More and Less

It started with a simple question my classmate asked me while we were on the shuttle: "After taking anatomy, do you think you're more or less likely to want to donate your body to medical science?"  I paused, sat back.  It was--to borrow a cliché--really complicated.


How much did I know about the fate of a donated body before I stepped into the anatomy lab in scrubs with scalpel in hand?  On one hand, thinking of young aspiring physicians, I could have romanticized the role of a donor.  The invaluable experience of learning from flesh rather than books.  The indelible impact of feeling for organs, finding them, taking them out of their cavities, scrutinizing them, remembering them, and using the knowledge gained to cure others.


However, the past six weeks have been graphic.  Sterile donor consent forms are not sensual experiences.  They do not show the prodding of genitals and orifices with probes.  They do not replicate the sound of sawing the skull in two.  They do not convey the smell of rummaging through the bowels, or the feel of dry, leathery flesh.  Now that we are "informed"--in every sense of the word--would we want the same fate for our own bodies?


Or--now, do we even more acutely realize and appreciate the significance of such a gift?  Would this inspire us to want to give back to future generations of those like us?


Curiosity led me to send out a one-minute, five-question survey to my 200 classmates.  I received 75 responses.  The raw results are below.  In the next post, I will analyze these numbers further and discuss them.

Rather predictably, more students--nearly 50% more--began to think about their own body donation after taking anatomy.  No one who had answered "yes" for the former question answered "no" for the latter.

Before taking anatomy, about one third of students considered themselves "likely" or "very likely" to donate their bodies.  After taking anatomy, this fraction dropped a bit.

The more striking difference was the increase in students unlikely to donate their bodies after taking anatomy.  Fewer than half considered themselves "not likely" or "not at all likely" to donate beforehand.  After the course, that number grew to greater than half.

To note:

No one in any instance who had answered “yes” for the previous questions (they had thought about body donation) left these questions about likelihood blank.

Before anatomy: Since only 44 students claimed they had thought about body donation, I expected to receive this number of responses for the follow-up question.  However, 11 people most likely interpreted the question conditionally ("If you had thought about body donation, how likely would you have been to donate?") and thus answered.  I kept their responses for completeness.

After anatomy: Once again, based on the last question, I expected to receive 65 responses.  Similarly, I am including the extra 5 answers for completeness.

These results are consistent with the findings that taking anatomy caused more students to become less likely to donate their bodies.  Several questions remain.  How often did students experience complete changes-of-heart, such as switching from "likely" to "unlikely"?  Did students with stronger feelings about their likelihood of donating stick with them more steadfastly?  How did the 21 students who had not thought about donating their bodies before anatomy feel after it?

Since I have the individual surveys, I can be transparent and specific.  Next post coming soon.

Dear Third Space

Third Space Magazine is a student-run literary magazine for Harvard medical students, residents, and faculty. It publishes fiction, prose, poetry, and art biannually.

I am currently involved in the Chief Complaints section, a mock advice column.  My first contribution:


Dear Third Space,

I dislike my anatomy lab partner, but I dislike confrontation even more.  Do you have any suggestions about how I can passive-aggressively voice my displeasure? 

Signed,

- Silent Rage Behind the Scalpel

Dear Silent,

The important thing to remember is, when donning the blue scrubs and gown, one must remain professional.  As we learned during Introduction to the Profession, being professional involves not raising your voice, not using your scalpel to nick your partner’s forearm, not burying fat in your partner’s hair, not naming your cadaver after your partner, not spraying formalin in your partner’s locker, not hiding your partner’s pants in the changing room, and not taking a hammer and chisel to your partner’s kneecaps.

It is also important to remember that every medical student in the anatomy lab is nervous and frightened to be there.  She may have had bad experiences in anatomy labs before.  Maybe she mistrusts the anatomy directors.  Maybe the anatomy labs here are not like the anatomy labs she is used to.  You must find out more about your partner as a person.  Instead of making assumptions about your partner’s expectations regarding anatomy lab, take the time to talk to her about them.

A good place to start would be to ask her what brings her into the anatomy lab today.  Try to obtain her explanatory model for why she thinks she is here.  It is also important to make empathic statements.  If she accidentally cuts the phrenic nerve, you may say, “This must be hard for you.”  Try to make your questions non-judgmental, and make the transitions natural but clear. Perhaps while she is dissecting the liver, ask her how many drinks she has each week.  While she is looking for the bulbospongiosus muscle, inquire “men, women, or both?"  While you both dig through fat, ask her if she is interested in exercising more.   Try offering advice about STD testing, AA meetings, or birth control in passing, just to let her know your door is open for additional questions.  Ask her how many children or grandchildren she has, and what she is most looking forward to doing when she leaves the anatomy lab.

No matter what, it is important to maintain an air of professionalism and understanding.  Remember, not all of this has to be accomplished in just one session.  Sometimes you may have to broach sensitive issues repeatedly on follow-up meetings until she eventually gives you satisfactory answers.  The partner-partner relationship is a unique, delicate, and long-standing one and should be treated as such.

Sincerely,

Always Professional

The Fifth Member

In this post, I am not going to be a hypocrite.  We have not called our "donor" "our donor" in a very long time.  In fact, I don't think we ever did.  He is "our body" and "our guy."  It doesn't feel right in writing.  It is jarring, but it is honest.  So I will call him that now.

One night, alone in the anatomy lab, I was reviewing our body's abdominal and pelvic organs.  I knew that the next time I saw him, I would be dissecting his face and neck.  There would be little time for reflection.  I lifted the sheet that had covered his face for the last month.

