One Eye Open, One Eye Shut

I need to delve into a little theory (sorry!) but I think this is my most important post yet:

Pablo Picasso painted a picture called the Head of a Medical Student in 1907.  Famously known for his abstract style, Picasso portrays the medical student with one eye opened and one eye closed.  To a large extent, medical school training involves desensitization to the body and trauma.  This happens from the very first semester during anatomy as one begins the process of dissecting a human into a series of body parts.  The process of desensitization continues as one watches a trauma response to a car accident victim, a neonate who is not breathing, a psychiatric patient with hallucinations, and a surgery with unexpected complications.  We are taught that desensitization is a good thing, that it is something essential to our ability to practice as physicians.  We need to be desensitized, to keep our emotions in check, in order to do our jobs.

But at the same time, we are taught to empathize with our patients.  We try to learn their life stories and listen to the very intimate details of their lives.  We are taught to pay attention to body language, draping, positioning of chairs, and the way we ask questions in order to make patients more comfortable.  We learn to be aware of social disparities in health care, access to insurance, and different cultural beliefs in medicine.  Yet, I still feel that there is an "us" versus "them" mentality between doctors and patients.  So I need to ask the question, are we doing enough?

I propose that physicians learn to see the world with two eyes open.  Why do we actually need to be desensitized?  I have yet to be in a surgery or dissection in which I was not aware of the fact that I was cutting into a human body.  I can remember several experiences in which I was fully aware of the emotional and moral consequences of a procedure.  Basically, it is the understanding of "what is at stake" for the patient.

For example, when I was on my surgery rotation, I had a patient with pancreatic cancer who was brought to the OR to attempt a risky procedure to remove the tumor.  Due to the extensive nature of the cancer, which was unexpected, we had to stop the surgery and close up her abdomen.  I remember physically feeling the hard tumor on her pancreas with my own gloved hands.  I was aware of more than just the fact that I wasn't going to see a Whipple procedure.  In actuality, I was consumed with the concept that as soon as we closed her abdomen, we were going to have to deliver some devastating news.  It was like looking death straight in the face and feeling utterly unable to do anything to prevent it.  I even remember feeling so sad about this that I was near tears.  As I continue to follow this patient post-op, I remember being a little wary of what I was going to say.  What could I, as a medical student, offer to this patient?

Rather than shy away from her room (as it is so easy to do while on the wards), I tried to bring myself into her room at least once every afternoon to sit down with her and have a conversation.  I did not talk about disease or treatment, but I just listened to her voice her concerns and tried to answer her questions if I could.  Some time later, I realized that these were the most valuable things that I could offer to her: my time and my ability to listen.  In this way, I gave her a chance to emotionally react to her illness and I hopefully allowed her to diffuse some of her burden. According to medical anthropologist and psychiatrist Arthur Kleinman, when a caregiver shares in someone's suffering, "The caregiver becomes a sufferer as well, who first acknowledges and then intimately experiences what is at stake for the other person" (2006).  I was attempting to see this situation with "two eyes open", to explore what was really "at stake" for this patient, rather than medicalize her as just another patient with cancer.

Doctors often forget that we are not immune to disease.  The "doctor" versus "patient" delineation is false, considering that we are all people on a varying continuum of health and illness at any given point in time.  The "two eyes open" analysis allows us to interact as people with other people.  Perhaps this will enable us to better understand the consequences of the illness experience for any of the individuals under our care.





Reference: (A MUST-read article if you are in medicine)
Kleinman, A. & Benson, P. (2006). Culture, Moral Experience and Medicine. The Mount Sinai Journal of Medicine, 73(6), 834-839.

My Week in the Psych ED

I spent this past week working in the Psych ED.  My week basically went like this:

Methamphetamine Monday
Suicidal Ideation Tuesday
Crack Party Wednesday
Hallucination Thursday
Living Life Friday (since I had zero patients this Friday, I can only assume that they are doing things that will land them in the ED later on in the night)


Puts new meaning to the song Manic Monday:

High School with Scalpels

So I don't often watch Grey's Anatomy, but here's a great quote from season 3:

CALLIE: "Four years of high school, four years of college, four years of med school. By the time we graduate we're in our late 20s and we've never done anything except go to school and think about science. Time stops. We're socially retarded. Ha, I mean, look at me, I'm in love with a guy who won't say he loves me back and here I am, in his kitchen, just hoping he comes home and notices me. I'm that girl, who sits in the back of the class and eats her hair. And Meredith, she's 17 years old, we're all 17 years old. This is high school with scalpels, Finn."
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Trouble in Teaching Hospitals

Take a look at this article about the culture of women in academic medicine.  Just another one of the reasons why I feel the need to describe the experience of medical culture, particularly the "moral distress" that physicians feel within the hospital and why an institution might be "dehumanizing".  This is a topic that interests me and one that I will continue to explore.

