I saw this on the health care blog, a blog that surprisingly discusses healthcare:

One of the day’s patients was a man in his forties who had been diagnosed with high blood pressure four years prior. Uninsured, he received inconsistent treatment for his condition, leading to a heart attack two years later. The attack precipitated heroic emergency room and then hospital treatments, free to him but expensive to the rest of us, including placement of a stent; however, with the immediate crisis over, lack of money for drugs led once again to gap-filled care. Key in his follow-up care should have been the drug Plavix, considered critical for avoiding clotting after stents, but he couldn’t afford it so he stopped taking it ten months too early. Now, just two years later, he’s developed severe high blood pressure that has damaged both his heart and kidney. Our medical system will provide him once again with heroic and very expensive hospital care, all of which likely could have been avoided if proper health care insurance had enabled his condition to be systematically managed for the past two years. The system as a whole, and likely government funding in particular, will end up paying hundreds of times more because his care was so poorly managed. Of course, we’re also losing a potentially productive man all the while, if not forever.

I think these antidotes (edit I meant anecdote! hah!) about people who don’t have insurance and have poor outcomes really doesn’t illustrate the full picture and furthers this myth that somehow insurance will now mean people will take good care of themselves. For that person, continuous healthcare could have lead to a much better outcome, although it sounds like from reading between the lines, this person’s high blood pressure is more of a problem than just a simple fix. It’s a story of someone who developed severe high blood pressures early in life, and had end organ damage much sooner than most. However, I’ve seen clinical situations where people who have limited access to care are given all they need – social work helps set them up with housing, transportation to doctor’s visits, medications, all the care and social support they need to achieve a good outcome and in the end – they still come into the ER, a mess of what happens when chronic medication conditions are not managed well. I think we forget how independent we are and how much we just don’t like going to doctors and doing the things that are right for our bodies. I think it’s a terrible mistake to just blindly fund healthcare and all these uninsured people will suddenly see the light, stop eating badly, will exercise and become advocates for their own health. It’s easy to see this evidence of goal blood pressures and the much better outcomes… but what is behind that is every three months this patient coming in, daily medications, filling medications regularly, etc.

On the other hand, I did see a clinic while I was a medical student where people who were homeless received care. And how surprised was I when out of the ratty backpack came out a book to write down their sugars and their daily sugars were logged. So I don’t think it’s impossible to help people, and help empower them to want to be an active participant in their health. But I think it’s a mistake to just assume it’s a lack of insurance, it’s often a much larger causal pie – slices of poor access to care, distrust of the medical system, lack of knowledge and motivation about health. I know this is not the focus of the healthcare debate about how to fundamentally change human behavior, but I just can’t help but to think that is what is going to matter in the end not just having insurance.

Before I started internship, I read this very interesting article in the NY Times called “Taking Time for the Self on the Path to Becoming a Doctor” I’ve always loved the columns Dr. Chen writes because they talk about things like being compassionate and reasonable in medicine along with the real practicalities of being in medicine, as opposed to an outsider to whom these things might seem reasonable but in reality they are not. Here’s the part that really struck a cord with me.

Do I have to lose my self in order to become the doctor I want to be?

I learned the answer to that question partway through my internship. Not in the hospital but in the checkout line of a local grocery store.

The customer in front of me was an older woman — she wore a faux camel-hair coat and had hair dyed a matching color. I remember that she had wanted her groceries bagged in a particular fashion, but the sales clerk, a young woman with impossibly long pink acrylics, was perplexed by the woman’s demands.

I felt as if I had stepped into an avant-garde theatre production. Each time the young woman bagged the groceries, the older woman admonished her and asked her to go through the process yet again. The muscles of my jaw tightened with each round of bagging, and even though I was off for the day, all I could think was: I’ve got sick patients to take care of, I can’t wait for this!

Unable to bear it any longer, I stepped forward and bagged the woman’s groceries myself, shoving the plastic bags into her arms while resisting the urge to push her on her way. I imagined steam rising from my head as I ranted. But a part of me was as shocked as the people still standing in line. I had never lost my temper in a store, and I had never raised my voice in public. Now, a few months into internship and with a three-minute provocation, I had the capacity to act like a grizzly bear sprung loose from a trap.

I walked out of the store horrified. That night thinking back on the event, I grew more ashamed of my behavior. But I also realized that it was not the first time I had snapped. Over the previous months, I had thrown myself into my work and shunned everything I once enjoyed and nearly everyone I loved. I believed I needed to do so in order to become a surgeon.

But I had lost my self in the process, and the stress made me irritable. I was no longer the nonconfrontational person I once was.

