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This month... COVID-19, Chapter 2

Gregory Rutecki

The late Eighties was the worst of times in medical education--the era when doctors in training worked a virtually unlimited number of hours each week. This unceasing and inhumane workload led residents, understandably, to view patients purely as collections of physical ailments.

Back then, I was an attending physician at a community teaching hospital. One day, as usual, I was preparing to make morning rounds and, simultaneously, to do my best to teach my team of internal-medicine residents.

Fourteen patients awaited us, every one of them quite sick. As my team and I proceeded from one bedside to the next, struggling to cram the patient interviews into ever-dwindling snippets of time, I felt a familiar sense of growing pressure; it was a struggle to focus fully on each patient.

Despite this, our last patient's chart notes grabbed my complete attention.

Mr. Ryan, age seventy-six, was sicker than most of our patients--and he was a veteran. He'd been sent to our hospital after being deemed unfit to travel to the nearest VA facility.

All of my first-degree male relatives served in the military during WWII, and I pride myself on being a WWII buff.

Scanning Mr. Ryan's problem list, I knew we were in for a long haul. Like so many veterans of the Greatest Generation, he had the usual diseases that accompany sixty years of cigarette smoking--chronic lung disease, atherosclerosis and heart failure. I noted that the last problem on his lengthy list was "blind oculus sinister."

"How did he lose the sight in his left eye?" I asked my residents. "Was it glaucoma, a blood clot or macular disease?"

After a moment's hesitation, one answered, "We didn't ask about his eye...His other problems were so urgent, we thought it was more important to address them first."

When we entered Mr. Ryan's room, I studied him for a moment. He seemed comfortable, no longer short of breath. But when I introduced myself, he didn't look at me or reach out to shake my extended hand.

I decided on a different approach.

"Before we do anything else, I want to thank you for your service to the country," I said. "What branch of the military did you serve in?"

"In the Army," he replied tersely.

"What years did you serve?"

"Nineteen forty-two to nineteen forty-five."

"Where did they send you?"

His expression brightened, and he looked me in the eye.

"Europe was my destination," he said. "And it wasn't a vacation."

"Where did you see the most action?"

"I landed Utah Beach* on D-Day," he answered briskly.

"I heard you guys missed your landing zone, so you took fewer casualties than the guys at Omaha."

"Maybe so, Doc, but I lost a lot of friends."

The residents may be right about his left eye's significance in the greater scheme of things, I reflected, but I'm still in charge of "teachable moments." And I was on a roll. I decided to push my luck.

"What happened to your left eye?"

"Caught shrapnel at Utah and finished the war as a one-eyed rifleman," he said. "I didn't want to leave my men."

So much for fewer casualties and missed landing zones, I thought.

By the time we got to the physical exam, Mr. Ryan had become so talkative that I couldn't hear his heart or lungs for the flood of words. A widower whose children and grandchildren lived too far away for a visit, he now had a captive audience. Knowing that I was fascinated, he rattled off battlefield vignettes at a superhuman clip, and I drank it all in.

As for the medical portion of his story, it was straightforward. The residents had already prescribed a diuretic, inhalers and antibiotics for his diseased, waterlogged lungs, and beta blockers for his heart. When I asked them for his echocardiogram and lab results, they answered without a moment's hesitation.

Leaving the room after I'd bid Mr. Ryan a reluctant goodbye, I found myself wondering what the residents had made of our encounter.

Did they notice how quickly he was transformed from a silent invalid into a living, breathing WWII historian? In our short time together, he completely forgot his nagging chronic illnesses. He was lonely and sick, but reliving his finest hours invigorated him.

"How many of you saw Saving Private Ryan?" I asked the team. Everyone raised their hands.

"Do you think maybe you missed something by not asking Mr. Ryan about his eye?" I went on.

They gazed at me, their faces radiating nonchalant confidence.

"It was the key to what he most valued among his life accomplishments," I pointed out. "He feels defined by his trial by fire at Utah Beach. You may not agree, but I believe that giving him a chance to share his experiences with us was more therapeutic than any other aspect of his medical care."

Their expressions didn't change.

The next day, before rounding, I overheard the residents chatting.