Our guy was entirely dissected, in some places far less than perfectly.  During lab, I no longer mused about the now bloated, skinless hand while I was wrist-deep in intestines and embalming fluid.  I no longer thought about "the person" or "the patient" while I cursed the smell--an unfamiliar and unpleasant mixture of embalming fluid and bodily contents--that strongly emanated from our body, particularly when we dissected near the rectum.  (I had long given up trying to breathe through my nose.)  I often wished that our guy weren't so darn moist, and yellow, and fatty--that, like our classmates, we could easily distinguish among arteries, veins, nerves, and ducts.

It is amazing what a difference a face makes.  I looked at his face, completely intact, feeling a combination of awe and shame.  His eyes weren't completely closed.  His nostrils flared a bit.  He had strong, gray stubble.  Who was this person?  What would he think if he knew what we were doing to him?  How much worse was it than what he'd imagined?

I thought about this man with the metal knee replacements, the hardened coronary and femoral arteries, the strong tan arms, the large amounts of visceral fat.  Sometimes during lab, we would hazard guesses about who our guy used to be: a fisherman?  A construction worker?  A park ranger?  We were probably horribly, offensively wrong.  My three labmates and I knew him in ways that no one else, including he, ever would.  Yet at the same time, we knew nothing about him at all.

If this were a movie, we would probably we treated to flashbacks about this man's life while we puzzled over his innards.  Maybe he would be shown at the dinner table, eating a hearty meat-and-potatoes meal while his arteries slowly calcified.  Maybe we could see how he developed such strong muscles, surprisingly well-formed even years after death.  Perhaps we would see him contemplating what he wanted to do with his body after death, having deep discussions with his wife and children.  Was he ever in a hospice, on a "death bed"--or did he die suddenly, perhaps of a heart attack?

Who was this man?  Would he have laughed along with us as we surreptitiously tried to get our instructor's attention with some well-placed coughs?  Would he too have flinched at the smell?  Been frustrated by the layers and layers of fat?  Felt disappointment when we accidentally cut a major nerve instead of preserving it?  Felt that same awe when we held his heart and lungs in our hands?  When he donated his body to science, how much did he know what the aftermath would look like?  That he would be groped deeply in cavities he probably never knew he had.  That he would get a circumcision.  That he would be seen every day by at least forty students--but not really seen so much as "looked past," as though he were part of the decor. This sounds more like a horror story than a gift.

The moment I stared into his face was oddly sad.  In some way, I felt as though he were witness to our work all along, a fifth member of our group.  I wished I could have a conversation with him.  I wished I could tell him what he looked like inside.  I wished I could tell him that we are just kids, to ignore our pouts and moans when we can't find what we're looking for and when we're tired of digging.  I wished I could tell him that holding his heart was the most humbling experience of my life.  Throughout lab, I sometimes imagined I could find a clue as to who he was by searching through his body, that physical signs could somehow magically impart answers.  Of course, this was fruitless.

If this were a movie, perhaps we would be rewarded with a final scene, a culmination of our efforts and his.  A meeting, of sorts.  A brief but meaningful conversation that would change how we viewed each other.  A videotape delivered by his family.  A hand-written letter.  A spiritual epiphany.  But there are no such endings here.  Our reward is learning anatomy.  This is the psoas muscle.  Sometimes I wish it were all bit more Hollywood.

Internal Happenings

There was a certain ignorance I had about the body before dissecting it from shoulder to foot (head and neck are up next and last).  Some of what I've learned was surprising, disconcerting, and fascinating:

1. The female urethra is very, very short.  I was aware that it was only a few centimeters in length, but seeing the bladder so close to the outside world (and the anal opening) made me wonder why every woman doesn't always have a UTI.

2. The body is almost entirely shades of brown, yellow, gray, and red.  The gallbladder and its contents are the only exception: a stunning bright olive-green (in live people, it is robin's egg blue).

3. We have an internal apron: a layer of visceral fat, several inches thick, that hangs from our stomach.  It helps protect our stomach, accessory digestive organs, and small and large intestines.  This is different from subcutaneous fat, which is what we usually think of when we put on weight.  The female "apron" is thicker than the male (she has more internal organs to protect)--which unfortunately leaves the door wide open for sexist jokes.

4. Even if you do not smoke, your lungs will probably end up black and speckled from what you've breathed in over a lifetime.

5. The appendix elicited a large amount of anger from my labmate.  It looked puny, flat, and unnecessary.  Since it is at the beginning of the large intestine, it easily gets infected.  Appendix pain has been said to be the most agonizing pain there is.

6. Our bodies can differ substantially, with apparently no impact.  There are certain things we'll never know about ourselves unless a careful anatomist dissected us.  Some arteries, veins, and nerves run in different directions, taking tortuous routes--and some simply do not exist.  Sometimes the right kidney is higher; sometimes the left is.  A thigh can have a large benign mass, made entirely of fat.  Cysts are very common, sprinkled throughout the body.

7. Your body gets hard when it ages.  Calcifications develop in the cavity holding your lungs, coronary arteries harden, cartilage disappears and leaves rough bone in its wake.

8. In one day, our kidney filter 150-180 liters of blood.  We can survive with reduced kidney function or just one kidney.  One kidney is only about the size of a computer mouse.

Grossness in the Lab

There have been many, many books, articles, essays, and poems written about the cadaver.  There have been a similarly large number of writings about why death fascinates us.  I will try my best to avoid the obvious and cliched in this post.

Today marked the third day of dissection.  Every day, for the greater part of a month, we enter the gross anatomy lab at 8 am and spend the next two and a half hours palpating bodies, cutting through skin and subcutaneous fat, slicing fascia, probing superficial and deep muscle layers, and searching for nerves and blood vessels.  We started with the back, a relatively impersonal region with well-defined, thick muscles.  We then stayed with the donor prone, moving to the posterior upper and lower limbs during subsequent labs.

