I used to think that a doctor was either an internist or a surgeon. He wore a stethoscope or wielded a scalpel. When I was young I knew I wanted to be a doctor, but I never heard the word--- psychiatry. The first two years of medical school were the basics, gross anatomy, biochemistry, physiology, bacteriology, pathology. Four hours of lectures in the morning, four hours of gross anatomy lab in the afternoon. Study in the evening, little time for play. Study, sleep and eat.
That was the first year. The second year was the same, lectures and labs, only the labs were physiology and bacteriology, recording muscle twitches and growing bugs on petri dishes. We were wondering when we would see an actual patient. This was not what I expected of medical school, but the basic sciences were groundwork for what was to come later.
Between the second and third year was summer vacation and I got a job as a medical extern, not quite yet an intern. We were to watch and learn and begin to apply our basic science knowledge to actual human beings sick in the hospital. We were given our first white coats and we made sure our stethoscopes were either sticking out of our pockets or hanging around our necks. Since we had two years of medical school, we were almost doctors, pre-doctors, and could take histories, perform physical examinations and take part in clinical discussions.
For me, my first patient proved to be momentous and a turning point. I was given a thick chart and told to read it and then see the patient, which would involve taking a history and doing a physical. It took over an hour to get through the chart and what was in it was mind-boggling. I learned later that they gave the new extern the most difficult patient; it was a form of hazing. Still, the chart was fascinating, because the lady had eleven laparotomies (cutting open the abdomen) and each time no pathology was found! The thickness of the chart was made up of endless lab tests, consultations in every specialty, as well as numerous descriptions of the surgery and pathological reports of the surgical specimens.
The surgery reports were repetitions of "lysis of adhesions." The path reports showed connective tissue (adhesions, benign). I asked what caused adhesions, and the answer came back, surgery. Surgery caused adhesions (scar tissue) and with repeated surgeries there were more and more adhesions. Hm. No other pathology.
Why did they keep cutting this woman open, looking around, and then sewing her up again? The reason was that she was coming in to the emergency room repeatedly (about once a year) with an "acute abdomen." What was that? It's the kind of abdomen you get with acute appendicitis, painful, rigid and tender to touch. Usually indicative of serious pathology.
Back in the second year one surgery professor advised a conservative approach--- "don't do a laparotomy looking for pain." It's better to be patient and take time and make a presumptive diagnosis, better than using a laparotomy as part of the physical exam. That was 'good medicine,' or in this case, 'good surgery.' Why was that not practiced here, where all the medical school professors saw their own private patients? Didn't they practice what they preached?
It turned out that this patient was a 'special case,' a 'diagnostic problem,' and the rule was overlooked. She was an exception. All the consultations were unable to come up with a diagnosis, and so the thick chart was given, (with a smirk and a wink) to the new medical extern. That was me. After reading the chart I wracked my brain but of course could come up with nothing. If all my profs couldn't make the diagnosis, how could this rank beginner?
I went into the room with some trepidation, expecting to see a very sick lady, the day after her eleventh laparotomy. Same history, she came into the ER with an acute abdomen. I was shocked to see her sitting up with a nice breakfast tray in front of her, alert and chipper, her face made up, her hair nicely combed and sitting pretty in a beautiful pink silk bed jacket. She greeted me with a smile and invited me to sit down. I told her she looked very well in spite of her thick chart and many surgeries. Just yesterday she had severe abdominal pain, probably due to adhesions, and she had another laparotomy. 'Lysis of adhesions' was the way to go.
She said she didn't know what caused the pain each time, but it was always very bad and the surgery took the pain away. After the surgery she got the usual Demerol (a narcotic) for postop pain. That made her very cheery. My intuition led me to ask about her home situation. Her face dropped a little and said she was lonely, rattling around in that big house. Her husband was a successful businessman and workaholic, so she didn't get to see him much, but he provided very well for her.
I asked her how did she feel about having so many surgeries. Her face lit up again and she said she felt fine; she never gets such good treatment and such nice attention as when she is in the hospital. A lightbulb went off in my head, and I became a psychiatrist at that moment. I realized that all my profs missed the boat; they were taking care of her in the 'standard-of-care' of that time, doing whatever needed to be done to keep the lady comfortable and make her happy. The laparoscopies were a relatively benign treatment for her condition. I suppose the rationale was this--- Better she be taken care of by medical school profs than local yokels in the boondocks, where God knows what 'treatment' would befall her.
I was beginning to learn some Freud, and he contended that many people make themselves sick and wanted to be sick, and sometimes remain sick because it fulfilled deeper needs. It was clear to me that this poor lady needed attention and found a way to get it. Otherwise she would be depressed and lonely, simply sad and unhappy. There must be a better way to treat such people, and so I headed into psychiatry and ultimately into psychoanalysis.
My first patient became another turning point in my life.