I heard the saddest words today. I spend one afternoon each week working in an adult/peds medical clinic where I see mostly infants and toddlers for their well-child visits. I talk with mom about the baby's diet, ask about sleeping behavior, feeding habits, etc. I advise on things the parents should be doing, things they should not be doing, and things to expect in the upcoming weeks/months as far as their child's development goes. Sometimes there is crying involved, sometimes I end up with a little slobber on my tie, and sometimes I open the diaper to find a little surprise waiting for me; but all in all, these visits are pretty low stress.
There is however, at least one visit each week where everything with the patient (the child) is going very well, but the child's environment is crumbling. My first week on the job, the mom just flat out said she doesn't like her one year old girl. Forget love, we are just working for a "like." Another week, after ten minutes of conversation, the mom shared with me the fact that she was going to be kicked out of her apartment by the end of the week. She wanted to know where the nearest shelter was that she and her baby could stay. For some reason, I like those moments of the visit the best—second favorite is the moment I take the baby from mom to do the physical exam, twisted, huh. I think that I like the moments when the visit takes a turn for the worse because I see it as a challenge. What the challenge is exactly is not clear. Maybe for me to connect with this mom and really communicate, really understand what is going on in her and her baby's world. This is the part of the visit that no algorithm can handle. That is why this is my favorite part of the visit.
Today, my last appointment of the day was the special visit where the algorithm got tossed —That is only considering the well-child checks, because I did see a latino man paralyzed by a gun shot to his 4th lumbar and now dealing with a giant flesh eating pressure ulcer on his right foot. He also was my first patient where I got to use my Spanish. Back to the special visit, the patient was a five yr old male accompanied by mom. The child had been performing poorly this year (compared to last) in school. The teacher called frequently to report behavior and overall performance problems in class. The mom had noticed similar behavior at home, etc. The mom came to a stop in her story, then, it was my turn to figure out why the abrupt change in behavior. My face contorted to a pensive shape and I think the mom realized the game I was about to begin. She cut me off before a question could be asked and just said straight up, "I know what the problem is, he wants his father around but his father don't wanna be around."
Punch to the stomach. The part of my brain working on the first round of questions shut down and I started to focus all of my thoughts on the father, or lack thereof. Images of all those Salvador Dali paintings with the father/son shadows started to fill my mind, no, just kidding.
Actually, what struck my mind, and I report for some reason with some chagrin, a news clip I saw on CNBC or something last week about the epidemic in America of fatherless school children. I also thought of a case I read earlier this morning where the resident suspected child abuse and totally lost his cool with the mom's boyfriend right there in the examination room. Could you imagine me pinning the dad against the wall in a fit of anger? Me neither. Besides, dad or ex-boyfriend wasn't even there to pin against the wall.
The frustrating thing about this visit is that there was little I could do outside of the algorithm routine. I talked about mom spending extra one-on-one with the little guy. I gave him a sticker and a book and talked to mom about reading with him; but aside from that I had to consult the social worker about availability for family counseling. Social workers, I love you!
Should I have asked more about the parents' relationship? The mom wanted the father around; that much was obvious by her body language; but he didn't want to be there, and he obviously didn't want to be at the doctor's appt. What could I do? What could she do? This episode reminded me of when I was in Ecuador. So, so, so often, many, many, problems stemmed from a bad relationship between mother/father, boyfriend/girlfriend. If things were OK between the two, everything else seemed to fix itself. I probably failed to appreciate the complexity of those situations, but I often wished people would just change their heart, like that Beck song. The way I saw it, everything else would be fine. In today's case, I wasn't hoping for any change of heart. I just wanted a wand to wave over the situation and put the father back in the home. So I'm barely into this medicine thing and I'm already looking for magic solutions. Hmm, that isn't the best of signs.
Moral of the story: Don't be making kids UNLESS you're gonna be together (child-makers) to do the entire child development part. For serious!
This map suggests that the Bible Belt is due for a change of name. Seriously, who carries their Bible on their belt? Let's tell it like it is: The Obesity Belt. Notice this graph is just deaths related to CHD between the years listed. If it were to show obesity rates in 2008, every state in the US of A would be dark red. The epidemic has reached every state of the Union. And the Belt continues to expand its circumference around the globe. Cholesterol levels are skyrocketing in China as they westernize.
