Friday, December 28, 2007

Just your average campaign song: "Bring Me My Machine Gun"


This is Jacob Zuma, the new leader of South Africa's ruling party, the African National Congress--and because of this, the instant front-runner for the presidency. He's singing Mshini Wami, "Bring Me My Machine Gun", his signature song, one that dates back to the liberation struggle. I can't say that it seems like an entirely good thing that Zuma is on track to be South Africa's next president, but watching him sing this song with his supporters embodies some part of what is wonderful yet terrifying, unstable yet enduring, and both ugly and beautiful about South Africa.

Wednesday, November 21, 2007

The Differential: Pain vs. FOS vs. Pain + FOS


Some addicts we love...

...and--despite our best efforts at forgiveness--some addicts we loathe.

photos: Andre Royo as "Bubbles" from HBO's The Wire; Rush Limbaugh in his booking photo from the Palm Beach County Sheriff's Office in April 2006, from Wikimedia Commons; below, Papaver somniferum from Wikimedia Commons.


Sometimes I prescribe medicine; sometimes I prescribe drugs. Prescribing drugs is much more difficult.

The Drug Enforcement Agency gives every doctor a number, which allows tracking of prescriptions for "controlled substances"--in other words, medicine that can double up as what we more often call "drugs", i.e., the stuff that can get you high. Because I'm an intern, my DEA number only works when I'm working for my hospital; but it works nonetheless.

I am reminded every day of the distinction between medicines that can't get people high and medicines that can. I print up pages of prescriptions when discharging patients, and then go through them and--pulling out my DEA number from its concealed spot on my person--write out the number for the controlled substances.

Going through the list, I know that this one is an antibiotic that could send someone into anaphylactic shock, but it doesn't get my DEA number; this other one could destroy someone's kidneys, but it doesn't get my DEA number either. These medicines can be dangerous, but they're just medicine. They're controlled by professional self-regulation, and ordinary prescription and medical licensing laws.

But this prescription is for an "anti-anxiety medicine." It can roughly be thought of as vodka in a pill, and it does get my DEA number. And this one to treat pain--I only write for the exact number of pills required to get the patient to her next primary care appointment--is basically heroin in tablet form. These medicines are "controlled" in a different way. These are the medicines that the apparatus of the state won't just entrust to the good intentions and professional pride of doctors. If we write bad prescriptions for medicines, we can lose our medical licenses. But if we write too many prescriptions for "drugs"--for the controlled substances--we can be charged and imprisoned.

Though various drugs fit into the category of "controlled substances", it's the opiates--the variations on the chemical structure of the opium poppy--that cause interns the most trouble.

There are a lot of people who have pain serious enough to require intensive medical therapy, so we need to prescribe opiates fairly frequently. But there is also a whole class of people out there who are addicted to prescription drugs, the Rush Limbaughs of the world.

The two sets of people overlap considerably, so drawing a line between the "good" opiate-takers and the "bad" ones is as impossible as it is morally dubious. Even for someone who has no pain, the way to feed the addiction is to create the appearance of pain when coming into the room for the doctor's visit. And what is more subjective than pain? Who am I to say you don't have pain, when you say that you do?

This is where interns come in. Most of us start getting resentful early, because the structure of academic medical clinics means that people looking for prescription opiates are often looking for us. First of all, we look like easy marks; we maybe haven't seen every scam a dozen times yet. Also, we're the ones who are accepting new patients and have plenty of new patient appointment slots to fill. That's perfect for "doctor shopping", which is how some people try to get either the single doctor who prescribes the most opiates, or a bunch of simultaneous legitimate prescriptions for the same opiate medicine.

In the hospital, we're the doctors who actually write the orders; who see the patients most often; who get paged first when the patient hits the nurse call button again and again demanding to see the doctor. (If there's anyone in the hospital who gets more enraged and embittered by prescription drug addiction than interns, it's nurses, who spend exponentially more time than we do responding to requests for pain medicine.) So we have a lot of contact with people asking for opiate medicines.

The majority of the time they're asking for those medicines because whatever put them in the hospital hurts, a lot. Sometimes, though, we're not sure how much of what drives the request is pain and how much is craving. Or we're frankly pretty sure they're trying to feed cravings we don't want to satisfy. How we diagnose this formally is hard to say, exactly, but our gut feelings are unmistakable. In our workroom the other day, a colleague of mine said, "Sometimes you just want to give the diagnosis of FOS"--Full Of Shit.

I actually like caring for heroin addicts who are open about their use. I hope they kick the habit. But if they don't, I'm fine with talking about clean needles, getting tested for hepatitis, and avoiding skin infections. I'll look for endocarditis, send out HIV antibody tests, keep an eye out for toxic exposures from drug contaminants, and work the phone for liver clinic follow-up appointments. I'll even sit and listen to self-pity for a while, because maybe within some of the self-pity will come the realization of hitting bottom. And that's an opening for change.

Within all of this--much of which is difficult, and some of which sometimes involves some scams and silences and lies--at least the patient and I are both talking about heroin for what it is. It's an addictive substance that gives both pleasure and relief, and also carries risks and problems. It's a substance that someone is taking of their own volition, and isn't asking me to prescribe.

But much as I'd like to be the humanistic doctor who isn't bothered by what bothers other doctors, I have to say that prescription drug addicts do stretch me to my limits of forgiveness. They need me to prescribe them their addiction, in a cleaned-up denial-inducing form. And they inspire doubt in me even in my clearest moments, because I don't want to leave pain untreated. They know that my doubt is an opening, an emotional wedge.

I want to avoid being manipulated by people with hidden agendas. But I can't simply turn off my capacity for worrying about pain. How do I know at the beginning of a clinic visit that my empathy is not a human gesture, but merely the potential key to the DEA-regulated lockbox? And when someone says to me that I am not successfully treating their pain, how can I possibly know for sure when they're lying to me? (We do have some tricks up our sleeves to try to figure this out, but their reliability is somewhere from uncertain to quite low.)

At the end of an interaction with someone I think has crossed the line from complicated pain treatment into simple drug addiction, it is almost impossible to feel proud, or good at my job. And it is impossible not to feel a little abused.

I am not laboring under the illusion that by withholding or limiting prescriptions for opiates, I'm curing addiction. Far from it. I know that the pharmacy of the street contains every drug that the chain-store pharmacy carries, and more. If someone wants this stuff, they can get it. But I don't want to put a clean white coat over someone's addiction. I don't want my training to become someone else's denial. And if I'm not curing addiction by holding back on certain prescriptions, at least I'm not feeding it.

The problem with this is obvious. It's for all of these reasons, and more, that much of chronic pain does go undertreated in the United States. The prejudices that get layered onto this struggle also mean that an unemployed black man with a lot of back pain is probably less likely to get his pain treated than an employed white man with much less back pain. At the same time, it's simplistic to say that everyone who rates their pain as "10 out of 10" should get their opiate dose doubled as some kind of democratic principle.

I spent a lot of time in medical school thinking about what it meant to be a democratic doctor. In my ideal world, I am a doctor who acts as a consultant to people who are trying to manage their own health. I am not taking care of people; I am helping people take care of themselves.

But every democracy has its vulnerabilities, its way of being subverted by anti-democrats. Every democracy depends on a predominance of good intentions, and so too does the democratic clinic. Prescription opiates are where the democracy in my clinic is most tested, and where I most commonly fall short of my ideals. My eyes narrowed and my heart suspicious, my hands grip the lock firmly; I will let no one else open the box. My DEA number is mine, and mine alone.

When it comes to opiates, my democratic clinic is constantly at risk for becoming a failed state. Generally my clinic muddles along more or less as it is supposed to. The trains don't run on time, but they run. But with opiates, the slightest difficulty provokes an untenable choice between a chaotic ungoverned world of individual self-interest, and iron-fisted dictatorship.

The opium poppy: you say you want it for the receptors in your central nervous system, but is it really for the hunger in your heart?

Saturday, November 17, 2007

Go team!


pictures from Jimmy Huang's blog

How do those crazy kids give congratulations these days? Uh... MAD PROPS? I don't know. Anyway, congratulations to San Francisco's Lincoln High School biotechnology team, who worked in a UCSF lab to create a synthesome (read the article which explains it, and the blog by a team member which gives the play-by-play). Their team went head-to-head with college kids from around the world, flirted with cute cell wranglers from China, made the list of finalists, and ate at Toscanini's. This coming-together of my SF life and my Cambridge life made me happy today; sure, team Lincoln/UCSF, Toscanini's is no Mitchell's, but there are some good flavors, and I wish I'd been there to congratulate you.

Lincoln High website

Friday, October 26, 2007

Dreams

Many large mammals seem to dream. Photo from www.tanzaniaparks.com

Earlier this week I dreamed that someone from my residency program--it wasn't anyone I know in real life--plunked down a piece of paper in front of me with a dollar amount. (About two month's pay.)

