Sincere

A friend of mine came to town to help me move things into my new home.  I had told him about the park nearby with the basketball courts with nets that reminded me harnesses.  After moving everything in and finding myself a kitchen table in the depths of an outlying suburb, we scurried over to the park to catch the last glimpses of daylight.

The court itself was a considerable walking distance from the actual parking lot.  An island of concrete in the middle of a long field.  Without good lighting or nylon nets, this court lacked the glamour of Rucker Park street ball and the amenities of a suburban park district

"This field would make a good ultimate field.  It's so big," I said as we trudged through the grass.
"Yeah, until you turn your ankle," he replied, noting the numerous rough patches and uneven surfaces that littered our path.

Arriving at the court we noticed a shirtless black guy in dreads and a while heavy-set girl, both on the bench.

"You want to play Chicago?" He yelled out.

Unsure of both what he was talking about and who he was yelling at we ignored him and proceeded to shoot around.  Rims were friendly, the hoops of appropriate height.  The court itself boasted several cracks through which the green grass triumphantly made its way through.

'Hey, you want to play a game?  You want to play Chicago?" He had now made his way towards us.  He had several tattoos on his arms and torso.  A bowling ball sized belly accompanied his dreads.  He must have been somewhere in his mid to late 20s.  Possibly older.

Eventually we agreed to play.

"What's your name."
"Sincere."
"How do you spell that?"
"S-I-N-C-E-R-E."
"Like the word?"
"Yeah."
"You live around here?"
"Yeah, around Franklin Park area."
"Oh?  Me too."

He showed me his pinky.  It was bent out of sorts.

"I got shot the other day and they had to sew it up in the hospital."
"Oh, that does look kinda nasty.  Whereabouts?"
"Oh around here.  Off of Main." 

We started to play.  The guy was clearly out of shape, had no shot, and air-balled more than his fair share of jump shots and layups.  I felt kinda bad just watching him.  As my friend pointed out later.  We weren't Jeremy Lin by any stretch of the imagination, but this guy was so bad we had to feel a little sorry for him.

"Hey girl," he yelled towards the female on the bench, "This one's for you!" His three-point shot clanging off the back iron to the left.

Yes, he was pretty bad.  To quote Shaq, he was "horawful."

"So, are there any parts of town that I should be more careful around?" I inquired, figuring it wouldn't hurt to get a local's take on the area.
"Nah, it's all good around here.  I was just selling some weed."  He hoisted up another air-ball.

He was huffing and puffing pretty badly by this point.  So after he missed yet another shot, he abruptly took off towards his girl.  As he was walking away, I called out to him to see if he still wanted to play.  No response, and that was it.  It was pretty dark at this point, and so my friend and I turned once again towards the green field of imperfections.

"First contact with the neighborhood, eh?" my friend teased.
"Yeah, check back with me in a few months.  See how I feel about it then."

Magical Dinosaurs

Larry Lindahl was a general internist and geriatrician with whom I spent a month during the summer of my M4 year in medical school.  It was supposed to be a time for me to study for my board exams but ended up being so much more.  This man had a wonderful reputation from the residents and students, and my four weeks was one of the few times where reality matched expectation. 

There is a picture of Larry with his grandchildren that sits on his bookshelf in his office.  It is a black and white photo of him reading to his grandchildren.  He is sitting on a couch with both kids flanking him.  All three of them are leaning forward to read.  The chiaroscuro employed in the photo is stunning, giving it the life of a renaissance painting.  Larry’s glasses show his age but the light reflecting off his hair reminds you of his once reddish hair which has since been infiltrated with a more distinguished grey.

”That is such an awesome picture,” one of the residents said out loud one day.  I agreed wholeheartedly. 

Dr. Lindahl’s knowledge as a general internist was inspiring.  I use this word because he was able to speak to you in such a way that was both didactic and encouraging.  Much as the warmth in that photo, he had a way of telling you that you were wrong that both made you feel like you let him down and yet that everything was still going to be alright. 

