Almost coded

Late this morning, while finishing up the last of my work and hoping for an early exit from the hospital, I rounded a corner of a hallway to have my heart sink within me. For as soon as I rounded that corner, a group of nurses at the other end of the hall turned and said "there's a doctor!"

This is almost never a good thing. But in response to their earnest gesturing, I hurried to the room to see a very pale woman lying on a bed gaping at the ceiling with eyes closed. Meanwhile, in one ear I was hearing "just checked on her, was smiling a minute ago," and in the other I was hearing "there's no pulse on telemetry, just bradyed down and stopped, I think she might be DNR."

I am, in looking back, pleased with my calmness as I said "bring the code cart and her chart, see if she's DNR/DNI." By the time I reached the patient's bedside though, a nurse was standing in the doorway with the chart, telling me this patient was DNR/DNI. The code cart was pushed back to its familiar home and the crowd started to disperse.

I told the nurse to page the resident of the primary team and the staff physician as I felt the carotid for a pulse. Feeling none, and hearing no heartbeat, I realized I had just seen my first death in the hospital. First death ever, actually, which is an odd thing, I think, a sign of our times, a mark of the twenty first century, in which people die in small rooms away from home, attended by a select group of people to whom the experience becomes familiar. And until you join that group, you are insulated from the event, one that comes to us all.

The intern from the primary team drifted in. Though it may not have been the right thing to do, I let him pronounce the death.

"Time of death, July 17, eleven fifty AM."

It would be false to say this affected me greatly. I had never seen the patient before, never spoken with her, never heard her story, except her diagnosis. And I wonder what to make of that. I came into medicine partly because it allowed me to treat people, to be around people, who are dealing with real questions, and to deal with them myself. Somehow the presence of the "unveiled mysteries of life and death" seemed to add profundity to my experiences.

I thought as a medical student. As an intern, I'm harried to the point that thought beyond "what do I need to do now" is difficult. If I'm not moving, there's something wrong. I'm so used to hearing my senior resident say "what aren't you writing this down? You should be writing this down, Nathan" that it has become a bit of a joke. All this action, all this doing, keeps me from thinking.

And so, as I stood in that room, a little nervous, a little relieved that I didn't have to run a code, and a little awestruck by the whole situation, I wasn't really processing. I wasn't having grand thoughts voiced by Longfellow or grim ones by Thomas. I was tired, and after the details were passed on to the primary team, I went to grab lunch before heading back to work.

5 reasons

I've been tagged with "5 reasons I blog" by Medstudentitis, so here goes.

1. I started this blog to tell stories. At the time it began, I was discovering that even the most indulgent of friends and family tire of graphic descriptions of hospital life. This was a great way to share.

2. In many ways, sharing the odd and amazing stories that form life in a hospital can seem like showing off. It certainly is an enthralling lifestyle at times, and that exultation can be wearisome to those who do not share it. Here, since I know only the smallest fraction of my readers personally, they cannot think less of me for exulting. And most of you know exactly what I mean anyway.

3. Working in a psychiatry ward, as I was back when this started, can make anyone feel they ought to be a storyteller. However, telling the same story fifty times can be trying, and this was a great way to let all my interested friends get the story without exhausting the teller.

4. As I progressed in blogging, I decided to work through some more difficult issues for me, as a developing physician, through this medium. I certainly learned a lot through writing here, especially the three posts "in sickness and in health," "as long as you both shall live" and "Parenthood" which are linked in the sidebar under "Key Posts". Probably others were just as good, but those are the ones that come to mind.

5. Less of a reason why I blog, and more of what's been going through my mind lately: I've been away from the hospital, in the legendary lull of fourth year medical students, cramming what enjoyment they can into the last few weeks of freedom before we all start actually working for a living, and so I haven't been blogging a whole lot in the last month. I've questioned whether I will start again once residency begins July 1, and if I do, what shape that will take. A commenter here a while ago took exception with one of my posts, believing that I was laughing at a patient's expense. Though I wasn't, it caused me to more closely consider the Hippocratic Oath, specifically the line "All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal." I'm not sure how much of what I do, and how much physicians do in general, "ought not be spread abroad." Certainly, there is a rather considerable precedent for blogging about the hospital, but precedent does not make ethics. If there are any medical bloggers out there who have actually made it this far, I would truly appreciate your input on the subject. I'm not worried about HIPAA, as I've very clearly stated multiple times that all names here are invented, but I do think law is a poor substitute for societal moral pressure, and I'm trying to determine where that lies here.

