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?

Where the Soul Swims

Since the last entry, much has transpired. If anatomy is the metric by which I can track my progress and medical education, then I have ascended to the next level of understanding: we saw our cadaver's face. Some said that the visage of their cadaver will remain impressed on their memory cells (which ironically we removed later in lab). While I'd like to believe that there can possibly be eddy's in this new flow of information in and out of my mind, collecting pools of memories and emotions, I know too well the results of fast paced learning: everything is forgettable and it is often not under the control of the individual which experiences crystallize permanently in our memory and which become fleeting moments.

The exposure and removal of the brain was truly existential. Exposing the centerpiece of human existence to the open air, removing and feeling it, and realizing that I had cut through not only the skull but also the dura mater surrounding the cerebrum and the brain tissue itself was a new kind of exercise. I found myself thinking about where in the brain itself my experience of seeing the brain was stored. Dr. Stefan told us that some people say that the soul 'lives' in the ventricles (the open spaces) within the brain and then contended that, if the soul did in fact live there, it would in truth be swimming since the ventricles are the factories that produce the
cerebrospinalfluid which coats the brain and spinal column. Is this woman's entire existance contained in the 4 pound mass that we held in our hands?

As I was driving home from Lynn today, I was listening to a program on the radio of an interview with a Eboo Patel (his blog, his organization), I was struck by his statements about American’s pluralism. He summarized his organization’s goal as one which builds an environment (or in his words, a “movement”) of “religious pluralism” by fostering respectful relationships whereby people from varying backgrounds can celebrate their commonalities and at the same time understand their differences. I think this is important and all, but this idea is nothing new to me.

What struck me was when he continued to flush out the aspects of such respectful relationships, noting that we discover and define ourselves when we meet others that are different. I was reminded of my own periods of the continual self-discovery while abroad, when my homestay father and his son would ask me questions like: “Why is it that in America, people move out the house when they turn 18?” and “What is important in America?” and “How on Earth do you Americans pay for college (opening up an interesting series of discussions on the notion of credit)?” My mind turned to one of the women that we met at the New Americans Center in Lynn. She was an immigrant (or perhaps a refugee) from Russia and as I looked around her office, I noticed artwork and trinkets which encapsulated the different aspects of her culture: a matryoshka doll and a menorah both on her bookshelf, an abstract drawing of a concentration camp, and another Jewish-themed drawing on the opposite wall. Marks of a Russian Jew. My mind jumped again to a dinner conversation with my girlfriend’s father about how his grandparents were “Old Country” Russians and how the only shoes they wore were black boots that laced all the way up above the ankle. I found myself there, in that woman’s office, in the same mental pickle that I found myself in while I was in Nicaragua talking to my host-family about my (American, Jewish, suburban, twenty-something, etc.) customs. Again, I was trying to answer the question: “Who am I?” in the context of “Where do I come from?”

What's in a Name?

As we went around the room today, learning names, I realized after labored attempts that I the only names I had remembered of the seven who were introducing themselves were the two, European-derived monikers which fit my European-derived mental framework. The other five African identifiers simply slipped in one ear and out the other without any chance of being learned. During my travels abroad, I had been able to fit new terms into an old system, appending my own European/American culture with items that were foreign, but still connected at least linguistically. Even the myriad of new medical terms finds its place in my mind in the Latin skeleton that I created from seventh to eleventh grade (five full years!) which itself rested upon that majority of English words which is connected phonetically to its Latin roots. I suppose that what they say about teaching an old dog new tricks applies to me.

Nonetheless, these newcomers, nearly all of whom must be awestruck by the mere industrialization of an American city, who must be struggling with the humbling nature of realizing that their old skills and wisdom are not easily transferable to our culture, and some of whom are (according to some readings we received and common sense to boot) battling post-traumatic stress disorders, are expected to do just that: learn new tricks. I mean, simply, that English has no common derivation with the languages that these refugees use to express themselves and insofar as the transformation of language parallels the transformation of cultures, neither does their culture relate to American culture (although this is somewhat of a less scientific comment). However, sympathy is about as far as anyone can go on the emotional scale for these new Americans; their timeline for assimilating is ambitious—4 months—and learning the language and the culture is only a means to the goal of becoming self-sufficient. In fact, I felt a sense of emergency, rather than pity, when considering the fact some of those with whom I spent time teaching how an “uncle” is related to his “niece” or how a “grandmother” is related to her “granddaughter” had already been in the country for a month, one fourth of the allotted time for finding a job and avoiding welfare.

