A Familiar Patient

By Gelareh Homayounfar

My patient is 88 years old, but she tells me that someone once told her she would live to be a hundred.  She says this happily and responds with “oh, wonderful” nearly every time I share an encouraging test result or our team’s plan for her care.  Part of me wonders how much of this pleasant, accepting manner is due to her diagnosis of dementia, but seeing things in a positive light as I tend to do, I imagine she must have been a lovely person when she was younger, too.  Her son shows me a picture saved on his cell phone of his mother holding him, then an infant.  “Mother used to be beautiful, like Grace Kelly beautiful,” he says.  He wants me to see her as she looked then, in contrast to her aged, bruised face now, after a recent fall.  I look on, thinking that she’s still beautiful and that she must be a wonderful mother to inspire such devotion in her children. I share only the latter thought with him, remembering my instruction on maintaining professional boundaries between doctor and patient. 

No boundary can keep my mind from wandering toward the fact that this family reminds me so much of my own.  Though we are at different stages of life, the similarities between us are both substantive and coincidental.  This son’s tone of voice when speaking to his mother is much like my mine, reflecting love, admiration, and respect.  My patient once worked as a nurse; so does my mother.  We all once lived in the same state.  I wonder what the future holds for both families.  My family is healthy now, but the hospital is a daily reminder of how lucky we are.  Rather than making me fearful of the future, this family and their response to dementia reassure me. They seem to be a model of effective coping and embody the decision to value quality of life.  It really can be done, I think!  I know that one day I may start to lose the mind that is at the core of my self-concept. Or I may see one of my parents go through the same process.  Three years ago, I went to a hospice on a field trip of sorts, as part of a course on end of life issues. Our professor asked the group of students, most in our early twenties then, how many of us thought of the possibility that we may one day be like the hospice residents.  I was surprised to find myself the only one raising a hand.  As my peer group gets older and loses the feeling of invincibility of youth, I doubt I’m as alone as I was then in allowing myself to acknowledge the possibility of shared experience.  This acknowledgment makes me more empathetic towards my patients and, reciprocally, more accepting of frailty in my personal relationships.

Not all of my patients remind me of my family in quite the same way.  The commonalities aren’t always as obvious.  This is only natural.  Nevertheless, even if not obvious, I know that there are always commonalities to be found and will always strive to care for each patient as I would want my family to be cared for.

 

Gelareh Homayounfar is a third-year medical student at Harvard Medical School in Boston.

Thoughts on Third Year

by Hannah Jackson

The first thing I reach for as I exit the hospital or clinic every day is my phone. I make my first personal call of the day after the sun has already set. I call a friend or family member and, despite all intentions of having a lazy, respectful back-and-forth conversation, I immediately start rambling at rapid pace about my day.  It is only when I am ready to hang up that I remember to politely ask, “And how was your day?”

I think I do this for two reasons. The first is that as third-year students, not one minute of our day from the time of arrival until we are dismissed is about us, personally. If conversations in a team or with a preceptor do verge on personal, it is the medical student’s role to be a passive listener. If the student feels comfortable enough to participate, it is always with the hierarchy in mind and so never truly feels “real.” In fact, our most cherished “alone” time is with our patients, when the encounter is rightfully all about the patient. And any “free” moments are actually opportunities to help others or to look up pertinent medical information – also as it should be. But the net effect is that I am shamefully selfish in my first real conversation of the day.

The second reason I go straight for my phone is that every day of third year is packed with new, and sometimes defining, experiences: good and bad, exhilarating and frustrating.

The truly great moments this year are the moments when we feel that we have made an impact on a patient’s morning/day/week/life. I keep them in reserve for the future, as reminders of why I am here and a guide for the kind of doctor I want to be. And that is what third year is about, isn’t it? Answering the question: what sort of doctor do we want to be?  At its most basic, the question is asking what specialty or path we will take when medical school ends. More importantly, however, we are figuring out how we will approach our personal practice of medicine and care of people.

This becomes increasingly difficult in our roles as third-years, however, because in every situation or conversation, we are never on equal ground to share our point of view in its totality. We are constantly corrected and told how to think, act, perform, write, speak, and treat by people in ways that do not always coincide with what we may believe. For example, when a superior walks out of a room with someone who has mental health issues in addition to a more traditionally-medicine-based chief complaint, and disparaging remarks are made about the misfortune of having to “deal with” the patient’s “psych issues,” I am left feeling uncomfortable.  Even worse is the way very obese people are spoken about. Often, there is an attitude that the patient is actively trying to make the team’s day worse, whether by being sick, old, helpless, or overweight.

