Much can happen in small spaces of days, rooms, a smattering of people and conversations, a flow of observations and semi-blurred details. I've loved my first week on my medicine rotation at the VA, where the patients are generally older males with one shared experience that's as widely varied as the fingerprints they made us give in order to work in a government hospital.
There's a lot about this place that suggests a bit more space in a profession that can often feel limiting, restrictive. My first patient from day one was still here at the end of my first week. An elderly man with blue eyes and the charm to match, he gives me recipes, flirts every other line, does a little dance when we walk him on unsteady feet, and worries about his wife while he's the one in the hospital. The pace of the VA makes it so I can talk to him several times everyday, and so I remember he likes 2% milk and hates his oxygen, and he begins to know me as the one with cold hands and notices before I do a new scratch on my face.
He's been worked up and treated for four separate problems, one of which brought him here and three that have arisen or noticed since, covering his lungs, his liver, and his joints. He let me learn about so many different things in one person, and reminded us that care is continuous and multifaceted. We treat the cough and sometimes its persistent presence smothers the pain of a swollen leg; his pleasantness we enjoy disguises the weakness of his muscles after illness. I'm amazed at how my medical team considers all of these, amazed that openness can require so much more learning on my part, amazed that this comes not as a disappointing realization but as a worthy goal.
It's been a hard argument to sell, but I generally counter worries about the negatives of medicine by pointing out the appeal of a challenge. A geriatrician made mention of things worthy of fight, during a conference about how to talk to patients about end-of-life care, noting that often patients don't see their difficult treatments as burdensome, but as a measure of how much they're willing to struggle for their lives. She made many, many good points during this talk, that will contribute to concrete changes to how I'll approach this in the future. Key terms include outcome, uncertainty, and decision. Patients make decisions based on outcome, not on treatment, but doctors often present their options in terms of treatment ("would you want to be intubated?"). It isn't whether they want to have their chest compressed, but whether they want to live afterwards with 10% of the quality of the life they had before, or 20, or 50, or 75, or 100.
But even as we offer possible outcomes of the different options, we have to relay the degree of uncertainty we have. Because we want to be and because we want to make it easier on everyone, we seem more sure of our words than we can be. And patients need both what we know and what we don't know, because as the speaker noted, decisions change as the possible outcomes become more or less nebulous, more or less likely, more or less intense. It's hard, because people do seek something definitive; we have to remember that no one wants to make these decisions; we get so caught up in asking for their preferences that we forget they need to figure it out too. This isn't too hard to appreciate for someone who finds it difficult to choose a flavor of steamed milk, but this brings up again the need for continuous care, to which I haven't given as much conscious thought. As things go one way or the other, degrees of certainty change and so do how people feel, so this is an ongoing, organic conversation. The speaker also gave objective advice: have families hear from the patients themselves what they want; studies have shown that patient and family preferences often diverge in significant ways, and it's hard for families, amidst so much emotion and uncertainty, to make distinctions between their wishes and those of their loved ones. Ask patients not how they want to be treated, but what outcome could they live with and then how much they would be willing to endure to get there. Begin with their subjective goals, and fill in the technical details for them about how they could get there objectively.
This goes back to the fact that patients don't want to make these decisions, and the speaker made an excellent point about how we can share the burden. This point is very hard to conceive in our minds, and then very hard to articulate, and I respected her very much for forming the thought and then conveying it. I won't be able to do it quite as well, but essentially--she told us that we don't have to make people feel as though they're deciding about every possible intervention or treatment. Instead, they can focus on the parameters for how they want to live. This is something people often feel rather than rationalize, and the hardest part can often be trying to rationalize how we feel. Our role is to implement the rational, while leaving them full control of the emotional, with our rationale only taking reign after being guided by their feelings. We let them know that we understand that end goals for quality and quantity of life are individual, but we can design our options and path to lead to their goals, and once we know how they feel we can steer them to those goals, allowing them to feel both empowered and taken care of.
I started this post and didn't have time to finish, and it's now the end of my second week. I can't quite remember what else I wanted to say, and since then much more has accumulated, so instead of trying to backtrack I'll let it be.
