you go dizzy until you fall

Frequent episodes of syncope have flip-flopped my role in the health care system from physician in training to patient in waiting.

The rhythm of my day continues to beat with unraveling the mysteries of disease. I join my classmates in lecture as a veritable parade of pathology marches before us. With the advances of modern technology, we are no longer limited to word-descriptions of disease, but youtube provides us with streaming footage of embodied illness. As dispassionately and professionally as can be mustered, we gaze from the dance-like possession of Huntington's Chorea to the drunken-esque stumbling of cerebellar ataxia.

I am not sure anyone quite knows how to acknowledge what it is we are viewing. Some of our lecturers will try to soften the blow by making quips (Neurology: diagnose and adios). Others will tell us that the patients often look worse than they actually are, and maintain a high quality of life. Perhaps the best reaction we can hope for is a moment of silent acknowledgement before pushing the powerpoint forward.

~~~
I have had 12 doctor appointments, 2 urgent care visits, and 1 Ambulance-mediated ER visit since the onset on my presyncopal episodes this past August. To date, blood work, EKGs, aggressive behavior modifications, and enough drugs to put a smile on Pfizer stockholders face have not eliminated my chest pain, fainting, and other symptoms. This Friday, I will add an echo-cardiogram and a holter-monitor test to the collected data about my body.

I tend to present the persistence of this illness as "second year-itis". This may not be entirely false - medical students are renown for diagnosing their stomach aches as dissecting aortic aneurysms and nighttime distraction as late-onset ADHD. It doesn't help that many of the post-mortem cases we review are of men and women in the prime of their youth. (It is irresistable to keep my mind from wandering to a self-diagnosis of mitral valve prolapse or Ehlers Danlos syndrome.) We have just enough information to be completely panicked and in a practical medical sense, entirely useless.

But, despite what I say out loud, I am anxious to resolve this and name what is going on inside of me. Still, the experience has not been all bad - support in the form of an exceptional framily of BC alums and Harvard second years has huddeled around me - to accompany on medical appointments and serve as gentle reminders that maybe (just maybe) I should not jump to the conclusion that I have inherited an extremely rare collagen disorder, but rather should remain in the waiting.

The waiting.

For a future physician, this practical experience of allowing time to pass in the unknown abyss may be the most valuable lesson I earn for my future patients.

Empathy, it seems, is not easily taught (even with youtube).

I'll be sure to keep updated on what comes next.

Mother forget me now that the creek drank the cradle you sang to

My mother wrote with elegant calligraphy handwriting.

It was all I could think about during medical school today. In elementary school, it was impossible to fake her signature on notes from my teachers. This downside was balanced out by her help when fancy handwriting was a must on school projects. Her intricately developed script intensified the impressiveness of my Science Fair soda volcano.

~~~
Here in medical school, our day to day emphasizes the characterization of pathology. We have moved from a year I emphasis on the “normal” to the year II emphasis on the “uh-oh”.

Part of our curriculum involves case based learning, where we work in small groups to fully characterize disease patterns. This week in neurology, our focus is on CIDP, Chronic Inflammatory Demylenating Polyneuropahthy (what a mouthful). Over the week, we become temporary experts on the course of the disease; representations of macrophages eating away at the glistening myelin sheaths of peripheral nerves cover the board. One student reports that successful treatment depends on early identification of the illness, and halting progression. “What about reversal of symptoms?” another student asks. Unfortunately, the freshly highlighted NEJM article provides no help; “I don't see anything about that” he half stumbles, half apologizes. Whether for his lack of knowledge or for medicines lack of cure, I am not quite sure.

The discussion moves forward, and we rattle off the associated symptoms of this progressive disease. Without treatment, most peripheral nerves will be destroyed beyond repair, leading to multi-focal sensory aesthesia and motor paralysis over time. In addition to the loss of gross movement in the arms and legs, fine motor skills are lost. It is a disease which, unchecked, will cause decades or more of total body paralysis, and eventually death.

Our time in tutorial is over; my classmates move to our next assignment.

But I am still - frozen in my chair. The case of the woman we are studying is invasive and
familiar. My mind retraces the pathology we have discussed and attempts to match it with my distant memories of high school, a time when I was a daily observer as my mother slowly lost her own sensory and motor function to this insidious disease. I linger over thoughts of how different the two perspectives of this illness are.

Today, I learned more about the pathology of CIDP than I could have ever understood as a lay-person. Years of science education have led me to understand (to the best of what science has found thus far) the objective “how’s” of her illness.

