Prologue

I wish I could have met my grandfather, Dr. Thomas Benton Hutto, but he died in the 1930s when my mother was very young. And I do not remember when I decided I wanted to be a physician, but it was probably around the time I started to hear my mother’s stories about her father. Having a serious childhood illness with an early exposure to medications, procedures, and prolonged admissions to hospitals inevitably played some part as my early role models were the compassionate physicians and nurses caring for me. My grandfather became another inspiration over the years as my mother shared her reverent stories about his care of patients in rural Arkansas.

While I was a medical student at the University of Virginia, I returned to Arkansas to attend my grandmother’s funeral. This was decades after my grandfather had died. After the funeral, I wanted to be alone for a few minutes, so I escaped the gathering to explore the “smokehouse” behind the main farmhouse. As a child, I was fascinated by the discarded farm equipment and paraphernalia scattered randomly around the largest of the three rooms of the smokehouse. The smokehouse was smaller than I remembered but still had a familiar musty smell with a hint of hickory that had been used to smoke meat years ago. During my foraging expedition, I found an old crate in the corner of the smokehouse. It was covered with dust, looking as if it had not been touched for years. When I opened the crate, the first thing I saw was an old copy of a Dorland’s medical dictionary. I had an updated version of Dorland’s on my desk at the University of Virginia in Charlottesville so I immediately recognized the book with its crimson book cover. For those not familiar with medical textbooks, the Dorland’s medical dictionary was a well-established reference book dating back to the early twentieth century along with other traditional mainstays such as Gray’s Anatomy and the Merck Manual.

When I opened this dusty copy of Dorland’s, I immediately noticed a time-worn picture that appeared to include my grandfather tucked between the tattered pages. I had never seen this photo before, but I recognized him from family photos, including a formal portrait still hanging in the farmhouse. He appeared to be at the head of an operating table administering an open-drop ether anesthetic to a patient. To his side, there was a formally dressed woman who seemed poised to assist him. At the other end of the table, there was a seemingly older gentlemen who looked like he was ready to amputate this unfortunate patient’s leg. At his side was another woman who appeared solemn but ready to perform her duties as his assistant.

I presented this picture to my mother later in the evening. She stated that my grandfather was indeed administering an anesthetic and the older gentlemen was my great uncle, Dr. John Hutto. I noticed my grandfather was dressed impeccably, wearing a white shirt, dark vest, and bowtie. My mother smiled and her eyes glistened. She responded that her father always dressed as if he was going to church on Sunday. This did not resemble the attire I wore as a pediatric anesthesiologist: comfortable surgical scrubs with a stethoscope loosely slung around my neck. My great uncle looked more like a typical surgeon wearing a surgical gown and holding what looked like a knife or saw.

There were no masks or gloves being worn, which was standard practice for the early 20th century. While there was also an absence of familiar machines and monitors, I did note my grandfather had a finger on the patient’s left wrist, probably palpating his pulse. His right hand held a cloth most likely soaked in ether. A finger on a radial artery may now seem to be a very primitive way to monitor a patient while delivering an anesthetic but at that time it could provide valuable information to the caring physician such as the patient’s heart rate and rhythm, as well as the presence or absence of a blood pressure. I later learned that my grandfather also performed surgical procedures when he was not administering the anesthetic. This picture was obviously staged given the posed and stoic appearance of the four professionals with a skeleton hanging on the back wall. I am sure they were not so stoic or passive when administering an anesthetic or performing surgery without being photographed. I also noticed there was a skylight in the ceiling that appeared to provide adequate illumination for the anesthesiologist and surgeon to perform their respective procedures, which would have been necessary given they did not have electricity in the farmhouse.

My mother shared that her father and one of his brothers sometimes did surgery in one of their farmhouses. As general practitioners, they took turns being anesthesiologists and surgeons. They had placed a skylight in the ceiling facing the east so they could operate with light from the morning sun. A lot of questions on my part followed and I learned my grandfather had two brothers and three cousins who were also physicians in northern Arkansas. A couple of decades later, I learned one of my grandfather’s cousins, Dr. William Hutto, built the first hospital in the county just a short distance from the farm in the small town of Clinton, Arkansas. The hospital had thirty-two beds with living quarters for both patients’ families and the hospital staff. A more modern hospital now sits on this site.

