Sherwin Nuland's Tales from the Bedside
Steve: Welcome to Science Talk, the weekly Podcast of Scientific America, hosted on April 23rd, 2009. I'm Steve Mirsky. This week on the podcast, Dr. Sherwin Nuland talks about his new book, The Soul of Medicine: Tales from the Bedside. Plus, we'll test your knowledge about some recent science in the news. Sherwin Nuland is clinical professor of surgery at the Yale University School of Medicine and a fellow at Yale's Institute for Social and Policy Studies. He is also a prolific writer: How We Die: Reflections on Life's Final Chapter spent 34 weeks on The New York Times best seller list and won him the National Book Award. Nuland's latest work, The Soul of Medicine: Tales from the Bedside was just published. He visited Scientific American's offices on April 22nd, and we spoke in the magazine's library.
Steve: Dr. Nuland, it's a pleasure to speak with you.
Nuland: Oh! It's a pleasure to be here.
Steve: This is a book that, I have to tell you, I was purposely trying to slow down my reading speed at the end, because I didn't want it to end.
Nuland: Oh! What a wonderful thing to hear!!!!
Steve: It's too short, we need a volume II. It's a really interesting take on doctors and their patients and it's done in this Canterbury Tales-esque Chaucerian fashion. Why did you decide to do it that way, first of all?
Nuland: Well, There are two reasons. The first reason and the primary reason is that like every hospital probably in the world, at around midnight, the residents get together and start telling stories in the cafeteria. I went through six years of residency, and I think just about every night, unless there was emergency, I was up in that cafeteria hearing wonderful stories. And I began actually to think of medicine as a bit of a storyteller's art. I can well understand why people like Anton Chekhov, or Lewis Thomas for more modern times.
Steve: Somerset Maugham.
Nuland: Somerset Maugham ... as a matter of fact, the greatest medical writer for my money is, was William Carlos Williams, and essentially he was telling stories in his stories of his everyday life; and he never magnified anything, it was just as those of us who were doctors recognized it. So, I follow in this tradition of telling stories. The reason I chose Chaucer, The Canterbury Tales, is because of the hospital cafeteria thing. Plus, I belong to a small discussion group at the university, and one of the members is this marvelous woman, Marie Borroff, who is one of the world's experts on Chaucer, and I adore Marie and some of it is in tribute to her.
Steve: You spoke of this tradition and there is this tradition of physician writers, and does it come from the fact that the stories are inherently dramatic? You know, we're never gonna run out of hospital-based television programs because the stories are just inherently interesting, and it's the human drama. Or is it also something about the practice of medicine requires you to write these charts everyday? I remember very distinctly, having caught a glimpse of a chart on my mother and the very beginning said, "A pleasant 81-year-old woman". I'll never forget that word, 'pleasant' because it indicated that something else was going on with that doctor. There was an evaluation of the person, not just the condition.
Nuland: We were taught to write our histories as narratives and even the smallest detail in a narrative makes a huge difference; because by the time you finish reading someone's narrative, you must have an image in your mind of what that patient looks like, what their personality is like. I understand them from what I've seen, that nowadays the younger people are more likely to make short shrift of that narrative because they rely much more on technological maneuvers and new modalities that didn't exist in my time. But this is the way all of our narratives were, and I'm not the least bit surprised to have heard that this word "pleasant" appear[ed], because that becomes very important. For example, if someone is acutely ill, do they appear to be pleasant? They don't. If someone is a hypochondriac or has symptoms that are being magnified, are they likely to
be see[m] pleasant? Not at all. You can almost tell that this woman is a reliable narrator of her own story, just from that one word, "pleasant", and if you were to have read the rest of that so-called present history, as we always called it, you would have come away recognizing your mother as written by someone who had never laid eyes on her before.
Steve: It's a fascinating part of the skill of being a physician that people who are outside that profession probably don't recognize, and that's something that's not really portrayed in popular presentations [like] ER. Why don't we talk about some of the tales in the book. There are some that are just kind of inherently interesting and then there are some that are hilarious. Why don't you tell us a story very briefly about the scene in the emergency room where one surgeon is chasing another one around and he gets his foot caught in a stool.
