Always two there are, a master and an apprentice…

Gentle Readers,

After Dr. J. posts this, he is off to attend a memorial of a late, great senior colleague, emeritus, Dr. B. Dr. J. has known Dr. B. since Dr. J. was Med Student J. here at NAITMC*. This grandfatherly figure was a physician, scientist, fellowship training program director  and division chief over his storied career. He oversaw the training of a legion of physicians, and even after his retirement came to work at NAITMC to learn, teach, write and hold court as a resident Philosopher King.

What made him great was that he saw everyone as his student. It mattered not whether a full Professor with an endowed chair or a fellow was presenting at Grand Rounds, our Clinical Conference, or Journal Club, Dr. B. would amble over to him† after his talk and give him constructive criticism  from notes he wrote on a napkin on how he could improve their presentation next time. It was done with love, and a desire to make that individual better at presenting.

At our conferences, he would speak up and remind the audience about important fundamentals in medicine that we get away from in our algorithm and benchmark mired profession as it exists today. He reminded us of prognosis, Bayesian Analysis in diagnostic testing, and the true clinical impact of the therapies we deliver. All of these are things that he would want us to keep forefront in our mind along with technology we are beguiled by. Along with these advances come increasing costs. He reminded us to consider the true impact and value of care we deliver to the individual, our fiduciary responsibility that individual and to the taxpayer and premium payer dollars whose dollars we are entrusted to spend responsibly in delivering effective quality care. He also reminded us that medicine is a profession, and not a job, and wanted doctors to take the idea of a profession seriously. It is because we’ve drifted over the last quarter century that we have allowed our profession to evolve into the mess that it currently in.

He also challenged us to think about the cost effectiveness of our current MD/PhD training programs. He believed that it was important to make sure we are getting a ROI on the free education those programs provide. Are we creating clinicians who were willing to get a PhD as the price for a debt free medical education, or were we creating physician scientists. He asked the same question with regard to the NIH Loan Repayment Program for physician scientists.

Dr. J. not only enjoyed knowing him through his discussions with the division at our conferences. Dr J. would often have lunch with Dr. B.

One time, Dr. B. asked us a question while we were eating lunch.

“What do you think the biggest advance in medicine was?”

A couple of fools talked about the latest greatest drug or pacemaker. Dr. J. posited antibiotics, a colleague one upped him with vaccination. A public health oriented individual suggested clean water and sewage.

Dr. B. conceded that clean water and sewage lines were most responsible for the increase in life expectancy in the US over the course of the 20th century, his answer went back further.

He informed us that the most critical advance in medicine goes back to Hippocrates and that creation was the mentor. The ancient Greek physicians were the first to discuss the process of educating the next generation of doctors in addition to describing their observations and treatments of maladies. Since that time there has always been, in the western world, an apprenticeship where junior physicians trained at the foot of senior physicians. Abraham Flexner, wrote a report in 1910 describing the state of medical training in the US and proposed a formalized program that improved the quality of the mentoring that was received by young doctors from their seniors, as prior to that time there was the potential for variable quality in the education received in the private setting.

During Dr. J.’s time with Dr. B., he had his turn to mentor the mentor. When Dr. J. was a fellow, he had the privilege of teaching Dr. B. how to use powerpoint. He eventually became quite proficient and after a year or so no longer required Dr. J.’s services.

Now Dr. J. didn’t always agree with Dr. B. Dr. B. was more progressive in his views of medicine, especially as he became older and advocated for a single payer system which he would never ‘enjoy’ the fruits of. Recently, before Dr. B. took ill, Dr. J. challenged him as we discussed the idea of the growth of health care systems, the rise of doc-in-the-boxes and other such changes in the local and national market. Our argument broke down as to how each of us saw cost. He felt costs should be contained and any dollar spent on health care was ‘cost.’ Dr. J. argued with him that the only ‘costs’ Dr. J. cares about are costs to him. If someone expands their hospital network and it fails, those aren’t Dr. J.’s dollars. Those are the hospitals dollars. If someone opens an urgent care clinic, that isn’t a cost to him. Consumers will either go to those local clinics and hospitals, or not, but they will get the care they are requesting somewhere. When his tax and insurance dollars are spent on him or others in his group, those are his ‘costs’. Anyway, to make a long story short, the discussion broke down into a debate regarding single payer with the physician as gate-keeper versus a market based model with the doctor being an advisor and teacher to a patient making decisions where they make their own cost benefit analysis. Dr. B. said felt the patient wasn’t savvy enough to make their own decisions. At that point Dr. J. countered that by Dr. B.’s logic, Dr. J. isn’t sophisticated to make an informed decision regarding the purchase of tires for his car as he relies on the advice and council of the tire dealer. Dr. B. while he disagreed, conceded the point with a certain sense of pride that one of his pupils was not afraid to respectfully challenge the master.

Over the last several years, Dr. J. has evolved from a neophyte faculty member to a mentor to his minions. Early on he had minions who overlapped in training with him. They all called him J. The institutional memory of Dr. J. as a trainee is gone, and they all refer to him exclusively as Dr. J. now. He is seen as their teacher. He has taken the lessons from Dr. B. and applied them. He challenges his disciples to think carefully with regard to the history, examination, when to use and how to interpret diagnostic testing and how to make the right therapeutic decisions tailored to that individual patient. He also challenges them to lead the residents and medical students on rounds and to teach them what they know.

Today he saw a patient with one of his minions and the patient was a living history of the management of atrial fibrillation. She, Dr. J.’s minion was flabbergasted that the patient was on archaic therapy for 45 years. He was on medications he was taking since the 1960s and missed the advances in therapy in the intervening years because was that strategy worked from the 1960s up until today. This patient created a series of teachable moments about antiarrhythmics, anticoagulation and the idea of doing no harm. If cinchona bark (quinidine) and foxglove (digoxin) worked for 45 years, why not leave it alone? That was something Dr. J. learned from another elder statesman, Dr. D.

Now this strategy finally stopped working and it was time to apply plan b. What was great was that Dr. J.’s minion learned quite a bit from this otherwise routine patient, and Dr. J. was able to pass on wisdom he learned from his prior mentors on to her. He knows that she too, will be passing this wisdom on, perhaps even to the Lil Resident. That is, after all, what mentors are for.

* New Atlantis Ivory Tower Medical Center
† It is wholly appropriate to use the male gender rather than saying ‘him/her after his/her talk’ ask The Czar, our Castle Grammarian. It is better to be grammatically correct than politically correct as Dr. J.’s Gothic Comp Lit Professor used to say…

Dr. J.