Mark D. Tyler-Lloyd - The Real Life of an Internist (Kaplan Voices: Doctors)

The Real Life of
an Internist

Mark D. Tyler-Lloyd MD, MPH
EDITOR

Dedications

To my parents, the late Reverend Nathaniel Tyler-Lloyd and Mrs. Portia Tyler-Lloyd, whose prayers and sacrifice allowed me to fulfill my dream of becoming an internist.

And to Dr. Melissa M. Freeman, my internist, who inspired me to become a physician when I was a little boy.

C ONTENTS

A N INTERNIST, PLAINLY put, is a physician who specializes in internal medicine, often referred to as adult medicine. Training in internal medicine provides the skill for the diagnosis, treatment, management, and prevention of a vast spectrum of adult diseases. An extensive fund of medical knowledge and an aptitude for problem solving are essential (but not necessarily sufficient) requirements. In a broader context, internal medicine is the parent of more than 15 subspecialtieseach of which demands layers of further study and training, but from which the requisite knowledge and fulfillment of expertise in internal medicine must first be established.

This book examines the life, the real life, of an internist. It illuminates the experiences of those at various stages of a rugged and rewarding journey and offers the reader a penetrating view into the private but unusual world of the provideropenly and candidly described. From medical student to medical resident, to private practitioner and subspecialist, this book is an authentic review of an existence few enter and even fewer understand. The stories contained herein replicate the unique environments that are characteristic of the internists world, and remind the reader that sickness, suffering, dying, and death are both foes and companions of lifebut always the rival of the internist. Whether treating patients in an exclusive, elite academic institution, a regular outpatient clinic, or even a small, austere rural hospital, providing quality patient care amid the obstacles of disease, defiance, and overwhelming difficulties truly defines the internist.

Within these essays, the variety of patient encounters are vividly portrayed through the lens of both doctor and patient, and the physician-patient relationships are eloquently and elegantly depictedterrifying and terrific at the same time. The strength of this physician-patient relationship allows doctors to help new patients, even with medical issues that require specialized care beyond the internists training. Likewise, this powerful relationship reflects the fusion of many tender attachments and tasks often indistinguishable from one another: healer, advisor, advocate, counselor, consultant, and confidante. It is an awesome bond that connects the two with a most precious and treasured agenda: the quality of health and life. As a result, the reader will come to appreciate the internists responsibility as much more than a career and far greater than an occupation. For as one author claims, it is a calling: a pressing beckoning from deep within for which one is chosen. And when answered, the experience is meaningful, stressful, agonizing, and mysteriously fulfilling.

This book underscores the poignant fact that the practice of medicine has as much to do with practice as with medicine. Therefore, these honest portrayals reveal mistakes as well as miracles and illustrate the complexities of multiple diseases, the challenges of ethical dilemmas, and the powerful therapeutic effects of a touch and the simple act of listening. From these stories the reader will be reminded that the physician is, above all, humanso capable, talented, skilled, gifted, and courageous, yet so vulnerable, broken, weary, wounded, and oftentimes more fearful than fearless. The reader will witness, through the words of these dedicated practitioners, genuine frustrations, surreal panic, real doubt, humility, humiliation, triumph, tragedy, and the compelling paradox of compliant patients with complaining families or rebellious patients with supportive relatives, as well as the plight of those who have no one and struggle more with isolation than with illness.

The sincerity of the stories within this book brings to light those delicate challenges which are inescapable themes in the life of an internist. Among them, it will be revealed that the internists life has nearly as much to do with death as with life. As caretakers of adults, internists are frequently challanged with infirmities that are chronic, ongoing, and longstanding. Many of them we do not cure but desperately try to slow: high blood pressure, diabetes, and illnesses of the heart, liver, kidney, and other vital organs. Even when the collective efforts of both doctor and patient reduce or halt ailments to a stalemate, eventually all things must surrender to time. The young and the healthy ultimately age, slow down, and inevitably succumb to end-of-life issues. It is this aspect of the internists life and lifestyle that cause the deepest wounds and richest rewards. Inasmuch as the physician is committed to the preservation of life, the death of a patient is a constant reality. And yet, at the interface of life and mortality, our patients teach us the fortune of life and of dignity in death. And, to that end, we become better physicians and better humans.

M RS. HERNANDEZ DOESNT speak English, and Jenny is not here. Sometimes I think the entire clinic would fall apart if Jenny didnt take the bus every day to translate for the helpless doctors taking care of the large Spanish-speaking patient population. But shes not here today, and Mrs. Hernandez is waiting. Ill make do with my broken Spanish. I walk in and introduce myself. She seems pleasant enough.

This will be a quick one, I think to myself, an in-and-out type of visit. I start by asking her the reason for the visit. Thats mistake number one. The ailments come out one after another, and before I know it, Ive got a case of total body dolor (total body pain) on my hands. I cant handle it. Im post-call; Im tired. I cant go through with this. My mind drifts, and I watch Mrs. Hernandez speaking earnestly, pointing to her neck, her back, her stomach, her legs, wincing, frowning, moaning. Shes coughing, too, she says. Shes been coughing for a year. I scan her chart while she talks. Ten urgent visits in the past two years for this cough. Chest X-rays have been ordered, ACE inhibitors have been taken off and put back on, Robitussin with and without codeine has been prescribed. But this cough persists.

However, I notice she has not coughed once since she started speaking. I start to feel impatient. Before I know it, I dont believe her anymore. So when she points to her right upper quadrant, wincing in pain, and tells me she has an inflamed liver, I feel like Ive had enough.

Mrs. Hernandez, Seora Hernandez, please sit over here, sientese aqu ; Id like to examine you. I can tell shes not finished talking, but Im finished listening.

She hobbles over to the exam table, wincing in pain, clutching at her back as she limps across the room. Once she is seated, I approach her, and while pulling out my stethoscope, I notice little red marks on her chest called spider angiomatas. These are classic for patients with cirrhosisadvanced liver disease. I ask her about a history of liver problems; I had not seen a mention of it in her chart.

I was about to tell you, she says, I was about to tell you about my inflamed liver.

I dont know what to say. I sit her back down, take a deep breath, and pull out my pen, and the real visit begins. Now Im listening, but I feel as though Ive already failed her.

Mr. Pratts is crying. His entire 380-pound frame is shaking, and he is sobbing like a baby. His legs are swollen again, and he cant get out of the wheelchair because his knees give way. Hes fighting with his lover.