CHAPTER ONE

Why Are You Here?

I started medical school expecting to become a research scientist. While still in college, I had joined a professor in his efforts to study biological membranes using a then-new technique called magnetic resonance imaging (now referred to by its acronym, MRI). As a member of his research team, I was named as a co-author of a paper he published on the work, and I imagine my acceptance into Stanford in the early 1970s was based partly on my participation in this new line of research. Indeed, I soon found a professor in my new California home with whom I intended to continue these studies. What I never expected was to become a clinician, focused less on research than on seeing patients.

At Stanford I actually started clinical work immediately. I had pushed myself to finish high school before turning sixteen, and as an undergraduate at Indiana University I had persuaded professors to let me take medical and graduate school biochemistry courses. These gave me advanced standing when I entered Stanford at age eighteen. As long as I took a necessary pharmacology course concurrently, I was ready to start seeing patients on clinical rotations. I was on track to finish medical school in June of 1975, with the required nine-quarter minimum. A decade later I learned I was Stanford's youngest ever peacetime graduate, at twenty-one years of age.

The challenging part for me was not in learning about pharmacology and anatomy but in understanding other doctors. There were numbing lists to memorize, of course, of nerves, muscles, bones, blood vessels, symptoms, diseases, drugs, and side effects; but compared with the knottier puzzles of philosophy or higher mathematics, nothing taught was all that difficult. There was plenty to memorize, but all memorization takes is time. The problem for me was that my interpersonal skills had languished in my race through high school and college. Thankfully, I had a new wife to coach me in the car on the way to dinner parties and social events. Professionally, though, I was on my own.

Medical students on clinical rotations were expected to examine patients and entertain a diagnosis. We would discuss our potential diagnoses, and the treatments and medications they implied, with the faculty physician. The challenge was to show that we had considered every possible diagnosis and had either ruled it out or planned the necessary tests to confirm or disconfirm its existence. Although most patients suffer from common diseases, we relished considering all the outlandish possibilities. First prize went to those who, in the end, turned in exactly the diagnosis our faculty physician had already reached -- we had to learn his or her style and mimic it. At nineteen, much to my own detriment, I was still young enough to be idealistic. I thought it was more important to think for myself than to try to think like someone else.

I also thought other doctors shared my own ideal of medicine: that its purpose was to restore unwell persons to health. Imagine my surprise on hearing a renowned professor of internal medicine begin a lecture by noting that the physician's job lay in "slowing and making less painful the patient's inexorable and inevitable progression toward death and decay."

Despite this my first rotation -- three months in neurosurgery -- was challenging and rewarding. I had already done work in college on the neural functions of rats. I was studying a particular brain rhythm, hoping to show that a molecule called serotonin triggered it. To do this, I implanted electrodes into rats' brains, then measured what happened when I introduced serotonin to different sites of their limbic systems. If the rhythm was produced by the serotonin, I would have strong evidence that serotonin was a neurotransmitter -- a message sent by a nerve to the cells in the vicinity. Neurotransmitter molecules are the only verbs a nerve has at its command; which molecules are produced, and how many, determine a message's content. At the time, scientists were certain of only two neurotransmitters; we have since identified twenty-six. These few molecules and the simple messages they carry from one to another of our three billion brain cells are the vital chemistry behind human thought.

Although this wasn't the concern at the outset, neurotransmitter research eventually had the practical yield of all sorts of drugs. Now we know, for instance, that serotonin depletion often accompanies depression. Drugs that increase the availability of serotonin, like Prozac, are common treatments for depression. Prozac, which belongs to a class of drugs known as serotonin reuptake inhibitors, works by blocking the enzymes that cause serotonin to be reabsorbed.

I found that rat brains produced the theta rhythm I was interested in when serotonin was introduced to certain sites "upstream" of the hippocampus -- which, in plain language, meant that serotonin was indeed a neurotransmitter, at least for rats. This was a publishable result. With my professor's advice and assistance, I finished my first solo paper and published it in a neurosurgery journal. I was very proud to become a part of a centuries-old tradition of expanding the known limits of scientific knowledge.

