Together

Repost of a post I wrote for the Global Health Diaries, the blog of the Global Health Program at the University of Vermont Robert Larner M.D. College of Medicine and the Western Connecticut Health Network. Find the original here.

“Here, you can just about always find an internal medicine resident who speaks the patient’s language,” the resident I was working with said, smiling, “It’s amazing.” Another resident had just stopped by to say that one of their colleagues did, in fact, speak that obscure Southern Asian language the translation service did not cover that they needed for an acute patient. I smiled because it was amazing. This was exactly the type of place I’d wanted to train to become a physician.

It was standard that everyone on my teams during my internal medicine rotation had a different accent. And when two of us did have the same accent, our divergent places of origin and cultural backgrounds made up for the lack of difference in how our English sounded. What I liked most, was that in this hospital everyone came from different places – the patients, the nurses, the residents, the physicians, and the other hospital staff. Even in modern America, it’s somewhat uncommon to work in a hospital where the physician diversity almost reflects the diversity of the patients. The hospital where I did my internal medicine rotation in Connecticut was very close to having its physicians reflect the different groups of people who made up the greater community of the hospital.

One thing I found interesting upon returning to Vermont after almost a decade away was how much I missed the accents and the challenge of finding connection across cultural differences I’d experienced during my years in the Washington, DC and Paraguay. There was a subtle feeling of stagnation, almost boredom that crept into my professional life as I began my medical career in my home state. Of course, Vermont has pockets of diversity of all kinds but it’s not like living in an urban area or a foreign country.

After my second year of medical school, I moved to LCOM’s Connecticut campus. As I settled into my new community, I learned that where I lived in Connecticut was a melting pot that buzzed and hummed in ways that more homogenous communities do not.

What better time to dive into a diverse medical community than right after the release of the COVID vaccines? As I listened to the accents of the residents and attending physicians with whom I worked during my Connecticut internal medicine rotation, I was struck by how the medical community is just as connected as the general human community is connected. Afterall, COVID has definitively illustrated how communicable diseases can spread easily around the world. But, also, the speedy development and dissemination of the COVID vaccine showed how we humans can solve dire problems when the minds of people all around the world come together.

There was something unique about how my internal medicine teams came together to solve patient problems. Of course, good medicine transcends culture – some medications and interventions just work. But, in terms of decisions about how to interact with patients and their families, each of us brought our own cultural beliefs and backgrounds to our practice of medicine.

One of the neatest things about working with team members who aren’t like you, is that you’re forced to reflect on your own ways. You’re forced to examine other ways of being. And, in medical school where it’s easy to get caught up in the nitty-gritty of disease states and medication dosages – I was grateful to be reminded of the humanness of the residents and attending physicians around me. And, also, to be reminded that my patients brought their humanity with them when they came to the hospital.

Most of the hours spent on internal medicine were dedicated to identifying the best course of treatment for our patients. But as rounds ended for the day, there was often the lucky opportunity to hear what medical school was like in other countries and how physicians from all round the world had come to find themselves in Connecticut. The walls of the hospital seemed less limiting when I realized that it had taken a global community to staff the hospital itself.

Pride and the Human Experience

The patient was muscular and wore coordinated clothing, both uncommon for someone admitted to the hospital. One of my tasks was to deduce his age from observation; the moment I saw him I knew it’d be hard. He was one of those mystical people who appear much younger than their age.

There are a series of questions we always try to ask our patients in the hospital. They seem silly, but you’d be surprised how often patients can’t answer all of them. “What’s your full name? Where are we? Why are you here? What’s the date?”

This patient made great eye contact. He sat on the edge of his bed with his spine perfectly straight. He used his hands when he spoke. He said his name purposefully. He stated our location without pause.

“Why are you here?” I asked.

“I’m here to evaluate the hospital systems. I have a solution for your computers,” the patient said.

I looked at his wife who was sitting in a chair a surprisingly far distance from the hospital bed. She grimaced. “He’s been fixated on the idea of attending a business conference recently. I can’t seem to get him out of it.”

The neurology exam unfolded (an exam looking at nerve, brain, and muscular function). On the nerve and muscle function part the patient did well. He was nibble and coordinated. He was very strong. Especially for his age. However, his cognitive score was significantly below the normal level – low enough that despite our newness to testing cognitive function the other students and I were confident that he had scored low enough to count for a diagnosis of a memory disorder. How long had his memory been declining?

As I and the other medical students interviewed the patient, his wife interjected ever-so-politely when he denied he had any health concerns. She’d taken over multiple tasks to manage their household, slowly. Now she managed all the finances and everything else too. She mentioned that the patient would fly into a rage for almost no reason which was unlike the man she’d been married to for many years. He’d always been a calm man. He’d always been a connector and a successful man. He’d always been so well organized.

His memory and brain function were poor enough that the man could not complete all his activities of daily living (things like paying bills, buying groceries, among other things). This memory loss and brain function decline had been going on for over 6 months. In other words, the patient met the textbook definition of dementia.

~

The other medical students and I told the physician we were working with what we’d learned about the patient. The physician requested only the information that would change his management of the patient. So, in the end, we shared very little about what we’d learned about the patient. What makes medicine interesting (to me) is the story; however, diagnoses and treatment mostly depend on the distilled details of signs, symptoms, tests, and timeline.