Excerpt from: http://well.blogs.nytimes.com/2012/11/29/sharing-the-pain-of-women-in-medicine/

But both women and men expressed similarly negative feelings about a lack of support from their institutions for their work. And the men were just as likely as the women to feel what experts have termed “moral distress,” a sense of being trapped and forced to compromise on what one believes is right or just.

“We have this dehumanizing organizational culture in academic medicine that doesn’t allow people to realize their potential or be as vital and productive as they can be,” said the lead author, Dr. Linda H. Pololi, a senior scientist at Brandeis University who is also the director of the initiative. “It’s hard to ignore the far-reaching consequences of a work environment that has trouble modeling compassion and care.”

Reason #1 why my life is turning into a television show

Love this show!  Basically this is how I would answer questions in an interview...

The Point of this Blog

It's probably about time that I explain why I started this blog.  This blog is really an experiment in medical anthropology.  In examining the stereotypes, nuances, vocabulary, and assumptions of doctors-in-training, I think it is possible to describe the culture in which we interact.  To some extent this "guide" is meant to guide others to understand what medical school is like.  On the other hand, I also feel the need to document some of the thoughts and experiences of this year.  Perhaps it is therapeutic.  Perhaps I just want to better remember some of these encounters.  Either way, I feel that personal anecdotes are useful as a form of self-ethnography, in which broader sociological and anthropological theories can be grounded.  I encourage any comments/suggestions that you have and I welcome you to share your own anecdotes.  Thanks for reading!

The House Always Wins

I was in the elevator of my apartment building the other day when someone asked me about my work schedule.  It was late at night and I was coming home in scrubs after being on call at the hospital.  I groaned and complained a bit about how I was coming home late tonight and had to be at work early the next day, and he said to me: "The house always wins."

Though this statement is a reference to gambling, I began to think about the hospital as the "house" and what the hospital might be "winning" from us.  This analogy is an easy one to make.  We are surrounded by "house officers" and "residents", terms which suggest that one lives at the hospital.  Interested in this concept, I set about to do some research on where the origins of the term "resident" come from.

1. The idea of a resident is based on the medieval European concept of an apprentice.  Terms used for doctors-in-training during 1500-1700 include: walkers, dressers, clerks of the house, house physicians, house surgeons, residents, and interns.
2. Apprentices had to pay for the privilege of medical training (much like we pay for med school...) 
3. "Rounds" is a concept that also developed during this time period.  Trainees would watch the master at work as he attended to the patients.
4. Residents actually resided at the hospital long-term and received room and board.
5. Residency was an indentured apprenticeship.  They had to pay back time working for the hospital after residency in exchange for training.
6. The current length of medical school plus a 3-year general residency is equivalent to the length of indenture by apprentices in the 1600s.

So basically our current model for rounds and residencies dates back to more than 400 years ago - what?! Considering that there have been drastic changes in medicine since that time, it is astounding that we still manage our patients and trainees in the same way.  So can a medieval model of physician training still meet our needs in the 21st century?  Well, that's a whole other issue.

In our own era, medical students and residents spend so much time in the hospital that it feels like they live there. This makes it hard to separate work life from home life because Work = Home.  When these lines blur, one feels that all of one's energy is being consumed by the hospital.  And so the hospital eventually wins our time, our money, our effort, and our ability to care.  The house always wins.  

Make Way For Ducklings, part two

There is a specific order in which medical students follow around other members on their team.  This is based on the hierarchical nature of medicine.  Some rotations follow this more strictly than others.  This is also very implicit.  No one tells you in what order you should walk in/out of a patient's room, through a doorway, or down the hall during rounds.  You just pick this up and start realizing that you are the bottom of the hierarchy in every sense, which is physically represented as being the last in line. 

