Welcome to anyone who is finding this blog for the first time through the Healthcare Blogger Code of Ethics. I am proud to have been accepted into the HBCE community. I am using this recognition to renew my commitment to protecting patient confidentiality and the ethical use of health information, and I welcome dialogue on this subject or whatever other feedback you have for me. Thanks for reading.
May 10, 2009
Reflections on Psychiatry, my last patient-oriented month of third year
Psychiatry was a very difficult rotation for me. Despite their relative physical health, many of the patients on the Inpatient Psychiatry service – a locked unit in a part of the hospital many doctors didn’t know how to find – seemed even sicker to me than patients on other services because the level of impairment experienced by some of the patients on the unit was so devastating, even worse than many patients on inpatient medicine units. Mental illness is powerful enough to reach into every part of a person’s life, and many of the patients had lost their jobs, their homes, their relationships, and their physical health—not to mention their self-esteem, pride, or even identity. For many patients on other services, whatever illness brought them into the hospital was threatening one or more of these aspects, but rarely all of them. In particular, it was tragic to see how, unlike medicine, in which a loved one’s illness often brought spouses or families closer together, many of the psychiatric illnesses struck directly at these relationships. Watching a patient with probable borderline personality disorder interact with her mother, I saw how warped their interactions were and how tested their relationship had been because of the daughter’s mental health issues. Similarly in schizophrenia, it was heartbreaking to listen to a patient refer to the family that had struggled for years to keep him safe and care for him at home as “just faces I see every day”; as much as the family members understood the patient’s condition, this “autism of schizophrenia” must have felt like a constant slap in the face. I can’t imagine the pain of watching someone you love be turned into “someone else” by mental illness in a way no physical illness could.
Just as the condition of the patients on Deaconess 4 was more serious than many patients on other floors, it was also much harder for me to maintain an emotional distance in order to protect myself. In other rotations it has been easy for me, as a young woman with no physical illnesses more serious than allergies and mild migraines, to enforce a separation between myself and my patients: I don’t have diabetes, I don’t have liver failure, and so on, and so I was able to view their conditions objectively while still empathizing with the patient as a person. In psychiatry, the border between my mental experience and that of the patients is much more blurry. We all have coping mechanisms (adaptive or not), stressors, thoughts, and moods; we all have a psyche. Many of us “normal” people (i.e. the caretakers) have even had our own mental health problems. It felt like the difference between “us” and “them” was only one of degree, or luck. There but for the grace of God go we… While this made empathizing with the patients easier in a way, it also made any degree of empathy threatening to my own equilibrium as part of the treatment team, by opening myself up to the pain of their illness and being unable to dismiss it as something that happens only to other people. As a daily defense mechanism on the unit, I observed and certainly sometimes participated in humor that derived amusement from patients’ behaviors. At other times, I just went home and watched television for hours, to try to hide from the emotions stirred up by the day.
It was in this context of the push and pull of extreme emotional empathy and extreme emotional distancing that I finally felt the cord tying myself to a patient as fellow human beings snap – not permanently, but at the time completely, or so it felt. My day on the psychiatry ward had ended, and I was attending an early evening session of a bedside teaching elective that had spanned the year. An email had informed us of a special opportunity for some students during this session to accompany “Dr. P”, one of the senior psychiatrists, and discuss interviewing “difficult patients” rather than our usual pulmonary physiology or cardiac exam findings. Since I was on the psychiatry rotation and therefore had the chance for regular teaching sessions with Dr. P already, I asked to be in one of the regular groups. Through an administrative misunderstanding, I was put in his group anyway.
