The Half-Naked Stranger

I knocked on the exam room door for my usual Thursday clinical training session with John, my usual standardized patient. John wasn't there. Instead, before me sat an old man I'd never seen before. He sat slightly slumped on the end of the examination table, his scrawny limbs dwarfed by the gut protruding beneath the flimsy hospital gown. His eyes were bloodshot. He looked tired.

I felt sick.

I introduced myself and began my usual "routine"of meeting a new patient -- asking some basic questions, making smalltalk about the weather as I washed my hands, establishing a "shared agenda" for the visit. I asked more specific questions about his symptoms and associated observations and life events. I was cognicent of how nervous I was. I was choppy, my thought process disorganized.

This should have been no different than any other standardized patient encounter (yes, this man turned out to be a "substitute" standardized patient). But it wasn't. The context was entirely different: I didn't meet him in the context of being a trained instructor tasked with teaching me to care for a human being; I met him in the context of being a stranger in his underwear and a gown. His vulnerability was threatening, reminding me again of the profound trust and responsibility in this unnatural dynamic. This felt real.

Before long, I was uncovering portions of his bare body, kneading into his abdomen, digging for the edge of his liver, tapping my own knuckles over the surface of his abdomen and back (to make sure it sounded hollow in the right places), asking him to repeatedly breathe on command as I listened with my stethescope at locations that allegedly sound different from one another.

I didn't even know his real name.

Vulnerability is a big deal to me. My own experiences of physical, psychological, and/or emotional vulnerability have carried heightened appreciation for my multidimensional trust in another human being, a powerfully rewarding awareness. But what contributes a backdrop of security during vulnerable moments is an equally powerful awareness that there exist people in one's world who deserve that level of trust.

I didn't do anything to deserve that trust other than show up with a nametag with my name and the words "medical student." The fact that my new world is structured to afford me opportunities and privileges that I haven't earned strikes me, on its face, as crazy. Just crazy.

But I guess it couldn't be any other way...

Slicing, Sawing & Feeling

I started this blog to force myself to actively engage and process the daily experiences of my medical training experience in real time, lest I miss the opportunity to soak up any valuable subtleties. I envisioned sitting down to update it every few days or so, just to make sure I didn't miss out on anything.

WHOOOOOOOOOOOOOOOSH. Two months passed. It all happened so quickly. Just like that, I went from writing about vague fears of future hypothetical conversations with patients to an utter avalanche of profound absurdity. In two months, I had broken through a human being's vertebral canal with a chisel, cut a human head in half (and later cut off) with a saw, cleaned out a human heart in a sink, performed examinations of the limbs, eyes, nose, ears, lungs, heart and breasts, scratched away the layers of an eyeball, and memorized more than 3500 muscles, nerves, arteries, veins, and "spaces."

And I didn't write about any of it.

This is not to say that I didn't reflect on this nonstop inflooding avalanche of stimuli. I've certainly spent time thinking about the insanity that has marked my present life. I've engaged my deep feelings of inadequancy and attempted to develop coping mechanisms for every assault to my self-efficacy. I've even choreographed Spinning classes (unannouncedly) based on what it's like to feel like I'm drowning in my present AND my future, and effective ways of re-establishing control and self-efficacy -- which are as effective for me to put together as it seems it has been for my riders. I've gotten so good at reflecting and processing that I don't even MIND feeling like I suck at life a good deal of the time. I've accepted it as allllllll part of the journey, re-fueled by the times that I don't suck at life. And while I haven't been writing about the specifics of my experiences, I'm satisifed with the amount of time I've invested in maintaining important relationships with key characters in my non-med school life -- including the opportunities to share some of the things I never got around to writing about for myself.

But I'm a writer. It's what I "do." It's how I learn, how I think. How I devise creative solutions. How I take charge of my world. I suppose that each of these alternatives has served this purpose in its own way -- but to the end that I've been able to fully abstract some sort of deep appreciation for the subtleties of these experiences, that will in some life-altering way bear on my life taking care of patients? I don't know. And I guess I never will.

