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.

Inpatient Medicine

In the morning, we round on patients and monitor their progress. In the afternoon, we make phone calls to track down patient records, call primary care physician offices to schedule follow-up appointments, update other physicians on the progress of their patients, and on top of that try to deal with the myriad of social issues that inevitably arise with our patients. In the morning, we do what most people would imagine a doctor to do. In the afternoon, we do all the crucial busywork in an attempt to ensure some form of lasting continuity to whatever clinical improvement is made during a patient's stay at the hospital.

The term that keeps coming up in the hospital in reference to some of our patients is the word "babysitting." We make calls to their doctors when they should be doing it themselves. We repeatedly try to convince them to take their insulin when they complain they don't like getting shots to prevent one or more of the innumerable consequences of diabetes. For all the complexity that goes into learning about obscure diseases and the latest evidence based medicine, playing the social game is often just as difficult and a hundred times more draining.

It would be easy to blame all of this on patient lack of education, but the reality is that the messiness extends to all levels of society. Richer people may be more knowledgeable and compliant (and even this isn't a guarantee), but this does not always guarantee gratefulness or the ability to cope with dire circumstances. The mix of uncertainty, anger and denial will make the most educated person irrational--and all it takes an already stressed-out intern or jaded senior resident to turn a normally workable situation into an intolerable one.

It is this afternoon work that often drives many residents to do everything they can to avoid the social mess that is the modern health care system and pursue careers in outpatient specialties or more surgically oriented fellowships. After all, why should one go 200K in debt to subject him or herself to rude patients, patient who won't take their medications, chronic drug abusers who abuse the health care system as much as they abuse the drugs, and have to spend hours calling hospitals just to track down some test that was done 5 years ago that may not even end up being useful in the end? Why wouldn't you want to go into a field where you can dictate the patients you see and only have to deal with patients who actually want to see you?

Inpatient medicine is not merely Patient X has Disease Y that must be diagnosed by test Z and treated by drug 1 or Surgery 2.

No, it is much more often Patient X with disease Y will not take Drug Z for his condition Q which causes him to come into the hospital with complications A,B, and C leading to hospital stays that require expensive testing 1,2,3 that are ultimately paid by the taxpayer because Patient X is on Medicare or unemployment.

Refeeding Syndrome

It was the second time they went to go see him. It was the wing of the hospital furthest from the main building, the Forest, they liked to call it. He had a lot of problems. Cancer, fungus in his blood, cystic fibrosis, and probably a multitude of other opportunistic infections. The attending followed by the intern followed by the medical student. They were the infectious disease team consulted by the primary service to manage something.

"You look a little tired today," the attending said, dressed in the yellow isolation gown.

No response. He was known for not always being particularly responsive.

"Are you having trouble breathing?" He clearly was, but was still capable of speaking. He looked at them blankly and annoyed. The physician looked at him concerned.

The intern coming up along the bedside took a brief glance at the patient. With a quizzical look on his face he turned to his attending and remarked, " I think he might have refeeding syndrome. Sometimes after people haven't eaten for a while, their body has a hard time readjusting to oral intake creating increased carbon diox--"

"Listen to me," the emaciated 25 year had spoken. His hoarse, weak voice conveying the severity of his condition.

"The reason why I'm tired is because I can't sleep. Every night I have nurses that come in a readjust this and readjust that. I'm in pain. When I finally do fall asleep, I'm woken up again at 4:30 am so they can draw blood. Then for some reason, when the nurse comes in to get my blood, the other nurses think it's a good time to come in and take my blood pressure, take my temperature. Next thing I know some doctor is coming in at 6:00 am to ask me questions. Now it's bright out. Then when everyone finally leaves me alone you guys come along and ask me even more questions, see me tired, and think I have some refeeding syndrome. Now I don't claim to know as much as you doctors with all your knowledge and training, but what I do know is that if I could actually get some sleep here, I might not be so tired when you guys come around. What I do know is that I don't have no refeeding syndrome"

Silence blanketed the room. The attending turned to the intern, "I don't know why they have to draw blood at 4:30 in the morning. We'll try to stop by earlier in the morning so that he won't be interrupted as much."

And wishing the patient well, they turned around and left the room leaving the sick man to attempt sleep once more.

