Wednesday, December 22, 2010

On Death...


It’s the holidays so I felt like I would spread some holiday cheer by making my first post on death. Death is one of the unavoidable parts of life. In school, we are always talking about “quality of life” vs. “quantity of life.” It makes us ask the question, that comes up all the time in medicine, “are we playing god?” But don’t worry, I am not even going to attempt to answer that question – smarter people with more credentials and more experience are better suited for that. I am only here to talk about my experience with death.
I dealt with death directly this past spring with the passing of my grandmother. She lived a wonderful life, had 4 kids with her husband that she loved. However, the past few years of her life were riddled with hospital visits and a decreased quality of life. Modern medicine was able to keep her alive – and for that I am incredibly grateful. Due to these interventions I was able to experience a few more years with her. These years however, were not like the years before. I found myself talking to her on the phone answering the same question multiple times – again, I didn’t mind because I was still able to talk to her; a luxury I don’t have any more. As a future doctor, I have been thinking a lot recently about treating a patient / family like this in my future.
As a good doctor, you have to understand your limitations. Sometimes, it is necessary to let go, and allow the natural course of life take its progress. Ashes to ashes, dust to dust. Doctors need to realize when patients are ready and not push it. Then again, we also need to be ready when a patient is ready to let go but their family is not. I will take an example that I have recently experienced.
Hospice is a place where people go to die. By definition, you can only stay in hospice if you are terminally ill and are expected to die within 6 months. Some escape, most don’t. The average stay in hospice (at least where I went) is 14 days – 2 measly weeks. Like I said earlier, its where people go to die.
A woman I met at hospice was at the end stage of cancer. As the doctor’s so eloquently put it, they were giving her a garden hose of morphine to make her ride out easy keeping the morphine 1mg away from death. The look in her eyes clearly stated that she was ready to give up; she was spending the last of her days in a drugged haze saying good bye to her family. She knew it was time to go, and was getting prepared for it.  On the other hand, her family was not ready to let go. They insisted that every last measure was taken, every drug tested, every therapy tried, and every needle prick done – all in the name for a few more months of a narcotic high. Clearly not her decision.
For every woman like that, there is another completely opposite. For instance, another patient in hospice wanted to return to the hospital because they do not do heroic procedures at hospice. He wanted to be fed through his vein, have his ribs broken chest pounding CPR, and everything besides his liver being done by a machine all in the name of staying alive. In my opinion, this is not a good way to live. His family realizing this pushed, for him to sign DNR. To this day, he has denied it.
These are just my notes and my highly unrefined thoughts. I am sure that I will return to this in the near future and add on. I am writing this because two of my good friends are in the midst of losing a loved one. Death is a natural course of life and it reminds us we are mortal. In addition, and most importantly, it allows us to reflect make us decide how we want to LIVE our life. Happy holidays, and make sure you make this new year count. As a note, I hope that both of my friends have success with their family members – which ever path they want.

Sunday, November 28, 2010

My First Patient


One of the selling points medical schools are using these days is early “patient encounters.” My school is no exception. On the first day of class we did a thought experiment where our professor stood in the front and talked about a patient he had in the past. We sat there, mind you with no medical knowledge, fumbling around with questions we should ask the patient.  As an educational tool, it was marginal at best; as a tool to humble us, it is second to none. They preached to us (a class of 150) that this was “our first patient.” However, I consider my first a man that came a few months later. 

In our curriculum, we spend a multitude of days in the hospital or other healthcare settings. For instance, I have had the opportunity to spend time in the Labor and Delivery department of the local hospital (and got to see a vaginal birth!), as well as oncology, ultrasound, hospice, and the neonatal intensive care unit to name a few. These experiences will have to wait because my most influential moment so far has come on House Calls.

Many think that House Calls are a thing of the past. My mother has told me plenty of stories of the doctor coming to her house with his little “black bag” of medical toys and menageries to check on the “sniffles.” House calls are even highlighted in Michael Moore’s idealistic protest for universal healthcare documentary, “Sicko”. He even shows how Paris has a doctor that goes around in a swanky little car to check on a stomach ache. Daringly, he even asks why in a great nation like the USA, can we not have house calls? Well, Mr. Moore, we do.

It was a warm late summer afternoon, I had already had a long day at school full of lectures and other exhausting activities. I was despising that I was going to have to spend the rest of the afternoon traveling around the city dressed up and in my white coat (for which everyone seems to wear EXCEPT doctors these days). I reluctantly went with my partner to the headquarters to figure out which house we were going to meet our doctor preceptor at.  The receptionist printed off a google map image with directions for the first house.
House calls – at least at the hospital I work at – are reserved for patients that have difficulty, monetary or physical, making it to the main campus or one of the countless clinics that seem to be at every corner of the city. A doctor is sent to the house where a full examination can be done including such pedestrian objects that litter most houses. 

