Learning to Take in Order to Give

So this is it. I’m officially a real fake doctor now! I have just completed my first clinical rotation. Thus far, I spend 99% of  my time thinking “where am I?” and “am I annoying my resident/intern/attending by being in the way?” and the answers are usually “lost” and “yes.”

I am on neurology and one of our first patients of the morning was a middle-aged woman who had recently been diagnosed with ALS (Amyotrophic lateral sclerosis) a few months prior. ALS is a degenerative neurologic disease that is characterized by progressive loss of motor function. Patients end up losing the ability to move, talk, eat and eventually breathe. This patient had already lost the ability to talk and eat on her own.

My fellow medical student and I went to see her after rounds so that we could get a better idea about what a neurologic exam would look like in someone with ALS. When we got there the patient was in obvious pain and her daughter told us that she wanted morphine. The patient (who communicates now by writing) pointed to her pad where she had written “Ouch. Pain. Help.” Being lowly peons, we don’t yet know how to find a band-aid much less put in an order for narcotics so we quickly left to find the resident (who assured us that the order was being processed by the pharmacy). Given her level of discomfort, there was no way we’d ask her to undergo another exam so I just asked if there was anything else I could do to help. She got out her pad and started writing something.

“How can I help you?” she wrote in painstaking capital letters.

Here was a woman who had just been given a devastating prognosis. She had already lost the ability to speak and her disease will continue to progress, causing her to lose all motor function and die within a few years (median survival is 3 years from onset of weakness). She had been poked and prodded by the medical team, the neurology team and she had just undergone a serious procedure. On top of this she was in serious pain. Yet still she wanted to know how she could help me.

 “I….well…” I didn’t know what to say to this amazing woman. Sometimes medical school stinks. Plain and simple. We don’t have much to contribute at this point in our careers except time and enthusiasm. Our only job is to learn, which makes it feel like an inherently selfish process sometimes. Indeed, I have spent most of this week feeling in the way. Her small act of kindness nearly unbalanced me.

“You are already helping us,” I told her. “We are medical students and this is our first week ever working in the hospital.” She broke into a huge smile.

“We are trying to learn as much as we can from our patients. For example, even though I’ve read about it, you are the first patient I have seen with ALS and I will always remember you because of that. I am going to go home and read as much as I can about it so that some day I can take care of patients myself.” She broke into a huge smile, touched my arm warmly and gave me a thumbs up.

Throughout my first year and a half of medical school I have been blown away by the generosity of those who contribute to medical education:

• My LEAPP patient (a patient who we followed throughout our first 1 ½ years here) whose family let us sit in on her appointments, ask them countless questions and literally invited us to their home.
• Our course director for dermatology who came to speak to my interest group, personally showed me patients during dermatology grand rounds and then spoke about career paths with me for an hour.
• My MS3 “big sister” assigned to me by the Elizabeth Blackwell society who gave me invaluable advice about surviving my pre-clinical years and gave me all the books I needed for my clinical years.
• The MS4 who brought me on board with her project, helped me understand clinical research and is trusting me with presenting our work at a conference this spring.
• Our lecturers and small groups leader-physicians who volunteer their time in order to instruct us on everything from psoriasis to palliative care.
• The resident I worked with in Botswana who taught me how to think clinically about a patient this summer and then this fall coached me through writing a case report that she could easily have written herself.
• The countless patients who spoke movingly and openly to our class about living with cancer, mental illness or rare genetic disorders.
• And now - starting with this patient - all the patients who allow us as medical students to participate in their care.

I know that this is a cheesy story. I know that it’s not possible or advisable to get emotionally wrapped up in every patient you care for. I know that this outpouring of “touchy-feeliness” would earn me an eyeroll from more “seasoned” medical professionals. But I don’t care. And I know that I will remember this incredible woman. I am going to carry her with me throughout my rotations. Because she reminded me that every patient gives me a gift. They give me the gift of sharing their story and helping me learn. I may wear a white coat but for now all I can do is take. Take in the knowledge that is being shared: by the patients and by the physicians, nurses and staff who are helping me learn. One day hopefully I will be able to give something: care for my patients and, if I’m lucky, the ability to teach someone else. But first I need to figure out where the heck I am.

The Beginning is Near!

I'm a firm believer the world won't end in 2012, but I guess we'll find out soon enough.

This is not a regular Christmas for me. The end of this year symbolizes a small (but important) transformation in my life. Just yesterday, I started "working" in the hospital for my clinical rotations. Gone (mostly) are the lecture halls and didactics that have been my home for more than a decade. Now, I start my on-the-job training.

I've mentioned this a couple of times before - the clinics are something I've looked forward to for a long time, something I've worked towards for many years. But it also creates a lot of anxiety. I feel woefully inadequate to take care of patients. But people reassure me that the training I've received so far is much more comprehensive than I realize. That I am more prepared than i realize. That small consolation goes a long way.

Then again, I guess this kind of anxiety is a good thing. A little bit of stress does improve performance... but more importantly, it harkens back to an important lesson from my differential diagnosis class - don't assume you know everything about the current situation. This is the cornerstone for a good differential diagnosis: you always keep your mind open to other possibilities, and you force yourself to think of counter examples - what else could it be?

By walking into clinics assuming I know less than I do, I'll force myself to keep my eyes and ears open. It forces me to be on my toes just a bit more. At a personal level, this means I'm hungrier to learn more. But the more important (and bigger) effect it'll have will be for my patients: I'll be taking second, third and even fourth looks over their plans, histories, results... the works! I'm hoping this second guessing will make me a better student now, and (eventually) a better doctor.

So here's to the end of a beginning and the start of a new phase in my education. On the job training isn't something new to me - I worked in the corporate world for 5 years before coming to medical school. But this is a very different animal. Sappy as it sounds: lives are on the line.

There will be many more "ends of beginnings" to come, I have no doubt of that. But I believe recognizing and respecting milestones (like this one, even though it's a small one) is crucial to the learning process.

This is a bit tangential (and if this is your first time reading my blog, you'll realize that I almost always have tangents in each post), but times like this remind me of what it takes to be a good doctor. For some reason, whenever I think of that, I'm taken back to a scene from Scrubs (one of my favorite shows).

This is one of the most powerful scenes from the show and it has stuck with me for many, many years. A great doctor is someone who is very invested in his patients... but knows the importance of staying objective. Walking the line and keeping tragedies from debilitating your work is not the easiest thing to do, but I believe it is an important lesson to learn. Here's hoping I learn it.

Enjoy the New Year!

- Karthik