Patient Persons

During one rotation that involved an outpatient clinic, I had one resident who would yell at you for looking at the chart prior to meeting the patient. "You now know too much," he would say. "Just go in and meet the guy."

In my memories, I imagine him slamming my chart closed, and shoving me towards the patient door. This probably didn't happen. What did happen, however, was I tried his advice thoroughly, even after we ended up on different services.

I eventually decided that this advice just didn't work for me. Naive medical histories took longer, sure, but also required meticulous sustained collection of detail in the more complicated patients. I didn't see any gain in the fidelity of information, and actually saw a loss when I had to cover more ground in the same amount of time. Above all, patients could find this practice obnoxious, especially when they have been asked the same questions over and over again. Reading the chart first, I realized, provided a framework for building my patient history, and I could confirm or repeat information as needed.

Recently, I find myself walking into patients' rooms, not as a medical student, but as a researcher. I walk into a patient's room with little more than their name and age. My white coat is left draped over in a corner of the nurses' station, and I've traded my stethoscope for a folder, a notebook, and tape recorder. I'll knock on a door, as I've done hundreds of times, walk in and introduce myself.

Everything is different.

Without the chart, all I see is a person in the room. Diagnoses, lab reports, x-rays, vital signs, numbers and figures used to float through my memory during an initial encounter. Now, my focus is on the balloons in the corner, a meal tray pushed aside, a laptop with a Facebook page, the books in the corner. We sit and we talk, as if new friends or old colleagues.

Others have previously written about the dawn of the iPatient (see Verghese 2008), but I never personally felt the extent to which medicine can dehumanize. I felt like I've always done a good job of keeping the person and the patient in mind, but doing research on the wards has forced a sharp lens onto the process. I meet a person, have them sign a few consent forms, and we chat for a bit. Eventually, I read through their chart, and slowly, they become patients again.

As a third-year medical student, the process was reversed. One of my advisors once suggested that it was important to take the time to check back in with your patients at the end of the day. To just swing by and say hello, he said. You get a very different sense of what goes on in the hospital.

It was during these off-service hours that the patients became persons again. There was something nice about seeing the early evenings in the hospital, when things tended to be a lot calmer. I got to hear about how people's days went, what they were eating for dinner, and how they were anticipating the night. Throughout the rest of my clinical rotations, I ended up trying to do this for as many patients as I could sanely handle-- I would pay for it with a few extra minutes, sometimes at the risk of being "caught" and being dragged into something else. Or, honestly, I would often just go home to get some rest. But on days when I did follow through, those late-day conversations totally made the extra minutes in the hospital worth it.

There was also something oddly powerful about saying "I'm just here to say hello." No physical exam, no procedures, just hearing about how things were going. I sat with one particular elderly patient for a long while once, and listened to her share details about her life as we watched the sun set through her window. "You have a beautiful view,"  I said.

"That's right," she said. "I do." Her pain was well-controlled, and she was looking forward to going home tomorrow. And so we sat, watching the shadows turn long as the hospital wound itself down towards the evening. Slowly and suddenly, we became human again. 

Welcome Transitions

The transition of my old blog is complete! I do love that new blog spell.

It's funny how inspirations can randomly strike, but thanks to encouragement from a certain Grady Doctor, recent experiences with an Atlanta storytelling group, and a series of awesome conversations with freelance writers-- I've finally stopped procrastinating my plans to rejuvenate this blog.

The new title also reflects my new hopes for this blog, which will continue to cross medicine and anthropology, but will be a bit more variable. I love education, grad student life, technology, research, and above all else, this blog will hopefully be a space for exploration. And, I'd love to have you along for the ride!

Here's to a new year of adventures.  

February 16, 2010

During this time of third-year, much of our class is embroiled the tough decision of what to do with our lives, for the rest of our lives. It's a question I've been wrestling with myself, and although my decision is postponed for a few years, I still wonder what I want to do with myself when I grow up.

I was running by some of ideas with Dr. Allan, one of my mentors, and I started to talk about some of my concerns. "I really liked surgery," I said, "but the lifestyle seems so terrible." I told him about the long hours we had, even as students, and our attendings and residents who were overworked, tired, and who seemed to constantly lived in the hospital.

Dr. Allan surprised me by suggesting that deciding a career based on lifestyle was a bit of a fallacy. "A lot of the people you see working those long shifts," he said, "have other things going on. If you want to make balancing work with other aspects of your life a priority, you'll make it work. If you want to live on the beach all day and still make tons of money, that probably won't work out-- but I think people have more control over their lives than they realize."

In many ways, this was a shocking message, and despite how awesome of an advisor Dr. Allan is, I couldn't help but approach it with some skepticism. Really?