My classmate “H” eagerly volunteered her patient “Mr. C” as our interview subject. As the small pack of us entered his room, she brightly called out, “Hello, Mr. C! It’s me, H!” He muttered something unintelligible. Dr. P introduced himself politely and explained that he was teaching this group of third-year medical students about interviewing, and they began their conversation. What followed is hard for me to remember in detail, because it was a dizzying blur of contradictions, non-sequiturs, and barely-speech. Dr. P modeled perfect interviewing behavior by starting with open-ended questions: “Tell me about yourself.” When that produced a tangle of thoughts that trailed off, he tried again with more specific questions: “Where did you grow up? Any siblings? Were you ever in the military?” The answer to that last one was no; a few minutes later came a fragmented story about his time in the Air Force. It was like trying to use one of those notoriously poor internet-based language translators: each response that came back was nonsensical, yet delivered with complete confidence in its sense. Dr. P tried gamely for several more minutes, but it was clear that this interview was exhausting even his normally extensive patience and persistence. We thanked Mr. C for his time and left the room.
In the small conference room at the end of the hall, with late afternoon sunlight streaming through the windows and an eleventh-floor view of the surrounding leafy neighborhoods, including my own, Dr. P pieced together a discussion about difficult interviews. My mind was still in the room with Mr. C. I witnessed the way he lay almost motionless in his hospital bed; the lines and monitors tangled around him; the sores on his legs; his broken-down appearance that looked like more than old age (he was in his early sixties.) He did not seem to be suffering, or in pain. His history was hazy—something about alcohol, maybe also an accident. Sitting in the conference room, I looked down at him through my own eyes and felt… nothing. No stir to empathy for the depth of his deficits. No urge to help. No reproach for perhaps drinking himself into oblivion. Not even pity, of the kind that builds walls. Just an emptiness. In my mind I responded to his unstated but unavoidable question of, “Well?” with, “I’m sorry. I have nothing to give you.”
While I have known patients this year who were difficult, trying, mean, or just too far gone, patients who stretched our abilities even to hold our tempers much less to provide any kind of care, this was the first patient who inspired no feelings of any kind in me. And that was terrifying. All of the others at least felt like human interactions: relationships marked by dislike, disgust, enmity, and of course warmth, friendship, grief, compassion, and caring. But never before a failure to respond on the most basic human level. This, I realized, is burnout. I cried as I walked home, leaving the hospital by the back entrance and blinking in the beauty of the sunshine and the Fens. The tears dried up quickly. I threw on shorts and sneakers and went for a run, pounding the sidewalk with angry feet. I flopped on the couch and watched TV shows back to back to back while I ate leftovers.
When I began my third year, I vowed to myself not to lose the idealism that brought me to medicine, my compassion for people that moved me to understand them and to care for them. When I began my third year, I didn’t see how anyone could lose that, how bright-eyed medical students became the jaded, uncaring doctors we have all heard about. I think that this one patient encounter, this one empathic failure, was a sobering gift at the end of my third year. People often ask me how I have changed during third year, and I think it’s this: even this early in my clinical experience, I have developed a far more nuanced understanding of how compassion inspires doctors to do what they do. We don’t love every patient; far from it. But we can come to medicine out of a desire to help people, out of a belief that all people deserve to be helped, and this gets reinforced and rekindled by the patients who do touch our hearts. For the rest, as I discovered on my Neurology rotation, we do our job anyway and give them good medical care. So when I call this patient encounter a gift, it’s because it was a humbling warning, a call to attention that will help me to continue forward with a more subtle and also more durable sense of purpose. I learned that I might not always have empathy for all of my patients. But never on that day or since did I question whether I should, or could, be a doctor.
May 7, 2009
Where I am at the beginning of my third year
Where I am at the beginning of my fourth year
age: 24
age: 25
residence: Boston, MA – medical school dorm
residence: Brookline, MA – apartment with a roommate
relationship status: four years seven months, and engaged
relationship status: five years seven months, and still engaged (twelve more months to go…)
exam status: USMLE Step 1… passed, I hope
exam status: USMLE Step 1 passed (plus Surgery, Medicine, Pediatrics, Ob-Gyn, Neurology, and Psychiatry shelf exams), Step 2 CK and CS on the horizon
expected date of graduation: May 2010
expected date of graduation: May 2010
future career: physician, academic medicine in a large urban area, mostly clinical and some education (student and resident levels)
future career: physician, academic medicine in a large urban area, mostly clinical and some education (student and resident levels)
front-runner for future specialty: Child Neurology
front-runner for future specialty: Child Neurology
other possible specialties: adult Neurology, other Pediatrics subspecialties, Ob-Gyn?
