Monthly Archives: August 2006

It might still be too early to tell exactly what the character of my generation, the so-called Generation Y, might be, or if it even has a distinct character. One TV show, Wonderfalls, a one-season production that was sadly cancelled by its short-sighted network, took an interesting take on my generation in its second episode. In this episode, the main character was being stalked by a journalist who was trying to paint her picture as the quintessional Gen-Yer: unambitious, self-centered, detached, overeducated and unemployable, but also inexplicably cool. Of course, not everyone in a generation acts the same way, but I think that distinct behaviors can be pervasive: sometimes the tail can wag the dog, and the crowd can sometimes identify and try to act like the few, even if those few are on the margin rather than at the center. Thinking about where we are coming from as a group of young people, I think about what has shaped our lives:

– no major wars that have truly affected the continental U.S. in a mobilizing fashion (whether for or against the conflict), like the Vietnam War

– increasing political apathy, particularly with President Clinton’s sex scandal and the second President Bush’s façade of stubborness, indifference, and ignorance

– desensitization to extremes by an increasingly polarized media, increasingly scantily clad pop culture figures, etc.

– the advent of the Internet, the initial stage of digital isolation, and now a complex mish-mash of half-online/offline social networking and blogging-voyeurism

– the myth and the reality of terrorism, and the perceived or real threats that might end one’s life at any random, given moment

With that in mind, it’s no wonder we’re all seemingly disenchanted, detached, and disaffected. In some ways, I feel that the 1990’s were not altogether unlike the 1950’s, a peacetime boom, and the first decade of the third millenium is not so unlike the early 1960’s with some small-scale outcries against political corruption, except that the children of the 1960’s are our parents and we’re too cool and apathetic to be like them. Plus, they’d disown us if we were.

Nonetheless, getting back to the theme of this blog (i.e. medicine), today I’m suddenly concerned what this future generation of doctors is going to be like, because a generation of doctors is like a generation of anything else – there are some common traits, feelings and attitudes. I’ve obviously never been through this process before so I don’t know what sort of changes to anticipate, but I wouldn’t be surprised if many of my classmates believe that the greater part of their personal development has already happened. If that were the case, I think we’d be screwed (patients and doctors alike), because doctors aren’t supposed to be nonchalant or “cool” or apathetic. Certainly not all people of this generation are – there are many examples of outspoken individuals, but does the majority follow? I think my generation has grown up believing that the weight can be pulled by a select few hypermotivated individuals; afterall, maybe nothing has been so important as to truly require the hands of a multitude.

Looking around me, I wonder what sort of doctors these people will be. I have no doubt that they are good people, but are they good enough? Perhaps at its core, the medical education is designed (or perhaps has been adjusted) to shock and awe, because many of my classmates are probably not ready on a psychological or emotional level to handle being responsible for the life of another person, much less hundreds or thousands. Most of them probably have never seen another person when he or she is dying and in excruciating pain, or if so, that person’s illness or disability was more likely than not attributable to age. It’s incredibly shocking to see an adult, and much more so a child, suffering from a terrible disease or in great pain. I’ll share a story which I could be embarrassed by or for which some might perceive as an admittance of weakness, but thanks to J. K. Rowling and Professor Lupin, Harry and I can both understand this sort of experience as indicating the depth of our emotional experiences and the extent to which these experiences shape who we are and how we interact with and see other people. When I was shadowing a pediatric oncologist, I had the opportunity to observe a bone core biopsy performed on a young girl who was very sick from her cancer. She was under conscious sedation, so she wouldn’t retain any memories of the procedure but she would be able to talk and express pain during the procedure. As the core biopsy was being performed (in this case, poking an enormous, thick needle into the hip bone and pulling out a sample of bone tissue), the girl was crying out in pain. For me, being a premed college student with no purpose there but to observe, it was a very painful experience: all I could do was listen and feel the pain she was feeling, and even as I was slowly losing vision and starting to black out, I could hear her screaming in my head, a type of screaming and a magnitude I had heard many times before. Her pain and suffering completely enveloped me, and that’s all I could think about. Fortunately, I didn’t completely lose consciousness or collapse, but instead tightly grabbed on to my girlfriend’s arm (she was also there shadowing), and she and a nurse helped me find a chair because I was as rigid as a board. When I sat down and the screaming left my head, the doctor was pulling the needle out and her pain was starting to subside. This girl’s excruciating cries of pain literally opened up a world of pain for me: one that had been locked away in my memories of my mother’s long battle with cancer. One in which I would be lying in bed at night while just across the wall she would be grasping her abdomen and trying not to cry out in pain and wake us up. Years later, after talking to and interacting with so many other patients, I still wasn’t prepared for that one moment when it all came crashing back down on me. Perhaps it’s because of the extreme magnitude of the pain (a core biopsy needle is not trivial). Perhaps it’s because she was so young, and I hate to see a child in so much pain. Perhaps, even, it’s because I’m too soft on the inside, and I can’t handle that sort of blunt force emotional trauma. I know now, at the very least, that the third reasoning isn’t true, and that I would have reacted very differently had I been the one inserting the needle, holding the patient still, or monitoring her vital signs. Though it happened to me without warning, I can take from the experience the knowledge of how much pain can hurt and how much that pain makes me want to do something rather than run away or ignore it. But this experience posed one very important question to me: Do you shield yourself from the emotion and the pain, or do you embrace it?

