Musings on Medicine

Author Note: This was published through Facebook several years ago, but as part of this blog’s reboot, is finding a new home here.

As long as I could remember, I have always wanted to become a physician. This dream was fostered through a combination of a childhood illness, my mother’s experience in the medical profession, and a passion for both the complexity of science and the art of the human experience. Over the years, I never questioned or wavered in my choice. Medicine, to me, was a calling, a noble profession imbued with deep significance since its inception centuries ago. Yet paradoxically, for nearly all of my life, I neither truly understood the implications nor the consequences of my career choice.

Only recently, in my last semester of college, have I been able to untangle some of the deceivingly cryptic catchphrases used in medicine. I would like to consider two recent musings here:

1) Medicine’s goal is to improve the human condition.

This phrase is so simplistic and profound. Few other professions embody such an idealistic outlook towards not only the work of its tenants but the benefits of that work for society and the world. No wonder that variations of these words (such as its (in)famous cousin, “I want to help people”) have been used by medical professionals and interviewing students alike. However, Foucault in his work The Birth of the Clinic: An Archaeology of Medical Perception offers a unique thinking point:

“But to look in order to know, to show in order to teach, is not this a tacit form of violence, all the more abusive for its silence, upon a sick body that demands to be comforted, not displayed?”

Foucault describes in an excerpt of this work the rise of the hospital system due to the advent of scientific reasoning. As a consequence, the physician develops a “gaze,” an ability to see what has not been seen before (not only literally through technological advances but also figuratively through this new form of thought). The gaze subsequently creates an object out of the subject. Objectification is the subject of the quotation; in the hospital environment, patients become objects of training and research, a far cry from improving the human condition. Examples ranging from Henrietta Lacks to some free clinics continue to illustrate this principle. No matter how genuine the scientific inquiry or mentorship might be, no matter how much prodding and poking eventually leads to a remission or cure, such efforts comes at a potnetial expense to the patient, if not in physical cost then an emotional one. Based on current socioeconomic factors, this expense is often placed disproportionately on the poor.

2) Medicine is imperfect. 

Not all patients can be saved. Not all pain and suffering can be prevented. And, based on the previous musing, not everyone is treated fairly. One area of medicine can be held to a paradoxically higher standard. Consider this example:

RW is a middle age male patient who has been treated his entire life for schizophrenic episodes. For the past five years, he has undergone regular follow-ups at a large, teaching hospital with the same psychiatrist and mental health team. One day, RW’s mental health begins to deteriorate for unknown reasons. The medical staff is notified of the change in condition by RW’s family and a next-day appointment is scheduled at the medical center. Medical staff provide pertinent health information to the patient’s family and a staff member is able to speak to RW over the phone to assess his health status. After the conversation and based on his medical history and past episodes, the staff member determines that an immediate in-person psychiatric evaluation is not necessary. The family is advised to call the medical center if anything changes.

In the evening, RW experiences a serious psychiatric episode and becomes combative. Police are called by the family. An altercation develops where RW assaults a police officer with an improvised weapon; in the aftermath, RW was shot and killed by the police while one police officer was injured. Media reports cite misdiagnosis and mishandling of RW’s case by the medical center. Health professionals and community leaders reiterate the need for stronger mental health services in RW’s community.

Now consider this alternate case:

A cancer patient, CH, who is in remission undergoes continuous follow-up to monitor her condition. In her fifth year of remission, between two of her follow-ups, a mass develops. Treatment is promptly initiated but despite her medical team’s best efforts, the cancer becomes metastatic and she passes away just months later. Her family and her medical team hold a memorial for CH.

In both examples, a chronic, debilitating condition is monitored with stringent follow-up and prompt treatment. A “medical failure,” an inevitable event, occurs in both examples. Yet, in the latter case, there is no backlash, no blame towards the medical profession. Maybe a key difference lies in the harm to others that mental health cases could pose, combined with the social stigma that accompanies a mental health diagnosis. Yet, a slight irony exists in the double standard that society has created with respect to psychological versus biological health.

