A Stanford-trained doctor tells how he gave up the promise of a lucrative practice to learn more about the Native American healing arts his ancestors used and describes his efforts to incorporate the benefits of modern and ancient medicine. 35,000 first printing.
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William L. Simon is a screen and television writer and bestselling author.Excerpt. © Reprinted by permission. All rights reserved.:
Why Are You Here?
I started medical school expecting to become a research scientist. While still in college, I had joined a professor in his efforts to study biological membranes using a then-new technique called magnetic resonance imaging (now referred to by its acronym, MRI). As a member of his research team, I was named as a co-author of a paper he published on the work, and I imagine my acceptance into Stanford in the early 1970s was based partly on my participation in this new line of research. Indeed, I soon found a professor in my new California home with whom I intended to continue these studies. What I never expected was to become a clinician, focused less on research than on seeing patients.
At Stanford I actually started clinical work immediately. I had pushed myself to finish high school before turning sixteen, and as an undergraduate at Indiana University I had persuaded professors to let me take medical and graduate school biochemistry courses. These gave me advanced standing when I entered Stanford at age eighteen. As long as I took a necessary pharmacology course concurrently, I was ready to start seeing patients on clinical rotations. I was on track to finish medical school in June of 1975, with the required nine-quarter minimum. A decade later I learned I was Stanford's youngest ever peacetime graduate, at twenty-one years of age.
The challenging part for me was not in learning about pharmacology and anatomy but in understanding other doctors. There were numbing lists to memorize, of course, of nerves, muscles, bones, blood vessels, symptoms, diseases, drugs, and side effects; but compared with the knottier puzzles of philosophy or higher mathematics, nothing taught was all that difficult. There was plenty to memorize, but all memorization takes is time. The problem for me was that my interpersonal skills had languished in my race through high school and college. Thankfully, I had a new wife to coach me in the car on the way to dinner parties and social events. Professionally, though, I was on my own.
Medical students on clinical rotations were expected to examine patients and entertain a diagnosis. We would discuss our potential diagnoses, and the treatments and medications they implied, with the faculty physician. The challenge was to show that we had considered every possible diagnosis and had either ruled it out or planned the necessary tests to confirm or disconfirm its existence. Although most patients suffer from common diseases, we relished considering all the outlandish possibilities. First prize went to those who, in the end, turned in exactly the diagnosis our faculty physician had already reached -- we had to learn his or her style and mimic it. At nineteen, much to my own detriment, I was still young enough to be idealistic. I thought it was more important to think for myself than to try to think like someone else.
I also thought other doctors shared my own ideal of medicine: that its purpose was to restore unwell persons to health. Imagine my surprise on hearing a renowned professor of internal medicine begin a lecture by noting that the physician's job lay in "slowing and making less painful the patient's inexorable and inevitable progression toward death and decay."
Despite this my first rotation -- three months in neurosurgery -- was challenging and rewarding. I had already done work in college on the neural functions of rats. I was studying a particular brain rhythm, hoping to show that a molecule called serotonin triggered it. To do this, I implanted electrodes into rats' brains, then measured what happened when I introduced serotonin to different sites of their limbic systems. If the rhythm was produced by the serotonin, I would have strong evidence that serotonin was a neurotransmitter -- a message sent by a nerve to the cells in the vicinity. Neurotransmitter molecules are the only verbs a nerve has at its command; which molecules are produced, and how many, determine a message's content. At the time, scientists were certain of only two neurotransmitters; we have since identified twenty-six. These few molecules and the simple messages they carry from one to another of our three billion brain cells are the vital chemistry behind human thought.
Although this wasn't the concern at the outset, neurotransmitter research eventually had the practical yield of all sorts of drugs. Now we know, for instance, that serotonin depletion often accompanies depression. Drugs that increase the availability of serotonin, like Prozac, are common treatments for depression. Prozac, which belongs to a class of drugs known as serotonin reuptake inhibitors, works by blocking the enzymes that cause serotonin to be reabsorbed.
I found that rat brains produced the theta rhythm I was interested in when serotonin was introduced to certain sites "upstream" of the hippocampus -- which, in plain language, meant that serotonin was indeed a neurotransmitter, at least for rats. This was a publishable result. With my professor's advice and assistance, I finished my first solo paper and published it in a neurosurgery journal. I was very proud to become a part of a centuries-old tradition of expanding the known limits of scientific knowledge.
