Gold Plated Mercedes

I spent today in surgery. 95% of this time was anus-related. When my preceptor left for clinic and handed me off to another surgeon, he looked at her next case on the board and said with a smile, "Oh, this can be your butt day!"

Among the lower GI tract things I saw was a colonoscopy preceding another operation. It was the first time that I've experienced the amazingness of all that gas they pump in you coming back out again. W.O.W. My wife and her brother on their worst days combined could not rival those amazing sounds. The human body does not cease to amaze.

But I digress. As the title suggests, what was most on my mind today was this other aspect of life in surgery: money and prestige. The dear safety-net hospital where I'm spending my third year is not exactly a hotbed of stereotypical egomaniac fancy-car surgeons. The attendings are by and large nice, even if their unanticipated questions can be scary, and with few exceptions actually seem to realize that they treat human beings rather than body parts.

But our residents are not from the dear little hospital. Indeed they are not. Now we've had nice residents, residents who like to teach, residents who send you home when they can. And we've had grouchy residents, apathetic residents, residents who say nasty things about patients or the medicine team. But before today I hadn't hung out with a cares more about money than people resident.

His reputation preceded him, having told my classmates that a gold-plated Mereceds was in his future. Needless to say, I went in with some trepidation, but I was still thoroughly dumbstruck. First I was put off when he returned from a consult saying "that patient was being an idiot so I had to put a nasogastric tube in him." Which is not only crappy and dehumanizing, it doesn't even make sense. Then, while closing up after a gall bladder surgery, he started telling me how he's really not sure what kind of surgeon he wants to be yet.

Him: I mean, realistically, you have to think of the money. The way things are going, you have to go into something you can count on. Really plastics is the only thing that makes sense.

I try to figure out what to say to him. Something like, "I'm pretty sure that all full-time surgeons are wealthy by any reasonable measure," might have been appropriate.

Him: But I really value being the best, and the best surgeons are really the transplant surgeons.

This sounded somewhat better to me... I mean even if he doesn't care too much about patients, I appreciate that he cares about doing a good job. But, of course, before I could say anything...

Him: But you know, different kinds of people need transplants. There's just no money in it, you end up having to take care of all these people without insurance and poor people.

So much for medicine being a service profession. This is when I was wishing that thinking, suturing, and speaking weren't so hard to do all at once.

Him: Or I could do GI. It's just a one-year fellowship so I could be making money right away. But you have to be on call. Really nothing makes as much sense as plastics. Even if Obama screws up health care more and reimbursement falls off, you can just do more cosmetic cases.

At this point I was in full-on medical anthropologist mode, taking mental notes on how not to be. Plus it was about his third nonsensical Obama dig of the morning, but in the moment I was more fascinated (car-wreck style) than pissed.

I'm not sure what bothers me more, that he seems to be more interested in money than patient care, or that he's so blatant about it. It's been said time and again, that going into medicine for money just doesn't make sense. Getting into a to business program is a much better return on investment by far. That knowledge just serves to piss me off further that people take up room in medical schools and competitive training programs when their end goal could be better served elsewhere and their spot could be filled by someone who wants to make peoples' lives better. When you have that value set, money over people, becoming a doctor strikes me as a cover. You can be an ass, but still get some social cred for doing good.

Not to mention that the idea of wanting a gold-plated Mercedes is totally outside my understanding of reality. I am more effected by the consumer culture than I would like to be, but I can still recognize that money and stuff won't actually buy me contentment. Money doesn't buy happiness, we know this. It seems like someone steeped in the culture of evidence-based medicine ought to delve into some sociology research and reexamine life choices.



Through an incredible giftfromthegods type fluke, four of my outpatient clinic preceptors are on vacation this week, leaving holes in my schedule that even our incredible schedule populating program coordinator couldn't fill completely. What this means is that not only am I left with very few items on my "to-do right now" list, but also when an elderly patient I was on the phone with asked "couldn't you just come over?" I actually could.

For the people who know me and don't think of me as "shy," it might surprise you to learn that there are some things that indeed I am shy about. Visiting an old person in chronic pain at their apartment isn't exactly in my comfort zone. But much like cold calls to hospitals I've never seen and patients I've only met for 10 minutes, I'm trying to build a new comfort zone.

She lives in one of the many high-rises for older folks in the area, a drab construction with a surprisingly difficult to find front door. I managed to navigate the elevator conversation and complicated door-knocker situation. She steered her walker to the door to let me in, smiled to see me, and launched into a description of her current symptoms. She's feisty, but trapped in a cycle of chronic pain, with ever elusive solution. We talked for an hour, mostly restating the same problems differently. We made sure she had the right phone numbers to call for appointments and I cut some of her pills in half. In the end, we left with the same conclusions as the previous conversations we've had over the past two weeks. But if her resolve has moved only by inches, my ease of stepping across bounds I never saw before is growing by miles.

