doc w/ Pen

Any halfway decent cook knows that you can’t put certain fresh fruits — kiwi, pineapple, and papaya, to be exact — into gelatin (commonly known as JELL-O). Well, you can … but the gelatin won’t set. Which rather defeats the purpose of making JELL-O, doesn’t it?

Any halfway decent scientist knows why. And after Monday’s biology lab, all of the students in Dominican University’s Biology class (including myself) do too.

I will explain. But to do so, we must zoom in to what’s called the “particulate” world, the world we can’t see with our own eyes …

The failure of the gelatin to set has to do with a type of enzyme (protein) called “gelatinase” found in those tropical fruits. (In case you were wondering: Yes, these fruits do contain protein.) If active, gelatinase breaks down the gelatin protein found in your typical packet of JELL-O, preventing the JELL-O from setting.

How does this work? Understanding this phenomenon requires a bit of biology and a bit of chemistry. (But don’t be scared! It’s actually really cool how this works.) Proteins, such as the gelatinase found in the tropical fruit mentioned, are organic molecules that have very important roles in the function of living cells (including our own cells). One role that many proteins have is that of an enzyme, or biological catalyst. These catalysts basically facilitate chemical reactions in living cells by reducing the amount of energy required for those reactions to take place. Without these chemical reactions, life would cease. So proteins (as enzymes) are pretty important to us, and to other living things.

Enzymes function as a result of a very specific three-dimensional structure. This structure is determined by the DNA that “spells out” the instructions for making the enzyme. Each enzyme, then, has its own unique structure. Because of this individualized three-dimensional structure, each enzyme usually fits, in the same manner as a lock and key, with only one other molecule (called a “substrate”) and catalyzes a reaction there. So each enzyme does one specific job. The enzyme will not function (act as a catalyst) if a different molecule is present. This property is called “enzyme specificity” or “substrate specificity.”

However, proteins are very sensitive. If they get too warm, or the solution around them changes in pH (how acidic/basic the solution is), then the protein can lose its three-dimensional structure. And when that happens, the protein can no longer bind with its substrate — the key doesn’t fit into the lock anymore. This is called “denaturing” of a protein.

Now let’s return to the “macroscopic” world, the world we can see unaided by microscopes and chemical models. The world of the lovely, green, sweet-and-sour kiwi …

Like all good scientists, once we learned the principles of how enzymes work, we tested them out. Using (yes) kiwis and (yes) gelatin. Raspberry gelatin, actually. The experiment was simple, yet elegant, explanatory, and enlightening. Here is my data chart. I will explain it below.

We tested 10 tubes of solutions (five different mixtures, each mixture done twice to see if we got the same result). After mixing the solutions, we set them all in an ice bath to find out whether they would set into hard gelatin, or remain as liquids.

Tubes 1 and 2 had only gelatin + water (no gelatinase). These tubes were what is called a “negative control” — they had a known negative test in an experiment (no enzyme activity). Tubes 3 and 4 had gelatin + a “known gelatinase” — an enzyme from a pineapple prepared by our lab professor. So as predicted, they did NOT set because there was active enzyme present. These tubes were “positive controls”– a known positive test (enzyme acting on the gelatin). Tubes 5 and 6 were test samples — tubes we were interested in the results of. And they behaved as predicted — the gelatinase from the kiwi extract did interact with the gelatin and prevent the gelatin from setting! Contrast this with tubes 7 and 8, which contained gelatin and boiled kiwi extract. Remember that heat will “denature,” or unfold, an enzyme. That’s exactly what happened — boiling the kiwi rendered the gelatinase ineffective, so tubes 7 and 8 did set (more negative controls). Tubes 9 and 10 were filled with agar, another jello-y substance, and fresh kiwi extract. This time, we were testing the “enzyme specificity” concept — would the kiwi’s gelatinase also work on agar, as well as the gelatin? The answer, we found, was “no.” The gelatinase is specific to the gelatin, and would not work on a different substrate (agar).

As I said, simple yet elegant, and very hands-on. My kind of learning.

