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Monthly Archives: May 2007

I want to say a million things. I want to shake your hand again, redo our brief conversation, asking all the right questions and saying all the right words of encouragement. Hearing my friend choked up on the phone brought me back to that day, only a handful of months ago, when I ran into you at a coffee shop I frequent.

In the same way that all everyday tragedies begin, I have to admit that I didn’t know you well: maybe it’s an attempt to relieve myself of the responsibility of feeling overwhelming grief, or maybe it’s an acknowledgment that whatever I feel is felt a thousand times worse by someone else, someone closer to you. Nonetheless, with my backpack slung over my shoulders, full of medical school books demanding my time and attention, I walked into that coffee shop, shook your hand, and made small talk, happy to see a familiar face. As I always do, I asked “How are things going?”, and yet this open-ended question didn’t elicit the response that I, standing as a shadowy intruder in the memory of that day, so desparately long for. Or perhaps, as I dissect away the fragments of that memory, my preoccupied self, listening to your response, didn’t listen closely to the hesitation in your voice, the clues in your statements. Perhaps your humor and gregariousness masked your pain.

How could I have known that your father committed suicide half a year ago? Perhaps that was the reason why you were taking time off, and in my long absence from the world I once felt I reigned over like a prince, responsibility-free but respected and adored, I did not receive the news. Instead of staying to chat, I adhered to convention: a few friendly statements, getting the general public-safe idea of where we are in our lives, and then parting ways to return to our preset schedules. I probably went to the other side of the coffee shop to study Anatomy, or perhaps I was leaving the coffee shop when I spotted you or you spotted me. Would my time have been better spent if I sat down with you, asked you more about your life, and heard your story? My retelling here is lacking in detail, because I’m lacking the paint with which to paint your portrait.

Each day I get closer to becoming a doctor, I wonder what the effect of each death will have on me: will I become desensitized over time? There’s a certain sadness to diseases of the body, but these deaths carry a mixture of random chance, personal choice, and sometimes a blow to one’s professional self-concept. However, diseases of the mind, particularly in the mind of a friend, can make one feel at a loss as a person: it feels like a personal failure, not a professional one. People die all the time, and sometimes we feel more strongly about some than others. I’m not an explicitly religious person, but I do believe in a god, heaven, and hell. I believe that heaven is in the memories of those we have loved, those who have loved us, and every person we have touched in some way: they remember us, and we live on through them. Hell is being forgotten or being remembered in a bad light. If this is the way it is, I know where you’re headed, with your humor, your good nature, your creativity, and your warm, generous welcome. It is the deaths of good people that hit us the hardest, that hurt us the most.

In two weeks, I will be done with my first year in medical school! My last class was on Friday, and my last clinic shift was last Tuesday. The next couple of weeks consist only of three exams, so I will probably take several opportunities to break from studying and write reflections on this past year. Today is a particularly good day for that for me: it’s Mother’s Day, and my mom is the person who played the most significant role in inspiring me to pursue medicine as my means through which to change the world for the better.

At the beginning of the year, our Chief of Medicine welcomed us and spoke to us about perfection. He posed and answered four questions: “What is it (perfection) made from? What is its form or essence? What produced it? For what purpose do we pursue perfection?

In response to the last question, he told the following story (which I will try to recreate as best as I can):

On Tuesday I had the morning off, and I did what most New Orleans people do… I went to a coffee shop. (laugh) So I was sitting down, sipping my drink, and I saw this couple waiting in line – well, they weren’t a couple… yet. They were standing about two people apart, and the man was ahead in line, chatting with the woman. It was clear that they were hitting it off. The guy was stalling at the register as he was being asked what type of milk he wanted. Same milk as he had yesterday! (laugh) But no, he was delaying, trying to make his drink as complicated as possible so as to keep talking with the lady, and eventually when his drink was done, he stood there like this… “So… would you like to go out sometime? I mean, only if you want to, no pressure or anything..” (laugh) “Sure, sure, that would be nice to go out.” Now, of course, my memory might be a bit off, and she might have asked him out, I guess that happens too nowadays, but the important thing is that they met, and I imagined what he would’ve been like on Tuesday night, sitting by the phone, doing the whole dialing up until the last number and then hanging up deal. But eventually the feeling would overwhelm him and his wondering whether it’s too soon, and then he calls, “Hey” “Hey” “How’s it going?” “Good” “So, do you still want to go out?” “Yeah, sure.” “When’s good for you?” “Friday is good.” “Dinner?” “Sure” “What would you like to eat?” “Oh anything’s fine by me, you?” “Same, anything’s good…” (laugh) “Hmm” “Let’s see… how about Chinese?” (laugh) “Sure, that’d be great” “Great” And so on, and then tonight they’ll be going out to dinner and it’ll be the beginning of a beautiful relationship. They’ll make small talk, talk about their favorite music and books and what they like to do, and they’ll hit it off again, and later that night he’ll be dropping her off and there’ll be that moment for the good night kiss… (laugh, some noise from the audience) Keep it clean, kids… anyways, a good night kiss, and he’ll be driving away, and he’ll be thinking to himself: (arms outstretched) Nothing can be better than this! And everything in his world is great and makes sense, and he’ll be driving home, and at the very moment, a single cell in his body will snap, and that’ll be all it takes – that’ll be the start of his lymphoma, and five years later – it takes that long for it to be detectable – five years later he’ll be coming in for his checkup and you’ll be just done your internship. Will you be the one to tell him the bad news, the one to find the lump and walk him through what needs to be done? Yes, you will, and five years later he’ll walk right back in that clinic, this time with his wife and his kids, and you’ll say to him, “You’ve made it through the window. It’s statistically almost impossible for the lymphoma to come back now. Go live your life with your wife and kids, and do all the great things you want to do.” And he’ll take his wife and kids in his arms, and he’ll think to himself: Nothing can be better than this. And it’ll all be because of you – because you were there to catch that lymphoma and beat the disease. And hey, it starts now: somewhere, there is someone in this exact same situation, and the exact same consequences will happen five years from now. Will you be there to catch the disease and beat it? It’s a race between you and the disease, and that race begins right now.

