Also surprising was the study’s finding that only 14% of those students had an opinion about “appropriate interactions between physicians and pharmaceutical companies.” How could 86% of medical students not even have an opinion on such a hot subject?
The New York Times recently ran a column by one of its editors, “In Praise of Nurses.” Nothing wrong with gratitude for nurses, who are certainly under-appreciated or mistreated, both in real life and in media portrayals of them. Where it gets gnarly, apparently, is how to praise nurses in a vacuum, without comparing them to physicians, and without the snarky jabs.
To generalize: Nurses are warm, whereas doctors are cool. Nurses act like real people; doctors often act like aristocrats. Nurses look you in the eye; doctors stare slightly above and to the right of your shoulder. (Maybe they’re taught to do that in medical school?)
-Consciously keep “patient as a person” in mind while we conduct our interviews. While starting, we even had a separate category entitled this, which would often include vocation, home life, and hobbies.
-Ask for a patient’s explanation of his/her illness. “Why do you believe that?” is usually a good question and leads to better care.
-It’s not an interrogation. Seat ourselves during the interview at a slight angle to 180 degrees, so that we are not directly facing the patient.
-Body language, body language, body language. It’s like a first date. Encourage conversation; it’s information you need. Make direct eye contact, nod, say “mmhmm” or “go on.”
-Attend an AA meeting. Watch alcoholics who have been sober for decades counsel alcoholics who have decided yesterday to quit. “Today is a new day.”
-Listen to victims share their domestic abuse stories. Ask questions. Listen some more. It happens at the most unexpected times to the most unexpected people.
-Learn how to take an appropriate and sensitive sexual history. Don’t assume anything–married or not, “straight” or not, “educated” or not.
-Make a home visit to a patient. We see “disease”; he experiences “illness.” What is it like?
If something is going wrong with the author’s doctors, unfortunately it is in spite of what our dedicated and caring preceptors teach us in medical school.
Thank goodness the Health Policy course at Harvard is not optional. Health care coverage is relevant, nonintuitive, and downright confusing. Economics, policy, and politics are certainly not topics I have learned much about from a source other than the media. Every day, for four weeks, we learn about geographical variations in health spending, insurance, Medicare and Medicaid, cost growth, managed care, medical malpractice, health care quality, and health care reform. This is week one.
I am curious about our class’s sentiments about how health care should be funded. I am also interested whether that sentiment will change after we are (presumably) better educated by the end of this month. (I plan to send out an identical survey at the end of the course.)
The survey simplifies almost to the point of ridiculousness. Should funding for health care head in a private or public direction? Of course, there are many, many different and complicated models of coverage: for example, “universal coverage” does not necessarily entail a single payer or even completely public funding. I intentionally left out the concept of mixed (public and private) funding, since that is what exists today and I suspect most of my classmates would fall into that camp. I am more interested in the direction that they think health care coverage should go–should we encourage private or public entities to fund it? Which way do we lean, on a very superficial level? Does it correlate with self-reported knowledge of policy? Will it change after this course?
Caveat: “Self-reported knowledge” is an incredibly subjective measure. It could also reflect ego more than knowledge.
The average knowledge score for those who leaned toward private funding was 2.9, and for those who leaned toward public 2.3.
No one who self-rated a 1 on knowledge leaned private.
40% of those who self-rated a 4 on knowledge leaned private.
Now that we are in medical school, stereotyping specialties seems unsavory. So long to brain surgeons as an off-the-cuff representation of intelligence.
From our Population Health lecturer today (emphasis added by me):
“What do we do to reduce the harms of tobacco? It doesn’t take a….[pause] rocket scientist…. People shouldn’t start smoking, and if they do smoke, you should help them quit.”
