When John Castaldo, MD, joined Lawrence Levitt, MD, in a neurology practice in 1983, they decided to share both an office and a desk. Their relationship became special — not just in sharing the care of patients — but also in the care of each other. The thirteen stories in The Man with the Iron Tattoo and Other True Tales of Uncommon Wisdom (Benbella Books, 2006) — a collection of stories focusing on the complex interactions between doctors and patients — relate lessons of uncommon wisdom that they learned from their patients, families, and their daily discussions.
Dr. Castaldo is chief of the neurology division and head of the Stroke Center at the Lehigh Valley Hospital in Allentown, PA. Dr. Levitt is senior consultant in neurology emeritus and founder of the neurology division at Lehigh Valley Hospital. They spoke to Neurology Today this month about what prompted them to write a book about their experiences.
WHY DID YOU DECIDE TO WRITE A BOOK ABOUT YOUR EXPERIENCES?
JC: When I was at Dartmouth, my attending, Jim Bernat, got me into the practice of keeping a chronicle of each patient in a small notebook, just as he did. It was a habit that I continued with Larry when I joined his Allentown practice after residency. Over time we came to realize that the lessons we learned from encounters with our patients were not only about the usefulness of a particular drug or treatment, but also about the healing power of love and faith, and about how people are able to carry on in the face of difficult illness.
LL: We had been keeping journals for the past twenty years. Five years ago the idea occurred to us that perhaps we could convert these logs into book format, but our first attempt failed. Our reviewers felt that our vignettes were too short and our discussions too lengthy. We simply needed to tell the stories and the lessons we learned and to trust our readers.
WHAT ARE THE CHALLENGES OF WRITING THIS TYPE OF STORY FOR A LAY AUDIENCE?
LL: The challenge was in making the complicated simple, using simple language and simple words. John and I have tried to do that in communicating with patients and their families.
WHAT WAS YOUR SCARIEST OR MOST ANXIOUS MOMENT AS A DOCTOR, AND WHAT DID YOU LEARN FROM THAT EXPERIENCE? WAS IT RELATED TO THE PATIENT WITH THE IRON TATTOO?
JC: Yes, this patient [the man with the iron tattoo] was either delusional or a highly creative liar. [He was brought into the hospital without identification. He was malnourished, dehydrated, and had suffered a head injury. His skin was covered in several extensive and fierce-looking tattoos. He said that he was a former Navy Seal who was sent on secret missions and confided that he had been wounded in battles that the State Department would deny. He trusted no one and repeatedly questioned his care.] When I ordered an MRI of the brain, he refused, claiming that he would burn up in the unit due to his Persian tattoos. This created a scene, causing the nurses to request sedation. At the last moment, I discovered a 1986 Medline reference to Persian iron ore tattoos and the risk of third degree burns by MRI. The test, which I had thought of as benign, could have killed him. I realized that even if you don't have a trusting relationship with a patient — in which you don't believe everything that's said — try to believe some of it.
LL: John's case of the man with the iron tattoo was every doctor's worst nightmare. The lesson I saw John learn was one in humility, that it's fine to say “I don't know the answer,” and to get a second opinion or ask your partners for help.
WHAT HAVE THESE PATIENT ENCOUNTERS TAUGHT YOU?
LL: We learned that the power of the doctor-patient relationship often supersedes science. Recovery from illness depends on medicine or surgery, no question. But healing also comes from deep wellsprings of hope, trust, and optimism. My own family crisis related in “A Vigil for Anna” taught me that every patient is a precious individual, each with his or her own inestimably complex life and history.
[Anna, Levitt's wife's 80-year-old grandmother, was admitted to the ICU with a fever of 105, a total body rash, and severe hypotension. When she went on to suffer a stroke, her senior attending told the family that her condition was unlikely to be treatable. But a dedicated young intern, who refused to stop trying, discovered that she had Brill's disease — recurrent typhoid — and Anna lived another ten years.]
WHAT DID YOU LEARN FROM YOUR EXPERIENCE WITH YOUR WIFE'S GRANDMOTHER?