The more I reflect, the more ironies and paradoxes I find in what we have defined as medicine and healthcare. I now see how buzzwords such as humanistic medicine or holistic care have a depth of meaning that I can only begin to appreciate. As medicine transitions into an era fraught with new challenges in gaps in access and care, in combating historically incurable diseases, we should pause. For how are we supposed to foster systemic changes and push the frontiers of science without a deeper, philosophical, understanding of the field to guide us.

On the Corner of Scott and Skidmore

The corner of Scott and Skidmore is a place known to very few. It offers the rare observer a view of a bleak yet paradoxically serene landscape. A pristine blanket of snow covers the ground, punctuated only by the spindly trees. Beyond the road and tree line, past a pair of well-worn train tracks, the partially frozen Scioto River begins its sharp bend towards Columbus proper. A mix of small industrial buildings rounds out the scene, lying dark and quiet along the street. The area seems devoid of life, save for several pairs of footprints tracking towards the river.

The footprints are of various depths and age, suggesting a well-used path by persons unknown. The tracks continue through a break in the thin tree line, across the well-worn tracks, and towards the Scioto. There, amid a grove of leafless trees, one can discover a harsh truth amid a forgotten urban wilderness.

This is the home of a couple who endeavor to share what little they have with others, even though they have so little themselves. Here are the shelters of men who wake up at four in the morning to find paying work to support themselves. And in this small grove sleep veterans of war in the shadow of the Franklin County Veterans Memorial, long forgotten by the country that they served. 

The grove has been raided by police backed by politicians, who threaten its inhabitants with un-payable fines, eviction, and imprisonment. It has been the target of a merciless Mother Nature, who batters the shelters with snow, wind, and freezing temperatures. And its residents must navigate through a convoluted and overburdened social service system if they hope to receive any type of organized aid. 

Although some grapple with issues of alcohol abuse, drug addiction, or mental health problems, all of the homeless of Columbus are ultimately in a battle each and every day to simply survive. If you pause and listen to their stories, you will hear a tale that often shatters the image of the persistent panhandler or comatose vagrant. Instead, their voices will tell you a very human story…

Author Note: The homeless camp described in this vignette is actually a secondary camp created after the first was forcibly evicted by the city a year earlier. At that first camp, situated off of an abandoned road off of Greenlawn Avenue, a de facto camp mayor, homeless himself, and long-term or permanent residents, had created a functioning society in the middle of another stretch of woods. They coordinated with non-profit organizations and church groups for aid and helped new residents settle in, find working wages, and abide by camp rules.

The first camp soon came to the attention of city officials, who responded first by placing concrete barriers on the abandoned road to prevent local non-profit organizations from reaching camp inhabitants. Months later, police officers were sent to arrest and relocate any remaining residents of the camp. All camp shelters were torn down and the residents were transferred to local homeless shelters. It is unclear how many of the residents sent to these shelters were able to be placed in stable housing and how many ended up back on the streets.

This essay was written nearly six years ago to this posting (shared first through Facebook, then a now-defunct medical blog, and finally finding a new home here). At the time of the writing, city officials and local police were regularly threatening eviction. It is likely that, today this camp no longer exists…

As an aspiring physician, some of my future patients will have extenuating circumstances, some of which, like the lives of those described here, will be extraordinary. These circumstances will adversely affect their ability to access, receive, and maintain their connection to health care systems.

Without an appreciation of these difficulties, we as healthcare providers run the risk of mislabeling poor circumstances with poor motivation, of confusing mistrust with belligerency. Only through understanding, not only of our patients’ circumstances, but also of the social services and support systems available in our local communities, will we have the ability to truly help our patients beyond the clinic.

A Broken Heart

2D Echocardiogram– $220.00

Hospital Consult– $110.00

Select Coronary Angiograph and Cardiac Cath Imaging– $10,000.00 (give or take)

………

The list, a fading hospital bill from over 15 years ago, goes on and on. I had never seen the bill until today, when my dad handed it to me while cleaning out some old files, but there are many things that I do remember.

