Tuesday, November 24, 2009
meat
Realized that in my last two entries I used the phrase, the "meat" of something. On both these nights I'd eaten ground beef for dinner; in spaghetti for one and in ma po tofu for the other (http://ineluctable.org/ieatfood/ma_po_tofu/ma%20po%20tofu-9.jpg). I hope this means substance is brewing.
Monday, November 23, 2009
essays
In the hospital I become acutely aware of what I'm good at and not good at. The latter list is extensive: picking up things on physical exam (I'm tone deaf! I can't tell whether that's dull or resonant. And why can't I elicit reflexes, ever?), immediate differential diagnoses, remembering yesterday's lab values, the finer points of the plan for a patient, interpreting radiological studies. Sometimes in these moments of incompetence (and also through the first two years of med school when I realized I knew about 1% of the basic science my classmates knew and was also 1% as quick to learn new information, resulting in an exponential lag between me and them), I think back to when my primary occupation was one in which I was relatively competent. That is, being an English major and writing about stories other people had written. There are a lot of ways I'm a shoddy English major (probably most of the ways one typically thinks of). I can't remember a lot of what I read other than how I felt about it, I can't quote anything, and I even get my eras of literature mixed up because my wayward sense of direction also applies to chronology before my time.
But I did like writing essays and like others taught in the form of close reading, could write a decent one. It takes me a long, long time to write one. I remember my college roommate pulling all nighters to write amazing papers, but it would be literally impossible for me to complete a good essay like that. This roommate visited recently, and we talked about missing essay writing. But even before that, when I screw up the many forms to be learned in medicine, I drift back to those days in our cozy house library, to when I had a system. I'd go through the text first: picking out lines, turns of phrases, images, structure of chapters--pay attention to why this word was chosen, what it conjures, where it's placed in relation to another. I'd type out all the quotes in a document; I enjoyed the false productivity of filling my pages with someone else's words and it helped me immerse in the text. As I did this I'd stream-of-consciously type my commentary on the quotes, and let my ideas and thesis emerge organically from what I found and thought. There's a certain rush after you've been chugging along, either with a boring stream of nothing much or with spurts of disconnected epiphanies, and you suddenly string things together. This begins a flurry of grouping related thoughts and possibly in a general order. And then the introduction can be written. Some say to save this for the end, but for me it was always the most time consuming and important, to know what I wanted the essay as a whole to say, and that's what the introduction does. Even as it sets up the structure for the rest, it's the most free flowing part of the essay too, because it doesn't require immediate, constant concrete evidence. It's just a promise.
In the midst of the forest of scraggly trees that is becoming a good doctor, it is sometimes nice to remember what it's like to take a complexity and reform a small part of it into an essay. An order with enough loose strands to keep it interesting and realistic but overall compact and from the bareness of your hands.
Here is one introduction from my favorite English class in college, a seminar on criminals and misfits in literature.
*
The Real Prison of a False Identity
“He who is subjected to a field of visibility...inscribes in himself the power relation in which he simultaneously plays both roles; he becomes the principle of his own subjection.” -Michel Foucault, Discipline and Punish (323).
The cover of the 1995 Random House edition of Franz Kafka’s The Trial depicts a man’s face, colored in red, behind black bars. The image of a prison is evident, but whether it is the actual solid bars or the rectangular segments of the man’s face that comprise the prison is less clear. Initially, the black bars appear to restrict the man’s freedom, demonstrating a traditional view of imprisonment. However, the red face can also be perceived as the imposing force that breaks the unity of the black background. This dichotomy is similarly reflected in the portrayal of the “gaze.” In “Panopticism,” Michel Foucault asserts that power resides in a supervisor’s ability to view a prisoner while remaining hidden from him (321). Because his face is visible, the man on the cover seems to be the prisoner. Yet, closer examination reveals that he is likewise the supervisor: the prominent eye amidst a hazy face suggests that he sees more than is seen. Both the criminal in the Panopticon and Joseph K., the protagonist of The Trial, unknowingly exemplify this duality.