Nuland: Oh! This was in the operating room actually.
Steve: The operating room...
Nuland: It became legendary at the hospital—Canterbury Hospital as I call it, that I was trained in and continued to work in for 30 years after that—[about] this fellow who was leaning over the operative field, he shouldn't have even been in the operating room, he was observing.
Steve: And he knew that the surgeon always looked straight down at [the patient]...
Steve: ... and would not realize that he was in the room.
Nuland: Totally focused, in addition to that is something I mentioned about that particular surgeon in another chapter, which is [that] he had very bushy eyebrow[s], so he couldn't have seen upward even if he wanted to. So here's this long drink of water of [a]
our fellow, leaning all the way over and, in fact, saying something to the intern, who, [or] the resident who was assisting about the best way to feel this particular vessel; and the Professor, as we always call[ed] him, turned around in [a] rage and here this gangly guy sort of leaped off the stool on which he was standing, put one foot without meaning to in a sponge bucket and then went stomping out of the operating room with the professor chasing him, [uttering] the professorial equivalents of [vile imprecations].
Steve: It's just a funny scene to contemplate happening in an operating theater. You have other stories that are heart breaking. There is a terrible story about a victim of child abuse and the reaction of the medical student who has to confront this situation and what it does to the medical student after he has seen the perpetrator of the child abuse.
Nuland: The abuser was the boyfriend of the child's mother, and the child had been beaten very badly with injuries that were really beyond belief; very bad head injury which of course in the end carried him away and everybody was so unbelievably outraged about what had happened that they made sure they recorded this in the chart. And it's perfectly clear reading that chart just how furious everybody was and wanted to make sure that the person who had carried out such a deed was probably punished, which he was.
Steve: There are approximately 25 stories.
Nuland: It's about that, perhaps a few less, not many
Steve: And you tell two of them personally, the other ones are told by the specialists in their fields. The first one you tell is just an amazing story about what can go wrong in the human body when it's treated the wrong way, but then there is the story within the story about the reaction of this same surgeon-in-chief with the bushy eyebrows when you think—this is when you were a novice surgeon—and you think you've realized something new. Why don't you briefly tell the story of this young fellow ...
Steve: ... presents himself and you won't believe what was in him.
Nuland: This fellow came in, he was 19 years old, and he came in with a very high fever on the medical service and the medical health staff were putting needles in his chest trying to get some of the fluid out, which could be seen on x-ray, just in the left chest, couldn't do it, called the chief resident on the chest service, who was me, [at] that time. I used bigger needles, couldn't get anything out, finally took him up to the operating room to do what was called a mini thoracotomy. I just took about an inch of rib out and opened into the chest cavity and to my amazement, my assistant's amazement, little pieces of stool fell out in the middle of the pus, the pus had this dreadful feculent odor, the whole place was filled with it; I changed gloves, everybody changed whatever they were wearing, we opened the chest under general anesthesia and discovered that we were looking down on his diaphragm and there is this perfectly flat sheet of muscle of the diaphragm with a hole in it about the size of my fifth finger, through which a couple of inches of large intestine had snaked, gotten twisted off, perforated and stool from the large bowel was actually emptying out into the chest cavity, which caused the response and the fluid and the pus and all this. And I did what needed to be done, I short circuited the bowel by making a colostomy out of it. I closed the opening, this little opening in the diaphragm, closed the chest and went downstairs— by now it was about 3 o'clock in the morning—and tried to get a nap, but there was grand rounds, the big conference of the week, the following morning.
Steve: And this injury had been sustained years earlier, he had been knifed.
Nuland: When we finally found out what caused it, we looked at an old emergency room sheet that everybody had neglected to look at, and it told the story of this boy at age 15 having come in with a superficial wound just through the skin and fatty tissue, it seemed from a knife fight, someone had tried to steal his Mets jacket or some such thing.
Steve: I think it was a Red Sox jacket.
Nuland: It was a Red Sox jacket.