Monday, October 19, 2009
Wednesday, October 7, 2009
quality
A card from college friend--
On the front, a little one plucking shiny hearts from a nebulous flurry amidst a black sky. "She sows seeds of kindness." Inside: "I'm still drinking tea & honey, but I've moved to Mission Bay. Sometimes, I miss the East Coast and the autumn chill and New England foliage. The beaches in Norcal are frigid too! What are you going to be for Halloween this year? I made a costume last year, but didn't have time to wear it. You should come visit me. We can go wine tasting or eat raw oysters. Ah, medical school gets so hectic, but someday we should spend a nice summer in a cottage."
An email exchange with med school friend--
Me: I got another pair of boots.
Him: Might I recommend you make a facebook album profiling all your boots. Can we do a double makeover. I'll do one for you and you do one for me. We can have a set budget.
Me: Sure, but how am I going to make you any better?!
Him: Your flattery doesn't fool me! There are many things that could make me better.
Me: What's the budget... I'm curious as to what you'd make me over as.
Him: A stop light. Budget of $30. On the cheap.
A self-described long and complicated email from high school friend--
Thoughts on seeing self and what's around; this natural openness to seeing being the reason for and result of never settling for the sake of ease. It's a struggle we value, and reminds me to always feel with awareness.
A stamp-sized letter from elementary school friend--
It's a real letter with a tiny envelope and a tiny stamp and a tiny wax seal. So small that it comes with a little magnifying glass to read the letters, though I could do without if I read hard, and this is how it makes me feel it's just for me. "We've been friends for 14 years, can you believe it?"
Someone recently said that I'm too trusting of people, which I think was a slight misreading of openness to how far people go beyond our impressions of them. Openness is for everyone whereas trust is reserved for quality, and it's knowing such quality people over the years that makes openness worth the risk. I'm getting my best friend from high school and my med school wife to meet up in California, which makes me happy like e.e. cummings when he says "we're wonderful one times one."
On the front, a little one plucking shiny hearts from a nebulous flurry amidst a black sky. "She sows seeds of kindness." Inside: "I'm still drinking tea & honey, but I've moved to Mission Bay. Sometimes, I miss the East Coast and the autumn chill and New England foliage. The beaches in Norcal are frigid too! What are you going to be for Halloween this year? I made a costume last year, but didn't have time to wear it. You should come visit me. We can go wine tasting or eat raw oysters. Ah, medical school gets so hectic, but someday we should spend a nice summer in a cottage."
An email exchange with med school friend--
Me: I got another pair of boots.
Him: Might I recommend you make a facebook album profiling all your boots. Can we do a double makeover. I'll do one for you and you do one for me. We can have a set budget.
Me: Sure, but how am I going to make you any better?!
Him: Your flattery doesn't fool me! There are many things that could make me better.
Me: What's the budget... I'm curious as to what you'd make me over as.
Him: A stop light. Budget of $30. On the cheap.
A self-described long and complicated email from high school friend--
Thoughts on seeing self and what's around; this natural openness to seeing being the reason for and result of never settling for the sake of ease. It's a struggle we value, and reminds me to always feel with awareness.
A stamp-sized letter from elementary school friend--
It's a real letter with a tiny envelope and a tiny stamp and a tiny wax seal. So small that it comes with a little magnifying glass to read the letters, though I could do without if I read hard, and this is how it makes me feel it's just for me. "We've been friends for 14 years, can you believe it?"
Someone recently said that I'm too trusting of people, which I think was a slight misreading of openness to how far people go beyond our impressions of them. Openness is for everyone whereas trust is reserved for quality, and it's knowing such quality people over the years that makes openness worth the risk. I'm getting my best friend from high school and my med school wife to meet up in California, which makes me happy like e.e. cummings when he says "we're wonderful one times one."
Friday, October 2, 2009
adult primary care
A good friend/classmate of mine said to me recently that it's hard to help people. Now in medical school, we realize how elusive is the goal for getting here in the first place, that catch-all "I want to help." It's true, what they say: doctors can do more harm than good, in the flurry of work they can forget to be considerate, and there are indeed many other ways of helping people, so how can that be the sole reason to choose this profession?
