doc w/ pen

a journalist becomes a doctor before your eyes

Month: January, 2018

Running the mental gantlet

This essay was first published in the online magazine The American. You can see the original version here.

 

Learning about a patient is like digging into a demanding novel: plot and characters need fleshing out.

Running the mental gantlet

Some people compare starting a new clinical rotation in medical school – something you do every six or eight weeks for an entire year – to starting a new job. A job you’ve never done, and one you feel wholly unprepared for. I liken the experience to being dropped into the middle of a novel. Dialogue explodes around you. But the speech lacks context and you struggle to make any sense of the words. Characters fall in love, have sex, shoot each other, but you can’t always tell the good guys and bad guys apart. For heaven’s sake, you don’t even know where you are. Russia? Iowa? The moon?

That’s how I felt when I started my inpatient psychiatry rotation on a summer Monday last year. I arrived promptly on the unit at 8:20 a.m. as I’d been instructed. I knew the names of the attending, resident, and medical student I would be working with, but not their appearance or where I was expected to meet them. I sheepishly hung out with a kind, chatty nurse until the 8:30 a.m. team meeting – a meeting I had no idea I was supposed to attend until the friendly nurse told me. A dozen or so of us entered a room and sat or stood around a big table to discuss general issues – safety concerns, upcoming discharges, new admissions, staff absences, special activities.

After this combined meeting, we had another meeting just with my team to discuss more specific updates on our own patients. Since I was new, those present introduced themselves. Overwhelmed by it all, I promptly forgot most of their names and their roles.

I got slight comfort in telling myself I’d pick up the details after everything settled down.

I noticed that the woman running the meeting had two binders. One bore the name of my attending psychiatrist, the other the name of a different attending. Not all the patients were covered by my team, which made me wonder where exactly they wanted my focus.

As the meeting progressed, with notes and updates on specific patients, I noticed that my medical school colleague, who was sitting next to me, occasionally scribbled a few notes. “Should I be taking notes?” I wondered.

I didn’t want to be perceived as not paying attention, but I had no idea who these patients were, which ones (if any) were my responsibility, and which updates mattered.

One of these updates might consist of something like this: “On Saturday, Jane Doe took her medications. She spent most of the day with her family. She expressed her needs appropriately. She slept well.”

That sounds bland, but perhaps this was the first day Ms. Doe had agreed to take her medications. Perhaps sleeping well was a major improvement for her. I just didn’t know.

With patient names and behaviors swirling in my head, I did my best to keep the confusion at bay, reminding myself that this was my first day, my first hour. I couldn’t be expected to keep things straight. Not yet.

Then the team resident, my classmate, and I talked individually with patients in one of the unit’s small, private meeting rooms. The resident immediately launched into questions. Sleep? Appetite? Mood? Hallucinations or delusions? Medication side effects? Thoughts of hurting yourself or others?

Between patients, my classmate tried to give me a brief synopsis of the next patient: diagnosis, treatment plan.

With only that to go on, I struggled to make sense of the encounters. The journalist in me cried out for each patient’s fuller story. Understanding the past would help me understand their present, and their prognosis.

As the patients answered the resident’s questions, in my own mind the replies only provoked more questions. One patient made a vague reference to a brutal childhood trauma. Another hinted at magical powers. How could I not want to know more?

Making matters even more complicated I had little understanding of what my supervisors (the psychiatry resident and attending) expected of me for the next four weeks. The medical student told me what he’d been doing – interviewing two of our five patients one-on-one daily, and writing a progress note on each. But more concrete information was hard to find.

I finally went to the source, asking the resident what her expectations were. She told me to do essentially what my classmate was doing — pick a patient or two, spend some extra time with them, and write my own notes. I had figured as much, but now it was official.

