by Cap Lesesne
I could do that. I wanted to do that.
I’d found something exciting, something important, and something I was passionate about: medicine.
By the time I returned home for Christmas break, my grandmother had got wind of my interest, and she arranged for me to meet Dr. Henry Ransom, a longtime acquaintance of hers who was professor of surgery at the University of Michigan. On a snowy December day, Grandma and I drove the hour and a half through a snowstorm to Ann Arbor, to meet the doctor at University Hospital. Dr. Ransom had grown up on a farm in central Michigan, Grandma told me on the drive, and he was known as a great teacher and an excellent surgeon. He had neither wife nor children. He was in his eighties now, a professor emeritus.
When we pulled into the parking lot, it was the first time I’d ever been to a university hospital, and it was not at all like Dad’s hospital – St. John’s in Detroit, the inviting, humanly scaled institution my father had been affiliated with since I was a kid, the place I felt so eager to stop in to see him, always feeling comfort inside its walls, even pleasure. But this place, University Hospital, was gigantic, cold, impersonal. For the first time, I understood the anxiety that ripples through most nonmedical people when they set foot inside any hospital.
While Grandma and I rode the elevator to the top floor, I wondered if perhaps this place wasn’t the norm, St. John’s the exception, and whether I needed to reevaluate my new, curious, nineteen-year-old’s urge to spend the remainder of my waking life in dungeons just like it.
Had you hung a stethoscope around Henry Ransom’s neck and slipped a black leather doctor’s bag into his hand, you could not have made him look more like the classic physician. When we got to his office, he was sitting behind a big desk, in his white coat. My eyes immediately went to the surgeon’s long, thin fingers. Dr. Ransom looked the epitome of an emeritus anything: white-haired, elderly, elegant.
After some pleasantries, the doctor asked about my background. I told him I was at Princeton. Despite my unexpressed reservations in the elevator ride up about the hideousness of University Hospital as a workplace, I said I’d become interested in pursuing medicine.
“Would you want to work in our department of surgery?” he asked me.
The offer was so sudden, and he knew so little about me, that I thought he deserved an equally impetuous answer.
“Yes,” I said, having no idea what the job entailed.
And just like that he was up from behind his desk and motioning for me to follow him. “I want you to meet someone,” he said, and we walked into the neighboring office, where a balding, slightly overweight man sat.
“Jerry?” said Dr. Ransom. “I think this young man would be a good researcher.”
That was it. My grandmother must have been well regarded by the doctor, I thought, because unless I was wrong, suddenly I had a summer job waiting for me the end of sophomore year, in the department of surgery, at the University of Michigan. And I had yet to take organic chem.
To his credit, the man to whom I’d just been introduced, Jerry Turcotte, the chief of surgery, didn’t act put-upon (which said a great deal about his respect for Dr. Ransom). Dr. Turcotte had an easy smile. He’d grown up in Grosse Pointe, too, it turned out, two blocks from my house on Fair Acres Road.
“I know just the spot for you,” said Dr. Turcotte. “We’re doing research for kidney transplants.” Quickly, I was realizing – though I’d had ample evidence to learn it while growing up, from my father the doctor – that medical people, especially surgeons, don’t pussyfoot. They don’t have time to. They make bold decisions – quick, yes, but bold, first and foremost.
The “research” they had in mind for me that summer, it turned out, did not involve my poring over a bunch of medical texts and data readouts.
They wanted me to cut open dogs.
The doctors in the department were working on an important experiment. They wanted to see if a particular drug, administered just after surgery, would improve the rate of acceptance for kidney-transplant patients. Back then, in the mid-1970s, a kidney transplant was a last-ditch, usually unsuccessful strategy to cure someone suffering from kidney failure. But it was hypothesized that if the patient was given cyclosporine, which reduces the body’s rejection of foreign cells, transplants would be much more likely to “keep” and could thus save thousands of lives a year.
