Suiting up to give labor is like preparing to go to the moon, but with more blood. I have waited for this day for two months now. I break the silence of the room when I enter, as a cacophony of greeting comes from every corner. “We’ve heard so much about you Tom!” I redden and raise a hand in appreciation. It comes off awkwardly as part wave, part salute. But they get the point. My patient gushes with an enthusiasm I rarely see in her. The last time I saw such raw enthusiasm was when she jokingly threatened to blow up the clinic. This time her smile veers away from maniacal and more toward true joy. This is her day: packed in a room with four family members and a boyfriend, she is the center of it all. The family speaks of the upcoming baby lovingly, yet as a novelty item. “I hope it doesn’t have thunder-thighs like its aunt…. I wonder what color hair she will have… Will she be a gymnast or a dancer…” I wonder to myself what other possibilities there are – journalist, schoolteacher, biologist, engineer. These options are not entertained. I wonder what will happen when the baby gets home, what her first birthday will be like, what her favorite book will be.
I am both thrust into her life and distant from it. My professional boundary allows me free access to the in’s and out’s of her life in fifteen minute spurts. I am written into her history, as a page in the baby’s scrapbook, tucked in a shoe-box under the couch until holidays and anniversaries. Then I will be unearthed for discussion – “remember Tom the medical student… how he told the boys that the baby’s butt looked big on ultrasound… remember how he skipped out on work to visit after the delivery.” I wonder if she will remember that I believe in her goodness, that she is smart, that she can and will be a great mom. I want to convince her to go back to school, to go to psychotherapy, to treat her boyfriend better, to actively fight against the desire to read her history into the baby’s life. Oddly enough, everything I want for her has very little to do with her medical care. Yes, I want her to be healthy, but this is the easy part. I wonder whether I have helped her at all – whether hours of listening, friendship and consolation can be measured. I realize that I ask this question scientifically, in search of empirical evidence. Even now, I cannot escape my training – in the last three years I have been measured on everything from my ability to show empathy to calculating neuronal cell potentials. And now, in the words of a wise friend, “this becomes part of my consciousness.” I want to measure her A1C, the babies Apgar’s, her level of patient satisfaction. Yet all of this measurement doesn’t encompass the breadth of my influence.
When I think about what I hope to accomplish as a physician, I think about a few levels of change: biologic/medical change, personal growth/behavioral change and societal change. As I discuss this loosely with a child psychiatrist, he expresses to me that the heart of medicine is in the second level – it is one thing to know what to do for a patient, yet another to actually have them do it. While I agree with this sentiment, I am most fascinated by the last level. How does my patient’s underlying socio-economic conditions effect her health? More importantly, what is my role as a physician to address the underlying societal conditions that lead to her welfare, smoking, uncontrolled diabetes?
At 3am this Tuesday morning, I hold her beautiful daughter as she, her boyfriend and I watch the end of an episode on Adult Swim. For one of the first times in medical school, after memorizing tens of thousands of slides, taking hundreds of exams, and feeling like I never knew enough, I feel an arresting sense of satisfaction. In contrast to most nights of piercing anxiety, I drive home, curl up into bed, and sleep soundly.
12.12.09
6.10.09
what if?
I have been reading Erich Fromm recently and am struck by his simple and elegant depiction of humanism. I agree with him that in our age we have transferred our focus from who we want to be to what we want to do, to produce, to make. I am also struck by his conception of choice – that the best way of approaching creating a free society is to allow conditions to flourish that maximize human choice and agency.
In regards to my medical training, I am still somewhat at a loss of whether I want to do this with my life. In medicine, we ask a whole lot of questions regarding specificity and localization of pain. And yet, we never ask “what if?” When people do research in the basic sciences, they ask this question periodically to use to guide their research protocols. And then comes the hard-core scientific questioning and experimental design. As a medical student, I am never in a position to ask this question and have the time or agency to pursue an answer to it – there are just too many knowledge-based questions that get in the way of this. What if the clinic was structured to counsel patients in groups and bring in families with similar concerns? What if we followed up with patient’s in another context than a 1-year outpatient visit to ensure that they were following our recommendations? These questions interest me, but perhaps not as much as more societal questions that I feel office-based medicine fails to address. Among these are, what if we placed all of our intellectual resources into transforming not just a patient’s symptoms, but the social conditions that reinforce their poverty and pain?