How much did I know about the fate of a donated body before I stepped into the anatomy lab in scrubs with scalpel in hand? On one hand, thinking of young aspiring physicians, I could have romanticized the role of a donor. The invaluable experience of learning from flesh rather than books. The indelible impact of feeling for organs, finding them, taking them out of their cavities, scrutinizing them, remembering them, and using the knowledge gained to cure others.
However, the past six weeks have been graphic. Sterile donor consent forms are not sensual experiences. They do not show the prodding of genitals and orifices with probes. They do not replicate the sound of sawing the skull in two. They do not convey the smell of rummaging through the bowels, or the feel of dry, leathery flesh. Now that we are “informed”–in every sense of the word–would we want the same fate for our own bodies?
Or–now, do we even more acutely realize and appreciate the significance of such a gift? Would this inspire us to want to give back to future generations of those like us?
Curiosity led me to send out a one-minute, five-question survey to my 200 classmates. I received 75 responses. The raw results are below.
Rather predictably, more students–nearly 50% more–began to think about their own body donation after taking anatomy. No one who had answered “yes” for the former question answered “no” for the latter.
I am currently involved in the Chief Complaints section, a mock advice column. My first contribution:
Dear Third Space,
I dislike my anatomy lab partner, but I dislike confrontation even more. Do you have any suggestions about how I can passive-aggressively voice my displeasure?
In this post, I am not going to be a hypocrite. We have not called our “donor” “our donor” in a very long time. In fact, I don’t think we ever did. He is “our body” and “our guy.” It doesn’t feel right in writing. It is jarring, but it is honest. So I will call him that now.
One night, alone in the anatomy lab, I was reviewing our body’s abdominal and pelvic organs. I knew that the next time I saw him, I would be dissecting his face and neck. There would be little time for reflection. I lifted the sheet that had covered his face for the last month.
Our guy was entirely dissected, in some places far less than perfectly. During lab, I no longer mused about the now bloated, skinless hand while I was wrist-deep in intestines and embalming fluid. I no longer thought about “the person” or “the patient” while I cursed the smell–an unfamiliar and unpleasant mixture of embalming fluid and bodily contents–that strongly emanated from our body, particularly when we dissected near the rectum. (I had long given up trying to breathe through my nose.) I often wished that our guy weren’t so darn moist, and yellow, and fatty–that, like our classmates, we could easily distinguish among arteries, veins, nerves, and ducts.
It is amazing what a difference a face makes. I looked at his face, completely intact, feeling a combination of awe and shame. His eyes weren’t completely closed. His nostrils flared a bit. He had strong, gray stubble. Who was this person? What would he think if he knew what we were doing to him? How much worse was it than what he’d imagined?
I thought about this man with the metal knee replacements, the hardened coronary and femoral arteries, the strong tan arms, the large amounts of visceral fat. Sometimes during lab, we would hazard guesses about who our guy used to be: a fisherman? A construction worker? A park ranger? We were probably horribly, offensively wrong. My three labmates and I knew him in ways that no one else, including he, ever would. Yet at the same time, we knew nothing about him at all.
If this were a movie, we would probably we treated to flashbacks about this man’s life while we puzzled over his innards. Maybe he would be shown at the dinner table, eating a hearty meat-and-potatoes meal while his arteries slowly calcified. Maybe we could see how he developed such strong muscles, surprisingly well-formed even years after death. Perhaps we would see him contemplating what he wanted to do with his body after death, having deep discussions with his wife and children. Was he ever in a hospice, on a “death bed”–or did he die suddenly, perhaps of a heart attack?
Who was this man? Would he have laughed along with us as we surreptitiously tried to get our instructor’s attention with some well-placed coughs? Would he too have flinched at the smell? Been frustrated by the layers and layers of fat? Felt disappointment when we accidentally cut a major nerve instead of preserving it? Felt that same awe when we held his heart and lungs in our hands? When he donated his body to science, how much did he know what the aftermath would look like? That he would be groped deeply in cavities he probably never knew he had. That he would get a circumcision. That he would be seen every day by at least forty students–but not really seen so much as “looked past,” as though he were part of the decor. This sounds more like a horror story than a gift.