~

The physician examined the patient. “What would you do if your house was on fire?” the physician asked.

“I’d go outside,” the patient said.

“Then what?” the physician asked.

“I’d communicate with people I know,” the patient said.

“Like who?” the physician asked.

“Well, I know some firefighters. They’re friends of mine. I’d probably talk to them,” the patient said. The room was silent for a few seconds. The physician watched the patient, but I watched the wife. Most of us would call 9-1-1 if our house was on fire. I hope.

~

When we left the room the physician said, “You didn’t tell me how bad he was!”

“You only asked for the information that would change your management of his condition,” I said.

As we discussed the patient in greater detail, the patient’s wife came out into the hall to show us a picture of her husband when he was still working. In the picture, he was dressed sharply and similarly to the physician I was working with. We all nodded and smiled. She looked at the picture with love, but her body was tense.

~

The vision of the wife holding up the picture of her husband stuck with me. I hoped she knew it was going to get harder. It was possible that her husband would have angry outbursts more frequently. It was certain that his memory and ability to function would decline. And it was unlikely that even that picture of him as a younger, healthy man would propel her through the remaining years of her husband’s decline if she didn’t have help. Dementia takes a toll on the loved ones of the person who is slowly losing their brain. There is no magic pill or procedure to fix the brain when it breaks in the way that causes dementia. Dementia is a progressive disease with a fatal end where, along the way, the person who began the illness is not the person who dies from it. Dementia reduces our ability to function and, also, transforms our personality.

Despite the frustration of memory loss, one thing that this patient illustrated and continues to strike me about people with dementia, is that they keep their pride much longer than many other aspects of their original personality. The vision of this patient sitting tall and answering our questions confidently floated in my mind next to the picture of him when he was younger. Why is pride something the brain clings to even as other functions are lost?

The patient’s wife noted that his outbursts most often occurred in moments when he realized he was forgetting things. In the beginning stages of dementia, many people are aware that their memory is going. I thought about how this patient’s wife must struggle to strike a balance between supporting the autonomy of her husband while also knowing he could not grasp the intricacies of complex concepts and decisions like he once could. When she looked at him, she seemed reflective. Perhaps she was recalling the grand times they’d had together. She also looked tired likely because their life together was more difficult at the time she brought him to the hospital than it had been previously.

The longer I stay in healthcare the more I come to realize that illness, while very personal to the person experiencing it, is not only an individual journey. For patients lucky enough to have friends and family at their side, their disease impacts their family and friends in profound ways. For patients alone in the world, their illness impacts those who care for them whether it be their primary care provider or their care team when they land in the hospital. And much like pride which clings on even as the brain becomes weak, the odd realization that illness is often a social experience lingers in my mind as a dark side of the human experience.

Grateful

I found myself lying on the floor. The sun had set but it was still early – a tragedy of New England once the summer fades. I was not tired or sad. My to-do list was as robust as ever and my goals circled high above my head, seemingly in the clouds. Yet, I was lying on the floor not even stretching. No music, podcast, book, or movie playing. To be fair, I spent a fair amount of time sitting on the floor (my preferred studying location is at my floor desk) so lying on the floor wasn’t that much of a change. It was the stillness and purposelessness of the activity that was unusual for me.

There was a period of my existence when I could not be still and had to always be actively engaged in something. However, the need for constant stimulation dissipated when I was in Paraguay and, I’ve often thought, “good riddance.” I recall my early 20s. I worked fulltime, studied in college fulltime, trained for marathons, went to parties, and built my first career. It was exhausting. It was the way of life I knew. The way of becoming successful. Of fulfilling the American dream. Then I moved to Paraguay where everything seemed so slow. Hours sitting and drinking terere in the shade. Hours spent sitting and sometimes chatting, often staring into space silently, sometimes cooking or napping. I came to enjoy rainy days where it is common for rural Paraguay to shut down. Rainy days were filled with lounging and drinking mate. I precisely remember the moment I realized that when the Paraguayans told me they were doing “nothing,” they meant it. What an odd thing nothing is.

I’ve reached that point in medical school where I’d rather it was over. That point when the hours of studying, sitting in the hospital, trying to learn everything I can, and testing to see if I know enough to care for my patients are quite tedious. I do NOT say this out of despair; I still know medicine is exactly what I want to do professionally. I still love patients and the puzzles they present, but I’m ready to be good at something again. I recall a similar feeling junior year of high school, junior year of college, 6 months into my first professional job after college, and 6 months into my life in Paraguay. There’s a time in all learning curves where it’s truly a terrible slog. That time when you’ve learned an unfathomable amount, still feel mediocre at managing what you know, realize you still have a ton left to understand, and know that it will still be a while before you’re “good at it.” Whatever the mysterious “it” is.

And that’s where the gratefulness comes in. I’m grateful these days because I’ve played this game before. I’m grateful because I know myself better than I did last time I played the game of learning something completely new. I’m grateful because I know already that I’m attracted to activities that seem impossible yet, at some point (after many days of struggle), I do wind up being excellent at them.