Steve: According to the book
Nuland: It was a Red Sox Jacket, [oh] he was in New Haven, [of course it was] a Red Sox jacket. And he went to the emergency room and thought it was nothing, put a little antibiotic gauze on it and said come to the clinic. Of course, the kid never came to the clinic, and we could easily figure out what had happened, which was that the knife had been plunged in, in an upward direction, pierced the diaphragm and this fellow had pulled the knife out. Now a hole like that should heal, but for some reason it didn't, so the boy was left with this very small hole that he had been carrying around for about four years. And then one day, probably about a week before his hospitalization, the gut decided here's my chance and made its way up into the chest. So getting back to that night, I couldn't sleep, I was to meet the professor at 7:30 in the morning, just before grand rounds—we did that every day, so I could tell him what had happened during the night. And I told him the story and I was really very excited about it, and I said, "Gee! This must be our first, we are going to publish this, and you never know, it might get itself called—Nuland Syndrome!" So he looked at me with a stern Swedish Norseman, I could just see him coming over the horizon and then the country folks scared to death. He looked at me and said, "I suppose, you think, you're the first surgeon that has ever seen something like this", and then I knew he had me, because he was a historian. And he took me into his office, he pulled down this 16th century book, a real octavo volume book, big thing, started turning in the pages and little bits of brown papers began coming off the pages and there in the Renaissance French was the description by Ambrose Pare of a certain major, who, in one of the battles that the Catholics were always having with the Protestants, got hit with a harquebus or a musket—I can't remember which right now—and he died two weeks later. And when they did his autopsy, his chest was full of pus and he had a hole and it was described in the French, the hole, "comme un petit doigt"—like a little finger.
Steve: Which is exactly the way you had described it.
Nuland: Same thing. So Nuland really got his comeuppance.
Steve: But at the end of this little interaction between you and the chief of surgery there, there was this very kind of paternal moment that you had not seen exhibited from him before.
Nuland: Never, never before. It was a wonderful moment, because essentially we had shared this thing, essentially he had brought me along in something that he was interested in—medical history, which I had not yet gotten interested in (as a matter of fact, this story started my medical history career)—and feeling so pleased with both himself and me, he put his armor around my shoulder and together we walked into grand rounds.
Steve: He was actually quite proud of you.
Nuland: Exactly right, yeah.
Steve: And the other story you tell also culminates with a doctor putting his arm around you; the story you tell about the discovery of your daughter's hydrocephalus.
Nuland: Yeah, there are a number of stories in the book, that bring to light for the general reader the sense of the humanity of physicians which often transcends what is expected of this profession; where so many people think of self importance, pomposity. My little girl was my fourth child, was born with hydrocephalus, which manifest[ed] itself at first by only an enlarged head, and her brilliant diagnostician father missed it, completely missed it. In any event, just to shorten the story, the diagnosis was made finally by her pediatrician. We had to take her down late at night to the emergency room and this neurosurgeon—who was not the neurosurgeon we wanted to get, in fact a man known for his arrogance—came in, examined her and said she's got to go to the intensive care unit, I'm going to operate on her first thing in the morning. And then here I was, so many years senior to him, a couple of ranks senior to him in the academic hierarchy, and he knew just what to do because I was only somebody's father. At that time, he put his arm around my shoulder, and it was nurturing, it was reassuring and to me it represented the best kind of medicine.
Steve: It's a very touching story about the way that roles can just rapidly shift in that world of such stress and high stakes. The world of medical education, is in some ways, still back in the days of apprenticeships. I mean, we know that all of our physicians now go to medical school, but medical school is really the very beginning of training. I think, you know, I'm a fan of the TV program Scrubs. I don't know if you've ...
Nuland: Never seen it actually.
Steve: But there is an illustration there of a relationship between a senior physician and a newcoming physician, and I think it does a better job perhaps than many other programs have done of showing that relationship and how much education really happens once the former medical student sets foot in the hospital. The training is really one person showing another person how you do certain things rather than a classroom kind of training.
