A Move to Scientific American

“Curious, have you considered joining a blogging network?” was how Brian Mossop, then Community Manager of PLOS ended his email to me over a year and a half ago.

I hadn’t.  It only took two phone conversations–one from Brian and one from then PLOS blogger David Kroll–for me to get excited about the possibility.  I already knew of PLOS and appreciated its open-access mission.  I was impressed by how quickly its new blogging network had attracted a close-knit and talented group of writers.  I couldn’t wait to join.

I’ve loved my time here.  I’ve loved the editorial freedom, the community, and especially the readers.  But after a year and a half, I’m moving again.  I recently joined Scientific American‘s blogging network, where I will be writing bimonthly posts.

I sincerely hope you follow me there.

I would also like to thank Community Manager Victoria Costello, for her work and support.  She asked me to add this to my farewell post, and it is truly an honor:

Shara Yurkiewicz’s insights into the human condition, filtered through the extreme circumstances faced by students going through the second and third years of medical training, uniquely inform the open access biomedical research that forms PLOS’ core publishing mission.  As I wrote recently in Ten Essential Qualities of Science Bloggers, “Shara shows the heart of a lioness…always with a healthy dose of self-deprecatory humor.” We’ll miss her narrative talents as much as her attention to scientific detail. And we wish her well at Scientific American Blogs.

– Victoria Costello, PLOS Blogs Manager

Category: Personal | Comments Off

Being Sorry

“You’re not sorry.”

Within two days two different patients said this to me, each with hatred in his voice.  Each time I was alone, each time I had known the patient for only a few minutes, and each time the rage was directed at me and only me.

For seven months, I had avoided being the bad guy.  When a patient got upset, he accused my superiors, and I hid behind their authority with relief.  With no power came no blame.  I would offer sympathetic eyes during the blow-outs and weigh how much of what the patient perceived was in line with reality.

The last two episodes were on an entirely different level, not because of their intensity but because no one but me stood there to shoulder them.  Now I see patients alone and project a greater air of confidence, which naturally leads some to believe that I am the one making their decisions.  My usual intellectualization and analysis were non-existent; I experienced a pure visceral response.

The first episode, in retrospect, was merely a preamble.  I walked into the clinic room and was greeted with “You’re 45 minutes late.”  I apologized.  The patient insisted I wasn’t sorry but that I was unprofessional.  I don’t quite remember all the personal attacks he added over the next few minutes because my sympathetic system had taken over: my cheeks flushed, my heart pounded, and all I wanted to do was flee.

I managed to squeeze out that we were running  behind because we spent more time with sicker patients than we had anticipated.  What I wanted to add was that he was setting us more behind.  What I wanted to add was that even though his appointment was only for 20 minutes, we would spend more than 20 minutes with him, like we did for every patient.  What I wanted to add was that his behavior was self-fulfilling: suddenly I wasn’t sorry anymore.

Instead, I withdrew.  I’m fairly certain I took a less thorough history with him than I do with other patients.  I’m pretty sure my plan was more rushed since he questioned my judgment at several junctures.  I know that all I wanted to do was get out of that room and away from an unpleasant person that I had originally wanted to help to the best of my ability until he compromised my ability to help him.

The following day, I was back in the hospital with a much sicker patient.  I walked in to do a physical exam and the patient demanded that I get him food.  I explained that he couldn’t eat independently because he was at severe risk for swallowing the wrong way and having the food go into his lungs and causing an infection.

“You f*cking b*tch,” the patient yelled as loudly as he could with his weakened voice as he tried and failed to get out of bed and reach his food.  I apologized and once again I heard the cutting response: “You’re not sorry.”

Again, I felt the familiar flushing as the patient called me creative names and instructed me to do creative things.  This time, I had no response at all.  After the first minute, I felt sorry that the patient was hungry and couldn’t eat.  I felt sorry that he had such poor hand dexterity that he needed someone else to feed him.  I felt sorry that he didn’t deserve the medical hand he had been dealt.

After several minutes though, my empathy faltered and finally gave out.  My thoughts turned from the patient’s plight to a more inward stance: I don’t deserve this.  That single thought amplified until the hungry patient in front of me no longer existed.  I don’t deserve this.  I knew it wasn’t personal because he would have screamed at anyone who happened to stand in my place.  But at the same time it was personal because it happened to be me.

