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.