Saturday, March 31, 2007


After many loud denials and proclamations against it, I have reversed my position: I have purchased a class fleece.

But before we come to why I finally committed this dastardly act, it's worth explaining the broader phenomenon of medical fleece. I'm not sure exactly how it happened. But I'm pretty sure it started happening about two years ago: every health-related group started getting fleece jackets and vests with their logos and team names embroidered on the left chest.

This is not unique to healthcare. In fact, I think the first local fleece explosion came from the Harvard Business School students. They've been walking around town for the last several years with HBS fleeces, each with their section name on them, full of mysterious significance. The HBS logo, initials and class year are accompanied by a big proclamation of "Section A" or "Section C", and so on, generic and externally meaningless, only serving to alert fellow HBS students to the room of people to whom the fleece-wearer was randomly assigned. In fact, it is their sheer meaninglessness which is their meaning. The fleece above all is an expression of group membership, and what is more in-group than a piece of arbitrary jargon? I'm sure that computer companies and consulting firms have been handing out team fleeces for even longer, and for the same reason. (I feel like I've seen fleeces that say stuff like "HDC Implementation Task Team" or similarly obscure nonsense, but who can remember that kind of thing?)

Last year or the year before, I'm not sure which, doctors-in-training in the Boston area joined the fleece craze. They started getting fleeces with their hospital logos and the name of their department: "Internal Medicine" or "Surgery." Soon after, nurses and attending physicians started getting more specific kinds of team fleeces: "Obstetrics L &D"; "MICU"; "Emergency". (This has the effect of one-upping the housestaff fleece. Because it says you work on a particular floor, doing a particular job, it also says that you are not a trainee.) These fleeces began replacing the white coat as a way to walk around the hospital and look like you belong there. For medical residents, they also were a proclamation of your team. If you were a meddie, you walked about in your team fleece that said "medicine" loud and proud.

Other hospital fashion changes started earlier, and I think they're related. Housestaff long ago started wearing scrubs around the hospital, even in situations where they clearly don't really need them, as did many other kind of healthcare workers. Scrubs have become a hospital worker uniform. Doctors and radiology techs can all wear the same pajamas.

It's not like hospitals have ditched hierarchy. So we should probably wonder why scrubs appeal to so many different healthcare workers regardless of status.

The first reason is utilitarian. The hospital gives them to you and then takes them back and washes them; you don't have to iron anything; and they're comfy.

But scrubs also signify more than sheer laziness. For those who wear them when they don't have to, scrubs signify a kind of industrial worker of healthcare, too busy saving lives to put on pressed shirts and ties. There's a kind of reverse glamour to scrubs. Scrubs originally come from the operating room, and they're designed for people who are ready at any moment to get themselves splattered with blood. Now people in the hospital who have nothing to do with surgery or fluid-splattering of any kind wear scrubs, as if to signify that they are part of the larger project of fluids splattering about, even if they personally are not going to get splattered.

I think scrubs and fleeces are part of the same set of social changes. Obviously no one intends to get their $100 Patagonia logo-embroidered fleece jacket splattered with body fluids. And yet it's common for fleece-wearers to be wearing scrubs underneath the fleece, walking down the empty lonely corridors in what is an outfit of pajamas, a jacket made out of material that feels like an infant's blanket, and round shoes without laces. In other words, medical fashion and toddler fashion have nearly met up. This is about comfy coziness, and definitely not about fighting through spurting arteries.

Housestaff and other healthcare workers sometimes wear their fleeces over other outfits, too. It's common to see medical housestaff wearing clogs, khakis, a shirt and tie, and their fleece, with their ID flapping around on a lanyard over the fleece. This is where the social functions of the scrubs and the fleece are headed in the same non-toddler direction. These are elements of a postindustrial factory-floor look. The fleece takes the role of the corporate identity (the hospital and department, without specifying the profession), rather than the white coat taking the role of the professional identity (the doctor, from a particular hospital).

As long as they avoid those nutty teddy-bear print scrubs that so many nurses have unfortunately become afflicted with (talk about toddler fashion!), the outfits of nurses and doctors start looking more and more alike: scrubs, fleeces, clogs. (Folks like radiology techs, respiratory therapists, and physical therapists can all potentially get in on the act too, although they've been slower to get the whole outfit together.) The scrubs and the fleece become about team membership, just like a white coat is about team membership. But it's in the hospital team sense rather than the professional team sense. I'm not sure that this provides any less distance from patients, but it's a different kind of distance. It says, "We're part of the hospital" rather than "I am a doctor."

So, why am I getting a medical school class fleece? Partly because my partner J says, "I got some of that college stuff when I graduated and later I was grateful"; partly because I want another warm zip-up sweatery thing for spring and fall. And then there's the problem that I'm just dying for a team fleece, even as I know it's a little ridiculous. I'm secretly as eager to be part of the world of medical fleeces as I once was to be a paramedic and wear a special paramedic uniform and drive around in a red truck with sirens.

At first, I had proclaimed against the fleece because it had our school's coat of arms. Also, it was crazy expensive. But proceeds beyond the retail price of an unadorned fleece jacket go to some kind of class party, which is fine. And at the end of the day, I have to admit that I'm actually proud to be graduating from medical school. I went from not remembering how to multiply fractions when I decided I was going to try to take chemistry, to getting a medical degree from a coat-of-arms kind of place. If the medical school fleece is some kind of aggressive status symbol, I at least feel as if I more or less earned it.

