Chapter 36: Integrative Medicine

October 21, 1986, McKinley, Ohio

"Carl, Jenny, Nicole," Doctor Getty said, "this is Michael Loucks, who is a Second Year and is here on a Preceptorship. Mike, if it's OK to call you that, please meet Doctor Carl Strong, PGY3 Resident; Jenny French, Fourth Year Sub-Intern; Nicole Short, Third Year Clerk."

"Nice to meet all of you, and yes, Mike is fine."

"Which religious order?" Doctor Strong asked.

"I'm not Roman Catholic," I replied. "I'm a Russian Orthodox deacon."

"The church with the onion domes north of town?" Nicole asked.

"Yes."

"Loucks doesn't sound Russian," Jenny said.

"My mother's maiden name is Borodin, and my grandparents came over in response to the Russian Revolution," I replied. "My dad is of Dutch ancestry, and they've been here since Manhattan was part of the Dutch Colony of New Amsterdam."

"Decided on a specialty?" Doctor Strong asked.

"I'm leaning heavily toward emergency medicine, but I'm giving consideration to surgery."

"Class rank?"

"First."

"Hell, you should go for the true challenge and the big bucks — neuro or cardiac surgical specialties! And at one of the big hospitals."

"I have time before I have to worry about that," I said, temporizing. "I'll decide after I take the first part of the NBME Exam in May. That seems like the best time to decide where to try to interview."

"The NBME Exams are a bear," he replied, "but if you're ranked first in your class, you should pass easily."

"Jenny," Doctor Getty directed, "please describe the procedure we just performed."

I pulled my notebook from the side pocket of my medical coat and a pen from the chest pocket so I could take notes.

"We performed a percutaneous transluminal angioplasty following a diagnosis of atherosclerosis on a fifty-five-year-old male with a history of smoking. Using the Seldinger technique, we accessed the right femoral artery, inserted a sheath, then introduced the catheter. Using fluoroscopic guidance, we advanced the wire to the affected region, then inserted a catheter with a balloon. Once it was properly positioned, we inflated the balloon to eight atmospheres using contrast dye for visualization, resolving the condition."

"Good," Doctor Getty said. "Nicole, what are the risks?"

"Embolization, bleeding, hematoma, pseudoaneurysm, and contrast-induced nephropathy."

"Post-procedure monitoring and discharge instructions?"

"Monitor for swelling or bleeding around the insertion venipuncture, renal output, cardiac anomalies, and vitals. The patient should be out of bed after four hours. He will be released tomorrow if there are no contraindications. Resume normal activity in a week. Referred to a nutritionist, advised to immediately quit smoking and begin a light exercise program.

"Good. Mike, how's your Greek?"

"Which term?" I asked.

"Angioplasty."

"It's the combination of two Greek words, «ἀγγεῖον» (angeîon), meaning 'vessel' and «πλάσσω» (plássō), meaning 'mould'."

He nodded, "NPO?"

"Latin, not Greek," I replied. "«Nihil per os», or 'nothing by mouth'. Though I have seen it written out in English in medical journals, rather than using the abbreviation or the Latin phrase."

"Yes, that's the style the AMA uses. There is a push in some circles to have all instructions in English rather than Latin. May I see your notebook? It's not necessary, but if you're willing, I'd like to see it."

"This is a brand new one for this Preceptorship," I said. "So you'll only see the notes I've made in the past five minutes."

"One per Preceptorship?"

"Yes. And for the ones that match a Clerkship or Sub-Internship, I'll continue in the same notebook."

"If you don't mind, I'd like to see it in eight weeks."

"I don't mind at all."

"Are you able to arrive early on Tuesdays?"

"I could be here an hour earlier without any trouble."

"Non-emergent procedures are scheduled at 7:00am and noon."

"What time would you want me here so I don't disrupt anything?"

"11:45am. Can you do that?"

"Let me speak with Doctor Alvis," I said. "But missing the last thirty minutes of Advanced Doctoring isn't going to cause any real trouble, and I believe I'll learn more here than in thirty minutes of class."

"It's October, so I suspect you're going to be doing pre-clinical hospital visits, right?"

