Friday, August 20, 2010


Sometimes you make choices that you're not particularly proud of.

My choice to not make time to write about any of the incredibly formative life experiences I've had over the past four months? Not my finest.

When I started this blog, it was to serve as a forum for self-reflection: to process, in real time, the subtleties of the thoughts, experiences and exposures that shape my world for better or for worse; to evaluate my choices along the way. Most of the time when I don't write, it's because I'm satisfied with the way I superficially process it as it's happening or, more frequently, because I'm too emotionally exhausted after telling my now-fiancé about a particular event that writing a "second processing" feels forced and chore-esque as opposed to cathartic.

But there's also something about the environment of medical training that makes me want to detach from thoughts and emotions alike. Something that makes me want to stick it in my back pocket, be glad it's done, and move on. Something that makes me just a little bit afraid of owning it, lest that give me the opportunity to regret it.

I did make some good choices recently, though.

On my psychiatry rotation in May, I chose to intervene in a child custody case. I chose to advocate for my patient, despite her history of severe mental illness and substance-induced violence, and chose to personally drive her and her mentally ill boyfriend an hour each way in my car to a hearing (after the hospital and child protective services refused to pay for a cab) that single-handedly enabled her to be able to keep her newborn son out of foster care and have a chance at supervised, safe recovery. I didn't necessarily think that she would be Mother of the Year; I didn't say that I did. My medical assessment of her psychiatric state, however, was that she was no more likely to make a bad parenting decision than hundreds of thousands of people who don't automatically get their kids put in child care -- and that she should at least have the opportunity to advocate for herself. My dramatic action (to seek the permission of legal services, my supervisor, and her supervisor to transport two homeless strangers, one of whom I was moderately fearful, in my own car) was the only thing that could have afforded her that. When I spontaneously offered, I didn't want to do it. I just felt that I had to. I couldn't not. It was the one thing, in that moment, that I could do to be useful, to contribute. It was my job.

On my internal medicine rotation in June, I chose to intervene in a patient's cancer evaluation. After I heard how pompously and jargon-esquely an oncologist explained my 93 year old patient's options to her, I chose to acknowledge that she understood 0% of her situation (including her option to do nothing). I chose how to re-present it to her, neutrally, and was fortunately able to find words that meant something to her. I asked her questions that helped elicit her underlying priorities and life values. Surrounded by 25 family members all crowded in the hospital room, I helped her frame the choice at hand (whether or not she wanted to know if she had cancer, based on whether or not she would do anything to treat it). My words found their place for each person in the room. There were tears and sighs and questions, so many questions. I patiently backed myself out of the equation, enough for her to make her choice clearly. I chose to hold her for the next hour as she sobbed on my shoulder. That was my job, too.

On my gynecology rotation, I didn't have a job. My role is ill-defined, and the circumstances of my environment contributed very little to any motivation to define it for myself. And I find that this very directly shapes the choices I make, new choices that I don't think I would have made before.

Calling upon my framework for evaluating new phenomenon: Where did this come from?

It comes from 4:15AM wakeups, 15-hour days where conscious patient interactions are limited to waking them up at 5AM (while they're supposed to be recovering from surgery), inquiring about their bowel movements, and forcing them to painfully contort their bodies to participate in a cursory exam that will be repeated an hour later by somebody else once I return with the rest of my overwhelming "flock" of white coats. It comes from how badly my feet burn after 9 hours a day standing in a freezing operating room, both temperature-wise and temperament-wise. It comes from the sterile, hostile surgical environment where the people entrusted with my development are more interested in advancing the tradition of 'education by humiliation' (which is actually preferable to hearing them mock and disrespect their patients' body habitus). It comes from being surrounded by overworked, exhausted residents who complain, talk dismissively of their patients, and are systematically forced to prioritize getting people out of the hospital over even attempting to connect with them. It comes from, from the minute I wake up, already wanting to go home.

Do I like it? Not one bit.

So on this rotation, I experienced almost the exact same situation as the previous one I described. But the players were different: a resident who in no way empowered me to take ownership of any of my experiences. The motivation was different: I didn't empower myself to do so either. The hours, the stressors. The excuses.

My resident explained my patient's options to her for evaluation of an ovarian mass that was causing her unbearable pain, which may or may not have been cancer: 1) do nothing, 2) drain it, which might be a temporary fix, or 3) have surgery, which would be a permanent fix. The trouble was that she had severe congestive heart failure, diabetes, hypertension (a significant risk factor for stroke), and severe lung disease. Surgery, for her, was a huge risk for death.

"Well, the thing about surgery is that you might not be able to get extubated... you might have to go on a ventilator for a little while," explained the resident.

Ventilator for a little while?! A little while, until her family may or may not have decided to take her off of it. A little while before death. That's a pretty important qualifier to include.

"Oh, no problem! A little while on the ventilator doesn't sound that bad," said my patient. "I'll go for surgery!"

"Ok, think about it some more - we'll come back this afternoon. See you later!" She and the rest of the team left, returning to the rest of their lives.

My heart sunk. My patient, who had no independent mechanism for evaluating her risk, was about to make what might be an irreversible choice. It would be her choice, of course, but based on things that we as her treatment team had a responsibility for communicating effectively. We failed.

I stayed behind.

"Mrs. W," I began. "You realize that you don't have to choose one vs. the other. You can try the low-risk option, the draining, and see if you get better. Then this way, you might not have to go through the dangerous risk of surgery."

I was leading her. I detected my own agenda, and I stopped. I didn't underscore the risks of surgery. I didn't underscore my concerns about all the reasons that she was more likely to die than not. I was a mere third year medical student; I didn't feel that I had the right to have an agenda. It wasn't my place to scare her. It wasn't my place to sit down and assume control over her life. The words I chose had powerful direction; however I chose to frame it and explain it, that's the way she would understand it. If I wanted to scare her, I could. If I wanted to make her understand, I could.

This profound responsibility, which should humble and thrill me, now frustrated me. I was tired. I was hungry. I was discouraged.

The optimistic smile on my patient's face brought tears to my eyes. And right there, I chose to check out. This wasn't my job.

But it should have been.

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