I selected my patients and dug into their medical records, combing through the notes in each person’s electronic chart. I was back to reading the novel, starting at the beginning and working my way forward. I began with each patient’s presentation to the psychiatric emergency department. That gave me a sense of how they were when they first came to the hospital compared to how they were now. I then moved to the initial evaluation note from the psychiatric unit (where I was now working). These two comprehensive notes helped me understand each patient’s present psychiatric illness, as well as past psychiatric history, medical history, family situation, and other life factors. I also read what are called “collateral” notes. These are conversations between a medical practitioner (often a medical student) and someone else in the patient’s life — a spouse, friend, psychiatrist, therapist, or caseworker, for example. They provide an outsider perspective on how the patient’s current condition compares to their norm. Last, I read daily progress notes, finishing with the one written that morning. These brief and focused progress notes told the story of the patient’s day-by-day existence on the inpatient psychiatric unit. How they were eating, sleeping, behaving, and overall living while in the hospital. These daily updates clued me into whether someone’s delusions or insomnia had improved, for example, or whether they were tolerating an increased dose of a medication.

At the end of that first day, I was still in the middle of the novel, on page 200 or so. But I’d gone back and at least skimmed the first 199 pages. And with that background, I was now ready to move on to the next chapter: the next day.

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Sit back and listen

The art for the fictional podcast “Alice Isn’t Dead,” which is about a female truck driver searching for her missing wife, is just brilliant.

Some time ago, I wrote a post about the true crime podcasts I’d discovered. As I explained in that post, I spend so much time in front of a computer screen both for medical school and in my personal life that the idea of relaxing in front of another screen (i.e., my TV) just doesn’t always appeal to me. Plus, there’s something about simply listening, hearing the narrative but without someone else’s visual interpretations, that sparks my imagination. I get to paint people’s portraits and create the contours of the landscape. So for all those reasons, radio is ideal. Magical, even.

But as I was listening to one of those nonfiction podcasts awhile ago, I realized that I really just wanted … a story. Not a real one, not one that truly happened. I wanted to escape into the world of fiction. I’m actually surprised that this didn’t occur to me sooner. I’ve always loved reading fiction. And as a kid, my dad would read aloud to my family each night from a chapter book — our own version of a serial audio story. So I started poking around iTunes. Before long, I had amassed an overwhelming list of fiction podcasts to try. Here are the ones I’ve tried so far and highly recommend. I’ll include each show’s link and official description, as well as a few words of my own.

The Black Tapes. This docudrama is one of my favorites. The best way I can describe this spooky and addictive show is that it’s like the podcast “Serial” meets “The X Files.” There are three seasons out now. From the show’s official description: “The Black Tapes is a serialized docudrama about one journalist’s search for truth, her enigmatic subject’s mysterious past, and the literal and figurative ghosts that haunt them both. How do you feel about paranormal activity or the Supernatural? Ghosts? Spirits? Demons? Do you believe?”

Rabbits. This is another addictive docudrama, just finished with its first season. It took me a couple of episodes to get into the show, but then I was hooked. From the show’s description: “When Carly Parker’s friend Yumiko goes missing under very mysterious circumstances, Carly’s search for her friend leads her headfirst into an ancient mysterious game known only as Rabbits. Soon Carly begins to suspect that Rabbits is much more than just a game, and that the key to understanding Rabbits, might be the key to the survival of our species, and the Universe, as we know it.” This show is from the same people behind The Black Tapes.

Limetown. I blew through this show’s remarkable episodes in a couple of days. My only disappointment is that there isn’t more to listen to, although apparently a second season is coming out soon. It’s another conspiracy-paranormal-docudrama. Apparently, this is my genre. From the show’s website: “Ten years ago, over three hundred men, women and children disappeared from a small town in Tennessee, never to be heard from again. American Public Radio reporter Lia Haddock asks the question once more, ‘What happened to the people of Limetown?'”

