My Two Years with Dr. Loeb

In 1955, Clifton Meador, a graduate of Vanderbilt University's medical school, entered a medicine residency under the legendary Robert F. Loeb at Columbia-Presbyterian Medical Center. For two years, Dr. Meador suffered the range of indignities and praise that make memories of Dr. Loeb still vivid 50 years later. This excerpt from Dr. Meador's upcoming book, "Twentieth Century Men in Medicine: Personal Refl ections," describes coming full circle with the great Dr. Loeb.

Robert F. Loeb
The inscription, though faded, reads “Cliff Meador — with admiration and good wishes for
the future.Robert F. Loeb, 6-27-57.” By inscribing the photo to “Cliff,” Dr. Loeb had placed
Dr. Meador at the highest rank of salutation, a system Dr. Meador describes as measuring
Dr. Loeb’s satisfaction with house staff.
DR. LOEB USED SEVERAL GRADATIONS OF SALUTATIONS TO address us. Most favored was First-Name-Only. Next level, and clearly a step down, was Last-Name-Only. Next level and out of grace was Doctor-Last-Name. Worst case was just plain Doctor (No Name).
     I became Clifton after I saw a patient who had developed ascites quite rapidly. I noted as I palpated the liver surface that it pitted with finger pressure. I reasoned that the outflow veins of the liver were either under high pressure or they were obstructed. The patient did not have congestive heart failure or constrictive pericarditis. I put down my initial impression as Budd Chiari syndrome (a very rare condition caused by thrombosis of the out flow veins of the liver) and admitted the patient.
     By some miraculous convergence of luck and maybe even divine intervention, the patient did have Budd Chiari syndrome, a diagnosis proved by measurement of the hepatic vein wedge pressure. Dr. Loeb saw my admitting note. “Pitting edema of the liver” somehow caught his fancy. He said it over and over. Every time he saw me on rounds he brought it up. “Clifton,” he would ask, smiling broadly, “found any more pitting edema of the liver?” I would shake my head and feel the glow of his attention.
     For several months, I could do no wrong. I was riding high with “Clifton this” and “Clifton that,” mostly from my finding pitting edema of the liver on that one patient.
For several months, I could do no wrong. I was riding high with “Clifton this” and “Clifton that,” mostly from my finding pitting edema of the liver on that one patient. My fall from grace occurred in my second year.
     My fall from grace occurred in my second year.
Understanding Dr. Loeb’s major clinical love, diabetes mellitus, is important to the telling of my fall from grace. Diabetes mellitus to Dr. Loeb was what a medical disease ought to be: Some chemical (insulin) is missing from the body. The missing chemical has been discovered through rigorous scientific investigation. The absence of the chemical causes severe abnormalities in the chemistry of the body (elevated blood sugar levels and also keto-acidosis). When this missing substance (insulin) is given to the patient, all deranged physiology is corrected. For Dr. Loeb, diabetes mellitus epitomized man’s triumph over nature.
     The medical service had a special six-bed metabolic unit for patients with diabetes mellitus and other intriguing metabolic problems, especially those with diabetic ketoacidosis or Addisonian crisis (Addison’s disease was Dr. Loeb’s second favorite disease).
     I believe Loeb’s service at the time held the world’s record for consecutive diabetic coma patients (well over 70) with no deaths. This was phenomenal given that the death rate was easily 10 percent or more in most people’s hands. Dr. Loeb found success by standardizing the treatment of acidosis to a finely tuned protocol (at a time when protocols were unheard of). We recorded time from the moment the patient hit the front door of the emergency service until the patient got the first insulin injection and the first intravenous fluids. The mean time that elapsed from appearance of the patient to the injection of insulin was very short — a matter of minutes — and it was always the first bit of data Dr. Loeb wanted to know.
     We were well over 70 consecutive cases with no deaths when I was assigned as the metabolic unit’s resident. We lived in dread of being the house officer who lost the first case of acidosis. Even Doctor (No Name) would not be low enough if that happened. Fortunately, the series of successful treatment continued, and my fall from grace stemmed from other circumstances.
     My intern had worked up a morning admission and left for Washington, D.C., to deal with his impending draft status. I agreed to cover his duties and mine while he (I’ll call him Fred Jones) was gone.
     Dr. Loeb came ambling into the unit with his six medical students for his 1 o’clock teaching session. The group stopped at the bedside of the patient who had been seen only by my intern at that point. The patient was a 35-yearold woman with diabetes mellitus. Dr. Loeb had seen her on the service when she was 10 years old. Twenty-five years later and he still remembered her, her family, the exact bed she had been in, and who the intern and resident were. He called for me, “Clifton, can you spare a moment?” I went over to the bedside.
