Back-dated journal entry from the Team Training sessions with the medical simulators.

“I think our group did a good job of sharing our knowledge with each other, dividing up tasks, and working through the medical problem level-headedly.

One thing that was difficult was trying to arrive at some sort of consensus in the context of a time-pressure situation. We gave our simulated patient fluids to counteract low blood pressure, a decision that I think some members of the group did not support but we didn’t really feel we had time to methodically consider all viewpoints. When the patient got worse, those viewpoints resurfaced and we ended the fluids, but not without damage to the patient. I think if we had been more accustomed to working with each other and to each other’s personalities and styles, the more forceful members of the group would have known to step back and make sure everyone was on the same page before acting.”

I have a feeling my thoughts on this topic are going to expand a lot before my medical career is over…

Back-dated entry from the day we learned Basic Life Support (CPR, use of Automated External Defibrillators, and choking relief specifically for healthcare providers).

“I found it pretty exciting to learn BLS on the dummies just because I felt I could envision actually being in an actual life-saving situation with a real patient, and it felt good to know that I now had some real skills that could save someone’s life. For some reason the pediatric and infant CPR and AED units affected me more this way. I guess lately I have been feeling a growing interest in pediatrics, so it makes sense that I would feel closer to those patients and somehow emergencies seem more high-stakes and emotional with young patients than with adults. All that being said, I definitely felt that there was a lot of information to try to remember, particularly about when to do what in what order depending on the patient and the responder situation; I was somewhat anxious trying to remember all of it with the dummies today and I think I would be very nervous doing CPR on a real patient until I got more experienced.”

I took care of my first patient today. He was a 72-year-old man named Fred with emphysema from a lifetime of smoking, and was having trouble breathing. It took us a while to get his blood oxygen saturation stabilized, but we did eventually figure out what was wrong with him thanks to our morning’s training in history-taking and vital signs. We got his medical history, took his pulse and clocked his respiration, monitored his blood oxygenation/pulse rate/blood pressure, and had to intubate (insert a breathing tube) at one point which is never enjoyable especially for someone that old. Good thing he was a simulation dummy! You can meet him here and here.

Tonight’s journal answer:

“The highlight of my day was realizing how much more medically empowered we were as caregivers for our future patients after just a morning’s worth of vital signs training. They really are “vital” signs – I hadn’t realized just how many problems could be elucidated just by taking vital signs, and especially by knowing vital signs combined with even the most basic medical history. I felt capable of anticipating or at least understanding what was going on with each of our group’s three patients (the one simulation I did and the two I watched) just based on my newfound knowledge about blood oxygen saturation, blood pressure, and respiration rate. I was also amazed by how much you can learn from an EKG, as demonstrated by the two highly capable anesthesiologists who taught us EKG interpretation.”

Yesterday and today were our first Clinical Case Study, using the case-based learning method that is a hallmark of HMS’s New Pathway (now technically the New New Pathway, or the Ever-Renewing New Pathway, or some such). I really enjoyed this unit of the Introduction to the Profession Course.

First, it was more than just small-group sessions, which is what I had thought it would be. Instead, we had two small-group tutorials (90 minutes each) each day, in which we watched short videos of a patient interview with a man with HIV/AIDS talk with his AIDS specialist about everything from the clinical history of his disease (infection sometime in the early 1980s when the first cases were recognized, then full-blown AIDS upon appearance of PCP, pneumocystis carinii pneumonia) to the psychological and social issues he has faced and how his personal identity and sense of self have changed as a result of the disease. We discussed the videos in the small group, each contributing whatever previous knowledge we had plus the topics we had chosen to research further between meetings. We were guided by a wonderful faculty member who struck the perfect balance between guiding/informing us and letting us loose to explore the case. We had two lectures, one on the history of the epidemic and one on translating HIV/AIDS research into clinical practice. Finally, we were afforded the incredible opportunity of meeting the patient and his physician this afternoon. As someone who learns well by learning repeatedly and from multiple sources and in multiple formats, the combination of small-group exploration, individual research (with the help of an orientation from the friendly folks at Countway Library and the ridiculously rich digital resources of the Harvard system), and (high-quality) formal lectures worked really well for me. I felt that I was able to retain information from one “piece” of the case to the next and to establish linkages between things I learned at different times and in different settings. I’m still working on getting the overall big-picture/framework (see previous entry) for HIV/AIDS but I think I’m light-years further along in my knowledge and understanding of something I knew very little about before, and obviously something that is of crucial interest to the healthcare profession and the world in general.

