fellowship

Time travel

1989

ME

The game says Carmen Sandiego converted her dollars to yen. What country uses yen?

MY MOM

Japan

ME

You’re so smart!

………………………………………………….

2016

ME

This Likert questionnaire database needs converted to a weighted numerical score based on intensity, frequency, and duration. How do I automate this so I don’t have to manually calculate it for everyone?

MY MOM

Like this [does magical computer things]

ME

You’re so smart!

No matter how old I am or how complex the problem, my mom has got my back.

fellowship

I posted this on my personal facebook page earlier today, but as facebook is a bubble, I want it to get a wider audience. Also because facebook doesn’t allow links or citations, and as a physician and a scholar, I live for links and citations. This is the one and only time I’m going to mention politics on this blog. Discussion is welcome; rudeness is not. 

So, I’ve been reading a lot lately about how poor little Trump voters are feeling harassed because everyone assumes they are racist and misogynists. I’ve been reading a lot about how the liberals and the women and the minorities need to stop being so condescending, to reach across the divide, to forgive these people for voting Trump. Because we’ve hurt their feelings by calling them names, and it’s up to us to apologize.

No.

First of all, I’m sure people who voted for Trump don’t think of themselves as racist or misogynist. Very few people do, outside of the KKK and Steve Bannon (*cough*). But there have been a lot of studies looking at implicit bias and unconscious racism, both in HR decisions (which resume to pick up) and, hitting closer to home, in medical decision-making (undertreating pain). Unconscious racism is very much a thing, a pervasive, pernicious thing. Similarly, unconscious sexism or internalized misogyny; check out the Heidi-Howard story, for instance. I can quote this stuff to you all day long, because I have been guilty of this shit myself, have educated myself about it, and I am trying every. Single. Day to be aware of it and to do better.

But to the bigger point, that calling out someone’s unconscious bias, holding someone accountable for what they’ve condoned, is somehow worse than the bias itself.

Also no.

Let’s remind ourselves that Trump’s views were never secret. At every one of his rallies and at every one of his debates, he made it clear that his was a campaign fired by stereotype and hatred — of women, of disabled people, of POWs, of Muslims, of Mexicans, of African Americans. (Remember that time he saw a black man at the town hall debate and immediately chanted “inner cities” about 25 times?)

Trump voters, you gave two thumbs up to a man who promised to recreate the Berlin Wall. You said sure no prob to calls for Muslim registries. You condoned talk of repealing marriage equality; you were fine with a return to the illegal abortion era when hundreds of thousands of women died of butchery. You were so short-sighted about your health insurance premium that you sold the country to a man who wants to dismantle the only protection you had against skyrocketing medical bills, not to mention flat-out denying coverage to your friends and neighbors who might have had a stroke, or multiple sclerosis, or any one of a number of “pre-existing conditions.” Perhaps most disturbingly, you voted into highest office a man who has called women pigs, who has felt up his own child, who has gloated about sexual assault, who has been accused of rape by a dozen women, one of whom was 13 years old at the time. If none of that was enough to make you vote for anyone else — Hillary, Gary Johnson, Jill Stein, Egg McMuffin, a god-damned yellow dog — you ARE racist and misogynist.

So Trump voters, I am sorry that your feelings have been hurt. I hope that at least some of you will participate in some good old-fashioned consciousness raising to learn some empathy for those who have been and will be directly harmed by your racist, sexist, selfish decision.

But I will NOT apologize for calling out hatred, and the effects of hatred, when I see it. And if that’s condescension, I’m the Queen of England.

fellowship · neuro

Doctor on board

I just got back from a family vacation, which was perfectly lovely. What was not lovely, was the air travel involved. Is it just me, or has air travel become increasingly unpredictable in the last 5 years or so? I’ve been taking cross country and transatlantic flights since I was a babe in arms, and I never remember significant delays, missed connections, being rerouted. Whereas looking over the last few years, I can count on one hand the number of times I’ve made it to my destination on time.

Our outbound flight, for instance, was a transatlantic jet. We were delayed five hours due to “mechanical issues,” whatever that means. When we finally got airborne, they served “dinner” immediately (at like midnight) and then turned off the lights so everyone could get to sleep.

In the middle of the flight, somewhere over the Atlantic, I was jarred awake by a loud thump/shudder. What was that? In the aisle, a fellow passenger has collapsed. Like, totally out cold. Holy shit. I’m in the window seat, my mother’s by the aisle (also awake), I climb over her and kneel down next to the woman on the floor.

“Ma’am? Are you ok? I’m a doctor, can I help you?”

