Thursday, November 30, 2006


I'm going to take the last major test of my fourth year, and of my medical school career. After this, there are no examinations worth troubling about between me and graduation. (I have some intra-departmental exams remaining, but as they are written by amateurs, they are not tough, at least to someone like me, who has pretty much one practical skill: taking standardized exams)

This exam has become a graduation requirement only in the past few years. It was originally designed for foreign medical graduates, to ensure they had the requisite command of English to embark upon a residency here in the States. I guess even British and Canadian graduates had to take it, which is actually funny. Anyway, the exam is the same now as it was then, and consists of eleven (I think) simulated clinic encounters, with actors of varying degrees of capacity playing the patient. The student goes in, asks some questions, does a basic exam, and then comes out of the room and writes up a short note.

Since the exam was designed to see if you speak English and can understand English clinical conversation, it isn't tough. 96% of American medical school graduates pass, and about 80% of foreign graduates pass. I'm not worried. (I'm sure Medstudentitis and Angry Medic won't have any problems either, should they need to write this exam) Unfortunately, it is both expensive and inconvenient to get to, as it is offered in only five places in the country: Houston, Chicago, Philadelphia, Atlanta, and Los Angeles. So I get to ride Amtrak for the first time in my life to the closest of those cities and get a hotel so I can wake up early tomorrow and take this thing. So I guess the exercise for today will be comparing the American and British rail systems. I think I know who's going to come out on top.

Wednesday, November 29, 2006

One year later

So my blog is now one year old. I'm pleasantly surprised that it has been so much fun, and that I've been relatively consistent with it. 204 posts according to blogger, but there are a few unpublished drafts, mostly fragments that were worked into other posts, lying about and figuring into that count. Still, that averages out to a post every other day or so.

Thanks to all you regular readers. I started this thing partly to connect with people, and partly, way back then, on psychiatry, I felt I needed some kind of outlet to maintain sanity. I did not expect to have regular visitors from five continents just a few months later. Knowing my thoughts are read, my experiences shared, and my stories enjoyed by others motivates the effort. The title of this blog comes, as some of you have guessed, from a poem with a rather bleak view of human contact, but I'm glad the picture isn't as bad as all that. Not quite anyway.

So thanks, keep dropping by and I'll try to make the next year at least interesting as the first.

Year after year
The leaf and the shoot;
The babe and the nestling,
The worm at the root;
The bride at the altar,
The corpse on the bier—
The Earth and its story,
Year after year.

Monday, November 27, 2006

Another Intersession

My school has decided that the best way to standardize the education of its students, who rotate through different hospitals and *gasp* might learn different things during those rotations, is to bring the whole class back together for more classroom experience before letting us have a winter break.

It has been, for all my complaining, an illuminating experience. I sat at lunch today with six of my most successful classmates, the kind of people who already know where they are matching, because the residency director took one look at their scores, saw them on the wards, and accepted them on the spot. Among this group of luminaries, I posed the question: looking back at all this, would you come to medical school again? Not a single person said yes.

The afternoon was a series of three classes on "Shared Decision Making" which is a fancy way of saying "be nice, and don't pretend you're a god." I figure if you haven't figured that out, you're going into surgery, and if you have, you're not going to learn anything from it. The last thing I need is to hear some know-it-all tell a moving story and then follow it up with a threat to "sue a doctor I doesn't[sic] like." I felt all the compassion they were trying to bolster draining out of me as she droned on with her poor grammar and utter inability to face the fact that her medical problems were largely due to choices she had made, and that the projection wasn't becoming.

That's not very compassionate, I know. Chameleon-like, I can take such attitudes from my surroundings. And when I think back to first year, contrasting the classes then with the one today, I'm struck with the memory of people actually smiling then. People excited to become doctors. Now it seems we're just exhausted and angry. Sam Shem in The House of God says something about being able to tell, just by looking at them, the difference between a student just starting their third year and one just starting their fourth, because the fourth year is the one with the cynicism about the entire enterprise. I don't think the cynicism really abates until after residency, and sometimes, not even then. But I can definitely feel the pull towards it I was warned against while starting med school. People say "don't let them change you," but like Vader said: "you don't understand the power of the Dark Side of the Force."