As expected, unexpected things have surprised me about anatomy lab.

Before our first day, our anatomy professor spoke briefly about the special (and privileged) experience we were about to undergo.  It sounded almost sacrosanct: "You will remember where you were standing.  You will remember where your lab partners were standing.  You will remember the first cut."

Though I write with less than week between that first cut and me, what I can say is that that cut was not our first interaction with the cadavers--and it was also not the most memorable one.  After we unzipped our body bag, we saw that our cadaver wasn't lying on its stomach, prepared for our incisions on its back.  We would have to flip it.  For several minutes, my labmates and I struggled to lift the heavy man--literally dead weight, and filled with gallons of embalming fluid--and carefully turn him onto his stomach.  I grabbed a left arm, a left leg, to steady the body, and I felt slightly sick.  Physically manipulating a dead body, feelings its contours, struggling with a rigid unmoving object, turned out to be much more crass and jarring than making restrained surgical incisions through his skin.

What I found throughout lab was that the worst, most disturbing moments were the most familiar ones--the ones when the body resembled a living human's.  To position the arm for cutting, I had to twist it carefully.  The elbow joint still worked, and the flexion resembled a living person's--not the stiff unbendable limb I had imagined.  Brushing against the man's fingernails--grime still underneath them--was unpleasant in its familiarity. Seeing toughened skin and hair on the man's arms and legs gave me the same feeling.

It was the new, the unrecognizable, that unsettled me least.  Never having seen anything beyond animal muscle, seeing human muscle and its surrounding fascia fascinated me.  Pulling on a certain muscle to move the cadaver's thumb felt like a surreal version of a marionette--but still too unnatural to elicit a strong reaction.  Cutting away human fat, an inherently unpleasant task due to its color and texture, only vaguely differed from cutting away animal fat during dinner.  Rolling up the skin and subcutaneous fat like a carpet after we had removed it was still too far removed from reality to make me shudder.

Before I entered the laboratory, I was fairly certain that the experience would feel laden with emotion and that I would not be comfortable if my labmates treated the situation with anything other than intense seriousness  Again, surprisingly, this attitude changed fairly quickly.  I realized that "respect" didn't stem from how we felt or what we said--it came from our deeper attitude towards the task at hand.

What would I want if I donated my own body to science?  What would upset me?  What would satisfy me?  I can't presume to know the donors' motives, but I can say that my own would be to teach someone something unique.  I wouldn't particularly care whether students put on a--perhaps artificial--air of solemnity during dissection.  I would rather they treat my body as a specimen, something they could learn a whole lot from.  The worst form of disrespect, in my view then, would be wastage--students rushing through procedures, not being prepared to identify structures, and worst of all, not caring about what was in front of them.

To help further classify my feelings, I divided them into several categories: 1) unpleasantness from something that would disturb me if seen on a living person, 2) unpleasantness from something that reminded me of death but wasn't directly related to the body's appearance, and 3) unpleasantness stemming from the appearance of the body itself.  I believe only category 3 is particularly sad and something I would like to lessen.

These classifications have helped me hone my idea of "respect" for the cadavers.  Our instructors talked quite a bit beforehand about this concept.  We were told not to give them names (they already have names; we just don't know them).  We were told nothing of their age or cause of death.  (There are many arguments about whether this dehumanizes the cadavers or protects their status and anonymity.)

Today, when we palpated the gluteal muscles, feces emerged from the cadaver's anus.  This happens sometimes, and it's not particularly common or uncommon.  Should I feel embarrassed that I was thoroughly disgusted?  I certainly would feel about the same way about a living person, and I'm not ashamed to admit it.  It is really any more respectful, then, to hide a feeling of disgust when the subject happens to be dead?  (This falls into category 1 of aforementioned unpleasantness.)

Similarly, I was fairly horrified the first time I held the cadaver's cold hand for an extended period of time.  Probing my feeling, I found that it wasn't the hand itself that repulsed me; it was that it very explicitly symbolized death.  It was inhuman.  This, also, I don't feel is particularly disrespectful--to have a visceral reaction against death.  (Category 2 of unpleasantness.)

What about making small jokes, at no one's expense (including, and especially, the cadaver's)?  I surprised myself by laughing during lab.  When we dissected down to the trapezius muscles, I mentioned that it was cool to see the muscles that felt so good when they were massaged.  My labmate gently squeezed them and said, "Yeah, it's like he's getting a really deep massage."  It felt okay.

So what wouldn't I want if I donated my body to science?  It's not an easy question to answer.  Clearly, we want our sacrifice to be taken seriously--though not to the extent that emotion renders us less effective learners.  I realized that I would be bothered if people were disgusted by my remains.  Not of my feces, not of my cold hand, but of the natural processes that my body undergoes as a result of being dead--that is, category 3.

It would sadden me, for instance, if someone saw my long toenails, or squished backside, or flaking skin, and as a result, saw me as less than human.  I don't mind if people see my feces as disgusting, or as death itself as disgusting.  I suppose I do mind if people see what I've contributed as repulsive.  It's a dehumanizing feeling--to repulse someone--and it would put me on a separate plane from my dissectors.  We are no longer the same species; I am alien.  They cannot see themselves in me.  Understandable, of course, but sad nonetheless.

Tomorrow we dissect at 8 am.  It may be serious, but hopefully not too serious.  It may be enjoyable, but hopefully not distracting from all we need to accomplish.  It may even be disgusting--but hopefully for "better" reasons.

