Sunday, January 22, 2012

On Foppery

Our personal style of dressing broadcasts to others how we see ourselves and how we would like to be seen by them.  It's quite amazing how effective the strategy is. 

For example, wearing striped ties to class from middle school through college might accomplish your longstanding desire to become president of the local golf club. Wear three piece pin striped suits in your law practice and clients just might begin to believe you are actually worth eight hundred dollars per hour.  After all, clothes, as it is said, makes the man - and woman.

Without saying so we want people to know if we are gentle or rough,  liberal or conservative, heterosexual or homosexual, playful or serious.  Our clothes billboard the answers with laser accuracy.

Clothing also permits us to indulge ourselves in various fantasies.   That's why we drive our Ford pick-up wearing leather racing gloves or take to coming to the office decked out in a Stetson hat.    

Even the survival of the species benefits from a Darwinian fashion show of clothing.  While other animals attract each other and preserve their species utilizing color markings, we depend heavily on clothing to propagate ours.

So it was a big shock to me when I commenced my internship and discovered that my wardrobe was to go in storage and be replaced by a uniform which would do very little to either preserve the species or promote the persona I hoped to cultivate.

The uniform consisted of a short white jacket, white pants and white shirt.  They were all starched to a point that one had more of a  feeling of breaking into them rather than putting them on.  This cold, stiff, white landscape was relieved only by our neckties.  While it was mandatory to wear them, we were given free rein in buying them, leading to a cacophony of colors and patterns, which gave us a modicum of individual expression.

So we held on to our neckties as if they were lifeboats.  Most of us packed as much individuality as we could into our very limited haberdashery.  I favored ties with interesting color combinations hoping, I suppose, to be seen as 
artistic and sensitive. 

But selecting my own ties did not dispel for me the feeling of anonymity and enforced conformity.

So why were we exiled to this fashion Siberia?  What message was our hospital attire supposed to convey?   

The relentless white was possibly to project a pure and sanitary image despite our regular tramping around in gobs of purulence.  

It was widely believed at the time that germs (any bacteria, almost all friendly) were public enemy number one and television ads were awash in pitches for toilet bowl cleaners (Mr. Clean was an icon) and kitchen sanitizers.  The sparkling white color of our hospital clothes must have, as a result, been very reassuring.

The stiffness of our outfits might have subconsciously suggested moral rectitude though it is equally possible that the hospital laundry got a sweet deal on starch and felt free to starch the daylights out of our uniforms.  Which ever the case, my cohort  and I had, by common consensus, more starch than rectitude.

So when I finally entered practice, escaping three years of a deflating dress code (and two years in the army where I came to detest the color olive nearly as much as white), I vowed to never wear anything white.  This included white shirts and lab coats, long or short.  It surprised me how commonplace it was for practitioners to wear long white lab coats and I was grateful that the group I joined did not.

Long white lab coats on internists seems to  me like over - egging the omelet.  They give the impression of  a doctor who not only talks to you and takes your blood pressure, but also conducts animal studies in the basement and is regularly splashed with blood and an assortment of nasty discharges.  In fact, these contingencies are pretty far-fetched.

Moreover, the lab coats suggest priestly robes, giving them an air of authority which is disturbing.  While studies have shown that a majority of patients find doctors who wear the lab coats more professional and trustworthy, donning of the robes can create a divide which does not accommodate  open discussion.  After all, who will challenge or question a man or woman wearing priestly robes?

There are of course many internists in lab coats who encourage and successfully create open dialogues with their patients, but the coats are in many ways institutional props that, under the radar, stifle communication, and thereby deserve to be mothballed.

My second vow on entering practice was to not wear neckties.  In part I saw them as superfluous and uncomfortable and in part I admit to playing the gadfly.  But my chief aim was to cultivate a persona that painted me as open, flexible and somewhat unconventional.  Tossing off my ties was a metaphor for these qualities.

My seniors were scandalized by my open collar look which they regarded as subversive and unprofessional.  On the other hand, my  patients barely noticed and I doubt that I lost any patients as a result.

Today, at least thirty-five years later, the open collar is the rage among politicians, celebrities,  doctors, pundits, even lawyers. 

Furthermore, the tie is now regarded as a pariah in the medical world by some researchers who have shown them to be a breeding ground for pathogens and a rich source of hospital acquired infections.  Some hospitals in the UK have banned them and many others, here and abroad, discourage them.  

In some ways then, clothes indeed can make the man or woman.  At the very least, their presence or absence (my long gone ties) are vehicles for how we see ourselves and hope to be seen by others.  Whichever style we might adopt, it should feel natural or else it flops. Otherwise, most fashion sorties hit the target as long as there is not even a hint of sloppiness. 

Perhaps the best advice  I ever received about clothing was from my father who exhorted my brother and I to dress British and think Yiddish.  Its pretty good advice for anyone: create an image but remember where you come from.

Dress British, think Indian; dress British, think Polish; dress British, think Mexican and so on works equally well.




Saturday, January 7, 2012

Pack Your Bag

The blog that follows is based on my actual experiences but the names are fictionalized.

