Categories
Opinion Reflection

Dear Doctor

Dear Doctor,

I hear you when you speak of that girl in the hospital ward. The ‘overdose in bed three.’ I hear the harsh judgements sneering through your lips, the sighs and the mutterings of ‘what a waste of life.’ As a student, I am all too privy to such remarks made in the corners of these hospitals. I have fallen upon them again and again.

Please do not be so quick to stereotype. Do you know how it feels to have your mind infiltrated by such intense emotions of self-hatred and loathing? Do you know how lonely it can be to lie curled within the four walls of your bedroom, just you and your mind waged in an eternal battle?

Yes, I realise how cliché that sounds. I know you have just come back from speaking to a young gentleman who has been paralysed. I know you have spent your years dealing with the terminally ill, holding the hands of the dying as you speak to a family overwhelmed with grief.

How can a teenage girl compare? Yes, she may appear to have everything. But aren’t humans’ more than just molecules and proteins? Don’t we all have dreams and desires of our own? What is it that makes us human? Our relationships, our goals, our ability to connect with one another. How would you feel to have these vital components torn away from you? No, it is not the equivalent of the man next door whose wife has just died. But that does not mean that she does not deserve your attention and your respect. You may have lived through the battles of the emergency department, the grievances of the families, the diagnosis’s of tumours to children barely in their teens. But she has not.

Look at her, sitting on the bed, her head bent over her lightly covered shoulders. Look at her, fingers fidgeting with the bed sheets, unsure what to touch or who to speak to. She is scared. She is in a new place. There are bright lights glaring down upon her, strangers rushing past her, eerie machines beeping at her. And inside her mind, the battle is continuing to rage. Look at the scars glistening upon her skin as she cowers in a blanket, trying to hide her wounds from the world. Aren’t those battle scars as well?

Imagine how it feels to have a mass of doctors suddenly gathering around your bed, all looking upon you with pity. Do you realise how exposed it can feel to be probed with such personal questions? The intricacies of your mind held open for a stranger to dissect.

‘Do you have any plans to end your life?
What methods have you thought about?’

She needs a friend. She needs someone to take her hand and ask her how she is feeling. Forget the Fluoxetine, the charts filled with drug doses. It is not a prescription pad that she needs. She needs a human touch.

I know she cannot hear you as you make your curt remarks. I know you will walk towards her filled with smiles and concerning eyes. I have seen that gentle handshake that you have mastered over the years, the slight pitch in your voice as you gently prod your questions. There is no doubt that you have a bedside manner. And within one minute you are gone, the prescription chart left upon her bed for the nurse to dispatch the drugs. The girl still sits there, her posture unchanged, unsure if the conversation had taken place.

I know you are busy. I know you have a team of doctors to command, a list of patients to see, a hospital to run. Yes, I know you have sat through hours of exams, studied well into countless nights to get to where you are standing now. I have respect for the devotion you have put into your career.

But please do not forget that young girl. Please remember to hold your tongue the next time you see a teenage overdose. Yes, to you it is another statistic to keep record of, another prescription to fill out. But to that teen lying in the corner, throwing up the contents of her stomach? She wanted to die just two hours ago. Do you know how that feels? To feel hopelessness so deep, that the future is but one long tunnel, filled with uncertainties and fear. Do you know how it feels to hold a bottle of pills in your hand, staring longingly at the container, at the hope it contains inside?

Yes, she will be fine. She will be discharged within a few hours, another free bed to fill. But please, the next time you come across such despair in someone’s eyes, do just one thing; sit down on the bed beside them, and ask them how they are. Look into their eyes as they speak, and let your whole being be encapsulated by their story. Let them open up to you, with patience and empathy. If someone had done this to them before, do you think they would be in this position now?

Please, the next time you blurt out another cutting remark, a sneer at the cries for attention. Look across the room at your patient sitting there. Look at their posture, their body language, their eyes. Does this look like the sort of person who needs your judgement? Or does this look like someone who needs a listening ear?

 

Featured image:
Writing with Ink by urbanworkbench

Categories
Poetry

For Med17: Thank you.

I find a glimmer of light.
It is the shape of a keyhole
and wavers. I crawl
blindly in a sudden desperate desire
to find the lock
and the source of light that is behind it.
The keys in my pocket jangle.

When I am in the hospital I am a stranger
amongst other strangers. Only
because I am wearing a white coat
I am supposed to know where
to go. The hallways bustle with white noise.
I hug myself and move quickly so no one
can see me shaking.