Sunday, November 26, 2006


This is priceless:

"The medical student is likely to be the one son of the family too weak to labor on the farm, too indolent to do any exercise, too stupid for the bar and too immoral for the pulpit."
- Johns Hopkins University President Daniel Coit Gilman

And then, to confirm, in more concise language, the essence of my last post, we have the British Journal of Medical Psychology, saying the desire to become a physician goes from "helping the needy" to "needing the helpless." Later, in the same article:

Knowing that one is a physician allows people with a very shaky self-esteem to find a becomes a crutch to their self-esteem....Being needed by their patients may reinforce a sense of grandiosity, but it is [an extremely fragile mechanism,] a process which has to be endlessly repeated, and being so dependent on one's patients to maintain a sense of self may generate feelings of anger and resentment towards them.*

And I am six and twenty, and oh tis true, tis true. (apologies to Housman)

*Johnson, WDK British Journal of Medical Psychology 64(1991):317-329.


It is isn't difficult to find the pain in life. It may even be easier in the world of blogging, since I think there's a remarkable tendency in people to be more open about the tragedy they experience in an online forum than in person. So today I wasn't particularly surprised when, following some links from another person's blog, I randomly found a blog that deals almost entirely with the pain the writer has experienced. What makes this even remotely relevant is the fact that her theme is infertility and she writes extensively about her relationship with physicians and midwives.

Obviously, if you've read any of my posts, I'm not going into OB/Gyn, but I was reminded in reading her words of two things. One, that medicine, to me, to the practicioner, is a job, albeit a very fulfilling one, but one that can easily be seen as just a job. It is entirely possible, and probably common, to drift into autopilot and see patients as nothing more than a set of problems to resolve.

Two, that this withdrawal into oneself, leads to very poor writing. People are interesting as people, and interesting to write about only as people. Unfortunately, the best writing comes from difficult circumstances. There is a reason stories end with "and they lived happily ever after": it's a great close if you like that kind of story, but it's a rotten opener. We want tension, dragon-slaying and damsel-rescuing first.

So this explains to me a few things. The reason I've had difficulty writing anything interesting (to me anyway) lately is that I've fallen into that tired, withdrawn state that regards patients as problems, for despite the fact that it sounds cliche (and really is, within medical writing) it is, oddly, true. And that to write anything interesting I need to be assisting people who are dealing with stress. When I'm writing, I'm generally happy, or at least fulfilled. So, where I am most happy is with patient contact in stressful situations. It's also where I find it easiest to see patients as people and be the kind of doctor I would want to have.

That's a lot of threads of reasoning left untied. If I may be indulged a general resolution paragraph, I'm trying to say that I've been writing poorly lately, due to the fact that I've not been enjoying my job, and I've been acting as the kind of doctor people love to hate, the kind that sees only the problem and not the person. It took reading a patient's perspective to return me to this healthier view of my profession. It is not my desire to be this kind of physician, and I realize to avoid being that type of physician, I need to deal with people who are sick, and I need to deal with them in a longer-term setting than consult cardiology.

This may also mean that cardiology isn't for me. Cardiology attracts a set of people who act more like surgeons towards their patients than any other medical subspecialty. They are great, and manage to maintain their humanity and compassion in that environment, but since I'm more the handholding type, that may not be my niche. We'll have to see.

Friday, November 24, 2006


So, what do medical students enjoying a holiday do, besides sleep in? Make coffee to stave off withdrawal headaches, and then watch silly videos online, that's what. Check this out:

Thursday, November 23, 2006

Handholding, or why I love internal medicine

Shortly before ending my cardiology rotation, I saw a patient in consult whose diagnosis I figured out as soon as she started talking.

This woman, Mrs. Hickory, suffers from fibromyalgia, which disease is quite possibly the source of more frustration in physicians than almost any other. It is a disease of unknown cause which causes debilitating chronic pain, without any anatomical basis. The disease is often referred to, in a slightly deprecating fashion, as "supratentorial," which is the medical professional way of saying "it's all in your head," referring to the tentorium, a membrane which roughly divides higher from lower brain function. (Feel free to clarify, S. Lee) Anyway, I've seen enough of these patients to be able to pick them out across the room. Generally female, 30s to 50s, and usually with a constant facial expression of someone who has been wronged. They usually talk with a bit of a whine in their voices as well.