So, I found myself lying on the floor. It was junior year of medical school. It was the breaking point. It was about to be a landslide into graduation. In a couple of blinks, I’d start residency. I was closer to becoming a physician than I’d ever been. I lay on the floor contemplating the joy and misery of learning. I thought about some patients who had changed my worldview ever-so-slightly. I thought about the amazing teachings and mentors who I’d encountered while wandering about the hospital wards. I thought about the first day I showed up to work on an ambulance (my first clinical experience), years ago now. “I won’t let you kill anyone,” my chief had said then. I contemplated this. Soon, it would be I who had to prevent patients from dying if it could be done. That was kind of a big deal. I felt humbled. I had much to learn despite having learned so much. I was grateful for this moment of pause while lying on the floor. Life is quite a whirlwind when you seek out challenge. The secret, therefore, is to be grateful for the moments of calm when they come. Even the worst storms have eyes; I remind myself of to look for them.

A Cup of Coffee

I saw the physician I was working with return from the cafeteria with her normal cup of coffee and a second small coffee. She walked by our computer station and into the patient’s room.

The patient had been plagued by a headache that morning when I saw them, not long before the physician arrived with a cup of coffee. The patient had requested coffee because it usually helped with their headaches. Of course, they would get coffee with their breakfast tray later, but that could take hours.

The patient had had a rough year. They’d been in the intensive care unit several times after trying to kill themselves, the first time almost not surviving. They’d lost a child to overdose. Their life had other stress-causing features. The patient was calm when they were under our care, but they’d attacked their nursing staff earlier on during their hospital stay.  

When the physician returned to our computer station, I thanked her for getting the patient a cup of coffee. Little acts of kindness like that are not as common as you’d like them to be. The hospital is full of burnt-out thoughtful people (also known as staff). It’s also full of people with all kinds of diseases. The diseases of the brain can be quite tough. When a psychiatric illness sends people to the hospital, there’s the suffering of the patient and there’s the challenges that they sometimes pose for medical staff. The brain is a powerful organ and when it gets sick it can do all kinds of things. As such, when healthcare staff are overworked (which is always these days) and when the hospital is full (which is most of the time), patients with brain diseases do not always receive the kindness that they deserve from their care teams. But, on that morning, this patient did.

I thought about that cup of coffee. It brightened the patient’s morning. It can be hard to remember the little things we can do to help others. But, on this occasion, the physician I was working with reminded me by setting an example.  

One Example of Sexism in the Operating Room

Often enough to be considered a pattern, the men in the operating room chose to discuss the annoyance of the hospital’s anti-harassment yearly training videos and anti-harassment policies when I was the only female in the operating room with them or when it was just an older female nurse, them, and me. And while I also find the hospital’s anti-harassment training videos frustrating (for entirely different reasons than my male counterparts), I did not appreciate when a surgeon said he could get tips from the scenarios in the video. I did not appreciate his comment (despite his humorous tone) because the truth is that harassment doesn’t just occur in training videos. It occurs all the time and in all settings of women’s lives.

And I found it interesting that these men were complaining when most of them are fathers of daughters, and many are fathers of young daughters. And if the risks weren’t so high for me, I would have asked them the questions I pose now, “How old do you think your daughter will be when she first gets cat-called so badly she feels unsafe? How long riding public transportation will it take before she has a set of rules she follows because of the physical and verbal harassment she experienced from male passengers?” The use of “when” and not “if” is intentional.

You see, women close to me have been strangled and shoved into walls. I’ve sat by as a younger woman asked for advice from an older woman about what to do because her husband raped her every night. I’ve been called by friends in tears because they were cat-called so badly they were shaken. I’ve sat with women as they hid behind dark glasses waiting to get photos of their bruises to use in court. On my first day of one of my first jobs, my preceptor told me how to use the printer and warned me to be careful of our male boss. He left the company before I had to worry about exactly how careful I had to be. By the time I’d worked in healthcare two years, two of my female friends had been groped by male patients. I’ve only been training in the hospital as a medical student for six months and already two female physicians have taken time out of their busy schedules to have lengthy conversations about how to keep my head up and build my career despite disrespect from male colleagues and male patients.

And the reason I would ask the fathers of young daughters the questions above is because I know they love their daughters. And I know they can’t fathom that they are being exactly the type of men who will get in their daughters’ way as they reach for their dreams. And I would ask the fathers of young daughters these questions to remind them that they cannot protect their daughters from the future. And, truth be told, they will likely never know the harassment episodes of their daughters’ life. And I would ask these questions to recommend that they learn how to respect women so that they can set an example for their daughters of what it’s like to be respected. That way, when their daughters do experience disrespect, they know it is not their shortcomings but the shortcomings of the disrespectful one. In other words, it’s worse to be a daughter of a father who doesn’t know how to respect women because he sets a poor example of the male gender. And the behavior of these men in the operating room made it clear that they still had much to learn about respect despite surgeons being among the most highly educated people around. What an unsettling reality to have so many years of education and still lack competency in a basic principle like respecting all humans.

