"The Harvest Team"
by Sarah Chambers P&S Class of 2004

Every first-year medical student at Columbia is given a remarkable opportunity to carry the "transplant beeper" for a day. If called, the student goes on a heart transplant run with the harvest team. Today was my day. I sat in my small dorm room, beeper clipped to my belt, trying to read. As my classmate had reluctantly handed me the beeper before class that morning, he told me that no one had been called for four days. I was reading about the anatomy of the leg when it finally beeped.
I fumbled clumsily with the beeper, then reached for my phone and dialed.
"I'm the first-year with the beeper today — you just paged me?"
"We have a heart," the resident said. "Be outside the hospital at 5:30 p.m. sharp. Wear scrubs. If you're late the ambulance will leave without you."
Climbing into the ambulance, I was painfully aware of the sharp creases still in my scrubs. But after the airplane and a second ambulance ride, when I was rushing into a Connecticut hospital carrying a cooler filled with surgical equipment, scrubs were the last things on my mind.
I imitated the surgical resident as she ritualistically donned a cap and booties, and followed her lead in pulling on gloves. I tried to burn the cardinal rule into my mind: If you're not scrubbed in, never touch a surgeon or anything on a blue cloth. If you do, the heart is ruined.
On our way to the OR, we flipped through the chart. The donor was a 3-year-old child; there had been a car accident. I barely had enough time to comprehend the words on the page when we pushed through the doors of the OR and took our places around the table.
The liver team had been there for a couple of hours. All they were waiting for was our team to cross-clamp the great vessels. I stood at the head of the table, peering over the blue cloth that tented the anesthesiologist, and praying that I wouldn't lose my balance. Below me, our surgeons dissected out the heart. There was barely room for the two teams to work.
"You're a first-year, right?"
It was one of the surgeons on the liver team.
"Come down and take a look at this ... we have some interesting findings. How far have you gotten in Anatomy? Know about Meckel's diverticulum? Look." I looked. The heart team called the cross-clamp in at 9:45 p.m. Both teams worked furiously now, in a race against the degeneration of death.
The heart can only last a few hours outside the body until it is unfit for the recipient. Caught in the hurricane of activity, a clinical self whom I had barely known before this night watched, fascinated, as the organs were painstakingly dissected out. I helped to prepare the potassium solution as the heart, less than half the size of my fist, was fixed and put on ice.
There were chicken fingers and mozzarella sticks waiting for us on the airplane. As I sat down I realized how hungry I was. We all dove for the food. Between bites I gulped down a Coke — I was going to need the caffeine.
At the door to the next OR, I said goodbye to the harvest team. After seven hours they were headed home — they'd seen this all before. For the second time in a night, I experienced a moment of shock as I saw the size of the 2-year-old body on the operating table. The surgeons were already at work, and once again I took my station with the anesthesiologist. There would be no tours this time.
With intense precision, the skilled and practiced hands stitched a heart into its new body. I focused on the little boy in this room, knowing that there was nothing to be done for the child on the other table. For the 10 people here, this room was all there was.
Other hands worked their magic around the surgeon. The pulmonary technicians monitored the monstrous looking heart-lung machine and answered my awed questions with a mixture of pride and amusement. The anesthesiologist's eyes flicked between monitors as she seamlessly integrated information from countless displays and coolly administered the drugs needed to maintain the blood pressure, the heart rate, the blood saturation. Between orders she quizzed the third-year med student: "What would you give here? Why shouldn't I give him this? Is this reading within normal limits?" Here and there I caught a word or phrase that I knew.
At 2:15 a.m., they stopped the heart-lung machine and a different, new blood flowed through this tiny heart for the first time. And there it was, weak but unmistakable — the first beat. There it was again, but now stronger. The heart, taken from ice, was beating anew. But it was too fast, the blood pressure was shooting up. Orders were barked, drugs were given, numbers were shouted, and finally relief replaced the well-masked panic on the faces around the table.
It was another hour before the surgeon turned over his instruments to the chief resident: "You can close." And he rolled out of the swinging double doors.
It was after 3 a.m. when I walked back along New York's streets, arriving at my dorm room where books were still open on my desk and clothes were left in an untidy pile on the floor. I stepped out of my crumpled scrubs and stood under the shower, letting the steamy water bombard my senses. I could still feel the wonder of that first heartbeat, could still see the small body that had been given such a gift. I saw too the other body, the little child who had given it. And I cried.
Sarah Chambers started a pediatrics residency at the Morgan Stanley Children's Hospital at New York-Presbyterian Hospital/Columbia University Medical Center in July. She received the William Perry Watson Prize in Pediatrics at commencement ceremonies in May. This piece about a first-year experience in 2000 is reprinted from "Reflexions," a student publication, Volume XI, Spring 2004.