I think some doctors build a wall around their inner cores so that the pain and suffering they see around them won’t affect them. Others take it in and internalize it, perhaps too much, and feel overwhelmed by the extent of the suffering they witness around them. I think that while some who are excited to be doctors and have high EQs will tend toward the latter, quite a lot of the future doctors in my generation will tend towards the former: emotionally cut themselves off from patients, because it’s less traumatic for the doctors and they can more easily maintain their performance without having to wade through the emotional quagmire presented by disease. Sympathize instead of empathize. In some ways, it’s a matter of the your own personal emotional wealth: how much have you experienced, and what will happen if you experience more? A patient’s experience, and perhaps much so your own experience or that of a loved one, can pull you to both extremes: the worst moments in life when the pain is greatest and the prognosis is dismal, and the best moments when you know she’s going to live and that you will be able to continue your life together and be happy again. Ultimately, I think the attitude of apathy and the stategy of shielding will fail and do a great disservice to medicine, to the community of doctors, and to patients. Especially in a time when the world around us seems increasingly less stable and the future seems increasingly more uncertain, people will look towards us, doctors, as though we are pillars of strength, anchors against the storm. They may have some skepticism in their minds, but we can’t let that skepticism of our mettle, our character, and our dedication to serving others grow. There’s no room for apathy or being cool or being noncommittal in this profession and in the world we’re entering: we need to be steadfast and engage ourselves as much we are willing to give, because people all around us need so much from us. And in this case, we have to be a lot more willing to give than we’ve ever been at any other time in our lives, because we’re going to become something very different from what we were.

Every once in a while, I see an article in the news that discusses the roles that “e-medicine” and “telemedicine” play in delivery of medical care in the U.S. The articles vary in tone: some support these services as tools for patients to use to better prepare themselves for their appointments with physicians, while others condemn the services as being damaging or a hindrance to the patient-doctor relationship. I think my stepmom, a physician, approaches this in the best way. She tells her patients, “Bring in any information you find, and we’ll discuss it.” In doing so, she can take a positive stance on the patient’s proactive approach to their own care while encouraging the patient to be better educated about their health conditions, a goal that is ultimately at the heart of modern medicine (i.e. better education for better prevention and thus better health outcomes).

There appears to be a rising trend, though, of the introduction of new services that some perceive as being ways of eroding the power and influence of physicians – and the need for physicians. For example, a relative of mine, also a physician, had a startling encounter with Aetna, a health insurance provider. She has severe asthma, and she discovered during the care of her condition that Aetna was hiring nurses and sometimes social workers to dispense medical advice via telephone to patients in lieu of paying for patient visits to the doctor’s office. Two questions immediately come to mind: “While nurses probably have enough medical expertise to be able to advise on asthma care and the prevention of asthma exacerbations (attacks), do social workers have this knowledge? Also, is asthma ’sufficiently difficult’ enough to understand such that an appointment with a physician is necessary?”

Regardless of the answers to these two questions, two facts are very important to note. First, these nurses and social workers hired by Aetna can be seen as practicing medicine without a medical license, something that might be acceptable and under-the-radar with your own family and friends but isn’t acceptable on a professional level. Secondly, and more importantly in my opinion, organizations like Aetna and the patients who believe that this trend isn’t a bad thing are missing the importance and the uniqueness of the role of the doctor in the patient’s care.

