Each year, I spend a month attending on general medicine, serving as the supervising physician for two house staff teams that, together, care for about 20 to 30 patients at a time. Although my colleagues elsewhere are amazed that I still do ward work, I enjoy the time with the trainees, taking, as our former chairman said, “a sabbatical from your lab.”
With a schedule that demands intensive patient follow-up and documentation, I round seven days a week. Unlike the house staff, I do not have a limitation on the number of hours I work in the hospital. Although I do not spend nights prowling the wards or taking admissions in the moonlight hours, my days are filled to overflowing because my other academic work does not really stop. Taking care of sick patients is very tiring because, in the world of hospital medicine today, there are no easy admissions.
For a rheumatologist, general medicine is familiar territory. While called subspecialists, we are really generalists because our diseases are incredibly diverse, spanning organ systems and pathogenetic mechanisms. No other subspecialty has to treat patients with so many different afflictions. I often try to think of the common threads of our diseases. After all, what unites fibromyalgia, vasculitis, and osteoporosis—not to mention rheumatoid arthritis and myositis, among many others? My best answers are pain, complexity, and systemic involvement. I could also add treatment with steroids for many.
Just like a camel, which is a horse designed by a committee, rheumatology is a specialty designed by tradition, accident, and the penchant of rheumatologists for variety and the opportunity to grapple with problems that have eluded others. A general medicine ward is the perfect place for a rheumatologist because, after all, for our rheumatic disease patients we constantly think about strokes, myocardial infarctions, pulmonary emboli, infections, and unremitting pain. I know a little about a lot, but I think that’s doing better than most specialists.
Munchkins Aspiring to Be Giants
Attending on a general medicine ward provides an opportunity to look back as well as forward. My mind bubbles with a litany of war stories from my own house staff days. During one of my intern rotations in the 1970s, we alternated between schedules called Black Week and White Week. During Black Week, we were on call in the hospital Saturday, Sunday, Tuesday, Thursday, and Friday. White Week was only Monday and Wednesday.
For those of you who like to do math, Black Week was 140 out of 168 hours. When I went on call for the consecutive dubious double, I packed a suitcase full of extra shirts and underwear as well as a stockpile of food in case I missed a meal while toiling on the ward. During that era, there were no floats (day or night), and expectations for performance were high even if we were starved for sleep and on the verge of hallucination. As house officers, we were munchkins aspiring to be giants.
We did our own laboratory work and everything else necessary for our patients. Although called an intern or resident, I was a medical handyman and utility infielder. I pushed patients to and from X-ray, ran blood to the labs for stat readings, took EKGs, put in IVs and Foleys, counted cells on a hemocytometer, and stained sputum, urine, or cerebrospinal fluid, looking for rods or cocci or something that snapped red. Because there were no computers, I entered laboratory values on flow charts and in progress notes, using a special red pen so that the numbers were easy to see.
Given the system then, medicine was truly a matter between doctors and patients. By contrast, in medicine today, the lines blur because the doctor changes every few hours as each morning a float comes in to take care of the previous night’s admissions. Alas, the float only floats for a few hours, bobbing in the torrents of the day’s frenzied work, and then there is a hand-off to the next team, which will work through the night. Sometime the next morning (an hour precisely determined to avoid a violation of some regulation), there will be another hand-off to allow the on-call team to get finished before the clock ticks for their duty hours or, as in the Cinderella story, they turn into pumpkins or I get reported to the American Council of Graduate Medical Education.
Fortunately, modern medications can often be very effective, and it often doesn’t really matter who enters the electronic order for moxifloxacin or enoxaparin. Today, the computer is the medium of all transactions in medical care, and the doctor–computer relationship reigns supreme.
Just like a camel, which is a horse designed by a committee, rheumatology is a specialty designed by tradition, accident, and the penchant of rheumatologists for variety and the opportunity to grapple with problems that have eluded others.
Changing Times
The other day on rounds, we had a patient with a mass lesion in the brain, and increased intracranial pressure was a worry. I asked the house officer what the fundoscopic exam showed. The house officer honestly replied that, one, the patient had had a CT scan, and there was no evidence of brain swelling and, two, he didn’t have an ophthalmoscope. I gasped and sputtered.
“Why don’t you have an ophthalmoscope?” I said, recounting the story of one of my attendings who asked us the following question: If you were stranded on a desert island, which medical instrument would be most valuable? An ophthalmoscope was the right answer because it could show, for example, the devastation resulting from hypertension, diabetes, or imminent brain herniation. Thinking of my own scope (the thoughtful gift from some drug company), I remembered my diligent but often futile searches for hemorrhages, exudates, cotton wool spots, cytoid bodies, arteriovenous nicking, spontaneous venous pulsations, and the many other signs we were expected to recite at rounds.
I cannot imagine what would have happened had I told my attending that not only had I not looked at the fundus, but that I didn’t know where to find an ophthalmoscope on the ward. Nevertheless, my house officer told me, the fundus is hard to see and, anyway, he didn’t know what those things at the back of the eye looked like.
Times change. Maybe looking at the fundus is not that important, especially when the CT scanner or other whiz-bang imager tells us everything. I don’t believe that notion, however, because an essential part of medicine is the intimate contact with a patient and an intense and sustained effort to figure out what is wrong by listening, touching, and even peering into those body spaces where it is possible to gaze inside.
I cannot speak for other specialties but, from my perspective watching others on the general medicine ward, I think that in rheumatology, the doctor–patient relationship is alive and well in its visceral and sensate way.
Good for us. Let’s keep it that way.
Dr. Pisetsky is physician editor of The Rheumatologist and professor of medicine and immunology at Duke University Medical Center in Durham, N.C.
