Category: Lessons

Categories
Lessons Nonfiction Observations Reflection

The Club.

Though you are now a member of the club, you don’t know it.

It feels like no one understands and that you’re alone. The memory of what happened to The Person You Love is heartbreaking.

The feeling seems endless. Perhaps you feel it in your body; maybe it feels like a hollow weight in your chest. Maybe your head feels heavy. Maybe most of it unfolds through your thoughts: You hear good news and your heart floats for a few moments, but then you remember what happened. Even good news somehow seems sad.

Sometimes it feels like time doesn’t move the way it did before it happened. Thoughts like, “This is the youngest I will ever be… will I remember this?” become regular visitors to your mind. You grasp those little things that bring you joy and cling to them:

  • The summer watermelon is cool, crisp, and sweet against your tongue. Will this be the last watermelon I ever eat?
  • How wonderful it is to see the splashes of peach, pink, orange, and purple across the evening sky! Will this be the last time I witness this supernatural work of art?
  • He has a delightful laugh! I hope that this won’t be the last time I hear it.

Life takes on a quiet desperation.

Because you don’t know if you will experience these moments again, gratitude overwhelms you:

  • I turn on the faucet and hot water comes out in seconds! I get to take a comfortable shower every day!
  • I have a place to live! My mind doesn’t have to spend every waking moment worrying about where I will sleep tonight!
  • I have friends! We talk, we laugh, we spend time together, we enjoy ourselves!

Life is beautiful and sublime.

You dream about The Person: Sometimes the dreams are comforting, sometimes they are disturbing, but they are all cryptic. You wake up, your limbs heavy in bed, and wonder: Is she really dead?

That feeling comes back. You know the answer to that question. She is, but you’re not, so you get out of bed.

There are moments throughout the day when you do forget what happened. The weight disappears and you focus on the things in front of you right now. Things shift, and your mind begins to make associations that you didn’t make before:

“I look at grass and I think of tombstones now.”

You concoct explanations to comfort yourself, though sometimes they don’t:

  • Molecules of air that were in her lungs are still in the house. When I inhale, some of that air is now in me.
  • Though she is dead, her genes live on in me. The genes continue to experience the world, even if she does not.

Some things don’t matter anymore. Kindness becomes essential. Relationships with people become vital.

When people in the club learn that you are a new member, they welcome you with a grace that you didn’t realize existed. You acknowledge that you had no idea that they were a member of the club.

“That’s how it works,” they reply.

They spend time with you. They share wise words. They share wise silence. They comfort you.

You then realize that you’re not alone, that there are people who understand. They appreciate how heavy the weight is in your chest and help you carry it. They remember the difficulty and loneliness of having to carry the weight alone. They also know that, ultimately, you often must carry it by yourself.

Everyone eventually joins this club. If you, too, are a new member, know that you are not alone. There is no club uniform, badge, or pin, but we are here and share your grief.

Categories
Lessons Medicine Observations

Four Adages.

Four adages I learned in medical training that I still speak of today:

“Common things are common.” (The alternate version of this that might have more appeal to zoologists: “When you hear hoofbeats, think horses, not zebras.”)

This cautions physicians to remember that it is more likely that the patient has a common condition than a rare one. Although it is prudent to consider all the possible diagnoses that might match a given clinical presentation, one should not seek confirmation for an exotic condition first.

Urinary tract infections are more common than bladder cancers. High blood pressure is more common than pheochromocytomas.[1. A pheochromocytoma is a rare tumor of the adrenal gland, which is a small lump of tissue that sits above the kidneys.]

Once you’re sure that there are no horses present, though, then begin the search for other ungulates.

“Treat the patient, not the number.”

This is a reminder that physicians should treat the person, not lab results.

If a patient’s blood count is a little low, but she’s not experiencing any symptoms, then do nothing. If someone’s lithium level has been low for months, but they haven’t had any mood symptoms, then don’t increase the dose of lithium.

This, however, does not apply to all conditions: People with alarming blood pressure numbers often feel fine. Same thing with high blood sugar numbers.

“The longer someone stays in the hospital, the longer he stays in the hospital.”

Hospitals are not sanitary places. The longer a patient stays in the hospital, the more likely he will develop an infection that is resistant to multiple antibiotics. This leads to complications that lengthens the hospital stay.

