LGBT in America: What have we (not) done?

As I round on patients in the hospital each morning, I wear a small but conspicuous rainbow-colored pin on the lapel of my white coat. The pin is the Caduceus, the most well know symbol for medicine in society today (two serpents wrapped around a winged staff), while its colors represent the well recognized “gay pride flag.” Why do I wear this on my white coat, and is it really appropriate? After all, shouldn’t I keep any personal agenda of mine outside the clinic walls as I take care of patients? After all, who am I, a lowly scientist and junior clinician in the hospital, to mix politics or my feelings on human rights, with my work?

Nobel Laureate AV Hill, famous for his contributions to our current understanding of muscle metabolism, published a piece in the premier scientific journal Nature in 1933, speaking out against the persecution of the Jews just after the Nazis came to power, long before we knew what would come with the discrimination against the Jews: “Freedom itself is again at stake…100,000 in concentration camps, often for no cause beyond independence of thought or speech, something over 1,000 scholars and scientific workers have been dismissed…” He goes on to urge other scientists to speak out and be activists about this early discrimination against Jews in Germany. It will give you a cold chill to then read the reply from Prof J. Stark in an issue of Nature soon after that, where he replies that Germany is merely attempting to “curtail the unjustifiable great influence exercised by the Jews” and explains that such prominent scientists (e.g. Einstein) have “voluntarily given up their posts” while those in concentration camps are there “because they have been guilty of high treason…” Of course, we now know what would come from these early anti-Semitic movements, and history helps us easily side with the correct view on the issue. While current discriminations do not begin to approach the travesty of the holocaust, it helps to remember that the holocaust began as simple discrimination against a group of people.

One need not look far back in our own country’s history to see embarrassing examples of blatant abuse and bigotry toward other humans. It was once commonplace for Americans to own slaves; even after their emancipation, gaining equal rights with white citizens continues to be a long, hard fought battle. Likewise, women were not allowed to vote, much less contribute in most positions outside the home until relatively recently. Even today, they may struggle with being paid less for equal work in the workplace.

Luckily, these “norms” of society have been gradually changing as one, then two, then more people stand up and speak out against them. Today, with history on our side to offer important perspective, it is easy to criticize our ancestors and their seemingly tremendous ignorance. Yet what do we do today that future generations may judge us by? In one of our major historical guffaws, we now discriminate against people based on sexual preferences they have. Sadly, this is something we will all one day have to answer to our grandchildren: Imagine the questions: Grandpa, did homosexuals break the law? Were they hurting someone? What if someone decides that liking chocolate ice cream is bad – will I think be denied rights because of what I prefer in my personal life?

All questions of nature vs nurture aside, the simple fact remains that we have discriminated against a large population of people for a long time for no crime or disruption. Fortunately, this great country has a rich history of at the very least trying desperately to correct our grave discriminations of the past (e.g. affirmative action, title IX in sports). Sadly, these stopgap solutions are often delivered too little, too late, and with many problems. In the current situation, the solution could be simple – grant all people regardless of sexual preference equal rights. This includes the right to choose a partner one loves and marry that partner should one choose. Individual religions would still be free to define marriage as they see fit.

AV Hill used his prominent position in society to speak out against discrimination of a group of people; imagine if he had been better heard. In medicine, too often lesbian, gay, bisexual, and transgender (LGBT) individuals are given poor care by clinicians with little understanding or empathy for who they are. While my simple gesture of wearing this lapel pin might not change anything, my hope is that when my LGBT patients see this, they know they have a provider who respects and cares for them, and feels they deserve equal rights and standing in society. If respecting all people’s rights is ever considered inappropriate or unprofessional in the clinic, then I’d rather take off the white coat and walk away before I take off this pin. I hope you too will find your small way of supporting those we continue to discriminate against in society.

(Finally, while I welcome replies, I would caution that going on record as supporting discrimination of any people is often viewed unkindly by future, more informed generations. As you might have guessed, Prof Stark eventually was arrested and served time in prison after WWII.)

Normal Burns - Ice??

I am not sure I am going to keep doing this, but I figure I might as well list a few posts of "common injuries" advice, since I get to learn this stuff, question it, and practice it everyday now...

When you burn yourself in the kitchen when touching a hot pot or pan, most people put ice on it - DO NOT DO THIS. Simply run cool water over it and then monitor it over the next day (severe blistering, turning black, etc may be concern for more severe injury and need for medical attention). Putting ice on a superficial burn only causes vasoconstriction to underlying dermis and causes the injury to worsen.

Please feel free to respond to this blog with questions for me to answer!

Recumbant Bikes in Hosp Rooms

Why is there no exercise equipment in the hospital?

Why aren't there trainers or assistants to get my patients moving? (PT evaluates and often cannot see them that much - they need trainer like people)

Why do we leave these people lying in bed all day? Who thinks this is at all a good idea, particularly after surgery, where you risk collapse of alveoli in lungs and clots in the legs from just sitting. Instead, why not have recumbent bikes next to each bed? They can strap in and just pedal. I am going to ask for a grant to do this study I think, but from who?

Surgery: In the OR

First of all, I LOVE surgery and will likely operate in some way for a career. They have a problem, then they work to solve it. And its fun.