"We'll give you this much to buy you out of your contract," the person said. They didn't want me to be an intern anymore and were going to pay me to stop working for them.

In reality, I would never be confronted with that kind of choice; I'd be fired or I wouldn't. But the dream made the prospect of being fired even more dreadful: I had to choose to be fired, and take the money; or refuse to be fired but not get the money while knowing that my bosses wanted to fire me anyway. I realized this in the dream, and began thinking, "This is terrible--they're going to stop me from being a doctor, they don't think I can be a doctor, but I've worked so hard to be one, I want so badly to be one"; and then I woke up suddenly with a terrible feeling. I quickly realized that I'd been dreaming.

"I'm doing fine," I thought to myself, in the dark of early morning, Ms. Dr. Hemodynamics and the Hemodynamic Cat sleeping soundly in the bed as I woke up and looked around at the real world. "That's not what's happening." Or rather, it wasn't what was happening in my actual life, where my bosses do not seem displeased with me. But clearly some portion of it was happening in my emotional life, my submerged world of fears.

Later that week, I led a presentation about a particular case, designed to start a discussion among interns, residents, faculty and guest experts about how to think about a patient's problem, and the issues it brought up. I did some work I didn't absolutely have to do on the presentation, and I hope it showed. Anyway, two faculty members told me I'd done a good job.

In the most literal sense, I have never dreamed of such a thing. I have imagined it or hoped for it in the daytime, and I have experienced it before. But I don't remember ever waking up from a dream in which one of my bosses or my teachers had just told me I'd done a good job, even though that happens much more often than someone firing me. Maybe I have those kinds of dreams. Maybe I just don't wake up from them with that startled dread that makes me remember a dream. Or maybe fear requires more overnight processing than hope or optimism do.

Freud said dreams represent narratives of wish fulfillment. I don't buy it, or not exactly. I read The Interpretation of Dreams in a film class when I was seventeen, and in retrospect I think it may remain more important for filmmakers than it does for clinicians.

I don't think I want to be fired from my job, or bought out of my contract. And I'm not prepared to do the interpretive backflips Freud and his followers required to turn that common kind of dream into a narrative of some kind of unconscious wish. It's a dream about a fear, which in the organization of the mammalian brain has got to be at least as powerful as a wish. If the brain is going to spend a lot of processing power on learning, fear is probably a better way of organizing learning for survival than wishing.

I'm a person of my era, not Freud's, and in my simple-minded way of thinking about dreams, I think of dreams as the brain reprocessing the material of the day--the intellectual material and the emotional material too. Whether they are wishes or fears, they get processed.*

Maybe the common ancestor of people and chimps slept in a forest, dreaming about her fellow apes turning on her for stealing fruit she didn't steal, horrified as they advanced towards her, shocked by this unreasonable turn of events; then, I hope, waking to find herself among peaceful family members. Now my great ape brain dreams about my bosses telling me I'd better fire myself from my job. If my dream has its ancestral predecessor, both of us apes--the ancestor great-great-great-grandmother ape and me--would be dreaming ourselves a deep social lesson, processed and then wired through many redundant circuits, which says, "Don't anger the apes around you."

For me, at least since junior high school and probably before, countless dreams have reinforced variations on this theme. Whatever imagined events these dreams are processing, their emotions and narratives surely help me be a more or less polite and socially appropriate person during waking hours. And that kind of dream creates such a powerful dread on waking that it is hard not to imagine that its mechanism must be deep and ancestral, dating back to that great-grandmother ape dreaming many millennia ago.

***

For practically every patient I admit to the hospital, I put in an order for "vital signs per routine"--which means they get woken up at night and early in the morning. People in the hospital also get woken up by their roommates, or their roommates' televisions; or worst and often most disturbingly of all, by other patients, delirious, their hallucinations representing a waking state of dreaming, or a dreaming state of waking, screaming "HELP ME!" or "GET AWAY FROM ME!" or "DON'T TOUCH MY PENIS!" across the hall again and again.

Once in a while you meet someone who can sleep through it all even without a lot of sedative on board. With one recent patient like this, I came to think that he'd spent enough time in hospitals that he'd figured out how to sleep while in a hospital room, including what had clearly become a nearly instinctive ability to fend off medical interns in the morning and keep sleeping despite their questions, pokings, and proddings. (This is not an easy task.)

Alone among my patients, this man was likely having dreams, full dreams, rich dreams. Did they make him better? Did they help him figure things out? I'll never know. I just hope that if I appeared in his dreams, I was never one of the apes who was hurting him.

<<>>

*Considerably less simple-minded descriptions of this kind of processing can be found in this article in Science for those who have access to it through local or academic libraries.

Monday, October 8, 2007

Fear is the mindkiller, part 3


My slogan for internship: "I will not fear. Fear is the mindkiller"--from Dune. But there seems to be no getting around fear.

***

I've been feeling burdened lately. I had the day off on Monday, and I was at a grocery store in a wealthy neighborhood getting myself the best coffee in town. I was there because I felt that with everything I'd been through in the previous week, I deserved a treat.

A young mom wearing some outfit that a skinny person would wear to yoga (the pants were tight and stretchy, not loose and concealing) had run into someone she knew. "Oh, I'm a little stressed right now," she said. "The kids are starting sports, and they're in school now, so lots going on, it's been a little bit overwhelming."

I wanted to turn to her and say, "Are you f***ing kidding me? Seriously. You're at the gourmet store buying $20 a pound cheese and hanging out with your kids, and what you have to say for yourself is you're stressed?"

Then I reminded myself that maybe for her motherhood does count as 80+ hours a week doing a terrifyingly high-stakes job, and although I do have to say that taking kids to soccer practice and the gourmet cheese store doesn't sound THAT stressful, what do I know?

Anyway, I realized that my reaction to her was not about her. It was about my stress, and how annoyed I was that someone else would claim to be as stressed as I am. In other words, I'm starting to feel sorry for myself. It was inevitable that it would start sometime--self-pity is probably the one thing that almost all medical interns have in common at one point or another--and I now recognize that it has started.

But I have always been willing to work reasonably hard, and for long hours. And there are many things about the work that is interesting and challenging in all sorts of good ways. So it isn't the time or the work that makes me feel burdened and sorry for myself. It's the fear.

I have a low-grade fear that never really disappears, like watching a scary movie while the main characters are driving around doing something innocuous. You know something bad is going to happen, but you’re not sure what.

I make mistakes all the time. Most aren't a big deal, and the few mistakes that could have become more worrying were caught by other people. There are only one or two mistakes that can still haunt me. The worst one came very early on in internship, when I didn't recognize an acute problem as it was beginning, until it required more serious intervention than it might have if I'd recognized it earlier. No one blamed me for it. Like many intern mistakes, it was an error shared by several people. And the outcome of the patient's hospital course was unlikely to have been any different as a result.

When I came back to the incident a couple of days later in a check-in session with my attending of the time, he said, "This is why you do residency. You just have to see it often enough to recognize it. If medicine was all things you could learn in books, we could just turn you loose after medical school. You can go ahead and feel bad about it, and in fact, you should, so it won't happen again. But this is what residency is about." He said that I was right on track for where I should be in terms of my skills as a physician.

I guess I took his advice: I didn't let the mistake stop me from coming to work the next day. But remembering that morning can still clench my stomach with a special force. No matter how much I reassure myself or other people reassure me that such mistakes are part of the normal course of my development, mistakes still frighten me.

It's mostly just the most recent mistake or two I've made that I remember at any given time, though, because the main reason the more inconsequential mistakes matter is that they remind me of my potential to create harm. That clutching clenching weight inside my abdomen, the horror of the near-miss, returns even when I think about the smallest errors. It's not usually the errors themselves that make me feel that way; it's the fact that I continue to make errors.

For the first couple of months the excitement of being a doctor, and the new confidence I have as an intern that I didn’t have as a medical student, was enough to compensate for this sensation, enough to keep my energy and enthusiasm high. But recently I think that constant sense of near-miss or about-to-hit, that chronic fear, is starting to exhaust me a little bit.

I don’t want to get rid of the fear, because it makes me a better doctor as I make my lists and check them twice. But I want to figure out a way to live with the fear. I don't think it stops with internship. There are doctors I see who look totally relaxed, but they've been doctors for a long long time, and anyway, I'm not sure they should be as relaxed as they are. What's worse in a doctor than overconfidence?

In other words, fear is necessary. But it is also burdensome. More than the hours, more than the work itself, fear is what makes me feel like this is especially hard. Fear is what makes me feel secretly sorry for myself. Fear is what makes me tired and irritable; fear makes me hate some mom in a grocery store. My task for the year is not only to become a good doctor. It is learning how to live with the constant fear of being a bad doctor.