other possible specialties: other Pediatrics subspecialties, Ob-Gyn
outside activities: … (when I can: yoga, meditation, jewelry-making, cooking)
outside activities: TV, gym/running, jewelry-making and other craft projects, cooking, wedding planning, NYTimes Sunday crossword puzzles
vices: chocolate, online bead stores with free shipping, Target, shoes, Target shoes, jewelry, kitchen stuff, a very messy room, RSS feeds, cuteoverload.com
vices: chocolate, Second Time Around (that’s nothing new), kitchen stuff, a usually messy room, wedding-related RSS feeds, cuteoverload.com
listening to: Tammany Hall NYC, The Weepies, or anything else from the Scrubs/Garden State soundtracks; misc. alternative/indie rock, soul, Ella Fitzgerald
listening to: Bic Runga, Ingrid Michaelson, lots of mixes
with me at all times: keys, HMS ID, wallet, cell phone, migraine meds, makeup, my Nalgene
with me at all times: keys, hospital ID, pager, iPod Touch, wallet, cell phone, migraine meds, makeup, my stainless steel water-bottle, NYTimes crossword puzzle
last time I read a book: last night
last time I read a book: umm… uhh… does Martha Stewart Living count? [edit: I technically just got back from Spring Break, during which I read about 1.3 books, but before that...]
last time I went out to a movie: I truly can’t remember…
last time I went out to a movie: I truly can’t remember…
average hours of sleep per night: seven
average hours of sleep per night: six and a half (very variable)
coffee consumption: one per day, usually drip made at home
coffee consumption: one per day, usually drip made at home, then a cup from the cafeteria at lunchtime, and sometimes Starbucks when I think I deserve it…
All in all, not a lot has changed… at least not a lot that is captured on this list. Stay tuned for a post on how things have.
May 7, 2009
A reflection essay for Patient-Doctor III about the same patient:
I have observed often during my clerkships that the hardest patients to deal with–for myself, and for my team–are the ones who are not easily categorized. I have heard comments about so many variations on “those people,” perpetuating stereotypes about people with back pain, diabetes, obesity, or high blood pressure. Regardless of their veracity, they sometimes seem to help residents redirect their frustrations and the stresses of their job towards a depersonalized amorphousness based on diagnosis, rather than towards a given individual. And I am well aware that over the course of the year I have absorbed many medical prejudices about what “those people” are like and how they will behave while under our care and after they leave the hospital. It is unfortunately cynical, but also a defense mechanism counterbalancing some of my naivete. Still, it is hard to only be a little cynical, or only lose a little optimism.
A patient on the neurology consult service this week challenged my developing familiarity with these stereotypes and prejudices, not because he contradicted them in any way but because he was simultaneously so frustrating and so inspiring of sympathy. He was a middle-aged man who came in with a chief complaint of “seizures,” describing two episodes of falling to the floor and shaking his limbs. No one else had witnessed the events, but he was insistent that they were seizures. Red flags started to go up when, after hearing that a seizure meant he would be unable to drive, he began to change his story and said that “maybe it was just vasovagal.” The team got more suspicious as he told different versions of his history to different people at different times and deflected any of our attempts to redirect his circuitous and occasionally self-contradictory tale, as if he wanted to stick to a script he had in his head. He perseverated on certain topics, repeating them in response to unrelated questions, particularly his chronic pain after a neck injury in an accident; another red flag, another “those people” category. He was obese. He included extraneous information about his job, his dog, and his experiences at other hospitals. All of this already meant he was labelled as a “difficult patient”–difficult to round on because he took so much time to talk to, and automatically raising the ire of the members of the consult team, who felt they were being manipulated. The last and most overwhelming piece of evidence came when we got him out of bed to watch him walk. Unsuspecting, I questioned to myself whether the two petite female neurologists on either side of this very large man would be able to do anything at all if he started to fall. He did sway and lose his balance, numerous times in the short walk around the room, and each time I jumped forward to help them catch him. But he never actually fell. The attending remarked to the resident “Hm, astasia-abasia,” and we left the room soon after. I learned in the hall that astasia-abasia is a “nonphysiologic” gait disturbance; in other words, a psychogenic problem, with no true neurological cause.
