Archive for December, 2008

Knowing Too Much/Not Enough

December 20, 2008

We’re nearing the end of our second year of medical school now; time for me to witness a second round of medical school interviewees waiting in the lobby with their name tags and black suits.  A lotta learning has happened in the year and a half that separates those pre-meds and myself, but the fact of the matter is, most of that education has just shown me how much farther there is for us to go.

A few days ago, a friend of mine told me that a near relative of hers had to be hospitalized with a disease that we had literally taken the final on less than a day before.  I think that by itself, it is a terrible thing to go home to and confront.  But it is made even worse by having that academic knowledge suddenly become so mortally relevant.

Thinking on the situation, I couldn’t help but feel disgusted that life would be so cruel as to force my friend to confront what had been a page in Goljan’s, in a member of her own family.  I think on some level while we are learning about these diseases in class, and we see the faces of the stricken patients on our power point slides, we know that these diseases are not good things, and that they affect real people.  But for most of us, those faces are anonymous, and more important than how crippling and mortal these lymphomas, leukemias, fractures, and infections  are, is what our instructors are going to expect us to know for the examination.

There are so many diseases out there, so many terrible ways to get sick, that while we are learning them, we have to tune out just what this costs in human currency.  One of our pathology professors was presenting a case to us, about a girl who was currently in the hospital.  She had a malignancy, but nobody could figure out exactly what was wrong.  Our instructor described the course of her disease to us, and showed us slides of biopsies that had been taken and such.  She concluded the presentation by sort of shrugging her shoulders and telling us that still no one could really figure out what was wrong, and that ‘she wasn’t doing well.’  Sitting in the audience, it occurred to me that what that really meant was she was going to die.

Hearing about that girl I’ve never met was difficult enough, but when something like that befalls someone near and dear to you, it must be very hard.  It makes me want to shout indignantly that we shouldn’t have to deal with these things.  Not yet.  That we are still students, that it is difficult and stressful enough without being confronted by the painful reality of what we are learning.  That we’re not ready to start facing the morbid fact that people we know, good people with lives and histories who laugh and have families will get these diseases.  But I guess this is real life, and life is not always benevolent.

And making this hard introduction to the reality of our curriculum even more difficult, there is nothing we can do about it.  At this point, we know just enough about these diseases to know what it means when they say that our relative is intubated, in an ICU, has a particualr diagnosis, but we don’t know nearly enough to be of any use to anyone.  All we can do is watch and comprehend, but we cannot help.

I don’t know.  I bring all this up because I was a bit rattled by all of this.  Saddened and worried about my friend and her family, and confronting in my own way what this sort of thing really means.

Anyhow, I hope that wasn’t too morbid for everyone this close to the holidays.  I have a fair amount of free time this vacation, so hopefully more upbeat writings to come.  Take care everyone.

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Limits

December 12, 2008

We just finished a particularly difficult group of classes recently.  I met up with a friend here in my native San Francisco, and over wine and desserts we talked about the nature of the work in medical school.  Everyone talks about how it’s hard, and it’s tiring and all that, but I thought some interesting things came out of our discussion.

For one thing, everyone in medical school is a relatively bright individual.  I complain to my sister sometimes about how hard it is and such, and her reply is always “Good!  If it were easy, I might have my doubts about you guys as doctors!”  The truth of the matter is though, with that ‘intelligence’ comes some degree of intellectual hubris.  For people who have spent their life wending their way through the halls of academia, in your own estimations, if you are not smart, you’re not much of anything.  For someone who has gone to school for eighteen years, it is easy for your sense of self-worth to get wrapped up into your scholastic achievements.  I say it myself half-jokingly at times; I’ve got no other skills in the world besides learning.  I don’t know much about computers, I can’t fix cars or plow fields.  The only thing I know how to do is learn.

You might say that isn’t such a big deal; that learning isn’t such a bad way to be, and I wouldn’t disagree with you.  The problem is when you get to the limit of that cherished ability, when you must confront your own intellectual limitations.  And that I think is one of the reasons why it has been so hard for me and my class of late.  Medical school really does push you to the limits of your mental ability; there is so much out there to know, so much they try to teach you all at once, you cannot learn it all and sleep at the same time.

