Friday, September 11, 2009

Joe Wilson's war

For all the fuss about Joe Wilson disrespecting Obama by shouting "You lie!" (to which, it can only be said, he never would have said that to a white president)--

the biggest crime is not disrespecting the president, but that he was doing so in the cause of trying to make sure some Guatemalan girl can't deliver her baby, and some Chinese guy can't get treatment for HIV infection, and some old Mexican lady is going to die for reasons regular medical care could have prevented.

And now, politicians are bending over backwards to say, Joe Wilson is disrespectful, but to his larger point, they only respond, please, fellow Americans, be assured, we won't be taking this love your neighbor thing too far.

Saturday, August 1, 2009

Night float

Our department chair decided at some point that the people on night float shifts--interns who cover the medicine patients overnight, and residents who admit new patients coming in after the regular teams have stopped admitting--should have a teaching session. And so we met this morning, all the night float residents and interns. I've been doing a pinch hitter sort of job, in which I do overnight medicine consults and also support the night float interns; next week I'll be doing admissions. The relationship among all of these people is an odd one. Except for me (because I spend a reasonable amount of time checking in with my early-in-the-year interns and backing them up in various medical crises), we are mostly working alone. But we see each other through the night, crossing paths in the hallways or sharing a workroom for an hour here or an hour there.

In our conference this morning, we started talking about a patient. It turned out she'd been admitted two days prior by one of the admitting residents. An ICU resident on call overnight came down to evaluate her when we thought she might go to the ICU, and spent a good long time afterwards thinking about the patient's situation. In a workroom, thinking aloud, getting excited about some ideas about the patient's situation, the ICU resident talked to another nightfloat resident, and had pitched her theory to a couple of us. One of the interns had been called a couple of times to go see her overnight, and I'd gone to back him up for some of the hairier calls, and I had helped arrange the patient's possible transfer to the ICU before we decided she was OK to stay on the regular medical floor.

In conference, then, the admitting resident presented the case, but the group started talking about it in an engaged and interested way, because so many of us had thought about the patient, cared for the patient, or heard about the patient already. I'd seen the admitting resident a couple of nights before and had talked about this patient even then, because the resident was excited about the admission. She wasn't too busy and with an interesting case to think about and read about, she got the chance to do real medicine instead of setting up a holding pattern to be handed off to the day team. I'd spent a long time thinking about the patient when I was trying to figure out whether she should go to the ICU. And the nightfloat intern had spent a lot of time seeing the patient because of multiple problems over several nights, trying to figure out which of the calls represented real crises and which ones didn't.


I was reminded of another time I was in the ICU and a patient came in with an unusual problem; within a couple of hours, cardiologists, pulmonologists, and oncologists had mobilized for procedures and studies, teams were passing the chart back and forth as they worked on plans and notes and recommendations, and people kept buzzing in and out of our MICU team rounds to give updates on the latest detail of the plan. A cardiology fellow showed up and so did an echo tech, and within an hour of us asking for the study, there was a detailed echocardiogram and an attending reading it. Someone else was planning for a biopsy. One consult team was calling another consult team to help work out details.

"This is when I love being at a teaching hospital," I said quietly to one of my fellow residents, as our intern was presenting data and we were watching out of the sides of our eyes as one of the consult teams was bustling about nearby. "These moments of this massive mobilization of expertise, all of these people with this insane amount of training, coming together for one sick person. It's beautiful."



Overnight, the hospital often seems like it's in a holding pattern. We try to keep people alive until care can be advanced during the day. So it was a surprise to me to find myself in conference with a little bit of that teaching hospital feeling: the feeling that there were all of these smart and engaged and caring people watching the progress of one sick patient and sometimes being a part of her care, wondering how it would turn out, wondering whether she would come to the unit or stay on the floor, wondering whether she'd get sicker or better, hoping for the best.

