Thursday, November 19, 2009

A Burden.

I walked into the room, and I wanted to snuggle him. Before me sat an 84 year old man, dressed to the nines with a tweed blazer, corduroy pants, black loafers and white socks. Beside him sat his son, a burly construction worker whose pained, glossy eyes penetrated my soul.

"Dad's memory isn't what it used to be," the son told me and my preceptor. He spoke softly and gingerly. The old man looked straight ahead, unfazed. "He gets confused."

As the interview unfolded, we learned of a life in isolation. The man lived alone in a trailer, which he kept immaculate. It's all he had. He was disconnected from his world -- he couldn't hear well enough, see well enough, process well enough to engage. His son did all he could, and they both knew that it wasn't enough.

We assessed the pressing medical issues and developed plans for the next steps to evaluate his memory, vision and hearing difficulties. We said goodbye, and approached the door.

"Should I bother keeping on?"

My preceptor stopped dead in his tracks. Slowly, he turned to face his patient.

"Absolutely. You have to. You have so much to live for. We're going to work together to get through this. I'm here with you."

My eyes glossed over.

"Sometimes I don't know if it's worth it. I can't do what I'm told. I'm stupid. I'm useless," he whimpered. "I'm such a burden on my family."

It was a textbook list of "common concerns" of which I'm supposed to be mindful when interacting with older people. Except it was real, delivered through desperate, painful, hopeless sobs. And I didn't know what the hell to do about it.

My preceptor left me alone with the man and his family, tasked with administering a Mini Mental Status Exam (MMSE). I've seen it done several times in my forensics life and had a lecture on it in school last year, but I'd never administered one before. I was nervous.

I sat down at the desk beside him, touching my sharpened #2 pencil to the first question. Breathe. Ready. I looked up at him. His eyes were glossed over, looking at me helplessly as if he wanted me to fix him. I didn't know how.

I ransacked the archives of my brain for prototypes of experiences like this one: discouraged person looking for answers he or she expected me to have. No, not that one. Not that one. No. No. No. Yes. Flash back to the day after Thanksgiving last year. One of my Spinning students in New York confided to me after class that she was struggling with an eating disorder. She felt helpless, and thought that I might have some magical insight to end her suffering. The responsibility of being trusted to share in her burden was heavy, painful. I felt inadequate. I couldn't erase her challenges; I didn't know how. But then I had a moment of clarity. I wasn't supposed to "fix" this. I was in control of how I defined my function, and I could choose a useful one. So I started asking questions designed to help this young woman frame her challenges within the context of her goals, and to identify the cognitive structures that helped and/or distracted her. Maybe it didn't make a difference in the long run. But for at least the next 10 minutes, she felt empowered to fight. And that was enough.

"It sounds frustrating to feel like you can't remember the things people tell you..." I began.
His eyes held my gaze.
"Have you ever tried repeating back the things people tell you, to hear the instructions in your own voice?"
He looked confused.

I simulated a conversation with the man's son.
"Dad, come over Sunday at 12pm."
"You want me to come over Sunday at 12pm?"

I explained how there are different pathways in the brain that are responsible for processing things we hear vs. generating speech -- and that some people's brains work differently, and are better at some pathways vs. others. I told him that, as a medical student many years his junior, I need to engage the other pathway in order to remember stuff. He smiled. So we practiced a few more rounds with his son, and I could feel the anxious fog start to clear.

I started the MMSE.
"What year are we in?"
"You know, the date... the year?"
"2000 and..."
"Oh. 1002. I mean, 1007."
"Ok, what state are we in?"
"GREAT!" I exclaimed, far too enthusiastically. I was so eager to validate him.
"What county are we in?"
"You know, the part of the state..."


His eyes squinted, and he slammed his fist into his forehead.
"I AM SO STUPID. Stupid, stupid. I don't know anything. What am I going to do?"