A man confined to a cell in the Panopticon is highly conscious of his lack of space and movement. K. resides figuratively in a similar prison but with one crucial difference: he does not see his boundaries. Whereas the prisoner in the Panopticon knows that he dwells in the periphery of the structure, K. envisions himself at the center. Neither person realizes that he also assumes the opposite role. Because individuality connotes one identity, these opposing forces negate the existence of a self. Unaware of this duality, however, the Panopticon prisoner and Joseph K. harbor illusions of self-identity which ultimately facilitate their self-destruction. The imprisoning structure maximizes its power by instilling in the criminal what is otherwise typically liberating--a sense of individuality.
*
Looking back, I enjoy it as I did then. I also think, in the end, it is as limited as medicine can often be. The senselessness of semantics and vocabulary, creating complications, wondering what the use is. But each form of practice and expression pushes us to work beyond its parameters. I find that the real meat in writing an essay about a piece of literature or a history & physical for a patient isn't so much to come to a conclusion (even though we sound like we do and this is the stated, accepted and expected reason for doing it), as it is to grapple and stumble. I like how literature and medicine as fields complement, parallel, and contrast one another at different points in my life, my day. They can play tug of war with me the knot in the middle, or gang up on one side with me on the other, or it can be we three against who-knows-what. I'm willing to stumble a lot for that range of visibility.
But I did like writing essays and like others taught in the form of close reading, could write a decent one. It takes me a long, long time to write one. I remember my college roommate pulling all nighters to write amazing papers, but it would be literally impossible for me to complete a good essay like that. This roommate visited recently, and we talked about missing essay writing. But even before that, when I screw up the many forms to be learned in medicine, I drift back to those days in our cozy house library, to when I had a system. I'd go through the text first: picking out lines, turns of phrases, images, structure of chapters--pay attention to why this word was chosen, what it conjures, where it's placed in relation to another. I'd type out all the quotes in a document; I enjoyed the false productivity of filling my pages with someone else's words and it helped me immerse in the text. As I did this I'd stream-of-consciously type my commentary on the quotes, and let my ideas and thesis emerge organically from what I found and thought. There's a certain rush after you've been chugging along, either with a boring stream of nothing much or with spurts of disconnected epiphanies, and you suddenly string things together. This begins a flurry of grouping related thoughts and possibly in a general order. And then the introduction can be written. Some say to save this for the end, but for me it was always the most time consuming and important, to know what I wanted the essay as a whole to say, and that's what the introduction does. Even as it sets up the structure for the rest, it's the most free flowing part of the essay too, because it doesn't require immediate, constant concrete evidence. It's just a promise.
In the midst of the forest of scraggly trees that is becoming a good doctor, it is sometimes nice to remember what it's like to take a complexity and reform a small part of it into an essay. An order with enough loose strands to keep it interesting and realistic but overall compact and from the bareness of your hands.
Here is one introduction from my favorite English class in college, a seminar on criminals and misfits in literature.
*
The Real Prison of a False Identity
“He who is subjected to a field of visibility...inscribes in himself the power relation in which he simultaneously plays both roles; he becomes the principle of his own subjection.” -Michel Foucault, Discipline and Punish (323).
The cover of the 1995 Random House edition of Franz Kafka’s The Trial depicts a man’s face, colored in red, behind black bars. The image of a prison is evident, but whether it is the actual solid bars or the rectangular segments of the man’s face that comprise the prison is less clear. Initially, the black bars appear to restrict the man’s freedom, demonstrating a traditional view of imprisonment. However, the red face can also be perceived as the imposing force that breaks the unity of the black background. This dichotomy is similarly reflected in the portrayal of the “gaze.” In “Panopticism,” Michel Foucault asserts that power resides in a supervisor’s ability to view a prisoner while remaining hidden from him (321). Because his face is visible, the man on the cover seems to be the prisoner. Yet, closer examination reveals that he is likewise the supervisor: the prominent eye amidst a hazy face suggests that he sees more than is seen. Both the criminal in the Panopticon and Joseph K., the protagonist of The Trial, unknowingly exemplify this duality.
A man confined to a cell in the Panopticon is highly conscious of his lack of space and movement. K. resides figuratively in a similar prison but with one crucial difference: he does not see his boundaries. Whereas the prisoner in the Panopticon knows that he dwells in the periphery of the structure, K. envisions himself at the center. Neither person realizes that he also assumes the opposite role. Because individuality connotes one identity, these opposing forces negate the existence of a self. Unaware of this duality, however, the Panopticon prisoner and Joseph K. harbor illusions of self-identity which ultimately facilitate their self-destruction. The imprisoning structure maximizes its power by instilling in the criminal what is otherwise typically liberating--a sense of individuality.
