Category: Observations

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Medicine Nonfiction Observations Reflection Systems

What Doctors Look Like.

I don’t remember her name, but I do remember her light brown hair, the simple nose ring that looped out of her left nostril, and the calm and centered presence she had with patients. She came across as unassuming, professional, and caring. We were both in medical school, though she was two years behind me. I admired how she treated people.

I don’t remember his name, but I do remember that he worked as a nephrologist (kidney specialist). He had a slight paunch and frequently wore dress shirts with short sleeves. The knots of his neckties were always loose. Students regarded him as an excellent teacher who revealed the mysteries of the kidney with tireless enthusiasm.

The nephrologist and I, among others, taught a course for junior medical students. Someone praised the bedside manner of this calm and centered medical student. The nephrologist interjected, “That might be true, but she doesn’t look professional. It’s the nose ring. Physicians shouldn’t have nose rings.”

I didn’t say anything in response. He was still an attending physician and I was just a medical student. His comment struck me: Did it really matter what doctors look like?

I have thought about that snippet over the years. Did he ever give her that feedback ? If he did, how did she take it? Did anyone else find his remark curious? Did any of the other attending physicians disagree with him? If they did, why didn’t they speak up?

After I became an attending physician and navigated ongoing perceptions of what I “should” look like, more questions have come to mind:

What if the medical student was a white male and had a nose ring? Would the nephrologist have made that comment? (Probably?)

What if the medical student was a stellar student and demonstrated clinical excellence? (My impression is that she did well in her coursework and that the comment about her nose ring was in the vein of, “If only she didn’t have the nose ring….”)

What if the medical student wore the nose ring for cultural reasons? Would that have mattered to the nephrologist?

What if the nephrologist learned that certain populations of patients were more likely to trust her than with him because of the nose ring?

What did the nephrologist think doctors should look like? (Clearly, he did not think they should wear nose rings.) How did he learn what doctors should look like? Who determined the definition of “professional” in the world of medicine?

Did it really matter what doctors look like? To medical students, of course it did. When we started our clinical rotations, we saw the attire of resident and attending physicians: Think Banana Republic or J. Crew, with the requisite long white coat on top. So what did we all do? We started shopping for “professional clothes”, except few of us had the money to buy stuff from Banana Republic or J. Crew. We cobbled together outfits from shops we could afford.

The pressure to conform, however, went beyond what we wore. There was only one female trauma surgeon who worked with medical students and, while students spoke well of her, resident physicians sometimes remarked that she was “too emotional”. During operations, male surgery fellows told female medical students, “You should feel this lung now, since you’re probably going to go into pediatrics or family practice.” Many of the attending physicians were heterosexual white males. Those of us who were not—men of color, women with or without nose rings, those who identified as LGBTQ—navigated how to conform to the values and behaviors of heterosexual white males, such as the nephrologist. Though some of these values and behaviors have no clinical relevance (e.g., wearing a nose ring does not affect how a physician washes her hands, gathers a history, or conducts a physical exam), they do affect how one goes through medical training. If enough attending physicians make comments about the nose ring, you might stop wearing it, even though the nose ring is something you value as a person.

What do you do, though, when the issue isn’t a nose ring, but your skin color? sex? accent? sexual orientation? culture?

When surveying the community, many people comment that they feel more comfortable working with health care professionals who look like and share the same experiences as them. Many women, for example, prefer to work with female gynecologists. People who speak languages other than English often feel more comfortable working with physicians who also speak the same language. Americans who are not white often comment that it is often easier to talk with non-white physicians about health concerns.

People with tattoos and nose rings may find it easier to talk with a physician with a nose ring. If the goal is to help keep people healthy and living the lives they want to lead, is it fair to say that nose rings are unprofessional? If the physician with a nose ring is able to connect with her patients and thus serves her community, should we indoctrinate her with the idea that nose rings are unprofessional?

Out of habit I still wear slacks and dress shirts when I see patients. I was trained that I should dress a certain way to both show respect to my patients and demonstrate that I am a professional.

The only time I did not routinely dress in slacks and dress shirts was during my time doing outreach to people who were sleeping outside. Part of this was due to function—it’s much easier to jump over puddles and slide past chainlink fences in jeans and a sweatshirt—but part of this was also because a doctorly outfit was often a liability in these settings.

How would you react if, while eating lunch outside, someone wearing a white coat and a stethoscope around her neck came up to you and asked, “Hi. How are you doing? Are you okay?”