Primary care, what I think I want to go into, answers some of this for me in a somewhat ironic way, in that it's proven to me just how hard it is to help. There are two parts to this: the purpose, and the methods. As seems logical, let's start with the purpose, and then the methods get all mixed up in there. If I want to get as simple as it gets, I think of medicine as taking care of a person. Specifically, what does this entail? Concretely, to prevent and treat illness to the best of our knowledge and range of resources. More abstractly, it means knowing a person, from conversation (how to ask questions, how to listen, how to explain and advise) to examination (how to look at their eyes and check their necks, how to situate them in a chair or table, how to maneuver their clothing to hear their hearts). It requires all sorts of memory: science, and personality. You have to know the medicine, but you also have to know who you're treating. Is she a person who likes feeling natural and keeps medications to a minimum? Does he have to construct garage doors for a living and finds muscle aches more problematic than his high cholesterol?
Taking care implies maintaining a certain level of quality of life. My friend brought up the question of whether we help at all, because we treat high blood pressure and high blood sugar, without necessarily healing the people with these problems, without helping them literally feel better, without adding the degree of happiness to their lives that would give them real quality, not just lab values that fall within normal. In primary care, the visits are too fast, the issues too many. It doesn't always seem possible to deal with all the health within the context of someone's life and feelings. So this happens frequently--tests and drugs are thrown at people without them having any sense of what and what for, mood is ignored and if seen, dealt with solely through meds, and privacy and tact has been lost in routine.
But awash in this background, the potential of what we can do is bright. The doctor I work with knows every one of her hundreds of patients by face and by name like the back of her hand, not only every illness they've ever had but everything about their personal lives that they've shared. Illness is vulnerable, and so is the personal, and I'm amazed every day at how much people bare, how much my doctor absorbs and holds. Primary care means that you take care of people through everything, not just when they get sick enough to be in the hospital, and you know about everything they have.
Intellectually, I find it more challenging than it's perceived and admittedly, more than I expected. A lot of "interesting" or serious diseases don't present with symptoms that land patients in the hospital; it's often progressive worsening of these diseases that put them in the hospital, under diagnoses made by the PCP. My doctor makes an extraordinary amount of first diagnoses for her patients, only sending them to specialists after high suspicion of what they have or for further treatment, and also always following up with each of the illnesses that they have, remembering what they go to the GI doctor for one week and why they see the cardiologist the next week. She is the one to screen and frequently finds cancer, and she is the one who already knows through and through, the person to whom she has to give that information.
I also love taking care of chronic problems, like diabetes and asthma. People find this boring after awhile, but in seeing people live with these problems day to day, you get such a better sense of how they live and what it means to have a disease, than when you treat them for an asthma exacerbation in the ER. Having people share, directly and indirectly, how they cope, what drives them and what makes them weak and strong, has the most sustaining power of all the things we experience. There's the pure pleasure of knowing people, not just the substantial stuff like their families and what they do, but are they organized? absent-minded? anxious? laid-back? funny? shy? tough? We naturally live in spaces occupied by people relatively similar to us (when you look at the entire scope of people in the world), and this gives us the chance to not just meet, but know, so much outside of ourselves.
Even with the best of purposes, it can be hard to get through and follow through. My friend compared the bleakness of what we do, alongside the happiness he was able to induce by making his roommate a delicious fruit shake. The sweet made his roommate happy, and that in turn made him happy. Because we're treating things that people sometimes can't feel, especially in primary care and preventative measures, and because we focus on long-term goals at the risk of not seeing people's immediate feelings, often we don't think we're helping or even that our profession is designed to help.
But I've learned from people I respect (both people personally in my life and the health staff in school) that everything is felt, such that small pushes soften thick walls. Connecting to people in any way gives a certain something that's vague and difficult to describe, and it can't be validated with science. I thought about this when realizing that one of my favorite parts of this rotation so far has been the Vietnamese patients. My doctor has a surprising number of Vietnamese patients, such that I see on average one a day. Even for the ones who can speak fairly good English, you can tell that speaking in their own language gives them that something. And with everyone, asking a person what it is that they want, how has it been with this-or-that, being gentle and mindful with the physical exam (and despite previous thoughts that these should be obvious, I'm grateful to Yale for reminding us of this so relentlessly)--I've seen it go noticed, seen it make a difference in one minute of the day. People who are at first a bit standoffish, or skeptical, or gruff, start to open and give way, in their own ways. People notice when they're listened to, when they're respected, when they're given a little extra consideration, and whether you're dealing with disabling pain or you're a healthy person with the standard stressful stressors, it can give that certain something. And what I really like about primary care is the potential to be a continuous source of this something, a place that people feel is always there.