“Synthesize.” When I worked as a textbook editor at McGraw-Hill, we used that word all the time in our literature textbooks. (Usually in the context of asking — rather, telling — students to synthesize a number of elements.)

And now here I am, a student myself. And yes, I am synthesizing, too. But I will get to that shortly.

First, what is synthesizing and synthesis? It is, according to Merriam-Webster’s online dictionary, “the combining of often diverse conceptions into a coherent whole.” In other words, taking different pieces of evidence, material, readings, experiences, and so on and making sense of them when put together. It is an incredibly complex cognitive process, far beyond mere comprehension, even above analysis.

At the university level, it is rather taken for granted that students are capable of synthesis. Homework, quizzes, and exams require it. So to do well, it is necessary. But what is really exciting is the synthesis that happens independently of all of that required work. It may not boost your grade, but it should boost your confidence that you are understanding — and connecting with — the material.

At least, that’s what it does for me. It also encourages me that I am on the right track with what I am doing. Because making these kinds of connections (when it’s not required by a professor, that is) requires not only knowledge, but interest. And a little passion doesn’t hurt, either.

For me, the lightbulb flared this morning as I was reading my biology textbook. I will be honest — reading that monstrous (read: insanely heavy) book was not what I felt like doing at 7:30 a.m. But I wanted to be prepared for my morning lecture, so read I did. While the whole selection — relating the evolution of mammals — was fascinating, the true reward lay in a nugget on the very final page: a one-paragraph blurb on a gene called FOXP2, thought to play an important role in human language. (And since language is one thing that sets us apart from our ape cousins, this gene is also thought to play a role in the evolution of Homo sapiens).

“FOXP2 … FOXP2 … FOXP2 … where do I know that from?” I asked myself as I finished reading. I knit my brow, cocked my head, and pursed my lips as I searched my brain for a possible link. Because I knew I knew that gene from somewhere. And then it dawned on me: my summer research. Olga had been looking for evidence of FOXP2 expression in her lung cell samples. Because while FOXP2 is involved in language development, it is also involved in cell proliferation (growth) in the lungs, and hence could signal the presence of stem cells.

My eyes lit up and I laughed out loud. Synthesis indeed.

As I write this, I realize that maybe it sounds strange to get all warm and fuzzy about genetics and research. But I just can’t seem to help myself.

Of course, I had to tell someone who would really appreciate this “discovery.” (Telling my husband, Geoff, didn’t quite do it — merely the letters “D – N – A” make his eyes glaze over). So I headed to my bio professor’s office hours after my last class and told him I’d had an “interesting encounter with our biology textbook.” That sure got his attention. We had a nice talk. He knows me a little better, and vice versa. One of the best parts of my undergrad education was getting to know my professors well and being mentored by a handful of them. I hope for that same kind of experience this time around as well.

I am officially a pre-med student.

Correction: I have been for just over a week now. But it hasn’t really sunk in yet, because this is still the honeymoon stage. All love songs, hugs, and kisses — no slammed doors, curse words, or broken dishes (yet).

Everybody is still in friend-making mode; there are few cliques or ways to feel excluded, if you make an effort to be social. Everything comes easily at the moment: I still remember all that we have “learned” so far, even though I’ve barely touched a biology, chemisty, or physics textbook in more than a decade. Every grade is an A right now — we haven’t had any assignments, exams, or quizzes on which to lose points. The sun is shining, the future is bright, and everyone still has a chance to get in to medical school.

Soon that honeymoon will end. There will be late nights up studying before exams. And then the actual exams. Weekends lost to lab reports after hours spent in the lab during the week. The anxiety of eventually applying to medical school. The dread of not getting in.

So why do it? Is the destination worth it?

Hell no.

Don’t get me wrong — I can’t wait to be a doctor. I think I’ll be a pretty good one, and I have a feeling I’ll enjoy it. But getting there is a long road. Years, literally, of your life. Anyone who thinks they can just push through without having any appreciation for the journey there will be incredibly miserable for an incredibly long time. And, I think, become bitter and angry about it. Yeah, that bodes real well for a person’s bedside manner, doesn’t it?