Since I already loved research, it was no surprise to find the data-gathering aspect of the neurosurgery rotation appealing. But I was unprepared to find how much I enjoyed simply working with people, practicing clinical medicine. Even if I was still more comfortable in a lab than on a ward, two months into the rotation I was starting to consider a career that wasn't pure research but combined research with clinical work. Perhaps I would become a pediatric neurosurgeon. Three months later I was on my second rotation, in urology, about to meet the four very sick men who would challenge my career plans even more profoundly.

It was a foggy April morning outside the renal room of the Intensive Care Unit at San Mateo County Medical Center (SMCMC), a major teaching hospital of Stanford University. A nurse introduced me in a perfunctory manner to the first three of the four men inside. There was little hope for them. The fourth man -- whom I will call Juan Martinez -- had a chance to survive. He was a forty-two-year-old carpenter from Los Gatos, in the foothills of the Santa Cruz Mountains. He had lost one of his kidneys in a San Jose hospital. After the operation, his remaining kidney had stopped working. When Señor Martinez's twenty-three-year-old daughter offered him one of her healthy kidneys, he had been transferred to SMCMC's renal room to be evaluated for a transplant.

My job was to begin a pre-transplant evaluation of Sr. Martinez to decide if there was any reason not to proceed with the surgery. I wondered what had happened to the man before he lost his kidney -- what had brought him here. I started by asking when he had last been well. We had to speak up to be heard over the bustling doctors, the efficient nurses, the constant drone of the voice of the paging operator (these were the days before beepers). Only his three drugged roommates were quiet.

The carpenter was lying on his back, holding himself perfectly still, looking more like a quadriplegic than a dialysis patient. His face had the texture of an onion skin. His muscled arms lay uselessly on the sheets. He took longer to answer than I expected; he seemed to be searching for an answer to a question much bigger than mine. Finally he said, "I was never sick."

"What do you mean?" I asked. He was avoiding looking at me, focusing instead on the grains in the ceiling panels overhead.

"There was nothing wrong with me," Sr. Martinez said flatly. His usually dark Hispanic complexion was blushing ocher, and he began to cry quietly. His jaw continued working after he spoke, as if there were more to say but no words with which to say it. I glanced out the window. The morning's fog had dissolved into a light rain, unusual weather for April in San Mateo. Water ran slowly in crazy currents down the window panes. I found myself shivering.

"What do you mean, there was nothing wrong with you?" I asked when it was clear that the carpenter wasn't going to go on. He was clutching the bedsheet.

"They said I had protein in my urine -- but I didn't feel bad or nothing," the man said without emotion. His face was expressionless except for the silent tears in the corners of his eyes.

"And then?"

"They ran some tests. Then more tests. They took a biopsy of my kidney, and I got this infection that almost killed me." The man gazed down the length of his sheet-covered body. "It did kill my kidneys," he said. His jaw stopped working and his lips began to quiver. Our conference was interrupted by an officious nurse who had come to change his IV. Feeling worried and confused about what had happened to her charge, I left her to the task.

Later that morning I read his chart in the conference room behind the nurses' station. Just a few months earlier, he had been framing houses in the canyons outside San Jose. On weekends he went hunting and fishing in the northern California wilderness. His doctor had discovered the traces of protein in his urine during a routine insurance physical. Proteinuria can be a normal enough finding in a person who has been exercising strenuously, but it can also be an early sign of serious kidney ailments and autoimmune diseases.

Although Sr. Martinez had no symptoms of any of these problems, his internist ordered a full workup. A series of ordinarily innocuous medical procedures had led, for Martinez, to the worst possible complications. After his doctors biopsied a kidney, Martinez got an infection, then began to hemorrhage. His doctors repaired that damage by removing the injured left kidney; Martinez's right kidney responded by shutting down. He developed sepsis, an infection of the blood that can spread anywhere in the body. Doctors at SMCMC managed to clear up the infection but couldn't get the right kidney working again. Martinez's best hope now was a new kidney. As for the biopsy that had kicked off the whole process, it had been inconclusive. Nobody had any idea why Martinez had once had traces of protein in his urine, and now nobody was trying to find out. That problem -- if it had ever been a problem -- no longer seemed important.

I sat in the conference room looking out the hospital's narrow windows at the rain and thinking about the man in the room on the other side of the nurses' station. His old charts and records were heaped on the table before me. I thought of the dark forests of northern California, where Sr. Martinez had hunted, of the deep lakes the forests held, of the ancient trails that led up past the timberline into a world of rock and ice and snow -- a world Juan Martinez might never see again. Then I reread his chart, hoping for some clue to his predicament.