Feedback I often received throughout my medical training (and continue to receive now) is that I do not speak up enough during rounds and related meetings.[1. Even though this post is over one thousand words, it’s true: I actually don’t talk much when working.] My seeming reticence partly reflects my introversion; it also reflects Chinese Confucian values. Medicine has trained me to talk more. I will never know if my taciturn tendencies have caused more problems for my patients (I hope not), though we all appreciate someone who is willing to listen.

And while I am sure that the nephrologist would have disapproved of unnatural hair colors, I can’t count the number of times vulnerable people with significant psychiatric symptoms were willing to talk to me simply because of my locks of curious color. This holds true even for people without any psychiatric symptoms.

I trust that the medical student who wore the nose ring has become a fantastic physician. I wonder if she still wears a nose ring. I hope she still does.

One way we recognize physicians is by their white coats. The rest of it—sex, skin color, accents, nose rings, tattoos, hair color, age, height, weight, etc.—shouldn’t matter.

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Observations Systems

Devastation and Vulnerability.

We are all devastated that children died. Again.

Even though we know that the causes are complex, we want to reduce the issue down to one factor.

“There’s not enough access to mental health services!”

“Agencies with oversight didn’t do their job when they learned concerning information!”

“We need gun control!”

It’s complicated.

We are all devastated that children died. Again.

When kids of color die in mass shootings, do they get the same front page headlines? prime time coverage? threaded tweets with tens of thousands of likes?

Many people who own guns never shoot people. They never craft plans to kill other people. They don’t have impulses to kill themselves.

Is it fair to blame only guns and take them away from people who own them, when most are responsible citizens?[1. To be clear, I do support more regulation on firearms. It is possible to support responsible gun ownership AND gun reform.]

Many people with psychiatric disorders never kill people. They never craft plans to kill other people. They don’t have impulses to kill themselves.

Is it fair to blame only psychiatric disorders and the people who experience them, when most are responsible citizens?

We are all devastated that children died. Again.

Many have expressed displeasure with the wide and toothy smile in the photo, his thumb extended for all to see.

Is it fair to blame only him and his administration, when nearly 63 million people voted for him? Most of whom are responsible citizens?

We are all devastated that children died. Again.

This devastation is a reaction to learning the news that young people died through no fault of their own.

Was the murderer’s decision to kill young people at a school a reaction to something else? Was it a self-contained reaction, a reaction born solely of the release and reuptake of serotonin and dopamine and epinephrine and acetylcholine?

Or was it a reaction to the trauma that all young people experience as they live through the cruelties and injustices of the world?

Why was this—killing students with a gun—his reaction?

What is the reason behind your reaction to him?

Or is your reaction due to multiple reasons?

Are we all blind to the hubris of blaming one thing, one condition, or one person? How are we so sure?

We are all devastated that children died. Again.

To sit with our devastation, to embrace it and understand how it affects us, to witness how it shapes what we say and do, is hard. To acknowledge that our emotions don’t feel under our control, to realize that feeling pain makes us vulnerable, is hard.

It’s hard for everyone else, too.

We must accept and respect the vulnerability in ourselves and others if we want our reactions to change. Only then will the devastation will stop.

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Nonfiction Observations

Expectation.

He was scowling all morning, so I decided it was worth a try.

“Hi.” I leaned in. “What is orange and sounds like a parrot?”

Still scowling, the jail officer working in the psychiatric unit glanced at me, then tapped his thumb a few times on the desk.

“I dunno. What?” he mumbled. At least he was willing to play.

“A carrot.”

It happened in less than a second: His face softened, he rolled his eyes, and then the groan became a chuckle.

“A carrot! That’s so stupid!” The wrinkles around his eyes danced as he smiled.

Success!

The inmate was pacing the length of the block. The uniform was too large for his slender frame. Though the cut was uneven, his hair was shiny and thick. Further evidence of his youth included his smooth and unmarked skin.

The jail officer, grinning, walked towards the inmate.

“Hey, Doe,” he started, his voice smug, “what is orange and sounds like a parrot?”

The inmate stopped walking, but made no eye contact with the officer. The officer looked at him with expectation and condescension.

“A carrot,” the inmate replied, as if the officer had asked him the time. He immediately resumed walking.

Crestfallen, the officer frowned. “Even he knew that one?”

I turned around so the officer couldn’t see me smile.