You can look up the statistics in the US for harassment and rape of women (and other demographics) if you’re curious. It’s an easy Google and the numbers are almost as bad as the news that makes the front page of the newspaper. If you want to get really dark, look up statistics related to intimate partner violence. The numbers are horrific. And the numbers always surprise me because all women are daughters and perhaps sisters, mothers, and partners. Fathers and mothers see the statistics and are inclined to tell their daughters to be careful. To not drink too much. To not wear too revealing clothing. To never set down their drink. To not walk alone at night. To not live on the first floor. To lock their windows and doors. To always go out with friends….the list goes on. But the question I always wonder when I hear these statements of warning is why don’t parents just tell and teach their sons that “no” means “no,” “stop” means “stop,” respect applies to all people regardless of genitalia, and that drunk or not you are responsible for your actions? Because all men are sons, and many are brothers, fathers, and partners. It would seem more helpful to prevent the problem of people harassing others, than react to the problem by telling the victims to avoid harassment.

I also find parents’ lectures of caution stifling because they do not address so many of the manifestations of sexism their daughters will experiences. Yes, there is the risk of rape and physical abuse. But for those women going into competitive or historically male professions many of the troubles we face as women are more subtle and persistent than acts of violence. The times we’re told we’re mean or bossy when a male counterpart with the same behavior is considered strong. The times we’re ignored, spoken over, interrupted, and discredited despite consistently being correct. The times (like in the operating room when men decided to complain about harassment protection for women) when we’re othered and made to feel like demanding respect isn’t a right, but a burden we place on our male counterparts. The times we’re underpromoted, underpaid, and passed over simply because we are women. The times we must dig deeper than our male counterparts not because of shortcomings but because our parents taught their daughter to be cautious and taught their sons to be bold.

And as these fathers of daughters discussed sexual harassment policies as an annoying restraint placed on them, I thought about their daughters. I knew when they’d be cat-called. I knew how long it would take on public transportation before they developed their safety rules. And I hoped for those daughters’ sake that they would have men that set an example of what it’s like to be mutually respected. It had made such a difference for me to coexist with many men who looked at me as a person and not some different creature. You see, it’s helpful to know respect is possible because at times it seems like a fictional concept. I thought about those young daughters one day standing where I was. I sent them strength. As much as I hoped the world would change in the years between us, I wasn’t sure it would because these men I stood with in the operating room would still be here. And their sons who had them as role models would be here too.

And I was once again weary, not so much because of the long hours I was spending studying or the fact that I was scoring equal or better to many of my male counterparts in medical school while also getting cat-called and navigating colleague and patient sexism, but I was weary because these men in the operating room, like so many others, stood in the way of my father’s daughter. They stood in my way because they made things more difficult for me than my brothers simply because of my genitalia. None of this was new or surprising, but it did make the hours in the operating room seem especially long. And if the operating room had been a safer place for me, I would have told these fathers the reason I didn’t like the hospital’s anti-harassment videos was because they were triggering for those of us who have been sexually harassed and spoke of a justice system that I have not found anywhere I’ve worked. And I’ve worked in many places.

Surgeons

I sat waiting for the surgeon I’d work with to arrive at the hospital. Being a medical student involves a lot of waiting. On the wall across from where I sat and next to my surgeon preceptor’s office was a wall of fame, of sorts, of surgeons gone by. The black-and-white photos caught my attention because every single surgeon depicted there was a white male. The irony was that most of the surgeons I would come to respect in the weeks to follow would fit neither or only one of the “white male” descriptors. The surgeon I was waiting for, for example, was neither white nor male. She would single-handedly show me what it meant to be an excellent surgeon.

The operating room is cold. The lights are stark. If you are helping with an operation you “scrub in” (which involves washing your hands in a special way and putting on sterile gloves and a sterile gown). Once scrubbed in, you maintain sterility the entire procedure which includes only touching sterile things and keeping your hands in front of you and between the level of your bellybutton and chest. Bathroom breaks and snack breaks aren’t an option for medical students in the operating room, so I tried my best to do those things before entering the room.

Once the patient is settled on the operating table, they’re put to sleep by anesthesia.  As soon as it’s confirmed that the patient is asleep, their eyelids are closed with tape to protect their eye structures and a tube is placed down their throat to help them breathe.

While the patient is asleep surgery unfolds. All surgeries are done with a team of people, the surgeon is only one member of that team, and the surgery is not successful without every team member. The patient is covered with drapes except for the area where the operation will occur. This is interesting because the humanness of the patient is lost. Their body becomes a workspace once the drapes are placed. It may sound disrespectful, but it isn’t. Rather, the drapes are meant to protect the sterile workspace and maintain patient modesty.

Surgeons are the artists of medicine. Much like carpenters and painters and jewelers and other craftspeople they make their living by using their hands. The difference, however, between surgeons’ hands and carpenters’ hands, for example, is stark. The surgeons’ hands are soft and their fingers nibble while the carpenters’ hands are rough and their fingers strong.

Surgery is all about feel and dexterity. Surgeons tie knots with thin thread to keep arteries from bleeding. They sew with curved needles using plyer-like instruments. During surgery, it’s the surgeon’s hands that impress. Their fingertips can feel the difference between disease and health in tissue. Their hands can somehow hold more tools than you thought possible.

Ask a surgeon about surgery and about the operating room and their eyes become bright. They smile. They draw pictures and use their hands to describe structures. They talk about the neat surgeries and bodies they’ve seen. They talk about how many operations they’ve done. Surgeons are like artists. They love their craft and exude a love for their studio (the operating room).

