Somerset Maugham

Cell phone camera fun!

Somerset Maughm, describing the experience of seeing clinic in "Of Human Bondage," sums up a great deal of what being a doctor seems to consist. It certainly encapsulates the experience I have had as a clerk over the past six months:

"There was humanity there in the rough, the materials the artist worked on...But on the whole the impression was neither of traegedy nor of comedy. There was no describing it. It was manifold and various; there were tears and laughter, happiness and woe; it was tedious and interesting and indifferent; it was as you saw it: it was tumultuous and passionate; it was grave; it was sad and comic; it was trivial; it was simple and complex; joy was there and despair; the love of mothers for their children, and of men for women; lust trailed itself through the rooms with leaden feet, punishing the guilty and the innocent, helpless wives and wretched children, drink seized men and women and cost its inevitable price; death sighed in these rooms; and the beginning of life, filling some poor girl with terror and shame, was diagnosed there. There was neither good nor bad there. It was life."

I look forward to starting internal medicine in January. Without my knowing it, this is what drew me to medicine. Like Philip, I've considered many things, and tried a few, but more and more I am convinced that no other profession would satisfy my temperment.

Reflection

A vacation and a recent conversation gave me opportunity and motivation to consider again what I learned on psychiatry. I think the big thing was that Axis I disorders are real. I used to be highly skeptical of mental disease, a byproduct of my stern upbringing. (Which was in itself a result of my Germanic heritage, according to the absolute best teacher I have ever had.) But my views have softened somewhat. I've seen and treated PTSD, MDD, and Bipolar I and II. They are real, and the chemical imbalances which cause them are treatable. Axis II disorders besides retardation I am still a bit skeptical of. They may also be real disorders, but the symptoms are often merely those of someone with poor self-discipline.

I'm thrown back, in considering all this, to that core discomfort of mine: the mind. As science attempts more and more to elucidate the nature of consciousness, that "awareness of awareness" that sets us apart from mere animals, the answers are progressively more uncomfortable to someone with religious convictions. If depression is merely a deficiency of serotonin, what is religious ecstasy? If epileptics seem to have religious visions as a part of their seizures, is the depth of our own convictions merely chemical? William James pointed this out an hundred years ago. Was he right?

So is there a "ghost in the machine"? Is there, somewhere, a point at which progress will stop, and we can say there is something more, something beyond what can be demonstrated with neurotransmitters in a lab? That point may be far in the future, as neuroscience is still in its infancy. Still, the scientist and the mystic within me wait with trepidation.

Fourth year decision

One of my professors spoke about my current dilemma. He said that "this isn't the last time in your career in which you will be called upon to make a decision with less than a complete data set." Most reassuring. But true, nonetheless. So the decision for now is to set up my year to go into internal medicine, and thence to cardiology, and if peds blows me away when I rotate through there to adjust as necessary.

A friend of mine, dissappointed in my recent decision not to pursue surgery, said he'd "give me a pass" if I decided on cardiology, since that was as respectable as surgery. Oddly enough, another friend said she "totally sees" me as a pediatrician. Though I was encouraged at first, I realized that I have to quit living for other people's approval in this. I'm choosing internal medicine because of the possibilities for specialization, and the fact that I can go anywhere in the world with it. Probably not as universally usable, especially in the MSF sense, as surgery, but I think I'll be able to find a niche there too. Plus I like it. The challenges are primarily cerebral, and my mind has always been my strong point.

C'est la vie. Laissez le internal medicine roulez.

Fourth year thoughts

The next real order of business is to decide what to do about my fourth year in med school. I've got to decide what residency to try for, and set up, in the next few weeks/couple months what I am going to do for the rest of my life. I have ruled out surgery, and OB/Gyn was never much of a possibility, but other than that, I'm adrift in a sea of possibility. Medicine or Peds are the most likely and appealing choices at present. I know I liked the pediatric parts of all my rotations so far, so I am tempted to lean that way, but part of the reason I didn't like psych was that none of my patients were really capable of conversing with me on a peer level. Peds is a lot like veterinary medicine in that none of your patients can tell you what is wrong. Plus I am not the univerally happy person that is generally found in peds. But the positive is that I can hang out with kids, and I can sub-specialize, which is very appealing. Also peds patients usually get better and go on to lead normal lives. A lot of medicine, I understand, is fixing people who have destroyed their own lives. Exempli gratia, someone who smokes a pack a day for 50 years finally shows up with lung cancer.

