halfway across the bridge

I want to tell you a story about a patient I just met. I'm going to tell you his story in his words and then I'm going to tell you his medical story - or rather, his story put to medical language.

Jack* is a 55 yo man who lives nearby with his four grandchildren (ages 4-11) who have lived with him since their mother died and absolutely adore him. He lets the 8 year old paint his nails and do his hair. He does not believe in physically punishing kids, because he wants them to fear consequences, not him. Other family members on the children's father's side have been trying to take the kids away from him ("for a welfare check" he says) by enticing them with toys and vacations, but they choose to stay with him because they adore him.

He was a marine from age 20 to 35, where he trained dogs with a magical touch and met the love of his life. Things were going great until he found out on a random physical (the marines have these pretty often) that he had diabetes and was discharged. In the time that followed, he and his wife raised three daughters and he worked in local construction. After his children moved out, he got divorced - though his wife "is still my best friend" and lives across the street.

After a life of caring for other people but not himself, his body is wrecked from diabetes, both his lower legs have been amputated, and his kidneys are failing so he's on dialysis 4x/week. He's trying to stay positive and take care of the kids, but he's been feeling bored and useless when they're at school. He's trying to volunteer to train dogs, but all 4 places he called told him that his wheelchair is too limiting. When he feels low, he wonders if he should just stop his dialysis and die within 7-10 days.

He comes in today because he has a cough that just won't go away.

Now, the medical story:

55yo white man comes in today with a non-productive cough x 2weeks. It comes on about 5x a day, causes him to gag, and is worse in the morning. He also complains of knee pain where his prostheses connect to his stumps. He is allergic to penicillin and fluorescent dye.

His medical history includes poorly controlled diabetes, resulting in end-stage renal disease for which he is on dialysis 3x weekly and peripheral vascular disease with two amputations which have caused him to ambulate in a wheelchair. He also has congestive heart failure, COPD, depression, and high cholesterol. He takes 14 different medications for his diabetes, cardiac disease, depression, and back pain - including oxycodon. He is a current smoker with 60 pack/years and drinks alcohol occasionally.

He is divorced, unemployed, and lives with his 4 grandchildren (ages4-11) who he has cared for since their mother died 1 year ago.

***

When I walked into the room to talk with Jack* I was not looking forward to talking with him. I was ready for a grumpy man who clearly didn't care about his health or anything else and was ready to just give up.

But after talking to him, I saw how kind and thoughtful he is, how much he loves his grandchildren, and related to how much he wants to feel useful.

I felt incredibly guilty for how much I misjudged him but feel lucky I had the chance to prove my own snap judgments wrong.

We ended up giving him a prescription for a "therapeutic" dog and adjusting some of his medications to try to help him with his cough. He'll be back in a few weeks to see how it's going.

*obviously not his real name; some other facts have been

altered slightly to protect his anonymity

~~~~~~~~~~

"you're starting out on the journey across this bridge, this education,

and right now you are on the same side as your patients.

as you get halfway over the bridge, you'll find yourself changing

and the language the patient had and you had

is being replaced by this other language -

the language of medicine -

their personal story is being replaced by the medical story

when you find yourself on the other side of that bridge

you're part of the medical culture.

while you get there,

I want you to hold on to every bit of your old self

your now self

I want you to remember the stories of these patients."

-Dr. Alita Anderson,

Yale Medical School

I think that's maybe part of what I'm trying to do with this blog... ?

photo source

right here, right now

"and though the breezes through the trees

move so pretty, you're all I see

let the world keep spinning all around

you hold me right here, right now"

-jason mraz, lucky

*

just worked a 14 hour day with virtually no letup -

it was pretty awesome

stay tuned for some incredible stories.

right now? sleep.

photo source

Quick Little Beats

today was amazing.

I heart got to play with babies AND hear fetal heart sounds! Each time I placed the machine in the right place, I felt my heart leap my throat and my eyes tear up because it was so incredible!

the beat is so quick and you can actually hear the valves open and close. I think I was happier than some of the moms - even the really happy ones. I actually said to the first mom "Oh my goodness, your baby's heart is SO BEAUTIFUL!" Of course, she actually spoke Mandarin as her first language and didn't quite understand me, plus she's exhausted and super pregnant and has been feeling her baby move for quite some time now - so she mostly rolled her eyes and smiled like, "yup, silly medical student, of course it's a miracle"

miracle, indeed.

Book Review: Every Patient Tells A Story

Q: What book have you read lately that feels really relevant?

A:

I have two actually - one is Zeitoun, by Dave Eggers, which tells a story about one family's experience with Hurricaine Katrina, the disaster that was the response to it, and the prejudice against Islamic Americans in the aftermath of 9/11. Until I read Dave Eggers narrative, I don't think I truly grasped just how horrible the US's response to Hurricaine Katrina was. I recommend it highly - it's beautifully written and super easy to read.

The other is maybe more relevant to what I'm learning about right now - "Every Patient Tells A Story" by Lisa Sanders, MD, a columnist for the NYT who was a journalist before going to medical school and is the current medical advisor for the show House, MD. The book is filled with all the puzzles of the cases in her column and on House, but also with some lessons in what skills good doctors have to approach these puzzles. The first lesson, maybe unsurprisingly given everything I've written about on this blog (or just the title of her book), is that really good doctors LISTEN TO THE PATIENT'S STORY.

I'm about to begin my clerkship rotation in Family Medicine, which besides strictly diagnostic fields like Pathology and Radiology, is the division of medicine that does the most problem solving - and unlike Radiology and Pathology - it's reading the PATIENT, not his tissue sample or X-rays. Dr. Sanders' book is awesome in that it's fascinating, but also because it reminds us that being doctors is not so unlike being detectives - that not only do you have to know what the clues mean, but you have to actually notice they're there in the first place.

In her intro, Dr. Sanders says that studies have found that Doctors interrupt patients in the first 11 seconds of their story, and that if they waited, they might get a whole lot more information. My goal for my family medicine rotation is to not interrupt my patients to ask questions unless it's absolutely necessary (still have to stick to some time limits)

