Posts Tagged ‘Medicine’


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 . . .


May 13th, graduation day, seems like a generation ago. I am now a resident physician in Pediatrics at Seattle Children’s Hospital.   I am 4 months in and the big question, of course, is “What is residency like?”
Residency is like a whirlwind- a lot of activity, direction not always clear.

Residency is like an intense championship game- you are surprised by what you and you team can do under pressure

Residency is like a great cup of coffee- when you can sit down and actually appreciate it, there is a lot to savor

Residency is like a power cord- sometimes your best efforts still fall short

Residency is like a great meal with a good friend- you walk away feeling more complete, more alive

Residency is like a murder mystery- never seen this before

Residency is like an assembly line- seen this too many times

Residency is like dawn- new possibilities abound each day

Over the next 3 years, I will tell the story of residency, right here, in weekly posts.

Of course, I am not on this journey alone; I have an extraordinary group of co-residents at work and my home team, the family. I will let these pictures tell the rest of the story:

Camz taking a nap with Snow and Storm, our first pets!


Camz, set for football practice


Christian and friends, first Homecoming at Shorecrest High School


Anne, taking it all in at Richmond Beach, Seattle


Celebrating Anne’s graduation from her Architecture program


Day off at Richmond Beach


The Dream Team, my co-residents


Downtown Seattle and Mt. Rainer , from Kerry Park

Donning the long white coat for the first time

Flashback to graduation


With Anne at BMA senior banquet


With “Mom-Kenya” and “Mom-USA”

image

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 . . .

 

Theatre_Masks

Credit: Prince George Speech Arts and Drama


The email started with “Congratulations” and then five minutes later I received a text that began with “Sorry to let you know that” The first was an educational/career opportunity, the second was a loss in the family. I felt alternating excitement and sadness and was reminded of an acting exercise I used to do with my students in which for ten seconds they had to pretend that their partner was their long lost twin, and then that their partner was an immediate physical threat. The point of the exercise was to demonstrate that Theatre is about the extreme moments in life. Intense good or intense bad. There is not, to my knowledge, a play that has succeeded on the premise of brushing one’s teeth or sorting laundry. The moments we remember most in life also fall into one of those two categories. The Great. The Awful. And yet, what do we do when these happen so close to each other? To offer a medical example, how do I break the news to a patient that mom made it but baby didn’t, or the other way around. We talk a lot in medicine about breaking bad news, but what about breaking mixed news?

I think the answer may be found, in part,  back in the acting exercise. The exercise worked best when there was no hangover from the previous situation. When the actors inhabited the physical threat fully or the wonderful possibility of meeting a long lost twin fully. It worked, even if the switch was sudden. When faced with mixed news, I think we’re tempted to gloss over the part that makes us uncomfortable. We rush over the good news because we don’t want to seem insensitive or feel guilt about seemingly not empathizing with  the closely accompanying bad. Or we gloss over the bad because it’s hard and then strike a false cheeriness based on the good. The result is this emotional no man’s land in which we are not present because we are more concerned with what we ought to be feeling than what we are actually feeling. One of my favorite scriptures is “mourn with those who mourn” and “rejoice with those who rejoice”. There is no caveat for inconvenient timeframes or close proximity between events. All anyone expects or really needs whether it is a patient, friend, or a family member, is that you honor that particular moment, joy or pain, fully. Have you noticed how sweet the first laugh is after you have just talked about a tragic experience? We are most alive in those moments allowing for truer connection. And so, I will celebrate the good news in the first email and mourn with my family members for the bad news in the text that closely followed. May I honor both moments . . . .

perfect-timing

Photo Credit: Steve-eilertsen.com

The line fell flat and I didn’t get why. Just the previous night, the same line with the same pace, inflection and volume got huge laughs from the audience but that night, nothing, except perhaps a polite chuckle. The only difference? I paused for an extra second to deliver the punchline and that killed it. The following night I used my original timing and the laughs were back. Could comedy be that clinical? Apparently so. And if timing proved to be important in my Acting, that only increased in medicine.

If a patient has a heart attack or a stroke, the two expressions you will hear are “Time is (heart) muscle” or “Time is brain.” The same intervention delivered too late and the effect is lost. I still remember pounding on the chest of a 32 year old heroin addict brought into the Emergency Room in cardiac arrest after an overdose. Every chest compression was filled with the knowledge that time was slipping away and when our team could not revive him, time stood still as the time of death was called. A young life gone too soon. Could a phonecall have prevented this overdose? Could a visit have come sooner and found him in better shape? We’ll never know.

Here’s what we do know. Timing is not simply about chance:

tim·ing
noun
noun: timing
  1. the choice, judgment, or control of when something should be done.