I touched his shoulder.
"I understand that you're frustrated... because you expect yourself to be able to do this stuff. But a lot of people don't know their county. You don't ever have a cause to think about it in your daily life. And the thing is, the part of your brain that handles attention is affected by how frustrated you are. When you get frustrated, it doesn't work so well. So maybe if you try to be more patient with yourself and take your time, your recall will kick in. Take a deep breath and..."
"Washington County." he interrupted me.
"See? Perfect."
"You're right. It's really 'in there.'"

The rest of the exam continued. Word repetition, number counting, backwards spelling, instruction following. Most of it pretty dismal. Occasional episodes of forehead-slamming, lip-quivering. I felt awful; he felt worse.

The last step is to copy a figure of interlocked pentagons. I expected this to be painful for him. I told him that I think it'd be painful for me -- that this test is designed to assess many different domains of function, that some people just simply aren't "spatial." He began to draw.
"No... this isn't it."
"That's ok. Try again."
He tried again.
"Just one more... I can do it this time."
"Go for it."
And he went for it. Twelve more times.

When he finished those damned pentagons, he looked up at me and smiled triumphantly.
"See? I did it."

The pentagons weren't exactly pentagons. But there were 10 angles, and the shapes sort-of touched. It wasn't exactly what anyone would hope for. But from the look in his son's glossy blue eyes, it was good enough. Enough to affirm that there's nothing else I'd ever want to do with my life.

Sunday, November 8, 2009

"Changing the Narrative"

We're all telling ourselves a story. This is not so much reality as it is the deliberate choices we make about how to respond to reality. Splicing it, spinning it, shaping it. Owning it.

That's what this blog is, really. Forcing myself, despite the burdens of time and resources, to tell myself the evolving story of my road to 'doctorhood.' It doesn't have a beginning, a middle, or an end exactly. But, so far, it's a pretty sweet story.

I wrote some time ago about story-telling in patient care, and how I saw narrative medicine -- the thoughtful, collaborative weaving of the themes and values that make up the broader context of a person's life (of which their illness is only one part) -- as a major influence in the way I hope to one day care for people. The symbols, the irony, the various devices to layer awareness and reflection -- all designed to empower people to heal themselves through the tools that doctors, patients and the characters of their lives all work together to develop.

Narrative medicine, of course, is just as powerful a vehicle for me as a trainee -- and will continue to be, for the rest of my life. Writing allows me to construct and reconstruct the formative events of my world, to give them meaning -- to frame it all in a way that teaches me as I go, and will continue to teach me as I look back upon it. Tapping into recurrent, intersecting themes is comforting for me -- the power and confidence of consistency is enormously gratifying. Last year, I had a "thing" about what I called "practicing commitment" (which is how my immunology course director used to describe the process of building confidence in coming to a diagnosis and standing behind it -- which I extended to apply to EVERYTHING that ever happened...). I found my "champion" symbol in the hematopoetic stem cell (en route towards various paths of differentiation -- unlimited possibilities, yet unable to turn back the farther along it proceeds). I practiced "practicing commitment" as an athlete, as a coach (HOW many training sessions have been specifically themed around commitment -- to a specific intensity, to a specific challenge, to a specific breathing technique, to an awareness -- over the past year? Hundreds. Commitment for the sake of commitment, even. The idea of demonstrating one's ability to husband all of one's resources upon a specific task -- how gratifying that can be.), as a medical student. As a human being.

As it turns out, we revisited hematopoesis last week in school. As slides of myeloblasts and lymphoblasts, and dozens of genetic translocations that result in their failure (that I'm magically supposed to encode for life -- or at least, for my Boards) flashed before my eyes, I was comforted by associating these "characters" with the way I conceptualized my life story. Or something like that.

Ironically, this coincided with quite a few epic developments to said "life story."