I just don’t know if my participation in primary care medicine goes far enough in addressing these concerns. I am skeptical and optimistic; I feel that I am behind in thinking about my life. I am anxious that I have stopped thinking critically and creatively – that now in thinking like a doctor I will stop wondering about the potential underlying strings vibrating through a patient’s lymphoma, or whether I will look forward to lunch everyday, as opposed to desire to work through it, because it is work that sustains me. I sympathize with Fromm when he says “I believe that these men of good intention should not only arrive at a human interpretation of the world, but must point the way and work for a possible transformation. An interpretation without wish for change is useless; a change without preliminary interpretation is blind.” Right now, I am charged with the task of interpreting the world as I examine neonates, take histories from children in the emergency room, and make plans for treating kids with cerebral palsy. My ability to change their lives and the scope of the community I work with is limited in my role as a medical student. Insofar as I can teach kids on the weekends, plan after-school programs in my free time, and engage in self-dialogue about social change, I venture into the land of broad-based change. In virtue of thinking in these terms, I fall prey to conceiving of myself in terms of my consumption and production, rather than in terms of my convictions, sense of wonder, and ability to love. So, what if I focus on my convictions, wonder, curiosity, and love and see where it takes me?
In regards to my medical training, I am still somewhat at a loss of whether I want to do this with my life. In medicine, we ask a whole lot of questions regarding specificity and localization of pain. And yet, we never ask “what if?” When people do research in the basic sciences, they ask this question periodically to use to guide their research protocols. And then comes the hard-core scientific questioning and experimental design. As a medical student, I am never in a position to ask this question and have the time or agency to pursue an answer to it – there are just too many knowledge-based questions that get in the way of this. What if the clinic was structured to counsel patients in groups and bring in families with similar concerns? What if we followed up with patient’s in another context than a 1-year outpatient visit to ensure that they were following our recommendations? These questions interest me, but perhaps not as much as more societal questions that I feel office-based medicine fails to address. Among these are, what if we placed all of our intellectual resources into transforming not just a patient’s symptoms, but the social conditions that reinforce their poverty and pain?
I just don’t know if my participation in primary care medicine goes far enough in addressing these concerns. I am skeptical and optimistic; I feel that I am behind in thinking about my life. I am anxious that I have stopped thinking critically and creatively – that now in thinking like a doctor I will stop wondering about the potential underlying strings vibrating through a patient’s lymphoma, or whether I will look forward to lunch everyday, as opposed to desire to work through it, because it is work that sustains me. I sympathize with Fromm when he says “I believe that these men of good intention should not only arrive at a human interpretation of the world, but must point the way and work for a possible transformation. An interpretation without wish for change is useless; a change without preliminary interpretation is blind.” Right now, I am charged with the task of interpreting the world as I examine neonates, take histories from children in the emergency room, and make plans for treating kids with cerebral palsy. My ability to change their lives and the scope of the community I work with is limited in my role as a medical student. Insofar as I can teach kids on the weekends, plan after-school programs in my free time, and engage in self-dialogue about social change, I venture into the land of broad-based change. In virtue of thinking in these terms, I fall prey to conceiving of myself in terms of my consumption and production, rather than in terms of my convictions, sense of wonder, and ability to love. So, what if I focus on my convictions, wonder, curiosity, and love and see where it takes me?
30.9.09
Getting lost in the woods...
The clouds hang like hot dogs above the treeline: horizontal, bursting with yellows and oranges. As dusk sets the yellow faded to pinks, then deep purples. We walk with no direction or timeline. I try my hand at navigating the woods, and orient my mental compass at every divergence. Yet the woods are too impenetrable and windy. So we focus on the basketball sized fungus protruding up at us, glimpses of the hiding sun, and plastic deer sculptures. What if I walked like this everyday? My abstract freedom comes at the cost of geographic certainty. The sun is truly setting. It is cold.
