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.