~~~~~~~~~~~~~~~~~~
"...It [diagnosing a sick patient] is a wayward process

filled with unreliable narratrators - both human and technological -

and yet, despite the unlikeliness,

that answer is often reached and lives are saved"

-Lisa Sanders, MD

the role of a physician is NOT

The past few days have been focused on many issues that mainly affect women - obviously this interests me a lot, both because I am a woman and because I'm interested in women's health. I reviewed pelvic exams yesterday and breast exams today, talked about prenatal care and the changes that happen during pregnancy, then learned how to do an endometriol biopsy and place an IUD, talked all about contraception, then had the afternoon to discuss intimate partner violence. The afternoon was challenging, so I thought I'd share some tips.

The first is that a statement of confidentiality - that the doctors office is confidential, that nothing will be said to your partner without your permission - is very powerful. This seems to most naturally fit in right before I start to ask questions about alcohol, drugs, sex life. Just a simple "I ask everyone these questions and I just want you to know that..." And before asking specifically if the person feels safe saying "Because violence is so common, I try to ask everyone about it every time".

The second is that the role of a physician is NOT many things that any person would instinctively want to do (especially one who is spending so much time on a career path to solving problems and helping people).

Namely, the role of a physician is NOT:

to end the abuse,

to make the person leave their abuser,

to solve the victims problems nor is it

to provide lengthy counseling

I think that would have been more difficult for me to accept if I had not just had my psych rotation. But now I am beginning to understand that much of medicine is about giving someone the option to make their own choices. It can be more dangerous to try to get someone to leave their abuser or to confront the abuser or to call the police than it is to wait until the person who has being abused has decided what they want to do.

The role of a physician DOES include:

asking people about intimate partner violence

telling the person it's not their fault

telling the person that no one deserves to be treated like that

providing resources that the patient could use

including an emergency 24 hour hotline

continuously assessing the person for escalations in violence

helping the person get help in whatever way they want it

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

photo source

(I'm not sure this totally fits, but it kept running through my head this afternoon: )

"will I lose my dignity, will someone care

will I wake tomorrow from this nightmare?

there's only now, there's only here

give into love, or live in fear

no other path, no other way

no day but today"

-RENT

intubation

this past week I had a "bridge week" between clerkships where we learned all about

Anesthesiology.

which really means 5 big things:

*I went into an OR during a surgery for THE FIRST TIME.

(I know what you're thinking, your FIRST time in an OR? how long have I been in medical school? but yup... I also felt the need to announce that it was my "very first time in an operating room" to the entire room - which got me some strange looks, but maybe a little extra help too ??)

*I learned what an anesthesiologist actually does (and how much fun anesthesiologists are)

*I placed IVs, then let people practice placing them on me

(actually totally painless thanks to a lidocaine injection and excellent technique from my fellow medical students :) )

*then I INTUBATED TWO PEOPLE -

which, for anyone who isn't quite sure what that means, kind of looked like this video from the TV show ER except a whole lot less dramatic.

