Anxiety

Nearly two years ago, I sat with my younger sister at the airport in Houston, Texas waiting for our respective flights.  She was going back home to New Jersey, and I was headed back to California.  While waiting, she passed the time browsing SAT prep sites on her iPad.  Her oldest child, my nephew, was starting his junior year of high school that fall, and she wanted to make sure his summer was well spent, and that he had the opportunity to prepare for the exam which would determine his future college options.  As she talked about the merits of one approach over another—classroom instruction versus private tutoring– I felt my anxiety level rising like an uncomfortable expanding bubble in my chest, gradually cutting off my air supply.  The pressure was palpable.  After listening for a few minutes, I said to her, “Please stop talking about this—you’re making me very nervous and I’m not even TAKING the exam.”  She looked at me in surprise, and we moved to other topics.

 

On Sunday evening on our way out to dinner, I went with my daughter to take sign out from the intern who was leaving the ward service the next day, and turning the very sick patients over to my daughter’s care.  I tried to position myself unobtrusively, in the far corner of the residents dictating room, sinking as deep into the shelter of my wrinkled hooded raincoat as I could, but even from my self made cocoon I could hear them discussing in hushed tones the low platelet counts, the mucosal bleeding, the fevers unresponsive to antibiotics in these acute leukemic patients.   It was seven pm after a long weekend on call, and the interns and residents looked exhausted.  The white cubicles and the scuffed linoleum on the floor reflected the fluorescent ceiling lights overhead. The faint smell of stale fried food and sweat combined to form a vaguely nauseating aura.  Suddenly I was transported back thirty-five years to my own internship, and to my first night on the cancer service and in that instant, I felt every bit of anxiety that I felt so many years ago.  For anyone who has done an intensive medicine or surgery residency, these feelings form the impetus to learn and become competent—the overwhelming sense that a human being’s life is in your hands, and this night, and every night, you must be vigilant; you must perform and do your very best.  The end of shift can never come soon enough.

 

It’s been many years since I taught a class of high school students, or staffed an inpatient service run by interns and residents.  But if I ever do either again my recent “flashbacks” will serve me well.  It’s good to remember the fear and tension associated with being a learner in a stressful situation.  Teaching has always been a passion for me, and those are the memories and feelings which will make me a better teacher.

Who We Really Are

When I was a resident in radiation oncology, I thought I already knew a lot about medicine.  After all, I had just completed an internal medicine residency, and had taken and passed my boards.  Needless to say, I was more than a little bit irritated the first time a patient “coded” in the radiation therapy department and I was shoved out of the way by the intern on the code team.  After all, he was an internal medicine intern at the World’s Greatest Hospital, and I was a lowly radiation oncology resident. My protestations of “I can HANDLE THIS!” were lost in the general hubbub of excitement and confusion surrounding a cardiac arrest.  The patient survived, despite my bruised ego.

I found out very quickly that I didn’t know much at all—in fact, I didn’t know how to write a proper history and physical.  On my first rotation, my attending corrected my very first sentence, stating emphatically that “Mr. So and So is NOT just an 86 year old Caucasian male who presents with lung cancer. He is an 86 year old retired firefighter and grandfather of eight who presents with lung cancer.  There is a big difference.  You will see!”  From that point on, I was charged with adding descriptors beyond the age, sex and race of my patient so that I would know that patient as a PERSON, and not just as a disease.

My daughter is going through her internal medicine residency right now.  I remember how easy it was to de-humanize a patient by calling her “the myocardial infarct in ER bed 8”, or the “renal failure in 222”, or the “nursing home placement on the 9th floor”.   If we call them by their disease, they cease to be the living breathing mother of high school age twins, or the father of a disabled son, or the principle of the local school for the deaf.  They’re just diseases, to be treated and discharged, or “buffed and turfed” in the old House of God parlance.  It’s much easier to be detached from a disease, than from a human being that one might just have something in common with.

Because of my first radiation oncology attending, to whom I will be forever grateful, I’ve made a point to pay attention to the person, and not just the disease.  I teach my medical students the same thing—that it’s not enough to just copy and paste the social history—the history of whether the patient is married, has a profession, has children, smokes or drinks alcohol or takes her religion seriously.  I try to learn about the person, and when I do, and convey that to my entire team of physicists, therapists, nurses and front office, I know that the patient gets better care.  It’s just human nature to empathize, and sympathize, if we truly know the human being behind the diagnosis. And it’s especially true for the difficult patients, the mean and angry ones, the ones we would prefer to dismiss.

But sometimes I slip up.  Recently I treated an elderly man postoperatively for rectal cancer.  He was a quiet elderly gentleman, but his son, a tech writer, made everyone in the department miserable with his demands for his father.  I never asked the man what he used to do, before he was eighty six with rectal cancer.  But another one of my patients was a little more curious.  He and the old man were side by side in the waiting room day after day of treatment until finally, the younger man asked me, “Where is Mr. __ from?  I can’t place his accent.”  I said, “I don’t know—I suspect he might be German but I never asked.”  So I did ask.  And was surprised to find out that my elderly patient was Israeli, born in 1925 in what was then Palestine. A true “sabra.”  He grew up in the Holy Land to become one of Israel’s foremost songwriters.  In fact, they still play his songs in Israel and recordings are available on YouTube. And I would never have known that if another patient had not cared enough to ask.