I’m one of those crazy people who actually likes school. When I’m interested in something, learning about it is a pleasure (most of the time — ask me at 3 a.m. and I might tell you a different story). I’m excited about where I’m going, but I’m also excited about what I’ll be doing along the way. And to do this, you have to be.

That’s why it’s OK that the honeymoon will soon end. Because when it does, that signals the beginning of a deeper, richer relationship with the subject matter. (For this school year: biology, chemistry, and physics.)  Sure, it will be harder. And sure, I may complain about that sometimes. I may struggle. I may even use four-letter words (*gasp*). But I wouldn’t trade places with anyone.

Stay tuned.

In my last post, I explained how I think that I might have a decent start when it comes to developing a good bedside manner–i.e., working well with patients. What I didn’t take into account in that post, however, is that you don’t only work with the patient. You also work with the patient’s family. And that can create its own set of problems, dilemmas, and conundrums, as a hospice nurse I know explained to me this week.

Take the case of Mr. Martinez,* a terminal lung cancer patient. Most hospice patients have a DNR–a “do not resuscitate” order, which directs hospital and emergency personnel to NOT use life-saving techniques such as CPR or a ventilator, but to let the patient die naturally. Mr. Martinez, a native of Argentina, does not have a DNR, although he would like to have one. Why? Because his son, who still lives in Argentina, wants the father’s life prolonged until he can make it to the United States to say goodbye to his father. The father doesn’t have the heart to disagree. While this seems like a natural desire in a way, it really is very selfish, the nurse explained–it would mean keeping the father alive, perhaps in pain, just so the son can meet his own emotional needs. And it’s not like the son never sees the father; he visits every couple of months, and has had plenty of opportunity to say a meaningful goodbye. Because what do you really gain from seeing an empty, non-communicative shell that’s kept alive by a machine?

The nurse I know said this is a common situation–family members simply can’t let go, even when the end is imminent. So it has become her job to try and convince the son–via e-mail, since he is in Argentina–to encourage the father to have a DNR. Not a task I envy, that’s for sure. It’s one that requires great finesse, compassion, and understanding. And a thick skin, to boot. All done in a one-way conversation, without facial expressions, body language, or vocal inflection–all tools that can be extremely helpful when trying to talk about something so serious and traumatic.

Mr. Martinez’s son, an out-of-town family member, is what one of the nurse’s co-workers calls a “seagull”–someone who flies in, sh**s on everyone and then flies out. They want to help, and they (usually) have the best of intentions, but they don’t really know the day-to-day situation or the intricacies of their family member’s care (or health condition). So they rather muck things up. Often, they step in so aggressively and vehemently because they feel guilty for not being there on a more regular basis, the nurse told me, so they feel they must “fix” what seems “broken” to make up for that absence. When really, the opinionated assistance often does more harm than good.

But it’s not just the “seagulls” who can cause a wrinkle in a patient-care situation. Nearby relatives, even daily caregivers, can create serious problems, the nurse told me. She related the story of one family where two sisters were, in her words, “at each other’s throats.” Just about literally, it seems. One of the sisters actually called 911 on the other sister because she felt that sister wasn’t appropriately administering the patient’s medication.

The kicker? The patient’s problem was agitation. I doubt if sirens, police, EMTs, and whoever else showed up helped alleviate the symptoms the sisters *claimed* they were so concerned about.

This is another situation that, as a health care worker, would be a sticky one to resolve (if a resolution was even possible–a temporary cease fire might be your best bet).

This is not to say that family members are always a source of trouble and ire. As the nurse told me, “Family can also be the greatest resource.” When that happens, it makes the health care worker’s job infinitely easier and richer. So you hope and pray for this scenario.

But for those times when the family members seem to be working against you rather than with you, I imagine you must tap deep into yourself for strength, composure, patience, and endurance. And still, even though it seems undeserved, compassion. Because while the family members may be making your life hell, you have to realize that their life is hell right now, too.

Come alongside. Understand. Empathize. And then maybe you stand a chance not of changing the family, but of helping them to decide to change themselves.

* Names and details have been changed to protect patient anonymity.