ILLUSTRATION: TOBY MORISON

"The Personal Realm
of an Absolute Stranger"
by
Aaron Sylvan Lord
P&S Class of 2007

At the beginning of medical school this year, one of the first lectures I attended was an introduction to our course in clinical anatomy. Our class journeyed through the fascinating, and often tumultuous, history of anatomists dating back to the early Greeks.  The controversy surounding the use of cadavers repeated throughout history, even at my own school, where early Trinity Church officials implemented stone covers to keep curious Columbia medical students from grave robbing. Sitting there in lecture, it seemed like the successes accrued by medical science since those early days would have removed any doubt from our conscience as to the value of educational human dissection. But with the advent of computerized teaching models, and the recent controversy surrounding the misuse of specimens at UCLA, the place of the cadaver in medical education has, as many times before, come under scrutiny.
It is easy for the members of curriculum committees, facing arduous faculty searches and the expense of operating a cadaver program, to forget what it was like the first day they walked into the anatomy lab, the white drapes covering a more visceral reality. For many of us our cadavers are our first patients, a special meeting between those just entering the practice of medicine and those having exhausted its care.  It is our first invasion into the personal realm of an absolute stranger — the territory physicians navigate their entire lives. With every new lab, small details emerge (a double knee-replacement, a hysterectomy) and lab groups begin to assemble a fragmented narrative of their patients' lives. Just as in practice, a professional relationship develops and occasional humor lightens the gravity of a serious situation. Time spent in the dissection room, however, is not merely a facsimile of practice. The inability to do real physical harm to our patients at once lowers the stakes, yet also raises them by providing an unparalleled access even surgeons do not have — the ability to trace a nerve as it traverses its entire course, or to resect a muscle to better examine those beneath it. Our cadavers, or "bodies" as we call them, also serve as a crucial introduction to the world of death, reminding us of the ultimate fate of every one of our patients, and of ourselves. Never again will we have a patient with a greater impact on our understanding of humans and their bodies.
Having just completed my final exam, I have no doubt that the scores achieved by those using virtual models and other technological resources will equal those of us dedicating hours to the laboratory. But the scores do not tell the whole story, and reliance on such an evaluation system — one dominated by two-dimensional, gray-scale figures — is exactly the perspective medicine is trying to escape. Aren't we emphasizing a richer, more colorful model rife with the intricacies and texture of mankind? Can we teach respect and wonder for the human body using Java — or is the real thing prerequisite? As medicine progresses into the digital age, ours must remain a profession dedicated to people — and to enshroud ourselves in humanity can only grant us greater knowledge of whom we are here to heal. I cannot imagine a first year of medical school without my first patient, Helen, a woman I have learned a world from and am honored to have met.


"William"
by
Lisa Schneider
P&S Class of 2007

His heart lay before me on the table.
Folds now flaps, inside out
Chordae severed and arteries splayed

In life his heart
had sucked and pumped life into him,
Raged, fell in love
And survived a triple bypass
Before the day it stopped

He gave me his heart and
offered his body, full of imperfections

I am your first patient, he said
Poke me, I won't flinch

learn from how I have been created
my miraculous clock-work insides
what I always suspected will be known

Intimacy beyond comprehension
I held his heart in my hands
How pure his heart must have been to give of itself so freely

My first patient and yet
how wonderfully was the formula reversed
a patient instructing the ignorant doctor
on the beauty and mystery of medicine

The poem by Lisa Schneider and the essay by Aaron Sylvan Lord were read at the annual memorial service for first-year students to remember individuals who donated their bodies to advance medical science at P&S.

