Since 8 AM on January 2nd, I’ve been engrossed in a new semester. My three readers (hi Mom, Dad, and Dan!) may have noticed, not coincidentally, that I’ve posted only once since the new year. You can imagine that the course directors who wanted me back in the class at the crack of dawn after New Years Day probably don’t much care about my complaints that they’re sucking time away from my blogging.
The new course combines embryology, anatomy, physiology, and radiology into one glorious package. It’s the dopest. I learn how the heart forms, what the heart looks like in my cadaver (hi Judith!), how the heart does what it does, and what the heart looks like in blurry x-ray images all at once. It really is a blast, but it’s taking up way too much time.
As I while away my weekends with books and flashcards spread out all over my apartment, I thought it would be nice to revisit the time in my life when I made the decision to start a medical career. That occurred five years ago when I found myself in the South Bronx, locked in a classroom with three dozen six year olds and one terrifyingly under qualified assistant teacher.
The kids were great, and stories about them will follow later. The assistant teacher, however, defies description. Let’s give her the briefest of introductions and then try to paint a more complete picture with a short vignette.
Though she’d never married, Mrs. W always introduced herself as “Missus”. She was fifty-some years old and had been teaching in some capacity for several years, though she'd never earned credentials or undergone a formal observation by the school administration. At least two or three students in my class read at a higher level than she did, and the class routinely taught her our first grade math content (on the first day, I kid you not, they taught her how put the numbers one through ten in numerical order). She referred to make-believe stories as “friction,” a line that’s level to the ground as “horizona,” and the tusked marine mammal from the arctic as a “walrusaurus.” From day 1 until the end of the school year, Mrs. W called our one Chinese student “Ching Chong.” To be fair, she didn’t remember the actual names of any of the students. But this particular student’s name, Jackie Chen, should have been easy to remember.
One day, Mrs. W was reading to the class from a story called Three Friends Together. The story was about a penguin, a whale, and a seal who were the best of friends. But, as the three of them played together day after day, one of them invariably felt left out. One time it was the whale, who couldn’t play with the penguin and the seal up on the ice floes. Another time it was the penguin, who couldn’t hold his breath underwater as long as the seal and the whale. And then, if I remember correctly, the seal upset his friends because he wanted to hug the penguin’s sister inappropriately. It’s a good story.
When Mrs. W finished reading the story to the kids, she closed the book and declared, “I like that book. It makes me think of when I was a little girl trying to learn to roller skate with some of my friends.”
If you’d ever seen Mrs. W improvise a lesson, you’d understand how worried I was at this point. Undaunted, she continued.
“You see, my friends were all real good at skating, but I never skated before. So they all got up and were skating around real well, and I couldn’t go fast at all.”
What’s this? Did Mrs. W grasp the moral of the story she just read? Did she make a meaningful connection between the text and her own life? Is she not even going to mock the children?
“So, we was skating. And all my friends was getting father and farther ahead of me, and I was getting farther and farther behind. And they all made it to Manhattan and back, before I left my neighborhood in the Bronx. And I remember, I was so sad. I went to tell my dad what had happened. And he said not to be so sad. He said that all my friends were good skaters and that I was just learning, and that soon, I’d be able to skate to Manhattan and back with my friends. And you know what? I never learned to skate.”
Ta da! That’s the stuff!
So thank you, Mrs. W, wherever you are. Even if your roller skating story never truly inspired the students, it continues to motivate me on a daily bases. Every time I feel exhausted or overwhelmed, I recall the emotions I felt upon the conclusion of that tale, and I enthusiastically return to my piles of reading with a renewed sense of purpose.
Sunday, January 28, 2007
Sunday, January 14, 2007
Stranger in a Strange Land
Medical school’s a strange place for an English major. It’s not just that I’m grossly underprepared for a basic science curriculum (though that’s no small part of it), but the comfort and familiarity with English prose that I’d developed as an undergrad is absolutely useless in medicine.
I’d been told that a medical curriculum is primarily about learning a new language, but I rarely listen to what people tell me (I’m going to be a great doctor). Maybe I hoped that my doctors didn’t just sound like they knew what they were talking about, but, in fact, had some substantive, applicable knowledge that they could use to cure me of whatever disease might come my way. It appears that medicine involves a healthy mix of both comically abstruse language and a useful breadth of real knowledge.