More on Mortality

This past weekend I attended a course--Practical Aspects of Palliative Care--held by palliative care physicians and specialists from Harvard's hospitals.  It was attended by physicians, nurse practitioners, nurses, managers, social workers, and chaplains from across the country.  I was very different.  Greener than green, I have not yet taken part in the dying process, much less the process on a regular basis.

Apart from seeing glimpses of cadavers in various anatomy labs while interviewing at medical schools, I have only seen a dead body once in my life.  It was in the basement of a hospice I had volunteered at in college, and what struck me was how lonely it looked.  Fewer than 24 hours ago, that same figure had been surrounded by doting loved ones whispering tearful expressions of affection.  She had been the center of attention, of love, of comfort care.  She had appeared almost identical to how she looked now, but everything else had changed.  She was alone on a cold metal gurney.  When the volunteer coordinator turned off the light and closed the door to the basement, I had an instinctual reaction--wait, are we just going to leave her there?

Later, outside the confines of the hospice, I probed my discomfort over leaving, and I realized how difficult it was for me to separate a body from the person who had occupied it.  For better or for worse--despite rational mind-body dualism--we are our bodies.  When our bodies fail, who we are is profoundly affected.  When we're in pain, our relationships with others change.  When we don't have energy to speak or to move, some priorities shift to the forefront while others fade into the background.  Health is a foundational good that we can take for granted until its status changes.

During the conference, there was a workshop on how to avoid burnout and fatigue.  Participants listed the "perfect storm" of events that could cause them to hit an emotional wall.  For some, patient-related issues contributed: seeing particularly young people die, or seeing people who bore striking resemblances to themselves.  Professional dissatisfaction was a cause too: feeling a lack of control over the system or over resources within the system, or not being able to help as much as one would like.  Personal life certainly played a role, as well as general challenges unique to working in palliative care.  Who do you turn to when you need to share something particularly challenging or frustrating?  Do those outside the field understand--and even if they do, how often can they hear about it?

I waited to hear answers along a particular line of thought.  Loss of faith.  Spiritual questioning.  Seeing so much suffering as to feel as though life itself were unfair and meaningless at times.  Existential anguish.  These were noticeably absent; answers were fairly grounded.  I'm not sure what that means.

I wonder if it takes a particular type of person to go into this field.  Does the special emotional resilience--the ability to transition from distancing to empathizing--stem from deeper beliefs about life?  Do you have to have some sort of spirituality or religion to give events a greater meaning, so as not to become disillusioned by the physical fragility of the human condition?  I would very much like to know if palliative care professionals are more spiritual/religious than other health care professionals, and if so, if it's correlative or causative.  At a certain point during the course, I began to see all of us as the walking future dead.  How could these professionals see such tragedy and still function despite these continual reminders of their own fate?  I think this is something I am wholly unprepared for and will have to learn gradually.

Death isn't carved out neatly into palliative professionals' hands simply because they have more experience with it.  Most doctors will have to face it.  I will be facing it during my third year of medical school.  I will be facing it in two days, in seeing my first "patient," a cadaver.

It seems like a great juxtaposition to go from a palliative care conference--focusing on transitioning from the living to the dying--to the anatomy lab--focusing on learning from the dead.  It seems like an odd backwards cycle, but I'm glad for it, emotionally.  There will be no suffering, no unmitigating symptoms, no difficult decisions.  Our learning takes place after all this, from the great gift left behind.

I'm Starting to Get It

From Ellen Lerner Rothman's book, Becoming a Doctor at Harvard Medical School (she graduated from our program about a decade ago, and her book chronicles her experience):

At times it felt as if death were everywhere.  In anatomy lab we finally uncovered the facial shroud and opened the skull to dissect the brain, and that was okay.  I talked to a patient who had nearly died the previous evening and would certainly die within the next months, and that was okay.  I came home, and my goldfish had died, and that wasn't okay.  I sobbed for half an hour.

This past week culminated in a similar sense of emotional drain that is very new to me.

On Monday, I met a 48-year-old patient who had been in and out of the hospital for severe abdominal pain for the last five years.  He had been forced to retire, lived alone, and had only his dog for company.  After the interview, he didn't want me to leave the room.

On Tuesday, I shadowed a neurologist for several hours.  I saw a 29-year-old man who had just been diagnosed with multiple sclerosis and couldn't feel his legs, a confused elderly gentleman who had had a series of seizures resulting in his increasing levels of incapacitation, and videotapes of two patients suffering intense seizures.

On Friday, Saturday, and Sunday, I attended a conference on palliative care, with physicians, nurse practitioners, nurses, managers, social workers, psychologists, and chaplains from all over the country.  Every person there experienced dying on a regular basis.  They shared details about basic mechanistics and interventions during the actual dying process, how to communicate prognoses and do emotional "damage control" after a patient has exhausted treatments, how to support families, ethical and legal dilemmas on withdrawing or withholding care, and how to deal with fatigue and burnout.

This Thursday we start dissecting cadavers.

Suddenly academic rigors do not seem like the hardest part of medical school anymore.

"Do You Want to Listen to my Heart or Lungs or Something?"

We have a weekly course called Patient-Doctor, in which we interview patients at our school's teaching hospitals to learn how to take a medical history and present clinical cases orally and in writing. We also try to incorporate the idea of "patients as people," inquiring about their social support networks, hobbies, work, or other meaningful components of who they are.

What we can't do in the least is help them medically. They know more about their illnesses than we do.

On one of my first sessions, I interviewed a middle-aged man who experienced acute episodes of debilitating pain in his abdomen, most likely from complications stemming from his gastric bypass surgery a decade ago. The pain was bad and always there, he said. When it was particularly severe, he couldn't do much other than lie down, and his dog would lick his hand until he'd feel better again (he lived alone). He had been forced to retire from a job he loved.