Musical break: Senegal Fast Food






Listening to Manu Chao's new album on this rainy day off from the hospital, I went to his website and found this song ("Senegal Fast Food") he did with Amadou & Mariam--not on the new album, which like this song is both infectious and addictive. The plot of the video sneaks up on you, especially if (like me) you only get 1/10 or 1/15th of the French.

Monday, September 24, 2007

How I'm changing... part 3




As internship was about to start, I was writing about how medical school had changed me; now internship is 25% done and I'm watching myself change in new ways. Back then I wrote wondering about whether I should aspire to having some kind of secular-spiritual version of love for all my patients. Now I feel like that's beside the point. One of my friends wrote back then that love like that might or might not be a good thing, but either way it's exhausting, and a different job than the one I already have to do.

She was right, as it turns out. The other day I was at work and was thinking, maybe there is still something to be said for the idea that I should love all my patients, but whether or not I should, I just can't, and don't. One of my co-interns says that in some way the definition of professionalism is acting like you care about people that you don't necessarily care about. That might be a little harsh--there is still something about human decency and compassion that I'd like to think exceeds simple professionalism. But right now, it's too much work to love everyone and also get all their discharge paperwork done and lab tests ordered; human decency has to be enough.

I do love some of my patients because they are sweet, or thoughtful, or charismatic in some way. And some of them are so totally insufferable as to become comic and therefore lovable in their own way.

But these days, what moves me through the day is not love. It's something much simpler: I move through the day because I need to get to the end of the day.

Saturday, September 1, 2007

Take it to the limits, one more time...




I page the infectious disease fellow, who's staffing the antibiotic approval pager. I know him: he was a resident when I was a medical student. He calls me back. I tell him briefly about the patient, and say, "We want IV vancomycin."

"When you were in medical school," he says, joking with me but also not, "You were this cool progressive socialist guy, ready to fight the system. Now you're calling me with this. So, I'll approve it, even though it's a NIMBY thing that will increase antibiotic resistance for other people. But what happened to you? What happened to the idealism?" He's making fun of me a little, but also I think wondering about the actual answer to the question.

"If I thought about health policy for more than a minute of my day," I tell him, "I couldn't get anything done."

I once heard an ICU nurse, frustrated with the night's project of keeping some very old and utterly unconscious person alive with expensive equipment and unclear benefit other than satisfying the person's relatives that "everything is being done", and she blurted out, "This is insane. We should be taking this money and investing it in children." Fair point. But either she ignores that point of view for most of her day or she's going to have to get a new nursing job.

I send people to MRIs all the time; as one attending of mine said, Boston probably has more MRI machines than all of Ontario. The availability of MRIs drives our willingness to order new studies; if it was harder to get someone into an MRI, we'd accept the slightly less exact findings of a CT, and so on.

Obviously from a policy point of view this suggests we should probably send less people to MRIs. But as an intern, my job is to carry out the medical plan, and to suggest aspects of that plan. I don't have the final authority over that plan. It is usually not for me to decide if someone gets an MRI or doesn't, at least not on a policy basis. It might not even be for the attending to decide: if other people in the area usually get MRIs for a particular problem, it begins to become negligence if the attending doesn't get their own patients the MRI.

Either way, I order IV vancomycin and MRIs all the time, among many other things, much of it on the federal government's Medicare tab, while the president says the federal government shouldn't get more involved in making sure children have health insurance. It's not like this cost comes out of nowhere; when healthcare dollars go to MRIs, there's somewhere else they're not going. When we use broad spectrum antibiotics to "cover" someone with a fever we can't yet diagnose, it costs money and increases bacterial resistance.

But if I'm honest, it's not just the system that demands this of me. My own views are full of contradictions: when facing an individual I am ready to go all out, to order everything that might have some benefit.

When thinking about the society, I think that there should probably be some limit to this. But I'm not the one who makes the limits. More often, as an intern in a large teaching hospital, I push the limits.

I say something about this to the ID fellow, and say that even if I had any power at this point, I'm not sure what I would do about this contradiction of wanting limits and abhorring them. We're quiet for a second.

Then I say, "Anyway, we want our IV vancomycin."

"Another resistant organism being created, at exorbitant cost," he says.

"Yep," I say. "Still, we want it."

"Done," he says, clearing it off the approval queue on his computer screen.

Sunday, August 26, 2007

Finishing BMT.


photo: leukemia cells. From PLOS Biology.

I'm now finished with the bone marrow transplant service--or what is really the hematologic malignancy service, which serves people with lymphoma, leukemia or other problems of their blood and immune cells. It was a tough month, with long hours, as my lack of posting at this blog will reveal.

One snapshot:

The floor below is a labor and delivery floor. On the elevator up, a family of kids and adults is talking excitedly, carrying a congratulatory balloon. One woman stands quietly on the side; the oncology/bone marrow transplant floor button is already pushed when I get on. The family leaves at the labor and delivery floor, and the door closes, leaving her and me in the elevator. She says, "It's amazing how different those two floors of the hospital are." We get off at the next floor; it is quiet.

A sign at the entrance to the BMT wing tells visitors that children under 6 are not allowed. Small children and their microbes are among the many things which pose potentially mortal danger to people getting bone marrow transplants. They are sitting in their rooms, waiting for their new immune systems to grow.

Thursday, July 26, 2007

HIV meets diabetes meets HIV

In the early 1990s, I never believed it would happen. But in mid-February 2007, I heard a cardiologist talking about the cardiovascular effects of HIV, who then put his talk in context by casually saying, “Even so, I’d choose to have HIV over having diabetes.” The doctors-in-training listening nodded in agreement. They probably didn’t remember that people used to talk about comparing HIV to diabetes like it was an impossible dream.

In 1992, Bob Rafsky, a person with AIDS and a member of the activist group ACT UP, wrote in the New York Times, “It's always possible we'll win. The drug, or drugs, that will turn AIDS into a chronic illness like diabetes will finally be discovered.” But, he wrote, “it's not likely, at least not in time for me.” Rafsky died the next year, in 1993.

Just three years later, starting in 1996, the kinds of drugs Rafsky had hoped for arrived in wealthy countries like the United States, used in combinations of medicines that together became more than the sum of their parts. Along with other improvements in HIV care, that allowed people to live with HIV for much longer periods of time than before.

Even back in 1996 and 1997, people were starting to say that living with HIV could finally be like living with diabetes, a difficult but manageable chronic disease. This didn't mean that it would be easy.

With modern medical strategies, the most common and serious effects of diabetes aren’t short term crises of sugar levels, but the effects of long-term damage to blood vessels: problems like stroke, heart attacks, kidney failure, blindness, nerve problems, and foot and leg infections that can sometimes require amputation.

Avoiding these problems over the long-term requires constant vigilance. In fact, as HIV medications become easier and simpler to take, sticking to them is often less complicated than sticking to diabetes regimens.

Especially early on, most Americans with HIV got the virus either from unprotected gay sex or sharing needles, which is part of how HIV got the stigma that it still has today. By contrast, Type I diabetes often comes in childhood, as a result of an autoimmune problem; no one blames people with Type I diabetes for their disease.

But stigma does influence how society responds to the much more common kind of diabetes, called Type II diabetes. Whether people get Type II diabetes has a lot to do with genetics. But higher amounts of body fat are associated with higher risk for Type II diabetes. That’s political poison for mobilizing a response to Type II diabetes, because Americans tend to misunderstand why people gain weight, think of fat as a kind of moral shame, and vastly underestimate the difficulty of losing weight and keeping it off. And so society can distance itself from Type II diabetes, by blaming the disease on the people who have it.

When AIDS was a more lethal disease in the US than it is now, it inspired intense fear and stigma and discrimination. In the late 1980s and early 1990s, people with AIDS and their allies, including activists like Bob Rafsky, began speaking against that fear and demanding the solidarity of others. They won the support of many; red ribbons became de rigeur for celebrities for a while. That kind of activism (both the angry kind and the syrupy Oscar ceremony kind) helped bring the day that HIV infection became more like diabetes.

Now, as Type II diabetes becomes more common, and also stigmatized for its increasingly well-publicized association with fat, the new challenge might be for Type II diabetes to become more like HIV—in which people with the disease and their allies stand up to demand that the society get over its prejudices, and start paying more attention.

Saturday, July 21, 2007

Night float: "MD aware"

Last night I was on night float--this time, a one-time thing, to give other night float interns a night off. Today, I'm spaced out and headache-y. Some of the other interns are getting together for dinner and drinks tonight, and I should go, but I feel as if I can't bear to talk to anyone or go anywhere. Instead, I'm sitting in my apartment while Ms. Dr. Hemodynamics is on call. I'm listening to KCRW on the internet, writing this after cooking myself some dinner.