I remember the snow, then the fever. I remember being taken to my family physician, barely able to stand on the scale. I remember being transferred to a big hospital. I remember the first night in the pediatric ICU, where they heaped icepacks that chilled me to the bone and refused to take them off, despite my complaints.

Then there was the cold stethoscope held by a different hand each time. There were the injections, the constant in and out of people, the worried face of my mother, the presents, the cold rolling ball of the echocardiogram probe, the sticky electrodes from EKGs. It was a daily routine of procedures, tests, consults, and of course, the sickness. I was four-years-old at the time, and even now, I still remember.

What I didn’t remember was one phrase I told my mom; I didn’t learn about it until probably a year ago. About five days in to my ten day ICU stay, I had said to my mom,”I don’t want to live anymore.” Weighty words for a four-year-old, and something that broke my mom’s heart.

But regardless of my young opinions, I did live. On day ten, the fever went down. I ate my first bit of solid food in over a week, a cereal with a frog on the front of the package (Honey Smacks—had to look this up while writing this). I also remember that I actually didn’t like the cereal, but it didn’t matter. I was too hungry to care.

On day eleven, I was discharged, returning back to a semblance of normal life…

Over the years, this patchy childhood memory was filled with new bits of information. I learned that I had Kawasaki’s Disease, a rare disease of unknown etiology, possibly fatal if left untreated (It also turned out to be a perfect textbook case, which made me quite an attraction among the medical students, residents, and fellows). And unfortunately, I didn’t come out unscathed; the ordeal left me with three coronary artery aneurysms, one of which has never healed.

Even to this day, I still have a “broken heart,” but the ordeal has only empowered me to live my life, achieve my dreams. I had wanted to become a doctor even before I became ill, but my experience didn’t scare me away; instead, it emboldened me.

I have no illusions about what I’m getting myself into. Medicine is an imperfect profession that strives for perfection. Its practitioners are held to a golden standard of idealism that is impossible to uphold. It seeks to cure, but often falls short. It seeks to heal, but memories and scars never fade away.

I know all of this. I’ve experienced it firsthand. But regardless, I still believe.

For if we don’t believe—in an idea, a dream, a goal—then what are we living for?

Effortless

While sitting here on a Friday night,  I figured it would be a good time to write this short reflection:

Effortless. It’s such a simple word yet its use is restricted—for life is anything but effortless. But there is one thing that I could describe as being nearly effortless in my life, and though usually being able to perform something effortlessly is a good thing, I see it differently.

I’ve always been good at academics. Ever since I was young, I’ve always had a knack for picking things up—letters, words, number, patterns. And this ability only grew throughout school. I fought through the usual battery of exams, projects, and standardized tests and finally graduated with honors, college bound.

But it didn’t end there. Since I was four, I’ve always wanted to be a doctor (for reasons that deserve a post of its own). And so, I made it a point to find a university that would make that possible. After several supplemental applications and interviews, I finally found that school, a well-known public university which offered me not only a substantial scholarship but conditional acceptance to its medical school.

True, I worked hard to get to where I am now, but I also consider myself very lucky, too lucky, in fact. I have a spot in medical school saved for me upon graduation, but I became eligible through a standardized test—a test that I not only didn’t study for but barely “passed” the school’s internal benchmark. I’ve worked as a research student at a medical institution for the past three years. Yet, I got the position through a stroke of luck. This year I received a national grant,  a notoriously difficult and competitive process, through (yet another) stroke of luck and a mentor’s generosity. And so it may have seemed effortless how I reached this point in my life, but in all honesty, it was a combination of hard work, a little bit of talent, and a lot of good fortune.

Which brings me to another point. People don’t seem to understand when I try to downplay these achievements.  “You should be proud” is the most common phrase that is directed to me. I am proud, and I am happy with where I am with respect to my education and career.