At this point in my career, I have identified two aspects of care that physicians bring to health care that cannot be replaced or provided by any other health care provider:

1. Medical Expertise

No matter how well-educated a patient may be, the expertise of a physician in her field is paramount to any other opinion or deduction. Even physicians as patients must seek the medical advice of other physicians when the health condition is outside of their own discipline. Why? The physician is extensively trained to provide medical care in a particular area, and you want to give yourself the best chance of recovery. This is the same as in any other field: for example, you wouldn’t want to defend yourself in court if you were going against the best prosecutor in the world, and in the case of health, the opposing side always has the advantage if you’ve come to the point where you are seeking medical advice from anyone. You want the best advocate, the best player on your team, the one who will work with you to make the best outcome happen. Nurses, social workers, and others simply don’t have the same extensive training, and as amazing as they are in providing care for patients (in some areas and roles, much better than physicians), they don’t have the bank of knowledge, and more importantly, the clinical diagnosis skills to provide the best medical care possible. Even if all of the medical knowledge ever used in the care of patients is available on the web, patients, nurses, and others don’t necessarily know where to look and how to put all the information together. This is not to say that physicians are the stars and kings of health care: the fact of the matter is that of all the various niches in medical care, the physician is one that is completely irreplaceable, even based solely on the technical aspect of medical expertise alone.

2. Guardian Angel

However, the part that most people miss is not the medical expertise that physicians have, but rather it is the difficult-to-describe aspect of the patient-doctor relationship which I think of as being the role of the physician as a guardian angel for the patient. As much as other sectors of health care (from HMOs to hospitals to pharmaceutical companies to unappreciated nurses) attempt to insert themselves between and exert influence over the patient and the doctor, the most valuable asset the patient has in U.S. health care is the patient-doctor relationship.

Being sick or injured is inevitably a stressful, if not traumatic, experience for every patient. In approaching this experience, some patients choose to guard themselves from what they see as being the hassle, inconvenience, and expense of health care by taking on the role of an angry and demanding consumer – they want results, not fluff and broken promises. While I understand this sentiment from having sat in waiting rooms for hours at a time and having felt unsatisfied by the explanations doctors and nurses have given me as a pediatric but intelligent and conscientious patient, this approach will ultimately be disastrous for the patient – perhaps not on an individual level, but definitely collectively and with increased risk as time goes on. Being guarded may help when health problems are relatively minor. However, the more you guard yourself (as opposed to simply being proactive and open-minded), the more likely you run the risk of suffering severe psychological and physical damage when you are very sick. Most people underestimate the extent to which psychological stress can be physically debilitating, and this may be a powerful factor that influences the health outcome of a patient in a life-or-death situation (or perhaps a healthy-life-or-disabled-life situation).

However, there is another way. The patient-doctor relationship is multifaceted, but many people only observe the transfer of knowledge because they believe the relationship is strictly transactional. It can be, but this is at the risk of the patient. It ultimately is important for the patient to be well-informed, but this shouldn’t be used (or perceived by doctors) as a way of supplanting the doctor’s role in health care. No one, after all, wants to go through 4 years of medical school, 5-7 years of residency and subspecialization, and another x years of practice just to be able to self-diagnosis and self-treat, especially since you wouldn’t know going in what disease you’re going to have. As knowledgeable as you are, you need to trust the physician that uses her judgment wisely (which will be the vast majority of physicians) because they want to be on your side, and you also really should want them to be on your side when you’re sick. You can never be as confident in the advice of any other health care provider, be it a nurse, an alternative medicine practitioner (which I personally have experienced and appreciated), or other, and when dealing with disease, you want to start off on the right foot right at the beginning before it’s too late. While I don’t think that physicians should be seen as saviors, it would be just plain dumb for patients to see themselves as being merely clients. When standing on the edge between life and death, health and disability, what would you rather have: a lawyer or a priest? Trick question – a priest might help with the afterlife if you believe in that, and a lawyer can’t help you if you’re dead. You want a doctor who can stand beside you, hold your hand, and help pull you back from the disease. Doctors are unique in the role they can play and have played in health care, and it would be a disadvantage for all to have the patient-doctor relationship continue to erode or have it be removed entirely.

To future physicians: reach out to your patients, be patient with them, and help them learn and know that you are there for them, as much as they might be hesitant to trust you. No other word can describe your relationship to them besides “doctor” – it’s what you are, what you must be to them, and what cannot be replaced.