Other times, during rounds or in clinic, a person’s depression, anxiety, misunderstandings or socioeconomic limitations can seem glaring, and I feel that addressing the issue would not only help the patient in that specific realm but also positively impact his or her other medical issues, preventing a quick return to the ER or office. Yet these issues are set aside or ignored by oftentimes over-worked superiors. We don’t have the choice to continue an appointment to address important lingering questions or issues; the decision of when to move on is not our own.

Of course we are told, or intrinsically know, to take note of these moments and to store them. What did you see today that you would want to aim for? What do you want to avoid? What is effective and what isn’t? Do you want to be the doctor who is always on time, despite a patient’s circumstances, or will you be the doctor who is always an hour behind, allowing for longer visits and more dialogue but keeping your patients in the waiting room? Will you design the perfect medication combination to treat the long problem list or will you spend more time counseling? What helps your patient more in the end? Of course a combination of all of these is ideal, and the easy answer is that you will strike a perfect balance, prioritizing different aspects of care depending on the patient sitting in front of you. But, in practice, consciously or not, this healthy balance is often not attained – and in the process of prioritizing, parts of doctoring are lost.

And so, in knowing that I am no more mindful, compassionate, intelligent, or responsible than my superiors in a profession aimed at healing, I am left wondering: when and how do we begin to make concessions? And how do we make sure that the concessions we do make are our own and in tune with our own fundamental beliefs and moral code when the road from student to resident to fellow to attending includes so many years of having to do it someone else’s way? These are questions that continue to stay in the front of my mind and to which I do not have answers, leaving me uncharacteristically quiet. We speak more openly now about the “hidden curriculum” and are encouraged to self-reflect more than our predecessors, and it is likely that both of these will help.  Despite this, I am not convinced that many of us fully understand when these changes or concessions begin or occur, and I will continue to worry that I will not fully control who I will become.

Hannah Jackson is a third-year medical student at Harvard Medical School in Boston.

The Masked Medical Student

Some medical students weasel their way into a surgery the very first second they can.  They stand outside the OR, peering through the window like a wistful puppy dog, waiting for a sympathetic surgeon to finally wave them in so they can gaze reverently at a two inch long appendectomy incision.  Those are the future surgeons.

I was the opposite.  I dreaded seeing my first surgery.  I had already come close to passing out during a renal biopsy during my medicine rotation and that didn’t even involve blood.  In the months leading up to my surgery clerkship, I had horrible visions of my unconscious body sprawled across the sterile field.  My goal for my surgery rotation wasn’t to impress the attendings or get a good grade.  My goal was to not faint.

I was assigned to the thoracic cardiovascular team and my very first surgery was a carotid endarterectomy.  Whatever that is, right?  We took a little class on “how to scrub” the day before, so I got to try it out for real on the morning of the surgery.  I was extremely slow.  Three other people started and finished scrubbing in and I was only on my third finger.  You know, I honestly don’t think those other people were scrubbing every quadrant of their fingers ten times each.

When I finally finished scrubbing about two hours later, I went into the OR.  What you do is you back into the OR holding up your freshly scrubbed hands and the scrub nurse has a gown ready for you to put on, then she puts your gloves on for you.  I was so scared of getting contaminated, having to re-scrub and probably just spend the entire surgery scrubbing.  It seems almost arbitrary what’s sterile and what isn’t. For instance, you could be digging around in someone’s guts and still be clean, but if you touch your facemask (which is disposable), then you’re contaminated.  Sensing my uncertainty, the scrub nurse instructed me to keep my hands “at boob height.”

I went around telling everyone in the OR that it was my first day (even though I’m sure it was painfully obvious) so that when I passed out, they’d be understanding.  The surgeon was a tall man with an Irish accent who everyone called Colin.  He didn’t even introduce himself to me.  He just said, “Is this the medical student?”  Allow me to introduce myself: I am The Medical Student.  That’s what they call me.  Actually, I sort of liked being anonymous.  I already had a mask.  All I needed was a cape.

I asked the scrub nurse what to do.  She pointed to a draped area on the patient’s body: “Put your hands there.  They’ll be safe there.”  I obeyed.

I had no idea what to do for the first half hour. I just kept my hands in The Safe Place so they wouldn’t get contaminated. The surgeon Colin handed me the suction and let me suction off the bovie fumes (bovie = little electric cutting device).  When he finished cutting, the scrub nurse said, “Do you want the medical student to keep holding the suction?”