There are several keys in my pocket.
Keys made to open to secure
to keep safe to rescue.
Keys that are purposeful and always always
come with a lock. But there
one key is still being formed
is new and raw
is lockless.

The streets are full of ice
and wherever I step
the dark glimmer cracks.
I feel that if I am not careful
I may miscalculate a step and then
the crystal surface of my confidence
hair-thin
will collapse, will bring me ankle-deep
in barely frozen water rushing unintuitively upwards
rising into my socks past my white coat
soaking my barely used scrubs
ice-water surging towards my knees
femur gasping in its acetabulum
thoracic spine shaking
like a suffocating fish.
I am drowning in the thought that
I am not enough.
The snowbanks drip in the sunlight
and sparkle.

I sit amidst all my past and present identities
and begin to make out a new one ahead.
It is mirrored in the M4s: knowledgeable mature
scruffy in a responsible doctor-like way.
Will I too become like them?
I am not afraid of how I might change but rather
what I will lose after a year in the hospital.
The lock to my growing key remains unknown.
And yet, I sense its existence—
a path of light filtering through the darkness
towards me…

…and you too. Your light
your key
your lock
our journey.

Med17: thank you
for the past two years
and for the years to come.
I have my key in one hand
and your hands in the other
as we search for our hidden locks together. We walk
and look and celebrate when one of us finds a lock that fits
that opens up a bright new world of excitement.
Where will you be?
Where will I? Only time and walking and sharing together will tell.
And the doors one day will open
leading to new rooms and new doors
and our keys will jangle
like the sound of clapping hands
like the sound of many smiles
breaking ice.

 

Featured image courtesy of Stephanie Wang Zuo

Categories
General Lifestyle Opinion

I Will Not Try To Fix You

Disability—The Oxford dictionary defines disability as “a physical or mental condition that limits a person’s movements, senses, or activities.”

Although some disabled people have medical ailments, the two conditions are not synonymous. While a disabled person might require medical attention, disability is defined by social barriers, not pathophysiology.

It is an umbrella term and includes impairments and activity limitations. Impairment is a problem in the body’s structure or function; activity limitation is a difficulty encountered by an individual in executing a task or action.

Disability is a complex phenomenon, reflecting the interaction between features of a person’s body and features of the society in which he or she lives. Overcoming the difficulties faced by people with disabilities requires interventions to remove environmental and social barriers.

Those with disabilities have capacities for motor, sensory, and cognitive tasks that differ from the “norm.” Each individual has different qualities and capabilities, but defining this “norm” is practically impossible. Society can create barriers that do not allow an individual to develop to his or her full potential. Likewise, society can remove disabling barriers. A wheelchair user cannot get into a building with steps at the entrance, but a ramp or a lift completely removes that particular barrier. Seated before a ramp, is an individual in a wheelchair disabled?

An individual with Down Syndrome can hold meaningful employment if provided with appropriate support. Down Syndrome itself is not a disability; it is a medical condition. An individual will experience specific barriers that emerge because of the relationship between impairments and societal barriers. The presence or absence of medical conditions can cause one individual to vary from another in terms of motor, sensory, and cognitive function, but an individual is only disabled when appropriate accommodations are not made.

As a societal construct, disability fluctuates in different settings. In a completely adapted home, or with adequate assistance, an individual might have no disability at all; while, in an environment without assistance, this person might become disabled.

Physicians treat medical conditions and, as such, they tend to focus on the “limitations” and “abnormalities” associated with disabled people’s conditions; heart disease, for example, in those with Down syndrome. Disabilities, however, are not medical conditions in and of themselves. The role of a physician is to assess the health of a disabled person, provide treatment for associated symptoms, and anticipate as well as prevent future complications. This can greatly improve a disabled person’s quality of life, and, in some cases, even prolong life. Fixing the disability is not in the doctor’s job description.

How do you, as a medical student, perceive disabled people? Do you feel as if medicine failed them by not being able to “cure” them?

Disability is not tragic; it is tragic that society doesn’t appreciate the abilities of disabled individuals.

Disabled people often report being patronized by medical staff, being described as having “a fate worse than death”, or carrying an “unhealthy gene”, as well as “suffering” from a condition. Consider the power of language. Great advances have been made in both medicine and technology, and even more in the public’s perception and understanding of disability.

Disabled people have more freedom, independence, and equality than they did previously, but there is further work to be done. Rather than making a distinction between disabled or not, physicians should be leaders in embracing diversity and independent living for all of their patients, including disabled people.

