FEATURE
ment was a powerful source of joy and pride for me . It is common practice in a small town to send unsolved and complex cases to the newly arrived “ rookie specialist ” ( perhaps to teach him or her some humility ). One of those patients happened to be a 50-year-old schoolteacher who stated : “ Doc , I have become the laughingstock of the school ; when I try to write or draw on the black board , my hand starts going wild . They call me ‘ Batman ’ because my hand has frenzied movements like the wings of a bat . No one seems to be able to figure out my problem and help me . You are my last resort .”
I examined him diligently and noted the large amplitude postural and kinetic tremor of the upper extremity at the shoulder with additional findings of cerebellar dysfunction . “ Bat wing ” triggered reverberations in my memory network and I recalled description of similar cases in the classic textbook of neurology authored by Dr . S . A . Kinnier Wilson . Corneal examination showed the typical pigmented ring and blood work confirmed low ceruloplasmin . The “ instant diagnosis ” of Wilson ’ s disease and improvement in tremor following penicillamine therapy was a rewarding experience , which made the teacher and me quite happy .
I can ’ t help talking about a success story from many years ago , that comes up in the top 20 “ joy instances .” A 40-year-old bartender started feeling unsteady after standing for a few minutes accompanied by fear of fall . The problem had been increasing steadily over two years to the point she had to quit her job . She found it very difficult to stand in any queue , such as the line at the grocery store . She was an avid traveler with plans to visit Rome and Paris but feared long lines at the airports . She had been seen by several specialists with no clear diagnosis or treatment . When I examined her , I was initially troubled by the lack of any objective neurologic findings and the likelihood of a functional neurological disorder . Standing still even for two to three minutes provoked anxiety and a sense of “ loss of balance ” but she felt totally relieved when she started walking or sat down . There was no decrease in blood pressure or change in heart rate when she stood up to suggest postural orthostatic tachycardia syndrome ( POTS ). The thought of POTS instantly triggered consideration of a condition with a similar eponym : POT ( primary orthostatic tremor ). The presence in surface EMG of characteristic high frequency tremor on standing , which disappeared promptly on sitting , confirmed this rare disorder . She was started on clonazepam , known to be effective in some POT patients . It was very gratifying when she sent me a card from Rome , thanking me for helping her .
I previously had the privilege of directing a clinic for epilepsy patients and an inpatient seizure monitoring unit . One of the goals then was to identify patients who might be candidates for surgical treatment of epilepsy . My neurosurgery colleague had undergone training at Montreal Neurological Institute , where Dr . Penfield pioneered epilepsy surgery . We shared many joyous memories of patients whose lives were changed to the better by the surgical resection of seizure focus . Let me describe a patient very dear to me . This was a 30-year-old female , who experienced rare partial-onset seizures from childhood ; she was excellent in studies and became a faculty in the local college teaching music . The seizures gradually became more frequent often leading to convulsions and poorly responding to antiepileptic drugs . She could not drive anymore or keep her job . She was getting very depressed with suicidal thoughts . Five days of continuous EEG monitoring showed a seizure focus on the right anterior temporal lobe . My colleague successfully resected the seizure focus , and the patient eventually became seizure-free . She was able to resume her job as a music teacher and expressed her gratitude by sending a thank you card on the anniversary of her surgery each year . This certainly is an instance that combined the joy of diagnosis and the pride of finding a cure , the very best that a physician yearns for .
In the past decade , I have limited my practice to performing a procedure that evaluated nerve and muscle function , universally disliked / feared by patients . Trying to find “ little joys ” in this situation has been difficult . I tried to train myself in the art of distracting the patients ’ attention from the discomfort and pain involved in the test . This needed some knowledge about family , job and interests of the patient ( travel , music , books , games , movies and the like ) so that I could engage the patient in distracting conversation . I also relished the interaction with patients , who often were eager to tell their life story ( especially in this time of COVID-19-mandated social isolation ). Getting patients through the painful test and witnessing a smile on their faces at the end has certainly been one of my recent “ little joys ” of medicine .
Discussions with colleagues convince me that anecdotes like these are in no way unique and every physician has experienced such joyous moments . Remembering such anecdotes tends to deepen love for the practice of medicine . The joy and the sense of accomplishment continue to be strong motivations despite the frustrations and setbacks that we all face in our daily medical practice . I can ’ t help restating conclusions from the recent insightful paper by Warsame and Price : 1 “ Joy is cultivated by purpose and meaning in work . Connectivity to patients and colleagues is a cornerstone of that joy . Hard work and challenges do not prevent joy .”
Let me end with a quote from William Osler : “ The practice of medicine is an art , not a trade ; a calling , not a business ; a calling in which your heart will be exercised equally with your head .” If we keep this mantra in our minds , we can possibly avoid burnout by discovering the little joys in medicine .
Reference :
1
Warsame R , Price KA . Seeking Joy in Medicine During Uncertain Times COVID 19 and Social Unrest . Mayo Clin Proc 2021 ; 96 ( 7 ): 2003
2
Girgis L . Has the Joy of Medicine ben lost ? Physicians Practice March 28 , 2018
Dr . Iyer practices at the Neurodiagnostic Center of Louisville and is a retired professor of neurology at the University of Louisville School of Medicine .
This essay was a submission to the 2022 Richard Spear , MD , Memorial Essay Contest .
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