On Proposing Solutions

No one likes to be wrong.  I would wager that most of us don’t even like to be disagreed with.  That’s why the most popular articles and thoughts tend to be the ones that are–literally–popular.

My sister recently wrote a very good article on the ethical challenges of prenatal testing.  It was a clear, articulate overview that identified and explained the arguments on both sides–reproductive freedom vs. discrimination.  But when it came to proposing a possible way to approaching a solution, she confided in me that she was hesitant to take a stand.

“I just like to say ‘…and this is the problem.  These are the issues.  Everything is hard,'” she told me.  I found myself agreeing with her, noting that I tended to do the same.  “I’m comfortable identifying blurs.  But someone has to draw the lines,” my sister said.

Ilana did end up suggesting a solution in her article.  But her reluctance to do so stemmed from her desire for her article to be well-received.  And to be well-received, people have to agree with it.  Obviously, this is particularly relevant for those of us who are young, low on the totem pole, and have fewer credentials we can stake an opinion on.

In our medical ethics course, we learned the relevant issues at stake in specific medical scenarios.  We could identify values and conflicts.  But at what point should we go beyond saying, “This is an example of the overmedicalization of normal variation” and actually attempt to draw lines in the sand?

It is hard to disagree with the aforementioned quotation.  Draw a single line, though, and the entire class will poke holes in your argument.  There will be rebuttals, counterexamples, and slippery slopes.  This is the point of an ethics class, of course.  But what about in a more public forum, one that is less conducive to debate?

Say, an article.  It is not fun when an audience pokes holes in your article.

There are certain people who I admire who do not hesitate to propose bold, original theories and solutions.  Paul Graham and Penelope Trunk come to mind.  Yet these same people are also accused of oversimplifying the issues at stake, or being too confident, or being too rigid.  They are either loved or hated.

I think most of us would choose to be simply “liked” rather than “loved and hated.”

But this is also why we have far more articles with themes of “this is a complicated issue with no easy solutions” than we do with “here’s an innovative proposal that just may work.”

I know I can’t please everyone, and it’s intimating to propose in a public forum something that won’t.  Still just a medical student here.  Still twenty four years old.  Still scared to death of being “hated.”

But I recognize that often the most polarizing figures are also the ones who change the world the most.

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Making it Worse

“So how great are you at handling weird shit?”

The instant message box popped up from an acquaintance.  We barely knew each other beyond our sparse interactions online.  Apparently there was no else online to talk to.

With weak reassurance from me, he dropped the bombshell.

There was no right way to react, he admitted.  There was also nothing in particular he was looking to hear.  Still, I felt more impotent with each response I gave.

Empathy led to sarcasm.  Additional questions led to evasion.  Expressing uncertainty about how I was reacting led to silence.  I was sure I was making things worse.

He had some whiskey and left the keyboard for awhile.  When he came back, the subject was over.  He thanked me for listening.  “I don’t know how I’m supposed to feel,” he finally said.

Me neither.

I chalked up my incompetence to my barely knowing him.  Surely if I knew him better, I’d know exactly which conversation buttons to hit to help him cope.  But I didn’t know him at all.  This was the first time someone who I barely knew confided in me something life-changing.

We learn a lot of things about how to react to raw vulnerability in people we don’t know.  We have our stock phrases and tricks about how to validate feelings.  “This must be hard for you.” “I’m sorry.”  “Take all the time you need.  “This is not your fault.”  “A lot of people go through this.”  “Your reaction is normal.”

What I didn’t learn until now is sometimes nothing–absolutely nothing–works.  Sometimes it’s the moment, sometimes it’s the person, sometimes it’s both.  And so you have silences, and missteps, and too many apologies.  Out of desperation, you say inappropriate things like, “I’m pretty sure I didn’t do anything to make it better, but I hope I didn’t make it worse either.”

You may make it worse.

But maybe the game is rigged.  Maybe every door to making things better is locked.  Maybe I’m not the person with the key.  Maybe there’s nowhere to stand but in the hallway, offering nothing for now but a bit of body warmth.

Note: I asked for (and received) consent to write this.