I knew that learning the science would be tough, but I didn’t anticipate the difficulty learning the language. I like it when authors use as few words as possible to describe something, and I’m just not accustomed to wading through drawn out prose. In some cases, my anatomy text employs a perfect economy of language. For instance, the artery that turns behind your shoulder and then wraps around the bone of your arm, that’s called the “posterior circumflex humeral artery.” Terrific! I can remember that. It’s the goes-behind-then-around-the-arm-bone artery. Beautiful! But then, just when I’ve reconciled myself with medical language, I come across this:
“The articulations between the superior articular surfaces of the lateral masses of the atlas and the occipital condyles, the atlanto-occipital joints, permit… the neck flexion and extension occurring when indicating approval.”
Now I’m not complaining about the unfamiliar words in the first part. I know that there are lots of names of lots of body parts that I’ve got to learn. My concern is with the stuff that follows the ellipses. If these authors are unwilling to lower themselves to using the two-word phrase “nodding yes” instead of “the neck flexion and extension occurring when indicating approval”, can I trust them to clearly describe the thousands of other anatomical phenomena out there? Unlikely.
Geneticists are one group of folks who are trying to take these erudite physicians down a few pegs. They’ve found a back door into the clinician’s lexicon, and they’re doing some tinkering. It turns out that (for the time being, anyway) geneticists have free rein to name whatever genes they discover. Typically this begins in some non-human organism like the zebra fish, so the geneticists will name a gene something clever like, say, “one-eyed pinhead.” Once the equivalent of the “one-eyed pinhead” gene is found in humans, well, nobody really wants to go through the effort of renaming the gene, so they just hang on to the old name. This makes it really difficult for clinicians who are forced to discuss genetic abnormalities with their patients. Imagine listening to an obstetrician discussing a newborn child’s severe facial malformation with the child’s parents. The obstetrician would have to explain that their child’s condition was due to an improperly functioning Sonic Hedgehog gene.
Other genes out there that may make their way to the clinic have names like “faint sausage,” “fear of intimacy,” and “lunatic fringe.” Anyone out there who thinks it’s a good idea to let geneticists name their own genes, generate the neck flexion and extension necessary to indicate approval.
Over the next four years, I’ll have to learn to make sense of the elements of this awkwardly cobbled language: the concise Latin terminology; the unnecessarily verbose phraseology of textbook writers; and the sophomoric jokes of lab scientists. I’m not worried, though. I’d guess that a patient would understand perfectly well if I told her that a piece of her DNA’s garbled, or if I told the victim of a car accident that his goes-behind-then-around-the-arm-bone artery was nicked in the crash. That would certainly make more sense than if I pointed out a patient’s fully functional fear of intimacy or his appropriately sized faint sausage.
I’d been told that a medical curriculum is primarily about learning a new language, but I rarely listen to what people tell me (I’m going to be a great doctor). Maybe I hoped that my doctors didn’t just sound like they knew what they were talking about, but, in fact, had some substantive, applicable knowledge that they could use to cure me of whatever disease might come my way. It appears that medicine involves a healthy mix of both comically abstruse language and a useful breadth of real knowledge.
I knew that learning the science would be tough, but I didn’t anticipate the difficulty learning the language. I like it when authors use as few words as possible to describe something, and I’m just not accustomed to wading through drawn out prose. In some cases, my anatomy text employs a perfect economy of language. For instance, the artery that turns behind your shoulder and then wraps around the bone of your arm, that’s called the “posterior circumflex humeral artery.” Terrific! I can remember that. It’s the goes-behind-then-around-the-arm-bone artery. Beautiful! But then, just when I’ve reconciled myself with medical language, I come across this:
“The articulations between the superior articular surfaces of the lateral masses of the atlas and the occipital condyles, the atlanto-occipital joints, permit… the neck flexion and extension occurring when indicating approval.”
