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.
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.
Both of your cases are instructive -a reminder to me that we physicians can often do more for our patients than we think we could.
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