When I first heard that story, I wrote this:

“I’m probably not doing it justice, but you might see how such a simple story can be meaningful for a student going into medicine. He mentioned that one of the tragedies of medical education that he discussed with his peers is when students enter aspiring to do all manner of good and leave just wanting to do well. I think it’s important for young physicians to keep a good perspective about what we’re doing. As important as it is to be humble (i.e. not develop a God-complex) and realize our limitations (i.e. that much of medicine is the patient’s decision and responsibility, even if they hold physicians accountable for it, justly or unjustly), I also think it’s important that we know how much we can do for patients and how big a difference we are making.

A year later, I still feel the same way, despite having learned a great deal about the problems of health care through reading and contextualizing, having experienced some of the frustrations and obstacles that physicians face as they try to provide great medical and personal care for their patients, and having waded knee-deep through the burnt remains of the New Orleans health care system. Where others may see insurmountable barriers and despair, I see room for improvement and the greatest challenge of our lives. I realize now how much variance there is in the experiences of physicians across disciplines and practice settings (and even great variance in the learning experiences of medical students in the same class at the same medical school): accordingly, I understand now how little use there is in criticizing the way people feel, even if those feelings are tainted with frustration and are seemingly insensitive. I think a lot of the doctors who express the most frustration and bitterness about the current state of health care are those who have to deal with the full brunt of this system’s failures. With that in mind, I’m very grateful for the education I’ve received thus far at my medical school: I’ve had a chance to see a health care delivery system at its worst, in its most dilapidated state, and also see the good people who remain shed sweat, blood, and tears as they struggle to pull the pieces back together. Some are bitter, angry, and hardened in a way that most people will never be, and yet they hold on to their convictions and commitments for as long as they can bear it. Others are more optimistic, hopeful, and eager to get beyond the pitfalls and the problems. I tend more towards the latter, but without understanding the former (and experiencing it), anything I say about health care in general, any dreams and reforms I might pursue, would have little meaning.

Keeping all of these experiences and feelings in my memory, I look forward to each day that I develop a little more into the physician and leader I want to

Sitting quietly while the nurse inflates the blood pressure cuff on his arm, he keeps a straight face and listens to the music. He hates this tune: it’s agitating, like the loud rap that young kids blare from their rolled down car windows. Beside him, his wife reads a magazine, turned away as one would be to give someone privacy as he changes his clothes. They are a quiet couple and a satisfied one, having spent thirty-eight years of their lives together and having brought to life three beautiful children. It’ll be another seven months before the family reunites for Christmas, but by then, his first grandchild will be born. He secretly hopes it will be a boy.

The tune picks up again, and he shifts in his seat as the nurse makes her exit, promising that the cardiologist will be in to see him soon. He’s not too worried about anything he’ll say: he’s fit, well-built, and feeling as good as he could expect for his age. He’s never felt the panic and anxiety preceding a heart attack. And yet, there is a heaviness in his chest as he waits. Tight-lipped, he pulls in a thin stream of air, and blows out as though whistling, half-expecting some relief. A few minutes later, the cardiologist arrives, followed by another white coat. The cardiologist introduces the medical student, who greets him with a smile and shakes his hand. He doesn’t smile, but gives a polite nod of acknowledgment.

The cardiologist reviews his records: everything looks good. His LDL and triglycerides are down, his HDL is low but improving. The doctor then moves on to the question he was anticipating: “Are you still smoking?” “Yes.” The doctor says, “Hmm,” evaluating this disturbing detail. The man’s face remains expressionless. The cardiologist takes out his stethoscope, unbuttons the man’s top shirt button, and places his stethoscope over four points on his heart. He then listens to the carotid arteries in the man’s neck. “I’m going to listen to your lungs.” The doctor places the stethoscope on his back, and he breathes in deeply. “Ah, come here and listen to this,” the doctor says to the medical student.

The medical student fumbles with the stethoscope for a moment. As soon as he breathes in again, the student says quite suddenly, “Wow. I’ve always wondered why rhonchi are described as musical.” The cardiologist asks the man, “Do you want to listen?”, offering him the stethoscope. The man immediately says, a little darkly, “No, I can hear it already.” The cardiologist and the medical student sit down, and the doctor says, “Your heart’s fine. The problem is with your lungs. They’re going to quit on you, unless you quit. You really need to stop smoking.”

“I know,” the man says, noting his wife looking intently at him from the corner of his eye. The doctor asks if he’s tried using a patch or another smoking cessation treatment. “No, that’s not for me. If I’m going to stop, it’s going to be with the power of my own will.” He’s worked hard all of his life and never asked for sympathy, favoritism or crutches; he’s made a life for himself with his own hands. He’s not about to start now. The doctor says, with a note of skepticism in his voice, “It’s your choice on how you do it. But you need to stop smoking. Let’s set this as the goal for the next visit in six months.”

As the doctor and the medical student make their departure, the man and his wife stand up to leave. He knows what’s coming, and the tune rising from his chest is only the first sign of things to come. As he takes his wife by the hand, he feels her squeeze it a little more tightly than usual, and he feels a little more resolved. He’s no quitter: he’s not giving up this fight yet, his eyes tell her. But the music keeps playing, the same tune over and over again, like the song of the sirens drawing him closer, and closer, and closer.

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