The senior admitting resident had come up with a long set of possibilities for what might explain the patient's symptoms, and ordered a bunch of tests right away to start sorting them out. The ICU resident was pitching an obscure diagnosis but one with some credibility; though I wasn't buying it, I had to give her props for zeroing in on a particularly striking lab value which I had skimmed over. I was pitching another theory, but at the same time telling the intern to cover for gram-negative infection, which was actually a counter-move to anticipate what could happen if I was wrong. The attending, writing a note in the morning when we emerged back onto the floor from our conference, thought we were all wrong, was stopping the antibiotics I'd told the intern to start, and had another theory entirely. But we all had opinions without certainty, which meant that we really listened to each other, and we all had a sense of suspense:

"Poor lady," said the attending, "I haven't seen a case like this for a while";

"I really think the team should start treating now, even without knowing everything!" opined the department chair;

"I know what you mean, but they could get in trouble with that in other ways," said the chief resident, deferential but firm;

and the intern, new to it all, was listening to the primary attending with eyes much brighter than his fatigue should have permitted, truly a part of this thing that we all had spent so much time working towards, and which he had finally just joined a few weeks before.

We felt ourselves to be a part of a community of highly trained people, late at night when others are asleep, part of the world of doctors as doctors themselves hope for and imagine it should be. A team of experts and people becoming experts, mobilizing, caring, theorizing, arguing; and at the same time, perhaps above all, walking briskly down the hall towards the patient's room after getting a page from the nurse about low blood pressure.

Saturday, July 11, 2009

Becoming the Fat Man.

Sleep-deprived and worried for my interns, I start spouting half-true or all-wrong or kind of right aphorisms as if I was aspiring to be the new Fat Man:

"All patients lie. All patients are crazy. And it is our job to love them anyway."

(Said to an intern who is tempted to believe everything his patients tell him, to his patients' potential detriment.)

A pair of nurses, overhearing this, do a double take and tighten up as they hear me start this, then visibly relax as I finish. One says, "You saved yourself with the last part there." I try to save myself a bit more: "Well, we all lie sometimes, even when we don't realize it, and we're all a little bit crazy, right?"

Still, I thought, Am I really the resident who blurts out cheap half-truths as if they were wisdom?


It is an inevitable temptation of power--even the minor power of a senior resident at the beginning of an intern's year--to start spouting bullshit. On reflection, I think I succumbed.


At the same time, I don't think it does any favors to patients to subscribe to a false humanism, some kind of big happy medical friendship bracelet of co-dependence between needy doctor and needy patient.

I got at what I was trying to say a little better a couple of days later, with the help of talking to Dr. Ms. Hemodynamics, who had more clear things to say about this problem, which I then said to an intern, with words something like this:

"It is inevitable that when we are feeling doubtful about ourselves as doctors, we want our patients to like us, because that makes us feel like we are good people. But it's not the point of being a doctor to have your patients like you. Your patients should come to trust you, and to respect your counsel, and value your role in their life. But liking you is beside the point, and it's dangerous to them for you to need that from them."

This I do believe.

To boil it down to a Fat Man-style law:

"It's not your job to have your patients like you. It's your job to love your patients enough not to care."

Friday, July 10, 2009

100% true dialogue from the wards



The attending, the senior resident, and the intern are sitting in the work area, discussing a patient. The senior resident, a bespectacled and bearded graduate of Harvard Medical School, is cautioning the intern on jumping to conclusions:

"I understand that you're taking the evidence and trying to see if it matches your theory. But actually, you want to do the opposite. You don't want to try to prove yourself right. In the philosophy of science, Karl Popper wrote about 'falsification'--the idea that you take your hypothesis and try to prove it wrong, until, failing to prove it wrong, you decide that it's the best theory for now."

The intern: "OK, yeah, I see your point."

The attending: "Karl Popper, huh? You've read Karl Popper?"

The resident: "No. But I've read about Karl Popper on Wikipedia."


Attending: Falls out laughing; retells the incident for laughs to another attending on rounds a couple of days later.

Resident: Laughs too; retells the incident on his blog a couple of days later.

Tuesday, June 16, 2009

Doctors, nurses, and medical students in Iran, June 16


Above: a video from YouTube, with the title
16 JUNE 2009 - Doctors and nurses are protesting in a major hospital in Tehran - Iran
with the following caption:

At 1:41 one of nurses is shouting "8 people died in this hospital last night". of them1 died by a headshot...which said that poor brave man shoted by sniper. at 1:35 you can see on that board which writen in persian "28 wounded...8 died"

Morning of 16 June...Rasoul Akram Hospital's doctors and nurses are protesting about what happened in the last night gunshots by Goverment's militia (basij) and police. 36 people shots By Gun 8 dies and 28 injured .


