Wednesday, August 5, 2009

Power & Privilege

Drip. The septocaine dripped pristinely from my needle as it approached her shiny, pink flesh. I caught the drop with my gloved finger, then tightened my grip on the steel ring. Pulling back the patient's cheek pinched between my two fingers, I squinted one eye to verify the alignment of the most lethal thing I've ever held in my hand with the pterygomandibular raphe between her gum and her bone. Breathe. PLUNGE. Holy shit. I just injected a human being's jaw.

Yesterday, I injected a toe. The idea of sticking a needle into a human being -- having them trust you to literally seize control of a body part and insert a sharp object, introducing a dangerous substance into said body part -- is, on its face, absurd. Not as absurd as taking a pair of forceps, gripping a toenail, and peeling it off like an orange peel. But I did that, too. This somehow became my life.

Later in the day, I observed one of the PAs perform a physical exam on an adolescent girl. I contributed little; I was content to stand in the corner and observe a series of awkward interactions and then return to my regular scheduled programming of color-coded Excel spreadsheets. Suddenly, a voice interjected itself into my concentration.

"Sparky!" called a nurse (yes, that's what they call me at the clinic; and, yes, I answer to it). "Do you want me to do a vision test?"
"A vision test. Like, with the eye chart. Do you want to order that for the patient you just saw?"

Order a test? Like, without consulting with someone else who's licensed to practice medicine or remotely knows what he or she is talking about? Am I even qualified to make this decision? No. Definitely not qualified. Wait. It's a vision test. Duh. You can totally decide to do a vision test. Why wouldn't you do a vision test? Why is this person even asking me? Oh shit. Because I'm a medical student; I'm a stand-in for a representative of medical decision-makers.

"Uh, sure, go ahead. Why not?"
"Ok, Sparky! Right away!"

WHAT?! Did that just happen? Yes, it did. And welcome to reality. This is how it's going to be: someone who knows a shit ton more than you about, well, EVERYTHING (i.e., a nurse) is going to look to default to your judgment just because you are en route to one day to a prescribed position of hierarchy. On its face, absurd -- just like peeling off a toenail. But this, too, somehow became my life.

I continue to spend a lot of time reflecting on the profound privilege, honor, and absurdity that is being trusted by people without expending any effort to earn it, apart from putting on a white coat. I didn't earn the trust of the two men who let me examine their testicles today. Or the woman who let me witness the unveiling of her painful, gnarly atrophic vaginitis. Or the guy who let me insert a lubed, gloved finger in his rectum. No, I did not earn any of that.

When it happens, I am always grateful. I thank people for their generosity in contributing to my education and development: I look them in the eye and tell them how much I appreciate the opportunity they afford me -- how I'm always so surprised at how generous people are, how I can never believe that anyone lets me do or see or learn half what I do all day. I rant and rave because a) these folks deserve to be thanked, and b) it's almost an act of earning trust/confidence in reverse order -- as in "See? I'm a good person! You let me do this absurd thing, and look how good a person I am -- you should feel great about your decision to let me do this absurd thing." In the end, it's the only effort I expend to earn their impression of me. I earn the warm and fuzzy smile I get next.

Today, a patient consented to let me observe the interview portion of her visit with a PA but not the exam. Totally understandable. I stood in the corner and tried to stay out of the way. I fixed my eyes on the woman, her pearl necklace and earrings in jarring contrast to her examination gown. In jarring contrast to her elegance, to her pride. I listened thoughtfully with my eyes. I smiled and nodded at appropriate intervals. She snuck sideways peeks at me.

"So when you said that you've had these symptoms for th..."
"Wait. When we get to the exam, she can stay," the patient interrupted. "I feel comfortable with her... you... now." She turned towards me and smiled.

It was a routine physical exam, with a routine pap smear. But it was one of the most memorable visits I've had the privilege to observe -- because I actually felt like I EARNED the opportunity to be there. When I thanked her afterwards, my words gushed with effusive gratitude.

"You're going to be a great doctor," she said.

I touched her shoulder on the way out of the room, knowing that this moment would touch my life forever.

Armed by this dose of validation and confidence later in the evening, I grabbed the chart of a patient who came to see my preceptor for a cough. Great. An acute problem. I am TOTALLY qualified to go in and take a history and do examinations of organ systems I've actually formally learn how to examine. Then I can come out and present to my preceptor and feel really great about myself. Yes. Good plan. Let's go.