Cyclosporine had already been tested on rats, with extremely promising results. It was time to move up the food chain. But before Dr. Turcotte and his team could win approval to test cyclosporine on humans, they would first have to test it on something else.
Dogs. And not just any dog. A specific strain of beagle – one that looked an awful lot like Snoopy from Peanuts – was chosen as the, well, guinea pig, because its DNA displayed important similarities to human DNA. Before the dogs were operated on, they were pampered and fed only the best food (should you wonder if the animals were being mistreated). Two surgical teams would work side by side. The dogs were sedated, a pair at a time. Each was spread-eagled, on its back, its paws gently tied back. A breathing tube was placed down its throat. Each surgeon would cut open a dog’s abdomen, nudge the intestines aside, and isolate the veins and arteries; this was done by dissecting down to where the artery comes off the aorta and the vein comes off the vena cava – the two main valves leading to and away from the heart. The surgeon would dissect on the ureter (the vessel running between the kidney and the bladder) and cut the blood vessels around the kidneys, to free them. The vessels would be tied and clamped so blood didn’t gush out of them. With the kidneys now free, the surgeon would remove them and put them in a bowl, swap bowls with the other team, then plant the foreign kidneys into their new host dog, suture the vessels together, remove the clamps, and make sure there were no leaks (or that we hadn’t accidentally sewn a blood vessel to itself). The abdomen would be sewn up. Cyclosporine would be administered.
It was a straight kidney swap. Very science-fictional.
Finally, blood would be drawn from the dogs to see if the new kidneys were working. Was waste being cleared – proof that the kidneys were doing what kidneys should do?
My “research,” then, was doing actual surgery, right alongside other surgeons, residents, and researchers. The lab administrator put me through intensive training, teaching me the surgical ABC’s – what the instruments were called, what they did, different types of sutures, how to make knots. In my life to that point, I’d cut open all of one frog, in biology class at Andover.
Three weeks after my training began, I was deemed ready to do transplants.
At first, I felt clumsy and pathetic. I put my thumb and index finger through the holes of the instruments so that I had a firm grasp of them, but it didn’t feel natural. Gradually I got to see – got to feel – that if I covered the hole with my palm and exerted pressure with and through my palm, I could move faster and more dexterously. (This technique, called palming, I’ve employed in every surgery I have done since.) At first, I held the scalpel too far down the instrument and way too tightly – more rookie mistakes – but as I grew adept, I realized how lightly I could hold the scalpel, and how far up the shaft, and that doing so allowed for more sensitive touch.
Perhaps as important, the experience that summer gave me my first whiff – and I do mean whiff – of a rough-edge sensibility particular to many surgeons. One day, a pair of surgical residents operating on the beagles kindly offered to show me the intricate and fascinating anatomy of the aorta and vena cava.
“Hey, Cap, look at this,” said one of them, leaning forward and urging me to join him for a closer look at the beagle’s interior. He assured me it wouldn’t hurt the dog because retractors were in place in the abdomen to keep the ribs spread apart.
I leaned forward for a look – at which point the other resident, who’d tiptoed behind me, shoved my face into the dog’s abdomen.
I will never forget the stench of warm canine abdominal cavity.
I shot out of there, blo
od on my glasses and forehead and mask, and staggered back, head spinning.
“Welcome to the surgical corps,” chided one of the residents, though I couldn’t see which one.
I groaned weakly, teetering in the direction of a window, to replace the smell in my lungs with fresh Midwestern air.
Just then our supervisor walked in. He seemed to know right away what was going on – not that it took a genius. The scene – residents laughing; me, distressed, wiping blood off my glasses – was fairly self-explanatory.
“You boys are in big trouble,” the supervisor warned the residents. Their laughter ceased immediately. Even in my fog I noted my surprise at how genuinely scared they looked.
My head had stopped spinning. I was no longer going to heave.