Now I’m not complaining about the unfamiliar words in the first part. I know that there are lots of names of lots of body parts that I’ve got to learn. My concern is with the stuff that follows the ellipses. If these authors are unwilling to lower themselves to using the two-word phrase “nodding yes” instead of “the neck flexion and extension occurring when indicating approval”, can I trust them to clearly describe the thousands of other anatomical phenomena out there? Unlikely.
Geneticists are one group of folks who are trying to take these erudite physicians down a few pegs. They’ve found a back door into the clinician’s lexicon, and they’re doing some tinkering. It turns out that (for the time being, anyway) geneticists have free rein to name whatever genes they discover. Typically this begins in some non-human organism like the zebra fish, so the geneticists will name a gene something clever like, say, “one-eyed pinhead.” Once the equivalent of the “one-eyed pinhead” gene is found in humans, well, nobody really wants to go through the effort of renaming the gene, so they just hang on to the old name. This makes it really difficult for clinicians who are forced to discuss genetic abnormalities with their patients. Imagine listening to an obstetrician discussing a newborn child’s severe facial malformation with the child’s parents. The obstetrician would have to explain that their child’s condition was due to an improperly functioning Sonic Hedgehog gene.
Other genes out there that may make their way to the clinic have names like “faint sausage,” “fear of intimacy,” and “lunatic fringe.” Anyone out there who thinks it’s a good idea to let geneticists name their own genes, generate the neck flexion and extension necessary to indicate approval.
Over the next four years, I’ll have to learn to make sense of the elements of this awkwardly cobbled language: the concise Latin terminology; the unnecessarily verbose phraseology of textbook writers; and the sophomoric jokes of lab scientists. I’m not worried, though. I’d guess that a patient would understand perfectly well if I told her that a piece of her DNA’s garbled, or if I told the victim of a car accident that his goes-behind-then-around-the-arm-bone artery was nicked in the crash. That would certainly make more sense than if I pointed out a patient’s fully functional fear of intimacy or his appropriately sized faint sausage.
Thursday, December 28, 2006
What I Did on My Winter Vacation
The semester drew to a close in mid-December. Since then, I've made a deliberate effort to get out and see some of the New York nightlife and not to sit inside getting a head start on the embryology and physiology reading for next semester. The fiancee and I went out to what I was told was a "bar" on my first night off. The next day, I spent a luxuriously quiet morning and afternoon cleaning and organizing the apartment, followed by an early night watching the most recent disc of Carnivale delivered via Netflix. The next night, the fiancee and I met up with a med school friend and a couple of my buddies from college for a rollicking night of celtic rock in midtown followed by an equally rollicking, non-celtic rock extravaganza on the upperwest side.
And that was about all of the nightlife I could handle. The fiancee and I, along with the future in-laws, needed to kick back and spend a relaxing day visiting the Bodies exhibit at the South Street Seaport. Much less lame than cracking that physiology text, right? Right.
Before we saw the exhibit, the father-in-law-to-be voiced some ethical concerns about the show. Some folks claim the bodies on display were those of Chinese prisoners who were executed in order to feed a booming black market organ industry. One might guess that these people never gave explicit permission to have their bodies dissected and put on display for gawking foreigners. At the very least, the origin of these bodies is uncertain. The folks who run the exhibit maintain that "the bodies belonged to people from China who died unidentified or unclaimed by family members." You can read more about the controversy here and here, but believe me when I say that nothing takes the fun out of flayed corpses like nagging ethical concerns.
Undeterred, we marched on down to the South Street Seaport to get us a look-see. And we weren't the only ones with the idea. The place was mobbed with all sorts of people. The crowd comprised folks of all colors, ages, backgrounds, and views on personal hygeine. The young and the old walked hand-in-hand past men cut in half to expose their viscera ("Grandma, why doesn't the man have any skin?" "That's what happens when you write an inflammatory letter to the editor in the Shanghai Gazette, Timmy."). There were people who had obviously studied human physiology for much of their lives, and others who evidently had only a cursory understanding of the typical number of human limbs or the placement of skin relative to the rest of the body. But everyone appeared equally fascinated.