The Message. This show’s first episode didn’t really impress me, and I was about to move on. But I read some incredible reviews of the show, which hit No. 1 in iTunes when it was first released. so decided to stick with it. I’m glad I did. You will be too, if docudramas about aliens is your thing. From the website: “The Message is a new podcast following the weekly reports and interviews from Nicky Tomalin, who is covering the decoding of a message from outer space received 70 years ago. Over the course of 8 episodes we get an inside ear on how a top team of cryptologists attempt to decipher, decode, and understand the alien message.”

Life After. The premise of this incredible sci-fi show reminds me of “Her,” the 2013 Spike Jonze movie (also highly recommended). From the show’s official description: “The 10 episode series follows Ross, a low level employee at the FBI, who spends his days conversing online with his wife Charlie – who died eight months ago. But the technology behind this digital resurrection leads Ross down a dangerous path that threatens his job, his own life, and maybe even the world.” By the same people who created The Message.

Archive 81. The show’s official description is short: “A podcast about horror, cities, and the subconscious.” I understand why. It’s hard to characterize this podcast. It’s about a guy who goes into this cabin deep in the woods to archive these weird tapes, and horrible things happen from there. It’s gripping. I don’t recommend listening to this one alone in a dark room (which is, of course, what I did).

ars PARADOXICA.  Physics, time travel, awkward scientists, political corruption, and intrigue … this is the world of ars PARADOXICA. From the show’s official description: “ars PARADOXICA is a story about people searching for meaning in a universe that aggressively lacks one, and who occasionally find the next best thing in those around them. It’s also about the way power corrupts. When you’ve got a time machine and the backing of the most powerful nation on Earth, you start to get the idea that you can always tilt the scales in your favor, but there is cost and consequence for every action. Above all, it’s about science, America, and the deeply human desire to fix our mistakes.”

The Deep Vault.  This is another super creepy one, which apparently is another thing I’m into. Also do not recommend being alone in a dark room for this one unless you like imagining that shadows are monsters. From the official description: “The story follows a group of longtime friends as they journey from the uninhabitable surface world into a mysterious underground bunker in search of safety, shelter, and answers to their past. Robotic servants, tooth-filled monsters, and terrible computers collide within the claustrophobic, steel-reinforced walls of The Deep Vault, a modern day homage to the golden age of sci-fi radio drama.” Like Archive 81, this one definitely has horror undertones, but I mean that in the best possible way.

Welcome to Night Vale. I saw one review on iTunes describing this as Garrison Keillor in “Lake Wobegone” meets Stephen King. That was enough to get me to listen to an episode. From the show’s official description: “Welcome to Night Vale is a twice-monthly podcast in the style of community updates for the small desert town of Night Vale, featuring local weather, news, announcements from the Sheriff’s Secret Police, mysterious lights in the night sky, dark hooded figures with unknowable powers, and cultural events. Turn on your radio and hide. ”

Alice Isn’t Dead. This show’s narrator, Alice, a female truck driver, is incredible. As is the writing. The official description: “A truck driver searches across America for the wife she had long assumed was dead. In the course of her search, she will encounter not-quite-human serial murderers, towns literally lost in time, and a conspiracy that goes way beyond one missing woman.”

The Bright Sessions.  This show’s premise is unlike any other. It records psychotherapy sessions between a woman named Dr. Bright and her uniquely talented, but troubled patients. The official description: “The Bright Sessions is a science fiction podcast that follows a group of therapy patients. But these are not your typical patients – each has a unique supernatural ability. The show documents their struggles and discoveries as well as the motivations of their mysterious therapist, Dr. Bright.”

Homecoming. This is a psychological thriller about a human experiment gone horribly wrong. From the show’s description: “Homecoming centers on a caseworker at an experimental facility, her ambitious supervisor, and a soldier eager to rejoin civilian life — presented in an enigmatic collage of telephone calls, therapy sessions, and overheard conversations.”

