Pushing Glass-A Reluctant Choice

The Doctor's Doctor

"The noon time Morbidity and Mortality Conference is now beginning in fourth floor conference room."

The hospital speaker blared as James scurried up the fire exit stairs, hospital elevators were always too slow, especially when he was already late. He carried a slide carousel and a small folder summarizing the biopsy results on one of the cases that was being presented. Haas would oversee his presentation but it was James' show. His time to shine or flop. She would be scrutinizing his every word, ready to interrupt his discourse if he missed an important point. He felt his stomach muscles tighten as he envisioned the audience of attendings, fellows, residents, and medical students all listening to his explanation. Why did the patient die, Dr. Deetan? What do you mean you don't know? Aren't you the doctor's doctor?

The doctor's doctor!

James placed his slide carousel on the projector and took his seat next to Haas, in the front of the room.

"You're late."

"I'm sorry, Dr. Haas. It was a frozen section, we ran over."

Haas frowned. "Next time, get someone else to cover. The chief resident should have been there. Are you ready?"

James nodded. "Yes maam."

"Speak slowly and clearly..." Haas looked at James and pursed her lips, "Sometimes people have difficulty understanding you when you speak quickly."

That hurt. He hoped no one else heard her observation. He prided himself on the efforts he took to extinguish his accent, a combination of Chinese and Tagalog. Back home, he was often complimented on his precise and clear diction. Here, odd looks or snickers followed him whenever he spoke. Once, when he was standing in line in the cafeteria, in conversation with one of the other residents, a surgical resident standing in front of him turned around and declared, "You talk funny!" James had all the tell-tale habits of a Filipino; the b for the v, the r for the l, and the cadence! He had a tendency to drop his words at the end of sentences. Listening to his own dictations, it was a daily humbling experience, reinforced by the transcriptionsists who repeatedly asked for word clarifications.

"Let's get started. First case is being presented by the department of surgery. Dr. Morris?"

As the conference began, James allowed his mind to drift back to his third year medical student rotation in surgery. It seemed an eternity but it was only four years ago when James first learned of the doctor's doctor. Third year of medical school was filled with endless hours on call, running down labwork, x-rays, and admitting patients. The relentless pace was broken by numerous conferences and lectures. Most conferences were simply another hour of lecture, a chance to sequester free donuts and coffee. M and M’s were different. It was a conference where medical students were never pimped, never questioned incessantly about minute and obscure medical facts. On the contrary, attending physicians were on the interrogation stand and decidedly hated it. The hospital reviewed all deaths and complications that occurred during the previous month. It was widely loathed by any attending whose patient was being presented, since in essence, the physician was being presented.

James remembered Dr. Ong, the chief of surgery, as he stepped to the podium, resplendent in a navy blue suit with vanishing pin stripes and yellow tie decorated with a slightly lighter shade of blue dots. James barely recognized him sans his surgical scrubs and cap. A surgeon in street clothes was an infrequent, but certainly eye-inviting sight in the hospital. A quick perusal of other surgery attendings found a fashion display worthy of the pages of GQ magazine.

“Thank you for coming to April's Morbidity and Mortality conference. Let’s get started, we’ve got a lot of cases to cover. First case is Luke Santiago, Dr. Chan’s case. This is a 45 year old man admitted for acute cholecystitis. Laparoscopic removal performed without complications. Post-op day 1, he spiked a fever of 102F. Blood cultures grew out Methicillin-resistant Staph, and he was started on Vancomycin. In spite of this coverage, he continued to spike fevers. Chest x-rays revealed an interstitial lung infiltrate. Infectious disease was consulted but further sputum and blood cultures were negative. Wound cultures were also negative and the laparoscopic site was healing well. By day 6, platelet count began drifting lower to 80,000 and hemoglobin dropped to 7.5. Hematology was consulted and subsequent lab workup found increased fibrin split products and elevated LFTs. Their assessment at that point was DIC, probably secondary to sepsis. He was transfused 3 units of packed cells, given FFP and platelets which initially stabilized his values. By day 8, however, he had several episodes of bright red blood per rectum. GI consult was obtained but the patient was considered too unstable for endoscopy. Barium swallow was obtained and the radiologic impression was gastric stress ulcers and probable colon diverticuli. Patient’s condition continued to deteriorate, becoming obtunded by day 10. He died on post-op day 12. Consent for autopsy was obtained by the family. Dr. Chan, you performed the laparoscopic surgery, what was your diagnostic impression at the time you admitted him?”