*we talked a whole lot about management and leadership, and about doctors as leaders. These discussions were probably the coolest part. The difference between management and leadership is that Management helps maintain a system and Leadership is how you change a system.

Doctors need to be a part of both.

For the final day, we read an article about how to evaluate your life in the HBS Review. The author says in order to make sure your energy and time go to the right things, ask yourself 3 questions (paraphrased):

(1) how will my career make me happy and fulfilled?

(2) how will my significant other and my family be a continuous source of happiness and growth?

(3) how will I stay out of jail?

He says the third question seems like a joke, but one of his classmates was Jeff Skilling, the infamous CEO of Enron, so maybe not...

~~~~~~~~~~~~~~~~~~~~~~~~~~

"the first responsibility of a leader is to define reality,

the last is to say thank you"

-max depree

Children After 30

According to new research, older parents are happier than younger parents. It seems that before the age of 30, parents with children are less happy than people without children. However, by age 40, the trend shifts so that people with children are happier. Additionally, the researchers found that this varied a lot by culture - in cultures where most support later in life depends on family, people had more positive associations between children and happiness, whereas in cultures where most support is public, children and happiness were less closely associated.

Interesting stuff, huh? I think this is a little bit like finding research that supports chocolate as being good for your health - it just makes sense to me. There's so much to do in your 20s that having kids could prevent you from getting to enjoy as thoroughly, whereas having children, cultivating a family and a life focused on that family is a huge part, culturally in the US, of our late 30s/early 40s.

photo source

~~~~~~~~~~~~~~~~~~

Come, my love

we have mountains to climb

wilderness to wander

-Saul Williams

10 Lessons of Psychiatry

I met today with a small group of students who also just finished their psychiatry rotation to share some of our experiences and some of the emotions it brought up in us - a sort of "burn out prevention" group, as the psychologist facilitator said.

As we went around the room sharing our experiences, I realized my peers and I were stating the big lessons of psychiatry. They were funny, horrifying, profound, and maybe most importantly - cathartic. Here are some of the stories and their lessons:

(1) even if someone looks like or acts like someone you know, someone you love, that kid who teased you when you were in middle school - they're not. so don't treat them like they are. One medical student in my group talked about how one of her patients looked just like one of our friends in medical school - and how she found herself really concerned about him and even more disappointed that he had caused permanent brain damage with heroin use.

(2) after all this studying, including the boards, after which we finally feel like - come on, we must know almost everything. Now we're ready to save some lives! We're confronted with the cold truth of medicine: third year medical students don't really do that. often times, the whole medical system doesn't really do that. helplessness is one of the hardest lessons for people who have dedicated their lives to such a trying path in the hopes that at some point they'll feel, HELPFUL.

(3) sometimes the story is false, but the pain is real. and sometimes even the pain isn't real - but that just means you have to look for deeper problems. One medical student in my group talked about a patient he felt that he really connected with - they both had lost someone close to them recently and the medical student left the interview in tears, but full of hope that the patient would get better. Later, he found out that almost everything the patient had told him had been false. At first he felt angry and betrayed - but eventually, he told us, he felt sad for the patient and wondered what he gained by lying to a third year medical student; he thought perhaps the patient was ashamed of being depressed without knowing why so he created a reason.

(4) it's rarely, if ever, actually about you. even though it feels that way a lot. A few of us told stories about specific patients targeting us in various ways. For me, it was a very sad man with schizophrenia who always rambled aloud all the things he was thinking (as in "today for breakfast I had eggs then I drew a picture I feel like I might have to go to the bathroom I really don't like that picture on the wall) - and one day, he started rambling about me. I wasn't even sure if he knew I could hear him, but he started getting incredibly sexually preoccupied and it made me very uncomfortable. So much that I ended up closing off - not just around him, but around all patients, and even my friends. I think I went into survival/protection mode and just was afraid. Which made me feel like a horrible person - here I am being afraid of this man who is so sick - but I was afraid. Eventually, I sort of resolved it in my mind, but I have such guilt about the relief I felt when he was discharged and I knew I would never see him again.

(5) Humor is a mature defense mechanism. I keep meaning to write one more psych blogpost about defense mechanisms, because it's so important to understand them. But humor really is a mature defense mechanism, because it's taking a situation that could be personal and making it relatable for everyone without projecting the grief or fear you feel onto anyone else.