I had, for example, raised my voice a couple of days earlier at a receptionist in the radiology department when she couldn’t schedule my patient for a CT scan. I had scolded a nurse who had had the misfortune of being the fifth person to page me as I scrambled to finish a procedure. And only a week prior, I had squabbled with my family after my mother innocently asked, “Why do you have to work so hard?”

It reminds me of an encounter I had the other week with a patient. On night float, the team covers the whole obstetrics (pregnant ladies) and gynecology (mainly ladies who are after an operation like removing the uterus, ovaries, and gyn oncology) services. At times, it can be extremely demanding on your time as there are ladies in labor, people on the floor who have various issues that come up, preterm ladies who are hospitalized because of a problem in their pregnancy who start contracting, admission in the emergency room, etc. Part of the whole training is learning to handle the stress of having 1000 things to do, learning to get started on one end of the workup, taking care of other tasks, and then finishing or moving on with the workup of something else.
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I have my first real day on Wednesday. I’ve been in orientation thus far, but the real scary stuff begins on Wednesday.

I found this very interesting article “Taking Time for the Self on the Path to Becoming a Doctor” in the NY Times that I’ve been circulating around, and even been sent to me :) Here’s a clip, and I hope you read the whole thing.

Over the next two weeks in hospitals and medical centers across the country, new medical school graduates will begin their internship. Among their many worries — moving to a new city, meeting new colleagues, adjusting to medical training — is a more profound, existential concern that had once plagued me.

Do I have to lose my self in order to become the doctor I want to be?

I learned the answer to that question partway through my internship. Not in the hospital but in the checkout line of a local grocery store.

The customer in front of me was an older woman — she wore a faux camel-hair coat and had hair dyed a matching color. I remember that she had wanted her groceries bagged in a particular fashion, but the sales clerk, a young woman with impossibly long pink acrylics, was perplexed by the woman’s demands.

I felt as if I had stepped into an avant-garde theatre production. Each time the young woman bagged the groceries, the older woman admonished her and asked her to go through the process yet again. The muscles of my jaw tightened with each round of bagging, and even though I was off for the day, all I could think was: I’ve got sick patients to take care of, I can’t wait for this!

Unable to bear it any longer, I stepped forward and bagged the woman’s groceries myself, shoving the plastic bags into her arms while resisting the urge to push her on her way. I imagined steam rising from my head as I ranted. But a part of me was as shocked as the people still standing in line. I had never lost my temper in a store, and I had never raised my voice in public. Now, a few months into internship and with a three-minute provocation, I had the capacity to act like a grizzly bear sprung loose from a trap.

I walked out of the store horrified. That night thinking back on the event, I grew more ashamed of my behavior. But I also realized that it was not the first time I had snapped. Over the previous months, I had thrown myself into my work and shunned everything I once enjoyed and nearly everyone I loved. I believed I needed to do so in order to become a surgeon.

But I had lost my self in the process, and the stress made me irritable. I was no longer the nonconfrontational person I once was.

I had, for example, raised my voice a couple of days earlier at a receptionist in the radiology department when she couldn’t schedule my patient for a CT scan. I had scolded a nurse who had had the misfortune of being the fifth person to page me as I scrambled to finish a procedure. And only a week prior, I had squabbled with my family after my mother innocently asked, “Why do you have to work so hard?”

The list is split up between the medical students, and as soon as that’s done it’s time to go see patients. I get impatient when there’s silly conversation before we split up, and if it lasts too long I break from the group. I have things to do, and being that I don’t know what has happened with my patients overnight – I want to make sure I have enough time. I am intensely goal oriented. Don’t get in my way. My fellow med students have made fun of me for this, but !! I have things to do!! Don’t dare take that chart from me!

My new patient for the day is an late 70 something year old woman. She’s been through a lot – her acute medical problem was attempted to be resolved by medical management but that failed so she ended up having to go to the OR. She has a colostomy now (a colostomy is when they take a piece of your intestine and connect it to the outside and you have to wear a bag to collect what comes out of the intestine, done for various reasons and can sometimes be reversed – depending on the various reasons why it was done). I can immediately tell she’s just fed up with all of this. Not so fed up she’s about to jump out of the bed to leave AMA (against medical advice) but pretty darn frustrated.

Really, as far as my end goes – infection standpoint she’s doing excellent. This I hope, will be something I can use to life her spirits. I also don’t need to ask too many probing questions since she’s doing well, so more time I spend with her can be hopefully helping her feel a little bit better.