I would eventually join a surgery led by the surgeon I had waited for by the surgeon wall of fame. A resident and I were helping her. The resident was soon to finish and become an independent practitioner. The surgeon was busy operating; I was holding a camera (used to see inside the abdomen); and the resident was doing something else to help the surgeon. “People will not take you seriously because you are a small female,” the surgeon said to the resident. “Don’t be disheartened. Respect is earned.” The surgeon would go on to discuss the importance of appropriate financial compensation for your work and doing excellent work. I would hear this message about differences and respect several times during my surgery rotation. I would feel why multiple women ahead of me thought they needed to tell me and my colleagues this information. Yet, it wasn’t new information because I, like most others, didn’t make it through my 20s without learning how my different identities help and hinder me.

There are many things that you could die from if it wasn’t for surgeons. But, as lifesaving as surgery is, it is also fraught with risk. Your surgeon can kill you. Having life and death literally in one’s hands is not a light matter, and you see its weight on the shoulders of surgeons when you work with them. The riskiness of surgery is also why the road to becoming a surgeon is a long, hard one. It involves many years filled with unfortunately long workdays. Apart from a grueling training marathon, surgeons have high personal standards for their work. High standards coupled with hard training leave many surgeons with a robust ego.

Egos aren’t all bad. You want a confident, proud surgeon. This is because you want someone who is very good at what they do and who takes pride in their work to operate on you. However, egos can be detrimental too. Too much ego can lead to poor listening skills, lack of self-reflection, and a complete disrespect for others. High-quality surgeons are confident because they are good at their work and love it, proud because they save lives, and humble because they know they are human and will make mistakes. The best surgeons are not only confident, proud, and humble but also curious. Curiosity makes the best surgeons because they not only love operating but, also, dig to the bottom of their patients’ stories, investigate thoroughly any mistake or less-than-perfect outcome, and keep up on the latest research and recommendations in their field.

On our last day working together, the surgeon that made me understand surgery had time to sit with me in her office by the surgeon wall of fame. She gave me some advice and her philosophy on medicine. “It’s nice when patients appreciate your work. You saved their life. But, they don’t have to and that’s not why I do it. I like to help people,” she said. The conversation continued for a bit. “People talk about quality of life. I don’t think it’s fair to say that you don’t want to do surgery because of the quality of life. Quality of life is something you make. For example, right now I pick up lots of call [24-hour shifts]. I do it because I am well compensated but, also, because it is good experience. I like to help people… I like having the cases [surgeries]… But, I won’t pick up call forever. Right now, it makes sense… It’s all about tradeoffs. You can work less and then you make less money… You can set the terms of your work,” she said.

As I left the hospital after my last day working with her, I thought about the surgeon I’d worked with. She was a calm and patient teacher – something that is rare. She had saved many lives. She had seen the inside of the body many times. Her hands could tell the difference between a fat glob and a cancer by feel alone. I’d seen her talking to patients with a patience you don’t find in all surgeons. I’d seen her interacting with all levels of hospital personal with a respect and kindness that was genuine. I’d heard her talk through her clinical reasoning; it was thorough. I’d seen her do surgery; she excelled. She was exactly what I’d call an excellent surgeon. I would have no hesitation sending my patients or family to her because I knew she’d treat them well and operate with precision. She was the first surgeon to go on my mental surgeon wall of fame. After that first day waiting outside her office, I’d decided to construct my own wall of fame (for surgeons and other types of physicians) because the one I’d seen in the hospital was outdated.

Autonomy In Medicine

Set Up

I’ve been thinking of patient autonomy and the humanness of physicians a lot recently. In my short time training to be a doctor, I’ve had many experiences that have brought these topics to light. Here are a few examples:

  • An attending physician told me he usually first recommends pills to women seeking birth control because he believes that women find it reassuring to have their period every month. Odd perspective as my experience as a woman is that some women find periods reassuring and many find them annoying. Odd perspective as my short time in his clinic showed implant and injectable birth control methods as the most common forms of birth control requested and used by patients. Odd perspective as research has shown LARC (which include implants and IUDs and NOT birth control pills) have greatly decreased unwanted pregnancies because they’ve removed the mishaps of having to remember to take a pill every day. Medicine is complex. It requires both keeping up with research and checking your personal beliefs at the door. The approach I’ve seen most physician take when discussing birth control is to outline the different available birth control options so patients can decide themselves which is best for them.  
  • I overheard an attending physician talking to a resident physician about a D&C they did recently. A D&C is a procedure that can either be used to end a pregnancy early on or clear a miscarriage that occurred early in pregnancy. The patient these physicians were discussing had the procedure to end pregnancy. The resident physician stated that she thought the patient was looking for validation from the attending physician for choosing to have the procedure. The attending physician shrugged. I (medical student) asked what the attending physician had told the patient. The attending physician said, “She doesn’t need to give me a reason for the D&C. I told her she doesn’t need to give me a reason to terminate the pregnancy.” I found this statement to be a powerful example of approaching medicine without imposing personal beliefs on a patient.
  • An attending physician walked out of a patient room and told me the patient’s problem was that she was naïve. This was his reaction to the patient (a pregnant woman) planning to visit friends/family in another city while in the third trimester of her pregnancy. The patient had gained too much weight during pregnancy. She also had high blood pressure at this appointment. When asked the patient described improving her diet. The physician laughed at her when she described eating salad. In self-defense, the patient then described eating very healthy-sounding salads. The patient’s trip would delay the follow up blood pressure reading the physician wanted by two days. The physician did not explain why he was concerned about hypertension specifically in the last weeks of pregnancy. I wondered why he didn’t recommend that the patient monitor her blood pressures with a home blood pressure cuff and bring in a log of her blood pressures when she was able to schedule her next appointment. It seemed the risk of delaying a blood pressure reading in the clinic by two days might be outweighed by the benefit of social support during the final weeks of pregnancy. I questioned the choice of “naïve” as his diagnosis. Why should she know about preeclampsia if he didn’t tell her? Naïve is a loaded term and isn’t one I’d be quick to use to describe a pregnant and uninsured woman with friends/family in multiple cities. Medicine is a team sport. Patients are the captains and physicians are the coaches. It’s important to remember that the patient is part of the team and that while they don’t bring medical knowledge, they do bring life knowledge.
  • The patient told the attending physician that they stopped their antipsychotic medications. The physician recommended that the patient continue taking their medications. The patient refused. The attending and the patient came up with a plan to watch for warning signs that the patient’s psychosis was returning. The patient continued to attend group therapy even though they stopped their medications. This allowed the group therapist to send a community crew out to the patient’s home to check on the patient when that patient showed psychotic behavior at the online group therapy session. The patient did not self-identify that their psychosis was returning. However, because they continued to attend group sessions they were still connected to care and were brought to the emergency room before their psychosis led to self-harm. I found this case an excellent example of a physician respecting autonomy while also trying to prevent serious health outcomes for her patient.

Reflection

Medical school, residency, and being a physician teach us to solve complex problems. They teach us the complexities of the human body and how to cure diseases and treat symptoms. They teach us to think critically and sift through data efficiently. They provide us with guidelines and treatment recommendations. But, medical school, residency, and practicing medicine don’t and can’t teach us the complexity of each patient. They can’t give us the ability to foresee the future or understand patients’ life goals better than patients do themselves. And, despite our great knowledge as physicians, we can’t (and will never) have all the answers. Despite extensive training, medical research, and detailed guidelines medicine is still decided by humans (yes, physicians are just humans) and is (therefore) based partly on intuition, experience, and practiced guessing.

In medicine we are fixated on being right. Our goal is to reduce suffering, cure disease, and help patients navigate illness. And while as doctors we strive to cure, as humans we know that life can be more complex than curing. As humans we know life is paired with death. As humans we know not all questions have an answer and not all problems have a solution (at least yet). And as humans we know that health, sickness, healing, recovery, pain, and death are individual experiences that share commonalities across individuals but (ultimately) are unique experiences that each person endures differently.

In my short time in the hospital, I’ve already observed patients losing their autonomy. I’ve seen patients’ wishes ignored and explanations of why skipped or glossed over. I’ve seen us (medical experts) angered when patients don’t follow all our recommendations, insulted when we’re asked why, and forceful that our way is the only right way. And I’ve seen patients suffer. I’ve seen patients suffer taking our recommendations and I’ve seen them suffer when they refused our recommendations. And while suffering seems to be a part of some points in all lives, it also seems that sometimes in addition to our patients suffering we (physicians) push our patients to accept a treatment plan that is discordant with their values and life goals. It seems sometimes that we add to suffering by piling on shame or judgement.

In medical school, in residency, and as physicians we are taught to find the truth and to be right and to be directive. We are taught to recommend the best medicine has to offer. Yet, the best options based on evidence are not always the best option for an individual patient. And even if they seem right, the best options are not foolproof. The best options are based on probabilities, percentages of effectiveness and likelihood of reducing disease or preventing further harm. Probabilities are helpful, but they are not certainties.   

I’ve been thinking of medical recommendations and patient autonomy and the humanness of doctors because medicine can be hierarchical. It can be rigid with the attending physician setting the law; a mix of other players like nurses, medical students, and resident physicians in the middle; and the patient disempowered.

There are more cases than I presented above that I’ve experience which illustrated the complexities of patient autonomy and the humanness of doctors. Medical school is a whirlwind of learning. What I’ve come to discover, however, is that all the learning isn’t strictly medical. I’m also learning how I’d like to conduct myself when I’m an independently practicing physician, the ethics of medicine, and the challenges of working in a field where the outcome is dependent on the efforts of all team members.

As I reflect on the hierarchy and the complexity of medicine, if I could hold one piece of advice for myself as my training continues it would be to ensure my understanding of medicine is excellent while also remembering that patients are autonomous individuals. This advice reminds me that my job is ultimately to help people navigate the complexities of health and illness. This advice acknowledges that patients can say “no” and that the “why” is just as important as the “right answer.” This advice helps me to remember that my patients and I are a team. And just as I can decline or refer a patient to another physician if I am not comfortable with a patient’s request, my patient can also decline my recommendations or seek the medical expertise of another.

Update from Labor and Delivery: Non-Surgical Edition

We worked to the rhythm of the fetal heartbeat, ticking along at 140 beats per minute.  We hadn’t met the baby yet, but the baby was getting ready to come out and greet our world.

