WHEN DOCTORS GET SICK

WHEN DOCTORS GET SICK

Edited by

HARVEY MANDELL, M.D. The William W. Backus Hospital

Norwich, Connecticut

and HOWARD SPIRO, M.D.

Yale University School of Medicine New Haven, Connecticut

Springer Science+Business Media, LLC

Library of Congress Cataloging in Publication Data

When doctors get sick.

Includes bibliographies and index. 1. Physicians—Diseases. 2. Physicians—Psychology. 3. Sick—Psychology. I.

Mandell, Harvey N. II. Spiro, Howard M. (Howard Marget), 1924- . [DNLM: 1. Patients—psychology. 2. Physician Impairment. 3. Physicians—psychology. W 21 W567] R707.W49 1987 616'.008861 87-14104 ISBN 978-1-4899-2003-4

ISBN 978-1-4899-2003-4 ISBN 978-1-4899-2001-0 (eBook) DOI 10.1007/978-1-4899-2001-0

First Printing—September 1987 Second Printing—July 1988

© Springer Science+Business Media New York 1988 Originally published by Plenum Press, New York in 1988 Softcover reprint of the hardcover 1st edition 1988

All rights reserved

No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming,

recording, or otherwise, without written permission from the Publisher

To Marjorie Mandell

Marian Spiro

FOREWORD

When a doctor gets sick, his status changes. No longer is his role de­fined as deriving from doctus, i.e., learned, but as from patiens, the present participle of the deponent verb, patior, i.e., to suffer, with all the passive acceptance of pain the verb implies. From pass us, the past participle, we get the word passion, with its wide gamut of emotional allusions, ranging from animal lust to the sufferings of martyrs. It is the connotation, not the denotation, of the word that defines the change of status. When a doctor is sick enough to be admitted to a hospital, he can no longer write orders; orders are written about him, removing him from control of his own situation. One recalls a sonnet from W.H. Auden's sequence, The Quest, which closes with the lines:

Unluckily they were their situation: One should not give a poisoner medicine, A conjuror fine apparatus, Nor a rifle to a melancholic bore.

That is a reasonable expression of twentieth-century skepticism and ra­tionalism.

Almost all medical literature is written from the doctor's point of view. Only a few medically trained writers-one thinks of Chekhov's Ward Six-manage to incorporate the patient's response to his situa­tion. Patients' voices were not much in evidence until well into the twentieth century, but an early example is John Donne's Devotions upon Emergent Occasions (1624). Written over 350 years ago, it describes the feelings, perhaps recollected in tranquility, of an articulate Jacobean clergyman and writer with respect to an acute, febrile, life-threatening illness that struck abruptly in December 1623, when he was 51 years old.

Donne, ordained a priest in the Church of England in 1615, was appointed Dean of St. Paul Cathedral in 1621. Two years later he was suddenly taken ill. We know the onset was acute, because in the first of the twenty-three Devotions he writes, "This minute I was well, and am ill, this minute. I am surpriz'd with a sodaine change, and altera-

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viii FOREWORD

tion to the worse." But an exact diagnosis remains unknown. Various writers have given such labels as "spotted fever," which merely indi­cates a skin eruption, "relapsing fever," which merely indicates that the fever was intermittent, and "typhoid fever," which in those days was not clearly distinguished from typhus fever. The last of these is not improbable; James I's eldest son is supposed to have died of it in 1612, and London's drinking water was hardly free from fecal contami­nation. However, Donne's "spots" seem to have developed late in the course of the disease and may well have been the petechiae of a rickett­sial infection rather than the rose spots of typhoid, which characteristi­cally appear late in the course of the disease. Establishing a precise diagnosis is not essential. What is important is Donne's reaction to his disease-how the patient felt. Apparently he made a few notes during the acute phase and wrote the set of Devotions while convalescing in the winter months of 1624. He comments:

he feels that a Fever doth not melt him like snow, but powr him out like lead, like iron, like brasse melted in a furnace: It doth not only melt him, but calcine him, reduce him to Atomes, and to ashes; not to water, but to lime.

Donne seems to have been ambivalent about his physician; he had little faith in the medications:

it may be that obvious and present Simples, easie to bee had, would cure him; but the Apothecary is not so neere him, nor the Phisician so neere him, as they are to other creatures.

He also complained of abandonment, suspecting that his physician was afraid of contagion:

As Sicknes is the greatest misery, so the greatest misery of sickness, is solitude; when the infectiousness of the disease deterrs them who should assist, from coming; even the Phisician dares scarce come. Solitude is a torment which is not threatned in hell it selfe .... When I am dead, and my body might infect, they have a remedy, they may bury me; but when I am but sick and might infect, they have no remedy but their absence, and my solitude ... it is an Outlawry, and Excommunication upon the Pa­tient, and separats him from all offices not only of Civilitie, but of working Charitie.

Donne's Devotions contain many other passages a physician might well read to his advantage, especially to prepare himself for the time when he too will suffer from the ills to which the flesh is heir, but the climax is in the familiar passage in the seventeenth Devotion:

Perchance he for whom this Bell tolls, may be so ill, as that he known not it tolls for him .... No man is an nand, intire of it selfe ... any mans death diminishes me, because I am involved in Mankind; And therefore never send to see for whom the bell tolls; It tolls for thee.