Second, I am going to tell you a true story:

In my FIRST day in the OR, I am scrubbed in on a case (sterile) along with the resident doctor and the attending doctor (a BIG shot pediatric surgeon). Well, she is yelling at nurses about everything and just not happy about the scene in general (in really crazy ways, like expecting unreal things from them).

So, she is doing stitches and I am "following" her (holding suture and pulling as she goes). Suddenly, her hand is pulling a stitch through and she brings her hand UP BY HER HEAD to pull the string taut. I am standing there and get hit in the HEAD with her hand. I have not moved an inch. She flips on me - "get out of here! you just ruined the sterile feild - scrub out and dont even think about scrubbing back in!" I backed away, staying calm, then derobed and stood in the corner as she went on. It was awkward, but a great story (not doing it justice here I guess).

Funny thing is it never bothered me - it was kind of funny, kind of sad, etc. But none of it really bothered me other than it gave me a GREAT story to tell!

The next morning we had breakfast together and then did an operation together where she was really sweet to me. However, she tore a new nurse a new one over the culture tubes.

(full story is funny)

Long story short, I love surgery, even with these maniacs. We have a problem, we talk about, then we go fix it. And to boot the residents say hello to me and introduce themselves to me. Its actually a good atmosphere. No bullshit time wasting so far...

Anyways, to bed for me - we have 4 nonemergency cases tomorrow (which means with emergency it could be much more).

I am finally looking forward to getting up in the morning.

I spent today following a young intern around, and then his attending.

I hate this all. Here is why: when someone "outranks you" here they treat you like less of a person. For example, you will start a question like, "Ok, when I get back from this meeting, where should I meet you" and before it all comes out person outranking you has turned away and is talking to someone else. If I want to speak I have to wait to be achwkowledged (Which will not happen) or just want til he is done talking to the upper ranked person and try again. It's just hospital culture - you outrank someone so you treat them like shit. It is absolutely absurd. I feel bad for these people. Everyone treats everyone like shit here. I am done with it. These people do it bc they ve dreamed about being a dr and part of this special club since they were little...well turns out the special club treats each other like shit.

When you think your doc is being kind of a prick to you - think about this: you are seeing by farrrr his good side.

Of course there are some great docs AND great people, but they are rare. Also, for a long time one of our senior deans has asked "why are the students so nice as first years and full of ideas and energy, yet they leave apathetic, tired, and just obeying orders?"

The system does it. If given the chance I wouldn't do it again. Each day it chips a little more away from me and I have no idea how to hold on to who i am.

Fleeing the Madness

It has been over a month since I posted. In that month I grew to like medicine less and less. In fact, while the science of medicine is still my love, the actual practice of medicine has chipped away at who i am day by day. I find myself readjusting my goals in life each day. And it's hard to pin down exactly what is so difficult.

1. My expectations were way off. I thought it would be more about medicine, science and learning. Instead it's mainly about rank and prestige. It's actually quite sad cause now is the time we need good doctors.

2. Constant pressure from others telling me i need to "beat" my classmates. This surprised me. Why am i trying to beat them? Should we not be working together to some greater good? From all angles people are telling me, "all you need to do is make honors" on medicine and surgery to get a decent residency....Well, to make "honors" you need to be in the top 15% of the class or so. AND, this is based on eval letters from housestaff at the hospital and a final exam. Remember, this is 100 people out of 6,000+ that applied for our seats in med school. Its like taking the best player from each NBA team and putting them on one team and then saying "Now you 5 play together out there, BUT the one that scores the most points will get the big contract!"

It ain't exactly the best way to encourage team play....and this is in a hospital! So you get students sneaking out to go study, doing the least they can to "get by" with their patients...It's a disgusting way of doing things. Why in the world would you have grades at this point? It should be a final you have to PASS to demonstrate proficiency in the area and then comments/letters. The grade should simply be pass. It is all so absurd and simply engenders poor pt care. I learned VERY early NOT to look deep into the literature on my pts problems, but memorize a list of things from a book to spit back. That is what is encouraged. That is what they want.


No wonder health care fails here in so many ways. For as creative as we are in every other industry, medicine has failed to understand the value of good minds and creative people.

I wish I could change it, but I don't see how. It seems too big. My only vision is to start over with my own medical school.

In the last few days I started to readjust my goals in life a bit - perhaps to be outside of the madness that we call medicine in this country...

Talk about a tough crowd: on making a dying man laugh

I haven't posted in the past few days because i have been relatively depressed by medicine in general. I have found my niche, so things are getting better, but it still tends to NOT be how I want to spend my days. I miss the lab so much more than I ever thought I would. A few of the recent things that have happened in my last 4 weeks. I have spent the last 2 weeks in the ICU at Memorial Sloan Kettering Cancer Center, the 2 before that in the Coronary Care Unit (CCU) in NY Presbyterian.

In the CCU, we "round" for 5 hours each morning. This is where you walk around to each room with the housestaff (Residents) and the Attending (older doc thats in charge). One morning on presenting my patient I said "he had a thrombus (clot) in his (specific vessel) so they went in and removed the occlusion". My attending is crazy. She was like "woa woa woa, they removed an occlusion? How do you remove an event???" I reply, "like i said, the occlusion was a thrombus, they removed the thrombus" "RIGHT, they removed the thrombus, ...." on and on she went.

As busy and stressed as drs are I cannot imagine this helps, especially as we know stress, fatigue, etc leads to many errors.

