Alpha Omega Alpha Inductees and Lecture by Bilal Ahmed, M.D.

Dr. David Guzick, M.D., Ph.D.

February 13, 2009

There are several days in the calendar of the medical school that mark important milestones—The White Coat Ceremony, Whipple Dinner, Match Day, and Commencement come immediately to mind. An important date on this list is the day we recognize our new inductees into Alpha Omega Alpha, the medical honorary society. Families travel from points far and wide to attend the AΩA lecture and dinner, and all concerned – faculty, staff and families – beam with pride. There are warm feelings all around.

This year's celebration occurred on February 5th. The 15 medical students selected for AΩA this year (by a faculty committee of AΩA members) elected a student President (Lisa Mead) and Vice-President (David Wilson), and also selected resident, faculty, volunteer faculty and alumni inductees.

Perhaps most important, they selected as their speaker Dr. Bilal Ahmed, Vice-Chief of Medicine, Highland Hospital, and Associate Program Director, Internal Medicine Residency Program. They could have selected anyone inside or outside of Rochester; the fact that they chose Dr. Ahmed, a previous winner of many student teaching awards, speaks volumes about their respect and admiration for his devotion to patient care, and his passion for communicating his message of humanistic medicine.

Dr. Ahmed's lecture follows. Also shown below is a listing of our 2009 AΩA inductees.

2009 AΩA Inductees

Students

Zarina Ali
Charles Eisenhauer
Lisa Mead
Jennifer Riehl
Alexis Weymann

Zachary Borus
Stephen George
Rene Myers
Solomon Shaftel
David Wilson

Elizabeth Crafts
Kimberly Lai
Brock O'Neil
Andrew Tompkins
Jonathan Wood

Residents

Jonathan Marcus, M.D., Department of Neurology
Melissa Samuelsson, M.D., Department of Neurology

Faculty

Jonathan Mink, M.D., Ph.D., Professor of Neurology,
and of Neurobiology & Anatomy & of Pediatrics

Volunteer Clinical Faculty Award

Teresa Chang, M.D.
Clinton Family Health Center, Rochester, NY

Alumnus

Elias Zambidis, M.D., Ph.D., Class of 1998
Assistant Professor, Oncology & Pediatrics
Johns Hopkins University School of Medicine

Keynote Speaker: Bilal Ahmed, M.D.

Bilal Ahmed, M.D.

It is a great honor for me to be invited to speak at the 2009 AΩA lecture. I am not a basic science researcher. I have not made an earth-shaking discovery. I am just a humble clinician. I do, however, have a very simple message for you. Each one of you has chosen and been given the unique opportunity of pursuing medicine as a way of life. I personally cannot think of a higher calling in life. My message is that how you utilize this opportunity depends not only on your competence in the practice of medicine, but in developing the art of doctoring.

Our personalities and character are shaped by the circumstances in which we grow up. Just like the stories we read, our lives have a beginning and an end. We plan, we dream and we act. There is a whole army of main and supporting characters and yet, some of us manage to shape our lives as we want to, in spite of all the odds stacked against us, and some of us fail to do us even when there are no obvious reasons to fail. Is the secret of success easy to decipher? I believe that as far as physicians are concerned, this secret lies in our ability to listen to the stories that our patients narrate to us.

The art of story telling is as old as the origin of our earliest ancestors. Narrative has always had the power to move the narrator from the pain of the moment to the possibility of a good outcome. Recounting one's story to someone who can offer the possibility of a cure or of help gives rise to hope, and hope has a powerful connection to the healing process.

Medicine holds within it a great paradox. On one hand, it is among the most dispassionate and fact-based branches of knowledge, while on the other, it is objective: health, sickness, healing and dying are among the most emotional parts of human existence. How do we deal with this paradox?

The clues to resolving this paradox lie in our patients' stories; if only we could listen to them less critically and cynically, they might inspire us to the more practically important discoveries of what truly ails them.

