Archive for September 2006

Little old lady

September 26, 2006

Although I more or less like all little old ladies, there’s a certain subset of the genre that I love. The ones who are over 80 with the skinny bodies and the voices creaky like rocking chairs–they completely do me in.

When I go into their hospital rooms early in the mornings, I watch them for a moment before I wake them. I love their little heads drooping to the side like heavy blossoms while they sleep. I love the curls their skinny hands make around the covers. I love their little bellies, soft and round like puppies’. God help me, if it’s wrong to love an old lady’s belly, I don’t want to be right.

I love these little old ladies, but I hate waking them up. They’re always a little confused at first, then sweetly tired like children, snoring when I ask them if they had any trouble overnight. They usually don’t remember it, and I am grateful for that.

I just discharged one of these patients today, a little confection of an eighty-six year old named Shirley (well, of course she’s named Shirley). She’s absolutely beautiful, with clear eyes and bright skin, and she wore a pair of diamond stud earrings the entire week she was in the hospital. She is incredibly funny and, despite her failing health, incredibly independent, and wanted more than anything to go back home to her cute apartment and just be by herself. She sucked up hours of my time just with joking and fretting, and I didn’t mind a bit.

When I went in to see her this morning, she was sleeping the way old ladies do, and I watched her for a moment, the way I do. I woke her up the way my friend Val taught me to, by putting my hands on her legs and saying her name softly. She opened her eyes.

“It’s so early,” she said. “How early is it?”

“It’s six-thirty,” I said. Then, cringing, “I’m sorry to wake you.”

“No, it’s alright,” she said. “I just don’t like for people I like to have to be awake so early.”

I don’t like being awake so early, either. But if I have no other choice, at least I get to spend a few of those early morning minutes with the belly belonging to the nicest patient ever.

Community hospital

September 24, 2006

 

This month, I’m rotating through a small community hospital that is affiliated with the academic center where my residency program is based. For residencies based in well-staffed, well-resourced academic centers, the point of having their residents rotate through a community hospital is to expose them to the real world of medicine. A significant proportion of the hospitals in this country are community hospitals, and because these facilities have little to none of their budget devoted toward research, they often have far fewer specialty services and facilities than academic hospitals do.

 

This doesn’t make their care any less good than that of academic hospitals—it just makes it less specialized. At a community hospital, you could probably get a perfectly good laparascopic cholecystectomy, or maybe a course of intravenous antibiotics for a bad pneumonia, but you might not get an experimental treatment for breast cancer, or a cardiac catheterization for a heart attack.

 

All that said, the rotation I’m in at my local community hospital—I’ll call it the Sixth Portal of Hell, or SPOH for short—is, to me, harder than any rotation I’ve done yet, either in medical school or in the short span of intern year that has passed. It’s not because the hours are longer, although they are—it’s because medical care at the SPOH is incredibly inefficient; startlingly subject to the whims of human error and carelessness; and perpetrated by administrators and clinicians who are shockingly variable in their giving of a shit about the consequences of all of this to patients and families. I don’t think I’m the only person who feels discomfited by the place; there’s a higher-than-average level of passive-aggressiveness among the secretaries and nurses, and I wonder how much it is produced by their sense of being part of something below par.

 

For better or worse, my tolerance for bad systems (my own personal ones excepted) is pretty low, and yet I have no status and no influence in this particular system. My job at the SPOH is to put up and shut up, and when I see so much dysfunction around me, that’s a very hard thing to do.

 

Our general medicine service is, at the moment, full of pretty sick people with an abundance of social issues. There’s a deaf man with metastatic rectal cancer who bounces between shelters here and in a metropolis 5 hours away; and a cocaine addict with poorly controlled diabetes, a kidney infection, and the expectation that we will find her an apartment before she leaves the hospital. I’m in the hospital to round on my 11 patients earlier than ever, and I leave the hospital later than ever and feeling beat down in a way I haven’t before. I’m beginning to understand what people mean when they say intern year sucks.

 

Complaining is not something that’s encouraged in my profession. We are doers, all of us, and when things aren’t so good, we suck it up at work, bitch to our loved ones at home, and keep our noses to the grindstone. I’m not sure whether this is the reason that so many people have told me they actually enjoy working at SPOH, or whether there is some hidden magic about the place that I’m missing.