I had twenty minutes to take a brief history: his present symptoms, what he thought caused them, how long they lasted, and how they affected his life. He opened up to me in a way that even surprised my preceptor, freely admitting that he had been a heavy drinker and smoker.

As our minutes together ran out, I thanked him for his time and sharing his story. My hand was proverbially on the doorknob when he asked me, "Do you want to listen to my heart or lungs or something?"

I'm not sure why he asked. Did he think I had more authority or qualifications than I actually did? Did he want to help me learn better? Or did he just want me to stick around longer, to talk, to listen, to understand?

When I told him unfortunately I couldn't do that, he said he understood and told my preceptor that he should send other students in if he wanted.

At the time, I was too wrapped up in my own thoughts about how I would present the case to think much about the patient after I left his room. Later, when I presented his case, I was concise. I stuck to the organized structure of a medical history, throwing in a few personal facts as per the formula to make this patient come alive to my audience. Then my assignment was over. My brief relationship with this man was over.

Hours later, I couldn't sleep. I wondered how he was doing. He was still probably experiencing some form of pain right then. Quality? Severity? Worse? Better? How? Why?

I felt an intense sadness that I would probably never be able to know how he felt again. I couldn't listen to his heart or lungs, but could I... "something"?  The thought flitted through my mind that perhaps I could email my preceptors and ask if I could visit this man again. No interview pad, no scripted questions, no rigid time restraints. But a mixture of timidity, discomfort, and a fear of doing something outside protocol got the best of me. Would such a request sound inappropriate and naive? I wrote a draft of this blog post and tried to get back to sleep. Perhaps writing that email instead would have been a more fruitful and less self-indulgent endeavor.

When the gentleman asked me that question, he needed help. He was looking directly at me, earnestly, waiting for me to do something. I thought I couldn't do anything. I was not qualified.

Now I wonder if I could have qualified in a different way, had I seriously explored possibilities beyond strictly medical help.  Maybe my attempts would have failed; maybe there was policy prohibiting me from visiting again. I still do not know. I should know now though, because I should have asked then. Next time I will. I'm just sorry it will not be for this particular man with this particular pain.

RESOLVED, Joining the AMA

So far, I have been to two events associated with the AMA (American Medical Association). 

One event was the first local chapter meeting, held by the Massachusetts Medical Society (probably best known for its publication, The New England Journal of Medicine).  It was one of eight annual meetings, entirely student-run, and attended by several dozen students from the four medical schools in Massachusetts--Harvard, Boston University, Tufts, and the University of Massachusetts.  After giving the newcomers an overview of the organization's history, membership, and goals, the governing councilors had break out sessions to learn more about advocacy and policy, community service, leadership, and membership.

Our school chapter receives quite generous funding from the AMA and the MMS to hold events and lectures, organize community service activities, and attend national conferences. 

The AMA has a shaky reputation for being overly conservative to some, both among inside and outside the profession.  At its peak in the 1960s (when it spent heavily to block Medicare), it encompassed about 70% of physicians.  Today, it represents less than one third of physicians, and about half of those are retired.  The AMA remains opposed to any national insurance health care plan.  Although it eventually supported the recent health care reform bill, it successfully lobbied against the 5% tax on elective cosmetic surgery.

The AMA founded the Student American Medical Association (SAMA) in 1950, to provide medical students a chance to participate in organized medicine.  However, in 1967, SAMA cut ties from the AMA and became the independent and student-governed AMSA (same words, rearranged).  The organization took stands on more typically social justice medical issues, such as civil rights, universal health care, and global health.

Both the AMA and AMSA are represented here at HMS.  I understand the reasons for creating a separate student chapter that consists of more like-minded members (such as pursuing certain goals without facing resistance at each step), but I want to stick with the AMA.  I believe the best way to help control a system is to do it from within.  The AMA is an organization that reflects the views of its members, and if we want certain views represented, then it is best to participate.  The AMA encompasses students.  It specifically has different chapters for medical students, residents, "young physicians," and physicians, in which each group can mingle with those in their own or those outside their own.

Recently, drafts of student resolutions (which will eventually be passed along to the AMA) were due.  Over 40 ideas were presented, including an opt-out organ donation policy, improved student health insurance standards, disability resource services, promoting a standard nutrition education for primary and secondary schools, interstate Medicaid cooperation, and broader regulation of direct-to-consumer genetic testing.  Interestingly, only about one fourth of the resolutions applied to medical students.  The rest applied to society at large.

Though I am certain I want be a participating member of the AMA, that doesn't mean I don't have mixed feelings about the organization in general.  The AMA is a special interest group, and it protects the interests of its members.  Because of its lobbying efforts, I will enjoy a high salary, job security, and a certain amount of autonomy.  But tell someone (even another physician) that you are part of a lobbying effort to keep doctors' salaries high, and you are painted in a certain light.  Somehow, I get the feeling that unions for other professions are seen as more necessary and "legitimate" than unions for doctors, since we are seen as more privileged and powerful. 

But to get to where we are today, a lot of people needed to be self-interested.  To stay where we are, a lot of people still do.  Admittedly, I probably would not enthusiastically undertake these efforts myself, but I will be the first to admit that I appreciate the benefits, whether I approve of the methods or not.  I am grateful that because of them, I have the opportunity to help shape policy for those in less fortunate positions.  At the local chapter meeting, a second year student from HMS submitted a project grant application requesting funding for a community service activity in which medical students prepare and serve dinner for a local residence for cancer patients and their families.  It was unanimously granted.  It's a small step, of course, but I can firmly say this represents my views.