FOREWORD ix

Donne's emphasis on the interdependence of making is not only one of the roots of medical care, why we minister to the sick, but also the root of any civilized society, and the day may yet come when, as a later poet wrote: "AUe Menschen werden Bruder. II

For the present we have a book by some fifty doctors, each describ­ing a sickness of his own. It would be easy to dismiss such a compila­tion as anecdotal but, in fact, what we know about medicine is the sum total of cases we have studied, and each one adds its increment to our knowledge. That is partly because each case is unique-"an nand intire of it selfe"-yet all share in a common humanity. As individuals, each doctor's experience is unique and so is his insight. Assembled, they provide a rich variety of medical experience as seen through the eyes of patients trained in medicine, and in this way we learn from the ex­periences of others.

WILLIAM B. OBER, M.D.

Director Emeritus Department of Pathology

Hackensack Medical Center Hackensack, New Jersey

PREFACE

Doctors get sick even as other people do. We doctors have no magical immunity to ward off devils or germs, whichever you think causes dis­ease. People may not know that we ever get sick because we tend to work just the same unless the illness is significantly debilitating. We physicians are in general a hardy lot and few of us stay home with the flu. This may not be good epidemiology but it helps to foster our su­perman and superwoman egos.

Most of us doctors are not neurotic about our health. Medical school and the years of internship, residency, and fellowship may lead us to the conclusion that if we can survive these programs we may just be immortal.

You will seldom find us admitted to a hospital or even having out­patient work unless we are very sick. Most of our medical "care" con­sists of a telephone call to a colleague, or a hospital corridor or doctors' parking lot consultation. Doctors' reactions to health measures other­wise seem to be, in general, rational and sensible rather than hysterical or obsessive. Few doctors smoke cigarettes and most, at least the young ones, seem always to be playing tennis or skiing. Running and jogging occupy the leisure time of many. Obesity at morbid levels ap­pears to be less frequent among physicians than in the general public.

Most doctors know about illness only from their patients and jour­nals and texts. Physicians who say the patient "has a low pain thresh­old" have probably not had the same disorder that is causing "the low pain threshold" patient to howl with agony at the passage of his ure­teral stone. We have never heard a physician who has had a kidney stone or a "disc" belittle a patient's description of severity of pain. We have never known a migrainous doctor to make light of the discomfort of headache. How many physicians know firsthand the anxiety that ac­companies the wait for a doctor's call with a report of a biopsy?

This leads inevitably to the question: Should doctors be sick with a painful or debilitating illness themselves before being permitted to take care of patients? Not very practical, and not likely to attract many volunteers even if the answer is yes.

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xii PREFACE

We have shared both an abiding interest in physician behavior and an extraordinary delight in being published. Although one of us has had cancer surgery and the other no more challenging procedures than root canal and colonoscopy without anesthesia, we have often thought that physicians and others might be interested in reading about physi­cians who have become patients with serious diseases. This is, after all, a unique group of patients who have found in their experiences much to learn and much to teach.

We asked a few physicians who had been seriously sick if they would be interested in writing about their illness for a collection we hoped to publish. We asked the prospective authors how they discov­ered they were sick, how they chose their physicians and their hospi­tals, what it was like to be a patient and what the experience did to them as physicians and human beings.

The initial response was so promising that we began to search for physician-patients with increasing vigor, using acquaintances all over the United States and Canada and keeping a careful eye on the occa­sional anonymous pieces in the lilncet and the British Medical Journal, in which physicians in the United Kingdom described their illnesses.

The editors brought different viewpoints to the project. One of us, the cancerous one, is an obscure New England country doctor. He has spent his career in a community hospital, where the emphasis must al­ways be on the practical management of patients who are acutely ill. The other is an amiable if peripatetic academic teacher and clinician among whose duties are thinking and ruminating. The collaboration has been amicable, and each editor is prepared to blame the other for any matters of concept or style that may irritate readers.

Since every physician cannot have every disease and since male obstetricians can never know firsthand the pain of labor and no female urologist can ever experience the pain and terror of torsion of the tes­tis, we thought physicians might benefit, if not prosper, from the ill­nesses of their colleagues as related by those colleagues.

HARVEY MANDELL, M.D. HOWARD SPIRO, M.D.

ACKNOWLEDGMENTS

All honor to our doctor-patient-writers who bared their souls in these essays as once they bared their bottoms in their hospital johnnies. A megathanks to Karen Hall, who pushed their manuscripts into the word processor and pulled them from the printer, performing bits of surreptitious editing on the way. Her rare brief snatches of testiness were more than compensated for by the excellence of her performance in all things. We thank Helen Markell Lewis, Chris Wajszczuk, Julie Sage, and Carrie Toth for their good efforts. Thanks to Janice Stern, who saw promise in the idea for the book and lured us to Plenum. Her enthusiasm and guidance gave us sustenance. We thank our wives, Marjorie Mandell and Marian Spiro, with their combined 72 years of monogamous marriage, for their love and their understanding of our preoccupation with this volume for the past several years.

