Dissected

The anatomy article is running today.  I want to be a writer--not for my diary but for the public.  I know I've got to be open to scrutiny.

But damn if I don't feel entirely dissected right now.  On display, vulnerable.  The irony hasn't gone unappreciated.

Nonsense

It was a story incomplete.

The very last post I wrote about anatomy lab was a reflection on our donor, the night before we dissected his head and neck.

A few of my anatomy posts have been stitched together by a gifted editor and will run as a front-page story and feature in the Health section of the Los Angeles Times this coming Monday.  Several times, the editor asked for more concrete details about dissection above the neck.

It would mean I would have to think about it, and worse, write about it.  And there was a good reason that since November, I have done neither.

I am ashamed about what happened in lab.

We had a ceremony honoring our donors in January.  The pieces read and thoughts expressed were elegant, kind, and thoughtful.  That is the way I would like to remember anatomy.  But, in a way, reflections are sugarcoated.  They are certainly honest, but by definition--they occur after much thought.

What happened in lab occurred with no thought and is no less honest.  The day after I wrote the post reflecting on our donor, we entered lab to begin the dissection.

There was the saw—our way into the brain.  The only other time we had interacted with bone was when we banged through the kneecap with mallet and hammer to observe the joint and cartilage inside.  It didn’t feel particularly disturbing, since orthopedic surgeons basically do the same thing.  Above the neck was different.  On no level, in any instance, would a doctor ever do what we were about to—saw through the skull.

Our donor ceased to become human for me after we peeled off his facial skin like a mask to reveal the small muscles underneath.  Without hair on his head, chin, and brows, he was a specimen.  This made the next part of our task considerably easier—cut through skull, reveal brain, pull brain apart, distinguish cranial nerves that control our five senses and movements.

When you saw through a skull for ten minutes, the room—your world—becomes that skull.  You inhale dust particles, acutely aware of where they came from.  Saw against bone shrieks, notes stumbling, uneven in pitch and length.  It is anything but mechanical.

It was surreal to watch my labmate in scrubs, apron, and goggles, with saw raised in hand.  He looked no different from a madman in a horror movie.  Were we the same people who wore suits to our school interviews and gushed about how much we wanted to help people?

There was no analogy my mind could make, no particular moment in my memory that in any way compared to this one.  The whole situation seemed nothing short of ridiculous.  For some reason, the absurdity made me giddy.

I giggled.  Instructors like to use the term "nervous laughter," but I didn't feel nervous.  I felt outside myself.

My reaction was contagious.  All four of us breathed in dust and formalin and laughed above the roar of the saw.  Dentures flew out of the cadaver’s mouth and clattered onto the floor.  In this warped reality, we took this in stride and giggled harder.  Of course, I thought sarcastically, when you cut through someone's head, their fake teeth fly at you.  What else could I expect?  It was a nonsensical situation; we responded in kind.

Back in my room and in street clothes, I called my mother and described the scene in vivid detail.  When she reacted with the appropriate concern, I told her, “No, no, you don’t understand.  It was really funny!”  I was convinced.

I sobered up after a few minutes, horrified about what I had done.  I asked my mom what kind of person my reaction made me.  “It’s a coping mechanism,” she said.  “But I didn’t feel like I had to cope with anything,” I protested.  “That’s the point, isn’t it?” she said.

If everything we do is to rationalize or make ourselves feel better, what isn't a coping mechanism?  Does that make it justified?  Does that make irrationality rational?  That was the first time in my life I have had a public reaction that I could not bring under control.  It's difficult to think about, so I don't very often.  But when I do, I still struggle to make sense of it.

Or maybe it's all just nonsense.

"What Do You Think Caused Your Disease?"

Our first assignment for medical school involved reading and discussing Anne Fadiman's The Spirit Catches You and You Fall Down, which describes how a clash of two cultures (medical and recently immigrated Hmong), miscommunication, and misunderstanding led to tragedy.  Poignantly narrated, the book had the take-home message: if a patient does not agree with a physician's reasoning why a disease developed and how it can be cured, then even the best treatment won't help because the patient will not stick to it.

In the novel, Hmong parents believed that their daughter's seizures were caused by spirits and not overexcitable neurons, so they relied on traditional healing methods (prayer and sacrifice) instead of medications.  Although perhaps the story represents an extreme example of a mistranslated message, unfortunately more minor ones do exist and can often impact care.

Does the diabetic patient understand why monitoring blood sugar is vitally important?  Why should someone with celiac disease avoid certain foods?  Does a smoker realize the extent to which he worsens his COPD when he goes through a pack a day?  Is it ever okay to have a drink when you have hepatitis B?

The answers to these questions help physicians understand how patients see their disease--and, as a consequence, what sorts of measures and discussions can best help them manage it.