Christ was clear to his apostles that the gospel should be preached to everyone, that it should spread to all the Earth; But what if obesity has its way. It's a showdown: the good word vs the saturated fat. Hmm, maybe there is something to the mandate that missionaries exercise daily?
We were lectured to this afternoon by a preventative cardiologist. The take home message was this: DON'T EAT ANYTHING ASIDE FROM GRASS AND/OR ANIMALS THAT EAT ONLY GRASS! EXERCISE! JUST DO IT. REGULARLY!
The message was enough to get me out of the library and over to the gym tonight. I can feel the LDL Cholesterol going down already!
Exercise! And eat well! In case you missed the point.
A few weeks ago, our class held a memorial service in behalf of the donors who's bodies we used in the anatomy lab. Individuals volunteer to donate their body to our anatomy lab when they die so that young medical students such as myself can learn a little about the marvels of the human body. So I spoke at this service. Read below.
Jan-16-09
Can anyone tell me what nerve is making my heart race right now? And where its cell body is found?...(I'm moving the podium around hoping that my palms will dry up and that my voice will refrain from any cracking; you probably know that's a problem of mine that failed to resolve itself post-puberty).I was sort of volunteered to share some thoughts with you today, and I sort of volunteered to speak today.[i]
There are times when ideas fill your mind like water rushing from a geyser, and there are times when the ideas appear more like dew on the morning grass. The water from the geyser is strong, and direct, the dew is ubiquitous but very difficult to collect. I felt like I was gleaning dew as I prepared a few words to share today. An idea appeared in my head a couple months ago as we started the anatomy lab. Like the dew, I was certain it appeared; but when I took a moment to articulate the idea, it was difficult to gather. I moved on with life, and into block II[ii] and the idea came back. I tried then to give it a little structure but again, I came up with nothing. This process went on for the remainder of our time in HSF, which could mean one of two things, either 1) the idea itself was of little substance, or 2) it just needed some more patience and attention from me to develop into something meaningful. My hope is that the latter is the truth, but don’t hesitate to let me know if it was the first.
I remember feeling pretty nervous about the anatomy lab. There was anxiety about how it would feel to skin the back, the arm, the hands of another human being, to look at this person on the inside, literally. Was this OK? Seeing a person on the inside was supposed to be just a symbolic thing, right? I had never cut into a human back before; knowing that anatomy lab was an inevitable part of the curriculum, I tried to reason away the uneasiness. Was it ethically OK? Yes. Would I be capable of the lab work? Yes. I couldn’t find a reason why this would be wrong, so I ruled any anatomy dissection from here on out, OK and attributed any uneasiness to the fact that running a knife through a human body for the first time was not supposed to feel OK. Whatever the reason for the concern, in less than one lab, my nervousness was fully replaced with fascination. I quickly realized that this donor would submit to everything I and my tablemates deemed beneficial to our learning. There was mild protest at times manifest through a stiff arm or extra tough fascia, but that was negligible. The donor let us cut open her back on that first day, just as she would soon open her arms to us. And she did, just as she gave up her lungs. And after beating its final beat, she gave up her heart, shedding the pericardial sheath to share it in the flesh for the very first time. And then came the neck, the head, and of course, the brain. Dr. Piekut was at my side to help cut free the remaining cranial root as I lifted the brain up and yelled, “It’s a girl!”
These were exciting moments. We were seeing the human body in ways that we never had and may never again see. An author once described the anatomy experience as an intimate connection with another human being because we see the body in its entirety. The author claimed that the experience was more intimate than making love. Is that true? Did I get to know this donor as deeply as the author suggests? I just described some very intimate experiences with the donor, but is that really getting to know the person?
This question about “knowing a person” first came to me, albeit from a slightly different angle, while studying one afternoon in the anatomy lab. I was carefully going through the nerves and muscles of the forearm. I sat on one of the steal stools beside the donor with my left hand separating the muscles to better understand what was there and where it was going. With my right hand, I picked up the donors left hand to appreciate the underside. And there I was, high-fiving with the donor. But there wasn’t anyone on the other end, right? Well, who’s hand was I holding up if there was no one on the other end? I was obviously holding a hand that was attached to an arm that was attached to a torso where a neck and head attached. Judging by everything I could see there was a person on the other end of this high five. At one point, that was true, but despite what my eyes told me in the anatomy lab, there was only the body of a person, but not a person. I could touch, poke, smell, see, even taste this body but it would not allow me to truly know this person.
