Archive for the ‘Medicine’ Category

At 3pm each day on the Hematology/ Oncology Service we attempt to rip ourselves from our wards work to take in a teaching session. It was during one of these sessions that our presenter made this provocative statement: “Pain is not the same as suffering. We can take away a patient’s pain but she may continue to suffer. We may not be able to take away a patient’s pain, but she may yet find a way not to suffer” 

This statement stopped me in my tracks. Each morning we evaluate our patient’s pain, especially important on the cancer service. There is usually a number involved between 1 and 10, giving us a nice clear target to shoot for. When we get that number down to zero, we feel good that the patient is not in pain. And yes, that is a worthy target. But how do you quantify suffering? The presenter offered this definition of suffering “To not feel whole.” 

Patients suffer by being reduced to an illness; they feel less than whole. I once had trouble getting through to patient until I walked into his room without an agenda. We just talked, person to person, not doctor to patient. A doctor can inadvertently cause suffering, the very thing our oath compels us to avoid. At the end of the classic Greek play, Oedipus, the title character is in a great deal of pain, having just gouged his eyes out after realizing he had, despite his best efforts, fulfilled the prophecy of killing his father and marrying his mother. It is a horrific realization and yet he is finally complete in the knowledge of this truth. He is in pain, but he is emerging from suffering. 

The challenge is how we ease not just pain but suffering in others. Or put another way, how do we contribute to another’s sense of wholeness? 


One of the toughest emotions to deal with is a sense of lost vitality. I witness this emotion when working with sick patients and their families. We all must individually confront this question through the arc of life at some point. While walking along the beach (quickly, it was cold!), I noticed a single tree stump which may offer a thought for us in such moments:

Stump By The Sea:

Been a long time
Since sap flowed through my veins

Since I fed vibrant leaves

Since I showed off my perfect bark

People don’t look at me 
Like they used to

When I was alive

But I’m still here-not dead

I have a great view

Of my friend the ocean

Who swims right up to me daily 

My other friend, the sun

Still flashes that amazing smile each morning

So maybe I am more fragile

Than I once was

But I am surrounded by beauty

And so, somehow, stronger. 

Image Credit: Pinterest.co.uk

There are many reasons to love 90’s hip-hop and R & B. Only recently, I offered a brief lecture to my ward team in which I deconstructed the iconic music video “Motownphilly” by Boys II Men. The exercise provoked teenage memories of working on synchronized high energy dance moves with one of my good neighborhood friends, Martin. The moment when your conscious effort fades away and the music takes over your body as you execute the moves to the building cheers of friends at a party is one of those great life feelings. 
Residency feels like learning a dance . . . 

But, I don’t always learn the steps in order.

There are many steps! 

I can be asked to perform at any time “What do you want to do for the patient?”

The music is always changing, from the steady mid-tempo of the wards to the upbeat Emergency Room to the slow dance of clinic (of course, the music can instantly change within all three settings as well). 

I can’t lead all the time- sometimes I only get to the best part of the room by letting my patient lead. 

I sweat, I get tired, I wonder how many minutes are left in the song. Can’t I leave the dancefloor for a minute? Then, this little dancer in clinic shows me a new move: It’s called “Hug the Doctor.” It’s a great move and easy to learn. It also gets me to the end of the song . . .

And sometimes, the music skips. I can’t figure out the problem or what to do next or how to get past an impasse of opposing lyrics. 

And sometimes, I’m back on the dance floor with Martin. The patient presentations flow with energy and purpose. Everyone recognizes the beat of a good plan. The steady drum of knowledge is overlaid with a couple of compassion tracks and we have a hit. The team may not be dancing on the desks of the nursing stations, but they’re thinking about it . . .

Photo Credit: HealingwithDrCraig
The look was the same . . . trembling lips, searching eyes, streaming tears, furrowed brows. The only difference between the grieved face of the father of slain officer, Patrick Zamarippa, and Alton Sterling’s son was the hue of their skin. The pain was identical. This was a harrowing week in America and I won’t cheapen the moment by offering political viewpoints on how we find ourselves here. I have appreciated the calls by both black and white people to love not hate, but I think we all know that Facebook statuses alone are not going to change the situation. In medicine, when patients present with medical conditions that are years in the making, a diseased lung following years of smoking, we understand that no medication no matter how powerful will simply erase the problem. The most effective solution is twenty years past its time. So, I humbly submit that the most potent forces for change were the babies born on each of the days that these men died and left holes in their families. Death can only be overcome by life. These babies do not yet know hate; we can teach them something different. We can dare to move past the natural discomfort we all feel with unfamiliarity and connect. 