*
Looking back, I enjoy it as I did then. I also think, in the end, it is as limited as medicine can often be. The senselessness of semantics and vocabulary, creating complications, wondering what the use is. But each form of practice and expression pushes us to work beyond its parameters. I find that the real meat in writing an essay about a piece of literature or a history & physical for a patient isn't so much to come to a conclusion (even though we sound like we do and this is the stated, accepted and expected reason for doing it), as it is to grapple and stumble. I like how literature and medicine as fields complement, parallel, and contrast one another at different points in my life, my day. They can play tug of war with me the knot in the middle, or gang up on one side with me on the other, or it can be we three against who-knows-what. I'm willing to stumble a lot for that range of visibility.
Sunday, November 22, 2009
thirteen virtues
In high school English class, our teacher had us list Benjamin Franklin's 13 virtues in the order we personally found most important. We then split the room into 13 areas and as our teacher counted down 13 to 1, we walked to the virtues corresponding to that number on our list. I think Jen mentioned these on her blog awhile back, and for whatever reason I thought of them again today. I don't remember distinctly what my order was back in high school, but can't imagine it's much different.
1. Justice
wrong none by doing injuries, or omitting the benefits that are your duty.
2. Humility
imitate Jesus and Socrates.
3. Sincerity
use no hurtful deceit; think innocently and justly; if you speak, speak accordingly.
4. Resolution
resolve to perform what you ought; perform without fail what you resolve.
5. Frugality
make no expense but to do good to others or yourself; waste nothing.
6. Tranquility
be not disturbed at trifles, or at incidents common or unavoidable.
7. Order
let all your things have their places; let each part of your business have its time.
8. Moderation
avoid extremes; forbear resenting injuries so much as you think they deserve.
9. Industry
lose no time; be always employed in something useful; cut off all unnecessary actions.
10. Silence
speak not but what may benefit others or yourself; avoid trifling conversation.
11. Chastity
rarely use venery but for health or offspring, never to dullness, weakness, or the injury of your own or another's peace or reputation.
12. Temperance
eat not to dullness; drink not to elevation.
13. Cleanliness
tolerate no cleanliness in body, clothes, or habitation.
Groups of values are easier than the ones among them; I can easily choose the top five, the bottom few, all that should go in the middle but between those it's difficult to sort out, though the top two are clearly the top two for me. Number 3, 4 and 5 seem equally important to me and that order changes in my head from moment to moment such that it drove me crazy just to get that order and I give up. Those top five are hardest for me to accomplish, along with a couple of the mid-bottom, like silence. There are several qualifications of these values that caused shifts in their order ("cut off all unnecessary actions"--does the necessary unnecessary count? "trifling conversation"--does necessary trifling count?...these things are part of happiness, silliness, wholeness). Also, cleanliness as #13 doesn't mean I endorse mess, but rather than cleanliness I think "order" is more...necessary. I agree with the latter part of chastity (and personally or for modernity, could replace "health or offspring" with "love or connection") but the meat of it is about injury, and isn't that justice. Temperance seems to be solely related to food and drink, and moderation everything else, so that is low. If I had to make it up on my own, it'd be a little different. But these are important.
Come to think of it, not too good at most of these. Reminder.
1. Justice
wrong none by doing injuries, or omitting the benefits that are your duty.
2. Humility
imitate Jesus and Socrates.
3. Sincerity
use no hurtful deceit; think innocently and justly; if you speak, speak accordingly.
4. Resolution
resolve to perform what you ought; perform without fail what you resolve.
5. Frugality
make no expense but to do good to others or yourself; waste nothing.
6. Tranquility
be not disturbed at trifles, or at incidents common or unavoidable.
7. Order
let all your things have their places; let each part of your business have its time.
8. Moderation
avoid extremes; forbear resenting injuries so much as you think they deserve.
9. Industry
lose no time; be always employed in something useful; cut off all unnecessary actions.
10. Silence
speak not but what may benefit others or yourself; avoid trifling conversation.