This all sounds very ideal, but I'm not oblivious to the obstacles. I've been more tired on this rotation than any other, including the rotations with longer hours and weekend work. There's more paperwork, more thought to legal issues and insurance, and we're always an hour behind in appointments. Being responsible for routine health maintenance AND chronic diseases AND acute problems that arise is exhausting. And as we've been persistently reminded in this time of supposed reform, most of what I've described above as fulfilling and helpful isn't billable, and doctors have to cater some of their time to what will enable them to stay in business. There are also the patients who make it hard for you to give, those who need more than you can give, and you will fail even those you can help. I've found myself frustrated by language barriers, difficult personalities, the chaos of papers and phone calls, my patience wearing thin in minutes, the openness I claim to want closing in on me.
So to help is hard, and to help in the particular niche of medicine is hard. But having seen that this niche is in fact particular--that it's true that you can help in many ways, but this way is a unique one that I really, really want--makes me transition from deciding whether this is something we want to do to considering whether it's something we can do. I've talked to friends in different paths of helping, and it seems that a common theme is frustration with how difficult it is, amidst systemic and personal barriers, to help. On top of that, I think that a lot of people want to offer this help to those from whom it's been unjustly withheld, so battling deficiencies with a deficient system makes it all the more frustrating. But this has made me think--all the more reason to keep trying, because there is such a gap, such need. If it were easy to help, it would become a routine that forgets to remind us of the need for patience and openness, of how much frustration and fatigue that certain something is worth. And I think, I hope, these things deserve more than our hard work; they deserve us testing our commitment by not letting the illogical and unreasonable and unjust and ugly push us away. I'm not saying that it should be this way--our healthcare system should be a million times more just, and we as individuals can always be more fair; it shouldn't be so difficult to give people basic needs and that something more. But it being hard is not reason to leave but to stay, and makes me think of when Obama said during his inauguration, that "what began in the depths of winter must not end this autumn night." I'm going to try to keep this in mind, as it just became October and already freezing.
Primary care, what I think I want to go into, answers some of this for me in a somewhat ironic way, in that it's proven to me just how hard it is to help. There are two parts to this: the purpose, and the methods. As seems logical, let's start with the purpose, and then the methods get all mixed up in there. If I want to get as simple as it gets, I think of medicine as taking care of a person. Specifically, what does this entail? Concretely, to prevent and treat illness to the best of our knowledge and range of resources. More abstractly, it means knowing a person, from conversation (how to ask questions, how to listen, how to explain and advise) to examination (how to look at their eyes and check their necks, how to situate them in a chair or table, how to maneuver their clothing to hear their hearts). It requires all sorts of memory: science, and personality. You have to know the medicine, but you also have to know who you're treating. Is she a person who likes feeling natural and keeps medications to a minimum? Does he have to construct garage doors for a living and finds muscle aches more problematic than his high cholesterol?
Taking care implies maintaining a certain level of quality of life. My friend brought up the question of whether we help at all, because we treat high blood pressure and high blood sugar, without necessarily healing the people with these problems, without helping them literally feel better, without adding the degree of happiness to their lives that would give them real quality, not just lab values that fall within normal. In primary care, the visits are too fast, the issues too many. It doesn't always seem possible to deal with all the health within the context of someone's life and feelings. So this happens frequently--tests and drugs are thrown at people without them having any sense of what and what for, mood is ignored and if seen, dealt with solely through meds, and privacy and tact has been lost in routine.
But awash in this background, the potential of what we can do is bright. The doctor I work with knows every one of her hundreds of patients by face and by name like the back of her hand, not only every illness they've ever had but everything about their personal lives that they've shared. Illness is vulnerable, and so is the personal, and I'm amazed every day at how much people bare, how much my doctor absorbs and holds. Primary care means that you take care of people through everything, not just when they get sick enough to be in the hospital, and you know about everything they have.
Intellectually, I find it more challenging than it's perceived and admittedly, more than I expected. A lot of "interesting" or serious diseases don't present with symptoms that land patients in the hospital; it's often progressive worsening of these diseases that put them in the hospital, under diagnoses made by the PCP. My doctor makes an extraordinary amount of first diagnoses for her patients, only sending them to specialists after high suspicion of what they have or for further treatment, and also always following up with each of the illnesses that they have, remembering what they go to the GI doctor for one week and why they see the cardiologist the next week. She is the one to screen and frequently finds cancer, and she is the one who already knows through and through, the person to whom she has to give that information.
