Cancer and AIDS, AIDS and Cancer

For Dr. Abraham Verghese, who inspires me.

This evening on the way home from Boston I finished a book that I had started more than a month ago, on my way back from Albuquerque.  Well, that is not entirely truthful.  I stopped reading on page 408, because if I had kept going everyone on the plane would have seen me cry.  I finished it at home a few hours later.  The book is called “My Own Country—a Doctor’s Story” by Abraham Verghese.  I had read his novel, “Cutting for Stone” last year and wanted to read more.  This book, “My Own Country” is autobiographical, detailing the author’s early years after residency and a fellowship in infectious disease in Boston, as doctor caring for the first HIV positive and AIDS patients in rural Tennessee in the early 1980’s, when there was no treatment for the infection, and doctors watched helplessly as each and every patient they cared for died.

I am old enough to be all too familiar with this scenario—in 1982 I was a resident in radiation oncology married to an attending in pulmonology and infectious diseases and we were both seeing the ravages of this disease for which there was yet no blood test, only a constellation of symptoms and opportunistic infections that had heretofore been seen only in the most immunosuppressed cancer patients. It would be a few years before the medical profession figured out the exact mode of transmission, and discovered the retrovirus that caused the illness—and a few more years before the first treatment, the drug AZT was approved.  In the meantime, we watched the patients die, and it was not pretty.  In lighter moments, I would joke that we were the “fun” couple at the cocktail party—cancer and AIDS, AIDS and cancer.  In private, I realized that if I had to choose between one or the other, I would choose cancer.  At least most of my patients had a fighting chance.  My husband’s, at the time, did not.

Verghese left Tennessee, and a job he loved but which had clearly taken its toll on him personally, in 1989.  My husband left his post as the Chief of Pulmonary Medicine at the New England Deaconess Hospital in 1992.   If you ask him, he will say it was the lure of the biotech boom, and the promise of stock options and an early retirement.  But I think there was another side to it, the side that is difficult for doctors to talk about, that part of the job where each time a patient dies, a little part of the soul of the doctor dies with him.  In Boston, the pediatric oncologists at the Jimmy Fund were my heroes—to me, watching children die would be the hardest job of all.  The AIDS doctors, before the development of the drug combinations which have turned HIV infection into a chronic disease, had the second hardest job.

I’ve moved around quite a bit in my career—five years here, five years there, Houston, Boston, San Diego.  Every five years or so, I start to get a bit restless, and I look for something new, something different.  I like to say I need a new challenge.  Tonight, finishing Verghese’s book, I realized that he was able to put into words that nagging need for transformation, relocation, and change so I will quote him:  “It all happened so suddenly.  I left my own country, my beloved Tennessee.  Perhaps my perennial migrations, almost hereditary, are a way to avoid loss.  With deep roots come great comforts.  Yet deep attachments are the hardest to lose.  Maybe that is why drifters avoid them.”

For most of us doctors, leaving is easier said than done, for medicine is our own country.

Let’s Get Physical

In his great book “Cutting For Stone”, Abraham Verghese describes one of his main characters, Dr. Marion Stone, as being obsessed with a certain aspect of the physical exam.  Dr. Stone, as the dictatorial chief of surgery at a major Boston teaching hospital, has drilled into his residents the necessity of performing a rectal exam on every patient.  One intern forgets to do this, and is so terrified of his mentor’s wrath that he proceeds to chase the newly discharged patient out on the street and into a bar to do the deed.  On that particular night in the place where everybody knows your name, “bottoms up!” takes on a whole new meaning. In real life, Dr. Verghese teaches at the Stanford University School of Medicine, and is as devoted to the art of the physical examination as Dr. Stone is in the book.  In a New York Times article published two years ago entitled “Physician Revives a Dying Art: The Physical”, science writer Denise Grady rounds with Verghese and a group of third year medical students who are clearly impressed watching a master clinician point out the stigmata of liver disease and diagnose cerebellar ataxia without a CAT scan.

All medical students are taught to do a careful physical exam. When I was a student, we practiced on real patients. Now there are “standardized patients.” Trained actors are paid to report certain symptoms, and to say ouch when the student hits the right spot. Quite amazingly, there are ladies and gents who get paid to teach the finer points of the gynecologic and rectal exams (as one of my colleagues joked, “Here’s your paycheck ma’am, and would you like a psychiatric consult with that?”) In the fourth year of medical school, a test is administered nationally where students go from room to room encountering 10 or so such standardized patients, and are given 15 minutes to take a focused history, perform a specific aspect of the physical, and write up their findings. They must pass this test to graduate.  So what happens to our students between the time they finish medical school and when they become your family physician who spends 5 minutes with you typing on his or her laptop, “takes a listen” through your shirt, signs a stamped prescription for a Z-pack and sends you on your way?  Time pressures, limitless technology at our disposal, fear of malpractice and fewer opportunities for bedside teaching have all contributed to the demise of the detailed patient exam.

My chosen specialty of radiation oncology has become perhaps the most technology driven in all of medicine.  All of our treatment planning is done from a CAT scan—nearly all radiation therapy departments have their own scanners.  We are fairly low down on the food chain of medicine when it comes to making discoveries on a physical exam—by the time the patient sees us, with the notable exception of head and neck cancer patients whose tumors are best cured by a combination of chemotherapy and radiation, those tumors have been scraped off, whacked out, frozen, melted or otherwise assaulted.  Oftentimes there is nothing really to examine—I have mentioned before my mentor who said “Radiation works best when there’s no disease!”   Knowing that my CAT scanner is just around the corner, I sometimes feel a little silly doing a thorough physical exam.  So you can imagine my complete shock a few months ago when asked to examine a patient who had some very nonspecific complaints of fever and malaise on her first day of treatment, and to hear a big WHOOSH WHOOSH WHOOSH as I listened to her heart. I looked back at my initial physical—there had been no heart murmur two weeks earlier.  I sent her directly to the hospital, and 24 hours later she was in the OR having both her aortic and her mitral valves replaced for acute bacterial endocarditis, an infection of the heart valves brought on by an infected chemotherapy catheter.  I can only imagine the eye rolling that took place in the emergency room when the radiation oncologist called in a case of endocarditis—I mean they all know we’re the guys in the basement playing with computers and pushing buttons!  It was not the first time, but it was probably the most important time that my three years of internal medicine training had a huge payoff for the patient.  It saved her life.

In the NYT interview, Dr. Verghese said something else about the physical exam that struck me as an uncommon truth.  He said that a proper exam earns trust, and is the ritual that transforms two strangers into a doctor and a patient.  My daughter is interviewing for an internal medicine residency at Stanford next month.  If she ends up with Dr. Verghese as a mentor and teacher, she will be very fortunate indeed.