"There are studies that look at the factors determining prognosis after cardiac arrest. The most important thing is to determine whether his brainstem is working. There are some reflexes we test, and he had two of them. When we shine a light in his eyes, the pupils get smaller. When we put water in his eyes, he blinks. Two of the reflexes, he didn't have. When we moved his mouth tube, he didn't cough. When we put water in his ears, his eyes didn't move in the direction we would expect. Based on these, his chance of recovery is small. I know this is a really emotional time for you. But I want to be factual, and blunt, and I don't want to lie to you. I also don't want to take away hope. We will check him again when 72 hours have passed since he collapsed, and after all the effects of the sedative drugs we've given him have worn off."
One is thin and able to stiffen herself before hearing, such that her back is as straight as her lips except for at the corners, holding herself against the possibilities, and never releases. The other talks.
..."We've heard of people who have strokes, and their brain has been damaged, but afterwards they recover somehow and are still able to use their brain...?"
"The brain can't regenerate. When one part of the brain is damaged, the rest of the brain that is still working uses other pathways to recover. With a stroke it is usually one part of the brain that's affected. The difference with him is that his brain has been globally affected by the loss of oxygen. We will have to see how much of the brain was affected."
..."We'll test him again on day 3...?"
"Yes." Turning to walk away, he remembers: "And don't talk in front of him. We don't know how much he hears."
****
He's been on three Vietnam tours, and when he returned, he was knocked off a telephone pole by a haphazard car navigated by two underage drivers who too small to reach the pedals with feet used their hands instead, hit by said car, and dragged by said car. He broke too much for me to remember. Eighteen months in the hospital and forty years later, he speaks to all of us with salted candor and a sweetness more tactile than his bristly face.
****
Today someone mentions him, "...if he survives and makes it..."
When we first saw him in the morning, his daughter is sitting next to him reading Harry Potter. We subject him to all sorts of random maneuvers; he's not completely aware but he tries to oblige. He really, really tries. When we see him in the afternoon he's still intubated and can't speak, and his arms are tied to the bed. He intermittently nods in response. He tries to write, but in the end there's no communication. We ask him to do more sorts of things, the majority of which the confines of this place restrict him from doing. Open your mouth, say ahhh. Squeeze my fingers. He lends himself to us, for whatever it is that we're doing. When we applaud a task completed (he keeps his arms up against our pressure, he presses his feet down on our hands)--"Great!!"--and break out unconsciously in smile, he raises and shakes his fists in victory. Sometimes he rewards us with a thumbs up in both hands. When we shake his hand goodbye, he holds on tight. When we let go, he grabs again and squeezes long and tight, and the brave tenderness wraps around. When asked if he likes the classical music his family has left playing for him, he smiles around his tube, his teeth releasing the plastic and revealing the dark space of his mouth.
Tuesday, August 25, 2009
Monday, August 17, 2009
physicality
Hepatic sinusoidal obstruction. Encephalopathy. Hypoglycemia. Sepsis. Hypotension. Lactic acidosis. Intubation. Multiple organ failure.
Prepositions strung these words together, a litany of the goings-on in her body and what ultimately took her life. Having a slight sense of what these mean, the words were bullets. Instead of blood, they drew salted water. It can never be as visceral as it is for a person whose physical life is slipping, but it reminds us that it is visceral, and today I felt that maybe that's part of what they mean when they speak of all this as a gift. We tend to polarize, sometimes focusing on the science and other times emphasizing the emotions, with elbows nudging us to meld the two. In between lies something less lectured, less considered, equally present--physical sensations, from which so much flows.
I started my neurology rotation today, and we began by observing neurological exams on a couple of patients. Neurology more than other disciplines draws quite a bit from the physical exam; you can often localize what part of the brain has been damaged by what part and side of the body can't move, or what the person can't say. The brain is the center of complex feeling and thought; it's also the source of tactile sensation and bodily movement, and to me this can often be the most touching loss.
One test requires a person to close their eyes. Without visual balance, one should still be able to center themselves. When our patient closed his eyes, I heard a gasp slide from the classmate behind me. When our patient closed his eyes, he swayed to his right side, and had we not known this to be a possibility, he would have fallen. One way to treat his condition, which causes vertigo because deposits in the inner ear dislocate and end up in the wrong place, is to rotate your head and roll your body in various directions, to shift the deposits back into place. We marveled at this cure, so simple beside the antibiotics whose names I can rarely remember and the surgeries involving anatomy I often can't visualize.
A bit later we observed our first stroke code, meaning the standardized protocol when a person is suspected of suffering from stroke. Aside from the acute event, she had a past medical history of HIV, hepatitis C, breast cancer with metastases to the liver, COPD, and obesity. The four of us, students with nothing to do but watch, huddled in the corner but there was no way not to be in the way. Red stained needles and whatnots fell to the floor inches from us and we were benignly smacked as people went to and from a corner of the ED made flimsily separate with shoddy curtain. As all this went on, a doctor spoke loudly in the woman's ear: Close your eyes. Open your eyes. Stick out your tongue. Say your name. Lift your arm, and hold it there. There is a point system that adds up a person's ability to follow these commands and thereby determines how dire the state of a person's consciousness is. There's no modesty, much noise, and carved out among this are the listless failures of a body to move.