Hows and whys from a patient's perspective are called "the explanatory model."  To boil it down, the conceptual framework includes:

What do you call the problem, What do you think the illness does, What do you think the natural course of the illness is, What do you fear?
Why do you think this illness or problem has occurred?
How do you think the sickness should be treated, How do want us to help you?
Who do you turn to for help, Who should be involved in decision making? Why do you think this illness or problem has occurred? How do you think the sickness should be treated, How do want us to help you? Who do you turn to for help, Who should be involved in decision making?

No doubt these questions are key.  In fact, this is what we learn to inquire about during our patient interviews, somewhere between taking the history of present illness and the social history.

But, we are not doctors.  We don't yet have the finesse or the time or the practice to incorporate all of these questions in a brief standard interview.  And, in my experience, what usually comes out is an ugly stand-alone question:

"What do you think caused your disease?"

So far, patients I have interviewed have included those with congestive heart failure, arthritis, spinal cord damage, severe abdominal pain, leukemia, cirrhosis, and hepatitis.

I have cringed with awkwardness upon asking this required question.  How could a previously perfectly healthy 63-year-old recently diagnosed with leukemia possibly answer?  The patient with cirrhosis claimed he never drank.  The patient with hepatitis blamed an unsterilized tattoo needle from when he was 19 (which my preceptor later said was an unlikely reason).  I can only imagine the discomfort in the room when I pose a lung cancer patient this question.

I'm not sure how patients feel when I drop this inevitable inquiry.  They generally answer with "I don't know" (which is completely understandable given the nature of many illnesses) or something unrelated.  At that point, I get even more uncertain.  I do not have the knowledge or authority to correct them.  It's not my responsibility right now to comfort, diagnose, or treat them.  I'm not their physician, I do not report to their physician, I am not part of their care in any way, and I will never see them again.  I simply write down their answers to present later.  I feel guilty.  I feel tense.  I am embarrassed for embarrassing them.

My patient interviews are strictly non-therapeutic.  At best I'm a comforting presence and at worst I'm an annoyance.  Nothing about the above question is comforting.

Perhaps I should buttress it with additional questions so that it doesn't land in the room from left field.  Perhaps I should phrase it differently.  But it's difficult to improve when I'm there on a simulated fact-gathering mission without providing the logical consequence of treatment, relaying information to a care team, discussion, or counseling.

To the patients I have asked this question: I apologize.  I'm sorry that you may not feel comfortable disclosing to a 23-year-old first year medical student who is not a part of your care that your heavy drinking to cope with your divorce may have led to your cirrhosis.  I'm sorry that I had to ask you why you think you got cancer, as though I expect a philosophical discourse.  It's just a contrived question right now for training purposes--a piece of a puzzle that is so out of context that it's a disservice. In a few years, I promise I can try to help.

Jargon Deciphered

Because it was 3:30 am and I had exhausted the contents of cute kittens on the Internet, I found myself on PubMed.  Just for fun, I decided to type in the name of a common medical condition that a family member has to see if anything interesting had come out on it.

I couldn't believe how much I could glean from the dense titles.  Not only did I recognize individual terms, but I understood larger concepts about why those terms could and should be related in the first place.  All of a sudden, I had context.  I could recall a few characteristics about a certain physiologic condition, a few underlying mechanisms about a cell signalling pathway, a few cytokines, a few relevant diseases.

This is the first time I have ever understood anything on PubMed unrelated to very narrow research projects.

"Leukocyte adhesion deficiency."  "Subclinical left ventricular dysfunction."  "Population-based cohort study."  "Fumarates."  "Hyperkeratosis."  "Thrombocytopenia."  "Ankylosing spondylitis."  "Serum IL-16 levels."  "Suppression of VEGFR2 expression in human endothelial cells."

Now it is 4 am and I feel that--despite the doubts--something indeed has happened to my brain this past year.  My classmates and I moan how much we have forgotten about the little we seem to have learned--and that there is still so much out there that we don't have the slightest clue about.  This may still be true.  But the frustration over the details I have forgotten is now outweighed by sheer amazement as I interpret the cumbersome jargon-y titles that had been out of reach to me mere months ago.

Interestingly enough, this insight did not come after an exam, during a lecture or discussion, or even during regular hours.  It snuck in, on the tails of cute kittens on YouTube, on a quiet Monday night/morning.

I still cannot fathom the day when I will ever be an authority on anything.  But then I consider the 16-year-old me who began her first research experience in a laboratory while taking AP Biology.  I committed hours of (often fruitless) background research on PubMed--wading through foreign and incomprehensible knowledge and concepts, lost and lacking any way to distinguish what was relevant and the big deals from the smaller ones.  From that vantage point, breaking into a literate scientific circle seemed decades away.

Thinking about that version of me, I still cannot quite believe where I am now either--breaking in.