Dr. Chris Smith – a disabled associate professor of communication arts and sciences at Calvin College, USA – recently spoke about perceptions towards disabled people, stating that “the ultimate test of living in community is found in our willingness to change our minds about one another.”

People with disabilities have the same health needs as non-disabled people – for immunizations, cancer screening etc. They may experience a narrower margin of health, due to both poverty and social exclusion, and also because they may be vulnerable to secondary conditions. Evidence suggests that disabled people face barriers in accessing the health and rehabilitation services they need in many settings.

As future physicians, it is important to view disabled patients equally to all others, whilst acknowledging the barriers they face. When approaching your disabled patients, do not define them by their impairment, do not pity them, do not try to “fix” them; rather, appreciate their abilities, recognize them for their values and behaviors, support them to achieve their aspirations, and, most importantly, listen to them.

Featured image:
disability by Abhijit Bhaduri

Categories
General Literature

Moby Dick and Medicine

Last weekend, my classmates and I went on a ski trip to a most excellent resort in Vermont. This trip was partly a literature retreat for me, as I chose to reread a large portion of Herman Melville’s Moby Dick on the drive there and back. Upon arriving at the resort, I was inspired to write this post for two reasons. Firstly, the main room had a scenery that I felt to be most conducive to writing (see photo). Secondly, I had been thinking during the drive up to Vermont about how rereading Moby Dick, or any other piece of imaginative literature, is related to rereading texts in medicine, including our current lung unit’s clinical cases (as some of my classmates had been doing in the van), or even re-“reading” a real-life scenario during a pulmonary ward rotation. I realized that there are many similarities, some of which I will share in this post. Again, my central question is: what is the usefulness of reading imaginative literature for the progress of science and medicine?

Photo courtesy of Tony Sun
Photo courtesy of Tony Sun

First, I’d like to introduce, or for some readers, re-introduce Melville’s Moby Dick, a supreme example of American Romanticism. The Romantics were involved in a movement that affected Western art, music, and literature, primarily in the 19th century. In America, the chief Romantic writers were R.W. Emerson, N. Hawthorne, H. Melville, W. Whitman, and H.D. Thoreau. These writers wrote about the art of rereading texts, created characters that had to re-experience situations, and presented the meaning of redoing what has already been done or experienced. The last is of crucial importance and is what unifies the first two themes: rereading and re-experiencing. For any belated reader or writer, there is naturally an anxiety of comparison with precursor writers and readers. Belated individuals may ask themselves: how can I read in an original way, or, how can I write original ideas? For Melville, his question might have been: how can I create and write an original character that embodies vengeance, when Shakespeare had already done so with Iago, or John Milton with his Satan. But Melville overcame this anxiety. He created Ahab, a fusion and reworking of the characteristics found in Iago and Milton’s Satan.

You may ask: how does Ahab and Melville relate to science and medicine, and how is Romanticism related to the art of medicine? I see two main links, one being that reading the Romantics enables one to be more knowledgeable about the issue of originality, and two being that observing how the Romantics handle the art of redoing enables one to redo something and still retain originality. These two links are not mutually exclusive, and the second naturally follows the first—learning what originality is enables one to redo things in original ways. Take this for example: a pulmonary intern (keeping the lung theme) sees a case of fibrotic lung disease that had been presented recently at grand rounds. Now, repeat this situation maybe ten times, that is to say, the intern sees ten more patients with fibrotic lung disease and goes to ten more grand rounds on fibrotic lung disease. Could such repetitiveness lead to boredom for the intern? I can’t answer this from experience, as I’m only a first year student, but I’ve heard the answer to be: “Yes.” A bit of originality could help the intern out here, so here I invoke the experience of reading and rereading Melville: when I reread Moby Dick, or reread any other book, I remind myself to be more aware of where I reread, how long I reread, and how I feel when I’m rereading. And then I compare these to my previous experiences of reading Moby Dick, that is to say, where I first read it, or, where I previously read it. I would argue that the intern can try something similar with clinical cases and grand rounds: where did I last see this case of fibrotic lung disease? And how did I feel when I last saw this case? These questions can make each case of fibrotic lung disease original and interesting.