“It was a straight-forward case.” Dr. Chan began. “He had a two month history of an intermittant low grade right upper quadrant pain that developed into an acute abdomen on the day I admitted him for surgery. Prior ultrasound revealed several gallstones and I presumed this was the contributing factor for the acute cholecystitis. Post-op was uneventful. Frankly, I am mystified by this tragic outcome.”

Dr. Ong nodded. “You saw the patient in your office two months ago, if you had operated on him a month earlier, we may not be discussing this tragic outcome.” Dr. Chan shifted uncomfortably in his chair. “Dr. Santos, you did the ID consult. Why do you think the patient continued to spike fevers in spite of appropriate antibiotic coverage?”

Dr. Santos shook his head and mumbled inaudibly. Dr. Ong continued, “Did you consider changing antibiotics or consider a viral infection not detected by the cultures?”

“We were at a loss to explain the continued fevers and probable sepsis. Yes, we did consider a viral infection but titers to herpes, CMV, and adenovirus were negative.” Dr. Santos hoped the answer would appease his interrogator.

“And enterovirus titers?” Dr. Ong interjected.

“We did not order enterovirus titers.” Dr. Santos’ expression sank.

“How is that the infectious disease service does not consider enterovirus when three other patients admitted to this hospital over this past month had documented enteroviral infections?” Dr. Ong turned to Dr. Chen, the hematologist.

“Dr. Chen, by the time you saw the patient, he was in DIC. You managed to stabilize him with transfusions. What were your impressions?”

Dr. Chen was the youngest of the attending physicians, one of the few women. Summoning her courage, she answered in a seemingly prepared statement, “Dr. Ong, I consulted with several colleagues including my mentor with whom I trained in Boston. I regret that we were all stymied by this complicated and disturbing case.” Dr. Chen’s gaze never wavered from Dr. Ong as she braced for the denigrating comments.

“Dr. Chen…I am pleased by your dedication and compulsiveness to the care of this patient. Indeed, this is a complicated case, one for which I, regrettably, have no answer.” It was one of the rare occasions that Dr. Ong was humbled by the complexity of a case.

“As in all our complicated cases, we turn to Dr. Torres, our pathologist, who performed the autopsy.” Dr. Ong smiled as he looked in Dr. Torres’ direction.

Dr. Torres’ flowing white lab coat was neatly buttoned to the top to just reveal a red striped tie. He was in his mid-50’s, medium-build, with a few wrinkles around his eyes, that otherwise betrayed a face much younger than his true age. He was mestizo, with a fair complexion and brown hair completing a handsome visage. The slide carousel was positioned on the projector as the lights were dimmed. The first slide revealed a color photograph of the patient’s gallbladder. Dr. Torres spoke in lucid and precise tones.

“This 52 gram intact gallbladder revealed an acute cholecystitis but was truly remarkable for the numerous pigment-type gallstones, evidence of a chronic hemolysis. Pigment stones are distinctly unusual, usually seen in patients with a chronic hemolytic anemia indicative of ineffective erythropoiesis, of the type seen in thalassemias or sickle cell patients, not a clinical consideration in this patient.” James marveled at the enormous amount of information Dr. Torres conveyed with each sentence.

Dr. Torres continued with photographs from the autopsy. “At autopsy, there were no significant gross abnormalities except for slight hepatosplenomegaly. However, on microscopic examination, nearly every organ exhibited extensive lymphovascular invasion with these pleomorphic cells.” The slides focused on the blood vessels of the lungs and liver, stuffed with the cells that have the characteristic hallmarks of malignancy. “These cells had hyperchromatic and enlarged nuclei with prominent nucleoli. Occasional multinucleated and bizarre tumor cells were present. The clue to the origin of these cells is seen on these next slides…Note, the faint brown pigment apparent in the cytoplasm of some of these cells.” The brown pigment was faintly visible only to those who were in the front row. Nonetheless, the entire audience nodded in unison, faithfully believing the description.

