Chapter 60: Philosophy of Medicine

December 5, 1988, Pittsburgh, Pennsylvania

I stood as a balding, bearded, bespectacled doctor entered the small conference room where I was being interviewed.

"Good morning, Michael," he said. "I'm Mark Gleason, Chief of Emergency Medicine."

"Good morning, Doctor Gleason," I said, shaking his hand.

"Grab a seat, please. I see you have coffee."

I sat down.

"I've read your application, as well as your medical school transcripts and evaluations, and I have to say that I'm impressed. I also checked our records, and found that you were accepted to our medical school, but chose McKinley instead. Would you explain your decision?"

He was cutting right to the chase, and I had to be careful how I responded, lest I foreclose any possibility that they would list me among their Match selections. I truly didn't expect to need anyone to list me except McKinley, but I didn't want to do anything that created even the smallest window of opportunity for the Match computer to screw me out of a Residency Match and force me into the Scramble.

"There were a number of factors," I replied, "most importantly, my bishop's intent to ordain me a deacon and, at the time, my upcoming marriage."

"My condolences for your loss," he said.

"Thank you. Word seems to have gotten around."

"Things like that do," Doctor Gleason said. "The medical fraternity is pretty tight-knit, and we hear about things like that. Did they do a CAT scan?"

I shook my head, "No. The CAT scanner was installed after that, and wasn't active until January of this year. Not that it would have mattered, as Doctor McKnight, the pathologist, said the condition was routinely fatal."

"He's a former classmate of mine, and spoke very highly of you. Would you explain the rationale behind doing a pathology Sub-I?"

"It was suggested by Doctor Roth, a surgeon, as a way to improve my knowledge of anatomy and give me a chance to use a scalpel. He's tried very hard to convince me to Match for surgery."

"You only applied for emergency medicine here, right?"

"That's correct, and that's the same as for Ohio State, Indiana University, and the University of Cincinnati."

"All in the Midwest? You aren't considering any of the major teaching hospitals on the East or West Coast?"

"No. I'm a Midwestern guy who wants to stay in the Midwest."

"You're originally from southern Ohio, right?"

"Yes."

"And all your family is there?"

"My paternal grandparents live near Chicago, well, my grandmother now, as my grandfather succumbed to a heart attack a few weeks ago."

"My condolences for that as well."

"Thank you. My maternal uncle lives in St. Louis, and the rest of my dad's relatives are in and around Chicago."

"Do you have any ties to Pittsburgh?"

"I have friends who live here, and I've been a Penguins fan for a decade."

"How did that happen?"

"When Cincinnati lost their pro team during the NHL/WHA merger, I picked the Penguins over the Red Wings, Blues, and Black Hawks. In addition, there's a monastery not too far from here where I've made several visits."

"In your church are ordinands assigned by a bishop to a specific church?"

"Yes, though I resigned my position because I wanted to be able to remarry, which I could not do if I'd remained in the ranks of the clergy."

"OK. Tell me, please, who Michael Peter Loucks is."

I spent the next fifteen minutes answering his question, starting with a short biography, and then explaining my desire to be a physician and my approach to medicine.

"I think that matches what I read in your evaluations," Doctor Gleason said when I finished. "Including the 'he talks too much' comments."

I smiled, "Guilty as charged. I don't think any of the evaluations mentioned my nickname in the Emergency Department."

"Not that I recall; would you mind sharing?"

"'Kid Whisperer'," I replied. "Because I have good interactions with teens and younger kids."

"How did that develop?"

"I think from being a Sunday School teacher since age fifteen, and focusing on teaching teens and young adults at my current parish."

"Developing good rapport with patients is important, but it can go too far, as I think you understand from your evaluations. That's especially true in urban trauma centers, though we aren't Cook County!"

"Nobody is Cook County except Cook County! One of the ED docs at Moore Memorial did his clinical rotations there, and he has some war stories to tell."