One common clinical scenario has become so familiar as to be regarded as paradigmatic of our distaste for the subjective. We frequently suspect patients are exaggerating their pain to obtain more narcotics, so we check to see if they are tachycardic, or whether they perspire or writhe in their sheets, ever on the lookout for more reliable objective signs of what our patient's suspiciously anecdotal description fails to convey. Yet even in the face of science and language's shortcomings and betrayals, understanding the patient's narrative ultimately helps us, if only we are willing to believe.

You might say that I am asking you to believe in "anecdotal evidence". In spite of all these stories and anecdotes which make us what we are, we are still trained in empiricism and are asked to reject what is not properly evaluated in a scientific trial. But have you noticed that in the same breath that we reject "anecdotal evidence", we also describe a personal experience of a particular patient to underline our argument? When the anecdote being described is of a person known to the physician, who in turn is known to the audience, that anecdote can have a greater influence, and it becomes both memorable and believable.

Learning from anecdotes, experience, mentoring and stories is essential to good medicine. It enables us to deal with patients as individuals and to respect their uniqueness as a person. I, too, have been trained to view the anecdote with the greatest amount of skepticism, if not outright disdain. The anecdote, though beguiling in its familiar engagement of our human sensibilities, is, we are all taught, the enemy of objective, dispassionate observation. But whether we choose to admit it or not, the anecdote continues to be an important engine of novel ideas in medicine. I look at the patient's narrative as the compass which guides us through a sea of tests and interventions.

What I intend to do today is recount some stories from my career which have helped shape me into the kind of person I am. These stories are also the driving force behind my desire to pass on the skills I have learned to the people who have embarked on journeys similar to mine. Most of the stories I will recount to you today are followed by a short poem that I have written pertaining to the circumstances surrounding those patients. Writing poems serves as a catharsis for me, especially after managing a particularly challenging or interesting patient. There is an old Greek saying: "Painting is silent poetry, and poetry is painting with a gift of speech." In my mind, poetry and narrative should be in the doctor's black bag, and can serve as our diagnostic and therapeutic tool.

One such story, which unfolded on the first day of my residency, spanned the disciplines of pharmacology, biochemistry, pathology, the power of observation and history taking skills. In the midst of an extremely busy shift in an East-End London Hospital Emergency Department (the same hospital where Jack the Ripper's victims were brought, and Jack the Ripper has a connection to Highland Hospital, but that is another story), I was asked to see a family of three children and their parents, who were brought on two different ambulances. The emergency services were called by the father who said all three children fell unconscious soon after drinking sweetened tea. The same fate befell the parents after they got to the hospital. The emergency crew was astute enough to bring the tea and sugar from their home. All family members appeared to be very cyanotic, and soon had to be intubated for respiratory distress.

I was attempting to draw a blood sample and noted that the blood was almost black. Not aware of the significance, I mentioned this fact to a well-known clinician and an astute observer for whom I had great respect. After hearing the story, he asked me about the significance of dark-appearing blood in this instance; I, of course, had no idea. He then quickly drew an Oxy-Hgb dissociation curve in context of this family's clinical appearance, and arrived at a diagnosis of Methemoglobinemia. (Now that is something to read about tonight.) Socratic teaching at its finest. We then quickly set up an IV drip of Methylene Blue. This family indeed turned out to have Methemoglobinemia due to ingestion of sodium nitrite, which they had mistaken for sugar. The father worked in the meat curing industry and had brought sodium nitrite home from work. Everyone survived, but not before sending me back to my books and teaching me lessons for life. I now never forget my oxy-hemoglobin dissociation curve and am always on the lookout for 'dark-appearing' blood samples and "BLUE PEOPLE". Coincidentally, we talked about Martin Fugate and the blue people of Troublesome Creek earlier today at lunch. They all had congenital methemoglobinemia.

This experience also made me realize that I had a lot to learn from my teachers, not just the ones teaching me in person, but my teachers through the ages, whom I had never seen. This case also marked the beginning of my experiments with poetry, and the poem I wrote was:

SOCRATIC WHISPER
Moonlit night
Quiet
Except for my footsteps
Over a road well trodden
I see and I hear
The shadow and the thoughts
Like infants just awakened
Voices long gone
Paying their overdue visits
I look at the dark trees around me
They give me the strength and resolve
That I never had
Are they showing me the path?
Yes
But only if I listen

Because of this and numerous other examples, I resolved to myself that I will do my utmost to pass on the importance of developing keen observational skills, and continually sharpening my deductive abilities by performing a thorough physical examination and paying attention to my patient's story.

