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."
.

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.