The Sustenance of Teaching

It was one of those rare lulls practitioners savor. Brief but refreshing. The piles could wait. The mood invited reflection. The door granted solitude with a gentle nudge.

The allure of medicine had been powerful. How were my classmates? Their stories had been similar. Nurtured by a kindly role model with a healing touch and compassionate smile. Driven by idealism. Awed by the science. Stimulated by the intellectual challenges. Charged by the character and power of its practitioners. Determined to make a difference.

I followed. If they could do it, so could I. Noble aspiration came later.

“Dr. C., they called to reschedule the committee meeting tonight. I still need to talk to you about the new receptionist.”

“Sure. Let's do it after the next patient.”

Reality had been different. The sprint of training was replaced by the marathon of practice. There were many opportunities to be jaded. Conversations drifted to declining reimbursement, the oppression of paperwork, the hectic pursuit of productivity. Demanding patients. Multiple commitments. Broken marriages. The business of medicine.

“Dr. C., I finished with my last patient. Can I tell you about her? She says your sons are friends. She is real interesting for an old person.”

The smile was irrepressible. Pulling my chain again.

“She is a 44-year-old woman who just got back from vacation in Florida. While there, she noticed her abdomen was swelling, and she gained 18 pounds. She feels fine except for a right groin ache when she stands. She has to void more often. She does not drink alcohol. She is basically healthy and has not been seen here in 4 years except for allergies. She does not itch, has no dyspnea, orthopnea, dysuria, or ankle swelling. She had a vaginal hysterectomy for a fibroid in 1995, and her only other hospitalizations were for pregnancies.”

Her soft voice eased the burden of the content. She was an apt learner. Enthusiasm was now coupled with an evolving mastery of saliency and succinctness. Her focus commanded mine. It had not always been so. She radiated her achievement. The satisfaction was contagious.

“Her vital signs are normal, and she is afebrile. There is no jugular venous distention. Her lungs are clear, and she has no gallops. Her abdomen is distended. I think she has ascites. Her liver does not seem enlarged. I did a pelvic exam. I could not feel either ovary, though she says they are there. It was hard to tell. There may be something on the right. Her urinalysis is clear.”

I felt heavy. Would she get it? What to hope for? The diagnosis? The patient? She was starting to hesitate. Uncertainty? Angst? Her expression favored the latter. Momentary silence seemed sacred. A time for colleagues.

“I think she has ascites. I am worried it is her ovary. She looks too well for cirrhosis. She is not nephrotic. I think her heart is fine. Maybe it is something else. I think she needs a CT scan.”

Solid. No prompts. Joy in that. Sunshine in the darkness. What could I add? The merits of CA-125? The patient's perspective? Solace?

“Hi, Doc. Long time no see. Think I am pregnant?”

A quick smile. A look that lingered. Her eyes probed during the bimanual exam. A steady gaze. She knew. A water balloon filled her pelvis, merging superiorly with shifting dullness. Try feeling it this way. There. Now you've got it. More ballottable than palpable. A catheter yielded 15 mL of residual urine.

“So what do you think, Doc?”

I listened as the explanation flowed. Balancing reality and optimism seemed easier as a team. What next? We would compare notes while she changed. Our hands met. The grip was sustained. The grasp of friends. Our lives were joined. The serpent was engaged.

Outside, the plan was completed. Arrangements were made. We reflected on acumen. The nuances of exam. The fear that bound us. The oath that guides us. The legacy that sustains us.

She returned to the patient. I, to a prickly secretary.

• Copyright ©2004 by the American College of Physicians