The title of my blog is, obviously, My Bedside Manner.* So far, though, I haven’t done much talking about my own bedside manner. Mostly because I haven’t had much of a chance (aside from the summer I spent working in an ICU back in 1999) to develop one, officially speaking.

That doesn’t mean, though, that I haven’t thought about it. In fact, I’ve thought about it a great deal. And I’ve come to the conclusion that, in all likelihood, my initial bedside manner won’t be so bad. It might even be a tad bit good. And hopefully, it will get even better as time goes on.

How did I come to this conclusion? It all started with my grocery cart dilemma. I was at the local Mexican produce market and had just finished loading my trunk with fresh fruit and vegetables for the week. I had parked about as far away as possible (not on purpose, believe me), and it was at least a sun-blazing 90 degrees outside. So when I saw a cluster of about a dozen other shopping carts circling a streetlamp in the parking lot, I was sorely tempted to wheel mine into the bunch rather than back to the storefront. But then I sighed, realizing that I am not the kind of person who leaves the grocery cart in the middle of the parking lot. It just feels wrong to me somehow, unnatural. I would have driven away feeling guilty, and I didn’t want that. So I marched off toward the store, cart in tow.

After my sweaty walk back to the store, I returned to my car and switched on the AC. As I sat waiting for the hot blasts of air to cool down, it occurred to me that my reaction to the cart dilemma might say something about me as a person. It might indicate that I can be thoughtful, even when I don’t know who will benefit from my thoughtfulness. That I don’t like to make extra work for other people if I can help it. That I have a sense of responsibility, and that I take things seriously even when so many people around me (i.e., the other customers) do not.

OK, I will come clean: I am far from perfect. I do not always take the cart back. But I tend to. And so I think what I have just said has some validity.

I got to thinking more about that tendency to take the cart back. Not only what it might mean about me as a person, but also what it might mean for the kind of bedside manner I will have. Thoughtfulness, pitching in where needed, a sense of responsibility? These sound like components of a decent bedside manner to me, as well as a recipe for getting along with my future hospital or clinic co-workers.

“Are there any other clues as to my future bedside manner?” I wondered to myself. Driving home, I thought through some of my other habits (my husband would be more likely to call them “quirks,” but then again he’s allowed that privilege). Of course everyone has habits, but I was looking for habits linked to my ability to relate to others (especially strangers), and to care for them. Sure as Sherlock, I found my clues.

“Eva.” She was my first clue. I don’t imagine she gets called “Eva,” which is her real name, very often during the 9-to-5 workday. But when I stop by the Student Union at the University of Illinois at Chicago for coffee, I do call my barista by her given name. We exchanged names a few weeks ago, and have had little chats ever since. (I’ve had to remind her of my name several times, which is fine–she has dozens of customers every day; I have only one barista.) I don’t pretend that I’ve solved all the problems in her life, but I do believe that I’ve shown her the respect she deserves, but doesn’t often get because she’s working an “unskilled labor” job (and is surrounded by hoity-toity doctors who are more than happy to point that out).

In a hospital setting, that would translate into exactly the same thing: learning people’s names, and using them. Rather than, for example, calling someone “the gall bladder in 241” or “the stroke in 332.” Yeah, not much respect for the person there. Learning someone’s name shows that you care about them as an individual person, and (in the hospital) not just about their disease or what kind of health insurance they have. That’s pretty important for building the patient-doctor relationship.

Using a person’s name is one important aspect of communication. Another is saying “thank you” when someone deserves it. Of course, when you’re at the grocery store, most people say “thank you” when the bagger hands over the plastic sacks. I’m not talking about those automatic situations. I’m talking about going out of your way to thank someone, where it really makes them feel special and rewards extra effort.

I have found that this really goes over well with people. Although that’s not why I do it. I do it, perhaps, because I like being thanked. Or maybe because my mom forced my sisters and I to write thank-you notes for every little gift we ever received as children, so it’s ingrained in my head now. Regardless, I do it. Like when I was at the craft store the other day. The cashier rung something up as regular price. I thought it was on sale. Rather than tell me to go find another item with a more accurate tag, or call someone else to check on it, she went over to the shelf herself. Turns out, she was right. Regardless, I thanked her for making the extra effort to verify the price for me. She smiled, and I think she even blushed.

