FALL 2007 | Issue home
BEFORE SIMULATIONS
I am a 1965 graduate of Pitt Medical School. I have enjoyed reading Pitt Med over the years but have not been back to Scaife Hall since my graduation. I was struck by the article in the last issue by Elaine Vitone entitled “The Modern Deathbed” (Summer 2007). When I became a physician, we did not make use of simulations or actors to portray dying patients.
I grew up in Aspinwall, the youngest of four sons of a steelworker from Blawnox mill. I played football at North Catholic and was lucky enough to get a partial football scholarship that allowed me to attend St. Vincent College. At that particular time, tuition, room and board was $1200.00 per year and you could take as many credits as you wanted. I was co captain of our football team in college.
The only medical school I applied to was Pitt for the simple reason that it was the only one that I could possibly afford. In those days it cost state residents $500.00 per semester. I recall verbatim my “essay” on the application. The applicant was asked to write an essay describing their future intentions with regards to medicine. Two sides of an 8 x 11 sheet of paper were provided for the “essay”. I wrote: “I intend to attend the University of Pittsburgh School of Medicine, obtain an M.D. degree and practice medicine in the city of Pittsburgh.”
I was asked to come for an interview in July of 1964 and was interviewed by Dr. Bill Early at Western Psychiatric Hospital. We talked mostly about St. Vincent’s upcoming football season. I was admitted to medical school before reporting to fall football camp. In retrospect, I think besides being an athlete, Dr. Early must of liked my answer to his question “What makes you think you would be successful at Pitt Medical School?” I told him that I studied less that the rest of my college class, drank considerable amounts of beer and felt like I was like an 8 cylinder car that had been running on only about 5 or 6 cylinders. I knew I would have to work harder in medical school but felt sure that I had more than enough gas in my tank to do so.
During my time at Pitt, the medical curriculum was dichotomous. The first two years were mainly classroom lectures in a variety of sciences. The last two years were purely clinical. When we walked out onto the wards to start our junior year, one was expected to have certain basic skills: know how to do a history and a physical, basic lab exams, start an IV, draw blood, pass an NG tube, put in a urethral catheter, do a spinal tap etc. I was fortunate that I was drafted into the army during gross anatomy and was only able to avoid reporting to Fort Knox by joining a Navy program called Ensign 1915. I spent the summer before my junior year at Great Lakes Naval Hospital where I learned all the procedures I was expected to be facile with when I started my clinical years at Pitt.
During that period at Pitt, we students were given responsibilities for actual patient care. The senior medical rotation that I had at Magee Hospital was especially valuable. I had two months there—one with the outgoing intern and the other with a brand new intern from Pitt, Jim Poth. I was essentially an acting intern and certainly made mistakes. We had a staff internist make rounds with us once a week, but for the most part we were on our own. It amounted to what we in the Navy termed OJT, or on the job training.
Following graduation, I was assigned as a Navy intern at Philadelphia Naval Hospital. This was during the height of the Vietnam War and the average daily census ran close to 4,000 patients. We had a grand total of 18 interns and were on watch every other nig ht. During this year I had a growing respect for the education that I had received at Pitt. Some interns were simply overwhelmed by the volume and nature of the diseases that were commonplace at Philadelphia. Pitt had prepared me well. There were too many patients and too few staff to expect to have your hand held. You either had to fish or cut bait. At times, there was no other physician available to help you. I distinctively remember doing three emergency tracheotomies in bed with only a goose neck lamp for illumination. Interns were expected to do their share of patient care. Usually an intern and a resident were assigned to each large ward and split the patients. As an intern, you would work up the patient, order appropriate tests, do appropriate procedures and discuss the management and prognosis with the patient on your own.
Mid way through my internship while on medicine, I worked up a 39 year old male veteran by the name of Jim. He was a smoker and presented with a pleural effusion on chest x-ray. I did his H & P and also did his thorocenthesis. His follow up chest x-ray showed a pulmonary mass and the cytology on his fluid was positive for malignant cells. I got the results on a Thursday and called Jim into my office and told him what I had determined was going on. I told him that it as quite serious, but that we would consult with radiation and perhaps there were some medicines that might help. I told him that it was likely that this tumor would eventually take his life. He accepted what I told him without showing much emotion. He told me that he had to go home on leave because he was engaged and would have to tell his fiancé what was going on. I walked his request through the front office and he was permitted to go home on Friday morning. He was to return on Sunday night before 9 p.m.
