clinic · ethics · MS-4 · narrative medicine · neuro

I spoke too soon. Last night’s class was the best yet; the debate was really intense, and even the really quiet ones had a lot to say. See, that’s the power of a really great story — it attacks you and forces you, sometimes against your will — to pay attention. Moments like that really make me love teaching.

Today, workwise, I was down on the Eastside practice with my preceptor, and then seeing patients on my own in the residents’ clinic.  It ran the gamut. The Eastside is private, very classy with paintings on the walls, patients who have done their homework, pleasant staff. The residents’ clinic is in the old, old part of the hospital, with cinderbrick walls and tiiiiny little exam rooms — I think the one I was in used to be a closet. Not even joking.

Of course, the quality of care is no different, because these are the same doctors, with the same brains. But I can’t help but wonder how much the ambiance affects the patient’s perception of the visit. It really disturbs me, the extent of the rich/poor dichotomy here. (Fun fact: our ED is in a different building from the hospital because the donors apparently did not want the uninsured rabble being too loud for the private patients. And don’t get me started on the Fancy Rich People’s Ward.)

I suppose that in the end, it doesn’t really matter, because the doctors are the same, the medicine is the same, even the computer system is the same. How much difference can a pretty painting make, when you’re sick? Both practices have access to Really Smart People, and both function very smoothly. But as a patient, I definitely know which one I would rather go to — even if that induces a fair amount of middle-class guilt.

medicine · MS-4 · narrative medicine · New York

Not done yet

I had brunch with a good friend today, down in the West Village.  She is a literature PhD candidate, about to switch careers and head down the med school route.  And I was telling her about my own near-career switch, back when I was a fourth-year undergraduate so in love with my comp lit thesis that I was about to withdraw all my applications to medical school and apply to lit Ph.D. programs instead.

“But I’m glad I didn’t,” said I between forkfuls of an exceedingly delicious Greek salad with herbed goat cheese. (You can order things like this in the West Village — such a change from the chicken-and-rice cart outside the hospital.) “Because then narrative medicine turned up, and I got to do that instead. I needed that year, but I missed clinical medicine so much.”

“And it sounds like, from what you said about your thesis, that you weren’t done with literature yet, you still wanted to explore.”

“Yeah. And there’s a lot more still to explore — I feel like I just learned a lot of new vocabulary and am barely getting past the surface. Maybe I’ll go back, do a PhD later. But for now… I really need to take care of people.”

I think I’d never articulated that to myself before. Back in November, I started really missing medicine in a very visceral way. I missed the process of history-taking, the back-and-forth, the reconstructed (co-constructed?) timeline of events. I missed the thrill of physical exam findings. (The differentiation between aortic stenosis and hypertrophic obstructive cardiomyopathy is hot.) I missed curbsiding my friends on other services to ask their opinion about xyz, or frantically UpToDating at the nurses’ station. I missed the putting-it-all-together, the generation of a coherent story to pass along to my resident and attending.  As soon as I could rearrange my schedule appropriately, I began volunteering at the free clinic, in order to get at least a little of that back.

There was a re-learning curve at the beginning of this month — I had to look up how to write notes, I had to look up the most basic principles of pathophys, I even once had to look up the normal values for coagulation factors. *shame* But now that I’m back in the swing of things, I feel too excited by it ever to want to leave again. I mean, I helped convince a man to make a lifestyle change that has already dropped his weight by 110 pounds. One hundred and freaking ten pounds — that’s a me. Formerly inside him; like Athena and Zeus. The man now feels better, breathes easier, walks longer. How can you not be excited by that?

So, no, I’m not “done yet” with literature.  But more importantly, I’m not done yet with medicine. As frustrating as the hospital can be at times — one of my patients has been hanging out for a week because of discharge planning problems — it’s also hugely fulfilling. Not necessarily just in the “good outcomes” way, but also in the sheer pleasure of doing something that is of use to other people.

Our conversation moved on to other things, like the evils of the application process (med school vs. residency), the commercialism of Times Square, the sheer awesomeness of Zadie Smith. But that “not done yet” line of K’s lingered in my brain.

Who knew that such profound moments could arise in a slightly hipster joint off Christopher Street?

narrative medicine

Survived!

At a quarter to two, I scurried over to the Medical Education Building/Library/Hellhole of my Preclinical Years to deliver this lecture.  Walked into a large group of chatty kids. Chatty is always good before a lecture; it means people are relaxed and comfortable.

I was having all kinds of sympathetic surges on the way over, but as soon as I got there and began reading my talk, it all went away. I relaxed into my informal style, swinging between “teacher mode” and “senior student mode.” Perhaps I doth protest too much, but I always feel like I have to pitch narrative medicine when talking with a medical crowd.

I should probably have realized that premeds actually like this stuff — Illness Narratives and Bioethics were hands-down the most popular humanities electives for premeds at my undergrad. It’s only when you get to medical school that people start complaining that it’s fluffy or worthless. And thankfully, that attitude dissipates in the clinical years, because as you transition into the caregiving role, you realize just how ill-prepared you are for what you are going through.

I’m not pretending that I have all the magical secret answers to preventing burnout. But I do think narrative helps, because it pulls you out of your little neurotic head, away from the p-values and labile pressures, into something completely different. Perhaps I’m biased, because I am a very literary person myself, and I recognize that not everyone is a writer or a reader. But I do think that, for all the value of art and music and film, there is something very, very unique about the written or spoken word, something about the way it engages your brain and makes you do something totally different.

culture · health policy · infectious disease · narrative medicine · New York

The Normal Heart

Friday night, I went to see The Normal Heart, a revival of a 1985 play about the early days of AIDS. (Starring Lee Pace! And Jim Parsons! More on them later.) It was quite shocking to us, for whom HIV/AIDS has become … well, not a commonplace, but a fairly straightforward chronic disease. I was on the infectious diseases service last January, and it was one of the most difficult months of my life, but we knew was wrong with these patients. We knew it down to the molecular level. We had drugs to extend their lives. We couldn’t cure them, not quite yet, but we could do something. 

And so forgive my naivete, but it was a shock to step back nearly 30 years (the play is set 1981-1984) and see a time when that wasn’t possible. The Normal Heart is basically a rant against the people that twiddled their collective thumbs while young men died. It’s happened before, and it will happen again. It’s probably happening now, and I just don’t see it because of the New York bubble. The title comes from a poem by WH Auden, which you should all go read because it’s Auden, nuff said.

The didacticism and emotional manipulation did get a little heavy-handed at times, but there was enough nuance to just save it. The relationship between Ned and his conservative brother Ben, for instance — love, uncertainty, and depth. The City government and the NIH bear the brunt of Ned/Larry Kramer’s diatribe, probably fairly, but they do come across as straw men. I guess it’s easy to attack institutions, but I would have preferred to see the people within those institutions.

And fantastic acting all around. Lee Pace as a jerk (though hints of backstory suggest non-jerkish behavior)! And Jim Parsons — holy crap. He had very few lines, but he just commands the stage in this understated and powerful way. Everyone was amazing, but he was just on point.

I was thoroughly impressed and should probably read And the Band Played On at some point. Why don’t we talk about this stuff in medical school?