This also applies to staff: The longer a physician stays in the hospital (beyond her shift, for example), more things will come up that she will have to address, which will will keep her there even longer.

“When you only have a hammer, everything is a nail.”

This is a reminder to consider other perspectives. It is also an exhortation to recruit the minds and skills of others.

If the psychiatrist only knows how to prescribe medications, then all of his patients will receive pills. The surgeon might believe that cutting out the offending tissue is the only solution.

One wonders when these phrases first came into being. It’s an oral history that physicians pass along every July.

Categories
Education Informal-curriculum Lessons Medicine Observations Reflection

Guiding Principles for Medical School.

Dear Jane:

Thank you for asking me about my perspectives on medical school. Here are some general principles that you might find useful in your own training:

View everyone as your teacher.

Everyone you encounter will teach you something. Be open to what they have to offer.

Yes, your professors and attendings, the “official” teachers, will educate you. Patients, however, will often be your best teachers. Listen to what they say, watch how they react to what you do, and acknowledge and accept the feedback they give to you. Their teachings are often the most useful and valuable.

You might see a physician condescending to a patient and decide that you never want to do that. You might see a nurse offer quiet comfort to a patient and decide that you want to mimic that manner. You might witness a technician help a patient feel less anxious before a procedure and decide that you will steal that technique. You might talk to a physician on the phone and decide that you will adopt that professional and kind manner when you talk to other physicians.

In this way you can be a student for life.

Reflect on your experiences every day.

This can take many forms: You can keep a journal. You can talk with friends. You can meditate. You can go for a ten-minute walk around your neighborhood. You can sit in a chair and stare out the window. It doesn’t have to be a big thing.

Reflecting on your experiences will help consolidate what you learn so you can apply that knowledge in the future. This applies to “book” knowledge (physiology, pharmacology, etc.) and “non-book knowledge” (how to redirect a patient or your colleague, how to manage your emotions in the face of disease and death, etc.).

There will be times when you will feel overwhelmed and cannot or choose not to reflect. That’s okay. It happens.

You will see terrible things.

You will see people suffer. You will see people die. You will hear hospital staff say derogatory things about patients. You will see your colleagues lie about things they should not lie about. You will see everyone—the patient, nurses, doctors, technicians, family members—work as hard as they can and none of it will help the patient. You will see people who need help, but don’t want it.

Remember the discomfort you feel when you see things you don’t like. These experiences are your teachers, too. They will help you stay human and humane. Medical training can steal that from us.

You will do terrible things.

You yourself will do things you will not like. (Hopefully infrequently.) You will snap at patients. You will be snarky to staff. You will bend the truth, if not lie, because you won’t know what else to do.

You must reflect on these events so they don’t become habits.

Connect with physicians who do not work in academic centers.

Some physicians in the community will have practice patterns and work in systems that will appall you. Some will inspire you. While academic medicine does happen in the “real world”, it’s often different from what is in the community.

Exposing yourself to the non-academic world will help you learn about a greater variety of patients, creative and innovative developments in health care, and provide more context about medical care in the world. Even if you end up working in an academic center, these experiences will shape your practice.

After you decide what kind of doctor you want to be, take rotations in every other specialty.

Medicine is compartmentalized, but people are not. Your patient with high blood pressure may become pregnant… develop a painless red eye… fracture a bone… have her gall bladder taken out… or develop an alcohol problem. Learning about a variety of conditions will help you take care of people, not just diseases.

The most useful guiding principle for me during my training (and now) is to remember that your work is to take care of the patient. It’s not about the letters after your name, long titles, or how big your salary is. Medicine isn’t about you. It’s about the patient. That attitude will keep you humble, curious, and grateful.

Congratulations on your admission to medical school! May you find the work rewarding and meaningful.

Categories
Lessons Observations Reflection

Length of Day.

The long, glorious days have arrived in Seattle. The sun rises shortly after 5am and sets after 9pm. We’ve savored the warmth of the sun on our faces; the sky has been more blue than grey in the past few weeks.

The tradeoff is that, in the winter, the days are short. The sun rises close to 8am and sets before 4:30pm. Furthermore, the pewter clouds and rain blot out the light of the sun. The days are dark.

These cycles, though, are predictable. We celebrate what light we have during those winter days as we step through puddles and under naked trees. During the summer, we relish the long days as we witness the alpenglow of the sleeping volcano, hike the verdant mountains, and squint at the sparkling waters of the sound.