Testing, Testing

Our first exam is on Monday.  It covers two weeks' worth of biochemistry and molecular biology, which is about the equivalent of half a semester's worth in undergrad.

It is pass/fail, only out of 40 points, and we get nearly unlimited in-class time for it.  It's not really a matter of getting a high grade on it.  I guess, in the back of my mind, I am worried that I am going to fail.  Fear--not neuroticism or gunnerism or pride--is what's motivating me to study for hours on end.  I need to prove to myself that I didn't get in here solely because my application was "unique"--that I did cool things like science journalism, that I wrote a passionate personal statement, that I was able to charm my interviewers.  I need to know that I can also master the material itself, which is the real reason I am here (despite what I hear from others about how "necessary" or "relevant" the nitty gritty details are to practicing medicine).

Our class has gone above and beyond in cooperation.  On our class email list, old midterms, study guides, flashcards, and group meeting opportunities circulate.  It's actually possible to feel overwhelmed by those alone (and I do!).  With a pass/fail system, there is no reason to hide anything--we share the mentality that we do what we have to do to get ourselves and our classmates to pass.

It is interesting living in a nearly all medical/dental student dorm, where everyone is on the same schedule.  We are away from the main campus, so we study here, in our class building across the street, or at the library next to that.  We live on a block filled with hospitals.  Basically, within this radius, it is all medicine, all the time.

So far, I've gone out to greater Boston at least once a week.  This is the first time I've stayed within this medical bubble.  It is very different from undergrad, where you could hear what you were missing right outside your window.  (Now, all we hear are hospital sirens and helicopters.)  You don't have roommates or classmates on different schedules tempting you to go out for the night.  Here, it is perfectly acceptable to say to the girl you see in the bathroom on Saturday morning that all you did was study last night.

My classmates had originally scheduled a global health meeting for today and just cancelled it because we have a test on Monday.  This is starkly different from undergrad and from "real life," where opportunities present themselves and you have to make decisions about them.  Here, with 200 others in precisely the same boat, we don't have to make those choices and can pause things at will.  This isn't the kind of reality I am used to.

Monday will be the new Friday, and I mean that as literally as I can.  Here, we set our own calendar and thus our own reality.  The world--undergrads, grad students, patients, people--is not our world right now.  We're a class--a cult in the best sense of the term.  I love the cohesion, but at the same time I am concerned.  I had forgotten that today was September 11.

I already feel myself not having the energy to explain the details of my day to my outside family and friends.  Maybe after this exam is over, that will change.  But after dozens more, will it still?

An Arm Inside and Outside the White Coat

The last few months have been filled with firsts. On the second day of school, we received our white coats, initiating us into the profession. A few weeks later, we wore those white coats to interview our first patients in the hospital. We have taken our first (and second and third) finals. We have attended clinics, listening to patients struggle with Huntington's disease, alcoholism, and androgen insensitivity syndrome. We have made our first incisions on our cadavers' backs... and our last ones to get to their eyes.

In other words, we are becoming acculturated.

Right now, there is not much that separates us from the patient that is in room 206 of Massachusetts General Hospital, other than the fact that we anticipate one day caring for a patient in a room 206 somewhere. With that anticipation comes a code of behavior that we are learning now, years before we enter that room.

It is not merely about respecting the patient, listening to our colleagues, empathizing, and so on. As members of a profession--a medical culture--we actively shape the image we present to the public, and that image reaches beyond the confines of the workplace.

Our professor gave an example of this new responsibility. "Let's say one day you're on the shuttle with your classmates and you're talking about what you observed in the ER. 'It was the coolest thing!' you might say. 'There was blood everywhere and this guy's leg almost came off and...' It's perfectly normal--and not bad at all--for you to feel that way; you're excited by what you're learning and experiencing. But think of the passengers on the shuttle who overhear your conversation. They are going to think that you--and that doctors--sound incredibly callous."

It is an interesting concept: that our professional identity follows us even during after hours, and that there are boundaries that have been drawn--fairly or unfairly--not directly by us. Is there ever a reprieve? Should we watch what we say at the gym? In the supermarket? To our non-medical friends at a dinner party? Did I really sign up for something so all-encompassing?

For me, the question became pertinent fairly quickly as I realized that blogging fell into one of those gray categories. Before my first post, I solicited advice from my professor about the levels of appropriateness. Certainly, explicit details about patients were off-limits (due to violating HIPAA), as well as specific names of professors or individuals. But what about opinions on medical education or patient care, drawn from my observations in classrooms or on the wards? What about recounting a good patient encounter? And--more difficult--what about a bad one?

My professor told me that being a medical student means that others are very interested in hearing about our experiences as "insiders." She told me that I have to remember that when I am writing for others, what I say reflects on the profession and even may shock some, and so I should be sensitive about what I share. When I asked my society advisor, she admitted it was a tricky question and suggested that I ask permission from those I mention fairly explicitly. "People aren't going to trust you enough to talk to you if they think you'll have no restraint in writing what they say," she said. (Oh, the irony that I now quote her!) "The classroom would no longer be a safe place."

But otherwise, there is little policy or precedent with regard to social media. It is new turf, and its boundaries are being tested by those of our generation.

Are we really writing from inside the white coat? It's a grandiose claim, and one I surely don't deserve nor want yet. But I am not taking it entirely off either, because what I write about is inextricably linked to knowledge accessible only because I am allowed inside this coated world. What exactly does my pen owe that world?

Many questions remain. With time (and with some faux pas, no doubt), I hope to strike a balance. Maybe I'm only partially dressed at times, with one arm inside the coat and acculturating and one arm outside, writing about it.

So we write and interact in this new medium, with what I hope is caution, thoughtfulness, and sensitivity. It is the best we can do for now.

