That is what poetry can do. It speaks to us of what does not exist, which is not only better than what exists, but even more like the truth. — Zinaida, from Ivan Turgenev’s First Love
While studying for Step 1, medicine was a huge, fantastical world, full of puzzling presentations, key symptoms, surprising lab tests, and brilliant diagnoses. Only the brightest brain could get the diagnosis, and save the life.
Now that I’m halfway through my 3rd year rotations, I’ve found that “real medicine” is a far cry from medicine as it’s depicted in Step 1. And it’s much less glamorous. In sharp contrast with the paroxysmal nocturnal hemoglobinurias, hereditary spherocytoses, and hereditary hemorrhagic telangiectasias of Step 1, my daily practice now confronts the stark reality of common disease, chronic disease, and the uncertainty that comes with treating real illness.
One of my first patients of my internal medicine rotation was an 88-year-old female presenting with a subacute mental status change. Up until recently, she had been unfalteringly sharp and fiercely independent. Over the course of the last few months, this all started to change. Her son recalled a dinner party where she persevered over the same subject, bringing it up again and again, causing concern among her family. She had started making lists and engaging in obsessive behavior. Once in the hospital, things got worse. She rarely slept. She thought that her doctors were appearing on the TV and the staff was conspiring against her.
For several days, no one could figure out what was wrong with her. Psychiatry and neurology had been consulted; a CT and MRI of her brain were done; and the answer wasn’t a whole lot clearer. “We favor a gradual process, like Alzheimer’s dementia,” said psychiatry. “She’s likely at [a new] baseline” said neurology.
That’s where I came in. I intended to get to the bottom of this. A few interesting symptoms stuck out at me. For one, her blood pressure was highly labile. She’d be 180/110 one morning, and 100/60 the next. This suggested, to me, dysfunction of the autonomic nervous system. Suddenly, I remembered a case which was presented to me during Resident Report just a few days ago. A male patient with prostatic hyperplasia had presented with mental status change, and was found to have acute urinary retention. Apparently this alone was sufficient to cause confusion and delirium in this patient, and after catheterization he had returned to a normal state. On further research, I found that this was a known entity called the cystocerebral syndrome.
That’s it! Her labile blood pressures suggested dysautonomia, which could just as easily cause urinary retention, since bladder function is controlled by the autonomic nervous system. That could explain her delirium. That morning, I suggested we bladder scan her.
A few hours later, the nurse poked her head into our office. “Bladder scan showed 800 ccs post-void residual.” It was full practically to burst! I slammed my hand on the table and turned towards my attending. “I think we may have solved this,” I said. “I think you may have, too,” she replied.
The next morning, I asked my chief resident if she was doing any better. “She was up all night talking to herself,” he replied indifferently. The catheterization had done basically nothing. She was now no less delirious.
I will at least say that I had an impact on her care. She was ultimately discharged to a skilled nursing facility, with order to in-and-out catheterize her every day. This order would not have been placed were it not for me, and she would have continued to experience urinary retention and overfill incontinence.
But I can’t say that I cured her. The cause of her deteriorating mental status likely included, but was not limited to, the cystocerebral syndrome, and likely also included some sort of dementa, whether gradual-onset (Alzheimer’s) or more rapid onset (Lewy body dementia, multi-system atrophy). The days of Step 1 were over. Her illness was much more extensive than that which can be solved with a single lightbulb.
Complex, multifactorial illness is the norm, not the exception, on the wards and in the clinics. True, there are some diseases that can be solved with a single lightbulb. But these diseases are often so exceedingly rare that to even consider them becomes comical. In the pediatrics clinic, one mom told me a worrisome story, indeed. “My two-year-old has had a fever every two weeks, or so, ever since we took her to the fair in October, where she got hand, foot and mouth disease. I don’t know what’s going on. I was worried that my 6-month-old would be catching whatever she’s been having, but he’s been largely healthy.”
I recounted this child’s story to my preceptor. She cut me off partway through my lengthy exposition: “Is this kid in daycare?” I stopped to think about it. “I guess her mom did mention that, yeah.” “Good. Then we’re done,” she announced. “Do you want me to work up this kid for Familial Mediterranean fever? She’s in daycare. She has kiddy crap.”