I was still searching when a resident in urology, Musaf Habra, walked in and set two Styrofoam cups of tea on the table. Dr. Habra was a Saudi general practitioner who wanted to teach at the Saudi Medical Center in Riyadh after he finished training as a urologist at SMCMC He was the sort of gentle man whose constitutional kindness can be mistaken for weakness. He had won my admiration at a recent party, where he played the violin with a sensitivity that was anything but weak.

"Reviewing Señor Martinez's case?" he asked, nodding at the charts on the table.

"Trying to make sense of it," I said.

"Sense?" Dr. Habra gave me a quizzical look. "What 'sense' are you looking for?"

"I'm not sure," I said. "The logic behind the biopsy, I suppose. I'm trying to understand how this could have happened."

He shrugged and pushed one of the cups of tea toward me. "His doctor wanted to know what was causing his proteinuria," Habra said in a matter-of-fact tone that served to mask what he thought about the whole thing.

"But he says he wasn't sick," I countered. "And I can't find anything in his chart that indicates any other symptoms or diseases."

"He didn't have symptoms. He had proteinuria..." Habra thought a moment and lowered his already quiet voice. "And he had the 'advantage' of the best preventive health care in the world."

"You wouldn't have biopsied him in Saudi Arabia?"

"Iwouldn't have biopsied himhere,"Habra replied. He raised his eyebrows. "But you Americans are so much more advanced than we Saudi." He winked. "Wanting to know the answers to everything can be deadly." He parodied his own accent a little, lending it a playful hint of intrigue.

I agreed with Habra's critique but was hurt to be included by him among "you Americans." Of course I was one, but I didn't identify at all with the culture that lay behind the unnecessary renal biopsy that had destroyed the carpenter's health. I wanted Habra to see me as something more than just another American. I was aNativeAmerican, for one thing, and I hoped that somehow made me different.

It seemed to me my medical student friends and I were more like Habra than he knew. A small group of us were naturally drawn together -- Native Americans, Hispanics, and Asians -- because we all had different cultural perspectives from those prevalent at Stanford. Though we didn't have strong social ties, we did hang out together in school. It took the edge off our feeling of not belonging. Some of my fellows had come to Stanford straight from their reservations and found themselves in an entirely new, often incomprehensible culture. Spurred by my new friendships, I began to reconsider my own Native American heritage, which my mother had long ago turned her back on.

While I was thinking about what Dr. Habra had said, David Vickory breezed into the conference room. Dr. Vickory was a decisive, energetic man with an encyclopedic knowledge of kidneys. In his late thirties, Vickory was juggling two ambitious careers, running a busy research lab and simultaneously winning a reputation as one of the best nephrologist -- kidney specialists -- in the country.

"Well, boys," he said, rubbing his hands together as if they were cold, "what do you think of my man, Martinez -- is he a good candidate for transplant, or what?"

Dr. Habra thought for a moment. "There is the matter of his infection --" he started.

"We've licked the infection," Dr. Vickory interjected. "His fever has long since lifted. He's ready for the knife. Unless..." He turned a chair backward and straddled it. "Unless you've found something I missed." His tone was challenging. He waited barely an instant and turned toward me. "You look troubled, Dr." -- he glanced at my name tag -- "Mehl. Didyoufind something I missed?

"I told him I hadn't.

"And yet," he continued in his light, teasing tone, "you do look troubled. Our man is stable. We've cleared his infection. We've got a kidney standing by. And still something worries you."

"Actually," I said slowly, "I'm struggling to understand how he got here in the first place."

Vickory's face went blank for a moment, and his cheerful demeanor vanished. "You have a question about how patients get infections?"

On one level, it would be a ridiculous question for a medical student to ask: even premeds know that microbes cause infection. But on another level, the question was worth pondering. Why did this particular patient succumb to microbes when most others do not? The first question would be too basic and the second too philosophical to warrant discussion in the urology conference room. Vickory was trying to figure out which of these transgressions I had made.

I saved him the trouble. "Of course I know what causes infection. I was wondering why we did a renal biopsy on a healthy man."