The Good, the Bad, and the Ugly

Listening to patients for the past two weeks, we learned quite a bit about what patients appreciated about their doctors and what had left them hurt and confused.

The good:

M., an elderly lady with a very close relationship with her primary care physician, said she had been to many bad doctors in her life.  She knew right away that her current doctor was different, that she "could just tell."  M. didn't feel like she was wasting the doctor's time.  What was so special about her?  "She listened.  She really listened."  When asked to elaborate, M. had a difficult time describing the intangibles that struck her.  The two just clicked.  "It's a gut feeling."

From a doctor, three A's: "ability, affability, availability."

I interviewed a cardiac patient and his family in the hospital who were very grateful for the team of doctors that cared for him.  The family mentioned a doctor at a different institution, who, after a long day, took them aside for a private conversation.  He asked how they were doing and if they were taking care of themselves.  "Are you sleeping?  Are you eating?" he had asked.  "You need to take care of yourselves so you can take care of [the patient]."  He spoke to the family for 45 minutes, until nearly 10 pm.  "During that time, his wife called him several times," recalled a family member.  "He just said he'd be home soon."

The bad:

That same family recounted a time when their father/husband was undergoing a fairly long surgery.  After waiting for any sort of news, the family finally heard from a few staff members that the surgery turned out fine (no more detail than that). A bit later, they noticed the surgeon step out and they approached him and asked him for additional information.  "Did you talk to my staff?" he asked.  They said they had.  "Then you know it was fine," he answered brusquely and turned and walked off.  "It was as though he considered any of his time talking to us a waste."

The ugly:

A classmate of mine mentioned that when she had interviewed a patient, the patient had mentioned that she had surgery which had left a scar on her chest.  Her doctor had told her that it shouldn't be a problem, since she was never going to wear a bikini anyway.

Letter to a Young Doctor

Thursday was our final day of Introduction to the Profession, a course which had us shadow doctors, interview patients, "save" simulated patients, discuss professionalism and cultural competence, and work through clinical cases and meet the real patients afterward.

During the last hour, we were asked to write a letter to our 2014 selves reflecting on what characteristics and attitudes we want to retain, as second-week students, over the next four years.

Dear Me,

I hope you're healthy.  I hope you're well.  I can barely imagine the changes you will undergo, the people who will change your life, the experiences that will leave their indelible imprint.  As I think of what the next 48 months will bring, questions flood my mind.  Do you still cry at the drop of a hat?  Did you keep your sense of poetry?  Of imagination?  Of empathy?  Does the idea of taking care of a human being still terrify you?  Are your arteries clogged with four years' worth of frozen dinners?  (Please learn to cook!  And find time to zumba!)  But most of all, are you happy with the path you've chosen and with what lies ahead?

Today I sit and think I know myself well.  I am a layperson's layperson.  I call heart attacks "heart attacks" and not "myocardial infarctions."  I have been outside the white coat more than I have been in it, and I still associate with patients.  I sometimes mistrust doctors, I don't consider medicine a monolithic profession, and "medical culture" is still foreign to me.  I worry that as my classmates and I grow closer through emotionally and mentally demanding experiences, we will become acculturated--part of a profession that has its rewards and excitements, no doubt--but part of a culture that also encourages a divide between provider and patient, healer and healed.  I fear that I will succumb to the mantra, "They don't know what we go through, what we see.  They don't really understand.  They don't get it."  I hope I don't see the world as a "they."

I recognize my personality quirks, and I welcome changes in behavior, especially with patients.  I am shy and unsure, and I hope I can grow into the role of physician.  I don't expect to eliminate unsureness, but I do hope to act within the bounds set by it.  I hope growth comes as I learn more about my likes and dislikes, strengths and weaknesses, and frankly as I learn what is realistic and what is not.  Will I still want to be a hematologist/oncologist or a neurologist/psychiatrist once I work in the fields?  What and who will lead me to make my specialty choice--and what will I research, and who will I teach?

I hope I am knowledgeable, and I hope I am responsible.  I hope I still sometimes look in the mirror, see my white coat and scrubs, and wonder what I did to earn this incredible privilege.  I hope I am still humble, and I hope I am still awestruck.  I hope to never have an ego the size of Jupiter.  I hope to keep reflecting, and I hope to keep writing.  I hope I have dilemmas, because if I don't, I am colorblind.  I hope to sometimes be mystified, but not to be paralyzed by indecision.  I hope always to keep options for my patients, and to never dismiss one or reach a dead end.  I hope I maintain close ties to my old life, and I hope I have the patience to explain to my family and friends what I experience.  I hope I act nicely, and I hope I am not faking.

I want to keep the passion and the drive to become the best physician, the best researcher, the best writer, the best teacher, and the best person I can be.  I hope I find love, in whatever form it may take.  And... I just hope.

I wish you all the best, and I'll see you in four years,
Shara, '10

My Little Shadow

For first years, shadowing is a basic part of our clinical experience. I recently had the pleasure of shadowing an oncologist one-on-one in an inpatient setting. He was fairly high up on the totem pole, and after two hours and five patients, I could see why.