So you have a combination of a mysterious disease, a large proportion of physicians who don't believe it is real, coupled with a personality which is not, to put it mildly, endearing. You can see why people avoid rheumatology.

But I actually like fibromyalgia patients. They do whine sometimes, and some of them have an almost amusing inability to talk about anything but their pain for more than 30 seconds or so, but I think part of why they have the expression and manner they do is the fact that no one believes them. It's a maladaptive response to the fact that their disease pushes them to the sidelines of life.

What is it I see in them? They are, for one, the absolute best test and best encouragement of bedside manner I have yet to experience. A patient who is in pain no matter what you do to examine them, wincing even at the stethoscope being placed on their chest, is a challenge, surely. But I feel that if I can connect with and gain the trust of someone hard wired to distrust and feel threatened, I can gain anyone's trust, right?

There are a couple of key points in interacting with these patients that are not intuitive, but they transfer well to other patients too. First, I have to remember that the pain they feel is real, even if I can't discover the source. It's like Morpheus in the Matrix: "[What is real is] electrical signals interpreted by your brain." That's horrible metaphysics, and I'm not an empiricist, but it is where you need to start with these patients. I suppose, though, a deeper point could be made that the essence of understanding is the recognizance of a person outside yourself, so that the interaction, from the first, proves a reality outside oneself. But fibromyalgia sufferers are rarely so philosophical.

To return, accepting the patient's perspective on events is necessary to start. Secondly, I have to let them talk. This can be challenging, but more than a lot of other patients, these need to be heard. That's what I'm there for, so I let them talk. Third, when I start making plans, I have to engage the patient and make sure they understand what we are doing fully. Making sure they have a voice, that they do not feel as marginalized as their disease can make them, is vital here. And fourth, sometimes a little handholding goes a long way.

I'm not a real big physical contact kind of person. I don't generally hug friends, etc. Probably because I'm male, but the point is, medicine has taught me that you have to have physical contact. It's part of the interaction. Hospitals are rather antiseptic, and it is possible to do a large part of the typical exam and workday without actually touching a patient. Even a stethoscope allows some distance, and was actually designed for that purpose. (True story: The stethoscope was invented to allow physicians to hear heart sounds without placing their ear directly to the patient's chest, as it offered some young ladies offense. Not to mention the expense saved on ear-cleanings. I made that last part up) So when a physician, or physician to be (176 days!) like me actually touches a patient, holds their hand while speaking with them, places a hand on their shoulder while using the stethoscope, it makes a difference. At least, that's what my patients have told me.

All of these points can profitably be applied to any patient, but it is toughest with patients who force me to be intentional about all this. Anyone can be nice to someone sweet. It takes real grace (or long practice) to be nice to someone who is not sweet at all.

So from fibromyalgia patients like Mrs. Hickory, I am taught patience and compassion. More important, I'm taught how to be both patient and compassionate professionally. And as I sat on Mrs. Hickory's bedside, holding her hand as she cried out her story of pain and misunderstanding, I remembered why I came to medical school.

But leave me a little love,
A voice to speak to me in the day end,
A hand to touch me in the dark room
Breaking the long loneliness.

Monday, November 20, 2006

Jacta Alea Est!

I've finished my cardiology rotation, and now all that is left to wrap up my long odyssey is to drive home to the metropolis. I think I've accomplished my purpose of networking and impressing the requisite people here, and now I just have to await match day and enjoy the last bit of my fourth year.

I'm excited to see the results of the match actually. I'm fairly certain I'll get either my first or second choice, and of the two, I like different aspects of each. It will be fun to await a surprise with almost no downside.

It's all out of my hands now.

The Decemberists - The Crane Wife

Have you ever listened to an album that expressed, with almost every chord change, exactly your mood? I have recently listened to two albums which have done this for me, and one of them is this, the latest by the Decemberists. When I first tried to listen to this one a month or so ago, I wasn't real impressed, and I had bought another one along with it. So this was relegated to a drawer and I only pulled it out today while I was packing to leave my last away rotation and head back to what will only be home for a few more months.