Since I already loved research, it was no surprise to find the data-gathering aspect of the neurosurgery rotation appealing. But I was unprepared to find how much I enjoyed simply working with people, practicing clinical medicine. Even if I was still more comfortable in a lab than on a ward, two months into the rotation I was starting to consider a career that wasn't pure research but combined research with clinical work. Perhaps I would become a pediatric neurosurgeon. Three months later I was on my second rotation, in urology, about to meet the four very sick men who would challenge my career plans even more profoundly.
It was a foggy April morning outside the renal room of the Intensive Care Unit at San Mateo County Medical Center (SMCMC), a major teaching hospital of Stanford University. A nurse introduced me in a perfunctory manner to the first three of the four men inside. There was little hope for them. The fourth man -- whom I will call Juan Martinez -- had a chance to survive. He was a forty-two-year-old carpenter from Los Gatos, in the foothills of the Santa Cruz Mountains. He had lost one of his kidneys in a San Jose hospital. After the operation, his remaining kidney had stopped working. When Señor Martinez's twenty-three-year-old daughter offered him one of her healthy kidneys, he had been transferred to SMCMC's renal room to be evaluated for a transplant.
My job was to begin a pre-transplant evaluation of Sr. Martinez to decide if there was any reason not to proceed with the surgery. I wondered what had happened to the man before he lost his kidney -- what had brought him here. I started by asking when he had last been well. We had to speak up to be heard over the bustling doctors, the efficient nurses, the constant drone of the voice of the paging operator (these were the days before beepers). Only his three drugged roommates were quiet.
The carpenter was lying on his back, holding himself perfectly still, looking more like a quadriplegic than a dialysis patient. His face had the texture of an onion skin. His muscled arms lay uselessly on the sheets. He took longer to answer than I expected; he seemed to be searching for an answer to a question much bigger than mine. Finally he said, "I was never sick."
"What do you mean?" I asked. He was avoiding looking at me, focusing instead on the grains in the ceiling panels overhead.
"There was nothing wrong with me," Sr. Martinez said flatly. His usually dark Hispanic complexion was blushing ocher, and he began to cry quietly. His jaw continued working after he spoke, as if there were more to say but no words with which to say it. I glanced out the window. The morning's fog had dissolved into a light rain, unusual weather for April in San Mateo. Water ran slowly in crazy currents down the window panes. I found myself shivering.
"What do you mean, there was nothing wrong with you?" I asked when it was clear that the carpenter wasn't going to go on. He was clutching the bedsheet.
"They said I had protein in my urine -- but I didn't feel bad or nothing," the man said without emotion. His face was expressionless except for the silent tears in the corners of his eyes.
"They ran some tests. Then more tests. They took a biopsy of my kidney, and I got this infection that almost killed me." The man gazed down the length of his sheet-covered body. "It did kill my kidneys," he said. His jaw stopped working and his lips began to quiver. Our conference was interrupted by an officious nurse who had come to change his IV. Feeling worried and confused about what had happened to her charge, I left her to the task.
Later that morning I read his chart in the conference room behind the nurses' station. Just a few months earlier, he had been framing houses in the canyons outside San Jose. On weekends he went hunting and fishing in the northern California wilderness. His doctor had discovered the traces of protein in his urine during a routine insurance physical. Proteinuria can be a normal enough finding in a person who has been exercising strenuously, but it can also be an early sign of serious kidney ailments and autoimmune diseases.
Although Sr. Martinez had no symptoms of any of these problems, his internist ordered a full workup. A series of ordinarily innocuous medical procedures had led, for Martinez, to the worst possible complications. After his doctors biopsied a kidney, Martinez got an infection, then began to hemorrhage. His doctors repaired that damage by removing the injured left kidney; Martinez's right kidney responded by shutting down. He developed sepsis, an infection of the blood that can spread anywhere in the body. Doctors at SMCMC managed to clear up the infection but couldn't get the right kidney working again. Martinez's best hope now was a new kidney. As for the biopsy that had kicked off the whole process, it had been inconclusive. Nobody had any idea why Martinez had once had traces of protein in his urine, and now nobody was trying to find out. That problem -- if it had ever been a problem -- no longer seemed important.