“I performed additional immunoperoxidase studies on these tumor cells. Stains for S-100, Vimentin, and Mart-1 decorated all of the cells; they were uniformly negative for cytokeratin and leukocyte common antigen. Lights.” Dr. Torres surveys the befuddled audience and smiles. “This patient had disseminated malignant melanoma!” Dr. Torres stepped back while the audience visibly gasped. “The pigment stones in the gallbladder were the clue. This patient’s chronic hemolysis was secondary to the widely metastatic melanoma which produced the low grade disseminated intravascular coagulation. This led to a chronic destruction of his red blood cells and consumption of his clotting factors and platelets. This coagulopathy exacerbated his bleeding gastric ulcer. All of his post-operative complications were a direct result of this underlying malignancy. The medical literature documents rare case reports of a metastatic melanoma causing such a devastating outcome.”

Dr. Ong interrupted, “Where was the primary melanoma?”

Dr. Torres smiled. “Once I discovered the cause of death, I returned to the patient and did a Wood’s lamp examination of the skin. Under this ultraviolet examination, I discovered a hypopigmented patch of skin on the patient’s back which I biopsied. This biopsy demonstrated findings consistent with a regressed melanocytic neoplasm, not an uncommon finding in patients with disseminated melanoma. This patient probably had a melanoma in this spot which subsequently metastasized leaving behind this biological calling card.”

The audience was stunned into silence as Dr. Ong returned to the podium. Surveying the room, he effusively thanked Dr. Torres. “As always, it is the doctor’s doctor, our pathologist, who solves our most complicated problems and teaches us how to become better physicians!”

“The doctor’s doctor!” It was a preacher’s call to the pulpit and James accepted the invitation. James would become the doctor's doctor. Four years since he answered the call, thousands of miles away from home, James doggedly clung to his faith. No denigration or belittlement would distract him. His calling was to become a pathologist, the doctor’s doctor. He would enlighten the other physicians.

"Can we review the pathology?"

The moderator, Dr. Silverstein, chief of medicine, motioned in the direction of James and Haas. James approached the podium, attempting a confident stride but keeping his hands in his lab coat pocket, hoping no one could see the shaking. Heads in the audience bobbed and whispers of "He's just an intern," and "He looks so young," followed his steps. Just don't trip, James kept repeating to himself.

As he stood at the podium and surveyed his audience, the room seemed so much larger, filled with white coats and surgical scrubs. The doors were also packed with late arrivals, unable to find a seat. James braced his hands on the sides of the lecturn and fingered the control for the slide carousel. The first slide appeared on the large screen pulled down behind him to his right. An image of a neatly dissected pancreas appeared, recognizable only to about three knowledgeable physicans in the room.

"We received the Whipple resection containing the head of the pancreas, a portion of the duodenum and stomach and accompanying omental tissue. Dissection of the main pancreatic duct revealed a fungating tumor measuring 2.5 cm in diameter that extended into the surround pancreatic tissue." James flashed his laser pointer on the tumor. "Dissection of the peripancreatic lymph nodes revealed grossly metastatic disease in 3 of the 17 nodes." James advanced the slides. "On microscopic sections, a poorly differentiated adenocarcinoma was identified with extensive areas of perineural invasion." The laser danced around the screen as James pointed out the sinister course of the tumor. "Final diagnosis is adenocarcinoma of the pancreas, poorly differentiated, metastatic to 3 of 17 lymph nodes."

The lights flipped on. James waited for the applause.

"Fine. Dr. Harvey, you saw this patient in consultation for radiation oncology. What was your impression?"

That's it? Uncertain whether to remain at the podium, James stood motionless for a few seconds, wondering if he was needed. A glance over at Haas as she pointed to her empty seat next to her answered his confusion. Bored and glazed looks followed his descent. Perhaps his presentation was so good, nothing more could be added? Regardless, he had brought honor to the pathology department.

"Next time, hold the laser pointer with both hands. You were so nervous it looked like a flea jumping from one dog to another."

"Yes maam."

Next time, even Haas would not be able to deflate his performance. Next time, they would all acknowledge him as the doctor's doctor.