I was blown away. The first track is still not a barnburner, but I should have left the CD playing. Track two is epic, rising from standard Decemberists ethereal guitars and drums to a sythesizer solo that probably makes Keith Emerson jealous, winding down to a beautiful guitar piece. That is followed by a duet with Laura Viers, and the hits keep coming. Great packing music, with energy and variation enough to keep this obsessive complusive medical student at least mostly engaged in his task.

And I was pleasantly surprised with the lyricism. Colin Meloy often has catchy lyrics, but often they are more than a little shocking. At least on Picaresque, but I should have expected it from an album with a song title Odalisque.

This one's going to be keeping me company on my long drive back to the metropolis. I have yet to make up my mind entirely about the lyrics, but there is nothing like a long car trip for close listening to an album.

Saturday, November 18, 2006


Some random things that have made me laugh recently.

One of my residents is given to rather odd, often vulgar, but usually hilarious phrases. Some of his latest gems include:

"They" and "them" are spirits of darkness. When someone tells you "they" all do it, run the other way.

Don't give him heparin, ambulate the motherf@#%&r.

Giving this guy predisone is Kosher as Christmas.

Overheard in the waiting room, from a very obviously newly married couple:

"Kix? You put sugar on your Kix?! I thought I knew you!"

Thursday, November 16, 2006

Shortened contacts, deadened feelings

I have struggled these past few weeks to write anything. Nothing comes, and certainly nothing poignant or meaningful. Not that I have not enjoyed myself, indeed, much of what I've been up to has been fascinating, but not in a sense it is easy to relate. As I said in an earlier post, I'm not sure I like not having much contact with my patient, seeing them for an hour, tops, before going to write a note and wash my hands of them, in essence.

And I regret it. One of my patients was in WWII, and is quite excited to relate the fact that he was in the Pacific campaign for 36 months. He fought his way from Australia towards Japan for three years, but even now, I don't have to try and make up a pseudonym for him, because I don't remember his name. He's the guy with a probable pulmonary embolism.

So I'm left reconsidering whether specialty medicine is for me. Specialists do have better hours, fewer headaches, and more interesting cases, not to mention more knowledge and more respect, but they also see only a narrow piece of their patients lives. At least on a consult service.

The good news is, I have two years to make up my mind about a specialty. And the better news is that in less than six months, I'll be Nathan, MD.

Wednesday, November 15, 2006

Worthwhile purusal

Joel has an interesting post here, discussing where to draw the line in deciding how strenuous an intervention should be made to preseve the life of a child born with disabilities. My most recent response, which I'm posting here for the double reason that I have little else to say at present and that I want to preserve it here as well, is as follows. I've disabled comments on this post, since Joel kicked off this discussion, I'd like to continue it there.

Drawing that line is complicated. I think, in general terms, that if the person in question (for except in some very, very extreme cases, I think all these children are persons) will be able to live with minimal to moderate assistance, or even if there is a question of them being able to live with minimal to moderate assistance, then all reasonable measures to sustain their lives should be taken. If, and only if, there is no question that the person involved will require exceptional measures to sustain their life for the entire duration thereof, I would have very little problem not taking those exceptional measures at the start. I do not think, with this Anglican declation (as far as I can tell) that the ability of the parents to care for the child should affect the decision. Isn't it the role of the Church, from Acts onwards, to assist those in such straits?

I think the right decsion was made in the Terry Schiavo case, for the record. The clip that got so much air time, of her apparently responding to her mother, was just that, a clip, not more than a few seconds long, taken from over 4 hours of video. In that amount of time, any random action could be taken as proof of ability to communicate. She had been in that same state for years. I think her husband's incription on her tombstone said it best: "departed this earth 1990, at peace 2005."