Grown men and women would walk up to a display of the preserved vasculature of the kidneys, they'd grab the little box with both hands, bring their noses right up to the glass, and squawk excitedly about how little the blood vessels are and how amazing it was that, without any of the surrounding flesh, those vessels still make two distinct little kidney shapes. You'd see a dozen people standing around a body that's posed holding a football, and every one of them would be reading the display while mimicking the motions needed to hold and throw the football. They'd be feeling for tendons in their hands and reaching around themselves to feel the movement of various muscle groups. Surrounding the display of a smoker's lungs, I could see high schoolers glancing anxiously at their friends, their hands migrating unconsciously to cover the box-shaped bulges in their pockets.
I no longer meet new people who aren't in my class, but I used to meet new people on occasion before I started school. Invariably, when those folks found out I was going to be a medical student, the first thing they mentioned was gross anatomy. "Oooh, are you going to have to cut open a dead person? I couldn't handle that," and less frequently, "awesome, I've always wanted to cut a guy." Either way, this seems to be the aspect of medicine that most universally intrigues people. Nobody's ever said to me, "Oooh, do you have to spend hours hunched over textbooks highlighting? That sounds gross," or "awesome, I've always wanted to slowly turn every page of a book flourescent yellow."
Of course, gross anatomy is one of the things that really excites me about this upcoming semester. I fully expect to be one of any number of students grabbing those kidneys with two hands, pressing my nose up against the retroperitoneum, and exclaiming, "look how kidney-shaped these little guys are!" Logistically, it only makes sense that this experience is usually reserved for medical students and communist prison wardens. However, it's apparent through the wild success of the Bodies exhibit, that there are lots of folks out there, folks of all ages, colors, and creeds, who've always wanted to cut a guy.
So, you know, heads up.
And that was about all of the nightlife I could handle. The fiancee and I, along with the future in-laws, needed to kick back and spend a relaxing day visiting the Bodies exhibit at the South Street Seaport. Much less lame than cracking that physiology text, right? Right.
Before we saw the exhibit, the father-in-law-to-be voiced some ethical concerns about the show. Some folks claim the bodies on display were those of Chinese prisoners who were executed in order to feed a booming black market organ industry. One might guess that these people never gave explicit permission to have their bodies dissected and put on display for gawking foreigners. At the very least, the origin of these bodies is uncertain. The folks who run the exhibit maintain that "the bodies belonged to people from China who died unidentified or unclaimed by family members." You can read more about the controversy here and here, but believe me when I say that nothing takes the fun out of flayed corpses like nagging ethical concerns.
Undeterred, we marched on down to the South Street Seaport to get us a look-see. And we weren't the only ones with the idea. The place was mobbed with all sorts of people. The crowd comprised folks of all colors, ages, backgrounds, and views on personal hygeine. The young and the old walked hand-in-hand past men cut in half to expose their viscera ("Grandma, why doesn't the man have any skin?" "That's what happens when you write an inflammatory letter to the editor in the Shanghai Gazette, Timmy."). There were people who had obviously studied human physiology for much of their lives, and others who evidently had only a cursory understanding of the typical number of human limbs or the placement of skin relative to the rest of the body. But everyone appeared equally fascinated.
Grown men and women would walk up to a display of the preserved vasculature of the kidneys, they'd grab the little box with both hands, bring their noses right up to the glass, and squawk excitedly about how little the blood vessels are and how amazing it was that, without any of the surrounding flesh, those vessels still make two distinct little kidney shapes. You'd see a dozen people standing around a body that's posed holding a football, and every one of them would be reading the display while mimicking the motions needed to hold and throw the football. They'd be feeling for tendons in their hands and reaching around themselves to feel the movement of various muscle groups. Surrounding the display of a smoker's lungs, I could see high schoolers glancing anxiously at their friends, their hands migrating unconsciously to cover the box-shaped bulges in their pockets.
I no longer meet new people who aren't in my class, but I used to meet new people on occasion before I started school. Invariably, when those folks found out I was going to be a medical student, the first thing they mentioned was gross anatomy. "Oooh, are you going to have to cut open a dead person? I couldn't handle that," and less frequently, "awesome, I've always wanted to cut a guy." Either way, this seems to be the aspect of medicine that most universally intrigues people. Nobody's ever said to me, "Oooh, do you have to spend hours hunched over textbooks highlighting? That sounds gross," or "awesome, I've always wanted to slowly turn every page of a book flourescent yellow."
