No postings in a while because of the upcoming biochemistry midterm on Monday, and because unfortunately there wasn’t a patient for me to interview on Monday for Patient-Doctor. So no updates on that front for another two weeks because PD is cancelled on Monday due to the Jewish High Holidays… leading my classmates to the unfortunate idea of holding a First-Year Mustache-Growing Competition, to be accomplished and adjudicated before our next patient encounter. At least there is a streak of lightheartedness in the student body; a subset of my classmates also make very observant pilgrimages to Taco Bell (far away and by foot, though no mountains or blazing deserts), and tonight’s culmination of the two months of “LIFE events” is a movie-making competition between the New Pathway, HST, and dental students put on by the second-years.

Despite exam pressure, I went to a lunch talk today by Dr. Perri Klass on the importance of promoting early literacy (prior to age 5) as an integral part of pediatric primary care. She is the president of Reach Out and Read, a both simple and impressive program that gives books to children of low-income at all of their checkups from age six months on and encourages physicians to teach parents about how reading can promote their child’s linguistic and cognitive development. I won’t go into some of the statistics Dr. Klass shared with us but suffice to say that early reading and language ability, and their long-range effects on literacy levels, are amazingly predictive of future success in school, socioeconomic status, and (especially important for us as future healthcare providers) things like teen pregnancy and substance abuse. I really appreciated the view of reading as a “health behavior” and the understanding of literacy’s role in health, which as she pointed out is a huge issue that has only really become appreciated in the last decade or so. I also liked how well this dovetailed with some of the work I did at Talaris in the summer of 2002.

Dr. Klass is also an author with quite a few books of various sorts to her name, as well as many articles in medical and popular magazines. She now is a professor of both pediatrics and journalism at NYU. I will admit that I haven’t read any of Dr. Klass’ books (although I have read her pieces in This Side of Doctoring), but she is now on my reading list. Anyway, I told her about my interest in combining writing and medicine, as she has since her years in medical school, and she was very encouraging. I hope to keep in touch with her because down the road I really would like to publish… something… I don’t have any idea yet what that something might be, but I am guessing that themes will emerge out of things like this journal. I am also starting the Mind-Body Medicine elective today, which has a reflective paper requirement, and I just found out that I was accepted into the Mentored Clinical Casebook Project (see also), so there will be boundless opportunities for writing this year!

Incidentally, loosely tying Dr. Klass together with the previous topic of med student quirks, I was amused to hear that when she was a student at HMS she was one of many students who were rabid knitters–she has actually written articles about this–and apparently the current third year class is also really big into knitting. Wonder what the class of 2010 will be known for…

This semester in Patient-Doctor I, we will be learning to take medical histories. This week we only observed one of the faculty (a very astute and skilled clinician, by the way) interviewing a patient, but this coming week (tomorrow, ulp) we will be doing our own interviews. While I have certainly spent time with patients before, and even “interviewed” one as part of the Introduction to the Professions course, I feel that this will be different because of the many and specific purposes of the medical interview as an institution within medicine. There is so much information to be gained and so much that can be done to establish or reinforce a positive doctor-patient relationship within a fairly short time, and doing or not doing (including noticing or missing) little things can make all the difference between a correct diagnosis/trusting relationship and the alternatives. All that being said, I am certainly not expecting my first interview tomorrow to represent me at the height of my clinical prowess, so I’ll settle for not being too nervous in front of the patient (and video camera!) and coming across as the kind of caring doctor I want to be someday.

We do weekly write-ups for Patient-Doctor I. I’ll excerpt the reflection sessions of them here whenever it seems appropriate, with identifying information removed.

Personal Reflection

At first glance Patient X seemed to be a model patient, particularly for this first interview; he supplied the majority of his medical history unprompted and was well informed about his health, particularly prior to the accident. I responded positively to his jovial tone and his obvious enjoyment of getting to act the part of “teacher.” He reminded me at times of my own grandfather’s often humorous and good-natured reactions to his own health problems and the care he received. By contrast, other people who witnessed the interview found his manner to be off-putting and felt that they were not being “let through” a façade that X was cultivating. Looking back on the interview afterwards, I didn’t know whether to accept my own impressions or to question my acceptance of Patient X’s behavior as his true personality. I can certainly understand how his humor, denial of pain, and didactic tone could all be mechanisms for coping with the fear, pain, vulnerability, and disempowerment of his accident and his subsequent hospital stay. I am hoping in future experiences to compare his approach with that of other patients in comparable circumstances. I do agree with the points raised by both faculty members and classmates about wanting to probe deeper into questions about his support structures, possible depression and alcohol abuse, and lifestyle changes that would permit him the independence of for instance traveling to [southern state] as planned but without the potential dangers to him or others of having him driving alone.

A few thoughts that are more about next week, though seen in the light of this week: I will admit to being somewhat apprehensive about doing my own first interview this week. Even though Patient X was so easy to interview in virtually all respects (no significant language or culture barriers, willing to talk, generally knowledgeable about his own health and care), I was definitely impressed by Dr. A’s ability to listen and respond appropriately no matter what Patient X said, to draw him out more and even to get him to approach subjects with which he was obviously less comfortable. I am sure I’m going to forget major parts of the interview and miss obviously important details, and I am looking forward to learning more about how to balance appropriately the direction the patient wants to take (or doesn’t want to take) in the interview with my own needs for information and establishing rapport.