Now, in all our minds, this patient had become one of the worst of “those people”: a malingerer. It was revealed that he had been trying unsuccessfully to get disability benefits. From the tone of the conversation, it was obvious that we were all feeling used, exasperated, and also bored: now that we had him categorized and we had “diagnosed” his problem, he was no longer neurologically interesting, and we couldn’t wait to sign off.
Still, I left the room shaken, not by his obvious creation and magnification of invented problems, but by the depth of his true problems and the suffering they caused. Even without knowing where exactly truth stopped and fabrication began, it was obvious that what he told us had some basis in his reality. He had been healthy, a lean and muscular gym-goer, until a fall on the job damaged his neck. Unable to exercise, he went from a husky Irishman to what the stereotypes told us was just one more morbidly obese patient compounding his own medical problems. His work as a contractor had fallen on rough times already because of the economy, and now he could seldom take whatever jobs he was offered. He was homeless and lived in a shelter. He had at some point developed atrial fibrillation. He felt weak, and had two of these seizures or whatever they were, so he wouldn’t be able to drive even if he had a car. He was depressed, he told us, and had thought about suicide. He seemed still in shock about how different his life had become, and how with each new problem it seemed harder and harder to get out of his hole.
In an in-class exercise for a writing course that night, I wrote about him as I imagined he saw himself, rather than as we saw him: not as a schemer or a whiner, but as a man somehow suddenly fallen from grace, coming to us because he had no one else to turn to. Looking back to our encounter and tapping into a wellspring of sympathy for him was effortless. Yet it had also been effortless to join in the categorization and subsequent dehumanization, and even disgust, the consult team collectively experienced when we met him. There was no way to reconcile the conflict of this juxtaposition, because both realities were true.
In the hall outside his room, as we began to exchange knowing looks and tear apart the inconsistent story and impossible exam, my senior resident spoke up. “It sucks for him that he’s a malingerer. It means we’ll automatically give him worse care.” Her words stuck with me because they were neither the cynicism I had come to expect from many residents, nor were they credulous sermonizing about being open-minded and treating everyone with love. What she said acknowledged the tension between resentment and sympathy this man inspired, and let it continue to exist, only pointing out our duty to give him good care regardless. Her comment captured the unresolvable conflicts that I have learned over the course of this year are confronted in every field of medicine, especially between unguarded caring and get-it-done practicality, and reminded us of our role as medical professionals. Then we all got back to work.
May 7, 2009
An in-class for my writing elective, in which we were instructed to write about a patient as if he were the protagonist in a story:
He paused, but only for a moment, as he stacked five cans of Coca-Cola on the table next to his dinner. There was a time when he would have come home from the gym, covered with sweat and blazing from the glow of a personal weightlifting record broken, and eaten carefully: lean protein, vegetables. He would have driven home in the beat-up but powerful car he was no longer allowed to drive after the seizure. He would have come home to pour a bowl of water for his dog, an enormous mutt with a bite missing from its left ear. He no longer did that when he came home; the dog was long gone, and he had no home to come to.
Before he moved out, one month too many of rent unpaid, he had cast a last look at himself in the mirror previously overgrown by boxes and cast-off clothes. His once full hair was long, thin, and greasy–he stuffed it under a faded Red Sox cap. His proud Irish barrel chest that once gleamed as he ran shirtless now sloped down into a sagging belly barely contained by an oversized gray t-shirt. His legs buckled slightly from the pain in his spine, always there since the accident, but sometimes worse.
