Fridays

Finally it is the last day of the work week. Fridays are something to look forward to for many reasons (the upcoming weekend is an obvious plus), but I also very much enjoy an afternoon in probably my most challenging clinic. Usually the mornings are filled with either Radiology lectures or our "Master Clinician" series (a case-based discussion with many of Asheville's finest physicians). This is followed by a few hours of studying/continuity, and then Psychiatry in the afternoon. Psychiatry has offered some of my most colorful and challenging patients, as well as the best opportunity to really get to know my patients as people. In our initial interview, we (the students) spend an hour listening to the patient's story and asking questions. Only then do we take about ten minutes to discuss the case with our preceptors, and then we all talk as a group for the remaining twenty. So the students actually spend way more time than the physician with each person. And, unlike the outpatient clinics where we may only have ten minutes, there is usually very little pressure to accomplish any "agenda." It is a much more relaxed setting.

However, I must admit that Psychiatry hasn't always been a "relaxing" clerkship for me. I have always strived to get out of my comfort zone, and Psych has offered the best opportunity to do that this year. This is a field I certainly had no experience with prior to our orientation in October. For the first few months, I was almost always nervous before meeting each new patient. I never knew the "chief complaint" before starting the interview, and so every encounter was a surprise. Would the patient be manic? Schizophrenic? Suicidal? Thus, it honestly took me longer than usual to get truly comfortable with asking the important questions... Have you ever attempted suicide? Have you ever thought about hurting yourself? Have you ever harmed someone else? Have you ever felt like you were ever physically or sexually harmed? I usually acknowledge the confidentially of the patient-physician relationship first, but I initially felt uneasy asking the hard questions.

One thing this experience has taught me is to keeping asking and asking until you have an answer. Psychiatry is the ultimate "tell me more about that" specialty. Once I got comfortable asking patients the tough questions, I realized that sometimes I was moving on without getting a true answer.

Have you ever thought about hurting yourself?
No, not really.

At the beginning of the year, I would move on. But, "No, not really," is not really an answer. Tell me more about that. As I delve further into that line of questioning, I realize that many times patients just don't want to answer outright. Maybe they are scared or uncomfortable. This may be the first time they've admitted such feelings. Often it requires gentle prodding to fully understand the situation. I have found that "No, not really," actually may mean, "I only think about hurting myself when I'm alone. Yes I live by myself, and yes I own a firearm." Continuing to ask questions, and geting the full picture, is something that I have had to work on throughout the year.

Psychiatry has also given me a crash course in crisis management. Numerous patients have called me contemplating suicide, a number of people have called for prescription refills (won't be for a few years!), and some patients have called just to talk. Taking a step back, these are the encounters that remind me what an honor it is to be a physician-in-training, and how great the responsibility of being a doctor will be. My Grandmother once told me, "With great power comes great responsibility." My Psychiatry patients remind me of this constantly.

With the danger of putting too many thoughts into one Post, I will just make "one quick little teaching point, only if you can stand it" about Radiology. This is a field that many medical students get zero medical training in, unless they choose it as an Elective. Fortunately, we have been lucky enough to receive biweekly imaging lectures throughout our longitudinal months. I have spent many half-days sitting in the Radiology reading-room, and I absolutely must do Radiology during a month in fourth year. I doubt I could make a career out of sitting in a dark room most of the day, but it is a field that is constantly expanding and becoming an integral feature of every specialty. So, I've tried my hand at images about once a month since October (hopefully with some improvement).

The other specialty I need to try fourth year is Nephrology. Third year has taught me that I know nothing about the Kidney, probably due to my absence throughout much of Physiology during 1st year. For that, I have Ronnie Milam to blame, and 5 Star Nerve to show for it. 

The Med Student's Tale

Inspired by Sherwin B. Nuland's The Soul of Medicine: Tales from the Bedside, I want to tell you a short story. Dr. Nuland's book offers a variety of tales from his many esteemed colleagues, detailing some of the most memorable patients that they have worked with over their long careers. My "career" (if you can call it that) in clinical medicine has been brief - barely consuming the entirety of my third year of medical school. However, there is one patient encounter that I am sure never to forget. I have not told this story before, as I was so bewildered by the whole experience in the moment. But I think enough time has past, and I have collected my thoughts (though my bewilderment continues). The central character of our tale is a young 20-something named Jamie (her pseudonym from henceforth), whom I met in our Gynecology clinic. Before even knocking on the door, I knew the encounter would proceed poorly. I could hear her crying loudly from down the hall.

Before I go any further, I should self-admit that I was initially terrified of my six weeks on Obstetrics and Gynecology. Having finished six weeks on Surgery, I was transitioning from my probable career choice to a specialty that was the lowest on my potential vocational list. I had no prior experience in the field, and the entire "vaginal vault" remains a mystery to me even to this day (even more mysterious is why the medical profession deems it necessary to use the term "vaginal vault" - the female gentalia bears no resembles to a safehouse for banks to hold their valuables). Never being accused of having too little to say, one of my close colleagues likes to remind me to this day of how silent and ghostly pale I was on that first day - frightened with apprehension. Had it not been for starting off in the operating room on Gynecology-Oncology, the transition would not have been nearly as smooth. Ultimately I learned some valuable lessons during those six weeks; the most important being that I had no desire to pursue a career in female reproductive care, or the birthing of babies.