"Yes. Observing dialysis, chemotherapy, physical therapy, and other things which aren't covered in our Preceptorships."

"If Ben Alvis gives you any trouble, let me know, but missing some of that won't negatively impact your progress or education nor cause any problems on your exam."

"Then I will be here at 11:45am starting next Tuesday. What should I do if you've bumped a scheduled procedure for an emergent case?"

"Come to the scrub room for the cath lab or the OR, and the scrub nurse will know if it makes sense for you to scrub in."

"Two procedures per day?" I asked.

"Yes. That works out, as I'm sure you can do the math, to about five hundred per year. That's about right for being the only dedicated cardiac care unit for four counties. We do around seventy emergent procedures a year."

"What's your position on stents?" I asked.

"Damn!" Doctor Strong exclaimed. "Those are just being developed!"

"He's paid attention to something other than his studies," Doctor Getty observed. "What have you been reading, Mike?"

"The Lancet and JAMA, when I have time. I mostly look for articles on emergency medicine, then cherry-pick articles which discuss something interesting or new."

"Who suggested you read those?"

"Doctor Gibbs, a Resident in the ER."

"It wouldn't hurt to add The New England Journal of Medicine to your list. The reason for that is that they have a strict requirement that any article submitted for publication has to follow the Ingelfinger rule, which says that the article cannot have been published or released elsewhere before appearing."

"Other than making sure they make a profit, what's the reason for that?" I asked.

Doctor Getty laughed, "To prevent duplication and ensure the content is fresh. But obviously, NEJM also wants to preserve their revenue stream."

"I'll get a subscription, but that'll mean being even more selective in what I read."

"You'll discover, as you go along, your available time will force you to only keep up with your chosen specialty, and perhaps one other in which you have interest. You simply won't have time to read everything to keep up with everything. Here at Moore Memorial Hospital, we do monthly brown bags where each service presents the developments in their field or interesting cases. And, of course, there are the M & Ms. Back to your question about stents — they look very promising and ought to reduce restenosis. It's time for the post-procedure checks. Doctor Strong, if you would, please. Mike and Nicole, go with him."

Nicole and I followed Doctor Strong out of the office and walked down the corridor to the patient's room.

"How are you feeling, Mr. Phillips?" Doctor Strong asked.

"A bit out of sorts, but nothing hurts."

"That's a normal result of the medication we gave you to keep you relaxed. You've met Nicole, and this other student is Mike. Nicole, would you check for bleeding or swelling please?"

She examined the patient's right leg and stated that there was no bleeding or swelling. Doctor Strong reviewed an EKG strip, which showed no abnormalities, then listened to Mr. Phillip's heart and lungs.

"Everything looks good," Doctor Strong said. "You can get out of bed to use the toilet and walk for five minutes every hour. I'll have the nurse come in to assist you. If everything continues to look good, you can go home first thing in the morning."

"Thanks, Doc!"

We left the room and returned to Doctor Getty's office, where Doctor Strong made his report. The rest of the afternoon was uneventful, with additional patient checks and a consultation in the ER to rule out a heart attack. When I left at 5:00pm, I was really looking forward to the next Preceptorship session when I'd get to watch a procedure.

October 22, 1986, McKinley, Ohio

"My period is basically done!" Elizaveta exclaimed on Wednesday morning.

"You don't ovulate for at least two weeks, so there's no rush," I replied with a sly smile.

"And your point is?" she demanded fiercely.

"That you can't get pregnant until you ovulate, so as I said, no rush."

"You promised, Mike!" my young wife protested.

I chuckled, "You are so easy to wind up, Kitten!"

I felt her hand on my groin, and she closed it around my sack.

"I'll wind THESE if you aren't careful!"

"Which would defeat your purpose!" I said smugly.

"Husband..." she threatened, squeezing gently.

"Damage those, and no babies, ever!"

"Will you stop teasing me and start trying to make a baby, please?"

"I suppose," I replied flatly.

"Enough, Mike!" Elizaveta said firmly,

"Sorry. I pushed the teasing just a bit too far. Forgive me?"

"For that, we have to do it three times before school!"

"I suppose we can miss a day running," I agreed, pulling her to me.