He left the house behind, and did not go to work, because that too was over. He was still waiting for the disability payments that might have kept him a little longer from being homeless. A grown man, an Irish man, a strong man, a working man–he thought that for the first time in his life he would sit down on the ground and just cry. Or he could drink. Or maybe he could find some quiet place, under a sheltering tree on a grassy hill. He could take all the pain pills left in the prescription bottles in his backpack, and hope that they would be enough to end the life he still could not believe was now his.
March 21, 2009
This made me cry a little… and then giggle a lot, when I looked out of a window the other day and spotted Sponge Bob the Construction Crane. I hope that will be true of my future career in pediatrics: a little crying, a lot of giggling, and a very warmed heart.
And check out this insightful take on it from Joe Wright’s Hemodynamics.
March 9, 2009
I’m happy to announce the publication of my second column for the March 6 issue of Focus newsletter. Something much more lighthearted than my previous one… Enjoy!
—
“Medical School, Season Three”
Focus
by Miya Bernson
Looking back over my 10 months of third-year clerkships, one pattern emerges. No matter whether I’m flopping on the couch exhausted at the end of a long day, entertaining myself while on the elliptical machine, or trying to get my mind off the frustrating or sometimes heartbreaking experiences I’ve had in the hospital, I do the same thing. I watch medical television shows.
It struck me as odd when I first realized that this had become one of my main uses for the limited time I have outside the hospital. I joked about it with my fellow third-years: there must be some weird psychological explanation for my obsession with Chicago Hope, a mid-1990s drama about surgeons, while I was struggling through the harder parts of my surgery clerkship. After I finished the first season of Chicago Hope, as well as the clerkship, I moved on to my medicine clerkship and the 1994 season of ER. I have seen every episode from all eight seasons of Scrubs, though I quit House M.D. at the end of the fourth season. I can’t say that I have gotten turned on to Grey’s Anatomy yet … but I do still have a few months left in my third year.
What is it about these shows that captivates me? Why do I turn to them even when, one would think, I would want an escape from the hospital and the notoriously all-consuming third-year clerkships?
Certainly, the explanation for the popularity of so many medical shows is that, even (or especially) for the general public, the field of medicine offers situations and relationships that are inherently fascinating. Watching the complicated unveiling of rare syndromes by the masterful diagnostician Dr. Gregory House, the title character of House M.D., has all the addictive qualities of a good Sherlock Holmes story—with reason, since author and physician Sir Arthur Conan Doyle’s works greatly inspire House and were themselves based upon the logic of Conan Doyle’s esteemed colleague Dr. Joseph Bell.
But House lost much of its appeal to me after the first few seasons as the medical conditions became increasingly far-fetched. This happened to coincide with my first two years of medical school; my growing factual knowledge from classes and boards preparation allowed me to recognize House’s medical fallacies as well as its flagrant violations of the diagnostic dictum “when you hear hoofbeats, think horses, not zebras.”
The answer to the question of why my love for House has waned as my love for other medical TV shows has grown is that in the latter, I see truth—truth both personal and professional, which have never before in my life been so intertwined.
As the technically skilled, if emotionally troubled, surgeons on Chicago Hope saved life after life in the span of the swing of an operating room door, I recognized in their successes the fundamental attitude of the surgeons I met during my clerkship: this patient is broken, but we can fix him. And they often do.
ER third-year medical student John Carter’s struggles to balance humanism and clinical efficiency all while pleasing his resident are clearly based on the experiences of another Harvard medical student: the recently deceased Michael Crichton, the show’s prolific creator. His character struck a chord with me during the beginning of my medicine clerkship, as I fumbled to find my role on the team, learn the computer system, memorize antibiotics, present cases clearly but efficiently, and reconcile my idealism with the fact that I rarely got to spend more than 15 minutes a day with each patient.
