hazards, moral and otherwise
In our CCU (cardiac care unit) we take care of some patients whose hearts are failing. This can mean a lot of things, but the intuitive way of thinking about it is probably also the most accurate: a heart is failing when it can no longer pump blood to the rest of the body. In severe cases, when medications and devices are no longer effective in restoring the heart’s ability to squeeze, it can be the case that the only treatment option is a heart transplant.
Organ transplantation is a peculiar business. Hearts are harvested from people who die from non-cardiac causes; the classic donor is someone who died in a motor vehicle accident. The holidays are an especially productive time for organ harvesting — just a couple weekends ago, over the MLK holiday, 6 different hearts became available for one patient alone. More travel, more hearts. Our attending made a dark joke the other day about supporting motorcyclists so that we can keep a steady stream of hearts coming. Like all jokes, it wouldn’t be as funny if it weren’t true.
Yet what’s peculiar to me about heart transplantation isn’t just the morbid side of collecting the hearts from foolish people on motorcycles, but also the significant proportion of end-stage heart failure patients who have heart disease not because of congenital reasons but because they did cocaine when they were young and smoked a pack of cigarettes every day and ate McDonald’s all the time not because they were poor but simply because they wanted to (ahem). It’s replacing the heart of one reckless person with another’s. Thinking about it makes me uneasy at first — such an enormous investment to save someone whose disease is the result of his/her poor judgment — but then in an odd, almost twistedly sensible way, it seems appropriate (and even just) that the organ donor should be, say, a Ducati enthusiast.
What’s quickly becoming the most challenging aspect of my job is to feel the same level of compassion for patients who have been dealt bad hands in the health game as I do for patients who clearly don’t give a shit about their health. Especially in cardiology, where heart disease seems so obviously tied to bad habits. It’s difficult as I get older to not succumb to the notion of each individual being entirely self-made, that people have enough agency and mobility to choose their own fates. You’re sick? You must not be taking care of yourself. You’re poor? You must be lazy. The recent presidential election projected some of these ideas rather vividly, with numbingly repetitive references to Ayn Rand and “incentivizing” people to do various things, appealing to people’s tendencies to act primarily out of self-interest, while also assuming that they easily can.
This has bothered me for a while now, the tension of taking care of adults despite themselves, treating illnesses caused by their own poor decisions. It’s the ugly side of altruism. It bothers most physicians, as I’m sure it also bothers nurses and social workers and firefighters and policemen. However, I’m learning not to think reflexively of good health as something deserved. Yes it’s frustrating to see the same patient admitted to the hospital again and again because he won’t take his medications, and no I’m not arguing that there isn’t a place for some kind of rational rationing of care. But the best, most fundamental part of medicine is still the giving. The providing. Providing a second chance, and with little thought as to who deserves one. Maybe a new heart is what it takes for someone to turn his or her life around, to be a better parent, a better spouse. Is there ever a good reason not to wish it so?
In Ayn Rand’s Atlas Shrugged, the protagonist John Galt makes the case for individualism and self-determination to the extreme. He scoffs at altruists:
It is for your own happiness, it says, that you must serve the happiness of others, the only way to achieve your joy is to give it up to others, the only way to achieve your prosperity is to surrender your wealth to others, the only way to protect your life is to protect all men except yourself-and if you find no joy in this procedure, it is your own fault and the proof of your evil; if you were good, you would find your happiness in providing a banquet for others, and your dignity in existing on such crumbs as they might care to toss you.
He goes on:
And if it is not moral for you to keep a value, why is it moral for others to accept it? If you are selfless and virtuous when you give it, are they not selfish and vicious when they take it? Does virtue consist of serving vice? Is the moral purpose of those who are good, self-immolation for the sake of those who are evil?
One gets the sense that Jesus would not have put it quite this way. And that he didn’t think much of the idea of people “deserving” heart transplants, or deserving much of anything, really.
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Tags: doctoring
make, believe
It’s been a busy few months since I “graduated” from residency. There wasn’t any graduation at all, really — one day I was a resident, and the next day I became a fellow.