After all, a great portion of medical school is dedicated to the idea that we have no power, and more so, work is absolutely paramount. Often, we don't know where we're going the next day, or how long we'll be there. Although we're still students, we work long hours and weekends, at least compared to many of our peers on Wall Street or in other industries, but they normally don't have to go home after a long shift to study. On some rotations, skipping meals and subsisting on granola bars is the norm. We even hand off our life decisions to the machine, the Match where a computer determines our residency placements and the next decade of our lives.

Even our student evaluations forms have a section where we are rated, on a scale of one to five, on whether or not a student "consistently places patient needs before personal needs." Our evaluation forms place a clear message that we should no longer expect our personal needs to be paramount-- doing so would detract points from your grade.


Now that I'm no longer on the wards, I find myself a few pounds lighter, out of shape, less in touch with my friends and family, and perhaps unsurprisingly, with a ton of personal issues that I've piled up over the year. And, unfortunately, I find that I can't only blame the system. The reality is that to some degree, Dr. Allan was absolutely right-- for myself, I realized that it was often easier to take care and think of others than myself.

After all, what do my petty problems compare to my patient lying on the floor, with a mystery illness that we had no idea how to treat? Or the kid in the ER who we're admitting for suspected child abuse? Or my buddy Mr. Galloway, who is likely to be dead in a few months thanks to a challenging liver cancer? Or even the simplest of cases in the hospital-- ear infections, pneumonias, broken ankles, at least these are issues that have clear, easy prescriptions. These are problems and issues that are either prioritized or concrete and easily fixable. Either way, they are problems that are worth more of my attention than my own.

These days, I find myself flooded with loose ends, personal things to ponder and think about, and relationships to restore and develop. I used to blame the hamburger machine of med school, but at the same time, I can't help but realize that I, too, share much of that blame. Sometimes, being selfish is the most difficult task of all.

February 13, 2010

I'm having some incredible trouble focusing-- I was supposed to study, but instead I find my mind wandering, replaying memories and thoughts from the past year. I tell myself it's because of Lunar New Year Eve, and in many ways I feel grateful to be born into a tradition that celebrates two new fresh starts a year, forcing you to reflect on how time has progressed.

On the other hand, it might also be my lack of clinical duties at the moment. As a medical student, so many things happen to us so quickly, and we're so busy that we don't have much time to really process or digest our experiences. Everything is a blur, up until the moment you finally stop to breathe.

***

"We're taking a field trip," my upper level resident said, rather abruptly. I looked at the other students a tad nervously, and we've definitely never taken a field trip in the hospital before. "In fact, it's a taste test."

We followed her into the elevators, and up to the pharmacist's office. On his desk were a pile of small syringes, each filled with brightly colored fluids of different shades. There were a few cups of water, and, improbably, a bright red M&M dispenser. He didn't have much in terms of introduction. "Ampicillin," he said, handing each student a syringe.

I squeezed a small amount of fluid onto my tongue, and watched the other students gag and reach for water. Apparently, I didn't have the taste receptors for it, but I remember a sickly sweet, almost alcoholic sensation on my tongue.

We repeated this process for several antibiotics, a corticosteroid, and who knows what else. It was a bizarre scene-- all of us in our white coats, taking shots of medications interspersed with palate-cooling drinks of water. "The cefalexin is delicious," someone said. I remember a sweet brightness, with notes of citrus and berry. And then there was the Cipro, which has a taste difficult to describe without profanity. Everyone was gagging, one classmate reached for the trash bin, and the water didn't seem to help. I found myself wishing, oddly, that we had shut the door. Instead, I reached quickly, desperately, for an M&M.

Two weeks later, the same resident brought us down to the microbiology lab. There, we received a tour and waved hello to the staff. We learned about what happens after a lab is drawn, and the people who dedicated their careers to hunting and growing microbes. One tech passed around a series of a petri dishes, where we wafted odors of bacteria up to our noses. Each microorganism had a different smell-- odors of rot and decay, dust and mice, and the surprising sweet grapes of pseudomonas.

Later, I peered down at a series of cells through a microscopic in a darkened room, a series of cells glowing bright red and yellow and green against the darkness. The thought that I was seeing light reflected off antibodies attached to viruses was thrilling. Before, a virus seemed almost like a fantasy, a child's story of invisible animals comprised of nothing but a membrane around some nucleic acids (they sometimes wear coats). By seeing the light, even the most fantastical organisms became real.

These field trips, held in the final weeks of my third year, had the weird effect of making everything I was doing with my patients seem as real as the glowing viruses.

I found this unexpected. For all its powers in the applications of science, medicine has this odd way of making you forget the reality of the situation. I found it a weird paradox that even in clinical medicine, when the patient is literally right in front of you, it's still so easy to distance yourself. In many ways, having just a little bit of decreased empathy is adaptive. It makes it that much easier to draw their blood, cut open their skin with a scalpel, and it's an easy way to let you sleep soundly at night, knowing that the patient you just admitted is likely to be gone in the morning. You distance yourself because it's the easy thing to do, and when you see a series of drama after drama, sometimes the troubles of others becomes mundane.

