April 19, 2006: Perspective

There’s a person in that bed
Learning to doctor at the bedside

By Robert E. Becker ’55

Robert E. Becker ’55 recently retired from an academic career in medicine and now researches new methods of making patient care more scientific. He will speak about “concern for the patient” at the World Psychiatric Congress to be held in Istanbul, Turkey, in July.

After completing my third year of medical school, I accepted a position as a summer “extern” at a rural community hospital in Massachusetts. It was my first hands-on experience in medicine outside the shelter of school. As was common in the 1950s, the hospital doctors were only available on call from home, and so, being present when needs arose, I delivered babies, managed patients with heart attacks, provided the first treatment for people who had been in serious accidents on the Massachusetts Turnpike, and tried to help until a doctor arrived. Most were rewarding experiences. I looked forward to qualifying as a doctor.

One night the nursing supervisor called me to see a young woman. The woman had been run over by her boyfriend’s car as she lay in its path to keep him from leaving her. She was in shock from internal bleeding. There were tire marks across her abdomen, running from just under the ribs on the right side over the pelvis on the left. I drew a blood sample as I started an intravenous infusion to replace blood volume. I asked if the doctor on call had been asked to come in. He had been. The nurse and I agreed to call the surgeon, as well as a laboratory technician so we could cross-match blood, an X-ray technician, and staff for the operating room. Soon the doctor and surgeon arrived; they examined the patient — who seemed to be maintaining her breathing and blood pressure sufficiently that she would reach the operating room alive — and withdrew.

Time passed — too much time, it seemed, without blood coming down for the patient, the X-ray technician appearing, or preparations beginning for surgery. I asked the nursing supervisor where the blood was. “They canceled the orders and had me call everyone and tell them it wasn’t necessary for them to come in,” she said. I struggled to find words to respond, and still do. This situation seemed an impossible break with what I had learned in my study of medicine. I asked the nurse to stay with the patient, who was still conscious, so I could speak with the doctors, and found them in an adjacent room. “We don’t want to treat this kind of patient here. ... It won’t be necessary for us to get involved. ... There is nothing we can do. ... There’s no point in sending her on to Worcester — she will not make it.” These phrases have never left my mind.

I saw no alternative but to do as I was instructed. I did not respond: “We can try,” though “we can try” seems important in medicine. At the time I spoke silently to myself: “I am a student, they certainly know more than me about these situations.” This was neither satisfying nor reassuring. I went back to the patient and kept the fluids going. In about 30 minutes she became unconscious; then, she died.

The state medical examiner agreed that I could attend the autopsy. We found a three-inch laceration in the liver with only minor bleeding, two fractures, and a tear in the internal iliac artery. The woman had died from blood loss into the abdomen through the torn artery. “Why didn’t they open her abdomen and sew this up?” the medical examiner asked me. “I don’t know,” I said, relating what I was told and defensively noting that I was a student.

I have never forgotten this experience, although I seldom spoke of it. I feared that were I to practice medicine, I would act like the doctors in this incident. I did not know if I would remain a doctor concerned for patients. Conflicted over becoming a doctor, during my last year of medical school I did the minimum amount of work necessary to graduate. It was only later, in my internship, that I found a role for myself in medicine and overcame my ambivalence.

On an internal medicine ward at the University Hospital in Seattle, we had a patient who was losing blood into his gut through his intestinal walls. Testing showed no unaffected area; surgeons saw no feasible interventions, and internists could reach no diagnosis that suggested a way to stop the blood loss. On Friday, the blood bank notified us that at the rate the patient was using blood, it would be out of suitable blood midday Sunday. We presented the situation to the attending physician, Wade Volweiler, who went over the findings with us, examined the patient, and then asked the patient to excuse us from the room. In the hall he said, “We have to tell the patient that there probably will be nothing more we can do but try. I would like to give him the decision if it is all right with you — unless one of you has some other ideas we should discuss?” We did not.

Dr. Volweiler asked the patient if he could sit on the bed to talk with him. At that time we were trained not to sit on a patient’s bed out of respect. This break with protocol signaled to me a different, very personal shared moment in the relationship between doctor and patient. Dr. Volweiler’s decision to sit with the patient still expresses to me that some day each of us will be in that bed. Dr. Volweiler explained the situation, telling the patient gently but directly that we saw little likelihood of his surviving, so the patient could arrange to speak with his family before the apparently inevitable moment of crisis. He pointed out that the patient had a choice — he could receive whatever blood was available, or he could choose a time to stop adding new blood and leave some for others who might need it. The patient thought for a time that seemed longer than it was, then asked if he could arrange to be with his family Saturday morning and to stop the addition of blood at noon Saturday.

I was off duty that weekend. When I came in Monday morning, a new patient was in the bed. I still feel pain, tears, helplessness, and loss when I remember this incident. I respect this patient’s courage and dignity, and Wade Volweiler’s example of how, in extremes of suffering and sorrow, we can be decent with each other and with ourselves.

Nearly a half-century later, these events live in my memory as lessons about the choices I can make in my profession and my life. In the Hippocratic tradition, people do not become invisible in the presence of disease. For me this means somehow understanding all human disease and suffering as both a disorder of the body and a reaction of the soul. Unfortunately, now medicine seems to have fallen even further under the influence of priorities that so scarred my soul in that Massachusetts hospital emergency room. The voices that speak for the human decency shown by Wade Volweiler seem silenced by medicine turning molecular science into its idol.

I now think that I took too long to understand medicine’s more comprehensive heritage of both care for the person and scientific treatment for the disease. I sometimes fear it is too late to save these traditions from the new technologies and their machines. Yet I will always hope and work for a medicine that will preserve us as individuals, a medicine that is ready to balance the impersonal explanations of molecular science with personal understanding of the patient.

This essay was adapted from a longer article and is reprinted with permission from the American Journal of Psychiatry.