Thursday, February 16, 2012

New home at Scientific American

I’m happy to report that Unofficial Prognosis launched today on the Scientific American Blog Network. From now on, all of my posts will be here.

Looking forward to being a part of the new community.

Thursday, February 2, 2012

Moving

First, my apologies that I have not posted in a while. But there is a good reason: I am moving! 

Well, my blog is moving. Last week, I was honored to receive an invitation from Scientific American to have Unofficial Prognosis become a regular blog on their network. I immediately accepted.

The blog is in the process of being set up (logistics, logistics…), and I will give an exact link once it is. In the meantime, here’s a link to the terrific group I will be joining. Once there, I will also be posting much more frequently – four times a month, to be exact.

Thanks to everyone who has read so far. I hope you will continue to read Unofficial Prognosis on the Scientific American Blog Network very soon.

Thursday, January 19, 2012

When does a medical student overstep her boundaries?

How does a medical student handle the requests of family and friends asking for medical advice?

My parents received devastating news in December: a close family friend was diagnosed with cancer. Somehow, I was thrust into the position of local medical expert.

While it is one thing if people ask about a medical phenomenon because they are genuinely curious, it is quite different if they are asking for their own personal use. It is plainly wrong for a first-year medical student to offer any sort of advice. But is it acceptable to offer objective scientific facts? How much is someone else’s interpretation – or misinterpretation – of those facts my responsibility?

Over the past month, I have grappled with how I dealt with my family situation and whether I overstepped my boundaries.

This dilemma is the subject of my newest piece, posted today on the Scientific American Guest Blog. I hope you’ll read it here. And, as always, I would be grateful to hear your thoughts and insights.

Sunday, January 1, 2012

Code (a work of fiction)

“I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgment, the following Oath and agreement.”
The hospital hall: a flock of white coats. Peeking from beneath, neatly tied ties on the men, crisp button-down blouses on the women. A swan, hugged by shiny metal stethoscopes, speckled with brown clipboards – and the uniform clack of heels as it swarms through the hospital halls. Well-groomed, well-meaning. Inquisitive young minds and idealistic young hearts.
Room 10-625: a 72-year-old Caucasian female. Presented with shortness of breath, chest pain. Past medical history: Diabetes Mellitus, hypertension, history of cigarette smoking, stage 4 kidney disease. First differential diagnosis: chronic obstructive pulmonary disease. Second differential diagnosis: hospital-acquired pneumonia. Unofficial prognosis: not good.
The elevator devours the swan, and up it swims, up, up, ten floors up. Right, left, right again, through the halls it flutters and fleets. Internal idleness. Did you notice how there’s no more frozen yogurt in the cafeteria? How about that bulging vein in Dr. X’s neck! Shh now, this is the room. A knock on the door, and a trickle of white inside.
The dance of sheets, enveloping a frail body.  Wrinkled sheets; wrinkled gown; wrinkled skin; a person dissolved, into an indistinguishable mass of crinkled beige. Tubing from her nose, tubing from her mouth, it webs. A trail of drool, culminating in a patch of crust on her gown. Creased eyelids covering the windows to her soul. Where is her soul? A body: attenuated by time, atrophied by pain.
Around her, the drip of dialysis. The rhythmic beep of the EKG. The hum and whirr of machinery, looming arrogantly. We are keeping you alive.
A single hiccup and the coats descend, encasing their prey. They pound on her, inject into her; a scuffle of syringes and solutions. The barking of orders, and a mist of multisyllabic words.  A few castaways fly free and paste themselves against a wall, shuffling desperately through clipboards. You won’t find the answers there, cygnets.
From beneath the scuffle, two pale feet leak out. They pray; then a twitch; and finally resignation.
The drip of dialysis. The hum and whirr of machinery, cowering shamefully. All we can do is postpone death. A flat line.
The tender swan reassembles. Injured – but not slain. Off-white coats, and the fresh stain of heartache.
“I will… never do harm to anyone…. If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men [and women] and in all times; but if I swerve from it or violate it, may the reverse be my lot.”