Life is not predictable. We do not know if our lives will be like a day in December or June in Seattle. We only know the length of day after the sun sets, after someone dies.

When his mother died, my father followed the custom and wore a black braid around his left bicep.

“How long did you wear it for?”

“Ninety days.”

He gave me four pieces of black yarn. While on the plane I created an uneven braid with the yarn and wrapped it around a black armband. I will wear it until August 20th.

The thing about death and dying is that, even though you know it will happen, it’s still abrupt.

This is why it is vital that you say what you need to say and do what you need to do while you still can.

You don’t know when someone you love or care about will die. If you have stuff you need to tell someone—your apologies, your love, your hopes, your affection—tell them now.

We regret those things that we could have done, but, for whatever reason, chose not to. Regret sucks.

And even if you do say everything you need to say and do everything you need to do, know that it may still not be enough. For those that we love, we can never tell or show them enough how much we love them, how grateful we are for them, how much we want them to have happiness and peace. When they die, that ache of regret may still persist: You wish you could express your love to them one last time.

It will be too late.

I told my mother everything I wanted to say in the six months between the time of her diagnosis of cancer and her death. She took advantage of the time, too, and shared her hopes, fears, dreams, and wishes with me.

I thank her. And I miss her.

Categories
Consult-Liaison Education Lessons Medicine Systems

Have You Thanked Your Nurse Today?

As I noted earlier, hospitals permit around-the-clock observation of patients. If you don’t need around-the-clock monitoring, you don’t need to be in the hospital.[1. “But what about ‘social admits’?” you may cry. “They don’t need to be in the hospital, but we admit them anyway.” True. “Social admits” reflect the intersections of social policy, politics, health, economics, and the lack of resources. That topic is beyond the scope of this post.]

Who is doing this around-the-clock monitoring? Nurses.

Therefore, whether you are a patient or a physician, one of the best things you can do is get on the good side of the nurses.

If you are a patient, a nurse watches over you and your care. Nurses make sure that you won’t fall. They make sure they give the right dose of the right medication in the right route to the right person at the right time (which can be easier said than done). Nurses provide education about medicines, tests, and health conditions. They make sure you know what day it is, where you are, and who you are. (Also easier said than done.) They monitor your progress and try to ensure that your health only improves. Nurses can also page the doctor for you or your family. They can find out when you are scheduled to go through a procedure. They can find out what you are waiting for. Nurses advocate for you.

Sometimes it may seem like they’re not “doing” anything. They are. They’re keeping an eye on what is happening with your health.

If you are a physician, you must already recognize the value of nurses. (If you are a medical student or resident and have fantasies that, one day, you will be “running the show”, don’t be a fool: There is no way you could do your work in the hospital without the help of nurses.) Nurses serve as our eyes and ears. They tell us information about patients that patients themselves cannot or will not tell us. They do triage with us when we have multiple patients who are not doing well simultaneously. They tell us if someone is starting to look a lot worse… or a lot better.

While it is true that nurses provide around-the-clock observation of patients in hospitals, it is also true that nurses provide around-the-clock monitoring of doctors in hospitals.

Nurses know when doctors typically meet with patients. They know which doctors are more likely to spend time with patients and answer questions. They know which doctors work in collaboration with nurses and which ones treat them like second-class citizens. They know which doctors return pages promptly. Nurses quickly learn how to alter their approaches with various doctors to get work done.

This is yet another reason why, as a patient, you want to get on the good side of nurses. Nurses manage doctors. Skilled nurses will know how to work with different doctors to help you get what you want (e.g., answers to your questions, a meeting with your family, better pain control).

(Patients, you should also know that nurses also manage you. Nurses tell doctors which patients yell at nurses, which family members are berating them, which patients are trying hard to follow recommendations, and which family members left cookies and treats for them.)

Physicians, thank your nurses for helping you do your job better. Positive reinforcement and good manners go a long way. The more you acknowledge the skills and efforts of your nurses, the more they will want to work with you and make your job easier.

Patients, thank your nurses for watching over you. Nurses play an essential role in your care in the hospital. Be kind to them. The more you acknowledge the skills and efforts of your nurses, the more they will want to work with you to get you back to health as soon as possible.