It’s a strange term, “fellow.” Strange because it’s so nonspecific and… nonmedical. I still always think about the scene in ‘Heat’ when Al Pacino and Robert De Niro finally meet as cop and robber at a diner, and towards of the end of their cracklingly tense exchange Al Pacino takes a mental step back to reflect on how absurd it is that they’re sitting together over coffee, like “just a couple of regular fellows.” Somehow that’s entirely appropriate.
The most striking thing about fellowship thus far has been the autonomy. Whether it’s functioning as a consultant during the day like I am now, fielding questions from other physicians in other specialties about heart-related issues, or when I’m on-call over the weekend or in the evenings and an emergency arises, I now have an enormous amount of latitude in making decisions. I suppose the surgeon’s creed applies here as well: Sometimes wrong, never in doubt. It’s like I became a heart expert overnight. But there have been many moments already where I’ve had to take a mental step back of my own to consider just how “expert” I really am.
I had two such moments recently — one yesterday, in an expected way, and one last week, in a not-so-expected way.
…
This morning I received a message from one of the nurse practitioners in the oncology ward about a patient hospitalized with shortness of breath. He was concerned that the patient was having trouble breathing because her heart is weak, and when a heart is weak and starts to fail, blood and fluid back up into the lungs, causing shortness of breath. The most likely cause of her heart failure is a chemotherapy medication that she received last year for leukemia treatment. Weakening of the heart is a notorious side effect of the medication, but another known side effect is impairment of the immune system to the point where patients become highly susceptible to infection. This is exactly what happened to the patient just last month, when she was hospitalized for an infection that she’s still being treated for now. And this is what makes patients like her so challenging to treat: for a weakened heart you want to keep extra fluid off the body by way of diuretics, but for an infection you want to keep the body well-hydrated with liberal intravenous fluids. It’s often a delicate balance, and an especially finicky one at that.
After reviewing her medical record, I headed over to the oncology floor to meet the patient. Outside her room was the nurse practitioner and the rest of his team. They thanked me for stopping by but warned me before I entered her room that the patient’s daughter is “difficult.” I gave my best, knowing half-grimace. I opened the door to the room, and inside were an obvious mother-daughter pair. The mother — the patient — lay in bed, smiling warmly but looking quite frail and tired. The daughter — a pretty, energetic blonde with her mom’s nose and smile but none of her warmth — stood up to greet me. I introduced myself as I usually do nowadays: “Hi, I’m Albert Luo, one of the doctors on the cardiology team. It’s very nice to meet you.” They each shook my hand, and then the daughter began to speak.
“My mom isn’t like everyone else. She keeps coming in again and again for antibiotics, for blood transfusions, for whatever else, and each time they give her extra fluid and I tell them, I TELL them, she’s going to get short of breath if you give her so much fluid. She has a bad heart, and the extra fluid is going to kill her. And each time they ignore me and say no, she needs the blood and the saline, and they refuse to give her a diuretic afterwards. No one listens to us. So here we are again.”
I’m paraphrasing here, but, if anything, the daughter was more forceful, more exasperated, and repeated herself more than I’ve expressed. Her mother tried to interject a few times here and there, vocally offering the benefit of the doubt to the prior doctors and nurses who advised giving fluids. The daughter waved her off, annoyed.
Having gotten an initial sense of the situation, as well as the dynamic between the patient and her daughter, I tried first to stake out a neutral position. I expressed empathy for their frustration with the previous providers who had a different assessment of the patient from the daughter’s, but I also began to explain to the daughter how it’s often tricky to get the fluid balance just right, and how there’s good reason to fear dehydration in a patient as sick as her mom.
She would have none of it. She continued:
“No, I told you already — my mom isn’t like other patients. She will DIE if she has too much fluid. Other people might die from dehydration, but that’s not what’ll kill my mom. You’re what, you’re a cardiologist? So you know about the heart. I know you’re concerned about the heart only, and I’ve heard before from other cardiologists that ‘The heart can’t pump if it doesn’t have enough fluid, blah blah,’ but I’m telling you, my mom is different. She is DIFFERENT.”
Over the past several years — I think ever since I began working in the hospital in medical school — I’ve become more prickly. I’m irritated easily by anyone I perceive to be inconsiderate or inattentive. But what’s never irritated me, oddly enough, is getting yelled at by patients and/or their families. Whether it’s right or wrong, it’s like a switch flips in my head and I suddenly think, “These people are yelling at me out of fear, so the best thing I can do is be calm and gentle and understanding.” Unfortunately, this usually ends up with my being incredibly patronizing as a result. Not that any of you reading this could possibly imagine that.