She groans and struggles to her knees. I give her my hand and try to help her stand, but she cannot bear her own weight. I ask her a few more questions, she grunts and can’t answer. There’s something dark on her lower face, but I can’t see properly because all the plane lights are off. Seems totally dazed, but tries to crawl to her seat, just a couple rows ahead. Because the flight is so empty, she has the entire row of 3 to herself, so I help her back into her seat and she tries to lie down to sleep… and promptly falls off the seats again.

At this point, I’m legit worried about her cognitive status and apparent aphasia. This is not just a simple mechanical stumble-and-fall. She seems concussed. Maybe hypoglycemic. Maybe post-ictal. Stroke unlikely, as she’s young, but we’ve all been sitting for a long time with lots of opportunity for venous thrombosis, and if she’d been walking back from the bathroom where she’d Valsalva’ed….

One of the other passengers has pressed the call bell for the flight attendant, and between the two of us, we are able to lift the ill passenger back into her seat. A couple other flight attendants hover nearby, nervously. One is holding the Green Sheet, the medical assessment summary, which I’ve filled out before on other passengers for much less. By this time she’s a little more alert, says she’s fine, says she’s sleepy. I want to take her back to the galley, where there is some light, and examine her properly. The flight attendant refuses, saying “She looks ok now. Maybe she just fell asleep.” I think of Natasha Richardson but bite my tongue.

“Ok,” I say. “I’m a doctor. I’m just a couple rows behind, in that seat right there.”

The flight attendant thanks me. The Green Sheet disappears. I climb back over my mother into my seat, my eye still on the ill passenger. She sits up a little while longer, talking to the person in front of her, then lies down again.

I check on her once more later in the flight, surreptitiously, when walking to the bathroom. She’s lying Roman-style across the seats, watching a movie. She looks alert. Later, as we’re waiting to deplane, I overhear her talking to some other passengers, explaining that she’s passed out before inexplicably, she must have been tired and/or dehydrated, she feels much better now. She says she has only a hazy recollection of what happened.  There’s some dried blood along the vermilion of her lower lip; she must have split it on an armrest. But other than that, she looks quite normal.

Was I over-reacting, friends, to be thinking of life-threatening things like untreated (undiagnosed?) epilepsy or stroke or epidural hematoma? Maybe. I’m glad she did well, and that my original suspicion of concussion was likely correct. But I don’t think I was wrong to consider those more serious, if statistically less likely (but still biologically plausible) possibilities. This is how doctors generate a differential: what’s the most likely? what’s the most serious? As one of my attendings loved to say, don’t anchor on something (patient said she’s sleepy, therefore she must have fallen asleep… while walking after sitting in a relatively brightly-lit airplane bathroom) without considering evidence for and against all the other possibilities.

I’m still a little annoyed at myself that I didn’t insist on examining her properly though. I’m a neurologist. Of all the possible inflight medical emergencies, this is what I do. I’ve been consulted for far less by the ED back on terra firma. And to defer to a flight attendant, whose medical qualifications include … CPR? Why on earth did I do that, unless it was because he was in a uniform and I was in jeans?

If this ever happens again — and I hope it doesn’t, but I bet it will because I’ve been the “doctor on board” at least once a year since I was in medical school — I’m not going to back down. If someone ever had a bad outcome because I didn’t examine them properly, I really don’t know what I’d do with myself. To be honest, there’s not much I could have done, if I’d diagnosed stroke or epidural hematoma over the Atlantic. But to go against my own better medical judgment because of some perverse sense of not wanting to cause a scene…. ugh. I need to be better than that.

fellowship

What’s a little dementia between friends?

Clinic appointment request: “URGENT MOVEMENT DISORDERS. Pt needs to be seen in 1-2 days!!!” No additional information provided (like, what’s the consult question, why is this urgent, what’s the relevant history).

Patient shows up on time, but no records, no idea why he’s here. He is nearly blind and very hard of hearing but he can’t see his hearing aids to put them in. Wife, who drove him to the appointment, also is not sure why they are there. I spend 20 minutes going through every possible movement disorder symptom I can think of — too much movement, too little movement, acting out of dreams, loss of sense of smell, trouble walking, tremor, falls, balance, clumsiness, memory — nope, nope, nope, nope, oh wait, memory problems yeah doc I got memory problems.

So unsurprisingly dude ends up scoring terribly on his brief cognitive screen, even accounting for the blind-and-nearly-deaf part. No movement disorders issues at all. So I order a cognitive workup, arrange for him to see General Neurology, and send him on his merry way.