We had to rush through showers and breakfast, as we'd used up every bit of our usual morning time working on our first baby, and even then, Elizaveta was cutting it very close for arriving at school on time.

"I still say we should try to meet for lunch," Elizaveta said.

"You don't have a long enough lunch to get home and back, and we wouldn't get a chance to eat! On the weekends, we can manage midday."

"Then before dinner tonight!" Elizaveta declared.

I laughed, kissed her, and she got into her Thunderbird for her drive to school. Once she'd driven off, I went back inside to study for thirty minutes before heading to the medical school.

October 25, 1986, McKinley, Ohio

"What time do we need to be in Goshen?" I asked Kim on Saturday morning when I arrived at Taft for band practice.

"The dance starts at 7:00pm, so I'd say 6:00pm."

That would mean missing about an hour of class, but that wasn't uncommon amongst students for the Friday class, and we didn't have a quiz or exam. That said, unlike most students who skipped or left early, I'd speak to Doctor Leonard in advance.

"OK. No problem with bringing Elizaveta, right?"

"No. We're allowed to have whatever 'crew' we need, though the rules say none of us are permitted to mingle with the students."

"They're afraid those High School girls will turn into groupies?" José asked with a smirk, earning him a soft smack on the arm from Dona.

"They actually had a problem with a band a couple of years ago. Seems the lead singer decided to 'entertain' a couple of girls during the break between sets."

"Fifteen to twenty minutes for two girls?" Sticks asked with a grin. "I feel sorry for the guy!"

We all laughed.

"What happened?" José asked.

"The girls were over sixteen, so other than the band being told they couldn't come back, nothing."

"How did he get caught?" Sticks asked.

"A teacher saw the girls coming out of the room, adjusting their clothes," Kim said. "I found that out from the girl who's head of the dance committee."

"Well, unless you plan to pick up High School boys, I think we're safe," I said.

"No thanks!" Kim said, shaking her head. "Shall we practice our Blues Brothers songs?"

We had a good practice and agreed we'd do a full run-through on Thursday night, and after I packed up my instruments, I left the music room and went to meet Elizaveta. We walked to the car, got in, and headed for Kroger, as was our usual practice for Saturdays.

"Kim scheduled a practice for Thursday evening," I said. "We'll run through our songs, and Robby and Sophia will do their patter."

"OK. I'll make sure dinner is almost ready when you get home, so we have time for baby-making before we eat!"

"You have a one-track mind, Kitten!"

"So?" she challenged.

"It was just an observation! Fresh corn again?"

"Yes, please. Get enough so we can serve it Monday night as well."

I picked out fourteen ears and put them in a paper bag, bought bananas, which we'd use at breakfast after I practiced suturing, and then moved from the produce section to walk up and down the aisles, with Elizaveta pointing out items and checking them off the list as I put them in the cart. When we finished shopping, we went to the checkout and our groceries were bagged. After I paid for our purchase, we headed out to my car, where we loaded the bags into the back. I returned the cart, walked back to the car, got in, and we headed home.

"We'll need to put away the milk and other refrigerated goods when we get home," Elizaveta said. "But everything else can wait!"

I laughed, "You are certainly focused on achieving your goal!"

"It also has the side benefits of lots of orgasms!"

"Braggart!" I teased.

"It's not MY fault you can't have as many orgasms as I do!"

"I suppose it makes up for having a period every month and going through labor."

"My periods aren't too bad. Some of my friends have serious cramping and other troubles, but not me. In your classes, did they say what position worked best?"

"You seem to have orgasms whichever way we do it!"

"I meant for getting pregnant!"

"Oh," I replied. "No, they didn't. But we didn't really talk much about fertility problems. In fact, I probably won't really study very much about fertility because it's so far outside my focus."

"The one thing that's surprised me about medicine is just how specialized it is."

"I was discussing that with Doctor Getty on Tuesday," I replied. "There just isn't enough time to keep up on the development outside your chosen specialty. That's why I make sure I read the articles on emergency medicine and difficult diagnoses first, then pick and choose interesting or innovative topics. Nobody has time to read everything, and that's why doctors call for consults."

"The doctors all seem to be treating you better than you expected when you started."