I happened to have the in-house duty that particular Sunday. My office was directly across from the elevators that led to our ward. When Jim walked off the elevators he looked like he had literally aged thirty years. I invited him into my office and asked him how he was doing. He told me the following in a monotone. “Well, Doc…I got home to Scranton by about 2 p.m. on Friday. I called up my fiancé and made plans to take her to a nice restaurant. I thought that I would then take her home and give her the bad news at her apartment. She lives on the third floor of this old house, and when we was walking up the steps she said she was having some pain in her chest. She said it was probably what she had had for dinner. When we got to her door, she let out a sort of cry and fell over dead. She had a massive heart attack, I guess.”
As I finished listening to this horror story, I simply began to cry. Tears flooded down my face. I told Jim I was really sorry and just got up and walked out of the office. I never felt so impotent in my entire life. The next morning, I told my resident what had happened and told him “Hey Dale…how about you take care of Jim on your side of the service and give me one of yours…I just can’t hack it with him.” Dale Boyd didn’t make anything of it. He was understanding and happy to do it.
Our staff man on that rotation was an internist by the name of Vic Stoka. He was the only St. Vincent grad and Pitt Medical graduate that I had ever encountered in the Navy. In fact, never again did I meet up with anyone with my same background for the 24 years I was to spend in the Navy. The ward nurse told me that Dr. Stoka wanted to see me in his office. It was about 3 p.m. I thought as I walked down to the end of the ward to his office that he was probably going to tell me what a good job I was doing, and how tough it was to deal with someone like Jim. He was seated behind his desk with some x-rays on it. As soon as he realized I had entered his office he began to assault me. “McCarthy…there isn’t any room in medicine for wimps…if you can’t stand the heat get out of the kitchen…people don’t want some teary eyed wimp standing around when they are sick…they need someone that they can count on…someone that will support them. I’m ashamed that you went to St. Vincent and Pitt…get the hell out of my office!”
I had that night off and recall discussing what had happened with my wife, Alice. I told her that if that was what was expected of clinicians, then I would go into pathology. I liked path at Pitt and was good at it. The patients would already be dead when they got to me, so I wouldn’t have to deal with any of the other horrible details that preceded death.
It was customary in those days that Navy interns were assigned to a fleet of billet before starting a residency. I applied for a pathology residency at Philadelphia and actually was accepted and scheduled to start the following July. I did quite a bit of introspection in the remaining months of my internship. I liked urology mainly because of the wonderful experience I had at Pitt working with the legendary Dr. Reginald Hancock. The first day I spent on urology with Dr. Hancock, he took me to lunch at the Duquesne Club and had me over to his house for dinner that night. He had a swimming pool shaped like a kidney and a diving board shaped like a phallus! Ultimately I decided to abandon pathology and pursue urology and somehow learn to deal better with death and dying.
There was an acute shortage of submarine medical officers at the time, and I was able to get into submarine school beginning that July. I made two patrols as the medical officer aboard the Andrew Jackson, SSBN 619, a Polaris submarine. I had encountered two urologists at Philadelphia who had trained at San Diego who had impressed me. I decided to apply for a Navy urology residency with the stipulation that I would only accept a position in San Diego. If my request were denied, I would get out of the Navy and come back to Pitt to train with Dr. Hancock and Dr. Jimmy Lee. They had told me that they would be glad to have me as a resident. I recall that when I knew I was going to be going on sub patrols, I called Dr. Hancock and asked him if he had any reading materials that could read while I was out at sea. He gave me a brand new set of Campbell’s Urology Textbooks and a year’s worth of the Journal of Urology still in their wrappers. I remember him telling me that he was too busy to be able to read “that stuff” anymore. I was accepted as a resident at San Diego Naval Hospital to begin my residency July 1, 1968.
Prior to beginning my residency, I was assigned to Submarine Squadron 12 in Norfolk Virginia. That year as a squadron medical officer was probably the easiest year of my medical career. I was stationed on a submarine tender, the USS Orion, and was responsible for the health of 10 submarine crews. I was entitled to submarine pay and only went to sea for a week at a time every three weeks. I had a senior E9 chief hospital corpsman working for me, and he screened everybody who wanted to see me at sick call. There might be a dozen or so submariners show up in the morning for sick call. The chief would get me a cup of coffee and tell me that he would have sick call ready to commence in 15 minutes. When he got through, there were perhaps two or three patients left for me to see. I routinely played some sort of competitive sports at lunch and was free to head home by 3 in the afternoon.