But, today I can’t find my breath. The veil has lifted and I recognize now how necessarily limited my medical education has been and will continue to be. In each case, we don’t discuss how illness breaks apart families and orphans children. We don't go over how often patients are never identified as having the illness and never treated. We don't mention that treatment doesn't work for everyone, and that disease often obstinately progresses forward unchecked by the best efforts of modern pharmacology. We don’t discuss what it’s like for patients to lose the ability to write in calligraphy. We certainly don’t linger over thoughts of how illness robs patients of their identity. And most surely, we do not discuss how illness and the frailty of our own humanity has refined and shaped us into the people we are today and the clinicians we will be tomorrow. Instead, we observe objectively and distantly, as though we are above the vulnerability to illness that is endured by our patients.

~~~

I am certain both ways of seeing are necessary.

In fact, I doubt I could make it through medical school if I was acutely aware of how much suffering is actually endured by any given human being. I don’t know yet how to stand in awe of those who endure such suffering; who face the terrifying uncertainty that comes when our own bodies and minds betray us.

I am sure after this week I will gratefully go back to a more objective way of seeing. Still, my deep hope remains that as I come alongside people afflicted by illness - I will learn to be with them in our own vulnerable and precious humanity - while we are in it and until it ends.

qui enim nescit simulare, nescit curare

The day before a big exam seems the perfect time to update.

Tomorrow is the Microbiology exam. I had no idea, but it turns out "Microbiology" is synonymous with "Everything That We Come Across in Medicine and How We Treat It". It has been incredibly interesting; we have covered a wide range, from the pathogenesis of bubonic plague to the appearance of elephantiasis; why you never give tetracycline to a pregnant lady and why scotch tape is the best diagnostic tool for finding pin worms around somebody's anus.

This class also tested my ability to shove new words in my brain; Now that all is said and done, I have *learned* over 500 new terms, 114 new diseases, and dozens and dozens of drugs. It feels a little bit like academic bullemia though - after tomorrow, will I remember that it is E.Coli 0157-H7 that doesn't ferment Sorbitol on MacConkey Agar?


Less boringly, school is almost over! This summer I will be working for the VA in west roxbury. I am excited for the chance to get back into actually providing care, and am interested to see the way a government health system operates. My only exposure thus far has been the woman from human resources who told me "you der done good" after I had gotten my work physical done on time. More updates to come, I am sure...


Hard to believe first year of medical school will be over in less than a month. It is exhilarating to take a look back and see all that has happened, and yet still I am constantly reminded that there are mountains beyond mountains to climb.


ok, enough paul farmer puns, back to studying.

So you want to be a doctor?

These past two days (4/3-4/4) I was invited to speak at an over-night conference for BC undergrads. The title of the conference was "So, you want to be a doctor?". It was run through the intersections office (the same lovely people who brought you halftime) with the goal of helping students on the pre-med track have time away from campus to do some good old Ignatian reflection on the sacrifices and joys of pursuing the physician track.

All the students were engaged and genuinely interested in the mysterious combination of diligence, sacrifice, passion, and luck it takes to get into medical school and follow such a path. It was great to share with them some of the wisdom I took away from the entire experience of applying and my first year, as well as to liberate them from the idea that there is one set path to getting into medical school. Rather the process of self-actualization does more for getting you into medical school (meaning, finding out 'do I actually WANT to be a doctor?!') than any MCAT strategy or personal statement secret incantation could ever do.

Two topics of particular interest we covered were sacrifices and limitations.

Limitations.

I cannot do everything. I cannot even do most things. In fact, I am finding, really, that I can do medical school well and than maybe one or two things for fun. Anymore than that I can do, but I get really tired, cranky, and burnt-out.

There are other people around me (classmates) who amaze me with their ability to take on more and push through the challenges that would keep them from taking on more. But maybe in my own process of self-realization, I am finding that I like doing a few things well. I get stressed even when I think about doing more things right now, fun or otherwise.

Sacrifices.

And so, I led this retreat, and then it was necessary to say no to other invitations for this weekend (dinners with friends, social time, a little bit of sleep... sleep is always inviting me). It's only one weekend, no big deal. But as we talked about at this conference, it is not just this weekend, it will continue to be an escalation of life choices, deciding what must get cut. There will come a time when I will miss out on the weddings of friends, school plays... the freedom that is afforded by a 9-5 job. But, I write that paragraph not as a remark of "my life is so hard", but rather that it is a serious decision to go into this profession, and one that really does require a feeling of being called. Every profession, every following-out of who you are requires sacrifices - the essential part is knowing which ones you are capable of making.

We all have gifts to share, possessions to steward. In many ways, as a physician the gift you continually give to your patients is time and presence. For now, my patients are only figments, but today, these Saturday hours, are a joy-filled gift to them, an investment in their well being. An affirmation that these are sacrifices I am called to make.

Atrocities and Activism

The twinkling light of the holiday season has been ebbed away by the swirling dark of the January sea

:: end melodrama::

A warm San Diego break and I find myself back in Boston, ice skating to school (well, not literally, but I did get passed by a man on cross country skis a few days ago) and trying to ward off the cold in my below freezing house (this, unfortunately, is not melodrama, as i returned from California to a house below 30 degrees F, frozen pipes, and an icicle dripping off of the faucet of our kitchen sink!) Thankfully, an electric blanket was among the gifts I received this Christmas, so I am managing to survive our house's version of winter camping.


Classes have started again, and the winter-term finds us (among other things) planning out the research/studies we will complete. Before the break, I had solidified plans to take an intensive Spanish course in Boston and then travel to El Salvador where I would continue Spanish training, and onto Guatemala, where I would work in a rural clinic sponsored by the Harvard community. Dastardly, sometime in December the HMS administration decided to cut funding for the Boston based medical Spanish classes.

More-so than the anxiety created by needing to come up with a new fundable project fast, I am distressed by the priorities of our administration. Harvard is an institution with many personalities: there are (for sure) voices among the faculty who advocate the importance of services and skill sets to benefit the under served, yet there are (seemingly) a multitude more who believe that the above is the first cargo to be thrown overboard during a storm. And tragically, they control the purse strings.

In response, I took on my first ever "stick it to the man" project. I spent yesterday crafting a petition about the issue of funding cuts, and the absolute necessity for funding re-distribution. I had a few of my liberal arts friends check it for spelling, grammar, and cuss words, before sending it out to my class list serve. About 1/3 of the class has signed it only 5 hours after my having sent it to them.

Now the question is, what do I do with it?

(You'd think I would have had a plan, but I'm new at this). I think I will go to the Dean of Student Affairs, first. I am sure it will be plainly evident that I have no experience in this and no idea what I am doing, but somehow I am certain that I should be doing this. If we don't emphasize the importance of Clinicians learning the language of their patients now, then when? I have browsed through our curriculum and (shockingly) it does not slow down.

Maybe I have too high of standards set for Harvard, but I don't think so. Even with the financial crisis this institution has a crap-top of money (scientifically speaking) and I will give Spanish it's due defense.