“Yeah,” Colin said.  “It’ll give her something to do.”  I don’t think surgeons can talk directly to The Medical Student.  I think we’re too many levels apart on the hierarchy and some kind of translator is needed.  Like if a man needed to talk to a beetle.

So anyway, I stood there and watched, gripping my little suction hose.  To my surprise, I didn’t feel faint at all. It didn’t seem real… it was more like dissecting the cadaver in anatomy class. The whole body was covered except for the small area where they were dissecting out the carotid. And they were cutting through the tissue like the person was already dead.  If I didn’t think about it too much, it really was no big deal.

Then things started to go wrong.  The shunt fell out and the incision site filled with blood.  “This is one of my ten worst carotid endarterectomies,” Colin declared.  He then started cursing and yelling, which I later found out that he did a lot, and made the nurses shut off the music.  Let me tell you, if you go in for a surgery and there’s music, and then when you wake up, someone has shut it off, that’s Bad.

“Get on the other side of the table!” Colin yelled at me.  I carefully tried to navigate around wires and cords while keeping sterile.  “Why aren’t you helping the medical student?” Colin yelled at the scrub nurse.  Then he actually reached across the table, grabbed me by my gown, and yanked me where he wanted me.  Oh, Colin.

In my new position, I was responsible for holding the retractor.  I was pleased by this development, because that’s what the medical students always do on TV.  However, I quickly became overwhelmed by this crushing responsibility.  What if I let go of the retractor and the patient died?  I gripped the retractor so tightly that my fingers turned white and tingly.

Then things really started going wrong. After Colin stitched up the artery, it started popping tiny little leaks. The blood was squirting out like from a crack in a dam.  What we needed was a teeny little Dutch boy to seal it off with his finger.  All the while, Colin was cursing loudly. Each time the blood started squirting, I got hit like he was aiming for me. By the end, there was blood all over my hands and gown. There was even blood on my bare neck.

But miraculously, the surgery finished up successfully, lasting three hours total. “This was my third worst carotid endarterectomy ever,” was Colin’s final official ranking.  He looked me over, “Hey, the medical student got more blood on her than we did.”

The Medical Student bows, then snaps her cape and flies off into the night.  And by that, I mean I ate a stale bagel in the locker room and returned to the OR for a five hour removal of an infected aortic graft.

Sara Weiner is an attending physician in physical medicine and rehabilitation.

So… second year.

In a small bay of our skills lab, seven of my classmates gathered around as my friend A gripped a small mace and shut one eye as he bore down slowly into a slice of brain. I don’t know about the others but I for one wasn’t breathing.

“How did it feel?” we asked him when he exhaled (so I wasn’t alone) and looked to us for affirmation.

“It’s strange,” he said. “It felt softer than jelly.”

Then he picked the knife up and sliced the brain again, and again, and again.

So much surrealism is contained in our neuroanatomy block. Such long hours, so many diagrams of remote nuclei and signaling and circuits that I may or may not remember one week from now. So many zombie jokes.

This month has been something of a metaphor for second year. Things are getting heated and we’re all losing our minds.

Last year, I could count on one hand how many hours I studied per day. This year, I count on one hand how many times I remember to shower in a week.

Last year, I called and skyped friends from college and home ALL THE TIME. This year, I found myself blanking on a friend’s name, rushing to Facebook to try and find him, and then diagnosing myself with aphasia.

Last year, my friend J and I bitched about skinny girls by calling them ‘ano’. This year, we do the same thing (because we haven’t grown up) but call it marasmus.

Give me a few more months and I’m going to need a halfway home if I ever want to go out in society again.

The other day, for the first time ever, I experienced retail therapy… online. (Time’s in a pinch, ya know) Did I experience the same kind of euphoria that I usually do when I swipe down my credit card and gather up my new apparel close to my heart? Not really, but I still got to hang up a few new sweaters in my closet. It’s not classy, it’s not sexy, but it’s getting the job done.

“You just cut through countless memories,” I said to A, when he was finished with the brain.

“Or a bunch of prions, you know,” he returned. “It all depends on how you slice it.”

Samyukta Mullangi is a second-year student at Harvard Medical School in Boston.

