Pay Attention

“Being a professional is doing all the things you love to
do on the days when you don’t feel like doing them.”
-Julius Erving, former professional basketball player

I was raised by two college professors. With the exception of a large scene of a pig roast that my father’s aunt (who was a cloistered nun) had painted for us, there were far more books lining the walls than decorative pieces. Learning was our religion.

When I applied to medical school I only wrote to universities far from home. All of my life I had been the son of the Garrigas. I wanted to be known for my own merits. My first two years of med school I rebelled. Studied only on the night before the test. Made fun of my roommate’s study habits (He was extremely conscientious). I played a lot of volleyball in the gym; I always found a reason not to apply myself.

Early during my junior year one of my classmates told me about a very interesting patient that he had seen during his pediatrics training. It was a very rare case: an unusual mutation that proved to be uniformly fatal for the children who were born with it. I made fun of his enthusiasm.
It’s not like we’ll ever see a case like this again.

He was visibly, and vividly, hurt.

“This is important!” he said.

I was taken aback. The next day, as if by divine intervention, one of my professors asked if he could talk to me in private. He was a kind man; uniformly admired by the interns and residents who took care of his patients.

“We talked about you at the grading session.”
Am I in trouble?

I knew that I was doing an OK job. I was not in danger of flunking.

“We feel that you’re a diamond in the rough.” He paused for a second. “You have tremendous talent. The residents tell me that you’re great with patients. The presentation that you made to me was at a much higher level than what we see from students at your stage of development. But you have to do better. You cannot take a day off from being responsible. You’re going to be a doctor. I will not allow you to be less than what you can be. You must step it up.”

I had always been the star student. No one had ever been that stern with me. My eyes watered as he spoke to me. I had always wanted to be a doctor. Now this man that everyone agreed was a great one had told me that I wouldn’t be good enough.

“You don’t need to do anything different than what you did for the case that you prepared for me. Just be consistent. We believe in you.”

These two “interventions” turned my life around. I decided not to take any working days off. I began to listen to what the older doctors had to say. I asked as many classmates as I saw every day if there was an interesting heart murmur, or enlarged thyroid, or unusual X ray that they had seen. If any student complained that they had seen a “boring” patient, I went by that patient’s room to try to find something about their lives, or jobs, or family that I found interesting. I found out that the radiology department kept a “museum” of unusual films. Once a week I’d check a few of them out, then I’d badger a professor to explain them to me. I asked questions: dozens of them. More than one professor became exasperated at me when I interrupted their lectures to ask something that I didn’t quite understand. At first the people in the conference room gave me looks. I noticed that, after a while, the professors were grateful about an insight that I had brought into the conversation.

I took off. I developed special relationships with a few mentors, who helped me with internship applications and recommendations.

I read. A lot. Instead of classical novels I devoured textbooks and journals. One of the residents who had taken a liking to me showed me how he filed medical journal articles that he found interesting. Soon I had dozens of file folders brimming with paper. I had index cards and a large box to keep them in order. They accompanied me in every move I made. I became a regular at the copying machine in the library.

I chose to do my internship in an extremely busy public hospital. There was a mountain of work to be done, every day, without end. I got to the hospital by 7AM. I left at 7PM the next day; having had no sleep for 36 hours. I went back the next day for more of the same. I saw twenty souls who were barely clinging to life on a daily basis. As soon as one left the hospital, there were more waiting to get in. I calculate that, by the time that I finished my third year of training, I had taken care of 2,000 different patients, the overwhelming majority of them critically ill.

I served in the Navy for two years. I was stationed on an outpatient clinic. It was supposed to be easy work; 9 to 4; no critical situations; quick visits and fast, low-pressure decisions.

I was wrong. These patients were not dying, but they needed someone to listen to them. It was clear to me that they thought that they were terribly sick. I had to learn how to listen; how to make sure that everyone felt satisfied with the care that they had received. Appointments were slotted ten minutes apart. There was no time. Yet I found a way.

My patience paid off. Two; three times a month, in the middle of a sea of relatively harmless ear infections and children with hyperactivity, a life-threatening condition would show up in my exam room. At first I was surprised to find occult cancers and ectopic pregnancies in this setting. As if these people should know that their particular ailment required a different level of care. Then I thought about my father, whose master’s degree was in statistics. It made sense. If one percent of the population has a serious illness, then one out of a hundred people that I saw would require extra care. I should expect to see the very ill, even in an outpatient setting. The problem was: which patient was the one that would tax my knowledge?

It didn’t take long for me to figure out the answer. I had to treat all of them the same. Establish a routine and follow it. Ask the same questions. Carefully listen for the answers. Make sure that there was enough trust established, so that a patient would feel comfortable coming back to tell me that our initial encounter had not been helpful.

Soon I was on a first-name basis with the specialists at the Naval Hospital. This is where patients were referred when they needed an operation, or chemotherapy, or detailed testing. I got used to being asked how I had been able to make this diagnosis, or suspect that there was a change in a patient’s behavior. The best answer that I could give is that I was always thinking: What’s the worst thing that could possibly happen to this person? Then I did my best to rule out that possibility.

I saw an additional 1,500 patients during my days as a Navy medical officer. Thousands more during fellowship training and private practice. It’s gotten to the point where many times I can detect a look in a patient’s eyes; a way that he or she talks and walks; a word that a family member uses to describe what’s happening to the person that they love so much.

You could call it experience. I prefer to think that all I’m doing is paying attention.

A few years ago one of the med students that rotate through my office was surprised that I had made a diagnosis of a foot fracture on a patient that came in complaining of arthritis. I ordered an X ray. I predicted that it would show a broken bone. I even said which bone.

When I showed him the films he shook his head. I also noticed that he was a bit anxious. I remembered, back in my student days, how I had wondered how in the world I would ever master all of the material that was being placed in front of me.

I patted him on the back.

It’s OK. I’ve seen cases like this one before. Years from now you’ll do the same as I just did. All you need to do is pay attention.