In the preclinical years of medical school, the opposite occurs. Although we do a good job of making sure we had the occasional patient contact, at the end of the day the majority of your time is dedicated to books. The diseases seemed almost theoretical, esoteric even, as the effects of the diseases in the real world are often muted out by the science. I remember there was a dramatic shift in the class when one of the patients who came to speak with us about cystic fibrosis suddenly died a few weeks later. She was young, energetic, a hero. I found myself oddly upset, perplexed as I didn't really know her at all. Instead, after coming home to my apartment, I stared at my pile of books, wanting to cry for a girl I barely knew.

Now, I'm forced again to study nothing but my books, reading about diseases I've seen. I flip through the books to realize that for many pages, I see faces of the patients I've met, the stories I've collected, the connections I've made to the lives behind mere names of diseases. I wonder where they are now, and whether are not if we really made a difference in the end.

Yet for many sections, there are words on the page but my memory is blank. These are diseases I have yet to see, and they remain so on the page, only barely real. I spend my days treating artificial patients projected onto a computer screen, patients whose problems are solved by multiple choice. It becomes easy, again, to forget that what I'm learning affects actual lives. In many ways, I already crave being back on the wards. I wish I had the sweet taste of cefalexin in my mouth, reminding me that it's the mastery of both theory and practice that ultimately makes the magic of medicine.

February 11, 2010

There have been so few postings on here because, apparently, people have begun to find out about this blog. Suddenly, the simplest post becomes even more nerve-wracking. It's even harder when you realize that the people you write about may actually be reading this thing.

It's a question of confidence, really.

In thinking about my extraordinary inabilities to actually post on this blog, I realized that much of medical school has been about the development of confidence. And not necessarily by increasing competency, but rather, we're taught at the minimum to portray a phenotype of outward confidence.

This lesson is often taught in  one of the rituals of teaching in medical school known as "pimping"-- when the resident or attending physician asks a series of questions where the student must answer on the spot. Much has been written about its efficacy (and pitfalls), but in the proper hands of an experienced physician-teacher, pimping works very well in engaging the student and transferring knowledge.

The secret un-spoken lesson that is taught, however, is that sometimes you need to exude confidence even in the face of complete uncertainty. One of my attendings was very explicit about this fact, embodied in his sometimes-not-so-gentle ribbing of students who would answer his questions awkwardly or in the tone of a question. In the OR, he might ask, "What innervates the section of the foot I'm cutting?"

"The superficial peroneal nerve?" you might answer.

"I don't know, you tell me!" he might reply. Or, he might ask why you're asking him. Or, he might just blatantly accuse you of answering his question with another question. You quickly learned to give the answer in a direct tone, even if you didn't have the least bit of a clue as to what he was talking about.

One day on rounds, we had started to joke about these almost-cheesy responses to our answers, he suddenly explained himself. "When you walk into a patient's room to tell them they have cancer," he said, "you can't be wishy-washy about it. Even if you have no idea what's happening, you need to be confident in your plan."

At that moment, I couldn't help but think about how I would personally respond if my physician gave me bad news, filled with "ums" and hints of uncertainty.

Our attending's point wasn't that we should deceive our patients, nor misrepresent how much we knew. In fact, he encouraged us to be honest with our patients about our knowledge or uncertainty, but to be certain and confident in our mannerisms and the next steps we would take.

A similar lesson is found in our interactions with standardized patients, who are all real actors with fake illnesses in fake clinic rooms with hidden cameras. Every effort is made to ensure realism, but sometimes it's hard to forget you're being videotaped and that nothing is real. And in these simulation sessions, I found it horribly ironic that outside of our medical knowledge, what we're really being assessed for is our acting abilities-- and sometimes explicitly so. "I didn't feel you had any empathy for me," I once heard a standardized patient tell one of my classmates. "You either need to get some empathy or learn how to fake it."

The hidden lesson is many of these simulations is that we need to present ourselves in a certain manner-- one that is empathic, confident, and caring, despite what we're actually feeling inside. Of course, ideally we should be expressing these factors genuinely, but at an absolute minimum, we need to know how to fake them if the need arises.

In the past year, I've learned to be more confident despite my own ignorance--  becoming more confident of my own ignorance. I do genuinely care about my patients, but I'm also very aware of my own gaps of knowledge as a medical student. I stride into a patient's room confidently. "My name is Howard, and I'm a student doctor," I'd say. "I'm the lowest person on the ladder here, and I have the least amount of experience. But, I usually have the most amount of time. Feel free to ask me any questions you have, and if I don't know the answer, I'll find it out for you. It's my job to make sure that you know what's going on."

November 18, 2009

My first month of internal medicine ended abruptly at 11:30 AM today, when our attending physician suddenly decided to send us home. "You guys have class until the afternoon anyway," she said, "and there's really no point." We were already running late, so we packed up our stuff, thanked our team and everyone we ran into, and ran off.

