People expect a very old doc – I’m one, pushing 89 -- to tell heart-warming little anecdotes about old patients. So here are two anecdotes, neither one exactly heart-warming. The first tells more about me than my patient, the second about me as a patient. A very young hotshot internist, I had just begun taking a history from a very old man, maybe pushing 89, perched awkwardly atop a big examining table. You know the kind. I started by asking the then routine question, “What’s your complaint?” It was clear he was confused and stone deaf and hadn’t caught what I’d asked. Finally he rather faintly ventured a question rather than an answer, “Faint?” Offended that he wasn’t answering as he was supposed to, I shouted loud enough to be heard over an NFL game, “HEY POP! I DIDN’T SAY ‘FAINT,’ I SAID ‘COMPLAINT – COMPLAINT! WHAT’S YOUR COMPLAINT?” This imperious bedside manner I’d adsorbed as an intern age 23, in the 1950s, at a huge 3,000-bed metropolitan hospital for indigents, most of whom were old and deaf. For the last 10 years, since revving up in the 6th or 7th grade, I had done nothing but intense study, no social life, head in books. Now I was eager to break loose, test my wings and fly like an eagle, act like a doctor. And a huge county hospital was just the place, being manned totally by the “house staff” composed only of interns, fresh out of med school, and residents fresh out of internship, plus a gaggle of med students who started the IVs and did the blood counts. In those days many such hospitals didn’t have laboratories. A mob of kids, grandly known as the “House Staff,” we ran the whole show and did everything, and that was a helluva lot. And that was just what I wanted. The way we ran the place was by running, rushing, never stopping, hardly pausing. For example, each of the ten General Medicine Service wards (I was keen on the specialty of internal medicine) admitted patients every other day. So every other day each of us would “work up” from 12 to 25 new patients, over 50 per week, many of which were old, deaf, or alcoholic cirrhotics, a condition requiring little diagnostic expertise, just a lot of work. It was a rare admitting night we got any sleep at all. Later activists described such conditions as grueling and inhuman and demeaning (both to us and our patients), and in violation of child (that’s us!) labor laws if not civil and basic human rights, and privacy, But we, running everything and doing everything, everything, felt proud of being thus challenged and of having the young strength to meet and exceed the challenge. We were hotshots. But to accomplish all that we were impatient with patients, had to be. “HEY POP!” shouted into an old fellow’s ear became the normal salutation whether or not he was deaf or didn’t understand English. Many didn’t. Nominally, we kids were under the supervision of older more experienced and mature physicians, called the “Attending Staff.” “Supervision” would consist of a 1 hour visit by one of the “attendings” a couple of times a week, when he would stand at the foot of a patient’s bed and listen to the intern read from the chart, and then proceed without ado or looking at the patient to check, say, the patient’s heart and excoriate the intern if he had missed a certain murmur, and then move on to the next bed, and the next and next. Seldom did the attending interact personally with the patient. So as interns we received a little supervision and little formal training in medicine, and a lot of patient experience and a lot of enforcement of our hotshot bedside manner. For my residency I figured it was time for less patient volume and more high-level bedside teaching. As I had been top man in med school three of the four years, I was accepted for a medicine residency at Harvard’s hospital (Peter Bent Brigham), famous for teaching future teachers. With offices right there in the hospital, the attending staff were accessible 24/7, not just for a token hour a couple of times a week. And the patient load was light. As a reference hospital, the Brigham had just a couple of hundred patients, limited to the most baffling cases referred from all over the world, naturally winnowing out the merely old, deaf, alcoholic. My patient load on admitting nights might be no more than two or three, but I didn’t get any more sleep than as an intern. I spent most of the night in the library preparing for presenting a single patient to the chief tomorrow. Besides reviewing basic texts, I boned up on the latest medical literature. The chief would be a Harvard endowed professor and