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Finished Year, Unfinished Business

The jury’s still out on reflective first year sentiments, but it’s been gratifying to share my thoughts back from the very beginning of medical school.

I had the honor of reading my “Letter to a Young Doctor” on the medical documentary series White Coat, Black Art. The radio show ran on the Canadian Broadcasting Corporation (Canada’s national public radio and television broadcaster–similar to America’s NPR or PBS).

Link to audio–my piece is at 22:00.
Link to June 10 show description.
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I’m officially a “rising MS-2,” or second-year medical student.  During the last few days of school, we were asked to write a two-page reflection statement about first year.  I meant to write something original, but it proved difficult.  Nothing I was thinking seemed remotely appropriate to hand in to a person who could be writing my recommendation letter.  I didn’t (and still don’t) really feel anything at all right now.  I don’t feel particularly learned, or empathetic, or acculturated right now.

The dorm is quiet.  Our lecture hall/study center is quiet.  In April, the former second years became third years.  They started on the wards in their respective hospitals.  They no longer spend long hours in the computer labs studying for boards or mingling with our class in common areas during lunch breaks.  They no longer live with us either; many have moved out out of the dorm to be closer to their hospitals or because they finally desired their own bathrooms.

Right now, we exist in a strange sort of orphan limbo.  The former second years are no longer in our proximate space to give advice, guidance, reassurance.  The incoming class will not be arriving until August.  Without other classes for comparison, perspective is difficult.  The changes do not become evident simply because it’s the current assignment.

I am a guest editor of the AMA’s ethics journal Virtual Mentor.  One of my main responsibilities is to describe a clinical situation in which the physician faces an ethical dilemma.  I write a short narrative depicting the situation–the doctor, the patient, the setting.  Then, there’s what the editor in chief calls the “trigger.”  There needs to be a very specific event that occurs that ignites the dilemma.  It could be a patient’s question, a lab result, a colleague’s comment.  A solicited author then writes commentary on my proposed situation and “trigger,” using a larger ethical framework to buttress arguments.

The “trigger” in various clinical situations constitutes the backbone of the journal’s cases is appealing to me on a number of levels.  It is a concrete and focused way to think about nuanced and abstract philosophical issues.  The “trigger” is unique, and yet it isn’t.  Although physicians may not have experienced identical situations to the ones proposed, likenesses make the situations realistic and relevant.

What I’m missing right now is the trigger.  Perhaps it will be a former second year laughingly recalling how terrified I was before our first exam.  Perhaps it will be when an incoming first year asks me how it’s possible to memorize the names and functions of nearly every muscle in the human body.  Perhaps it will even be when a patient tells me that I what I said was particularly sensitive, or knowledgeable, or clear.  What I do know is that staring at my computer screen has not been the trigger.

Out of desperation, diplomacy, and a desire to be honest, I ended up smushing together two previous blog posts as a reflection.  Both had triggers: a USPS mishap, and a late-night perusal of PubMed.  Both accurately represented thoughts from various points during the academic year.  Both (I believe) were reflective.

I’m still waiting for a trigger before I can wax poetic about the entirety of first year.  Luckily, there are no deadlines this time.

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Final Countdown

I would love to think about things other than viruses, worms, and fungi, but alas–it’s going to be two more days until I get that luxury.

Last exam of the year this Friday.

Integration week (no details on what exactly this entails. some things? all things?) from Monday-Thursday next week.

Then medical school will be one quarter over.  Wow.

Can’t wait to look up from the grindstone and think a little more about life since last August.  Soon.  So soon.

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"Five" "Fun" Facts About Bacteria

No illustrations for this one.  I’ll leave image searching to the hardy, the curious, and the self-punishing.

…Right.  So today I’m going to talk about bacteria.  For those of you who want to read about interactions with humans, now’s your chance to click away.

I haven’t seen a real patient in a month.  Last week during Patient-Doctor we went to an art museum.  Before that were videotaped exams during which we interviewed standardized patients.  (Best moment: Me: “You mentioned you were hard of hearing.  Do you wear a hearing aid?” Patient: “What?”)  Next week is our final reflection session, which will have a few Doctors, ~80 Medical Students, and no Patients.

Don’t say I didn’t warn you.