And what about the rest of us? Can we change? Absolutely. But it will take something radical, beyond ourselves. When our heart has a major physical problem, we recognize that we need expert help in the form of a cardiologist or cardiothoracic surgeon. Why then would we think that spiritual heart defects are do-it-yourself projects? I realize that not all who read this may agree with my spiritual framework, but I have realized that real change in my heart requires God, who called himself “the great physician.” There is a wonderful verse in the Bible in which the Word of God is referred to as able to “pierce to the division of soul and spirit, joints and marrow.” Sounds like a surgical instrument to me. In fact, one translation describes the Word as a “surgeon’s scalpel.” I recognize that I am a surgical candidate, requiring both the operation that can transform my heart as well as the supportive care of people of goodwill thereafter. Change is possible.

I want to leave you with an image that came to me as I was praying this morning for the families of those lost. I imagined light challenging the darkness of violent acts, a light we can call carry. But I remembered that even those carrying light may still be carrying pain. So perhaps there are tears streaming down the face of light. But the light shines through those tears and, as physics teaches us, a rainbow is created. Not only is darkness dismissed, but color as beauty, not as color as divider, is introduced. This is our opportunity . . . 

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Alicexz.deviantart.com

One of the interesting things about being in medicine is that friends and family consult you with all kinds of medical questions at any time. The questions span speciality (I was asked about a brain tumor, cramping and a bad cough in the same week!) Honestly, I enjoy it: it’s like an unplanned case of the day, and it’s a chance to be helpful. In many cases, I can simply put someone at ease. The movie “Dead Poet’s Socity” spoke about two kinds of professions, the “life sustaining” ones like medicine and engineering and the “life enriching” ones like literature, music and the fine arts. My reward in Acting was to (ideally) give my audiences a meaningful emotional experience by the end of the play through the life of my character, that is enrichment. In medicine, my reward is to use medical knowledge and skills to help patients feel better, sustainment. So, I appreciate the inquiring phone calls and texts and I would like to take you back to one in particular . . .

Last week, my sister texted me, concerned that her daughter (my ridiculously cute niece:) had a high fever and a cough. As I gathered the history and started working through the mental algorithms for what could be wrong, I happened to catch my niece’s voice in the background. She simply asked “What is that?” I think I have may have gotten more information from that audio signal than almost anything else in her story. Why? People who feel very sick are not curious. One of the things we learned in evaluating pediatric fever is that the exact tempertature is not as important as how the child appears. That takes observation, attention. I appreciate that because it feels clinical. A computer can work through algorithms but a only a clinician can be a medical Sherlock Holmes and notice personal, intangible atrributes that crack the “case.”

Paying attention matters not only in diagnosis but treatment. While on a neurosurgery service last year, I encountered a patient who required an operation to remove a brain tumor. Due to the tumor size and location, the patient had a devastating choice, to either lose the ability to read or to hear on that side, depending on which surgical approach was taken. Losing hearing or reading is more than a medical choice, it is a human one. One must ask the difficult question of which option would reduce one’s sense of self more profoundly. This question is approached by a patient who pays real attention to who she is, as well as family members and yes, doctors, who have done the same. No matter our profession, we will learn the same algorithms: law students learn the law, pharmacy students learn the drug mechanisms, but effective decision making in the grey areas seems to reward those who pay close attention to the nuances that no curriculum can adequately capture. Even in the enrichment professions, the actor who not only knows the lines but pays attention to the demands of the performance moment will respond with that spontaneous artistic choice that we recognize as brilliance . . .

By the way, I think we made the right call on my niece. She is doing well . . .

 

Embrace

Photo Credit: EmbraceGlobal.org

I have never considered myself a DIY, use my hands to fix stuff sort of guy. I have always assumed that inclination was part of a different personality type. I am more naturally drawn to ideas, language, music, abstract science concepts and other things you can’t hammer a nail into. But in coming home this week from an interesting event called #wemakehealth I was forced to challenge some of my assumptions. #wemakehealth is an example of the “maker movement” a growing group of people from professions as diverse as medicine, business, design, and technology united by a common purpose, to make everyone into a maker.

So, what is a maker?

I understand it to be anyone who decides that she will not wait for a solution to handed down, but will get her hands dirty and build one now. And that is physically build it.  One speaker referred to it as “democratizing engineering”; an example would be the people who helped develop a warming blanket (known as Embrace) for premature babies in developing countries; this simple device is saving multiple lives where incubators are not available. The idea for this blanket emerged from a graduate school class assignment . . .

So what assumptions does this movement challenge?

That most of us can only be consumers of something someone else has made.

That if you’re not naturally “crafty”, building things is not really for you.

That you need tremendous background in design and engineering to build something from scratch with your hands.

