Who taught you what medicine is?

The patients and colleagues in a small West Virginia town helped this scientist learn how to be a physician.

By Gail Gier Larkin, MD
Family Physician/McMinnville, OR

I started my career as a scientist, not a doctor. After seven years in hematology research, I entered medical school because I was interested in the science of medicine and the molecular basis of disease. For me, medical school was a biochemical trivia dream.

But I didn't end up in a laboratory. After a transitional internship that emphasized trauma surgery, intensive cardiac intervention, and other hospital-focused care, I took up solo general practice in a National Health Service Corps satellite clinic in rural Appalachia—and there my education as a doctor began.

My first patient was Ed Cantera. (I'm not using real names.) "These piles are killing me, miss," he greeted me. "You gotta do something about them so I can get back to work." A cursory exam (all he would permit) revealed dusky purple lumps the size of my thumb protruding from his rectum. "Um, these look really painful," I muttered. "Let me see what we have to help take care of them. I still don't know where everything is in this building."

Outside the exam room, I leaned against the wall to steady my shaking knees. As a trauma team intern, I'd never seen a hemorrhoid and hadn't learned how to treat them. I dashed down the hall and explained the situation to our physician assistant, Dave Bookman, a former Navy corpsman whom I'd met about three hours before. Over the previous seven years, while he and other staff members watched seven other physicians come and go, they'd provided the only continuity of care to this tiny community.

Dave gathered some equipment, stepped into the room and told Ed, "The doc says this is something simple that I can take care of, so let's get you on the road." A few minutes later, Ed clapped Dave on the back and said, "Thanks, Doctor Bookman, I feel better already." Turning toward me, he added, "See you again, Miss. It was nice to meet you."

Dave then quietly told me what my options were for treating hemorrhoids in this rural outpatient setting. We agreed that I would stay in the room whenever he did a procedure that was new to me. We told patients that as the new physician responsible for overseeing Dave's work, I wanted to see how he performed each procedure.

As I stumbled through the rest of that week, patients repeatedly told me how the first doctor in this town had arrived 22 years before on a bicycle, with all his worldly goods in a suitcase on the handlebars. They lamented the passing of the second physician—who had treated everything with some combination of injectable lincomycin, corticosteroids, vitamin B₁₂, or meprobamate—and listened to my recommendations with suspicion.

Never mention the "C" word

The second week I met Anthony O'Doul, a 43-year-old black-haired, blue-eyed, Irish-Italian singer. He had gained 10 pounds in one week, had dyspnea at rest, and evidenced no lung sounds. Uninsured, he refused my near-hysterical recommendations for a chest X-ray, oxygen, ambulance ride to the hospital, and new prescriptions. Between gasps he explained that all he needed was his "shot"—200 mg of Lasix—to treat his viral cardiomyopathy.

I finally gave it to him, after having him sign a formal refusal of treatment. When I left town four years later, he still was singing, still had an irresistible twinkle in his eye, and still laughed about how scared I'd been when we first met.

A few weeks after I met Tony, he sent me 78-year-old Mary Capriotti. Mary was traveling more than an hour to a nearby town twice a month for her "ulcer treatment" and was hoping I could give it to her instead. Her attending physician told me that four years before, during a partial gastrectomy, she had been diagnosed with gastric adenocarcinoma. The pathology report revealed that the margins of resection contained extensive tumor.

Mary had been on bimonthly low-dose 5-FU IV ever since, after refusing further intervention. There was no scientific basis for this regimen, but somehow Mary thrived. Her weight remained stable; she felt no pain and had a good appetite; she did her chores, attended religious services daily, and played with her grandchildren.

Her close-knit extended family had told her only that she had an inflamed stomach. She had decided it was an ulcer, and her family threatened me with the direst of hexes if I ever mentioned the "C" word in her hearing. Despite my strong belief that patients deserve to hear the truth about their health, I reluctantly did as Mary's relatives asked. She died peacefully in her sleep three years later. The grateful family sent me flowers.

I had little respect for perceived crackpots until I met L.D. Hoggett, a 67-year-old coal miner and borderline schizophrenic. Hoggett was missing an eye and I never learned why. He had prostatic hypertrophy, severe hypertension, asthma, hearing loss, and irritable bowel syndrome to go with his arthritis and significant kyphosis. But he still chopped wood for elderly ladies, gardened and shared his crop, and told wonderful stories. I never once heard him complain about his health, although he had a great deal to say about the "danged gov'mint" and how scandalous prices were.

We always knew when L.D. needed to come for a visit or see the mental health specialist, because a neighbor would stop by to tell us he had blasted his television with a shotgun again. The community fed him, took away his gun when he got too wild, gave him rides to the clinic, and generally accepted him as one of their own. Despite his considerable physical problems, he survived to bring me home-made pickles when I was leaving.

I was promoted from "Miss" to "Missus"

During my four years at the clinic, some things never changed. Patients continued to call Dave "Doctor Bookman" despite his repeated attempts to explain that he was a PA. Some continued to call me "Miss," although eventually most addressed me as "Missus." I considered that an accomplishment: It was the most honorable title a woman could hold in the community then.

Other things changed slowly. Dave got used to having a foreign city woman—especially one who didn't know how to remove moles or incise hemorrhoids—as his supervisor. I taught him what medications to give patients with heart failure, how to treat diabetics, and how to care for patients prospectively rather than just deal with presenting symptoms.

But most of all, I changed. I came to understand why what we do is called the "practice" of medicine. And my many patients taught me something I didn't even know I needed to learn: how to balance being a scientist with being human and a doctor.

Gail Larkin. Who taught you what medicine is?.

Medical Economics

Feb. 7, 2003;80:47.