Even Scrubs to me reflects fundamental realities, despite careening as it does between absurd doctor–patient interactions, soap-opera-worthy romantic entanglements, and even main character Dr. John Dorian’s fantasies about all-staff sing-alongs or curing patients with boxes of kittens. Scrubs’ frenetic pace reflects the fragmented and unpredictable nature of the hospital, where in one room a person is dying while in the next a person is being born, and some patients make miraculous recoveries while others unexpectedly spiral downward.
As for Dr. Dorian’s lapses into fantastical re-imaginings of the situations he confronts, perhaps they reflect the same underlying impulse as my own escape into the imaginative world of medical TV shows. Just as much as they are an escape from the current pressures and hardships of hospital life, they are also ways of making some kind of sense out of the experiences of physicians and physicians-in-training, acknowledging the drama and finding the humor in what we do, in order to return the next morning, ready for another day in the hospital.
December 5, 2008
This beautifully written article in the New York Times reports the death this Tuesday of Henry Molaison, a.k.a. H.M., the most famous and influential neurological research subject of recent decades of neuroscience – the Phineas Gage of the 20th century. I won’t repeat their synopsis of his contributions to the understanding of the science of memory, one of the most inherently fascinating domains of neuroscience.
I do want to point out that H.M.’s life was another example of the uncomfortable truth that sometimes what is worst for patients is what is best for the intellectual endeavors of scientists and physicians. I hope to write more about this in the future, because it is something that I have seen repeatedly this year, particularly in my very defined role as a student, constantly learning from every patient interaction and every view into the workings of the medical system. I recently met a young patient with HIV since birth, now uncontrolled (and definable as AIDS) since she refused to take her medicines, who came to us with a lump under her skin that had become painful. The biopsy results aren’t back yet, but it is almost certainly cancerous. It was an incredibly tragic situation. But the flurry of medical activity that sprung up around her was medicine, and education, at its best. She was supervised by the Adolescent Medicine service, but was well known to the Infectious Disease/Immunocompromised team. They consulted (personally making attending-to-attending phone calls) to Oncology, Radiology, and Surgery. In the midst of it all, Psychiatry was trying to make some headway with the girl’s refusal to take her medications and the fear around the biopsy. All of these teams–each with its attending, a fellow or two, and sometimes another resident or NP–were swirling in and out of our already cramped conference room, where I could listen first hand as they discussed what to do. I followed them into her room several times to hear how they said what they had to say. And I was trying my best to help facilitate the interactions of all of these different teams and participate in this exemplary interdisciplinary medical effort. It was a situation that was painful and terrifying for the patient, and educational and exhilarating for me as a medical student. The positive view is that she is definitely in good hands, but that doesn’t stop me from feeling uncomfortable that, again and again, whether it is the thrill of making a new diagnosis or the joy of seeing different providers come together to care for particularly complex cases, the events and experiences that are best for me and the medical system may be the worst for the patient.
November 14, 2008
Returning from a blogging hiatus with a special announcement: I’m published!
My first piece appeared in the Student Scene column of the November 3 issue of WebWeekly, an online newsletter for the Harvard Medical School community. The same piece was published in the online and print editions of the November 7 issue of Focus, a newsletter for the Medical, Dental, and Public Health schools, in their Forum section. I will be writing for both semi-regularly, and I will announce here when my pieces appear. I am excited and grateful to have this chance for my writing to reach a wider audience and hope this is the first of many such opportunities.
—
“Confronting Pain”
WebWeekly and Focus
by Miya Bernson
“I feel my world shrinking, and it terrifies me,” she said. She used to be an athlete and yoga practitioner. Now she was one more patient in the Pain Clinic hoping for an explanation and a cure. As we talked, I felt I was standing on both sides of the divide between patient and doctor. Pain is a universal human experience, and I could easily “feel her pain” as her limitations increased. However, she had come to me and to this clinic for treatment, not just for empathy. And that was not so easy.