To finish this post, I’d like reflect on my previous post. In my first post titled “Imaginative Literature and Medicine,” I laid out my objectives and motivations for writing in this blog, and I identified three focal points that I can discern in the medical humanities: 1. a literary focus, in which writers identify characters in literature that are scientists and doctors and write about these characters; 2. a medical focus, in which doctors and scientists reflect on personal anecdotes and write about them creatively in the form of poems or short stories; and 3. a practical focus, in which writers identify links between literature and medicine and argue for the usefulness of reading imaginative literature in practicing medicine and science. My interest is in the third category, and admittedly, I think this is the most underdeveloped of the three categories. This second post on Melville, Moby Dick, and medicine (a convenient alliteration, I might add) is meant to not only continue where I left off in the first post, but also to start a trend for future posts, in which I will be drawing more links between medicine, science, and the American Romantic writers: R.W. Emerson, N. Hawthorne, H. Melville, W. Whitman, and H.D. Thoreau.

Featured image:
Ahab reloaded by José María Pérez Nuñez

Categories
Innovation Lifestyle

Pathographies

“Illness is the night side of life, a more onerous citizenship. Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick. Although we all prefer to use the good passport, sooner or later each of us is obliged, at least for a spell, to identify ourselves as citizens of that other place.”
– Susan Sontag, Illness as a Metaphor

Words are important. They allow us to meet on a common ground, to share experiences and learn from each other. They can evoke every emotion and open new friendships. They can also be therapeutic, and a way to fill the gap between doctor and patient.

Pathographies, defined by the Oxford Dictionary as ‘the study of the life of an individual or the history of a community with regard to the influence of a particular disease or psychological disorder’, have become more popular over the years (1). Walk into any bookstore and you will eventually come across the healthcare corner: a small stack of books by people who have crossed the abyss into the land of ill health. Such stories speak of hope, love, loss, and despair as patients and their families come to terms with the sudden invasion into their lives. Treading through illness can be an isolating experience, filled with pain and uncertainty.

The Database of Individual Patient Experience is a UK-based charity that runs two websites: healthtalk.org and youthhealthtalk.org. It was created by Dr Ann McPherson, a GP who was diagnosed with breast cancer, but found that she had no one to talk to and share her experiences with. As a result, these websites are filled with patient’s experiences of their illnesses, how they coped, and their family’s reactions. Such websites can open a common ground for those who are suffering, those who are newly diagnosed, and the friends and family who may want to learn about how they can help.

“I am tired of hiding, tired of misspent and knotted energies, tired of the hypocrisy, and tired of acting as though I have something to hide.”
– Kay Redfield Jamison, An Unquiet Mind

How can they help us?

Pathographies are about putting the patient at the heart of healthcare and asking the question: can I truly understand what a person is going through if I have never suffered that ailment myself? By putting experiences into words a bridge is created, allowing those of us who work in healthcare to reach out that bit further. These stories can help us to take a step back from our jargon-filled lives; to not see the routine dialysis, but the precious hours spent with the husband; not the dry numbers of oxygen steadily increasing upon the hospital charts, but the feeling of accomplishment when one is able to take that first breath unaided. Illness is not just a list of problems that need to be crossed off. It is a continuous process filled with dark corners and dead ends.

In an increasingly globalized world, an appreciation of the cultural diversity lying upon our doorsteps is ever more needed. Everyone experiences illness in a different way. The culture we grew up in influences how we look at ailments (3) and the way we handle pain (2). It is through Pathographies that these worlds of illness and health are brought together, creating a narrative that allows us to delve inside the patient’s mind regardless of ethnicity or race. We look beyond the clinical terms, the graphs and the numbers, and not only does this help us to see the patient through a broader lens, it also breaks barriers with the next person we meet. This cultural understanding allows us to look after the ill in the way that they want to be treated – with dignity and compassion. It puts control back in the person’s hands at a time when chaos reigns. Pathographies can help to break the formulaic clinical story. A person is not a machine with a broken part, but an autonomous being with desires and goals, whose need for help cannot always be fit into a category.

All too often we can get caught up in the stereotypes: the smoker with COPD, the teenage overdose, the forty-year-old female with gallstones. We must remember our own biases as we sit in our staffrooms: our own assumptions built from our privileged educations. We no longer live in the world of the authoritative doctor dressed in his white coat. Instead, we let the patient’s words fill the silence.

Instead of opening another lengthy medical textbook, looking up the obscure and the malignant, we can open up a Pathography and step into our patients’ lives. No matter what our role, whether it’s inside healthcare or not, the voice of illness speaks in everyone’s ear and it deserves to be heard.