Nuland: We talk a lot in medicine about the concept of mentoring. Now, when one thinks of a mentor, one thinks of an individual who has taken on a younger person as his mentee, if that's the correct word. But in actual fact, mentoring takes place along the entire length of the residency program. In our surgical program, which I think was similar to probably most other surgical programs, the second-year resident felt the responsibility for the training of the first-year resident, and the third for the second[-year] resident, all the way up to the top. And we all took those responsibilities very, very seriously, and when we were the junior person, automatically sought out a senior person with whom we could identify. But there was always then, the man—very few women in those days, but by and large—the man who seemed like the sage, the man who was much older than us, who had had a vast amount of experience and who was nurturing us along to become very much like he was. Because it's not uncommon, certainly was not uncommon for me in all my years, of course, [to think] "How would Dr. Hayes have handled this problem?"—the great Mark Hayes, my major general surgical mentor—and I think almost any doctor who is in the specialty can tell you a story like that.
Steve: So that the tradition gets passed down. If you ever speak to a concert pianist, they can tell you what their lineage is going back to Beethoven. Beethoven taught Liszt who taught this person, who taught that person, who taught me. I know the geneticists love to trade, there is actually a computer program to trace your lineage back to Thomas Hunt Morgan. But in medicine this is also true, it's much more extended, although in many cases, it does still go down to one person, perhaps, who do you mention from Johns Hopkins?
Nuland: William Stewart Halstead, and I can trace my lineage directly back to William Stewart Halstead as so many American surgeons can. Mark Hayes trained me, Sam Harvey trained Mark Hayes, Harvey Cushing trained Sam Harvey and William Stewart Halstead trained, of course, Cushing himself
Steve: Right. So there is that relationship where these people are really, you are standing on the shoulders of giants as you sit side by side with them, as some wag said. Let's finish with a funny story from the book: Somebody was treating the son of an airline executive.
Nuland: That somebody, Steve, was me.
Steve: It was you! That's right. You also tell that story toward the end.
Nuland: Well, now Yale has a very sophisticated health plan for all of its students, but in the old days, about half a dozen of us used to do all the surgery for the Yale students, and they were housed in an infirmary which was about a mile from the medical school. And it was good for me because my house was on the other side of the infirmary, so I could, on the way home in the early evening, stop by the infirmary and see my postoperative patients. And I stopped in one evening to see a postoperative appendectomy and the nurse said, "Would you see this fellow in the next room? He has got a dreadfully dislocated shoulder." And I said, "You know, I'm not an orthopedist, I don't know a lot about dislocated shoulders." "Yeah, but he is in so much pain, maybe you could prescribe something, because nothing has been prescribed." And I go in and I see this kid, [he] turned out, I believe, to be a sophomore, and he is sitting up in bed with his right hand clutching the top of his left shoulder, not where one would ordinarily be holding for a dislocation, and his shoulder looked perfectly normal to me. And I said "How did this happen, this injury of yours?" "Well, I was playing soccer, and I got knocked down," he said, "and I don't specifically remember having my arm or my shoulder hit the ground, but this son of a gun he kicked me in the abdomen as he went by, and I was all out of breath. So they brought me here, and lo and behold, I have this dislocated shoulder." "How do you now it's dislocated?" "Well, I ha[d] the same pain when I was in the high school, same circumstances, and it was dislocated." Well, I always worry about someone who won't lie down because it means when he lies down, some irritating fluid is sloshing up against his diaphragm and causing what we call referred pain to the top of the shoulder. And I said, "You were knocked down, you were kicked in the abdomen, and now you're having pain which is much less when you sit up and much more when you lie down; my boy, you've got a ruptured spleen." And we did some very quick lab work, and lo and behold, he was getting anemic, his white count was going up. I put him in my car which was right downstairs, I took him right to the emergency room, called the operating room, said "We've got a ruptured spleen here that I've to operate on immediately" and as always they said, "Fine let's go." I got him up there and sure enough his spleen was bleeding like stink, and I took it out and he did very well. But before I did the operation, I called his parents. It turned out that his father was a vice president of a major airline, no longer in existence. He was the vice president for engineering, and he said, "We will be there in a couple of hours because, of course, they could take one of those planes and come to New Haven from the midwestern city in which they lived. So, they stayed for a few days, and at the end of the few days they were leaving, and the father said to me, "Dr. Nuland, you know about my position with this airline. If you ever need any help with any travel that you are going to take, you just let me know, and I'll take care of everything. So I thanked him. And it turned out, this was in the early spring, that I was going to England with my whole family that summer, I think it was to be in July or August whatever. And so I thought I'll call my friend, my new best friend. So I sent him a letter and within about five days, I got a response from his secretary, and he or she enclosed some travel brochures to aid me along [the] way and that was it.