For fatal cancer, for benign vertigo, for someone in limbo--it can be these everyday sensations that are stolen, and sometimes never given back. A friend of Natasha told us in Natasha's words how she felt about her cancer, and she said this when she had relapsed: lucky, without regrets or a wish to turn back time and eradicate the experience. Because of it, she felt beyond what she called earthly, and I believe that must paradoxically be some kind of sensation too. We talk a lot about feeling happy, what seems a communal and obvious and ever elusive goal. It seems to me that between the innate and fragile capacity to feel the "earthly," and the "beyond" that we acquire and earn--there lies the most honest, coveted desire to merely feel.
Prepositions strung these words together, a litany of the goings-on in her body and what ultimately took her life. Having a slight sense of what these mean, the words were bullets. Instead of blood, they drew salted water. It can never be as visceral as it is for a person whose physical life is slipping, but it reminds us that it is visceral, and today I felt that maybe that's part of what they mean when they speak of all this as a gift. We tend to polarize, sometimes focusing on the science and other times emphasizing the emotions, with elbows nudging us to meld the two. In between lies something less lectured, less considered, equally present--physical sensations, from which so much flows.
I started my neurology rotation today, and we began by observing neurological exams on a couple of patients. Neurology more than other disciplines draws quite a bit from the physical exam; you can often localize what part of the brain has been damaged by what part and side of the body can't move, or what the person can't say. The brain is the center of complex feeling and thought; it's also the source of tactile sensation and bodily movement, and to me this can often be the most touching loss.
One test requires a person to close their eyes. Without visual balance, one should still be able to center themselves. When our patient closed his eyes, I heard a gasp slide from the classmate behind me. When our patient closed his eyes, he swayed to his right side, and had we not known this to be a possibility, he would have fallen. One way to treat his condition, which causes vertigo because deposits in the inner ear dislocate and end up in the wrong place, is to rotate your head and roll your body in various directions, to shift the deposits back into place. We marveled at this cure, so simple beside the antibiotics whose names I can rarely remember and the surgeries involving anatomy I often can't visualize.
A bit later we observed our first stroke code, meaning the standardized protocol when a person is suspected of suffering from stroke. Aside from the acute event, she had a past medical history of HIV, hepatitis C, breast cancer with metastases to the liver, COPD, and obesity. The four of us, students with nothing to do but watch, huddled in the corner but there was no way not to be in the way. Red stained needles and whatnots fell to the floor inches from us and we were benignly smacked as people went to and from a corner of the ED made flimsily separate with shoddy curtain. As all this went on, a doctor spoke loudly in the woman's ear: Close your eyes. Open your eyes. Stick out your tongue. Say your name. Lift your arm, and hold it there. There is a point system that adds up a person's ability to follow these commands and thereby determines how dire the state of a person's consciousness is. There's no modesty, much noise, and carved out among this are the listless failures of a body to move.
For fatal cancer, for benign vertigo, for someone in limbo--it can be these everyday sensations that are stolen, and sometimes never given back. A friend of Natasha told us in Natasha's words how she felt about her cancer, and she said this when she had relapsed: lucky, without regrets or a wish to turn back time and eradicate the experience. Because of it, she felt beyond what she called earthly, and I believe that must paradoxically be some kind of sensation too. We talk a lot about feeling happy, what seems a communal and obvious and ever elusive goal. It seems to me that between the innate and fragile capacity to feel the "earthly," and the "beyond" that we acquire and earn--there lies the most honest, coveted desire to merely feel.
Wednesday, August 12, 2009
gone
During an episode of Scrubs the other day in which the show quoted the statistic that 1 in 3 hospitalized patients die, J. asked me whether I identified more with the characters now that we were on the wards. I replied that I haven't had enough comparable experience to really empathize more than anyone else. We were talking about this again today, and J. mentioned how she's learned that one's person tragedy affects so many, often touching far beyond those who knew the person.
Two and a half hours after that conversation we received news that Natasha Collins, a student in the class below ours who has been battling an aggressive form of leukemia, has passed away.
Several months ago her class began a national bone marrow drive to find her a donor, and the registry was overwhelmed by the response and support. Friends to whom I've passed on the message did the same, and followed her story as one intimate to them. Because of the concerted effort of her loved ones, and the accumulated reaching out of strangers, she received a transplant last month. Earlier this month, she battled an infection with more perseverance than any of her doctors had anticipated, getting through in a few days what we'll spend the rest of our lives questioning, imagining, considering, without knowing. Today she passed away.
As with the passing of Mila, who I also didn't know, during our first year, I'm stunned by how deeply we're affected, how communal a community is, and how far commonality extends. Back then I was also surprised by how much was connected by this tragedy, these ever prevalent and recurring themes that seep into daily life, thrown into hard relief by the suddenness of something gone.