It felt so anticlimatic.

The hospital had become our second home. For the last few weeks, we worked twelve or thirteen hour days, and ate and breathed and lived on the floors. We learned to stride the corridors with confidence, and we knew which floors had the best copiers. I sent my teammate at least one desperate page, HELP I AM STUCK IN THE STAIRWELL PLEASE LET ME OUT K THANKS. I wanted to say goodbye to my favorite consulting physicians, nurses, and techs, and to say thanks for the teaching-- and for putting up with our incompetence.



We had finally settled in, and now we'll be thrown into a completely new setting to start all over again. And if this isn't jarring enough for us as med students, I can't even imagine what our patients are feeling. Suddenly we are here, and suddenly we are gone.

In many ways, it's not fair that everyone is subjected to the constant shifts in the system, but the patient by far suffers the most. We switched attendings twice during our month, resulting in many confused looks the next day. The patients would ask where Dr. So-and-So is, and why suddenly he or she has been replaced by someone else. If the attending didn't get a chance to say goodbye, I found myself in the awkward position of explaining the system and assuring the patient of the new physician's competence, but in many ways, the feeling of abandonment is hard to shake for everyone involved.



There is already a bewildering number of people involved in the care of a patient. The patients sit in the center of a complicated network of personnel. There are the nurses, who change shifts every twelve hours, and not always the same nurse comes every day. There are an equally bewildering number of techs, who support the patients and nursing staff. There are phlebotomists, which some of my patients have not-so-fondly called "vampires, and other technicians for EKGs or special tests. We have the patient transport team, who ferries the patient around in a variety of neat-looking wheelchairs. Social services and case managers address a variety of issues, as do chaplains. There's also a group of support staff who we don't normally think of coming into contact with the patient, but they do anyway-- for example, the janitorial service, who maintain their own rounds through the hospital.

And then there are the medical teams. We were the internal medicine service, and we liked to think of ourselves as the heart of the hospital, but in reality we were constantly paging colleagues and friends to consult on patients. There's cardiology and infectious disease and nutrition and physical therapy and occupational therapy and a gazillion other "specialty" services. Each team, in turn, will often have an attending and residents.

All of this is further confused by throwing us students, medical and nursing and pharmaceutical, into the mix, and it's very quickly easy to imagine how a patient with a complicated set of problems could run into many, many people throughout any given day. Suddenly, "Have you seen your cardiologist yet" is not always a simple question to answer.

I'd like to think that as medical students, we play a part in navigating this maze of personnel. We sit down with the patient, explain the teams and the tests, and just what everybody means. Often, I find myself explaining roles, and reminding patients who exactly is that handsome tall doctor who is always walking around with me (answer: my intern, and yes, it's confusing because I actually work for my intern, not the other way around). Our strongest role is probably as navigators, and for patients who face heaven, hell, and in between, it is always hard to say goodbye.

September 19, 2009

"You want to write when you get sad." I was chatting with Ant, one of my classmates and, I guess, fellow bloggers. Perhaps that wasn't exactly what she said, but after talking about our writing styles and habits, it was the main message. Writing helps us release stress, thoughts, anxieties.

The inherent challenge, then, was to write about something happy. And, cheesy as it sounds, I found myself wondering about the happiest moments of my clinical training so far. My memories brought back patients I liked and loved, moments where I found pride, funny moments with jokes and shared laughter.

There was one unusual moment that I remember clearly. We were in the operating room, with Dr. Packard, one of my favorite attending physicians. I wasn't even scrubbed in, but I was standing on the side watching the case. The patient had a large melanoma, a type of skin cancer, on his left foot, and required an excision. I found melanoma to be a fascinating disease, perhaps precisely because you could run your finger over the black, irregularly bordered spot. Ugly, your mind thinks. Cancer.

The procedure involved removing the skin containing the cancer, as well as a reasonable border around it to ensure that all of the cancerous cells are removed. The result was a large circular hole, red and gaping even after the bleeding was contained. Then, I watched my attending use a small dermatome-- which reminded me of the ham slicers you'll see at the deli-- and removed a thin strip of skin from his upper leg. He brought this thin strip down to the foot.

Dr. Packard arranged the skin graft, like so, and marked out the sections that will connect with the rest of the foot. Slowly, the strip was stretched and sewn perfectly, covering the previous hole with a new layer of skin. The stitches was perfect, and the graft was round and symmetrical. What was originally an ugly cancer had been turned into an even uglier site of trauma, but was now newly covered. It's difficult to describe, but it was as though looking at a painting, deep and detailed and masterful.

I had never seen anything so beautiful.

Then, the attending cut four small slits in the center of the graft. "It's to relieve pressure if fluids pool underneath," he said. "Like a pie."

The attending then said exactly what was on my mind. "You know, the only thing cooler than the actual procedure is the fact that someone actually figured all of this out."