Of course, gross anatomy is one of the things that really excites me about this upcoming semester. I fully expect to be one of any number of students grabbing those kidneys with two hands, pressing my nose up against the retroperitoneum, and exclaiming, "look how kidney-shaped these little guys are!" Logistically, it only makes sense that this experience is usually reserved for medical students and communist prison wardens. However, it's apparent through the wild success of the Bodies exhibit, that there are lots of folks out there, folks of all ages, colors, and creeds, who've always wanted to cut a guy.
So, you know, heads up.
Friday, December 08, 2006
Your chart indicates that you've recently visited the hospital cafe...
Sitting through a few hours of lectures on biological molecules is no easy task. It requires a good night's sleep, a good magazine, and a good cup of coffee. Yesterday, I stopped by the medical school's cafe to pick up some coffee only to find that it had been shut down because of health code violations.
That's right. Our coffee shop, housed in the same building as one of the nation's top 10 hospitals, is no longer allowed to serve coffee because the Department of Health can't ensure that it won't make people sick.
Now, I'm no health inspector, nor am I a mathematician, but the cumulative score on the cafe's Inspection Report (which is displayed proudly on its door) was a negative 64. That seems bad, doesn't it?
That's right. Our coffee shop, housed in the same building as one of the nation's top 10 hospitals, is no longer allowed to serve coffee because the Department of Health can't ensure that it won't make people sick.
Now, I'm no health inspector, nor am I a mathematician, but the cumulative score on the cafe's Inspection Report (which is displayed proudly on its door) was a negative 64. That seems bad, doesn't it?
Wednesday, December 06, 2006
The voices in my head want you to get the hell out of my office
In all fairness, I was warned that everyone else is crazy.
During my first day meeting with patients, I watched a doctor elicit a woman's family history. The patient had high blood pressure and high cholesterol, so the doctor asked if there was any history of heart disease in her family. The reply was quick, "Nope."
"Any high cholesterol in your family?"
"Nope."
"High blood pressure?"
"None."
"None? No high blood pressure or high cholesterol in your family?"
"Nope."
"Do you have any brothers or sisters?"
"Yeah, two brothers."
"Any high blood pressure or high cholesterol in either of them?"
"Nope."
Was he serious? Did the doctor think his questions were unclear? I was incredulous. I almost felt as if he were insulting the patient by asking the same thing over and over again.
"Your mom, does she have high blood pressure or high cholesterol?"
"Oh, yeah. She had real high cholesterol. I think her pressure was high, too. She had a heart attack last year."
The doctor nods, making notes in the patient's file, "what about your dad?"
"He passed from a heart attack 8 years ago."
What!?
Is it possible that this patient is so uncomfortable in an examination room, that the doctor has to ask the same question a half dozen times before he can get an answer? It's not really so far-fetched. This patient has just been told that she her body doesn't work properly, and then was asked by a serious-looking guy in a white coat, "Is there any history of heart disease in your family?" Should I really be surprised that she rushed to her own defense? "Back off, Doc, my family's fine. And I feel great."
The simpler answer though, is the one I've heard a dozen times from family members, employers, teachers, friends, cab drivers, space aliens, coworkers, and unicorns: Everyone else is crazy. And watch out for them. But once you hear that advice a dozen times from a dozen different people, it turns into a logic problem. I've come to believe that, perhaps, those aliens aren't as smart as they think they are.
It seems more likely that we all think in a way that is fundamentally incongruous with the way everyone else thinks. A not-so-insightful observation that, if true, would make patient care much more difficult than I'd imagined it would be.