Fragmented Intimacies

His face was four inches away from mine.  I tried not to blink as he shined the ophthalmoscope’s light into my left eye and stared into my pupil as though it were the most interesting thing in the world.  He frowned, placed his hand on my head, and used his thumb to pry my eyelid higher.  He maneuvered for about 45 more seconds while I sat stone still, and then, suddenly, his face broke into a grin.  “I see it,” he announced.  “I definitely see it.”

And then, completely awestruck, “Wow.”

I was my classmate’s first visualization of the optic disc.

Our opthamology instructor previously had shown us dozens of images of the inside of the eye, some normal, some frighteningly abnormal.  “Before I say anything else,” he began, “the first thing I want you to notice is how beautiful the eye is.”

Indeed it was.  Snaking along the back of the eye were tiny red delicate blood vessels, converging to become thicker until they crossed over the optic disc.  The optic disc, a pale yellow standout among the redder hues, is unique because it is the only part of the central nervous system that we can non-invasively see.

When my classmate saw my optic disc, he saw a piece of me that no one had ever seen before.  He saw my central nervous system.

Later that night, I friended him on Facebook.

It’s not surprising that medical school is an intimate experience.  When we learned to test for reflexes, I unabashedly hit my partner’s forearm until it bruised.  When studying for my microbiology final, I and a few others sat in the computer lab eating and complaining, finally shuffling out together at 1 am.   When I interviewed my first patient in the hospital, my partner watched me stumble over the most basic questions–and later told my preceptor he thought I did a great job.

What has been surprising is the complete lack of continuity among these experiences.  I have parents, I have a sister, I have a best friend, I have close friends in my class, I have had the significant other.  These people see me as a person with a complete set of experiences.  They have seen me at my highs and lows and middles, they have listened and re-listened to my secrets and fears, they have offered me unconditional support.

But–still–sometimes, no matter how hard I try to paint a scene with words, they are still several degrees of separation away.  They see my world through my eyes, their sense of vision stemming from my words.

Then there are my classmates who have seen me on the front lines, seeing a side of me that deals with the emotional or bizarre or just plain new.  But–oddly–for each experience, it is a different and sometimes unfamiliar person who shares it with me.  I am used to creating memories with those closest to me, but in medical school, when the assignments are as random as the patient encounters, no such coherency exists.  The thread of experiences continues but it is broken.  I am the only witness to the whole.

I recently sat on a panel to give advice to first year students.  One of my classmates stressed the importance of finding a mentor.  She was lucky and had found someone she could completely confide in.  Her mentor knew her professional aspirations, her personal goals, and her progress in achieving them.  Sitting next to her, I felt a little less lucky.

“I don’t have one mentor who is my be-all and end-all for every issue I have,” I told the audience.  “I’m interested in ethics, and I have a professor who I respect and can talk to about that.  For writing, I have mentors hundreds of miles away.  My faculty adviser knows the most about my personal issues.

“In short, I guess I don’t have a single mentor.  And I think that’s okay too.”  I wanted to believe my words.  But I admitted to myself that it would be a heck of a lot more convenient to have just the one.

My other experiences in medical school, some intimate beyond words, have been similarly fragmented.

I went to an Alcoholics Anonymous meeting with two of my classmates one night as part of an assignment.  We walked back slowly in the darkness, discussing, avoiding each other’s eyes.  In that moment, all three of us felt that it was just a bit of fortune that separated us from those whom we had met that night.  We were grateful.  We were empathetic.  We had changed.

During anatomy, I was partnered with three different classmates.  Together, we explored every cavity of our cadaver’s body.  We made off-color jokes.  We retracted skin and guided each other’s cuts.  We held the lungs in our hands and marveled.  We scraped the skin off the face and sawed through the skull and disengaged ourselves to do so.  Six weeks later, we had changed.

This year, during a psychiatry clinic, three different classmates and I interviewed a woman with paranoid schizophrenia.  Talking to someone with an illness in the brain is an entirely different experience from talking to someone with an illness anywhere else.  Her story involved violence, abuse, homelessness, isolation, and denial.  The narrator herself, by definition, was unreliable–to the point of ironically insisting that paranoia was the wrong diagnosis.  It was sad.  She was sad.  We were sad.  It was worse than sad.  We had changed.

I am changing, more than I had imagined.  I am grateful that I have classmates who are changing with me, sharing experiences that I can’t do justice with words when I am talking to those closest to me outside medicine.  I am grateful that our paths converge, if only briefly, for those intense moments.  I wonder how they perceive those moments, as time eventually blurs the details.  I’m sure that my classmates have stories of their own: their individual journeys at their individual paces.  I’ve heard some of them.  But in my story, I am the only one who can put the fragmented pieces together.