But today, I couldn't risk not writing about. Today, I experienced the most generous act that a human being has ever bestowed upon me, barring my own birth. Today, I performed my first testicular exam. While my standardized patient gets paid as a job to carry out these roles and to be available for my training, the idea that a person would purposefully enter this vulnerable state solely for the purposes of me to learn -- as opposed to, say, for the purpose of seeking relief from an actual medical problem, as would be the case in a regular clinical exam -- strikes me as an overwhelming gift. As overwhelming as accepting responsibility for someone's completely vulnerability, at a point where I can't possibly be knowledgeable enough to deserve that trust.

I guess that's all part of the road: accepting this life role and developing the mindset and confidence to accept the responsibilities, and privileges, that come along with it.

I did a decent job. I'm confident that, at the very least, I wasn't awkward. I was composed, methodical and deliberate. But here was another example, like the others I haven't written about but have perhaps shared verbally, of being SO aware of my limitations. You can follow protocols to a tee and still not detect the things you seek -- like the slight "wshhh" or "kkkhhh" of a heart, or the crackle of a lung (which is fainter than the crackle of your own sleeve brushing against the stethescope cord). And here with a part of the body that I've not "spent time with" in the context of looking for structures that are supposed to be a certain way (like the spermatocord), it is quite discouraging to lack the confidence of even finding what needs to be found. Today, for example, I guess I felt SOMETHING -- but as for whether that's how it was supposed to feel or is likely to feel, who knows?

On the other hand, I also performed my first abdominal exam. I had been anxious because I knew I'd be super-discouraged if I sucked at this, given my gastroenterological ambitions. But I didn't suck at this. I knew exactly what I was feeling for, knew exactly what it would feel and sound like. (As a practical matter, I can't possibly have every kind of medical ailment possible as a way to know what it feels like! But it works here...). When I heard a clicking in my patient's left lower quadrant, I nearly cried. I was so overjoyed. I looked down at her with utter glee, and I saw an amused flicker of delight in her eyes -- and I imagined that she must enjoy seeing trainees have "lightbulb" moments like that where they take confidence in a new skill (I imagine that's why she works as a standardized patient in the first place...).

It's nice to LIKE stuff for a change.

Frosted Glasses

With both eyes open, it feels as though someone took a stick of butter and smeared across my right eye. I can see well enough to function (well enough to have driven this morning, even), but am impaired enough to be mindful of the fact that there's something wrong. When I close my left eye, however, the situation is very different. It's as though the world is covered with wax paper: I know there's something interesting on the other side of it, but it's just as likely to be a tray of brownies or dog shit.

I am struck by my frightening inability to take in the world around me. But the experience of my corneal abrasion has thus far been enlightening in terms of enhancing my appreciation for handling impairment, and relation to those affected and unaffected.

Typically when I reflect upon an experience in the role of "Patient," it's after-the-fact -- once I've already come out on the other side, restored to health (even when I took notes via Crackberry on my distressing experience at the NYU ED on my last day in New York -- which I will one day make time to write about on this blog -- I was stabilized and very much improved). This is different: I'm in the thick of it, whatever "it" means.

I decided years ago that I would do whatever I could to learn about how other people experience things I've never experienced -- not for any great noble good, mostly so that I sound like less of an idiot when I encounter other people who have experienced the same things. In clinical settings, I've found that people really like to talk about their symptoms and experiences-- to get an extra ear of someone who has more TIME to really listen, even if said someone (i.e., me) can't do a damned thing to improve their state of affairs. Sure, listening counts, but it certainly has its limitations -- and, to me, acknowledging those limitations of what one is able to do FOR a patient also means acknowledging the limitations of what one *should* seek FROM a patient. I've always limited the directions of my questioning to the specific areas that either a) directly inform me in areas important to my research or as a follow-up to an area of their clinical care that I can impart to a patient's physician; b) work to establish rapport, to facilitate criterion "a." That's it -- anything more, I experience as unfair -- regardless of the "contribution" it would make to my learning process. In non-clinical settings, I've had varying degrees of success of acquiring specifics without getting too "clinical" -- though that has indeed been easier once people in my life forgot I was ever in Mental Health World (there is a fascinating correlation between "years since abandoning psychology as a profession" and "extent of misperception that I am forever 'psychoanalyzing' the world"). I've learned quite a bit through gentle, casual efforts at merely projecting (genuine) interest in people's experiences. It's one of my favorite medical training tools -- and, yes, I do conceptualize it as such. It always amazes me at how casually the Welnerisms I've retained from what I initially encoded as "forensic interviewing techniques" -- but, in reality, are just "good ways of interacting with human beings" sneak out, and successfully so.