Which leads to the second thing I enjoyed about the case study: the choice of HIV/AIDS as a topic to study. Like perhaps no other illness, HIV/AIDS acts as a point of intersection for all of the things I wrote about in my introductory entry in this journal, and more. Scientifically, it is a devastatingly complex entity encompassing mechanisms of viral transmission and replication, the complicated and sophisticated mechanics of the immune system, and the mutation and the evolution of the virus itself as it has continuously outrun whatever we have done to try to stop it; the challenges and the victories of HIV/AIDS research are pretty amazing to learn about. Medically, it can affect virtually every system of the body either itself or through opportunistic infections; today I researched AIDS-related peripheral neuropathy, numbness/tingling/pain indicative of nerve damage in the feet and caused by either inflammatory responses to the HIV virus itself or by antiretroviral therapies’ toxic effects on mitochondria, which are present in every cell in the body… Emotionally, it can not only produce neuropsychiatric complications (AIDS dementia, depression due to subcortical brain damage) but also obviously serious and complex emotional and psychiatric problems (e.g. depression related not to brain/functional damage but to social isolation, constant stress, etc.) – all very MBB. Socially, there are all the issues of transmission, detection, prevention, stigmatization, education, isolation, community, activism… Our patient also made clear that his individual identity had become inextricably entangled with the disease: he had to reduce to part-time his very high-powered legal career, which had obviously been hugely meaningful to him, in order to take on a new identity or career as a patient with an acute fatal, and then chronic manageable, illness. Changes to his health and to the treatment options available changed everything about how he lived and moved in the world and how he saw himself. The patient himself was just an amazing and inspirational guy; through all of this, watching 90% (he said this) of his friends with the disease die, suffering terrible complications and side effects and quite a few times thinking that he was near death, he has remained incredibly humble and grateful for everything he has. He is doing quite well now on a newer cocktail of drugs, and now he is reaching out to help others in various ways – “What an honor it is to be in a position to help rather than be helped.”

Finally, I’ll leave the reader with some concise advice from the patient in his in-person interview: “Never underestimate the importance of likeability.” In a nutshell, as pithy as it is, that might be the message we are supposed to take from this course: no matter how small or insignificant, or insurmountably hard, it may seem, you have to act like a good human being for your patients to see you as a good doctor, and more importantly for you to be a good doctor. The message is being sent in this class, from the very beginning, that it is not optional to be caring and compassionate. It is not an extra, a special feature, an add-on, or something you can worry about developing with age and experience. It begins now, quite literally in the first week of medical school.

Postscript: I fortuitously read this just after finishing my last edit on the post. Again, my religious learnings tie perfectly to my medical ones, and you may substitute “medicine” for “UUism/religion.” “I suppose what led most of us to Unitarian Universalism is our understanding that the central question of religion is not whether one lives forever but whether one lives.” – Devon Wood

Spent the day at the hospital shadowing and interviewing patients, with time for “debriefing” after each. I was so amazed by the thoughtfulness and intelligence of the nine or so other first-years in my debriefing group, by the wisdom of our faculty leader, by the patience and gentleness of the pediatric surgeon I shadowed, and by the emotional maturity of the college-age patient we interviewed. Such an emotional day and so many learning experiences, I’ll never be able to put them all into words, but here is my response to the journal prompt “What was most striking from your experiences today?”:

“I think by far the most striking message from my experiences today – which were phenomenal opportunities that I’m very grateful to have had! – was how big a difference simple things could make to the patient’s experience. I commented during the first debriefing session that the pediatric surgeon I shadowed in the morning always found a way to touch each young patient early in the encounter, in a gentle and reassuring way. It took a matter of seconds, and he did it seemingly without thinking about it, but at least from the outside it made his relationship to his patients seem so much closer. With the parents, he listened patiently to every question or comment even if they seemed over-anxious or irrelevant, and the parents all seemed to leave their encounters satisfied that their concerns had been addressed. One woman from a former Soviet republic brought in her baby son who had really nothing wrong with him but I think she thrived on the doctor’s kind attention and reassurance. Finally, in the afternoon patient interview, our wonderfully courageous and thoughtful patient emphasized to us over and over again how big a difference–positive or negative–little actions on the doctor’s part made to him. His worst experience was with a doctor who answered a phone call in the middle of a patient encounter with him and made a dinner reservation right then and there; that physician probably doesn’t even know his action had any impact, but years later that is the thing our patient singled out. He also commented about the little things doctors had done to make him feel like a real person and an individual, showing him respect and listening to his opinion (he is a pre-med, so he has a lot of scientific and medical knowledge and has spent a lot of time reflecting on his medical experiences!).

The afternoon debriefing session confirmed this idea that small gestures, words, and actions on the part of the physician, even ones that only take seconds “away from” the diagnostic and biomedical part of the patient encounter, have an enormous impact and can make the difference between a good doctor and a bad doctor in the eyes of the patient. And I was shocked at the general sense that physicians forget and neglect these things… and, frankly, terrified that someday that could happen to me, because I can’t believe that many physicians start out being callous and impersonal. Our faculty member blessed us by sharing her own personal experience as a resident in the ER when she had just been assigned a new patient at the end of a shift, rushed in and hurriedly inserted a needle for a line or whatever, and only then did the patient say the doctor’s full name – it turned out the patient was the mother of a dear friend, and was dying of metastatic cancer. The doctor realized she hadn’t even taken the fraction of a second to look her patient in the face at the beginning of their meeting. That physician is now an incredibly compassionate, thoughtful primary care internist who has obviously never forgotten the lesson she learned from that experience, and I hope experiences like the ones I had today can be the things that galvanize me to never lose sight of the humanity of my patients and their families.”

I’m too tired and (positively) overwhelmed to write about all the day’s events right now, though I’d like to come back to them in detail, but I’ll paste here the first of our nightly assigned journal assignments for Introduction to the Profession. “Thoughts on the white coat?”

“Haven’t had a lot of time to gather my thoughts about my white coat specifically yet. I very much appreciated that Castle Society’s ceremony focused more on the people than on the coats. We had an extremely powerful session of each sharing why we are here, in medicine or at HMS/HSDM specifically, and some people’s stories were just so riveting and impressive in terms of the obstacles they overcame or still face, their courage, and the passion of their commitments and dreams. The speaker then went to get their white coat while the next person had started speaking, so people’s attention was focused on the next person’s story. There was a great sense of community and intimacy in the room; people were opening up far more than they might have been expected to in a room of forty near-strangers. I appreciated getting to know each person better as a unique individual before they donned the white coat that is in many ways both an equalizer (making us all part of the same group entering the same profession at the same level) and unifier (bringing us together as a community of future physicians). I am sure I’ll have more thoughts to report soon about the significance to me personally of the white coat, but for now it is as much a collective as an individual symbol.”

The first day of med school was a combination of overwhelming and uneventful – I think tomorrow will be the “real” first day, as we are welcomed by the deans and then don our white coats. Symbolism and ritual work for me.

Anyway, rather than post about today’s instructions in respirator fitting and use of the online course portal, this bit jumped out at me from our reading for tomorrow:

“Medicine is by its very nature imprecise. It will require you to live with and tolerate uncertainty and ambiguity every day. You will learn to make the best possible judgments, based on your knowledge of empirical findings, personal experience, professional values, and the wishes of your patients – all requiring critical self-reflection and ongoing self-assessment” (emphasis mine). Reading that made me realize that I am not typically good at dealing with imprecision, uncertainty, and ambiguity – in fact, I’m pretty terrible at it. I feel stupid for it, but I am pretty irked that we don’t have a sense of when meals will and will not be provided (or at least scheduled to be taken together) these next two weeks, because that keeps me from being able to plan out when to cook what and make the best use of all my groceries; although my life is more food-centric than it should be sometimes, I think in this particular case it is more about a coping mechanism, of trying to get at least one element of my life thoroughly pinned down while a lot of other things are out of my control or otherwise up in the air. This is not to say that I can’t deal with novelty or the unexpected, but I think that the way I deal with those is to maximize the information I have. When I first arrived for my summer in Madrid, I felt pretty out of place and awful… so I started working out bus and subway routes all over the city, until I felt able to get anywhere I wanted to go or at least to fit any place into a framework. But in medicine, there will be times – probably even more than I can now anticipate – when I can’t get all the information. It doesn’t exist, nobody knows what “all” means, there are conflicting answers, there isn’t time or money or patient cooperation, there are communication barriers, etcetera etcetera. Something I knew about medicine but hadn’t really articulated until now. And I’m not sure how I am going to be able to deal with it.

I think what I said about the geographic framework for Madrid might be a piece of the answer – Dr. Treadway in her introduction to our Introduction to the Profession course today emphasized that we cannot be expected to know everything, but what we should seek to develop during our courses is a framework to fill in and build on over the course of each class and from class to class moving through these years.

The second piece is the part I emphasized above – “critical self-reflection and ongoing self-assessment.” Maybe part of my lifelong phobia of ambiguity or incomplete information derives from too narrow a definition of knowledge or of “the answer,” one in which I equate a complete answer with having filled in all the blanks and having seen all sides of the argument. Maybe in medicine I will need to come to terms with an alternative understanding of the final answer: one in which gaps may still exist, but those gaps have been acknowledged, minimized, and put into appropriate context. If I know that I can never have all the information I wish I could, but also that I have enough information that has been rigorously evaluated to make a correct diagnosis and that I have through self-reflection confirmed that my thinking was clear and logical and my perspective was broad and multi-dimensional, then I can accept my conclusions and stand by them. So this journal can be part of the process of developing a new way of understanding my own intellectual and emotional cognition and getting to the point where I can be sensitive to what I do and don’t know as well as what I do and don’t need to know.

Spent the whole day shadowing a pediatric neurologist, first in his resident clinic at Children’s Hospital in Boston (fun link) then in his neurology clinic at South End Community Health Center. He came and talked to FUNC on a faculty physicians-and-community panel on Tuesday, which was amazing. Anyway, he is a wonderfully warm and encouraging person, and I hope to see more of him either in subsequent shadowing/mentoring opportunities or in his role with the Office of Enrichment Programs/Division of Service Learning.

First eye-opening experience (at Children’s, not South End CHC): a black woman who I assumed (rightly or wrongly – see below) to be a low-income single mother, and I picked up on some cues that made me doubt her literacy level, who was absolutely passionately trying to pursue medical attention and care for her son. He was a cute third grader with a toothy grin who had been kicked out of one school after another for repeatedly not paying attention and not following directions. She had been going from doctor to doctor trying to get someone to understand that he wasn’t a “bad kid” and needed to be tested to find out if there was a medical problem. Turns out he was suffering from frequent absence seizures and he really couldn’t help it if he blanked out while a teacher was giving instructions. His teachers probably had never heard of this kind of epilepsy (seizure disorder); for the sake of journalistic integrity here, they might also have made the same stereotypical assumptions that I had, in guessing–based on race, dress, and other cues–that this was a single-parent low-income family, and maybe they took that a few steps even further than I did and thought that he was just a kid with a tough home/family/socioeconomic life who lacked proper discipline or behavioral examples or whatever. [The latter is just an example of how someone's thought process might have worked; I hope that my own conclusions were appropriate and fact-based rather than prejudicial. The article "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care" that was assigned to my entire class for our Introduction to the Profession course does a great job of teasing apart prejudice, stereotyping, and bias in interactions between patients/families and medical caregivers/systems/others.]

Second mental image: the huge but then steadily dwindling stack of patient charts on his desk as the doctor methodically but kindly dealt with patient after patient after patient in his South End clinic. By the end of the afternoon he had probably seen… twenty? I lost count. Some were routine, and just took a refill prescription and a “see you next month.” Others came with insurance problems, multi-system health complications, language barriers, troubled families, job issues, and all kinds of other things that weren’t even their primary cause for complaint in that particular instance. Many of the patients complained of migraines; if I think of how incapacitated I can be by a simple occasional headache, I can’t imagine trying to deal with migraines on top of everything else in some of these patients’ lives.