The second week of May in 1968, I was called to the Commodore’s office. The squadron had received a radio message from the USS Scorpion, SSN 589, a nuclear attack submarine from our squadron. The hospital corpsman on board was requesting advice. One crew member had apparently been given a PPD test, was unknowingly PPD positive and was in the process of sloughing part of his forearm. A second crew member’s wife had recently delivered a baby and was diagnosed with a post partum depression. The Commodore wanted my opinion as to if these crew members should be evacuated home. I thought that the Scorpion’s corpsman and the depressed wife would both be better off if they were extracted. On May 17, 1968 off the coast of Naples, Italy, the Scorpion broached and the two crewmen were evacuated by a Navy helicopter and subsequently flown home to Norfolk.
On Friday, May 22nd, I returned to my home in Virginia Beach around 3:30 in the afternoon. My wife met me at the door and told me that Captain Jason Law, the squadron’s chief of staff, had called and told her that I was to return to the Orion immediately. I wondered during the drive back to work what it could be about. When I arrived at the piers I noticed that there was a crowd of dependents on the pier and remembered that the Scorpion was due to return that afternoon. When I came onboard, the Officer of the Deck told me that Commodore Clark wanted to see me in his quarters ASAP. When I returned to his quarters, the Commodore and four Navy Captain division commanders were present. I immediately grasped that they were in some sort of emotional shock. The Commodore told me that the Scorpion had been lost at sea.
I asked him if he knew for certain that this was true. He told me that it was confirmed. It was obvious that he was very upset and looking at me, a lieutenant physician, for some sort of guidance. I told him that the first think I would do would be to make an announcement to the dependents on the pier telling them to go home, that the Scorpion was delayed and that he would provide them further information as it developed. I then told him that I would gather all the assets I could and start informing the sub’s dependents what had actually happened. He immediately went topside and made the announcement just about word for word from what I had suggested. The word was then passed that all squadron personnel were to stay on board that night. I had been given a private stateroom as the squadron physician but had never slept there.
The next morning I was awakened at 0600 by a sharp rap on my door and a steward told me that Commodore Clark wished me to join him in his stateroom for breakfast at 0630. I had no shaving gear and only the uniform I had worn the previous day. I took a quick shower and joined the Commodore at his table. I was impressed with the china and silverware. A white coated steward asked what I would like for breakfast. My order was promptly prepared and delivered. The Commodore made some small talk during breakfast. When I was finished, he picked up a standard issue clip board and turned in his chair to face me. He said, “Dr. McCarthy…this is a list of the 83 widows from the Scorpion along with their addresses. There is a Navy vehicle along with a Marine driver on the pier. I suggest you finish you coffee and then begin to visit these women and tell them they are widows. Anything we can possibly do for them we will do.” I remember him passing the clip board over to me and I recall irreverently replying “You gotta be shitting me!” He then informed me that this was my duty as the squadron physician. I was dismissed and instructed to get to work.
I stopped at my office in sick bay and got out the PDR and looked up MLD for Librium. I remember that it was essentially impossible to ingest enough Librium to be lethal. I found a jar of 1,000 pills and grabbed a handful of medication envelopes. As I left the Orion and walked to the black Chevrolet, I recall thinking that there was no way that I was capable of handling this catastrophe emotionally.
I sat in the back of that non air-conditioned Chevrolet as we headed out towards Virginia Beach and the home of the commanding officer of the Scorpion, whom I knew socially. There were four wardroom wives gathered there. It was already hot and humid and I had already sweated through my uniform blouse. I sat down around a coffee table in the family room and told them that their husbands were all dead. I told them their husbands had died aboard the scorpion in the service of their country. Tears abounded from the four recent widows and the squadron medical officer.
I continued to make such visits around the clock until early that Sunday night. At some point I had stopped crying. I had reached the point that I could deliver this life changing message in at least a semblance of a professional manner. I said whatever I needed to say to attempt to comfort them. I gave out a lot of Librium. I have subsequently described this experience to other physicians as having an intensive 36 hour seminar in death and dying.
I began my residency in urology at Balboa Naval Hospital on July 1, 1968. My first assignment was to the enlisted urology ward that had 60 patients. My chief resident, asked me if I knew anything about testis tumors. I told him that I had heard that they were rare. He then asked me if I knew anything about chemotherapy of testis tumors. I told him I didn’t know a thing about that. He then told me that I should get up to speed as quickly as possibly since we had 14 patients on the ward with metastatic testis tumors and that I was going to be their chemotherapist. There was not a department of oncology in existence at that time. All fourteen of my testis tumor patients died. I developed my own style of dealing with death and dying.
