What I really think of sick people

The other day, I was listening with my stethoscope to the sound of a patient breathing. Even though I have no idea what to listen for, a doctor will occasionally ask me to “come on over and listen to this.” So I do. I blindly mimic the timing and technique with which the doctor shifts the bell of his own stethoscope first to one quadrant of the patient’s back, then to another, then another, then back to the first, then to the last, then to another. Invariably, the doctor asks, “so what’d you hear?” Usually, I say something awkwardly vague like, “sounds lungish.” Sometimes I’ll try to vocally relay what I hear, “You know, sort of, hhhhehehhh-scschchhhhhh…. Hhhhhehhhhhh-schchschshhhhhhh.” But with this patient, I could actually make out some relevant noises. “The left side,” I said, “sounds a lot less lungish than the right.”

To which the doctor replies, “you’ll usually hear quieter sounds from the left side, because the left lung has only two lobes and the right lung has three.”

News to me.

He continues, “but this man also had one of the lobes of his left lung removed due to cancer.”

To which I audibly whispered, “Awesooome.”

Now, I hope it’s clear that I don’t think cancer is awesome. Nor am I in any way glad that this patient had a piece of him wrested from its casing. I just get giddy when I encounter some medical phenomenon that I can understand. I’ve heard of lungs, I have some understanding of what they do, and I can imagine what might happen if you lost a part of your lung.

This kind of thing seems to be happening more and more frequently – I suppose that’s to be expected over the course of a medical education. Even though my first semester has focused on molecules, cells, and other things that don’t really puss, bleed, or throb, I still occasionally learn about disease. Often, the diseases we learn about are really obscure things you might only come across in the movies. We started with a case study of xeroderma pigmentosum (remember the movie The Others, with Nicole Kidman? The kids couldn't be exposed to sunlight. That’s xeroderma pigmentosum) and moved onto osteogenesis imperfecta (remember Unbreakable? Samuel Jackson’s character “Mr. Glass” had really brittle bones that always broke. That’s osteogenesis imperfecta). Last week we studied something called maple syrup urine disease, a metabolic disorder in which the afflicted individual's urine smells like maple syrup. While I haven’t seen any movies about maple syrup urine disease, I’ve mentally classified this disease as fictional for two reasons. First, if you were the first to identify a metabolic disorder, wouldn’t you come up with a less ridiculous name? Second, if this condition exists, then it’s not a disease. It’s a superpower.

On occasion, though, our curriculum covers diseases that I might come across in practice. And when I see patients with these conditions, I try my best to conceal my unmitigated joy.

“So you were recently diagnosed with Hashimoto’s Thyroiditis.” Don’t say awesome, don’t say awesome… “That’s… VERY… nice. I mean, great. Really great. Super.”

It may be even more awkward when I get excited about the diseases afflicting people I know and love. There was a moment this Thanksgiving when I was discussing a family member’s recent bout with gout.

“So I just woke up in the middle of the night, with this excruciating paint in my toe.”

“Aw…awesoooome. Had you eaten a big, proteiney dinner that night?”

“Yeah, steaks.”

“Awesooome.”

Realizing my biochemistry texts appeared to be right about the existence of gout, I mentally shifted that particular condition back into the “nonfiction” category.

I suppose my excitement about disease is more of a benefit than a liability. If I get this excited seeing how things go wrong with people, imagine how thrilled I’ll be once they tell me how to fix these things.

“So, you’re telling me that you took those pills I gave you, and now your kidneys don’t hurt at all?”

“Nope, they feel great. Thanks, Doc.”

“Uh… sure. That’s great. Really super…” Don’t say I can’t believe that worked, don’t say I can’t believe that worked… “What I mean to say is, you know, that’s totally awesome.”

Incubating biologists

About five years ago at my first high school reunion, I took a tour of our new science center. It was pretty ridiculous. The building was equipped with things like a scanning electron microscope and, for reasons that aren't immediately clear to me, cooling towers. On the tour, we saw bio labs with water tables and a tropical marine aquarium, as well as physics labs that have high school-kid-sized merry-go-rounds. When we finished the tour, my buddy The Beav, a filmmaker and tobacco enthusiast, shook his head and said, "Man, if we'd had this science center when I was here, I'd've been a biologist."

Beav was lying, but that doesn't dissuade me from my belief that science education in America could be so much better. I don't think that it's tremendously nerdy to say that science is super dope. Even the simplest science demonstrations we saw on Mr. Wizard stick with us for decades (anyone ever see a hardboiled egg get sucked into a bottle? or celery stalks turn red? That was all much cooler than phonics lessons.)