Our Fair City. This podcast is lovably bizarre. “Campy,” according to the official description — and in the best possible, melodramatic way. It’s a post-apocalyptic drama complete with lunatic scientists, the woken dead, mole people, man-eating wolves, and so much more. All of this is packed into episodes that are usually about 15 minutes long, so great for a quick study break. Or a long binge … the creators (based in Chicago!) are currently on season 8, so there’s lots to listen to.

The Leviathan Chronicles. This is an absolutely incredible sci-fi show, another one of my favorite podcasts overall. It follows the lives of people who have become immortal, conflicts between different factions of immortals, and clashes between immortals and mortals. It sounds bizarre, I know, but the story is wonderful, suspenseful, and engaging. There’s also great acting, sound effects, music, etc. It’s supposed to be 50 episodes, but 30-some-odd in, the creator’s wife died of cancer, so there was a long hiatus. But he’s apparently back and working on episodes again, which is exciting news.

There are so many incredible podcasts out there, both fiction and nonfiction. This is truly a return of the golden age for radio (albeit radio you listen to on your phone or computer). While I’ve found some incredible shows, I know I’ve only scratched the surface. If you come across any other podcasts you love, post a comment or send me a message. I’m always looking for new ones to try.

Six-word stories: doing more with less

When you have limited space for your words, you choose those words very carefully. I learned that lesson well when I was working as a reporter for the weekly newspaper The Forest Park Review. Each week, I was given a newspaper page plan with allotted space for my stories — space that was, for the most part, set in stone. I learned to condense my thoughts into 500- to 750-word stories without compromising the content.

Ernest Hemingway set a much higher (or lower, depending on how you look at it) bar for word precision with this famous six-word story.

For sale:
baby shoes,
never worn.

In a half-dozen words, Hemingway conveyed a grief and emptiness that are all the more profound and affecting because of how short the story is.

I came across the six-word story concept recently while toodling around the Internet. Apparently, it became quite the sensation on Tumblr and reddit awhile ago. (I’m a little behind the times, I know.) I recommend doing a Google image search for “six-word story” — it’ll make you smile, laugh, think, and sigh, all in a few seconds’ time.

Here is my own attempt at a six-word story. Note that I am not a fiction writer. This is an autobiographical piece based on something that happened to me this past summer.

Manhattan morning stroll:
sandals, pigeon diarrhea.

Friendly inspiration

When I was in Chicago over winter break, I spent most of my time with my family. But I also caught up with my old “crafternoon” buddy. We talked shop, discussing the best paper collage glue and the sharpest scissors for maximum cutting precision. We also wandered the aisles of Hobby Lobby, picking up random treasures to use in our respective craft projects. Going to Hobby Lobby with a fellow craft addict is both marvelous and dangerous. Marvelous, in that you inspire each other with ideas on how to use this or that trinket; dangerous, in that you rationalize each other’s ever-expanding pile of purchases. But it’s mostly marvelous. My friend also graciously gifted me some vintage children’s book and magazine images, as well as other colorful paper.

Below are some of my recent origami crane cards, made with these new acquisitions. Click on any photo to open up a slideshow with larger images.

 

Only in medical school … (#2)

The other morning, I was standing in front of my bathroom mirror, getting ready to head to the hospital. I had planned to leave at 6:50 a.m. It was already 6:45.  I felt rushed, running late. I still needed to put my make-up on. But in this moment, I was struggling with my hair. My springy red curls just weren’t sitting quite right around my face. So I grabbed a comb out of a bin on my bathroom’s narrow windowsill and with it parted my hair just left of center. I examined the new distribution of my curly locks.

“There,” I thought. “That looks better.”

But as I stared at myself in the mirror, I noticed that the hair on either side of the part wasn’t laying down flat. It bowed upward, each side threatening to defect to the other. I reached into that same bin and pulled out a bottle of hairspray. I spritzed the part and gently smoothed down both sides to prevent mutiny.

“That will keep my part patent,” I said aloud, to no one but myself.