I didn’t say much and walked out, feeling shaky.  More disturbing thoughts snaked their way into my consciousness and wouldn’t let go.  No, I wasn’t sorry anymore.  No, I didn’t really care what happened to him.  And then probably the worst thought I’ve ever had in my life: in that moment, I didn’t really care if he lived or died.

With that realization, I found a bathroom to cry in for about half an hour while I ignored the page from my resident inviting me to get lunch.

Within an hour, my limbic brain had yielded to my cortex and I was able to analyze what had happened.  Ironically, it was the analysis rather than my raw emotion that brought back empathy.  I reread the patient’s notes, talked to his son, and felt as though I had a better grasp on the reasons behind his intense anger.

Within a few hours, the patient was transferred to the ICU.  (Thankfully, the turn of events was unrelated to the care I did or did not give him.)  Half of me felt sorry but the other half still felt relieved that I would not have to see him again.

During our psychiatry rotation, we had had a lecture on how to think about “difficult” patients.  We were encouraged to think about the feelings of helplessness, uncertainty, anxiety, and fear patients felt, in addition to the destructive medical processes impairing their minds and bodies.  We were told never to forget that context when we dealt with someone whose behavior didn’t conform to our expectations of how a “good” patient should act.  It was a very valuable lecture, and I sat in the safety of our conference room absorbing it.

On the floor, feeling vulnerable and alone, feeling attacked and helpless, I lost sight of that lecture.  I was feeling the same things my patient most likely felt, yet to a fraction of an extent.  Although I didn’t verbally abuse anyone the way he did, my internal verbalizations were probably just as abusive.  Destruction need not be loud and it need not be an action.  Perhaps it begins with a thought,  one that snakes into your consciousness and amplifies.  Perhaps it ends in inaction, with you walking out of the room too early.

On the first episode of Scrubs, one of J.D.’s first patients passes away suddenly from a pulmonary embolism.  He narrates.  ”I’ll never forget that moment.  The way he looked exactly the same only completely different.  The shame that all I could think about was how hard this was for me.”  Seven months after I have started this thing called hospital medicine, I have finally felt that shame.

Before I wrote this post, I checked on that patient’s status.  He had recently passed away.  I hadn’t known.  It hadn’t been an expected event.

I wonder if I had known how close he was to death if my thoughts of him would have changed in that moment when our lives intersected.

I also know that the answer shouldn’t matter.

Here’s to the start of being the bad guy with good intentions.  Here’s to the start of trying harder, of keeping those good intentions during the most difficult moments–those when no one else believes you have them.

Note: Certain patient details have been changed to preserve anonymity.

Category: Patients, Personal | 30 Comments

Oasis

“By the way,” my chief resident told me on the first day of my inpatient psychiatry rotation, “don’t lick your lips in front of him.”

“Wait, what happens if–”

I fell silent as the patient walked into the interview room.  The resident wanted to discuss his paranoid delusions; the patient wanted to discuss his discharge.

The patient wasn’t ready to leave because the medications that made the demons stay away were also making his muscles twitch involuntarily.  More drugs would have to be added to his already potent cocktail to counteract the side effects.  The upside was that this week at least there was no poison in the water.  The military was still lurking in the background, though, and they probably would be no matter what dose of drug we overwhelmed his synapses with.

He raised his voice in frustration, his tone becoming more urgent, his speech rapid as he described the soldiers who were stalking him.  ”They’re so smart, they’ve got you convinced you that they’re a delusion.”  He leaned forward.  ”Everyone can hear them, but I’m the only one who can admit the truth.

“And I am getting pissed off.”

I didn’t utter a word, but I had never been so aware of my tongue in my life.

Three days earlier, I had finished my surgery rotation.  Suddenly the rules and culture I had absorbed for the previous 12 weeks fell away.  On the inpatient psychiatry ward, a new code governed not human anatomy but human behavior.

Although the outside door was locked, patients here wandered freely from room to room.  Upon entering, I brushed past the security guard outside the door of the isolation room, past a few small rooms with games and crafts, past the large main room where a flat-screen television hung on the wall and where meals were served.  I wandered into a spacious conference room that sometimes doubled as a group therapy room.

I peeked into the “Oasis Room,” a smaller room where each patient was interviewed daily by physicians and social workers.  It had no windows, but it was lit by an overhead light with clouds on it.  The walls and overstuffed chairs were a soft green.  A painting of trees covered an entire wall.  This was the official interface between doctor and patient.  It was designed to be comfortable and non-threatening.  Most importantly, it was designed to optimize treatment.