“We were just having some fun,” I said, shrugging. The supervisor looked at me for a moment, expressionless, then walked out of the room. He never said a word about it.
When he’d gone, the residents smiled at me, grateful.
But I was the grateful one. I was just a kid, yet they’d initiated me into the medical fraternity, where both friendship and rivalry are unusually intense.
As to the kidney-transplant research: It was a spectacular triumph. We succeeded in showing that, at least in this breed of beagle, using cyclosporine as part of kidney transplants helped greatly in the acceptance of the new organs. A paper would be published about it, with Dr. Turcotte’s name on top, and my name mixed in somewhere with the team’s. Years later, the drug was approved for use in human kidney transplants, and a once risky procedure became fairly routine. Today, a kidney transplant involving a living donor has a 90+ percent chance of success. Dr. Joseph E. Murray, the man from Massachusetts General Hospital and Brigham and Women’s Hospital who had, a generation before, laid much of the foundation for all transplant surgery, would win the Nobel Prize for Medicine for his contribution – the only physician, amazingly, ever to win the prize.
The team’s success was a perfect example of what I mean when I say scientific knowledge builds on previous knowledge to increase understanding and better people’s lives.
Just as important to me back then, not one single beagle died during any of the surgeries that summer. Not one of those opened and closed by the surgeons or residents, or by me. My childhood dog, a blond Lab named Fresca, would have approved.
Thanks to Dr. Ransom, Dr. Turcotte, and the rest of the team, my decision to pursue medicine seemed vindicated. And I was grateful for the way they had included me, the youngest guy there. A kid never forgets who’s been good to him.
For all my feeling for those men, though, I did not want to be a surgeon. I had decided on another branch of medicine, one that delighted my mother and thrilled my father.
I was going to be the world’s greatest pediatrician.
I Don’t Have What It Takes
Focus and drive.
It’s hard to find two words that describe better what it takes to become a successful surgeon.
Focus and drive.
It’s what defined my last two years of college. I took all the premed courses I didn’t take my first two years.
Senior year, I also managed to find the time, somehow, to fall in love for the first time. Victoria was a sophomore from New York City. Smart, intellectually curious, five feet eight, brunette, nicknamed Tory. We biked and played tennis. Our time together was always sweet. I knew that someday I wanted to be married, have kids, probably lots of them – not at all surprising for someone who came from a big family, and who has mostly happy childhood memories.
On graduation day, Tory was there. Life was perfect. But even greater joy lay just ahead.
The challenge of medical school.
It was at Duke Medical School that I learned how to be a doctor.
Sounds dumb, right? You go to medical school to learn how to be a doctor.
Except it doesn’t always, or even often, work that way. Yes, of course medical school teaches you, in class and in clinical rotations, a basic fund of knowledge. Some concept of disease. Some concept of the treatment of disease. Medicines.
But to be a doctor, to really know how to care for patients rather than how to deal with them – that deep understanding may not happen at medical school. For me, I was fortunate already to have had a taste of it, by witnessing Dad’s devotion and sense of rightness. The simple message of his coming home late so often – when I knew how much he loved his family – taught me that you can’t ever turn off your responsibility to your patients. Ironically enough, his not being around – which had been the greatest deterrent when I was younger to my even considering a medical career – now revisited me as an important lesson to help prepare me for the difficulty, the relentlessness, of what I was about to embark on.
But as much as my father taught me, it was mostly secondhand observation: watching him through the car window as he made another house call; seeing him once every few months at the hospital; feeling his absence at home. (Later on, he became – and remains today, even in retirement – an even greater professional influence. Recently I phoned him with an immunology question that had stumped me. Dad knew the answer. It’s pretty great having a man with a half century of medical experience always on call.)