And...
From Nico Pitney at the Huffington Post, an email from an Iranian medical student:


Hello,

It's painful to watch what's happening.

I don't want anything to do with what has been said this far, as I neither have the strength nor the resilience to face all these unfathomable events.

I only want to speak about what I have witnessed. I am a medical student. There was chaos last night at the trauma section in one of our main hospitals. Although by decree, all riot-related injuries were supposed to be sent to military hospitals, all other hospitals were filled to the rim. Last night, nine people died at our hospital and another 28 had gunshot wounds. All hospital employees were crying till dawn. They (government) removed the dead bodies on back of trucks, before we were even able to get their names or other information. What can you even say to the people who don't even respect the dead. No one was allowed to speak to the wounded or get any information from them. This morning the faculty and the students protested by gathering at the lobby of the hospital where they were confronted by plain cloths anti-riot militia, who in turn closed off the hospital and imprisoned the staff. The extent of injuries are so grave, that despite being one of the most staffed emergency rooms, they've asked everyone to stay and help--I'm sure it will even be worst tonight.

What can anyone say in face of all these atrocities? What can you say to the family of the 13 year old boy who died from gunshots and whose dead body then disappeared?

This issue is not about cheating(election) anymore. This is not about stealing votes anymore. The issue is about a vast injustice inflected on the people. They've put a baton in the hand of every 13-14 year old to smash the faces of "the bunches who are less than dirt" (government is calling the people who are uprising dried-up torn and weeds) .

This is what sickens me from dealing with these issues. And from those who shut their eyes and close their ears and claim the riots are in opposition of the government and presidency!! No! The people's complaint is against the egregious injustices committed against the people.

Monday, June 15, 2009

The AMA doesn't speak for me

I've started a Facebook group:
"I'm a doctor, and the AMA doesn't speak for me"
I hope my colleagues will consider joining.

One of the group members linked to this article:
Abraham Verghese on the AMA

Monday, June 8, 2009

the future of the future



Wikimedia commons photo: Samuel Delany. NASA photo: Charles Bolden in 1992


Yesterday, I was registering the fact that President Obama has appointed Charles Bolden, an African American astronaut, to run NASA. I googled him, thinking about how it's not that incredible anymore to have black people go up in space, and that therefore it doesn't seem incredible that there's a black astronaut in charge of NASA. And then one article, which included various people gushing about Bolden, included a comment from his astronaut buddy Franklin Chang-Diaz, whose daughter is a Massachusetts politician with the same last name.

I don't want to dwell on the point, but "Franklin Chang-Diaz" used to not be an astronaut kind of name, nor a Boston politician name either. In fact, it is hard to know which would have seemed more improbable in 1950, or 1960, or even 1970.

I don't want to be the white guy who looks on in wondrous rapture about little victories of diversity as a way of ignoring inequality and discrimination. So let me pause and register that the world is still what it is; inequality still is the rule, not the exception. At the same time, the world is different than it used to be.

NASA made a decision, when it started the shuttle program, to change what astronauts looked like. Now, many years later, there are a fair number of black astronauts, women astronauts, astronauts from different parts of the world. Some of them are rising through the ranks. There are still plenty of white guy astronauts and white guys slapping each other five in Mission Control--the world hasn't changed so much--but it's different than Apollo.

This got me thinking about science fiction. I've mostly left the genre behind in my own reading over the last few years. My friend S. knows it better and is able to write about it more seriously. Still, from the reading I did in years past, I can say there are a few different versions of the society of space in science fiction. One of those versions comes from an often quietly utopian impulse, which involves more small-bore problems of dealing with difference, or of trying to make a better society, or of living in a different way than we now imagine. It does not describe utopias, but its broad imagination, its sense of possibility, is a form of utopianism. It is a way of saying, anything is possible. This genre uses science fiction as a way of stretching our imaginations about what could be. Some of the practitioners of this kind of science fiction, people like Octavia Butler or Samuel Delany, were African American, and the humans who inhabited their worlds were often of many colors, not to mention genders and sexual orientations. In fact, not at the time, but retrospectively, some people call them pioneers of Afrofuturism.