And this is the idea that I want to share, that we cannot truly know a person, a disease, a whatever, if all we go on is observation. What we observe is never what is truly there; it is only what we are able to observe. In other words, observation is not capable of bringing us to a full knowledge. This is certainly the case in the art of medicine. Look back at the cancer screening lectures of yesterday and the day before. After all of the meta-analyses, the only certainty is that we certainly don’t know what to do about screening. Any search in Up-to-Date will show the same thing, one anecdote followed by a recommendation that replaces the previous collection of anecdotes and recommendations. What is unsettling and true is that all of what we are learning in medicine is grounded in observation. Which leads us to a postmodern predicament: how can we say to our patient that we know what is going on with them if all we go on is grounded in an incomplete modality: observation.
I’m going to leave medicine for a minute in its little quandary and now ask if it is also true that to know a person we must supersede our faculties of observation. I am sure that many of you can relate to a mental flash where a classmate from grade school pops into your head. Their name, face, maybe even one particular interaction suddenly comes to mind, and then you realize that although you went to the same school for four, six, ten years, their memory is reduced to that one interaction or maybe just a face or name. Did you really know this person? Can you say that you know this person anymore?
Every observation you made of that person was added to a mental file and stored until updated by a future observation. Just as in Up-to-Date, our brain is busy adding to the mental files we store on the people in our life and with each new anecdote comes a revised recommendation e.g., avoid this person, love this person, listen to this person, laugh at what this person says, etc. Our knowledge of this person and therefore our behavior is based on a very limited set of data. How can we be sure that we actually know our colleague? How can we be sure we know our patients? It doesn’t seem like we can. We will continually operate on incomplete information, our biased and short-sighted observation, leading us to act with incomplete understanding.
Recognizing this state brings to mind the words of the apostle Paul to his fellow saints in Corinth, “Now we see through a glass darkly.” It was true then, and despite all of the wonderful innovations in the world, your glass and mine remains dark. Our understanding of medicine is incomplete, and we don’t fully know our neighbor.
So what? You might be thinking. “Thank you for pointing out that my glass is dark. Is that it? Well, yes, but there is something we can do as we look into medicine and look into people through our shaded glass. Paul, in his same letter to the Corinthians, identifies three things that will enable us to overcome the limitations of our darkened glass i.e., our incomplete understanding. These are faith, hope, and charity. Faith is recognizing that there is more to this person than what we now see. It is acting on this belief to discover more about them; it is basing our judgments not only on anecdotes but on the eternal nature and goodness of the person. We can have faith to research and discover more about a disease. We can have faith in our classmates; in our professors; in our patients. Hope gives direction to our faith. We hope that good things will come out of our actions and our interactions. We hope that the treatment will work; that the grant will be accepted; that greeting our patient with a smile will help them feel at ease; we hope that a nod to a classmate across the lecture hall will communicate something, we hope it will communicate that we are glad to share this space and this experience with them. Charity is forgetting about our self, it is leaving the self-interest at the door. With charity, we stay until all of the patients are seen. We forgive the person who was harsh towards us. Out of charity, we fill out our course evaluations. I have faith, and I hope that you get the idea here. I will now exercise some charity and end this talk.
In closing, I believe it is through faith, hope, and charity that we can move beyond observation and truly know a person or a disease. These principles enable us to observe as God observes all things in their true and complete state. I give thanks to the donors who through faith in us, hope in our future, and charity in their soul shared everything they could. Now let’s try to apply these principles to enrich our experiences in life with a more full knowledge and to enrich the life of those around us. Thank you.
[i] Our anatomy professors who were in attendance were known for their zeal in testing our knowledge of nerve fibers. They loved to point to an organ of the body and ask what nerves innervated said organ and where the nerves originated. Thankfully, this opening that did in fact come to me just before I got up to speak got the audience laughing and helped me feel a bit at ease—I was really nervous, sweaty palms and all, pathetic, huh.
[ii] The class that involved the anatomy lab was called HSF. It was organized into four blocks that covered a little over three months time.