"He wasn't healthy," Vickory corrected. "He had proteinuria. That's something we work up. It's the standard of care, as you know -- or should know." He could probably see the beads of sweat on my forehead starting to form. I hadn't started out to challenge his authority, but I could see Vickory was thinking I had.

"His proteinuria wasn't causing him any problems," I countered. I could see Habra pursing his lips and shaking his head, but I couldn't understand this taboo on discussing the biopsy. Vickory, after all, was not the one who'd ordered it, so even if it had been a mistake, it wasn't his. "It just seems like they could have waited to see if there were any real problems before going for a piece of the guy's kidney."

"Is that the way it seems to you, Dr. Mehl?" Vickory asked. "Well, maybe..." He stroked his chin with his thumb and forefinger and pretended to think about it for just an instant. "But those of us who study kidneys for a living have found that guys who have protein in their urine usually do have a real problem. Maybe someday you'll show us how to identify the lucky ones who don't. Until then, we're just going to have to stumble along doing biopsies. We know from experience that we'll find a lot of renal disease that way. We also know that in a few cases -- not many, but a few -- there'll be infection." His voice was intentionally slow and flat. "It's unfortunate, but it's life. And it's irrelevant to the business at hand -- which is whether or not to give Martinez a new kidney. That's the question on the table this morning," he said, rapping hard on its Formica surface with two fingers. "So you let me know if you see any reason we shouldn't transplant this guy. Until then, Dr. Mehl --" Vickory nodded dismissively and walked out of the room.

I felt stunned and embarrassed. My heart had hammered through every long second of his speech; I wasn't used to conflict, and it frightened me. I was young, I worried what people might think of my youth, and I wanted desperately to do well to compensate. I was scared of Vickory. How could I have had the audacity to challenge him?

"Be careful," said Habra. "If you keep acting like that, you'll never graduate." I was surprised to hear no trace of sympathy in his voice. Although I had not expected him to stick his neck out to defend me from Vickory, I thought at least he would be a confederate afterward. He shook his head as he gathered up the charts. "You might consider which you want to do, debate the philosophy of medicine or become a doctor anytime soon."

"I want to do both," I muttered in a voice barely audible over the background noise of the hospital.

"Good luck," he said without inflection. It was hard to tell whether he meant what he said or precisely the opposite.

When Habra and I went back to see Señor Martinez later that day, we found him lying deathly still on his back, moving only his eyes -- from Habra to me and back again. He looked bewildered while Habra spoke to him.

"We can give you a transplant," Habra told him, "if that is what you truly want. But I insist that your daughter talk to the psychiatrist. She must know what she's risking. She must know what the chances are that you'll reject her kidney. She must know what she's getting into, and I must know that she knows or I would never forgive myself."

Habra had surprised me again. In the few months I'd spent on rotations, I hadn't come across any other doctors who would consider holding this kind of conversation with a patient, acknowledging that it was possible for the physician to be emotionally affected by a treatment's outcome. But if Martinez was surprised or moved by hearing a doctor mention his own feelings of guilt or responsibility, he didn't show it. His eyes continued to float like the bubbles in his leveling tool, looking for a spot on the ceiling to comfort him.

"Tell your daughter to give me a call," Dr. Habra said, placing one of his cards on the bedside table. He searched the corners of the room for clues about how to proceed. "I am sorry for your misfortune," he told the carpenter shortly, standing up from the bedside chair. "We will see you in the morning and talk again then." Martinez managed a nod.

Habra rubbed his eyes as we made our way to the next bed, where lay Dr. Jackson, a forty-eight-year-old professor of English from the University of California at Santa Cruz. His story was nearly identical to his neighbor's, beginning with proteinuria and ending with two useless kidneys. Dr. Jackson's infection, however, was out of control, and dialysis was failing to cleanse his blood adequately. Habra and I had been asked to determine if surgical removal of his kidneys and debridement of the region (cleaning out the infected tissue) might help. It might, we decided, and should be tried, because it was his only chance to beat the infection. But even this radical treatment might fail. Unless our debridement was accompanied by a miracle, Dr. Jackson did not have a very good chance of leaving the hospital alive.

Neither did a fifty-one-year-old store clerk, Mr. Brasher, nor a thirty-seven-year-old postal worker, Mr. Brown -- two more men who had begun with protein in their urine and no other symptoms, who had run the gamut from biopsy to infection to the loss of kidney function. We trudged past their beds, murmuring short greetings and shorter good-byes.