"Being first in my class makes a big difference, especially given I want to Match at Moore Memorial. I get the drift they don't get too many applications from students who are top in their class. All the doctors and medical students are surprised I'm not thinking about someplace like Stanford or Johns Hopkins or whatever."

"You've never really considered that, have you?"

"No. The only thing Clarissa and I considered was applying to Emory and Stanford for medical school, but we decided that was silly as I wanted to stay here, and it was pretty much a lock that I'd get in. So we just applied to four other relatively local schools as backups."

"How will studying work once you start your clinical rotations?"

"I'll be expected to know the steps for every procedure that is being done. For scheduled procedures, that's pretty straightforward — I just study it the night before. For other stuff, I'll read as much as I can and do my best to be prepared."

"So what happens if you don't know the procedure?"

"As a Third Year, not much, so long as you make the proper effort and can answer most questions. As a Fourth Year, it can cause you to fail."

"What else could cause you to fail?"

"Just about anything," I replied. "A poor attitude, personality traits, not following directions, not being able to answer questions, or pretty much anything an Attending doesn't like. Think about what tripped up Melissa Bush."

"Bigotry?"

"That is the root cause, and it manifested as a poor attitude and violations of the medical school code of ethics. Even if she passes the exams at the end of Fourth Year, she's unlikely to Match because, and you can never repeat this, she's being blackballed."

"That can happen?"

"Yes. The doctors and the medical school know she's a problem, and they do not want her as part of the profession. That can happen to anyone, and it's part of the reason medical students and Residents don't speak up about things which are just plain wrong. Clarissa and I have discussed quite a few things we believe need to change, but we're mostly keeping that to ourselves until we're Attendings and actually do something about it."

"Like what?"

"How women are treated, for one. The fact that some Attendings and Residents are required to teach but are poor teachers, for another. The need for more hands-on work as soon as it's possible. But for now, we have to keep it between us, or other trusted medical students. Until we're in a position to speak up in a way which will matter, we have to focus on learning as much as we can and make sure we actually get to be Attendings."

We arrived home, and once we'd put the frozen and refrigerated items into the freezer or refrigerator, Elizaveta practically dragged me to bed so we could make two more attempts at getting her pregnant.

October 27, 1986, McKinley, Ohio

"Mike, do you have a moment?" Doctor Worth asked when Clarissa and I walked into the medical school building on Monday morning.

"Yes," I answered, then turned to Clarissa, "Coffee, please, Lissa?"

"Meet you in class," she replied.

"Let's go up to my office," Doctor Worth said.

"Now what?" I asked warily.

He laughed, "You're not in any trouble! I need a favor."

We arrived in his office and I sat down across from him at his desk.

"We had a resignation from the Student Ethics Board. We'd like you to fill the position."

"Why did the person resign?"

"Because a friend of theirs is being investigated, and they intend to testify on the friend's behalf. They resigned to take away any question of improper influence."

"Why not just recuse?" I asked.

"They were afraid it might look like they were trying to influence things behind the scenes."

"How much time is this going to take?"

"We usually have no more than two or three cases a year. The Ethics Board only meets when there is a complaint and serves as the jury once the investigation is complete."

"This isn't a rubber stamp or a kangaroo court, right?"

"You think that little of us?" Doctor Worth asked, rocked back in his seat.

"No, but I was asked to serve on something like this once, and the conclusion there was foreordained. I was used as cover for what amounted to a show trial."

"Where was that?"

"Sadly, my church."

"What did you do?"

"I went to a higher authority and blew the whistle, so to speak. But it was too late for the accused, who had a stroke, which I blame partly on the results of the tribunal. I don't want to see a repeat of that."

"If the Ethics Board finds there was no violation, that's the end of it. If they do find a violation, an appeal can be made to me. But I do not have a vote on the Ethics Board, and I do not take a position in front of the Board."

"I do have another concern, and that's Melissa Bush."

"I can't go into details about the agreement we reached with her, but she won't ever appear before the Ethics Board."

"I was more concerned about painting a target on my back."

"If I may be blunt, I doubt this will have any effect on what she does. I'm positive she's going to sue us, and this won't affect that one way or the other."