No matter how wide the perceived gulf between science and the humanities, and no matter what new technologies may deliver in terms of more precise tests and life-prolonging therapies, the work of doctors will always necessarily take place at the intersection of science and language.

I will now digress slightly. Apart from the fact that we have to develop the skills to listen to our patients' stories, we all have our own stories to tell. We all have stories of how we got to where we stand today. We are shaped by our own unique circumstances, as are our patients. What are we but a conglomerate of our own stories, experiences and anecdotes? My own story has numerous twists and turns. How I happen to be standing here today is the result of thousands of sets of circumstances which very well could have produced different results. This is indeed true for all of you.

My great-grandfather was the son of a farmer in the Himalayan foothills. For some reason, an American Missionary decided to found a school in his village in the late 1800's. The presence of this school lit a spark and a love for education in my great-grandfather, but did not impress the rest of his family because he, like everyone else, was expected to earn his keep. He later accepted a post sorter's job in the local post office to support his education, and was found there reading Homer's Odyssey by Mr. Pickering, the visiting British Post Master General. This so impressed Mr. Pickering that he extended the offer of a free education at Oxford University to my great-grandfather, and he went on to become the Chief Justice of the International Court of Justice by the time he retired in 1950. The rest, as they say, is HIS-tory, or MY-story.

I stand here before you today because of Homer's Odyssey. It is a classic family story; all of us have grown up with these stories. These ancestral figures become a major part of our imaginative lives and subconsciously shape our personalities. Just like our families begin to tell us their stories when we are as blank as we are ever going to be, the stories our patients narrate to us paint a powerful picture of what ails them when they are confused and vulnerable.

I often imagine this picture that our patients paint for us starting as a black and white print with the colors gradually getting filled in as the story unfolds. Interrupting this process results in a very hazy print, leading to questionable treatment plans. Developing the art of "Narrative Competence" is about developing the ability to acknowledge, absorb, interpret and act on the stories and plight of others. The dichotomy between connection and detachment, listening and categorizing, compassion and objectivity has a long history in medicine. Rather than look at these as dichotomies, it might be wiser to accept them as insights from the nature of healing itself.

Part of my training in the United Kingdom was in the Manchester Royal Infirmary where Sir Thomas Percival first proposed a code of ethics for physicians and surgeons in a pamphlet published in 1794. I became interested in this document and am still impressed that in his writings he enjoined physicians to "unite tenderness with steadiness" in their care of patients. By "tenderness" he meant humanity, compassion and sympathy. Under "steadiness", Percival included objectivity, reason and integrity. He talked at length about the "coldness of heart" that develops in physicians who do not cultivate such virtues. Our failure to respect patient narrative and our detachment leads directly to the "coldness of heart" to which Percival referred.

As I say this, I also recognize that on one hand we emphasize that narrative constitutes the heart of medical practice, and empathy is the basis of a healing relationship. Yet when you eventually graduate, and you may have seen this already, you encounter an extremely powerful 'anti-narrative' culture. This teaches you that stories may actually obscure the problem. Very quickly the stories degenerate into 'hard' data, like labs, x-rays and Imagecast, etc. In a remarkably short time, you may learn to discount these stories; you learn to avoid speaking to patients and to yourselves and devote your energies to body pats and biochemical processes. The "coldness of heart" predicted by Sir Thomas Percival sets in.

I would implore you not to fall in this trap. So how does good listening help with healing? When patients are allowed to tell their story, they are no longer isolated in their suffering. The telling of the story may also help them to achieve a critical distance from their afflictions. To suffer is our existential destiny, but being able to relate our story to a healer can open the gates for interpretations and make change imaginable. Physicians often unknowingly erect barriers to patients telling us stories of loss, trauma or illness.

