When I was a house officer in the 1970s, my friends and I would often talk about the age of the giants, speaking of them with mixture of amusement, envy, and reverence. Who were the giants? They were our forebears in medicine, physician heroes of the previous generations. In the age of the giants, the house staff lived in the hospital, worked every other night for pennies, and fought mightily against illness with the most meager of weapons.
The giants, even if their legends hid a different reality, were nevertheless great men. Indeed, they were almost all men because this was the era before women entered medicine in any number, the feeling being that “the weaker sex” did not have the strength or gumption for such an arduous career. Despite the unbalanced roster, the giants created scientific medicine as we know it and forged a drive for excellence that underpins academia today.
Compared with them, one of my co-interns once said laughingly, “We are munchkins.”
Some training experiences were not enjoyable, but I look at them with a certain appreciation and gratitude because I was learning my craft from people of knowledge and unyielding standards.
Giants of Rheumatology
At the top of the pantheon of giants were the department chairmen. These were people endowed with fierce intelligence, great vision, and strong leadership. Given the state of medicine then, many were clinicians or clinical investigators who studied human disease and often gave their name to syndromes that they described. They were not gene jockeys like today. They were genuine doctors.
Each of the top medicine departments had one of these men—Osler, Thorn, Hurst. The textbooks still carry their names, such as Harrison and Cecil and Loeb. At my institution, Stead ruled a department for over 25 years and “Stead-trained” was a sign of smarts and fortitude that augured well for future success.
Medicine does not use the term coach, but these men were head coaches. They were the “Bear” Bryants, Bobby Knights, and Dean Smiths but their temperaments and personalities were different than the coaching legends of sports. The giants of medicine were brilliant, elegant, and austere. Reserved and often distant people, they did not shout, but could communicate their feelings with a quick glance over their reading glasses or the slightest tensing of their face.
The chairs of the old era were imposing and intimidating and, like their counterparts on the gridiron or hardwoods, they demanded excellence and inspired loyalty. The expectations for work were outlandish, and complaining was simply not done.
One of my colleagues, who is my vintage, told me how, as an intern, he became overwhelmed on a grueling every-other-night service. Tired and frazzled, he went to his chairman to confess his worries about his lagging ward work.
“I’m exhausted all the time. I don’t sleep and I’ve lost weight. What should I do?” he asked.
“Get your thyroid checked,” the chair said, looking disdainful and dismissive.
Of course, some of this macho attitude is nuts, but at its core it can represent a drive for achievement. In athletics, this drive makes champions and is rewarded royally.
MD Coaches Who Inspired Awe—and Dread
Sports and medicine are different universes. Unlike sports, where the coach is omnipresent—prowling the sidelines, barking orders, stomping his feet—the chairmen of medicine coach episodically, contacting trainees at grand rounds, chief-of-service rounds, or at morning report.
At the time of my training, morning report was a stressful occasion, ranking with an M and M (Morbidity and Mortality) conference as a time when patient care would be put under a very public microscope and unmercifully critiqued. Morning report can be analogized to watching game film in sports. Both endeavors involve dissection of previous work with the goal of discovering flaws. Whether the team wins or loses, mistakes are made and they have to be found and analyzed for immediate correction. Indeed, in sports, victory can be deceptive and—unless the film is broken down—the mistakes become ingrained and losses loom.
I occasionally give morning report now. It is quite pleasant because I am presented a case about something I know and the house officer gives an evidence-based medicine (EBM) review. I usually complement the management of the case and the EBM discussion. There are sometimes delicacies from Panera and a steaming urn of their finest house blend, making a most enjoyable interlude.
How I wish morning report was like that when I trained. My morning report was a time of reckoning with the chairman. For the chairman, think Joey Dorsey with a white coat and stethoscope. Every case that came in the night before would be ripped apart. Even if the outcome were a resounding success—paroxysmal atrial tachycardia instantly banished with carotid massage, Addisonian crises reversed with a squirt of Solu-cortef—the chair would find something amiss.
“So, Dr. Pisetsky, what did the EKG show before you ran potassium on the diabetic ketoacidosis patient?” the chairman would ask, his steely eyes drilling into mine.
“We didn’t check it, sir,” I would say, squirming. I would be tempted to say that the patient’s creatinine was 0.9 and the urine was gushing and that we had brought the sugar from 500 to 100 with nary a bump. But explanation would be futile and could lead to a trip to the library to do penance by looking up articles.
“You could have precipitated a fatal arrythmia,” the chairman would say as he stared at me down the length of the table. “Also, next time, get a clean white coat.”
The only solace I would have is that all of the house staff faced similar inquisitions.
Tough but Invaluable Training
These experiences were not enjoyable, but I look at them with a certain appreciation and gratitude because I was learning my craft from people of knowledge and unyielding standards.
Medical training is changing as the work hours are plunging. We are now at 80 hours a week for interns and residents, and 65 hours is in the offing. In the next column, I will discuss the impact of the new training models on the coaching we do and, indeed, whether academic medical centers can provide coaching at all.
Dr. Pisetsky is physician editor of The Rheumatologist and professor of medicine and immunology at Duke University Medical Center in Durham, N.C.