And so it ends

The next time I introduce myself to a patient, it will be as "doctor." Today was my last clinical day for the rest of my medical school career. And so Mr. Jefferson, who is in his 20s and just discovered he suffers from narcolepsy and sleep paralysis, will be the last patient to have heard me introduced as "a medical student in here today."

I was trying, on my drive home after my shift, to remember the first patient I saw in the hospital, just for comparison. But I can't remember him well. I do remember he was an elderly gentleman, with heart failure and a body suggesting no immediate danger of starvation, but I can't place his name.

More instructive, perhaps, is to try and remember how I interacted with him. I can recall my checklist, the 3x5 card crammed with obscure questions I generally forgot. And I also recollect that I had not yet learned the physical exam, so my three quarters of an hour in his room was solely to gather his story.

Most of what I've learned has been piecemeal, I think. Starting back in first year with interviews, progressing to the physical exam, learned in parts with a classmate first, then practiced as a whole on patients, trimmed under the influence of surgery attendings and residents mocking the "medical student exam" for its thoroughness to a cursory affair, lengthened during medicine, and focused when my knowledge expanded sufficiently. I remember first year, picking up a copy of the New England Journal of Medicine, forcing myself to read through an article, understanding half the the words at most. Now I can pick up that same article, and at least understand 95% of the words, usually I can follow the concept, and I'm beginning to think how I would apply that article to my own practice.

Though it is still scary to think of calling myself doctor, to think of being a doctor, to make life and death decisions, it is easier, thinking how far I've come.

The next two months are pretty laid back. A month of reading medical history, and a month of "transition to residency" classes. Then graduation, vacation, and the specter of July 1.

Development

Mr. Thomas is not doing well. He was admitted to the ICU because the surgeons taking care of him thought his atrial fibrillation was beginning to give them difficulty managing his blood pressure and heart rate on the ward. About two hours after being transferred to us though, Mr. Thomas proved the surgeons wrong by going into septic shock, taking several days to recover. Now he has two problems, which have taught me another rung on the ladder towards being a doctor.

The first problem is his kidneys are dying. The creatinine level in his blood, a measure of how well your kidney are filtering junk, is going up, from an almost normal value of 1.0 on admission to almost 4.0 now. An increase of that magnitude over a week is pretty ominous, so we called nephrology to get their input.

The second problem is related, and is in his lungs. Mr. Thomas' chest x-ray implies that he has too much fluid in his body, and the cure for that is a diuretic. There is a risk in using diuretics, because they are essentially poisons for your kidneys, but the one we're using, furosemide, is pretty well tolerated.

Son, your ego is writing checks your body can't cash.

Here's where the real problem lies. Nephrology took a look at the labs I had ordered, and decided that Mr. Thomas' problem was acute tubular necrosis, or ATN, meaning his kidneys had just taken the episode of septic shock poorly. Their recommendations were to increase the amount of fluid Mr. Thomas is getting, allowing his kidneys to get more blood flow, and to hold off on the furosemide. My attending though, thinks that the problem is acute interstitial nephritis, AIN, and believes that the chest x-ray is showing increased fluid, not pneumonia. The problem then, is that my attending thinks nephrology is wrong, and the patient needs less fluid, and to have a regular diuretic dose, and the nephrologists think my attending is wrong, and that the patient needs more fluid, and no diuretic dose. Neither has a rock-solid case for their opinion, but nothing in medicine is 100%. So what do we do?

When I became a man, I put away childish things.

The process of moving from medical student to MD involves a steadily increasing level of knowledge, experience, understanding, responsibility and decision-making ability. As third year starts we report facts and accept blindly the decisions of superiors. As that year progresses, ideally the medical student learns, and starts making suggestions, always expecting to be wrong, but still starting to think, to put the patient's picture together. By the end of fourth year, we should be making decisions with a high expectation of being right. After all, for someone like me, starting July 1 of this year, I'll be making treatment decisions for very sick people at all hours of day and night, so I should be getting pretty comfortable with making decisions and giving orders, bearing in mind of course that I am still learning, and that if I'm not sure, I most decidedly should be getting my superior's opinion.