When I was a girl scout, I absolutely dreaded cookie drop off. Once the mountain was piled in our living room, it meant I had to call everyone I had sold cookies to, even my parents' co-workers, to tell them they were ready to be delivered. I can still feel the sense of cold foreboding that would fill my belly as my mother complacently handed me the phone. But these days my to-do list is increasingly filled by "call..." at first these were suggestions from others, but now I've found how easy it is to say "how about if I just call That One Clinic and find out what they think the plan is..." or whatever it may be. And it's not hard anymore.

For some people, it's over-stepping social bounds like touching others' naked bodies that really jar the ingrained sense of normal. For others it's asking deeply personal questions, talking about death or even just poop. We all have barriers in taking on this doctorish role. Today made me realize how much having assumed this new role has given me this space where pushing past my own fears is so much easier.


Change You

Back during the first weeks of med school last year, there was much talk of how medical education "changes you." It is something I still feel many ways about.

I can embrace being changed, when I view it as a sort of "change lite." This is the process of expanding knowledge of human function, emotion and disease, growing manual and relational skills. The most significant one here is control of affect, learning to convey empathy while withholding disgust, devastation, fear, etc.

The real change, though, the one that many seem to undergo in medical education, is one that I want to avoid. This is the evolution from to someone who doesn't just suppress emotions in front of patients until they can be experienced safely but who no longer feels many things. It is the process of replacing human patients with bodies and disease processes. I have been told that I cannot continue to feel the normal sadness I would have felt two years ago upon learning of the cancer diagnosis of an acquaintance or friend's child and survive in this profession. But I want to continue to believe that that isn't true. I think that these emotions are at the foundation of true empathy. There are these moments, when day after day of memorizing disease names and processes out of textbooks without attachment to the real people's live they impact, that I see that staying connected to my former self will require vigilance.

Last week, I sat with some students and a preceptor as we watched a video of a patient relating the devastating story of losing one of her twins in utero. As she spoke, I fought back tears, telling myself it wasn't the place. At the same time, a nagging fear crept up in me. If this wasn't an OK time to demonstrate sadness as a medical professional, when was? But as the clip ended, I turned around to see my instructor, suit-and-tie clad man in his 50s, had made no such effort at self-restraint. He audibly sniffed and tears tracked down both cheeks as he turned to us to open the discussion.


Being a Doctor=Not Gay Disneyland

Shall we resurrect this blog? Indeed.

Tonight the LGBT student group at ye' olde med school hosted an "Out in Medicine" panel. It featured several faculty members who direct courses or lecture in the clinical years in addition to attendings and a resident. The ranged both in age and medical interest. They shared anecdotes and insights and answered questions. It was, among other things, good to remind myself that we are a plentiful enough bunch. Though this bunch had primarily spent time in the "Gay Disneylands" of Boston, San Fran and LA, they carried experiences from many kinds of environments.

It was, on the whole, an optimistic evening. All have had the luck of good careers and supportive colleagues. It is generally agreed that medicine is at least perceived as a conservative institution. That perception is all too often a reflection of reality and is one piece of the root of disparities in health care quality for LGBT people. Even so, it really isn't my colleagues in medicine that I worry about being accepted by. One can choose colleagues. Though it may be hard to really understand the culture of a hospital or practice before you get there, some insight can certainly be gleaned and changing jobs is not impossible. What I worry about, are homophobic patients and my own emotional resilience.

As a second-year student, I am not yet tasked with any real responsibility for patients' health. Every Wednesday, I meet with bored patients in the hospital and practice taking a medical history and performing a physical exam. My instructors grade presentations and patient notes that I write, but no one who actually cares for those folks will ever see my work. This is strictly practice and principally for my own benefit.

Several weeks ago, I interviewed an elderly gentleman. As he began to relate some of his health history to me, the middle-aged daughter of his roommate said good-bye to her father and headed home. Not five seconds after she closed the door behind her, this fellow smacked his hand down on the table and said "Well, let me tell you about that one." He went on to relate to me, in melodramatically shocked tones, that his roommate's daughter was gay, and had come to visit with her "girlfriend, or boyfriend or whatever they call it." What followed was the longest homophobic tirade I've been subjected to since being harassed by passers-by while protesting "Don't Ask, Don't Tell" in Times Square a few years ago.