I thought of the surgeon’s “Oasis Room”–the operating room.  It too was comfortable and non-threatening, but only for the unconscious patient.  An awake patient, while sedated and being wheeled in, was warned, “Okay, bright lights and cold room.”  Before falling asleep, a patient once commented on the dozens of sharp tools that rested on a table near her barely draped body.  Sterile and sensible, though, it optimized treatment.

And there was the patient.  Anesthesia gave ultimate behavioral compliance.  Chaos in the operating room meant a nicked major artery.  An abdomen full of feces.  A heart that beat wildly out of rhythm.  These things were scary because they were unplanned, difficult to control, and physically dangerous.

But on my first day of my psychiatry rotation, without any of these risks, I was scared.  Patients with minds very different from my own roamed throughout the unit.  Sometimes they interacted with me.  Meanwhile, I struggled to look like the “Oasis Room”–comfortable and non-threatening.  I now worked in a world where licking my lips could mean nicking a major artery.

After I interviewed a patient, my attending gave me feedback.  ”Patients, especially the paranoid ones, watch your every move.  They are afraid of being judged.”  Though my words were appropriate, my body language could have been construed as suspicious.  I had jiggled my leg.  I had rubbed my boots repeatedly.  I had scribbled down too many notes.

On my first day on surgery, I accidentally brushed the sterile sleeve of my gown against an unsterile instrument.  The nurse had hurried to find me a sterile sleeve to slip over my contaminated attire.

On psychiatry there is a whole new set of ways to contaminate your environment.  Situations can escalate and human behavior, like the heart, can beat wildly out of rhythm.

There are new ways to interact with your patients.  You peer inside them, but it’s no longer literal.  You trace boundaries, but around their insight and judgment and not their vessels and ducts.  You try very hard not to sever anything crucial.  If you do, you pray that you can reverse it.

Instead of anesthesia, we have motivational interviewing and mood stabilizers.  We do not wear gowns or gloves or even white coats.  There is only one item that designates our role: “Without your ID, you are a patient,” my chief resident told me.

The rooms have changed.  The rules have changed.  The relationships have changed.

I am ready to change.

 

Note: Certain patient details have been changed to preserve anonymity

Category: Patients, Personal | 3 Comments

Waking Up

An elderly man startles awake after a man in a white coat touches his shoulder.  He looks around and sees three other white-coated people standing around his bed.

“Sir? Good afternoon, sir. How are you?” says the man who touched the patient’s shoulder.

“Oh, I’m fine.”  He’s perfectly calm.

“I know this is a silly question,” continues the man, “but do you know where you are right now?”

“Of course, of course. I’m at home.”

The slightest pause. “Sir, you’re in the hospital.” The man in the white coat names the hospital.

“Oh yes, the hospital,”the patient agrees. It’s as though being at home were just a slip of the tongue and not the mind.

“Do you know why you’re in the hospital?” the standing man presses.

“I’m here… I’m here because you’re giving me circulation to my leg.”

“Actually, you just had an amputation of your leg.”

The patient’s expression freezes, but like many people with dementia, he covers whatever internal processes he has.

“Your leg was just amputated.”

This is not the first time the patient has woken up after his surgery.  According to the nurses, he had been tearful all day trying to cope with the loss of his leg.

“Can you repeat that after me?  Your leg is amputated.”

The patient repeats it, in a tone that I’ve used to talk about the weather.

“Okay?  Your leg is gone.”

And just for good measure he lifts up the blanket and shows the patient the nothing that is there:

“Your leg is gone.”

The doctor turns and leaves.  The other people in the white coats who are not in the patient’s home not giving circulation to his leg follow his lead.  The whole encounter takes no more than 120 seconds.

The third year medical student in the white coat looks back at the man’s frozen expression. With this glance, she has already fallen out of step with the team.

A social worker enters as we leave, pulling the curtain around the patient’s bed.

A curtain around a man who doesn’t wake up from nightmares but into them.

Someone please tell me.

Someone please tell me how to make a box in my mind and put patients into it and seal it and make the patients stay in there until I say they can come out and–actually, on second thought–maybe I’ll just never let them out.

Because I am having nightmares too. But at least I am waking up in my home with both my legs still there.

Someone please tell me how to steel myself against this profession I have chosen.