And in the case of Mr. Thomas, I'm making that transition, though perhaps inappropriately. I'm with the nephrologists, in that I think the x-ray is showing pneumonia, I think Mr. Thomas needs more fluid, and that his kidneys are showing ATN. But I can't make that decision over the top of my attending, so I have to write notes that reflect his opinion. It is immensely frustrating to write something I don't believe, but maybe I need to get used to that too. I just don't want Mr. Thomas to pay the price.

We'll see what happens. The good thing is, having done some reading just for this little post, I have a few ideas that might help me sort out what's really going on. And who knows, I might even be wrong.

Drugs

I just recently found this hilarious picture via Kevin, MD, which is a shot of Pharmaceutical Rep Barbie. And it reminded me (since, thankfully, neurosurgery is over and I don't have to think about it this evening) of a lecture I had a while back from one of the cardiologists I have worked for. Great guy, ridiculously intelligent, and coiner of some of the all time greatest hospital aphorisms. Anyway, he was talking about drug reps, and how they get doctors to prescribe their medications. Strategy number one, said he, is the "Catherine Zeta-Jones Approach." I'll attempt to recall the way he described his first exposure to this phenomenon:

"So, I'm working as an intern, horrendous hours, I haven't seen the sun in weeks, and all of a sudden, this, vision, appears out of nowhere and says "Doctor, have you heard about the efficacy of [drug X]?" Now, no, I hadn't, but it really didn't matter. This beautiful creature, she called me doctor. I stared, open mouthed, as she gave me the paper discussing the drug and said some things I barely recall. And I prescribed [drug X] several times after that before really thoroughly reading that paper."

Once he read the paper, he discovered that the techniques used to show the efficacy of the drug were almost unheard of. The study used a variety of complicated statistical tricks to evidence Twain's quip about three kinds of lies. And when he did further research, he found that the study's problems were noted before publication, and the only way they got the article published was by calling up the editor of the New England Journal and telling him they would purchase 10,000 reprints of the article, enough to cover the Journal's operating costs for a year.

The story did more to change my opinion of drug companies than anything has. I tend to be fairly reserved in my opinion about them. Some drug reps are nice, some are obviously salesmen (actually, usually saleswomen, see above) and I take everything all of them say with a shaker of salt. I know from my chemistry background how difficult and expensive drug design is, so I find the arguments the average "bring down those on high" politician makes to be completely laughable. I still do. But hearing this story of subversion in the foremost academic medical journal in the world made me reconsider a bit.

Thankfully, the editor responsible for that fiasco is gone. But the story demonstrated the lengths some companies will go to in order to sell drugs. Scarier still is the direct marketing to consumers, something which almost certainly leads to abuses in the system.

* * *

During the whole process of thinking about this post, I was listening to my iPod, shuffling away random selections, and oddly enough, the Rolling Stones "Mother's Little Helper" which has the line "And though she's not really ill, there's a little yellow pill..." came on. The song recalled a factoid I memorized during my psychiatry rotation: fully one third of people in developed countries are depressed at some point in their lives. Which of course brings up two questions: one, is there something about our lives that makes us this way; and two, are we just giving a name to something natural in order to sell something? These questions can (and should) be broadened to include most diseases, in the mind of the doctor.

I think ADHD is almost certainly over diagnosed, in a culture averse to the time commitment involved in raising children. It was frightening on my peds rotation to hear mothers say (and I heard it twice, in two weeks of clinic): "I just want you to give him something so he'll sit still." Um, hello, you have a 5 year old boy, sitting still is the last thing on his mind when he's not in school. Why don't you take him to the playground and let him run around instead of giving him an XBox to teach him that immediate gratification is a universal, and drugging him up for the occasions when he finds that isn't true? Sometimes I think the surest case for our culture being locked in a death spiral is the fact that we spend millions of dollars on getting children addicted to amphetamines.

A long time ago, the ending of a Choose Your Own Adventure novel I read had the protagonist wind up attached a machine that kept him warm and comfortable, but trapped, for the rest of time. Periodically he would be lowered into a warm pool and forced to swim, keeping his muscles from atrophying, but otherwise, the warm, senseless oblivion was all he would know forever. For the majority of people, this vision, I am afraid, seems less like a nightmare and more like a paradise every day.