There was one man who especially struck me and who was also especially having trouble learning his new tricks. I happened to glance at his résumé, which the IRC helps its clients to create, and saw that, prior to the eleven nine years that he spent in a refugee camp in Tanzania, he had been a farmer for 19 years. For nearly as long as I’ve been alive, this man had tilled fields, cultivated land, and harvested crops. He had lived the simple (romantic) life that many of this nation’s forefathers dreamed of fulfilling themselves. Then, in 1998, something had drawn him away from what he had likely been doing for a hefty majority of his life (I’m not sure how old he was) and brought him first to a refugee camp and then to 101 Tremont Street where he was trying to learn English. It was heart wrenching for me, especially because his identity as a farmer could serve no purpose in the urban or suburban landscape, short of learning how to mow a lawn or if he were lucky, start his own garden (which plants that would undoubtedly be foreign to him). He essentially had to start with a clean slate at some mid-life age. When trying to transpose this circumstance onto my own life, I am at a loss for how I would manage to retain, frankly, my own sanity.

Perhaps even easier to relate, but along the same vein, was a news report that I heard on the radio while running errands last week: Iraqi medical students relying their frustrations with having to interrupt their medical training because of the seemingly ceaseless war. One interviewed student said something to the effect of: “I entered medical school because I want to help people and now my country needs help, but I cannot be there because our schooling has stopped. I don’t even know how I can conclude my training so that I can fulfill my dream to help.” Stripping someone of their dreams is perhaps the most debilitating of malices, especially when that person is already on the path to achieving them. Again, I don’t know how I would manage similar circumstances in my life.

My goal for this clerkship is to understand how better to help immigrant and refugee populations that I may encounter in my professional career. While one component of that will certainly be having knowledge of support services and opportunities, I believe empathy and understanding is another.

My Mind Wandering About Genetics Before the Exam

Check these out:
http://www.or-live.com/

Also, typing "surgery" into the search function of Google Video dumps you into a myriad of keyholes into the world of a surgeon. It's pretty amazing that 1) we can perform procedures like laproscopy, brain surgery, and lazik 2) any Joe Shmoe, from the comfort of their home can watch these surgeries. Surgeons are becoming more and more like Roboticists in that it seems they work with their hands less and with their machines more.

I wonder about the future of medicine often with the speed of innovation pointing our society more and more to computers. I especially wonder what will happen in the coming decade as we further explore the human genome - its inner mechanics, its nuances, and its faults - and eventually learn to control it. I mean, what happens when Science discovers how to do away with useless body parts like the appendix, wisdom teeth, and other unneeded organs before the womb? Or when we decide that humans are better off with four arms and extra muscle? What about when we discover that DNA and protein complexes are not the more efficient way to store and transmit genetic information. I am very eager to see these discoveries take place but it begs the question: in what field should I investment myself now which will enable me to be involved in change - whether scientific, social, or governmental?

Change and Goals

My life is slowly being self-refined to improve efficiency and output. I suppose anyone who realizes that time is limited while ambitions are boundless needs to make the choice to section life down to the essentials, whatever those may be. I'm still trying to figure out what my essentials, my essence, is. Strangely enough, time doesn't really factor into some kinds of mastery. I find it ironic that, since medicine is both and art and a science, there are aspects of this field that counter every pre-medical, hardworking, stay-up-until-four-in-the-morning-to-cram-for-the-test instinct that I've cultivated over the years. Building relationships comes not from hard work, although can be a prerequisite; relating to people does not follow a straight, predictable path. Finding a connection with someone is not like learning information, where clearly the more time that you spend studying, the better you will know the material. No, connecting to people is like Zen Buddhism (from my limited understanding of it) whereby you Do By Not Doing and Progress Forward By Moving Sideways. In fact, sometimes ambitious effort is retroactive. This is obvious to most, but what it means is that my learning here is split between working to synthesize information, connect concepts, and comprehend the scientific face of medicine, while at the same time, understanding how to be a professional in the face of sickness, sorrow, or sometimes simply check-ups. It is developing dueling and quite different skills and layering on top of these my own person, my own preferences, style, and...essence.