A few weeks ago, I had a date that almost turned into an experience like this. We got to talking about his struggles with quitting smoking -- a struggle so profound that he couldn't get through our 20 minute picnic lunch without breaking out a cigarette, or at every two miles of our bike ride. He was apologetic, and expected judgment - of which he found none. While this was certainly a deal-breaker for me from a dating perspective, I was more curious than displeased. I asked him what a cigarette craving felt like, that I wanted to try to understand it and how it differed from other kinds of experiences (actually, I don't think I phrased it like that -- and looking back, I should have. That was very 'Welner,' and I think it would have been effective). He was surprised, but not unwilling, to answer. I disclosed my own (diagonally related) struggles, and he appreciated the comparison. Did his answer enlighten me to the depths of addiction? No. Did it change my life at all, even? Not really. Its value was moreso in relating to someone with a common inability to express a common phenomenon. I'll be more likely in my life to have discussions with people who CAN'T articulate their struggles than with those who can. Did I ask the question for "practice?" No. I asked for knowledge. But was it good practice, even if not good knowledge? Absolutely.

As it relates to vision specifically, I once read an article that mentioned a few medical school programs that required their third-year students to walk around wearing frosted glasses so as to experience what a patient suffering from glaucoma felt like. I made a 'note to self' that I want to do that. I didn't connect this with asking someone whom I KNOW who suffers from this (which I do know, and knew that I know...). I don't know why. And it's this very limited impairment (by comparison) to my own vision that is only now prompting me to seek this information out. I haven't attached a value-judgment to my delayed decision; I don't think it needs one. Just observing.

I'll (mostly) limit the discussion of my experience with medical treatment of this injury to that of my post-consultation self-care. After waiting in an exam room for 90 minutes to get examined by a nurse practitioner who didn't even wash her hands (as I was supposed to be studying for my exam on the spread of bacterial infection and its relationship to hand hygiene!! Oh, the irony.), I was diagnosed and provided with a patch to wear for 24 hours. At my own request for a prophylactic antibiotic, I was given a thick, goopy antibiotic ointment for a week. I didn't want to appear ungrateful for my request being honored -- and not having to pay for the ointment, so I said nothing about being totally unable to reach the site of my injury (my tear is at the very top of my eyeball, essentially -- I can't even reach it with a q-tip, really. A drop would reach it fine; a gel, which requires active direct spreading, not so much). Since I can't apply the gel to the site of injury, I instead have to apply to the likely entrances for bacteria -- and when I do that, I can't see a damned thing. So, I had to make a decision to only apply the ointment before bed -- so that it minimally compromises my vision when I wake up, as opposed to my ability to FUNCTION all day long.

When I share this with any of my fellow medical students, I get the same reaction: "You're so (GASP) non-compliant!"

During my first week of medical school, I attended a lecture on clinical decision-making -- which featured a review of how the "ideal" patient encounter is never as such. At the treatment stage, the lecturer encouraged us to drop the term "non-compliance" from our vocabularies -- that the patriarchal notion of "I, doctor, tell you, patient, what to do --- and you do not comply!" is entitled and short-sighted; it does not take into account a patient's psychological, social, economic, and other life circumstances that may be in direct or indirect conflict with all or part of a treatment plan. Hearing it presented that way, I totally agreed! I'd been using the concept of "compliance" and lack thereof for years already -- it was so part of the medical culture to which I'd been exposed, both among the physicians at TFP and Sinai alike. Never thought twice about it. Once that lecture changed my reference frame, I found my friends' reactions to my antibiotic debacle to be utterly offensive.