1. Attending
2. Chief Resident
3. Mid-level residents
4. Intern
5. Sub-Intern/4th Year Med Student
6. 3rd Year Med Students

Make Way For Ducklings

There are many times when I feel that the multiple 3rd year students on any given service look like ducklings as they trail behind an intern, resident, or attending.  There are several reasons why this occurs.  3rd years, just like young ducklings, must face many dangers in their new environment.  Some of the perils that await the 3rd year during his or her first days in the hospital:

1. Hospitals are mazes.  They are like casinos in their ability to disorient you to direction and time.  3rd years are used to the safety of the lecture hall and the library, the domains of the preclinical years.  The bright lights, identical hallways, and multitude of oddly named buildings of the hospital take some getting used to.  
2. People will ask you for directions.  You are wearing a white coat and/or scrubs.  You have a badge. You look like you belong.  Well, that's a joke.  You are barely able to find your own locker let alone the radiology residents' reading room (bam, alliteration!) that you were asked to find.
3. Some people have looks of horror on their faces when they enter an elevator full of White Coats. Just be aware of this and don't take it personally.
4. You will lose your attending.  He or she will momentarily duck into a patient room or go to talk to a nurse and you will have absolutely no idea where he or she went.  You will look like a lost puppy.
5. At 6am (or some other absurdly early time), all of the ducklings will enter a patient room with the Mother Duck for rounds.  I can only imagine that many patients have nightmares about how a room full of doctors is going to interrogate them in the dark when they are barely awake.
6. You are not sure of your role in the hospital.  Hence you attach yourself to people who look like they know what they are doing and wait to be asked to do something.  Yes, it is as vague as it sounds.
7. Finally, just try to keep up, no matter the length of your stride in relation to that of the resident.

Superlatives

Working in a hospital is a little bit like high school.  The cliques (or professions) are very clearly defined and seem to represent certain personalities and attributes.  These are just some stereotypes that I have observed.  I realize that these are huge generalizations, but I think that there is some truth behind them.  Let me know what you think.

Best dressed: Female surgeons

Worst dressed: ER docs

Best looking male residents: Anesthesia

Most use of foul language: Orthopedic residents

Nicest people: Pediatricians

Most fun to joke around with: General surgeons

I'm not the only one who has thought about these stereotypes.  See the Scrubs link below for how ob/gyn is like a sorority:

Less Is More but sometimes More Is Good

I feel like I have a very cynical attitude towards medicine.  I'm often surprised by how little we can do to help some patients.  There are even times when I feel that we do too much and are too invasive.  I want to scream that "less is more".  I want to tell the patient to leave the hospital or to refuse treatment.  But occasionally, my faith in medicine is actually restored and there comes a scenario or two when a life is actually saved.

A little boy with a severe asthma exaacerbation and possible anaphylactic reaction was in acute respiratory distress...  It is scary to watch a young child struggle for air with complete panic in his eyes.  The parents are crying and do not know how to help their son.  Life or death really does lie in the hands of the physician at this point.

This situation occurred last night when I was on call in the Emergency Department.  Although my shift was over at 11pm, I stayed until 2am just to make sure that this kid was still breathing.  I listened to his lungs and have never heard a more severe exam.  There were no normal breath sounds.  The space between his ribs was visible as his work of breathing increased.  This is what I call Stress.

Thankfully, a barrage of medications, including an EpiPen, nebulizer treatments, and several IV meds, calmed his breathing.  He was eventually able to fall asleep.  On exam, I was amazed to hear that his lungs were completely clear.  It was as though this episode had never even happened.

In this acute case, it was necessary to use as many medications that could possibly help.  The stakes were so high.  And despite the vomiting and shakiness and headaches that followed some of the medications, this boy was able to breathe deeply once again.

Thus, my rule in life is that "Less is More but sometimes More is Good".  I think that it is our job as future physicians to learn this distinction.  We need to determine when we have done enough, when the body is better off healing without our help, and when we have pushed the limits of our knowledge.  But we also need to determine the situations in which a well-orchestrated intervention can mean the difference between life and death.