Bill Bryson recently wrote a book called A Short History of Nearly Everything. It's described as Bryson's "journey into the most intriguing and intractable questions that science seeks to answer." The fiancee and her mom both read it (educators, the lot of them) and seemed to find the intricacies of our collective scientific know-how fascinating. And it is. The stuff we know about our world is crazy cool, and how we came to discover it is equally interesting.

I went into medicine because I wanted to know how the body worked. I'd like to think that the country's interest in medicine is reflected in the Nielson ratings of shows like ER and Grey's Anatomy (as it turns out, the human body likes to have sex with pretty people. Who'd've guessed?). I think that there's a lot of latent interest in the sciences, just waiting to be activated by a compelling curriculum.

The reason I bring this up is because I'm about to give you a hyperlink to a video that I think is awesome. I don't know whether or not it's at all entertaining for those of us without a background in cell biology, but I'd like to believe that stuff like this might make a high school biology class a little more tolerable. Or it may inspire those biology students to be filmmakers.

The Good Life

I returned to the fold this weekend by spending Saturday afternoon at Teach For America's "What's Next?" workshop. There, I met with Corps Members considering careers in medicine who wanted to know more about my decision to change careers and the process of applying to medical school. This, of course, was not my idea. The fiancee volunteered herself and "inadvertently" told a TFA New York administrator that her betrothed was ALSO an alum of the program. Apparently TFA had nobody else who was in a position to speak about medicine, because they overlooked the giant red flag waving menacingly atop my record and welcomed me with open arms.

The event was being held at the Association of the Bar of the City of New York (subtext: BE A LAWYER!), and began with a panel discussion by TFA alums with careers in various fields. The room where the panel discussion was held is enormous, with - I don't know - 100 ft high ceilings, and portraits of fancy lawyers in pretty suits covering the walls (subtext: BE A LAWYER!). The panel included a school administrator, a teacher, a TFA program director, an investment banker (or some such business-type guy), a lawyer, and a city planner. Guess which of these folks was the best dressed, most articulate, and most charismatic? Well, it was the banker, but the lawyer came in a close second (subtext: well, ok, be an I-banker, OR A LAWYER, just make some MONEY).

As a side note, I don't have any problem at all with the unspoken prong of TFA's mission. In a very real way, the schools and the districts in which we work don't have the infrastructure to support meaningful change. So while one prong of the mission is to supply failing schools with dedicated, smart, grossly underqualified teachers (who, I believe, do a fair amount of good in their own right), the second prong invites alums to try to rise to positions of power, from which they might be able to impact policy. The truth is that policy makers, for reasons that aren't entirely clear, seem not to listen to teachers. But they'll listen to a guy with a nice suit and an MBA from Columbia.

So I'm watching this panel discussion, and a girl asks a questions that sounds more or less like the following: "I've worked a couple of office jobs in the past, and I always found those offices reasonably quiet and comfortable. When I started teaching, I couldn't believe how hectic everything was. But eventually, I got used to my classroom always moving, and full of noises, and students stopping me just to hug me. Now I'm worried that I won't be able to go back to an office. So I guess my question is, how do you get used to the boredom of being back behind a desk?"

This was not a concern that I held as a teacher. I remember one day, during my second year of teaching, a friend and former teacher came to visit the school after spending a few months working as a paralegal (...CLOSER). Remember when you were a kid, and one of your buddies found out that his dad subscribed to a special channel, like channel 97 or 99, with naked ladies on it? And that kid was saddled with the momentous task of trying to describe this wildly wonderful and totally inexplicable thing to you and all your friends? Well, this was what it was like to hear Ms. G reporting on her new office job. She tried her best though, as a small group of us gathered around her in the halls after school let out. "I just... I mean. When I need to go to the bathroom, I can just, you know, leave my desk. And go to the bathroom. Literally, whenever I want. Except maybe when I'm taking an important phone call." Our eyes widened as we glanced back and forth at one another. "But that's not even... I mean... I sometimes leave my desk even if I don't have to go to the bathroom at all. We have a water cooler, with cups next to it, and sometimes I go there to get a cup of water. Sometimes I'll stop by a friends desk on the way back to my desk. And we'll chat. And when I get back to my desk, it hasn't destroyed itself while I wasn't watching."

But I didn't even need the luxury of all you can drink water and unrestricted trips to the john. During my second year, I was summoned to jury duty. For the week before my day at the courthouse, I was on cloud nine. I couldn't believe my good fortune, and neither could my friends. I was in court for a single day. I sat for some 6-8 hours on a miserably hard wooden bench, but I might as well have been on a beach in Acapulco. For those 6-8 hours, I quietly read a novel, and was only occasionally interrupted by some guy reading off a list of names that weren't mine. Simply glorious.