When I’ve worked with younger medical students in the outpatient setting, I sometimes talk to them about finding something that the patients eyes light up about and they smile about. Especially for outpatient medicine where patients can do whatever they want with what you tell them – forming that relationship is important. I don’t know if there’s even been evidence based medicine but it makes intuitive sense that you’ll take advice more seriously from someone you feel a bond with. Although this is in the hospital, I know if I can do that with this patient – maybe she’ll feel a little bit better from this endless stream of people coming in her room, poking her, interrupting her sleep, and never quite giving her that warm smile that she needs.

I emphasize as I talk to her that I know she’s been through a lot, but am careful to be too much on the side of “Wow! You’re amazing!!!” because my guess is that it will turn her off. I notice when I discuss her eating she’s particularly unhappy about her diet at this point. I note that when she’s back on a full diet this will be something, hopefully, she will be able to feel encouraged about.

However, I’m just spinning my wheels. I’m not reaching her. Sometimes I’m just not the right person – or maybe I’m just not “getting it.” The moment arrives though when I take her hand and she looks me right in the eyes and I do my best to show and say that I hear her and although I’m not in her shoes, I can imagine what it might be like. I smile at her, and try to make sure that our encounter ends on a positive note. She needs that. And when we come back in with the fellow – I smile at her – and a small smile is on her face when she sees me. :)

So now, many hours from being at the hospital and seeing her, I wonder how she’s doing. I know that last week, one of my patients had a really down weekend and I really wish I could have dropped by to his room to have a silly conversation – we had bonded over a couple of trips he had taken. He refered to me as his friend even though I’m really Heather the medical student. I worry that this weekend this patient will continue to feel frustrated, and I know that her feeling encouraged and positive is more medicine that the antibiotics my team had carefully selected for her. I wonder if this comes at the expense of the people in my life. And that working to help patients takes away from me being the nice smiley person at home because I’m too tired to do that anymore. But, I worked hard to become a doctor (31 days till graduation) and being compassionate is far too important to me. So I don’t know that balance, but luckily Wolfie brings me the soccer ball (well actually tonight it’s a duck! maybe because we chased some ducks today!) to play regardless – he knows that if he wants my attention, he has to ask for it.

The patient on the service has AIDS. A new diagnosis of AIDS. No HIV, no careful months of monitoring viral loads and CD4 counts – and when the CD4 counts reach the level where opportunistic infections become more likely antiviral medications are started… and more careful monitoring… just AIDS. And an infection that is an AIDS defining illness – one that means your immune system is compromised and cannot fight something off that a normal immune system would fight off easily.

The patient looks like they have had a hard life. They act like they have had a hard life. When they don’t like what you say, they meet you with stony silence. They don’t have the boundaries of proper society, they get angry and become overally abrasive. They blame the medical establishment for not listening to them. They have a history of leaving the hospital against medical advice.

But the thing that breaks your heart is the questions they ask in those honest moments where they are vulnerable and desperate. Can’t you just order dialysis and cure them? They heard that worked. Or how about just removing all of my blood? And it’s clear that they never had the chance that you did in life and you’re standing there in your nice clothes, brain full of education, and a support system there behind you… and you just feel like all the chances you had in life they never had weren’t really fair but isn’t that just how life is?

You know you’ll go home, and cry like you do over these conversation you hear. It’s not the first time, and certainly not the last. Wolfie will come running over, concerned, and lick your entire face over, with special attention to that spot at the corner of your eye where the hot tears come from – and you’ll never feel those tears turn cold because a poodle licks them up to fast. And it doesn’t matter to Wolfie when you begin to sob about the injustice of it all – his tear roundup service is always ready.

Then a few days later when the patient’s family member begins to ask about using herbal treatments, special diets and you watch the attending patiently explain that they won’t cure HIV or AIDS. You watch the group of attending, resident, students walk away – and see the family member wipe tears away. You feel unsettled, because you know this situation repeats over and over again.

Everyone wants to know outcomes – what will happen to this patient? It depends – but the biggest barrier for these types of patients will be themselves and the rough tough exterior they have used to get them where they are. Hope for the best.

I came across this via my favorite newspaper the nytimes, Doctor’s Diaries. For those of you are really interested in what it’s like, I think this is really great to watch. I normally keep interesting links and the such over in the tumblr blog (listed in the sidebar) but so many of the moments captured are the things I that remember the strongest as far as the medical school training end goes.

My favorite parts –
-The description of the hierarchy in medicine, from the attending as the deity and down to the 3rd year medical student, a trembling monk.
-Watching the fumbling during the physical exam trying to learn the equipment and practicing on each other. Many fond memories of that :)
-Kind patients who tell you that you’ll make a great doctor as you fumble your way through things – and even though you feel like an incompetent idiot they still tell you they want you to be their doctor when you finish.
-The discussion of at fourth year how far they’ve come and how they wouldn’t have expected that even during 3rd year.