Post Call Disorientation Syndrome

I propose that Post Call Disorientation Syndrome should be a new category in the upcoming DSM-V.  You can identify this syndrome if you meet the following criteria:

1.   When asked a question during morning rounds (24+ hours after you first entered the hospital), you just start laughing at the fact that they actually expect you to know the answer and to speak intelligently.  You know that your central nervous system lost these capabilities previously in the night and cannot recover them so easily.

2.   Eating, showering, and sleeping are all equally urgent priorities.  It can be difficult to know which one to do first.  Like the Sims.

3.   When you wake up and don’t know the day, time, or place, and yet you must still assess the mental status of your patients.  This can lead to awkward questions such as “Is today really Friday?” and “Wow, it’s November already?”.

4.   You start getting hungry at random times and Pop-Tarts seem like a good idea for a meal at 2 am.

5.   Your scrubs definitely smell weird, whether you are aware of this or not.

6.   When post-call conversations with parents are initiated by incomprehensible blabber and usually followed by the subsequent questions: 1) did you eat; and 2) is the patient alive?

7.   You appear slighlty manic when you leave the hospital and really, really hope that you don't see people you know on the way home.

8.   You notice that you hold your hands in a neutral position above the waist at all times, even when not scrubbed in to a surgery.  You start to wonder about classical conditioning…and if you will ever be free again.

9.   You leave the OR after x number of hours and are blinded by sunlight.  This is equivalent to a vampire being burned by the sun.  Or a newborn animal just entering the world for the first time.  Or a blind person that can miraculously see again.

10. Post-call sleep transcends space and time.  You go off the grid for several hours, ignore phone calls and text messages, and have strange dreams that involve the hospital.  


Post Call Disorientation Syndrome is aptly demonstrated by this gem:
http://whatshouldwecallmedschool.tumblr.com/post/29683353941/leaving-the-hospital-after-a-24-hour-im-call

Meet the Newborns

The Newborns (neonates, if we are going to get technical) are interesting creatures in medicine.  Having spent all of my previous rotations dealing with adults, it was surprising to find out that newborns' heart rates normally approach values that I've only ever seen on my elliptical's heart rate monitor (when I was really, really in shape) and that premies can commonly forget that they are supposed to breathe.  Yup.

Breathing is something that we take for granted, but when you are born into this world that first breath is hard.  Watching a newly delivered baby turn from blue to pink is really an amazing experience.  You want them to cry and scream and fight against you.  You want them to be severely pissed off that you have taken them from their mother's warm tummy and thrust them into this world with its Air and Light and Noise.

It is common among students to refer to newborns as little aliens.  I even heard one person refer to them as "gerbils" because they are kept in plastic cribs and incubators.  But if you pause to think about it, we must seem like the actual aliens.  Existence in the womb is based on the sounds of your mother's heartbeat and voice.  Breathing is not necessary.  You are floating in fluid, feeling the weightlessness associated with buoyancy and the security that comes with confinement.  At some point, you are forcefully expelled from an overstretched uterus, pass through a bony canal (watch out for that pubic bone!), and are held, blue and writhing, in some physician's gloved hands.

Today I watched a woman deliver her baby while she watched the process in the mirror.  The mirror was positioned between her legs at an angle so that she could see her baby's head emerge.  This was a little too much for me.  I pretend to be all about this sort of thing, but in reality, I think that I would faint if I saw the damage being done, you know, "down there" while I was giving birth.  

Also, if you ever have some extra time in clinic, take the time to peruse the What to Expect books.  Mostly this is for the entertainment factor (they are wildly outdated).  For example, I learned that chicken soup is actually good for a cold, but it can't be the Campbell's kind.  If you actually decide to boil some chicken parts and vegetables and make your own chicken stock, then you can feed this to the infant.  Don't forget to skim the fat.  I'm not sure what you are supposed to do with the crying, sick infant while you are homemaking some chicken soup.  The book failed to provide any strategies for this conundrum.

I looked up the meaning of my name in a baby name book (ok, so I had a lot of time waiting for patients to show up to clinic) and it said: "from Greek mythology, goddess of the moon, hunting, and fertility".  That's an interesting combo and I'm not sure how to interpret this, but I do like the part about being a Greek goddess.  Let's just say though that this goddess of fertility will not be holding up a mirror to watch her little alien be born anytime soon.