Listening and engaging patients can also make us cognizant of subtle clues which can open doors to a healing relationship. We may not realize this, but we are at center stage for patients and family members; they study us as if we are performing at a recital. They watch for visual clues, body language, our level of confidence and whether we seem distracted. Remarkably, there is now a Masters of Science course in Narrative Medicine at Columbia University, and its founder, Dr. Rita Charon, describes the "doorknob" phenomenon. It is the words physicians dread to hear at the end of their office visit, "Oh, by the way". This could be a reference to a harmless freckle, or more often than not, a preamble to revealing a frightening or an embarrassing situation. The best strategy to bring out these valuable clues to a patient's presentation is to stop talking, start listening and to simply ask "Anything else?"

Jerome Groopman, in his book "How doctors think", says that most of us use shortcuts. We interrupt patients within the first 18 seconds of the conversation and generate an idea in our mind of what is wrong with the patient, and spend the rest of the time trying to prove ourselves right.

In fact, this process of early closure or "pre-judgment" starts even prior to our interaction with the patient, and might be based on the patient's previous medical records or a conversation with another doctor. I recently (rather surreptitiously) decided to follow a group of medical residents and students when I was called about a 72 year-old patient in the Emergency Department. The patient had presented with symptoms of acute onset of shortness of breath. The first thing the team decided to do in the ER was to look at the patient's CXR, followed by his previous medical records in the CIS. It transpired that the patient had presented in a similar fashion three times in the past six months and was always managed as a "CHF exacerbation". The team then proceeded to talk and examine the patient who was indeed acutely short of breath with bilateral crackles, and was saturating in the low 80s on a 50% VentiMask. It subsequently did not take a leap of faith to treat this presentation as another episode of pulmonary edema and a high dose of Lasix was ordered.

So far so good. Or was it? I stepped into the drama at this point, and encouraged them to metaphorically take off the rose-colored glasses of our pre-conceived assessment and to revisit the assessment and plan based on a careful history and physical examination. It turned out that there was a remarkably different aspect to this presentation. The patient had chest pain relieved by leaning forwards. Careful exam revealed a JVP of more than 12 cm H2O, and then we decided to test for Pulsus Paradoxus. How old fashioned, some would say, but the patient had a paradox of 50 mmHg. An emergent Echo revealed a pericardial effusion estimated to be >1litre with acute cardiac tamponade. The patient had a pericardial window placed and subsequently did very well.

Giving this patient Lasix would probably have led to his demise that night. How much longer did it take to make our subsequent assessment, maybe seven more minutes than the first time around? The lesson is that the team I just described was not incompetent; they were doing their best, as they had been trained. Therein lies the reason I am making this speech today. There is something profoundly wrong with the way we are learning to solve clinical puzzles and care for people.
The Bayseian analysis whereby we evaluate in a linear way (i.e., history, physical, tests, results, followed by statistical probabilities) is fine. But in our efforts to be exquisitely evidence-based, we are forgetting what humans have done and developed over thousands of years. The visual impression of a patient as soon as we first see them, the tactile feedback of a handshake, or the hand on the shoulder help us in formulating hypotheses and diagnoses which can then be corroborated by tests—not the other way around.

IT IS ALL CLEAR
Where to start
Where to end
Terrible Illusions
Horrible Delusions
Forgotten Discoveries
Unsolved Mysteries
Intellect beyond my sphere
Is now clear
I now comprehend
The chain of thoughts
Hitherto, without an end
Light prevails
Because
I listened to my patient's tales.

Physician-author Abraham Varghese elegantly described the birth of the "iPatient" on our wards in a recent article. Today's doctors spend an inordinate amount of time in front of the computer monitor, charting in the EMRs, looking at labs and writing orders in CPOE, doing our best not to fall afoul of insurance company requirements, and that the lawyers are kept at bay. The patient is still at center stage, but more as an icon for another entity clothed in binary garments and tracked and trended like the Dow-Jones Index. Pop up flags remind care givers to feed or bleed. iPatients are handily discussed in the bunker, while real patients keep the beds warm and ensure that the charts bearing their names stay alive.

