When does it become about the Patient?

Before my philosophical rant about the above question, a few updates:



1) My computer is dead. I have tried various fixes to no avail. However, I have access at work (at least for the next few days) and so I'm not totally cut off from the world. Plus, my BlackBerry can send and receive my email, so in reality, I'm just as linked in as I always was. The only difference is that (at least for the time being), I cannot upload pictures, so I'll have to steal pretty pictures from other websites rather than displaying my own.

2) My girlfriend Andrea arrived on Thursday (July 3), so this may become a bit of a joint effort between the two of us.

3) My days at 1854 Calle Mcleary have ended and I was able to find a place close by which we moved into on Tuesday.

So now, the question at hand: When does it become about the Patient? This is something that I began thinking about during the early morning cold walks to school and the morning routine that proceeded them this past winter. Medical school of course cultivates doctors and teaches them to care for patients in, insofar as it is teachable, compassionate, caring, human ways. But how teachable are the abilities to empathize, sympathize, and relate? I have often found myself, under the scrutiny of a precepotor or physician-professor, thinking more about how I am presenting myself, than about what the patient is presenting to me.

We as medical students are graded not only on the tangibles: whether or not we can remember and reproduce the steps in a biochemical process, the proper drugs for treating a given syndrome, and the correct identification and pathology of cells as viewed under the microscope--or computer; but also on the so-called intangibles: empathy, respect, ability to comfort someone, etc. The question for me then becomes: When does the presentation of these seemingly admirable qualities, necessary by anyone's standard for the caregiver to embody, stop being motivated by the medical student's desire to excell, and start being motivated by a inner wish to in fact BE compassioate, empathetic, and sympathetic? When do you cease to consider your own performance as a physician--especially in the light of so much competition in the medical field--and begin to think only of the healthcare of the patient? I don't know the answer to this question, but I think that my very asking it shows that I have a long way to go.

Spanglish

There is much to relay about the intricacies of Dengue Fever (as I myself learn them), some history about Puerto Rico (main sources: my Moon's Guidebook and Wikipedia), and my own experiences here, but I think the most appropriate place to start is to tell you about a new language (not really new; remember that movie with the same title?) called: Spanglish. Sure, you've likely figured out that it is simply a mix of Spanish and English, but isn't English after all just a mix of Latin, Greek, and German (and a few others)? I was walking on the beach and stopped to ask a group of twenty-somethings who were playing dominoes and drinking beer (a standard evening activity) a question. I asked them first: "Cual idioma prefieren: Ingles o Español?" ("Which language do you prefer: English or Spanish?") Their reply, a resounding: SPANGLISH! They proceeded to speak, flawlessly and nearly without accents, in both languages.

What's interesting is that the language here is really a symbol of the cultural, socioeconomic, and even physical evolution of Peurto Rico, an island which has roots in both the Spanish culture that followed the conquistadors and the American culture that tickels down from the north. And the result is something uniquely different from both.

When I arrived here, in Puerto Rico, it was clear that I was not in the USA (well, technically, I was and still am) but I was also not in Central America. It differed too from the Carribean Isles (although Puerto Rico is very much one). Signs are in kilometers, except for speed limits which are in miles per hour; Old San Juan is surrounded by castles and an ancient wall, within which lies (as I mentioned in my last post) a McDonalds, a Burger King, a Starbucks, and a Marshalls; the poverty rate here is 54% (compared to about 12% in the whole US). On the other hand, a drive through the countryside here in Puerto Rico was quite distinct from the countless drives I took into the "campo" in Nicaragua, Guatemala and Costa Rica. Houses were all made of concrete. People had cars, satellite cable, paved roads, shoes, and front doors. The land itself was strangely similar, but the people that inhabited that land were distinctly different...well, barring their common language (Spanish, not Spanglish).

I just finished reading the prologue to Thomas Freidmann's book Longitudes and Attitudes and it talks about how the growing New World Order of globalization which is replacing the Old World system of the Cold War is characterized by interconnectedness, linkages, by integration. He summarizes these principles by stating that globalization's mascot, or perhaps its seed, is the World Wide Web. Perhaps, then, Puerto Rico and the unique mixture here is a mirror of the principles of globalization (understanding of course that Puerto Rico's integration began in 1898 when it became a part of the US and not after the fall of the Berlin Wall and the advent of Web). For me, trying to piece apart what I see here and attempt to understand what has contributed to it is exciting. Then again, I think I need to work on my Spanish before I can really speak Spanglish.

School's Out for Summer!

Well, the first year of medical school has come to a close, I've passed the proverbial threshold* onto my second year, and I've already embarked on and returned from one adventure and then began my summer trip to Puerto Rico and Peru! It's amazing how time flies. Not to mention the fact that I've been in Puerto Rico for over a week! Furthermore, I looked at my last entry which was in January...as if nothing noteworthy occured between January and June, bah!

So, let me switch gears a bit and introduce you, the reader, whoever you are, to what is in store for the summer: I'm here in San Juan, Puerto Rico working at the CDC's Dengue Branch (the official title, for all of you who hate government bureaucracy is: the Centers for Disease Control and Prevention, Cordinating Centers for Infectious Disease, National Center for Zoological Vector-Born and Enteric Diseases, Division of Vector Born Infectious Diseases, Dengue Branch, whew!) helping to catalogue last year's dengue fever epidemic in Puerto Rico by looking at fatal cases of Dengue (and its evil counsins, Dengue Hemorrhagic Fever and Dengue Shock Syndrome) and understanding patterns in the diagnosis and treatment based on the signs and symptoms that were progressively presented to hospital staff. What does that actually mean? Well, I am doing my best to march through medical records from these fatal cases and extract out key pieces of information to see what was going on. Is this the crazy public health field work that I might have otherwise been doing? Not exactly, but it is epidemiology at its core, not to mention that fact that the CDC's operations are pretty impressive to see, experience and be a part of.