I sat in the conference room looking out the hospital's narrow windows at the rain and thinking about the man in the room on the other side of the nurses' station. His old charts and records were heaped on the table before me. I thought of the dark forests of northern California, where Sr. Martinez had hunted, of the deep lakes the forests held, of the ancient trails that led up past the timberline into a world of rock and ice and snow -- a world Juan Martinez might never see again. Then I reread his chart, hoping for some clue to his predicament.
I was still searching when a resident in urology, Musaf Habra, walked in and set two Styrofoam cups of tea on the table. Dr. Habra was a Saudi general practitioner who wanted to teach at the Saudi Medical Center in Riyadh after he finished training as a urologist at SMCMC He was the sort of gentle man whose constitutional kindness can be mistaken for weakness. He had won my admiration at a recent party, where he played the violin with a sensitivity that was anything but weak.
"Reviewing Señor Martinez's case?" he asked, nodding at the charts on the table.
"Trying to make sense of it," I said.
"Sense?" Dr. Habra gave me a quizzical look. "What 'sense' are you looking for?"
"I'm not sure," I said. "The logic behind the biopsy, I suppose. I'm trying to understand how this could have happened."
He shrugged and pushed one of the cups of tea toward me. "His doctor wanted to know what was causing his proteinuria," Habra said in a matter-of-fact tone that served to mask what he thought about the whole thing.
"But he says he wasn't sick," I countered. "And I can't find anything in his chart that indicates any other symptoms or diseases."
"He didn't have symptoms. He had proteinuria..." Habra thought a moment and lowered his already quiet voice. "And he had the 'advantage' of the best preventive health care in the world."
"You wouldn't have biopsied him in Saudi Arabia?"
"I wouldn't have biopsied him here," Habra replied. He raised his eyebrows. "But you Americans are so much more advanced than we Saudi." He winked. "Wanting to know the answers to everything can be deadly." He parodied his own accent a little, lending it a playful hint of intrigue.
I agreed with Habra's critique but was hurt to be included by him among "you Americans." Of course I was one, but I didn't identify at all with the culture that lay behind the unnecessary renal biopsy that had destroyed the carpenter's health. I wanted Habra to see me as something more than just another American. I was a Native American, for one thing, and I hoped that somehow made me different.
It seemed to me my medical student friends and I were more like Habra than he knew. A small group of us were naturally drawn together -- Native Americans, Hispanics, and Asians -- because we all had different cultural perspectives from those prevalent at Stanford. Though we didn't have strong social ties, we did hang out together in school. It took the edge off our feeling of not belonging. Some of my fellows had come to Stanford straight from their reservations and found themselves in an entirely new, often incomprehensible culture. Spurred by my new friendships, I began to reconsider my own Native American heritage, which my mother had long ago turned her back on.
While I was thinking about what Dr. Habra had said, David Vickory breezed into the conference room. Dr. Vickory was a decisive, energetic man with an encyclopedic knowledge of kidneys. In his late thirties, Vickory was juggling two ambitious careers, running a busy research lab and simultaneously winning a reputation as one of the best nephrologist -- kidney specialists -- in the country.
"Well, boys," he said, rubbing his hands together as if they were cold, "what do you think of my man, Martinez -- is he a good candidate for transplant, or what?"
Dr. Habra thought for a moment. "There is the matter of his infection --" he started.
"We've licked the infection," Dr. Vickory interjected. "His fever has long since lifted. He's ready for the knife. Unless..." He turned a chair backward and straddled it. "Unless you've found something I missed." His tone was challenging. He waited barely an instant and turned toward me. "You look troubled, Dr." -- he glanced at my name tag -- "Mehl. Did you find something I missed?
"I told him I hadn't.
"And yet," he continued in his light, teasing tone, "you do look troubled. Our man is stable. We've cleared his infection. We've got a kidney standing by. And still something worries you."
"Actually," I said slowly, "I'm struggling to understand how he got here in the first place."
Vickory's face went blank for a moment, and his cheerful demeanor vanished. "You have a question about how patients get infections?"
On one level, it would be a ridiculous question for a medical student to ask: even premeds know that microbes cause infection. But on another level, the question was worth pondering. Why did this particular patient succumb to microbes when most others do not? The first question would be too basic and the second too philosophical to warrant discussion in the urology conference room. Vickory was trying to figure out which of these transgressions I had made.
I saved him the trouble. "Of course I know what causes infection. I was wondering w...
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