"Wasn't yesterday strange?" said one. "Dr. Rutecki seemed so excited about that veteran's story, even though it had nothing to do with the reason he was admitted."

I felt let down; the teachable moment hadn't connected as I'd hoped.

It seemed clear that we all had a lot to learn. I resolved to read more about Utah Beach. And I hoped that my residents would somehow make time to reflect on this encounter from our own personal Private Ryan.

I wanted them to see that, in terms of healing power, listening to a patient's WWII stories might transcend even the best treatment guidelines. Our veteran knew that his diseased lungs and heart would be the victors in his final battle; he wanted to tell his story before he vanished with the rest of his generation. I hoped the residents would see how the act of sharing his story with me had created a strong, intimate doctor-patient connection that was ultimately more therapeutic--for both of us--than antibiotics or steroids could ever be.

Not long after that day, medical educators grasped the folly of expecting residents to work seven days a week, with no time off. Legislation was enacted to cap residents' work hours and allow them "time to heal," as advocated by medical historian Kenneth Ludmerer in his book of that title.

This was a much-needed improvement--but, I've realized, it was still only half of the equation. My encounter with a real Private Ryan was possible because of the serendipitous overlap between his life story and my personal interests--and because I was willing to devote the time needed to explore our common ground.

I worry that, unless I can somehow teach my residents a willingness to open up and listen, and to care for the patient on every level, they will overlook their own Private Ryans--and miss the chance to give and receive the deepest kind of healing.

*"Historians generally overlook the Utah Beach invasion in favor of the much larger and costlier Omaha assault...Indeed, when one adds the 82nd and 101st Airborne components to the troops who landed on Utah, the Omaha and Utah invasions were comparable in size...Furthermore, when the casualties suffered by airborne units on D-Day are added to those suffered by VII Corps on Utah Beach...the two major American contributions to the D-Day invasion, Omaha and Utah, were similar in both size and cost." --J. Balkoski, Utah Beach: The Amphibious Landing and Airborne Operations on D-Day, June 6, 1944 (Stackpole Books, 2006), p. xiv.

About the author:

Greg Rutecki practices general internal medicine at the Cleveland Clinic. After graduating in 1974 from the University of Illinois Medical School in Chicago, he trained as an internist at Ohio State University and then completed nephrology training at the University of Minnesota. Since then, he has practiced nephrology and has been a teacher. Over the last ten years, he has written medical-humanities pieces on topics such as the impact of composer Gustav Mahler's endocarditis on his Ninth Symphony, and the use of radium to treat opera composer Giacomo Puccini's laryngeal cancer.

Story editor:

Diane Guernsey


# Ron Banner 2017-06-12 06:17

To simply read about Aida in Wikipedia, we would miss all the drama and emotion that hearing the opera (the actual words, music, etc) brings - to say nothing about the connection between the audience and the performer - and what that means to future "performances."
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# Sally 2017-06-09 08:13
Fondly remember you from your days at Aultman. This is a wonderful article. I will be searching for your piece about Mahler
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# greg rutecki 2017-06-14 12:26
send me your email and I will get a copy to you/ greg
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# Ellen Rand 2017-06-05 11:29
This is such a wonderful piece. As a hospice volunteer, I had the privilege of regularly visiting a 90-something man who was at Utah Beach. Clearly it was the singular, defining time of his life. His family is fortunate because he told his story to a writer who did a self-published book about WWII remembrances. So now they have that history on record, so important now that he's gone. So many families aren't so fortunate.
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# Amy Cowan 2017-06-04 14:23
Thank you so much Greg for sharing this story. It's powerful and true. I work closely with IM residents at the SLC VAMC and encourage them to ask the veterans questions. Most of what we hear you couldn't make up. I think I'll start bringing your story and read it the team on long call days. The power of narrative! Maybe in thinking about a veteran's narrative they will reflect on their own story. Thank you again!
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# Janice Mancuso 2017-06-11 13:28
Amy, what stood out most about your comment was that you would "read" this compelling story to your team. I think programs such as Poetry Out Loud, The Moth, and NPR's StoryCorps are so powerful because we get to hear spoken words and the emotion the words convey. I may have shared this Native American proverb on Pulse before, but it's appropriate to share again here... “Tell me a fact and I’ll learn. Tell me a truth and I’ll believe. But tell me a story and it will live in my heart forever.”
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# Debbie Traver 2017-06-04 14:02
So said but true. The majority of medical personnel today see a number, a diagnosis, their next day off, the end of this day everything but the patient as a human being. I was an RN for over 40 years and the state of healthcare now is discouraging and frightening.
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# Don Middleton 2017-06-04 10:38
A story that reflects my own experiences teaching residents. Two differences: 1) the 80s were not the worst of times in medical education and 2) when learning how a Korean war veteran on our service lost his hearing and 6 of the 15 man in his platoon after they all stumbled into a minefield, my residents broke down in tears. As to the first point, in the 1940's my father-in-law as an intern, a term standing for just what it says, was allowed to leave the hospital for 6 hours a week on Saturday night from 6 to midnight. That was devotion. Thank you for the wonderful piece.
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# Ashrei Bayewitz 2017-06-04 09:19
This was great; thank you. Some of my favorite and most influential clinical moments were unexpected connections that became a main focus of the clinical encounter. I really liked the way you brought this episode to life and showed its importance.
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# janet 2017-06-03 14:09
Thank you for this.
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# rachel hadas 2017-06-03 12:40
Excellent story and interesting comments as well. Greg, a propos of your medical humanities work, Maurice Ravel (I believe it was Ravel and not Bizet or Poulenc!)had some undiagnosed neurodegenerati ve ailment, probably in the FTD family...as did my late husband George Edwards, a composer (see my memoir STRANGE RELATION).

