Tuesday, July 21, 2009

Meaning "Something."

His eyes darted back and forth, tracking nothing. He grasped reflexively, mouth agape. Tubes connected his gut with a bag, his airway with a honking block of metal. A honking block of metal with an on/off switch next to my foot. I dared not make any volitional movement, lest I trip or bump or in any way interact with that switch.

Persistent vegetative state was his diagnosis. He wasn't making any volitional movements, either.

My new friend, a 4th year student doing a rotation at the clinic where I'm working this summer, and I made a house call to check out a potentially infected stoma site of a 39-year old man who'd been this way for the past 2 years after blowing off the top of his skull in a welding explosion, with exceptionally poor prognosis of regaining any function whatsoever. His parents cared for him on their own in their home, and fervently believed that he'd walk among us any day now.

"I ask him sports trivia and ask him not to blink for one choice, and to blink for another. He doesn't blink at the right times." the mother told us. "And I read all about them stem cells. Stem cells, that's the trick."

The man's father, a stoic crusty old Vermonter, became tearful as he recounted to us what their family had been through since the accident. We stood before his rickety old porch, looking out onto his vacant, barren farm. Tattered laundry strung past us on clotheslines. The early evening sun's glare blinded me, though not enough to miss the quivering lip and glistening sadness of the old man's eyes.

I have never felt so useless. I'd not been asked to do anything or say anything, or in any way make any mark on the situation I was taking in. But the fact that I literally lacked the capacity to interact with the world around me and its instant characters -- it paralyzed me.

My colleague, though, was brilliant. He had all the'right' things to say. The easy small-talk, the gentle balance that allowed him to neither crush nor inspire false hope. I was inspired by his confidence, his charm -- inspired in a way that somehow seemed more "accessible." He has two years more training than I do; in a mere two years, would I be able to carry myself as he did? I doubted this very much, though it inspired me to ponder the possibility of carrying myself with such grace.

This moment captured what much of my time at the clinic this summer has been about. Lots of ideas circulating with little forward movement. Not accomplishing much, feeling generally useless. Not feeling like my presence has been serving a purpose. I linger in hallways, awaiting an opportunity to demonstrate my utility. I pace anxiously. When I get sick of myself, I invite myself to tag along to observe a patient visit (like I used to do, before I started this medication safety project to meet with the miniscule number of patients who bring their meds with them to the clinic) and feel more connected. Beyond the two such visits I do per day tops, I manually type out long Excel formats into color-coded cells that spit back data that nobody really cares about. I know that I will redo every single one of those formulas in an order of mere weeks -- and yet, I type over and over and over again the tedious characters, as my one shard of remaining hope to avoid being perceived as idle and initiativeless -- trying to carve out a specific role that may or may not actually be needed. Even the patients with whom I meet don't necessarily believe in my function. It's hard to psyche myself up for it, even if I believe in it -- and hard to get anyone else in the clinic psyched about my function, since I'm so sub-enthusiastic.

So imagine my surprise when a nurse sought me out to ask me if I wanted to meet with a patient who was specifically coming in to talk about her medication concerns, and bringing her 20 meds in tote.

63 year old woman with a 35-year history of treatment-refractory major depression. She looked down at the floor, evading eye contact. She answered my questions with curt, one-word replies. She brooded and sighed, hunched over herself in the chair beside me. I introduced myself to her and described what I was going to try to do for her.

She started to cry.

"I'm so scared! I'm on all of these medications and they're too many, and I'm so scared!"

My major life-upgrade during my first year of medical school was to take up reading for pleasure. One of the most insightful books I've ever read, Prozac Nation by Elizabeth Wurzel, described a young woman's lifelong struggle with major depression. Not in a rote, cursory, cliche way. Raw, painful. Ironic. I inhabited the author's existence, practiced anticipating the consequences of the way she saw the world, and painfully observed how simultaneously rewarding and discouraging it felt to get good at this sort of anticipation. Sometimes I wonder whether I should spend more time studying and less time doing the stuff that most med students don't do. Today, I was so mindful of how this book specifically prepared me for this specific moment. I 'got' it. I was there. I connected.

I spent 2.5 hours with this woman. I asked her to talk about what it was like to wake up and move about, and dress and eat and get about her day. I asked her to talk about what it was like to leave the house, to interact with her family. To go food-shopping, to attend church. To process the world around her. To communicate with her doctors, her therapist. To feel alone, discouraged, purposeless. Hopeless.

I waited an hour before I brought up her medications; I needed her to trust me first -- and, unlike an actual doctor, I had all the time in the world. I asked her if it'd be alright to go through each medication one by one, to make piles of the ones she thought were helpful vs. the ones that she might want to revisit. I wanted to empower her to appreciate that she was in the driver's seat, that she had complete control over the elements of her world. She was willing to humor me, at least.

By the end of 2.5 hours, the woman acknowledged that 10 of her 20 medications "definitely" were helpful to her. That was a big deal. And along the way, we tapped into issues that I wondered whether they'd seen the light of day before -- her anxiety about how she communicated with imprecision, about remembering certain key things in her day. I didn't know how to manage her meds; she probably really did need all 20 of them. But I knew about her anxiety. I've not had any training -- but I knew EXACTLY what to say, how to prompt her to evaluate her thought process.

Everything out of my mouth was fluid and confident. I knew that I knew what I was talking about, and I just did it. And she did it. She engaged the questions I asked her, engaged the concept of asking herself questions, of rehearsing her coping mechanisms in advance of encountering challenges, of developing an arsenal of experiences to draw upon that demonstrate her strength and confidence.

As each word passed my lips, I line-item compared it to those that have spouted during Spinning rides, blog posts, car rides, and all of the other opportunities I've given myself to practice, inadvertently, for this one moment.

As I deliberately carved each word to empower this woman to motivate herself towards change, with the exact same words that I'd used for so many literal and figurative hills for myself and others, I was so mindful of how directly I was speaking to myself just as intently as I spoke to the woman before me.

This was what I had trained for; this is what I had trained myself for.

I made her a list to take home with her of three skills she had developed and practiced during our time together. Her ammo against her depression that was all of her own active creation, to help the meds work better. Her way of reminding herself that she was in charge, actively constructing her own experience.

She smiled and took my hand.

And I knew that I could and would never practice medicine in any other field besides primary care.

When I departed her company, I got tearful. I'd never felt so useful. It wasn't any particular skills or talents -- this really WAS just all about having unlimited time in a setting where time is a finite resource.

When I presented what had happened to the clinic's director, her physician, he was more amused than anything else -- apparently this visit theme was something of a pattern ("complain about meds" --> "threaten to stop meds" --> "come to admit that most are a good idea"). I felt a bit sheepish at first. But I knew that in 2.5 hours of truly connecting with a person who avoided and denied connection, this wasn't just more of the same. It had to have been different.

It didn't need to mean everything. But it needed to mean something.

And even if it were only to me -- for once, that was enough.

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