Rounds today is this intimidating time when everyone tries to shine and the attending picks at whomever they can. I actually don't mind it - I often just laugh at the attending. BUT, I do not think this is good for patient care - but people don't seem to care so much about that it seems. As one prominent physician that trained at Harvard told me "at rounds it was a feeding frenzy - you came ready to knock anyone down you could and show your stuff - if a little patient care came out of it, fine, but that certainly wasn't the goal."

In the ICU, I had an attending correct me for giving him the Ventilation settings NOT in the order he wanted. This is more humorous when you consider that I was giving the info in the order that the last person I was with wanted it in. I just laughed and said, "ok, what order do you want?" And he said about 8 things more quickly than I could write them down, when it was obvious i was trying to write it down. The point wasn't to do it that way, I learned, it was to lightly haze me. Patient care? Not so sure that is high on the list.

Actually, things have gone quite well. I guess I am giving you only recaps of the things that bother me. In reality, I have had some AMAZING residents take me under their wing and help train me. Both of my last 2 weeks I had a patient mainly to myself. Both pts will die sooner rather than later, which it turns out is where I excel. My gift so far has been talking to families about diseases and what they mean, particularly with an eye on death.

Turns out I love nothing more than making a dying man laugh or explaining to a spouse what a disease means and putting all the articles on treatment I read the night before in context of the patient. My lab interests fuel my interactions with patients. Particularly, I find that as much as I want to leave medicine and go into comedy or some other public speaking avenue where i can tell jokes on stage, I have found nothing more fulfilling than making a dying man laugh.

I'll close with this, about my patient with incurable and untreatable stage 4 (spread everywhere) esophageal cancer:
I watched as people came in and out of his room, the psychiatrist, the family, the cancer team. All with the same looks, all with the same news. Time to be comfortable, we cannot treat you - you are too sick. Any chemo would kill you. We are sad the family says. Can't you fight more the wife says? Can you help him suffer less the mother of the man says to me. In and out of the room they go, he sits there, stoic. I talk to him often. In fact, I am in there with every team that comes in, and unlike the docs from different teams bouncing in and out on to different rooms or lunch, i began to feel the dreary mood in the room. He never has the luxury of escaping it. I share with him that my grandpa was a merchant marine like he was. He smiles politely and says nothing. I let him be for days.

After some days, many with intense talks of death and DNR orders, I walk in to update him. "Matthew," he says. "Yeah?"

"What did they find on the spit - the test where they had me spit up stuff?"

"Oh, nothing really. They found bugs, but its the usual bugs that live in your mouth"

I realized immediately that explaining this concept was probably fruitless- I should have just said "they found nothing" rather than try and explain they found normal oral flora which means nothing.

"Bugs???" He said wide eyed.

"NO no" I said, "you know how those yogurt commercials talk about how its for the good bacteria of your gut?"

"yeah" he said.

"Well they found some of the good bugs like that - so you have no infection...think of this way, from mouth to butt, you got bugs, and that's what we all have, its normal."

He just broke up laughing, the first time I had seen him laugh. I cannot explain the feeling.

"From mouth to butt, I have bugs, eh?" He says and then laughs more.

"I like that, you're funny man," he says.

I wasn't sure why it was so funny, but I just laughed with him.

I've made big groups of people laugh at me while on stage, or college classes laugh as i taught, or my family laugh at the dinner table. But none of these compared to the feeling I got from making a dying man laugh. It is all worth it, it turns out. For that one laugh. My grandfather died years ago from esophageal cancer. My mom wanted me to travel up there with my dad so I could keep the mood upbeat, be funny, lighten the atmosphere some in the tough times. I'm not sure I did anything particularly special on that trip, but it opened my eyes to how my gifts could help the dying.

We all die, there's no reason to be in a bad mood as it approaches.

Goal: Family Medicine...in Rad Onc

I noticed that I get the most satisfaction out of the patients that have extended stays - particularly the ones that we end up providing palliative care to so they can die in peace. The patients here emergently or just for a day or two bring me no pleasure- for me there can be real care in taking care of someone over a long time.

Thus, today I had a vision of Family Medicine for my career, but within Radiation Oncology. I could provide palliative care to my patients or whatever their need might be, but they would become part of my "family." They would have email and phone access to me as they went through their cancer struggle. Just like family it would not be for emergency purposes (yes, I would still go on vacations, live life, etc), but it would be like family - they could call when things got difficuly, particulary if they were left with no family to be there for them.

I have noticed that both my grandmother and mother (and father) would take people into their house at all times, making many of our friends part of our family. And it wasn't unique to any of us - I have a brother that my sister once dated and a best friend who visits my family without me sometimes!

My vision is to have a small practice with cancer patients like this...unfortunately, this niche is hard to carve out in our current, fragmented system!

Watching Death

The weekend was WONDERFUL - a sad reminder that I just dont like practicing Medicine, atleast not how it is practiced here. In fact, more and more each day I understand why Docs seem to pick their specialty based on the people in it with them. I understand why a 55 yo Dr contacted our lab at Auburn because he was sick of spending his days with MDs...I get it. Its a nasty group. As I explained to Mandy tonight, they all think they are so pleasant, so clever, yet most of them are complete bears to be around, atleast so far. Felt like they were rushed or rude to you at your last visit? Join the club - they re like that to me too...When I arrive in the morning no one says hello. I simply join the room. When I leave, I say bye, but to whom? Myself mostly. And the bad choice I made by pursuing a life in medicine. I will be clinically depressed if I don't find relief. The only way I have learned to do this so far is by getting up and just walking into one of our patients rooms...I continue to be AMAZED at how wonderful patients are.