I agree that the teachable moment probably did indeed happen, even if your students showed nothing at the time. Wonderful story.
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# greg rutecki 2017-06-09 13:10
thank you! I have a paper in press about radium use for rectal cancer in Debussy and Laryngeal cancer in Puccini/ did not know about ravel
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# Warren Holleman 2017-06-03 10:44
What a wonderful story--thanks for sharing. I resonate with your frustration over what appears to be a lost teaching moment. But my guess is that it wasn't lost at all, it was just that the learning took place later. "When the student is ready, the teacher will appear." Perhaps the students weren't ready, which is understandable given their long working hours and exhaustion. But my guess is that once they recovered from their own D-Day experience of working 80-100 hour weeks, they reflected back on this and had an incredible teachable moment in hindsight.
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# Dr. Lou Verardo 2017-06-03 08:42
While you may not have thought your team understood the importance of what you showed them that day, I believe they will appreciate that moment at some later point in their career, when the mechanics of care become supplanted by the need for an excellent bedside manner.
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# Marianne Lonsdale 2017-06-03 05:24
This is a terrific piece. I'm from California and traveling in France right now and was at Utah Beach a few days ago. So all the more meaningful and thank you.
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# Pris Campbell 2017-06-03 04:35
What a wonderful narrative on the value of listening to patients. I wish this was the norm rather than the exception. I also wish doctors were allowed more time and energy to do this. I have a great internist but insurance contraints limit him to tops 15 minutes. I've often wished we could share a half hour from time to time to talk in more detail but how would he pay his staff, his rent, himself?
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# Kathryn Vaughn 2017-06-02 21:55
I agree. These teachable moments embody both an important aspect of treating the whole person and create the joy of medicine. But it is no longer allowed in our medical system of 15 minutes for everything you do for each patient. I am heartbroken. I don't see how we can add back those extra minutes to really share our patient's life stories. But I continue to hold hope that it will one day be allowed (and paid) again.
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# Annette Simmons 2017-06-02 21:52
Story-listening may be the most healing form of story.
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# Joshua Freeman 2017-06-02 21:20
This is a great story about teaching, teachable moments, and the importance of people's life histories.
Thank you
[PS I don't think you mean the late '80s was the "worst of times"; perhaps the end of the "worst of times". I trained in the mid-70s; many folks lived in dorms in the hospital, and the folks who were 5 or 10 years ahead of me had it much worse. There is a reason that this job role was called "interns", "residents" and "house staff".
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# Joan Bowker 2017-06-02 20:42
Excellent piece on what's really important in the healing process. Personal connections are the foundation.
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# Gildon Beall 2017-06-02 22:38
Thanks. I graduated in 1953 so have seen this evolution in understanding of our patients.
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