Meeting Dr. Smith at the patients house, she sits me and my partner down as explains the patient to us.  “This is an 86 y/o male, who is suffering from dementia, weight loss, and had a stroke a few years ago”. What she did not tell us was that this man has lost the ability to talk, hear for the most part, see, and even move. I was not prepared when I was taken into the room to find Mr. Jones who was barely alive. For the sake of full disclosure, the cadaver that I am learning anatomy from appeared to have more life than this man. Looking around the walls I can see pictures from when he was younger, a prominent male in the community of considerable size and presence. Now, he is a lifeless corpse with the ability to moan being his only form of communication left – and this ability is transient at best. 

Dr. Smith with her desire to teach us, unleashed us with a stethoscope and a sphygmomanometer (blood pressure cuff) both of which we learned how to use a week before, and told us to do a complete physical. I took his pulse, blood pressure, and temperature; as well, as listening (or auscultation) to the lungs and heart. As we fumble through the procedures Dr. Smith is quizzing me – to which I answered maybe 1 or 2 questions correctly. The entire time, Mrs. Jones is watching. To say the least, I was thoroughly embarrassed. I can only imagine the amount of pain that Mr. Jones was in, not to mention the “torture” he was put through, all in the name of education. 

I felt like Siddhārtha Guatama, stepping outside of the kingdom for the first time and learning what pain and suffering means. Although, I do not think that I am on my path to becoming Buddha, Mr. Jones showed me how little I know – a powerful lesson, especially from a man who cannot speak, hear, see, or move. For this, I am eternally grateful. Thank you Mr. Jones, you truly were my first patient.

Sunday, August 8, 2010

More than a death sentence…


Thirty years ago, the United States experienced a pandemic unrivaled since the Black Plague in Europe. A disease surfaced with no cure, no treatment, nothing. The only thing that was available was hospice care for the infected. The disease…. Human Immunodeficiency Virus – HIV.
At the time, being diagnosed with HIV was like being on death row – except without any appeals. Since then about 600,000 have died from complications resulting from HIV. Today, I have met people that have been living with HIV for over 15 years, but that was not always how it was. In the 80’s there was no survival rate; you got HIV – you died. Today, we might be heading in the same course. As advocacy for domestic HIV decreases so does its funding. For instance, in Ohio there is a waiting list for people who can’t afford their HIV medications, and many patients who are getting assistance are not getting all of their medications. Although, as Barak Obama says, “We are citizens of the world” – which is true – we need to consider the needs of our kin before looking outside our house. The HIV / AIDS epidemic is unequivocally worse in Africa than it is in the United States, but who is to say if we neglect the needs of American’s then our incidence won’t increase to a level that is just as unimaginable as was in the 80’s.
To get off of my public health soap box, I am going to transition into the one – on – one interactions that I have had with people both living with HIV and those that have had a significant other in their life die because of it.
Joe Smith (with a clearly changed name) is a 55 year old African American, film maker, concession worker for the Cleveland Browns, and an HIV advocate. I was fortunate to hear his life story while I was visiting the AIDS Task Force of Greater Cleveland. He was diagnosed with HIV 16 years ago and has been living with it ever since. He grew up in a small southern Georgia town in a relatively conservative family. Throughout his entire life, he has struggled with his sexual orientation. Since his family was conservative, he could not come out as gay to his family. Joe coped with this added stress by turning to drugs (pretty much every kind you can think of) and alcohol. As he says, “For twenty years, I did not live my life. The drugs lived my life, and I was just along for the ride.” Living his risky lifestyle, sharing needles, unprotected sex (especially men with men), etc he contracted HIV. Throughout his life, Joe had been to a lot of funerals for all of his friends that had died of HIV, and he decided to change his life with this. Since then, he is on the mend, “living life day by day”, decades later he is still alive and healthy, taking classes at Cleveland State University and has a passion for becoming a movie director. One could say Joe is lucky. However, the recently his Social Security was cut (lack of government funding) and he has no way of paying for his medications. Within months all clinical signs of HIV will return and he will potentially be dead within 16 months.
The Rodriguez family moved to America from Cuba to start a new life. Jose, the father, moved first to get a job and to send for this wife, and daughter. Six months in America, Jose’s wife, Clara, got a letter saying that Jose has found another woman and is leaving Clara and their daughter, Maria. A year later, Clara gathered enough money and moved both Maria and herself to the Cleveland, Ohio area and obtained a job working in a factory. This was enough money to support her family, and allow Maria to go to a public school and succeed; Clara was going to go to college. However, at the end of the first year, Clara got a phone call from Jose, saying that he was so sorry that he left and he wants to come back into his ex-wife’s and daughter’s life. As Maria described, it was her mother’s loving heart that made her take him back. In that year, Jose had a child with his mistress and during childbirth his mistress died. Clara’s loving heart again, decided that she was going to raise this extra child as her own. However, 6 months after the family reunited Clara got really sick and was forced to go to the hospital.
At the hospital, she was diagnosed with HIV. This was a surprise because she was celibate since moving to Cleveland. As part of the diagnosis, Jose was tested and he was also HIV positive. As it turned out, Jose’s mistress was living with undiagnosed HIV (which caused the complications during childbirth) and had even passed it on to their newborn daughter. Maria, now living with both of her parents and her sister as HIV, had to drop out of school – forgetting her dreams of college, to support her family.
Within five years, all three members of her family were dead and for a while Maria had survivor’s guilt (feeling guilty for being the one that survived) and turned to alcohol to help her deal with the issues / betrayal that has happened in her life. What moved me in this story, is the concept that the one’s with HIV are hardly the only people effected with this awful disease. Decisions and in turn their consequences are not made in a vacuum and even though a small proportion of America has HIV – it is truly an epidemic that affects us all.