I have also learned that I want to do palliative care and NOT round with a team each day. I want to TEACH the concepts of medicine (does anyone do this anymore??); ideally I would teach most of years 1-2 in a medical school AND practice where I can make complicated, calculated decisions for my patients. Ideally as they face life and death. Radiation Oncology continues to be at the top of my list. I HATE how in medicine we "hear" a case from a colleague in 3 minutes, make huge decisions, and move on to assimilate the next data on the next patient in 3 minutes. It really is crazy. I want to follow patients long term, ideally dying ones. Its hard to explain why, but I like helping people at the dark time when so many seem so timid. It's part of life, death it, we all go through it at the end. Rich, poor, famous, etc.

Today we had a patient who looked wonderful get terminally extubated. I heard it was coming (we had her in the ICU for the last week+ and I thought she was one of the healthiest in there!!) Her only problem was that she couldnt breathe on her own. Today I heard she was going to be extubated so she could die in peace. All of her loving family were there to say goodbye. She was alert, oriented, and answered with nods of the head and facial expressions (Cannot speak with trach tube in!).

Later in the day, I saw the resident directly in charge and simply said to him "I am very interested in palliative care, and I dont want to get in the way, but iw ant to learn about how these things work."

"sure," he said.

"So i can follow you?" I asked.

"yes" he said.

And I did. The pulmonary specialist, the resident, and me joined the family in the room. We answered the woman's few remaining questions. Her husband sat teary-eyed holding her hand the whole time.

"You've been very brave," the specialist said. "We are not going to let this be uncomfortable for you."

There was a sad smile in her eyes. Her daughter in the corner of the room cried. She was certainly too young to die, but her lungs refused to work, and the only option left was a nursing home, where we would just wait for infection to kill her as she lived out her final days away from her family on a ventilator).

They then explained to her how it would go. "We are going to up the morphine and then we will pull these tubes out...it will make you cough and choke. Before you breathe in, I need you to couch and spit as I pull it out." She nodded sweetly.

The morphine went up. People cried.

I stood at the bedside, trying to not be in the way. About 10 family members were in the room with us. The pulmonary specialist, a resident, and a nurse stood there too.

The tubes came out. She choked and coughed.

Her husband encouraged her to cough and patted her back. People cried. I stood there.

Coughing went on for about 2 minutes, then she layed her head back, eyes open and breathing.

The respiratory doctor said she did good and "goodbye." He left the room. I was confused, I thought we would all stay as she died...

Next my resident left and the nurse stepped out. It was just me. I was confused. Now what? Luckily, nurse and resident came back, and then when resident left again I left with him.

Oddly she was still alive and eyes open as her family held her.

I found a senior pulmonary care doctor I knew from class in the hallway to ask him what was going on.

Basically he expected her to live for several hours after extubation.

"Oh, she will live for hours like this" he explained.

"At some point the CO2 will get too high and simply put her to sleep as her breathing fails."

I realized I knew the physiology very well, it just never occurred to me how this might play out in a person in ventilatory failure - it could take hours, not necessarily minutes.

I also thought it was one for the nice perks of medicine that we supply high narcotic doses so patients do not have to choke and drown and suffocate as they leave this world.

Yes, more and more Radiation Oncology captures me - a chance to do calculated, precise work and palliative care with a large amount of research.

Time of death for her? I dont know, she was alive when I left tonight. I am quite sure she will fall peacefully asleep tonight. Forever.

What's this VO2max stuff?

All week I have been in the Cardiac Care Unit (Cardiac ICU). What an experience.

Medicine culture is really silly. By law, you are not allowed to listen to anyone "below" you. Good example: my PhD is in Exercise Physiology, where one of the things you do ALL THE TIME is measure gases that people breath during exercise testing. You might have heard of VO2max- the max amount of oxygen your body can use. Thus the equation is just VO2 = bloodflow X difference in arterial and venous blood oxygen. Thus, you know how much oxygen was used by the body. It is that simple. In the resident room a Cardiology Fellow (has been a dr for several years now) was trying to figure out cardiac output of a patient. Use that (VO2max) equation someone says.

"Yeah, VO2max - what does that mean again?" he asks.

They google it.

I sit smiling, thinking "really guys??"

"You must be able to estimate it from body surface area" he says.

I cant take it anymore "you definitely CANNOT estimate it from body surface area" I say.

They dont even turn around. "yeah, maybe not" one says.

"No, you definitely cannot," I say. "the variability is huge."

they ignore me and move on.

They go on to discuss what VO2max is. It is funny to me b/c this is my bread and butter. And it aint like I "Studied it as an undergrad" or even "did a thesis on it" as many young doctors like to say. (e.g. "yeah, my masters thesis was on heart failure"). My PhD is in this stuff AND i taught it for 4+ years at a University.

Sadly, in medicine it's all about ego. Why would i ever be able to teach them ANYTHING, i'm below them!! It's a sad sad culture.

On Life and Death

Our terminal patient who was going to die on extubation Sunday: things changed. A cousing flew in and changed the wife's mind. When I went in Monday he was still alive, and alarmingly, fitting the ventilator pretty hard (did NOT look comfortable). They were going to prepare him for surgery, etc they said.