The soon-to-be-mom wasn’t in as much pain as she had been last time I saw her. The epidural took the edge off her contractions. She could talk to us again and was even happy (albeit also tired).

The team got ready to start pushing. The contractions were the right distance apart and strong. The cervix was dilated to 10 centimeters. We explained the process of pushing the baby out – for each contraction she’d push 3 times, each for 10 seconds. While pushing she’d pull her knees out and back toward her ears because that opens up the pelvis and helps the baby fit through. The first contraction we practiced. Not many laboring humans get the pushing thing perfect on their first try. But, it didn’t take this soon-to-be-mom long to learn what to do.

Birth is trepidatious, exciting, and boring all at the same time. First there is a lot of wondering about how the whole process will go. Then there’s a lot of wondering what the baby will be like. Parents are excited to meet their child for the first time. From the health care perspective, there’s a lot of standing around. A lot of blood and mucus and other types of goop. The work comes in waves, as the contractions come and go. Between contractions the laboring human rests and the rest of us wait. It’s really all about the laboring human. The rest of us are just accessories and moral support. On this occasion, the soon-to-be-dad was a great team member. He was encouraging without being overbearing. He was engaged without hovering. The support people the laboring human brings with them aren’t always that good, but you’d be stressed too if your partner was doing all the work and all you could do was stand by waiting.   

This soon-to-be-mom tapped her tummy and sang to her baby in between contractions. She had made up a song for the baby that involved the baby’s name. She told us she had spoken to the baby throughout her pregnancy. She explained that she had told the baby when they were eating. She told us that the baby knew that they ate yogurt every day at 2:30 pm.

The soon-to-be-mom worked hard when the contractions came. The baby moved down the birth canal. As the baby came closer to meeting us, the soon-to-be-mom became more uncomfortable. If you’ve had a baby via vaginal birth you might know what the pressure of a baby’s head is like as it makes its way out – the rest of us can just imagine. The soon-to-be-mom had a good epidural, but it didn’t’ take away the pressure of the baby’s head. It didn’t take away the pain that came with tissues stretching.

We saw the baby’s hair for many minutes before we saw the baby’s head. Head then shoulders and then the rest. I helped deliver the placenta – best described as a warm squishy sac.

The baby cried upon entering our world, a sign of lungs waking up. The baby started covered in white wax and slightly gray, but soon turned pink. The baby snuggled up on the mom’s chest. The baby was perfect, as all babies are. All babies are both perfect and look like aliens if you ask me. Regardless of babies’ alienness, you still tell the parents congratulations on having their baby (this is very important).

Mom rested. She then sang the baby’s song. Once the placenta came out, we made sure the bleeding stopped. We made sure any tears (they’re common apparently) were sewed up. The obstetricians tell me vaginal tissue heals quickly. Life is a curious thing, especially the beginning and the end.

Mom and dad were lost in staring at their baby as we cleaned up mom. The nurses made little ink baby footprints on a certificate for the parents and on hospital paperwork. They took baby’s vital signs – baby was doing well with its itsy-bitsy everything.

We left their room. Time to return to our station. Many little hearts running between 110 and 160 beats per minute bopped along on our monitors counting down the hours until their parents got to meet the baby they’d made. We joke that labor and delivery is the only floor in the hospital were pain is a good thing, only because it means that it might be time to have a baby.

Birth is trepidatious, exciting, and boring all at the same time. I’ve seen the toughest cry at the sight of their child. I’ve seen smiles and laughter and looks of amazement and terror at being a new parent. And I’ve only been on labor and delivery for a few weeks. Imagine what it’s like to make a career of helping people bring their babies into the world.

The Psychiatric Rotation

Disclosure: The patient story here was written with a patient I saw in mind, but the details have been changed to protect anonymity. The story is reflective of many patients I saw during my psych rotation and while working in the ED. You will note that I chose nonbinary pronouns. This is because brain illnesses (just like many illnesses of other organs) set in regardless of gender. Brain diseases, like many other diseases, are related to genetics, life experiences, and other social and environmental factors. A tricky aspect about brain diseases is that we aren’t exactly sure how most of them develop and we are quite far from having a cure.

I looked down at them lying on the stretcher in an ED bed. They were snoring quietly, and their face was neatly framed by their hair. Their eyes were closed, and they looked peaceful. I didn’t have much time to ponder the full circle that this scene represented and the eerie foreshadowing of the end of my psych rotation. They had received the magic 5-2, 5mg Haldol and 2 mg Ativan. Haldol is an antipsychotic that is sedating and Ativan a benzo that’s also sedating. In other words, the patient was chemically restrained. Put again, they were put to sleep for a short time to end their psychosis. And a scary psychosis it must have been as it was filled with delusions of people hurting them and murdering children. We shall call this patient The Singer.