"Non-compliance" really does fail to take into account very REAL conflicts between this antibiotic gel and my life. Namely:
* USE ANTIBIOTIC --> CAN'T SEE A DAMNED THING
* USE ANTIBIOTIC --> EYELID WEIGHED DOWN TO THE POINT WHERE EYE IS ENTIRELY CLOSED --> FALL ASLEEP IN LECTURE --> FALL BEHIND WHEN THERE'S A TEST IN 3 DAYS
* USE ANTIBIOTIC --> CAN'T DRIVE --> CAN'T GET TO WORK AT 5:45AM --> GET FIRED

Non-compliant? How about "practical?"

An hour after I began this post, I still can't take external stimuli in from the world to the extent that I would want to. But I feel better for having brought my internal stimuli out to the world, in a way that no big ol' chunk scraped off my cornea can take away.

A Machine?

I wrote this reflection piece for an assignment in my Medical Student Leadership Group course, in response to a prompt about how the biomedical concept of "the body as a machine" impacts encounters between doctors and patients. I think there are aspects of it that I never want to forget I felt, so I wanted to include it here...

When my brain wears its “physician-in-training” hat, the phrase “body as a machine” is steel-cold: impersonal, robotic, non-humanistic – that is, everything I have strived to avoid in my patient interactions to date, and will forever strive to avoid in caring for patients in the future. When my brain wears its “cycling coach” hat, “body as a machine” means something entirely different: efficient, coordinated, empowered. I’ve appreciated this discrepancy/duality for some time now – for as long as I’ve been a cycling coach (and specifically, deliberately use the “machine” metaphor with my clients/students), I’ve also been on my road to medicine – and always been mindful of the avoidance of all the things associated with the first interpretation I described. The discrepancy never bothered me, however, until right now.

When I coach athletes to envision their “body as a machine” – that is, for those who find the approach effective – the comfort and confidence of being an entity that is deliberately designed to achieve is indeed empowering. That makes sense… for healthy people. The concept of a machine with parts that break – that need a “service call” to repair the specific broken component, which is sufficient to send the machine back out into the world on its way – strikes me as dehumanizing once health is removed from the equation. Healthy people can make the choice to envision their bodies as though an objective third-person for purposes of mental clarity; when people are sick and seek care from – in many cases – a stranger, objectification is an entirely different act.

I am mindful of how many times my clinical research patients, friends, or family have told me about physicians who “didn’t try to get to know (them) as people” – of the bad tastes in their mouth, the therapeutic distrust. I am mindful of my own personal experiences as a patient – what it felt like to know that I was conceptualized as a “review of systems” list, a set of imaging/procedure results. “Body as a machine” could not be less empowering a construct.

I remember my initial exposure to objectification from the “inside.” I had just made the transition from forensic psychology (my former world, before deciding to go back to school for my pre-med pre-requisites), and had landed my first legit “medical gig” as a clinical research coordinator in gastroenterology. My chief project was the development of a big bio-repository to support genomic/proteomic research in Inflammatory Bowel Disease – and I was in a prime location to recruit patients for it, but for the fact that my center was the go-to place for IBD in the area – meaning that many of the patients seen there were coming from all over, paying out-of-pocket, and thus of a relatively homogeneous socioeconomic class. My PI and I decided that it would be fantastic if I could also recruit at the weekly clinic where the GI Fellows saw low-income patients (general GI complaints, mostly – but it was worth a shot!). I stationed myself in the room where the fellows hung out between patients, and presented to the attending physician preceptors. I had never been in a room with so many doctors before. I was BEYOND intimidated – and BEYOND fascinated. The idea of doctors teaching doctors…. and being able to hear it all (and scribble notes furiously on, on the notepad I kept in the side pocket of my *gasp* white coat) – why, I thought it was the best thing to ever happen in the world.

Except when it wasn’t. Each Friday, I was “treated” to three hours of off-color, dismissive, and utterly offensive remarks in that “hangout room” littered throughout what was otherwise clearly thorough, diligent care. What amazed me was that so many objectifying remarks were delivered so casually – it was so ingrained into the culture.

"The Pouch in Room 5…” began one fellow. The what? This sort of thing went on, and gradually I came to learn common surgical treatments – and of how common it was to refer to people who have had to undergo them, and live with their aftermath, by shorthand names for their surgical procedures. I hated this and made a mental note to never, ever do this. My boss (my mentor) never did this, and I very much appreciated that about her.