I knocked on Jamie's door already assuming the worst. However, I did not assume enough.

Knock, knock. Ms. Johnson? My name is Robert... Hey now, what's wrong? Oh! The nurse just told me... (sob)... I'm pregnant... again!

She proceeded to be stricken with tears, which gave me just enough time to get my wits about me so as not to stutter. Still to this day, I'm not sure what I should have said... "Congratulations?"

Okay, well why don't we talk about it? No. I just can't deal with this right now. I JUST CAN'T!
I assume this wasn't expected? No... just... I... just get out! LEAVE!

I really had no other choice at this point. I told her I would be back, and that I was going to give her some time to herself. I needed some time as well. There was no way I was going back in there by myself, so I waited expectantly for my Chief Resident to finish up in one of the exam rooms down the hall. He must have known something was wrong from the look on my face. Change of plans. My Chief decided that given the circumstances, he would do the pelvic exam and pap (since Jamie was many months overdue following up on her last abnormal pap smear). He proffered that we should first take a look at her chart.

Jamie was 24 years old, and this was her fifth pregnancy. We scoured the records and saw that each of her four previous children had a different father. It was also noted in her chart that according to her "principles," she did not believe in using birth control, and would not consider having an abortion. Numerous doctors' written records were filled with quotes of how she had referenced not particularly caring for her children, and saw them as more of a burden than her responsibility. Nonetheless, she lived at home with all of them (the oldest now being 7 years old), and was working as a waitress.

Most bewildering for me was her number of sexual partners. To this day I will never forget her written answer, mostly because it was given as a "range." Despite her principles regarding contraception, Ms. Johnson listed a range of sexual encounters from 100-120. It might as well have been written in red pen, highlighted, italicized, and bolded, because it made that kind of impression. Herein lies the disconnect that I still to this day cannot comprehend.

100-120. Five children. No birth control.

We walked back in the exam room, nurse in tow to chaperone. Jamie had recovered, and had moved on into her five stages of grief. Somehow in the past 10 minutes she had moved past denial and gone straight to anger. Brows furrowed, her distaste was palpable throughout the exam. She sat cross-armed and fierce, head cocked to the side, staring at the wall as her legs lay apart in the stirrups. The Chief asked her what she was going to do with her pregnancy. She stated that she would keep the child, and her live-in-boyfriend / FOB ("father of baby" - pronounced "fob" as one word), would be paying for "all this shit." Medicaid would pay for the child's health care. She would deal. Life goes on.

It is here that I must reflect on the current situation. It seems to me that she should either choose the multiple partners, but take care to have safe practices, or have her "principles," but be willing to bear the consequences of what such actions may entail. It is sex and birth control vs. abstinence. This lady falls somewhere in the between, wanting to have her cake and eat it too. But these four, now five, children are caught in the middle, being brought up in an environment that no child should have to suffer.

In the room, it pained me to watch her so upset and angry at an opportunity that so many couples would cherish. The consequences of her actions are so precious. I think about all the individuals who are denied children, either for reproductive or legal reasons, who would fight tooth and claw for this chance. This case made such an impression on me because it is a worldview which I do not understand. It is so far out of my scope, I could only watch in astonishment. So many questions are raised about education, ethics, and justice, but I guess those will have to be considered at another date.

As the Chief Resident stood up with her legs still askew, the drape barely providing any modesty, he decided to broach the subject of contraception one more time - this time in a perfect southern twang. This was not the first time they had had this battle; it was one of many. Her response was definite, even if it was provided with such little forethought...

Hunny, what are we going to do with you? And what are you going to do about birth control?
I'm going to kick my boyfriend in the FUCKING nuts is what I'm going to do. I'm going to keep kicking that fucker until he has no balls left!

Ah, the miracle of life.

There was nothing left to do except exit stage left.


(As always, numerous details have been changed to preserve patient confidentiality. I have been assured that all identifying elements have been eliminated.)

Thursdays

Thursdays are just such wonderful days here in Asheville. The weekly four-hours-plus of lecture are over; the weekend's in sight. I also get to wake up to the fresh, bright, smiling, young-minds of America (or if they aren't smiling, they're certainly crying/screaming/biting). Thursdays are a double day of Pediatrics in the morning and Neurology in the afternoon, and I swear my Peds preceptor only schedules the cutest kids on these mornings. On several occasions I've left a clinic room hearing: "If you don't want to go into Peds after seeing a kid like that, something's wrong with you!" If I ever drop out of Surgery, this is where my heart lies...