(6) Find your own outlets. Everyone talked about how critical it was to have friends and family they could talk to, blogs/journals to write in, workouts or books that they could escape into, or places to go that were nothing like where we worked. Even this session seemed to be a critical part of not burning out, of continuing to want to help people, of striving to be the best medical students - and people - we can be.

(7) Addiction is bigger than anyone realizes. This will forever make me wary of prescribing addictive substances to anyone. This will make me take a thorough addiction history on every patient where it seems even mildly appropriate. Maybe everyone. Because someone needs to ask those questions - and if it's not your doctor, who is it?

(8) Ask an unscripted question. I stole this one from Atul Gawande's 5 Rules, but it's a good one, and maybe the most important in psychiatry, when getting a context for a patient is sometimes all you're trying to get. Some of my most productive questions this rotation:

When you are psychotic, what does it feel like?

Who's your support network?

If you had to name your reasons to live, what would some of them be?

What's it like to raise pigs?

Why do you think alcohol is different for you?

(9) There's not always an answer. As scientists, we are trained to create hypotheses, collect data, and analyze it to find the most likely answer. With problems involving people or emotions, and especially both - there's not always a right answer. Sometimes we just have to hold experiences until an answer comes, or we feel okay about not having one.

(10) While I don't think it's likely I'll actually be a psychiatrist, I feel so honored to have had this experience. And so prepared by it for all the other rotations ahead of me. Mental health issues are everywhere and having a better understanding of them will no doubt help me to pick up on things I might have otherwise missed. A big thank you to everyone who taught me or supported me along the way.

~~~~~~~~~~~~~~

A good question is never answered

it is not a bolt to be tightened into place

but a seed to be planted

to bear more seed

toward the hope of greening the landscape of idea.

-John Ciardi

babies going through withdrawal?

From an article in the NYT today about babies who were exposed to opiates in utero and the intense withdrawal they go through when pregnant women try to quit "cold turkey" - seems incredibly relevant given all the opiate addictions I saw in Florida.

stay tuned for a top ten list of things I learned during my psych rotation!

“Most of the literature suggests consistently that the drug exposure itself is not the primary concern,” ...“It’s the cumulative effect of the drug-using lifestyle — poverty, chaos in the home, domestic violence. All those things affect development.”

Not all newborns exposed to opiates have severe enough withdrawal to need medicine; at Maine Medical Center since 2003, about 55 percent of babies exposed to buprenorphine and 80 percent of those exposed to methadone have needed treatment. But it is hard to predict which ones will need it: a newborn whose mother was on a high dose of either drug might need none, while a baby whose mother took a low dose might experience acute withdrawal.

The Ryan Plan for Medicare AKA: break it.

In an extremely well-written editorial yesterday, Paul Krugman explains why Representative Ryan and the Republicans overhaul of Medicaid to save money is not just ludicrous, but cruel (actually that's the title of his editorial).

In short, it would switch Medicare funding to private insurers which would INCREASE the cost initially by adding middlepeople (hence, ludicrous).

AND it would create Medicaid vouchers that people could use to pay for care that the Congressional Budget Office estimates would only pay for less than 1/3 of the cost of private insurance by 2030, leaving many if not most older Americans unable to afford medical care (hence, cruel).

With all the health care reform underway, and all the criticism of the Obama Administration's overhaul of our medical system, no one has been ridiculous enough to suggest that we stop paying for health care for older people in order to make the system affordable.

Well, until Rep. Ryan got involved. Yikes.

Krugman adds, "as the Center on Budget and Policy Priorities points out, of the $4 trillion in spending cuts [Ryan] proposes over the next decade, two-thirds involve cutting programs that mainly serve low-income Americans. And by repealing last year’s health reform, without any replacement, the plan would also deprive an estimated 34 million nonelderly Americans of health insurance."

If you're interested in more views on the Medicare debate, check out this great article in the Atlantic: Undoing Medicare: The Real Death Tax

~~~~~~~~~~~~

"the pundits who praised this proposal when it was released were punked. The G.O.P. budget plan isn’t a good-faith effort to put America’s fiscal house in order; it’s voodoo economics, with an extra dose of fantasy, and a large helping of mean-spiritedness"

-Paul Krugman 

Quack in a Box

As a slight respite from writing about how psych is affecting how I view medicine and myself in medicine, I wanted to share this darkly humorous game that I read about on a great blog written by physicians about health policy. I love board games and they've been a great escape when we're out of the hospital into a land of set rules. This one might be a little too close to home...

While I hope to never actually practice medicine like this, it is a cynical view at the way our current system asks doctors to think about patients, treatment, and their own financial stability.