A few years later, I became the chairman of Balboa’s urology residency program at the ripe age of 37. I tried to teach by example and I would try to pass onto my residents what I had come to consider important in caring for my own patients over the previous five years. I would stress to them that our patients were our most valued commodity in that without patients there would be no need for our services…we would be out of a job. Every patient deserved to be treated with respect and dignity just as we or our family would want to be treated. Whenever we aligned ourselves with what was best for the patient, we could defeat anyone who opposed such care. We could force potential adversaries to put into writing that they were opposed to what was best for the patient, and that would amount to being against baseball, Chevrolets and apple pie. I stressed that we absolutely had to be available to our patients. We would see any patient that wanted to see a urologist, with or without a consult, with or without an appointment, with or without a chart. We would do this 24/7. Finally, I told them that in my opinion the secret of caring for the patients was caring for the patient.
As the boss, I had very few rules for my residents. Under no circumstances were they ever to lie to me. I would fire them if they ever took any kind of advantage of any of our patients or if they moonlighted. I told them that all the patients were mine and that I was going to allow them to care for them even though I was ultimately responsible. I told them that I expected to be able to walk up to any of the patients on our service and ask them three simple questions and I expected all the patients to know the answers if they, the residents, were doing their job. “Who is your doctor?” “Why are you in the hospital?” “What is the game plan for you?” The residents eventually learned what was entailed to insure that their patients knew these answers.
I also tried to help my residents come to grips with death and dying. I suppose all physicians who deal with this situation arrive at their own style. Unfortunately, there are still some who prefer to avoid dealing with these patients and their families if at all possible. I never told any patient that they had cancer over the phone or left a message on their answering machine. I always had them come in person with their spouse. I always told them that I would go over things again as often as necessary since often patient’s minds sort of shut down once they heard the word cancer. I never told a patient how long they had to live. I would tell them when asked, that was something from Ben Casey on TV. God alone knows how long any of us have to live. I would tell them in certain cases that it was likely that their cancer would, in fact, end their life. I always used to say, “But also, you or I could get hit by a falling safe on the way home!” This must be a Pittsburgh thing. Somebody, sometime, must have been hit by a falling safe before the advent of elevators.
I told my patients that I would always tell them the truth as I knew it. I mentioned Abraham Lincoln had once commented that no man was intelligent enough to be a successful liar, so I would be certain to tell them the truth even if it were painful. When discussing death, I used to tell patients that life was like a big room with two doors, an entrance and an exit. If we were able somehow to go back to our memories as we approached birth within our mother’s womb, it was probably that we were just as anxious and scared of what lay ahead as we are when we approach the exit door. It was like we were all traveling along a freeway, all going in the same direction, but not knowing where our exit was. A lot of really good people had died already. Jesus Christ…George Washington…Able Lincoln…their own parents, etc. As diseases progressed, I told patients that there were two things that they could absolutely count on. Even though most people preferred to die at home, if it got too difficult at home, there would be a bed in the hospital for them as long as I was the boss. Secondly, I told them that there was no reason to fear pain. We had in our arsenal enough powerful drugs to control any degree of pain. I explained to them that they would be in charge of their pain. As they required stronger and stronger medicines for the pain, it might come at the expense of something that they still enjoyed doing, like perhaps being able to read, but that they would be in charge. As the patients became bed ridden and in more pain, I used to use a compounded medicine called Brompton’s Solution that contained morphine, scopolamine and thorazine and was administered by drops under the tongue. I used to give them a two ounce bottle with unlimited refills.
I always practiced with the idea in mind that at some point in time I might again encounter patients that I had helped to die. I hoped that they would be glad to see me and would be thankful for my efforts in caring for them as they passed through their “exit”.
I spent ten years training residents at Balboa and another five doing the same job at The University of California at San Diego Medical School before retiring from practice in 1994. While at Balboa, the urology department was acknowledged as the strongest department in the hospital and also the busiest. No resident of mine ever failed any portion of the urology boards. From its beginning in 1970, The University of California at San Diego Medical School never had a single student opt for a career in urology. During the five years that I was on the faculty, 19 UCSD students were accepted into urology residencies. I was fortunate enough to receive the coveted Kaiser Permanente Award in 1992 that is given by each class at UCSD medical school to whoever they feel was their most outstanding teacher.
Despite the lack of actors or simulations in my training, I attribute most of my success to the medical education I obtained at Pitt. I was fortunate enough to take a senior elective in psychiatry. I learned to pay critical attention to the verbal and non verbal communications of patients while on that service. That experience, along with the basic sciences and excellent clinical experience provided by Pitt, contributed greatly to my success as a surgeon and teach of surgeons.
I always look forward to reading Pitt Med and wish Dean Arthur S. Levine continued success as the leader of one of this country’s finest medical schools.
Michael P. McCarthy (MD ’65)
Carlsbad, Calif.