LL: I learned not to give up too early and to project an attitude of hope even if hope looks dim. Doctors are taught that becoming emotionally involved will cloud our judgment and deplete our energy. But when our patients face serious illness, and are thrown into so much high-tech terror, someone has to care. Immediate family and the doctor can help a lot.
JC: We also learned that acts of caring, listening, and sitting by someone's side speak clearer and deeper than mere human words. The case, in which my decision about tPA administration was based on a dog barking, had a profound effect on me. [When Dr. Castaldo's patient, Bill, was brought to the ER with a stroke, the nurses decided that he was not a tPA candidate since there had not been a firm stroke onset time. However, when Dr. Castaldo learned that Blue, Bill's Australian blue heeler, had begun to bark loudly and carry on at a specific time, he decided to administer tPA. Bill went on to recover substantially and return home.] When patients tell us their stories, we doctors normally hear the words they speak and glean meaning from them. But there is so much more going on — in people and their illnesses — that often floats right by us.
DEPRESSION, EVEN SUICIDE, AMONG PHYSICIANS WAS A SUBJECT YOU TOUCHED ON SEVERAL TIMES. WHY DO YOU THINK THAT THIS IS SUCH A COMMON PROBLEM AND WHAT CAN WE DO TO ADDRESS IT?
JC: We have seen the fall of many of our colleagues. As physicians, we tend to keep ourselves functional until the end, so it's difficult for others to tell that we are suffering. We often respond by burying ourselves deeper in our work in a desperate attempt to hold on to self-esteem and a sense of meaning in life. There are other signs of sadness and stress — both subtle and obvious — that we can look for. Yet, we don't really do a good job of caring for each other and being supportive. Many doctors feel that it's not our job to look out for each other. But a good colleague should try to discover what's going on if someone seems to change, especially if he appears depressed, and help that person get treatment
LL: Group members should make a point of looking each other in the eye every day and asking each other how they are doing. If you are not a member of a group, make it a personal mission to find mentors. They may not necessarily be physicians, but should be people you can talk to other than your spouse. It also helps to have a very good buddy. I know that if I were to have a family emergency and needed to go to Cincinnati tomorrow, that John would drive me there.
TELL US HOW YOU COLLABORATED. DID YOU CRITIQUE EACH OTHER'S WORK?
JC: Our stories congealed during walks in the park. Although much of the selection process took place together, we did the writing on our own. When we completed a rough draft, we sent it to each other for review and critiqued each other's work very frankly. We also had a fabulous editor who pointed out to us those things that made no sense to a lay audience and others that should be emphasized.
SEVERAL OF THE STORIES WERE INTENSELY PERSONAL, FOR EXAMPLE, JOHN, YOUR SON'S CRITICAL INJURIES AND HOSPITALIZATION IN INTENSIVE CARE. WAS THIS A PAINFUL SECTION TO WRITE?
JC: That was not only the most difficult section to write, but also the most difficult to read. The images of his accident and his illness are burned into my heart and into my head. I wrote about it, not to share a sad story, but to share the lessons I learned from being the father of a patient in my own hospital. I found that many things were inadequate. What was most disappointing was not the medical care, but care for the emotional side. Now when I greet families in the emergency room and the intensive care unit, I know something that I did not know before. I look at them and I understand that perhaps yesterday their lives were carefree, and now suddenly today their loved one is at great risk, and I see their eyes full of shock and grief and their dreams leaking out of them. I need to help them through this as best as I can.
WHAT WOULD YOU HOPE THAT NEUROLOGISTS TAKE AWAY FROM READING YOUR BOOK?
LL: As neurologists, we have much to learn from our patients about life. Being humble helps us make correct diagnoses and may help save lives. I've also found that relationships with colleagues and with patients can be very rewarding.
What would you hope that non-physician readers take away from reading your book?
LL: Patients should know that they deserve their doctors' complete attention and listening when they are in the consultation room. They should know what is wrong with them and what to do about it, and if needed, ask that this be explained in layman's terms. We hope that patients will learn from the experience of others, things that may be helpful when they confront illness.