 

On my first day at SPOH, I had a sudden, terrible, unprovoked thought while waiting for the elevator: “I am going to unwittingly do something wrong and with awful consequences at this hospital in the next month.” I’m not much into magical thinking, so I shook it off and resolved to consume more coffee before coming in. And yet I now feel even more confident that I will make a bad mistake while at SPOH, and it will negatively affect the health of one of my patients. The foreboding isn’t just a sense any more; I know that the web of quality control that protects patients from our mistakes just isn’t there. It scares me.

 

One way or another, I’m spending 75 hours a week in a place that is supposed to be somehow cozier and more tightly knit than the Big House, and yet I feel less connected to people and more worried for my patients than I have before.

 

Some community.

The switch

September 16, 2006

“Is someone down?” asked T., who was driving. We were on our way back from an intern retreat day in the mountains, and while stopped at a traffic light, we had noticed a cluster of people standing in the oncoming lane of traffic. Looking out my door into the dark, I could make out three people looking down at a black umbrella. Under the umbrella was a body. “Yeah,” I said, “someone’s down.”

I got out of the car, crossed the street, and ran toward the umbrella. S. was close behind me, and T. got out of the car and followed him. A young woman was lying down on the ground with her legs bent at the knees and turned to one side. Squatting next to her was a man with dreadlocks. As I ran toward her, I yelled, “Is she breathing?”

She was. She watched serenely as we each arrived on the scene, moving only her eyes as our faces came into view. She said, in accented English, “I got hit by a car.” She looked as if she had laid down to take a nap.

We asked her questions. Can you breathe OK? Yes. Did you lose consciousness? Yes. Are you having pain anywhere? Yes. She had been hit at the hip and had some pain in her lower back, but she could wiggle her feet.

I realized with some shame that, while running toward the girl, all I’d been thinking was, oh my God oh my God it’s dark she’s down; there was, initially, nothing organized in my head, no clear thinking about what to look for when I got there, no clear thinking about what to do. A few seconds after I arrived at the girl’s feet, I almost physically felt it snap into place–the training I had that taught me to look for airway, breathing, circulation, and the urgency of keeping her still.

Between the car and the girl, I felt like just another panicked person on the street. Standing in front of her, however, she became a patient, and I was suddenly able to think about what might be wrong with her, and what I might need to do.

Turns out, we didn’t need to do anything. Fighting our instincts to intervene, we stood there in the dark road and talked to her until we heard the sirens. The ambulance arrived, and she was packed up onto a backboard and whisked away to the hospital. We thought to ourselves, she’s going to be OK, and walked back toward the car.

Earlier in the day, at the retreat, we had had small group sessions where experienced physicians shared their wisdom and we nodded while thinking about lunch. I wonder now whether, for those experienced physicians, changing their framework for interactions from person-person to doctor-patient has become easier or harder. Do they become more or less receptive to people at parties talking to them about their bowel movements? Are they quicker or slower to approach friends who smoke about reasons to quit? Do they more fluidly make the switch between spectator and resuscitator when they see a person lying in the road?

Does being a doctor when it’s helpful to other people become reflexive? Do I want it to?

In the car, someone asked, “What would we have done if she hadn’t been OK?”

I responded. “Our best, I guess.”

Parts

September 7, 2006

On my first day as a medical resident in clinic, one of the patients on my roster was listed as having a chief complaint of “genital rash.” No big deal, I thought to myself. I am a young, progressive, body-positive doctor. Everyone has genitals! I am unfazed by genitals! Let there be a genital jubilee in my clinic! I’ll make s’mores!

But when I walked into the room and saw the patient–a 24-year old guy with not-small shoulders and a great big smile–a policeman, for the love of God–my hands got clammy. I was torn between the urge to flirt and the urge to bolt. But I am a doctor now, so I faked as matronly a smile as I could, and said, “What brings you in today?”

Countertransference is something we discuss mostly as an issue in psychotherapeutic care, but in reality, it happens on every ward of every hospital. In simple terms, it is the projection of the care provider’s needs or feelings onto a patient. When a doctor countertransfers, he or she imagines the patient to play a role in his or her life that is oustide of the role of a patient, often to the detriment of the objective doctor-patient relationship.