The moment I stared into his face was oddly sad. In some way, I felt as though he were witness to our work all along, a fifth member of our group. I wished I could have a conversation with him. I wished I could tell him what he looked like inside. I wished I could tell him that we are just kids, to ignore our pouts and moans when we can’t find what we’re looking for and when we’re tired of digging. I wished I could tell him that holding his heart was the most humbling experience of my life. Throughout lab, I sometimes imagined I could find a clue as to who he was by searching through his body, that physical signs could somehow magically impart answers. Of course, this was fruitless.
If this were a movie, perhaps we would be rewarded with a final scene, a culmination of our efforts and his. A meeting, of sorts. A brief but meaningful conversation that would change how we viewed each other. A videotape delivered by his family. A hand-written letter. A spiritual epiphany. But there are no such endings here. Our reward is learning anatomy. This is the psoas muscle. Sometimes I wish it were all bit more Hollywood.
There was a certain ignorance I had about the body before dissecting it from shoulder to foot (head and neck are up next and last). Some of what I’ve learned was surprising, disconcerting, and fascinating:
1. The female urethra is very, very short. I was aware that it was only a few centimeters in length, but seeing the bladder so close to the outside world (and the anal opening) made me wonder why every woman doesn’t always have a UTI.
2. The body is almost entirely shades of brown, yellow, gray, and red. The gallbladder and its contents are the only exception: a stunning bright olive-green (in live people, it is robin’s egg blue).
3. We have an internal apron: a layer of visceral fat, several inches thick, that hangs from our stomach. It helps protect our stomach, accessory digestive organs, and small and large intestines. This is different from subcutaneous fat, which is what we usually think of when we put on weight. The female “apron” is thicker than the male (she has more internal organs to protect)–which unfortunately leaves the door wide open for sexist jokes.
4. Even if you do not smoke, your lungs will probably end up black and speckled from what you’ve breathed in over a lifetime.
5. The appendix elicited a large amount of anger from my labmate. It looked puny, flat, and unnecessary. Since it is at the beginning of the large intestine, it easily gets infected. Appendix pain has been said to be the most agonizing pain there is.
6. Our bodies can differ substantially, with apparently no impact. There are certain things we’ll never know about ourselves unless a careful anatomist dissected us. Some arteries, veins, and nerves run in different directions, taking tortuous routes–and some simply do not exist. Sometimes the right kidney is higher; sometimes the left is. A thigh can have a large benign mass, made entirely of fat. Cysts are very common, sprinkled throughout the body.
7. Your body gets hard when it ages. Calcifications develop in the cavity holding your lungs, coronary arteries harden, cartilage disappears and leaves rough bone in its wake.
8. In one day, our kidney filter 150-180 liters of blood. We can survive with reduced kidney function or just one kidney. One kidney is only about the size of a computer mouse.
There have been many, many books, articles, essays, and poems written about the cadaver. There have been a similarly large number of writings about why death fascinates us. I will try my best to avoid the obvious and cliched in this post.
Today marked the third day of dissection. Every day, for the greater part of a month, we enter the gross anatomy lab at 8 am and spend the next two and a half hours palpating bodies, cutting through skin and subcutaneous fat, slicing fascia, probing superficial and deep muscle layers, and searching for nerves and blood vessels. We started with the back, a relatively impersonal region with well-defined, thick muscles. We then stayed with the donor prone, moving to the posterior upper and lower limbs during subsequent labs.
As expected, unexpected things have surprised me about anatomy lab.
Before our first day, our anatomy professor spoke briefly about the special (and privileged) experience we were about to undergo. It sounded almost sacrosanct: “You will remember where you were standing. You will remember where your lab partners were standing. You will remember the first cut.”