We were sad - he had expressed that he did not want to live like this, yet not everyone was prepared, so on he lived.

When we came back Tuesday they had changed their minds again - he would be extubated and let die. Everyone was now ready.

Finally, today we returned to see him, and they had extubated him. He was gasping and gurgling, arms flailing. To our alarm the family had STOPPED his pain medicine drip that morning. I almost lost it. It was one of the saddest thing youve ever seen, and I'm not sure they even realized it. Doing what they did was purely selfish.

We immediately ordered the pain drip back on. I was disgusted. Here was a man who clearly said he did not want to live with tubes, etc and now they had stopped his pain meds because they seemed to think he had some chance of living that way. It was sad - he was drowning in his own secretions - choking on his spit and flailing his arms, unable to get air. I listened to his chest and could not even hear his heart through the "rales" of fluid in his lungs.

His eyes bulged out his head. He strained.

When I left he was still alive, if you can call it this. Hoepfully he was not in any more pain.

Lesson? Listen to your doctors as your loved ones approach death. There is one thing we ALL have in common - we all die. But we should be able to choose to die in comfort, not choking and gasping for hours on end. Sadly, most people only realize how this goes once they have already been through it.

In these times, think of your loved one that is dying,not yourself. Think of what you would want and what they would want. If you are unsure, ask them, get them to put it in writing, AND ask them to assign a health care proxy in writing as well. This is person that makes the health care decisions in difficult times like these.

What a tragic day, BUT it confirmed further my desire to work with terminal patients.

On another note, my residents all wrote extremely nice evaluation notes about me and my work on the team.

Are we all Charlatans?? On Evaluations

Time for end of rotation evaluations. I actually am supposed to hand these forms to people and then ask for them filled out with grades and comments about me. Upon talking to ANY upperclassmen I have been told this:

"Have them fill it out and give it back to you. Even if its sealed open it - if yuo received even average marks throw it away. Cornell doesn't track how many you get, only what you get score wise. An average mark from a resident that doesnt get it kills your chance of honors."

Even in my lame attempts to protest this i have been told "gotta learn to play that game, that's all. those that work hard and dont play the game get screwed, period."

It just made me reflect on how so much of training to be a Dr is about schmoozing, almost like we are salespeople. I guess in a away we are, always trying to convince people to do things healthier.

either way the eval stuff seems crazy.

July 22, 2011. Medicine: DEATH

Today at the hospital we got to deal with one of those life and death ethical situations that you learn about in cheesy "medicine, patients, and society" classes that most blow off. Turns out those classes are pretty useful.

This patient is an older man on a ventilator, unable now to breath on his own. He has a wife and children here and other children in other parts of the world. They do not speak English. They also are from a culture that views surgery and intervention as extremely dangerous. One family member referenced someone in their family who had a surgery and died when we were discussing his need for a permanent trach tube and a line into his stomach to feed him.

When we rounded on him in the morning, the sedative was letting up some and he was responding to our requests to raise his eyebrows, close his eyes, etc. Because he had a tube in his throat and was restless we turned up the sedation.

Suddenly three of the daughters arrived. We explained the situation and they argued over what to do. One wasn't ready for him to die, the other said he would never want to live like this. We explained we could send him to a nursing come cognitively intact but with a trach tube and a tube to his stomach. They argued, we asked where the wife was. She was in NY, somewhere, but old and unable to easily travel. We finally explained that if she were to come to the hospital, she could decide on what to do with him. Otherwise, all the 10 children would need to sign that they agreed with extubating him and letting him die.

Finally, the wife came and made the decision. She said he didn't want to live like this, and that was that. He will die on Sunday, when they remove the tube and say goodbye. I could go on forever about how we keep people alive for way too long, thinking "being alive" is the same as "having life." If we wanted, we could keep blood clean (dialysis) and lungs breathing (ventilators) and blood pumping (bypass) for years and years...Sadly, many people don't have living wills (directions as to what to do) or a "health care proxy" - someone designated as the decision maker.

Make someone a health care proxy today...let them know to the best of your ability what you would and would not want to live with, and then fill out your states papers showing this. Then let your family know. This way, one person is clearly in charge, and if your wishes are known to the family, there isn't much to argue about come that ill-timed moment that many people haven't planned for. We all die, so there is no harm in talking about it now to make it easier on everyone.

I went to look for Rico but he had been discharged to come back to the Onc clinic.

July 21, 2011. Medicine: METs

This morning we received a woman going through alcohol withdrawal. This of course can be very disturbing. She is heavily sedated, and yet when we ask her to stick her tongue out, it shakes wildly, fasiculating like I didn’t know a tongue could do. She hears bugs crawling, her hands are shaking wildly. This lady will die if we don’t keep intervening. After some other decisions, we decide we need a blood sample (I actually don’t remember why now).

My resident turns to me “You can get the blood, right?”

“Of course,” I say. As a medical student anytime you can do a procedure it’s a good thing. I gathered up my supplies and we all walked over to the bed. But as we looked for good veins they just weren’t there. Finally a resident told me to just get it from the radial artery (arteries don’t collapse like veins do – you should really always be able to get into an artery and get some blood).

I began feeling the wrist and then cleaned it. A resident gave me a few pointers.