Every morning he would discuss at topic with us.  We would meet in the physicians lounge and have a conversation.  His example would remind me that the physicians who had the most impact on my education were not necessarily the ones who knew the most or were the smartest, but the ones who shared their experiences, knowledge, and their lives.   Because in a way, these three things were inseparable, and it is unsurprising that my fondest memories were the ones in which all of these things were present. 

People always talk about bedside manner.  In some ways it becomes a terrible cliché.  But, having said this, this man had an unquestionably and authentically kind demeanor that I had not seen during my medical training.  I had never seen someone who made his patients feel so, dare I say, loved.  There was something about his demeanor that was fatherly—which was even more remarkable because he often dealt with patients who were old enough to his father.  For many of our demented patients, perhaps this is what they needed—someone to remind them that things were going to be okay, despite life’s uncertainties. 

I often thought patients came expecting a definitive, curative, treatment but there were many times I would leave the room with Dr. Lindahl realizing that the treatment was many times the reassurance.  Other times, I might leave the room with him feeling sad, but the sting of hopelessness would never be as acute as I expected.  In a way, this was the type of medicine I had envisioned before starting medical school three years ago.  After all, it was never about the cutting edge treatments, the academics, the prestige—everything boiled down to a story, a life, a person. 

In the hospital, Larry Lindahl was no less impressive.  In the sick rooms of patients he would sit on the bed and talk with the patient.  He was never in any hurry, always listening, and always caring.  As much as humanly possible, he would transform a room of disease into a room of healing, and somewhere inside of me the calluses built up from prior bitter experiences began to melt away. 

Larry was a conversationalist.  I knew I liked him when I spoke about not applying to California (“why would you want to be among so many shallow people anyway?” he had said).  When he encouraged me to read up on recent journals, I found myself wanting to do so because I wanted to be like him.  When he asked me what I learned in morning report and noon conference, it would be like a father asking his son how his day was.  When I did not attend (“Uh-oh” had been his initial words); the ensuing guilt was unlike any I had felt on any of my rotations. 

Dr. Lindahl gave a yearly lecture to the residents about the geriatric H&P.  As he had done during our chalk talk about the Beer’s List, he reiterated a phrase “cherchez la femme,” which was a French phrase that meant “look for the woman” who was often assumed to be source of all of life’s ills.  Larry had adapted this phrase for the geriatric population when trying to determine the source of altered mental status.  “Cherchez the drug,” he would say.  He would speak of establishing the narrative.  What was the patient’s story?  What was their living situation like?  In essence, he was telling us that you cannot begin to heal unless you understand the environment in which this healing will take place. 

Larry would always talk about how we should be aware that every doctor has his or her quirks, ways of doing things without any irrefutable medical evidence.  He would implore us to keep an open mind when judging other physicians.  He stated on numerous occasions that were probably many things he did that did not make much sense either.

My final day on the rotation I told Dr. Lindahl that I really enjoyed the last month with him.  I told him that while I wished things could have been a little busier, I learned more than I would have otherwise imagined and I wished more of our primary care experiences had been like this one.   To this, Larry said that he was probably more the exception than the rule.  “I am one of those old dinosaurs who managed to stick around long enough to see things change and who will one day probably be pushed to the side.” 

I should hope not, I remember thinking to myself.  Because dinosaurs like Larry are what the profession needs.  My time with him had both hardened my resolve to pursue primary care and also be the type of physician around whom the system works—not one who works for the system. 

Three months later I am sitting here writing these reflections.  I am on night call for my cardiology rotation; I should be reading EKGs.  Instead, I decided to write this because my patient who recently had an MI status post stenting has lapsed into a lethargic, uncooperative state, refusing to eat or take her medications.  Three days in, we decided to consult the geriatrics service—which, here in Peoria, is Larry Lindahl.  “Is he good?” The cardiologist had asked.  “Yes, he’s wonderful,” someone had said.  And I agreed wholeheartedly. 

And so this morning I was sitting reading up on my patients when I saw Larry walk by with his resident and medical student.  I greeted him and asked him how my patient was doing.  He had discontinued some of her medications that might be causing her delirium, increased her antidepressant, and were hoping for the best.  “Cherchez the drug,” I thought to myself.  Larry went on, “So, we’ll just wait and see what happens in the next couple days and hopefully, I can work my magic.”

