"It should be quite unnecessary to reveal the moral; the right
telling of the story should be sufficient. Do not moralize;
let the facts produce their own moral in the student’s mind.
- Bertrand Russell
He was known as one of our most stern and demanding professors. Students, residents, and even other faculty members mentioned his name with a mixture of respect and fear. On my first day as a junior student on the medical floor I saw a patient with clear-cut symptoms of an overactive thyroid. After I finished my exam and drew the necessary blood tests the medical resident gingerly approached me.
"This is a good teaching case," he said.
I enthusiastically agreed. This young woman looked like a picture that had dropped out of the textbook. Bulging eyes; fidgety behavior; a fast heartbeat; a very enlarged thyroid gland. One could not ask for a better subject to use to teach a student about thyroid disease.
"We have to present her on professor's rounds tomorrow," he added.
I quickly nodded.
"The problem is, it's Dr. Perkoff's turn to make rounds tomorrow."
So?
Immediately he understood that I did not know about Dr. Perkoff. He asked an intern and a fellow resident to come closer to us.
"He needs to get the Dr. Perkoff tutorial."
All of them smiled. The kind of smile you get when people feel sorry for you, but not too much, because they have been in the same boat, and now it is someone else’s turn to be initiated. The new student had to be subjected to an experience like a fraternity's "Hell Week."
They poured on the advice. Between teaching me all that they knew about thyroid disease and warning me about what not to say or do, I spent the next five hours immersed in an intense learning experience.
Dr. Perkoff was an internationally renowned specialist: he had written the definitive article about alcoholic muscle disease. At some point in his career, he had decided to drop research: he would spend the rest of his life taking care of patients, almost exclusively the poor and forgotten. He became head of the Washington University internal medicine service at Saint Louis City Hospital.
He was known for his unrelenting demand for scholarship and attention to detail. Students who presented a case to him were expected to memorize the patient's history, to encompass all prior surgeries, hospitalizations (including the year and the doctor who was in charge), current medications, occupation, number of children, allergies... everything. No "cheat sheets" were allowed. All current lab tests had to be reviewed. It was not enough to say that the hemoglobin was normal: he wanted us to remember the exact number for this test and many others. He expected us to look at all blood specimens by ourselves, and not to rely on the lab tech's interpretation. The same for the urine, and the sputum if there was any.
He wanted his students to read extensively on the disease in question. There was no use in bluffing, because he read every journal and remembered most of what he read. He was known as the only professor who did not need to be told ahead of time which disease was being discussed. Most professors did some reading on their own before they came to rounds, to make sure that they were up to date. Not Dr. Perkoff.
At ten the next morning I was a bundle of nerves. This saved me: I reached the point where I no longer cared what Dr. Perkoff would do to me. When he walked in, I was surprised to see a bald man who was three inches shorter than me (I expected a ten-foot giant). He had a large scar on one side of his neck (I later found out that he was a cancer survivor). He smiled, gave me a firm handshake, and in an instant changed to what I later came to know as his "game face." A serious, almost angry look. What one would expect to see on a boxer who is ready for a fight. Once I got to know him well, I realized that he was getting ready to fight disease, not his students.
"What do you have for me today?"
There were two dozen people in the room. I went on to rattle off all the facts. I led him to the patient's bedside. I demonstrated the bulging eyes, and the swollen thyroid. I showed off her brisk reflexes. I submitted to Dr. Perkoff's grilling, and to my surprise, I was able to answer most of his questions.
The ordeal took two hours. Shortly before noon the discussion ended. Dr. Perkoff shook my hand again, again with a smile. The angry look was gone.
"That was pretty good. For a medical student who has only had a few hours to prepare, that was exceptionally good. Come see me some time."
I did. Over the next six years he became a respected (not feared) teacher, a counselor, a mentor, and a friend. I understood his passion to extract the best from all of us. Yes, he did frequently shout "YOU WHAT!" at a bewildered underling, but he never kept a grudge, and he always made sure that the recipient of his ire had another chance at redeeming himself (I never saw him "beat up" on a female student).
When I decided to leave the medical center to start my own practice, I went to say good-bye to my mentor. He was getting ready to walk out of his small office. I told him that I would be joining an older physician in practice. That I finally would get to fulfill my dream of being a physician.
“I am getting ready for rounds. Do you want to come along, for old times’ sake?”
One last professor's rounds with Dr. Perkoff! Who could say “no?” Who would dare say “no?” As we left his office, he explained that he had chosen to switch careers once again, so it would be his last clinical conference. Twenty students and residents followed him to the medical ward.
The student presenting the case was five minutes into his talk when the man who occupied the bed next to our patient began to scream for the nurse. He was an alcoholic; a derelict who had been admitted to the hospital because he was drunk, and it was cold outside, and the city shelter was full. He looked like he was not completely over his intoxication.
There were no call lights in City Hospital’s wards. Any patient who needed a nurse’s attention had to scream. If he (she) got lucky someone would stop pretending not to hear. He screamed, and then screamed some more, and then louder. There was no way that we would be able to conduct rounds in this manner.
Suddenly Dr. Perkoff excused himself. He walked around our patient´s bed and stopped next to the disturbed man’s head. He leaned over a bit.
"Can I help you, sir?"
It turned out that the man had soiled himself in bed. He wanted to be changed. There was no nurse in sight. In this hospital, his wait for attention could be long.
"We will help you," said Dr. Perkoff.
He asked me to get a pail of warm water. A student went to fetch gloves; another one went for soap and clean sheets. Within a few minutes Dr. Perkoff had taken off his lab coat, put on gloves, and proceeded to gently clean the man's rear end. He dried him, helped him to put on a clean gown, and changed the bed sheets. The entourage was flabbergasted. A full professor of medicine at Washington University; a world-famous internist; a division chairman was tending to a homeless drunk as if he were a VIP.
"I know what you are doing here," I said to myself. "You are teaching me something. This is my present. You are giving me a farewell present."
I smiled.
When he was done, Dr.Perkoff announced that rounds were over. I could see that most of those in attendance were stunned.
“He did not teach us anything,” I overheard one of the students say. I came close to telling him that he was obviously not paying attention.
A fitting end to our relationship. I got busy; he moved out of town; I never saw him again. The man who had taught me endless facts about medicine slipped me this most important nugget as I started my career.
It was not going to be about me: the practice of medicine was never going to be about me. It would always be about that poor soul who was lying helpless in front of me and who needed my help. It was not going to be about rank, or titles, or how important a person this next customer was. I always had to be ready to do the right thing. No matter the hour, or how tired I was, or how obstreperous was the patient´s behavior, I had to be ready. Most important: there was a chance that the patients that I so assiduously took care of would be in no position, or disposition, to thank me, or pay me. The practice of medicine had to be a labor of love.
Twenty years later, I decided to get in touch with him. I sent him a letter to thank him for all that he did for me. For the many times that he went out of his way to lend me a hand, to gently nudge me forward. I told him that throughout my career as a physician I had done my best to follow his example.
He wrote back.
“I cannot thank you enough for your warm and wonderful letter. To know that you attribute some of your values to my example is especially heartwarming.”
My professor changed careers for a fourth time. He died years ago. He left thousands of students an enduring legacy of dedication and hard work. He did more than teach me medicine: he showed me how to be a good man. He led the way.
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