I thought I would post a link to this amazing movie created by two Harvard professors and a computer graphics studio to illustrate basic cellular processes. The quality of animation is incredible, and admittedly the music helps a lot in creating a mood too, but I really think it illustrates some of the sentiments of my previous post. All those things are occurring in every cell all the time; the part that seems to be least realistic (by admission) is the amount of watery space, so just imagine all of these things happening crammed together in a much smaller volume and I think it makes the complexity even more amazing.

No posts in a while because medical school has suddenly gotten very intense with the beginning of our first “real” class, Molecular and Cellular Basis of Medicine and Development. Of course, now–when we are most buried in the science, and the work, and furthest from the patients–is when I need reflection most to keep me aware of why I am learning all this. Fortunately, every day brings minor epiphanies. To attempt to synthesize:

Most religions seem to share in common some idea of a creator God, and many creationist religious viewpoints related to things like the evolution “debate” take as their examples the complexity of living organisms, especially humans. I don’t subscribe to the same understandings of God, but the more I learn about some of the most complicated aspects of our physical existence, the more in awe I am of these bodies we live in. Every slide from every class reveals the unbelievable complexity of biochemistry: endless chains of molecules acting and interacting, control and regulation of processes to the most minute degree, shapes and functions exquisitely tailored to their extremely specific function… Moreover, the class has so far done a wonderful job of correlating the basic science to clinical problems, and when a single mutation of a single DNA nucleotide can lead to a single difference in the amino acid sequence that codes for a single protein that has a role in a single pathway that spirals into a debilitating or even fatal disease, it quite truly makes me ache with the wonder and appreciation that enough things ever go right for us to be alive.

And all this is just the most basic biochemical knowledge that is given to first-year medical students; it is only a fraction of what the scientific world knows about the body, which is surely only a fraction of what there is to know. This degree of complexity is both beautiful and terrifying, because sooner or later it becomes so elaborate as to be beyond our comprehension. And that which is so complex and beautiful and terrifying as to be beyond our comprehension, we cede to God. Where the line is drawn can vary. While the people who passed out pamphlets outside my middle school attributed the cohesion of atoms’ like-charged nuclear particles to Jesus holding them together, I may know that it is actually the strong nuclear forces. But the mystery of how the incredibly intricate, interconnected machinery of protein synthesis (for example) came to be leaves me awestruck and unsure that science has the tools to explain it to me. This is by no means meant to say that God ends where knowledge begins, or that we could ever so fully eradicate ignorance of the workings of the universe as to have edged out God. In some ways, learning so much so quickly about the basic stuff of existence–rapidly pushing the envelope of my own knowledge–feels to me like treading into what traditionally has been God’s domain. But rather than see this as blasphemous, my hard-to-define current understanding of a non-entity God closely allied with concepts such as beauty and complexity makes this exploration of the borders of human comprehension a profound and spiritual practice. When I remember to let myself experience it, that is.

Why is complexity so beautiful? The music of J.S. Bach is as tightly constructed and intricate as the most complex biochemical pathway, and especially in the opinions of many musicians he reigns supreme above all other composers; he is known as “the musician’s composer” because the musician who plays Bach is in the optimal position to appreciate the complexity the music contains. Before Bach’s time, medieval and Renaissance ears took almost absurd delight in things like twelve-part motets, in which the ear and brain simply cannot possibly keep track of everything that is going on at once. Is there an aesthetic of simplicity as well? Of course. Shaker furniture, Japanese teaware, Beatles lyrics, and the smell of warm chocolate chip cookies. But in biomedical science, the complex and the simple often go hand-in-hand, which adds just one more dimension to the beauty of the subject. The great experiments, the stuff of Nobel prizes and the obligatory history section at the beginning of each new course, are virtually without exception described with the word “elegant”–simple ideas, using an economy of resources or a clarity of thinking that cuts through the complexity to the heart of the matter. My guilty procrastinatory pleasure of late has been Agatha Christie detective stories, specifically those of the eccentric Belgian detective Hercule Poirot, whose “little gray cells” (apparently unmyelinated) process all the tangled motives and red herrings and false alibis of exceedingly complicated cases to find the simple pattern that provides the decisive and maddeningly simple resolution. In the same way, Bach’s music is simple: he builds entire pieces from repeated figures, changing only a note or two each time. At the root of every single bit of what it means to be alive and a functioning organism is an alphabet of four letters, ATCG… four. The movement of air into my lungs, the color of my eyes, and my ability to stand upright–much less paint or sing or create a child–are all based in four letters. At the most microscopic or basic of levels, biology too is maddeningly simple, showing the elegance and economy of Bach and Poirot and the Nobel prizewinners. If God’s complexity is beyond our comprehension, so too is God’s simplicity–the most extreme extent of acuity and design, whether that design was guided by intelligence or by self-engendering natural processes.

Human consciousness awakened to find itself suffusing a universe so delightfully complex and so delightfully simple that the human joy of discovery–whether or not it was given to us by any God or spiritual force, creator or otherwise, inclined towards benevolence–ensures that at its core the universe always has been and always will be a joyful place.

Back-dated journal entry from the day we spent talking about professionalism in medicine. Just a few kernels of bigger thoughts.

“What was most meaningful about today was what I will be taking away from this course as a whole: that the clusters of compassion/humanity/empathy and professionalism/skill/science not only can but should go hand-in-hand in the practice of medicine. I appreciated the way professionalism and professional duty were linked to altruism and the humanistic motivation of medicine. Finally, I was glad to be told not ways to suppress our humanity and individuality in order to be a good doctor, but rather ways to use those parts of ourselves–indeed, every part of ourselves–as a clinician.”