In the doctor-patient relationship, it’s the doctor who’s helping the patient, and who should be thanked. So my habit doesn’t apply. Right? I wholeheartedly disagree. In any relationship, there is give-and-take. One has to help the other, and vice versa. Sure, the patient has come to the doctor looking for help, and it would be nice if the patient thanked the doctor, but that’s not why the doctor does his or her job. However, the doctor can make his or her job a bit easier by saying “thank you” to the patient. This may not work in all situations, but it will in many. For example, a patient reveals something very personal that was difficult to say, but necessary to treating a condition. “Thank you,” says the doctor. Or the patient comes early as requested to fill out some paperwork. “Thank you,” says the doctor. You get the idea. The obvious corollary of this is for the doctor to say “I’m sorry” when he or she has done something wrong, is running late, etc. Both appreciation and apology go a long way toward building a relationship with someone, and maintaining that relationship. This is the philosophy I have developed so far, and the one I intend to implement in the future.

A common thread here so far has clearly been respect. So if I want to have a good bedside manner, I want to avoid disrespect (this is obvious, but bear with me). One of the most disrespectful inventions in the history of man, in my opinion, is telephone call waiting. It has its purpose, I understand. And I use it from time to time–but ONLY if I am expecting a particular telephone call, and one that is extremely urgent. If I am talking to someone, and another person calls, that second person can either leave me a voicemail message or call me back later. End of story. Because I consider it in very poor taste to interrupt my first conversation to (ostensibly) find out whether the second call is more important, and should therefore be given priority. This call waiting fetish says much about the “NOW” need in our culture, but I will not go into that. Suffice to say I ignore my call waiting 95 percent of the time.

OK, I admit, this one won’t work in the physician setting. If, as a doctor, I am on the phone with a patient, I may very well get a phone call from someone else (another patient, the hospital, a resident, etc.) that may very well be urgent, but I won’t know that until I find out who it is or what it is about. So I will have to make some philosophical adjustments here.

However … my principal still holds in another respect: respecting a person’s time. (Because when you break it down, that’s a large component of the problem with call waiting. You’re saying one person’s time is more valuable than another’s.) For example, if a physician is talking to a patient, that physician should, whenever possible, give his or her full attention to that patient. Doctors filling out patient charts while they talk to a different patient about a potentially life-threatening condition, and having to ask that patient to repeat things because the doctor was busy writing something down on the chart? That’s not respectful. That’s just like saying, “I’ve got another phone call. Hold on.” Again, there will be plenty of urgent, and warranted, interruptions. That goes with medicine. So make those five minutes, if that’s all you’ve got, count. That’s my plan, at least.

Along with paying attention, there’s another aspect to respecting a person’s (and a patient’s) time. That is running on time. Also not always possible, clearly, due to those aforementioned interruptions, emergencies, and so on. But I have seen a number of different medical practices at work–some run efficiently, others not so much. There are ways to running closer to being on time. Those ways sometimes cost money (i.e., salary for additional staff to process patients or shelf charts). But if your patients are happy, they are more likely to come back and pay you again. And if you, your patients’ doctor, is on time, your patients are more likely to be happy. Because their time is valuable, too. Having sat in more waiting rooms than I’d care to think about, I heartily and readily acknowledge this.

None of this is to say that I am extra special, am grandly talented when it comes to interpersonal affairs, am a superhero, or am the next Dr. Schweitzer. Nothing of the sort. I’m just saying that these habits, which really (so far) have nothing to do with medicine, illustrate that I respect people in various ways and that I am willing to put myself in their shoes to make sure that respect comes across. And that, to me, is at least part of what having a good bedside manner is about.

* My Bedside Manner was the title of the original blog I started. When I migrated from Blogger to WordPress, I changed the name to Doc with Pen.

Hormigueo (tingling). Escayalo (plaster cast). Expediente (patient’s file). Presión arterial (blood pressure).