Further Reading

Illness as a Metaphor, AIDS as a Metaphor by Susan Sontag
An Unquiet Mind by Kay Redfield Jamison
C: Because Cowards Get Cancer by John Diamond
Intoxicated by My Illness by Anatole Broyard

References
1. American Association for Marriage and Family Therapy. 2014. Chronic Illness [Online]. Available at: https://www.aamft.org/iMIS15/AAMFT/Content/consumer_updates/chronic_illness.aspx [Accessed: 28th October 2014]
2. Briggs, E. 2008. Cultural perspectives on pain management. Journal of Perioperative Practice. 18:468-471
3. Wedel, J. 2009. Bridging the Gap between Western and Indigenous Medicine in Eastern Nicaragua. Anthropological Notebooks. 15:49-64

Featured image:
 Speak no evil, hear no evil… by Personal Kaleidoscope

Categories
General Opinion

Be Kind to Your Med Techs (And Everybody Else)

Before I was accepted to medical school, I was a medical technologist. This basically means I worked in the laboratory at a large hospital. I was playing one of the “behind the scenes” roles that many of us probably played while we were getting the medical experience required to get into med school.

Med techs are the people who run the CBC’s, comprehensive metabolic panels, amylases, lipases, pregnancy tests, urinalyses, cross-matches, etc. etc. ordered by the doctors. Usually, I was in direct contact with the nurses and doctors, who either called my line directly or came down to the lab if something needed to be clarified or a specimen needed to be delivered.

I’ll tell you right now the difference between a good day and a bad day at work. Two factors contributed: how swamped we were with patient samples, and how good of a mood the doctors/nurses were in (I say “doctors/nurses” because the moods of these two groups of people usually parallel each other quite well on any given day, and often the doctors communicate to other staff through nurses).

Of course, no matter what part of healthcare you work in, there are going to be days when the patients just don’t stop coming and you can’t catch a break. That’s unavoidable; the only thing you can do then is pray to the all-powerful but oft malicious gods of healthcare for some sort of respite.

But the second factor is something you and I can do something about as future doctors. I don’t know what your feelings are on “Reaganomics” (a.k.a. “trickle-down economics”), but I can tell you for sure that “trickle-down attitude” is most definitely a thing. If a doctor has an ungrateful, self-important, entitled, or simply negative attitude, then all of the people that doctor works with will absorb that negative energy.

As a med tech, I absorbed plenty of this negativity while working long night shifts. I’ve been yelled at for not having the test results of an order that was never put in. I’ve been hassled unnecessarily for CSF WBC counts before the tubes had even gotten to the lab. I’ve been berated by frazzled nurses because I needed them to get me a redraw due to hemolysis. Every time this happened, it shifted my stress and discontentedness level up a notch. It only takes a few notches to ruin an entire shift,and a few bad shifts in a row can cause burnout to quickly sink in. Work becomes death. Getting out of bed before a shift becomes nigh impossible. It gets more and more difficult to be fully engaged at work, which increases the likelihood of errors.

It’s not just med techs, either. The same thing happens to all allied health professionals. Phlebotomists, X-ray techs, radiology techs, nurses, CNA’s, orderlies, and even janitorial staff are affected by how the doctors in the facility are acting. Whether we like it or not, being a doctor means being a leader. So please, I beg you: be kind to your med techs (and everyone else).

 

Featured image:
Work Hard And Be Kind Wallpaper by Clay Larsen

Categories
General

The Chasm Between Pre-Clinical and Clinical Medical Education

Depending upon which school you attend, the first one to two years of medical school are predominantly classroom-based learning. As medical students, we spend countless hours memorizing facts about disorders and diseases. We pore over diagnostic criteria, look for the minutiae in radiographs, and stress about the side effects of antibiotics and other medications.  While all of this information is useful and important, the reality of medical education soon changes when students start spending time in the hospital and in various clinics.

In transitioning from pre-clinical to clinical education, it soon becomes clear to medical students that what you learn in class and what you actually see in patients is quite different. Furthermore, even when presentations are clear it is still not trivial to determine what an actual patient’s diagnosis may be.

One poignant example, which I remember well, occurred while I was shadowing a local pain management Physician as part of the early clinical exposure course at our school. The patient whom we saw had a textbook case of C-7 radiculopathy with associated shoulder pain and loss of sensation. We had learned about radiculopathy in medical school, and I had a working knowledge of the diagnosis.  After I had spent some time interviewing the patient, my preceptor asks me what I thought the diagnosis was. I had some idea that the patient had a radiculopathy, but in my nervousness and uncertainty all I could muster up were a few whispers and murmurs.  My preceptor turns to me and basically says that this was a very clear case of C-7 radiculopathy.  After hearing the diagnosis, I distinctly remember thinking that I had known the disorder and had seen the symptoms in the patient, but had been unable to connect the dots.

