Sunday, October 24, 2010

Morning ritual

I dreamt of luscious hotel entrance to my simple apartment. Outside the world at every entrance, the lobby stretched so wide, you could traverse its length and arrive at entirely different neighborhoods and sub-worlds. and this is delightful, the notion of my humble home, the foundation and enclave, wrapped in grandeur, sweeping staircases, marble floors, silver platters, the bustle of a million maids and butlers in well pressed uniforms, a gorgeous big world, with a safe place in its heart. I dash up the stairs endless palace stairs, and i am small again like the little pig character of children's books, like the little girl who lives in the waldorf astoria, the world of beauty is big and i am joyously scurrying. But i must take a regulation staircase, a back way a fire escape i follow a woman, she gets off on four. I must arrive at six, and there is a severance of the staircase, an Escherian optical puzzle. I cannot get to the next floor.

And i wake.

I am in my brother's bed in my childhood house, the walls are plastered thickly with the gleam of sports cars and buxom women lounging upon them. My head is thick with cementing mucus in hidden crevices, weighing my mind and my skin is so dry with desert air it is crackling. There were other dreams, they are ephemera.

The day ahead seems dull. Somewhere in the larger picture progress must be made--on my medical training, on my research. I am short on money, someone at the university has delayed the check until i report my findings. What have I found? I have been meditating that at 28 I am not really a Young Woman anymore. A youngish woman. Long ago already i was Madame over a Mademoiselle, though i have neither married nor reproduced. I have a man i love, he is gently coy about these things. In the mean time, amid the clinic and the wards, the excel spread sheets and nights of sleepy love, the rolling hormonal sine waves keep time on my ovaries, which are in turn neatly bound and chemically gagged with FDA approved contraception.

Men do not generally face their finiteness for decades, but for women it begins at 35, and it begins in the pelvis (all things begin in the pelvis), then radiates outward.

The school counselor accuses me of escape into abstraction in my philosophizing (or perhaps it is i who accuses, and she who nods). The disciples of the mind think there is a different truth, the one that is bound up in the tangles and rolls of the individual psyche, the particulars of the organisms trajectory, of its shapes and deformities, of the particular drag and gravity in its subjective cosmos, and the course of collisions with other creatures. Perhaps each atomized vector can be integrated and an elegant tale can be told, the story (stories) that will predict the future. Like their brethren in physics, the disciples of psyche chase the mystical with the sober pretense of trading in mundane tools.

Oh this poor isolated animal. The French find the isolation inevitable and pitiable, the americans an aspiration and a celebration. I do not want to be alone. Life begins with a expulsion from another. It begins with separation and a life desperate for union again. The end carries the parabola forward to its inevitably lonely conclusion. But after we are gone, the fungi take us back, and we are reunited with all again. Dénouement, resolution, or catastrophe.

Remarkably un-comforting.

Yesterday my heart broke watching an injured bee, journey steadily across the suburban bathroom floor. Why was there a bumble bee in such an inglorious place? (And why do we hate flies and admire bees? We punish one for ridding the world of feces and rotten meat, and adore the other for cavorting amid the flowers and filling our cups with honey). (Actually this is quite reasonable). (The bees furthermore, are better dressed).

Once i have had my morning coffee, the meditations on death dissolve, like mist in the rising sun. Dreams flee, existential ennui and its attendant abyss constrict to a neat quiet scar line. In the glorious light of the frontal lobe, well fueled by the metabolic storm of caffeine, purpose begins. We trade out the dark shadows of existence, dreamscapes and Dostoevsky for the neat, clipped descriptions of the New England Journal. The disciples of physiology (like those who study spheres, and the mappers of mind) don the heavy cloak of coffee cups and linear regression models and the work of the world continues.

Thursday, October 14, 2010

Moving!

Soon! (this blog i mean)

Tuesday, October 12, 2010

Foreign Medical Graduate

From Verghese, My Own Country

"I had once tried to reach Dr. Patel, a cardiologist, to see a tough old lady in the E.R. whose heart failure was not yielding to my diuretics and cardiotonics. I called his house and his wife told me he was at 'Urology Patel's' house, and when I called there I learned he and 'Pulmonary Patel' had gone to 'Gastroenterology Patel's' house. Gastroenterology Patel's teen-age daughter, a first-generation Indian-American, told me in a perfect Appalachian accent that she 'reckoned they're over at the Mehtas' playing rummy,' which they were."

An Indian traveling salesman explains how to find a place to eat in a strange town: Count the number of Patels in the phone book and multiply by 60. "That will tell you size of Indian community. . . . Take my word: less than 10 Patels means no Indian restaurant. If more than 10, you call, say you are from India, ask them where to go to eat."

* * *

As Dr. Verghese traces the spread of the [HIV] infection, he also examines its effects on his own attitudes, and on his relationships with his patients. He identifies the less-than-lofty, self-congratulatory "front-rank soldier" pride of doctors who treated AIDS patients in the early days of the epidemic, before the mechanisms of transmission were better understood. As he considers his patients in Tennessee and their willingness to confide in him, he wonders how much it has to do with their relief at finding a doctor who is a foreigner, an outsider. "To come to a doctor's office, even a distant doctor's office, and tell their sexual secrets to a Caucasian face that could just as well have belonged to a preacher, a judge or some other archetypal authority figure in their town, might have been difficult." He is also direct and straightforward about the toll that his involvement with his patients takes on his wife and young children -- and ultimately on him as well, as the patients, one by one, begin to die, as he dreams repeatedly of his own infection and death.