I'm not sure when the concept of night float was invented, but it's become a lot more common with work-hour restrictions for residents. In overnight call systems, when residents literally lived at the hospital (hence the word "resident"), "call" meant not only admitting patients to the hospital but also cross-covering other residents' patients.

Now, the interns and residents on call stop admitting after a certain point in the evening, and a nighttime team takes over both admitting and cross-coverage. In our hospital, the night float interns respond to the problems of patients already in the hospital. The night float residents admit new patients who are coming in overnight.

That means that as an intern, I was answering pages from nurses for some large number of patients--I didn't want to know exactly how many. Something in the range of 50 or 60 or 70, I think, but I never counted; I just answered pages.

Some of these pages seemed simple; this patient wanted medicine for back pain, while that one wanted something to help him sleep. But for me last night, anything but the simplest and heavily chart-documented chronic back pain warranted a visit (was it new? where was it? was it a kidney infection or a spine infection? or just from sitting in a hospital bed for days?). Help with sleeping required at least a chart review (how was the patient's kidney function? liver function? what had they taken in the past? any psychiatric issues?) to try to figure out whether the easiest choices might make them crazy or dangerously sedated.

Then there were the pages that went something like "[Patient name] down to 90/56". A drop in blood pressure can be truly ominous: it can be a sign that someone has a new serious infection, or an acutely failing heart, or new internal bleeding. But the majority of overnight pressure drops last night were probably mostly caused by something simple: sleep.

One of my more alarming pages about low blood pressure last night was solved by turning on the lights and talking to the patient and listening to her heart and lungs with my stethoscope. When that was done, she was at an average blood pressure, and I was convinced by her quick wake-up and easy return to coherence and consciousness that she'd been doing fine all along. The unfortunate effect of this kind of evaluation: when the number on the screen means a nightmare for me, that's the end of sweet dreams for you. On the other hand, it's better than getting a bag of unnecessary IV fluids.

Some reasonable proportion of us, if we had telemetry monitors hooked up to us at home every night, would be setting off alarms all the time. But even when nurses are reasonably sure that this kind of normal situation is why the pressure is low, they need to page the doctor anyway. In the nursing note, they have to make note of abnormal vital signs, and they write something like "BP down to 89/56 during night while pt sleeping. MD aware."

As with my first night on the MICU, I was once again grateful for my hospital's well-educated and experienced nurses. In one case, a renal fellow talked to me about the patient in some detail in the late evening, and then checked back in with me in the morning about how the plan had gone. I explained that we'd stopped the fluids, and why; the fellow was pleased because this is what she'd called to recommend.

"Actually," I said, "the nurse called when the labs came back, and said we should stop the fluids, and I said that sounded like an excellent idea." The fellow laughed, and praised me for listening to the nurse.

I said, "I try to do what the nurses tell me, probably... mmm... 85% of the time." She laughed again: "Sounds about right," she said.

The rest of the 15% is complicated, and it's rarely due to some error on the nurse's part. More often, it has to do with differing priorities. For instance, since the nurse is hearing the patient complain all night, and is sick of answering the call button again and again, the nurse might be more ready to want the patient to get a sedative medication for sleep. Often, this is informed by knowing that a particular medication is given all the time, and knowing that a particular patient is medically stable, and knowing that it's really hard to get good sleep in a hospital.

On the other hand, for people with complex medical problems, a lot of these medications can be frightening for the doctor to prescribe, and if I can avoid prescribing them, I will. The most satisfying visit last night was with one of these patients, who had many medical issues. The patient and the nurse wanted a sedative to help him sleep. The idea was worrying to me, since all I knew about the patient was a list of medical problems, and the drugs I knew best each had some possible bad interaction with at least one of those problems. I was doing some other things, and took a while to come up to evaluate the patient, probably to the annoyance of the nurse and the patient. But by the time I got there, the patient was asleep without my help. (The ideal solution for this situation is for the doctor who is taking care of the patient by day to anticipate this problem and suggest a possible sleep medication for the night float intern to prescribe if necessary--but it's July, and that kind of hand-off is a ways off.)

The most frustrating thing about night float was one of the things that makes night float systems worrying to most people who think about their risks and benefits: hand-offs. I got some less-than-totally-informative descriptions of what was going on with some of the patients I got called about overnight. And on my end, hopefully just because it was my first night, the system I was using to keep track of overnight events turned out to be much-less-than-excellent, and I fear that I may not have handed off all the information I should have.

But looking at the hospital computer system from home, it looks like everyone is OK for now. The people I worried about didn't get the kind of labs drawn that would suggest problems (like arterial blood gasses, which are drawn for people in respiratory distress). A tentative sigh of relief: night float is over, and the day has come.

Sunday, July 15, 2007

Links

A little while ago, another blogger tagged me with a meme that I was then supposed to pass on. I didn't have it in me to send on the meme but then I realized that I therefore also hadn't linked to any other bloggers--and therefore had done nothing to support the nebulous but important community of bloggers.

To redeem myself, here are some links, not quite all blogs, and in no particular order, except the first:

1. Amanda of Ballastexistenz takes on the 8 random things in a literal way, much more lovely than my version--8 random things, photographed and explained.

2. In a parallel to my previous post, fellow internal medicine primary care intern/ MICU warrior/ blogger Dr Jess seems to be liking being a doctor too.

3. Just in case Dr Jess and I are warming your heart too much about doctors, though, the ever-scrappy Barbard Ehrenreich recently posted about the consequences of a healthcare system based on the drive for profit--including the tale of a truly terrible doctor.

4. At Acid Reflux, the always witty-and-pretty Miss Retro Virus is on her world tour. The sponsorships on her tour poster are a nice touch, but if that means that Miss Thing is really injecting T-20 (aka Fuzeon) 2x/day in Kigali, I truly salute her. Brian has lots to report in recent dispatches, including moving accounts of a meeting with people living with HIV in Rwanda.

5. If you're hoping that Miss Retro Virus will have a more fabu entry inhibitor soon, or you just want to get your own hands on one, keep tabs via the Treament Action Group's handy guide to antiretrovirals in the testing pipeline.

6. Chris at Methed Up continues to wrestle with how to make sense of his life as an addict, and is now looking back on the days before crystal meth came along. Crystal meth has been beating the fabulousness out of a lot of gay men (and, of course, others); and as a worried spectator when it was just a local West Coast curiosity, it's made me really sad to watch it spread coast to coast. But reading this entry reminds us that waves of new drugs don't hit randomly; they're most likely to hurt the people who had already been struggling--or would have been struggling--with the old ones. Like vodka, for example.

7. In theory, this link to Tundra Medicine Dreams should have something to do with health. In reality, it's for the really great sled dog puppy pictures and story of the retiring sled dog mom, by the rural Alaska physician's assistant who writes this blog.

8. And my longtime buddy from back on the West Coast, Big Sister, who writes about knitting but also has various other things to say (including some great recent travel pics that will make you want to go to Belize and the Alameda County Fair, in that order). In this post she showcases some items from Etsy.com. I then went to Etsy and found a slightly overwhelming amount of cool handmade arts and crafts to choose from.

Becoming a doctor requires imagining the obvious.

When I was in medical school, I worked hard; I was thoughtful about my patients; I got along well with most of the people I worked with. But my grades weren't as good as some of my colleagues' grades were. They were fine, but more often than I liked, I seemed to just miss the highest grade in my overall evaluations. Sometimes that was for blatantly unfair reasons, other times for reasons I understood perfectly. But most of the time, it was harder to tell why I'd just missed. I spent a lot of time thinking about how to improve, and asking people how I should be improving.

In the last part of medical school I was starting to get it. An ICU rotation gave me the biggest transition: I went from doing some of my worst clinical work (in that I was disorganized and confused in presentations and in my thinking about patients) to some of my best. A couple of other rotations towards the end of medical school also went well. Still, I wasn't sure exactly what had changed, and which of the things I'd done to try to improve had actually worked.

Now that I'm an intern, I still have a lot to learn. And I'm sure I'll still have many stumbles and falls ahead. But I feel more confident in a way that surprises me, but also explains a lot of my medical school experience. I recently realized that it took me until some point between getting my diploma and my 20th hour of internship to actually believe that I was going to be a doctor. In other words, until I became a doctor, there was some part of me that didn't understand that I was actually going to be one.

In fact, even during my first day on call the meaning of the job still hadn't 100% sunk in. I was just trying to keep up, to not do anything wrong, to keep my feet on the floor and my pulse within normal limits. Before I started, everyone told me to listen to the nurses, and especially with a bunch of ICU veterans like the nurses working with me, that seemed like great advice. Nurses were coming up to me and saying, "Mr T's pressure is dropping; I think we should give him a bolus of fluids." Great, I'd say. "Half a liter sound good to you?" I'd say, entering the order into the computer. "Mrs S's potassium is down," another would tell me; "Thanks, I'll order that now," I'd say, looking at the sliding scale to replete the potassium.