I think we can agree that most things are more interesting to do than to watch. Yet, we somehow accept that other people who are more talented, educated etc must do all our building for us. This doesn’t mean that we suddenly have to try building complex computers. In fact, many incredibly useful objects are quite simple in their design (that warming blanket). I feel like the perfect messenger for this message precisely because I didn’t grow up trying to fix things and build stuff. And yet, in medicine, I was strongly drawn to surgery. There is something undeniably fulfilling about physically fixing a problem and being able to look upon your work. When I was given the chance to close incisions on the babies we were operating on in Kenya, I would look over my work the next day on rounds and if the wound was “clean, dry and intact” it was a tremendous source of pride. I often side with those who argue that we are born creative but have creativity educated out of us, and conclude falsely that it is the reserve of a select few. Now, I also wonder whether if there is something fundamentally human about building, making physical creations. The creation may be a meal, a painting, a creative blood pressure monitor, but it’s something. Perhaps, we were not made only to consume or roam the halls of the abstract, however enticing. Making is also key to progress in healthcare where so many structures, devices, procedures and processes remain opaque. Can we make something better ourselves? Can we stop waiting? Incidentally, #wearenotwaiting is the hashtag for the NightScout project, comprising a group of parents who came up with a creative way to remotely monitor their diabetic childrens’ blood glucose levels on cellphones . . .

So, to explore these ideas further, I am starting a brief blog series on making. I’ll bring in voices from the maker movement as well as practical ways to explore your own potential as a maker. If can I do this, trust me, anyone can!

spelling-mistake-1

Photo Credit: TalentCode.com

Everything was going according to plan. I was putting the final touches on the latest revision of my clinical research paper when I caught something. It couldn’t be?! I had made a big mistake and substituted one bit of information for another, erroneously. All the subsequent analysis that my team and I had done was no longer applicable. It was a horrible, sinking feeling. I looked through the records to see how I had missed this error for so long. I put the pieces together, came up with a plan to fix it, and then had to write the humbling email to my team. I was direct. I explained my error, apologized for making it, and offered a plan to correct. And then I waited for their response . . .

Within minutes I heard back. The neurosurgeon leading our team simply thanked me for being honest, having integrity and for attention to detail. The rest of the team echoed those sentiments and they were repeated in subsequent messages. We were to present the data as is.

Truth matters. Even in a cultural setting in which the prevailing current of thought may favor what you can get away with or how skillfully you can bend the facts, the simple truth matters. My mistake, while real, was also interpreted as being attentive to detail when caught. The very thing we think could jeopardize our progress, can instead be a stepping stone. In a year and half, I will be making significant decisions about patients as I start residency. I will not always be right, but I can always be forthright. I owe my patients and colleagues that.

So if like me, you make a big mistake, here is what I have found works professionally (but I would argue makes sense for personal situations as well):

  1. Address the mistake in a timely manner
  2. Admit to your role in clear and active terms (not “an error was made” but “I made an error”)
  3. Have a plan to address it (even if a different plan is used; this shows initiative and further commitment to the project).
  4. Execute the fix quickly but thoroughly and circle back to your team.
  5. Reflect on how the error happened so as not to repeat it.

I feel for the medical personnel of Doctors Without Borders who had endure a bombing that killed 22 people this week in Afghanistan. The US government  said it was a mistake; DWB argue otherwise. What is the truth? We don’t know yet. But here is why developing an ethos of truth is so critical. One day, it’s a research paper, the next someone’s life is on the line. The seed of our decision making is planted long before we make the high stakes decisions. Will we be ready?

Daniel Coyle in his insightful article, How to Make Better Mistakes, refers to a study with an unusual result: Harvard Business professor, Amy Edmondson, studied a series of hospitals and found that the top hospitals reported TEN TIMES more errors than the bottom hospitals. In actuality, the hospitals were making about the same number of mistakes but top hospitals were proactive about reporting them. How did that help? That transparency created a safe zone and culture in these hospitals where employees still felt free to create and innovate without fear. The fearful approach of hiding errors because of consequences creates an atmosphere where the brain retreats and is paralyzed. Coyle puts it this way, “mistakes are not a verdict, but information to be sifted over.”

Errors should be avoided, of course, but if you have blown it, you are in good company. Of course, there will always be those who try and capitalize on our errors, but the principle is still worth it, even with temporary difficult consequences. Most of the time, though, people respond positively if given the chance. I still remember facing another actor on stage who had completely forgotten his next line (something every actor has faced) which was “What’s going on in town?” When I recognized his blank look I immediately said, unscripted, “You must be wondering what’s going on in town?” He lit up with recognition and said, also unscripted, “You read my mind!” Audience didn’t notice a thing and the play moved on smoothly. We had a good laugh about the whole thing backstage. Most of the time, people are gracious about our admitted errors because ultimately they recognize themselves.