11. Chastity
rarely use venery but for health or offspring, never to dullness, weakness, or the injury of your own or another's peace or reputation.
12. Temperance
eat not to dullness; drink not to elevation.
13. Cleanliness
tolerate no cleanliness in body, clothes, or habitation.
Groups of values are easier than the ones among them; I can easily choose the top five, the bottom few, all that should go in the middle but between those it's difficult to sort out, though the top two are clearly the top two for me. Number 3, 4 and 5 seem equally important to me and that order changes in my head from moment to moment such that it drove me crazy just to get that order and I give up. Those top five are hardest for me to accomplish, along with a couple of the mid-bottom, like silence. There are several qualifications of these values that caused shifts in their order ("cut off all unnecessary actions"--does the necessary unnecessary count? "trifling conversation"--does necessary trifling count?...these things are part of happiness, silliness, wholeness). Also, cleanliness as #13 doesn't mean I endorse mess, but rather than cleanliness I think "order" is more...necessary. I agree with the latter part of chastity (and personally or for modernity, could replace "health or offspring" with "love or connection") but the meat of it is about injury, and isn't that justice. Temperance seems to be solely related to food and drink, and moderation everything else, so that is low. If I had to make it up on my own, it'd be a little different. But these are important.
Come to think of it, not too good at most of these. Reminder.
Sunday, November 8, 2009
delirium
I met a wonderful 90 year old who came to the hospital for a serious infection in his lungs and blood, who would go in and out of clarity. There were moments where we could converse happily and he'd tell sweet, funny jokes; other times he'd blink slowly and stare blankly, and throughout his stay pain management was an issue. His intermittent moans of pain, physical and inner, gave slight insight into his distress and distressed his neighbors so that he was moved to his own room. Sometimes there was a physical source; other times it seemed expression for something deeper. A gland in his mouth was infected, making it painful for him to eat, dehydrating him. A nurse described his tongue as lizard skin, crusted over with yellow and white; his teeth and the back of his throat covered in the same film. I watched swabs be used to clean him, and I'd never seen so much foreign come from a person's mouth. Each day we'd check, and it looked better after that but I found myself compulsively swabbing him anyway. Brought heat packs and massaged the area, as recommended by the ear nose throat doctors, needing to do something concrete even though quite unsure of the use. In the hospital he began having pain in his rectum. He had diarrhea so much that the nurses put a tube in him ("fecal management system"), and we tried our best--creams, morphine, opiates delivered directly to the source of pain. Sometimes he cried. Not out of pain; out of sadness. He recovered from his infection, but with his continued delirium and inability to do physical therapy, the decision was made to move him to the hospice unit.
When we came to see him at hospice, he was clean. Every day now he says he has no pain. He draws our attention to his smooth skin, freshly shaven. One day he was in the hallway, and said he was waiting for a hair cut (a trim of handsome white peach fuzz). There are still moments of sadness, of his forming phrases--I don't want to leave you, I know all the answers but the game isn't there, I want to live, yes I know but more. And sometimes there are still hallucinations. But he is clean and without pain, and while we try to not let that be everything, we're grateful for that something.
Later we had a class on delirium. After going through a long list of causes of delirium (infection, decreased oxygen, too little salt, too much salt, kidney failure, dehydration, so on and on), our professor asked us how to prevent delirium. Antibiotics for infection? No. We drew a blank on how to prevent all the other causes, and he told us to give up because that wasn't how to think about it. Instead, he told us that studies had been done to show that when people are confronted with these illnesses, six things were shown to reduce the incidence of delirum: sleep, hydration, cognition, vision, hearing, and mobility. Ensuring lights out and reduced noise during hours of sleep, keeping people hydrated, playing daily memory games to maintain cognition, supplying visual and hearing aids, and having some sort of physical therapy--these things kept patients' senses functioning as their bodies fought sickness. Except for hydration, these things didn't target the direct causes of delirium; the people were still sick, but among those who were sick, their alertness and awareness, and thereby communication, interaction and general comfort, were healthier. So it makes much sense that a place like hospice, a place focused on comfort, kept his delirium a bit more at bay, and the idea of holistic care carries hope.