No solutions yet, but I'll be scheduling some counseling sessions soon. Wiser minds...

A Change of Scene

Psychiatry is over for now, and probably for good, unless I failed the shelf exam. Next up is a week of "intersession" which, aside from being a great excuse for the faculty to take away a week of our Christmas break, will let us "integrate our experiences" and "pool our knowledge" and host of other meaningless catchphrases. What will really happen is that from 8 to 3 we'll feel imprisoned, pass notes, catch up with friends, gripe about the "intersession", exaggerate the hard parts of our rotations, expound on the funny parts, and generally do what a group of fairly well-acquainted individuals do when thrown back together. Think high school after summer vacation.

Actually most of medical school is like high school. Maybe life in general is, but I'm not there yet. Everybody knows everybody else, everybody dates (and sometimes marries) each other, etc. The big difference is that most of us were the nerdy kids in high school, so while there may seem to be a "cool kid" set here, it is a definition of that word which would appear alien to any given ninth grader.

Med school flips one's entire perception of the world around. Suddenly embarrassing topics are normal, and normal topics are slightly disconcerting. It becomes difficult to remember what is appropriate dinnertime or even social conversation. Probably that's to be expected when we are taught (among other things) to frankly discuss the sex lives of total strangers. It bothered me at first, the loss of innocence. Performing a pelvic exam on a stranger the first time was quite uncomfortable, but I think it is worse when it isn't uncomfortable. What has changed within when I can do these exams as easily as I listen to a heartbeat, and discuss even the more deviant types of sexual activity without blushing? My convictions remain, and a part of me judges an interview as a confession. But thankfully (though strangely) there is nothing arousing about a gynecological exam. The "professionalism" training I laughed through last year actually helps.

Physicians cling to a sense of professionalism, because it is that which keeps them sane. Without the strong sense of purpose, the higher calling behind the actions, all that we do would be crass. Even the denial of self, the "ascetic in a sensual world" attitude which must be maintained would be unjustifiable without purpose. Monks are respected but the bachelor or spinster has bittersweet connotation to their denotation. Physicians must go between the two worlds on a regular basis, and that ability to switch from participant in life to observer of it is professionalism. At least part of it. But that's all I feel like exploring tonight.

Go directly to Jail, Do Not Pass Go

Today we discharged a patient directly to jail, which was quite an upsetting experience for her. The probation officer and (female) bailbondsman came to pick her up, and if anything, those two were sketchier than any of our patients. I think what was most disturbing was a tattoo which was only visible because of her considerable decolletage. Of the fifteen or so people who saw her though, none were later able to identify what the tattoo was a picture of. Scary.

The patient was not excited about her destination and started screaming at the top of her lungs, banging her head on the wall, and was very near to having to be sedated and forcibly restrained when she decided to calm down. I was all set to practice my psychiatric take-down moves for the first time too.

Sadly and realistically, jail will be good for her. It is a forced detox program, and just might improve the patient's attitude. It keeps her from killing anyone, including herself. The unfortunate thing about the situation of many patients like this is that they have no insight, which to a psychiatrist means they don't understand their situation. They externalize all blame for their misfortunes and don't realize they have a problem within. Really frustrating.

Oh yeah, what is she going to jail for?

Violating her probation by disobeying a restraining order. That's minor you say? Well she violated the restraining order by chasing the subject of it down the street with a knife while high on meth.

And the subject is her husband.

It is funny how much effect a simple compliment can have on one's perspective. Today I mentioned in morning report that I thought we should revise the diagnosis for one of our patients, and my attending asked me if I had plans to go into psychiatry since "every time you speak up, you're right on track, and you really know your stuff." I don't know what my plans are. But being appreciated, and realizing you know more than you think you do is powerful motivation. The rest of the day seemed just that much easier under the influence of that short conversation.

Other than that, I finished the paperwork to transfer a patient to another treatment facility that can better handle his condition. I'm learning the subtle, fine, and underappreciated art of pinning down the vulnerable link in a bureacratic chain and forcing it to do my bidding. I feel like my competency in both the mundane and esoteric is improving.