We reach an outlet to a New England suburban street: through the window of a two-story family house, the silouette of a father setting the table with his two children. We are still directionless, yet bound by the time of the night. Treehouses, barns, and mangy dogs greet us, and point us toward streetlights of civilization. And then, a highway – Mack’s truckhouse, and cars blazing at 60 with no shoulder to walk on. I want to keep walking until my feet hurt so much they blaze. I want to explode my narrowness, like when I read Kerouac and dreamed only of mountain sunsets and driving fast.
I sink awkardly into a cool metal fench, as I watch the traffic on Route 20. We are close enough to the road for motorcyles mufflers to pierce our ears, but far enough away to be unnoticable for the common passerby. This is good, we decide, as were anyone to see us here – two future medical professionals, we might lose what little reputation we have. She meditates with seamless ease. I try, but as usual, am bombarded by an overactive mind. What if I walked like this everyday?
We reach an outlet to a New England suburban street: through the window of a two-story family house, the silouette of a father setting the table with his two children. We are still directionless, yet bound by the time of the night. Treehouses, barns, and mangy dogs greet us, and point us toward streetlights of civilization. And then, a highway – Mack’s truckhouse, and cars blazing at 60 with no shoulder to walk on. I want to keep walking until my feet hurt so much they blaze. I want to explode my narrowness, like when I read Kerouac and dreamed only of mountain sunsets and driving fast.
I sink awkardly into a cool metal fench, as I watch the traffic on Route 20. We are close enough to the road for motorcyles mufflers to pierce our ears, but far enough away to be unnoticable for the common passerby. This is good, we decide, as were anyone to see us here – two future medical professionals, we might lose what little reputation we have. She meditates with seamless ease. I try, but as usual, am bombarded by an overactive mind. What if I walked like this everyday?
12.5.09
thoughts on medicine and social justice...
I’m burned out with school, but damn I need to start studying for the boards. Today was my equivalent of Sunday – I went to the Teach for America Boston event, talked to Aaron and then Cari for a few hours, while getting a modicum of work done. Life is going to become much more interesting very soon. I’m excited! As for where I am at with the doctor-teacher crisis, I feel in as good a place as ever. I’m convinced that what I’m doing now, if authentic and heartfelt, can only help what I want to do in the future. The future is a big place, which is very unpredicable, including what I may end up doing. I love the idea of spearheading an educational program somewhere – at a high school, community college, medical school, and then to take these skills and apply them to an urban school system context. And yet here I am studying medicine.
A few things that I’ve been pondering:
-How are we to define systemic change that closes the acheivment gap? We (Teach for America) say we are doing this in fields like medicine and law, but how to we quantify this? Should this be quantified?
-How do issues of nutrition, physical activity, access to health care impact our students? What is the physican’s role in this? Where is an acceptable sphere of influence beyond the scope of the office visit?
-If the key lever to fighting poverty is education, how do we prioritize access to health care? I realize that these are both human rights, but how are they intertwined?
-What is the role of medical professionals as advocates in schools?
What is unique about the role of a physician is the ability to be a source of scientific knowledge and emotional support through times of great vulnerability. To do this authentically, you have to believe in the inherent value of all lives, be comfortable with assisting patients in learning how to cope with illness, and to know that much of your impact on their lives will be on their emotional landscape and how they conceptualize illness, suffering, and their physical condition. After hearing the speaker at the Teach for America event tonight, I realized that for me, while I value these ethics, I feel called/compelled/drawn to the transformative capacity of education as a means of social change. The speaker spoke dramatically about the role of his teachers in his future successes, and argued that we have the ability to change the world tomorrow, not in five years, or ten years down the line. While I believe strongly in health as a human right and working with suffering, I feel personally drawn to the stories of my students – to Tony, Juan, Shakina, and Travis, who approach the world differently after being in my classroom. I’m curious to see what transformative process is possible in medicine. At the same time, I am aware that its aims are different: to minimize suffering, affirm humanity, rather than to invite dialogue, create knowledge, figure out one’s direction and change the course of one’s life.