I laughed. “Patent”? Who uses that word to describe hair? That’s a word we use in medicine to describe tubular structures in the body that are open and unobstructed, like healthy veins and arteries, or a stent that has been placed to keep a diseased artery open. Only someone in medicine would describe a part in their hair as “patent.”

Later in the day, I thought again about what I’d said, and how I should write this blog post. Again, I laughed, but for a different reason. I’d inadvertently applied one of my favorite literary elements, alliteration, to my inadvertent use of medical terminology in a nonmedical context. Alliteration is repetition of the same consonant letter (or sound) in adjacent or nearby words. In my statement: “patent part.” Only a writer would be likely to notice that.

In the busyness of clerkships, I find humor where I can. Sometimes, that means laughing at myself, and the funny fusion of my many facets.

Understanding the umbrella

I quickly snapped this picture while walking to the hospital this morning.

In Chicago, where I spent most of my life, “winter” means having to dig your car out from a mountain of snow and bundling up against sub-zero windchills. In New York, I’ve seen people wearing down jackets and gloves when the temperature plummets to *gasp* 50 degrees. When I see these people, I chuckle to myself.

“Wimps,” I whisper under my breath. “They think this is cold?”

But finally, today, we got a real winter day in New York City. It’s been snowing for hours now, with several inches predicted. And it’s coming down pretty hard, even by this Chicagoan’s lofty standards.

For perhaps the third time this winter (not counting the days I spent with my family in Chicago over Christmas), I donned my long, down coat. For the first time this year, I tugged on my heavy snow boots. (And was reminded just how heavy they are.)

As I trudged down the slick sidewalk toward the hospital, I wondered how those people who wore parkas in 50-degree weather were doing. I hoped they were surviving. I thought about how ridiculous all this thick, winter garb looks on everyone, but how no one cares (or laughs) because we’re all just trying to stay warm.

In New York, some people attempt to fight the snow with an umbrella. I took this picture to prove it.

And then I saw the umbrella.

Yes, the umbrella. I’d forgotten about the umbrella.

Different cultures handle adversity in different ways. New York City definitely qualifies as a separate culture. It’s practically a foreign country. And as I was reminded today, some New Yorkers handle the adversity of blowing snow by shielding themselves with umbrellas.

When confronted with this fact, I did exactly what I’d told myself we don’t do in winter: laugh at how people were coping with the weather. It just looks so ridiculous. This is not rain, people! It’s not falling straight down. It’s not even falling sideways. In this wicked wind, it’s swirling and blowing in every possible direction. The only way to truly protect yourself from being pelted is to hail a taxi. And lord knows how rush hour traffic in Manhattan is when it snows.

This is the thing about New York, though. Walking these streets, you see a little bit of everything. Everything from a woman wearing a turkey stuffed animal on her head to a guy strolling down the sidewalk in shiny-cotton-candy-pink spandex to commuters hiding under umbrellas in the falling snow. Sometimes you’ll stare, laugh, or shake your head. Sometimes another person stares, laughs, or shakes their head at you, because they think you’re the weird one. Somehow the city survives on this invisible undercurrent of understanding that we’re all a little weird, all a little different, and that’s ok. It’s actually pretty cool. Even if you carry an umbrella in the snow.

Be my doctor

Like it or not, medical school is full of tests. Some are useful. Others seem pointless. In a recent clinical assessment, I received important feedback that let me know that when it comes to patient care, I’m on the right track. I tell the story in this essay, which was originally published in the online magazine The American. You can see the original version here.

Be my doctor

On every medical school rotation, we have at least one OSCE, the clunky acronym for Objective Structured Clinical Examination. If I had my way, “structured” would be replaced by “stressful,” because that’s what it really is.

You’re asked to interview and examine a standardized patient (aka actor) while being both videotaped and watched live by real doctors, usually the people in charge of your clerkship, and your final grade. The observers work from a checklist (that’s where the “objective” comes from, I think) to measure your performance. Your “patient” has a different checklist.