Category: Patients, Personal | 20 Comments

Pain Control

She had only been in the hospital twice in her life: once when she was nine and now, 60 years later.  She had gotten tonsils out then.  She was getting tumors out now.

Her abdomen hurt when she was awake.  Her abdomen would also hurt during exploratory surgery, although she wouldn’t be able to feel it under general anesthesia.  Her body would feel it, though, and could respond by dangerously spiking or plunging her vitals.  She needed an epidural before surgery to keep the pain under control.

In the pre-surgery holding area–a busy room with twelve beds and dozens of doctors and nurses–we pulled a curtain around her bed.  She ungowned, naked in the back and naked in the front.  Two anesthesiologists stood at her back, setting up the epidural kit, feeling her back for bony landmarks, and scrubbing the area of insertion clean.

She bowed her head, waiting for the “pinch” that the doctor said she couldn’t promise wouldn’t hurt.  She held out her hands, and her adult niece knelt in front of her, squeezing them.  Her niece quietly spoke about people and places they knew.  ”Do you remember Sarah?  Did you know that on her first day as a nursing student, she fainted when she saw blood?  She must have toughened up since then, don’t you think?  I hope so.”

On the rear side of her, the needle missed.  Another shot of local anesthetic was given–another “pinch.”

“You’re being so good.  Things have changed a lot since you were last in the hospital, haven’t they?  You know what we can still do, though–get ice cream when you’re out.”

Whispers, instructions, and concentration from the back.   More slowly, the needle went in. It didn’t miss.  The catheter was threaded in soon after and taped in place.

“Look, that wasn’t so bad, was it?  Just a pinch going in.  And now it’s done, and soon enough you’ll be back from surgery, and I’ll be able to see you right after.”  Her niece didn’t let go of her hands.

I stood at the foot of the bed, splitting my gaze between the technicalities at the back and the interactions at the front.  Trying to glean how pain control came from both ends.

The patient regowned and lay back in bed.  Her mouth politely smiled but her eyes stayed anxious.  The anesthesiologists walked away for a moment to do their final preparations.  The patient and her niece looked at me.  ”So, do you know what you want to do with your life?” the niece asked.

Some combination of front and back, I thought.  How and what remained vague.  But I knew one thing for certain.

“Something where patients are awake.”

“We won’t tell them,” the niece said.

Note: Minor patient details have been changed to preserve anonymity.

Category: Patients | 3 Comments

Interesting

I pull up a test result for my patient, and the senior resident standing behind me lets out an excited squeal.

“I’ve never seen the imaging come back positive for this,” she says.  Our two-week-old infant, who already has a rare infection, also has a rare associated structural abnormality.  It’s not benign, but it is fixable.  The fix usually requires surgery.

As we walk over to the patient’s room to update her mother, my senior gushes about the zebra that was uncovered on the ultrasound.  She asks me if I’m excited.   “I dunno,” I mutter, which is somewhat more diplomatic than my discomfort that she is.  ”Her kid has to get surgery now.”

But in the room, the resident says all the right things to the patient’s mother, with the right amount of explanation, reassurance, clarity, and tone.  She shuts the door and looks at me, finally, in sad contemplation.  ”Let’s give her a bit.  I think she’s going to cry now.”

Since I work at a well-known teaching hospital, we get referred many cases you only hear about in textbooks.  Perhaps I’ve gotten spoiled: on my first day I picked up a teenage patient with a chronic disease with an incidence of 1 in 200,000.  Yet it wasn’t until my third week that I saw my first child with asthma–a condition that is 20,000 times more common.  A resident with four years of practice, meanwhile, has treated thousands of asthmatics, thousands of stomach viruses, and thousands of strep throats.  Seeing something for the first time in years must trigger that flurry of novelty that I still get on a nearly daily basis.

This rationalization does nothing to quell my unease that a doctor’s initial reaction to an unusual and undesirable test result was happiness.

Excitement about anomalies crops up in different ways.  Recently, a resident reported being “obsessed” with a patient’s cough.  He took a thorough history and physical exam, scoured the literature, wracked his brain.  He wanted the cough to be tuberculosis.  He tried to make the pieces fit the diagnosis, but they weren’t quite the right shape.

Why the desire for the cough to be more than just a cough?  Cinching an esoteric diagnosis is fulfilling.  If it is a dangerous but treatable disease like tuberculosis, then I imagine it is even more fulfilling.  In this case, perhaps obsession drives better patient care.  In fact, there is a school of thought that the best doctors are the most curious ones, and I don’t disagree.