Some interesting things about bacteria that are interesting to me and maybe not to you but hopefully to you too:

1. We are outnumbered 10:1 by bacteria on our own turf, our bodies.  (Note: this is by number only.  I’m not sure about volume.  Most bacteria are only a fraction of the size of human cells.)

2. I used to think “flesh-eating bacteria” (necrotizing fasciitis) were a certain species of superbacteria that you somehow pick up (thanks, Cabin Fever).  Actually, they’re normal bacteria species (or certain strains of normal bacteria) gone bad–instead of causing superficial skin infection, they chomp all the way down to the muscle and nerves underneath.

Many kinds of bacteria can be “flesh-eating,” and the scary part is that we’re all harboring them on our skin, in our throats, and in our GI tracts right now.  They’re just not in “flesh-eating mode”–and no one knows exactly what factors in the host or the bacteria trigger the often fatal change.

2a. The less scary part is that nectrotizing fascitis is rare.  One doctor said he saw two cases in six years.

2b. (Jim Henson, creator of The Muppets, died from it in 1990.)

3. Actually, the whole “normal bacteria turned bad” thing is true for many infections.  About a quarter of us have several strains of Strep in our throats… but we don’t have symptoms of the disease. A similar percentage of us have Staph on our skin, in our nose, in our GI tracts, and in our vaginas.  Our immune system generally keeps them in check.

4. A vaccine for Lyme disease was developed and made it to the market but was withdrawn because of anti-vaccine sentiment and low public demand.  Lyme disease is the only example of a sickness that can be combated with an approved vaccine that is currently not available to the public.

5. We are in a continual arms race against bacteria.  We develop an antibiotic that doesn’t let bacteria build their cell wall.  Bacteria select for an enzyme that neutralizes our antibiotic.  We make an antibiotic that inactivates the enzyme.  Bacteria select for modifications of their enzyme that don’t get inactivated by our drugs.  And so it goes.

5a. Note the wording: bacteria “select for” traits that evade our weapons.  The mutations exist before we introduce our weapons–they don’t develop in response to them.  Now the bacteria with previously arbitrary mutations survive, prosper, and share their genes with their friends, lovers, and daughters.

5b. MRSA (methicillin resistant Staph aureus) was first documented in 1961.  Now, about one third of people harbor it.  Although it used to be found only in hospitals, now it can be acquired in the outside community as well.  It is resistant to not only methicillin but many other drugs in similar classes.

Exam on Monday.  More facts must come, or I’m not going to pass.
Until then.

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I recently ordered thirty dollars’ worth of books from a private seller on Amazon.  In return, I received an empty box and a refusal from the seller to reship the goods, blaming USPS.  USPS predictably remained impenetrable and bureaucratic, offering no recourse or refund.

The innocent woman working in my dorm’s business office caught me mid-rant, and she commiserated.  “After working here for 15 years, I see what happens–you wouldn’t believe how often.  Now, I never ship anything using USPS.”

Years of experience had exposed her to not-entirely-uncommon mishaps that many individuals do not realize exist.  As a result, she had lost faith in the system, preferring to opt out.

I stayed angry for a few days.  But would I use the system again?  Probably.  I wondered how many mishaps it would take for me to change my mind.  I wondered if one expensive loss would be enough.

When I was an undergraduate, I was friendly with a clinical geneticist.  She was in her late thirties, and she and her husband had opted not to have children.  “There’s just too much that can go wrong,” she told me.  There were too many ways chromosomes could break and realign themselves, too many ways a vital piece of genetic material could be lost in a single cell division, too many dangers in utero that could cause physical and mental deformities.  “I don’t think I’d be able to handle taking care of a child like that.”

As a genetic counselor, she explained to couples the risk of having a child born with a particular disease or condition.  It was also her job to counsel the parents if said child was born with said condition.  Her days were spent considering unlikelies and talking to people whose lives had been touched by unlikelies.

I wondered if she had suddenly come to her decision after an especially sad case, or if her realization had been gradual after years of cumulative sadnesses.  I wondered if her risk-averse perspective was in her best interest.  She admitted that her biggest fear was regretting her decision twenty years down the line.