My mentor at Duke, Dr. David Sabiston, taught me how to conduct myself, every day, as a healer of people. Like my father, he was devoted to his patients, worked hard, and stayed disciplined. But it was Dr. Sabiston’s interaction with other doctors that was a revelation. I’ve never seen a superstar doctor – or any doctor, in fact – act so respectfully toward medical students, the indentured servants of our profession. If we med students did something wrong – and we were always doing something wrong – Dr. Sabiston would never admonish us publicly.
Yet he was stern. Each week during my rotation, one of us had to review a case history of a patient and present it to the doctor, other med students, and some of the residents. The chief resident would prep us a bit, but mostly it was up to us to bone up on everything, to be armed to answer all questions about the history and management of the patient’s disease. The presentations were made in one of the medical school libraries, a wood-paneled room decorated by photographs of previous chief residents, all of whom had obviously thrived at this kind of thing. The prize for a good presentation might be a phone call on your behalf, your final year of medical school – Dr. Sabiston calling the head of the medical residency program of your dreams and praising you to the stars. If you didn’t do well? Let’s not even consider that. Maybe surgery is not right for you. I was so nervous each time I presented to him, my knees actually knocked. I was grateful my lab coat covered the spectacle.
It was Dr. Sabiston who taught me probably the single most useful principle in my doctoring arsenal:
Do not treat without a diagnosis.
Again – sounds dumb, right? How could you treat without a diagnosis?
But the caution is more nuanced than that. It demands that, before you attempt to be a healer, you remember that first you’re a scientist.
Sort out the problem. Think it through. Do not treat without a diagnosis.
You’d think every doctor would have learned this last tenet – or, if not, would have intuited it himself. But no. This fundamental notion (perhaps the doctor’s equivalent to the lawyer’s mantra to provide one’s client with the best possible defense) is ignored and abused and forgotten by more doctors and hospitals than you want to know about. A few years ago, I got a call from a patient whose eyelids I’d lifted a year before. “This has nothing to do with plastic surgery, but I trust you,” he said, his voice shaky. “I have prostate cancer.” He then mentioned the name of a renowned New York-area hospital and said that they wanted to remove his prostate.
“How did they find the cancer?” I asked.
“Blood test,” he said.
I hesitated a second. “Any tissue sample?”
“No, but a blood test.”
“They’re going to take out your prostate and
possibly leave you incontinent without a tissue sample to verify that you have cancer?”
“See?” he said. “This is why I called.”
He went back to the doctor and insisted a tissue sample be taken.
It was negative.
This happens all too frequently. A physician starts treating without having the proper diagnosis and ultimately injures, rather than helps, the patient. It’s particularly infuriating because it’s often so avoidable and delays real diagnosis.
Why does this happen? Are these doctors lazy? Intellectually undisciplined? I don’t know. But every patient is entitled to a clear explanation of what is happening to him or her, why, how it’s being treated, and why alternative treatments were rejected in favor of the one being followed. It’s your body and your life, not to mention your peace of mind. Don’t be afraid to ask for the explanation. If you still don’t understand after it’s been explained to you, then ask again, or ask more pointed questions. If your doctor can’t explain clearly what’s going on, then he or she doesn’t understand the situation well enough. Get a new doctor.
In the end, Dr. Sabiston taught me only one thing, really. How to be a doctor.
I requested pediatrics as my first rotation.
Since Duke is a major cancer referral hospital – meaning it receives many of the most “complex” (read terminal) cases, largely from the southeastern United States – I saw dozens of children afflicted with cancer, some in infancy. Most of them suffered from leukemia or lymphoma. It’s a sad euphemism but, in this role, Duke was termed a “tertiary medical center.”
At the end of my first month in pediatrics, for whatever karmic reason, we received an unusually large influx of terminally ill children in a very short time – six in one week.
Of those, can you guess how many of them died by the following week?
Two?
One?
Four?
All of them. I saw every single one die.
When the sixth and last of those children died, I remember walking out of the hospital into the summer evening and taking a seat on the steps. I was more than just depressed. I was stunned, almost in shock, from what I’d just seen. I was literally dizzy with grief.