At the end of the show, the three main characters are each faced with a patient in danger of dying; three split screens fill the television, and for a split second we wonder who it will be: which 1 of the 3? In the end, all three pass. Because statistics are just numbers, and some days it will be more and some days it will be less. Each time, it will feel much bigger than 1 in 3; each time it will feel like there has just been one--correctly so--and now it is gone.
As with anything gone, we're left to remember and to continue better, for what they've given in passing. No one day, no one endeavor, carries the depth of strength that she showed, that having never touched her, we could feel carried from her air to ours. And so there is reason to continue.
Two and a half hours after that conversation we received news that Natasha Collins, a student in the class below ours who has been battling an aggressive form of leukemia, has passed away.
Several months ago her class began a national bone marrow drive to find her a donor, and the registry was overwhelmed by the response and support. Friends to whom I've passed on the message did the same, and followed her story as one intimate to them. Because of the concerted effort of her loved ones, and the accumulated reaching out of strangers, she received a transplant last month. Earlier this month, she battled an infection with more perseverance than any of her doctors had anticipated, getting through in a few days what we'll spend the rest of our lives questioning, imagining, considering, without knowing. Today she passed away.
As with the passing of Mila, who I also didn't know, during our first year, I'm stunned by how deeply we're affected, how communal a community is, and how far commonality extends. Back then I was also surprised by how much was connected by this tragedy, these ever prevalent and recurring themes that seep into daily life, thrown into hard relief by the suddenness of something gone.
At the end of the show, the three main characters are each faced with a patient in danger of dying; three split screens fill the television, and for a split second we wonder who it will be: which 1 of the 3? In the end, all three pass. Because statistics are just numbers, and some days it will be more and some days it will be less. Each time, it will feel much bigger than 1 in 3; each time it will feel like there has just been one--correctly so--and now it is gone.
As with anything gone, we're left to remember and to continue better, for what they've given in passing. No one day, no one endeavor, carries the depth of strength that she showed, that having never touched her, we could feel carried from her air to ours. And so there is reason to continue.
Monday, August 10, 2009
failures
During the first two years of med school, we went to the hospital each week and interviewed a patient. I liked the conversation and experience, and disliked never seeing them again, especially since the interaction was purely for the purpose of teaching us; we weren't involved in their care in any way. So it always felt a bit one-sided, and I mentioned a few times to people that I disliked the drop-in feel to it. I interviewed one patient who asked me to come back and say hello; he came back to the hospital regularly for chemotherapy. Given this chance, I thought I'd actually have something to offer. So I had my first (and only, at least before the wards started) second visit with a patient; we talked for a bit and planned to talk again right before winter break. But when I came back with chocolates to share for the holidays, he wasn't there; the chemo must've been re-scheduled. I checked one more time the next morning, but wasn't there. That day I went home for a few weeks, immersed in chaotic family friends and studies, and came back to more chaos of second semester of second year. In the midst of it, I kept thinking I should go back and see how he was, knowing that he was supposed to undergo an operation right after break. But I was perpetually tired and busy, and in the moments in between that I was lazy. So I never did see him again, and since his cancer didn't have a great prognosis I'm left with mostly doubts. I still have the chocolates, keeping them as both a trivial means of assuaging my guilt and a reminder of my failure to actually take the opportunity to do what I say I'd like to.
I was reminded of this today, when I saw a teenager with strep. Despite my very recent post about how we should read patients' charts, especially in primary care which is ideally continuous care, and address chronic issues at each appointment--I've already fallen into the established routine, of reading the two-line chief complaint written in by the nurse upon the patient's arrival, and checking the chart and problem list only when seeking certain information. Despite my confusion about why we don't ask about a patient's depression each time they come in, for something like back pain, I don't think to consider that each new patient I see might have similar problems. Despite my discomfort with purely focused physical exams and our school's emphasis on observation, I get caught up in the problem at hand and today, the red throat caught my attention more than other concerning findings. It's not that I missed them; I saw them, and for whatever reason, made in a half-second the decision not to inquire further. After the patient had already left, I looked at her chart again and discovered that this was a recurrent, chronic problem. To be fair, it wasn't listed in her problem list, an issue I brought up before, so I had to write that in, but it was in several notes from her previous visits. This is the sort of thing I've so recently thought and wrote so much about, the need for follow-up and detailed, wholistic care. I neglected the opportunity to address it, and not because I didn't have time--as a student the only thing I have more of than doctors and nurses is time--but just because in three weeks of outpatient care I've fallen into a habit of sacrificing depth. It's not that there haven't been models of comprehensive care; I've found the PCPs to be incredibly caring and mindful. It's the pace of things, and the necessary narrowing of things, that pervades all of current healthcare that has become practice even despite my mental barrier to it.
I hope hard that these experiences remind me not to repeat the same mistakes, and push me to try harder, because I'm disheartened that they happened so early on when we're supposedly at the height of energy and time. And it's okay, don't comfort me! I know we're all hard on ourselves; this isn't so much for the present me as the future me.