Sunday, December 18, 2011

"Bad doctors" and bad habits

“So. Why did you choose medicine?”
During the first few weeks of medical school, this question came up a lot in the context of getting to know our fellow classmates. We did icebreakers, learning one another’s stories, sharing our inspirations and motivations. We heard the huge range of narratives and experiences that led us here, to the same place, about to embark on the same journey.
Despite all our differences, I noticed some common themes. One was the “bad doctor” story.
It goes something like this. I, or one of my loved ones, was involved a devastating medical situation. We were scared and confused, and the doctor was just awful; (s)he was cold; (s)he was abrupt; (s)he said all the wrong things and didn’t care about us at all. It was a time when we were at our most vulnerable, and the person who had the ability to alleviate some of the anxiety made it worse. The story always ends with: I wanted to do better than that.
As of two days ago, my first semester of medical school is officially complete. My classmates and I are one-eighth of the way towards receiving an MD. Time for a status update. Are we doing better?
In class, we recently had a presentation that involved both a doctor and a patient. As the session went by, I found myself becoming irritated by the doctor’s interactions with his patient. His presentation about the science of her illness went on a little too long, leaving less time for her to speak. He interrupted her. Worse, he cut her off when she was recounting an experience that made her emotional, interrupting to remark on the biochemistry of the mechanism.
Speaking with some classmates afterwards, I found I wasn’t the only one put off by his behavior. Yes – what was with that doctor? Yes; he was out of line. We didn’t need to convince one another of anything. Independently, we had the same reaction.
Great, we might think. The new generation is better. Perhaps admissions committees’ shifting selection criteria, with an increased focus on empathy, are working. Perhaps curriculum changes designed to teach us communication skills and ethics in addition to science are creating more mindful physicians-in-training.
Still, I find it hard to believe that one heterogeneous group of people is simply better than another group.
Sometimes, when we are fortunate enough to have patients visit our classrooms and share their stories with us, a handful of students are more entranced by emails or text messages. Granted, these students are the exception, not the norm. And granted, they have been called out. I’ve seen another classmate tap one of the computer users and tell him bluntly to cut it out. Our professors have called them out too, with one recently saying, “it’s very easy to be high and mighty about those ‘other’ doctors who aren’t sensitive to patients... but if you’re the person who’s on your laptop while the patient is here telling us about [his or her] condition, you are that person.”
Bad habits start early.
For the rest of us who don’t fiddle with our laptops and phones in front of patients – who were able to recognize “bad” behavior in the doctor and in our peers – there’s still the obvious point that we’re not yet doctors. I realize that it’s easy to focus all our attention on displaying empathy when we’re not yet preoccupied with any real responsibilities. I am aware that our obligations at this point are minimal; we study, memorize, and pass our exams. We are not responsible for human lives.
Just wait until we’ve been doing this for fifty years. I wonder if any of the “bad doctors” started out like us. Were they once idealistic? Were any of the people committing empathy gaffes the same ones who were once able to detect the shortcoming in others? And if so, what changed? What eroded their ability to display compassion?
Medicine is notorious for jading people. I could see disillusionment in my own doctor, who talked about how he spent more time doing paperwork than seeing patients. I could see it in a resident I once shadowed, who bemoaned the fact that she essentially lost all outside interests because the only thing she had time for outside of medicine was sleep. I could even see it in a friend of mine, now just a third year medical student. Seeing him was especially disenchanting, as I saw the transition directly; I knew him when, back when he was bright-eyed.
Is becoming disillusioned inevitable?
I am curious to see myself and my classmates – who will then be my colleagues – several decades from now. Who will retain youthful energy and idealism? Who will be jaded? And, will any of us be that “bad doctor” who, by igniting indignation in a patient, unintentionally helps cultivate the next medical student?
One year ago, while interviewing for admission to a different medical school, I had the pleasure of speaking with an elderly family physician. Casually, after our “formal” conversation ended, I asked him why he ran interviews. “I love seeing the enthusiasm,” he told me. “You spend so much time in this profession, and people complain about everything… I am inspired by you guys who aren’t yet disillusioned.”
To that interviewer, I say: I’m afraid I can’t promise that I won’t become jaded. I can’t promise I won’t become stressed. I am sure I will make mistakes. I am sure I will have many moments that will make me question whether I am in the right field.
My one hope is that these doubts will never overwhelm my ability to be kind to patients. The last thing I want to be is a physician who speaks loudly about moral actions and then behaves regrettably when it actually matters. And if I ever do become like that, I want someone idealistic sitting next to me to tap me and call me out on it.
And if by chance, someone reading this happens to be doing so in a clinical setting, I ask you one favor. Maybe bad habits start early, but that also means there’s more time to fix them. So please, close this page. There’s something way more important right in front of you.