When we finished rounds, we ducked into the cafeteria. Habra bought himself a Coke. "What are the odds," he said, "that in any one morning we would do four such similar consults, that four men who had been well before visiting their physicians would all be lying in the same room together?"

"I don't know," I responded carefully. I wanted to know what Habra thought, but after the episode with Vickory, I was reluctant to set anybody else off. "It seems like something must be wrong with three people dying because of their physicians' best efforts."

Habra nodded. The rain had stopped and the sun was starting to shine. We walked outside. "But what exactly went wrong?" Habra asked. "No one amputated the wrong leg or prescribed incorrectly. No one missed a disease or made the wrong diagnosis. Perhaps Vickory is right -- perhaps this is the price we pay for good preventive health care."

"You don't believe that," I ventured. The chairs were still too wet for us to sit down.

"No," Habra said, "but you can't quote me. Anyway, my opinion carries no weight."

"But why is Dr. Vickory so defensive?" I asked. "He didn't make any mistakes."

"He has to defend his colleagues," Habra suggested. "After all, they were faithfully following the guidelines of our profession." We were leaning against the rough concrete walls of the building. We could see planes landing and taking off through the mist covering the San Francisco Bay.

"But is this what good care is?" I asked, genuinely agonized. "If you kill the patient, can you call the operation successful?" I finished my tea. Squirrels were climbing up and down the trees, and birds squawked overhead.

"Who can say?" Habra said as he opened the door to the hospital. "Maybe Vickory's right. Maybe finding the treatable cases justifies the losses, maybe those men we saw today are a statistical anomaly. We are simple soldiers on one battlefield. Maybe we cannot understand the war?"

"Like hell," I shot back, smiling.

"At least you're in a better mood," he said. "There's nothing I hate worse than a mopey intern."

My great-grandmother was a traditional healer in a rural area of Kentucky. I carry vivid memories of her but not of her theories and practices, since she died when I was five. I wish now I could ask her all kinds of questions that I wasn't concerned with then. What I do remember seeing was a number of very sick people coming to her to be healed. When I was older, I watched healings led by the local Christian snake handlers. I didn't know what magic these writhing, agile beasts worked. But magic it was, as far as I could tell.

At the time I was never much interested in the cause-and-effect relationships of anyone's "miracle" recovery. Nor was anyone else I knew. Where I came from, faith healings were accepted as natural occurrences -- nothing to arouse either doubt or skepticism. Later, my curiosity would come to rest in the concept of human transcendence, in the movement beyond illness that healing occasions. I would learn that healing sometimes calls for people to ascend the greatest heights they are capable of reaching. And then sometimes healing seems as natural and commonplace as weeds in a garden.

Before a person can be healed, one medicine man told me years after medical school, he or she must answer three simple questions: "Who are you?" "Where did you come from?" and "Why are you here?" This California elder believed that anyone who could give clear answers to these three questions would be well.

The third question seemed easiest to answer -- Why was I at SMCMC? I knew that the study of medicine would allow me to pursue my interests in biology, physiology, and psychology. So far these expectations were satisfied. I was only surprised to find, in medical school, that few shared the awareness and acceptance of healing I had known in Kentucky. Why could faith healing occur in the hills of my youth but not in a progressive hospital? I took it for granted that there was a spiritual component to illness, and wellness too, and that doctors would respect it. But I had no thought at that point of integrating my interests, of using the healing traditions of people like my great-grandmother alongside the scientific approach of modern medicine.

It wasn't until I experienced the shock of seeing four devastated but previously healthy men together in the same renal room that I began to think the healing traditions of my childhood might have something to offer the professors of Stanford. There must be an alternative, I thought. I was too naive to recognize that even the idea of healing -- without drugs, surgery, or other invasive care -- was considered déclassé and counter to the conventions of medical school.

Now, sometimes invasive procedures are entirely appropriate. But they aren't always. Too many of the doctors I was encountering lacked the critical insight of the healers I was later to meet, that a disease may bring balance to an otherwise untenable situation. Medicine people are careful not to act until they are certain of the consequences of their actions. Disturbing the body's balance without forethought can have disastrous consequences, as Martinez was learning, whether or not his doctor ever did. The true healer recognizes that every action produces a result, and that a patient's own intentions, conscious or not, can determine the direction of the result.