“Feel the pulse with both fingers, and dive right between them with the needle,” he said.

Since I was on the left side of the bed, I held the shaking arm in my right hand and the needle in my left. I didn’t even think about it. During my PhD training I had done dog surgeries. For whatever reason (thinking I might pursue surgery one day) I began doing the surgeries with my left hand. Many dogs later I was almost equally good with needles and suturing with both hands.

“Is that your dominant hand?” the resident asked.

“I use both” I replied, as 5 doctors and a nurse looked on.

I dove in with the needle. Boom. Bright red blood on the first try!

“Nice work!” a few of them said.

Walking away I realized what a cocky asshole thing it was to say that right before I dove into her artery with the needle in my left hand. Luckily, it worked and felt pretty easy. Luckily.

On rounds in the attending's office he was explaining a complicated acid base problem to us. He is brilliant and seemingly knows a ton about a ton. But I noticed he was saying the completely wrong enzyme in talking about glycolysis.

“And PFK is inhibited, so pyruvate backs up” he said.

“PFK? You mean PDH complex” I asked him. (PDH is the correct enzyme).

“No, PFK” he says. And explains it again.

I just sat there.

You have to understand the hierarchy in medicine. The attending knows TONS of medicine. Under him are many other doctors, the residents and interns. Interns are first year MDs, and residents are in their residency, which is anywhere from 3-7 years after getting their MD. They run hospitals, with an attending over teams of them. THEN there are a few medical students scattered over a few teams. That’s where I am. Each interaction with a doctor is a grading opportunity. They all evaluate you, all of 3rd year. And the cumulative result is how good your record for residency applications is.

Finally I couldn’t take it.

“I’m sorry, did you mean PDH?”

“No, PFK.”

“You’re saying pyruvate into mitochondria and TCA cycle, right?”

“Yeah”

“Yes, that’s pyruvate dehydrogenase” I say.

“I think its PFK” he says, and he looks it up on his computer. He sees it is PDH.

“Oh, I guess you're right,” he says, and moves on.

It felt weird, correcting him, but PFK and PDH complex are two VERY different enzymes with two very different jobs and what he was saying made no sense. I really was confused as to what he was saying. Nonetheless, I am sure my grade just dropped a few points. I am told that that is who wins in medicine - the ones who respect their elders and don’t questions things.

I hope they are all wrong about this. We need more thinkers in medicine.

The scan of RICO’s head came back. More mets. I went to find him on the Onc unit but couldn’t find him in a room. The computer says he is in the hospital somewhere, but I couldn’t find him.

At this point we don’t need the pathology results. He has testicular cancer everywhere. And somehow the surgeon was worried about an ambiguous ultrasound. More thinkers needed.

July 19, 2011. Medicine: RICO

The next day I made it my job to just hang out with Rico. We had gotten the CT back and there was a very large lymph node. On rounds that day I went straight to the attending to suggest we do a brain scan. He thought and said, "yeah, I guess you're right, we should."

One resident thought it unlikely.

"Just to be sure" I suggested, thinking I knew full well there would be mets. How could there not be at this point? We know many testicular cancers go to the brain, and this one has already destroyed his lungs.

Two out of the three markers in his blood were very high, telling us it WAS testicular cancer. These markers are simply never this high for anything else. The ultrasound was ambiguous – it looked like lots of water the physician reading it said, with some strange nodules.

I sat in his room and explained everything to him from how cancer spreads to what type I thought he might have and what that might mean. Hell, I even told him about My mother’s disease and about Lance Armstrong.

“I’m really sorry to hear about your mother’s disease” he said. I felt like an asshole for even bringing it up.

He opened up to me and told me things I never would have imagined. He came from Chile originally, with his brother to work. They both stayed. All the other family was in Chile. A few years ago he was scared of the surgery and was told it was a hernia; cancer was never mentioned. I asked if he had gotten ahold of his brother, as I had seen no family since he got there (and to make it worse he had been on isolation ‘til we ruled out TB).

“My phone is dead man, he doesn’t know.”

I was shocked. I let him use mine but he didn’t recall the number – like most of us it’s just programmed in and we never actually dial it. He told me had a blackberry, so I went off in search of a charger.

Looking for the charger it hit me: This kid stopped by the hospital with a bloody cough to get checked out. We isolate him only to come back and tell him he has cancer. His phone is dead and he can’t get his one relative here. Tell me a worse nightmare.

None of the nurses on the floor had one. Into the residents room I walked, “It’s for a patient, not me,” I say to a room of 20-30 young doctors. “But does anyone have a charger for a blackberry so he can get his family?”

“What is this, a hotel?” one yells. Another mocks me.

“Yeah sure, admit it if its for you!” Another says.

I just walked out. I could’ve killed everyone that opened there mouth. I searched on.

Amazingly, one of the nurses had one in her pocket for reasons like this.

I got him the cord and he got his brother. We also had a chance to talk more as it charged. When I left to check on another patient and came back, the social worker was leaving.

“What was that all about?” I asked him.

“The social worker – telling me they’ll pay for this visit but for nothing else since I don’t have insurance. No follow up, no treatments.”

“Wait, Rico, why don’t you have Medicaid?” I asked.

We looked at each other.

“You aren’t a citizen here are you?”

“No.”

He went on to explain all about how it works. Making a living, not getting deported etc. Not following up with a surgery for a hernia a few years ago now made sense. Being so stoic in front of us now made sense. He didn’t want to get deported.