The ability to connect the dots and turn pre-clinical knowledge into data that is useful in a clinical setting is a difficult skill to acquire.  You have to deal with patients that have varying presentations and many associated comorbidities, both situations that are not emphasized in much of the book and lecture-based learning of the pre-clinical years.  The only real method to attain proficiency in a clinical setting is hands-on experience.

Noting this need for hands-on experience, medical school curricula has changed substantially over the last decade. More medical schools now offer early clinical skills and patient experiences in their curricula, hoping to bridge the chasm between pre-clinical and clinical education. At the school that I attend, we start to see real patients in the second week of our first year. In the second semester of our first year, we embark on a year-long experience in local clinics where we work with practitioners to learn the ins-and-outs of clinical medicine and practice. Most other schools have implemented similar programs. Furthermore, the trend towards shortening pre-clinical education to one to two years is a direct response to student need for early clinical experience.

While early clinical exposure is important in medical education, it must occur with a solid foundation of preclinical knowledge.  Balancing knowledge acquisition with practicing clinical skills is a juggling match every medical student must deal with. Luckily, we don’t have to learn all of it during medical school, as medicine is a lifelong learning experience.

Featured image:
stethoscope by Dr.Farouk

Categories
Forensics

Forensic Pathologists: Public Servants

In this second part of my three part series on forensic pathology, I will be exploring the role of the forensic pathologist in society at large. Of all the specialties, forensic pathology seems to be largely ignored and/or unknown to the medical students I have met. Certainly, the prospect of working with dead patients doesn’t appeal to the majority of medical students, but hopefully a review of what forensic pathologists do will remind everyone that we should not take for granted the important social role they fill. In her book Postmortem: How Medical Examiners Explain Suspicious Deaths, Stefan Timmermans puts it the following way:

“Death is not an individual but a social event. When, with a barely noticeable sigh, the last gasp of air is exhaled, the blood stops pulsating through arteries and veins, and neurons cease activating the brain, the life of a human organism has ended. Death is not official, however, until the community takes notice.”

Many practicing physicians are surprisingly hazy on the subject, which becomes a problem when these physicians improperly fill out death certificates (a common occurrence which drains public resources to straighten out) or fail to recognize deaths as suspicious and warranting investigation.

Medical examiners are usually certified forensic pathologists who have been appointed to the medical examiner position as an employee of the government. They serve a vital role in the government’s public health systems; if a public health danger emerges of an unknown nature and is killing members of the community, who better to solve this pressing puzzle than a medical examiner? When death occurs under unexpected or unknown circumstances, i.e. when it is suspicious, then the probability that a public health danger is lurking about increases. If we don’t know why people are dying, how do we know who is at risk? How can we mitigate the threat? It is the responsibility of the medical examiner to figure this out, whether the threat is a murderer, an infectious disease, a faulty product on the market, etc.

When death occurs under certain circumstances, the body and investigation come under the jurisdiction of the medical examiner. In fact, by law (in San Francisco at least), a medical examiner must investigate the following types of deaths: violent, sudden, unusual, unattended by a physician in the last 20 days or with no medical history, related to an accident (either old or recent), homicide, suicide, due to an infectious epidemic, anything due to criminal acts, all deaths in operating rooms or following surgery or a major medical procedure, all deaths in prisons, jails, or of a person under the control of a law enforcement agency. Some of these categories are purposefully vague, in order to encourage doctors and other agencies to contact the medical examiner if the death is questionable in any regard whatsoever.

Medical examiners have the responsibility to unearth public health threats as they investigate all of these unusual deaths. For example, it was medical examiners who helped identify the mysterious and deadly powder distributed through the U.S. Postal Service in 2001 as anthrax, and who determine infant deaths are caused by defective cribs on the market, and who do the initial work in identifying infectious disease epidemics.

Bacillus anthracis
A photomicrograph of Bacillus anthracis bacteria using Gram-stain technique, courtesy of Centers for Disease Control and Prevention’s Public Health Image Library (PHIL)

Clearly, forensic pathology is essential in maintaining a safe and just society in modern times. Well trained medical examiners performing top-notch forensic work ensures the timely, correct identification of threats to the community. Their role as public servants should never be taken for granted. They may work behind the scenes, but their work is necessary for our society’s high standards of well-being.