I also remember my first exposure to the term “case” being interchangeable with “patient” – another thing I could never wrap my brain around, and hated so. “This sucks, I have 5 cases today,” I remember one attending saying in the hallway outside the endoscopy suite. I didn’t know what he meant. I thought about it for a minute or so, and I realized that he was actually referring to five PEOPLE who had to undergo an invasive procedure that scared the hell out of them, mostly under only conscious sedation (as would happen for patients without insurance a lot of the time). I was distressed. I began to hear it more frequently, and I accepted that this was “the way it was.” I never, ever used that term myself like that – I didn’t feel comfortable doing it, and might not ever. “Mrs. X’s case is complicated” was the modification I’d make, for example, which fortunately did not draw attention to my obstinacy.

Objectification also extended to stereotyping by diagnosis – a phenomenon that didn’t shock/disturb me as much as it should have at the time… until it hit close to home. My own gastroenterologist occasionally preceptored this fellows’ clinic from time to time – a very nice guy, someone with whom I had a fine therapeutic relationship as well as a very good professional relationship (compartmentalization worked well…). I was talking with him and one of the fellows in the same room where all of this craziness I’ve described all transpired. The fellow started to present the case of a woman having a flare of Irritable Bowel Syndrome. My physician, the preceptor, groaned and exclaimed: “Oh, you know those IBS patients… they just need to go home and get laid.”

Note: He treats me for IBS.

I took the experience in stride. I should have been offended, but I wasn’t. I just told myself that I would dedicate my life to never making anyone feel the way I should have felt right then. A year or so later, I shared this story with my boss – also a gastroenterologist – who, while horrified, attempted a rationalization… thinking that I would benefit from one. She offered that, during GI training, patients with certain diagnoses were overrepresented in the 3AM phone calls one would receive, etc. – and that objectification results as a coping mechanism, whether for good or bad. I acknowledged that I could see that as adaptive, sure. Was I naïve in my immediate conclusion that I would NEVER let that happen to me during my own training? If this “adaptation” is indeed adaptive – is it that much more adaptive than some other alternative I, and others, have and will develop over time?

Has “body as a machine” also evolved as an adaptation – to instill objectivity, to prevent against affective heuristics? I don’t know; maybe. I’ll certainly keep an eye out for it – trying to keep everything in context. At the end of the day, I would not be surprised if ultimately I learn to strike a balance: once I learn the specifics of the smooth, efficient “body as machine” and how to recognize when something goes awry, I might be able to cognitively process it that way – but as far as how I relate to a patient, I will be mindful of not projecting that outwards. I know too well how it hurts.

Saying Goodbye

Just in case I was wondering why I took last night off entirely from studying for no good reason (spending most of the night setting up this blog, presumably to reflect on an informal brownbag chat of which I'll attend 50 gazillion over the course of my training), it just became clear: so that I'd have this infrastructure in place to reflect on what just happened. And I mean JUST happened - I'm writing this during class, because I don't want to let any droplet of this evaporate.

Today I heard the story of an interdisciplinary treatment team collaborating in the care of a woman in the last days of her life. Through the eyes of her caregivers, I appreciated this woman's strength. I was mindful of the inspiration and awe that I've felt before when I've encountered patients who have heroically battled cancer, both successful and not. Reflecting back, I think that inspiration/awe has usually been a manifestation of anxiety and uncertainty: What would I do if this were me? What would I do if this were someone close to me? What would I do if this were my patient? I'm always aware of how I have no idea what I would do -- and, accordingly, admire those who do.

But today, there was a more striking experience. Listening to this story, I felt my body temperature and heart rate rise, my eyes glaze over with a burning sadness, the precursor to sweat beading up -- and, to be honest, 40 minutes later, none of this has waned. Towards the end of the presentation, a woman from the audience raised her hand to speak. She had been this patient's primary nurse during her treatment and reflected on one of her last memories of this patient. Almost as a throw-away line at the end, she used the words: "... and then I said goodbye to her." It hit me that I have NO idea how to handle that situation. I've been fortunate to have never had the experience of having to say goodbye to someone who is dying. I started flashing audio clips through my brain of sample parting lines against a stillframe of a hospital hallway, and interrupted each one with frustration and incompetence. A feeling of profound sadness washed over me.