It’s difficult to find yourself in the middle of the pack, or to realize that despite all the effort you are pouring into your studies, it’s not changing anything.  I guess what I am saying is, at some point, you have to realize you’ve got to top out somewhere, that you have a finite capacity for this learning and no matter what you do, some people are gonna be better at this than you are.  After a certain point, all that stuff your mother told you about trying hard ultimately bringing success needs to give.  I mean, a talented person who works hard will end up doing better than an untalented person who works hard.  It’s a difficult truth to confront I think, and that’s what has made the last group of classes particularly difficult for me and my class.  Our courses have thrown so much at us in so short a time, that a lot of us got pretty close to that edge, and it’s little wonder we didn’t like what we saw.  :shrugs:  This is probably not the most profound of posts, but I thought that it was worth putting words to/reasoning out after that rather hellacious block.

All that aside, it’s on to our penultimate grouping of classes before we hunker down and study for the boards.  Scary thought in and of itself.  Perhaps a slightly more lengthy post on that to follow . . .

Those We Don’t Like

December 2, 2008

A quick preface to the following blerb:

I wrote this as the closing remarks for a presentation a fellow medical student and I gave at an undergraduate conference on “Cultural Competency.”  Read the following with the understanding that I’m not the best writer (nor orator) in the world, though it never hurts to dream at times ;).

We have done our best to tell you guys about the drug user culture that we see at [my clinic], and to educate you as to why they receive second class treatment from many medical practitioners.  We wanted to show you the facts of the matter, but I feel that this is a problem that cannot be completely described by statistics alone.  In the medical profession, we all signed up because we wanted to help other people, to heal their hurts and cure their illnesses.  You might be asking yourselves, how someone can have those ideals but still exhibit this differential treatment of their patients?

I think that on the surface, we do it because we are afraid that they are going to dupe us, because we don’t like how they smell, or because they come out on the wrong side of that cold utilitarian calculation telling us how much medical care they should receive.

But I suspect that the real reason might be simpler, more visceral even than that.  I suspect that those may well be superficial observations, excuses covering an uglier side present in all of us – not just doctors – that we refuse to admit to in ourselves.  It is the reason why we ignore the homeless on the street when they ask us for money, or walk past that bum wheeling his grocery cart with our eyes straight forward and our conversation uninterrupted, refusing to even acknowledge his or her existence.  These, the people who need help most of all, we brush past with masks on and eyes turned inward.

Maybe we do it because we feel we cannot help them; because our willingness to help our fellow man goes just far enough to join that facebook group, but not far enough to spare a glance to the guy sitting on the sidewalk.  We come up with all sorts of excuses to ourselves, saying in our heads that they’ll just spend the money on booze, or that their problems are too big for me to fix by dropping a few coins into their cups.  These excuses are just covers for the fact that something in these people repulses us, and causes us to pull back into ourselves.

While unpleasant, this might be okay for every day people.  But as physicians, once you put on that white coat and drape the stethoscope around your neck you no longer get to use these excuses.  When someone reaches out to you because they are sick, and they want you to make them better, we are duty bound to help them.  When they come before us, whether standing on their own two feet or sitting in a duct-taped wheel chair, we must help them, because we are doctors, and as doctors we do not get to choose which patients are worthy of of our care and which are not.  Everyone is human, everyone gets the best treatment we know how to give, and as doctors that is what we strive to do.

But as we see patients, many many patients, we get burned sometimes.  The patient we thought to be in excruciating pain turns out to have been seen by a colleague before, under a different name but persistently seeking the same narcotic.  We treat the same alcoholic as best we can over and over again, and over and over again he spits and yells and screams obscenities at anyone who comes near.  These experiences cannot but hurt us, leaving scars that make it harder to treat the people who remind us of them.  It is hard to feel good about wasted efforts or failed interventions.  It is even harder to treat someone who, on some basic level, is distasteful us.   But all the same, as doctors we must be able to see past that ugliness, and trust that there is a human being inside who is hurting and needs you.  Just because it doesn’t feel good, just because it isn’t easy, doesn’t mean that we can shirk our duties as physicians; to treat them with the same basic dignity granted to all people.

It is easier to ignore these people, to push them off to the side, easy to treat them quickly and move on.  What is hard is to treat every single patient with compassion, to remember that no matter how smelly, rude, ugly, sick or downtrodden, they are still people.  It is a simple lesson, but one I think that too many of us both in this profession and in the world at large have forgotten.  But we owe it to our patients, and to those people who are not so lucky as us, to remember.