Hypernatremia w/altered mental status

He actually wasn't conscious when he first came in--of this we were aware. He came in last night, but that morning we met him as a team. Mouth perpetually wide open, hands wrapped in giant mittens to protect himself and others around him.

"Mister Griswolllld!" Our senior resident would yell out each morning shaking him by the shoulders. That morning he responded with unintelligible moans.

My intern whispered in my ear, "Hey Griswold. Where do you think you're gonna put a tree that big? Bend over and I'll show you!"

"You ever seen National Lampoon's Christmas?" he asked me.
"Parts of it, but never the whole thing"
"Alright. Your assignment for today is to watch some you tube clips of that movie so we have something to laugh about together."

Over the next week, Mr. Griswold would recover some form of responsiveness. Demented as hell, each morning he would be greeted and shaken. Eventually, the mittens came off when he was aware enough to stop scratching himself and pulling out his IVs. Then we noticed his hands.

"Hey, check out his lobster claw!"

His left hand sprouted three long and sinewy fingers and nothing more. The thumb, the index, and the bird.

"Watch out. Once he gets a hold of your arm, we'll have to chop it off cause you ain't getting it back!"

Those first few days we couldn't understand a word he said. Then, one morning, I went in with my senior for our daily shaking. He was already awake by the time we got there. Eyes open, he stared at us. We paused, startled at his consciousness. His ever gaping mouth slowly curling upwards, eyes fixed on her.
And then he uttered.

"IIII LUUUUV YOUUUUUU!"

"Awwwww" the inflection in her voice crescendoing as we left the room. "He said he loved me! Mr. Griswold!"

The last day I saw him we were planning him for discharge. Several steps from his room we smelled it. Clostridium Dificile. Shit. Literally.

"How you can tell it's C. Diff?" I asked.
"Just lift up his sheets and smell it."

And so he and his lobster claw were discharged from our service likely to relapse as soon as he settled into the nursing facility to which he was going, We had all come to see Mr. Griswold in a certain light. From unconscious, dehydrated admit to helpless, feces-ridden geriatric to lobster claw freak show, it's startling how little we actually knew about him.

"I loved Mr. Griswold," our senior mused.
"That's because he told you he loved you!" one of the interns replied.
"I know..."
"But he never seemed like the sort of guy that would have a history of being arrested several times for robberies."
"Oh, Mr. Griswold."

An Interesting Case

"Go meet Dr. Patel in clinic. She's seeing a patient of mine that I think would be good for learning. We're trying to decide whether she has acute or latent TB."

This is what he had been told, and like a good medical student one week into the medicine rotation, he scampered outside, through the snow, and up the stairs to the doors of the clinic.

"Dr. Patel's already in with the patient."

So down the hall and opening the door on his left he slid into a rather small room where the patient was seated in conversation with Dr. Patel.

Dr. Patel was gathering history. Have you any night sweats? fever? weight loss? hemoptysis? No, none of that, she said. She had had a hard life. Extensive medical history compounded by the common American co-morbidities. Any imaging? She thought she had some, but couldn't remember. On and on the history taking went. He picked up her medical records and glanced through them as the chatter continued.

Extensive psychiatric history. Well, given her history, who could blame her?

What did she do for a living again? Disability now, entrepreneur or something like that. They all failed though, her businesses. What were her businesses? He didn't ask.

She had been possibly been exposed to TB when she was a nursing student in the past.

Wait. What?

And then it clicked. He had seen this woman before. She did not recognize him. His memory stirred. Where?

The Ward.

She had wanted to kill herself. She was much more upset back then. He had tried to ask her about her history. She had snapped at him. Too many questions. Why did he want to know? She had left the ward and was supposed to go home but had disappeared according to police reports. That had been the last time he heard of her.

But here she was now. Sharing bits and pieces of a history not so unfamiliar. More psychiatric than medical in some ways, and more human than anything else.

Her most recent imaging turned out to be quite unremarkable. Disappointing from a medical standpoint. She would need further testing and there was no point in risking medication side effects when she was completely asymptomatic and without proper supportive imaging.

Walking back to the hospital, he thought about what she had told him before he left the room. She had told him that he would be a good doctor.