“Choice” “Judgment” and “Control” all imply deliberate action. Although we are not always in control of when certain things happen, we are in control of the timing of most things we do in our lives. But how conscious are we of that responsibility? Timing matters. Have you ever sent a text with either really good or bad news and had that one person who responds two days later saying all the right things, but somehow it doesn’t have the same effect? Timing.

I’m reading a provocative book right now “A Path Appears” which lays the case for how to make a meaningful difference. In the current chapter, the authors describe how tough the conditions are in a certain Native American reservation where up to two thirds of the male population are alcoholics. The unemployment and drop-out rates are unbelievable. So where do you time your intervention? The authors argue that trying to address unemployment before you’ve dealt with the fact that many children are born with fetal alcohol syndrome affecting their cognitive abilities is bad timing. Intervention can work but must be timed correctly.

As important as timing is, it is not adequately taught in school where the focus is on bodies of knowledge. But that knowledge is useless if not delivered in time to prevent a suicide or simply make a moment or day meaningful.

With timing in mind, I have taken a new approach to weekend activities with my boys. I used to schedule things I did with them where it made sense in the day, usually after taking care of my business earlier in the day. Reasonable right? But there was room for other things to interfere with the plan or I would get tired and I would not always get to things I wanted to do with them. Now, I start with them. Today we did big waffle breakfast, chores, an hour of reading together, countries of Africa pop-quiz and swimming back to back. This change in timing makes a difference in two ways: I am more likely to spend more time with them and that’s always a win, but I also convey implicitly that my time with them is so important that I start my day with it before anything else.

Timing makes a difference and it is a choice I am learning to be more deliberate about. And where it is not in my control, I have found peace in these words “He makes everything beautiful in its time.” Ecclesiastes 3:11

Apple World

Photo Credit: W Yuting, University of Oregon

If I were to ask you right now to list the most important qualities you want in a doctor, you would probably start with “Competent” and “Empathetic.” The first word out of your mouth would probably not be “Creative.” And yet, there is a growing trend in the medical literature and medical school curricula toward incorporation of the arts and humanities in physician training. Why?

Dr. Danielle Ofri, in her excellent article in the New York Times points out that creativity in medicine would not be unheard of: “Medicine is a field with a strong history of creativity, but its daily practice feels less and less so.” Creativity is tied to innovation and so should always be welcome if a field wishes to progress. But is getting medical students to read poetry and looking at paintings just a bunch of fluff? Not according to two well respected physicians at the University of Georgetown who offer this concrete example of how humanities sensibilities enhance medical clinical skills:

“Selected viewings of art with trained art historians,” in which medical students “learn context, practice description, and note emotion.” This could help to understand and identify “the different cultural and historical lenses through which images are filtered”—an important way to understand the assumptions they bring to their interpretation of a set of symptoms.”,

But what about at the day to day level, real patient, real person. What difference does it make when a doctor gets creative? Dr Ofri gives a  great example from Dr. Oliver Sacks in which a patient had Tourette’s syndrome with debilitating tics that were negatively affecting his home and professional life. He was prescribed Haldol, which eliminated the tics but also flattened his ability to improvise as a jazz drummer, one of his favorite activities. The non-creative doctor response would have been “You have to take the good with the bad”, as Ofri notes. But the creative doctor proposes “Take Haldol during the week so you can do your job, and hold at the weekends so you can play your drums like you used to.” The solution is not only creative but empathetic. And this is where I think the link is crucial. Because of how much I care about the entire health of my patient, my empathy fuels my creativity.

If there is one clear lesson I learned from my years in Theatre it is that people have many layers. Often, these layers contradict each other. I want to eat healthily, but have you tasted that burger or chocolate mousse? I want to give but I also want to take. I want to create but sometimes, I also want to destroy. Contradictions are part of who we are. That is why I think that Ofri proposes that computers can never effectively treat people:

“If all patients and their diseases presented in exactly the manner of the textbooks, then the algorithms would be sufficient . . . but the human condition is far messier — in health and even more so in illness.”

Anton Chekhov, a doctor, became one of Russia’s most celebrated playwrights precisely because of his fascination with human frailty or weakness, first physical and then psychological and emotional. He wrote characters who were compelling not because they were eloquent, morally outstanding or successful but because they were profoundly human, aspiring to be something greater even if they did not always succeed. The creative doctor is one who looks at this person first and the disease second.

That’s not easy. Using standard treatments and keeping on schedule in a pressurised healthcare environment is far more efficient. Stopping the world to “create” for your patient demands so much more from the doctor, often within a system that does not encourage it. And yet, if we are to stay true to the ideals of medicine, we must swim against the tide and be creative for our patients. Creativity is an act of empathy.

Do you want your doctor to be creative? I hope so.