But the conflict remains.  Do we wish an interesting tragedy on a patient over no tragedy at all?

“To be a doctor you have to be aroused by sickness,” my classmate told me.  I felt the unease creep up again.  ”I’m aroused by making sick people better, not by the sicknesses themselves,” I shot back, sounding a bit more confident than I felt.

My 1-in-200,000 patient had infected lungs.  With what, we weren’t sure.  We took his chest x-ray to a radiologist.  The diagnosis was inconclusive.  ”It’s an interesting case,” the radiologist said, looking thoughtful.  I thought about the interesting lungs belonging to the interesting patient.  He was upstairs playing Wii, unaware of just how darn interesting he was.

Can I simultaneously be fascinated by sickness and also wish it didn’t exist?

On one of my first days on surgery, I was stitching up a patient’s abdomen when I felt a sharp twinge in my finger.  I peeled off my gloves and saw a drop of blood that wasn’t the patient’s.   I uttered a few choice words under my breath, scrubbed my hands like Lady Macbeth, and went to the emergency room.

The chances of someone having HIV are 1 in 200.  The chances of contracting HIV via a needlestick are 1 in 300.  As of today, there is not a single documented case of HIV transmission using the particular needle I did.  If I get it, I would be really interesting.

I wonder if somewhere out there a doctor’s subconscious is rooting for the zebra that could kill me.

Note: Minor patient details have been changed to preserve anonymity.

Category: Patients, Personal | 13 Comments

Undraped

He was nervous about having his uterus and ovaries out.  I had gotten on well with him in the surgical holding area.  I didn’t get to ask what I really wanted to, instead skimming over shallower subjects like where he was from and who each person was who had to examine him before surgery.

He finally asked me if I had ever treated a transgender patient before.  I told him that I hadn’t.  I added that he would probably forget me in the haze of people while I probably would remember him for the rest of my life.  I’ve been saying that a lot to patients lately, since each one is usually my first something.

“How do you feel about seeing me?” he asked.

Seeing him?  I didn’t feel anything different, I said.  This was true for him as an individual.  On a larger level–seeing what he represented–I did.  I have strong feelings about our national squeamishness about sexual orientation and gender identity.  This was not the time or place to mention that, as he was getting drowsy from his first dose of medication.

Twenty minutes later, he was asleep in the OR and completely undraped, ready to be prepped for the incisions.  All of a sudden, he materialized as an individual patient, allowing himself to be opened up and treated.  No longer was he a political or social statement on society, or necessarily all of the qualities I wanted to project onto him.

www.withassociates.com

About thirty seconds later, the resident said to me, “You need to find things to do.”  It was rare feedback, because I am usually the one moving the bed to the hallway, putting boots on the patient to improve circulation, and taking apart the table.  I looked up, and all of those things had been done in the half minute my mind had been undraped with the patient.

I get it. The OR is not a place to reflect, if only for seconds.  Patient care depends on it.  I get it, but on some level I think I resent it.

The rest of the surgery was no different from any other.  His uterus and ovaries looked beautiful and healthy, and of course this was irrelevant.

Sometime during the closing of the incision sites, I thought of the Na’vi casual-yet-profound “I see you.”  For some reason, I saw this patient when I looked at his body rather than into his eyes.  Humanization and objectification entangled themselves in ways I’m still trying to sort out.

“How do you feel about seeing me?” he had asked, and I had answered.

Ask me again.

 

Category: Patients, Personal | 5 Comments

Plastic Lessons

I always feel awkward when I talk to plastic patients.  The simulation mannequins are impressive: their eyes blink, their chests expand as they breathe, they have pulses, they bleed, they burn.  A screen monitors vital signs: I administer a pressor and a dipping blood pressure perks up, or I order a beta blocker and a racing heart rate slows.  A physician in the next room lends her voice to play the patient, responding to what I do and say.  A physician in the same room becomes a tech, relaying results of my tests and nudging me through the next steps when I veer off course.

The situations are designed to be overwhelming.  I look helplessly at the “tech” when he asks me how many liters of saline I want to give the patient.  When the patient asks what’s happening or when fear enters her voice, I give automated reassurances while my mind wanders through differentials.  When the patient begins deteriorating for reasons beyond my comprehension, I pause for too long: listening to the beeping of the monitor, watching her oxygen saturation plummet, and waiting for the scenario to be over so I can be rescued.  During simulations, the student usually needs as much rescuing as the patient.