"You have a certain way about you, how you conduct yourself."

Really? Is that all there is to it? He had thought to himself. She didn't know him--just like he didn't really know her. The absurdity.

And then he remembered that this was supposed to be an interesting case. It had been, but not in the sense that he had expected--not medically or in a psychiatric dimension. He couldn't quite put his finger on how it was, and it bothered him. Another time, he would have to revisit it. Perhaps it would make sense then. In the meantime, another morning case presentation. 54 year old woman with a history of diabetes, hypertension, hyperlipidemia presenting with chest pain...

The 12 Days of Trauma

Inside the hospital, the only sign of the season comes in the form of festive bake sales, the occasional floor decorations, and maybe the occasional Christmas music in the OR. For those on the trauma service, winter is most welcome because it marks a decrease in the number of traumas. Unfortunately, people will drop by for a visit. During my trauma rotation I have experienced the following:

Black people shootings.
Old people falling (while hopped up on coumadin)
Young women motor vehicles colliding (into trees, other cars, +/- intoxication)
Many bones fracturing
Much rectal examining
And healthy dose of X-ray/CT imaging.

General Surgery

Having wrapped up the general surgery portion of my surgery rotation, I'm pretty glad that I had decided to not join any fantasy basketball leagues this year. Having been an avid fan since junior high, I decided last year to start playing again when a family member enticed me to join his uber-competitive cash-incentive laden league. I won that league, marking a successful comeback from my three year hiatus from fantasy sports. This year, however, I didn't think I'd have the time to really invest as I would like so I had to painfully decline the couple invitations this year.

These days, I find myself myself jumping on my computer to check on how my patients are doing. Instead of points, rebounds, and assists, I'm looking at vitals, progress notes, test results. Admittedly, these aren't the most exciting stats especially since we're not really shooting for extremes. Still, I'd like to think there's a certain head to head match up going on with death or even just surgical complications.

So every night I watch in anticipation and the following morning, I go see the results first hand. I realize it's probably not the wisest thing to compare patient care with fantasy sports, but the more I think about it, there's probably a good number of similarities that could be made. That's another post for another time.

Three things

One of the surgeons came up to me today and told me that I needed to learn three new things about every surgery I attended so that by the end of the rotation, I would have accumulated a nice fund of information from which to draw.

Today, I had only one surgery--the ventral/umbilical/incisional hernia repair. This is what I learned.

1. Repair necessitates cutting through the falciform ligament
2. Mesh should have at least 5 cm around the hole to ensure stability
3. Suturing the fascia to the mesh helps with stability and hematoma development.

I also present three things from the OR discussion relating to the implementation of new CT scans/pat downs in airports and the needless radiation exposure/invasion of privacy that this will generate.

Surgeon: I shouldn't have to subject my children to this (pat downs) just because I don't want to expose them needlessly to radiation.
OR nurse: If it wasn't the government doing this, these would qualify for sexual abuse.

OR nurse: I'll take the pat-downs over the X-ray any day. Heck, I'll even do it twice.
Scrub tech: Yeah, and while she's getting them, she'll probably forget why she's even getting them in the first place.
OR nurse: Everything I've learned I owe to you.

Nurse: my (Caucasian) friend recently got patted down at the airport while a 25-year old fellow Arab passenger got through untouched.
Indian Doctor: In that case, I'll be expecting my rectal exam when I go through one of those lines.
Nurse: Yeah, you'll be like, "Hey, that's not your hand..."

Thursday morning cancer conference

It was the weekly cancer conference, and it was optional. Yes, his attending would be presenting a couple cases, but this short white coat had long grown tired of playing this game of impressing his superiors. But, he went anyway. Come to think of it, he probably only went because he was chasing an interest that he really didn’t have—and, on a deeper level, a calling he could never fully embrace.
The first case presented sounded familiar: Adenocarcinoma of the lung. Brain metastasis. Post-radiation treatment VATS pneumonectomy. PFTs had checked out pre-operatively. Patient recovered relatively well. Residual ataxia from the neurological deficits.

This was unfortunate because he painted houses. How would he make a living for himself if he could not stand on a ladder? The cardiothoracic surgeon wasn’t sure. His shoulders shrugged with a hint of sadness and sympathy. This was the story that was often left untold when a patient left the hospital—even if the surgery was a clinical success.

