Title Page, Copyright, Dedication

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pp. i-vi

Contents

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pp. vii-viii

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Preface

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pp. ix-xiv

Like so many young people, I was totally ignorant of the reality of being a physician. I entered medical school in 1969 with the vague notion that I wanted to help people and an even vaguer concept that I had the capability to learn to do the job. There were supporting factors, which I would have acknowledged if asked. Both of my parents had suffered from tuberculosis in the pre-antibiotic era, which affected them deeply. They both recovered, with my father...

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Back Pain

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pp. 1-8

When I first met Mr. M., he was an imposing figure, and it was clear he was trying to intimidate me. He was over six feet tall and heavyset, with very fair, freckled skin and a thin patch of orange hair. He said, “So you’re my new doctor, eh?”

Accompanying him was his wife of forty years. She was a diminutive and quiet woman with obvious rheumatoid arthritis affecting her hands and legs. It was clear she let him...

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It’s a Small World

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pp. 9-16

A.S. was a forty-four-year-old information technology (IT) worker at our hospital who had been in good health all of his life. Born in the Philippines, he immigrated to the United States at the age of ten. He grew up in Houston and earned a degree from Rice University. He had been employed by our hospital IT group for the last eight years. When your computer froze or you needed help with a network program, he was often the one who showed up and fixed...

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Everything Really Can Go Wrong in the Hospital

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pp. 17-26

He was a spook. It was never clear to me what branch of government W.S. was in; all he would reveal is that he knew a lot about nuclear weapons and had worked with the State Department developing concepts for global and regional nuclear disarmament. He traveled by military air transport when he flew, so he must have been a somebody.

He was in his late fifties and a Yale Man—yes, some people of a certain stripe and vintage still would unabashedly...

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Friday Night at Five

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pp. 27-34

Like many of my patients, E.M. worked in the hospital. She was a psychiatric social worker who worked specifically with childhood cancer survivors now being seen as adult patients.

Large hospitals have employees who often have very specific preferences in physicians, and word spreads quickly as to which physician is good at what. This patient had first been seen by a partner of mine, with whom she didn’t get...

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Learning from the Patient

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pp. 35-44

First Year of medical school was torture, but Second Year was fun. Things have changed a lot in the more than thirty-five years since I graduated, and if they continue to change at such a rapid pace, medical students might actually be doing complex neurosurgery during their first two weeks of school, in the name of keeping their education pragmatic and patently useful.

But back when I went to medical school, our education was not so sped up. First Year...

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Explosive Illnesses Do Not Respond to Homeopathy

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pp. 45-54

She was a slight, reserved African American woman whose kidneys had stopped working. She had been urgently admitted from the ER to our inpatient service and had been feeling poorly at home for about a month. She had decided to cleanse herself with various homeopathic agents, but she noticed that she wasn’t feeling any better and had developed a cough that would not stop. When she started coughing up blood, she came...

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Sometimes, All We Get Is Close

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pp. 55-60

Mrs. H. felt fine until her first pregnancy. Her early childhood was completely normal. In adolescence, though she felt she was overly concerned about her weight and appearance, she never indulged in any dietary excesses or severe strictures. She was never the “triple cheeseburger, fries, and chocolate shake” kind of person, but she ate her fair share of unhealthy foods.

She was an outstanding student and won an academic full scholarship to her prestigious...

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Thinking Can Sometimes Make a Difference

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pp. 61-70

D.J. had always been obese. as a young girl, she hated gym period, as she was slow, heavy, and felt ashamed. She started and failed many dietary regimens into her forties. As she said to me, she knew more about calories and the values of certain foods than any doctor she had ever met—and certainly, when it came to me, she was spot on.

Physicians use a quick measure of obesity called the body mass index—the BMI. It has its problems as a metric, but it...

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The CPC

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pp. 71-80

Medicine is a profession and not just a job. That is both the good news and the bad. The public expects, and the profession demands, that care is not rendered like a job—where one shows up, does one’s work, and leaves without a further thought about work until the next day.

Part of what shapes medicine as a profession are the educational activities that have traditionally been utilized to train doctors. Many of these activities have evolved with the...

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Let the Facts Speak for Themselves

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pp. 81-92

“Dr. Mushlin, will you come in here, please?”

Nicole was a nurse on the tenth floor I had known for eight years. We had worked often together. She was resourceful, independent, and very capable. For her to ask me to help her was beyond unusual.