A little knowledge may be a dangerous thing, but what about a lot of knowledge?

I’ve felt my own perspective changing in medical school.  You spend your days studying mishaps.  Sometime’s it’s the likelies: one in two men will eventually get cancer, as will one in three women.  Many times, though, it’s the unlikelies: the debilitating autoimmune attacks, the odd bowel obstructions, the random vessel ruptures.  My classmates and I routinely joke that it’s a miracle we’ve made it this long.

Sometimes it seems as though being alive is an unlikely in itself.

I wonder if this sort of thinking is accurate on some level.

I wonder how this perspective will change my decisions.

I wonder if it will be for the better or worse.

I wonder if we’re going to go through life permanently skewed.

But I suppose there’s no opting out.

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The anatomy article is running today.  I want to be a writer–not for my diary but for the public.  I know I’ve got to be open to scrutiny.

But damn if I don’t feel entirely dissected right now.  On display, vulnerable.  The irony hasn’t gone unappreciated.

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It was a story incomplete.

The very last post I wrote about anatomy lab was a reflection on our donor, the night before we dissected his head and neck.

A few of my anatomy posts have been stitched together by a gifted editor and will run as a front-page story and feature in the Health section of the Los Angeles Times this coming Monday.  Several times, the editor asked for more concrete details about dissection above the neck.

It would mean I would have to think about it, and worse, write about it.  And there was a good reason that since November, I have done neither.

I am ashamed about what happened in lab.

We had a ceremony honoring our donors in January.  The pieces read and thoughts expressed were elegant, kind, and thoughtful.  That is the way I would like to remember anatomy.  But, in a way, reflections are sugarcoated.  They are certainly honest, but by definition–they occur after much thought.

What happened in lab occurred with no thought and is no less honest.  The day after I wrote the post reflecting on our donor, we entered lab to begin the dissection.

There was the saw—our way into the brain.  The only other time we had interacted with bone was when we banged through the kneecap with mallet and hammer to observe the joint and cartilage inside.  It didn’t feel particularly disturbing, since orthopedic surgeons basically do the same thing.  Above the neck was different.  On no level, in any instance, would a doctor ever do what we were about to—saw through the skull.

Our donor ceased to become human for me after we peeled off his facial skin like a mask to reveal the small muscles underneath.  Without hair on his head, chin, and brows, he was a specimen.  This made the next part of our task considerably easier—cut through skull, reveal brain, pull brain apart, distinguish cranial nerves that control our five senses and movements.

When you saw through a skull for ten minutes, the room—your world—becomes that skull.  You inhale dust particles, acutely aware of where they came from.  Saw against bone shrieks, notes stumbling, uneven in pitch and length.  It is anything but mechanical.

It was surreal to watch my labmate in scrubs, apron, and goggles, with saw raised in hand.  He looked no different from a madman in a horror movie.  Were we the same people who wore suits to our school interviews and gushed about how much we wanted to help people?

There was no analogy my mind could make, no particular moment in my memory that in any way compared to this one.  The whole situation seemed nothing short of ridiculous.  For some reason, the absurdity made me giddy.

I giggled.  Instructors like to use the term “nervous laughter,” but I didn’t feel nervous.  I felt outside myself.

My reaction was contagious.  All four of us breathed in dust and formalin and laughed above the roar of the saw.  Dentures flew out of the cadaver’s mouth and clattered onto the floor.  In this warped reality, we took this in stride and giggled harder.  Of course, I thought sarcastically, when you cut through someone’s head, their fake teeth fly at you.  What else could I expect?  It was a nonsensical situation; we responded in kind.

Back in my room and in street clothes, I called my mother and described the scene in vivid detail.  When she reacted with the appropriate concern, I told her, “No, no, you don’t understand.  It was really funny!”  I was convinced.

I sobered up after a few minutes, horrified about what I had done.  I asked my mom what kind of person my reaction made me.  “It’s a coping mechanism,” she said.  “But I didn’t feel like I had to cope with anything,” I protested.  “That’s the point, isn’t it?” she said.