I've been reminded to take care of myself during the intense medicine rotation, and I think I have. It is true that there is less time and energy to go around during this rotation, but aside from a handful of tiring nights it hasn't been overwhelming. The time to spare does have to be allocated and delegated carefully, and after taking care of myself there's not much left over, but this also means that I've paid good attention to the things that provide care, and subsequently relished them. Everyone has their own six things to keep them sane, with some basics and some variation, and third year had me finding them quickly: sleep, cooking, running, friends, dancing, and places. Sleep goes without saying. Cooking at least once or twice a week reminds me that the days don't have to be rushed or prepackaged. The other week I sat down and ate without doing anything else, for the first time in I don't know how long. No company, no phone conversation, no tv, no internet, no reading book or textbook. Eating, and eating alone, allows for rest and like with any other isolation, for heightened senses; in this case, taste. I also associate a certain strange satisfaction with finishing leftovers, so even those days held a certain sense of still functioning. Aside from a two week hiatus during the height of a cough I still have, I've been running a slow six miles at least twice a week. So far this pace and time is suiting my schedule better than faster or longer, and the thing I now remember with running is that what happens on one run doesn't predict the next. Some days you just feel better and faster, and other days you feel like crap, and I've learned to not feel bad about the crappy days. On those days I remember that it's good just to be moving, and that it's enough to do it, regardless of how, and that the highs and lows balance. And this makes me feel better about whatever else I might be doing not so well at the moment, or at other moments.
As for friends, I continue to be glad every day for the people in my life, here and around, presently and from my past, and find that every interaction affirms the gratitude. I feel lucky to be in an environment where I feel comfortable with a good number of people; namely, a small place, as I think the number of people had a lot to do with some of my isolation in college. I feel lucky to find time for snippets and sprawls of conversation, for the emails and gchats and calls and meals and outings, to know people I really love, and love knowing, and love knowing of their presence. These tend to be with people with whom I'm particularly close, while dancing can extend to my class as a whole. It makes me happy to be dancing with my college roommates on another Halloween, with whom I've danced so many good nights, remembering we don't need much else than ourselves to be crazy and escape-happy. It also makes me happy to be dancing with a crowd of classmates, many I haven't seen in months, in a flashback of our first year when we danced almost every week. Several have distinct styles that are equally awesome and smile-so-hard-it-hurts inducing. And there's just something inherently fun and wonderful about a group of people going crazy for no real reason other than that it's inherently fun and wonderful. This weekend we celebrated two class birthdays, both with a lot of dancing, one more club-style the other a la karaoke, and I wasn't anticipating such fun before either, so all the more reason to relish. It was nice and hilarious to see A., usually not so mobile, moving with such adrenaline; M. singing everything from Beyonce to Barbie Girl; and clusters of us interacting with each other through something simple and thoughtless.
Places may be the most vague, and maybe that's why I need it. The day when it was decided to move him to hospice, we happened upon an ethereal cemetery on the way home from the hospital, and we went. It was palpably cathartic, and beautiful. N. had never been to a cemetery before, and I'd never been to one in quite that way. The air was autumn crisp, with much sun, and we came back another day for pictures, lying on patches of leaves, and re-exploration of its huge open fields, the rows upon rows of stone, slopey hills, and wheat like weeds brushing the pond. We've driven hours north for fall leaves to come across shallow streams we don't dare drive across, and few miles away for a coffeeshop with rain stained glass where we hide until it comes down too hard to wait any longer. Each time I feel the distance from here, from knowing there is more and that though he will be in one room from now on the space is wide.
When we came to see him at hospice, he was clean. Every day now he says he has no pain. He draws our attention to his smooth skin, freshly shaven. One day he was in the hallway, and said he was waiting for a hair cut (a trim of handsome white peach fuzz). There are still moments of sadness, of his forming phrases--I don't want to leave you, I know all the answers but the game isn't there, I want to live, yes I know but more. And sometimes there are still hallucinations. But he is clean and without pain, and while we try to not let that be everything, we're grateful for that something.