Though I write with less than week between that first cut and me, what I can say is that that cut was not our first interaction with the cadavers–and it was also not the most memorable one. After we unzipped our body bag, we saw that our cadaver wasn’t lying on its stomach, prepared for our incisions on its back. We would have to flip it. For several minutes, my labmates and I struggled to lift the heavy man–literally dead weight, and filled with gallons of embalming fluid–and carefully turn him onto his stomach. I grabbed a left arm, a left leg, to steady the body, and I felt slightly sick. Physically manipulating a dead body, feelings its contours, struggling with a rigid unmoving object, turned out to be much more crass and jarring than making restrained surgical incisions through his skin.
What I found throughout lab was that the worst, most disturbing moments were the most familiar ones–the ones when the body resembled a living human’s. To position the arm for cutting, I had to twist it carefully. The elbow joint still worked, and the flexion resembled a living person’s–not the stiff unbendable limb I had imagined. Brushing against the man’s fingernails–grime still underneath them–was unpleasant in its familiarity. Seeing toughened skin and hair on the man’s arms and legs gave me the same feeling.
It was the new, the unrecognizable, that unsettled me least. Never having seen anything beyond animal muscle, seeing human muscle and its surrounding fascia fascinated me. Pulling on a certain muscle to move the cadaver’s thumb felt like a surreal version of a marionette–but still too unnatural to elicit a strong reaction. Cutting away human fat, an inherently unpleasant task due to its color and texture, only vaguely differed from cutting away animal fat during dinner. Rolling up the skin and subcutaneous fat like a carpet after we had removed it was still too far removed from reality to make me shudder.
Before I entered the laboratory, I was fairly certain that the experience would feel laden with emotion and that I would not be comfortable if my labmates treated the situation with anything other than intense seriousness Again, surprisingly, this attitude changed fairly quickly. I realized that “respect” didn’t stem from how we felt or what we said–it came from our deeper attitude towards the task at hand.
What would I want if I donated my own body to science? What would upset me? What would satisfy me? I can’t presume to know the donors’ motives, but I can say that my own would be to teach someone something unique. I wouldn’t particularly care whether students put on a–perhaps artificial–air of solemnity during dissection. I would rather they treat my body as a specimen, something they could learn a whole lot from. The worst form of disrespect, in my view then, would be wastage–students rushing through procedures, not being prepared to identify structures, and worst of all, not caring about what was in front of them.
Today, when we palpated the gluteal muscles, feces emerged from the cadaver’s anus. This happens sometimes, and it’s not particularly common or uncommon. Should I feel embarrassed that I was thoroughly disgusted? I certainly would feel about the same way about a living person, and I’m not ashamed to admit it. It is really any more respectful, then, to hide a feeling of disgust when the subject happens to be dead? (This falls into category 1 of aforementioned unpleasantness.)
Similarly, I was fairly horrified the first time I held the cadaver’s cold hand for an extended period of time. Probing my feeling, I found that it wasn’t the hand itself that repulsed me; it was that it very explicitly symbolized death. It was inhuman. This, also, I don’t feel is particularly disrespectful–to have a visceral reaction against death. (Category 2 of unpleasantness.)
What about making small jokes, at no one’s expense (including, and especially, the cadaver’s)? I surprised myself by laughing during lab. When we dissected down to the trapezius muscles, I mentioned that it was cool to see the muscles that felt so good when they were massaged. My labmate gently squeezed them and said, “Yeah, it’s like he’s getting a really deep massage.” It felt okay.
So what wouldn’t I want if I donated my body to science? It’s not an easy question to answer. Clearly, we want our sacrifice to be taken seriously–though not to the extent that emotion renders us less effective learners. I realized that I would be bothered if people were disgusted by my remains. Not of my feces, not of my cold hand, but of the natural processes that my body undergoes as a result of being dead–that is, category 3.