In the end I wrote out my first prescription (penicillin), asked our social worker to give her a call and follow-up, and stared at her chart for half an hour. It felt about as empty as not eating the chocolate.
I was reminded of this today, when I saw a teenager with strep. Despite my very recent post about how we should read patients' charts, especially in primary care which is ideally continuous care, and address chronic issues at each appointment--I've already fallen into the established routine, of reading the two-line chief complaint written in by the nurse upon the patient's arrival, and checking the chart and problem list only when seeking certain information. Despite my confusion about why we don't ask about a patient's depression each time they come in, for something like back pain, I don't think to consider that each new patient I see might have similar problems. Despite my discomfort with purely focused physical exams and our school's emphasis on observation, I get caught up in the problem at hand and today, the red throat caught my attention more than other concerning findings. It's not that I missed them; I saw them, and for whatever reason, made in a half-second the decision not to inquire further. After the patient had already left, I looked at her chart again and discovered that this was a recurrent, chronic problem. To be fair, it wasn't listed in her problem list, an issue I brought up before, so I had to write that in, but it was in several notes from her previous visits. This is the sort of thing I've so recently thought and wrote so much about, the need for follow-up and detailed, wholistic care. I neglected the opportunity to address it, and not because I didn't have time--as a student the only thing I have more of than doctors and nurses is time--but just because in three weeks of outpatient care I've fallen into a habit of sacrificing depth. It's not that there haven't been models of comprehensive care; I've found the PCPs to be incredibly caring and mindful. It's the pace of things, and the necessary narrowing of things, that pervades all of current healthcare that has become practice even despite my mental barrier to it.
I hope hard that these experiences remind me not to repeat the same mistakes, and push me to try harder, because I'm disheartened that they happened so early on when we're supposedly at the height of energy and time. And it's okay, don't comfort me! I know we're all hard on ourselves; this isn't so much for the present me as the future me.
In the end I wrote out my first prescription (penicillin), asked our social worker to give her a call and follow-up, and stared at her chart for half an hour. It felt about as empty as not eating the chocolate.
Saturday, August 8, 2009
pediatric primary care
This summer has been full of full weekends, and I've really enjoyed having time to spend with friends here and elsewhere. This weekend, I decided to take some more time alone bumming around, because things have been flying. In that vein, I decided to do better with more frequent blogging about daily life. I'm not capable of cultivating the stories yet, so recording will have to do for now.
I'm finishing my pediatrics rotation with two weeks of primary care at St. Mary's Clinic, a nice 45 minute drive from here. Primary care is outpatient, like your family pediatrician, where you go for physicals, colds, and non-urgent symptoms. Ideally, it's continuous, meaning that the same doctor takes care of you from birth to adulthood. Overall it's perceived as less intense than inpatient medicine in the hospital. The illnesses are more common and considered less complex than those requiring hospital or specialist care, though I imagine that with comorbidities there is a lot to consider as well. A lot of primary care focuses on prevention, chronic illnesses, and counseling, all of which the current healthcare system does little to support.
Most (95%) of St. Mary's patients are Medicaid patients, and the psychosocial elements emphasized in school come up often. In front of each chart is a "chronic problem list," to remind healthcare providers of long-standing issues that should be kept in mind during each visit. Among those I've seen listed include asthma, ADHD, depression. One of the things about primary care that appeal to me is this wholistic approach. I do see also that we're very good with recognition, but not so much with management. A lot of the more behavioral and social issues are beyond the scope of a PCP (or PMD, for primary MD...perhaps because of PCP the drug and PCP the infection), and even though the doctors here spend a great deal of time with their patients, addressing these things at every visit isn't always possible or done.
On the purely clinical side, I've enjoyed clinic. I've had the opportunity to consider differentials for chief complaints--shoulder pain, fever, headache. A little more than with the inpatient rotation, where much of the differential has been covered in the ER, here I get to ask the first questions. Remembering septic arthritis from gonorrheal infection, I ask a young teenager with shoulder pain about her sexual history, and had my first affirmative and conversation about sex with an adolescent. Remembering papilledema (swelling of the optic disk in your eye) occurs with increased pressure in the brain, I used an opthalmoscope to examine the eyes of a kid with headache, but still have trouble locating the optic disk (especially the left eye; my left eye is so uncoordinated).
With respect to the patients, outpatient pediatrics is a happy group. I get to marvel at beautiful newborns and infants; despite the familiarity of the idea of babies to most of us, I haven't actually spent much time with them and their concrete selves are a mystery to me--their fast heartbeats, compressible bellies, and funny reflexes. I like seeing the younger ones, because I didn't see any younger than five on my inpatient rotation, and I like the range of ages up to 19. The babies are miraculous, the kids adorable, and the adolescents fun to talk to.