"Which makes it fitting that it was combat surgeons who formed the Shock-Trauma unit there. We see some gunshot wounds here, but nothing like they see. Tell me more about your emergency medicine rotations. What was your most interesting case?"

"A retained condom, which was extracted by forceps."

"You did that?"

"Yes. Doctor Gibbs, my Attending, felt my rapport with college students was superior, and that they'd respond better to a lecture from me on proper condom use than they would from an older doctor. She allowed me to perform the procedure, which I knew how to do from my OB/GYN rotation."

"You've seen two of those?"

"Sorry, no, but I knew how to use the speculum and do a proper exam."

"You didn't do an OB/GYN Sub-I, according to your transcript."

"No, but I was more or less treated as a Sub-Intern rather than a Clerk on all of my Clerkships."

"I wondered about that because the evaluations read as if you performed procedures rather than observed, and I thought it was just a stylistic choice by your mentors at Moore Memorial when writing evaluations. Did you bring your procedure book?"

"I did," I replied, reaching into my bag to grab it and then hand it to him. "Anything marked with an asterisk is a procedure I personally performed; anything with a plus is a procedure with which I assisted; no mark means I simply observed."

Doctor Gleason took a few minutes to page through the book, then handed it back.

"You did more as a Third Year than many students do as Fourth Years. I'm curious about your psych rotation — where did you gain the experience to do intake and assessment?"

"A mix of things, including self-study, theological studies, and working with a clinical psychologist to care for a very close friend who was diagnosed with schizophrenia while we were at Taft."

"That's a rough diagnosis," Doctor Gleason acknowledged. "How is your friend doing?"

"Let's just say that the medical profession seriously failed her and leave it at that."

"You won't expound?"

"I've been advised not to by my stepdad, who is an attorney, who is representing my friend."

"Malpractice attorney?"

"Family law," I replied. "What I can say is that he was instrumental in forcing a change in her caregiving team, but I honestly have to leave it at that."

"What about mental healthcare in general?"

"It's deplorable," I replied. "We resort to medication too quickly, then over-medicate and do our best to hide individuals diagnosed with mental illnesses from so-called polite society."

"I'm not going to disagree with you, though in emergency medicine, that's obviously not our focus."

"I agree, but as I mentioned before, my approach to medicine is holistic, and we need to consider not just physical well-being, but also mental, emotional, and spiritual well-being. I read a recent article in The Lancet on improved outcomes based on the patient's mental and emotional state. They ignored the spiritual side, which is par for the course, but I've read articles in psychology journals about the positive influence of prayer. I've also seen evidence presented for improved outcomes for schizophrenics who attend church, and I've seen that first-hand with my friend."

"And in a busy, urban ER, how do you propose to do that?"

"Carefully," I replied with a smile. "In all honesty, a few extra minutes with a patient to improve their overall outcome is a win for the patient, the hospital, and society as a whole. Our job, as emergency medicine specialists, is to make that known to the guys who write the checks and convince them. Nobody else can have the same impact, no matter how much they lobby, agitate, or protest. Emergency medicine specialists saying 'this is our standard of care' would have an impact that could not come from anywhere else."

"And if the cost pressures prevent that?"

"Then we need to find a way," I replied. "Our job, as I see it, is to heal, and that isn't limited to the six sutures in a small arm lac or treating an accident victim or resuscitating an MI. My friend and classmate Clarissa and I actually discussed this on the drive here last night, and medicine as a whole needs to carefully evaluate 'progress' and make sure it really is progress. New tests and new technology are great, and are helpful, but the human touch is what heals."

Doctor Gleason smiled, "Ah, to be young and idealistic!"

"I've heard from Attendings that idealism gets run over by reality, like asphalt by a steamroller."

"The key is not to allow your idealism to give way to cynicism," Doctor Gleason said. "It's very easy to become cynical by the time you reach my station in life."

"My study group is close-knit, and we all agree that things need to change, and we're dedicated to finding a way to bring about positive change. Sadly, history and experience show that's not an easy task, and all one has to do is look at handwashing and what's called the Semmelweis effect, or Semmelweis reflex, to see why."