My friend sitting next to me observed that I was visually shaken, and asked me about this on the way out. I asked her if she had ever had the experience of saying goodbye to someone who is dying. "Not when they were in a state of being aware of what I was saying." I have been fortunate to have not even have had THAT experience...

I think, read, and talk a lot about the challenge of delivering bad news. In fact, I am mostly over my great fear of never learning an appropriate way of doing it -- I'm fairly confident that I will develop something sensititve and effective. But THIS... this, I've never thought about. Why have I never thought about this? I have no idea what I would do or say, and I need to.

I think I want to look into volunteering at a hospice, once I get a better handle on my schedule. Forced immersion in what I am most scared of... there's no doubt that this would be invaluable. I've never done something by CHOICE that I absolutely have no desire to do. Is it foolish? Is it selfish?

I don't know...

Ethics Case Conference

Last week, I finished my first course -- Intro to Clinical Decision-Making (ICDM), essentially a conglomerate of epidemiology/biostatistics, genetics, and ethics. I honestly wasn't looking forward to the ethics part, as important as I knew it was. I didn't want to confront the difficulty just yet; I didn't feel ready. But the ethics lectures were delivered by one of the most inspiring people I've ever met. A pediatric palliative care specialist who could not have been more simultaneously profound, thoughtful, gentle, and inspiring. I actually got teary-eyed during several of his lectures -- at so many instances, I was prompted to reflect on why I'm here in the first place and my goals for taking care of patients. As part of the course, we were also required to go through the process of completing an Advanced Directive (I need to re-do mine... when I do it again, I'll write about it. It was so unsettling -- not for spookiness' sake, but for the lack of resolution I have about really how I want certain situations handled). After I did my AD the first time, I profoundly appreciated that there is so much ambiguity as it relates to what decisions people can make, when they can make them and under what conditions -- and it scared the HELL out of me. I'd seen the flipside of all of this at The Forensic Panel -- mostly family members trying to weasel one another out of money by challenging their loved one's decision-making capacity, etc. -- but nothing at the crux of the precipitating factors leading up to that decision. I freaked out. I needed resolution. I emailed this guy and asked him for how I could observe this stuff first-hand, stat. He invited me to attend a committee meeting of the ethics group, which was to take place a few weeks later.

That was today.

I was nervous. I woke up this morning, anxious about being a first-year medical student popping into this "place I don't belong." I got dressed up, to try to psyche myself up for "belonging." I got to school and started making excuses about all the other stuff I should do during my lunch break (which was when this conference was to take place). I went all the way out to the hospital -- and was about to chicken out. Finally I walked in. Introduced myself. Remained calm. "I belong. Pshh, yeah, I belong." It's all about how you talk to yourself.

The group was informal. Ethics supervisor, a peds resident, a 4th year med student, various nurses, and some administrators. The Ethics consultant presented two cases that were recently called in for Ethics consults, and the group discussed them. I was entirely passive -- I had nothing to contribute, and just wanted to soak things up. I was mindful of the fact that, if this were a med school class, "people" (maybe not me) would share their views readily -- as though they knew what they were talking about.... and that, here, I was so mindful of this being "real life" and not a hypothetical example. I didn't trust my views, and that's okay. But what was really amazing was that the structure I'd learned in my classes was actually applied to real life, exactly as it had been taught to me. I felt grateful at how well I am being taught.

I plan to attend more of these conferences -- and maybe, just maybe, I might one day have the confidence to open my mouth. Maybe.

I Meant To Do This From the Beginning...

I vowed that I would blog from Day One of my medical training -- for me... and if anyone else happened to read it along the way, so be it. Four weeks later, I am only now setting this up. That's ok; better a little bit late than never...

Though this is designed to facilitate my own self-reflection (and thus should not require any sort of introduction, in theory), I will feel better with one. I don't have time to write it now, though -- so I'll fix this entry when time allows. For now, onto the experience today that compelled me to get this started...