If everything we do is to rationalize or make ourselves feel better, what isn’t a coping mechanism?  Does that make it justified?  Does that make irrationality rational?  That was the first time in my life I have had a public reaction that I could not bring under control.  It’s difficult to think about, so I don’t very often.  But when I do, I still struggle to make sense of it.

Or maybe it’s all just nonsense.

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"What Do You Think Caused Your Disease?"

Our first assignment for medical school involved reading and discussing Anne Fadiman’s The Spirit Catches You and You Fall Down, which describes how a clash of two cultures (medical and recently immigrated Hmong), miscommunication, and misunderstanding led to tragedy.  Poignantly narrated, the book had the take-home message: if a patient does not agree with a physician’s reasoning why a disease developed and how it can be cured, then even the best treatment won’t help because the patient will not stick to it.

In the novel, Hmong parents believed that their daughter’s seizures were caused by spirits and not overexcitable neurons, so they relied on traditional healing methods (prayer and sacrifice) instead of medications.  Although perhaps the story represents an extreme example of a mistranslated message, unfortunately more minor ones do exist and can often impact care.

Does the diabetic patient understand why monitoring blood sugar is vitally important?  Why should someone with celiac disease avoid certain foods?  Does a smoker realize the extent to which he worsens his COPD when he goes through a pack a day?  Is it ever okay to have a drink when you have hepatitis B?  The answers to these questions help physicians understand how patients see their disease–and, as a consequence, what sorts of measures and discussions can best help them manage it.

Hows and whys from a patient’s perspective are called “the explanatory model.”  To boil it down, the conceptual framework includes:

What do you call the problem, What do you think the illness does, What do you think the natural course of the illness is, What do you fear?
do you think this illness or problem has occurred?
do you think the sickness should be treated, How do want us to help you?
do you turn to for help, Who should be involved in decision making? Why do you think this illness or problem has occurred? How do you think the sickness should be treated, How do want us to help you? Who do you turn to for help, Who should be involved in decision making?

No doubt these questions are key.  In fact, this is what we learn to inquire about during our patient interviews, somewhere between taking the history of present illness and the social history.

But, we are not doctors.  We don’t yet have the finesse or the time or the practice to incorporate all of these questions in a brief standard interview.  And, in my experience, what usually comes out is an ugly stand-alone question: “What do you think caused your disease?”

So far, patients I have interviewed have included those with congestive heart failure, arthritis, spinal cord damage, severe abdominal pain, leukemia, cirrhosis, and hepatitis.

I have cringed with awkwardness upon asking this required question.  How could a previously perfectly healthy 63-year-old recently diagnosed with leukemia possibly answer?  The patient with cirrhosis claimed he never drank.  The patient with hepatitis blamed an unsterilized tattoo needle from when he was 19 (which my preceptor later said was an unlikely reason).  I can only imagine the discomfort in the room when I pose a lung cancer patient this question.

I’m not sure how patients feel when I drop this inevitable inquiry.  They generally answer with “I don’t know” (which is completely understandable given the nature of many illnesses) or something unrelated.  At that point, I get even more uncertain.  I do not have the knowledge or authority to correct them.  It’s not my responsibility right now to comfort, diagnose, or treat them.  I’m not their physician, I do not report to their physician, I am not part of their care in any way, and I will never see them again.  I simply write down their answers to present later.  I feel guilty.  I feel tense.  I am embarrassed for embarrassing them.

My patient interviews are strictly non-therapeutic.  At best I’m a comforting presence and at worst I’m an annoyance.  Nothing about the above question is comforting.

Perhaps I should buttress it with additional questions so that it doesn’t land in the room from left field.  Perhaps I should phrase it differently.  But it’s difficult to improve when I’m there on a simulated fact-gathering mission without providing the logical consequence of treatment, relaying information to a care team, discussion, or counseling.

To the patients I have asked this question: I apologize.  I’m sorry that you may not feel comfortable disclosing to a 23-year-old first year medical student who is not a part of your care that your heavy drinking to cope with your divorce may have led to your cirrhosis.  I’m sorry that I had to ask you why you think you got cancer, as though I expect a philosophical discourse.  It’s just a contrived question right now for training purposes–a piece of a puzzle that is so out of context that it’s a disservice. In a few years, I promise I can try to help.

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