"One Doctor Retires"
by
David V. Forrest
P&S Class of 1964

Recently I have witnessed a natural experiment that in its simplicity shows up any notion that doctors are replaceable functional units like sparkplugs in the engine of American medicine. George H. McCormack, M.D., one of our great New York clinicians, after 52 years of unflagging practice of internal medicine, sent letters to his patients early last fall that he would be retiring at the end of that year.
As a psychiatrist who is privileged to have a number of George's patients in psychotherapy, I have had a clear view of the effect of his retirement upon them. Although many of the patients are not currently physically ill, they were all profoundly moved by the imminent subtraction of his reliable medical presence. Clearly they were in a continuous medical relationship with him without seeing him now or needing to see him.
Their reactions were individual, but similar. A number had worried for years he would retire, saying things like "they aren't making doctors like that anymore." One called me as soon as she got the letter to tell me the news. Often they expressed concern about George, who is in good health, and wished him well in his retirement. There was an unstated anger that their protective figure was leaving them. One joked he was "a quitter" — after so many years. One imagined he might stay on in an ombudsman function. But, since they had been sent to me by him, there was also evidence of what might be called the referral transference. One asked if he would also have to worry about my retiring, although I am about 15 years younger. One said he had doubts about the fine younger internist to whom George had referred him, and that now he would ask me for general medical advice (I gently demurred, and his doubts eventually disappeared).
I have known George for four decades since he was my preceptor in third-year medicine at P&S. What was clear once again, as I had often realized in our long relationship, is how much my therapeutic alliance with the patients he had referred to me had benefited by the trust, respect, and gratitude of the transference from him to me. Referral to a psychiatrist does not always lead to a "take." This is not all due to a patient-therapist mismatch, because studies have shown that when patients are sent to two psychiatrists sequentially, they prefer the second one, even though the psychiatrists in the study are rotated so they are as often the first as the second one. It is difficult to open up emotionally to a psychiatrist, frightening and sometimes humiliating. The first encounter is frequently so taken up with initial history giving and arrangements that it is difficult to give enough back to the patient to facilitate much building of the therapeutic alliance. This is one reason I almost always see patients for a double initial session of an hour and a half. But when the patient arrives with an extremely positive and trusting transference from a referring doctor whom he or she perceives as caring and authoritative, the psychiatric relationship can initially piggyback upon this. George really referred patients well. He would tell patients he referred that I had been his best student (untrue, I know my classmates), and when the patients would tell me this, I would say that was most kind of him, but that there was no question he had been my best clinical teacher (true). As a result, his patients almost never failed to establish a therapeutic relationship with me, in contrast to those from some other referral sources, especially those self-referred from institutions and lists. The consistent "takes" also reflected George's empathic diagnoses and the appropriateness of his referrals of persons for my care.
A great deal of psychoanalytic thought has been devoted to the initial transference in psychotherapy. The transference variables have been thought to stem from the patient's formative years and subsequent experience of relationships. This ignores the powerful interrelatedness of the immediate medical referral structure, which managed care has sometimes sought to undermine. It also ignores evidence before our eyes of the beneficial power of the referral transference, which affects all medical and surgical referrals. We physicians are all linked in interdependent networks. Those who frequently refer, such as internists and gynecologists, are also dependent upon the credibility and performance of those who receive their patients, such as psychiatrists. When I sent George a congratulatory note to the retiring internist, he wrote back thanking me for being one of the people who made it hard for him to close up shop because I had been "a consultant steady as a rock and dependable as sunrise." He has a literary bent — and great clinicians seem to have a poetic sensitivity to language — but accessibility and dependability are foremost in a referring doctor's mind, well above any fancy expertise we might have. In return, we who receive referrals value a referring doctor's ability to inspire trust as a precursor of the referral transference as much as we value that doctor's expertise in diagnosing and medically screening the patient. It could fairly be said that one's therapeutic presence is partly the imaginative creation of the referring physician.
Finally there is therapeutic courage. We tend to forget how much we doctors need to persist daily in the face of clinical variety, and how difficult it was for us to acquire confidence as medical students and interns. But just as we learned in our combat psychiatric experience, clinical courage is in substantial part a product of small group cohesion and mutual support — here, the informal medical referral network.
One doctor retires. We shall firm up our ranks, but they will not be the same and we shall not be the same. David Forrest, clinical professor of psychiatry at P&S, is also a graduate of the Center for Psychoanalytic Training and Research.

Photos were taken during Peter Marcovici's five-week primary care clerkship in Whiteriver, Ariz., on the Whitemountain Apache Indian Reservation.

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