For most of that first day on call, this worked excellently. Our hospital's critical care nurses are excellent, my resident and attending were watching closely, and our patients did well.

At some point early in the morning, a nurse suggested another bolus of fluids on a patient. The patient had already had a fair amount of fluid through the day. I started worrying about what another half a liter was going to do to his lungs. "Actually, I'm hesitant to do that," I said to the nurse, explaining my reasoning. Together the nurse and I talked through an alternative plan, and I checked in with my resident. It was a tiny step, a tiny transformation, but I recognized it: actually, I was a doctor. The MD on my badge was more than some iconic token of my education.

Later, as I realized that I understood some of the physiology and basic science of another one of my patient's problems, and that my patient's nurse did not understand it in the way I understood it, I realized that those years of medical school did teach me something. It's not that her education and experience and observations didn't add up to anything. But it added up to something different. Patients are safer and better-served when nurses tell doctors when their medical interventions will cause unforeseen harm, and when they are partners in the conversation about what might be done next. But that doesn't mean that doctors, even new ones, can get away with just relying on the nurse to keep the patient well.

All of this is pretty obvious to an outsider, and probably to most medical students too. But now I realize that I hadn't ever 100% believed that I would become a doctor. That belief, I see now, is a big part of the intangible confidence that some of my colleagues with better grades had. It's part of how they looked like future doctors instead of current medical students. And when I at least mostly believed that I was responsible for being a doctor--as in my ICU rotation, and a couple of others--I did well.

Now I'm a doctor. And I actually believe it. As soon as I started believing it, I became a better doctor, in an instant.

Now, looking back and recalling that a medical student will, 98-99% of the time, graduate and become a doctor, I've been thinking about what part of me wasn't registering the obvious likelihood that I would also soon become a doctor. Some of the answer comes from who I was before medical school. The people who love me the most have always had great faith in me, and believed that I was capable of many things, but I don't think that when I was in my teens and up to my mid-twenties that anyone who knew me well would have predicted what I'm doing now. I thought of myself as an artistic person, and a political person, but not as a scientific person, nor as a person who would ever become such a normal thing. Willie Nelson instructed, "Mamas don't let your babies grow up to be cowboys"--instead, he sings, "make 'em be doctors and lawyers and such." I never thought I'd be a cowboy, but I didn't think I'd be one of those and-suches either.

Many of my classmates come from medical families. They believed they'd become doctors because the job and the social identity seemed natural to them. They might have resisted it when they were younger, in order to walk their own paths and not their parents', but when they returned to the path of medical training, the terrain was familiar. The medical students who didn't come from medical families often spent their lives, since they were children, working towards the goal of becoming a doctor. I think that many of these classmates, in both categories, always believed in their future as doctors, as soon as they walked into the hospital. They started to become doctors well before they were qualified to earn a medical license. That's actually sensible. You're 66% a doctor at some point in the third year of medical school; at that point you are really more a doctor than not.

When I look back and see the ways I was improving in the last part of medical school, I see that I was becoming a doctor, that the 85% doctor I already had become was directing my actions, even if my consciousness was still too aware of the 15% doctor that I was not.

It seems easier to imagine becoming an excellent and experienced doctor (which, nearly by definition, I am not) than it was to imagine becoming a doctor at all. The next part of my training will require more work, more cognitive strain, and a steeper learning curve than medical school ever asked of me. But in terms of how I see myself, and how I've had to change how I see myself, the hardest part might have just ended.

Thursday, July 12, 2007

My first patients...

I saw my first two primary care patients today, in the clinic that will be my regular clinic through the year.

I had two patients scheduled; the night before I read their records, nervous and excited, making notes about what past issues needed follow-up. In reality, one cancelled and one didn't arrive. Instead I saw two completely different patients.

I've had lots of outpatient experience, and I figured I'd be able to breeze through easily. I didn't. That was fine, actually--but it reminded me of how outpatient medicine looks easy at first, and then really isn't at all.

Saturday, July 7, 2007

8 random things





Photo: Cape Fur Seals, lovely pinnipeds, in Cape Town. Videos: opening sequences for the old TV show Emergency!
Chris from Methed Up tagged me with the meme of 8 random things, with the following rules:
"1. Each player must post these rules first.
2. Each player starts with eight random facts/habits about themselves.
3. People who are tagged need to write their own blog about their eight things and post these rules.
4. At the end of your blog, you need to choose eight people to get tagged and list their names.
5. Don’t forget to leave them a comment telling them they’re tagged, and to read your blog."

I'm leaving out 4 and 5... but here's #2.

1. My first language was Portuguese (but I stopped speaking it shortly thereafter, when my family moved back to the United States).

2. My college mascot was the Banana Slug.

3. Two of my favorite college classes: "Architecture of the Suburbs" and "Anthropology of Dance."

4. I am one of the two oldest people in my intern class, just as I was one of the two oldest people in my medical school class.

5. 44% of the kids who were in 9th grade with me dropped out by the time I graduated from high school. But none of my friends were among them.

6. My first career ambition (at age 4): to be a paramedic.

7. I'm a huge fan of pinnipeds.

8. I have started to think that I have become much more introverted than I once was, or perhaps I'm just realizing I was never as extroverted as I thought I was; either way, this is some part of the explanation for why I am not tagging eight other bloggers with this meme.

Sunday, July 1, 2007

How to declare people dead.



First step:

Examine the person who may be dead.

Their pupils should be fixed and dilated--that is, showing no responsiveness to light and remaining fully open. They should not have a blink reflex when something brushes against the cornea of the eye. They should have no heart sounds for one minute of listening. They should have no breath sounds, and no other evidence of breathing. They should be unresponsive to deep painful stimuli (e.g., pushing down sharply and rubbing the sternum--the middle of the chest). Especially if they have been brought from somewhere else rather than dying in the hospital, they are "not dead until they are warm and dead", because hypothermia can mimic death by slowing down and dampening down all bodily functions.


Next:

Write a note in the chart. Like all other notes in the chart, sign it with your name followed by "MD".

Declare the person to be dead by filling out a form for the hospital admitting office. Call the office and let them know the patient is dead. If need be, they can tell you your medical license number which you are supposed to put on the form; you've only recently become a doctor, and you can be forgiven for forgetting it.

If the death meets any of the criteria listed on the admitting office's form, call the medical examiner's office, who has the right to require an autopsy. You were told in intern orientation to make sure to get the name of which doctor at the medical examiner's office refused the autopsy, or at least which staff person you talked to. You might forget this part. Thankfully you can call back and the ME's office can remind you.

You're required to ask the family if they want the autopsy. The pathology residents require a certain number to graduate from their program, and they've asked you to please try to get autopsies. In theory, autopsies improve healthcare by showing what we might have done wrong, and showing whether our ideas about a person's medical problems were correct. Still, your own inner compass demands that you be gentle about this, and fortunately the vulture-like quality that might surround the request has been taken out of your hands, so that if the autopsy is obviously a dumb idea, you might simply say, "We are required to tell the next-of-kin for everyone who dies that you have a right to an autopsy, at no cost to you."

If the family wants the autopsy there is a consent form. Walk them through it. Once they've consented, sign your name, with "MD" after it.

Based on your earlier phone call, the hospital admitting office fills out the death certificate and pages you when it's time to come down to sign it. Bring the rest of the paperwork also. If you get caught up in something and lose track of time, they'll page you again.

Fortunately, they're there all night. At 4:30 am, as the morning lab results are just starting to trickle in on your MICU patients; as the x-ray tech wheeling around the portable x-ray machine is calling out "X-ray!" as he presses the button to take the morning chest x-ray from outside your patient's room; as he goes and pulls the x-ray plate out from under your sedated and ventilated patient's back, and moves to the next room to repeat the process; and before the sun begins to illuminate the glassed-in walkway between one part of the hospital and another, you can take the elevator down to the little no-windows office with cubicles and dull flourescent lights.

The admitting office workers are sitting in one of the back cubicles with stacks of paper around them. At that time of night one of the admitting office staff members might be doing a crossword puzzle when you arrive. But they know right where the death certificate is; your arrival is a key item on their to-do list, because it has to be done before they can release the body to the funeral home. Don't fill out any of the information on the form--they do that, and anyway, you'll just mess it up. If you start filling out the address and time and date information, they'll have to start a new death certificate. So just sign it with your name, followed by "MD".

Then, when you have a moment:

Recognize that the structure of modern society is to make life and death themselves medical and then legal matters, and to subject the most basic elements of our existence to professional authority. The birth certificate and the death certificate are signed by doctors, and then registered by the civil authorities. The "MD" proves the certificate's legitimacy as a reflection of an actual biological fact.