Perhaps it was the sleep deprivation, or perhaps it was the fact that it was my melanoma case, or maybe it was because I had just managed to answer a bunch of Dr. Packard's tough questions just a few minutes earlier. Maybe it was for stupid reasons, but there were few moments of real elation compared to this one. Although he was not my patient, I had met him clinic when he was dealing with his new diagnosis. At this moment, he began his transition to someone with a former diagnosis in recovery. I found myself reeling with the ramifications of the procedure, but also the simple elegance of the procedure itself. This was medicine, science, technology, art.


A few weeks later, I happened to be working at the clinic when the patient returned for a follow-up visit. I was anxious to see the skin graft, and nervously watched as the nurse removed the dressing. I found myself a bit disappointed; the graft took and now had some color to it, but somehow it wasn't as clean and pure as it looked under the operating room lights. However, there was no doubt that the graft was working and healing well.

After the visit, I saw the nurse struggling with the short sutures left on the compression dressing, and for the first time, I found myself sheepishly offering to give it a try. I immediately regretted it, for I realized that I would be doing a procedure with a patient who was not only awake and watching, but was an elderly retired physician. I later realized that we were both nervous as I picked up the curved forceps, but he visibly relaxed as I worked quickly to secure the dressing.

He eyed my work as I finished. "You tie those knots like you know what you're doing," he said. "Are you training to become a surgeon?"

I smiled. "Honestly? I have no idea."

September 14, 2009

During my surgery clerkship, I found it important to meet the patient before the surgery. Sometimes it'd be someone completely new, which was always a fun and oddly awkward experience-- I'd have to explain who I was, why I was there, and reassure them that, as much as I'd love to, I wouldn't be doing their operation. At other times, it'd be a patient I knew well from the floor, who I just saw a few hours ago. And we would hang out for a bit, saying hello to the nurses and the anesthesiologists and the overwhelming number of faces you meet right before surgery.

And then a variation of this conversation would occur. "I knew for a long time I'd be having this done and I'm ready," they'd say. "But I'm nervous." Some would smile through it; others would admit this sheepishly, as if ashamed. There was often a lot of humor, I would let the patient talk and often they would joke around, but the underlying message was the same.

"Well," I would say. "I really wish there was something I could say to make you feel better." Sometimes we would talk about the procedure, at others about the experience of the medical team. There was always an odd disconnect, for while the patient was going through the procedure for the first time, from the perspective of the medical team, the patient was only one out of hundreds of faces the team saw a year. The medical team was confident; we had the experience, the science, and, quite frankly, our perception of our track record to support us. This perspective was usually something that the patient couldn't see.

I sometimes found myself reminded of being on a plane, sitting next to people with bad flight anxiety. It's my first time flying, I'm terrified of something going wrong, they would say. They would not only share this with me, but also the crew, who were empathic but I could imagine their reaction. We do this every day, they would say.

"We do this every day," I tell the patient. "Don't worry, you have some very friendly faces around you." I would point out my favorite operating room nurses and techs, ask if there was anything I could get them. I would sit off to the side in the PACU, furiously skimming over the patient chart and cramming for the inevitable pimping in the OR until it was time to push back.

There was always an odd sense of paternalism. "Here we go," I would say. "We're headed for operating room 9. We're going to put on some funny masks now. Are you feeling comfortable? Here are some warm blankets. Can you scoot on over on your butt? I'm going to put some funny stockings around your legs." The banter was almost always the same despite the age of the patient, and even for a pediatric patient, the tone was eerily similar. The exception was the one fourteen year-old who requested rap music, and we did our preparations to Jay-Z and 50 cent.

I would like to tell myself that what I did was important, but the reality is that some of the patients either didn't care or were too drugged up for me to make a difference. And, strangely enough, the cases that bugged me the most were the cases where I felt like my presence was important. They were the ones who were the most thankful that bothered me the most.

It took me a few weeks to figure out why. They had nobody else. I soon learned to ask in the PACU how the patient was getting home. Often, someone was waiting in the lobby. At other times, they had no plan. The majority of my patients were admitted for a few days anyway, but some never seemed to have any visitors, and headed home on the Marta alone.

Dr. Stu, one of my favorite residents of all time, made the same observation one afternoon. "These are people who are about to have a major, major operation, and they don't have a single person who will be there for them. You'd think that out of family, friends, there'd be one person who could come." He shook his head. "It makes me so sad."

Sadly, it happened more often than we would have liked. Surgery is a scary, transformative process. You go in and you fall asleep, crazy things happen, and then you wake up permanently changed in some way. And, out of everyone I asked, the experience was different, harder than they expected. No amount of doctoring or talking before the surgery can concretize what the doctor sees and what the patient hears. For the patient, it's their first time, and for anybody, it's an experience outside of the imagination.

