Success and Recognition

“A man should say I am not concerned that I am not known, I seek to be worthy to be known.”

Confucius

I was halfway through my senior year in med school. Although it was not a requirement, almost every student who was considering a career in internal medicine was expected to take the Ward Medicine elective. There were two faculty members who took turns teaching this “elective” course. Both of them were excellent teachers. They were kind and considerate with the patients. They had a reputation for expecting 110% from the trainees. And they were world-famous. Several chapters in the medicine textbook bore their name. Anyone who wanted them to write a letter of recommendation better perform well in this course.

They were stressful times. I was six months away from receiving my MD, yet I was insightful enough to realize that I was way, way far from being a competent doctor. Soon I would be applying for an internship at a competitive medical school, and I didn’t think that I had enough knowledge to be a “superstar” intern, like all of our house staff was. Any time that any of my classmates spewed out some obscure fact I felt guilty that I had not stayed up late at night to memorize it. Although we were friends (and many of us still are), there was the definite presence of a competitive edge. All of us were applying for the same internships. Not everyone would get their first choice.

On the last Thursday of this six week rotation the students were expected to run the clinicopathologic conference, or CPC. This is a popular teaching exercise; it goes back more than a hundred years and still draws large crowds of students, teachers, and residents. A “difficult” patient history is presented to the discussants. In those days of no CAT scans or MRI’s, this often meant that the patient had died without a clear diagnosis having being made. A physician, usually a faculty member, is chosen to review the pertinent history, lab, and imaging studies. He or she is asked to make a diagnosis. At the end of the conference a pathologist is summoned to discuss the autopsy results. Most of the time the discussants are right, but every once in awhile there is a surprise, which can be embarrassing.

Again, these days we have so many sophisticated diagnostic techniques that it is rare for someone to die undiagnosed. Not 45 years ago. For one week prior to that fateful Thursday we spent a very large amount of time preparing to discuss the case. None of us knew when we would be called, or to discuss what. We had to know every single aspect of the case; every possibility. At the end we had to decide as a group what the cause of death had been.

We did great. The lady being discussed had numerous medical problems. We knew for sure that she had an infection in her bloodstream. She had died suddenly. Guided by the kindly professor, we provided an expert discussion of the status of her heart; lungs; kidneys; brain… It went on and on. Every student that was called had been terrific. Nothing had been left out.

I have to talk about the venue. Clopton Amphitheater at Barnes Hospital is affectionately known as “The Pit.”  It has very steep steps. The discussants stand at the bottom of the pit, while the packed audience seems to be hanging right above them. A very intimidating experience, particularly when you don’t know if at the end of the day you’ll be humiliated by the pathologist.

My classmates had decided that this lady’s blood infection was enough of a reason for her to die. I had a gnawing feeling that her infection had spread to her heart valves, and that a sudden heart or artery catastrophe had caused her demise. In the interest of unity, and because I was so insecure about my clinical knowledge, I went along with their decision.

The discussions were over. Throughout the hour, every time that one of the students had finished talking about their part, one could hear a murmur of appreciation from the crowd. As we got closer to the finish I could sense a feeling of anticipation. Everyone was really into this. Our professor asked one of my classmates for the final diagnosis. He discussed our reasons for blaming her demise on the infection. The professor got ready for summoning the pathologist when one of my classmates blurted out:

“Wait!  You haven’t asked Paco anything!”

Great. Thanks a lot, I said to myself. I would have been very happy to remain off the limelight.

The professor apologized.

“Francisco, is there anything that you want to add?”

I was speechless. There must have been four hundred people looking down on me, at the edge of their seats. All of my classmates had been spectacular. There was nothing pertinent left for me to say. But I had to say something.

This lady had Staph in her bloodstream; not a good thing to have.

Loud laughter from the crowd. I gained courage. Maybe this wouldn’t be so hard.

Although my classmates do not agree, I think that an infected heart valve was the principal event.

The professor nodded.

“So you think that she may have ruptured a valve, or an aneurysm?”

Yes.

The professor smiled and nodded again. The pathologist was summoned. He went over the findings in the stomach; the liver; the spleen; the lungs… Nothing fatal. Then he got to the heart. He showed us a picture of her perforated aortic valve. A huge murmur from the crowd. Then he moved to her brain, and showed us a ruptured cerebral aneurysm. Now the noise from the crowd was drowning his speech. He had to ask for silence.

“The cause of death was a ruptured mycotic aneurysm due to an infected and ruptured aortic valve.”

Now it seemed to me that we had a stadium full of people that were cheering after a Cardinals home run. Everyone in the auditorium was on their feet. They were clapping. One of my mentors who was very fond of me almost broke something rushing down the steps to pat me on the back.

For the rest of the day everywhere that I went in the hospital I could see people looking at me and whispering between themselves. Those who knew me dropped whatever they were doing to come to congratulate me. My day of fame.

The CPC’s at Washington University used to be published in the American Journal of Medicine, also known as The Green Journal because of the color of its cover. Only the most interesting conferences were chosen. Late during my internship year I received my copy of the Green Journal. When I reached the CPC part, to my surprise, there was our CPC. I’m ashamed to say that I went to the last page of the discussion first, so that I could see my moment of glory in print. To my shock and dismay, the editor had left my comments out. I had no lasting proof of my fleeting moment of notoriety.

I was at Clopton a couple of days ago. One of the nice things about retirement is how much fun it can be to learn without time pressure. I can linger after conference and ask questions; I don’t have to rush because there are patients waiting. It’s a lot smaller than what it felt like 46 years ago. At most 200 seats. It’s still steep, but it’s not that deep a hole. The lecture on Zika was every bit as fascinating as our heart valve discussion was way back when.

It made me think about success and recognition. It took me years of hard work to become a good doc. Painfully slow hard work. Many slips and slides along the way. Frustration that could not be adequately described even by Shakespeare. At some imperceptible point came the success and recognition. Maybe a colleague asked me to see his wife in consultation. Or the room was fuller than usual when I gave a lecture. Patients wrote letters of thanks.

Yet people want to be famous now. Even if they have to try to kill someone to get their name in the paper. Or expose intimate family secrets on Facebook.

I loved my moment of glory, but that feeling pales in comparison to the pride I feel when I look at what I have been able to accomplish. I got lucky at the conference; that was all. But the journey ahead remained. Would not have it any other way.

All of us should be able to go back to our own Cloptons. Maybe the Little League field where we hit that key single. Or the lecture hall where we answered a tough question correctly. See how everything is smaller than what it seemed at that point. How our brief moments of glory are smaller than the courageous way so many people make life work for themselves and their loved ones.

All of them, worthy to be known.