But no, I do try tap into whatever emotional reserve I have left when people are upset with me, and that’s what I did with the patient’s daughter. We went back and forth — she aired out more of her frustrations, and I tried to frame everything that’s happened to her mom, from the time of her cancer diagnosis all the way up through her hospitalizations and new heart failure and respiratory infections, as a common narrative that her doctors and I collectively have seen before yet recognize is unique and, therefore, still requires personalized attention. Which is why your oncology team called me, I added. (Temporarily) satisfied, she looked at her mom and nodded.
And then her mom turned me to and asked, “So then, you’re our new specialist. You’re the expert. What do I need to do to get better?”
…
Last week I went to see a primary care doctor for the first time since starting college. I’d already been a paragon of hypocrisy for some time, ignoring the very advice I’d been giving out to my own clinic patients about healthy eating and regular exercise. For years I told myself that, when I turn 30, I’ll finally go see a doctor. So when I turned 30 a few weeks ago, that’s exactly what I did.
I can’t adequately describe what a bizarre feeling it was to get checked in as a new patient, and I’m having a difficult time right now finding a good analogy. Just think of something you’ve been doing for years and years — maybe it’s a standard set of questions you ask a client at work, or a regular task you do for your friends or your kids or your parents — but suddenly having someone else do it to/for you instead. The nurse who ushered me into the exam room did all the things I’ve done now countless times over, yet to have her take my blood pressure and ask me if I have any allergies and what medical conditions my parents have… it was one of the strangest experiences I’ve had in a long while. After she finished, she asked me to strip naked and change into a gown, and the next thing I knew I was a patient like any other, trying desperately to keep my gown closed behind me so that my ass wouldn’t hang out, waiting for the familiar-yet-not knock on the door.
My primary care physician came recommended by a colleague, and it’s a small perk of my job that I was even able to get an appointment since his clinic is otherwise closed to new patients. But, he didn’t know I was a physician until he asked me as part of our initial conversation. After that, I could detect a difference in the way he talked, and he began to describe in much greater detail the rationale behind his questions and the evidence behind his recommendations. It struck me then that, no matter how many times I’d observed more senior physicians summon their experience and expertise when talking to their patients, I didn’t notice the differences in style as keenly as I did when I myself was the patient. My doctor isn’t even that senior — maybe five years older than me, at most — yet, suddenly it was if I’d never had internal medicine training at all. Just 40 minutes with my doctor and I already felt that he had a better handle on the state of my physical health than I do.
That, I thought to myself, is what an expert physician really sounds like.
…
Frustrating as she was, the patient’s daughter was a strong advocate for her mom, and I admire her for it. Our interaction was a reminder to consider how I’ll act when my parents eventually become ill enough to be hospitalized. Will I ask the right questions? Be considerate? Be forceful? Know when to disagree and know when to keep in line? And should my being a physician automatically mean my opinion counts for more?
I hope you’ll consider these things, too.
I was going to conclude here with an analogy, but on second thought I’ll just leave the excerpt below open to interpretation. In a recent issue of the New Yorker is an essay by Daniel Mendelsohn about the role of the critic. He writes:
[In response to negative criticism, the author] Dave Eggers went on, “Do not dismiss a book until you have written one, and do not dismiss a movie until you have made one.”
This superficially appealing notion is one you often encounter when people disagree with professional critics — as if expertise, authority, and taste were available only to practitioners of a given genre. But to tell a critic he has no right to review a novel because he’s never written one is a dangerous notion, because it strikes at the heart of the idea of expertise (and scholarship, and judgment) itself — it’s like telling a doctor that he can’t diagnose a disease because he’s never had it, or a judge that he can’t hand down a sentence because he’s never murdered anyone himself. The fact is that criticism is its own genre, a legitimate and (yes) creative enterprise for which, in fact, very few people are suited—because very few people have the rare combination of qualities that make a good critic, just as very few people have the combination of qualities that make a good novelist or poet…
Similarly, I wonder whether the recent storm of discussion about criticism, the flurry of anxiety and debate about the proper place of positive and negative reviewing in the literary world, isn’t a by-product of the fact that criticism, in a way unimaginable even twenty years ago, has been taken out of the hands of the people who should be practicing it: true critics, people who, on the whole, know precisely how to wield a deadly zinger, and to what uses it is properly put.