I recently found out that a friend was having surgery this week, and although he asked me, I found myself oddly stubborn, insistent that I will be there on Tuesday. I found myself strangely offended when he suggested that he'd be okay otherwise. I don't want you to go through surgery alone, I think. I don't want you to be one of those people, one of those brave few who are reliant on a medical student that they just met, trusting a naive gaze to monitor the fall of the scalpel's edge.

April 12, 2009

I walked into Mr. Jones’ room tired, frustrated, and exhausted. We had been in the hospital for fifteen hours. A surgical case went awry in the OR, forcing the cancellation of our other cases in the afternoon. The attending called for teaching rounds at 5:30 PM on a Friday night, and I managed to get every single question he asked wrong. We hadn’t eaten lunch. Everyone was irritable and sleep-deprived. I looked down at my cell phone to see some invitations to dinner. “FML,” I tapped out to my roommate. Fuck. My. Life.

Mr. Jones was sitting upright, and he leaned back into the bed when he saw me come in. We went through the same routine we’ve had in the last few days; we talk about his afternoon, his pain, any nausea?

In reality, I was just making small talk—I was trying to work myself up to give him the news. We had gotten to know each other so well in the past few days; Mr. Jones was 31, roughly my age, and a talkative character from West Africa. We had clicked immediately when he was admitted. He was diagnosed with intussusception, a rare condition that occurs when the colon telescopes into itself, causing bleeding and pain. In adults, it’s almost always associated with some type of mass, and the fear was cancer. He had four kids. I broke the small talk.

“Well, I’m here because your pathology report came back.” I paused without thinking, not for dramatic effect, but simply because I saw his eyes widen. “It’s not cancer.”

He breathed the same sigh of relief that I had when I viewed the report only ten minutes earlier. I told him what the report meant, and how although we don’t know what caused his condition, he doesn’t require any more treatment. Mr. Jones shook his head. I smiled. This was a happy moment.

Suddenly, he grabbed my hand. “Thank you so much.” And as suddenly, his speech turned into prayer. “Please God, take care of this man, for he has cared for me like a brother, and give him the strength and will to succeed during these difficult times.”

What he said was simple, but I suddenly found myself tearing up as he continued with the prayer. The pathology report was beautiful news at the end of an awful day, but I was extraordinarily tired and I found the sudden encouragement overwhelming. He looked up from the prayer. “It’s okay to cry, “ he said, in a sudden reversal of roles.

I struggle now to explain why this moment was so emotional. There was, of course, the matter of the path report. And, I had been exhausted and humiliated during the rest of the day, and to hear someone articulate support when I felt so beaten down let loose a floodgate of emotions. In many ways it was a recognition of fear, concerns that I was doing badly, and the realization that perhaps I’m not made for this work, that I’m not tough enough to tolerate the sleep deprivation, and that I’m not tough enough for medicine.

This was further confounded by the fact that I didn’t feel like I deserved his thanks in any way. He was so extraordinarily thankful, but in reality, my role as a medical student was very limited in his care. He has his surgeon to thank, as well as the chief resident, who made all of his major medical decisions. The medical student doesn’t even have the authority to write orders. Granted, we act as ambassadors from the surgical team, and we offer a face and conversation to help patients navigate their time in the hospital, but the reality was that if I was deleted from history, Mr. Jones would still have received his surgery and treatment, and his outcome would be no different.

I felt like a fraud, and I found that I could take little pleasure from his thanks. The most upsetting aspect of the day, however, was that the only lesson was that there is no lesson. Did this moment make having only four hours of sleep worthwhile? Why was I struggling so much to understand what was happening to me? How have I found myself suddenly standing at the bedside of a patient, talking softly but launching echoes of life?

December 30, 2008

I realize, with a shock, that it's been more than a year since the last posting on this thing. I'm a bit ashamed to admit that it's so hard to write in medical school, especially when I'm as OCD about my writing as I am. So perhaps it's time to let go.

I went to visit my grandma last week, and for some odd reason she started flipping through my First Aid book. "Wow," she said, "you have to remember all this?" Yup, yup, and then she started flipping through the pictures in the back. Then all the questions began.

And somehow, I suddenly found myself telling stories. Tales of how the body works like a machine, and where that analogy ends. We ended up talking about cholera, about germs that don't normally make us sick, unless they themselves become infected with even smaller germs. She pores over some of the histology slides. "It's so beautiful," she said, running her finger along the edge of the cells. "What is it?"

"That's, uhm, prostate." Awkward.

I think one of the things that medical school does so well is to kill the sense of wonder that we have if we sit back and think about the things that we talk about in medicine. I can't help but to blame some of our professors for this, especially the ones who come in and just try to cram our heads full of tiny, infinitesmal facts. But I know that I'm to blame for this too-- that I've become so distracted with learning the technicalities of medicine that I've rarely stopped to sit back and go whoa.