H.M. H.S.

xiii

CONTENTS

PART I: CARDIOVASCULAR DISEASES

1. Coronary Artery Disease and Coronary Artery Bypass Graft 3 MAURICE Fox

2. Coronary Disease.. .. . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 7 MAURICE H. P APPWORTH

3. Coronary Artery Disease and Coronary Artery Bypass Graft 19 BENJAMIN FELSON

4. Myocardial Infarction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 ROBERT L. SEAVER

5. Cardiac Arrest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 LEWIS DEXTER

6. Viral Myocarditis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 HASTINGS K. WRIGHT

PART II: ORTHOPEDIC-NEUROMUSCULAR DISORDERS

7. Guillain-Barre Syndrome ........ , . . . . . . . . . . . . . . . . . . . . . . . . 53 DENISE BOWES

8. Meniere's Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 WILLIAM D. SHARPE

9. Malignant Fibrous Histiocytoma and Limb Amputation . . . . . 63 HUGH L. DWYER

10. Lyme Disease............ ............................ ... 71 DAVID B. BINGHAM

xv

xvi CONTENTS

11. Prosthetic Hips. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 JOYCE L. DUNLOP

12. Multiple Sclerosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 MIRIAM C. CHELLINGSWORTH

13. Disc with L-5 Root Compression.......................... 95 STEPHEN N . SULLIVAN

14. Herniated Discs......................................... 105 SAM J. SUGAR

15. Parkinson's Disease .......................... " . .. . . . . . .. 119 DONALD B. HACKEL

16. Parkinson's Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 123 LOUIS B. Guss

PART 1lI: NEUROPSYCHIATRIC DISORDERS

17. Cerebral Concussion.. . . .. . . . . . . . .. . . . . .. . . . . .. . .. . ... . .. 131 LAWRENCE R. FREEDMAN

18. Alcoholism.............................................. 139 "DR. MAGOO"

19. Depression.............................................. 143 "LOUISE REDMOND"

20. Depression.............................................. 151 A. ROSEMARY MAcKENZIE

21. Manic-Depressive Psychosis ......... " . .. .. . . . .. . . ... . . .. 159 MICHAEL ROSE

PART IV: GASTROINTESTINAL DISEASES

22. Ulcerative Colitis and Avascular Necrosis of Hips.. . . . .. . .. 171 JUDITH ALEXANDER BRICE

23. Ulcerative Colitis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 193 "LOUISE SCOTT"

CONTENTS xvii

24. Ulcerative Colitis ........................................ 201 "MAURICE RASKIN"

25. Ulcerative Colitis..................................... ... 213 MALLORY STEPHENS

26. Crohn's Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 229 "R. F. SPOONER"

27. Crohn's Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 243 DAVID E. HEIN

28. Duodenal Ulcer...................................... ... 259 HARRISON F. WOOD

PART V: CANCER

29. Anaplastic Carcinoma of Neck......................... ... 269 "ALBERT LUTHER"

30. Brain Tumour........... ... .................... ...... ... 277 JOHN A. MCCOOL

31. Malignant Melanoma .................................... 287 HARVEY MANDELL

32. Malignant Melanoma ................................. '" 295 NICHOLAS V. STEINER

33. Hodgkin's Disease........... ............................ 305 CHARLES S. KLEINMAN

34. Cancer of Sigmoid.................................... ... 317 JAMES C. HAYES

35. Mycosis Fungoides ...................................... 321 "MOSES LLEWELLYN"

36. Acute Myelogenous Leukemia............................ 325 JACK J. LEWIS

37. Benign Giant Cell Tumor of Sacrum ...................... 335 RICHARD E. THOMPSON

xviii CONTENTS

38. Seminoma of Testicle.................................... 345 HAROLD W. SCHELL

39. Renal Carcinoma ........................................ 349 HADLEY L. CONN, JR.

PART VI: CHRONIC DISEASES

40. Chronic Renal Failure and Hemodialysis. . . . . . . . . . . . . . . . . .. 359 A. PETER LUNDIN

41. Diabetes Mellitus and Complications of Pregnancy. . . . . . . .. 369 "GWENDOLYN AUSTEN"

PART VII: ACUTE AND/OR SELF-LIMITED DISEASES

42. Anaphylaxis............................................. 383 BARBARA YOUNG

43. Viral Hepatitis. . . . . .. . . . . . . .. . . . .. . . . . . . . .. . . . .. . .. . .. ... 393 KENNETH W. BARWICK

44. Tuberculosis ............................................ 401 RONALD J. KARPICK

45. Trauma................................................. 405 BARRY L. ZARET

46. Ectopic Pregnancy and Complications of Pregnancy........ 413 "DR. SUSAN PAT"

47. Hemorrhoidectomy...................................... 419 WILLIAM B. OBER

48. Phlebitis .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 425 ROBERT SCHEIG

49. Bleeding Ulcer .......................................... 429 ROBERT E. KRAVETZ

PART VIII: AIDS

50. AIDS................................................... 441 STEPHEN K. YARNELL

CONTENTS xix

Epilogue. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 449

Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .. 461