I sincerely believe in the philosophy that the joy, excitement, intellectual pleasure, pride, disappointment, and lessons in humility that trainees might experience by learning from the real patient's body examined at the bedside is lost when residents and students don't witness the bedside-sleuth aspect of our discipline — its underlying romance and passion. Rather, they may come to view internal medicine as a trade practiced before a computer screen.

I must say that what I am doing today is exactly what I have preached against throughout my medical career. I do my best to avoid formal lectures. I sincerely believe that when it comes to teaching clinical medicine, lectures are a poor substitute to the teaching in what I call the "hallowed sphere" around the patient's bed. They lead us to contemplate masterpieces created on the blackboard by ourselves. This may be an excellent exercise for people who patronize the arts, but this is not the way to make an artist.

Osler once said: "Medicine is learned by the bedside and not in the classroom. Let not your conceptions of disease come from words heard in the lecture room or read from the book. See, and then reason and compare and control. But see first."

When I started my training as a novice intern at the Royal London Hospital, my teacher was Lord John Badenoch. He was a character right out of a Dickensian novel and was a stickler for detail. God forbid if you approached the patient from the LEFT side of the bed and not be able to observe and deduce at least 3 of the patient's afflictions BEFORE you had even started talking to the patient. The first question he would ask you after leaving the room would be something like, "So, what was Mr. Peabody's granddaughter's name?" Of course you'd be chastised if you had not noticed the child's signature at the bottom of the get well card on the patient's bedside.

Lord Badenoch showed the characteristics of the best of our breed—thorough, infinitely patient, compassionate, wise and with a great human touch. What I learned from him was the art of observation, and I still marvel as how he would arrive at a diagnosis with a very carefully obtained history and a thorough physical examination. One of the oft cited reasons for the rapidly rising health care costs in the US is excessive and sometimes needless testing. I would argue that some of this over dependence on tests is the poor diagnostic abilities and lack of confidences in our bedside skills.

I will now relate to you a few more stories from my career, which helped shape me as a person and a physician.

DEAD MEN DO TALK.

My grandfather was a physician, and to while away some time after college before I joined medical school, I used to accompany him on his home visits. We visited the home of a cab driver who had four kids. The father had a strong drive to perform some public service, and would voluntarily cook and deliver food to a God-forsaken TB sanatorium. One thing led to another, and he himself contracted TB, and my grandfather was following up to check PPDs on the rest of the family. I subsequently joined the medical school and forgot all about this little home visit. In my first year, two other students and I were assigned to a cadaver for anatomical dissection. I always used to get an uncomfortable feeling dissecting my cadaver, but put it down to nerves. After about a month, we finally cracked open the chest, and I had my first look at human lungs. They were extensively scarred. Our anatomy teacher immediately surmised that the person had died of pulmonary TB, and then It HIT me. I looked at the cadaver's face, and it was the same person I had visited with my granddad.

I subsequently decided to retrace my steps and went to see the same family. Unfortunately, every member of the family had contracted TB and did not have the finances to get treated. So we did what medical students excel at, we got together and arranged TB meds for the family. One of those children is now a world authority on Multiple Sclerosis.

LESSON: We are all repositories of what the world has given us. Our diseases and illnesses do not occur in isolation. There is a lot more to what patients bring with them when they come to see us, we only have to look.
I was so affected, that I wrote this poem at that time.

I AM NO GOD
When I was young
I knew everything
Could do anything
I was God
Today
I know, I know
So little
And am barely inches
Above ground
But contentedly
I am no God

LISTEN AND LEARN

I was working in a woebegone Welsh hospital in the Rhonda Valley north of Cardiff in the middle of an especially harsh winter. A Welsh sheep farmer was admitted through Emergency, and his command of English was very limited. He would go saying "Myfi Dodwy", which crudely translated to English means "I am laying eggs".

What would you do if a patient gets admitted saying that. RPC? Psych consult? We ended up admitting the patient as he had an infected central abdominal scar and he was started on IV Antibiotics.