There is no immediate relationship between Samuel Delany, a gay man with a big unruly beard who now teaches creative writing at Temple, and Charles Bolden, a former Marine and astronaut, who will now run NASA. They are both black men who are interested in outer space, but then, so was Sun Ra. I can't really imagine Borden and Delany at the same event. And though there must be someone who knows them both, I don't think they travel in overlapping circles. They have outer space in common, sort of (though Samuel Delany does not even depend on that trope). But one of them is interested in imagining different planets as metaphors for different ways of living. The other is interested in specific real different planets as places we might drive a space ship to. Delany is wildly progressive; Bolden is not, at all.

When NASA chose its astronaut corps for the shuttle program, it did so for political reasons that were very much of the here and now. NASA understood then and understands now that its work can either seem like an inspiration, a bold project of building human capacity, a project on behalf of nothing smaller than humanity itself; or, alternatively, a wasteful boondoggle and gadget racket that has nothing to do with anyone's concrete problems. Choosing a diverse astronaut corps helped keep NASA looking like it was staying on the right side of that line. That has nothing to do with anything as edgy or visionary as Samuel Delany. Yet, if you would have written a science fiction story, in 1969, that imagined a black president and NASA chief, you would have placed yourself firmly in the left wing of the genre.


There are all sorts of possibilities come true lately, which I've been noticing simultaneously. Less lofty but maybe more spectacular: in my pocket, my iPhone seems more spectacular than a lot of gadgets I read about in science fiction books when I was a kid, exactly because it is an everyday device. Without any mythic resonance, an improbable-seeming thing I carry in my pocket, the iPhone is not a super phaser or a scanning diagnostic tool that instantly does my medical work for me. It's just a phone, a newspaper, a street map of the developed world, a global positioning device (the very existence of which is improbable, much less that it is in my pocket), a massive encyclopedia written by a global collective, a camera, some video games, a music player, a way to write people brief letters or read letters from others, and other things as well. And I put it in my pocket and carry it around! Every so often, we do make note of how incredible this seems. Perhaps I'm just getting older, and remember more and more time, more and more of my own history, that took place before we could take such things for granted.



Whether for the head of NASA, or my iPhone, the future is harder to accurately imagine than it first seems, and not just because you thought the phone/clock/navigational device would be a Dick Tracy-style watch and not some pocket version of the monoliths from 2001: A Space Odyssey. Once the future arrives it seems ordinary. To imagine the future puts a wondrous glow on it.

The future is not simply a time like other times; it is a time when anything is possible and therefore it is a time made up of a larger-than-appropriate proportion of our hopes and fears. When we find ourselves in the time that used to be the future, there is no such resonance. Some things are newly possible, others not possible anymore, and we simply find ourselves in a new set of circumstances. We fear and hope for new things. AT&T sends a bill for the iPhone minutes. The future is no longer the future.

But there is something about this year, and I know I'm not the only person to feel this way, that feels a bit more like science fiction than most years. The dull apocalyptic dread of the American economic empire in collapse; a black president with a Muslim name; iPhones in our pockets; gay marriage through all of New England but not in California or New York; a black astronaut in charge of NASA. Some Puerto Rican lady gets appointed to the Supreme Court and it is the exact person that the press has been predicting all along, which makes her appointment seem like an almost unadventurous boring political move by our president, who--we're almost used to it now--is a black man named Barack Obama. (Afrofuturism, indeed.) We take the internet for granted but we're still figuring out how to use it; we're also now used to things like dance music made entirely by computer programming; and we forget how extraordinary it is that in so many ways, from dumb television to crucial navigation, we depend on satellites orbiting the earth.


It's not future shock I feel; just a sense that the present is improbable, and thus, that the future must be even more so, for better, for worse, or, simply, for different. Really different. All possibilities remain possible. We are in a time that feels like the future even as it arrives. This year, more than most years, I find myself in the future, still catching up.