I’d seen The Singer awake and stable during the first few days of my psychiatry rotation, weeks before I saw them sedated. When I first met them, they were being discharged from the psychiatric inpatient unit of the hospital. They’d been in the hospital for weeks. They’d been restrained many times. They’d spent a good chunk of their stay believing the hospital staff were hurting them. When I met them, they didn’t have those delusions. They were looking forward to finishing a song they’d started writing before entering the hospital. They were looking forward to going back to their job and were inspired to possibly start biking again. They were discharged from inpatient to home with quetiapine and an intensive outpatient treatment plan (dialectic behavioral therapy group sessions). Quetiapine is an antipsychotic. Did you know most drugs in its class are effective about 20%-50% of the time? That’s not a passing test grade. But, then again, 20% of patients helped is better than zero. And, of course, medications only have a chance of working if you take them.

As my psychiatry rotation marched along, I changed from inpatient psychiatry to outpatient psychiatry. I’d see The Singer in the outpatient setting too. I observed their dialectic behavioral therapy session (group therapy focused on developing social skills and strategies to manage emotions). I interviewed them at their medication follow-up meeting. At that meeting, they told us they’d stopped their quetiapine. They didn’t want to take it. They didn’t like it. We could not and were not going to force The Singer to take their medication. They complained about not being themselves when taking the medication. I couldn’t blame them because quetiapine is sedating and does sometimes make people feel flat, emotionless. The psychiatrist counseled The Singer on looking for signs that they might be slipping into psychosis again. The Singer identified not sleeping as one of the triggering factors. I worried for them. I worried their delusions would return if they weren’t on quetiapine.

After outpatient psychiatry, I transitioned to the consult service which determines if patients in the ED need psychiatric hospital admission and provides psychiatric evaluation of patients anywhere in the hospital. I was with the consult service when I saw the sedated version of The Singer in the ED. The Singer had been sedated because they were not safe. Their delusions of rape had returned. They were agitated and not taking care of themselves. They were making risky decisions. We hoped to help them by admitting them to the hospital.

I knew The Singer was a musician because the ED was the third setting in which I’d seen them; the first time I met them, they told me they were a singer.  I knew their living situation and their hobbies because I’d talked to them about them. I knew why they had stopped taking their medications and I knew that part of the reason their psychosis had returned was because they’d stopped taking quetiapine. After leaving their ED room, I drafted the psychiatry consult note that would be a record used as justification for involuntarily admission to the hospital for stabilization. We’d come full circle, The Singer and I. I started my time on psychiatry with them being discharged from inpatient treatment and I was ending my rotation with them being admitted again to inpatient treatment. Same cause. Similar presentation as last time. Had we made progress? How many times would The Singer repeat this cycle? I reflected on the fact that chronic illnesses are just that, a chronic struggle to be well. A chronic ebb and flow of good and bad days.

The ED consult note I wrote about The Singer was the first psychiatry note where I left the mental status blank and simply said they were chemically restrained at the time of consult. The mental status is the bulk of a psychiatry note. It’s where you summarize a patient’s emotions, thoughts, words, and behavior. A psychiatry note without a mental status exam is quite limited. Psychiatry is about talking to patients to understand their feelings, thoughts, and emotions. It is almost impossible to evaluate for feelings, thoughts, and emotions if you can’t or don’t speak to a patient. Sure, when patients aren’t sedated, you can observe them or try to use writing or sign if you can’t speak to them formally. But, talking is the core of psychiatry. Psychiatry is the one field of medicine that does not forget to ask the patient’s opinion. I reflected on that bit. It reminded me of the key lesson I hoped to remember on future rotations when time was crunched and my patience strained – you have to talk to patients in order to know their thoughts and story. It may sound simple. Perhaps it is. Perhaps the pile of labs and medications and interventions that occur in the hospital make it difficult to always remember that patients are people who got sick. The sickness doesn’t remove the fact that they might be a singer or a biker, it just adds another layer to them as a person. Seems straightforward. We’ll if it remains straightforward at the end of a 13-plus hour shift on surgery.

Medicine of the Mind

“It’s a privilege to learn their stories…really get to know people,” he said when I asked for his nugget of advice for us students as we continue our medical school journey. “In what time you think you have, try to know them [patients]…exercise your privilege.” Before we get into the weeds, let me clarify what he meant as this quote is just a piece of a longer conversation. By “privilege” he meant the honor of getting to meet patients and having the opportunity to hear their stories. By “exercise” he meant take the time to be a good doctor which includes getting to know people’s stories.

This piece of advice came from a retired psychiatrist who, as rumor has it, retired several times and each time his patients convinced him to come back to practice. The way he carried himself reminded me of my late grandfather – tall but not imposing, with straight white hair that covered just enough of his forehead, and a quiet voice. But more than how he carried himself, his curiosity caught my attention. He was an old human, an old physician at that, who the week before he gave the above advice had comfortably engaged in conversation about pronouns and transgender care. He was a physician who listened to learn when I offered a rudimentary definition of “nonbinary.” I’ve met many a young person, with far fewer years to settle into old ways, who showed less interest in uncovering the nuances of the human experience.

“Really get to know people.” His words made me hopeful because they showed that even at the end of a long career there are physicians who still have a passion for the human story as much as I do at the beginning of the Doctorhood Quest. Being only 5 weeks into working in the hospital as a medical student, I have a long way to go before I can offer advice to students. But, for now, challenge accepted good sir. Let’s see how I do in the coming weeks and years at uncovering stories while also learning labs, diseases, medications, and all the other factoids that will help me reduce symptoms and cure disease in the patients I see.