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an old man, filled with regret
“Plant your tears in the vision of the cross, and you’ll get rid of that self-pity. The thing that’ll kill you… weeping is fine… but, weeping in self-pity? Ah, that’ll make you a small, little person. Someone who can’t forgive, someone who is always feeling ill-used, someone who gets incredibly touchy and sensitive. So what are you gonna do? Look at the cross and say, ‘You have really suffered for me. My sufferings are nothing compared to yours. If you suffered for me, I can be patient in this suffering for you.’”
- Tim Keller
…
It’s been almost seven months since I last posted. A friend asked me last week why it’d been so long, and I didn’t have a good answer ready. It’s not for lack of interesting things happening — there’s been plenty of that, both all around and in my tiny slice of the world. Nor was it for lack of motivation to write, since God knows 2012 has already been quite the unexpected emotional journey (highlighted by that effing Procter & Gamble Olympics mom commercial; I haven’t cried so much since Dave Chao’s wedding). The easy, self-deprecating answer is that I was too lazy to write anything. The more accurate answer is that I was probably a little afraid to. And the best answer is that I lost a bit of my self-absorption over that time.
But now as I’m nearing the end of residency, I have the recently-assigned task of giving a “senior talk,” which is a responsibility of all the graduating residents to give a brief presentation about a (medically-related) topic of their choice. Predictably, I plan to talk about the role of writing in medicine — both historically and what I hope it looks like in the future — and in considering what I want to say, I thought I should process first some loose ends that have arisen since the last time I wrote in these pages. The self-absorption is back!
…
Earlier in the year I returned to the CCU for a third tour of duty. The CCU was where I began my residency, and among the many memories I still keep from that first month of intern year is the feeling of bewildered awe I had when I listened to the senior residents, the cardiology fellow, and the attending discuss the care of our most complicated patients. They were adjusting doses of medications I’d never even heard of, based on hemodynamic parameters and lab values that I had difficulty interpreting even with the help of a computer, and doing this all seemingly on the fly, like they were having a conversation about the weather or yesterday’s NBA playoff games.
Yet there I was again, back in the CCU, and somehow over the past two-plus years I’d picked up that same ability. I found myself not only talking in that same previously-foreign language, but at 3:30 am on the phone with my fellow or my attending I would be telling them that we should do X instead of Y… and they’d actually trust me and say ok (most of the time, anyway). In those moments I felt overwhelmingly proud to be a resident, because in those moments I could say to myself that I’d grown more skilled in tangible, meaningful ways since I began almost three summers ago.
I’ve always counted myself lucky to work a job I love. But to have it also be a job where the learning curve is steep but manageable, and to be able to see those incremental gains translated into something concrete, a decision of my own making, a decision that helps a patient eat or speak or leave the hospital a day or even just an hour earlier… professionally, there are few better feelings.
…
“Oh, good, let’s talk about money.”
- The Dowager Countess
Or so I’ve conditioned myself to think. Recently I went out to eat with a couple different crowds, and the conversations dominating these two meals were two sides of the same coin: all the money that continues to flow to startups and impending IPOs, and what the real estate market will look like here as waves of people become richer and richer. My opinion on this — that of an outsider’s — isn’t worth getting into here, but suffice it to say that I’m among those who think the volume of money being pushed around is WAY out of proportion to whatever benefit to society these companies may (or may not) provide. It’s an easy-enough statement to make, and it’s not at all a reflection on my friends, who’re almost uniformly smart and hard-working and well-meaning. But, as someone not in tech who’s nevertheless living and working in the belly of the beast, I find the contrast to be suffocating. And mind-bending.
It was reported in the popular press just this past week the results of annual survey of doctors conducted by WebMD. Among all 24,000 physicians surveyed, 11% counted themselves “rich,” whereas 45% felt “my income probably qualifies me as rich, but I have so many debts and expenses that I don’t feel rich.” If there were a subgroup analysis available for those physicians living in the Bay Area, the numbers would be even more extreme.