Besides how awesome the kids are, one thing I love about outpatient pediatrics is always being on the look out for something crazy (and I don't mean the parents). Behind the cool, calm, and collected exterior, you're a detective. The vast majority of kids are developing just fine, but it's your job to pick out the subtle anomalies. Amongst the health maintenance exams, flus, and the runny noses are the chronic granulomatous diseases, the Wiskott-Aldrich syndromes, and the one in a million genetic disorders. On the exterior, it looks routine. Ever wonder what the pediatrician is looking for when he or she checks your little one from head to toe? You don't wanna. Using the light to look in the eyes? Retinoblastoma. Squeeze the belly? Wilm's tumor. Moving the legs around? Developmental dysplasia of the hip. Trouble can be found anywhere. My preceptor told me about one mom who really wanted to know what he was looking for with each test. Despite trying to parry the question, she persisted. About halfway through the exam and explanations, she decided not to hear any more!

Probably one of the most important lessons I've learn in Pediatrics, however, has nothing to do with kids. The practice I work in (ABC Pediatrics) has six pediatricians, and they all love each other. They get along so well, and this has such a positive impact on quality of life. In picking a specialty, there are many things to consider. One thing I think it's interesting to ask is, "Who do I want my colleagues to be? Who do I want to wake up and see every day?" Based on my experience this year, both in and out of the hospital, I would want to work with Pediatricians. Laid back, fun, and they know their ish. I'm sure there are uber-intense Pediatricians out there, but they certainly aren't a dime a dozen. In general, finding a great group to work with makes such a difference, and I hope to be as lucky as this practice.

I also think it makes a big difference in patient care. All the parents I've talked to love the practice, and they are willing to see any of the physicians, even if they aren't their primary. All the docs are on the same page, they get along, and they have similar philosophies about approaching care. Because of that, I think there is more consistency for the patients amongst different styles. I have yet to hear from someone who doesn't like the practice, and I can see why.

As for the afternoon, it's off to Neurology. I have written about this clerkship before (see "Death Rate in America"), and will continue to write about it in the future. The patients I've seen in the outpatient clinic (and now on the inpatient service as well), tear me up. More to come on this front.

But now I must get ready for another week of Inpatient Medicine. See you on the other side...

Haaarvard Bound

Well, the deadline to make a decision finally came. After much agonizing (one day thinking I was going to Princeton, the next back to Harvard), I decided just to flip a coin. Heads Harvard, tails Princeton. When the coin flew into the air, was caught by the wind, hit the ground, and rolled into the gutter, I had to seriously sit down and make a list of the pros and cons for each place. Ultimately, being offered a Dubin Fellowship for Emerging Leaders (click here) was the deciding factor. Next year I will have the opportunity to study and work at the Center of Public Leadership (CPL), a program "devoted to creating an ever-growing and vibrant community of new leaders, social entrepreneurs, faculty, and researchers." About sixty students from the Harvard Kennedy School, the School of Public Health, and the School of Education amalgamate each fall to develop the practical skills and understanding to tackle the growing social issues that we face both here and across the globe.

More than anything, I am honored and excited to have the opportunity to work with this group of students (and faculty). Reading through the biographies of the CPL Fellows is both overwhelming and exhausting. The diversity of interests and experiences is humbling. I invite you to click on the link above, and take a look at the Fellows' bios: the Dubins, Zuckermans, Geiltsmans, etc. More impressive than the list of achievements is the subsequent narrative that each individual wrote. The passion and desire about social change is palpable. To be surrounded by people this dedicated to justice and the common good is motivating and infectious, and I hope these networks will teach me how other fields can inform us about maximizing patient care and eliminating health disparities in the United States. Reading about these opportunities makes me so excited for the fall that it is hard to focus on the 4 Shelves and 2 Steps to go...

That being said, it was extremely difficult sending in the letter to the Woodrow Wilson School declining admission. Though I have never regretted my decision to go to UNC instead of Princeton for undergrad, I certainly loved the environment at Princeton. The campus was beautiful, and I very much enjoyed the students I got to meet. Again, there were many "pros" about the place this go around: the 10 month curriculum (which would have allowed me to go to SE Asia for a month!), the coursework and focus on Health Policy, the financial support. It was truly painful clicking "send" on that email. I read the "new admits" message board every day, and was so impressed with the quality of my fellow admittees; so much experience and so enthusiastic (I think I was most impressed by an individual who was part of the National Security Council in Mexico). I know I will be working with these miraculous individuals later on in our careers.

Of course, the ultimate deciding factor was that now I can tell any new acquaintances that "I went to Harvard," preferably within 30 seconds of meeting them. This is a long standing joke between my father and me, and unfortunately I have found some truth to the statement. I would say that about 3 out of every 4 new people I meet who went to Haaarvard, tell me within that time frame. So, in recent phone calls home, I try to pepper it in after waiting at least a full minute (sometimes I just can't help it). This has prompted many promises to my family members that I will be in the 25%. Plus, as I have been reminded numerous times, I was indeed rejected from Harvard Med, so now I'm just batting .500.

There were no bad choices (I was constantly reminded of that). I was amazingly lucky to even have one. I had figured it would be one or none, but instead I was given a true gift of two choices. A special thank you goes to both my parents who gave me this opportunity, as well as appreciation to all the friends, faculty, and mentors who helped me talk through this decision.

Haaarvard bound!