I hoped so too.  I hoped because I hurt for the daughter who could not understand why her mother was not like herself even after the surgery.  I hoped because I did not want this woman to spend the last days of her life deteriorating in the hospital, and lastly, I hoped because somewhere deep inside of me, I wanted one more chance to see this dinosaur work his magic. 

Reggie

As I stand outside the Greyhound station in downtown Cleveland, I can’t help but think how backwards the interview process seems. Here I am, staying in luxurious hotels sometimes subsidized by the hospitals, being wined and dined for dinners and fed free lunches just to find out if I am a “right fit” for program XYZ. The contrast can’t be starker as I stand outside in windy cold of December evening with my backpack and my four-wheeled suitcase in a less than glamorous part of town. Considering that much of residency is spent taking care of underinsured, non-compliant, irresponsible, and disenfranchised populations, it would make more sense for programs to introduce us to the people we would actually be serving instead of touring us around the magnificent hospitals whose ever expanding presence testify to the failure of health care in this country. Wouldn’t it make more sense to see the homeless shelters, soup kitchens, and shanties that our patients would be coming from, the crack houses, drug warehouses, and other socially unacceptable settings from which many patients would return once they left the clinic?
It seems like an awful lot of money to be spending on such a self-serving cause. A part of me would much rather learn about the cities where I might spend the next three years or learn about how I would be serving the communities around these hospitals.

And still, in the midst of the grandiose thoughts, a man calls out to me. Inside I cringe because I know what is coming. I turn around and see a black man in a black cap smoking a joint.

“Hey, did the bus just get in?”
“Yes”
“Do you know if they found a wallet?”
“They did not.”
“Can you give me some money.”
“What do you need it for?”
“So I could get something to eat. I lost my wallet.”
"Did you go inside and ask if they found it?"
"Yes, they didn't find nothing."

I loathe myself because I know I shouldn’t go down this avenue of conversation. I know I have some cash in my wallet and am not in the mood to lie. Had I thought about this more, I would have asked how he got money for that joint. Instead, the following ensues.

“Is there somewhere you could get something to eat?”
“Yeah, there’s a Subway right around the corner.”
“How much do you need?”
“Five dollars…you know they have those five dollar foot longs.”
I pause and look around for the hotel shuttle. I wished it came earlier. I walk down the street to see if I missed it. Still nothing. I turn back to him.
“What’s your name?”
“Reggie.”
“Where are you from?”
“Toledo.”
“How did you end up here?”
“I’m familiar with this area. My people brought me here. I know the food pantries around here.”
His eyes look distant. He’s probably high.

“Promise me, you’ll use this for food.”
“Yeah…of course.”

I hate myself for this comment. But in the end I give the few bucks that I have. Because of my conversation I do not notice that the hotel van has come and that the driver has actually called out for me. I get in the van.

“Didn’t you hear me?” the driver asks somewhat irritated.
“No, I didn’t. Sorry. My bad.”

But at this point my mind is already lost in thinking about my encounter with Reggie and wondering what sort of drugs he’ll use the cash for next.

Love

He was an elderly gentleman in the hospital who had a urinary tract infection w/urinary retention secondary to benign prostatic hypertrophy. Speculation on his mental intelligence aside, this man could not provide a straightforward, concise history. His wife attributed it to his history of epilepsy which certainly played some role in it. Most times his responses were vague and his reactions "child-like." The wife affirmed that in actuality, this was normal mental status for him. It became clear that his wife would be the sole source of meaningful medical information; she was his primary caretaker, the one straight-catheterizing him and measuring his urine output in milliliters. Turns out, she was a nurse for the neurosurgeons in town, though one wouldn't have needed to know that to affirm her intelligence.

Outside of the room, the attending commented on how she was a little surprised at how a woman like her would end up marrying a guy like him. "She's clearly in love with him still...it's cute," she had correctly observed, "but she's just so...intelligent"--her words not so much conveying confusion as much as they did amazement.