The birth certificate is not simply an extra voter created by a political machine, but an actual person with a beating heart. The death certificate is not a way for someone to escape their creditors or start anew in another city or make an insurance claim; it reflects one body's stopped heart. The doctor declares a biological process to have definitely begun, or to have irrevocably finished; the declaration of biology is necessary for the legal and political legitimacy of the state. A modern state must be able to keep track of who is born and who dies. This is an important distinction between wealthy nations and impoverished failing ones.

A person who was born without a birth certificate is a person without a legal identity. And a person who is dead but does not have a death certificate is a body in limbo, kept in a hospital morgue until the form is signed with "MD". Without this the body can not be buried; our funeral rituals of helping the person to pass from this life into whatever follows can not take place until a doctor signs the form that verifies that the person has indeed left this life.

Taking the elevator, back up to the ICU, you might think how strange it is to hold a doctor's power. The fact that declaring death requires your presence, your examination of the body, your ritualized declaration, your signature on the forms, are all part of how we wrap death in our own forms of modern technical expert solemnity. You understand why it's a good idea to be sure that someone is dead before you declare them dead, and why a doctor is called on to make sure. Still, to find yourself called to verify the death of a human body that everyone knows is dead is a strange task. You understood that the power of prescription, and the knowledge you hold, and the social role you play, all give you power in the hospital and in the world. But you might now realize for the first time that you are also an official of biological fact, called on by your state to be the neutral observer, to translate the natural world into civil forms and statistics.



As I was taking pre-med classes, one of my dearest friends was going to get married to his then-girlfriend, who had also become a dear friend. They asked me to officiate at their wedding. Of course I was deeply honored, and went immediately to the internet to get myself ordained as a minister--because for the state, sealing the bonds of love requires other distinct forms of authority.

But I also asked them, "Why did you think of me?" Among the things they said was, "Well, you're, like, a doctor." And I said, "No I'm not!" (I still hadn't got through organic chemistry. The outcome was still deeply uncertain.) And they said, "Well, almost." And I said, "Anyway, what does that have to do with anything?"

They tried to explain, and I think what they meant was that by virtue of simply aiming to become a doctor, I had acquired a kind of gravity, a seriousness that was different than their other friends. Or perhaps even more likely, by announcing my intent of becoming a doctor, I had begun to publicly acknowledge the part of myself that wanted to play that kind of role within my community and my society.

That was a long time ago. The daughter they had well after their wedding now has opinions about tacos, burritos, and their relative merits. After all that time, I finally have actually become a doctor, and I have taken on that ceremonial gravity in other ways.

"...I examined him and found his pupils to be fixed and dilated; he had no corneal reflex; he had no heart sounds for one minute; he had no breath sounds, no air movement apparent at his mouth, and no chest excursions; he did not respond to sternal rub or firm pinching. Time of death: 4:45 pm.

Joe Wright, MD. Pager #81987."





*

Wednesday, June 27, 2007

Post-call

A keep-moving, no-sleep, two-declarations-of-death my-signature-on-the-death-certificates, multiple-family-meetings, this-is-great/I-totally-suck medical intensive care unit call night, in which I had some of my best and my most horrible times in my medical training so far. Post-call after a night like that--not like I've ever had a night quite like that one--I'm always emotionally raw.

Ms H and I have our call schedules off sync right now; she's on call in another MICU tonight. So I'm alone after a long nap; wandering through Harvard Square in the hot summer night, and now at home, everything seems beautiful or tragic or profound or all of the above. A pair of young guys singing bluegrass harmony in the square; a schmaltzy tribute to Paul Simon on TV; the Hemodynamic Cat stretching out on the bed. Pop songs make me cry. Time for bed. More soon.

Friday, June 22, 2007

Wise words: internship starting


Illustration: William Hogarth, Industry and Idleness, Plate V (1747). "The idle apprentice: turn'd away and sent to sea." The British Museum. (Sad: he probably violated rule #8, below.)

Internship starts tomorrow. I'll be starting with the medical ICU, and my first day will include an overnight call night.

Amidst all the emotions associated with the anticipation of such an event, some of the graduating interns came up with tips for us while on rounds, and one of them wrote them up and sent the list out to our email list. Here's an excerpt (the first six are mostly hospital specific):


7. Send each other funny pages--it will keep your spirits up. And make you laugh in the middle of an otherwise serious conversation.
8. Get your coffee on the way to work. Otherwise you'll never get it, and nobody wants that.
9. If you're thinking about writing an order, just write it. Don't make a box on your to-do list to write an order.
10. If you don't know the answer, don't lie and make it up.
11. Don't forget to pee. They trigger patients for more urine output than some interns have. And drink a lot of water.
12. We know you're scared to death. Under no circumstances (unless you are [name of graduating intern]) should you memorize ACLS protocols.
13. And from [name], a graduating senior: "Nobody ever died of note-penia. Just take care of your patients. The note will come."

Saturday, June 16, 2007

The bag kills the fear. The bag is the mindsaver.







Above: retro/vintage flight bags from KLM and Aeroflot, from inretro.net. Below: my bag..

Today, I bought a bag, and I fell in love with my bag.

My bag is a dorky bag. I wouldn't buy or wear it under other circumstances. It's like a wierd zipper-heavy backpack-influenced re-creation of airplane bags that the airlines used to give out in the 1960s, but without the cool retro airline logo design.

REI calls it a "Boarding Bag"; like its predecessors, it's designed to be a small carry-on bag that holds the stuff you want on an airplane journey. Probably only someone who was a little worried about flying would buy such a thing. I didn't buy it for flying. I bought it for the hospital. But I did buy it because I was worried.

To explain this dorky-bag purchase, I must first explain that among medical students, interns, and residents, there are white coat people and there are bag people.

White coat people take their notes and reference books and PDAs and energy bars and reflex hammers and shove them all into the various pockets of their short white coats. The very disciplined or the wildly neglectful can get away with this easily: either you pare your carry-around stuff down to an incredibly small amount of stuff, in which case your white coat can easily handle it; or you simply leave all your stuff at home and try to get by without it. (In which case you never look anything up unless you're sitting at a computer terminal, and you test your patients' reflexes by hitting them with the end of your stethoscope.)

The much more common approach is to jam your pockets full of as much stuff as you can get into them--and at my hospital, the pockets are really big, and durable. A woman at the education office said, "I had students show me how big the other hospitals' white coat pockets were, and then I went bigger." My hospital is nothing if not scrappily competitive.

Unfortunately, this creates two more problems: the gunfighter problem, and the water-carrier problem. Because there is so much stuff bulging out of your pockets, you have to walk around with your arms out, like a gunfighter, or a police officer. Also, the stuff is heavy and usually poorly-balanced, and weighs down on the doctor-in-training's shoulders and back, leading the unfortunate coat-wearer to walk around burdened as if constantly carrying water from a well.

For these reasons I've almost always been a bag person. But my bags are usually too big. For instance, I have a big black messenger bag that can carry a whole desk inside of it, and I'm a little bit of a pack rat, so that by the end of a rotation the bag usually does actually have about as much in it as my desk at home has on it. That means that the bags are heavy, and therefore they solve only the gunfighter problem but not the water-carrier problem.

Worse still, I'm constantly having to leave the bags in places like underneath desks in nursing stations, or in call rooms, because I need to go do something where I don't want the extra weight. Or I take the bags off when I'm examining patients, in which case I end up leaving the bags in patients' rooms. Having to come back into a patient's room to retrieve my stuff is a little embarrassing; it seems like a pretty amateur move, and not very confidence-inspiring, especially in terms of my confidence in myself if not for my patients' confidence in me.

I saw an intern this spring with a bag that seemed to solve these problems. Small enough to keep with him, large enough to carry the right amount of stuff, it looked just right. I asked him where he'd got it; and today, I chose this bag as my version of it.

Afterwards, I kept looking at the bag; looking inside it again to think about what I would put in its pockets; zipping and unzipping its various compartments. I would be able to put private personal things in private personal places, my notes in easily accessible places, and my reflex hammer somewhere handy. I could carry my medicine manual and my energy bars and my headache medicine and a little bottle of water. But the bag won't carry more than that--so I don't think I'll be able to jam it so full of stuff that it will become unwieldy and impossibly heavy, like most of my other bags.

I was so in love with my bag that it became clear that my love had gone far beyond the bag itself. My bag had become my metaphor: it would give me organization, control, and my own little secure space within the hospital, even if it is only about 9 inches by 12 inches by 4 inches. Seeing all of these things in my bag, I realized not only why I loved my bag--or at least, the idea of my bag--but also what I had been fearing the most about internship. I fear becoming disorganized; losing control; and never having a space of my own. The first two might harm my patients; the third will make me crazy. Until now. Now I have my bag. Now I need not fear, and I will not. Because fear is the mindkiller.