Monday, December 5, 2011

What single quality predicts a good doctor?

What is the most important characteristic a medical student should have? 

Intelligence? Empathy? Time management? 

I recently came across an article by Dr. Faith T. Fitzgerald, former dean of students at the University of California, Davis, School of Medicine, that pitches a different idea: 

Curiosity.

Dr. Fitzgerald wrote her insightful piece in response to a request from politicians that more humanities coursework be added to the medical school curriculum. The idea was to help medical students became more humane.

But the dean was skeptical. “I wondered what evidence supported the idea that being well versed in the humanities made one more humane,” she wrote.

So she did a study. She and her colleagues read reviews of third and fourth year medical students in their clinical clerkships, written by supervising physicians. They noted words that suggested humane behavior, such as “caring” and “warm.” They then looked to see if there was any connection between positive descriptors and coursework taken prior to medical school.

Surprisingly, there was. Medical students viewed as more humane took on more coursework in college – but not just in the humanities. The more classes students took, period – in the humanities or in the sciences – the nicer they were described.

But why? What does taking a lot of classes have to do with being compassionate?

According to Dr. Fitzgerald, there is a single trait underlying both the desire to learn in the classroom and to be empathetic on the wards. She writes:
“What is kindness, as perceived by patients? Perhaps it is curiosity: ‘How are you? Who are you? How can I help you? Tell me more. Isn’t that interesting?’ And patients say, ‘He asked me a lot of questions’; ‘She really seemed to care about what was going on with me.’”
That is, the same inquisitiveness that fuels students to seek knowledge in the classroom also propels them to find out more about their patients. And seeking to find out more comes across as a display of compassion.

There are many gems in Dr. Fitzgerald’s argument. One is that it calls into question the unfair yet enduring stereotype I mentioned in my last post: that of the cold, distant doctor (or medical student), who objectifies patients as intriguing problems to be solved instead of fellow human beings to be empathized with.

This stereotype is not unique to doctors. Scientists not in the medical profession may be even easier targets. I’ve always found odd the idea that an interest in science somehow suggests a person is emotionally detached. That it is impossible to harbor, in the same body, the ability to think through scientific problems and to care deeply about others. That students who choose to study the humanities do so with a moral advantage.

It does not make much sense to me that engaging with Nabokov instead of glycolysis makes a person more likely to donate to charity.

Speak with students passionate about the sciences and those passionate about the humanities, and you’ll find they are often motivated by similar desires. They summon similar concepts to explain their interest. Both want – that is, are curious – to understand some aspect of the world around them. To do so, they learn a language specific to their field and immerse themselves in it until they begin to discern patterns. The only difference is whether these patterns are in physical phenomena, or in the human experience.

A second gem from Dr. Fitzgerald’s article is the message of how to actually go about exhibiting curiosity. Watching talks given by Nobel Prize winning scientists for inspiration, she noticed similarities in their ways of thinking. They all seemed to toss around ideas with no pretense of linear thought, no semblance of structure, and, perhaps most importantly – no pretense of competence.
“The scientists seemed oblivious to intellectual constraints and unconcerned about being seen as naive or unknowledgeable.”
Dr. Fitzgerald hits upon something here that I have found particularly relevant in medical school. It is much more difficult to obtain knowledge, much less to propose something innovative, if you are preoccupied with proving yourself. In order to discover a good idea, you need the luxury to experiment with bad ones. To put forward incorrect hypotheses, explore false leads, and work through ideas without any particular end goal – or any guarantee you will uncover something at all.

The pass/fail system during the first two years of many medical schools is a good first step in cultivating a non-pressured, curious environment. Especially at this early stage of training, we should be more concerned with gaining knowledge than with showing off that we’ve got it. Don’t understand something? Ask questions. I try not to let a fear of sounding “dumb” overwhelm an opportunity to learn.
“Rather than stating that the study of humanities makes one humane, I propose that humane people are curious and therefore choose to explore the humanities as well as the sciences."
I am a bit late (now twelve years since her article was published) in lauding Dr. Fitzgerald for so elegantly pointing out a quality essential to many aspects of medicine. It is time we recognize that the sciences and humanities are complementary, not conflicting, and that it is counterproductive to construct arbitrary walls between them. Lopsided intelligence is not in vogue. Scientists can write compelling arguments, and humanists can solve puzzles. Viewing the world from diverse angles should be encouraged as a way of understanding it in a more complex, more meaningful way.
“Truly curious people go beyond science into art, history, literature, and language as part of the practice of medicine. Both the science and the art of medicine are advanced by curiosity.”
I am inspired by the idea that we can point to a single underlying trait that makes one more likely to keep up to date in the medical literature; to understand the biochemistry of a patient’s reaction to a drug; to propose improvements in health care systems; and to simply ask a patient: “how are you feeling today?”