No work today, but catching up on the news, I noticed this article about the emergence of antibiotic resisitance in yet another common, yet dangerous bug. It reminds me that, easy and fun as the life of a psychiatrist may be, it isn't why I came to this field. And though the hours may be longer and the job tougher elsewhere, in the long run, I think it will be more rewarding.

Today I led a group therapy session. It was a positively surreal experience. Picture Brad Pitt in 12 Monkeys, Michael Duncan from the Green Mile, Mrs. Bennett from Pride and Predjudice, the town drunk from any old Western, one relatively normal person (we'll call her Kristin Scott Thomas from the English Patient), two doctors and a medical student (yours truly) all sitting down for an hour-long discussion of our feelings. Well, mostly the patient's feelings. In that millieu, we had Mrs. Bennett accuse Michael of fathering Kristin's baby, Michael go on an anti-Catholic rant, and Brad Pitt started asking if he was in the psych ward because of the people he had killed. As far as I know, Brad hasn't killed anyone, and Kristin is definitely not involved with Michael. It was actually funny at times though. I felt bad for Kristin, because she's actually pretty much recovered from a relatively minor problem, and she definitely feels out of place as a participant and not a facilitator of such a group. It may be wrong, but sometimes the only way to react to the crazy things patients say is to laugh, of course well after you have left them. I also think one of the most reassuring feelings in the world is sitting in a group like that, but shifting in your chair and feeling the friendly poke of the key to the door in your pocket.

I had an experience straight out of The Shining yesterday. I was playing pool with one of the crazier patients, and he would pause every few moments to peer at the arrangement of balls on the table and laugh to himself. I kept asking what he was laughing at, and he would do nothing but look me strangely and say "nothing" in a clipped monotone. I didn't want to take my eyes off him for a moment. We lock up the cues and balls for a reason after all: they can be dangerous. No grand, scary ending to the story though. He actually beat me at our game and then went back to sleep.

One of the other patients, on the other hand, is both dangerous and ingenious. He broke his plastic spoon to make a shiv which he hid from us and has since (post-discovery) denied making. And another guy is trying to break out of the ward at every opportunity and has sworn to hunt down and kill someone he knows outside. He gave us her contact info, so we put it on top of the chart, in case he does escape, and we confirmed it is accurate.

Just another day.

G-d and mind

I think I've pinpointed what is most disturbing about the psych ward. It's in the very nature of the problem. What we see as a human is based upon the mind, and when the mind is disturbed, it is difficult to see the human.

Flowing from that, I wonder what the standing of the schizophrenic patient is before G-d. If someone lacks, or seems to lack, all capacity to reason, what are they? I guess the Western idea "I think, therefore I am" is an unconcious part of my value judgments. I realize, on one level, that G-d loves all His creations, and that the elect, no matter who they are, will be saved, but when there is literally nothing you can do to get through to a person, when there is no hope of external, human forces making any change on a person, it forces you back to utter reliance on the providence of G-d. There is no room for witness, no way preaching or demonstrating is going to change a mind incapable of change.

So what is to be done? I can pray for my patients, but little else. I know too much and too little. I know medically how little can be done, I know that the medicines we give them will give them diabetes or Parkinson's, but I know that without them, these patients will commit suicide, even without meaning to. I know spiritually that I can pray for them, I feel humanly that it is a failure of faith or effort on my part when they don't improve, and I know intellectually that G-d is in control. The conflict between free-will and predestination is quite clear. Can my prayers help more than medicine? Where is the boundary between professional ethics and spiritual responsibility?

I take heart in a poem by John Greenleaf Whittier, one of my favorites. He wrote to a young physician of his acquaintance:

The Healer
To a Young Physician, with Dore's Picture of Christ Healing the Sick

So stood of old the holy Christ
Amidst the suffering throng;
With whom His lightest touch sufficed
To make the weakest strong.

That healing gift He lends to them
Who use it in His name;
The power that filled His garment's hem
Is evermore the same.

For lo! in human hearts unseen
The Healer dwelleth still,
And they who make His temples clean
The best subserve His will.

The holiest task by Heaven decreed,
An errand all divine,
The burden of our common need
To render less is thine.

The paths of pain are thine. Go forth
With patience, trust, and hope;
The sufferings of a sin-sick earth
Shall give thee ample scope.