I think it’s especially important as a physician to reserve judgment. People do all sorts of remarkably stupid things, but they come to you for help – not for advice on what the stupid thing they did was. I don’t think it’s bad to tell a patient that what they did is bad for them or wrong, but in a way that empowers the patient (in the ideal situation too of course ;) ). Hopefully all of us were raised with a parent, two parents, or people who acted like parents and got all the scolding one should need in life.

I’m on the lung team and we don’t get many pregnant patients. We recently had one though, in the 2nd trimester who came in for cold symptoms. Urine drug screen was positive for cocaine and marijuana, patient also smokes cigarettes. Here’s where I think the reserving the judgment is incredibly difficult. Obviously, this mother is not making wise decisions and it’s worth mentioning that what she’s doing is a not good idea. Likely, she will become very defensive because everyone knows that pregnant women shouldn’t be partaking in that kind of stuff. It’s hard to not let your own biases come in to play as you speak with the patient, it’s hard to imagine why this person is making these choices. Luckily, the crack baby epidemic of mentally handicapped children never came to fruition and hopefully this child will live a healthy life. It is doubtful due to more of the social situation the child will grow up in as opposed to the fetal exposures, but I try to hope.

So I was at Dr. Shadow’s recently, the physician I’ve been in the family medicine office with since my first year. 4 years is a huge amount of time especially when you consider I’m in my twenties and I’m all changing/morphing/becoming a big girl inside. Then add to that learning how to talk to patients, play role the doctor, etc… Anyways, I would go in the room, go over whatever problem they had come in – and for many of the patient encounters they were set. They didn’t even ask when Dr. Shadow was also coming in. They seemed surprised that he was even coming in at all. Knowing how nervous I was the first year going into patients rooms – the terror is just more than anyone can ever imagine – it felt pretty great knowing that I’d really progressed and was no longer the little girl shaking her boots, trying to figure out what to do with a simple cold!

I had a patient recently who I sat with for a while since we were sending him over to the ER. Spending time like that with a patient never normally happens. I sometimes wonder about patients when I’m talking to them since I really only get to see the one side of them (obviously medical). For example, if you sat down with them at a meal, what little quirks would you notice about them? What sorts of things do they laugh about? What do they get annoyed about? I’m not sure how much of this would ever be medically relevant – and I’m sure you could make a great argument that it’s really important, but in the long run it’s most important to conform to the standard of care because in the ideal world that’s the medicine that’s proven to work and help people’s lives. Knowing that they laugh at knock knock jokes, hate waiting in line, and hold their fork funny isn’t going to change how you manage their disease most of the time.

Sometimes I feel frustrated, because I feel like I didn’t just go into medicine to treat one disease after another but this is where you run into the conflict of the dehumanization in medicine. I think it’s very important that you become desensitized, there’s far too much pain and suffering in this world to put on the plate. At the same time, I want to know that I treated a person, not just a condition or disease. Then mix in the reality of medicine where there are so many demands on your time. I sometimes just leave the day just feeling so dissatisfied with all the hard work I’ve done and the lack of caring I was able to communicate because I had to go do this or that. It’s a balance and one that I’m just really starting to see and understand.

I’ve been on what seems like such a long extended vacation from medical school since studying isn’t the same as being on rotations. Before that it was all the stuff with my Dad. I won’t even be back on rotations until Oct. 6. Its kind of weird… although I hate wearing the short white coat (it is hot and heavy- mainly due to all the books and crap I have in my pockets, a true sign of a medical student!) I do miss it – having the answers, helping patients, having to think on my feet, the constant activity… When I was with my Dad it was still kind of like being in medicine, especially since I would monitor how he was doing and report to the doctors who came in during the day and I did make a couple of suggestions to his care to make him a little bit more comfortable. But it was still very different from being the student doctor obviously.

I know that when I go back to rotations on Oct 6 I will be a profoundly different person than the girl who left rotations to go be with her father who was going to the ER for vague abdominal pain. I’m not sure how exactly it how I am different though. I know many people expressed to me that I would be a more compassionate physician for having gone through this. As I sat with my Dad he told me how he didn’t like how one doctor did this, or another did that and that he was happy that he was able to teach me to be a better physician. So I want all of this to have meaning, to not have been this terribly devastating storm that wrecked my life and my mother’s life and took my father away – but I’m not how to translate it all into me being a better physician. It’s not like I need to know that answer now, and it will probably not be obvious to me for years to come. It’s just this need to take what happened and make it into this wonderful positive thing because it is just so painful to have lost my Dad. :(