As for the dynamic, sometimes it's chaotic, with stressed parents, multiple kids in a room, and language barriers. There are many limitations in terms of time, resources, communication, and records. Things that have been documented aren't always re-read when patients return, especially things that aren't directly related to current symptoms, and many of the indirect things that comprise a person are lost in past. Three different health providers spent a total of an hour with the family of a wheezing boy with new-onset asthma, whose 15 year old brother took charge of the family's health problems while the mom, having dealt with traumatic stresses in the past few years, seemed unaware and unable to manage this chronic problem. We try to address the long-term with preventative care for the future, but the past is important too. As a silent observer I kept thinking of B's recent emphasis on mental health and PTSD on his psych rotation, and how after understanding what's important, how difficult it is to incorporate it all.
I'm still really interested in primary care. Also in talking to B, who asked me what I want to do, I felt slight inadequacy in not having more specific goals and ways of achieving my broader ideals. But I am surprised by how much sense of things we get from weeks of experience, and looking forward to more to come.
I'm finishing my pediatrics rotation with two weeks of primary care at St. Mary's Clinic, a nice 45 minute drive from here. Primary care is outpatient, like your family pediatrician, where you go for physicals, colds, and non-urgent symptoms. Ideally, it's continuous, meaning that the same doctor takes care of you from birth to adulthood. Overall it's perceived as less intense than inpatient medicine in the hospital. The illnesses are more common and considered less complex than those requiring hospital or specialist care, though I imagine that with comorbidities there is a lot to consider as well. A lot of primary care focuses on prevention, chronic illnesses, and counseling, all of which the current healthcare system does little to support.
Most (95%) of St. Mary's patients are Medicaid patients, and the psychosocial elements emphasized in school come up often. In front of each chart is a "chronic problem list," to remind healthcare providers of long-standing issues that should be kept in mind during each visit. Among those I've seen listed include asthma, ADHD, depression. One of the things about primary care that appeal to me is this wholistic approach. I do see also that we're very good with recognition, but not so much with management. A lot of the more behavioral and social issues are beyond the scope of a PCP (or PMD, for primary MD...perhaps because of PCP the drug and PCP the infection), and even though the doctors here spend a great deal of time with their patients, addressing these things at every visit isn't always possible or done.
On the purely clinical side, I've enjoyed clinic. I've had the opportunity to consider differentials for chief complaints--shoulder pain, fever, headache. A little more than with the inpatient rotation, where much of the differential has been covered in the ER, here I get to ask the first questions. Remembering septic arthritis from gonorrheal infection, I ask a young teenager with shoulder pain about her sexual history, and had my first affirmative and conversation about sex with an adolescent. Remembering papilledema (swelling of the optic disk in your eye) occurs with increased pressure in the brain, I used an opthalmoscope to examine the eyes of a kid with headache, but still have trouble locating the optic disk (especially the left eye; my left eye is so uncoordinated).
With respect to the patients, outpatient pediatrics is a happy group. I get to marvel at beautiful newborns and infants; despite the familiarity of the idea of babies to most of us, I haven't actually spent much time with them and their concrete selves are a mystery to me--their fast heartbeats, compressible bellies, and funny reflexes. I like seeing the younger ones, because I didn't see any younger than five on my inpatient rotation, and I like the range of ages up to 19. The babies are miraculous, the kids adorable, and the adolescents fun to talk to.
As for the dynamic, sometimes it's chaotic, with stressed parents, multiple kids in a room, and language barriers. There are many limitations in terms of time, resources, communication, and records. Things that have been documented aren't always re-read when patients return, especially things that aren't directly related to current symptoms, and many of the indirect things that comprise a person are lost in past. Three different health providers spent a total of an hour with the family of a wheezing boy with new-onset asthma, whose 15 year old brother took charge of the family's health problems while the mom, having dealt with traumatic stresses in the past few years, seemed unaware and unable to manage this chronic problem. We try to address the long-term with preventative care for the future, but the past is important too. As a silent observer I kept thinking of B's recent emphasis on mental health and PTSD on his psych rotation, and how after understanding what's important, how difficult it is to incorporate it all.
I'm still really interested in primary care. Also in talking to B, who asked me what I want to do, I felt slight inadequacy in not having more specific goals and ways of achieving my broader ideals. But I am surprised by how much sense of things we get from weeks of experience, and looking forward to more to come.
Friday, August 7, 2009
communication
In skimming a description of what babies look like if their moms have had alcohol during pregnancy, I came across the word "philtrum." Wikipedia tells me that the philtrum is the vertical groove between the lips and the nose. It "allows humans to express a much larger range of lip motions than would otherwise be possible, which enhances vocal and nonverbal communication." It's derived from a Greek word that means "to love, to kiss."
One thing I liked about anatomy was learning the words for things, even if it doesn't often enhance your understanding of it. It kind of made my day to learn what the philtrum is, partly for that reason and partly because I've been thinking a lot about communication lately, and had already planned to write about it today.