It would sadden me, for instance, if someone saw my long toenails, or squished backside, or flaking skin, and as a result, saw me as less than human. I don’t mind if people see my feces as disgusting, or as death itself as disgusting. I suppose I do mind if people see what I’ve contributed as repulsive. It’s a dehumanizing feeling–to repulse someone–and it would put me on a separate plane from my dissectors. We are no longer the same species; I am alien. They cannot see themselves in me. Understandable, of course, but sad nonetheless.
Tomorrow we dissect at 8 am. It may be serious, but hopefully not too serious. It may be enjoyable, but hopefully not distracting from all we need to accomplish. It may even be disgusting–but hopefully for “better” reasons.
This past weekend I attended a course–Practical Aspects of Palliative Care–held by palliative care physicians and specialists from Harvard’s hospitals. It was attended by physicians, nurse practitioners, nurses, managers, social workers, and chaplains from across the country. I was very different. Greener than green, I have not yet taken part in the dying process, much less the process on a regular basis.
Apart from seeing glimpses of cadavers in various anatomy labs while interviewing at medical schools, I have only seen a dead body once in my life. It was in the basement of a hospice I had volunteered at in college, and what struck me was how lonely it looked. Fewer than 24 hours ago, that same figure had been surrounded by doting loved ones whispering tearful expressions of affection. She had been the center of attention, of love, of comfort care. She had appeared almost identical to how she looked now, but everything else had changed. She was alone on a cold metal gurney. When the volunteer coordinator turned off the light and closed the door to the basement, I had an instinctual reaction–wait, are we just going to leave her there?
Later, outside the confines of the hospice, I probed my discomfort over leaving, and I realized how difficult it was for me to separate a body from the person who had occupied it. For better or for worse–despite rational mind-body dualism–we are our bodies. When our bodies fail, who we are is profoundly affected. When we’re in pain, our relationships with others change. When we don’t have energy to speak or to move, some priorities shift to the forefront while others fade into the background. Health is a foundational good that we can take for granted until its status changes.
During the conference, there was a workshop on how to avoid burnout and fatigue. Participants listed the “perfect storm” of events that could cause them to hit an emotional wall. For some, patient-related issues contributed: seeing particularly young people die, or seeing people who bore striking resemblances to themselves. Professional dissatisfaction was a cause too: feeling a lack of control over the system or over resources within the system, or not being able to help as much as one would like. Personal life certainly played a role, as well as general challenges unique to working in palliative care. Who do you turn to when you need to share something particularly challenging or frustrating? Do those outside the field understand–and even if they do, how often can they hear about it?
I waited to hear answers along a particular line of thought. Loss of faith. Spiritual questioning. Seeing so much suffering as to feel as though life itself were unfair and meaningless at times. Existential anguish. These were noticeably absent; answers were fairly grounded. I’m not sure what that means.
I wonder if it takes a particular type of person to go into this field. Does the special emotional resilience–the ability to transition from distancing to empathizing–stem from deeper beliefs about life? Do you have to have some sort of spirituality or religion to give events a greater meaning, so as not to become disillusioned by the physical fragility of the human condition? I would very much like to know if palliative care professionals are more spiritual/religious than other health care professionals, and if so, if it’s correlative or causative. At a certain point during the course, I began to see all of us as the walking future dead. How could these professionals see such tragedy and still function despite these continual reminders of their own fate? I think this is something I am wholly unprepared for and will have to learn gradually.
Death isn’t carved out neatly into palliative professionals’ hands simply because they have more experience with it. Most doctors will have to face it. I will be facing it during my third year of medical school. I will be facing it in two days, in seeing my first “patient,” a cadaver.
It seems like a great juxtaposition to go from a palliative care conference–focusing on transitioning from the living to the dying–to the anatomy lab–focusing on learning from the dead. It seems like an odd backwards cycle, but I’m glad for it, emotionally. There will be no suffering, no unmitigating symptoms, no difficult decisions. Our learning takes place after all this, from the great gift left behind.