I subsequently forgot all about him. It was a dark and a stormy night with a horrendous thunderstorm passing over the valley. Around 3 AM, the nurse came running down this long Nightingale ward and one look at her face told me that something was very wrong. She looked as if she had seen a ghost. "Doctor", she said, "You remember the patient who told you he was laying an egg? Well, he is laying one right now!" I had no idea what she meant. I sprinted with her to the patient's bedside and saw a drama unfolding from behind a moveable partition. The patient was coughing and a glistening white ball full of fluid of a jelly-like consistency was coming out of the central abdominal scar.

I do not know how many of you have seen the movie "Alien", but I of course had timed it perfectly and had watched it the night before! This was too much of a coincidence. To make a long story short, and to relieve you of your agony, the patient had a Hydatid Cyst which had been removed from his liver a few months earlier. Some of the contents of this cyst had ostensibly been spilled during surgery and he had metastatic cysts in his abdominal cavity and even in the intestinal epithelium. He actually was "laying eggs", as he was passing fully formed cysts with his stools.

Never again will I not believe what a patient tells me.

I AM INSIDE YOU
As the colors emerge from the painter's brush
Says the picture, I am inside you
As the ocean turns itself upside down
Says the fish I am still inside you
As the narcotic relieves the pain
Says the suffering, I am inside you
As the happiness strikes its moment
Says the pain, I am still inside you
As the life arrives in the early hours
Says death, I am still inside you
As you move on to the next patient
Says your healer's touch
I am still inside you

In addition to becoming adept at listening, I have put together some thoughts to help you as you progress through your careers.

Reflect on who you are. Dwell on your strong character traits. Each one of you brings a unique perspective to this world.
Strive for perfection, but don't be dismayed if you cannot always achieve it. Medical school and residency as well as life will present you with far more problems than you can possibly solve. This is not inadequacy on your part. Winston Churchill was quoted in the early days of WW2, "It is no use saying 'we are doing our best'; you have to succeed in doing what is necessary."
Most of your lasting medical knowledge will be learned from caring for your patients. Patients are our educators; I sincerely believe that talking to patients, sitting down next to them, doing a thorough physical exam, which by the way also adds human touch to the experience, is immensely more therapeutic and important than writing a 5-page admission note.
Develop tools to deal with "if only" scenarios.
Transmit what you have learned to people who follow you. Lead by example.
Find a mentor to help you find your way through the maze of life.
Take some time to reflect and write stories or poems or explore the world of arts. Successful physicians have more vivid imaginations, are more receptive to their emotions and are more attentive. It helps that doctors are immersed in stories. If the business of medicine is taking care of patients, then the currency used in the transaction are the narratives of illness told by patients and received by physicians. We spend a good chunk of our professional lives listening to stories. It's only natural that doctors would retell versions of these tales or craft their own new ones. All the elements of a story are readily available to any doctor: plot, protagonist, antagonist, setting, dialogue, and theme. Physicians witness struggle - disease, death, and suffering - all the time. Writers call it conflict. We regularly observe cures, acts of heroism, and even miracles. Writers refer to it as denouement. Doctor-writers have oodles of experience to tap from. There is a rich pipeline of poignant images, unforgettable language, colorful characters, and vexing irony that we observe in any single day. Writing about these experiences can be therapeutic and sometimes a path to atonement. You have now been elected to this august society. AΩA and the love of literature go hand in hand.
Finally, congratulate yourself. YOU HAVE ARRIVED, you have achieved a lot. As you go on to become the teachers and leaders for tomorrow, sprinkle in some empathy, humaneness, respect for your patients and be thorough. The sixth sense that you develop along the way by utilizing your five innate senses will guide you and compliment your quest for empiricism and scientific justification.

LIFE IS A STORY
It has no beginning And no end
It just happens
Without our consent
The twists
The turns
And the unexpected surprises
It unfolds in front of our eyes
We see it, but maybe not
We stumble
We fall
Then we finally learn
If we are lucky
To solve this riddle
And what do we find?
All it takes is an open mind.

Congratulations again on being inducted in the AΩA Society. But, if all of this does not make any sense to you at all, and you still think you are in the pits, I will quote Winston Churchill for the last time. "If you are going through hell, keep going."

Meliora,

David S. Guzick, MD, PhD
Dean, School of Medicine and Dentistry
University of Rochester

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