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?