I’m fortunate enough not to have medical problems that are seriously debilitating enough (and presumably chronic or permanent) to potentially jeopardize my career by making the existence of them public. On another note, it is unfortunate that, at least up to this point, physicians are often discouraged to expose their own medical conditions that their colleagues or their employers might perceive as being potentially detrimental to their performance in providing care (especially mental health conditions such as depression, ADHD, etc.). While I understand why an employer might hesitate to hire such as physician (for which there are many), it seems to me that it would be useful for medical schools to very aggressively engage the health issues of future physicians in order to insure that their health conditions are taken care of by or manageable by the time they start practicing. Medical schools do often require certain standard functions (i.e. motor skills), but they don’t seem to actively aim to deal with health problems of the future physician population. In fact, at least from my limited exposure thus far, health insurance plans for medical students is remarkably flimsy and short-sighted.

Back to my story: I’m feeling pain on the right side of my head (for you medical students out there – about two centimeters anterior to my right ear) from the removal of an epidermoid cyst, also known as a subcutaneous inclusion cyst, by a dermatologist. This sort of cyst is typically benign, and about a year ago a pathologist did a biopsy on the cyst and did indeed find that the tissue was not cancerous. Amusingly, I’ve spent the past few days after the initial draining of the inflamed cyst (of pus and necrotic, or dead, tissue) last Friday explaining to my fellow medical student classmates exactly what happened to the side of the head. To my delight, they have all taken a very professional approach to it (those that have asked). This experience reminds me of two very interesting aspects of the experience of patients in general: 1) pain, and 2) embarrassment.

Pain, for obvious reasons, hurts. I’ve found that that closer I come to becoming a doctor, the more readily I express feelings of pain. Why? Pain can be an important message from the body about what is going on, whether the problem is a matter of damaged tissue (i.e. via injury, deterioration, etc.) or the transmission of sensation (i.e. something is pressing against a nerve, or an improper signal is being sent to the brain). In fact, when anesthesia was introduced early in the twentieth century, surgeons hesitated to adopt its use because they typically used the pain of the patient as a route to understanding how to approach the disease during the surgery. However, I remember a time when I didn’t complain much about pain, and in retrospect, it’s very striking for me to realize how destructive and psychologically painful it can be to feel severe pain chronically or on a regular basis. When I was growing up, I had moderate asthma, and there was hardly ever a time when I wasn’t coughing, spitting out sputum, or wheezing. My throat was almost always scratchy and irritated, and my chest and abdominal muscles were frequently sore from all of the coughing. It’s unbelievably frustrating to feel constant pain – especially for young patients (i.e. less than fifteen years old), how does this change the way they view life? For me, some part of me felt that I was cursed and that it was unfair that I was feeling so much pain while others weren’t. However, that part was dwarfed by the sheer magnitude of the pain itself – you just can’t think about much else.

Concurrent with the years during which my asthma was most difficult to manage, my mother was suffering from ovarian cancer, a disease which caused her considerable pain, up until her death when I was 13. Perhaps not surprisingly, seeing her in pain and seeing the way she bravely and quietly dealt with pain actually served as a model for me when I was dealing with my asthma – I just bit my lip and waited for salvation. For her, it didn’t (at least, not in the form of a cure), but for me, it did: I grew out of asthma, and I also was an early beneficiary of the drug montelukast (better known as Singulair, and no, I don’t have a financial conflict of interest in mentioning this). Nonetheless, it was this experience with my mom, and not the advice of doctors, that shaped the way I dealt with pain. From my perspective as a pediatric patient, my pediatricians were not particularly concerned with any feelings of pain I suffered, and this may have been because I didn’t express them. However, when I did express them (i.e. when I felt pain that I didn’t know the source of), they were often attributed to “growing pains.” While probably the best explanation, I think some part of me liked my doctors a little less each time I heard one say that: after all, had they ever felt such pain? I think I wanted my doctors (perhaps unfairly or unproductively) to take my pain more seriously. Even if they didn’t address it more extensively, as a young patient, I still would have wanted someone to say, “I know what you’re going through. Lots of people have done it before, and I think you can make it through this too.”

On the second note, embarrassment, I realize now how difficult it is for people outside the medical community to understand and approach visible signs of distributed medical care that they encounter in everyday life. For example, I’ve been walking around with a huge wad of sterile gauze taped to the side of my head for the past few days. While some of the medical students around me have expressed intellectual curiosity, no one else I have encountered in public has taken it in stride. In fact, I’ve had my fair share of awkward stares and leers from passers-by, which makes me acutely aware that the general public doesn’t know how to approach uncommon signs of health care provision. Most people understand what happened when you see someone in a cast or a sling. But a bandage on the side of the head? Not so much. Again, it’s important to know what the other person is going through.

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