A few things that I’ve been pondering:
-How are we to define systemic change that closes the acheivment gap? We (Teach for America) say we are doing this in fields like medicine and law, but how to we quantify this? Should this be quantified?
-How do issues of nutrition, physical activity, access to health care impact our students? What is the physican’s role in this? Where is an acceptable sphere of influence beyond the scope of the office visit?
-If the key lever to fighting poverty is education, how do we prioritize access to health care? I realize that these are both human rights, but how are they intertwined?
-What is the role of medical professionals as advocates in schools?
What is unique about the role of a physician is the ability to be a source of scientific knowledge and emotional support through times of great vulnerability. To do this authentically, you have to believe in the inherent value of all lives, be comfortable with assisting patients in learning how to cope with illness, and to know that much of your impact on their lives will be on their emotional landscape and how they conceptualize illness, suffering, and their physical condition. After hearing the speaker at the Teach for America event tonight, I realized that for me, while I value these ethics, I feel called/compelled/drawn to the transformative capacity of education as a means of social change. The speaker spoke dramatically about the role of his teachers in his future successes, and argued that we have the ability to change the world tomorrow, not in five years, or ten years down the line. While I believe strongly in health as a human right and working with suffering, I feel personally drawn to the stories of my students – to Tony, Juan, Shakina, and Travis, who approach the world differently after being in my classroom. I’m curious to see what transformative process is possible in medicine. At the same time, I am aware that its aims are different: to minimize suffering, affirm humanity, rather than to invite dialogue, create knowledge, figure out one’s direction and change the course of one’s life.
11.1.09
Where's waldo?
I found myself at the gathering of the 8th annual Pantless Subway Ride in New York this weekend. This is among one of my favorite photos from the event. For those who haven't witnessed my impeccable, polished fashion sense, I am wearing a blue/white scarf and a striped winter hat. As I hope to one day have a job and practice medicine someday, please note this picture neither confirms nor denies the visibility of my undergarments.
What You Don’t Know Won’t Hurt You
This is one of the final pieces I wrote for my Creative Writing elective. The assignment was to write a piece from the perspective of a patient.
What You Don’t Know Won’t Hurt You
John Kerry and Edward Kennedy are looking out for me. I wrote them a letter about my condition, and they will – I mean, will help me out. I know you don’t believe me doctor. I may be mad, but I know that looks in your eyes, how you move your shoulders down like that when you try to listen to me but can’t. And how you roll your chair back. Yeah, like that.
And why is this medical student in here – he’s a waste of my time. I told him everything for thirty mintues when I could have been talking to you. My head rages and you still do nothing for me. Fine. Fine. I know I let him interview me, okay. But my head has been raging for minutes, hours. I have fibromalagia you tell me, but I really don’t. I DON”T. I still have Lyme in me, and maybe you don’t believe me doc, but I do. They can’t see it in my system. It lurks like mist on gravestones. It’s there. I’m going next week to Connecticut and the specialist will find it – he has a test for it, you know. And Kennedy, he got my letter. He’s out of the hospital now and is on my side.
And when the specialist tells me, finally, the truth, at least I will know. I may not feel better, but at least I’ll know it was Lyme from the start, and the other docs will stop fucking me around anymore. And if I’m wrong? How dare you ask me that? I think, but can’t say. You’re lucky you’re my Doc, to be able to say stuff like that to me. I’ll go on my way. If this test comes back negative, I’m done. I’ll do whatever you say after this. But I have a feeling about this guy. It’s been two years you know. My bones ache, my migraines pound my head in every day. And still they don’t believe us.
You think – ah, I see, you think this is like last time. That this is just another one of my “crusades?” I remember that. No. Last time, it should have worked out. I knew it could. My partner just screwed it all up. I had the equipment sent to my home – but he never did shit. I had to do it all. 40 grand. And what do I have now?