An FMG that Plays in Peoria

Two weeks into my inpatient medicine subinternship, I am tempted to dwell on the shortcomings of the rotation thus far. I can talk about how few patients I get to see on my own or how I have long since given up trying to impress anyone, much less my attendings. So, when I have very little good to say about myself, it's easy to think about the people that have made this rotation memorable thus far.

In the past, the patients have ruled this forum. Tonight, this honor belongs to a senior resident--not my senior resident, but the one on our sister team who I was reunited with after having her for a week on my M3 medicine rotation.

DP was a second year resident when our paths first crossed. What struck me was how assertive and forthcoming she was in both asking questions and finding answers. She was one of those self learners who would be any educator's dream. She was one of the few residents who aggressively taught the medical students anything. I still remember the first sit down session we had on EKGs with us.

She was the first person in medical school to openly espouse Wikipidia as a legitimate source of knowledge. After all, many of the medical entries were straight from Harrison's. Her advice was as follows. Whenever she found something that worked, she would keep doing it and doing it until someone told her she was doing it wrong. If said person could then explain convincingly why his or her way was better, she would be willing to change. Otherwise, she would persist in her ways. She was the first to tell me that despite what we were taught, that closed-ended questions were essential to efficiency. Ask your questions first, then let the patient have their say. Find out what's important to you as a physician first, and then let the rest of the history guide your decisions.

I realize that while her advice seemed to fly in the face of what I had been taught, it makes sense in a lot of ways as well. Especially when one is working with high volume, indigenous, low educated populations. In fact, I saw it work for her. She was not worried about making mistakes, because she was always wanting to learn from them.

Over the last couple weeks, she has shared some of her life stories, and the stories have sharpened my understanding of her. She was top 5-10% of her state in India, meaning she got free tuition. Before then, she worked as a lab assistant in the states, learning English in the process. Her husband was also in the states pursuing education but due to their limited opportunities they were often in different states. She ended up in Alabama by UAB and she told a story of how sent 170+ emails to different labs asking for an assistantship or any kind of opportunity. Of those emails, two replied and neither with good news. One of them, however, told her that her English was terrible and that her writing was chalk full of errors. The author proceeded to rewrite her letter for her and gave her a version to send out to employers.

After medical school, she applied to 180 residencies. She received 19 interviews and went to 14. The place in New York that she ended up at was, for all health care purposes, horrendous. The residents she met all had their stories about how they ended up in a dump of a residency. Many of them were tragic and undeserved for their caliber of clinician and quality of person. There was the former ER doc who was blackballed after standing by his principles to defend a clinical decision that rankled his superiors. There was another who left years as a critical care nurse to pursue his dream. Another was from the Caribbean and fully trained EKG tech who was happy just to train in the states. Every person had their story, and despite the crap she dealt with, Dipa wouldn't have traded that one year for the world.

Eventually she transferred to Peoria to join her husband. It was during the weekends on call where I would hear her stories and listen to her rants on how internal medicine was 80% social problems and 20% clinical. She would talk about ungrateful, entitled patients, lowlifes that used and manipulated the system at no disregard to cost or others. She was tired of dealing with these people and with many of them she would not hide her disgust. On one hand this seemed appalling for a doctor to act this way, but in many other ways, it was refreshing because it showed a certain degree of conviction. She was letting these patients know that she knew what they were doing and while she would still help them, she wouldn't bend to their demands.

In the end, she wants to do GI. If not that, then a hospitalist. Wherever she ends up, this I know. I will be grateful to have cross paths with her, and in many ways, I hope that I can learn to pursue my interests with as much tenacity as she has in her own life. Stories like her's make me immeasurably grateful for the opportunities I have been given; her story gives me hope that despite my deficiencies, I have been fortunate to have people such as her who have helped me to get this far.

How I learned about medicine this year

During my second year in medical school, I wrote an email to the rheumatologist with whom I spent some time during M1 year. I told her how I would more easily remember the insignificant, non-medical trivialities from my lectures rather than the testable, high yield, board-relevant material that I was spending so much time just trying to care about at times--let alone learn.