This frustration is where I'm at now. I'm stuck with the immense chore of stuffing a ton of information into my brain; useful information, for the most part, and then a lot of tedious unnecessary technicalities as well. And I'm so busy trying to jump through this hoop that I don't stop to look up, pause in the air to gasp at the view.

obama

My grandmother, who is 80 something and pushing 90 years old, pauses for a bit between telling me about living with a new, chronic pain in her legs. "If Obama is elected President," she said, "it would be an amazing thing to see in my lifetime. Wouldn't that be something?"

The sense of wonder in her voice reminds me of how much has changed in the last 80 years, if not the last quarter century in which I've been alive.

differential diagnosis

Tonight is the last night before our final anatomy demo, marking our final dissection. It's a bittersweet feeling; on one hand, I'm relieved that we won't have to bear the tediousness of anatomy much longer. On the other, it's been an amazing experience working with the cadaver.

I've had an odd relationship with the cadaver. At first, caution rapidly led to a feeling of warmth for the man. He had given up so much to allow us to learn. He had much to teach us, and rapidly became just another member of the team.

As the dissections progressed, however, he rapidly began to become less and less of a person. We removed his brain, dissected out his eyes, sawed his head in half. I no longer met the cadaver with a feeling of fondness, but rather an odd mixture of sadness and clinical distance.

I talked about anatomy with my uncle at my grandmother's funeral, an uncle I was meeting for the first time as an adult. I told him about the dreams I've had about the cadaver, about the mixture of gratefulness and guilt-- and an odd desire to find out what he was like as a person, his occupation, a name. We talk about these things over water and tea eggs while waiting for my grandmother's cremation, and it's here that I learn that my uncle has the ability to see spirits.

He says that he's had the ability since he was ten, and he can see and hear spirits. The spirits look like shadows, he says. They talk with him, and he talks back-- and he thinks that anybody can have this ability, as long as they tried. I'm amazed by the details he provides throughout the funeral, a play-by-play commentary on my grandmother's progression, and a report on the reincarnation status of my grandfather down to every last detail. My parents seem to believe what he says.

After listening to my dreams about the cadaver, he diagnoses me with spirit attachment. Many people who donate their bodies, he explains, often regret their decision after death. There's two possibilities here-- one, that the cadaver's spirit has attached itself to you and is mad for what you've done. Alternatively, the cadaver's spirit has left and a secondary spirit has found occupancy in the body, and now demands rent for our time. Things may become dangerous if the spirit remains attached, he says. You're in the States, so you need to buy yourself a Bible. And this is exactly what you need to do.

My uncle offered an interesting anthropological conundrum. On one hand, he offered a belief system that's not implausible, and consistent with the rest of reality. His system of beliefs even accounts for the polytheism on the planet, explaining how the Judeo-Christian God could coexist and remain as the one true God alongside Buddha and Guan-Yin. On the other hand, I didn't feel like I could really buy into his system of beliefs without evidence. Yet, as a student of medical anthropology, don't I usually declare competing systems of etiology to be equally valid? And at the very bottom line, if his beliefs are valid, do I really want to risk the consequences of spirit attachment?

I tell my anatomy partner about my uncle and his proposed treatment plan, and he points out that as a medical student, I'd have to conduct such a ritual late at night to avoid (perhaps not undue) mockery. Weeks pass by, and in the meanwhile, I wonder if there are other students with symptoms of spirit attachment. A classmate says that she sees fascia everywhere she looks; when she closes her eyes, up in the clouds. Another talks of dreams late at night of making sausages from human intestine. Yet another says his room his haunted, and how he's been plagued by nightmares for the last week. Regardless of etiology, spirit attachment may be a valid analogue for stresses that we encounter in medical school or in the anatomy lab.


Tonight, my anatomy partner and I completed our final preparations for our last anatomy presentation tomorrow. As we're cleaning up, I'm surprised to hear him speak the words that my uncle had suggested. We're thankful for this experience that you've given us, he says to the dead man. We thank God for all that we've learned. We both grab a zipper, and wave our hands in arcs to close the body bag in the center. We don't have a Bible. A shaft of light falls from our dissection lamp onto the table, and this is the image I hold in my head, as my anatomy partner gently clicks off the light from above.

October 31, 2007

My preceptor turned to the patient and calmly explained that we'll be right back, but then Howard will come in and take a look at you. Outside the room, he asks if he's making me nervous.

I tell him I'm terrified.

Two minutes later, I find myself walking confidently into the patient's room. I remember to knock and wash my hands, make idle chit-chat, about the weather, her kids. The lungs probably makes sense to do first-- deep breaths for me, please say ninety-nine, a as in apple. I look down her throat and into her ears, quick and professional as if it's routine and I'm almost bored. Thanks, ma'am, I'll be right back with the doctor.

It's so easy to hide behind that white coat. With the coat, I wear my confidence as brightly as the patch on my sleeve.

This week, I find out that I've been reassigned to a pediatrics clinic. On my way there, I realize I had all my equipment but I left the critical coat behind. During the commute, I couldn't stop thinking about the coat. I felt, oddly, naked that I should be walking into the clinic without one.