That morning’s mannequin was distraught.  She was bleeding profusely from her vagina and was terrified that she was miscarrying.  Her blood pressure dropped.  She wouldn’t stop crying.  She was asking a lot of questions.  The tech wanted to know what he should tell her boyfriend outside.  I used about 5% of my mental capacity in an attempt to soothe her and deflect her boyfriend’s worries.  The rest I reserved for piecing together the tiny bits of information I had gleaned so far on my ob/gyn rotation on how to diagnose and manage miscarriages.  I stabilized her blood pressure and admitted her for surgery, but she was still crying as the scenario ended.  In my eyes this was success.

Excited to get away from plastic people, I re-joined my team on the floor that afternoon.  I found our next patient in the surgical waiting area.  She had had a miscarriage.

There are eight beds in the waiting area, each separated by a few feet and three quarters of a curtain.  In a span of twenty minutes, the patient meets a slew of personnel: surgeons who explain what recovery will look like, anesthesiologists who verify medications and allergies, nurses who update physicians on the patient’s recent changes, and translators when necessary.  The room is busy but not chaotic; animated but not loud.

And there my patient sat, crying in her bed.

Everyone around me had a task.  Each person gave the patient words of sympathy–which eerily echoed mine from only a few hours before–and moved on to the next aspects of her care.

Although I was technically part of the surgical team, I was also technically useless at that point.  Unlike simulations during which I had to balance medical management with verbal comfort, this time I could allocate my entire brain to the latter.

I only wished it were merely as uncomfortable as it was with my plastic patient.

After introducing myself and uttering the requisite situational apology, my face molded itself into an expression of glum empathy.  I was amazed by the nurses’ facileness in switching their expressions as they moved from bed to bed.  Within my patient’s fifty square feet, they held her hand and lowered their voices.  Then, with their backs turned and sixty seconds behind them, they bantered with the next patient.  The physicians busied themselves writing notes, looking up records, and explaining to the patient what dilation and curettage meant.

With nothing to do but nowhere else to be, I stood silently by the patient’s bedside, unwilling to interrupt the medicine taking place, even when the medicine wasn’t being spoken aloud.  I was convinced that she perceived me as some sort of creepy extra during one of the worst days of her life.  But still, I didn’t speak.  I knew she’d remember a stupid or hurtful comment more vividly than no comment at all.

She seemed to sense that her doctors considered her impending procedure relatively short and safe.  (At twenty minutes and only somewhat invasive, it was.)  Through her tears, she tried to justify her questions.  ”I know you do these things every day, but for me it’s new and I’m terrified.”

I desperately wanted to tell her that I wasn’t like the rest of them.  It was new for me too.  Just as she would always remember this surgery, so would I.  But I remembered my superiors’ advice (approaching an order) not to let on to patients how inexperienced I was.

I needed her to know.  As she looked more miserable, my judgment waned.  During a lull in the preparations, I very quietly said to her, “I’m not going to do anything at all during the surgery; I’m only watching.  But it’s my first time too.”

“First time?  Join the club,” she repeated, too loudly.  I knew my intern had overheard. I could only hope that she wouldn’t be the one writing my evaluation.

Did I have anything at all to offer?  ”I’m just a student so I won’t know all the answers to your medical questions.  But I have a lot more time than these guys”–I gestured with my head to the rest of the team–”which means I have a lot more time to help you in any way I can.  If you need anything, please let me know and I’ll try to get it for you.”

She nodded, and I realized I had finally found my place.  It wasn’t big–about fifty square feet.  In fact, it was precisely the size of my patient’s world.  A bed.  A curtain.  An IV line and a monitor.  People who faded in and out of their own ever-shifting worlds.  A patient and her mother.  And me.

I thought back to the simulation of a few hours ago.  It was useful, but not immediately so.  With plastic patients, I am learning how to be a doctor and feeling overwhelmed with medicine.  With real patients, I am on the cusp of learning how to be a doctor-in-training and feeling underwhelmed with myself.  At some undetermined time, I hope the two paths will find a way to meet.

As we wheeled her bed out of the holding room and toward the operating room, her mother asked how long before she could see her daughter again.  I was the only one who heard.  Frustrated, I couldn’t even answer that.  I nudged my intern and repeated the question.