What’s mind-bending about it though is that, according to this year’s survey, the average salary of a cardiologist is $314,000. I know it’s gauche to throw numbers out there, but we need to call a spade a spade: $314,000 is a lot of money. By any reasonable standard, it is. And a lot of money should sound and feel like a lot of money. However, being out here in the heart of Silicon Valley, it doesn’t so much. An article in the Wall Street Journal quoted a well-known urban studies professor as saying, “if you’re a guy working for a Silicon Valley company and you’re married and you’re thinking about having your first kid, and your family makes 250-k a year, you can’t buy a closet in the Bay Area.”
I want a closet. I also don’t want to feel poor when I’m finally making an attending’s salary. I shouldn’t feel poor even with my salary now.
…
But that’s my problem more than it’s Silicon Valley’s (or Manhattan’s, or the District’s). After a particularly decadent weekend not long ago — meal after meal on the town, punctuated by glasses of expensive single malts and highlighted by one of those conversations about real estate — I returned to the hospital on a Monday and saw three homeless patients in a row. One was found by his friend lying facedown in his driveway, asleep in the middle of the day and twitching periodically. The second brought herself to the emergency room after having stayed in a motel room for ten days trying to hide from an abusive former boyfriend. And the third was a middle-aged man, impeccably groomed, trying to laugh off an unusual rash he’d developed but unable to hide his anxiety about how expensive the treatment for it might be. All homeless, all local. The last patient, after reassuring him that he was having a simple allergic reaction and nothing more, I actually thanked him for coming in. “Why?” he asked me, looking both puzzled and taken aback, “You’re the one diagnosing me!” I couldn’t explain to him why, but I thanked him again before he left.
I don’t know about you, but I don’t believe in coincidences. Working that day in the emergency room and meeting with those people less materially fortunate than I was exactly what I needed. We’re to give thanks in all circumstances, yet somehow I’d forgotten. Sorry about that, Paul.
…
So that’s where we are now. It’s funny, this adulthood business. My parents came to visit not long ago and we went to Napa for my dad’s birthday. At lunch I asked him when it was that he finally felt like an adult. Was it when he got his first job? When he married Mom? Or when I was born? To my surprise, he said it wasn’t any of those things. He first felt like an adult when he was a kid, because he was the oldest of four, because his parents gave him a lot of responsibilities growing up. It sounded like a funny answer at the time but I know he was being sincere. More than that, I laughed because I feel the same way. Friends tease me for being a prematurely old man but it’s true: I’ve always felt old, if that makes any sense. Not physically old, and certainly not wise old. But rather, emotionally old?
If I were to name the one prevailing theme of my time out here in California since graduating from school, it would be that internal rivalry between oldness and youth. Part of it is just my being a guy in his late twenties, but it’s more than that. For one, it’s the unusual Bay Area culture, which isn’t so much about visible youth like LA or even New York as it is about conspicuous youthfulness — dressing down, exercising outdoors, being progressive and current. It’s that, combined with living away from the Northeast and from my parents, which makes me contemplate in a more romantic way what it would mean to have a family and to raise kids with those characteristically East Coast values I still admire most. It’s also the wizened-ness that comes from having seem hundreds and hundreds of old patients and, for reasons I can’t define, somehow identifying more with them and their families than the with the typical can’t-wait-for-the-next-snowboarding-trip-to-Tahoe, can’t-wait-to-decorate-my-new-loft, can’t-wait-to-travel-to-some-exotic-locale yuppie Norcal citizen.
Of course, let’s not mistake any of this for some hypocritical form of ageism (hipster ageism?); it’s a rivalry between young and old because it goes both ways, and the tension is more balanced than I’m typically willing to admit. In a month I’m going to Japan for vacation and I can’t wait. If I hadn’t been working in the CCU this past March I would have made a trip or two to Tahoe. If I could afford a loft of my own I’d decorate it. And I enjoy plenty of other luxuries afforded to young people with means, whether it’s trying out the next Michelin-starred restaurant or making ill-advised weekend dashes to Vegas, all while being obligated to support no one else except myself. The life of a child, as a certain friend of mine in the State Department likes to say. It’s easy to make fun of myself for being old when clearly I’m not, nor am I in any rush to be.
What I am in a rush to have, though, is wisdom. Aren’t we all?
