Medicine, from the heart . . . Ciarán DellaFera, SOM ’12 Each Thursday, the Daily Voice showcases selected Thursday Morning Memos, reflective essays about clinical experiences written by faculty, alumni, residents and students of the Department of Family Medicine & Community Health. Thursday Morning Memos is UMass Medical School’s homegrown version of narrative medicine, in which the authors process their experiences through writing. To learn more, visit: http://www.umassmed.edu/news/articles/2011/personal_stories.aspx?
There are moments in life when something so unexpected happens, that you stop and ask yourself “did I slip into an alternate reality?” Just such a moment happened at the very start of my first third-year clinical rotation. I was rotating in surgery at Berkshire Medical Center in Pittsfield, Mass. In the fourth week of the clerkship, we were scheduled for a one-hour session entitled “Neurosurgical Emergencies” with the director of the Department of Neurosurgery. Most of us felt pretty good about our background in neurology, it being one of the most well-taught courses during our preclinical years, but none of us knew what to expect from a neurosurgeon (a sub-specialty generally regarded with a rare and unique mix of awe, fear and fascination). With that in mind, we sat around the conference room table speculating about what to expect, and generally trying to remind each other about the symptomatic manifestations of the Brown Sequard Syndrome and the critical CNS neurological tract crossings. In short order, in walked Dr. László Tamás. He plunked down some photocopied cases that we were to review, and asked us each to introduce ourselves. Lastly, in a remarkably soft-spoken voice, he told a bit of his story, and set to work trying to determine if each case was “surgical,” and if so, just how urgently surgery was needed. He asked for a volunteer to summarize the first case, and one of my intrepid classmates stepped forward to be the sacrificial lamb. In remarkably practiced style, especially for only the fourth week of third year, she quickly reduced the case to “A previously well 45-year-old female presents to the emergency department with a chief complaint of severe headaches times three months . . .” At this point, Dr. Tamás, in a gentle voice, asked if he could stop her for a moment. He softly, but clearly, asked her, “Is there something better that you could have said besides ‘45-year-old female?’” We all blinked and looked at each other and at our poor classmate in the hot seat. My mind reeled; um, err, ahh, personally, I thought she had done a pretty near perfect job! “A 45-year-old female with no prior history of headaches?” she tried. Perfect, I thought, she’s found the missing element! “Good,” replied Dr. Tamás, “but tell me more.” How about “a devoted 45-year-old mother of two,” or “a happy 45-year-old college librarian?” We all blinked at each other, and Dr. Tamás, in deep confusion. Standing in front of us, looking like nothing more than a large, wise teddy bear, was a neurosurgeon. No, not a neurosurgeon, but the director of neurosurgery, telling us that he wanted a more personal description of a patient. What happened to “just the facts ma’am, nothing but the facts?” I would have expected this approach from a family medicine doctor, or a pediatrician, but a neurosurgeon? I suddenly felt the need to do a quick reality test to make sure that the law of gravity and other critical factors that I’ve come to depend upon were still intact. As the remainder of the hour unfolded he revealed to us that, as far as he’s concerned, being a good doctor of any ability requires that you treat the whole patient by first establishing a clear understanding of that patient’s context, needs and concerns. If you do that, he related, most major concerns will quickly bubble to the top, and then you can perform the requisite diagnostic steps to confirm your fears and suspicions. I was so impressed with that hour that I sent a request to shadow him as part of my surgical sub-specialty rotations. I was informed that, because of staffing and patient volume, that wouldn’t be possible, but that Dr. Tamás was fine with my spending a day in the office with him, and then scrubbing in with him, if an appropriate case presented itself. When the shadow day rolled around, I joined Dr. Tamás in his office bright and early, and was treated to quite an interesting day of evaluating patients with him and his PA [physician’s assistant]. We saw several fascinating patients, including a gentleman with recurrent subdural bleeds who would require a surgery by Dr. Tamás on the following day. I got to scrub in and assist Dr. Tamás with his case, and then follow the patient as he recuperated over several weeks. However, the case that stood out starkly for me, and was very consistent with Dr. Tamás’ approach to patients, was an older woman with chronic lower back pain. Dr. Tamás and I reviewed her MRI, which showed only minor soft tissue changes, and then we went to see her and her husband, who were waiting in the exam room. He sat down next to the patient, placed his hand on her shoulder, and said something like: “Mrs. M. your condition is complicated. I handle mostly simple problems that can be corrected surgically. You don’t need a neurosurgeon; you need a primary care physician. You need someone who handles multiple medical conditions; someone who can follow you over time, work with you to get you through this exacerbation, and help you stay healthy in the future.” While that one visit was much less exciting than brain surgery, it taught me a great deal about my future plan to enter primary care medicine.