"Isn't it human nature to resist change?" Doctor Gleason asked.

I chuckled, "You have no idea!"

"What am I missing?"

"I'm Russian Orthodox, and something is 'new' for us if it's from two hundred years ago! Our liturgy is, with only minor modifications, the same one performed in Fourth Century Constantinople, albeit in English, not Greek. Nothing significant changes in our church without serious resistance and pushback. Church provides an anchor of consistency and constancy in this ever-changing world in which we're livin'."

"Live and Let Die?" Doctor Gleason interrupted, his eyebrow arched.

"I like James Bond, and I'm a music aficionado, so I'll make references such as that from time to time. But the point is, it's my anchor. Everything else changes, and the goal is to make progress, as defined by better overall outcomes for our patients in particular and society as a whole. Technology and pharmaceuticals figure into the equation, but nothing can substitute for what I would call being a 'good, old country doctor'."

"'Bones' McCoy?"

"Well, as one science fiction fan to another, he and Doctor Crusher are my style of doctor; Doctor Pulaski is not. I'd never go to her for anything because she's too cold and too clinical. Of course, we're only two episodes into the new season, so perhaps that will change."

"I take it you agree with McCoy that medical practice is barbaric?"

I chuckled, "He was referring to dialysis, given they'd found a cure for whichever kidney disease the elderly woman had. Ditto for needing glasses, though conveniently Kirk was allergic to the drug."

"Out of curiosity, if you had the chance to be Chief Medical Officer on a starship..."

"In a heartbeat!" I declared. "I'd call in every favor I could and use every advantage I had to get that assignment. And yes, on a Mars colony, or on the Moon, too. A ride in the Space Shuttle would be awesome."

"Even after Challenger?"

"Even after Challenger. Remember, before that incident, the only astronauts we lost all died on the ground. The Soviets lost some on re-entry, but we don't know many details about those. I really appreciated Richard Feynman's work on the accident, and Discovery flew a successful mission in September. More importantly, Atlantis is in orbit as we sit here. So, yes, in a heartbeat, Doc!"

"You'd have a better chance if you went through the military Match."

"Yes, but I don't feel like being assigned to an aircraft carrier patrolling the Persian Gulf for six years. I'd miss my daughter far too much."

"I think I have a very good picture of you, Michael. You have about ten minutes before the Residency Board interview. Stretch your legs, use the facilities, and refill your coffee or get something to drink, and be back here at 9:00am."

"Will do. Thank you, Doctor Gleason."

"You're welcome."

December 5, 1988, On the Road to McKinley, Ohio

"Are we stopping for food?" Clarissa asked as I pulled out of the hospital parking lot.

"I figured in about two hours, or about halfway home, if that's OK. Most likely around Zanesville."

"That's fine. Now that we're out of any possible earshot, what did you think?"

"That they have a more modern facility than we do, for sure, and we won't catch up until we have the new wings for emergency medicine and surgery in eight to ten years."

"Did you see their ICU with the bank of computer monitors at the nurses' station showing all patients' vitals and EKGs?"

I nodded, "The 'telemetry beds', as they call them, are totally cool. According to one of the Residents, some of it runs via radio, rather than cables. They're installing the same system in Cardiology."

"Think Moore Memorial will ever have the money for that?"

"I think Moore Memorial won't have a choice when it becomes the 'standard of care'. That said, not all patients need that kind of intensive monitoring, and it would mean some cardiac patients could stay in the ward, rather than the ICU, which would actually save money, given the nurse/patient and Resident/patient ratios are so high in the ICU."

"Mike Loucks, supporting the use of computers!"

I laughed, "Only by the loosest of definitions. I mean, technically, the EKG machine is a computer. And my objection was only to what I think are called 'general purpose' computers, or at least, that's what Katy called them when I saw her. And you know I think patient records should be computerized so we can more easily find out if a patient is a 'frequent flier'. That would help with drug seekers and, more importantly, battered women and children. And it might have helped that poor woman who had the tumor."