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getting access
In this week’s issue of The New Yorker is a provocative article by Atul Gawande about the value of coaching (credit to MTD for the link). If professional athletes require coaches for as long as they play, Dr. Gawande wonders, why don’t other professionals also use coaches? Why not classical musicians? Why not doctors? A surgeon himself, he recruits an old medical school professor to watch him operate and judge his surgical technique.
Simply reading his straightforward account of being “coached” was unsettling — after all, one of the most striking appeals of a physician or surgeon career is autonomy. Once you’re a full-fledged doctor, there’s no longer anyone looking over your shoulder. Dr. Gawande recognized this, the bizarre, humbling, and self-conscious feeling of suddenly going from master to student, and commented on as much:
And the existence of a coach requires an acknowledgment that even expert practitioners have significant room for improvement. Are we ready to confront this fact when we’re in their care?
“Who’s that?” a patient asked me as she awaited anesthesia and noticed Dr. Osteen standing off to the side of the operating room, notebook in hand.
I was flummoxed for a moment. He wasn’t a student or a visiting professor. Calling him “an observer” didn’t sound quite right, either.
“He’s a colleague,” I said. “I asked him along to observe and see if he saw things I could improve.”
The patient gave me a look that was somewhere between puzzlement and alarm.
“He’s like a coach,” I finally said.
She did not seem reassured.
I love reading Dr. Gawande’s writing because he conveys a humility that is uncommon among doctors (let alone surgeons who are also Harvard professors and New Yorker staff writers). The piece that made him famous was an early essay he wrote in 2002, which began with an unforgettable recollection of the first central line he ever placed. For those of you who don’t know, a central line is a giant IV that’s placed in one of the big veins in the body, usually either the jugular vein in the neck or the femoral vein in the groin. More commonly we place them in the neck, like so:
Scary, huh? Dr. Gawande thought so too. “This is a big goddamn needle,” he said to himself, when he first tried the procedure himself.
…
Placing central lines is standard fare for internal medicine, surgery, anesthesia, and emergency medicine residents. I’ve done enough that I’ve lost count. Standard technique involves using an ultrasound machine to locate the vein and then to also guide the insertion of the needle and catheter. As residents we’re taught to stand at the head of the bed, looking straight down at the patient’s neck, and holding the ultrasound probe with the left hand while simultaneously inserting the needle with the right. At first it’s as ungainly as it sounds, but with practice things happen more smoothly. Using an ultrasound machine certainly helps — although it’s bound to happen at some point, I have yet to miss the jugular vein.
Placing lines is even more standard fare for cardiologists, many of whom spend their entire careers placing venous and arterial lines in order to stent open blocked blood vessels. However, for reasons that are equal parts tradition, pride, and efficiency, cardiologists don’t use ultrasound machines for direct visualization of the veins (nor do many other specialists). The time-honored way of placing a line is to use anatomic landmarks. You see with your eyes, you feel with your hands, and then you shove the needle in. And not only do you shove the needle in, but you do it with your left hand. Instead of standing behind the patient’s head, cardiologists stand to the side of the patient, with the head to the left and the abdomen and legs and feet to the right. But, the needle still needs to be inserted towards the heart along the direction of the vein, i.e. left-to-right. Hence the left hand.
As I’m still only a resident, I’ve only placed central lines the super-careful, ultrasound-guided way. Today, though, I was asked if I wanted to try a cardiology procedure for a patient who needed a special type of central line. I jumped at the opportunity — not only do I love doing procedures, but I figured this would be my big chance to get in some early practice in the catheterization lab. And how hard could it be, I thought, if the cardiologists don’t even need ultrasound? My inner cowboy came alive, and before I even changed into scrubs I already imagined myself having successfully placed a transvenous pacing wire for the first time, a rare feat for a house officer. Future Stanford residents would talk about me for years. “Hey, remember that one resident who got to scrub in for a temporary pacer? Albert, right? Got access on his first try, too! What a badass.”
Of course, such sweet success was not to be. Things got off to an inauspicious start when the scrub machine spat out a pair of extra smalls which I, sadly, still fit into, but with far too much form-fitting in the crotchal region. I had the additional misfortune of being paired with one of our most demanding attendings. After putting on a lead apron and skirt (to protect against x-rays), followed by a sterile gown and gloves, I entered the catheterization suite where I then listened to a whirlwind set of instructions. The next thing I knew, in my left hand was a needle syringe filled with anesthetic. “Go,” my attending said.