Anyway, the boredom of an office job was never something that concerned me. And from the looks in the eyes of the teachers gathered around my round table discussion about careers in medicine, it wasn't a concern that many of these TFAers shared. "In medical school," I said, and paused dramatically, "you're asked to sit quietly while scientists talk to you about science." The giddiness rolled in waves through the crowd. "And then, when they're done talking, you go home and read books about what they were talking about. Sometimes you highlight words in those books." A few gasp audibly as they imagine such a peaceful day. A few teachers raise their hands to venture questions:

"These scientists, do they swear at you when you ask them questions?"
"Almost never."

Gasp!

"Tell me, do these scientists pee on your floor?"
"I've never seen anyone in my medical school, either teacher or student, pee on anything that wasn't meant to be peed on."

Surely he must be kidding!

"Do these scientists become enraged when other scientists touch their pencils or look at them from across the room?"
"Almost certainly. But they bury their fury as bitter pellets of hatred beneath oversized lab coats."

How wonderful!

It was a nice way to spend my Saturday. And I got a free lunch out of it. Then I walked across the island and caught a train back to the medical library, where I unfurled my supermap of metabolic pathways and began reading and rereading about various metabolic pathways to prepare for what's become our weekly Monday exams. I probably should have been a lawyer.

A man's gotta do...

I wouldn't be surprised if the doctor I've been shadowing is growing tired of me. After a couple of rounds of ludicrously moronic responses to straightforward questions, one would think he'd throw in the towel.

D: "So tell me what jaundice and cirrhosis are."
M: "Yeah, those are... you know, problems."

D: "What are microsomes?"
M: "Small... somes?"

No joke. Unfortunately. So you would think that the Doc's patience may be wearing thin, and that might give you some room to interpret what he said to me when I was leaving his office yesterday: "Maybe next week I'll schedule a sigmoidoscopy. Usually they're done in the mornings, but I'll see if I can do one in the afternoon."

To which I (of course) replied, "a what?"

To which he responded, "You take a sigmoidoscope, the patient bends over, and..." he then demonstrated the universally recognizable mime of feeding a fiberoptic tube up a man's rectum. Or losing at tug of war.

Awesome!

This August, on the first day of our orientation, I was watching some presentation about the first year's curriculum. The dean stood in front of us and told us that we would, throughout our time in medical school, be interacting with "standardized patients." Remember the episode of Seinfeld when Kramer's hired to play a patient with gonorrhea for medical students? He was a standardized patient. The school pays actors to help us practice taking a patient's history and administering a physical exam. These actors can then give you feedback on anything from your examination techniques to your demeanor. And as the dean was discussing the merits of using standardized patients, he says proudly, "this ensures that the first time you give a rectal exam, it won't be on a real patient."

So I laughed loudly. Because that's a funny thing to say. Right? Surely we're not paying actors to allow our little inexperienced fingers to plunge their rectums. Surely this was all a joke, right? A joke by the serious looking man at the front of the auditorium who seems entirely unamused by my very loud guffaw.

Looking back on that experience, I feel that there were some lessons to be learned that day:

First, despite the fact that I'm five or six years older than many of my classmates, they universally surpass me in maturity by several years.

Second, apparently, most student doctors get excited at the prospect of learning any medical procedure.

ANY procedure.

Third, there are harder ways to earn a buck than teaching first grade in the Bronx.

So I'm leaning towards the belief that the doctor I'm shadowing is trying to help me out. He did seem genuinely excited to able to offer me this chance (or he has fond recollections of losing at tug of war). We'll just have to see whether he's able to shuffle the schedule around next week so I can dive in on that sigmoidoscopy. If he does, I predict that, by the end of the year, there's going to be one blushing actor who's amazed at the expertise and dexterity of the medical student standing behind him.

Applicable skills

Most of our first year curriculum is packaged together into a single course that lasts throughout the fall. This course encompasses biochemistry, molecular biology, and cell biology. These subjects, it can be argued, are important, but they just don't seem nearly as exciting or relevant as, say, cutting someone open and poking at their insides. Right now, all I know about the human body comes from little schematic diagrams in my text book. If ever a patient complains to me that the red Pac-man looking thing in their cytosol has a small blue triangle stuck in it, I might be able to recognize that they've somehow picked up a nasty, constitutively active Ras protein. I could verify this because there'd be a bunch of other colored squares on which the Pac-man would have left a bunch of yellow circles with P's in the middle.

