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The practice of medicine: Moving beyond the science

Brian T. Maurer, PA-C

Brian T. Maurer, PA-C, practices pediatrics at Enfield Pediatric Associates, Enfield, Connecticut. He is the author of Patients Are a Virtue and a member of the JAAPA editorial board. Visit the author at www.lulu.com/briantmaurer.

Nearly 3 decades ago, when I first stepped out into the field of clinical practice, the science of medicine was top priority.

Like most PA students from that era, I spent the greater part of 2 years struggling to learn human anatomy and physiology, physical diagnosis, pathophysiology of disease, laboratory medicine, diagnostic radiology, and pharmacologic treatment. It felt like I was being force fed through a fire hose: I couldn’t swallow fast enough; and what I did swallow, I had difficulty digesting. Somehow, I made it through the rigorous training. As I prepared to start my first job at an inner city health clinic working with the urban poor, a wise old physician reminded me that my medical education was just beginning.

Two years later, I again found myself in a training program—this time a postgraduate residency for PAs in pediatrics. Once again, I struggled to learn the science behind treating the myriad medical problems of the premature infant, the compromised newborn, and the child with chronic disease. I learned how to intubate a depressed baby in the delivery room, insert an umbilical catheter to push resuscitation drugs and perform an exchange transfusion, manage tiny infants on ventilators, and calculate total parenteral nutrition requirements. I pursued electives in infectious disease and pediatric cardiology. I’ll never forget the fascination I felt the first time I watched radio-opaque dye pass through the chambers of a child’s beating heart, delineating congenital cardiac pathology in real time.

I also spent a month interning in the PICU at a regional teaching hospital. My first patient was a 14-year-old boy who had developed Reye syndrome when his mother gave him aspirin after he broke out with chickenpox. Among other things, he had a bolt placed through his skull to monitor intracranial pressure fluctuations. Another patient—a ventilator-dependent little girl with Alagille syndrome—developed severe bradycardia during morning rounds. Before the eyes of attending and resident physicians, I dropped the clipboard with my sign-out notes onto the bed and administered chest compressions until she bounced back.

By the time I completed my residency training, dressed in hospital scrubs, laryngoscope holstered at my side, a copy of the latest edition of Harriet Lane in one deep pocket of my white coat and a Braslow resuscitation tape in the other, I thought I was ready for anything that might walk through the hospital door.

Then came the day when I was paged stat to the emergency room to resuscitate a 1-year-old infant whose mother had run from her apartment five blocks down the street to the hospital with the child in her arms. She had no phone, only legs and lungs. I did everything in sequence, just as I had been taught: airway, breathing, circulation, cardiac drugs—all to no avail. The child died. I had to break the news to her mother. “I’m sorry,” I said with a slight tremor in my voice. “She’s gone.”

I sat with this young African-American woman and listened to her sob. Not knowing what to say, I handed her a box of tissues, a small offering to acknowledge her grief. She dried her eyes and began to talk. She told me everything just as it had happened: checking on the sleeping child she had put down for a nap an hour before; finding her blue in the crib; screaming her name; scooping her up and running out of the house in a panic—running, running, running. I listened to every word as though it were the dialogue of a blockbuster film on opening night.

In the end, she reached for my hand and thanked me. I had never felt so inadequate. Not only had I failed to save her little girl, but I could muster few words of comfort for this mother. Yet here she was, thanking me for all I had done.

Flat on my back, staring at the ceiling from the cot in the upstairs call room, I mulled things over. I walked to the bathroom and regarded my face in the mirror. The science of medicine—all that I had struggled to learn and apply—had failed me and my patient. I felt profoundly insignificant and very much alone.

The following morning I processed this event—the death of this little girl—with a senior colleague. “It sounds like you did everything properly,” she told me. “Stop beating yourself up about it. If you want to be any good in this business, you’ve got to learn how to suck it up and move on.” I know now that she meant well, but at the time her words brought little comfort.

Shortly thereafter, I began to search beyond the science of medicine for something more. Back then I didn’t quite know exactly what I was looking for—I didn’t even know if it had a name. But I knew that if I were going to survive in this arduous work to which I had been called, somehow I would have to find it. JAAPA