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.

That paler side of leaves

Here, this week, leaves all around me are turning over. That duller underside is maybe something special, but less pretty and harder to like. School. Once again, I am passing my days (oh, such long, long days) in a lecture hall. Two weeks ago I could barely catch my breath as I watched the end of summer, my last summer off ever in my life, whiz by at acela express train speed. The thing about school is that I know it is good. And there are lovely friends around me, who make it really quite easy to slide back in and feel right about the world.

Rolling down the last hill into the Sharon train station each morning last week on my bicycle did wonders for spirits. So did that first sip of coffee from my most perfect travel mug. And lunch with friends in the grass of the quad. (Question for the group: What is your favorite part of medical school? Easily agreed upon answer: Recess!)

I think that it is just good to feel grounded. To have plans and routine. I am, as they say, on top of things. That is about the newest leaf I could ask for. Being not super stressed is a priority for me in medical school. Not least of all because stress wrecks havoc on my ability to interact usefully with the important folk in my life, and being mean to Lion is not on the list of "things that are OK." Last year my approach to being stress-minimal was to not worry about things very much re: school. I'm going to say that I squeezed by just fine with that attitude. My Pass/fail classes were passed and I managed to "bring it" for the ones I considered most important. But I'm not sure that I can approach the coming year with the same surfer dude type approach. So I am turning over that leaf to it's matte green underbelly. Dull, but satisfying.

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.