Book #1: The Casual Vacancy

Oh my god, you guys. This book? Is good.Casual Vacancy, Wikimedia

Ignore the Amazon reviews. They are written by people who expected another Harry Potter book with TEH MAGICKS and were shocked / upset / generally kerfuffled that JK Rowling is not a one-trick pony.

(I liked the Harry Potter books a lot. But what was great about them was they were children’s lit written like adult lit, no punches pulled, no saccharine sentimentality. And what’s great about The Casual Vacancy is that it’s just … adult lit written like adult lit.)

The plot is straightforward: local council member dies abruptly, by-election is held to replace his seat. But the real strength of the novel is in the characters, drawn sharply and with an excellent eye. It reminds me in that way of Austen or even more of Middlemarch, but if Dorothea Brooke had a blog.

Perhaps it’s because I live in a relatively small city with similar class distinctions as fictional Pagford, but the characters, even the less likeable ones, were very real. Everyone knows a meddling Shirley, and middle-aged Samantha’s crush on a young musician is so common as to be almost a cliche. The teen characters are definitely the most well-rounded here and the most sympathetic, especially Krystal. Krystal’s heartbreaking. I can’t tell you why; just read.

Yes, it’s tragic and dark and the last few pages are like watching a slow inevitable explosion and you finish it in the middle of the night because you stayed up far too late and you just have to stare up at the ceiling. It’s a book with an impact even bigger than its tome-like size.

Apparently the BBC just did an adaptation starring Keeley Hawes, Michael Gambon, Julia McKenzie, which aired last month in the UK and will air here on the 12th of Never, because Masterpiece Bloody Theater would rather air their fifth Downton Abbey marathon than some new programming.  So if you are lucky enough to live in places where BBC player works, tell me, was it any good? Worth tracking down in the usual nefarious places on the internet, or give it a miss?

30 for 30

I went to my friend’s 30th birthday party this weekend. (When did we get so old?) She mentioned that she is doing a 30-for-30 thing this year, in her case hosting 30 events. Which … is a lot of events. I can’t even hardly get my stuff together to organize the residency retreat, let alone plan and host 30 parties in 365 days. The cleaning up alone would do me in!

But I really like the idea of commemorating a milestone year in a concrete way. You know what I think I can do, is read 30 books. I’m already partway there, thanks to a book club!

So here we go, 30 books (and reviews, of course) between now and Dec 31, 2014. Ready, set, read!

Patient letter

Dear Dr. [Scrivener],

Because of my chronic daily headache, I cannot get out of bed most days, so I cannot work and am now applying for disability. Can you fill out my paperwork?

Oh, and I need to reschedule my appointment with you next week because I’m going on vacation to the Caribbean. Even though I just told you I am bedbound and cannot work, I am still able to deal with airport security, cramped airline seats, and sitting out in the tropical sun sipping pina coladas on the beach. Can I get an early refill of Imitrex tho?

— Migraneur

Foul, fetid, fuming, foggy filthy….

I went up to Philadelphia last weekend for a wedding of a good friend of mine from medical school. The wedding itself was tons of fun — both the ceremony and the chance to catch up with our old med school crowd — but I confess I had ulterior motives. I’m thinking about applying to some programs there for fellowship, so it was a great excuse to try out the city in a non-pressured way.

Philly reminds me a lot more of Washington DC than NYC. By which I mean, it may be more liveable for me. You can see the sun so that’s good, I guess? I don’t know. It really breaks my heart to have to leave this town in a little over a year. As much as I complain sometimes about (non-existent) traffic, just spending the weekend in Philly reminded me of all the little annoyances of city living. Slush piles everywhere. Running errands on foot, especially hauling groceries several blocks or on public transport. Lack of greenery. People around ALL THE TIME. Better than NYC, but still, I was very happy, if a little exhausted, to come home.

More on patient satisfaction

The patient satisfaction forms I mentioned in the last post? Are making it to the residency program now, courtesy of JCAHO (I think).

We were each given a packet of forms, printed on hideously green paper with black type (who made these, the Wicked Witch of the West?) to hand out to our patients.

JCAHO’s coming! Quick, gel your hands!

The statements themselves are in size 10 italic font (great for our elderly patients! so readable!) and range from “My doctor introduces himself or herself” to “My doctor is sincere, trustworthy, and doesn’t keep information from me.” Patients have to rate the resident on a scale of 1-5.

No mention of other things like “My doctor seems competent.” or “My doctor can answer my questions or direct me to more information.” Medical knowledge, it seems, is somewhat irrelevant in this brave new world.

In non medical news, I’m currently reading Wolf Hall, by Hilary Mantel. It won a bazillion prizes when it came out, and it’s being made into a movie in the spring. It’s a tad introspective, but I do like it. Also slogging through The Martian, by Andy Weir, my book club’s official selection, which … it’s like a survival guide to being on Mars. There’s lots of info on how to generate oxygen from hydrazine. There’s lots of “Yay! It worked!” or “Boooo! The generator failed!” which makes Our Hero (TM) sound more like a pre-teen girl than a 30-something mechanical engineer.