Then I’m at home, writing up his note, and in digging through the chart, I realize that dude was seen by our clinic 3 years ago (well before my time) by the now-graduated fellow, for the same URGENT MOVEMENT DISORDERS consult from the same PCP, and had the same findings. Never did his dementia workup then, either.

books · fellowship

How are the mighty fallen

Back in the dark ages of medical school, I spent a summer interning at a health policy/advocacy group in DC. The office was down the street from a Barnes and Noble, so at lunch, I would often run over and read. That B&N was my private library that summer, where I discovered Jonathan Safran Foer, a (then) young author with a brilliant debut novel, Everything Is Illuminated.

61don2l7knl-_sx324_bo1204203200_

Some of the images in that book, particularly of the shtetl, have stuck with me for years. This was a time I was also reading Michael Chabon (Kavalier and Clay) and Zadie Smith (White Teeth), so the two protagonists theme was big in my literary life.

Fast forward to a decade later, JSF’s newest novel, Here I Am, arrives in my mailbox from Powell’s Indiespensable book subscription club. Yay! I think. I remember this author. I like him. So I settle down to read.

Ugh. This book. I just finished it, and it was out of a sense of duty more than interest. The story is ostensibly about a failing marriage against the backdrop of a massive earthquake in Israel, humanitarian disaster, war, etc. I usually eat that stuff up, the juxtaposition of the domestic with the epic.

Not this time. I couldn’t stand either of the partners here. Jacob is a spineless neurotic Woody Allen stereotype, and Julia is your stereotypical ice queen. No sense of why these two people got married in the first place. No sense of how they drifted apart. No sense of why they are bothering to get divorced, no sense of any pain it causes either of them, or joy at being free. They neither of them seem to have any emotions.

The Israel At War stuff was bizarre, heavy-handed, and had no bearing on the divorce plot. It was like a totally separate story that had somehow wandered into the domestic family drama and tried to take it over. Similarly, there was a random section written in the first person where everything else was written in third omniscient. WHY?

Also, dear god the philosophizing. Pro-tip, six year old children do not speak in fully articulate sentences about the nature of death. Also, the endless flashback digressions which interrupt conversations only serve to set up/explain a one-liner joke in that conversation…. ugh.

I’m really glad that book is over and done with, because my next step is to sell it on eBay. Anyone in the market for a signed first edition of JSF’s latest novel?

fellowship

Home

My residency program hosted a conference last week, and by luck, I had the day off to go down for it. It was so, so lovely to be back home. First time I’d been back since starting fellowship, and it felt like I’d never left. I got a chance to catch up with several attendings, as well as some of the junior residents who came.

I’d left in the near-pitch-black of night, a travel mug of coffee rattling along next to me. But as I left the city and suburbs behind, the sun started to rise just over my left shoulder, and the trees, still heavy with their summer leaves, started to glow. At one point, the road curved through farmland, and the mist rising up from the fields near took my breath away.

I tried, unsuccessfully, to wrangle my phone out of my purse and take a photo while zipping along at 55 mph. It came out poorly, as car window photography is wont to do, so I’ll spare you. It looked something like this:

1
Season of mists and mellow fruitfulness

And I can’t tell you how great it was to be back in my old space, seeing my old attendings and catching up, chatting with the junior residents, snarking in the back corner with some of my NP friends.

I do like where I work now. I feel supported at work, and like my supervisors care about my development as a neurologist. But the team of folk down where I trained, that was something special. The department here, maybe because it’s so huge, is pretty formal, standoffish … I don’t feel that I’ve gotten to know anyone, really, in a personal sense. I tried to organize a couple of smaller events among the fellows (Fourth of July picnic, free-admission day at the Art Museum, that sort of thing) but it fell flat because, I dunno, the culture is just different. Come to work, do work, go home, be home. I get that you don’t HAVE to be friends with the people you work with, but still. I miss that.

Sometimes I wonder if I have Stockholm Syndrome about residency. You know the thing … you get so brainwashed by a person or place or structure that you start to identify with it and think it is the greatest thing since sliced bread. Let’s be real, I would not go back to 30 hour calls or stroke codes, or the ICU.

But I also acknowledge that my training program was a gem. We had a wonderful role model of a chair, and a fantastically supportive program director — the sort of guy who, if you said, “hey, I want to disappear for 7 weeks to go study abroad,” he’d be like “yesss! let’s make it happen.” I’m realizing, talking to my co-fellows and seeing the day-to-day here, that not everywhere is like that.

That’s what really makes a home, I’m starting to realize. Not just “address on your tax return,” or some tchotchkes on the wall, but having a sense of belongingness. A local pub. Knowing the best place to watch the sunset; the best place to get your car inspected; the best running route through town. I’m starting, slowly, to build that here… and when I get down, I remind myself that my first year of residency was not all puppies and butterflies, that I was finding my home then, too.

But let me tell you, it was good to be home, even if just for a day.