So Time Passes...

The ego that sees others as "Thou" is different than the ego that sees others as "it."

Words of wisdom from Joseph Campbell.

Yes, We Cry

In taking care of patients, we have the opportunity to run the gamut of emotions. Patients can make us happy, angry, scared, and sometimes, either patients or their medical conditions can make us cry.

Medicine is strange field. It carries with it, maybe from years of being an "old boys network," a certain machismo. The unspoken code of conduct is that physicians should be "professional" (stoic) and refrain from acts such as crying in front of patients, even if you find yourself in a sad situation with nary a dry eye in the room. We work intimately with disease and death but there is very little in medical training that teaches us to acknowlede or process the emotions that arise. And while we may have seen more deaths than others, that does not make any death easier to take.

In training, unsuccessful resuscitations are seldom discussed. Each member of the resuscitation grapples with the grief and profundity of the experience in their own way. Patient deaths are likewise rarely discussed - sometimes they just disappear off the patient list, or are given a few words on rounds the morning after they passed. Some physicians may know to take time out and grieve, but for too many of us, the feelings are often repressed and neglected.

Just two days ago I was called to the bedside of a dying patient. She wasn't "my" patient in the sense that I was covering for the patient's doctor, but that didn't matter. And although she was an elderly lady with advanced dementia who probably had not recognized her family for a long time, and although the family was gathered, aware, and just wanted their matriarch to be comfortable in her passing, the pain in their eyes and quickly wiped away tears was hard to bear. After updating the family and making sure the patient was comfortable, I had to retreat to the call room and let the tears fall. Pain, illness, and death are never easy, and patients touch us in more ways than they know. We struggle when they struggle and we cry when they cry. We will bravely try to fend off death and treat disease, but we too are flesh and blood, and sometimes, all we need is a corner where it is safe to cry.

Always Learning

One of the greatest things about being in medicine is that we are lifelong learners and lifelong teachers by trade. Good physicians teach their patients about health (hopefully), their bodies, and proper management of their diseases. In addition, those who chose to stay in or stay involved in an academic setting get the opportunity to teach the next generation of physicians. As a student, the resident physicians and attendings that taught well were very much appreciated, and it is nice to be able to do the same for current students.

I used to think that great teachers were great regardless of who they taught. I still think that's true - but only to a certain degree. As a student, you are exposed to different types of teaching styles, but you are the only measuring stick for what a student should bring to the table. As a teacher, you are exposed to different types of students, and I have to say, students and their eagerness (or lack thereof) to learn taints the teacher-student relationship. Those who are in the field of education may chuckle at this obvious observation, but for those of us not officially trained to teach, this was a delayed but eye-opening realization.

In medicine, there is a lot of informal and formal teaching in the hospital. Students rotate on different medical specialties each month, and while many do not know what specialty they would like to pursue, some seem to have been born knowing that they were meant to be a pediatric interventional cardiologist (or some other ultraspecialized field). Still, even for those who have their hearts set on a particular field, most are still very open to learning all they can while on the different specialties. After all, if you're going to be a pediatric interventional cardiologist, your only exposure to internal medicine will be the few months you get during your medical school training. In addition, you will be a physician as well as a ultra-specialist - more reason to try to learn general aspects of medicine - and really, friends and family are going to ask you questions about general medicine, regardless of how specialized you become. This seems like common sense, but we've had a series of students come through that apparently don't believe that it's important to pay attention when rotating on their basic internal medicine rotation. A little scary...

It's been a challenge to try to figure out how to best teach this small group of students. Some of them are not interested in any teaching and just try to do the minimum to get by. Unfortunately, as everyone is busy on the wards, if you do not want to be taught, I probably will teach you less and less as time passes. Other students don't want to do any reading or learning on their own, and just want you to spoon feed them everything. There is no such thing as a dumb question, but there certainly are questions that show that you really didn't pay attention in medical school classes and you didn't bother to try to read the basic information every student should know. Medicine is a lifetime of learning! You need to not only learn as much as you can while training, mainly from reading about diseases that you come across, but you also need to learn how to teach yourself (where to find answers to questions) for the rest of your life. If you don't do this, what will you do after you are done with residency and go out into the real world? Will you stop learning because no one is there for you to ask questions to??

