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."