The painter had a name, and the short white coat sat there scrolling through the list of patients he had been generating over the last three weeks. All he remembered was watching the surgeons pull his diseased lung out between the ribs, and the painter’s face the day he was discharged to go home. He remembered that the painter had voiced concern about his job, but despite all this, the name eluded him.

He played the harmonica. He had brought in his harmonica that last day to see if he could still play it after the surgery. Indeed, he had found that he could. So strange; this was all he could remember. He played the harmonica.

The purpose of the conference was to provide a venue for oncologists, pathologists, and surgeons to discuss treatment plans, to collaborate so that future patients could be better served. At the same time, these conferences became a place to commemorate those that had passed through their care. Because for every 55 year old with adenocarcinoma of the lung and brain mets, there was a painter who painted no more—a painter who was recovering at home and playing his harmonica.

Fences and Elbow Room

Today while waiting for a cholecystectomy, my team of one attending, two residents, and two medical students sat in the physician's lounge chatting about various subjects. My attending raised the issue of how everyone in his affluent neighborhood was putting up fences around their yards. It was silly, my attending bemused, how our relationships with our neighbors were becoming increasingly defined by such a strict sense of privacy.

Sometime later in the conversation, my attending went on to share this story.

"So I took my kids to Disneyland and my son was all up in people's butts the whole time. I had to finally pull him aside and tell him that part of what defines Americans is how we want our elbow room," He propped his elbows up accordingly to show how he symbolically demonstrated to his young toddler the concept of privacy.

"And," he continued, "for the rest of our time there, my son was walking around with his elbows like this," he repeated the gesture a second time.

Thinking back to this conversation, I realize that the hospital is the exact antithesis of the coveted privacy that Americans pursue. Here, a patient is stripped down to their most basic needs (pain, passing flatus, urinating, ambulating, and appetite). In order to receive help, he must be examined, poked, prodded, cut open, and assisted in rudimentary clothing (the hospital gown) by strangers not of the patient's choosing. He is furthermore forced to trust strangers with their most intimate details (sexual history and social history) with really no way to ensure that their confidentiality will be preserved (nurse gossip anyone?). This is both uncomfortably alarming and yet intrinsically necessary to the current health care process (because even the nurse gossip becomes a way to preserve the sanity of the participating parties).

If people were willing to subject themselves to such treatment for the sake of personal health, how different our society would be if we were willing to place ourselves in similarly compromising situations for the sake of our fellow man?

The Bubble Boy

He showed up to his first day of perinatology not sure of what to expect. He was typing notes at a work station when his eyes met those of the attending to which he was assigned for the week.

"Are you with us this week?"
He nodded his head.
"Come along, then," the doctor said gesturing in a somewhat inviting somewhat melodramatic fashion.

And so, just like Jesus called his disciples, the slightly bewildered med student pended his note and followed his attending for the morning rounds. They were soon joined by a resident, a couple nurses, and a nursing graduate student. The rounds started off as benign as any other. Patients were seen, pleasantries were exchanged, and they moved on to the next room. Rounds went quickly with little explanation of the problems and little discussion. This was expected from this attending so the medical student thought nothing of it.

Throughout the day, the attending talked with pretty much everyone in his path. He treated patients kindly, cracked dry jokes from time to time, and went out of his way to try to make sure the nursing student would be able to do the things she needed to do for her schooling.

To the medical student, he said very little, and there was no harm in this in and of itself, but when a group of them would be in a room shooting the breeze waiting for the next patient, it became evident that the attending had very little to say to the medical student. The student in the short white coat thought this to be rather strange for someone who was so cordial to everyone else, and wondered if he had done something to offend the doctor, but could not think of a single interaction that had lasted long enough to even warrant taking offense.

And this continued throughout the rest of the week. The MS3 became increasingly annoyed with the indifference, and found his attending's behavior, in some ways, to be childish. He became annoyed with the whole system of large universities making heaping sums off indebted students for a training that often exposed them to "volunteer" faculty who simply didn't care to teach And, of course, much of these loans were government-sponsored. In some ways, it was a circle of futility. No one person could be singled out and yet everyone was at fault.

and so the week dragged on. Patients were followed, discharged, and admitted. It was a daily grind on the floors with nurses, physicians, even maintenance people, scurrying about, and somewhere, amid the routine of the hospital machine, a single medical student found himself lost within a world of progress notes, shelf exams, and meaningless rounds that went on as if that short white coat was but a ghost of the imagination.