“Rico, you HAVE to get chemotherapy,” I told him.

He looked over at me, as if all along he knew he wouldn’t get it.

“Without it you’ll probably die.”

He looked at me, eyes moist. I reiterated it.

“Rico, the film is awful, you have cancer all over your lungs. Now we have blood markers back, and we found another lymph node that is huge. You have cancer. You need chemotherapy or you will die.”

A long conversation followed. I explained it all to him. He was calm but understood it.

“You are going to get the chemo, Rico,” I told him. “Somehow you will.”

I left and talked to both our team and the Oncology floor. It was decided that he would get admitted for each Chemo treatment so that it could be paid for. Meanwhile, I overheard a surgeon on the phone saying he saw the ultrasound and it didn’t look conclusive so he didn’t want to operate. I could’ve smacked this guy. Blood markers through the roof, chest film with METs, testicular mass, and para-aortic lymph node (the correct ones from testis). And he was stuck on one ambiguous ultrasound. He delayed the surgery for at least a day. I only read it in the chart – he never told the patient and he never told him he could eat (he had been fasting all day for the surgery). It was disgusting patient care.

I walked down and told the patient, then asked the nurse to bring the poor guy some food. Finally, his brother arrived and I explained it all again: Medicine, Surgery, Oncology, and Urology are all were working on it, I told him. Then I told them both everything I knew about it, every test we had run, every conversation I had about it. "Likely cancer, and likely bad," I said. "How bad? We’ll know when we get the pathology, but people beat this all the time," I told them. "All the time."

July 18-19, 2011. Medicine: CANCER

Staying late to take call, my team started to get new admissions from the emergency department. One patient had come with coughing blood and shortness of breath X 5 days. I sat with one of my residents reviewing his records. Then we hit his chest x-ray. It looked terrible. White messy stuff everywhere. We looked at each other – what in the world is this? We tossed around ideas – a vasculitis (inflammation of vessels), infections (although we didn’t know one that looked like this), metastases from cancer? The thing is he was 29 yo. Hard to get such nasty looking lungs when you are 29, and it didn’t look like the diseases I knew (I knew it wasn’t TB).

The next morning before rounds our attending was very impressed with the lung film. “Wow, what is this??” He exclaimed upon seeing the film. We told him the top ideas – atypical pneumonia, vasculitis, maybe mets, but he reports no pain anywhere else. Later in the conversation our attending says, “of course, a guy this age, what should we check out just to be safe if we think mets?” I respond “his testicles.” “Exactly,” he says, “just to be sure.” (Testicular cancer hits mostly 20-40 yo).

In his room we went through a bunch of things with him. Finally we casually asked him to pull up his gown. My heart sank. I could not believe what I was seeing. His testicle was the size of a grapefruit. I knew immediately he had testicular cancer that had spread – it was likely in other places too – bone, liver, brain, lymph nodes.

We all examined it and walked out of the room. One resident said that it seemed mostly like fluid though, not a mass. I agreed that it was interesting, BUT we already know its cancer because we saw the film; it fit EXACTLY the clinical picture. I would soon learn that this idea of the “clinical picture” is reasoning new drs (and some old ones) seem to not have. Why would we think for a second that this wasn't testicular cancer? We saw the scary xray, we thought 'this is crazy,' then we said the only thing it might be is mets from a big testicular mass. We then saw just that – a big testicular mass! How could we make an argument now that he has a mass of only fluid (not cancer) AND mets from somewhere else at the same time? The odds of that would 1,000,000 to 1. Yet some people do one test and let it lead them totally astray. Little did I know that over the next few days this would become a bigger and bigger issue.

We ordered blood work for HCG, AFP, and LDH, and ultrasound of his testicles, and a CT scan. All looking for cancer.

I decided to follow him as my patient since I intend to go into oncology as a specialty. Later in the day I returned to chat. I just sat down and watched some TV with him. Seems stupid but I knew he needed someone to help with this stuff, and not one family member had visited. I also didn’t know if he understood exactly what we thought was happening.

After a few minutes the Urologist dropped by.

He introduced himself to both of us, then told me to grab some gloves so I could do the exam with him. I did just that.

Then, like a real teacher, he walked me through feeling the testicles and then checking the rest of his superficial lymph nodes.

“Ok, Rico, I’ve gotta check out your prostate” he says. Rico rolls over.

Urologist looks at me “Get over here and get in on this too” he says. Now, seems odd to most, but this was exactly how you have to teach in the hospital, particulary when it comes to sticking your finger up a patient’s ass. The last thing you want is him to ask “Matthew, would you like to stick your finger in this guy’s ass?” But he knows you gotta learn. I walked over.

“How many of these have you done?” He asked me.

“One.” I was trying to talk so Rico couldn’t hear me.

“Ok, well, you’re about to get number two,” he says cheerfully. His prostate was normal.

We took our gloves off and he broke the news to Rico.

“You have testicular cancer that has spread to your lungs. We will need to remove the testicle soon and you will need extensive chemotherapy.”

Rico took it all very stoically, asking only a few questions. It did get revealed that only a few years ago a Dr. noticed a lump in his testicle and scheduled a surgery. At the time, Rico was told it was from lifting heavy objects, and when the pain went away, he skipped going for surgery. Turns out it was cancer, and now its destroying his lungs.