The diseases patients are sick with tend to be mind-numbingly common, or extensive and multifactorial, or both. Neither is very permissive of lightbulb-like diagnosis and treatment. In another example, a patient on the medicine floor was a longtime smoker, with emphysema, and also a diabetic, with end-stage kidney disease. Not surprisingly, he had dysfunction of his lungs and kidneys. Things got a bit more interesting when he turned out to be positive for one of the serum markers for Granulomatosis with Polyangiitis (GPA), a rare vasculitis which happens to affect both the lungs and the kidneys. However, he wasn’t positive for other common GPA markers, which suggested that he may not have had the illness. The situation was anything but clear. Even the nephrologists and rheumatologists were equivocal. Ultimately, it was decided that he probably didn’t have GPA. After all, lifestyle-induced chronic lung and kidney disease, in this case, was the more parsimonious explanation. As for the positive GPA serum marker? It was probably a red herring. As the old medical adage goes, “an atypical presentation of a common disease is more common than a typical presentation of an uncommon disease”. Sadly, the former isn’t as likely to make me feel like a brilliant diagnostician.
Through the frustrations of 3rd year, I’ve often found myself looking back at Step 1 with longing. The medicine on Step 1 was so precise, so pure. Zinaida’s quote, listed at the top of the page, rings true here. It often feels like Step 1 is not only the better medicine, but even the truer medicine.
It’s ironic that Zinaida produced this quote, in Turgenev’s First Love, since it’s actually Vladimir Petrovich who finds himself taken by the fantastical. Like I’ve found myself partial to the fascinating, but false, world of Step 1 medicine, Vladimir finds himself spun into a dizzyingly-passionate, yet entirely one-sided, love for Zinaida.
Indeed, Vladimir falls for Zinaida the moment he first sees her. She’s standing in her garden, across the fence from Vladimir, playing a game where she raps the foreheads of her suitors. “The young men offered their foreheads so eagerly, and there was in the girl’s movements something so enchanting, imperious and caressing, so mocking and charming, that I nearly cried out with wonder and delight, and should, I suppose, at that moment, have given everything in the world to have those lovely fingers tap my forehead too.”
Such a “love” is certainly intense. But can it really be called love? Well, it would certainly depend on the meaning of the word. But we’d have a hard time calling this a love with substance. Consider the love between Raskolnikov and Sonya in Dostoevsky’s Crime and Punishment, for example, as a point of contrast. If the substance that underlies love is mutual understanding and respect, shared adversity, quiet companionship, and continued adoration in the face of it all, than Vladimir’s love for Zinaida is most certainly one without substance.
In fact, this so-called “love” becomes darker still, when the reader learns that Zinaida’s behavior towards Vladimir is not just not loving, but in fact, deeply cruel. One day, Zinaida finds Vladimir sitting up at his favorite perch on the high wall of the ruined greenhouse. ” ‘What are you doing so high up there?’ she asked me with an odd smile. ‘Now you always declare,’ she went on, ‘that you love me. Well, then, jump down into the road to me, if you truly love me.’ ” Of course, Vladimir jumps, and winds up bruised and battered. But Zinaida’s worried kisses make it worth it. Saddest of all, it seems that Vladimir doesn’t even realize, at the time, that he is being played with. “I thought with a certain pleasure that Zinaida could not, after all, fail to recognize my resolution, my heroism…”
Such a love can not be said to amount to any more than childish fantasy. Indeed, to call such a love true love is to blaspheme the notion.
At the same time, though, Vladimir’s feelings were so, exquisitely, real. After his first night out with Zinaida and her suitors, Vladimir creeps up to his room, and stays awake, staring out his window as lightning flashes silently over the Neskootchny Gardens. As he drifts off to sleep, he asks, “ ‘Oh, gentle feelings, soft sounds, the goodness and the gradual stilling of a soul that has been moved; the melting happiness of the first tender, touching joys of love — where are you? Where are you?’ ”
Again, we arrive at Zinaida’s quote. Vladimir’s love for Zinaida may be fantasy, but such a fantasy might be better even than real love, or real life. And, in some sense, it might even be truer. Here, we’re faced with a conflict between the idealization of some concept and the earthly instantiation of it. The latter is certainly more real, in that there’s a closer correspondence to day-to-day experience. But the former might be more true, in that it corresponds to some universal ideal. Who’s to say which of the two one should strive for?
All this said, though, it would be unfair for me to deny that there exists a steady joy in the daily toil of 3rd year. I may not always be working with lofty ideas. But I do feel, at least sometimes, that I’m working at the front lines, close to nature and humanity. I’m working with people one of my preceptors called “the salt of the earth”.