 

Featured image:
the colour of blood by anjamation

Categories
General Opinion

Imaginative literature and medicine

What is the usefulness of imaginative literature to the practice of medicine and science? This question continues to intrigue me, and according to Weill Cornell’s admissions dean Dr. Charles Bardes, it is an important question that “remains unanswered.” I approached Dr. Bardes in mid-November this year after being impressed and intrigued by the physicianship lectures he gave as part of our first-year Essential Principles of Medicine curriculum. One of his most memorable lectures was the October 9th presentation on how to take vital signs. His lecture started out with an introduction to taking body temperature. As many readers know, body temperature is often measured first when vital signs are being taken, and it’s one of the easiest measurements to take. But the meaning of a particular body temperature is not always so simple. In the course of his lecture, Dr. Bardes reminded students of the possible meanings of an increased or decreased body temperature relative to the average normal range. He then proceeded to explore one interpretation of a decreased body temperature: dying and death. He presented a historical (Socrates) and a literary (Falstaff) example of decreased body temperature as it relates to dying and death. Importantly, how Dr. Bardes chose to explore this relation was more interesting than what he chose (though I do share with Bardes a common fascination with the character of Falstaff). I quote, below, from his October 9th lecture:

Here you see a representation of the death of Socrates, as narrated by Plato, and painted by David. And the text describes how Socrates, after drinking hemlock—he’s just about to do so here—becomes cold. And he becomes cold beginning with his feet, and it gradually ascends up his body, and Plato says that when the cold has reached the level of the thorax, that’s when Socrates breathed his last. You can see here a combination of biologic observation, that is, that this sort of ascending coldness does in fact occur, but also a little bit of literary fiction—there’s nothing magical that when the cold reaches your chest, you die; that was another little bit of medical folklore. [Also] Here we have the death of Falstaff, which actually happens offstage in the play, but onstage in the Laurence Olivier movie, and Mistress Quickly describes how Falstaff becomes cold, ascending from toe to chest, until he is, in her words, as cold as any stone. Those are the meanings of…decreased temperature.

The Death of Socrates
Jean Francois Pierre Peyron (1744-1814), The Death of Socrates, 1787. kms7066, photo courtesy of SMK Statens Museum for Kunst (officiel)

 

Certainly, there are numerous ways to provide details and anecdotes on how changes in body temperature are related to changes in physiology. A keyword search in PubMed of “body temperature changes” reveals more than fifty-thousand articles on that subject. Dr. Bardes didn’t choose this path to present his lecture. Yes, one can learn a great deal about body temperature changes by reading any of the articles on PubMed, but what do such articles on case studies and molecular pathways not tell us? They don’t provide the human and historical context to the medical condition. Yes, case studies no doubt can include anecdotal material, but such material provides a limited perspective. What about the vast historical and literary contexts that are available to us? Why should we not look through such material and mine them for gems related to our subject matter? Socrates in human history experienced death and dying, as did Falstaff amongst Shakespeare’s universe of characters. Dr. Bardes wonderfully brought in such contexts to give each of us diverse tools to make meaning, and to quote again from the lecture: “these things [increased and decreased temperature] have meaning. Why do we do them, because they have meaning.” How we make meaning, then, and the tools we choose to do this, is up to us.

I continue, every day, to explore literature, medicine, and science; for me, they are just variations of the same thing: a desire to better understand and describe life, and to make meaning in life. Though the methods and jargon differ between those fields, their objectives should be common and coherent. If the objective, then, is to make meaning in life, then each field ought to be practiced daily with the same enthusiasm and joy we give to life itself. I practice all three–literature, medicine, and science—daily and with joy because I have fallen in love with all three. The best works in all three fields have been produced when their creators have fallen in love with their works, a cliched but true notion (on this note, I’ll cite Josh from the new-age Broadway musical I recently saw, If/Then, when he affirmed to viewers that “it’s cliche, which means it’s true”—indeed, it’s true that the best works were created by those who loved what they were creating). On this theme, the late Yale poet and professor John Hollander said this of Professor Mark Van Doren’s sublime book on Shakespeare, that he “enlightens us, not because he has any special knowledge or private advantages, but because his love of Shakespeare has been greater than our own.” A love of making meaning in life, then, I propose, will be found in the greatest physicians and physician-scientists, because they will produce the best works when they love what they do. I will, on this note, go out on a limb to surmise that if Falstaff had been trained as a physician, and not as a knight, he would have been an excellent doctor, though he clearly—and we love him for this—fails in his duties as a knight. He loves living, however, and making meaning as he lives. Harold Bloom, most certainly our best reader of Shakespearean in the last half century, said this of Falstaff, that “if you crave vitalism and vitality, then you turn…most of all to Sir John Falstaff, the true and perfect image of life itself.”

