Thursday, March 12, 2009

Stepping into the Role

My sense is that medical training is a continuum between "impostor" and "legit." The entire continuum carries its special responsibilities and privileges -- all of them up for the taking -- but the process of training, beyond developing a legit knowledge base and skills, is about developing into one's self and developing the confidence accept more and more of those responsibilities and privileges.

I've written before about how even gaining entry to this continuum on the "impostor" end affords you completely ridiculous opportunities. By virtue of my status as "medical student," I get to say, see, hear, touch, and smell things that the general population does not -- things carved out into the most intimate spheres' of human beings' existences. I've also written about how profoundly "wrong" this occasionally strikes me, despite my gratitude for the cultural infrastructures in place to allow me to learn. A few weeks ago, when I donned my white coat and anxiously tip-toed into a patient's room with an assignment "just to talk," I felt completely ridiculous. Who was I to seek out my own learning opportunity while not being able to contribute even 0.005% to this person's state of affairs?

When I reflected on this here and to some people in my life, a friend of mine told me a story about being hospitalized for her ulcerative colitis -- and how, what she remembers most from those difficult times, was the third-year medical student who spent time with her just talking, following up on details, holding her hand. Just being present with her. I sort-of accepted that this was true all along -- that listening, being around, was an important role that I felt that I'd be good at filling. But hearing this directly was tremendously empowering -- feeling that, just maybe, I would be able to do similar good for someone's life... just by "being there." Not an impostor, per se, just being good at ONE part of my role.

Yesterday, I had my first chance to explore this. It was my first day of shadowing at interdisciplinary rural clinic about which I have previously ranted and raved. And it was one of the best days of my life.

The day started with a monthly staff meeting, at which the clinic's executive director introduced me to the 60 people who worked there. Everyone was so welcoming and I could feel myself just GLOWING to be around them, soaking up their energy for just "being there." From there, I attended a separate meeting of the medical staff holding a Q&A session with a local urologist to educate them, as family medicine practitioners, as to parts of their patients' urological care that they could properly manage themselves. I was surprised at how much I could follow -- I didn't think I knew ANYTHING about urology. Turns out, a little bit of exposure to histological changes, ion transport, blood tests, and some informal knowledge acquired about procedures via my old boyfriend, went a hugely long way. I was "right there," following everything -- scribbling notes to myself about things I'd later go look up to fill in the details for my knowledge base.

It was then time to accompany my preceptor, the practice's medical director and quite possibly one of the coolest human beings on earth, on his patient visits. It was 3PM when we started, and I knew that his clinic day would end at 9PM. I was determined to stay the whole time, a) because I'd spend two hours driving to/fro... I may as well make it count; b) I wanted to spend as much time with this guy as possible, given his status as my new favorite human being; and c) I wanted to make up for my lack of knowledge with enthusiasm and dedication. I stayed til 10:30.

Just like in my Forensic Panel world where some of my coolest opportunities happened after sane people would go home, so it happened here. I got to make a HOUSE CALL around dinner time (whereas "dinner" = rice cake with peanut butter, which afforded the opportunity to be a resource about Celiac disease to this super-smart, accomplished guy. I liked that, too.) We drove out through the winding roads of rural Vermont in my preceptor's truck, and made a legit, bona fide house call -- right out of the movies. An elderly woman, bedridden with infected sores (colonized by a bacteria I actually knew about, pseudomonas aeruginosa -- identified through a distinctive smell) that were potentially a complication of her rheumatoid arthritis (which also happens in Crohn's disease, which I knew about: pyoderma gangrenosa). On the way back to the clinic, I was able to engage in a legit conversation about antibiotics' use and contraindications... RIGHT out the course I'd just finished. I'd retained way more than I thought I did.

In the car ride back to the clinic, we talked about stuff I knew nothing about and stuff I knew a lot about. I felt like an idiot for not knowing common things (#1 cause of cardiac arrhythmia = hypertension) but felt pretty good about knowing not-so-common things (where you see PG). It's a task of balance -- impression management, knowledge seeking, confidence building, empowerment maintenance.

I shouldn't have let 11 hours pass between leaving the clinic and writing this, as already the intensity of the experience has waned a bit. I saw SO much stuff yesterday. Maybe I'll transition into somewhat of a highlight-recording mode:

* Salty, crusty Vermonter -- crude, gruff, good-natured. I learned the importance of selecting sub-roles to play -- I had to up my confidence level, to roll with this patient's inappropriate jokes and not let on any embarassment or intimidation. My preceptor, who is 500000x cooler than anyone else on earth, even got cooler in this environment. "Adopting a character" is an art I've been working on for years; it's how I survived at TFP. I listened to his lungs and heard nothing. I suck at lung exams, and it embarasses me. I confided this in my preceptor and he assured me that we'd keep practicing.

