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A Piece of My Mind
April 18, 2017

The Living DonorA Tale of Money, Mania, and Clinical Mastery

Author Affiliations
  • 1UCSF Division of General Internal Medicine and Center for Vulnerable Populations, Zuckerberg San Francisco General Hospital, San Francisco, California
JAMA. 2017;317(15):1531-1532. doi:10.1001/jama.2016.17221

A few years ago, I received a call from my university’s development office informing me that one of my patients had donated $1 million to endow a chair for me. After my palpitations and quickened breathing receded, I was struck with the realization (given my well-honed skills as a master clinician) that this good news was highly unlikely to be verifiable, since I work in a public hospital, where nearly every patient is either undocumented, homeless, or from the working poor. So with much trepidation, I asked my development officer to name the purported donor to me. When she did, I realized something was amiss, as Mr $, while very generous in soul and spirit, was certainly not a man of substantial financial means.

Just before my next appointment with him, I wrestled with myself over the question of how to broach the tender topic of his charitable and bounteous commitment to so elevate and even merge my name with his to further the higher purpose and calling of medicine. Seconds into our visit, it became obvious that he had undergone a sort of personality transformation: where once he was friendly, chatty, and warm, now he was ebullient, effusive, and unstoppable. His monologue was spent telling me about the new businesses he had started that were bringing in millions every week. In part because of the pressured nature of his speech, my sensitive clinical feelers—nearly frozen into hibernation by the promise of the long sought-after Grateful and Wealthy Patient $ Endowed Chair—came to life, and I suspected that this all might be just a manic episode.

Now, at age 75, it would be clinically illogical for Mr $, a man with no psychiatric history, to experience a first manic break. This is the stuff of college-aged kids, of young adults exceeding their parents’ credit card limit purchasing dozens of the same (but variably colored) double-breasted suit or designer leather jacket. But the more he spoke, the more clear it became that the unlikely was becoming evident. It was with that thought—nimbly diagnosing a forme fruste of manic depression—that I doubled down and consorted with my better or at least other self, telling myself that it was just these sorts of acute clinical observations that should (and will, someday, no doubt) merit me an Endowed Chair, perhaps even yield the academic Holy of Holies, The Pinnacle of Pinnacles: The Endowed Professorship.

I quickly snapped out of my utopian academic reverie, however, in time to interrupt him and turn to his wife, an 81-year-old woman with moderate-stage Alzheimer disease who always was in tow, to ask her, “Has your husband seemed any different to you over these last few months?” After she delivered the all-too-obvious answers to my insipid question (“I can’t recall” and “No, I don’t think so”), my diagnosis was nearly confirmed when Mr $ exclaimed that his wife had undergone a miraculous recovery from Alzheimer’s, that her memory had completely returned, and that now that she was back to her old self, they frequently played chess together, and had he not been a Grand Master, she might even have won a few games. That’s just how good her short-term memory and executive function had become. She smiled and nodded as I asked her if she had indeed played chess these last few months. When I asked her to name a few pieces from the chessboard, my diagnosis was inexorably confirmed—because last I checked, the wheelbarrow was not a valid piece of the chessboard set, at least not one sanctioned by The World Chess Federation, headquartered in Odessa, Crimea, of the then Ukraine.

With my diagnosis of late-onset mania firmly established, being an unrepentant general internist, I proceeded to try to uncover the cause of what most certainly was a manifestation of exposure to either (1) an internal dysregulation of some kind or (2) an external toxin. I quickly ruled out the external: no use of stimulants, alcohol, or psychedelic drugs, drawing a conclusion his amnestic wife was quick to support me on.

With that possibility so efficiently and accurately eliminated simply by way of the low-cost and underappreciated art of gifted history-taking, I reflected on the possibility related to the internal humors. A thorough review of systems revealed no other central nervous system symptoms, nor complaints that could be attributed to thyroidal pathology (as I deftly recalled my endocrinology professor’s entreaty posed in the pedagogical tradition of Socrates: Question: “Give me the indications for checking thyroid function tests.” Answer: “Anyone who is sick.”).

The only light sneaking through a slit in the window of clinical inquiry was a tantalizing admission he had delivered with braggadocio: he had lost 13 pounds over 2 months. A thorough physical examination, including the kind of detailed neurological exam a third-year medical student would kill to administer, was—as always—entirely unrevealing.