I took a history, did a few basic exams, wrote up a pretty good note. Pseudo-awkward guy, a bit unfocused -- yet I found that I was able to reel him in, inject structure and chronology into his account, and connect with him about the context of his life. He's a cyclist: that was my hook. Just as I was about to go present the patient's case to my preceptor, he shot off a bunch of questions about the heart. What steps could he take to reduce his risk of heart disease? I totally could handle that but wanted to do it in the presence of my preceptor, so I validated his exercise habits and said that we'd talk about this more during the visit. Then he asked something about surveillance ultrasonography -- which I somehow, in that moment, felt more qualified to speak on. What?! So there I was, fielding his question which I have NO idea why on earth I felt comfortable fielding. Sure, I fielded it ambiguously and said we'd talk about it during the visit -- but responded with far greater detail than the diet/exercise (i.e., the things I know most about in the world) question. I gave him stuff to latch onto, stuff that overshadowed my "yeahhhhh, I'm just a medical student" disclaimer.

I left the room and presented the case to my preceptor, who praised me for my workup. Again, felt on top of the world.

We go back in, come up with a plan, wrap up the acute issue -- then I prompt the patient to raise his "heart questions." When he asks about cardiac risk prevention, I launch into an extensive discussion about fish oil, exercise, blah blah blah. Wonderful. Then he raises the ultrasonography question, and my preceptor's eyes widened. "Actually, there is no relationship between [insert EVERYTHING I said to this guy]." He continues by citing studies and important international bodies' positions on his question, distracting him from the fact that [insert EVERYTHING I said to this guy] was totally and utterly wrong.

Gulp. Breathe. Tongue on the roof of teeth, inhale (my new favorite trick, taught to me by my friend Shefali, to enforce diaphragmatic breaths). Exhale long. Breathing my heart rate down. It's ok. You didn't ruin anyone's life. You're allowed to sound like an idiot. Nobody expects you to NOT be an idiot. It's ok. Breathe.

Downside of the privilege of being trusted: Every word out of your mouth counts. If you don't have confidence in the words that leave your mouth, do not guess. If you think you know of a concept that is peripherally related to another concept, do not link them unless you have specifically seen them directly linked. I was mortified.

After my preceptor left, I apologized to the patient for misspeaking and thanked him for the prompt to learn something along with him. He told me it was no big deal. I then spent 30 minutes providing dietary consultation (we had referred him to a dietitian, and I doubted that he would ever go). I felt like I redeemed myself and re-earned the trust that I'd enjoyed before I decided I was a sonography expert.

I waited around an hour before my preceptor finished up with his last patient, so that I could apologize to him and assure him how careful I would be in the future. So that I could thank him for not embarrassing me in front of the patient, for finding a way to correct me without undermining my confidence.

He surfaced: "We need to talk."

Oh shit. This was worse than I thought. My whole relationship with this clinic was over. They trusted a first-year medical student to interact independently with their patients, and now look what happened. I failed. I disappointed them. I suck. How did I do that?! Why did I do that?!

I followed him to his office.
"I am so sorry..." I began.
"For what?"
"For misspeaking about the ultrasound. For disappointing you."
He laughed.
"That was so not a big deal. Come on, let's go meet about your project."

Crisis averted; lesson learned. Being trusted to answer a patient's question is the equivalent of being trusted to inject a potent, potentially lethal anesthetic into a patient's jaw. It requires just as much preparation and precision, assuming just as many risks. And when you do it right, just as many rewards.

Monday, August 3, 2009

One Year Later.

Saturday was the one year anniversary (or, as my friend Nicole calls it: "Vermontiversary") of my most epic life upgrade to date. One year ago, I began -- quite literally -- an entire new life. I shed my boyfriend of two years, 85% of my hair, my access to 24/7 Internet takeout, and completely and utterly started over.

I learned to drive. I learned to compost. I learned to be still, and breathe, and trust myself. I learned how it feels to carve out a world entirely of my own making.

My departure was not without drama. Taking a break from loading up the moving van for a Diet Dr. Pepper at the Duane Reade across the street from my home of 4.5 years, my first cold swig triggered an episode of vasovagal syncope. I blacked out and hit the tile floor HARD, losing consciousness for several minutes. An elderly woman waited with me for an hour until my father could come take me to the hospital; turns out, she was my next-door neighbor. We'd never met before -- how New York. Just as I would be tempted to bid my city adieu with the taste of coldness, isolation and detachment I'd come to develop in my mouth over time, here I was being reminded that there really was a sense of 'community' -- even if it were masked 99% of the time by exhaust fumes, deafening horns, and swearing cabbies. Symbolically, I was prompted to take an entirely different farewell snapshot to New York than I was prepared to stage.