* Elderly woman -- 81, double knee replacement, still super-active. A skiier, even. Had bursitis of her hip (like I did) and physical therapy wasn't helping. My preceptor asked her if she wanted a hydrocortisone injection (i.e., what I *JUST* learned about that morning). I watched him prepare the solution and identify the most tender spot on the woman's bare hip. She grimaced. He guided the syringe needle directly into the bone, retracted just a bit to be in the hollow sac of the bursa -- which I visualized from the "wet models" of my gross anatomy lab, trying to apply where that was... and how AWFUL that might feel in a living human being to have a piece of metal inside my bone). She started to wimper. Instinctively, I put my hand on her back. And she wimpered louder, I applied more pressure. She stopped. I felt, for the first time in medical school, that I actually contributed at a stage of my role that I felt confident and competent to fulfill.

* Kid with psychiatric condition, heavily medicated, with symptoms reflective of bad untreated allergies... or gastroesophageal reflux disease. My first pediatric exposure. Decided that I absolutely want nothing to do with treating kids. How awkward to not be able to communicate directly with your patient, to base ALL of what you do on an unknown third party's description of what your patient is experiencing. No way. Not for me. I tried a lung exam again. Maybe heard breathing; doubtful.

* Similar experience on the flip side, with an elderly patient suffering from dementia. She didn't know what state we were in, but did know that it was 2009 and that Obama was president. It was neat to see a mini mental status exam performed (I knew those are the kinds of things one asks, but had never seen it done). Everything was based on her daughter's account -- and everything in the patient's life was dictated by the daughter's intentions and efforts. Including a shitload of raw vegetables, beans, and milk. The woman's chief complaint was gas. My preceptor, for some crazy reason, actually lets me participate in these visits I observe -- and, turns out, I had some decent thoughts: increasing soluble vs. insoluble fiber, tricks for reducing gas, perhaps a dietitian consult. It felt fantastic to know something useful.

* Young woman suffering from IBS with some sort of urinary tract/bladder infection. My preceptor asked how I'd feel about going in to take a focused history by myself. It didn't help that I didn't know the "pertinent positives" or "pertinent negatives" of a UTI -- but I learned them without sounding too much like an idiot, and now I know them. I was surprised by two things through this experience: a) how much easier it was to connect with a patient when I was by myself, less nervous about performing -- was just able to be myself, and I was mindful of how well I was connecting with even this most awkward of a character (note to self: serving as a forum for people to talk about their GI woes is my absolute favorite rapport-establishing mechanism; I'm pretty good at it). I got awkward when I started asking about sexual history -- probably not legitimately awkward, but I felt awkward. Next time, I'll be less awkward. But I started to get nervous and distracted, so I forgot to ask her a few important things that I absolutely knew enough to ask (my preceptor didn't ask, later, either -- but I would have). It was very much like when I get nervous during clinical skills exams -- I don't breathe, and I don't focus. I blank out. I need to pay more attention to that -- to go through the structured protocols that I really do know back and forth.

This encounter gets a second paragraph, as it was one of the more meaningful parts of my day.
Pelvic pain, weight gain, missed period, hormonal changes. Think: pregnancy. I wasn't a huge fan of how my preceptor broached this issue with her. She was maybe 20. Unmarried, not in a relationship, swore up and down that she'd had no sexual activitity for 9 months. My preceptor was matter-of-fact and forthright, which struck me in the moment as a bit cold (even though he is the polar opposite of "cold"). I wondered how I might have probed the same issue differently. He asked her about hygiene risk factors for recurrent, persistent infections also in a manner I would have handled differently. I noted that I felt confident in silently rejecting vs. adopting stylistic things -- confident in filtering implicit knowledge, selectively integrating themes and concepts into my world. When my preceptor said goodbye and left her to give another urine sample, I had an idea. I asked her about "streaking" in her panties -- which many people with GI woes have, in that a "whoosh" of gas actually occasionally takes with it, uncontrolledly, remnants of stool in the rectum from a prior incomplete evacuation. Nobody talks about it, as it's super-awkward. It's the kind of thing that people don't even want to tell their doctors about -- even people who otherwise have no qualms about discussing their GI tract. So I asked her. I saw the relief pass over her eyes. "Yes, that happens all the time." I also explained to her that we do pregnancy tests all the time, that she's probably completely not pregnant, and that if she wanted to - she could wait around for the results. "I'd like that," she said. She wasn't pregnant. I told my preceptor about the staining; he hadn't realized that this is fairly common in IBS patients. We then had a whole chat about IBS; he asked my opinion about treatments and was genuinely interested in what I had to say. I felt so comfortable, right there, being a resource about something I knew so much about. I was really proud.

