Wednesday, December 20, 2006

If you're a close reader of the comments here, you'll have noticed that the tests turned out as I hoped, not as I feared. And another scary chapter of my life is finished. But the pessimist in me mutters as I write that "the book is not yet finished." The good thing, I guess, is that I'm fairly aware of the different ways you can get a needlestick.

And as I noted yesterday, I am away from the hospital until the new year. Probably the last break I'll have before internship, so I intend to enjoy it. Posting will probably be light over that time, but I'll be starting up with neurosurgery in January, and that should be fairly story-rich. No, this is not out of a new-found desire to be a neurosurgeon, it is simply a relic of the fact that my school assigns lottery numbers to students as we pick our required neurology rotations, and, as is already evident, I'm not particularly lucky.

An oddly bright moment today was opening my mail. On my last ward medicine month, I had really clicked with a patient, who then proceeded to offer me a week at his beachhouse out of thanks. I never took him up on that, but I did get a Christmas card from him, addressed to "Dr."

Almost, almost. And it is wonderful to know he's still doing well.

Tuesday, December 19, 2006

Choosing a doctor, finding patients

I'm on my winter break, hence the dearth of posting lately. But yesterday, I was in a music store, asking for a specific and (I guess) rarely requested piece of music for my guitar, Spencer Doige's Fingerpicking Joplin. Check it out here, but give the guy 22 seconds to start the real piece. And here. I digress.

Anyway, the woman helping me find this piece said "I assume you're a professional then, getting this book," which started a bit of a discussion about my job and what I'm going to do. And as we ranged over my theories on accupunture and osteopathic manipulations (I'm an allopath), she was evidently impressed. She stated finally that "when you get out of your residency, come back by, because I need a new doctor, and it's so hard to find good ones."

Which got me thinking down the road. I don't really know much of how someone in private practice goes about getting a panel of patients. We aren't taught a whole lot of that in school, and as an internist, most of my time for the immediate future will be in the hospital, out of clinic. But eventually, I'll be out in private practice, and I'm not sure I want to be a hospitalist, so I'll be doing clinic and needing patients. So I guess I'll start with the guitar stores to drum up business, eh?

Wednesday, December 13, 2006

Blogger Beta

I upgraded to the new version, and the first thing I noticed that changed was that it deleted all the authors to the comments, replacing them with "annonymous." Not an auspicious beginning. Anyway, I can't go back now, spilt milk and all, so I'll try to make it work.

Sunday, December 10, 2006


I've just had the last, one year later, make sure we didn't miss anything, blood test drawn to follow up my needle stick injuries from last year. And I'm actually fairly worried it will be positive for HIV. About six weeks after the one stick that concerned me, I got a febrile illness with night sweats and lymphadenopathy, and though the next test was negative, I've remained unconvinced. The next test was too soon after the illness, I think. And it is odd, maybe specific to medical students, that they worry about the diseases they study so much. It is harder here because with something so serious, your best friends and family aren't willing to entertain the idea, and no one knows what to say. Being met with either awkwardness or hearty, but not heartfelt, denial.

We are separated from one another by an unbridgeable gulf of otherness and strangeness which resists all our attempts to overcome it by means of natural association or emotional or spiritual unions. There is no way from one person to another.

Worry is a tricky thing. Though I philosophize a great deal, I'm not very philosophical, and though I know worrying about something I can't change and will know in a week anyway won't do anything positive, I worry anyway. "These are the times that try men's souls" Thomas Paine wrote, and though he was dicussing the acid test of patriotism, I think a similar case could be made for the slightly justifible hypochondriasis of the typical medical student. "The summer student, and the springtime physician..." or something, "will in this crisis" find if they are truly capable of handling the stress. So I will see. I will see if I can take a week of concern, thinking about the family I'll never have, the life which will revolve around the treatment for an incurable, fatal disease. Something my patients deal with every day. Certainly, even hypochondriasis gives perspective.

Saturday, December 09, 2006

And now for some light entertainment

Part of this Intersession was to sit in small groups and discuss our views on medicine and how they've changed. Some of my more recent posts were written with these upcoming discussions in mind and I feel it's probably ok to quote yourself, on occasion, even if you aren't yet 30. Right?

Anyway, one of my classmates paid me a rather humorous compliment. We were discussing the aging process, and the discussion leader, a more experienced doctor, said "you know, we're all going to get old and need a physician there to help us."

Without more than a second's pause, my classmate quipped "I call Nathan."

Nice to know I've got at least one vote of confidence.

Tuesday, December 05, 2006

What are people for?

Against conventional theodicies, and above all against a culture that has lost its way, where its answer to the question, "What are people for?" is, “For autonomy and control, for health and beauty, for performance and productivity,” Professor Young has lodged a considerable critique. Human beings, she says, are made for friendship, and human communities are made for hospitality. And it would seem to be the vocation of so-called disabled people to take this gospel to so-called indepedent, fit, and achieving folk.
- Kim Fabricus

The always thought-provoking Kim Fabricus recently posted this here. And it got me thinking, obviously. I've written on the idea of disability before, as it pertains to abortion, and I've commented on it at Truth or Vanity as it pertains to the passive euthanasia of children. And I realized that, beneath what I flatter myself is an eloquent veneer is really the clash of ideologies. And I have been allowing myself to be convinced of the essential utility of a Darwinist perspective as it relates to ethics. The veneer of rhetoric allowed me to ignore the essentials of what I was saying.