I had a couple of students like this in a row, and it was a little unsettling - as it was the first time I had seen this, I was trying to make sure that it wasn't the teacher or the teaching style that was creating this situation. Luckily, along came a student who wanted to learn, and that month was spent happily teaching her basics and clinical pearls of internal medicine. I'm still not sure that students who seem like they don't want to learn mean to be that way. Maybe it's a difference in culture at different academic institutions, or maybe it's something else... all I know is that when the student doesn't want to learn, the teacher does not want to teach.

Closer But Lonelier

Just had an interesting conversation with a colleague today. He's a pretty good example of the average guy in medicine - early thirties, not in a current relationship (either never married, divorcing, or divorced), still living off a resident physician's "whopping" salary, etc. We talked about his adventures in online dating, and that set off some wheels in the head.

How come, given all the great changes that have taken place in the last century - ways to connect us to those far away (airplanes, telephones, email), decreases in the amount of time spent on basic survival, etc, some of us can still be so isolated and lonely? If we were in a farming community of yore, we'd live spread out over farmland, maybe have to walk miles to see friends/family, but we'd all know each other (for better or for worse!) and there would be a community support system in place. Now, in an average city, we live and work physically closer than ever (think cubicles, apartments), and yet we seem more socially isolated than ever before...

We've become accustomed to easy communication - emailing, online dating, heck, even blogging, seem to have replaced good old face to face interactions. I still remember the college roomate who used to instant message the guy next door, even though, if he had raised his voice some, they could have carried out same the conversation verbally...

What are the social implications of this phenomenon? "Loneliness" is no longer relegated to the domain of the odd person who prefers his own company. If you believe "Google Trends," the Irish, English, and Americans are all pretty lonely... This brings to mind Professor X, who committed suicide when I was in medical school. He worked at a place that was bustling with people 24 hours a day. He taught students who loved him as a teacher, worked with colleagues who thought the world of his work, but no one REALLY knew him, and no one involved in his busy days thought to take the time to really know him. He was surrounded by people, but alone... How does this happen?

Nature's Formula: A Dash of Brilliance, An Ounce of Madness

March of the Penguins - If you don't know what this is, you're missing out.

For those who haven't seen it, it's a documentary on Emperor penguins in the South Pole and their yearly adventures in raising a baby. Summary: The penguins leave the water once a year and walk 70 miles to get to the breeding ground - the place where they were born. Once there, they find a mate, do their thing, and a month or so later, an egg is born. Mom needs to get back to the sea to feed, but before that can happen, she has to pass the egg to the father. Given the lack of hands and and the freezing conditions, the egg transfer is a tricky process that requires both speed and skill. Once the father gets the egg, he spends the next few months carrying it on top of his feet, shuffling around while balancing the egg. All this is done in weather that ranges from a sizzling -50 degrees WITH the sun to -100 without, days to months without sun at all, and the occasional blizzard with 100 miles per hour winds thrown in for good measure. When the eggs hatch, both fathers and babies starve as they wait for Mom to come back. Meanwhile, the mothers have made it back to sea, fed for themselves and their babies, and hurry the 70 mile trip back to feed their young. When Mom makes it there, she switches places with Dad, who walks 70 miles to fill his belly. They repeat this until the little penguins are old enough to survive on their own.

There are immense dangers at all steps of this process. Penguins can die on the initial march to the breeding ground. Penguins may fail to transfer the egg safely. Or the egg can make it onto Dad's feet, but die in one of those storms as Dad struggles to move against blinding harsh winds. Fathers risk death in the process of protecting his egg or waiting for Mom. Mothers can die during feeding, victim of a predator. Both Mothers and Fathers may die on any one of the return marches, and all has gone well, baby could still meet its demise in its first storm, or as the next meal of a seagull or other predator.

Thoughts after the documentary:

- Thank you Moms and Dads for all the sacrifices you have made for us.