Friday, June 15, 2007

khakis and button-down



Today at our hospital's ACLS training for incoming interns, the Harvard boys were clustering together a little more than we should have been. (Knowing myself and the others, the clustering was more social anxiety than it was snobbery, but of course that's a fine line.) More remarkably, of seven Harvard Medical chaps who were there, all seven were in some variation of khakis and a button-down, no tie. I think five had blue shirts on, and two had white shirts. (Or was it four and three?) One of our group of Harvard boys was dressed slightly more casually yesterday, but he fell into line today.

No one else among the incoming interns from other schools was dressed exactly this way. Most were a bit more casual. It was a training, and therefore there was no clear dress code. A few were as formal as we were but in different ways: with different kinds of colors, fabrics, and so on.

I didn't dress this way before. I lived in San Francisco and wore jeans to work; when I bleached my hair my workplace credibility as a community organizer went up, not down. My lab boss in Bethesda wore all black clothes (except she wore bright yellow clogs) because she didn't want to be bothered with the problems of matching colors; no dress code there either.

Harvard changed me. Harvard somehow made me think that I should dress this way. And I think we tuned ourselves to each other: we looked more alike the second day of training than we did the first. But clearly, long before this training, without anyone explaining it or demanding it of us, we all became the guys who wear the khakis and the open-collar blue shirts.

"It's what I'd wear if I was coming over here to meet with my research advisor," said A, one of my co-terns. I said, "Of course; me too." On some level, we both felt--well, what else would you wear? In fact, I had semi-consciously run through the differential on both mornings before the training days, looking in my drawers and my closet. I thought about a dark plain polo shirt but it seemed some combination of too casual and too golf-y. Jeans were out of the question. Definitely not a t-shirt. Not even an untucked short-sleeved button-down. I don't own any brightly-colored button-down shirts; if I did I wouldn't have chosen them. Yet other men there made all of these fashion choices, and others like them.

When I told her about all this, Ms. Hemodynamics said, "Well, sure. That's part of why they were recruiting you guys."

"But I find this distressing," I said. "That somehow the institution has taken my aesthetics and eccentricities and ironed them out of me."

She understood this; but she thought my clothes were still the right choice. And of course, my program had been recruiting her too.

Fear really is the mindkiller




ACLS training today. That's Advanced Cardiac Life Support--it's where you learn how to shout "Clear!" and deliver a shock; or, "One milligram of epinephrine!" Just like TV. (Except, you shouldn't shout.)

I passed the written part of the exam with 100% of the questions correct (not a super hard test, and my result was shared by many present, but still, it was satisfying). Then we went downstairs to do what the American Heart Association calls "Megacodes" which inspired some of us earlier in the day to keep saying "Megacode!" at random times during breaks. (Well, mainly me, actually. But I'm sure that others wanted to.) The megacode involved standing with a mannequin and a bag-mask and a defibrillator; while an instructor ran us through a basic simulation of cardiac or respiratory emergencies.

I was the first to volunteer to be a team leader, and it was brutal: I couldn't remember whether the pathway we were on led to adenosine or atropine. The sonic similarities of the two drug names caused me to merge these two drugs, which are not at all used for the same things. In the larger sense, I did the right thing in that I knew I was in doubt and asked my team members--who said, no, it's not adenosine. And though I was then able to say, "OK, right, atropine 0.5 mg IV"--still, I was miserable at the end.

The schedule isn't actually out yet, but I have reason to think I'll be starting in the ICU next Saturday. If it's true, that means I'll be on the code team starting within the first three days of internship. As long as my resident answers the code page as fast as I do, I'll be fine: I'll take orders, bag-mask, do compressions. We'll sprint down staircases in our scrubs, and as long as my resident is running right there beside me, I feel more or less ready. Excited, even.

But if the resident is in the bathroom? Doesn't hear the code page? Is dealing with some other emergency? It's unlikely, but I fear being, for even a minute or two, the only MD in the room. Because we are the ones with prescribing capability, we end up being the people who call for drugs. And therefore, the MDs generally become the team leaders. Even, it seems, when my ACLS instructors who work as respiratory therapists or nurses are also on the team. (I wanted to ask, "Seriously, you started working as a respiratory therapist when I was two years old, and I'm one of the oldest interns in the place, and I'm the one who's supposed to run the code?" But it didn't seem like the right time or place for that conversation; I'll save it for a night in the ICU when there is time and quiet.) Thankfully, asking for help is encouraged. As long as there are other people there--and if the code cart and the drugs that freak me out are also there, that means that someone else will also be there--I will be OK.

Still, mixing up the drugs when I was suddenly on the spot and feeling nervous was scary. That in turn made me upset and worried enough that I started having a hard time concentrating on the next cases and on what the instructor was telling us after I was done. I actually said to myself: "I will not fear. Fear is the mindkiller" in my internal Kyle Maclachlan voiceover voice, and with that, I was able to force myself back to the present, to the work in front of me.

Also I went around and talked to a couple of people to see if I could find a way to do some simulator sessions before internship starts. I want to pound on some mannequins, and see if that helps.

Thursday, June 14, 2007

All politics is local: Gay marriage is safe!


People in Spain celebrating their same-sex marriage victory in 2005; today, Massachusetts caught up.

The Massachusetts legislature knocked down the effort to try to advance a constitutional amendment to ban same sex marriage here. How did we win in Massachusetts? Well, many people made many different kinds of contributions.

From the New York Times today:
Senator Gale Candaras also voted against the amendment today, although she had supported it as a state representative in January. She said her vote reflected constituent views in her larger, more progressive state Senate district; her fear of a vicious referendum campaign; and the 6,800 anti-amendment e-mails, phone calls and faxes she received, one call every three minutes.

Most moving, she said, were older constituents who first supported the amendment, but changed after meeting with gay men and lesbians.

One woman had “asked me to put it on the ballot for a vote, but since then a lovely couple moved in,” Ms. Candaras said. “She said, ‘They help me with my lawn, and if there can’t be marriage in Massachusetts, they’ll leave and they can’t help me with my lawn.’ ”


More seriously, here's a lengthier statement from Senator Candaras on why she changed her vote.

Wednesday, June 13, 2007

In brief: fear=mindkiller, ACLS, medical grand rounds


Photo: "I will not fear. Fear is the mindkiller."

1. Medical Grand Rounds is up on Val Jones' blog.

2. Internship sort of started today with Advanced Cardiac Life Support training.

3. The movie Dune was on cable recently; it may be the best worst movie I've ever seen. Best of all, it featured the quote, from Kyle Maclachlan's thoughts, in voiceover: "I will not fear. Fear is the mindkiller." I have adopted this as my current slogan for the beginning of internship.

Friday, June 8, 2007

"Found Down": HMS/HSDM Commencement speech


"Each of these stories become more subtle and often more difficult versions of the same question: when we see suffering, do we look away, or go towards it?"
Photo: rescue staging area after Hurricane Katrina.



...More to write about graduation soon (it was yesterday, June 7). First, here's the speech I gave at the commencement ceremony of the Harvard Medical School and Harvard School of Dental Medicine.

I’m going to start with a story. It starts when a man falls down on the sidewalk. He might be drunk, or he might not. He might be unconscious because he fell, or he might have fallen because he became unconscious. Hopefully sooner than later, someone realizes that he has fallen down.

The call to 911 comes from the first person to realize this and to care. Next comes the ambulance crew, and even the cars that get out of the way when the siren goes on. As the story continues, there are triage nurses and doctors, x-ray technicians and respiratory therapists. Maybe the man found down has a strange rash, goes to cardiac cath, or needs a CT scan; maybe he has blood in one of his eyes, or a shattered bone. There will be more to the story, but this is its essence: a person falls, and in small and large ways, a huge network of people begins to pick him up again.

Today, we step into a new role within this network. But we have already been part of this group of people: those who go to the man found down, and try to help him up.

We can’t be too romantic about this story. Almost as soon as the man’s story begins, promises and demands of money start moving through the wires underneath the sidewalk onto which he fell, perhaps even before he has been picked up off of it. But today is not about that part of the story. Today is about what we do because of who we are, and not just who we are paid to be.

Each of us will encounter different versions of this story in our work. A child is frightened of her father. A veteran is overwhelmed with anxiety inside an MRI machine. And a family is just down the hall, waiting to hear the news of an operation, and someone must tell them that the operation went badly. Hundreds and maybe thousands of stories like this are unfolding at this moment, right outside this tent, in the hospital and clinic buildings all around us. And each of these stories become more subtle and often more difficult versions of the same question: when we see suffering, do we look away, or go towards it?