For The Medical Student Press, I have two main objectives I hope to achieve in my blog posts. Like Dr. Bardes, I’d like to share how reading imaginative literature, focusing on Shakespeare, has provided contexts and insights for my medical training. Secondly, and this will simply be an extension of my first objective, I’d like to share my enjoyment of literature, medicine, and science with colleagues and readers. In this manner, I’d like to fill what I think is a gap in the medical humanities canon. There has already been much written about medicine and medically-related themes in poetry and fiction, but such pieces seem too literary and theoretical for my taste. Another category of writing within the so-called field of medical humanities involves poems or short stories that seek to communicate personal anecdotes in medicine or reflect upon them. But there is a third category of writing, one that I think has been under-appreciated, and the goal for these writers is in describing the relevance and usefulness of imaginative poetry, fiction, and drama to scientists and physicians. This relatively unexplored third category is what interests me and what I like to write and think about. I end this post by echoing what Weill Cornell’s Dean Laurie Glimcher shared with us in her holiday greetings:

Do not go where my path may lead, go instead where there is no path and leave a trail. -Ralph Waldo Emerson Warm wishes for the holidays, Laurie H. Glimcher, M.D. Stephen and Suzanne Weiss Dean

 

Fetured image: and read all over by Jonathan Cohen

Categories
General Lifestyle

A Medical Student’s New Year’s Resolutions

With the end of 2014 and almost the whole of 2015 upon us, there is no better time to sit and reflect on the past year and to mentally anticipate the year to come. In this free time, I’ve thought a lot about New Year’s resolutions. Now, I’m not referring to resolutions like losing weight, exercising more, or eating healthier meals. I’m referring to resolutions that are specific to the medical student. We, as medical students, live unique lives that require a different set of resolutions than what are typical of most other people.

Here are my top 5 medical student New Year’s Resolutions:

Resolution #1:  Get on a sleep schedule that resembles normal circadian cycling
Medical school really screws up your sleep schedule. Late nights studying coupled with mornings filled with lectures leads to afternoon naps, which leads to sleeping later at night due to the fact that you aren’t tired. This vicious cycle continues throughout medical school, and your suprachiasmatic nucleus is all out of whack. Therefore, the first resolution I propose is to try to sleep at normal hours. Let’s face it, those hours of studying after 11 PM aren’t really that productive anyway. You’re probably better off going to sleep so that you’re rested for the next day’s study marathon.

Resolution #2: Preview material before the lecture
I feel as if this resolution is something everyone has already tried. Personally, I tell myself that I will preview material before every new block. I am even successful for a little while, usually keeping up the trend for the first few days of the course. However, like all things that are too good to be true, this habit usually falls by the wayside after “life” (read: laziness) catches up to me. Therefore, the second resolution is to make a conce rted effort to preview material before the lecture. The chances that this is successful throughout the entirety of the next semester are low, but you should humor yourself for a little while at least.

Resolution #3: Do more outside of school
We know medical school takes most of our time.  We come into medical school all but expecting as much. However, that does not mean you shouldn’t do other things outside of school, for both your physical and mental health. I’m talking about things you do for yourself that have no direct affect on your professional life. If you enjoy cooking, you should cook more. If you enjoy sports, you should play or watch more. If you enjoy any other hobby imaginable, pursue that as well. Pursuing such endeavors may decrease your studying and professional development time, but it will also prevent burnout and increase happiness.

Resolution #4:  Get out into the community
Ok, this one is kind of a continuation of the last one. But, I felt this recommendation was too important to not have its own category. One thing I think many medical students feel is that while they live in a certain place during medical school, they never really come to know that place because they are always studying or at the hospital. We, as students, need to get more in touch with the communities we serve in a non-medical way. Volunteer at local shelters, kitchens, or churches. Talk to the people that live around you. Explore the city’s historic landmarks. Eat at some of the city’s best restaurants. You may not recognize it now, but there is great value in really knowing and appreciating the nuances of where you live.

Resolution #5:  Get Better Every Day
Medical school is an interesting and challenging time in a person’s life. While at times it can be overwhelming, it is important to realize that medical school is a marathon and not a sprint. As such, it is important to focus on getting a little bit better every day. If you get a little better at something every day, you will reach proficiency sooner. This resolution extends not only to your medical life, but to other aspects as well. As long as you get a little bit better every day, no day is wasted.

 

Featured image:
365-001 time flies by Robert Couse-Baker