When Doctors Get Sick: A Reprise

Maurice Fox, M.D.
mlfox@leland.stanford.edu

  I was asked to provide a followup to my medical history. We all love to talk about ourselves and our illnesses, and doctors are no different from anybody else.

  Angina began in my late forties and was accompanied by the expected denial and deep seated fear. What if it really is angina? My father died of his second MI at age 61, so there was genetic precedent. By age 50 the presence of coronary artery disease had been established beyond question and the total cholesterol of 170 was interesting but did not warrant an explanation that no one was equipped at that time to provide. In December, 1982, an angioplasty was attempted and deemed unsuccessful, so in early January 1983 a coronary bypass procedure was performed. Vein grafts bypassed the obstructions of the circumflex and right coronary arteries and under the influence of a young surgeon who just recently joined the team, the left anterior descending coronary artery was bypassed by the left internal mammary artery, a procedure he had learned in New Orleans but at that time was not widely accepted. I recovered from the surgery uneventfully, started a long term rehabilitation program of exercise at the local YMCA, and went back to work practicing medicine and endocrinology at the Palo Alto Medical Clinic. But clearly life had changed. My previous perception that the horizons of my undertakings was limited only by my will now had to yield to the reality of physical limitations imposed by nature. I resigned from the American Board of Internal Medicine, and after a term as Vice President, my tenure as a regent of the American College of Physicians came to an end. Finished with all the travel that had characterized my life for the previous 15 years, I spent what energy I had on work at home. The laboratory director at the Palo Alto Clinic retired, and I took over that job, reorganizing the clinical laboratory, expanding automated analytical techniques and introducing a computer system. I continued to see patients half time and started every Monday, Wednesday and Friday at 7:00 AM at the YMCA exercise class.

  By mid 1988 the angina had recurred at sufficient severity so that my life was limited to a considerable extent. I could not walk up hills and cold windy weather caused considerable angina. All these symptoms made my trips to San Francisco, a hilly, windy city and the focus of much of our social and cultural life, uncomfortable and scarey. Even more disturbing were neurological deficits. Memory was compromised in a progressive fashion, and I was often unable to drive to neighboring cities because I was unable to conceptualize where I was going and exactly how to get there. A cerebral MRI showed minute calcifications but no one knew how to interpret that finding. I was able to continue working by exercising excuciating discipline and control over my life. Everything was where I had planned for it to be so I did not have to look for lost objects or files because I knew I would never find them. I gradually began to accept the notion that I could not long continue working with these problems. Then, because of increasing angina, a repeat angiogram was performed and revealed that all the vein grafts performed in January 1983 had occluded, and it was presumed that I was being kept alive by the internal mammary artery graft to the LAD.

  By the end of 1989 I was unable to continue working because of increasing angina, memory problems and reduced energy and I applied for early retirement at age 57 on grounds of medical disability. Fortunately, the Clinicís medical disability policy enabled me to retire with an adequate income, and on March 1, 1990, I started my new life as a disabled unemployed retiree. My life at that point had been so restricted that I did not expect to live much longer, and I had gradually convinced myself that the end was near and that it was probably for the
best.

  For years I had taught medical students that a correct diagnosis was often worth more to the patient than several highly priced high tech procedures. This maxim hit home when the underlying cause of my problem was finally diagnosed as being due to my having anti cardiolipin antibodies, a form of lupus characterized by a hyper coagulable state and I was started on anticoagulation therapy with warfarin plus aspirin 160 mg per day. Subsequently I took niacin, 500 mg daily which raised my HDL cholesterol from 28 to 60, and to top things off my high homocysteine level was barraged with pyridoxine and 5 mg folic acid. I continued a vigorous exercise program of walking two to five miles every day and continued the anti angina program of generous doses of beta blockers, calcium channel blockers and nitroglycerine in various forms. It was felt that my coronary artery status was probably not susceptible to improvement by a repeat bypass, but over the years I did have one more angioplasty and most recently in December 1998 an atherectomy performed with a high speed rotating drill via angiographic catheterization.

  At this point I am much improved. I still have daily angina and my travel plans are markedly restricted because of my need for daily exercise in a flat warm environment best achieved at home, but I live a normal life by and large. Memory has improved a great deal. My friends with whom I walk know that I have to set the pace, slow at first and then it speeds up after ten minutes or so of walking, by which time some vessels dilate or something happens to improve coronary perfusion. Angina is worse after a big meal or if I havenít slept enough. All in all, living with chronic stable angina is not bad as long as my complicated program of drugs and exercise can be maintained.

  Paradoxically, the major threats to my well being occurred in the hospital. In April 1997, I sustained a small myocardial infarction and was hospitalized in the coronary care unit at Stanford. My cardiologist was out of town and the cardiologist on call had not seen me before. They planned to do an angiogram the morning after admission which I thought unnecessary, and when I finally reached my cardiologist by phone, he agreed and cancelled it. The next day, when my heart rate was below 50 with long periods of asystole, I refused to take more beta blocker till the heart rate increased. This distressed the nurse and the resident but when I made clear my determination not to take more beta blocker when my heart was already too slow to be safe, they resigned themselves to accept my stubborness. In a few hours my heart returned to the usual sinus rhythm with a rate of 72 and I went home the next day. A medical education is very useful in surviving chronic illness. In the interim I dealt with an episode of the nephrotic syndrome which cleared in response to nine months of cyclosporine therapy. There was also an episode of prostate cancer with an elevated level of prostate specific antigen, which cleared with two months of radiation therapy. In all instances I was treated with sensitivity and great expertise by my physicians, for whom I am eternally grateful. People always ask how I spend my time in retirement. I find I am as busy as I wish to be. I spend several hours daily on my computer which I find to be an eternal challenge and a source of great satisfaction, especially when I finally solve one of the challenges it throws up to me. On my daily walks I listen to Books on Tape and have the opportunity to expand my knowledge of history which I find enormously interesting.

  For seven years after retiring I continued teaching second year medical students the course on Introduction to Clinical Medicine, a program that takes students with previous book learning and begins the process of turning them into doctors. I found this even more rewarding than the ward teaching I did when I was practicing, probably because of less time pressures now in retirement. My interest in health care policy in the United States has not diminished and I still sit on a few policy committees at the Palo Alto Clinic, but there is no doubt that my
perspective is more of the patient than the physician than it had been in the past. My relationships with my family have become closer during this time, first of all because I have more time for my wife and children, and undoubtedly due to the change the illness has brought about in me. I think I am quieter, less excitable and less emotional about issues that always moved me deeply. And I am humbled by the loving acceptance and eternal support of my wife who did not sign on for this illness, but accepts it with wisdom, kindness and goodness.

Judith Brice, M.D.
Ronald Karpick, M.D.
Robert Scheig, M.D.

Introduction  

Published: May 8, 2000