Some more details: I am living like a nomad. I flew in on Monday (June 16) and stayed with a woman who offered up what I thought was her apartment and turned out to be her bed (she slept on the counch) for cheap in Old San Juan (or more appropriately Viejo San Juan), the center of action for the late-night, dance-hungry Puertoriguenos as well as the primary drop-off spot for cruise ships passing through (the picture is from the 2nd story balcony in Viejo San Juan). The place is undoubtedly influenced by the American mainland but at the same time, clearly something else altogether. Like most things in Puerto Rico, the conglomeration takes on a personality of its own. The narrow cobblestone streets and colorful facades have a colonial flavor which is interrupted by the occasional "Burger King", "MacDonalds", "Starbucks" and even "Marshalls" (yes, there is a Marshalls in Old San Juan). The entire island-city is surrounded by a beautiful stone wall which connect two forts at the East and West sides. So that was Old San Juan.

Then, I picked up and moved to Ocean Park, a little farther East, from where I am writing now. I am house-sitting/dog-sitting for the woman who was my connection to the CDC here, who has taken her family to Thailand where she is taking a class on Dengue Fever in Bangkok until the early part of July. I am nearly within spitting distance to the beach and I have a companion to keep me company to boot! I'll be here until July 8, at which point Andrea (my girlfriend) and I will be finding anther place to inhabit temporarily, likely in the same, beautiful area.

Our next move, aside from a few weekend trips, comes on July 19 when we fly out of San Juan and to Lima, Peru where we will begin the next link in our travels.

So that's what is coming up for the summer. I hope you enjoy the reading and comment away when you feel the urge!

*Proverbial or physical threshold? My friend Abe came down with pneumonia and and we learned in physiology that glucicorticoids and other steriods which help your body cope with physical and mental stresses, moderate the body's immune system, perhaps one reason why mental stress can have physical manifestions. Take a look here for some more, official, analysis.

I'm Your Pusherman...

I was floating around the office of my LPP (Longitudinal Preceptorship Program) as I normally do--feeling and looking perhaps a bit awkward, not sure where exactly to stand in the narrow hallway, sporting my emblem of medical knowledge, the stethoscope and entertaining thoughts of what was in store for the afternoon in this pediatric practice. Gracefully, skillfully, she swooped me into conversation: Angela, making the hallway even narrower and impassable, introduced herself and proceeded to corner me into a conversation about current ADHD treatments and diagnosis. She was from J & J (that's Johnson & Johnson if you're outside of the biz). Perhaps the snicker that grew in the corners of my lips made it obvious to her that I was not listening to a word she said but instead churning over statistics about drug reps and their devious game. There is a really interesting report on the rules and tactics of this game here. Below are a few of the most interesting points:

• The rep categorizes the doctor based on 8 categories and tailors their tactics based on that categorization; this is a finely tuned science.
• Despite the self control that we all want to believe we have over our influences, those little samples that pharmaceutical reps distribute so freely actually affect the decisions that doctors make (otherwise, they wouldn't give 'em out!)
• As much training as physicians have in behavior change, the psychology of habituation, and the mind's interpretation of everyday events, drug reps are able to give doctors a taste of their own medicine. The gift giving works, the relationship building makes money, and, perhaps tritely, everyone is human--most of all physicians themselves.
  

As I was cycling through the information that I had heard about pharmaceutical sales watching Angela's lips move, I was reminded of a song by Curtis Mayfield and thought that this well-dressed, well-groomed woman was nothing more than a pusherman:

"...I'm your doctor, when in need
want some coke, have some weed
you know me, I'm your friend
your main boy, thick and thin
I'm your pusherman,
I'm your pusherman."

John Wood

The same issue that has come up for me in the past surfaced today. It is the problem only of the rich, the privileged, those to whom everything has been given and who began life already with more potential simply because of the income level of their parents; perhaps the social version of genetic, Darwinian, advantage. Dr. Michael Hirsh, the highly decorated, highly respected Chief of Pediatric Surgery spoke to our class about "Why He Entered the Field of Public Health". His story, what he called--after the Sioux tradition--a "sacred bundle", began with John Wood. John Wood was an impressive character by Hirsh's description. A musician, pediatrician-turned-surgeon, and a longtime Columbia man, he was Hirsh's colleague, friend, mentor. John was shot in the chest while working outside of Columbia's hospital in the Upper East side and Hirsh was the physician on call (ironically, a favor he was doing for Wood). He described the 26 bus loads of people that were shuttled to Princeton for the funeral and the feelings of rage that followed the initial shock.

This was Hirsh's foray into injury prevention, a staple to his professional career and clearly, to his personal accomplishments.

The story was captivating and heartfelt, although I couldn't help but think about what my "injury prevention" is, who or what my "John Wood" is and in recognizing that I don't believe that I have found either of those yet, how and when I would discover such a personal connection to a larger world issue. I find myself often stuck between problems of grand magnitude and greatest importance, not knowing which to invest myself in. I do not have a family member afflicted with HIV/AIDS; I never witnessed a shooting; I don't feel the pangs of emotion when I think of heart disease, disaster preparedness, environmental health, infectious diseases, the list goes on interminably. The point is that while I see the the intellectual and conceptual direness to each and all of these global issues, I feel no emotional attachment to them.

Am I empty, am I simply not examining my past hard enough, or should I simply continue to wait?