Some examples might help illustrate what countertransference is: If a doctor ignores her patient’s complaints because he reminds her of her whiny little brother, that’s countertransference. If a doctor aggressively pursues curative treatment in a dying patient because the doctor himself is afraid of death, that’s countertransference. And if a doctor avoids discussing sexual issues with a smoking hot 24-year old patient because she knows that if they had met outside the clinic, she would be gathering very different data points, and Jesus, why won’t he stop smiling at her–that’s countertransference.

It’s a good thing I’m aware of the issue.

The policeman smiled. He had some bumps, he said. They weren’t itchy or painful or oozing or anything–they were just there. He and his girlfriend were monogamous, so he wasn’t worried about a sexually transmitted infection. But still, could I just look?

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Hunky young men need medical care, too, and for better or worse, I occasionally have to provide it to them. It’s inevitable that I will find some patients attractive. Acknowledging this allows me to take note of the times when I need to be exceptionally careful in my workup: Whereas I often allow some elements of the history-taking, physical exam, and diagnostic strategy to be nearly reflexive, I make especially certain with hot patients that I can explain every choice I make. It’s both for their safety and my own.

Although the policeman was without much risk and entirely without symptoms, he wanted to be checked out for sexually transmitted infections. This meant having a look at his junk. I did so, chaperoned per office policy by Dr. B., a [female] attending physician. The patient seemed nervous and uncomfortable during the exam. I probably did, too. But everything looked normal, and a urinalysis was so clean that we didn’t even bother ordering any lab tests. I had him put his pants on and, because he was due for a full physical, asked him to make an appointment to return in a few weeks.

He did, with news: his girlfriend had been cheating on him. This changed things: he was now at greater risk. Even if he had no signs or symptoms of disease, I would need to test him for asymptomatic infections like Chlamydia and HIV. Which meant another look at his junk. I did another, more invasive genital exam, again chaperoned by Dr. B.

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In speaking with Dr. B. after examining the patient, I dubbed him “Penis Man.” Given the 1:1 ratio between his office visits and my encounters with his business, I joked, he might be coming to clinic not so much to address health concerns as to have his genitals carefully examined by me. The attending gave me a funny look. “You might be on to something there,” she said. “He sure does smile an awful lot.”

That smile could certainly have represented discomfort. I mean, I distinctly recall laughing hysterically through my first gynecological exam at the age of 16, and it wasn’t because I was happy to be there. The smile could have represented something else, however. I had been very conscious of my countertransference, possibly to the point of ignoring its reciprocal: transference, the projection of a patient’s needs and feelings onto a care provider.

It made sense for my patient to prioritize my station as a woman over my station as his doctor. After all, I had to work not to make a similar judgment toward him. I had devoted a lot of attention to making sure that my potential for countertransference didn’t impact his care. But he wasn’t being so careful, possibly because his career didn’t depend on it.

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The most obvious–and certainly, the most creepy–consequence of transference here is that there might have been a genital jubilee in my office less for the purpose of medical evaluation than for the purpose of patient enjoyment. But transference has another potential consequence: suboptimal patient care. What if this patient values the impression he makes on me more than he values the appropriateness of the health care he receives? In this case, he might modify his story to sound like he’s better-behaved than he is. Although I can’t say that happened with this patient, it’s easy to see how it could.

I wasn’t sure whether the policeman’s smile reflected nervousness, lascivious glee, or simple interest in me. I was also uncertain whether he felt he could be completely honest with me about his history. My solution? I thought that if I removed any mystery surrounding the dynamic between us, I’d remove both the thrill of the exam and the desire to impress–if either existed to begin with. So before the second pants-dropping, I looked Penis Man right in the eye. “This exam might seem like an uncomfortable thing,” I said. “But the simple facts are, your ‘parts’ are body parts, too, and as your doctor, I am as concerned about the medical health of those parts as I am about the medical health of all your other parts.”

Did it work? I don’t know. He did smile a little less during his third visit, during which I gave him the [negative] results of his lab tests. I’d like to think that his newfound focus was a result of his reorientation to both of our roles in his health care, but it might also have had something to do with the cotton swab I jammed an inch into his urethra.

I suppose only time will tell.