I distinctly remember one patient who was a coal-miner from West Virginia. In addition to mining, this man had worked in construction, plumbing, and in the factory. He had been exposed to “pretty much every chemical,” he had said with a laugh. This, and the fact that he presented with a huge unilateral pleural effusion, amounted to a red flag. Of course, it turns out that my Step 1 brain was wrong, and he didn’t have a malignancy. But I still remember his tan, weather-worn skin, (surprisingly) white teeth, thick accent, easy smile, and friendly manner. I remember being surprised to find that I looked forward to going into his room each morning for rounds.
Another patient from my gynecological oncology rotation comes to mind. “This patient is totally screwed,” said the surgeon as we scrubbed in that morning. “Stage 4 endometrial cancer. She’s screwed.” The patient probably knew full well her prognosis. The next morning, when I checked on her, though, she emanated a remarkable calm. She was hairless, from chemotherapy, and fairly obese, nursed a large abdominal incision underneath her hospital gown. But she was extraordinarily dignified. We chatted about how the procedure went, how she was feeling, and that her family would be there later to check on her later that day. Then, the room fell silent. But I felt no immediate need to move on and check on my next patient. We just sat there for a moment, and her presence was palpable; it was solemn, but hopeful.
There is reward, and meaning, which can be drawn from 3rd year, and which can certainly not be found on Step 1. And the same is undoubtedly true of Raskolnikov’s love, as compared to Vladimir’s love.
Importantly, though, the choice might not be as simple as that between reality and fantasy. Somewhere in the middle, we find the notion of living in reality, but continuing to search for the fantastical all the while. Let’s not forget that Step 1 was at least crafted from the principles of real medicine. Case reports represent an interesting middle ground. Of course, they’re real. But they’re often as astounding, or more so, than anything you would see on the tests. This case report almost seems like the “Beethoven’s 9th symphony” of medicine. Sure–I’ll probably never see anything this incredible in my entire medical career. But there’s a chance I will. That alone should be enough to motivate me to keep looking. At the very least, I won’t find it, but I’ll still be able to reap the rewards of working with people.
Even if I don’t ever diagnose hemophagocytic lymphohistiocytosis, I still expect to find medical intrigue, if only I look for it. Last week, we had a patient in the clinic with diabetes, valvular heart disease, and heart failure. It would have been easy to write it off as just that. In further discussion, though, my preceptor and I concluded that the heart failure was making the patient’s valvular disease look worse than it actually was. So, we decided to forego scheduling the patient for an expensive and invasive valvular replacement surgery. Rather, we decided to just treat her heart failure, which can be done medically. The expectation was that this alone would be sufficient to treat her mitral regurgitation.
We may not have to choose between a lofty but hollow ideal and a steady, monotonous real. Rather, we may have a better choice altogether, which is to search for the ideal within the real. It was Vladimir’s youthful, optimistic attitude which permitted him to fall too hard for Zinaida. But it was this same attitude which allowed him to draw incredible meaning from the simple township past the greenhouse.
Then I used to lock myself in my room, or go to the end of the garden, climb on to the ruin of a high stone greenhouse and, dangling my legs from the wall which looked out on the road, would sit for hours, staring and staring, seeing nothing. Near me, over the dusty nettles, white butterflies fluttered lazily. A pert little sparrow would fly down on to a half-broken red brick nearby, and would irritate me with its chirping, ceaselessly turning its whole body with its outspread tail; the crows, still wary, occasionally cawed, sitting high, high on the bare top of a birch–while the sun and wind played gently in its spreading branches; the bells of the Donskoy monastery would sometimes float across–tranquil and sad–and I would sit and gaze and listen, and would be filled with a nameless sensation which had everything in it: sorrow and joy, a premonition of the future, and desire, and fear of life.
Vladimir’s flame for Zinaida eventually subsides, rather unceremoniously. Eventually, he hears that she has died in childbirth. What was once the entirety of his existence has diminished to nothing. But what he takes with him is not any particular aspect of Zinaida, but rather, what it felt like, in general, to be consumed by passion for something, regardless of its object.
What has come of it all–of all that I had hoped for? And now when the shades of evening are beginning to close in upon my life, what have I left that is fresher, dearer to me, than the memories of that brief storm that came and went so swiftly one morning in the spring?