My grandfather’s brothers and cousins attended medical school at the University of Arkansas, with most receiving scholarships. After graduating, they returned to adjacent counties in Arkansas to practice medicine as general practitioners. Rather than completing a formal residency, they were supervised by other practicing physicians, often their own brother or cousin. Some of my mother’s most vivid memories were of traveling to farms with her father to watch him deliver babies and care for the mothers after giving birth, often for several days.

I still find myself looking at that picture of my grandfather and great uncle, wondering what it would have been like to practice medicine in rural Arkansas without current technology and with few resources. It must have been challenging, sometimes frustrating, but ultimately rewarding to be able to focus on each patient without the distractions of modern-day regulations, billing, and disruptive documentation processes. If someone were to ask, “Would you rather be a physician in the early 20th century or in the current 21st century?” I am still uncertain of my answer. What I do believe is that my grandfather’s professional identity with his commitment to a career path as a rural physician must have been formed much earlier than mine. Perhaps having fewer options for education and medical practice, family members as his exclusive role models, and a simpler training pathway made these decisions more straightforward. I believe my grandfather must have also known that his life and career would be hard, and unlike that of modern physicians, lack the financial benefits of a present-day career in medicine.

I remember when I told my grandmother I would be attending medical school. She was very subdued and contemplative. She had always been proud and supportive of everything I had accomplished up to this stage in my life. In retrospect, I realized I was the first family member in two generations to contemplate a career in medicine. At the time, I was confused by her lack of excitement. It took me several years and more conversations with my mother to understand why she had been so introspective.

Around the time a picture of my grandfather was taken in the early 1900s, the Carnegie Foundation commissioned a well-regarded educator, Abraham Flexner, to perform a comprehensive review of medical education in North America. The Carnegie Foundation felt that current undergraduate and postgraduate medical education was quite disorganized with uneven curriculums. After a couple of years of investigation, he published the results of his study in 1910, called the Flexner Report. Flexner found there were indeed large disparities in the quality of medical education across North America, with curriculums often devoid of strong foundations in science and/or best practices in education pedagogy. Not surprisingly, there were also inconsistencies in the quality and competency of physicians completing these programs. With the publication of the Flexner Report, there was a foundational change in medical education in North America. Many medical schools were forced to close as they did not have the funding or resources to comply with the higher standards and heightened regulations. As a result, medical education became more expensive and less accessible, especially for women and minorities. It has taken decades and innovative initiatives focused on increasing diversity, equity, and inclusion to begin to rectify these long-standing disparities of access to medical education.

In recent years, medical educators have recognized that training programs should begin placing a greater emphasis on the development of the core attributes and values that are the foundations of professionalism. Medical school curriculums and postgraduate training programs are now providing more opportunities for mentored or self-directed “deep dives” of discovery to reinforce the development of a future physician’s professional identity. As a medical student, intern, and anesthesiology resident in the 1980s, I do not recall ever being offered any such formal or choreographed “deep dive.” Fortunately, I did have self-identified mentors and seminal experiences that have served me well.

I always thought I would pursue a medical career focused on primary care. At the start of medical school, I remained focused on pediatrics and internal medicine. Based on my personal medical history and family legacy of general practitioners in rural Arkansas, I felt primary care was “my calling” as well as the career path most consistent with my personal values and goals. As I began clinical rotations in my third year of medical school, I realized I was more attracted to a medical career focused on acute perioperative medicine and critical care. Anesthesiology thus seemed to be a better fit than primary care. This was reaffirmed with my rotations in the operating rooms and critical care units at the University of Virginia. My interactions with anesthesiologists and intensivists only reinforced my attraction to this specialty. The intense focus and commitment of physicians in this specialty as well as my love of both the relevant science and acuity of the clinical practice were stimulating and satisfying. And I admired my mentors’ focus on advocacy and providing objective counsel to their patients in an acute care setting, sometimes challenging the conventions of surgical services or hospital administrations.

Rather than relishing in the discovery of anesthesiology as my future career path, I remained conflicted, feeling that I would be abandoning my “true calling” by choosing a specialty that was not primary care. I think this is a common conflict among many who begin an education continuum focused on a specific path. Long-standing personal and family expectations for a very specific career focus can limit an early student’s willingness to change course when they discover they are more attracted to another field as they gain experience and develop a more informed perspective. I believe this type of professional struggle is not unique to medicine.

Being intentional means you are more present and purposeful, making choices reflective of your values and career aspirations. I am indebted to the people who encouraged me to be more intentional in my life and career. I hope you can see intentionality as a virtue too.