My First Patient

The Color of Atmosphere

If answers were what I craved the most back then, poised as I was on the threshold of my medical career, then Mr. Williams was just what the doctor ordered.  Mr. Williams, as calm and patient as a snow-covered garden, answered every one of our questions that day, the relevant ones and all the others. I remember rebreathing my own air in that stifling hospital room as we asked him, self-consciously, about his drinking, and meticulously examined the dusty surface of his skin. It was the final question, or more precisely, Mr. Williams’ answer to it, his determination to be helpful, that startled me out of my stiff, new doctor role. We all want answers that fit, that reassure us of our rightness, our competence. We, the initiates in medicine as well as the experienced, the doctors as well as the patients, tend to harvest those answers as selectively – and sometimes as foolishly – as we plant our questions.
I was a second-year medical student at Georgetown, paired up with my classmate, Randy, for the Physical Diagnosis course.  After endless hours of barely intelligible lectures and countless slide shows in darkened auditoriums, we were finally going to be seeing and touching patients. We read all about how to perform a thorough history and physical – which is like reading all about how to sail a boat. Sitting in Randy’s living room, sharing a pizza, we made a list of all the questions we should ask.
Have you ever had double vision?
Do you have ringing in your ears?
Lumps in your neck?  Burning in your feet?
Then we wrote down all the steps of a complete physical exam, starting at the top.
Is there any unusual shape to the head?  Does the hair appear brittle?
Completeness was our watchword.
The next day we donned our hospital nametags, bolstered by the fact that only the most astute patient would notice the M.S. (medical student) after our name instead of M.D.  We gathered all our expensive new doctor toys – ophthalmoscope, otoscope, stethoscope, penlight – and packed them in our stiff new black bags, the kind used only by medical students and actors who play doctors on TV.  We drove clear across town to D. C. General Hospital, and wound our way through a maze of soiled hallways and slow moving elevators to the Internal Medicine ward, clutching those little black bags as if they were life-support systems.
D.C. General was as far from Georgetown as you could get without a passport.  For one thing, the nurses, all women of color, seemed exceedingly kind.  They handled us like little lost lambs that were under no circumstances going to get slaughtered on their shift.  This was very different than the  “I-could-squash-you-like-a-bug” reception we experienced on our brief forays into the healing halls of Georgetown University Hospital.  But “the General’s” healing halls had its problems too.  The floors weren’t going to lose that grayish-brown hue no matter how often they were scrubbed, and the walls wept for a new coat of paint.
Dr. Razi was the ward resident, an Iranian doctor who came to the U.S. to do his Internal Medicine training.  His last name wasn’t Razi.  His last name was difficult to pronounce, and in Georgetown’s orbit in 1977, if your ethnic name was too hard to pronounce, you either got a nickname, like Razi, or got called by your first one. It did not occur to me to question such a workable arrangement.
Dr. Razi was nervous and skinny, with a wild look in his eye, and he immediately began interrogating us about our role (as representatives of the U.S. in general) in propping up the Shah of Iran.  He became agitated when he realized we had only the vaguest idea of what he was talking about.  I guess I hadn’t questioned U.S. foreign policy too much, either.  I couldn’t wait till he found out how little we knew about heart murmurs.
Dr. Razi handed us a metal chart thick with handwritten pages.  The first unsuspecting victim of our medical careers was an aging gentleman with alcoholic liver disease. Our job was simply to check him over from head to toe, to get the feel of what it was actually like to talk to and examine a patient.  Randy and I sat down in a cluttered corner of the nurses’ station and combed through that chart like it was the Dead Sea Scrolls, searching for the information that was going to make us feel like we knew what we were doing. That avenue had been pretty much exhausted by the time the revolutionary reappeared to get our sorry imperialistic butts in gear.
“Haven’t you two started yet?” Dr. Razi demanded.
A few doors down the hall, in a room with rows of beds separated by drapes that were hung like shower curtains, Mr. Williams was laying on his freshly made bed, waiting for us. He had dressed for company, with crisp blue pajamas and a seersucker bathrobe tied neatly at the waist.  He had white hair and white teeth, and his brown face was a little raw, as if he had just shaved.  He looked pleased that we dropped by.
Randy and I introduced ourselves, and produced the clipboard that held our list of questions and our physical exam cheat sheet.  Mr. Williams graciously answered every question that we nervously read to him.  He assured us that he did not have facial pain, or droopy lids or fruity-smelling breath, or unusual rashes on his palms or soles.  As I stood perspiring in the airless room, our patient relieved us of any concern that his heart skipped beats or that pain radiated down his legs.  With unwavering dignity he denied any troublesome penile discharges or scrotal swelling.  And when he finished answering all those questions, Mr. Williams endured an equally exhaustive inquiry into his family history, straining for our sake to recall what he could about his grandparents’ health at the turn of the previous century.  He never asked for a glass of water, much less an attorney.