Last but not least: a good half of the afternoon clinic patient encounters were 100% in Spanish. This doctor taught himself medical Spanish, after “the clinic told me they could afford a full-time interpreter for my first week” or something along those lines as he told us at the Tuesday panel. He confirmed that medical Spanish competency is basically invaluable and will be all the more so by the time I become a clinician. I feel so blessed to have had (generally) good language instruction, to have fortuitously chosen Spanish to study in the first place, and to have had the Madrid immersion experience to solidify it. I’m now even more excited about this program. Anyway, it wasn’t particularly medically relevant, but I struck up a long conversation in halfway-decent Spanish (on my part) with a 21-year-old Guatemalan patient while the doctor had to take a phone call, and the patient asked me if I was Española! It seemed comforting to him to have someone just chat with him in his native language and talk about his U.S. experiences and his home country. He’s from a big family, basically the only member of his family in the U.S., and came here several years ago and has only been able to go back every few years. If that interaction helped him even a tiny bit, then it’s something I am lucky to have been capable of doing. Now I just have to go about developing more abilities! Classes start Monday…

Parting thought, with respect to the practice of medicine and to the human body itself, and once again borrowing the language of religion:

“So the challenging thing becomes not to look for miracles,
But finding where there isn’t one.”
–”Holy Now,” Peter Mayer

I am so glad to have decided to do FUNC (First-Year Urban Neighborhood Campaign) as my preorientation program, and to have been (randomly) assigned to Community Servings as my service site. The mission of FUNC is to start us first-years off from the very beginning with a perspective on medicine that always, always, always is thinking about the whole patient and not just the illness or the body part: bringing in an awareness of personal stories, social and economic disparities and injustices, the environment, cultural competence, etcetera. Community Servings does an awe-inspiring job of bringing all of that together. The organization cooks and delivers 3,125 meals each week (625 a day!) to patients who are homebound with AIDS or other  terminal illnesses and their families. The volunteer coordinator who gave us our orientation when we first arrived at their huge kitchen facility in Roxbury did an amazing job of pulling together the many different threads of what the organization does to improve the lives of patients and their families. For example, they have a full-time nutritionist who not only makes sure the food is healthy and balanced, but also tailors meals to take into account allergies, diets, food-drug interactions and other effects of treatment regimens, etcetera; their half-dozen chefs all come from different ethnic and culinary backgrounds, so the meals are also culturally sensitive. I’ve heard people talk about compliance problems with physicians’ dietary recommendations because the recommendations are culturally insensitive; now add that element to people who are also extremely ill, homebound, and almost definitely (95%) below the poverty level, and you can see how something that is as basic as getting food on the table to help nurse a sick person back to health or make the end of their life comfortable becomes an insurmountable obstacle… that Community Servings surmounts, three thousand times a week. And the ripples just keep moving outwards: parents who can’t provide meals for their children may have their children taken away from them, so Community Servings keeps families together. And on, and on, and on.

4. What do you think you need to work on or will be a challenge for you?

I am not always very good at memorization or at remembering details, so I anticipate this being something I will need to work on a lot. I am concerned about the amount and complexity of knowledge I will need to master, and I know it will be a challenge to learn things so that they really “stick” rather than just fading out of memory after exam-time. I think my study strategies as an undergrad worked well for the short-term, but I will need to find some new ways to learn things so that they will be available to me years later when I’m a practicing physician.

I am also worried about the responsibilities that come with medicine, specifically learning how to deal with errors or things turning out differently than expected. While I’m usually good at taking criticism from others, I can be very self-critical particularly when something doesn’t go the way I thought or hoped it would. I expect it to be a challenge for me to find the right balance in appropriately responding to mistakes or bad outcomes.

My mother has observed that I am not particularly tidy ☺ Finally, I have retained from college a bad habit of sometimes putting things off until the last minute (particularly when there are a lot of other things going on in my life at the same time), as evidenced by my late submission of these answers. That is definitely something I’m working on, and you have my apologies.