On Death

Sorry, it's a long one...

My first patient was a gaunt and scruffy man in his fifties. Six medical students and three physicians crowded into his hospital room. We watched as one of our preceptors demonstrated the patient interview, asking the open-ended questions we would learn to emulate, expressing empathy, finding points of connection to this man’s life. He answered each with an affect so flat he seemed less than human. A nearly imperceptible moment of anger, a half smile to acknowledge enthusiasm for the Sox, these were the windows into his emotional life. The medical details of his case hardly mattered, advanced cancer, failures of compliance. After the interview we speculated on his personality, his attitude around his illness, the effectiveness of the interview strategy. And that night I summarized him into three boxes, chief complaint, history of present illness, and the more amorphous “patient as a person,” a place holder for more boxes to come. A few weeks later, debating the relative utility of silent pauses, clarifying language or casual posture that first interview came up again. As the conversation turned, our preceptor said casually, “He died, by the way.”
Months later, an unusual afternoon left me alone in for over an hour with a vibrant woman in her eighties. If one thing has become clear, it is that all lives that long carry some burden of personal tragedy. She spoke with zest, and a warmth that conveyed gratitude, about her work as an artist. She countered each mention of her illness with the assertion that she had lived a full life, that she had been lucky. When she stated that she would be dying, “maybe not the day after tomorrow, but three days, I think,” it was matter-of-fact. She seemed the picture of a perfect death, beyond denial, grateful for a life well lived. Two weeks later, I saw her again, being wheeled by slowly in the hallway. I greeted her, smiling to this women I now felt I knew so well. She had further thinned and paled. She did not acknowledge me, her eyes focused somewhere beyond the tangibles around us. Then again I saw her, still not dead, two weeks after that being taken from the lobby. This time I made no effort to say hello. She clutched at the thin blanket gathered around her legs, somehow appearing wholly gathered into herself.
“You can’t ask a person that when they’re dying.” He said in response to only my second question: “How are you coping?” My first, the standard “What brought you to the hospital?” he had answered with: “Well, I’m dying.” This was only a few weeks ago. I put my pen and notepad away. It is obvious that no one life, or “history” as we like to call it, can fit into the neatly categorized summary we have learned to create. But he in particular seemed uninterested in leading me through any discussion that would translate to a standard write-up. I have started interviews with patients who did not want to talk to me, and seen others do the same. These end fairly quickly and we move on to someone more willing. But this fellow resisted my questions, but not my presence. He was quick both to anger and apology. “How can you ask me about my family?” he would ask. “You do right all your life and then out of no where… how did I deserve this?” And then, “I’m being rude. I know. I shouldn’t be rude.”
Death may have much more to do with why I am in medical school than life. Not for the heroism that apparently medical students as a group tend to misperceive as their destiny, but for the experience. The sheer, visceral stimulus of standing nearby death. Yes, I hope to be part of keeping those not ready from the edge. Maybe it is our overly virtual existence or a sheltered first-world life, but there seemed to me to be something about death coming home. I saw it as a great and palpable event, the one thing that can fully remind us that we are alive.
And yet, death has not been what it seemed. Even to death, I begin to apply one-word labels. My first patient: denial. The second I mentioned: acceptance. The third: anger. But how could it be that that first petite, dull-faced man could both ignore the inevitable and then pass so casually? His death merited a mention but no fanfare. Looking back at my notes from this first interview it is barely noted that his cancer “was now considered terminal.” Here it was, September 18th, and I had already become steeled against even noticing that the person in front of me was actually going to die. I am no weak chicken. I don’t think that I needed to put up an emotional wall against such reality. And I don’t that’s necessarily what was happening either. I think I just didn’t know what death might look like. My grandfather died when I was sixteen. We were very close and my tight-knit family responded only as our irreverent selves could. We cried, laughed, hugged each other and found ways to remember. Anger and outright denial, while not a response I’ve experienced personally, still seem to me emotions fitting for the profound nature of death. And so from this first man I learned that death can be profound but it can also be blasé. That this man’s life, while it surely mattered greatly to him and to others, had reached a point where it did not need to matter to me.
My second patient seemed at first to be the picture of a respectable death, a life well lived. She expressed messy regrets that humanized her so completely. On what she named her deathbed she related to me her life story, her medical history only an aside. I felt a real connection with her. But she was not dying, not imminently. Her physician in the hallway suggested that she had months if not years, not days. I still don’t know what this can mean. The common knowledge is that people know themselves, that like cats who supposedly find somewhere warm to curl up when their time has come, the elderly make peace and bed down. Did her seeming readiness to go and surety that death was near make her suicidal? Certainly not, but what was it? And what could be the meaning of her blankness in the next weeks? Perhaps she and her physician were both wrong, and I just can’t know what she is really experiencing.
The angry man was the first patient who came close to my expected experience. While he began the interview with mostly quiet two-word responses, his anger showed through and became increasingly more articulate. And finally he turned the tables: “How would you deal with this situation?” I dodged and returned the question to him, but he called me out and threw it back. I still dodged, saying what I do now know, that “death is different for everyone.” And then, “how can I know what it will be like before I am there?” But what I really wanted to say to, and perhaps could have albeit stated more carefully was this, “I would be a hell of a lot better at this than you are. I would do what I could with the time I had left.” And that would be true, even with the details of his story that render his anger so justified. I would be inspirational, but now I’m not so sure that I wouldn’t also be full of it.
When he first told me I could not ask my questions of a man on his deathbed, I was not nervous or uneasy or excited. I was interested. I would have spoken with him for hours. I never wrote-up that interview. I never asked for his HPI beyond “cancer.” I don’t know what CC brought him in that week. The details on his social history are sketchy and tragic. He brought home to me that there are so very many things that I do not yet and cannot yet know about myself. He showed me that try as I might, there are also many things that I will not understand about others. But he did not ask me to leave, and I left his room with the clear sense that it still makes sense to try.