So much that's important to me comes down to communication. The things I've been in immersed in as of late have been crowding my mind, all for reasons relating to this. With patients, learning how to talk to people from different backgrounds and struggling to bring down to earth those loose commonalities of health, respect, empathy. With friends, feeling such love for the big and small offerings of ourselves that we swap. With myself, reminding every day to be honest. With the outside world, fighting against the perception of people as simple to know, the categories, the dismissal of depth.
There is amazing variety in the kind of interaction healthcare providers have with their patients, and from the small bite of exposure we've had thus far, I've been better able to formulate in words what makes for real communication between people. I've always been awful at verbal articulation, but it's even harder than I thought to carry on a conversation that conveys both information and feeling. This morning my preceptor spoke to a mother in Spanish, who responded to a PA in Portugese, who then translated in English. The woman's toddler howled in tears. As students we have the perspective of naive eyes, and with those I wanted to put down what not to forget when our eyes get tired--
*Really wait for the answers when asking questions. Then listen to the answers, and ask follow-up questions. We pay attention to the factual answers about symptoms, but we fill in a lot of the how-are-you's ourselves without waiting for the response. *Speak half as slowly as you think you should, and remember that even in English we need to translate. I have two years of medical education (maybe half a year if you consider how much I retained) over most patients, and I have so much trouble remembering what was said, what people really have and how they got it and how they'll get better. *Acknowledge everyone. I've been grateful for the kindness that comes with a glance my way, sincere greetings, the shifting of objects to accommodate another's path. I think feeling each other's weight makes us more aware of our own, in a way that lets my hermit self retain its shell but also keeps us grounded in something more expansive. *Write legibly. Seriously, what's the point of writing something no one can read? *Move deliberately, not hurriedly. There's some illusion of efficiency dangling before all of us time-crunched busybees, the one that whispers to us to flip pages loudly, plop folders on the counter, walk briskly out rooms without closing doors, to speed-talk, to write illegibly, because it saves seconds, precious seconds. It might, but I've seen the steady hand say more and last longer.
These things can take a lot of effort (at all stages of the game--initially, once you get going, when you near the end). It's nice to come home at the end of the day or escape to during the weekends, to something I'm used to.
I have an amazing wife (my roommate; I can't actually remember how and when we started calling each other wife). She once said if this is really what marriage is like, it might be nice, and I agree. I'm always happy to see her, even if after we retreat to our rooms like the lone ones we sometimes like to be. She makes comfort Chinese food, including the best hot pot I've ever had. She's never once been mean to me, even when I'm neurotic or annoying or irritable. The few times I've gotten upset, she's sensitive, not defensive. She always tells me I look nice, and after a year of living together she's still considerate about washing the dishes. She listens to me struggle through being complicated, and what I see in me as the best and worst, she values. When I break things (often), she fixes them. She glued together one of my tea cups that I shattered. When one of the drawers detached from my desk, leaving a gaping hole, and the center slowly sunk from the weight of my books, she brought home another desk that looked almost exactly the same. When I complained about morning light waking me up and I was too lazy to get a face mask, she got me one. When I tell her an embarrassing story, she tells me one back. I can't describe how it works with a list of what to do and what not to do, but I know that a whole lot flows in the space between us, and each day we're at home I'm thankful for that.
Last weekend my college friend with the same name as wife came to visit New Haven, then I visited her in Cambridge. We don't see or talk to each other very frequently, but we caught up quickly at first and then slowly. She showed me the new stores in Harvard Square that replaced those familiar to me, and I had that sensation of things stretching and rearranging my skin. It didn't hurt like I thought it might. Instead it felt the way it does to see old friends. There's new growth to recognize, and old to unearth. J. has been through a lot and through it, became and remains one of the kindest and most genuine people I know. In reacquainting ourselves with each other's presence, I so admired the capacity to see and emulate good after having experienced not so good, a value I've only been able to articulate over the past few years. She's mindful of what's been given to her; yet she gives not out of obligation to give back but out of her nature. This generosity makes it easy to share, and in traipsing around our respective corners, things were exchanged through the pores and cracks--the confusion of the sliding doors at the subways where there used to be turnstiles, the way sunlight infuses the solid marble of the windowless Beinecke rare books library, the fatigue after walks in summer heat, the browsing for cheap clothes and purchase of matching bright checkered patterns, the fear of dodgy characters in the South End, the drives.
I know these are rare and to be kept close, because every so often I get mad at the tendency of the masses to paint over the cracks, the way I cover the sunken middle of a cake with extra frosting. Of the things that really bother me, among the top is people boxing other people up. I think of character as the full range of what a person can and will do and feel, and I've found that for most, this stretches quite wide. On a bigger scale, I dislike speculation about people from afar, the way classmates and colleagues are branded as such and such, concrete images built from smoke. Brushing aside mass perception--frequently misperception--can be tough in practice; I hate being misunderstood, and I hate that people settle for lesser explanations because the true one is complicated. So it's part personal, and it's part indignation at the substitution of gray for black and white. So I'm still learning to ignore all this, and rely on what I know, and in the end I'm thankful to be pushed to self-reliance.