Darwinism may well explain some things as biology, but as a philosophy, it is pernicious. It may indeed be the best case for the existence of God that we are still here, since left to our own devices, we tend to extend survival of the fittest to an all consuming selfishness that will destroy us. I am leaving aside the question of biology for now, because my subject, medicine, is really the spiritual side of biology. And if Darwinism is carried to its logical conclusion, there is no spiritual side to anything, except in the abstract complexity equals spirit formulations of Ursula Goodenough and her ilk. (A good friend of mine pretends to buy into this, but I think deep down he doesn't believe it.) Medicine deals with biology, but the best physicians are at least partly, if not primarily concerned with what effect biology has on the person as a person, not as a collection of homeostatic reactions.

What I'm driving at is what I've written at the top of my sidebar: "Without faith, without poetry, without music, medicine is pointless, for why save a life which is not special, and why dedicate so much effort to a cosmic accident? It would be worse than pointless, it would be cruel." In considering that life, which is so much more than a cosmic accident, the question that titles this post arises: what are people for? And relying on Darwinism, we have no answers that allow us to simultaneously affirm our rarified convictions and disapprove of mass murder of weaker individuals. Unfortunately, Darwin and Bentham are behind most of medical ethical reasoning. It is simply not possible to consistently affirm an empiricist, evolutionary perspective and also affirm the existence of evil as anything more than an opinion.

It seems to me then, to effectively function in a medical environment without becoming jaded or cynical, one must have a strong perception of "what people are for" underlying every action. And though I have assumed that my Christianity undergirded my reasoning, it seems I have been allowing some degree of Darwinism as well. This is worked into our training surreptitiously, and probably not intentionally in most cases. Since doctors play god, they become used to making value judgments about life and death which may not properly be the sphere of their control.

The problem is that, in the big picture, we need Bentham in medicine. There are a finite amount of medical resources, and those resources must be rationed. The question of how best to do that occupies numerous graduate theses and pet theories around the world. And I'm not sure what the answer is. Some of my more detail-oriented professors have stated that medical policy is not the purview of the physician, and we instead ought to solely be advocates for our patients, working to the get the most effective treatment for them at all times. Others insist we need to be mindful of the costs of the procedures we order, and the lives we expend effort in saving, because of the need for rationing. While I do not want to address the macro-scale subject of rationing now, the consideration of life and advocacy properly belongs here.

My conviction is that yes, Prof. Young is right. Humans are created, at least partly, for friendship and hospitality, not for some naturally selected drive to reproduce and leave as many beautiful, strong, autonomous descendants behind as possible. But if we approach medicine from that latter perspective, we will be unable to maintain hope in the face of despair. After all, if your life and work are merely prolonging the inevitable for the sake of the unworthy, it would be impossible to fend off despondency. If Prof. Young's perspective is true, then every action within that life and work serves the purpose of your life and work, making every moment and gesture meaningful, and every life precious. I don't think this perspective is possible to maintain outside of faith. At the same time, advocacy for a patient does not, and cannot always mean working to extend the quantity of their life. A balanced perspective, and a thorough understanding of what makes life meaningful must root all medical decisions. And that understanding is impossible to achieve, in cases where the person's capabilities with life are different from your own, without a more inclusive perspective than Darwin gives us. More than simply inclusive, we need a perspective which recognizes the essentially spiritual nature of mankind, a nature which makes him above the animals, more than simple biology, and worth preserving despite disabilities.

Saturday, December 02, 2006

It is done

I'm finished with the USMLE step 2 CS. If I didn't pass, I'll be very disappointed. 12 cases, all very, very simple problems, followed by a quick note on each one. Probably the funniest thing that happened on the trip was the streetside panhandler who told me I "look like Clark Gable and Clark Kent all rolled into one."

And yet, I'm still single.

C'est la vie
. Actually, I would have given him the dollar he asked for because of that line, but I had no cash. Felt a bit bad about that.

After the test, some of the local testees took a few of the travellers out for drinks. I'm struck more and more by the fact that physicians and physicians to be tend to hang out together a lot, even when they don't have to. At the last few parties I've been to, all the med students cluster together. At this test, we all naturally went out together and had a great time. My theory is that, despite all the complaining we do about the hell that is medical training, it acts as a kind of standardized fraternity hazing ritual, albeit one with a grander point than being considered part of Gamma Delta Beta, or whatever. This is also borne out by the point that the socializing tends to be congregation between training levels. Interns and fourth years have a large gap between them, and the fourth years look down, almost condescendingly, on the first years. Probably most professions are somewhat similar, though I doubt if many have the institutionalized beatings to pass from one rung of the ladder to the next.

But today, the sun is shining, the air is crisp, and I find it very difficult to be down about any of this. And I just found this quote, which shows so well what I ought to be aiming for, beyond this "place of wrath and tears."
There are men and classes of men that stand above the common herd: the soldier, the sailor and the shepherd not unfrequently; the artist rarely; rarelier still, the clergyman; the physician almost as a rule. He is the flower (such as it is) of our civilisation; and when that stage of man is done with, and only remembered to be marvelled at in history, be will be thought to have shared as little as any in the defects of the period, and most notably exhibited the virtues of the race. Generosity he has, such as is possible to those who practise an art, never to those who drive a trade; discretion, tested by a hundred secrets; tact, iried in a thousand embarrassments; and what are more important, Heraclean cheerfulness and courage. So it is that be brings air and cheer into the sickroom, and often enough, though not so often as he wishes, brings healing.
-Robert Louis Stevenson

So here's hoping all that pain guides the development of Hereclean cheerfulness and courage. Right now, I'm going to enjoy the day.