“An hour.”  Her mother nodded.

In my eyes this was success.

Category: Patients, Personal | 5 Comments

Walls

Last Monday I sat in a chilly exam center for eight hours and took a very important test.  When I arrived home, I looked at the walls surrounding my desk.  They were cluttered with upwards of seventy hand-written index cards.  Very methodically–and resisting the urge to tear them to pieces–I took them down.  Atypical anti-depressants and their side effects.  The organs behind your abdominal cavity.  Every anti-viral drug and its machinery of attack.  The biochemical pathway an amino acid takes to become a neurotransmitter.  Chemicals that turn your blood dangerously acidic.  Which bacteria need air to live.  What happens in your cardiac cells from hour zero to month two after you have a heart attack.

It wasn’t that I wanted to forget the knowledge that I had crammed and re-crammed into my brain.  It was that I didn’t want it to be the first thing I saw anymore.

The last few months of second year had been a blur of caffeine, question banks, ignoring phone calls, and sighing.  The exam itself culminated in the biggest blur of all, and for this I am grateful.

Two days after my exam, I attended hospital orientation and became a third year student.  This means that I will be an apprentice of sorts (the kind that still pays tuition), working full-time in the hospital until I graduate in two years.  Instead of seeing one patient every week or two, I will be seeing and discussing dozens each day.  Unlike in years one and two, when my entire job was to learn from the patient, now my role has expanded: to help the person in front of me.  All the interpersonal skills that have atrophied over the last few months will become important again as I contribute to patients’ care.  All the medical details that I have tried to file in my brain will become part of a larger picture as I apply them to make people’s bodies feel better.

Since I last wrote in January, I tried to write two separate blog posts.  They started very differently, and they both ended with the first sentence.

One post I wrote at midnight a week before my exam.  ”This is not who I am,” I typed, cringing at the clichéd and whiny words.  Then words stopped coming altogether, and I went back to studying.

The second I wrote at noon, several months ago.  I had performed my first (minimally) invasive procedure on a patient, and it was to help a medical team I was shadowing.  It was the first time I had ever interacted with a patient in a way that directly contributed to his care.  On a high, I wrote, “Today, for approximately 60 seconds, I did something that mattered.”

I really want third year to matter.

The walls around my desk are bare now.  The vast white space looks unfamiliar and slightly discomfiting in a place where I am used to seeing smudges and coffee stains.  But there is an energy in the blankness, and a nervous excitement as I wonder what will fill them.

I did keep one small card taped up.  It always looked different from the rest.  It was given to me by a terminal cancer patient I worked with who found her strength in religion.

“Don’t worry that you’re not strong enough before you begin.  It is in the journey that God makes you strong.”

Orientation is over.  My journey begins tomorrow.

Category: Education, Personal | 7 Comments

Provisions

Impersonal and self-absorbed as Manhattan may be, it’s still embarrassing to cry on West 32nd Street.  I looked for a store, any store, and ducked inside.  The pace of my steps and angle of my head as I buried myself into a back corner, thumbing through pants twice my size, gave me away.  A store clerk walked over and asked if I was okay.  I knew I’d have to meet her eyes, unable to hide the tell-tale redness and puffiness of my own.  I asked if they had a bathroom I could use.

Being Manhattan, there was no customer bathroom, but the store clerk very gently led me to the staff bathroom and told me to take the time I needed.  After five minutes of some fairly heavy crying, I spent the next ten desperately trying to disguise what I had just done.  I scrubbed my face until it hurt and molded my expression back into that of stoic, aloof New Yorker.  My insides didn’t feel much better, but at least my outsides didn’t betray that anymore.   I emerged, thanked the clerk, and took comfort in the fact that I’d never see her again.

My little episode had only intensified the all-consuming ringing in my ears.  The tinnitus had started two years ago, suddenly and unrelentingly.  Five doctors and five clean bills of health later, I was left with the unchanging advice: “We’ve ruled out anything organic and tinnitus isn’t dangerous, so you’ll just have to get used to it.”  No follow-up appointment necessary.

I was left to my own devices–which included the Internet, snake oil supplements, and my own obsessive mind–and I wasn’t using them well.  Besides being sleepless, irritable, and depressed, the far more damning thing was that I was without any hope.  I couldn’t imagine being able to live happily in my body.

Thinking back, I still can’t figure out why it didn’t dawn on me to consider a psychiatrist instead of an ENT or a neurologist.  The idea to see him wasn’t even my own.