I’d barely nicked the skin when my attending immediately started barking directions in rapid succession:
“Steeper.”
“No, pull back. Pull back.”
“Steeper. Steeper. No, pull back and go steeper.”
“Go lateral. See the line? Go lateral.”
“Pull back again. No, all the way out. Just pull the whole thing out!”
I never hit the vein. He asked me to step aside. “I don’t want this guy’s lung to get punctured, so I’m just gonna get access myself.” I silently watched the rest of the procedure as the fellow and attending completed the case, lamenting both my gimpy left hand and my too-tight pants.
As the saying goes, though: see one, do one, teach one. Maybe next time.
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plumbing the depths
To call someone “toxic” in the hospital is to peg them as an unhappy sort. Toxic residents complain constantly. In their eyes, everything seems to be working against them. Whether it’s the interns who are irredeemably incompetent, or the system that’s woefully inefficient, or the attending who’s unreasonable beyond belief, it’s oppression everywhere.
Unfortunately, being toxic can also be terrifically fun. It breeds an infectious underdog mentality, an us-against-the-world sentiment that makes it easy to commiserate. The character of the curmudgeonly food critic, Anton Ego, in ‘Ratatouille’ put it well: “[We critics] thrive on negative criticism, which is fun to write and read.” We’ve all been there, venting about this and that, hating on this and that. Dave Chappelle’s ‘Playa Haters’ Ball’ also comes to mind:
| Chappelles Show | ||||
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| http://media.mtvnservices.com/mgid:cms:item:comedycentral.com:24419 | ||||
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I’ve become toxic as of late. A stressful past couple weeks in the hospital have nudged me over to the dark side. The mere sight of certain people makes me lose my appetite. Worse yet, the prospect of seeing particular patients fills me with dread. There’s the lady I began caring for today, whose first words to me were not “Nice to meet you,” or even, “Help, I’m in pain,” but rather a request for a specific dose of a specific intravenous narcotic. It was akin to her asking me outright for heroin. The moment I met her — no, even before I met her, when I was simply reading her medical chart — I knew she was “one of those.” Listed among her dozens of drug allergies was Tylenol, which is automatically an enormous red flag, as it’s virtually impossible to be allergic to Tylenol. When I told her I wouldn’t opiates into hre veins she became livid, demanding to see another doctor, alternating between tears and cold glares. It was a Frank Costanza “Serenity now!” moment.
The rest of the day, I vented to my co-residents. I vented to my attending. This patient was making my already tiring day even more tiring, and I resented her for it. When I reenacted our conversation, it predictably elicited laughter, which made me feel better for a while. But, as I walked back to my car after day’s end, I felt awful again. After weeks of running on autopilot, I slowly began to recognize my transformation into a toxic resident, the very thing I’d set out not to become.
Some — many, even — might say I’m simply late to the party, that I was simply delaying the inevitable. I reject this idea. Not because I prefer to be a sunny optimist, or that I even possess an innate idealistic bent. I don’t believe in the false choice between being either toxic or naive. I do believe in a productive and satisfying middle ground to be tread.
I’ll elaborate in a subsequent post. It has to do with that sexiest of all questions: why is there suffering in this world? Not that I’m trying to answer that question, or even wrestling with it per se. But the question underlies so much of what we do — in medicine, specifically, but also in other service professions — and so it demands attention at least on some level.
For now, just thinking about my patient in a quiet moment is sobering. When she’s not in the hospital arguing with doctors, she lives long-term at a nursing home. Her physical life is, quite literally, defined by suffering. Knowing this, can I possibly in good conscience complain about anything she’s done to me? Anything at all?
Grace through faith.
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the captain
I dislike the Yankees. Always have, always will. I never liked Derek Jeter much either, at least since the Jeffrey Maier catch in 1996 that ultimately put my hometown Orioles out of the playoffs. Hard to believe that was fifteen years ago. My goodness.
But, like so many other Yankee-haters, I always respected Derek Jeter. He’s a winner, and he stays out of trouble. My favorite stat regarding his status as the latest member of the 3000-hit club is this: while he’s near the bottom of almost all offensive statistical categories among his 3000-hit peers, he leads far and away in number of championships won. Five, more than two titles ahead of everyone else.