- I should never complain! How can we pity ourselves when these poor things suffer in bitterly cold weather, months since their last meal, and fight for survival against deafening arctic winds?

- What drives these penguins to do this year after year? What drives salmon to make a death swim to the place of their birth to lay eggs? And similarly, what drives young men and women to give up twenty, thirty, forty years of their lives to give birth and raise children? Is it the brilliance of nature, a touch of madness, or really, a combination of the two?

Would You Want To Be There?

She died unexpectedly. Well, not exactly unexpectedly - she was a middle aged woman who died from undiagnosed heart disease and complications thereof, but the timing and day of her death was unexpected. It was a sad case because it was so sudden, because she was so full of life, and because, of all ironies, she had been in town on vacation.

She had been recovering slowly and had a sudden decompensation on the day of her death. As she died, 7 physicians and numerous nurses were at the bedside in a lengthy resuscitation that was unsuccessful. For those present during the resuscitation, there was no doubt in anyone's mind that every possible thing was being done, and that when we stopped, we had tried our best, and there was nothing more that we could have done. Still, my heart went out to the husband, who sat alone in the intensive care waiting room, periodically updated on his wife's condition. For him, his wife had gone from ill but stable in the morning to dead by noon, and all this was second-hand information.

Should we have allowed him to stand by the bed and watch the resuscitation? If I were him, I probably would chose to be present. There has been some research indicating that family members have more closure when they are present during the resuscitation, and some hospitals have integrated this into patient care. Others claim that having family members present in the controlled chaos of a resuscitation would be detrimental for the patient - family could get in the way and slow down the resuscitation, or they could be overly emotional and distract from patient care... There is also the issue of being able to tolerate what they will see. Will they understand that dying people gasp for air like a fish out of water? Will they know that the electric shocks are a desperate attempt at restarting the heart? Would her husband have been able to watch as the surgeon reopened her ribcage for cardiac massage after all else had failed? But all these issues aside, deep down, I feel that family should have the choice to be present. They can see, with their own eyes, that we cared, and we tried. And perhaps, for some patients, having family present would allow us, physicians entrusted with the care of the patient, to let go more easily. Oftentimes, we become too attached to the patient, too unwillingly to let go even though common sense states that it is time. It is a fine line to walk, to know when to let go, and when a refusal to do so causes more pain for the dying or dead patient. It is much easier when a family member, someone else who has the patient's best interest at heart, knowing that we have done our best, reminds us that it is OK to step back and let go.

Computers, Patients, Me, OH MY!

So today was the first day we had computerized charting in the clinic. Didn't like it. Not one bit.

First off, we've got some logistical issues to work out, which, when ironed out, should improve the situation a little. For example, we can't have a copy of the patient's chart open in the patient's room if we try to pull up a copy in the attending physician's room, where the case is being discussed. Which means that we're still printing out a copy of the chart, like we used to, and the attending still scribbles his notes on there. Like old times. Except now, someone has to enter in said scribbles back into the computerized chart, or else they never existed. And the same amount of paper is wasted.

Secondly, not having a piece of paper to jot notes on is frustrating. Frustrating because talking to the patient is a conversation, and when a patient rambles about something, it's nice to let them finish their thought before asking for clarification about a pertinent point. Which used to be easy - jot a note or mark the thing that needed more clarification. Frustrating because it used to be extremely efficient to write down the pertinent history right away, and now I have to either type as someone is trying to tell me all about their health problems or try to remember it all and spend extra time after the patient is gone trying to enter this information into this electronic chart.

Lastly, and most importantly, I have to somehow use a computer while someone is trying to tell me about all their pains and still try to convey that I care about them and their problem. Extremely tricky. The first patients of the day were subjected to this painful process. At the end of the day, the last patient had seated herself on the examining table, not the chair, which happened to be 180 degrees from the computer. So rather than swivel like an idiot, or ask her to please move to the chair so I could see and type, (what a silly request!), I gave up and reverted back to writing on a piece of scrap paper, which was used after the patient left to enter data into the electronic system. Behold, my friends, a case of wasted paper and extreme inefficiency, and a prime example of how technology solves and CREATES problems.