* * *

The story of all these people -- brothers and sisters, parents and children, doctors and patients -- is the story of a small city whose departed sons begin returning, one by one, sick with an infection that even the medical professionals of Johnson City had assumed would never hit close to home. Thus the doctor who sought security and a better life in the American South finds himself treating some of the sons of that South who had fled, searching for safety, acceptance and a fuller, freer life.

It was, as Dr. Verghese ultimately chronicled it for a medical journal, "the story of how a generation of young men, raised to self-hatred, had risen above the definitions that their society and upbringings had used to define them. It was the story of the hard and sometimes lonely journeys they took far from home into a world more complicated than they imagined and far more dangerous than anyone could have known."

Fluids, Fetuses, Foreign bodies, Feces and Flatus

SCIENTIST AT WORK | DR. ABRAHAM VERGHESE
Physician Revives a Dying Art: The Physical [excerpts]


Dr. Verghese (ver-GEESE) is the senior associate chairman for the theory and practice of medicine at Stanford University. He is also the author of two highly acclaimed memoirs, “My Own Country” and “The Tennis Partner,” and a novel, “Cutting for Stone,” which is now a best seller.

At Stanford, he is on a mission to bring back something he considers a lost art: the physical exam. The old-fashioned touching, looking and listening — the once prized, almost magical skills of the doctor who missed nothing and could swiftly diagnose a peculiar walk, sluggish thyroid or leaky heart valve using just keen eyes, practiced hands and a stethoscope.

Art and medicine may seem disparate worlds, but Dr. Verghese insists that for him they are one. Doctors and writers are both collectors of stories, and he says his two careers have the same joy and the same prerequisite: “infinite curiosity about other people.” He cannot help secretly diagnosing ailments in strangers, or wondering about the lives his patients lead outside the hospital.

“People are endlessly mysterious,” he said in an interview in his office at the medical school, where volumes of poetry share the bookshelves with medical texts, family photos and a collection of reflex hammers.

His sources of inspiration include W. Somerset Maugham and Harrison’s Principles of Internal Medicine. In addition to his medical degree, he has one from the writing workshop at the University of Iowa.

Dr. Verghese trained before M.R.I. or CT existed, in Ethiopia and India, where fancy equipment was scarce and good examination skills were a matter of necessity and pride. He still believes a thorough exam can yield vital information and help doctors figure out which tests to order and which to skip — surely a worthwhile goal as the United States struggles to control health care costs, he said.

A proper exam also earns trust, he said, and serves as a ritual that transforms two strangers into doctor and patient.

“Patients know in a heartbeat if they’re getting a clumsy exam,” he said.

He left Ethiopia at 15 for two years of premedical studies in Madras, India, and then returned to Addis Ababa for medical school. By then his parents, worried about Ethiopia’s stability, had moved to the United States. But he had no desire to leave.

“I loved that land,” he recalled.

The medical training was rigorous. Students spent a year dissecting a cadaver, and then had to pass grueling essay exams.

“It was almost brutal,” he said. “But it left us changed in some fundamental way, like formatting a disk.”

Medical students in the United States today spend far less time studying anatomy — too little to learn it well, he said, shaking his head.

***

He worked in Tennessee during the early days of the AIDS epidemic, before there were any effective treatments. Before AIDS, he said: “I must have been a conceited ass, full of knowledge. AIDS humbled a whole generation.”

He came to know many of his patients and their families. He visited their homes, attended their deaths and their funerals. One patient, near death, awoke when Dr. Verghese arrived, and opened his shirt to be examined one last time.

“It was like an offering,” Dr. Verghese said, with tears in his eyes. “To preside over the bed of a dying man in his last few hours. I listen, I thump, I don’t even know what I’m listening for. But doing it says: ‘I will never leave you. I will not let you die in pain or alone.’ There’s not a test you can offer that does that.”

***

“What’s the most important part of the stethoscope?” They stared at him. “The part between the earpieces.” They moaned.

“Name five things that are better outside the body than in,” he asked, not mentioning that the answer appears in his novel: fluids, fetuses, foreign bodies, feces and flatus.

Dr. Verghese smiled. “I am here to astound you,” he said.

Full NYT Article

The Stanford 25: Exam Techniques Every Doctor Should Know

Monday, October 4, 2010

There are* in fact stupid questions

There are in fact stupid questions. In fact, there are several. Further fact: the majority of things a medical student might say at any given moment will likely fall into the classification of stupid question, even if in other contexts they are reasonable questions. For example "where is the bathroom?" and "How do i stop the patient from biting me?"

Statements can also be stupid questions ("But i do not know how to do a cardiac massage.") as can inquisitive looks and breathing too loudly near the surgeon.

Stupid questions are punishable by smirking, derision, public lashings, private lashings through vivid evaluation remarks ("Please express to your parents my great sympathy for their having birthed a child too stupid to know how to dose diuretics properly" "Your usefulness to the team ranks below latex gloves status post rectal exam but above small puddles of body fluids to the left of the nursing station") and being physically assaulted in the operating theater (using proper sterile precaution) with either very expensive surgical instruments or fecaliths. Please note that any damage incurred to surgical equipment will be added to the student's tuition. Also any patient specimen used as a projectile didactic tool will need to be retrieved by the student and expediently returned to the pathology lab.

In conclusion please arrive to clinic or your respective ward teams knowing everything and kindly avoid making eye contact.

Monday, September 27, 2010

Thursday, September 23, 2010

The Heart of Medicine

"To practice medicine with good spirit does not mean to be in a place where there is no noise, trouble or hard work. It means to bring your calm and loving heart right into the midst of it."

http://www.theheartofmedicine.org/