The talking was just warm up.  After an hour or so of interrogation, which had probably violated several articles of the Geneva Conventions as well as the Hippocratic oath, it came time for the physical.  Randy and I double-teamed it, each of us causing the poor man temporary blindness, first in one eye and then the other, while doggedly looking for the optic nerve with our spiffy new halogen lights.  We worked our way down his body, looking for  congenital malformations of the ear lobes, and further down, concentrating on his heart sounds at great length so that we could match up the lubs, dubs and swishes to the unseen machinations under his chest wall.  We checked him for hernias, and noted every brown spot that had come to grace this man’s surface over the previous six or seven decades.  To our credit, caught up as we were in the mole counting and toenail inspection, we managed not to miss the yellow tinge of his eyes, or the fact that the rubbery edge of Mr. William’s liver, which we tried so insistently to locate at the bottom of the rib cage, actually extended several inches below it.
A diagnosis of alcoholic hepatitis.  Enlarged liver.  Got it.
Then, as now, nothing in this world seemed as satisfying as having the puzzle pieces fit together.
The formal mental status exam came last.  Randy and I had finished our four-week psychiatry course, and felt we knew a thing or two.  We had conspired in advance to check our patient for alcohol-related brain damage.  His unfaltering performance up to this point had somehow not settled the question for us.  A supervising doctor had taught us a “trick” in assessing cortical function: pretend to hold up a string, and ask the patient what color it is.  The patient should of course respond that there is no string there.  If he says its pink or orange, he is confabulating, meaning his brain cortex isn’t working so well.  He is sure that there is a right answer, so he makes up an answer that he hopes will fit.  So, with thumbs and forefingers pinched together, Randy held up an invisible string, and asked this saintly man what color it was.  It was our turn to be patient.  After some time, Mr. Williams gave us his considered answer:
“It is the cullah of atmosphere.”
A self-satisfied grin broke across Mr. Williams’ face.  Confused, I looked over at Randy on the other side of the bed, and he was frowning at the string himself, as if wondering if he’d missed something.  I scanned my clipboard uselessly.  We were a couple of ships without a rudder, startled into the sudden realization that all the factual information in the world couldn’t protect you from uncertainty. Sometimes, it could even protect you from the truth.  After all, it was the color of atmosphere.  Except, of course, for the fact that there was no string.
Of all the pearls that Mr. Williams offered us that day, this was the one I would carry with me throughout my career as a pediatrician.  Even as the practice of pediatrics evolved, the lesson never lost its relevance. There was, for example, pediatricians’ relentless use of antibiotics to treat the middle ear fluid that was ubiquitous in our patients, as we waged war against an imaginary epidemic of language delay.  We had plenty of scientific studies to refer to, plenty of supportive data that obscured the fact that our goal was invisible.  Hundreds of thousands of antibiotic prescriptions later, we finally took a more critical look, and reversed  that practice.
There have been plenty of other examples, outnumbered, but also camouflaged, by all our true accomplishments. Perhaps no where was the lesson more stark than when pediatricians grimly acknowledged how wrong we all were about SIDS and sleep position. For decades, contrary to the evidence offered to us by the rest of the world, we  stubbornly insisted that U.S. babies sleep on their tummies, and in doing so, unwittingly put these babies at risk. At the time our first daughter was born, not keeping your baby on its tummy to sleep was tantamount to neglect.  Three years later, pediatricians did an about face – literally –  my second daughter enjoyed all her snoozes on her back, and  the rate of SIDS in our country took a long, glorious nose dive.
Even now, as pediatricians accept the task of diagnosing learning issues, or treating mental illness, or tilting at the windmill of childhood obesity, I see our dedication and commitment – If we don’t take on these issues, who will? – but I have learned to pay attention to the illusive sense that it doesn’t seem appropriate, it doesn’t seem effective. I can’t honestly say that I see the string.
But back then, an initiate at Mr. Williams’ bedside, I couldn’t discern much beyond that hospital room.  All I could see was the blurring of uncertainty, the seduction of an answer that fit.  I slowly repacked my bag, neatly wedging my reflex hammer between the penlight and the coiled measuring tape, comforted by the way they all fit together.  Randy and I said our thanks and goodbyes as we backed out of the room, and turned to face the dizzying traffic of the corridor, hoping to make our getaway without running into the difficult medical resident whose name I had already forgotten, hoping for a chance to regain our footing.  We had just tripped over an unsettling reality that I was starting to sense more than see: It would not always be a simple matter to distinguish a satisfying answer from the truth.

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