First, the process of TELLING it. At clinic on Wednesday, I had a fascinatingly subtle discussion with my preceptor about self-narrative. I am so lucky that I have a mentor who spontaneously slips into casual evaluations of self-narrative (what?!). His premise was how it's futile to deny how much of the stories we tell ourselves are inextricably linked to our biases, our expectations, and our dreams. We project aspects of our stories onto other people; we see what is consistent with what we want to see -- what we tell ourselves that we're seeing. I wanted to tell him that he was wrong. I wanted to tell him that I was confident in my objective analysis of reality at all times. But he wasn't wrong. I reconciled my dissonance relatively quickly. I came home and told Scott "my story," and heard his. In so doing, I 'owned' every single one of those projections, biases, and distortions. And it was a pretty sweet story, indeed.

The week continued. It was Primary Care Week, so I had the opportunity to attend a bunch of family medicine-related talks and interact with a number of characters who are starting to make quite the impact on me. I also set myself up to attend another family medicine conference, this one the Vermont state professional organization. I'd attended this group's meeting last year, as my first introduction to the community I'd come to experience as "my people."

Yesterday, I met with my advisor (one of the coolest human beings on earth). I found myself comfortably, casually recounting the past 6 months of my life. When summarized and editorialized (i.e., crafted as a story), I felt really "together." Even recounting my flop of a study (that I'm SERIOUSLY going to work on this week!) felt pretty good. He was amused by all of my masochism (i.e., three Centuries, deliberately seeking out awkward/unbearable/AWFUL experiences in order to get comfortable being uncomfortable). He observed my hyper-self-awareness (which I didn't exactly have the sort of relationship where I really should have felt comfortable reflecting at the level I was reflecting -- but I suppose he experienced my candidness as refreshing). Our discussion left me really proud of the story I'd pieced together. It may not have felt so fluid in real time -- but the version that lasted was a useful one.

Then, last night I went out to the clinic to have dinner with my preceptor, the PA who treats me like a daughter (she MET my mother a few weeks ago - it was pretty epic), and another friend. We got to talking about prostate exams (I do them all the time, unsuccessfully -- my fingers are too short!) and pelvic exams (I've done four now...) -- both of which I haven't been formally taught how to do at school, yet am regularly invited to practice at clinic. While I can comfortably discuss my history of anxiety and panic attacks, my love for my boyfriend, and my self-narrative style with my preceptor -- what I blurted out next was somehow outside of my comfort zone. I've written about it a ton. But blog fodder is not necessarily "say out loud to your hero"-appropriate.

"I feel so guilty every time I do a pelvic exam. I feel like I haven't done anything to earn this privilege. There's no reason that someone is being so generous. So I just want to get in and get out and get them done with being vulnerable to me. I don't spend time really learning."

With no more than 5 seconds passing, my preceptor responded:
"So change the narrative. Tell yourself that this patient made this choice because they wanted you to learn as much as you possibly humanly can -- and it's your job to honor that underlying basis for her choice."

Whoa. This man is BRILLIANT. That is an entirely crafted, distorted narrative. It's a version of reality that gets me to adapt my behavior, my attitudes and my emotions. It's a version of reality that's TOTALLY going to work for me. Is it exactly true? No. Is it false? No, actually. Is it more true than it's false? Yes. Is it going to make me a better doctor? Damned straight.

So, today was the conference. I woke up with a reprise of my lung-hacking cough. I had no appetite. My GPS got me lost. There was a country song on the radio, and I found myself kind-of LIKING it -- just because it seemed so movie-esque to be driving down a dirt road as the sun rose, en route to a symbolic event to mark "my future."

Turns out, I was the only medical student there. I didn't know anyone. I was awkward. Irony: it was held at the hospital where I deliberately accompanied my preceptor those nights over the summer, for purposes of "owning my discomfort." HA. I owned my discomfort for 9 hours today!