I DID IT I DID IT

I finally cleaned out my email inbox! OMG this has been weighing down on my for maybe two months. So totally absurd that I could be weighed down by my email inbox, but true nonetheless! As my number of unread emails bounced between 200 and 400 I was starting to go slowly insane and constantly anxious that those messages held important information that I was just simply ignoring.

In the end, I didn't miss much by reading only the subject lines. After a valiant struggle, I have zero unread emails. ZERO.

Ok, whoa. I got two emails while writing that short paragraph (see why this is so hard for me??). I have now dealt with those two emails and I am back to zero. WHEW.

In other news: I finished our wedding invitations today. For whatever reason we have ended up sending them out in waves as we finished gluing them together. The final batch is enveloped and stamped. Another huge weight off of our shoulders. To be totally fair and with the giving credit where it's due stuff: Lion did the vast majority of the work.

It is always amazing to me how good it feels to accomplish tasks you've been putting off. Why is it that I can be smart at some things and yet rendered so miserable by procrastination?

Similarly, there are about 100 pairs of scrubs bound for a medical school in Nepal currently hanging on my clothesline. When was I supposed to get those washed? Hmmm.... December?

Medical School? Check.

I finally began feel like I am in medical school about six weeks ago. Before that I had certainly felt like I was in school. Make no mistake, there was a lots of studying and a veritable mountain of molecule names and body parts to commit to memory.

In terms of intellectual stimulus, the whole thing had been underwhelming. Intellectually hard, yes, by nature of the sheer and insurmountable volume of information to commit to memory, but infrequently inspiring in an academic sense.

And then came physiology. I should have known that I would like it. The physicsesque prefix, the geeky "ology" suffix all added up to the most fun version of "The Way Things Work" I've engaged in. Unlike tinkering with my bike or pulling apart old telephones, considering physiology was about the machine that is always with me. Though a lot of the inner workings were what you can't see, things like respiration and heart rate I could feel in myself. Suddenly I was reading notes on the train with one finger on my carotid and holding my breath or thinking about the catecholamine release and resultant speeding of my heart brought on a sudden blaring announcement over the loud-speaker. There was just something about it. Like the inside of a clock, it's just plain neat.

Physiology came as a relief to my overly self-analytical self. A relief to the constant question: should I be doing this? I haven't wondered if I really want to take care of patients, to be involved in the nitty-gritty of people's lives at their moments of encountering illness, life and death, in solving the puzzle of maintaining their own health. Each Wednesday afternoon we tromp out to one of the myriad of hospitals in this flagship city of health care to practice our patient interview skills. In those moments, the act of doctoring has clearly presented itself as a good path. But here I was, months into school, and I kept thinking "didn't I used to really dig science, too?" It's OK, I believe now, that cell biology, molecular biology and anatomy, weren't awe-inspiring to me. The study of how our body works on a macro scale has the most clear relevance to the practice of medicine, and so I was thrilled that I liked it the best. The last month we've sauntered into immunology and pathology. Though In some ways a step back into molecule hell and the tyranny of three letter acronyms, it is made up for by the fact that we are now learning about diseases. And diseases always feel relevant.

NAME THAT CLOUD

That's right, everyone, this is what I was actually doing when I told Lion on the phone that I was "studying."



How much do I rock?