The game is called "Quack in a Box" and was designed by an internal medicine doctor in rural PA. The basic idea is that all the players are doctors and each round you try to treat your patients. For each turn, you roll a die which determines the number of treatments you have to give your patients. You don't necessarily have to be treating the actual disease (what?!) but you just can't kill your patients or there are negative consequences. For example, exploratory laparoscopy (basically an opening up of your abdomen and looking around) kills very few patients, and costs your patient $2000, whereas completely a thorough physical or recommending prenatal vitamins to a pregnant patient, or yoga to a patient in for a check-up will earn you "cure points" for the patient, but as the doctor you earn $0.00, making it harder for you to treat anyone else.

If your patient gets cured, regardless of how many of the treatments you did were actually helpful, they pay you in full. If your patient dies, you accumulate "infamy" (malpractice suits?), too much of which will destroy your practice. The crazy thing is different patients are worth different amounts of infamy. If you accidentally kill a 60 year old homeless man with schizophrenia, 1 infamy point - but a 35 year old physician with two kids, 7 infamy points.

It's sick, really, but from the review by the doctor on the website - and everything I've seen and heard in our medical system in the US - it might not be so far off the battle that physicians fight daily.

Please let's change this. Step 1: do not privatize or kill medicare! (more on this soon)

~~~~~~~~~~~~~~~

"anytime you feel the pain, hey jude, refrain

don't carry the world upon your shoulders

for well you know that it's a fool who plays it cool

by making this world a little colder"

-the beatles, hey jude

International Medical Service Corps

A NYT article this weekend discusses some of the stories of physicians working in other countries. More physicians (and new graduates from medical school!) are interested in working abroad than ever before; this makes sense, as our world becomes more and more connected, refugees from poorer, war-torn countries have entered all of our lives, and we read every day about other countries falling apart (for now, I won't mention the ways in which our own is falling right with them...)

However, the way this is financed is incredibly scattered and often involves a component of financial support from the individual, which is not always feasible to medical graduates who are carrying many hundred thousands of dollars of debt. Vanessa Kerry MD (John Kerry's daughter), and Paul Farmer MD wrote an editorial in the New England Journal of Medicine, arguably medicine's most prestigious and well-read journal, advocating for the creating of a Peace Corps-like Medical Corps of new graduates and health professionals who would work with and train medical personnel in some of the poorest countries around the world. They argue that this would foster improvement in these countries economies - because they would have to spend less on the costs of pandemics - as well as foster better international relations.

This is something I hope to do after I graduate, but I won't be able to if I have to pay back my loans on the salary I make after residency. Therefore, I am very interested in these programs becoming more financially feasible.

~~~~~~~~~~~~~~~~~~~~

"She plans to deliver in the same place she gave birth before – in her cow shed. When women are menstruating or giving birth, they are considered to be ritually polluted and must stay outside of the home, often in cowsheds or cement rooms near toilet facilities."

-Gates Foundation Website about a Nepali patient

photo source

What Makes the ER Attractive

In case you are one of the four people who has not read it yet - the NYT had an article this morning called "More Physicians say No to Endless Work Days" about how physicians are shifting their career choices more towards ER and hospitalist jobs, where they care for patients in the hospital, but when they leave the hospital, their obligations to their patients leave with them. This is attractive as a lifestyle because it allows time with ones family to be sacred, instead of interrupted by phone calls about their patients.

I'm had a bunch of conversations about this exact topic with friends lately and I can say it is very true. I think about a third of the fourth year class at my medical school matched to ER residencies - one third (of about 100 people)! At dinner last night, Chris and I were talking about the pros and cons of being this type of doctor. You see your patients get better immediately, but a lot of them never get better, and the goal is really to just stabilize them until you can transfer their care to someone else. The ER doctor is the "jack of all trades" - broad knowledge, but not deep. A lot of this is incredibly appealing now when we all want to know and do everything, but I still can't shake the feeling that I want to have relationships with my patients. Not necessarily relationships that often trump those that I have with my friends and family, but maybe sometimes?

here's a quote from the article, which you should totally check out and let me know what you think!

“Look, I’m as committed to being a doctor as anyone. I went back to work six weeks after my boys were born. I love my job,” said Dr. Kate Dewar. “But I was in tears walking out of the house that first day. I’m the mother of twins, and I want to be there to feed them, play games with them or open presents with them on Christmas morning. Or at least I want the option to do those things without fearing I’ll be called back to the hospital.”