After the urologist left I went up and broke the news to my team; Rico knows the deal, he has cancer as far as we can tell (the true diagnosis comes back when a biopsy from his lungs returns). I said goodbye to him and went home. I wanted to give him a bit of time to digest what we told him. 29 years old. My age. Cancer.

July 17, 2011. Medicine: BEDPANS

I finally get to admit my own patient with a full H&P. Problem is that shes postictal (after a seizure) and this barely arousable. Luckily, her boyfriend shows up and explains to me exactly what happened. This is a story in itself. Turns out that most people are simply poor story tellers (seriously, think of the last dinner party you were at where person X droned on and on, jumping back and forth between past and present, etc. Now imagine trying to summarize that story CORRECTLY to someone when you got home. It aint happenin unless you ask LOTS of questions to redirect them to some sort of timeline (e.g. "now wait a minute, a few minutes ago you said she has seizures every night, now you say once a month - which is it now?...REPLY: yeah, what i meant was 5 years ago they were every night, then for a year or so every month, now every night..." And on and on.

At any rate, the best part of the story was this:
Lethargic, postictal woman BEFORE boyfriend arrived, "Doctor, I really need to pee."

Now, she is obviously in no shape to even sit up, much less walk to the bathroom.

"Ok, let me get a bedpan" I tell her.

I walk to the Nurses station, "umm, I'm sorry, where do I get a bedpan."

Nurse laughs, then shows me.

I return to her "Ma'am, I'm sorry, I've never actually used one of these with a patient, how the heck do i do this?"

Nurse laughs again and says "no problem, I'll come show you."

As we walk into the room I already feel a bit silly about all this, but I keep thinking that I am just looking out for the patient, so its ok. PLUS, the nurse has been VERY nice to me about it, so I was happy to learn.

Learn I did. As we uncovered the patient and rolled her over what do we see?

A foley catheter draining her bladder.

Nurse laughs at me. I laugh at me.

"Let's just keep this between us, eh?" I say to her.

"Happens all the time," she says "don't worry about it."

I put the bedpan down in the corner, not wanting to walk back out with it.

Clinical Medicine Begins

Clinical medicine. I have started year three of medical school, which means clinical medicine. Traditionally, students complete 2 years of "preclinical" years consisting of physiology, pathology, pharmacology, etc and then transition to "clinical" years for year 3 and 4 of medical school, where they learn to apply those basic science principles before becoming official MDs or DOs.

During the first two years of medicine I struggled with many things. Foremost among these was the type of thinking required. During college, I knew I had an excellent memory. Sadly, I studied very little in my life until college. I went to a typical southern public high school, where I made mostly Cs and Ds, spending half my day at the Fine Arts Center doing drawing, painting, and ceramics. The rest of my day was spent running and lifting weights. As a senior I was the state champion in the 2mile, and had scholarships to run in college. Then, as a freshman at Brevard College in NC, I recall studying for 2 hours before a psychology test and making a 100. Afterward I thought - man, what a big investment but it paid off! Little did I know most people studied much more than this throughout their lives and in college. Upon transferring to Furman University in SC for my sophomore year, I learned to really study.

And from then on, I made all A's as I would study an hour or two each night and then cram 2 hours of facts in my head at 5am on test days. Little did I know my classmates were studying much more than this and really learning material. I instead spent a great deal of my time training and well, frankly, talking to people! I also drifted more and more toward the lab and coaching athletes.

In the end, I decided to pursue a Masters degree in Education at Furman while teaching high school, then moved to Auburn Alabama to work on my PhD in LB Gladden's lab on lactate metabolism. When I arrived at Auburn I had not made a B since my first year at Furman, and I never made a B again through the courses at Auburn. However, I soon realized that memorizing facts contributed very very little in the research world. In fact, it became apparent that many researchers would say I was waisting my time memorizing lists of information, and I soon came to see how right they were. Often in the lab it was an idea or connection between ideas that changed the course of experiments, not a list of facts. In fact, I soon learned that the “very best” in research world were not the best memorizers, but were a different breed of flexible, creative, “out of the box” thinkers that seemed to be able to integrate ideas and concepts in such a way that new original ideas were generated. I was impressed with Mike Hogan from San Diego early in my career as one of these people.

So when I arrived at Medical school, I was continually disappointed with the lack of depth with material. Rather, we would have 1 week to cover a very broad topic (say cardiology) before moving on to the next topic. Often my grades suffered most in the blocks I was most interested in. I made a 67 on the heme/onc exam, mainly because I was reading articles on the nuances of bone fibrosis in diseases such as polycythemia vera (which my mother has), failing to memorize the mundane lists given to us. In fact, often times learning was not encouraged, memorizing was. I find it a dangerous place where facts are memorized with no understanding of the process.

Even as we completed year 2 and took our first medical certification exam, I was amazed at the great emphasis on factual recall, NOT patient care or problem solving. Often times patients complain of two things: doctors being cold and not caring and (from the brighter patients) doctors not being very curious or good at problem solving. Both are a direct result of how we select our doctors and then train them. This needs to change.

With two years and a board exam behind me, I was ready to hit the floors. But what awaited me turned out to be less about medicine or science and much much more about other things. Enjoy my account of these years; please note that names and places may be altered to confine to patient confidentiality. Everything else will be as true to my experience as possible.