Shaka and Surgeons

I have read (though it may not be true) that Zulu fighting regiments killed their own wounded if they were no longer able to keep up with the relentless pace held by the impi. And relentless it was. Zulu regiments would cover 100 miles over three days of campaigning, with a large battle thrown in there somewhere. The point here though, is not military history. The point is, anyone who doubts this capacity to turn on one's own, those who have fought and endured beside you, has never sat in the surgery intern's call room in a large hospital while the occupants discoursed on their brethern.

It is often true in surgery programs than not everyone makes it. Many programs accept more interns than they intend to graduate, realizing that not everyone can hack it. This used to be institutionalized, with the programs stating up front that they would not allow all the interns to progress, turning the already stressful intern year into a competition between, say, eight hapless souls for five spots. Thankfully, this is now illegal, but still, surgery programs do not have a 100% graduation rate.

As the interns warmed to their subject, they became very specific, pointing out the faults or strengths they saw in their classmates who had dropped out, or even in the residents and staff ahead of them. Most of the faults were unsurprising, and it was fascinating to see how willing how willing these doctors were to forgive almost any fault in someone decisive and thick-skinned. Dr. Neversmile, for instance, came up and was "pretty damn talented" or "gotta respect him." Even my former chief resident, aptly decribed by one of the interns as having his "default set to hating people" was not castigated further, because he is a "solid surgeon." But one of their classmates who dropped out was described in language that was ridiculously over the top. I've never met the individual, so I can't speak to the truth of the calumnies, but as soon as they all agreed that this person was "not decisive" and "thin skinned" anything was fair game. (full disclosure, the single vulgar word used for "thin skinned" was one I am not real comfortable typing out.)

The strongest language denouncing another resident I heard in my residency of choice was "weak." Medicine is a very intellectual specialty, so there is a lot more emphasis on thinking than on action, but more essentially medicine docs are not as "cool" as surgeons. Now medical school isn't exactly a random sampling of spectators at TRL, but there are always people everyone wants to be around, people everyone else wants to be like, people for whom an easy atmosphere of hip collegiality comes naturally. The kind of guys who can do those complicated handshakes without thinking about them, or looking awkward. At least, so it appears. And most of these people seem to wind up as surgeons.

Medicine is like high school, and you've got all the groups. Surgeons: the cool kids. Ortho: the football team. Nephrologists: the chess club. Neurologists: the Dungeons and Dragons kids. Ob/Gyn: the stuck up cheerleaders.
- a surgery resident


So it makes sense, to my mind, anyway, that the qualities praised in internists are different than those praised in surgeons. And it also makes sense that those who don't quite fit in, who are a bit more self-conscious, don't last long in this environment.

Though I've managed to get along with the residents here, sharing musical tastes and movie quotes, it has been an effort. And I'll be glad to move on. Tomorrow is my last full day here, and I won't be sad. Despite the stories, and the atmosphere I've attempted to convey, I haven't learned a great deal. At least about neurology.

Holistic thinking

I've been wanting to write a more substantive comment on the recent discussion ranging from here to ibid's and S. Lee's blog and back on neuroscience. Unfortunately, every time I try to string something coherent together, I am unable to express what I'm thinking. I keep returning to what one of the commenters said on ibid's post, "neuroscience is the frosting on the cake...analyze while you eat." Which, at first reading, was unsatisfactory. I thought the poster was ignoring the the issue at hand. But when I thought about it some more, I realized that's precisely the point. It is easy, I think, to become so wrapped up in details that the picture fades. As with a Magic Eye poster, you have to step back, and use the right filter, and suddenly the picture makes sense. Reality, similarly, is best appreciated holistically, and though the details are important, they are not the picture. To use another poster-metaphor, it is possible to make a photo mosaic of almost anything, using smaller, more detailed, but incomplete versions of the whole.

Returning from the world of metaphor, though the details are important to understanding, what is more important is the reality of which they are a small part. Even though the details, in this case neuroscience, may seem to give contradictory information, I am confident that the balance of reality will prevail, and that over a long enough time course, the scientists will find themselves saying, with Eliot:

We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time.