Saturday, June 19, 2010

The Beginning in the Middle


Where and when does a person decide they want to become a doctor? Is it very early on in life? Do many of the children interviewed on TV that say they want to become a doctor actually go through the process, take the tests / follow through with the entire application process? In my personal experience, many people decide later on in their educational career (and even some after an extensive professional career in a non- medical field). For example of the diversity, the school I am attending has an incoming age range of 19-42. So clearly age isn’t a great indicator of why people choose medicine. But what is?

During my junior year at my undergraduate college I had the wonderful opportunity to shadow an orthopedist (a self described “mechanic of the body”). As many medical school admission officers will attest, work in the medical field – through volunteerism, shadowing, etc – is almost as important as scoring high on your MCAT when applying . After one afternoon with Dr. T, as I will call him, I quickly realized why it is so important. Dr. T introduced himself to me and quickly went into a monologue:

In my mind there are three reasons why students want to become doctors. First, their parents are doctors, or lawyers, or in other esteemed professions, and they influence –his nice way of saying force – their children into medicine. Secondly, there are students who go into medicine because it is a lucrative field. Finally, there are students who feel that medicine is their calling; there is something deep inside them that says, “I can only see myself being a doctor.”

Before this point, I had always loved science. Minus a D+ I received in fourth grade science, I had always received A’s in all of my science classes. I took physiology in eleventh grade and that’s when I knew I wanted to be a doctor. However, as I went to undergrad I quickly realized that my love of science could be fulfilled in other ways. Academic pursuits in research stimulated excitement in me. This internal feeling made me consider other career paths, mainly the Ph.D. research program. With this internal debate I decided to talk to my premedical advisor – Mrs. S. She quickly sat me down, looked at my GPA (high enough for medical school) and my extracurricular activities (again, satisfactory) and just sat there thinking. After a few minutes, she took out a piece of paper and looked at her rolodex and wrote down a name and a number. This is how I met Dr. T. Within the first week of shadowing Dr. T, I knew that medicine was the field for me. Looking back at it now, I understand why work in medicine is important in the application process. For me, it quickly established that I want to work with people.

Going back to Dr. T’s quote, I feel that I fit into the third category. It would be ignorant to break the 18,000+ applicants accepted each year into one of the three categories. Some people would be a blend of the three – and many other categories. However, in my experience, many students mostly fit into one of the categories. But is it wrong to be in one of the first two? Are you less of a doctor if you are only in it for the money? That leads us to one of the most important questions, what is a good doctor? If low death rate was the metric then family medicine doctors would all be better doctors than trauma surgeons. If low malpractice rates were how to decide, then OB/GYNs would be worse than pathologists. In my opinion, a good doctor is also a bad doctor as well as being a so-so doctor. A doctor is only as good as his/her patients think he/she is. One person’s perfect doctor could be another person’s nightmare – the type you see people complaining about on 60 minutes. However, there are certain things that all patients care about – a topic for another post.

Today, I can confidently say, “I see myself doing nothing else besides medicine.” The road was long starting all the way back with the D+ in fourth grade, through high school physiology, and my shadowing Dr. T., taking the MCAT, applying and interviewing to schools (a year long process), and eventually deciding where to go. I am blessed to have been accepted to a school where I feel that I am a perfect fit. I am one of the lucky ones. However, I am only in the middle of my education. Graduating college marks the sixteenth year of my education and I still have a lot more to go (four years of medical school and at least 4 more of post graduate work). So I truly begin my writings in the middle.

Thursday, June 10, 2010

Introduction

The title of this blog was chosen because of its unsettling and disturbing truth as it applies to modern medicine. Even with nuclear studies, x-rays, gamma-knives, and a seemingly endless supply of prescription drugs, many illnesses cannot be treated. Even worse, many diseases that we can treat we do not detect early enough (if ever at all). Error, both human and systematic, adds to the plethora of possible complications that come up in even the most routine procedures. It is in this that medicine sits as an imperfect science.

The main purpose of my writings is to provide a firsthand account of how doctors are trained in America and the many issues doctors encounter on a daily basis. Currently, I have just finished my undergraduate education at one of the top liberal arts college in the nation and I am starting my next adventure at a top 20 medical school. I have the entire field of medicine in front of me, and not counting my minor training in molecular biology and biochemistry, I have no prior knowledge of medicine. I am truly a blank slate with no prior prejudices. I hope you will join me in these next few exciting years.