I entered the room of Ms. B., one of our new admissions for the day on the Intensive Teaching Unit. Ms. B. was screaming at Nicole and calling her all kinds of names, none of them...

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Cough

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pp. 93-100

Dr. C. is tall and very lean, and when I see him, I always think that he is one of my very true liberal friends. He is on the side of the working man, the disenfranchised, and the dispossessed. He tilts at windmills, daily, and never tires of it. And he gets into trouble for it. An administrator took him to task when he bought medications for one of his clinic patients who couldn’t afford them. To some, that’s a boundary violation; to me, that is simply Dr. C. His...

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Great Imitators, Part 1

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pp. 101-108

One of the reasons I was attracted to internal medicine as a medical student was the adventure of figuring out how to diagnose the great imitator diseases. At conferences, an esteemed clinician would often be given a particularly opaque case for diagnosis by a smug chief resident (who knew what the correct diagnosis was), and the clinician would test the case against the great imitators, those diseases whose manifestations are so protean and difficult...

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Great Imitators, Part 2

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pp. 109-118

Tuberculosis played a large part in my life, and it undoubtedly contributed to my becoming a physician. I grew up surrounded by its effects, and, as is characteristic of the illness, it continues to lurk all over the world, killing the impoverished, the imprisoned, and the unwell, as though antibiotics to treat it never existed.

My father was a first-generation American. His parents were immigrants, and they were poor. Once in the United...

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Moonlighting

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pp. 119-126

I had had a long night. I was moonlighting in a small fifty-bed hospital in the western part of the state. It was in a blue-collar area with a lot of factory workers. I had worked a Friday-night-to-Saturday-morning shift, and it was the day of the month the factory workers received their paychecks. Often, a significant percentage of the workers’ pay ended up at the local bar or liquor store, and I knew it would be a busy night....

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Playing the Ponies

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pp. 127-138

I went into private practice for a number of years. The reasons were multiple, but not the least of which was the difficulty I had supporting my growing family on an academician’s meager salary. I was moonlighting one or two nights a week on top of the ten-hour workdays of my regular academic job as a clinician/teacher—a prescription for fatigue and burnout. Faculty salaries in the late 1970s to the mid-1980s were notoriously poor, and it certainly would...

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Who’s the Greatest of Them All?

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pp. 139-144

Friends and family often ask me who the best internal medicine doctors are. I never hesitate to respond: infectious disease doctors. My opinion is, of course, fashioned from the people I have encountered and the places I have trained and practiced, but I would suspect that across the country, and perhaps even throughout the first world, this endorsement would endure.

I base my opinion on a number of factors....

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Making a List and Checking It Twice

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pp. 145-152

Mr. R. was obese. I mean, really obese. Obese to the point he had to use the only plus-sized MRI machine available in Boston. His wife, Mrs. R., was a doctor lover. She never was satisfied with just a second opinion. For every hangnail, freckle, or single change in bowel movements, she wanted three or four opinions. She was the captain of the marital ship and would be in the room whenever I talked to Mr. R. She remained in the room when I...

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Poems

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pp. 153-162

Mr. F. was a postal worker. He could have done a lot of jobs, as he was intelligent, read widely, and was an honorably discharged Vietnam veteran. But, whether it was because of his upbringing with a physically abusive father or his experience being “scared shitless” in the tunnels of Vietnam, he wanted a safe and easy job. So after a few years driving long-haul trucks, he passed the U.S. Postal Service exam and became...

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Iron Man

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pp. 163-168

Mr. B. lived to sail. Of course, he loved his wife and kids, but if you forced him to choose which one thing he could love, it would be sailing.

He had grown up on the south shore of Massachusetts, and from an early age he had been on sailboats. His family owned the local large hardware store and lumberyard, and the family business connected him to his many wealthy neighbors. When he was in his teens, he served as crew on boats...

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An Octopus Pot, Voodoo, and Chang and Eng

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pp. 169-174

They were the Boston equivalent of the residents of Downton Abbey. He was a Harvard grad who, after a career in the U.S. Marines, went to Harvard Divinity School and became pastor of a successful and charitable suburban Episcopal congregation. She was a Radcliffe graduate who raised the children and supported her husband’s careers while volunteering and doing good works. They were decent, honest people who saw the good in others and loved...

About the Author

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pp. 175-176