From my observations:

• The oncologist rarely used numbers. A treatment didn't have x percent chance of success, and a patient didn't have x weeks or x years. His words qualified, not quantified.
• He was frank with patients. Seeing a white coating inside a patient's mouth, he suspected the horse (thrush, a side effect of treatment) but did not hesitate to mention the zebra (oral cancer). Again, instead of tossing around numbers, he simply said, "It's probably okay, but I still have to check."
• He was franker with me regarding his expectations and frustrations. He mentioned that "I can get most patients to do what I want them to do, as long as I phrase it the right way or draw them the right pictures." But he expressed exasperation with intransient paients. Regarding a lady who, for inexplicable reasons, was willing to undergo an invasive bone marrow transplant but not a routine vaccination: "I'm working hard to save her life from cancer and she's going to **** it up and die because of something like that?" Another man's leukemia spread dramatically. With the patient, he was all business, making plans for treatment and not giving an explicit prognosis. When I asked more specifically about the prognosis, he predicted that he would probably die within the year.
• He strongly believed that a physician, with vastly more knowledge and experience than a patient, should not remain neutral on treatment options. "Never say to a patient, 'Here are your two options. You decide what you want to do.' Tell them what you would recommend and why."
• He never assigned blame. When I asked if a patient's cancer had spread because of his refusal to get treatment initially, he told me that it was dangerous to think that way and it's almost impossible to pin down murky causes like that.
• He said "I don't know" once but had a clear plan. Even if that plan was just waiting and watching.
• He was meticulous about details and trends. He continuously analyzed minor changes in blood cell count and cancer cell count (and informed the patients about these), and he did not jump to potentially unnecessary treatment without waiting a few weeks to gain a better handle on the bigger picture.
• He was a brilliant and compassionate physician, and it was an honor to shadow him.

My Big Bird

"Which medical show on TV is the most realistic?" the oncologist I was shadowing today asked me.

No way could it be House, Grey's Anatomy, or Scrubs.  Boston Med?  (The show was filmed at one of the hospitals I was shadowing at--was he tooting the institution's horn?)

Surprisingly, Scrubs--with all its quirks and absurdities--was his answer.  "It deals with the insecurities and doubts that we all face," he said.  The character traits are dead on.  "Plus, it's hilarious."

His favorite episode involved a patient who died because of a medical error.  The show closes with a powerful scene: to remember their mistakes, the four main characters walk around the hospital with his ghost following each of them.  Apparently, oncologists feel the same way about some of their patients (regardless of whether they blame themselves).  They don't easily forget.

In fact, later that day, the oncologist was going to a patient's wake.  He said it wasn't a common thing he did--but it wasn't rare either.

Jim the Sim

Today we confirmed that we are indeed alive.  In small groups, we practiced finding each other's pulses, taking blood pressure, and listening to lungs.  None of us had pneumonia (crackling sounds in the lungs), no one was dehydrated (drastically different sitting and standing blood pressures), and no one was having an asthma attack (whistling).

Taking the respiratory rate requires more social grace.  The only way to determine how many breaths a person takes per minute is to watch them breathe in and out for 15 seconds or so.  Staring at a patient for that long is probably a bit Hannibal Lecter-esque, so this is the time to make small talk about their hometown or the weather and count their breaths.

After taking vitals, we were introduced to a "model patient."  Six of us gathered around the simulator, voiced by our instructor in the next room.  "I'm Jim, and I was just practicing for a triathlon and then suddenly I couldn't breathe very well."

We look at each other helplessly and start asking questions.  Has this happened before?  Are you in pain?  Are you currently taking any medications?  Do you have any other illnesses?  Do you drink or do drugs?  His blood oxygen levels are getting dangerously low, so we quickly give him an oxygen mask.

Jim apparently had asthma and an inhaler, but "I lost it a long time ago."  Okay.

Then, "You guys are doctors, right?  Aren't docs always using stethoscopes?"  Hint, hint.

It takes the six of us a bunch of minutes to confirm crackling in his lungs.  Is it asthma?  An obstruction?  Pneumonia?  Let's get a chest x-ray.  "What's going on?" Jim asks.  "Is it that radiation safe?  I want to have kids."  It's hard to talk and think; throughout the exercise, we periodically forget to clue Jim in on all the procedures we're about to do on him or how he feels afterward.  (Another group was seconds away from sticking a chest tube into their conscious patient when one of them asked, "Oh, should we tell her what we're doing?")

The results pop up on a screen, and of course we have no clue how to interpret them.  Time to get the radiologist on the phone (also voiced by our instructor).

 "What's your patient's name?" he asks.  "Jim..."  Hmm, maybe we should've gotten a last name.

Jim's lungs are hyperinflated, a sign of an asthma attack.  Soon we are giving Jim an albuterol inhaler and he is breathing better.

His heart rate is still slightly elevated, though.  Is it just anxiety or something more?  Today, we have unlimited resources, so we ask for an EKG (the exercise is not a simulator for real world cost-effectiveness, apparently).  We get a cardiologist on the phone.  Why did you order this?  "His pulse is a little fast," we reply, feeling a little bit like the medical students who cried wolf.  "It's okay, I need to send my kids to college," he answers.  The EKG is predictably normal.

Should we use beta blockers to depress the heart rate, or is the heart rate just a consequence that will resolve since we've resolved the initial problem?  In our limitless world, we order beta blockers.

The pharmacist calls us up.  Tell me about your patient, he says.  After we do, he says, "Just to let you know, beta blockers are contraindicated in patients with asthma.  Do you still want to give them to him?"  Hint.  Um.... nah.

After a few more tangents, Jim's primary care doctor calls and tells us that elevated heart rate is a side effect of the albuterol.  Oh.  Where do we want to send him now?

What's on the menu? we ask the nurse (our other instructor).

"The OR?" No.
"Intensive care?"  No.
"The floor?"  Maybe.
"An observation unit?"  We can watch him there for 24 hours.  Sure.

And so, half an hour and a lot of tangents later (followed by a debriefing by our instructors), Jim has been successfully treated for an asthma attack by the greenest of the green: third-day medical students.

How Are You Doing?

Reposted on Medscape for the next few months.

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