Yeah, you did? You read the article I gave you. You should have because it’s the truth. I see your head nodding but it still does nothing for me. I’m still going to Connecticut. What’s that? You will support anything I do that I think will make me better? Well, okay. And my meds – I’m taking them allright but they’re not working. My diabetes – fine. My hand is shaking, Doc. I think I need a drink, but can’t tell you this. I need my home back.
Edward Kennedy knows about me. I called his office. My letter is seven pages – I typed it out last night. I sent him the article. And this doctor, he’s not like the rest. He’s a Harvard doc, he knows. So you’re happy for me? You think this might be it for me? It might help bring things together? You know too. I need my meds. And my cab – is it here yet?
I patient gruffly shakes my hand, and is off. Back in the office, I exchange looks with my preceptor – a mutual look simulaneously confirming our ignorance and intrigue. I muddle through the 5-minute consult book on the etiology of fibromyalgia. Meanwhile, my preceptor starts dictating the visit. She begins, “This was a thirty-minute consult, more than 50% of which was spent counseling the patient.” If only this told us anything about our patient.
What You Don’t Know Won’t Hurt You
John Kerry and Edward Kennedy are looking out for me. I wrote them a letter about my condition, and they will – I mean, will help me out. I know you don’t believe me doctor. I may be mad, but I know that looks in your eyes, how you move your shoulders down like that when you try to listen to me but can’t. And how you roll your chair back. Yeah, like that.
And why is this medical student in here – he’s a waste of my time. I told him everything for thirty mintues when I could have been talking to you. My head rages and you still do nothing for me. Fine. Fine. I know I let him interview me, okay. But my head has been raging for minutes, hours. I have fibromalagia you tell me, but I really don’t. I DON”T. I still have Lyme in me, and maybe you don’t believe me doc, but I do. They can’t see it in my system. It lurks like mist on gravestones. It’s there. I’m going next week to Connecticut and the specialist will find it – he has a test for it, you know. And Kennedy, he got my letter. He’s out of the hospital now and is on my side.
And when the specialist tells me, finally, the truth, at least I will know. I may not feel better, but at least I’ll know it was Lyme from the start, and the other docs will stop fucking me around anymore. And if I’m wrong? How dare you ask me that? I think, but can’t say. You’re lucky you’re my Doc, to be able to say stuff like that to me. I’ll go on my way. If this test comes back negative, I’m done. I’ll do whatever you say after this. But I have a feeling about this guy. It’s been two years you know. My bones ache, my migraines pound my head in every day. And still they don’t believe us.
You think – ah, I see, you think this is like last time. That this is just another one of my “crusades?” I remember that. No. Last time, it should have worked out. I knew it could. My partner just screwed it all up. I had the equipment sent to my home – but he never did shit. I had to do it all. 40 grand. And what do I have now?
Yeah, you did? You read the article I gave you. You should have because it’s the truth. I see your head nodding but it still does nothing for me. I’m still going to Connecticut. What’s that? You will support anything I do that I think will make me better? Well, okay. And my meds – I’m taking them allright but they’re not working. My diabetes – fine. My hand is shaking, Doc. I think I need a drink, but can’t tell you this. I need my home back.
Edward Kennedy knows about me. I called his office. My letter is seven pages – I typed it out last night. I sent him the article. And this doctor, he’s not like the rest. He’s a Harvard doc, he knows. So you’re happy for me? You think this might be it for me? It might help bring things together? You know too. I need my meds. And my cab – is it here yet?
I patient gruffly shakes my hand, and is off. Back in the office, I exchange looks with my preceptor – a mutual look simulaneously confirming our ignorance and intrigue. I muddle through the 5-minute consult book on the etiology of fibromyalgia. Meanwhile, my preceptor starts dictating the visit. She begins, “This was a thirty-minute consult, more than 50% of which was spent counseling the patient.” If only this told us anything about our patient.
do I ever muse about anything funny?
My good friend Cari informed me that whenever she reads my blog, she feels like jumping off a very tall building. In an effort to address this somewhat sobering criticism, I considered incoporating more bodily humor into my posts. I am still working on a post offering fart jokes, but this will have to do for now.