Every piece of the whole, eventually, leads us to a greater understanding of it. Einstein's famous theory may have changed the way we understand the orbit of Mercury, but it does not change the singular experience of watching that beautiful planet arrive over a ridge line just before the sunrise. Bernoulli's famous principle may have allowed us to fly, but it does not alter the wonder with which we watch a flock of geese winging south.

Though on the balance, I dislike the man, Walt Whitman reached a similar conclusion, and summarized it better than I can, when he wrote the following:

When I heard the learn’d astronomer;
When the proofs, the figures, were ranged in columns before me;
When I was shown the charts and the diagrams, to add, divide, and measure them;
When I, sitting, heard the astronomer, where he lectured with much applause in the lecture-room,
How soon, unaccountable, I became tired and sick;
Till rising and gliding out, I wander’d off by myself,
In the mystical moist night-air, and from time to time,
Look’d up in perfect silence at the stars.

We can do little less. I may know progressively more about the way my patients think, and the fact that they are crying before a procedure may tell me their amygdala is working overtime, but it doesn't change the reality that they are scared, and it doesn't change my responsibility to hold their hand and talk them through it. The reality of our perceptions is where each of us must live, and as a Christian, I must interpret that reality through the lens of Christ, who asks each of us to act as if we had free will, whether or not we truly do. He asks each of us to have compassion, whether or not that can be reduced to a set of electrochemical principles. Doing less, on the basis of conjecture, would be irresponsible and wrong. And those are two things for which we cannot write an equation. We must simply know their reality.

Thinking about neuroscience

Everybody's
talking
about
it.

To set the stage for those of my readers who do not read the blogs of the commenters here, I'll explain that of the four above links, the first two are blogs discussing the second two, which are articles. The essential question is, what are the implications for faith of neuroscience, which to hear Tom Wolfe tell it (third article), is rapidly approaching a point at which everything can be proved to be determined by our genes.

I want to write something on the topic, but S. Lee has gone and provoked a whole round of new musings, so that wil have to wait. I recommend checking out what he has to say, meanwhile.

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.

Trepidation

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.

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.

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."

Reevaluation

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.

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.

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.

...in 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.

Life

The part of life we really live is small. For all the rest of existence is not life, but merely time.

So today was my day off this week, and I spent part of the morning watching ER. I don't actually have TV at home, so when I'm away, living out of a hotel room, the novelty gets the better of me sometimes. Anyway, so I'm watching ER, and the thought came to me that yes, the heart wrenching decisions you see on a show like that are made, every day, in a hospital. But what they don't show you is the fact that sometimes, you don't even notice they are being made. There is humor and tragedy all around, but like the rest of life, if you aren't paying attention, it will pass right by you.

I think the most important moments of our lives often occur without a second thought. We don't always see them coming, and we don't necessarily notice while they are happening. It is only afterward, looking back, that we notice, and either exult or regret. Families don't think about living wills until after their loved one is comatose, and then they argue in the ICU over what is to be done. Mothers think two children is enough, and then, five years later with a new husband, listen with tears in their eyes as they are told the tubal ligation reversal didn't work, and that is all the children of their own they'll ever have.

I used to think (and maybe still do, in my conceit) that working where I do throws life into harsh perspective. That it makes each decision about life or death, and therefore more meaningful. But I'm becoming convinced, oddly enough sitting on a cheap mattress in a hotel room watching a mass market drama, that this is just life, and the perspective is what makes it meaningful.

September 11

I wasn't going to write about this day here. I don't know still that I have anything unique to add, that anything about my experience of a clear autumn day five years ago is much different than what 250 million of my fellow Americans experienced.

But I've reconsidered. I do think it is important to remember September 11, 2001. On that day, civilization itself recieved a blow from the barbarians, and just as those who sacked Rome in 476 AD, these barbarians want nothing less than the destruction of our way of life. It is important we never forget, for if civilization is to stand against barbarism, we must remember what makes us different.

I had here written a lengthy description of what I did that day. That really doesn't matter though. What matters, as I wrote for my school paper the next week, is how we respond. Yes, preservation of civilization is necessary. And yes, to defend a flock of sheep, wolves must sometimes be killed. It is important that we do not allow that killing to make us killers, and that we remember why and what we defend.

Though I wrote a poem on that day, like most poems attempted by amateurs, it isn't any good, so I'm going to close instead with some lines by a real poet, who saw the world change nearly one hundred years ago, and similarly, he recognized theat things would never be the same. He could have written this yesterday.

