snapshots of the VA

For two weeks, I'm on nightfloat at a Veteran's Administration hospital, a dark quiet place at night.

***

There's a big photo of the president at the entrance. Each night as I walk in, I think, I hope that photo looks a lot different next year.

***

There's no cafeteria at night. There is a room full of vending machines. I had a 20 dollar bill and I wanted a Coke Zero. In a quiet hour, I walked down to the emergency department and asked the clerk if there was a cashier anywhere who took payments at night, so I could get change. He sent me to the security desk, staffed by a VA police officer who told me that there was no cashier anywhere, and no change machine he could think of. I thanked him, and started to turn to walk away.

"But there's a stamp machine," he said; "You could buy a stamp and it'll give you change. It'll be all coins though."

"That's brilliant!" I said. A minute later I was the proud owner of a few US flag stamps, and seventeen one-dollar coins, sixteen of which had the picture of Sacajawea and her baby, and one of which had Susan B. Anthony. I filled my scrubs shirt pocket with them.

***

Near the physical therapy section, across from an office of the Disabled Veterans of America, there is a xerox copy of an article on a bulletin board commemorating the passage of the Americans With Disabilities Act. In a nearby hallway, there is a sentimental print of a painting of a man in a wheelchair, seen from the back, with each of his strong arms extending out to the hands of his children, his son on one side and daughter on the other. I say sentimental because of the style, a style of illustration that is seen on sentimental family portraits of all kinds; on the other hand, among the kitsch and sentiment of all the other hospital art I have seen, I have never seen this picture before.

***

At night, there are tasks that the nightfloat intern does that are done for us at the larger hospitals. For instance, I draw blood overnight, and take it down to the lab for processing.

Recently I went down to the lab in the middle of the night, around the corner from the darkened entrance to the building. In the waiting room just inside the entrance, a TV was playing Law and Order reruns to a dark lobby full of empty chairs. The lab itself, hidden behind a couple of turned corners, is a big brightly-lit room full of equpiment, which would be loud and busy by day, but is all quiet in the middle of the night. One technician was on duty, a friendly man who looked not too far from being eligible for his federal pension, and when I walked into the room, he was looking at a computer screen showing an internet page that said in big letters, "When You Will Die": an internet death clock.

***

In a back control room in the radiology department, there's a picture posted up, with a headline above it: "The terrorists have won the toss, and they have chosen to receive." The picture (of course) is of a huge bomber photographed from above with its potential payload of bombs and missiles lined up impressively on the tarmac in front of it.

***

We have a patient getting a scan, for which the nurse and I need to roll him down to radiology because it's the middle of the night. As we are in the control room, the tech says one or two things about the patient that are not too terrible, but not entirely kind. But after the study is done, as we transfer the patient back onto his bed, and start wheeling it out of the room, the tech looks down at the patient and says with evident sincerity, "I hope you feel better soon. Thank you for your service."

***

There is a whole sub-genre of New England VA patients, large men with large unruly beards. They live in Maine or New Hampshire in the woods or some back corner of a town, maybe in some shack or trailer, maybe just in their cars.

Without betraying the confidence of any one of these patients, let me just say that as I leave hospital rooms at night after being called to evaluate another such man, it is not infrequently that I recall the state slogan of New Hampshire, emblazoned proudly on every license plate, including cars used as homes by large veterans with unruly beards and worsening medical problems:

"Live Free or Die."

Handshake Drugs

Jeff Tweedy singing "Handshake Drugs".

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.

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?

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

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.

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*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.

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.