Can’t get no

The clinics here do patient satisfaction forms, and periodically we get aggregate feedback emailed out. For the most part, this is a good thing — helps us understand issues with workflow, ease of scheduling appointments, all those things that as a doc we don’t have direct access to, but surely affects patients’ perceptions of our clinic and our overall competence.

Then sometimes we get gems like this:

HONESTLY some of the questions I answered I had to guess. I did not know how to answer them. I did not have the all the knowledge needed to answer them.

I don’t … I can’t even …. In what world do you blame the clinic for your own stupidity? And if you don’t understand the question because of jargon or something, just SAY SO.

On a bigger scale these stats (% positive reviews) are almost certainly being including in some sort of pen-pusher quality metric. It’s part of larger moves in Health Policy. In the private world, I hear physicians’ pay is being directly linked to patient satisfaction ratings, which seems like a great way to produce a community of candy-men and sycophants. In academia, departments with more satisfaction probably get more perks, or something. They keep promising us that we’ll move out of the basement one day, but with reviews like this …..

My last patient of 2014

I’m settling in to the ICU workroom for my last overnight shift, thermos of coffee at my side. We’ve got just five patients — the small blessings of working over the holidays, when elective surgeries are on hold and we just have to deal with the real emergencies: bleeds, clots, seizures that won’t stop on their own. I’ve already stalked the list of patients in the Emergency Department and satisfied myself that there’s no one likely to come to me. Time for Netflix….

Then the junior resident, the one in charge of the floor patients, comes in. She’s just heard about a stroke patient who got tPA at an outside hospital and is being flown to us. Tissue plasminogen activator is a clot busting medicine, developed decades ago and still our mainstay of treatment for acute ischemic stroke. It’s a mega-dose of natural anti-clot compounds, designed to help dissolve the clog in the artery the same way Drano works on shower drains. Then we watch them in an ICU for 24 hours, so we can do hourly checks and make sure they are not getting worse — worse might mean bleeding.  I’ve taken care of so many post-tPA patients at this point in my residency, it’s practically autopilot. I copy down the information the junior’s got — not much, just a name, date of birth, last known normal — and we await our new arrival. This lady’s in her 90s. They tPA’ed someone in their 90s? What were they thinking??? *

The patient shows up surprisingly quickly. She’s terrified, you can see it in her face. Because of the stroke, she can’t speak or move her right arm, but as she’s being transferred into the hospital bed, she reaches out her left hand and clutches mine — freezing cold — and won’t let go. There’s a swirl of people — the flight crew, nurses, me and the other resident. Someone tugs the curtain closed, and she is subjected to the usual indignities. Gown comes half off for an EKG. Swabs of her nose and her rectum (with different Q tips, of course!) because she’s been transferred from another facility and might could be harboring a superbug infection. People — including me, asking her to do a million things, raise this leg, close your eyes, open your mouth, can you feel me touching your arm? Throughout it all, she doesn’t let go of my hand. It’ll be ok, I tell her, you’re in the hospital. You’ve had a stroke. You got some medicine for it. We’re going to get another scan. It’ll be ok. I finally have to wrench my hand away to go back to the workroom and write my note.

She kept me awake for most of the night, that one. First with chest pain. Then with x-ray results. Then with labs being wonky. Finally at 3:30 AM, I’m jarred awake — when did I fall asleep? — by the phone: her daughter calling for an update. That’s when I learn that Ms. TPA was receiving a highly prestigious award (we’ll call it the Badass Award, for confidentiality’s sake) when she had her stroke. It all sounds pretty dramatic, involving foreign diplomats, the press, and paramedics swooping in. So then, of course, I stayed up Googling her — thankfully there’s no mention of the stroke in any of the dozens of local news articles that come up — but I did come across a video clip of her, a week or so ago, talking about the events that merited her the Badass Award. She was sharp and funny — reminded me of a radio clip I’d heard of Doris Lessing in her 90s, telling Terri Gross that she only got married “because biology demands that when a war starts that people should get married and have a lot of sex. As we all know.” (Terri Gross immediately changes the topic, thus proving that Doris Lessing is infinitely cooler.)

There’s something very intimate about hearing a person’s story in their own voice, whether on NPR’s Fresh Air or via a buggy local news clip. This was clearly a lady with a lot of street smarts, now with such a profound expressive aphasia she couldn’t even say her own name. As neurologists, especially as residents who spend most of our time taking care of acutely ill hospitalized patients, we almost never know anything about our patients’ pre-morbid status. The hospital, when you spend so much time there, tends to breed an insular mindset; nothing outside the hospital truly exists. So those reminders, that people lived before getting sick, and they will go on living after being discharged, are so so important to our ongoing training and work.

And so I’m little ashamed to recall my incredulity that “they” at the outside hospital treated my last patient of 2014. Because if they hadn’t, I wouldn’t have had the honor of meeting a woman who had provided so much service, with so few resources, and seen so much.

* More on physician preference (a.k.a. bias) and tPA here. The original article from 2013 is quite good (one of the few that have really stood out from the Green Journal) but hides behind a paywall.

[And yes, I know I’ve been AWOL. I just re-read my earlier posts, and geez I sounded depressed intern year. Residency’s really not so bad; maybe I’ll post more this year to prove it!]