Dr. Gregory Tuddle, Chief of Medicine at a teaching hospital where I trained, taught me one of the most important and enduring lessons of my 
medical practice - all walls are to be breached.  This meant that knowledge and information that could benefit a patient need to be secured at all costs, whatever the obstacles.  

If walls blocked the way, the physician should climb over them, smash through them, dig under or sweep around them.  A trojan horse was fine by Tuddle too.

Dr. Tuddle never actually articulated this lesson.  It was his choreography of morning report (where students, interns and residents were required to present   the patients that they had admitted over the previous twenty-four hours, giving a critical analysis and defense of their management of the patients to him) that brought the lesson indelibly home to me.

Here is how the dance went.

One morning I presented a case to Dr. Tuddle regarding a very sick man with an infected heart valve. Tuddle listened intently before he went on a talmudic spree of the "on the one hand and on the other hand." That was his way: there were always more questions than answers.  One of his questions dealt with the wisdom of the particular antibiotic regimen I prescribed.  He challenged me to defend my choice, always preferring independent thinkers to parrots, even if it meant disagreeing with him.  (Tuddle loved when we disagreed with him.  While he insisted on politeness and fairness, he shaped us not to be intimidated by authority).

As we sparred (I hadn't landed a single punch), he asked an unusual question that flummoxed me - who knew more about infected heart valves than anyone else in the country?  I had no idea at first but then remembered an infectious disease super star from Boston, Dr. Lawrence Waldman, who had given a lecture at our hospital some years ago.

"Good, call him," Tuddle said.

I thought my  mentor had a flash of temporary insanity.   Afterall,  I had never heard of an anonymous resident calling a famous medical figure for advice.  The Chief of Medicine was asking me to break into the ivory tower and  provided no clues on how to do it.

I found Waldman's number and as the phone rang, prepared my introduction.  A woman answered, his secretary.  In just seconds, I realized that it was unlikely that  I was going to talk with the great man without her approval.  I imagined that her previous employment was in the secret service and that she must be a doyenne in the protection field.

But, after an immodest amount of groveling and flattery, I was put through to the doctor who, strangely enough, seemed thrilled to hear from me. Initially, I couldn't imagine why but the thought occurred to me that his secretarial protection was so thorough that he was essentially under house arrest in the ivory tower.  Even I was welcome.

He was very generous with his time and made many helpful suggestions that improved my patient's care.  He advised on at least two more cases  and was always welcoming when I called. While we were not equals, he made me feel that we were colleagues.  I hoped I could be as magnanimous as him one day.

So lesson learned - connect with anyone who can help a patient no matter how far away or exalted they may be - and a wall was breached.

Subsequently, my report on another case  at morning sessions resulted in Tuddle sending me on a fantastic journey that would leave many walls in ruins.  

The case involved a middle aged man with what appeared to be terminal liver failure of uncertain cause.  I was hoping Tuddle could pull the rabbit out of the hat but he was stymied too.   The only hope might be a liver transplant, but he seemed too far gone for that.

"So who knows more about liver transplantation than anyone in the country," Tuddle asked me.  This time I was ready.  " Dr. Sundale in Denver," I quickly replied.  "Good, call him, "he replied, true to form.

Emboldened by my experiences in Boston, I made the call with a trace of  confidence.  Sundale picked up the phone on the first ring and like Waldman was gracious.  After hearing the patient's history, I asked him if he had any suggestions.  He did - bring the patient to Denver - today.

I couldn't imagine how we could do that with such a sick patient, in such a short time, but told him I'd relay his thoughts to Dr. Tuddle.

Upon hearing Sundale's advice Tuddle got very quiet and asked me to check back with him in twenty minutes.  When I did he told me,  "Pack your bag, you are going to Denver with your patient today."

Impossible.  He had somehow commandeered a regularly scheduled Boeing 707 jetliner (no security checks back then) to take us to Denver just three hours after he first went into action.

Our entourage consisted of the patient, myself and two nurses on loan from the intensive care unit.  The airline removed about twenty seats for us then placed a curtain around the area, our makeshift hospital.  When we entered the plane, the passengers seemed both curious and animated to be rubbing  shoulders with what appeared to be modern medicine at 34,000 feet.

While the passengers seemed fascinated, I was intimidated by the responsibility that had been given me in a singularly unconventional environment.  Much could go wrong.

But the experience was heady too.  The captain came to me in the makeshift hospital to ask if  everything was ok.  I said things were going just fine and thanked him for his concern.  He then asked if the cabin pressure was ok.  I didn't have a clue, so  I asked him what he thought.  He thought it seemed good and I, after pausing a few moments, as if in deep thought, agreed.

We landed in Denver, thankfully without incident, where a waiting ambulance took my patient to the medical center.  He, alas, did not live more than another week but the trip might have been his best chance.

Lesson learned again.  Doctors should go far and wide when necessary to get their patients the best information and treatments and never be intimidated by celebrity.  When walls interfere, as they did in these cases, they must be breached, brought down and left in ruins even if you have to hijack, so to speak,  an airliner, Tuddle style, to do it.

During my career I had the great fortune to work shoulder to shoulder with some outstanding doctors.  They were a rich source of advice and consultation and I often called on them.  But at times, when we were stumped, I would hear a faint but distinct echo of Tuddle's voice exhorting me to cast the net wider still.