     “Clifton, this young lady was a patient of mine over 25 years ago and here she is and in such fine shape too.” Loeb was beaming. The patient was smiling too. It was a happy scene for a few brief moments. Dr. Loeb said, “And Fred’s (the intern’s) note says right here that her eye grounds are normal. Can you imagine? Over 25 years of
diabetes and no effects on her vessels.”
Doctor Meador, I will see you and the other Doctor in my office in the morning at 8.” With that he wheeled about and left the unit. Fred Jones never got back to Jones, he remained Doctor (No Name) and was dropped from the program at the end of the year. I moved back to Meador from Doctor Meador by the next day, but it would be several months before I got back to Clifton.
     He turned to me again: " Clifton, what do you say about her eye grounds?” It would be my last Clifton for a long time. I told him I had not yet worked up the patient and that she had just been admitted. “Meador, where is Jones?” Fred and Clifton had been instantly downgraded to Last-Name-Only. I told him about Fred’s trip to Washington. Dr. Loeb then asked for an ophthalmoscope and spent several minutes examining the woman’s eye grounds. I could feel my heart beating in my neck. He looked up at me with a withering look I had never seen before. “Doctor Meador, take a look at these eye grounds.” He handed me the scope. All I could see were hemorrhages and the vascular changes of advanced retinopathy. Fred had buffed the chart and I was taking the lick for it.
     “Doctor Meador, I will see you and the other Doctor in my office in the morning at 8.” With that he wheeled about and left the unit. Fred Jones never got back to Jones, he remained Doctor (No Name) and was dropped from the program at the end of the year. I moved back to Meador from Doctor Meador by the next day, but it would be several months before I got back to Clifton.
     To understand the full impact of my redemption to First Name, it is important to note one of Dr. Loeb’s four rules of therapy: Keep the patient away from surgeons at all costs.
     I was the resident on the admitting service when, late at night after the crowd dwindled down, I went to the microbiology laboratory to plant all body samples of the evening on the correct culture medium. It took all my will to stay awake and streak out the urines, sputa, blood cultures, and other containers of body fluids or swabs I found in the refrigerator.
     I noted that a tube of urine was deep red but assumed the color was due to a drug in use at the time for bladder infections. I looked at the patient’s name and recognized her as the teenager I had seen a few hours earlier in triage. She had an acute surgical abdomen and was admitted to surgery for an exploratory laparotomy.
     The red urine suggested the possibility of acute intermittent porphyria so I ran frantically to the student lab and did a Watson Schwartz test for porphobilinogen. Its strong positive result meant the patient had a good possibility of having acute intermittent porphyria, an inborn error in hemoglobin synthesis. Its clinical manifestation: periodic severe abdominal pain.
Clifton Meador, M.D.
     I called the surgical unit, and the nurse told me the patient was on the way to the OR. The nurse said the patient had not received any medication that could color the urine red. I ran down four flights of stairs, rushed into the prep room of the OR, and told the surgical resident who was scrubbing about the Watson Schwartz result. He looked dumbfounded and started to argue that, despite the test result, she had an acute surgical abdomen and needed surgery. The patient, still conscious, recalled two similar episodes of abdominal pain, nearly identical to this episode, and knew of two relatives who underwent multiple surgical abdominal procedures.
     Surgery was canceled. I had stopped an unnecessary surgical procedure. Word spread. The next day at his morning report, Dr. Loeb had me tell the story over and over. He was ecstatic. Unnecessary surgery had been avoided and from a rare disease at that. Doctor Meador, within a few minutes, was back to Clifton.
My number in the draft came up a few months before the end of my second year of training and I was headed to the Army Medical Corps. Dr. Loeb called me into his office, the only time I had been there alone. I asked him for a photograph of himself. He handed me the signed photograph and said, “Well, Clifton, what are you going to do after the army?” I answered that I did not know. He told me he would be glad to have me return to finish my residency, but I never saw him again. The picture of him still hangs in my office.

Adapted from “Twentieth Century Men in Medicine: Personal Reflections” by Clifton K. Meador, M.D., published by and available at Borders book stores and One chapter is devoted to Robert F. Loeb. Dr. Meador is professor of medicine at Vanderbilt and executive director of Meharry-Vanderbilt Alliance. He served as dean of the School of Medicine at the University of Alabama at Birmingham from 1968 to 1973. His most recent book is “Symptoms of Unknown Origin: A Medical Odyssey” (Vanderbilt University Press, 2006). “Personal Reflections” is his 10th book.

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