And what I earned is under the coat of arms: "MD 2007". The business school students can have their "Section A" and wear their fleeces like they're headed out to the team-building ropes course, I say smugly to myself; my fleece says "MD 2007" and I'm ready for the MICU. Their fleeces are practice for the consulting firms and investment banks which will give them their next fleeces; our fleeces are pre-hospital fleeces.

I'll get the actual hospital fleece soon enough. But for now, the medical school class fleece is a kind of hospital fashion/professional fashion hybrid. It's a white coat statement with a hospital floor sentiment. And right now, that's exactly who I am. That's the right fleece for me.

Friday, March 30, 2007

A guy wrote a poem

Donald Hall wrote a poem called "The Ship Pounding" about his wife in a hospital, getting chemotherapy. He talks about how he thinks they are traveling somewhere – that the chemo will get them both home. But as he returns to the hospital with her a little bit later, now with her delirious, and presumably still more sick, he sees the hospital as a ship forever in port, without destination, its massive engines churning as the ship stays still.

I was on a pain and palliative care rotation at the hospital where I suspect that he wrote this poem, and a patient was saying something – which, I have to be honest, I now forget. (Does this make the story better or worse? I'm not sure.) I remember that I said, "There was a guy whose wife was here for cancer treatment in this hospital, and he wrote a poem where he described the hospital as a ship with its engines going all the time but always staying in port." The patient said, "Not going anywhere." And I said, "Right." And the patient gave a little smile in recognition.

I think I marked the moment in my memory not for the rest of the conversation but because I was amused at the way I blurted out my literary reference, as soon as I had done it. Was I going to tell this patient that I was referring to a poem that a literature-minded teacher had passed around to a medical school class, or tell him I was referring to a poem written by one of America's premier poets? (Not to mention that the poem was also partly about one of America's premier poets, Jane Kenyon, who was the one with the leukemia and then the delirium.) No. Somehow it was intuitively important to me that I describe it just as a poem by a guy who'd been in this hospital, as casually as I could, as if he'd written it down on a piece of paper and someone at the nurse's station had xeroxed it, and a nurse posted it up in the break room, and a resident passed it around on rounds with everyone nodding and saying, "Wow, that's cool. That's a really good poem."

Although this is not how the poem found its way to me, it seemed useful to imply that it had. By acting like it was just this poem that the nurses had been handing around, I think I hoped to convey that I was just connecting the experience of one inhabitant of this hospital to another. Perhaps this was my barely conscious effort to play an old role, based on the idea that the doctor should exist only in the social role of doctor. The doctor lives not as the person who goes home and reads a book of poems, but only as one of the crew, on the ship, tending to the churning, pounding engines.

Thursday, March 29, 2007

Reason for consult: "This patient is driving me crazy"

I've just finished my last rotation of medical school. Half of it involved working on a psychiatry consult team, which was a new experience for me.

Consult teams are a big part of how big academic hospitals work; when your primary team calls in an expert to consult, your team is "calling a consult." And I found last month that a common reason to call a psychiatry consult can be summed up as "This patient is driving me crazy!"– expressed in more technical terms, of course. Some of the consult team wryly referred to these as "staff distress consults."

One version of the "this patient is driving me crazy" consult is often the question of capacity. Capacity is determined by doctors – mainly, psychiatrists. They decide whether you have the ability (and therefore the right) to make decisions about your own health care. This is one place where your right to autonomy can be taken from you: the law assumes that to be autonomous you need to have the cognitive capacity to make autonomous decisions. Reasonable enough, but obviously there's a lot of wiggle room in how you define that capacity, and who decides whether you have it.

Competence is the legal term; if you do not have capacity, a court can declare you to be not competent. If you're not competent, the court will require you to have a guardian to represent your interests – and if no one is immediately available or your family is arguing about who should do it, the court can appoint a guardian. If you google "capacity" and "competence" together, you'll get a set of instructions for residents from one institution about how to approach this issue. It rightly instructs doctors to evaluate capacity even when the patient agrees with their recommendations.

But I can't remember ever seeing a consult like that. In my limited experience, capacity most often gets evaluated when a patient disagrees with the doctor for what the doctor thinks are wacky reasons, and can't be budged: thus, the "this patient is driving me crazy!" undertone. A common variant: "The patient doesn't want surgery which I have told her she needs, and the fact that I can't just tell her what to do is driving me crazy."

When the patient agrees, even if they have completely cuckoo-for-cocoa-puffs reasons for agreeing, the doctor is more likely to feel that the patient has the capacity to make medical decisions, because the patient is making a good decision; that is, the patient is making the decision that the doctor has already decided.

Hospitals concerned about quality and patient dignity should evaluate the purpose of capacity consults, to establish the ratio of calls for a capacity evaluation of patients who disagree with their doctor, versus patients who agree. If capacity evaluations were being conducted appropriately, the ratio should be around 1:1. It doesn't take long working on a psychiatric consult service to think that a 1:1 ratio seems impossibly utopian. But it would be good to try.