Matthew 26:6-13

And it came to pass that a doctor was on duty at the charity clinic sitting in the office talking with her colleagues when they were interrupted by a nurse

“Doctor, there is a patient here to see you.”
“Oh?”
“Yes, she is in the front right now.”

So the resident left the room and came back several minutes later bearing a fruit basket and a bag of cupcakes.

“Look, the patient I delivered a week ago remembered my birthday and came by with these. Aren’t they beautiful? I feel bad because these are so nice and she shouldn’t have spent money on me like this.”
“Aww, how sweet,” another one of her fellow physicians commented.
“Yeah, and she also had brought me cake and cookies when I delivered her in the hospital. She really shouldn’t have.”
“That’s a nice gesture indeed,” their attending remarked, “Those fruit baskets are really expensive. She probably shouldn’t have even bothered.”

This last physician said this because he knew that this patient had a couple of other children to support and received monthly public aid checks--the same checks that paid for her expensive new cell phone, cigarettes, and the oral contraceptives that enabled her to carouse around with whomever, whenever. Such purchases often left the patient unable to pay her cell phone bill, which prevented the physicians from being able to contact her and follow up during her prenatal care. This was troublesome because her baby had a condition that needed consistent monitoring to ensure that it did not get worse. Of course, all of this was made possible by taxing other economically-burdened citizens who were struggling to make ends meet on a daily basis.

One of the nurses came in to the room.

“Wasn’t she sweet? She even brought cupcakes for the nursing staff. You know, it’s people like this that really uplift our spirits because so many of the people in this clinic just aren’t very grateful.”

And all of them could agree on this. Gratitude was a scarce commodity in the charity clinic. One would think that those without any health insurance would be extremely grateful for the services they received at no cost, but the reality of this situation was that many of them were non-compliant, refused to make lifestyle changes, and would simply come back with a sense of entitlement that would make even the most sympathetic health care provider shudder.

Despite this sobering reality, this was still a day to celebrate and be thankful. The doctor asked one of her colleagues if she wanted to split a cupcake and the other happily obliged.

The efficiency of social medicine

Yesterday I spent time at the free clinic that the ob-gyn residents run for indigenous patients. The last patient we saw that day was a post-menopausal elderly woman who presented with chronic cystocele and rectocele issues. This patient had already had significant spinal surgeries in the past and was wary of the complications involved in the post-surgical healing process. My resident showed a remarkable amount of tact over discussing the option of surgery. From a physician point of view, it's easy to take such delicate matters lightly when discussing patient options. It would be nice to believe that the decision is a simple yes or no decision or as medical people like to put it, "a matter of doing what's best for you," but the cost of surgery is more than a financial one; it is also an emotional and social one as well. Several times over the interview, my resident repeated herself to the patient regarding treatment options and quality of life issues. On one hand, this took more time, but on the other hand, I believe it also played a role in helping the patient make her decision. In the end, the patient still had to weigh her options.

Today, I went to see an ophthalmologist in town to discuss possible cataract surgery. The group here in town has a cushy facility that is a stark contrast to the clinic I spent time in the day before. The place was packed with the elderly. Having had to deal with congenital cataracts growing up, this was an all too familiar setting.

Somewhere in the large waiting room, an elderly lady voice asked a nurse,"Excuse me ma'm. Did they forget about me?"

As I ran through the litany of eye exams--the measurements, the letter charts, the dilation drops--I became increasingly impatient over the whole process. These were the things I had gone through my entire life, but over the past couple years, my failing eye sight had become a bit of sore topic whenever it came up among my classmates who really never understood quite what I was going through. "You really should get those checked out," they would say, or "I think you need glasses or something." These were the words of future physicians of the future. Beware of such "sympathies."