On a smaller scale, but often a more potentially harmful one, is the boxes we create from actually really knowing someone. I do it too. I appreciate the positive qualities people attribute to me, but those closest to me have learned that nothing is defining, or I still remind them because I know it's hard to let go of what we've built up. Some who saw me as rational and together recognized a bit late how emotional and lost I can get with relationships. I don't blame them; I was stunned by it too at first, but once you step beyond borders, you need to make room. I do fight and I am mean, quite possibly meaner in those arguments than people you naturally assume are confrontational. This applies to more trivial things too, that don't directly bother me but indirectly do by nature of pigeonholing people. I do like some rap music, I've kissed boys recently met (for relativity's sake--two), I've stolen, I'm even more neurotic than you already know, I'm envious of others' talents, I actually do like some sports but have gotten myself stuck long ago in a self-conscious image of conventional girl and never developed the skills to now get over it, yes I do like to keep things but I throw certain things away. I like knowing these for myself because they've helped me give other people leeway, to know them more deeply, or to at least be more open to whatever they offer. This isn't to say that our understandings of each other are flimsy; they're obviously shaped from real things. I'd hope that some baseline qualities remain underneath it all, and I'm guilty of expecting people to know me well enough to predict or assume my actions or feelings, which might seem to go against this idea of malleability. It's more that things can be rearranged, and sometimes they can be torn down; you don't need to assume that they have, but you shouldn't assume they haven't.
I mentioned this to a high school friend, someone I've mentioned in my blog before as the one person in my life who is completely open to who I am, who is never surprised by anything I say or do because to her I'm capable of being anything. She wrote back something that I imagine she typed freely: "i can't even begin to tell you how much i feel i've been pigeonholed about issues and situations, over and over again, like ppl can't accept contradictions and opposites, and such a simple thing as change. their limitations end up limiting me, and i start being convinced of their perceptions, but i'm learning to be strong.. i understand ppl can be jaded. but i'm jaded too. i still think everyone is a mystery. fun mysteries."
The past few years have me seeing those fine rifts between nose and lip, that are attractive in the manner of the hollow that ends the neck, the slight indent that lends delicacy and nuance. I think of those babies whose moms consumed alcohol, whose philtrums are flattened as a result. Knowing what it is to be dulled, I trace these lines again from time to time.
One thing I liked about anatomy was learning the words for things, even if it doesn't often enhance your understanding of it. It kind of made my day to learn what the philtrum is, partly for that reason and partly because I've been thinking a lot about communication lately, and had already planned to write about it today.
So much that's important to me comes down to communication. The things I've been in immersed in as of late have been crowding my mind, all for reasons relating to this. With patients, learning how to talk to people from different backgrounds and struggling to bring down to earth those loose commonalities of health, respect, empathy. With friends, feeling such love for the big and small offerings of ourselves that we swap. With myself, reminding every day to be honest. With the outside world, fighting against the perception of people as simple to know, the categories, the dismissal of depth.
There is amazing variety in the kind of interaction healthcare providers have with their patients, and from the small bite of exposure we've had thus far, I've been better able to formulate in words what makes for real communication between people. I've always been awful at verbal articulation, but it's even harder than I thought to carry on a conversation that conveys both information and feeling. This morning my preceptor spoke to a mother in Spanish, who responded to a PA in Portugese, who then translated in English. The woman's toddler howled in tears. As students we have the perspective of naive eyes, and with those I wanted to put down what not to forget when our eyes get tired--
*Really wait for the answers when asking questions. Then listen to the answers, and ask follow-up questions. We pay attention to the factual answers about symptoms, but we fill in a lot of the how-are-you's ourselves without waiting for the response. *Speak half as slowly as you think you should, and remember that even in English we need to translate. I have two years of medical education (maybe half a year if you consider how much I retained) over most patients, and I have so much trouble remembering what was said, what people really have and how they got it and how they'll get better. *Acknowledge everyone. I've been grateful for the kindness that comes with a glance my way, sincere greetings, the shifting of objects to accommodate another's path. I think feeling each other's weight makes us more aware of our own, in a way that lets my hermit self retain its shell but also keeps us grounded in something more expansive. *Write legibly. Seriously, what's the point of writing something no one can read? *Move deliberately, not hurriedly. There's some illusion of efficiency dangling before all of us time-crunched busybees, the one that whispers to us to flip pages loudly, plop folders on the counter, walk briskly out rooms without closing doors, to speed-talk, to write illegibly, because it saves seconds, precious seconds. It might, but I've seen the steady hand say more and last longer.
These things can take a lot of effort (at all stages of the game--initially, once you get going, when you near the end). It's nice to come home at the end of the day or escape to during the weekends, to something I'm used to.