Dear Mr. Obama: We're Still Hurting

At this moment I wish very sincerely that Barack Obama could have felt the way I did on election night. I don't now believe that he has any real understanding of what it meant for LGBT Americans, so many of whom worked tirelessly to put him in office, to watch the passage of Prop 8 in California. To see not just rights denied as in the many other states that have passed similar measures, but rights taken away from those to whom they had been granted, that was just crushing. We are still licking our wounds, even those of us who watched from across the country unable to do much more than send a bit out a medical student's living allowance to help the cause. If anyone reading this wants to get a better sense of that pain, go over to Lesbian Dad and read pretty much any entry from the last three months. And so, to choose Rick Warren to speak at your inauguration in the name of inclusion, just pretty much redoubles the pain we had barely begun to heal from. Why is it so important to include those who campaigned against Obama, but not those who worked for him? It is NOT OK for Rick Warren, a man who has equated Lion's and my upcoming wedding to a grown man marrying a child, to speak at inauguration, I don't care how eloquently the man talks about climate change. Look, I know that Obama doesn't openly support gay marriage and he hasn't been awesome on all of the the LGBT issues, but he opposed Prop 8 so it's not like this man is representative of his position. We are still hurting, Mr. Obama. It was disappointing enough for you to tease us with the possible appointment of a lesbian for labor secretary, but please don't give a national microphone to someone working to invalidate my life. DAMMIT. It's personal.

I guess what matters is that people who think with Warren hold a great deal of power in this country.

For some good analysis, see Bilerico, Pam's House Blend,

New Arguments

At this point in the game, I am sometimes shocked when I discover a new argument for gay rights or any other position I've been engaged in mulling over for some time. After many years as Captain Gay of many a gay club, and far too much blog reading it's just not expected. And of all sources, I hardly expected it to come from Jon Stewart. In the video below, which I stumbled across via feminsting, he takes on Mike Huckabee on same-sex marriage. Most of the discussion is old-hat, though interesting to hear played out face-to-face. What struck me was the point that Jon makes that one is much more likely to choose their religion than to be gay and that we protect people's religious practice as a right.

The Daily Show With Jon StewartM - Th 11p / 10c

Mike Huckabee Pt. 2

Barack Obama Interview
John McCain Interview

Sarah Palin Video
Funny Election Video

Now, I'm not really one for the "is it a choice or not" debate. A good liberal arts grad knows that the answer is unlikely to be either/or but rather both/and. BUT I often hear that things such as sexual orientation and gender identity do not deserve to be protected classes because one can't prove them to be inborn and unchangeable in the same way that skin color is largely inborn and unchangeable. While I've always rejected the premise of the argument that rights ought to be doled out on the basis of provably inborn and unchangeable-ness it never plum occurred to me that one could counter that so very simply and elegant with the example of religious choice. Holy rebuttal, batman!

Moms and Forgetting

Something adorably funny and oh-so-typical for our family happened to my mother this week. Dad reports in smatters:

“[My Mom] was doing an on-line recertification quiz late last night. It was one of those things where they ask you the question, immediately tell you if you’re wrong, and if so, they give you references to the right answer. She got one wrong and looked at the reference. It was a paper she had co-authored herself.”

Oh, the comfort I draw from such stories!

I’m just going to get it out there: I have a horrific and unreasonable Mommy complex.

1. I antagonize my mother at strange times for no significant reason.
2. I love, respect, ask for, value and am interested by her advice. And yet I am unthinkably skeptical the moment she offers it.
3. I am afraid that she’ll direct my choices for me even though she’s always encouraged me to be strong and independent (see 2).
4. I am afraid that I’ll become her, because we went to the same prep school and did some of the same things and now I’m in med school and interested in basically the same field of practice that she’s in. I’m worried that I choose these things because I already know what they look like from watching her, not because they are what I really want. At the same time I'm afraid I can't live up to her.

What’s crazy about being worried about being so much like her is that she is awesome as a role model and a mom. She is awesome in all ways! I mean, she is actually the kind of person that I do want to be. She is a great doctor. She’s very well respected in the community where I grew up as well as in her field. In fact, I had no clue how impressive and unusual her practice was before I started med school. She is a family physician who provides a huge range of care even beyond what the majority in her field do, such as c-sections. When I tell my classmates about her, they usually respond with “I had no idea that was even possible!” For the most part I’m probably more worried about living up to her example than anything else. This is why my dad's story is so awesomely comforting. I have always thought that I learned things best when I had to really articulate them to someone else. Thankfully, the educational method at this med school of mine makes me do that quite a bit. Hence, it has been really frustrating to realize that I can explain something quite well to a friend and then see it on an exam a week later and not really remember what it was. Knowing that not only do my mom and I share an amazing ability to underestimate how long things will take, over schedule, forget meetings, leave important items in restaurants/on trains, double-schedule, repeat conversations we’ve already had… but we also share the awesome ability to forget information we taught to others.