I didn't want to network. I just wanted to crawl in a hole and not be alone and out of place. But, at intervals, I changed the narrative. I was confident. I belonged. I had useful things to say. So I started... saying them. I met a handful of people who were really eager to encourage and support me. I talked with someone I'd heard speak a year ago, who really inspired me -- and there she was, eating lunch with me. There was another character, a junior doc, who probably recognized a lot of my young, naive, overly eager idealism. She inspired such comfort that I was able to ask her genuinely useful questions, and learn a ton from her experiences (i.e., elective choices, geographic options, etc).

Then, I had an idea.

A board member from the national umbrella organization for this state chapter was there, giving a talk on the future of family medicine. He started off with statistics about how very few people are choosing to go into family medicine and how it doesn't pay as well as x and y and z and blah blah blah. He then went into all of the mechanisms for reform under way, but completely omitted a discussion of efforts to increase the workforce (which tons of other speakers address). The difference is that this guy didn't expect a medical student to be in the office. But you know what? I was a medical student in the office. And suddenly, I felt compelled to be useful.

I spent 45 minutes during this talk plotting my next life event. My heart was pounding, unresponsive to breathing techniques. My legs were twitching. My vision started to blur. Own your discomfort. You don't need to make the anxiety go away. You just need to own it and keep going. You practiced this.

"Any questions or comments?"
Show time.

I raised my hand and in front of 60+ strangers, introduced myself as a second-year medical student for whom there was a 0% chance that I would do anything else with my life besides practice family medicine. I offered that I didn't know if my perspectives were useful, but that I felt compelled to speak up as the only student in the audience. I wanted them all to know that the reason I'm so committed to family medicine is because of experiences I've had with people like themselves -- the stories, the intangibles, the generosity of making time to give me the opportunity to learn from them and their patients. That I know they're busy and overworked, but that they should know that the time they make is invaluable to the future of family medicine -- that it means so much, that it goes so far.

I didn't stutter. I didn't cry. I didn't have a panic attack. And a few people came up to me afterwards and thanked me.

I got in my car and drove off, literally, into the sunset. I put "Who Knew?" by Pink on repeat for 45 minutes straight. Not because the lyrics mean anything to me -- but chords just kept striking the absolute perfect 'place' for me. I was tearful. Proud. Self-enamored. Peaceful. I even drove the speed limit the whole way home.

'Who knew' that I'd be telling myself THIS story? Or any of the stories that have directly led up to it? Every story of the experiences I sought to prepare me to do what I did today. The uncomfortable bike rides, the embarassing questions, the deliberate exposures to looking like an idiot -- just to get good at it.

Who knows what I'll be telling myself next?

Monday, November 2, 2009

Taking a moment.

It was right out of a movie. I met someone. And I fell in love. *BAM* And just like that, I have a whole new life. I've had this epic, cheesy, ridiculous over-the-top grin on my face for three straight weeks --glowin' on right through depressing renal pathology, indistinguishable hematologic cancers, and even a personal adventure with likely H1N1. (When I stopped hacking up my lungs long enough to have a conversation, a friend of mine accused me of glowing so much that I was emitting vitamin D). I'm just so utterly, ridiculously friggin happy.

Is my attention suffering? Maybe. Is my schoolwork suffering? Nah. Are my priorities skewed? I don't think so, either. Am I still making time for the things and the people I hold important? By and large, yes.

But there's one change that I don't think I'm okay with. I've not been writing.

In my last entry (a month ago!), I reflected on a concept in Jeremy Spiegel's book, Mindfulness for Medical Students, about how to own one's changes -- reflecting on them in real time, incorporating them into a larger context of "self" without being derailed towards another version of self that is inconsistent with one's original goals and values (as sometimes happens to doctors in training). Most of what Spiegel advocates, I've been doing for a while. But after internalizing his perspectives, I developed a framework that I decided would work for me:
1) "What's new?"
2) "Where did it come from?"
3) "Do I like it?"
4) "Is it consistent with my goals and values?"