An overarching theme in medicine, reflected from our culture today, is the worship of life, specifically long life. There is, in medicine at least, some reaction against that lately, and like most things, it can be taken too far. But I think a healthy appraisal of the value of a life, and respect for its owner's wishes, where possible, is necessary. Some people want to be kept alive at all costs, others don't want anything done. When the person can't communicate, as in Schiavo or a child, a balance must be found. Detractors might say we don't have the right to "play god" but that's an overly simplistic view. In the hospital we're working against Genesis 3 as a way of life. Sometimes I think we need to realize that in the end, the curse is still in place.

Sunday, November 12, 2006

Coffee, post 2

I love coffee. It pretty much keeps me alive, as I've said before. So today, in lieu of writing anything deeply moving or insightful, I'm going to post a comic strip I found hilarious, and perhaps a little close to home. Also, I want that backpack.

Friday, November 10, 2006


Why does the way of the wicked prosper? why are all they at ease who deal very treacherously?

I've recently lived exactly the kind of competition I find so distasteful and referred to in an earlier post. I'm working in the same department with a classmate of mine, and a week and a half ago, I saw a fantastically interesting case. Fantastically interesting, by the way, coming from a doctor or doctor-to-be generally means the patient is screwed. Fret not, this guy will live.

But his case isn't the point. The point is, this case is really rare, in that the condition itself is about 1 in 200 000 or so, and to have the right combination of enivronmental factors to bring out the manifestation we saw...suffice to say it's never been written up before and will undoubtably be published now in a major medical journal.

I saw this of course, and asked my fellow (the cardiologist I'm working with) if I could write the case up for publication. He said yes, and I started writing. Meanwhile, as we were only the consult team, we transferred the patient to the inpatient team. The inpatient team happens to contain my classmate, and as we made the transfer, I told him that I was writing the patient up. So, what did my classmate do? He talked to his fellow, and three or four staff cardiologists, and started writing his own article. And since the staff heard about it from him first, he gets the article.

I have only rarely been this displeased with another human being. He completely exemplifies the backstabbing, look out for number one attitude I despise in the ultra competitive medical student type. And though I very much doubt I'll have a say in his life in the future, right now, I'm fairly certain if I did, it wouldn't be a positive one.

Which is of course unhealthy and unchristian. And though I'm not going to actively work to undermine him, I don't think I'll have to. Surely karma will catch up with him. But even wanting him to fail is probably wrong. Big picture, this isn't going to matter a lot, and I should try to remain on good terms with him. But that's not a level of strength I have in and of myself.

Wednesday, November 08, 2006

Consult Cards

I'm doing consult cardiology right now, and overall, I love it. Cardiology, or "cards" as it is referred to occasionally, is an amazing specialty. If you liked physics, or math, because "it just made sense," you'd love cardiology. It is far and away the most scientific of the branches of medicine, in that it takes evidence based medicine very seriously. Every point has to be proved. For example, even knowing nothing about physiology, you'd probably guess that someone with "inducible arrhythmias and heart failure" is worse off than someone with "heart failure alone", right? Well, cardiologists felt compelled to prove that, in a trial called MADIT 1. That's the other quirk of this specialty, all the important studies seem to be named. MADIT, CONSENSUS, AFFIRM, ISIS... the list goes on for ever. There are over 2000 named trials.

But I am being sidetracked. The intricacies of cardiology are not my point here, interesting as they may be. What I wanted to say was the oddity I've noticed with consult medicine. As a specialist, you are consulted to see patients you don't need to follow closely. You are concerned with one problem, or at least, one organ system. And so the connection with the patient is not as strong as from the primary team. So I see dozens of patients, but have difficulty remembering names. I see a slice of who they are, but I'm being forced to consider only one organ system, and the others only as they relate to that system. It keeps the patient at arms length in a sense. I'm fairly sure I don't like that.

The good news is that no specialty is entirely consults, as far as I know. It is also possible to see clinic, and have your own patients, in all of the medicine subspecialties. So, while cards remains at the top of my list of favorites, sober judgement (and review of my grades) is causing me to keep my options open. We'll see.

Sunday, November 05, 2006

As long as you both shall live

Behold another dream is even now turned into mist.