chair of the department of Internal Medicine, a Nobel Prize Winner. He not only knew the latest literature, he wrote it. It was I and not the patient who was intimidated. In those long ago days, internal medicine was the most prestigious medical specialty, truly more an art form, a theatrical art form, than a science, as it had been in the Golden Age of Vienna in the 19th century when its virtuosos performed like opera stars. Not a craftsman like a surgeon, an internist was a thinker -- a theatrical thinker, as theatrical as a surgeon. Using only his preternaturally trained brain and his mystically sensitive hands, the “internist” deduced diagnoses from evidence, not pictures, like a Sherlock Holmes solves crimes. Nobody would argue with him. In those days, before CAT and MRI scans, there was no other way to make a diagnosis but by smarts. And here I was, at Harvard, which had imported Viennese Golden Age internal medicine intact. And of all the cerebral things a Golden Age internist did, taking the “history” from the patient was the most golden. Patiently or impatiently, persistently, tenaciously, brutally brooking no nonsense, the professor would grill, examine and cross-examine the patient to extract every last intricate detail, like the Gestapo or Special Prosecutor Mueller out after Trump. This couldn’t take less than an hour. I finished training and began the practice of Internal Medicine as both a bratty wise guy and a urbane prosecutor. Smitten by my rebuke, my old patient had slumped on the examining table, looking down with closed eyes, feebly shaking his head, and quivering. I moved even closer to his ear, repeated the question, louder. Finally he murmured in a small voice, “I, I don’t …. I can’t, just can’t describe it.” “WHADDAYA MEAN CAN’T DESCRIBE IT! Everything can be described. How can I do anything for you if you can’t even describe what’s wrong!” Fast Forward. Over half a century later. Another deaf, slightly confused, fearful old man, pushing 89, —me -- is perched atop an examining table. “Please describe your problem,” requested my young internist, one of those new geriatric physicians. Deaf as a coot, I hear him good enough – thanks to expensive digital hearing aids. So my inquisitor hasn’t got his mouth in my ear, he’s not even looking at me. His back towards me, he’s at his computer typing. “Well,” I say as positively as I can, “I can’t. It’s, I hate to say it, it’s indescribable.” Hearing myself say that, I was appalled! I’d just said exactly what had outraged me 50 years ago. I have always remembered, not infrequently mulled, my outrage. It had been unwarranted, indefensible. Embarrassment, chagrin, shame now hit me like a ton of bricks. It’s not what the Greatest Healer would have said. It is not how a physician trained at my med school – back then called the College of Medical Evangelists, now bearing a more generic name – should talk. Not a few of my old classmates would have had prayer with the old gentlemen. That old patient was right – I was wrong. Now I know what it’s like, and he was right, I was way wrong! When one is very old things are different, so different; you are different, so different. I wish I had it to do over again. Oh, that I were starting out in practice now. Now I know what the biggest and the most prestigious hospitals didn’t know. After several minutes of fervent contrition, I turn and look at my youthful internist. He seems not to have been paying any attention to me. Engrossed in ordering tests, and without looking up he quietly says, “I’m just as glad you didn’t hit me with a tedious description. CAT scans and MRIs and blood vitamin D levels are more informative anyway.” Then he glanced at his watch. My 12 minutes were up. Thanking him for his consideration, I left, on my cane . Waiting for the elevator another new thought occurred to me that wouldn't have 50 years ago or to many readers, to wit: When Christ returns, my old patient and I will no longer be deaf or old or beset by age. Now that will indeed be indescribable. ef NOTE: in the above mini-memoir I talk about being an internist. Well, after about 10 years of practice I decided I wasn't cut out for internal medicine and dealing with patients (the above certainly tells why I came to that conclusion), and made a mid-career switch to pathology, took a residency in it, passed certification, and practiced pathology for over 2o years. I didn't have to deal with deaf old patients, only youngish edgy surgeons. WHADDAYA MEAN, INDESCRIBABLE?

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Wesley Kime