I also love taking care of chronic problems, like diabetes and asthma. People find this boring after awhile, but in seeing people live with these problems day to day, you get such a better sense of how they live and what it means to have a disease, than when you treat them for an asthma exacerbation in the ER. Having people share, directly and indirectly, how they cope, what drives them and what makes them weak and strong, has the most sustaining power of all the things we experience. There's the pure pleasure of knowing people, not just the substantial stuff like their families and what they do, but are they organized? absent-minded? anxious? laid-back? funny? shy? tough? We naturally live in spaces occupied by people relatively similar to us (when you look at the entire scope of people in the world), and this gives us the chance to not just meet, but know, so much outside of ourselves.
Even with the best of purposes, it can be hard to get through and follow through. My friend compared the bleakness of what we do, alongside the happiness he was able to induce by making his roommate a delicious fruit shake. The sweet made his roommate happy, and that in turn made him happy. Because we're treating things that people sometimes can't feel, especially in primary care and preventative measures, and because we focus on long-term goals at the risk of not seeing people's immediate feelings, often we don't think we're helping or even that our profession is designed to help.
But I've learned from people I respect (both people personally in my life and the health staff in school) that everything is felt, such that small pushes soften thick walls. Connecting to people in any way gives a certain something that's vague and difficult to describe, and it can't be validated with science. I thought about this when realizing that one of my favorite parts of this rotation so far has been the Vietnamese patients. My doctor has a surprising number of Vietnamese patients, such that I see on average one a day. Even for the ones who can speak fairly good English, you can tell that speaking in their own language gives them that something. And with everyone, asking a person what it is that they want, how has it been with this-or-that, being gentle and mindful with the physical exam (and despite previous thoughts that these should be obvious, I'm grateful to Yale for reminding us of this so relentlessly)--I've seen it go noticed, seen it make a difference in one minute of the day. People who are at first a bit standoffish, or skeptical, or gruff, start to open and give way, in their own ways. People notice when they're listened to, when they're respected, when they're given a little extra consideration, and whether you're dealing with disabling pain or you're a healthy person with the standard stressful stressors, it can give that certain something. And what I really like about primary care is the potential to be a continuous source of this something, a place that people feel is always there.
This all sounds very ideal, but I'm not oblivious to the obstacles. I've been more tired on this rotation than any other, including the rotations with longer hours and weekend work. There's more paperwork, more thought to legal issues and insurance, and we're always an hour behind in appointments. Being responsible for routine health maintenance AND chronic diseases AND acute problems that arise is exhausting. And as we've been persistently reminded in this time of supposed reform, most of what I've described above as fulfilling and helpful isn't billable, and doctors have to cater some of their time to what will enable them to stay in business. There are also the patients who make it hard for you to give, those who need more than you can give, and you will fail even those you can help. I've found myself frustrated by language barriers, difficult personalities, the chaos of papers and phone calls, my patience wearing thin in minutes, the openness I claim to want closing in on me.
So to help is hard, and to help in the particular niche of medicine is hard. But having seen that this niche is in fact particular--that it's true that you can help in many ways, but this way is a unique one that I really, really want--makes me transition from deciding whether this is something we want to do to considering whether it's something we can do. I've talked to friends in different paths of helping, and it seems that a common theme is frustration with how difficult it is, amidst systemic and personal barriers, to help. On top of that, I think that a lot of people want to offer this help to those from whom it's been unjustly withheld, so battling deficiencies with a deficient system makes it all the more frustrating. But this has made me think--all the more reason to keep trying, because there is such a gap, such need. If it were easy to help, it would become a routine that forgets to remind us of the need for patience and openness, of how much frustration and fatigue that certain something is worth. And I think, I hope, these things deserve more than our hard work; they deserve us testing our commitment by not letting the illogical and unreasonable and unjust and ugly push us away. I'm not saying that it should be this way--our healthcare system should be a million times more just, and we as individuals can always be more fair; it shouldn't be so difficult to give people basic needs and that something more. But it being hard is not reason to leave but to stay, and makes me think of when Obama said during his inauguration, that "what began in the depths of winter must not end this autumn night." I'm going to try to keep this in mind, as it just became October and already freezing.
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