When you and I get sick, as we almost certainly will, we should all hope that our histories state who we really are, and that our admitting interns and residents care enough to ask.  They will be better doctors if they do, and we will get better care.

Nurses Talk

I think you all know how I feel about nurses now.  If not, go back through the archives of this blog and read my essay “Nurse!”  My patients and I have been supported throughout my career by some of the finest people on the planet, my oncology nurses.  As a medical student, as an intern and resident in internal medicine, and as a radiation oncologist, nurses have saved my neck and my ass as often as they have saved my patients’ lives.  “Advice to New Interns From a Nurse Turned Medical Student” http://www.kevinmd.com/blog/2011/07/advice-interns-nurse-turned-medical-student.html  should be required reading for any new medical school grad starting an internship.

Now it is my turn to help out.  An innovative new talk show has been created, aimed at raising the level of the public understanding of important medical issues from the perspective of nursing experts, educators and front line practitioners.   The show is entitled “Nurses Talk” and three TV quality episodes have been produced along with a trailer which can be viewed on their YouTube channel via their website www.nursestalk.com .  If you are as tired as I am of the talking doctor heads on network tv (and no offense meant, Dr. Oz and Dr. Phil!) have a look and if you like what you see as much as I do, please contribute to the campaign to keep this great effort going.  For more information, and for a way to contribute, go to http://www.indiegogo.com/Nurses-Talk-Real-Perspectives-from-Real-Nurses . Time is running out for funding.   Thank you, and back to my regular programming soon!  Miranda.

For Once, Then, Something

As I was leaving for Boston, I asked if anyone would care to contribute to this blog.  I am still processing the wonderful things that friends and family have sent me.  This one is from my husband.

One drop fell from a fern, and lo, a ripple
Shook whatever it was lay there at bottom,
Blurred it, blotted it out. What was that whiteness?
Truth? A pebble of quartz? For once, then, something.    Robert Frost

 
Our daughter is in the last year of medical school and is having a hard time deciding what career path to take. She has applied for a residency program in internal medicine, but a recent experience with her grandfather in Africa where she was able to assist in the surgical repair of a variety of physical deformities has made her wonder if a career in surgery might be a better fit.

Choosing a career is a really big deal. Since most of us have to live with the choice – good or bad – for much of our adult lives, it’s a decision not to be taken lightly. This is particularly true in medicine, where the training is long and arduous, and by its very nature is not something you want to repeat again should your first career choice not work out. Yet, there aren’t many “how to” books written on the subject, and few of us feel comfortable directing someone else along a career path that might not work out for them. So, what advice – if any – might I give my daughter?

Based mostly on personal experience and some library research I performed as an undergraduate, I suspect that many of us choose a career based on a “gut” feel. Sometimes a career just feels right. Perhaps it’s the intangibles or maybe just good fortune. I know in my case it was a little of both.

My daughter recently asked me how it was that I ended up being a pulmonary physician. The question brought to mind how many different career paths I actually explored along the way. Once, I wanted to be a psychiatrist. This was at the beginning of medical school when I was fresh from spending endless hours listening to the sometimes neurotic musing of my college friends. Hey, this was interesting and could be fun, particularly if you’re getting paid for it. So, I picked psychiatry for my first elective rotation in med school, and saw what real mental illness is like. One of my patients was a teenage girl, who seemed outwardly normal, but confided in me that she had had an immaculate conception and was going to deliver the Lord’s baby. When I asked the attending psychiatrist if there was a pill for this, he looked at me like I was the crazy one. Psychiatry was definitely not my cup of tea.

Then, I looked into neurosurgery. As an undergraduate, I did an essay on a famous neurosurgeon named Harvey Cushing. An amazingly gifted physician whose written descriptions of his patients – complete with very accurate sketches – can be found to this day on display at Mass General Hospital. It would be great to have a career like Cushing, so I signed up for a neurosurgery rotation. But, this didn’t appeal to me either. The patients didn’t improve very often, and perhaps equally as important, I just couldn’t identify with the attending neurosurgeons who didn’t appear to be as interesting as I imagined Harvey Cushing to be.

So, like my daughter I applied for an internship in internal medicine. From an intellectual point of view, this seemed like a good fit, and I did identify with the attending physicians who seemed smart and articulate. But, there are so many specialties of internal medicine; I really wasn’t sure which to choose. Then, something happened. I was reading up on a patient with an unusual lung infection when I came across an article called “In Defense of the Lung” by a physician named Gareth Green. It described the complex interplay of factors that protect the lungs from infection, and how someday it might be possible to modify lung defenses to help susceptible people actually resist pneumonia. Something about this notion resonated with me, and for the next two decades the interface of infectious disease and pulmonary medicine was my career focus.

Some people find themselves in the career they always imagined for themselves, but I wonder if this is a good thing or not. Did they get a chance to explore how other career paths might have worked out? Were they willing to experiment and take a few chances along the way? As I say, I don’t know if this is a good thing or not. It may be much easier to pick something and stick to it, like my wife has. And in her case, it has been a remarkably rewarding approach. But, I can’t help wishing that my daughter would keep an open mind about opportunities that might come along in medicine or in surgery or in some other branch of medicine. Once this happens, then it could well be that something unexpected and great will be in store for her. I hope so.