Skills for Life

I continue to intimidate myself with the understanding that what I am learning here and now will become the foundation of my life's work. While my experiences, lessons, thoughts, memories, moments, successes, and failures which have formed me into what I am and how I think were by no means for naught, there is a sense of eternity that this new information has. I feel as though I am shaping future career as a physician and so each time I sit down to study there is an added sense of urgency to remember every morsel of biochemistry, genetics, and anatomy which presents itself; it is the (perhaps false) feeling that everything now matters.

Then, this sense of eternity transforms into a reminder of my own mortality, to an understanding that if I put off fun and games now, that I will likely continue doing so until sometime in my 50s when I wake up only to realize that I've spent the past 30 years worrying about progressing professionally and I've neglected the simple important things in life and in doing so, lived a dry, monochromatic existence. Of course, these are two extremes, but it is difficult to how the road ahead will and more importantly, should traverse them.

We had our first biochemistry and our first anatomy exams, both of which were wake up calls and proved to be adequately challenging (that is a euphemism). They were good wake-up-calls to not only my own need to study, despite any level of innate intelligence I may or may not possess, but as well to the caliber of my peers and my predecessors: there are a lot of smart people in this profession. It was a reminder that excelling in this world ain't easy and that simply hard work and diligence are not even enough to succeed. It requires that certain je ne sais quoi which I have not found yet.

The Beginning

Medical school has begun and I've already received my second taste of death (my first, being in the anatomy lab, which I will touch upon later). My grandfather, aptly named "Pop Pop", passed away on Saturday; he was the last of my living grandparents. Even a mere twelve days into medical school, I can already see how medical school will inevitably change me. I saw myself mentally traversing between sadness and analysis as I watched, in the hospital room, my dying grandfather. I was of course deeply saddened by my Pop Pop's death and perhaps it was even more difficult to watch him struggle to stay alive, than it was to see his skin change from peach to pearl and to witness the nurse and then the doctor come in, check for vital signs, and then shake their heads. It was scary, though, to catch myself chugging through conjectures and hypotheses of what the cause of death was, for moments, as if I had turned off the sadness and turned on the science. I use the phrase "taste of death" purposely above, because it stimulates the same response in a careful reader as my own oblivious thought processes stimulated in me: "Is that normal to think of death in that way? Is it inhuman, cold, unfeeling?"

My first "taste of death" was met with similar confusion. The notion of anatomy lab, of dissecting a once-living-moving-thinking-feeling person, was, as described by a classmate of mine, "Exciting and nerve racking." It is, in my humble opinion, the medical school rite of passage. We had a lecture on the history of dissection, tracing it back thousands of years, followed by a talk about the UMass body donation program. Smell of fear stunk up the room as we first year students all realized that we would be carving and cutting in less than 24 hours. I imagine that this will not be the last time when fear will have to be buried in the name of performance. However, after the first incision, the four of us in my anatomy group realized that it was in fact easier (physically and psychologically) than we had thought to cut through human flesh, muscle, and fascia. Barely a week later, anatomy lab is equally awe inspiring but far more mechanical. My fear, then, has transformed from what it was before out lab--"Will I be able to do it?"--to something new. I now fear that routine will take over and my mind will convince itself that cutting into someone is not a note-worthy event. One of the many lines that I will have to straddle will be between mechanical, unfeeling, stone-cold precision on the one hand and emotion on the other. Both are necessary for my sanity and my future profession, but they can be mutually exclusive.

So, medical school and my training has begun.