"That was a pretty amazing catch, Petrovich."

"Even a blind squirrel finds a nut now and again! Or is it a blind nut finds a squirrel?"

"He finds a beaver!" Clarissa teased.

"You are SO bad, Lissa!" I exclaimed. "Returning to our serious conversation — you know why nobody caught it, and it goes right back to my point about GPs being the backbone of medical care, and, to reiterate, behaving more like Doctor Evgeni than so-called modern GPs."

"Before I forget, did you get a chance to call Kris?"

"Yes. The minute I finished, I used a payphone to call her and let her know things had gone well, though you and I both know this is furthest down our list, after Ohio State and the University of Cincinnati."

"Are you going to list Indiana second because of the program?"

"I considered it, but given Kris is going to Ohio State, that's not really possible. Even Cincinnati is a stretch. I'll take an emergency medicine Residency in Columbus over a trauma surgery Residency in Indianapolis. If I was going that far, I might as well go to Chicago."

"If we're listing them last, and you can't really do it, does it make sense to even interview? I mean, by the same standard, Pittsburgh is completely out of the question, too."

"I think we do them and list them, because we cannot take the risk. If something like that happened, we'd have to deal with it. And there is, in one sense, a bigger problem."

"That if we don't Match at Moore Memorial, we might not Match together."

"Exactly. The only way to absolutely guarantee that would be to go into the Match as a married couple, and they require a marriage certificate to allow that, so we couldn't even fudge it."

"You'd get access to a smoking hot redhead with freckles, Petrovich!"

"And I'd be the third wheel in the relationship, which you know is not something that would work for me."

"No, it won't, and I was teasing, of course. Out of curiosity, have you and Kris discussed that topic?"

"Not beyond her going on the Pill and waiting until after our crowning for our first kiss."

"Isn't that risky?"

"I'm confident she knows how to make babies," I replied.

Clarissa laughed, "And as you've said, the dumbest jock and biggest airhead cheerleader can figure that one out! But in all seriousness, I thought you agreed that Annette had a point about that."

"I do, but I'm also confident that Kris and I will find a mutually satisfying answer to the question. She's very much of the 'partnership' mindset where we discuss things and reach a mutually agreeable solution. Given what I know about her, I can't imagine she's going to stake out a position so far from what I'd consider typical that it could possibly be a problem."

"Not to be difficult, but you and your Kitten screwed ALL the time! I mean, constantly!"

"Something I could do before our clinical rotations started. That would have had to change of necessity, and we'd have found an appropriate compromise. You're going to have to find one with Tessa, too."

"You know it's way more about cuddling and kissing than orgasms, though we have those, too, obviously."

"Obviously. And yes, I know how much you preferred close intimacy with me without sex, and not just because I'm a guy. It's your nature to prefer cuddling and bubble baths."

"I know it's late in the game to ask this, but I have to, as your best friend — are you absolutely sure Kris is the right girl?"

"I am. Smart, logical, level-headed, sensible, and Rachel likes her. It doesn't hurt that she's a gorgeous blonde!"

"A bit thinner and smaller than your usual girl."

I shrugged, "As I've said to girls who worried their breasts were too small, any guy who objects to the size of any breasts he has access to is a moron! And in talking with Susana, she has times when she'd prefer smaller breasts."

"When she's forty and has back trouble! That said, she's impressive, and she'd make a great World War II era pinup!"

"Jane Russell in The Outlaw?" I asked.

"Or those girls you see painted on bombers. They all had stupendous boobs like Susana!"

"Jealous, Lissa?" I asked with a smirk.

"Oh, hell no! I'll keep mine the way they are and save myself the back pain!"

"I think you're the first girl I've ever heard refer to her bra size, except for Elizaveta when she 'complained'," I made air quotes, "about needing larger bras after she got pregnant."