We take two classes right now, a science class and a touchy-feely class. Last week in the touchy-feely class, a speaker came in to discuss his experiences as a patient. He's had a string of serious ailments that brought him in contact with a number of doctors and other health care providers over the last thirty years. One of the earliest doctor visits that he recalls took place during his first year of college. While showering, he felt a tender lump on his butt and immediately became anxious. He quickly dressed and headed over to the student health office on campus, where he was seen by an amiable, outgoing doctor. The doctor gregariously inquired about the man's ailment, and subsequently examined the affected area. The doctor declared that the lump was "just a hemorrhoid" and "nothing to worry about." He explained that hemorrhoids will resolve on their own. He suggested that the man try soaking in a hot tub and maybe eat more roughage. The visit lasted about 25 minutes.
I've tried to convey this story in a manner similar to the way I heard it from the patient himself. The only thing I left out were the patient's frequent references to the doctor as a "jerk" (though the description of amiable and gregarious comes straight from him). The interaction described above INFURIATED the patient, so much so that he still recounts this story - now thirty years later - with a seething, undisguised hatred. During his senior year, the patient came down with a horrible infection and refused to return to student health because of that doctor. He finally gave in when his temperature neared 105 degrees.
I heard this man's description of his trip to student health, and I thought the doctor sounded competent, professional, and engaging. All in all, this seemed to me to be a strongly positive doctor-patient interaction. All that's missing is the sticker.
The patient's impression of the doctor was that he was extraordinarily dismissive of the condition, and that he totally ignored the patient's intractable (though never verbalized) belief that the lump was a cancerous tumor. Furthermore, he never said how long the hemorrhoids would last and wouldn't prescribe any medication to make them go away.
What didn't came up during this visit, was that the patient was a recently-outed, gay man. He was coming to grips with his sexuality in the context of a) his new, autonomous life at college and b) his traditional upbringing in a religious, military family. His concerns about the lump on his butt didn't just come from hypochondria; he was terrified that he was being punished for his lifestyle and that this condition would make him less attractive to men.
The patient vehemently believes that it was the doctor's fault that a discussion of these concerns never took place. Maybe it was, I really don't know. I'm not retelling this story to investigate that question. All I want to do is point out that, although his impression of the interaction was drastically different than my own, the patient is probably not crazy. And that terrifies me.
I probably would have treated a frightened college freshman the same way that doctor did, because that's how I'd want to be treated. If I thought I had cancer, and I saw a trained physician who was absolutely certain that I had only a benign condition that would resolve itself with time, I would WANT him or her to tell me exactly that. It would freak me out more if the doctor dwelled on any possible diagnoses that were clearly not appropriate. And if I could clear this condition up without taking any drugs, all the better. Though I might be exhibiting some self-preservation here, I'd like to think that this position is also not crazy.
So we have two, ostensibly sane people considering the same professional interaction. One of these people is entirely satisfied that there's nothing wrong (absence of stickers notwithstanding), and the other is so wildly offended, that he has spent thirty years of his life railing against this doctor to audiences across the country. Is this just the nature of a profession driven by interpersonal relationships? Is there some way that a physician can account for all of the disparate personal needs, histories, and characteristics that walk through the door? Am I doomed to have any patient who doesn't think like I do leave my office in a fury telling people I'm a jerk?
Sometimes the science class is much easier.
During my first day meeting with patients, I watched a doctor elicit a woman's family history. The patient had high blood pressure and high cholesterol, so the doctor asked if there was any history of heart disease in her family. The reply was quick, "Nope."
"Any high cholesterol in your family?"
"Nope."
"High blood pressure?"
"None."
"None? No high blood pressure or high cholesterol in your family?"
"Nope."
"Do you have any brothers or sisters?"
"Yeah, two brothers."
"Any high blood pressure or high cholesterol in either of them?"
"Nope."
Was he serious? Did the doctor think his questions were unclear? I was incredulous. I almost felt as if he were insulting the patient by asking the same thing over and over again.
"Your mom, does she have high blood pressure or high cholesterol?"
"Oh, yeah. She had real high cholesterol. I think her pressure was high, too. She had a heart attack last year."
The doctor nods, making notes in the patient's file, "what about your dad?"
"He passed from a heart attack 8 years ago."
What!?
Is it possible that this patient is so uncomfortable in an examination room, that the doctor has to ask the same question a half dozen times before he can get an answer? It's not really so far-fetched. This patient has just been told that she her body doesn't work properly, and then was asked by a serious-looking guy in a white coat, "Is there any history of heart disease in your family?" Should I really be surprised that she rushed to her own defense? "Back off, Doc, my family's fine. And I feel great."