I confess that being watched, videotaped, and assessed against a detailed to-do list makes me nervous, which makes me more likely to forget things that I otherwise wouldn’t.

Two weeks into my eight-week internal medicine rotation, I endured a particularly stressful OSCE. You had 20 minutes to conduct a focused history and a physical exam. (In an encounter with a patient, “focused” means tailoring your questions and physical exam to respond to the person’s “chief complaint.”) You’re given five minutes to discuss your diagnostic impression and develop a plan. On the spot, you needed to figure out what was wrong and what to do about it. After which you left the exam room, had five more minutes to organize your thoughts, before explaining your findings, assessment, and plan to the observing “attending” in a three-minute presentation, morning rounds-style.

Unlike most OSCEs, you didn’t know what was on the checklist ahead of time. As with most OSCEs, you had to make good on a certain number of items to pass. If you didn’t pass, you had to repeat the exercise.

Anxiety is built into this territory. But once I get going, I’m fine. Early nerves give way to clinical instincts.

This OSCE was no different. About 10 minutes before we each met our patient, we received a clinical scenario along with some lab values and vital signs. After reading up and thinking through what I’d ask and do, I met with and assessed the patient to synthesize her signs, symptoms, and story with what I’d read. I asked my questions, examined her, and quickly thought through my differential diagnosis. I then presented her with the most likely diagnosis, along with my proposed treatment. As a medical student, I informed her I would discuss everything with my team before proceeding.

I asked if she had any questions. Though she’d been hospitalized with pneumonia, she was most anxious about her breast cancer, which had been diagnosed earlier. She told me she wanted her family involved in understanding what was happening. I was impressed with her acting skills – tears seemed to well up in her eyes as she lay supine on the examining table. I put my hand on her shoulder and reassured her we would bring her family in, and together discuss everyone’s questions.

I was about to continue comforting her when a loudspeaker announcement abruptly informed me the encounter was over. I should leave the room immediately. I felt myself flush with frustration. My patient was in distress, on the verge of tears, and I had to abandon her — something I’d never do to a real patient.

I followed protocol: I left, thought through my findings, and returned to present them before my attending and the patient. Then came the feedback. The physician asked how I thought I’d done. I said I thought my physical exam skills were rusty since I hadn’t been practicing them much since an earlier rotation several months before. The “patient,” who apparently has been performing this same OSCE for years, emphatically disagreed. She said I’d just performed one of the most thorough physical exams she’d experienced in this OSCE go-round. More significantly, at least to me, the patient told me she wanted me as her doctor. “What kind of medicine are you going into?” she asked me. “Are you going to be practicing in New York?”

Yes, the patient was an actor, but I got the feeling she was only half joking. She said she felt genuine empathy and compassion from me, things she doesn’t sense from everyone. When she was distressed, I stood closer to her (but not too close) and actually touched her. I offered to bring in her family to answer their questions. She described me as confident but not arrogant. For example, while I was sure of myself in explaining my diagnostic impression and treatment plan, I also emphasized my role as a medical student, and how I’d first confirm everything with my team. She said I had a sense of humor – I’d made an impromptu joke about hospitals based on something she said, and I’d gotten her to laugh. She told me I was a good listener, explained things well, and made her feel comfortable.

Her compliments disarmed me. All I could say was “thank you.” Both patient and preceptor also offered constructive criticism, which is essential so I can improve.

But when it comes to improvement, compliments can be just as important as criticism. My patient’s invigorating observations reminded me that I was on the right track and needed to stay on it.

The experience was a boost on a number of levels. Maybe it’ll help calm my nerves before the next OSCE. Maybe it’ll help bolster my confidence when I finally treat real-life patients on my own. Though I haven’t even graduated from medical school yet, I now know there’s at least one person who wants me as her doctor.