It seemed only by coincidence that I was even in a position to learn from this unfortunate convention of renal failures. During my first rotation as a medical student, in neurosurgery, I befriended a surgical intern, whose next rotation was to be in urology. The illness and subsequent death of a family member required his presence at home, leaving his position vacant. Asked to fill his spot, I was promoted to acting intern for the month, after only four months of clinical training. This was fine with me, but a few eyebrows were raised in the emergency room the first time I showed up in response to a call for a stat urology consult.

Now that I am more fully immersed in Native American spirituality, I recognize that my being made acting intern was no coincidence. I was learning firsthand that most doctors rarely consider the larger, encompassing questions about the body, mind, and spirit that medicine people address. And I was learning this at a young enough age not to dismiss it; a few years later, I might have ignored things that disturbed me in the interest of getting ahead.

The great thrill for most of my teachers was in diagnosis. As one neurology professor said, "Most patients are very boring. What is interesting is what they might have and making sure they don't have it. What is left after that -- the treatment and so on -- is either boring or difficult. Few diseases respond in the textbook manner to the drugs we offer them. Some diseases respond to no drugs. Invariably, patients never do exactly as they are told. Patients have the pesky habit of doing what they want, regardless of our advice." At Stanford, I learned a term for this phenomenon, too: doctors call it "noncompliance."

Throughout that April day I found myself wondering just how many treatable cases are revealed by those invasive biopsies, and how many biopsies it would take to justify what we had done to Señor Martinez and what we were preparing to do to his daughter. After all, removing a kidney is no piece of cake. She could develop an infection herself, even die. How many successes justify a loss? Who decides such things? I knew better than to talk to Vickory again. Habra was less than three months from graduating and returning to Riyadh, so I couldn't count on his sympathies, but maybe Friday night after rounds, when the urology department retreated to the Stanford Coffeehouse, I could talk with him over a beer.

As it turned out, I didn't have to wait long to hear the question debated. A little before eight o'clock the next morning, we gathered in the urology conference room for our weekly discussion of transplant candidates. Because this was a teaching hospital, senior physicians sometimes expounded on the more interesting cases. When I slid into my chair across from Dr. Habra and saw that Sr. Martinez was scheduled for discussion, I wondered if anyone would point out that his own doctor had caused his illness. Doctors have a word for that occurrence too, a long, Latinate word that allows us to distance ourselves from the truth of the idea. We doctors call a disease caused by one of our own "iatrogenic." Now I just call it bad medicine.

Vickory sailed in at 7:59, took a seat at a table at the front of the room, and gave a "You're on" signal to his resident. This businesslike young woman shuffled her pages of notes and then began to tell the gathering of physicians and students about the patient.

"Juan Martinez is a forty-two-year-old, married carpenter from Los Gatos," the resident began. Her hair was black and curly and seemed still damp from her morning shower. Perhaps she had been on call all night at the hospital. "He is status post treatment for sepsis and perinephric abscess with renal failure on the basis of acute tubular necrosis from sepsis." The resident moved crisply through her presentation. She talked about the removal of Martinez's left kidney in San Jose and worked forward from there, never mentioning how he had found his way into the world of nephrologists in the first place. "It has been determined that his renal function will probably not return. His daughter offers him a kidney, and we wish to proceed with transplant."

Vickory asked for questions. There was a brief discussion of the blood urea nitrogen and the creatinine, which serve as markers of renal function. That discussion ended quickly with the conclusion that Martinez's one kidney was not working. Then came a lull, the usual signal to move on to the next case.

I glanced around the room. Dr. Habra was shaking his head at me ever so slightly. But his warning wasn't necessary; I had learned my lesson the previous morning. I would not give Vickory a second chance to mock me. I had given up hoping that anyone else would see anything remarkable about Martinez's case when Robert Upton, the chief of our renal transplant service, spoke up.

"Hey, Dave," he said. Given his status as a transplant surgeon, Upton could call anyone by first name, including Vickory. "What was wrong with this guy before his abscess? Any idea how he got sick?"

"Complication of renal biopsy,

Excerpted from Coyote Medicine: Lessons from Native American Healing by Lewis Mehl-Madrona
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