Two weeks ago, I didn’t know any of this Spanish medical terminology. Sure, I’m fluent in Spanish, but these words — as well as a few dozen (er, a few hundred) others — simply never came up in regular conversation. I’m hoping that will change soon, as I have applied to be a volunteer Spanish translator at an urban clinic in Chicago.* Which means, of course, that I will need to know quite a bit of Spanish medical terminology to successfully do my job.

I never took this position lightly. But the more I think about it, and the more I learn about interpreting, the more I understand that “professional” interpreters can make the difference between a successful and an unsuccessful clinican-patient encounter, and between helping a patient making an informed versus an uninformed medical decision. I can help make that difference. I want to help make that difference.

When it comes to demand for Spanish interpreting, the need is only going to grow. According to a 2008 report from the U.S. Census Bureau, the Hispanic population is expected to grow from its level of 15 percent in 2008 to 30 percent in 2050. The percent of non-Hispanic whites is expected to fall from 66 percent to 46 percent — meaning whites are expected to no longer be in the majority, although they will still be the largest minority. And my home state, Illinois, is one of the centers of the Hispanic population. A 2006 U.S. Census Bureau document ranked Illinois as number 5 in the nation in terms of size of Hispanic population (1.89 million). Cook County, IL, my home county, was also ranked number 4 in the nation in terms of Hispanic population size, with 1.2 million Hispanic people.

Along with that increasing number of Hispanic people comes an increasing number of “Limited English Proficient” (LEP) patients in the medical context. These are people whose primary language is not English (Spanish, in this case), and who have difficulty reading, writing, speaking, and understanding English. According to a number of scientific studies, this language barrier can cause many health care problems, as summarized in an article published in Health, Research and Educational Trust in 2006 (“Do Professional Interpreters Improve Clinical Care for Patients with Limited English Proficiency?”):

• less access to routine care
• fewer physician visits
• lower rates of preventive care
• less follow-up for chronic illness
• poorer understanding of Emergency Room visits (i.e., diagnosis and treatment)
• less satisfaction with care
• more medication complications

When it comes to Spanish, the problem is often not the lack of a translator. The problem is more frequently with the quality of the translation. Very often, “ad hoc” interpreters — people who are untrained, such as family members, receptionists, or other people in the waiting room — are used, which results in inaccurate and sometimes disastrous consequences. Sometimes, it is that the interpreters who are used are simply poorly trained. Because unlike courtroom reporting, there are no  national standards, or even guidelines, for health care interpreting at this time. The National Council on Interpreting in Health Care, an organization dedicated to promoting professional and culturally conscious interpreting, is working to develop a set of training standards (which are set to be done at the end of 2010). The idea is to eventually have national certification for interpreters.

Right now, though, we are far from that. And it is affecting patient care, sometimes dramatically. One study, published in 2007 in The Society of General Internal Medicine (“Are Good Intentions Enough?: Informed Consent Without Trained Interpreters”), found that Latina patients who were at a prenatal clinic being given the choice of whether to have amniocentesis were unable to truly give their informed consent to the procedure. In some cases, their interpreters did not fully explain what the medical practitioner was saying, either because of a lack of fluency in Spanish or a lack of medical understanding in general. In other cases, the procedure was not presented as being “optional,” but as “simply the next step in the clinical process.” In addition, it was often not communicated that there were any alternatives to amniocentesis (while a woman could have an ultrasound instead, although this test is not as definitive).

In short, the complicated nature of translating medical terminology, risks, benefits, potential complications, alternatives, etc. is something that requires more than being bilingual or “good” at speaking Spanish. It requires training and a fluency in medical terminology, in addition to privacy practices and other issues related to health care.

At the clinic where I want to volunteer, there is an orientation/training seminar where volunteers are tested on medical terminology to ensure they meet at least a minimum of requirements. In addition, I have spent hours (and I mean HOURS) studying literally hundreds of flashcards with words copied from my new best friend, the Spanish Medical Dictionary. I may not have to pass a set of national standards at this point, but I have my own standards. And I have set the bar high. Because I am serious about this job — it’s an important one, and it’s even more important to do it right.

*I’m still waiting to hear back regarding my application; apparently they are currently reviewing my references.