The simpler answer though, is the one I've heard a dozen times from family members, employers, teachers, friends, cab drivers, space aliens, coworkers, and unicorns: Everyone else is crazy. And watch out for them. But once you hear that advice a dozen times from a dozen different people, it turns into a logic problem. I've come to believe that, perhaps, those aliens aren't as smart as they think they are.
It seems more likely that we all think in a way that is fundamentally incongruous with the way everyone else thinks. A not-so-insightful observation that, if true, would make patient care much more difficult than I'd imagined it would be.
We take two classes right now, a science class and a touchy-feely class. Last week in the touchy-feely class, a speaker came in to discuss his experiences as a patient. He's had a string of serious ailments that brought him in contact with a number of doctors and other health care providers over the last thirty years. One of the earliest doctor visits that he recalls took place during his first year of college. While showering, he felt a tender lump on his butt and immediately became anxious. He quickly dressed and headed over to the student health office on campus, where he was seen by an amiable, outgoing doctor. The doctor gregariously inquired about the man's ailment, and subsequently examined the affected area. The doctor declared that the lump was "just a hemorrhoid" and "nothing to worry about." He explained that hemorrhoids will resolve on their own. He suggested that the man try soaking in a hot tub and maybe eat more roughage. The visit lasted about 25 minutes.
I've tried to convey this story in a manner similar to the way I heard it from the patient himself. The only thing I left out were the patient's frequent references to the doctor as a "jerk" (though the description of amiable and gregarious comes straight from him). The interaction described above INFURIATED the patient, so much so that he still recounts this story - now thirty years later - with a seething, undisguised hatred. During his senior year, the patient came down with a horrible infection and refused to return to student health because of that doctor. He finally gave in when his temperature neared 105 degrees.
I heard this man's description of his trip to student health, and I thought the doctor sounded competent, professional, and engaging. All in all, this seemed to me to be a strongly positive doctor-patient interaction. All that's missing is the sticker.
The patient's impression of the doctor was that he was extraordinarily dismissive of the condition, and that he totally ignored the patient's intractable (though never verbalized) belief that the lump was a cancerous tumor. Furthermore, he never said how long the hemorrhoids would last and wouldn't prescribe any medication to make them go away.
What didn't came up during this visit, was that the patient was a recently-outed, gay man. He was coming to grips with his sexuality in the context of a) his new, autonomous life at college and b) his traditional upbringing in a religious, military family. His concerns about the lump on his butt didn't just come from hypochondria; he was terrified that he was being punished for his lifestyle and that this condition would make him less attractive to men.
The patient vehemently believes that it was the doctor's fault that a discussion of these concerns never took place. Maybe it was, I really don't know. I'm not retelling this story to investigate that question. All I want to do is point out that, although his impression of the interaction was drastically different than my own, the patient is probably not crazy. And that terrifies me.
I probably would have treated a frightened college freshman the same way that doctor did, because that's how I'd want to be treated. If I thought I had cancer, and I saw a trained physician who was absolutely certain that I had only a benign condition that would resolve itself with time, I would WANT him or her to tell me exactly that. It would freak me out more if the doctor dwelled on any possible diagnoses that were clearly not appropriate. And if I could clear this condition up without taking any drugs, all the better. Though I might be exhibiting some self-preservation here, I'd like to think that this position is also not crazy.
So we have two, ostensibly sane people considering the same professional interaction. One of these people is entirely satisfied that there's nothing wrong (absence of stickers notwithstanding), and the other is so wildly offended, that he has spent thirty years of his life railing against this doctor to audiences across the country. Is this just the nature of a profession driven by interpersonal relationships? Is there some way that a physician can account for all of the disparate personal needs, histories, and characteristics that walk through the door? Am I doomed to have any patient who doesn't think like I do leave my office in a fury telling people I'm a jerk?
Sometimes the science class is much easier.
Wednesday, November 29, 2006
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.”
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.”
Monday, November 20, 2006
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.
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.
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