Never before such innocence,
Never before or since,
As changed itself to past
Without a word - the men
Leaving the gardens tidy,
The thousands of marriages
Lasting a little while longer:
Never such innocence again.

From MCMXIV, by Philip Larkin


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Delicate conversations

One of the new experiences every medical student knows is that of having his friends and family members ask for medical advice. On a certain level, this is entirely understandable, we are, after all, studying medicine in order to relate our knowledge to others (probably wiser) who haven't given ten years of their life to its study.

But on another level, this is an intensely difficult situation. Medicine deals with the most intimate secrets of a person's physical existence, and, (not being a dualist) with their most intimate spiritual secrets as well. There is a certain level of secrecy which decorum demands we keep in our interpersonal interactions, and while it is jarring enough to see beyond that veil in a stranger, with friends and relations it can be staggering. The other side of this is that, as we get more used to knowing about people, and to reading the small details which betray so much about them, a comfort with that greater level of familiarity grows. Probably this explains the propensity of physicians and other health care workers towards crude humor.

But I am being sidetracked. I was reminded of this today, but only in passing. More important than any level of personal discomfort with medical knowledge is understanding the impact medicine has on others. Most people in medical school are young, and generally healthy. To practice medicine we have to have some level of health, and sometimes we forget how important that is. It is easy to forget how scary the unknown is.

Combining the two thoughts above, today I was asked by someone I know relatively well about a fairly involved medical issue. I've long gotten used to this sort of question, and I'm not far enough in my training to have tired of it. The second point about came to mind as I did some reading before getting back to my interlocutor. With any medical problem, from hang-nails to amputations, there is a range of severity in outcome. And this range is apparent in the medical literature. It is easy, when dealing with a person about whom you did not care one way or the other before they walked into your office, to rattle off percentages, and follow them with concern and cooperation in forging a treatment plan.

When you actually know and care for the person before the serious conversation, it puts a different perspective on things. You question how frank to be, how best to couch what you say, and what effect every single word will have on their perception of the problem.

Fortunately, the problem I was being asked about has an excellent prognosis. But even that phrase "excellent prognosis" can sound like medical evasion. And in explaining it, the necessity arises of discussing worst case scenarios along with best case ones. I suddenly understood, better than ever before, the paternalistic attitude of previous generations of physicians.

But the nervousness I experienced was instructive. For I realized that I should be that concerned with every patient. I think I am empathatic, to at least some degree, but I've never been so careful to relate pro and con, positive and negative. I very much wanted to convey exactly what I knew, without causing undue concern, but without hiding anything either.

This is why medicine is the art of science.

Learning to ask questions

I signed up to be a student interviewer for the incoming class of 2011, and today was the training class for interviewers. I was most impressed by one point the instructor made. She encouraged us to ask difficult, controversial questions of the applicants, just to see that they can think on their feet, etc. But she added, "the one question you aren't allowed to ask is anything relating to abortion." I was rather mystified. But rules are rules. The other great line, she said "please reserve a ranking of 1 (the highest we can award an interviewee) for someone who walks on water, leaves you breathless, and is generally everything you could possibly desire from an applicant."

I'm excited about interviewing though. I love my school, and I look forward to having some say in what its future looks like. I'm also looking forward to asking odd questions. When I prepped for med school interviews, we were told to be prepared for such off the wall questions as "who won the 1968 World Series" or "Who do you think killed JFK?" But no one ever asked me any odd questions. The hardest one I got was "what historical figure would you most like to meet and why?" I think that interviewer will probably always remember me, because my answer, with only a second's pause, was "Genghis Khan." That was an interesting conversation.

I wasn't accepted at that school.

More to the point, I'm looking forward to the opportunity to hone my interviewing skills from the other side of the table. I've done quite a few interviews in my scholastic and professional career, and seeing all angles will probably make me better at them.

I'm reminded, in writing this, of something I read today in Dorothy Sayers' Mind of the Maker. She states "[i]t is a plain fact that ninety-nine interviews out of a hundred contain more or less subtle distortions of the answers given to questions, the questions being, moreover, in many cases, wrongly conceived for the purpose of eliciting the truth."

Here's hoping I can elicit truth effectively and fairly, without distortion.

Good thing everyone gets two interviews, eh?