The ophthalmologist was a middle-aged male physician. A brief greeting without the handshake tipped me off that he might have been in a hurry, and as the interview progressed it became even more apparent that he was probably thinking more about the long line of people in the waiting room. He took a look at my eyes and asked me the purpose of this meeting. i told him my concerns and he presented with the surgical options. Somewhere in the conversation, the "doing what's best for you" cliche came out. When I had concerns about scheduling and financing, he referred me to his nurses. When I asked him about recent studies over new lens implants, he said they were "very good." As the conversation progressed, I began to feel hurried in my questions and concerns and increasingly irritated as well. I found myself repeating similar concerns because I sensed a growing anxiety within myself, but the hurried doctor sensed none of this. The interview ended with him getting up before me and having his nurse guide me out the door.

The moment a physician begins to feel or act hurried, regardless of how behind he or she is, you lose the essence of what it means to be a physician. What you essentially tell a patient through your body language or lack of explanation is that your time and comfort is more important than their well-being. Emotions are messy; they are, by definition, inefficient. They do not fit in your 15 minute blocks that a physician constructs in his or her schedule. I have little sympathy for doctors that take on heavy schedules to make more money at the cost of quality of patient interaction, especially in a private practice setting.

Driving home, I realized two things. One, I was going to find another one of his partners to do the surgery. Two, if I ever became a physician, I hoped that I would never conduct myself in such a manner. I understand stress makes people do things they might not normally do, but the doctor left a sour taste in my mouth. It's encounters such as the one I had today that make me even more cynical about the medical profession. Fortunately, for every doc like this one, I have had the chance to be with others, such as the ob-gyn resident, who demonstrate the ideals that I struggle to hold to as I continue in my medical training.

Marginal Zone Lymphoma with Recurring Abscess

This past Monday I met a marginal zone lymphoma patient and his wife. He had long grey hair that looked like it had seen better days and suspenders that one might find on the old college professor. The first question he asked after my attending introduced me was “So where are you from?”

Here in Central Illinois, my ethnicity is a conversation starter for the predominantly white population. Thanks to desensitization, my hairs no long bristle at the broaching of this topic.

Quickly understanding the question’s intent, I skipped the “Chicago suburb” formality and answered, “My parents are from Taiwan.”
“Oh.” he says, “The reason why I ask is because 12-14 of my students are Chinese. I teach piano.” And as he said this, his long, sinewy fingers played the invisible Steinway as fluidly as one could imagine possible.

The bulk of the appointment dealt with a persistent abscess that had developed in his right lung unrelated to the cancer. Though his cancer had remitted, this pulmonary lesion periodically forced him out of commission. We talked about the limited nature of antibiotics and the possibility of surgery. Our patient obviously hated how his illness forced him to cancel teaching. He pointed to his suspenders as evidence of the amount of weight he had lost over the last year.

On their way out, I felt compelled to speak with our patient again. I asked him what type of piano he taught. “Classical,” he answered. “I used to teach at universities.” When I asked him where, his wife quickly chimed it “He graduated from Julliard.” Her voice dripped with the kind of pride that remembers a spouse’s greatest moments.

I briefly told them about my musical background, and how I had a piano teacher who passed away from cancer. Before I could explain to him just how much she had meant to me, I had already begun to recall the bittersweet memories of our final lessons together. Even as the couple walked away, I could feel my dry hands chapped from freshman year gymnastics—because it always started with the hands—and those frustrated admonishments for not putting in the necessary practice. I could hear her pleading yet stern hoarse voice telling me that I needed to stop wasting both her and my time. I remember being at my sister’s condo on Michigan Ave. when I found out that she had passed, and I remember attending her funeral at her suburban Lutheran church, my back pressed up against the brick wall in the rear listening to her son uncontrollably weep in the middle of his testimony.

But of course you can’t tell all of this to a patient because life must go on (and lest we forget, the insurance companies will certainly remind us). As we age, we learn to be content with vignettes—if we’re lucky short stories—from each individual that steps through the door. Our fellow man, therefore, gives us snapshots by which we extrapolate the past, and we, in turn, are endowed with a memory through which we begin to move forward in the present.

And for a moment I found myself speechless, wishing that time would stop and let me ponder all of this further. Unfortunately, time halts for no one, and as we began to move on to the next patient of the afternoon, I gave thanks for the people that imbue our lives with meaning