Beside the unveiled mysteries
Of life and death go stand,
With guarded lips and reverent eyes
And pure of heart and hand.

So shalt thou be with power endued
From Him who went about
The Syrian hillsides doing good,
And casting demons out.

That Good Physician liveth yet
Thy friend and guide to be;
The Healer by Gennesaret
Shall walk the rounds with thee.

And yet it makes sense

I had a meeting this afternoon with my preceptor, the senior physician who tries to integrate my learning on this clerkship. And in the course of our discussion, I realized that despite all the frustrations, and the strange conclusions that Freud and Erikson seem to reach, when you actually get out and talk to people who are having a difficult time integrating in society, their schemas make a lot of sense. Some people don't get past Trust vs. Mistrust, or Initiative vs. Guilt. And when they get stuck at a given stage, they react to their environment in a socially unacceptable way.

That may not make any sense unless you have a some grounding in psychology. Basicallly, Erikson came up with the idea that people go through 8 stages of life, and that to react to the environment appropriately, to be "normal" you have to go through these eight conflicts. If they are successfully negotiated, the person is "well-adjusted" and if not, they have problems and may be mentally ill.

All this seemed a bit suspect to me until I saw it in practice. It may still be suspect, but it is an excellent way to frame the problem. And when you think in these patterns, a host of deductions can be made about people and what motivates them. It feels like playing Sherlock Holmes.

Most of medicine it seems is learning to think algorithmically, and once you understand the the algorithms of a given specialty, the third-year med student job gets much easier. I am, at the end of my psych rotation, finally grasping the algorithms of this specialty.

Also my preceptor made an hilarious comment. He said that "axis II patients we never forget. No matter how much we drink."

A relatively standard day on the psych ward. A patient trying to avoid jail time claims to be suicidal and homicidal. The patient with borderline PD has decided to start hitting on the patient with MDD, who actually shows some mild improvement with the attention, and a patient with paranoid schizophrenia who thinks that "they" are watching all the time keeps peering over at the group of doctors discussing her case, maintaining a knowing, watchful expression.

Psychiatry would be great if it weren't so depressing. The hours are short, roughly 7 to 4, which is phenomomally brief compared to OB or surgery. But there is something quite depressing about dealing with patients who lack the insight to know what is wrong with them. And with some patients, you wonder if there really is something wrong with them. For example, when a patient comes in complaining that her husband is trying to kill her, and the husband is denying it, who do you believe? Sure, she has some factors in her history which imply she might be psychotic, but she seems to make sense, and she isn't acting psychotic now.

Every day I wrestle with the idea of what exactly constitutes mental illness. How hyperactive does a patient have to be before they are considered "manic"? Sure, the DSM-IV gives us strict guidlines, but how much of that is just conjecture? Is being sad, or melancholic, always such a bad thing? In days past, some of the people on this ward, or being seen in this clinic would have been poets. Now they take their anti-depressants and go out to be "normal." I'm sure some of the painters or composers whose works we admire today would be treated now with quetiapine or ziprasodone. What do we lose as a culture by leveling everyone's performance? I'm sure it helps some, but how many does it hurt?

A lot of that may be idle speculation. Some of these patients, and maybe all of them, are indeed ill. Bio/Psycho/Social factors really have gotten the best of many of these patients and with help some of them can go back and lead what we see as normal lives.

Also, the steadily increasing amount of respect and attention my recommendations for patient care command is fulfilling. When I posit that a patient may improve with 10 mg Geodon bid, my chief actually agrees and countersigns an order to that effect. I am feeling more responsible for my patients, and I enjoy the feeling.

Most things have a beginning

Not a particularly auspicious title or first post, but it will have to do. I've decided to start a blog, to chronicle at least the next year and a half, my final time in medical school. I wish I had started sooner, to preserve some record of how I've changed, how this process changes those who go through it, but maybe, if this lasts long enough, I'll do that with residency. We shall see.

My only hesitation here is a quote from Theodore Dalrymple, who said (while discussing the fall of the British monarchy, of all things) that "for modern man, baring his soul is the only proof that he actually has one" But I think in the final analysis, my point here is less to bare my soul, such as it is, and more to record something which may prove instructive. And I might even have fun. So here goes.