While his parallel admission of sleeping only 3 hours a night might have explained such a dramatic shift in the energy in–energy out thermodynamic theory of weight management, my brilliantly well-tuned clinical ear connected the key words of “unexplained weight loss” with “75-year-old male” to my visual cortex. Thus, a clear image took hold of neoplastic cells somewhere in the geriatric corpus, possibly secreting ill humors that were adversely affecting, or rather supraphysiologically stimulating and warping, the inner workings of the geriatric mentis.

Puzzled, I excused myself from the hallowed examination room, and, with that image firmly rooted in my own mentis, I decided to commit some serious cerebral time to comb through my internal encyclopedic portfolio of paraneoplastic syndromes, sifting for those with neuropsychiatric sequelae, specifically mania. After investing at least a second or two deep in thought, I reached for my ectopic brain—yes, my iPhone (can we rename it “diagnostiscope”?). And lo and behold, after clicking on My Favorites to find the wildly popular and sophisticated medical app Just Barely Out-of-Date, I found, right there in black and white, in 4-point font displayed on a 3-inch screen, just such a list. Thankfully, it was short. And with what looked like gold-embossed lettering, a condition jumped out to stimulate that same visual cortex: pancreatic cancer. Usually associated with depressive symptoms, in rare cases, I now (of course) recalled, pancreatic cancer presents with mania.

Thus reminded of what I already knew, I returned to the examination room and informed my patient that we needed to run some tests, including an abdominal CT scan. After establishing that he currently did not represent a danger to himself or others, apart from the damage he might do to the credibility of our development office, I sent them on their way.

To obtain expert specialist input on diagnostic and therapeutic considerations, I also put in a phone call to the outpatient psychiatry service, knowing full well that such a quixotic effort could be construed in its own right as a form of psychosis on my part, since expecting a timely response from this insanely overextended public hospital clinical service was itself delusional.

Two weeks later, I received the call from the radiology department, reporting a 4-cm mass in the tail of the pancreas, infiltrating its body. Sir William Osler strikes again, in reincarnated form.

One month later, with the help of Adult Protective Services, harnessing all my motivational interviewing skills, I convinced him to move his wife into an assisted-living facility. Seven months later, after major surgery failed to provide the unattainable but forever sought-out cure, Mr $—now pleasantly but not excessively manic—passed away in the hospital, with me at his side.

And while his million-dollar gift never materialized, something about his aspirational gesture makes me appreciate more fully the holiday lumpia (sort of a fried egg roll) I routinely receive from my Filipino patients, the $5 bills hidden inside red envelopes from my Chinese patients, the golden and glittering bottles of rum from my Cuban patients, and the endless collection of scarves, neckties, and warm fuzzy socks from my longstanding patients of all backgrounds.

And the experience with Mr $ enabled me to bolster my well-deserved academic standing even further, despite the Endowed Chair That Wasn’t. As a result of his misfortune, I authored a new entry into the e-annals of Just Barely Out-of-Date. All one needs to do is search the e-table of e-contents for “Differential Diagnosis of Unexpected Endowments or Other Undeserved Patient Gifts.” Therein, one will find a lengthy and incisive e-description that touches on everything from the questionable behaviors of physicians that engender such gifts, to the pathophysiology of irrational yet boundlessly hopeful thought on the part of patients that leads to gift-giving, to the complicated ethical questions invoked when presented with such gifts.

And while I now realize that expecting an endowment from grateful patients in public hospital settings is an event as unlikely to transpire as curing locally invasive pancreatic cancer, I am reassured by the certainty that I am providing the medically and socially needy with my unparalleled gifts as a diagnostician. And given my reputation as having a clinician’s mind comparable to that of Maimonides, and knowing that my status as an academic giant worthy of an Endowed Chair, at least in theory, is firmly established, I feel comforted by the indisputable knowledge that, while Mr $’s name won’t be inscribed under my name in my university e-signature, my name will surely be inscribed into the Book of Life.

Section Editor: Roxanne K. Young, Associate Senior Editor.
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Article Information

Corresponding Author: Dean Schillinger, MD (dean.schillinger@ucsf.edu).

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for the Disclosure of Potential Conflicts of Interest and none were reported.