Sunday, November 27, 2011

Curiosity versus compassion

I never thought I would call cancer “cool.”

It was the last day of anatomy lab. Finally, we had dissected through everything: starting with the back, moving through arms and legs, hands and feet, chest cavity with lungs and heart, abdominal cavity with gastrointestinal organs, pelvis, and ending with head and neck.

Looking at our cadaver was disorienting. There were insides where outsides should be. Organs completely removed. The head literally sawed in half. Some of it was hardly recognizable as belonging to a body.

Before my labmates and I bade farewell to the body that had taught us so much, our professor handed us an envelope containing two pieces of information that had been kept from us throughout the journey: our donor’s date of birth, and cause of death. We tore it open eagerly.

“Cool!” I exclaimed, as one of my labmates simultaneously said, “We got it! That’s awesome!”

Our first response to the news of prostate cancer was gratification.

Stepping into pathologists’ shoes, we had made our guess several weeks earlier. During the pelvis dissection, we sliced through skin and fat and located the prostate gland. It is supposed to be the size of a walnut. The one we found was the size of a tennis ball. We reassembled skin and noticed tiny blue dots tattooed on our donor’s abdomen, indicating he had undergone radiation therapy. This must have been it; this was what got him, we had decided.

“I mean… um, cancer isn’t awesome,” my labmate clarified, embarrassed.

I knew exactly how he felt. As future doctors, we have to be especially careful as to what emotions we let on. Trust is eroding in the doctor-patient relationship. There exists a stereotype of a cold, distant doctor, who objectifies rather than empathizes, seeing patients as problems to be puzzled through instead of thinking, feeling human beings. It isn’t the fairest characterization. Yet its persistence means that we who are entering the profession must take extra efforts to combat it.

No one wants a doctor who thinks cancer is cool.

In medical school, I sometimes feel inundated with conflicting messages. On one hand, we are encouraged to think like scientists. To be curious. To ask questions. To form innovative hypotheses, and to test them. To find the beauty in discovery. Many times over the course of anatomy, our professor came over to a cleanly dissected region on our cadaver and called it “beautiful.”

And it was beautiful. As the weeks went by, I found myself increasingly awed by the elegance of the human body. I held a human brain, weighing a mere three or so pounds, and thought about all the things it can comprehend and create. There is so much happening beneath our conscious awareness, you’d think the human machinery would malfunction more often – or that we’d at least notice some of its efforts. The smooth inner workings of the body provide us the luxury to engage in everything else that makes us human.

And that’s the other message medical school sends. Be a humanist. Cultivate and display empathy. Care about people as people, not just as hosts of disease.

When to display each quality is a trickier matter. I wonder what the appropriate reaction would have been during that last day of anatomy lab. Should we have opened the envelope with solemnity? Summoned fitting empathetic remarks? Taken a moment of silence?

Our professor called our cadaver our “first patient,” implying we occupied a caregiver position. But was he really a patient? Should we have treated the news of his illness with the same compassion we would have expressed if learning a patient’s diagnosis? Is it ever appropriate to feel a sense of wonderment over illness?

We traverse the boundary between investigator and carer so frequently, it is hard to remember where we are supposed to be at any given moment.

I once interviewed a patient with advanced cancer. Tears came to his eyes as he told me about how he had to leave his job, couldn’t run around with his grandchildren, couldn’t do the things he loved, not like he used to, nope, not anymore. A single diagnosis had inflicted such profound devastation.

In an emotionally detached cadaver, cancer was cool. In a person, it was anything but.

As my training continues, I imagine that I will uncover more beauty in medicine. I imagine I will feel gratification when I diagnose something correctly, and that I will encounter phenomena that will make me think, “Wow. That’s so cool.”

I want to stay fascinated. I want to care.
                                                                   
It’s a clash of emotions I wonder if I can ever fully reconcile.