In my last entry, I took the concept of "riding Centuries" -- this thing I apparently now "do." I identified these dramatic undertakings as a direct consequence of my perceived inadequacy as a future doctor -- and my strategy of deciding that if I could dedicate myself towards continuous improvement of a concrete, measurable task of riding a bike for 100 miles, that I could build the confidence I need to dedicate myself to the less concrete, more unnerving, ridiculously high stakes goal of learning enough to be responsible for a human being's life. Does riding three 100-mile rides in an 8-week period mean that I'm going to be a better doctor? Of course not. But do I think about it under conditions of extreme self-doubt and awkwardness? You'd better believe it. So this change -- do I like it? Damned straight. And is it consistent with my goals and values? It's, in fact, the most precise embodiment of my goals and values that I've ever practiced.

So, now "what's new?" Me, the writer with a huge chunk of her self-concept staked within the domain of self-reflection, self-awareness, written expression, and the active "remodeling" of life experiences, stopped writing.

"Where did it come from?" There's only x amount of time in the day. There's only x amount of energy. I've made an active choice to redirect that time and energy. I've never been happier with the results of my choices. But my happiness has come at the expense of choosing not to write.

"Do I like it?" I don't think so.

"Is it consistent with my goals and values?" One of the reasons I'm so happy in my new relationship is that I've been accomplishing almost ALL of what I accomplish by writing, just differently. But there's something very specific about reflecting in written form, creating a record of my life experiences (that I really do go back and re-read within a new context, afforded by another week or month or six months' perspective) that I really cannot, and will not, do without.
I think.

Over the weekend, I had an experience that I knew that I would never forgive myself for not making time to capture the way I've captured so many moments that have led up to it.

I attended a family medicine conference in New York. I shouldn't have been there. My fever had resurfaced and I felt terrible. Just as I was prepared to retire at 7PM for the night (lame...), I decided to take another lap at the residency fair. I'm not applying to family medicine residencies for another several years. There was no need to. But I was curious. I was curious about a program somewhere near my new boyfriend's hometown in rural North Carolina. So I strolled over, and started chatting with a third-year resident about her experiences. I was quite impressed.

And just as I started to walk away, a gentleman who -- no joke -- looked exactly like my preceptor at the clinic where I train (Irony: my preceptor trained in North Carolina) started talking with me. I told him I was from NYC, and shocked at how much I love Vermont, and how this has taught me to be open-minded about the experiences that will bring me a sense of rewardedness. He began to speak of what makes him feel rewarded as a family doctor...

"I'd been taking care of a woman for 35 years. One day, she came to me and said that her husband wasn't doing well. I went over to their home to see him. I said I'd be back in 3 hours -- but by the time I arrived, he had completely decompensated.

I told her that her husband wasn't going to make it through the night.

She was frantic. She started talking about needing to call this daughter, and that daughter, and this daughter and rushing him to the hospital.

'No,' I told her. 'There's no time for that. Here's what we're going to do. Call one daughter... and then ask yourself: What would your husband want right now? How would he want to spend this time?'

'He'd want me to hold him,' she said.
'Then go do that. Go into your bedroom. Close the door. And just hold him.'

And that's how he died.

Moments like that.... that's why I'm a family doctor. Life is a collection of these moments, these lessons you'll never forget, where people allow you into their spheres of values -- and it's your job to help them make choices that reflect those values."

My eyes brimmed with tears. I told him that, for what it's worth, that this moment was going to be one of those lessons that I'll never forget for the rest of my life.

After we parted, my immediate response was to go find somewhere to write. I didn't. I had H1N1. I went to sleep. But not before sending a text message to my new Alternate Reflection Mechanism. I felt at peace.

When I returned to Vermont and shared this story in person, my reflection had a special quality to it that was a "moment" in and of itself. A moment I didn't need to document on a blog (but apparently am, anyway). A moment that stood on its own as the version I'd remember, that I'd call up when I needed it. A moment that would last forever.

"I'm going to be here to share in these life-altering moments with you. And I'm going to make even more of them."

I may be okay with not writing so much, after all...