In the first year of medical school, we learn how to talk about the symptom of pain, what the patient experiences. Where is it? When did it start? What makes it better or worse? This focus on the patient’s perspective in the Patient–Doctor I course leads to a compassionate but theoretical understanding of pain. We ask them, “On a scale of zero (no pain) to 10 (worst pain imaginable), how would you rate yours?” The answer may say more about the patient than the pain.
In the second year of medical school, we become more objective. Rather than talking about the symptom of pain, we observe the sign of “tenderness,” an experimental variable we can elicit. As we learn the physical exam in Patient–Doctor II, we report that a particular part of the body demonstrates “tenderness to palpation”—that is to say, it hurts when poked.
We learn ways to produce certain kinds of tenderness that are essential to making a diagnosis. We are told to not-so-accidentally bump into the bed to jostle an irritated abdomen and produce the typical signs of peritonitis. This condition can also cause rebound tenderness, a painful sensation when the abdomen bounces back suddenly after being compressed. The classic way to test for it without the patient suspecting is to listen with the stethoscope for bowel sounds, gradually indenting more and more, then suddenly letting go and watching for the patient to wince. Such maneuvers are meant to be clinical, not cruel. But we still apologize for them.
As second-years, we also learn about the Waddell signs, controversial tests and criteria intended to ferret out pain with a psychological cause, conscious or otherwise. These include complaints of pain that do not make anatomical sense, or tenderness that occurs in response to nonpainful stimuli and disappears when the patient is distracted. While our instructors have shied away from teaching us that positive Waddell signs necessarily mean a patient is malingering, discussing them reinforced how problematic pain can be for medical providers. Whose pain is “real,” and does it have to be real for us to treat it?
Now I am five months out of the classroom and into my third year of medical school, and it seems every patient I meet has pain. The humanism and pathophysiology of the first two years have given way to this year’s emphasis on management and treatment, and nowhere else is this transition more apparent than in dealing with pain.
My first-year training in empathizing with patients prepared me to recognize the constant anxiety that gripped the young man with raging ulcerative colitis, and connect it to his apprehension before the colonoscopy that would finally decide whether he would have his colon removed. He had made it through several colonoscopies before without much discomfort, but during this one not even the maximum doses of painkillers and sedatives, much less anything I had to offer, could keep him from crying out in pain and fear.
My second-year pharmacology class helped me understand why the drug addict writhing in his bed complaining of back pain had developed a tolerance to opioid pain medications, so that even massive doses would feed his addiction but not relieve his suffering. But no class taught me how to help someone like him. He had violated his “pain contract” with the outpatient pain clinic by seeking drugs from more than one doctor, so he was no longer welcome there.
As a third-year, I have had many opportunities to hone my skills of interviewing and examining, but for me to advance to the next level of medical training, I will also have to act: to give treatment. Medicine’s capacity to manage pain or any medical condition is imperfect, and the stakes are high. My responsibility now is to master the use of medications from ibuprofen to morphine, and to use them judiciously, balancing skepticism with sympathy as I assess the patients’ pain and attain the physician’s power to relieve it.
—Miya Bernson is a third-year medical student at HMS.
August 21, 2008
Having trouble even knowing where to begin writing about my experiences with inpatient medicine. Despite knowing how sick you have to be to get admitted to an American hospital in 2008, I was not prepared for the pain I have witnessed. Every patient seems to have so many problems: an acute exacerbation of their emphysema or heart failure on top of their underlying diabetes and vascular disease and drug abuse compounded by a history of heart attack, stroke, and cancer. Either that, or they only have one, but it’s the one that is enough. And I don’t know how to process the experiences I have had even in the span of a week, especially now that I have been able to take somewhat more responsibility for admitting “my own” patients.
One patient, a known drug abuser, writhed in pain in his bed. He was begging for pain medication, but little could be done: so much drug use had dulled his responsiveness to opioids. And he had broken his “pain contract” with the outpatient pain clinic by seeking pain medications from more than one doctor, so he was no longer welcome there.
