progress and was able to return to work part time in December and full time in January. I recently completed my sixth and, I hope, last course of melphalan and decadron. The monthly pamidronate infusions are to continue indefinitely.

So I stand before you this evening the beneficiary of the science and art of medicine. My monoclonal protein spike and back pain are gone, and my sense of well-being is restored.

As you can see, there are many ways to serve in our profession. Some of you know what you want to do; some of you think you know what you want to do but will probably change your mind more than once as you proceed through the curriculum and come under the influence of different individuals, different specialties, and different philosophies. My advice to you is that you find out what you do well and what you enjoy doing (I hope they will be the same) and do it with all your heart. Do not be excessively influenced by the marketplace or preoccupied with managed care. These conditions will change. But the essence of medicine, caring for the patient, will not change. If you enjoy your work and do it well, always keeping the welfare of the patient in the forefront of your mind, everything else will fall into place.

With that in mind I would like to share with you an excerpt from an essay by E.B. White, best known as the author of Charlotte's Web. E.B. White suffered from hay fever, or allergic rhinitis, as we are now inclined to call it. Because the condition, which used to plague him only at certain seasons, had started to bother him year round he decided to consult a specialist, and this is the experience he reported:

And when I went in at last to the doctor's office and was admitted I ... felt low in my spirits and spent, and it was the first time I had seen this doctor but he didn't look at me but just said: "What's matter?"

"My nose," I replied....

"What's trouble with nose?" the doctor asked.

"Stuffed up," I replied.

And he asked me how old I was and I said forty-one, and he wrote that down on a piece of paper, and I wanted to say "My nose is forty-one too," but thought better of it. So I told him about my hay fever, which used to rage just in the summertime but now simmers the year round, and he listened listlessly as though it were a cock and bull story; and we sat there for a few minutes and neither of us was interested in the other's nose, but after a while he poked a little swab up mine and made a smear on a glass slide and his assistant put it under the microscope and found two cells that delighted him and electrified the whole office, the cells being characteristic of a highly allergic system. The doctor's manner changed instantly and he was full of the enthusiasm of discovery and was as proud of the two little cells as though they were his own. ³

One can interpret this little episode in several ways. I think it is pretty obvious that the doctor was more interested in the cells and the disease than he was in his patient. Perhaps he would have been happier in a research setting than in a small town in Maine. These are the things you have to ask yourself as you consider your future.

Finally, I would like to share with you a quotation of Sir William Osler, the famous first professor of medicine at Johns Hopkins Hospital and School of Medicine. This is taken from his address "Teacher and Student" delivered early in this century It has a contemporary ring, I think.

In these days of aggressive self-assertion, when the stress of competition is so keen and the desire to make the most of oneself so universal, it may seem old-fashioned to preach the necessity of this virtue [humility], but I insist for its own sake, and for the sake of what it brings, that a due humility should take the place of honor on the list.⁴

It is difficult to be humble when you are so bright, but you are going to encounter some very humbling experiences during the next four years and in your career thereafter, so get used to it. An attitude of humility will endear you to your patients and colleagues without the least diminishing your knowledge and skills. There are many individuals in our school who embody these desirable characteristics. Seek them out and make them your models. I wish you well over the next four years and in your careers thereafter. Always remember this: "Whatsoever you choose to do, do with all your heart.⁵ Everything else will follow.

References

1. Levine EB. Hippocrates. New York: Twayne Publishers; 1971. p. 60.

2. Carey RM. Vision Statement. University of Virginia Health Sciences Center; 1997.

3. White EB. One Man's Meat. Gardiner (Maine): Tilbury House; 1997. p. 169.

4. Oster W. Counsels and Ideals. Boston and New York: Houghton, Mifflin & Co.; 1905. p. 82.

5. Paraphrase of Ecclesiastes 9:10: "Whatsoever thy hand findeth to do, do it with thy might."

Reproduced with permission from:
The Pharos of Alpha Omego Alpha, Summer, 1999, Vol. 62, No. 3, 35-39. Copyright 1999 by Alpha Omega Alpha Honor Medical Society.