It is easy, I suppose, to look on tragedy and hope for ease. It is easy to see the pain I do, and while longing to and working to ease it, nevertheless not wish it upon oneself. My previous post grows out of this easy route. But, in the fresh light of a new day, having seen not only fresh instances of the general curse laid upon humanity, but also the recently captured images of my three month old niece, I amend my thoughts.

It is true that Mrs. Walmswood is in great pain, and that her life, such as it remains, will be, in Hobbes' (the human, not feline, philosopher) words "nasty, brutish and short". But it will not be solitary or poor, the other qualities that singularly gloomy man ascribed to human existence. And that I think is the key to understanding here.

Humanity, with rare exceptions, exists in its most complete form only in concert. Life is a communal activity, and is meant to be lived as such. And though in isolation we can avoid certain kinds of pain, there are others we cannot avoid, and in the balance, it is better to be in company.

Shared joy is double joy, shared sorrow is half sorrow

And seeing Mrs. Walmswood, I recognize that even in my prior thoughts, I touched on the reason her husband is still with her. Despite the irritating, monotonous quality her voice has, it is still possible to see the humanity in her, the humor, the wit, the soul. She told me a joke that I still chuckle at, hearing it again in my head.

None of us know the future, though it is easy, watching the parade of sickness while in the health of youth, to assume immortality for myself. And the decision Mr. Walmsood made not so many years ago could just as easily have turned out the other way, with him on the bed, and a bright, jovial Mrs. W by his ailing side. Life, it seems, is a bit of a lottery.

And since none of us know the future, and most all of us desire companionship, it seems we must be willing to "take the bitter with the sweet" and promise to remain "in sickness and in health," trusting that the other, also not knowing the future, is making the same committment. I guess there is more wisdom in those words than I suspected.

So, did you hear the one about the dyslexic devil worshipper? He pledged his soul to Santa.

Thank you Mrs. Walmswood. L'chayim, l'ahava.

Saturday, November 04, 2006 sickness and in health...

Visiting a dying patient is nothing new to me. Seeing someone sick isn't either. Exposure to both over the past two years has slowly changed my perspective on life and love. I've been to more than a few weddings over the years, and at most of them the traditional vows are exchanged, almost a magic formula, the significance of which few, if any of those parties truly understand. I doubt many of those parties envision Mrs. Walmswood.

This woman is dying, but she has not been given a swift departure from the world. She is suffering from a very slowly progressive form of ALS, also known as Lou Gehrig's disease. And as her body's functions have been slowly taken from her, she has lost along the way the ability to inflect her voice, or speak at more than about 30 words per minute. Walking into her room for the first time, I was set on edge almost immediately. I tend to size up a person quickly, and my initial impression of this woman was that she was a bit mentally slow, and in general the typical obese diabetic with two or three psychiatric issues. As I got her history, I found that she has been suffering from her disease for over ten years.

What struck me was the fact that her husband was in the room, and he was smiling and upbeat. Actually, more striking even than his presence and attitude was the discovery that this woman had been a teacher in a nursing school, a very highly functioning individual. And as I tried to get past the irritation I felt waiting for her to finish sentences, I discovered that preserved within her was a wry sense of humor and a still-facile mind.

I guess what awed me was the fact that this man had made a commitment to this woman, and even as sickness has taken most of what, to an outsider, is attractive, he has stayed with her, and I imagine most days manages to see within the decaying mortal remnants that soul he married not so many years ago. But I must wonder if he ever regrets his choices.

In faith, I do not love thee with mine eyes,
For they in thee a thousand errors note;
But 'tis my heart that loves what they despise,
Who in despite of view is pleased to dote.

I don't doubt the ability of humans to make and keep promises. But the single guy in me questions the utility, marvels at the commitment, and ponders the components of those promises. Just as I wouldn't want to end up a patient on a medicine ward, I especially wouldn't want to have my wife (should I ever have one) end up a patient on one. It almost seems that it would be more worthwhile to live singly than live with that pain. I respect the strength I see in my patient's families, but I wonder if I even possess the ability to have that kind of commitment. Judging from success rate of marriage in this country, I think many of my fellow citizens suffer from the same weakness.

On me can Time no happier state bestow
Than to be left unconscious of the woe.
Ah then, lest you awaken me, speak low.