But if someone, anyone asked me if I had a choice, would I give it up? I wouldn’t hesitate. The answer is yes. I would give up that seat in medical school. I would give up my scholarship. I would give up the luck I’ve had. I would give it all up.

Although academics has been effortless for me, other things in my life have been a struggle. There are a lot of things I wish I had and if given the choice, between those things and a seat, I would take the former.

Because in the end, happiness, completeness trumps effortless.

An Unshakable Feeling

As I walked back to my car after running an errand, I took a moment to take in my surroundings. Above me, a perfect half moon was slowly emerging, taking the place of a crimson retreating sun. The weather, the temperature, everything was beautiful, and one could say calming. My day had gone perfectly well, despite my being a little tired, but during that brief walk, an all too familiar feeling began to surface.

It’s really difficult to describe. Imagine that very common feeling of disappointment or heartache that makes your heart/soul feel kind of heavy. Now imagine that feeling being diluted to the point where it just reaches the threshold of being felt, a “light” heavy feeling that surfaces out of the blue. It’s not fear. It’s not depression or even sadness. It’s in a class of it’s own, a feeling as if something is missing from your life or that something isn’t in place.

Of course there’s nothing actually missing, at least at the conscious level. I really am happy with my life, complete with purpose, good friends, goals, and various activities, among other things. But this feeling, this unshakable feeling, which comes and goes whether or not I’m happy, sad, or anything in between, still lingers. It feels as if something, someone is missing..

Who knows, maybe I am missing a someone (some fated friend, significant other, acquaintance, or rival). Or maybe I’m missing a something (an experience, a new purpose (already have a current one), hobby, goal, etc).

Regardless of the cause, the fact of the matter is that even as I write this post, this feeling still lingers.

An Invisible Observer

The following describes a scene from my volunteering days at a local hospital. As I sat waiting for a family member to come back from seeing her loved one, I was able to quietly observe. It was during that time that I was able to see a mundane hallway come to life with its own unique atmosphere, one that can be seen as a metaphor of the ebbs and flow of daily life:

“The skyway was bathed in the mid-afternoon sunlight; the patterns of the spotless floor were punctuated with the golden outlines from the large window panes. I sat alone on a ledge, an invisible observer.

About fifteen paces away, a new arrival, a man, was looking out the window. His white lab coat was neatly pressed and his brown face was furrowed as he focused his gaze across the urban landscape. Speaking intermittently into a utilitarian silver cell phone, his voice emanated a tone of understanding and empathy. When he paused, he would cock his head slightly, as if the slight change in angle would be conducive for listening to his conversational partner. As he stood, silhouetted in the rays of light, the man projected the image of quiet confidence.

I closed my eyes, blocking out all visual sensation. Only the soft hum of fluorescent lights punctuated with the soft staccatos of padded footsteps would punctuate the serene silence. I became unaware of the passage of time. Then, somewhere in the distance, the ringing of an elevator signaled its arrival to the second floor. A pneumatic hiss accompanied a whooshing sound as a pair of automatic doors opened. Now there were multiple footsteps and harsher chatter.

I opened my eyes. The man in the white lab coat was slipping his cell phone into one of his deep pockets. Passing me, he turned and walked rapidly around a corner, disappearing into the labyrinth of passageways. Two dark shirted individuals walked past my line of vision; their boots thudding resoundingly against the hard floor and the wheels of the bed they were rolling squeaking in protest to their rapid strides. A small herd of people could be heard as they laughed and spoke rapidly, emerging from an unseen niche and traversing the skyway. Suddenly, a man still wearing a mask rushed past me, causing a turbulence of cool, scentless air. As his footsteps receded, only the click of an elderly lady’s cane could be heard. She ambled past before she too disappeared into the labyrinth. When the sound of her cane receded, the area became quiet once again.

The soft hum returned to the hallway. Unseen by countless eyes, I remained, an invisible observer.”