"We never wear the white coat," one of the doctors explained to me. "It freaks out the kids, and then they just start crying. We want the kids to look at us and think of us as their moms. There's coats in the back that we take out to wear when we take pictures."

"So we can actually look professional," the other pediatrician said, laughing.

They say it was a slow day, but I was exhausted after two hours and five or six patients. There was something joyous about the place, and somehow I managed to lose my poise with the newborn. "I've never seen a newborn before," I stammered, "and she's beautiful." There were many excited new parents, where the conversation was suddenly between a doctor and another caregiver, rather than between a doctor and a patient. There were sad cases as well, a baby with a heart defect and a murmur that I couldn't even hear; the infant's heart beat was so fast. There was the kid who was born with crossed arteries, whose first experiences with the world included multiple surgeries. Yet underlying each case was a spirit of joy, an odd celebration of life, and the promise of hope.

We were handed these coats with tremendous ceremony, amidst speeches and photographs. I remember wearing the coat for the first time and looking into a mirror, and trying to find a doctor in my reflection. Surprised, I tugged at the sleeves, but the coat didn't seem to fit.

At the children's clinic, without a coat I look into a mirror, and finally see myself.

waste of time

I've been struck recently by the number of conversations I've had with people who were disappointed by the first two years of medical school. My preceptor told me that she "hated it" and considered dropping out of medical school. A friend, who's in grad school now, told me that he felt that he wasted two years of his life in medical school, and you forget everything later on anyway. It's what you learn in the clinic that really matters.

Just because people may think it was a waste of time doesn't necessarily indicate that it wasn't worthwhile. We may be taught right now how to think, rather than what to think. Perhaps more importantly, the socialization of the whole experience may play an equally important role. We're defining how we interact with patients, with each other, and being introduced into the world of medicine. Gradually. In a rather traumatic fashion.

I wonder who's done work on this stuff already?

checking out

I've been thinking a lot about death recently. Not in an I-want-to-kill-myself sort of way, and not even in a oh-shit-I'm-gonna-die line of thought. Just simply thinking about death and dying; maybe it has something to do with the fact that we had a weeklong course on death and dying, I went to a funeral over the break, and then we came back to school and started cutting up dead people.

On top of all that, today was the fifth time in my life that I looked at someone and realized that I was very likely never going to see them again. Without a see you next week or catch you later, just a flat out goodbye.

I feel like all of us operate under the assumption that we will see you later. Our culture is one that constantly denies death, and it's probably adaptive. We're kept going by not recognizing it fully, and I know I can't operate if I don't assume that I'm going to at least live through the next few weeks.

Thinking about death, however, makes me question these assumptions. I find myself getting pushed closer to the present, and valuing my interactions with others a little bit more. I question whether medical school is worth it. I don't really make plans for anything more than three months ahead.

Yesterday, I got a weird look when I told a close friend I'd be okay with things if I was dead by 35. Don't get me wrong, I wouldn't be happy about it, but at the same time, I figure that I shouldn't save too much for "when I get old." Stuff on the bucket list needs to be done, I need to live life the way I want it now, and honest things need to be said to other people relatively soon-- and not saved for an eulogy.

I don't feel sad, but I feel strangely old.

taipei zoo

Today I brought my eleven year old cousin to the Zoo.

The Taipei Zoo is probably the most underrated attraction in Taiwan. It has a reputation for being lousy and ghetto, and for a while that was likely true. I remember going to the zoo as a kid, especially the Butterfly House. The butterflies were kept in a large greenhouse, and instead of having a double set of doors, they installed a large bead curtain to let humans out and keep the butterflies in. It didn't work. I think the only butterflies I saw were one or two who also managed to escape through the curtain.

Now there's been a ton of renovation and the animal collection has grown. The zoo is still a bit suspect, but it's precisely this aspect that makes it such an amazing place. For example, the engineers seem to really push the safety limits of the fences and moats that keep you away from being eaten. No where else could you look into the eyes of an elephant from such a close proximity.

Today I also watched a tiger's multiple attempts to maim five year old kids through very thick glass, leaving me very thankful for the glass and very bewildered at the "aww wook at the cute tiger" from the adults.

There's also an amazing gift store with some prices that makes you think about getting yourself stuff that you couldn't have as a kid because the Bronx Zoo was just too damn overpriced. That gigantic stuffed penguin is suddenly looks like a fantastic deal.

All this for an entry fee of about $2 US, and $1 if you're a student. A one way trip on the tram within the park costs about $.15, and a giant stuffed animal will set you back around $10 - 25 USD.

The best part, however, is overhearing conversations from the primarily local crowd who go. It's a lot of kids, but occasionally you find adults. They tend to people who dream of things beyond the glitz of Taipei, things besides winning the lottery or a fancy car. These are people willing to stare into the eyes of the orangutan in the corner, waiting patiently to answer some very important questions.