Twenty Things I hope Never To Do In My Medical Career
1) After getting back blood work from a patient, exclaim to them “That’s the most fascinating case of [insert obscure idiopathic disease here] I have ever seen.”
2) Say “Oops”
3) After describing a patient in an editorialized story, lament “I then realized that [insert tragic name here concealing identity of real patient – Willie, Cletus, Sallie Jane, Alfonzo] was more than his symptoms.”
4) While cleaning out someone’s ear canal for the 100th time, think to myself “this is why I went into medicine” – and actually mean it
5) Practice exclusively in the United States
6) To my patient with chronic illnesses, instruct “If you had been compliant with your medications, none of this would have ever happenned.”
7) Ever use the expression, “Care to go out for a drink later?” or “Sorry, I wasn’t listening”
8) On Memorial Day, tell my last patient “You’ll have to come back tomorrow, I need to get on the Pike to beat beach traffic to get to my 2nd home”
9) To a jaded medical student, tell him “I can’t do anything about that sebaceous cyst of yours, until you scratch it out of your face in the next mindnumbingly boring pathology lecture. Then, I may be able to refer you to a plastic surgeon… but we’ll have to talk.”
10) To a 30 year-old woman on a routine visit, say “Congratulations, when are you expecting?” Followed by a few seconds of akward silence, and subsequent menacing glare of said patient
11) Cut corners
12) While giving a lecture to medical students, use more than one cartoon from the Farside to inject humor into my lecture
13) While talking to anyone, under any circumstances, muse “back when I was in medical school…” and continue talking uninteruppted for more than thirty seconds
14) Wear tan khakis, a blue blazer from Brooks Brothers, mocassions, and a “wacky tie” that really shows my creative personality
15) Become interested in yachts, sailboats, hunting, or Republicans
16) Enter private practice to make more money
17) During a bimanual vaginal/rectal exam, engage in a discussion with my patient about “how I can practice this with my girlfriend.”
18) Write a book about how my anatomy lab dissection changed my life
19) Tell my patients how to grieve
20) Lose my sense of humor
Twenty Things I hope Never To Do In My Medical Career
1) After getting back blood work from a patient, exclaim to them “That’s the most fascinating case of [insert obscure idiopathic disease here] I have ever seen.”
2) Say “Oops”
3) After describing a patient in an editorialized story, lament “I then realized that [insert tragic name here concealing identity of real patient – Willie, Cletus, Sallie Jane, Alfonzo] was more than his symptoms.”
4) While cleaning out someone’s ear canal for the 100th time, think to myself “this is why I went into medicine” – and actually mean it
5) Practice exclusively in the United States
6) To my patient with chronic illnesses, instruct “If you had been compliant with your medications, none of this would have ever happenned.”
7) Ever use the expression, “Care to go out for a drink later?” or “Sorry, I wasn’t listening”
8) On Memorial Day, tell my last patient “You’ll have to come back tomorrow, I need to get on the Pike to beat beach traffic to get to my 2nd home”
9) To a jaded medical student, tell him “I can’t do anything about that sebaceous cyst of yours, until you scratch it out of your face in the next mindnumbingly boring pathology lecture. Then, I may be able to refer you to a plastic surgeon… but we’ll have to talk.”
10) To a 30 year-old woman on a routine visit, say “Congratulations, when are you expecting?” Followed by a few seconds of akward silence, and subsequent menacing glare of said patient
11) Cut corners
12) While giving a lecture to medical students, use more than one cartoon from the Farside to inject humor into my lecture
13) While talking to anyone, under any circumstances, muse “back when I was in medical school…” and continue talking uninteruppted for more than thirty seconds
14) Wear tan khakis, a blue blazer from Brooks Brothers, mocassions, and a “wacky tie” that really shows my creative personality
15) Become interested in yachts, sailboats, hunting, or Republicans
16) Enter private practice to make more money
17) During a bimanual vaginal/rectal exam, engage in a discussion with my patient about “how I can practice this with my girlfriend.”
18) Write a book about how my anatomy lab dissection changed my life
19) Tell my patients how to grieve
20) Lose my sense of humor
Subscribe to:
Posts (Atom)