We’ll have to answer this question day after day. I once heard an ICU nurse in an urban hospital say, “All of our patients have the same chief complaint: found down.” July’s novelty and excitement will be followed by February’s bleak repetition. Just about any hospital has many people found down for reasons that are easy to diagnose, but can seem impossible to solve.

To respond to this sometimes relentless suffering, we’ll have to push back against huge impersonal systems, even when those systems beat us back again and again. And we’ll sometimes have to forgive terrible human frailty even as that frailty pushes us to our limits of forgiveness. And so nearly all of us will succumb to frustration and even cynicism from time to time. This is nothing to be ashamed of, as long as we don’t wallow in it, and as long as we don’t mistake bitterness for truth. We are graduating from medical school, not saint school.

Nonetheless, we can hope to meet the basic moral standard of looking towards suffering instead of away from it. In clinics and hospitals, in our personal lives, and in research and policy, we’ll constantly face this moral challenge. Even the best of us will often fail it. But that should not stop us from continuing to try.

When we do reach this standard, we have one final important task: to avoid congratulating ourselves too vigorously for our own forms of benevolence. Sentimentality about our special virtue as doctors can be as dangerous as cynicism, because it causes us to forget that we are joining something much larger.

Our medical training means that we will bring our expertise, our intellectual curiosity, our readiness to work hard. We can be justifiably proud of ourselves for what we have already accomplished, and we know for sure that the people in the audience today are already proud of us.

But today we also join others—paramedics, nurses, social workers—and dentists—and many others who spend their lives responding to suffering. In the few blocks around us, there are thousands of people like this. And even more importantly, there are many other people who are not healthcare workers, but just caring people who also see suffering and find ways to respond. I came to medical school because of people like this—people who responded to the crisis of the AIDS epidemic in San Francisco, people who taught me about courage in the face of disaster.

In small or large ways, most of us have probably come to sit here today partly because of people like this, people who taught us how to behave in the face of suffering: teachers, friends, family. They have usually taught us by example, often because they cared for us when we were suffering. Some of those people are here today. They have seen us fall; in one way or another, they have found us down and helped us up, sometimes many times. As we graduate, we honor their acts of faith in us. Today we mark a moment in which their gifts to us have come to fruition. Now, we will join them in helping those who are found down.

Monday, June 4, 2007

In brief: Poz blog carnival, internship preparation

1. The International Carnival of Pozitivities was kind enough to include my AIDS vaccine post in its recent round-up of blog posts related to HIV, AIDS, and especially, living with HIV.

2. I went to pick up my Advanced Cardiac Life Support manual from the hospital. Walking back from getting the ACLS manual, I saw a woman and a man walking in the corridor in the opposite direction; the man was in scrubs and was carrying a portable defibrillator. As they passed me, she said, "So, you're going to do the spiel to the new interns, right?" "Yeah," he said. She said, "That's a big one. Like, 200 MDs."

I thought:
--People are preparing for us showing up, and it's a big event.

...and...
--Ha! She said, "MDs!" She meant us! Ha ha ha! ... oh crap! I realized that other people think of us as doctors, more than they distinguish us from other doctors--even when, as in this case, they understand the distinction between us and other doctors. And that means that I won't be just an intern--I'll actually be a doctor also. Of course I know that the two categories of intern and doctor overlap, with intern completely contained within the larger sphere of doctor. But I've been a sub-intern and I can imagine being an intern. Imagining being a doctor seems harder. Even though, as I remember with a combination of delight and dread from time to time, it's actually the same thing.

Wednesday, May 30, 2007

Prevention Works still fighting in DC


When I lived in DC, I worked at an immunology lab, and I volunteered for Prevention Works, Washington, DC's beleaguered needle exchange program. Ron Daniels was one of the staff members who was often on the van supervising sessions where I was a volunteer. I did simple work like counting out new needles and giving them out to people, or explaining the basics of the program to new participants, while Ron and others would be talking to people about tougher stuff, like drug treatment options and doing HIV testing.

Ron and people like Ron are incredibly inspiring to me. For anyone who becomes a part of Prevention Works or supports it, needle exchange is a great way to make a difference. But for people like Ron Daniels, needle exchange is not just that; it's also a way of reclaiming the meaning and value of their own lives, and the lives of many other people as well. It's a beautiful thing.

Ron Daniels was recently in the New York Times in an article that gives a little bit of hope that maybe the Democratic Congress will finally take off the obscene funding restrictions that prevent the DC city government from spending its own local tax money on needle exchange. This restriction is not only a terrible piece of public health policy, it's an insult to the people of Washington, DC, who should have a right to make their own political choices. (For more about the wisdom of this choice, check this recent quick .pdf summary of the benefits of needle exchange programs.)

Lots of Washingtonians need what Ron Daniels and the other staff and volunteers of Prevention Point have to give. Please tell your congressional representative to lift the ban on funding. But until the Congress finally gets out of DC's way, I can't think of a better or more effective place to spend your philanthropic dollar. Here's a link to give the money that Republicans from Missouri and Oklahoma won't.

(And thanks to John S. for sending the NYT article around to an email list to which I subscribe.)


video: uploaded on Current TV, a video about Prevention Point's work.

Tuesday, May 29, 2007

How I changed, part 2: love and faith


Image: from Harvard Medical School's Countway library: a fifteenth century view of the Antichrist being born by C-section.

* * *

More in how my view of the world has changed since I started medical school, now that I’m graduating:

Before medical school, I used to believe that people were inherently good and that their bad qualities were the product of bad events that happened later. Now I don’t believe that people are inherently anything. Now what I wonder about is whether it is still important to love them.

I understand now that the willingness to try to love everyone in some way is not based on some factual insight about character, but on a large and partly irrational secular leap of faith. For example, when I am feeling nervous about a public speech, one of the things I try in order to summon the best part of myself is to actively think about loving the members of the audience, each one of them. This allows me to try to be my most generous, my most honest, my most enthusiastic. They may not like what I say or how I say it, but if I am in this mood, at least I can be sure that I have given them the gifts I have to offer, as best I can. Loving them is not the same as thinking that they are inherently good (whatever good is), but maybe it involves some faith in their potential for goodness.

At least sometimes, this is how I think I want to be a doctor. And talking about this to Ms Hemodynamics, I said, “I think I need that faith to be a good primary care doctor.”

Ms. Hemodynamics disagrees with this idea. She says that being a good physician means meeting people where they are, whether they’re good or bad; whether they’re good or bad isn’t even part of the question. And she says that she believes that who ever you are, you don’t deserve to suffer, or to be afraid, and that a doctor should believe that; but that a doctor does not need to believe that people are good, and does not need to love them.

I know that she and I both reserve some of our most pointed skepticism about a set of doctors who would at first seem to have much in common with us in their politics and their relationship to the medical-industrial complex. These doctors claim to love people, but actually when you get to know them as clinicians or teachers, you realize that sometimes they love The People more than they love actual people. And one can’t help but think that some portion of them love the idea of being loved by The People more than the idea of actually loving them. The line between The People and actual people is a fine one, but I want to stay on the right side of it: I’m no Ché Guevara, and I’m in no way convinced that The People even exist.

So maybe her approach is the best one: don’t worry about who the people are, or who The People are, and don’t worry about loving them, and definitely don’t worry about being loved by them. Just meet them where they are; figure out what they need; help them get it. When I think about it, this is how I often operate in a day-to-day way.

And yet I think that when I do the best job it is at least sometimes because I have found some kind of love for my patients. This is not always with my most lovable patients. In fact, to persist in trying to do a good job for some of my least loveable patients, I sometimes need to remind myself to try to love them—and that when I do, I often do a better job. This is an active process of trying to summon up some version of Buddhist loving-kindness—again without believing in the larger Buddhist scheme of things. The challenge, I think now, is to love people without becoming attached to the outcome of that love—to not be too upset, for example, when you know a patient is saying one thing to you and actually doing the exact opposite.

“But I love you,” some internal voice of mine has said at a couple of times in medical school with patients I’ve hoped might behave differently, mostly without clear words but just the feeling: “Why are you lying to me and letting me down?”

Given the inevitability of the range of human behavior, including some not entirely palatable kinds of behavior, and the inevitability that some of that behavior will take place in a clinic or in a hospital, it may be too much to ask of myself to love my patients. Or it may not. I’m not sure.

What I think now that is different from before I started medical school is that I don't think that people are inherently good, or inherently anything; I've stopped expecting to be able to find that in everyone. To walk into the clinic expecting something from one’s patients is a sucker’s game, and a sure path to bitterness.

Is unconditional love for my patients the cure for the cynicism that comes from disappointed expectations? Or is it a risk factor for disappointment, and thus, cynicism?

Or, probably most likely, both?