And so it’s fitting that for a player who’s always appeared to be a humble, classy winner, the ball he hit for #3000 was caught by — and returned by — an equally classy young guy.
Instead of asking Jeter for millions of dollars or saying he was going to put the ball up for auction, Lopez decided he was just going to hand it over to one of his baseball heroes.
“Mr. Jeter deserved it. I’m not gonna take it away from him,” Christian Lopez said. “Money’s cool and all, but I’m 23 years old, I’ve got a lot of time to make that. It was never about the money, it was about the milestone.”
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leading from before
Did you know that the upcoming sequel The Hangover Part II is titled as such in honor of The Godfather Part II? The original Godfather film was the perfect movie. Part II is also good but is darker, drags at times, and is rife with tense, simmering conflicts of personality. Not unlike my experience on wards as a resident instead of as an intern.
I’m six weeks into my two-month block of general medicine. This time around, I’m what we call a ward resident. My job is to run my team — two interns, sometimes a medical student or two, sometimes even my attending. In essence, I’m a manager, and I learned very early on that I am not a natural manager. More specifically, I am not a naturally good manager. And even more specifically, I have felt woefully underprepared to be a manager, my lack of natural ability notwithstanding.
I possess several anti-qualities that handicap me as a leader. My mild Asperger’s, for one, on which I blame my inability to maintain steady eye contact when talking. A tendency to mumble, especially when I don’t really know what I’m talking about. Slouchy posture. Random fits of indecisiveness. I’ve known for a long time these things about myself, yet they never struck me as being altogether consequential until these past six weeks. It was a rude awakening on my first day when I led my team on rounds and immediately found myself internally debating how I should talk to my interns. What kind of tone do I want to set? Should I be chatty and casual? Or more formal? Would formal convey authority and knowledge or just meanness? I should have figured this all out in advance, was my first thought. But my second thought was, should I even be having this debate in my head? Is rule #1 of good management to “just be yourself?”
Fortunately, for my first month as a ward resident I had an attending with a very high EQ, and I was able to talk through with her these concerns without her thinking me incompetent and taking away my autonomy. That was at the VA, but now I’m at the Valley, where it’s a whole new system, and a whole new team. That’s the other thing — not only do you suddenly become a manager as a resident, but the team you lead changes every two or three weeks. They really need to formalize a boot camp of our own to teach basic management skills in a condensed but still rigorous way. Arguing about my MBTI profile is not cutting it.
I was chatting recently with one of our chiefs about this. He has a background in consulting, and he made the point that, in so many other jobs — and in management consulting, of course — when you first start out you go through a boot camp of sorts on how to manage people. The expectation is that, should you become a manager yourself one day, you should be have some base level of preparedness. Not a profound idea, on the face of it. But not everyone at these companies ends up becoming a manager, either.
Contrast this to medical school and residency. Virtually ALL residents are managers at some point; it is a required step of our training. Moreover, we have a five-year, protected educational period from the beginning of medical school through the end of internship to learn how to be a manager. Yet, it’s not formally taught. At least it wasn’t in my medical school, anyway. Nor is it taught at Stanford, unless you devote an extra year to attend the GSB. I have been fortunate enough to have several great residents prior to this year whose styles of leadership I can at least try to emulate. You can imagine, however, that it’s not so simple as “seeing one, doing one, teaching one” when it comes to management skills.
Still, I am avidly consuming examples of leadership all around me. As someone who doesn’t believe in chance, I find it more than compelling that various bits and pieces of culture I have enjoyed over the past month are much to do with different types of managers. I am currently watching both ‘The Wire’ and ‘Arrested Development’ in parallel, slowly but surely. Barack Obama had Osama bin Laden assassinated not too long ago. I listened to a sermon on the parable of the shrewd manager in the book of Luke. Bill Simmons recently wrote an article on soon-to-be-ex-Lakers coach Phil Jackson. And I just finished reading Tina Fey’s pseudo-memoir, Bossypants.
Avon Barksdale, Michael Bluth, President Obama, Jesus, Coach Jackson, Tina Fey/Liz Lemon. What can I learn?
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