I have an amazing wife (my roommate; I can't actually remember how and when we started calling each other wife). She once said if this is really what marriage is like, it might be nice, and I agree. I'm always happy to see her, even if after we retreat to our rooms like the lone ones we sometimes like to be. She makes comfort Chinese food, including the best hot pot I've ever had. She's never once been mean to me, even when I'm neurotic or annoying or irritable. The few times I've gotten upset, she's sensitive, not defensive. She always tells me I look nice, and after a year of living together she's still considerate about washing the dishes. She listens to me struggle through being complicated, and what I see in me as the best and worst, she values. When I break things (often), she fixes them. She glued together one of my tea cups that I shattered. When one of the drawers detached from my desk, leaving a gaping hole, and the center slowly sunk from the weight of my books, she brought home another desk that looked almost exactly the same. When I complained about morning light waking me up and I was too lazy to get a face mask, she got me one. When I tell her an embarrassing story, she tells me one back. I can't describe how it works with a list of what to do and what not to do, but I know that a whole lot flows in the space between us, and each day we're at home I'm thankful for that.
Last weekend my college friend with the same name as wife came to visit New Haven, then I visited her in Cambridge. We don't see or talk to each other very frequently, but we caught up quickly at first and then slowly. She showed me the new stores in Harvard Square that replaced those familiar to me, and I had that sensation of things stretching and rearranging my skin. It didn't hurt like I thought it might. Instead it felt the way it does to see old friends. There's new growth to recognize, and old to unearth. J. has been through a lot and through it, became and remains one of the kindest and most genuine people I know. In reacquainting ourselves with each other's presence, I so admired the capacity to see and emulate good after having experienced not so good, a value I've only been able to articulate over the past few years. She's mindful of what's been given to her; yet she gives not out of obligation to give back but out of her nature. This generosity makes it easy to share, and in traipsing around our respective corners, things were exchanged through the pores and cracks--the confusion of the sliding doors at the subways where there used to be turnstiles, the way sunlight infuses the solid marble of the windowless Beinecke rare books library, the fatigue after walks in summer heat, the browsing for cheap clothes and purchase of matching bright checkered patterns, the fear of dodgy characters in the South End, the drives.
I know these are rare and to be kept close, because every so often I get mad at the tendency of the masses to paint over the cracks, the way I cover the sunken middle of a cake with extra frosting. Of the things that really bother me, among the top is people boxing other people up. I think of character as the full range of what a person can and will do and feel, and I've found that for most, this stretches quite wide. On a bigger scale, I dislike speculation about people from afar, the way classmates and colleagues are branded as such and such, concrete images built from smoke. Brushing aside mass perception--frequently misperception--can be tough in practice; I hate being misunderstood, and I hate that people settle for lesser explanations because the true one is complicated. So it's part personal, and it's part indignation at the substitution of gray for black and white. So I'm still learning to ignore all this, and rely on what I know, and in the end I'm thankful to be pushed to self-reliance.
On a smaller scale, but often a more potentially harmful one, is the boxes we create from actually really knowing someone. I do it too. I appreciate the positive qualities people attribute to me, but those closest to me have learned that nothing is defining, or I still remind them because I know it's hard to let go of what we've built up. Some who saw me as rational and together recognized a bit late how emotional and lost I can get with relationships. I don't blame them; I was stunned by it too at first, but once you step beyond borders, you need to make room. I do fight and I am mean, quite possibly meaner in those arguments than people you naturally assume are confrontational. This applies to more trivial things too, that don't directly bother me but indirectly do by nature of pigeonholing people. I do like some rap music, I've kissed boys recently met (for relativity's sake--two), I've stolen, I'm even more neurotic than you already know, I'm envious of others' talents, I actually do like some sports but have gotten myself stuck long ago in a self-conscious image of conventional girl and never developed the skills to now get over it, yes I do like to keep things but I throw certain things away. I like knowing these for myself because they've helped me give other people leeway, to know them more deeply, or to at least be more open to whatever they offer. This isn't to say that our understandings of each other are flimsy; they're obviously shaped from real things. I'd hope that some baseline qualities remain underneath it all, and I'm guilty of expecting people to know me well enough to predict or assume my actions or feelings, which might seem to go against this idea of malleability. It's more that things can be rearranged, and sometimes they can be torn down; you don't need to assume that they have, but you shouldn't assume they haven't.
I mentioned this to a high school friend, someone I've mentioned in my blog before as the one person in my life who is completely open to who I am, who is never surprised by anything I say or do because to her I'm capable of being anything. She wrote back something that I imagine she typed freely: "i can't even begin to tell you how much i feel i've been pigeonholed about issues and situations, over and over again, like ppl can't accept contradictions and opposites, and such a simple thing as change. their limitations end up limiting me, and i start being convinced of their perceptions, but i'm learning to be strong.. i understand ppl can be jaded. but i'm jaded too. i still think everyone is a mystery. fun mysteries."
The past few years have me seeing those fine rifts between nose and lip, that are attractive in the manner of the hollow that ends the neck, the slight indent that lends delicacy and nuance. I think of those babies whose moms consumed alcohol, whose philtrums are flattened as a result. Knowing what it is to be dulled, I trace these lines again from time to time.
Subscribe to:
Posts (Atom)