Steve: That was the extent of the freebie that you wound up getting.
Nuland: Oh yeah!
Steve: These travel brochures.
Nuland: When I heard many years later that the airline was going down the tubes, I felt a sense of justice.
Steve: There are great stories in the book, just, you know, many of them are about this doctor-patient relationship. Some of them are diagnostic detective work. I particularly like the one about how somebody who was trained to figure it out, trained to notice it when it appeared, saw that an ankle issue actually meant lung cancer; that's you know, we don't need to get it, we want people to get the book, so that they can really make sure.
Nuland: Yeah sure.
Steve: But that's a terrific story. The fellow who won the Silver Star but couldn't remember what he had done because the trauma had been so extensive that it wiped out his memory for those two days, just great stories like that. It was a pleasure to read the book, and I hope everybody who is listening reads it. It's too short as I said. You can read this book in a couple of hours, and it's really worth doing it. I thank you so much for being with us today.
Nuland: Thanks an awful lot Steve, I really do appreciate it.
Steve: To see a Charlie Rose interview with Sherwin Nuland where he talks about the future of neuroscience, just google "Sherwin Nuland" and look for the Charlie Rose episode that also features Oscar winning filmmaker Florian Henckel vonDonnersmarck, seriously.
Now it's time to play TOTALL....... Y BOGUS. Here are four science stories; only three are true. See if you know which story is TOTALL....... Y BOGUS.
Story number 1: An analysis shows that the Kindle 2, Amazon's electronic book reader that sells for $359, costs about $300 to manufacture.
Story number 2: The next space shuttle will carry a basketball that was once dribbled by Edwin Hubble, the man for whom the space telescope is named.
Story number 3: In opening day ceremonies at the new Yankee stadium, former players introduced included a prominent cardiologist and a man who has a surgical procedure named for him.
And story number 4: The energy wasted on spam e-mails in 2008 could have powered 2.4 million homes for the year.
Time is up.
Story number 4 is true. Antivirus software company McAfee says that there were 62 trillion spam e-mails last year and the electrons wasted sending and reading those e-mails could have powered 2.4 million homes for the year; the carbon used accounts for about 0.2 percent of all global emissions.
Story number 3 is true. Former Yankees who were introduced on opening day included cardiologist and second baseman Dr. Bobby Brown, of whom Yogi Berra once said, "He reads books that don't have any pictures in them"; and the ubiquitous Tommy John surgery is named for, you guessed it, pitcher Tommy John, who also appeared on opening day.
Story number 2 is true. Edwin Hubble was a forward for the University of Chicago basketball team between 1907 and 1909. Another Chicago alum is astronaut John Grunsfeld, and he intends to take the vintage b-ball into space to honor the athlete-astronomer. The ball will then go on display at the university.
All of which means that story number 1 about the Kindle 2 costing $300 to make is TOTALL....... Y BOGUS. Because an analysis by iSuppli found that it costs Amazon only about $185 to make, which means that if sales lag, Amazon could easily drop the price of the Kindle and still make money. It's doofuses who had to have one right away that keep the prices up—doofuses like me.
Well, that's it for this edition of Scientific American Science Talk. Check out SciAm.com for the latest science news, the new SciAm magazine article, "What Makes Us Human" and a slide show on what you should know about the new Prius hybrid, which does not have a HEMI, thank goodness. For Science Talk, I'm Steve Mirsky. Thanks for clicking on us.
Surgeon and author Sherwin Nuland talks about his new book The Soul of Medicine: Tales from the Bedside, a Chaucerian take on doctors and their relationships with patients and each other. Plus, we'll test your knowledge of some recent science in the news.