My experience at the Emergency Department was symbolic in its own right. In three hours' time, I experienced EVERYTHING possible that I would never, ever, EVER do to a human being. I was made to sit exposed in the waiting room in a patient gown. I was left completely topless for 20 minutes behind a half-open curtain waiting for an EKG. I was put into a bed soaked in someone else's urine. I was passed along a string of strangers, none of whom introduced themselves or even asked me how I was feeling. I was ignored by more than a dozen residents, nurses and techs evading eye contact as I bawled on a stretcher in a desolate corridor. I was dismissed and discouraged by the physician entrusted with my life. I was scared and alone and helpless, struggling to navigate the unknown amidst a hostile sea of strangers. There, literally "on the way to medical school," I had one of the most powerful training experiences I will ever have. Thank you, New York University, for contributing to my education. You'd better believe that this, too, was a snapshot moment.

What's in the snapshot I take today, one year later?

Here I am, on the screened-in porch of a rural Vermont cottage up a dirt road. I'm training at the clinic of my dreams, at the side of some of the most inspirational characters I could ever have invented to contribute to my development as a physician. I have a ridiculously elaborate new set of neural circuits that contain hundreds of thousands of new words and concepts and patterns, some of which have already contributed to human beings' lives. I've built a utopian coaching world here, where I can "do my thing" uninhibitedly. I've successfully acted on some pretty daring, quirky ideas: mindfulness trainings on a Spinner, an Intro to HR Training course, a legit scientific inquiry into the psychology of HR training (16 responses away from the finish line...). I'm 6 weeks away from my first 100 mile bike ride. I've invested in myself and in the things I've decided I want. Nice shot, indeed.

Last week, my preceptor returned to the clinic. I was ecstatic. Over the course of eight weeks, we've only been in town at the same time for maybe eight days -- he's been traveling a lot, which is disappointing because he's my absolute favorite person to train under. Everyone else teaches me well, extends me opportunities to practice various tangible and intangible skills, etc. But this guy is the only one who really directly empowers me to flex my 'usefulness muscles.' He lets me educate patients about diet and exercise (even heart rate training!) with great specificity. I'm not merely "filling in holes" -- for those particular moments, I perceive that I am genuinely contributing some specific added value. He knows that confidence is everything, and he takes it very seriously as his duty as my mentor to build my confidence through experiences he knows that I a) really enjoy and b) at which I am decent at worst, if not occasionally pretty good. I really only know 1% of useful medical concepts -- but he has a way of teaching me in a way that doesn't force me to frame it as such. "You remember that..." (when it's an entirely brand new concept). He describes his thought process to me on the fly ("I saw this, and thought that - so I tried this, and it worked/didn't work, so I knew this..."), which is a format I totally adore and am now making a 'note to self' to express my appreciation for that aspect of his style, as I work to develop my own thinking style. It's collaborative and gentle, and just WORKS. It's like that poster in the UVM library I reference a lot: "Knowledge is the ability to make the people around you feel smart." This guy is brilliant.

Upon his return, he took me out for a quick bite to eat during a gap in the night clinic schedule. "So you've got a week left," he started. "What do you want to learn? What can I do to contribute to your experience? What do you want more experience doing?"

Rewind back to the day I met him, in February.
"What do you want to do with your summer?" he asked me, then. For all intents and purposes, he was asking me what I wanted to do with my life.

And I didn't know. I didn't know anything, and thus I wanted to see and do and experience EVERYTHING. To the end that I couldn't specifically request ANYTHING. I was limited by my lack of limits.

If this summer has been about nothing at all, it's been learning to appreciate that it's OK to ask for what I want. And, without expending much effort to ponder this, the "what I want" part has presented itself on its own. Now I could answer the question, without hesitation.

I told him what I wanted. I told him I lacked confidence in working with my hands, and in describing my findings. I told him I wanted experience presenting patient histories and findings to him.

"Done," he said. "We'll do that."
And that night, we did. Right away, BAM. I got exactly what I asked for, just like that.

I didn't always know what I was doing or seeing, and I wasn't always useful. But I was confident enough to ask for clarification or elaboration when something didn't feel fluid. That confidence had absolutely nothing to do with my abilities or some sort of "natural progression" of events; it had everything to do with the deliberate, specific efforts of my mentor to contribute to the deliberate, specific experience I had expressed that I was seeking.

Knowledge is the ability to make the people around you feel smart, after all. One year later, the characters, the experiences, and the opportunities that mark my new life continue to remind me that this move was the smartest thing I've ever done.