Down the hall, a man on the cusp between middle and old age sat reading a mystery novel while an IV delivered fluids into his arm to treat his dehydration. “I was in the hospital when my ‘friend’ died,” he said, slightly accenting the word, “and I guess I just stopped taking care of myself after that. We were together for almost forty years.”
One of my patients was a diagnostic challenge from the minute she came in from her nursing home for nausea and vomiting. She was sweetly demented, so she couldn’t say much about what had been going on, and she would tell different members of my team that it hurt at different times in different places. We kept getting excited every time we thought she had a new disease to add to her extensive medical history, hoping she was sick: if those really were enlarged ventricles on the CT scan of her brain and she had normal-pressure hydrocephalus, it meant we could do something for her. Otherwise, she was condemned to her dementia. She sat on a board of trustees only eight months ago, her brother said, and my eyes burned. We still don’t know how to treat her urinary tract infection.
The same patient left me kicking myself when the neurology team gave her the diagnosis of not normal-pressure hydrocephalus, but Parkinson’s disease, a long-standing interest of mine. How could I have missed the tremor in her hands, the rigidity of her limbs, and the classic expressionless face? Easily: I was fitting her symptoms to the diagnosis (NPH), not the other way around, and I never stopped to ask myself the question “what else could this be?” We started her on Sinemet to replace the dopamine her brain has run out of, and I know it’s probably all in my head, but I could swear that overnight she became more animated. Her eyes met mine when I said goodnight to her today, and I realized it was the first time she had smiled at me.
The hardest patient was a middle-aged man with end-stage liver failure and untreated AIDS. His body looked alien, humanoid but not like any other human body I had ever seen. His belly was enormous, perfectly round and stretched with ascites, the fluid seeping into his abdomen because it could not pass through his cirrhotic liver. His arms by contrast were stick-thin, all the muscle melted away. His legs were puffy with fluid, soft swelling over sticks. And his head was so shrunken and wasted I could hardly believe it could contain his skull. He looked out at us through wet brown eyes in an emotionless face, tense and quiet like a scared animal. His breathing became unstable this afternoon and he was moved to the ICU, sedated, and put on a ventilator. I guiltily felt a little better once he was sedated because he didn’t seem quite as much like a conscious soul trapped in a distorted body.
My last patient today was a middle-aged man with metastatic cancer. His cancer was originally diagnosed in another country a year ago. They gave him symptomatic treatment, and he felt better, so he thought he was better. This week he started having pain again, and his CT scan showed the mass had spread to three other organs. It was Stage 4 of 4, inoperable. Not years but months. His son grasped desperately at other explanations – it was an infection, it couldn’t be cancer because his father didn’t look sick enough. He asked me in his own words to help him understand the biology of cancer, seeking answers in mutated DNA bases and cells that lose the ability to stop spreading, eating through walls into other organs. On the first day we thought the patient spoke only Portuguese, so we relied on his adult children and the interpreter. On the second day I found out he speaks some Spanish, and from then on our communication has flowed through a wide-open channel, mixing our “fazers” and our “hacers” and cracking jokes and crying. It wasn’t the first time this year I have been so grateful for my Spanish. Exhausted from having no days off for two weeks, being on-call last night till midnight, finishing my work at home, and then coming in at 6:15 this morning and staying until 8, I still went in to say goodnight to him after I dropped off my note in his chart. And time slowed down for a while as I sat on the edge of his bed and we talked softly. He still feels shocked, and shakes his head at what he understands about what he is facing, but his voice was full of peace. In half-Spanish, half-Portuguese he spoke with deep gratitude of the love and compassion and professionalism he has experienced during his hospitalization. I wound up leaving at the end of this whirlwind day feeling that he had blessed me and my work, and I was uplifted, even though he was so far the patient I have seen who has gone most dramatically from health to illness. Obrigado, senhor.