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Nonfiction Observations Reflection

Patients in a Resuscitation Room.

I didn’t post anything here last week because my dad, while walking, was hit by a car. (He is feeling better, thank you.)

When I arrived, my father occupied one of four beds in a resuscitation room. The other three beds were empty. It was still early in the morning and there were few people in the emergency department.

As the day wore on, other patients were wheeled into and out of the room. A pale yellow curtain with a floral motif enclosed the space around each patient. The patients and their visitors caught glimpses of each other whenever the ED staff pulled the curtains open.

While curtains provide visual privacy, they are not soundproof.

An inmate from the local jail came in with chest pain. He shared his entire medical history with his accompanying jail officer. After listening to the inmate’s monologue for about five minutes, the officer interjected, “I’m going to watch this TV show now.” The inmate, along with the rest of us, listened to what sounded like an action movie. The inmate sounded more disappointed than relieved when he learned that he did not need to stay in the hospital. He went back to jail.

A mother and father came in for reasons I never learned. Their young toddler with enormous eyes grasped the pale yellow curtain in her tiny fists as she explored both sides of the boundary. Their infant stopped wailing when the mother sang, her voice full and calm. When the family left, they took the laughter with them.

A woman with dark pink hair was wheeled in. Another car hit her while she was driving. Her voice was light and melodic as she expressed profuse thanks to the medics. Her voice cracked as she spoke to a friend on the phone: Was she ever going to get a break? Why did her friend hit her with the car? Why was this the third time in her life she was in a car crash? What if she never got sensation back in her leg? Why did she have so much bad luck? After she hung up the phone, she wept. She took her frustration out on the nurse. No one was at her bedside.

A slender man was wheeled in. He, too, was in a car crash. His answers to questions were short and quiet. The sadness on his face could have been new, though the wrinkles around his lips and eyes hinted that maybe he wore a sad face most days. He stared up at the ceiling. No one visited him.

My mother came into the room, too. My father recalled when he was last in an emergency department: His wife was short of breath and feeling exhausted. He remembered the week she spent in the hospital, all the questions, poking, and testing she had to endure, and how much she hated it.

“Now I understand why she didn’t like the hospital,” he murmured. The edge of the pale yellow curtain shifted, though no one was there.

Categories
Consult-Liaison Observations

Status Game Strategy.

How do you introduce yourself when you greet people, particularly those you don’t know?

Yes, your answer might depend on who you’re meeting. But what’s your general approach?

I try to emanate warmth: I make eye contact and smile. I do what I think will make the person feel comfortable. I listen and try to speak less than the other person… unless it becomes clear that the other person wants to listen more and speak less, too.

This strategy has worked for me: It helps me form and maintain relationships. This approach has produced few, if any, negative consequences.

Some people use a different strategy when they interact with others: They assert their superiority. They say things like they have “one of the great memories of all time” and “I went to an Ivy League college… I’m a very intelligent person.”

The other way to assert superiority is to denigrate others, such as commenting that others are “weak”, “lightweight”, and “fake”.

This, of course, is a status game. Who has higher status? Who should have higher status? And if I should always have higher status, how can I make sure that everyone around me recognizes that?

Sometimes people use this status game strategy because it’s the only way they know how to interact with other people.

Maybe they learned long ago that the people in their life only paid attention to them when they said something that asserted their high status. People only took interest in them when they said things like, “I’m a very rich person.” The attention of others makes them feel worthy, seen, and valued. It’s nice to have a lot of money, but some people crave a wealth of attention.

Asserting high status, though, becomes a vicious, reinforcing cycle. After a while, people won’t care when they hear things like “I’m a very rich person”. They’ve heard that before and won’t react the way they once did. So it escalates: Soon, these individuals have the best memory, the highest IQ, and the best words.

Even though these statements are false—and verifiably false!—it doesn’t matter. Remember that outrage and indignation are still forms of attention. And some people are never satisfied with the amount of attention they receive.

This status game strategy works for some people: It helps them form and maintain relationships. For whatever reason, it has produced few, if any, negative consequences.

There are other ways, of course, to interact with people. However, it takes time and practice to do something different. Why change what you’re doing if it’s worked for you for so many years?

People who behave this way don’t need our pity. Pity doesn’t help anyone. One wonders, though, what happened to them in the past. Despite being over 70 years of age, they still don’t know how to interact with people without elevating themselves or putting others down.