Though all of this stuff seems very abstract (or even completely made up), at least it occasionally has some gravity to it. The first thing we learned was how proteins get folded into their appropriate forms. Proteins are comprised of amino acids linked to one another like beads on a necklace. What makes a protein particularly useful (or deleterious) is the way that it's folded onto itself. As it turns out, small errors in the way a protein folds can produce some pretty taxing conditions. Cystic fibrosis, for instance, results from one protein that's only slightly abnormally folded. The normal protein forms a tube through which chloride ions can roll out of a cell, the defective tube forms a tube through which ions pass a little less frequently. This small abnormality has some tremendous consequences.

The other day, we learned about a misfolded ion channel in muscle cells. In order for muscles to contract, a current runs down the length of a muscle fiber. The current is created by a bunch of charged particles moving from one side of the cell's membrane to the other. However, in a condition called myotonia congenita, patients have a channel that doesn't conduct one charged particle quickly enough. As a result, the cell can't properly compensate when a muscle is quickly and repeatedly flexed, a patient won't be able to immediately relax their muscle.

I tried to imagine the consequences. Would a patient just crumple into a ball and slowly crush his internal organs with his own muscles? If such a person gets too excited, does his heart contract pump all of the blood out, and then sit like a clenched fist in the patient's chest? As it turns out, people with myotonia congenita tend to find it to be pretty obnoxious, but they can certainly lead full and productive lives.

So why, we all wanted to know, is this particular condition included in our curriculum? When are we going to come across it? As it turns out, only about one out of a hundred thousand people worldwide has it, and if they ever walked into my office, there's no treatment I could give them. So where might an understanding of this condition come in handy?

Goat farming. It turns out, myotonic goats can't jump without cramping up and falling over, saving goat farmers a fair amount in the building and maintenance of their fences. Also, these goats are adorable.

What am I doing?

During the first meeting of a course ominously called The Medical Encounter, our small group of 10 or so first year medical students was asked, "As students, what are you able to offer your patients." The answer, I thought, was simple: precisely squat. I don't know anything at all about medicine and even less about being a doctor. I'm not kidding when I say that I often find myself believing that the causes and remedies of all sorts of conditions are absurd and nonsensical things. Like, oh, the skin on your leg's peeling off, haven't been drinking enough OJ, have you? Or, oh geez, I've been dizzy for a couple of weeks, I should have a beer or two before going to bed tonight. It seems I've come to subscribe to a strange, modern belief in the four humors. We all, I've come to believe, are little more than an amalgam of orange juice, coffee, beer, and water. And when that balance is skewed, havoc ensues.

I probably shouldn't be a doctor.

Nonetheless, I find myself every week, standing whitecoated and bestethoscoped, in front of dozens of patients. Patients who call me "doc." And they ask me questions. Questions about what's wrong with them. This doesn't happen often as I'm rarely left alone with patients, but when it does, I typically laugh and explain enthusiastically that I have no idea... Although, what would you say your daily beer and coffee intake is?

I don't mind pretending to be a doctor. I kind of like it. I'm even becoming convinced that it's an applicable professional skill. It's going to be a long time - much longer than the 7-10 years it'll take me to start earning a real salary - before I'll be able to get through the day without ever feeling as though I'm in over my head. During those times, I'll be expected to maintain a professional facade, finger my stethoscope diligently, thumb through esoteric notebooks from the pockets of my luxuriously white coat, and explain that "I'm not quite sure what's wrong with you Mr. Jones, it could be a number of things. But when I figure it out, you'll certainly be one of the people I tell."

Recently, I was visiting a patient who had been put through the ringer at a local hospital. She'd had a number of invasive tests to determine what was wrong with her, but none of them were conclusive. The patient, let's say Ms. Patient, was understandably distraught. The doctor listened to her worry and dither and weep, and then left the room to pick up some free samples of a particular pharmaceutical for her to take home. While he was out of the room, I found out that Ms. Patient was a teacher. I told her that, for a few years, I had been a first-grade teacher, too. We talked about her school, her students, and how her condition was affecting her work. After only a short while, the doctor came back in the room and explained how to use the new drug and how the medication might help. Ms. Patient had difficulty understanding his instructions, and she soon fell back into her pronounced, dewey-eyed, funk. The doc looked up at the ceiling, then over at me. Then he asked, "How's work going?"

She looked at me, then at him. "It's fine. You know. Same old."

"What grade do you teach again?"

Again, she looks at me, then at him. She looks more confused now than she did when she recounted those weeks she spent in and out of the hospital. She asks, "Why are you talking to me like this?"

And then, for a fleeting instant, I believed I might have something to offer this busy family practice staffed by one doctor who doesn't always have the time to heap generous amounts of conversation and compassion onto his patients. I thought, just maybe, I could provide a meaningful service that would contribute to the health, well-being, and happiness of a patient. This woman, I realized, was wildly deficient in orange juice, something the doctor had never even mentioned. Next time I'll be sure to bring a carton or two.