* Waiting in the hallway to present this patient's case to my preceptor, the clinic's director wanders by. Says hello, makes small-talk. I got anxious. I'm always anxious when I don't know if someone important likes me or not; it's one of my major character flaws. So I decide that I should practice "adopting a character role" and pretending to be confident enough to practice being myself around this guy.

"I just took my very first official patient history!" I tell him, proudly.
He looks up from his paperwork and smiles. "Really? Tell me about it."
I tend to acquire far greater insights FROM people than using them as a sounding board for my self-insights. It's an art of prioritizing how you use your resources, and I'm getting decent at it over time. So I made that happen. So right there, in the hallway, this guy started telling me about his own medical school experience -- how he hated it, how he felt like such an impostor, how he felt so awful all the time... until the one day that he didn't. Until the day that he felt like he truly, naturally came into his role. It was so refreshing to hear that this important guy who has done so much in the world for other people -- starting this clinic from scratch, on a pipe dream that he could meet the needs of this community, becoming a federally qualified health center, expanding into mobile programs to meet the far-reaching stretches of rural Vermont -- went through the same things I am.

* 20-year old boy recently started psychotherapy for depression, referred by cognitive-behavioral therapist for pharmacotherapy. Nice kid. Bad habits. Watching him come into his own, acknowledging certain realities and challenges, was really inspiring. My preceptor counseled him on the natural antidepressant properties of exercise -- I'd never seen a doctor actually talk about the specifics of exercise, other than "you should do it." I was really excited by this. Another thing I felt like I'd be able to do confidently.

The last time I wrote about my trip to the clinic, I wrote about my interstate-driving epiphany on the way home that symbolized my experience of empowerment. So clearly, my car would HAVE to provide me with another opportunity to appreciate my experience in a different context. By falling apart and stranding me, throwing me into the fire with nothing but my wits and breathing techniques.

At 10:30PM, I went out to my car, started it and heard a strange scraping noise as I backed out of my parking space. Pulled forward. It got worse. Got out of the car. My still-detached bumper was a bit more out of alignment, but not enough to explain that noise. Drove forward, noise got worse. This was NOT ok. Climbed under the car, saw a piece of plastic beneath tbe bumper at somehow become detached, shredded, caught in the wheels, and scraping against the concrete. Also NOT ok. I didn't have the after-hours phone # at the clinic or my preceptor's pager # -- and he didn't hear the main doorbell (everything was locked, and his office was nowhere near the exit). I called my roommate to ask her to look up his pager # on my desk. Cell was off. Not ok. I tried to stuff the piece of plastic back out of the way -- but, honestly, it's a friggin car. You can't just push "pieces of car" out of the way. I took deep breaths. Avoided tears, avoided panic. I'd be able to handle this. It'd be fine. I drove out of the parking lot -- noise was worse. Came back to the parking lot. Tried again to ring the bell. I toyed with the idea of towing my car back to Burlington but decided that being alone in the pitch-black dark in an empty unlit parking lot to await such a thing was worse than dragging part of my car 50 miles on the interstate. Every mile I drove, I could feel my wallet draining -- how much more this would cost to fix, the more damage I did. Because of the way this dangling piece was blocking/re-directing air (like the underside of an airplane's wings), the wind was blowing me all over the place on the interstate. It was very much NOT ok. Still, I took nice deep breaths - dropped my shoulder and my elbows, focused my gaze on "where I want to go" (just like when I get scared on a bike, feeling like I'm not in control of my motion speeding down a steep hill), and it was fine. Over time, I reached a new, functional steady state of anxiety -- it felt like something I could manage, something at which I wasn't necessarily super-good at, but to which I was good at controlling my responses. Making technical adjustments, fine-tuning as I went, responding to what worked and did not work.

I made it home just fine.


Courtney said...

I havent' gotten to read the whole thing just yet but this is awesome and sensitive and powerful Melissa... I think i see the pilot for "Melissa's Anatomy."

I'm glad you are journaling all this--could make for a really good memoir once you're finished with the experience

Melissa Marotta said...

Thank you so much! I'm really thinking about your very suggestion, indeed. Everyone has their story, though; I'd want to wrap my brain around what could possibly make my account different.