Under Pressure

“People pushing down on me

Pressing down on you…”

From the song by Queen

I was in my last year of fellowship training.  I looked at several job opportunities in the area.  I did not want to stay at the large medical center, and it did not appeal to me to settle in an upper class neighborhood where everyone would want to see a specialist for any little thing.  Through my training I had made a strong effort to learn more than a little bit of everything.  I wanted to give complete service whenever possible, so I had spent a few weeks in just about every specialty rotation there was.

Except for dermatology.  I had left it for last.  Not that I wanted to: it was the most sought after specialty elective, and you either had to know someone or had to push very hard to earn a slot.  Every year that I was turned down I was told that senior residents had priority.  Now that I was beyond this level I was still on the outside looking in.  I was a bit alarmed.

I wondered if I was being blocked out.  The department chairman was very well known.  He was one of the editors of the premier textbook.  As a young and raw student he gave us an introductory lecture on his specialty.  After class I went up to him and patiently waited my turn while a number of classmates asked questions or introduced themselves.  Finally it was my time to step up.  I asked him which textbook I should buy.  An awkward silence fell over the group that had assembled around him.  He gave me a very stern look and mentioned his textbook.  I thanked him and walked away.  Within seconds five of my classmates surrounded me to tell me how gauche and ignorant I was.  I had no idea that he had edited a  book that was the standard; apparently everyone was supposed to know this fact.  I had an uneasy feeling that the boss thought I was playing a joke on him, and that he never forgot.

One day I was having lunch in the cafeteria and one of the derm residents sat next to me.  We had many acquaintances in common, but I had never gotten to know him well.  We started a conversation.  One thing led to another and I told him about my frustration at not being able to land a spot.

“I go to the VA on Thursday mornings,” he said.  “You can shadow me while I’m there.”

I explained that I had gone through channels and was told this was not possible.

He said I should come anyway.

I said I’d prefer to get the professor’s permission.

“He’ll say no,” my new friend said.  “He’s very protective of his residents.”

He was right.  I was turned down when I approached the professor.  I even told him my friend Mike was willing to take the responsibility.  He said no again, very abruptly, and walked away from me.

I approached Mike again.

“He’s like that.  It’s probably not personal.”

Not very reassuring, I told him.

“Come anyway.  We start at 8.  Dr. NO (let’s call him that) does not get there until 10:15.  This is when we have teaching rounds.  If you leave by 10 he’ll never see you.”

I did not want to do this, but Mike insisted and I did need the experience with rashes and dry skins.  The next Thursday I was there at 7:55 sharp.  Mike introduced me to the nurse who ran the derm clinic.  I was the new medical resident, he said.  Next he took me to the pharmacy director so that I could legally write prescriptions.  My signature went on the master file.

At 8:05 I went into a room with Mike to see my first patient with a skin complaint as his major issue.  A case of dry skin.  Mike spent a few minutes teaching me how to distinguish the mild from the serious cases, and how to deal with each.  Next a difficult rash; Mike asked the man to stay until 10 so that the professor could see him.

And so it went.  The routine cases were given prescriptions and sent home; the tough ones stayed until 10, at which time they were whisked into a large exam room, one by one, for the professor and his considerable entourage to determine a diagnosis and treatment.

I left at 10 sharp; a lot smarter than I had arrived.  Mike was an excellent teacher.  He fielded all my questions and gave me some reading to do.  So it went every Thursday.  Within three weeks Mike told me that I did not need him any more for most patients.  He gave me my own exam room, and the nurses were quite happy to help out because this way they could get done with clinic sooner.  Within ten weeks I did not need to consult with Mike for the lion’s share of what I saw.  I was feeling my oats, enough so that I was named the “go to” man at the medical school hospital whenever we ran into a rash that could not be easily explained.

My cockiness was my undoing.  I was ready to leave the VA on a Thursday at 10 when my favorite nurse asked if I would please see a man who had arrived late because he was lost.  I said that I had to leave, and she gave me a stern look.  It promised to be a quick one.  I went into the room, made a quick evaluation, wrote two prescriptions, and stormed out into the hall.  To run right into Dr. NO, who had arrived early, followed by the usual cadre of students, and medical residents, and derm residents, and even a few junior faculty members.  He gave me one of the nastiest looks I’ve ever had directed my way.  For a long time.

I felt that I had to run.  I waved to Mike as if to say goodbye.

“You,” said Dr. NO.  “Stay.”

I said I had to leave; teaching rounds at the other hospital; big hurry; late already…

“Stay.”  Almost shouting it.

Sure; of course I could stay.

We paraded into the teaching room.  I walked in last and stayed in the back row.  The first patient was brought in.

Dr. NO took a quick look.  He scanned the room until he found me.

“You!”  Now he pointed at me.  Describe the rash.

A wall of people parted to let me pass.  I took a look.

“Central atrophy; peripheral erythema; scaly; preference for the scalp and a few lesions in the trunk.

“Diagnosis?”
“DLE.”

“Treatment?”
I hit that nail on the head also.

Dr. No muttered an OK.  The next patient was brought in.  I began to ease my way out of the room.

“You!  Stay!”  I began to sweat.  Again I said something about teaching rounds, to no avail.

“Describe the rash.”

By now everyone in the room knew something was up.  The usual routine was for derm residents to be grilled about the teaching cases.  Medicine residents were never asked for their opinion, and I was a notch above a resident, and not even the derm fellows had to be grilled two patients in a row.

Rash described.

“Diagnosis?”

Correct diagnosis made; appropriate therapy prescribed.

Another OK; this one a bit louder.

I tried to sneak out again.

“You.”  The third patient was mine again.  I sweat more; there is this overwhelming feeling of sympathy and pity oozing from everyone in the room.  Except for Mike; I see that he’s smiling and somehow telling me that I can do this.

Right description; right diagnosis; hit the treatment on the nose.  Even gave a few references to a medical journal article that Mike had asked me to read a month ago.

Dr. NO smiled.

You can leave now.  As my hand reached for the doorknob he said: “You can come back next week.”

One of the most satisfying moments of my life.

I continued to come every week.  I switched my schedule at the big hospital so that I could stay for Dr. NO’s teaching rounds.  The man was an incredibly gifted teacher.  He had a vast fund of knowledge, and he was kind and patient with his subjects.  He always greeted me warmly, and once in a while he would ask me instead of his residents.  I finished the year with a perfect score.

Pressure.  It’s good for you.  It can kill you.  Some professors used to enjoy turning it on; many times I think in a forceful and abusive manner.  On the other hand, my test on the line of fire gave me confidence that I would never have had otherwise.

I can still hold my own in dermatology.