Today, as I prepare for boards, I find myself in a similar situation: fighting the urge to gloss over certain diseases, risk factors, etiologies of conditions that at times mean very little to me. Every so often I'll come across a condition that links to a friend I have, a patient I saw, or an encounter in the hospital. Myasthenia Gravis, Essential Tremors, Multiple Sclerosis are replaced with the faces of the friends and people who have played an instrumental and meaningful part in my life these last few years. For a brief moment, they become my daydream, my escape, an absence seizure from the world of medical terminology.

If you asked me about acute pancreatitis, I could not tell you Ranson's Criteria but I can tell you all about the homeless man that had it--how he was a boxer in his youth, could control his blood pressure with his mind, and how he would roam the streets at night living a life that you would only see in movies. If you were then to ask me about Meckel's Diverticulum, I could not tell you the specificity of scan to detect it (the sensitivity yes!), but I could tell you all about the anguish and cultural intricacies written all over the a Chinese mother’s face as she couldn't understand why the surgeons had performed the surgery on her son when there was no Meckel's to be found in the OR.

And so this is how it has been for much of the last year; it has seemed to me more of an experience than an education. I ask myself what exactly I did this year outside of accumulating a treasure chest of stories that I might one day dig out for the sake of good conversation.

Furthermore, in the back of my mind, I am terrified that this will not be enough--that these ruminations will be woefully inadequate for me to master the information I need to effectively convey to my future patients. I ask myself whether these reveries are but an expression of laziness that serve to convince me that I really am engaged with the material.

Having said all this I return to my letter to the rheumatologist. In her reply to me she wrote the following.

"I was always of the opinion that recall of all those meaningless trivial facts was the sure sign of a bright and inquisitive mind, one that had room for lots of stuff, not all of which came from books! I think it also means you recognize the humanity in us all, a good trait for a doctor to have! It helps to reinforce the concept that we take care of people, not just diseases, and that humanity thing is what keeps medicine interesting and relevant."

Looking back at her words, I take hope in the larger picture. For I am neither naive enough to believe that a better academic performance would have proved a greater personal dedication to my craft nor am I delusional enough to think that every mistake I've made is simply a product of a bright and inquisitive mind emerging from the chaos that is medical education.

The reason why I got into this was because of the people I met along the way. As much as I conceptualized what medicine should look like, the only reason why I am still in school is because of the people who showed me what medicine could look like. In the end, the latter is what I have to hold on to for now. With each new experience stones will shift, clouds will clear, and visions will change. That is to be expected.

For now, the words of my high school Spanish teacher ring through and through
"Lo que sera, sera..."

The Problem With Hipaa

From a patient care point of view HIPAA preserves the privacy of those within the health care system. It is necessary given the sensitive nature of the medical profession. For a physician, patient privacy is intertwined with the trust that is essential in the patient-physician relationship.

At the same time, HIPAA robs the patient of his or her identity. Violia Freeland becomes VF or "63 year old Caucasian female" when I try to describe her to someone else. The absence of the name reduces the subject into a collection of symptoms and attributes, many of which aren't particularly unique, but all of which together, forms a unique narrative and a special individual. It is within a person's name that everything becomes attached- chief complaint, history of presenting illness, past medical history, social history--all of this becomes significant because they comprise parts of this person's narrative. This is why the name is important; because without it, I must try to make sense of a faceless entity. Perhaps this is why so many medical students like reading cases instead of textbooks because instead of an outline of factoids, we are reading a vignette, a discussion about a story, how this story relates to others (a differential diagnosis) and a treatment that pertains to this specific case.

As this M3 year draws to a close, I find myself thinking about the many patients I came across throughout the year. I realize that there are many patients that simply became faces in a sea of daily activity and yet there are others whose names and stories will remain with me for quite some time. It comes to me as no surprise that I often have names to attach to the latter. This isn't to say that the former were insignificant experiences--there is still much value in them yet--but when it comes down to the core of medicine, I believe that there is a significance to beginning with a name, a face, a history before the physical. While the lab work and imaging studies receive much of the attention, money, and publicity when it comes to health care, I have to remind myself that the reason why I decided to stick it out this past year was because I hope to one day assist the Leonard Andersons, William Hartwigs, and Suzanne Bowens, to continue living their lives, no matter how long or short their narratives may be.