After getting to know me, the psychiatrist eventually suggested medications.  I wasn’t afraid of the side effects, and I began immediately.

A year and a half later, everything is much better, objectively and subjectively.  Though not gone, the auditory disturbances are manageable to the point where they hardly register emotionally.  I don’t much like talking about it, for reasons better articulated by Russell Crowe’s character in A Beautiful Mind:  ”I still see things that are not here. I just choose not to acknowledge them. Like a diet of the mind, I just choose not to indulge certain appetites.”

Of course, most times I go to the doctor, for any purpose, I am asked about the reasons I am on certain medications.  Usually my answer is acknowledged, and the appropriate empathetic response is conveyed.

Recently, I was surprised by one doctor’s version of empathy: “Oh, yes, tinnitus can make you literally want to drive off a bridge.”

Of course, this doctor doesn’t know that 18 months ago, I broke down in midtown Manhattan and wondered how I could live out the rest of my life at this rate.  She assumes by my demeanor that I am well-adjusted and perhaps always have been.  She doesn’t know that sometimes when I listen with my stethoscope for a patient’s heartbeat and I hear ringing, that familiar fear makes my own chest tighten.  Or that sometimes I “indulge” in anxiousness when a tinnitus spike occurs that I cannot ignore.  Or that the very condition she was treating me for was creating such a spike at that moment.

Regardless, I was in “no acute distress,” as the medical lingo goes.  I let it go.

I wasn’t even angry with her off-the-cuff remark.  I say silly things to patients on a weekly basis, and the only reason it isn’t more frequently is that I only see patients once a week.

What reminded me of her remark was a piece by Dr. Danielle Ofri in the New York Times, which was inspired by a New England Journal of Medicine article by Dr. Jerome Groopman and Dr. Pamela Hartzband.

All three doctors rail against the term “provider” instead of “doctor” for a number of reasons: the generic term connotes sterility, commodification, distance, and interchangeability.  ”The words we use to explain our roles are powerful,” Groopman and Hartzband explain.  ”They set expectations and shape behavior.”

This is all fair.  And, as a medical student, I should be in especially staunch agreement.  But I’m not.  As a patient, I’ve seen far more “providers” than “doctors.”

I went to the doctor who made the unfortunate comment about my tinnitus because I had an unrelated problem.  She took me seriously, she diagnosed me correctly, she prescribed the appropriate medications, and I got better.  Technically, flawless.  She provided excellent care.

But, Groopman and Hertzband write when we use a term like “provider,” it ignores “the essential psychological, spiritual, and humanistic dimensions of the relationship.”

From a patient’s point of view, though, all it takes it one insensitive comment from the physician to lose that humanistic dimension.  When my doctor made that remark, I relegated her to the impersonal role of provider, someone incapable of understanding my experience but capable of treating my physical problem.  I just wanted to get better.  As Dr. Ofri writes, “It makes [physicians] feel like a vending machine pushing out hermetically sealed bags of ‘health care’ after the ‘consumer’s’ dollar bill is slurped eerily in.”  That is exactly how I saw my doctor.

Was I happy with the care I got?  Sure.  If I have another problem, will I see her again?  Probably.  Was I bothered by her remark?  A little.  Did I care?  Not really.  I didn’t care because I depersonalized her immediately after.  If I cared, the remark would hurt.  I don’t want to hurt.  Is that fair to the doctor?  Maybe not, but I care more about me.

This example is far from unique, for me and for others as well.  There are many reasons people dislike doctors, and many of these reasons are not particularly fair.  But when the same complaints are heard over and over again (“He doesn’t listen to me!”  ”I can’t believe she said that!”  ”He doesn’t understand!”), one has to wonder which came first–the term “provider” or the doctor acting like one.

I’m not dismissing the argument that “provider” is irksome or suggesting that we shouldn’t spend space discussing its consequences.  But I wanted to spend some space on rationalizing why patients may already think in these terms: on how in many cases physical provision of health care is exactly what doctors do, and on how depersonalizing doctors can actually protect patients when their emotional or humanistic care is lacking.  And the term “provider” sometimes fits, even if doctors don’t want to wear it.

“But words do influence us,” Dr. Ofri writes about what doctors are called.  Yes, they do.  Now let’s take those thoughts and apply them to what doctors say too.

Category: Media, Patients, Personal, Policy | 24 Comments