Later we had a class on delirium. After going through a long list of causes of delirium (infection, decreased oxygen, too little salt, too much salt, kidney failure, dehydration, so on and on), our professor asked us how to prevent delirium. Antibiotics for infection? No. We drew a blank on how to prevent all the other causes, and he told us to give up because that wasn't how to think about it. Instead, he told us that studies had been done to show that when people are confronted with these illnesses, six things were shown to reduce the incidence of delirum: sleep, hydration, cognition, vision, hearing, and mobility. Ensuring lights out and reduced noise during hours of sleep, keeping people hydrated, playing daily memory games to maintain cognition, supplying visual and hearing aids, and having some sort of physical therapy--these things kept patients' senses functioning as their bodies fought sickness. Except for hydration, these things didn't target the direct causes of delirium; the people were still sick, but among those who were sick, their alertness and awareness, and thereby communication, interaction and general comfort, were healthier. So it makes much sense that a place like hospice, a place focused on comfort, kept his delirium a bit more at bay, and the idea of holistic care carries hope.
I've been reminded to take care of myself during the intense medicine rotation, and I think I have. It is true that there is less time and energy to go around during this rotation, but aside from a handful of tiring nights it hasn't been overwhelming. The time to spare does have to be allocated and delegated carefully, and after taking care of myself there's not much left over, but this also means that I've paid good attention to the things that provide care, and subsequently relished them. Everyone has their own six things to keep them sane, with some basics and some variation, and third year had me finding them quickly: sleep, cooking, running, friends, dancing, and places. Sleep goes without saying. Cooking at least once or twice a week reminds me that the days don't have to be rushed or prepackaged. The other week I sat down and ate without doing anything else, for the first time in I don't know how long. No company, no phone conversation, no tv, no internet, no reading book or textbook. Eating, and eating alone, allows for rest and like with any other isolation, for heightened senses; in this case, taste. I also associate a certain strange satisfaction with finishing leftovers, so even those days held a certain sense of still functioning. Aside from a two week hiatus during the height of a cough I still have, I've been running a slow six miles at least twice a week. So far this pace and time is suiting my schedule better than faster or longer, and the thing I now remember with running is that what happens on one run doesn't predict the next. Some days you just feel better and faster, and other days you feel like crap, and I've learned to not feel bad about the crappy days. On those days I remember that it's good just to be moving, and that it's enough to do it, regardless of how, and that the highs and lows balance. And this makes me feel better about whatever else I might be doing not so well at the moment, or at other moments.
As for friends, I continue to be glad every day for the people in my life, here and around, presently and from my past, and find that every interaction affirms the gratitude. I feel lucky to be in an environment where I feel comfortable with a good number of people; namely, a small place, as I think the number of people had a lot to do with some of my isolation in college. I feel lucky to find time for snippets and sprawls of conversation, for the emails and gchats and calls and meals and outings, to know people I really love, and love knowing, and love knowing of their presence. These tend to be with people with whom I'm particularly close, while dancing can extend to my class as a whole. It makes me happy to be dancing with my college roommates on another Halloween, with whom I've danced so many good nights, remembering we don't need much else than ourselves to be crazy and escape-happy. It also makes me happy to be dancing with a crowd of classmates, many I haven't seen in months, in a flashback of our first year when we danced almost every week. Several have distinct styles that are equally awesome and smile-so-hard-it-hurts inducing. And there's just something inherently fun and wonderful about a group of people going crazy for no real reason other than that it's inherently fun and wonderful. This weekend we celebrated two class birthdays, both with a lot of dancing, one more club-style the other a la karaoke, and I wasn't anticipating such fun before either, so all the more reason to relish. It was nice and hilarious to see A., usually not so mobile, moving with such adrenaline; M. singing everything from Beyonce to Barbie Girl; and clusters of us interacting with each other through something simple and thoughtless.
Places may be the most vague, and maybe that's why I need it. The day when it was decided to move him to hospice, we happened upon an ethereal cemetery on the way home from the hospital, and we went. It was palpably cathartic, and beautiful. N. had never been to a cemetery before, and I'd never been to one in quite that way. The air was autumn crisp, with much sun, and we came back another day for pictures, lying on patches of leaves, and re-exploration of its huge open fields, the rows upon rows of stone, slopey hills, and wheat like weeds brushing the pond. We've driven hours north for fall leaves to come across shallow streams we don't dare drive across, and few miles away for a coffeeshop with rain stained glass where we hide until it comes down too hard to wait any longer. Each time I feel the distance from here, from knowing there is more and that though he will be in one room from now on the space is wide.
Monday, October 19, 2009
seven days at the VA
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.
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.
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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