And I absolutely did not know what to do. Though I subject myself to hearing such things in the news, I have been blessed to generally avoid similar confrontations in my personal life. I know that in this moment I maintained a pretty flat affect, and inwardly I laughed that laugh of dark humor and discomfort. For days I blew it off as unimportant, but the more times I shared the story with friends, the more I realized how much it had affected me emotionally.

So tonight, I went to this panel with just one question: what do you do about homophobic patients. Not the ones who don't want to see you if they know you are gay, the ones who do see you, whether they know or not. And the answer was what it so often is in this field: self-sacrifice. Redirect to the task at hand, point out that whatever they are saying, be it homophobic, racist, sexist, is not what we are talking about right now. "Maybe, just maybe, and only after much later," I was advised, you will be able to address it in the future when you have an established relationship. This is a hard pill to swallow. For years, I have embraced being visibly out and I have worked to find ways to call out homophobic speech and attitudes in those around me. And after all that, it's hard to accept the idea of anything other than a direct confrontation of homophobia. But, things are changing in my life. The best health care I can deliver, that is becoming my new goal. Now, to complicate that a little bit, I am stuck on the knowledge that inequality, discrimination and disparities are all detractors from the positive health of our community. Part of me thinks that in confronting such attitudes in patients, doctors can do positive work. Yet the more time I spend with physicians I respect and their patients, the more I come to understand that the doctor-patient relationship can be a delicate thing. And it seems unlikely that any such positive work could be done in the moment or on a first encounter. The resident on the panel seemed, to me, most astute: treat the tirade as information. People at the doctor, especially in urgent situations, are vulnerable. This can bring out many things, including the worst of people. He suggested that an impulse to change that person's mind in the moment is more for you than the patient. The information you have learned can help you care for this patient.

So I asked myself, "am I obligated to treat homophobic patients?" And I wasn't sure. So I asked myself a moral extreme: "Am I obligated to treat murderers?" Yes, I really think that I am.


I Love My Friends

When I was figuring out where to go to school, something that HMS students kept saying was that their classmates were the best part of medical school. Even so, I was pretty wary of who my partners in medical education would be. Until I met E, who has indeed become one of my best friends, at revisit weekend, I didn't click with a single person connected to this school. So I really just didn't expect to really get close to people I met in med school. Maybe because I have continued to be at least some what suspicious about my own reasons for going into this field, I was just kind of suspicious about my classmates.

But my fears were largely unfounded and not only have I met a diversity of genuine and down to earth people, I have made incredibly good friends. It's exciting, even after a year, to be still getting to know these people better, but already trusting and loving them. I'm feeling particularly gushy right now because we just had this fabulous bonding weekend. Four of my friends came out to our house yesterday for a perfect day of peach picking, swimming in the lake and incredible barbecuing. We ate tons of veggies: peppers, onions, sweet potatoes, mushrooms, tomatoes, with breaded tofu, and chicken sausage. Plus home-made guac and a fantastic peach cobbler for dessert. Icing on the cake is that these friends helped to clean up.

Then, because we are super-cool medical students, we cleared the table and returned with cups of tea and our weekend take-home quiz. Hey, who doesn't like some scintillating saturday night group study? After having our fill of that lovely activity, we talked into the night over cups of decaf and delish liquor provided by K and then had PJ cuddle time and a sleep over. This morning was pancakes followed by dance party to late 90's pop and then I sadly escorted them out the door. Partly it was just wonderful to get to seem them outside of school.

Sigh. I love my friends.


My Friends Just Can't Stay Out of the News

Maybe I would be in the news too if I didn't come home to walk my dog after school instead of rabble rousing all the time. Anyway, go them! Maybe it will make Howard Brody blog about the hallowed institution again.


In The Thick of It

Seems like if I don't have a headache from too little caffeine, I have one from being dehydrated. And despite my best efforts over the summer and sticking to half decaf in the morning. Here I sit, jittery, headached, sleepy. And content.

It's days like today that make me look ahead to May and the beginning of my full-time clerkships and think "Dear golly, we have got to move into the city." It's the having such an abundance of work and commitments that I can't get home to see Lion before she's gone off for the evening that gets to me, and all I want is for us to live blocks from everything that takes us out of the house.

But then, I bike home from the train station through my wooded neighborhood. Harriet greets me with excited tail thumping and we run upstairs to the yard. There I discover that our lovely neighbors/landlords have gone to the trouble of installing for us a fantastic pulley-style clothesline to replace the one that I hastily stuck up in the shade without thinking twice eight months ago. And wonder how we'll ever bear to leave. There may be short commutes in Boston. There may be more action and there could even be other nice neighbors to be had. But there are not our neighbors. There are not our woods and our yard. Our house is not there. I only have eight more months before my schedule burgeons out of control, and I can't fathom that that could be enough time for us in what has become such a home.