Sometimes the story is lonely.  Sometimes it’s exhilarating.  But, ultimately–convenience be damned–it’s mine and mine alone to make sense of.

Shara Yurkiewicz is a second-year student at Harvard Medical School in Boston.

Using Bedside Stories to Unmuddy the Waters

By Neel Shah

Last year the nonprofit I direct launched an unusual essay contest—we asked doctors and other care providers to tell us about their mistakes, including times they made decisions that inadvertently led to unaffordable medical bills. We also asked patients to share stories about their struggles with lack of price transparency in the system. Ultimately, we collected more than 100 stories from patients and care providers across the nation that illustrate the importance of cost-awareness in medicine, and then made these stories part of the public discourse by widely sharing them. The stories generated an impassioned response in the national media, and showed how transparency helps patients financially plan for their care and also helps doctors keep medical bills affordable.

However we also learned that knowing what tests and treatments cost is only the first step. Then you have to know what to do with that information, and using cost information at the bedside can be both ethically and pragmatically challenging. How do you determine which tests are not only affordable but high value? How can cost-consideration be reconciled with our ingrained ethos to do everything possible? How do you fit the time and effort cost-consideration requires into a busy clinical workflow? How do you apply decisions to conserve resources in a way that is equitable to all patients?

As a result, we’re doing the contest again. For the second annual Costs Of Care Essay Contest we are not only asking for stories about unexpected medical bills or difficulty figuring out medical costs, but also asking for positive stories about ways doctors and patients have figured out to save money while still delivering high value care. To help judge the submissions we recruited incoming Harvard University Provost and health economist Alan Garber, along with former White House Budget Director Peter Orzsag, Surgeon General C. Everett Koop, and others. $4000 in prizes will be offered, $2000 of which will be reserved for medical students and other care providers.

The evidence says that there are ample opportunities to save money in our routine decision-making without compromising quality of care. A recent survey from the management company Bain & Co., indicates that as many as 80% of physicians believe bringing healthcare costs under control is part of their responsibility. The Physician Charter states that avoiding unnecessary tests and providing cost-effective care is part of our professional obligation. However, despite the opportunities to save and wide-recognition of its importance, cost-consideration has yet to penetrate clinical practice.

Ultimately, it will be up to a new generation of physician-leaders to carry this charge. Are we up to the challenge? The evidence is clear but sometimes a good story can be worth 1000 academic papers to catalyze change. If you have one, we would love to hear it. Submissions to the 2011 Costs of Care Essay Contest should be no longer than 750 words, and should be e-mailed to contest@costsofcare.org by November 15th.

Neel Shah, M.D., M.P.P. is the Executive Director of www.CostsOfCare.org and a senior resident in the Massachusetts General Hospital-Brigham & Women’s Hospital combined residency in Obstetrics and Gynecology.

Three poems

by Stacy Nigliazzo

I.
Source

He purged the sick with glinting
blades. Flayed their pain

into a sterile bowl.
Painted snowy trees on his days off

to try and forget.
When the white ran dry

he crushed pills to paste,
rounding out the landscape.

I carry his name,
dark hair and stethoscope;

spin words from thread to silver
on my days off

to try and forget.

II.
Rotation

I remember my first day as a student
in the OR.

It was winter, and just as cold
inside. We scrubbed

and cloaked ourselves in green gowns.
Shoe covers were required.

Out of the box they looked like pale boats
wrecked against the concrete floor.

The tread was silent.

During a routine cholecystectomy,
the surgeon slapped an incised

gallbladder into my gloved hand.
It felt like a baby bird

collected from the sidewalk.

I held it for several minutes
before surrendering it.

III.
Aubade

One of my first
patients

was a man with advanced
AIDS.  He was admitted with altered

mental status and a fever.
As I leaned over to check

his colostomy site he smiled
and touched my breast,

saying he loved me.

His partner quickly pulled
his hand away and apologized.

By this time, the patient was signing
Blackbird

and waving his arms like a symphony
composer. His partner and I

continued the song until
he fell asleep.


Stacy Nigliazzo is an ER nurse and a lifelong poet. Her work has been featured in
JAMA, Bellevue Literary Review, The American Journal of Nursing, and The Healing Muse, in addition to other publications. She is a graduate of Texas A&M University and a recipient of the 2006 Elsevier Award for Nursing Excellence.