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Labor and Delivery, Harvey Dent (AKA “Two Face”), and President Obama’s Speech

My last day of my third year clerkship rotations perfectly encapsulated much of what I love about academic clinical medicine and much about it that breaks my heart.

This final day began on the labor and delivery (L&D) service at the UCSD county hospital in Hillcrest. As the morning progressed, I found myself unconsciously checking off the boxes in my mind as tasks were completed. “Shut off my alarm at 3:30 am for the last time (for a few months at least), check.  Awaken women who have recently delivered a baby at insanely early hours to ask how they are doing and do a targeted physical exam, check. Frantically write my notes to get ready for rounds, check. Try not to look like an idiot on rounds, mostly-check.”

After the morning routine that becomes all-too familiar during third year, we ran the board on the L&D deck. The L&D unit was offering all the chaotic glory it had to offer that day: high risk-pregnancies, scheduled and unscheduled c-sections, and low-risk vaginal births attended by the certified nurse midwives were all in the cue. As I wondered where to get involved, my resident suggested I assist with the vaginal delivery of a woman, Mrs. Tran, who had just been examined and who felt ready to start pushing.

We walked over together, and as we entered the room, I felt an ambiance I had not yet experienced during my time on the L&D service. It was one of complete tranquility. Mellow, soft, flute and chime music played in the background. The shades were low, and the lights were dimmed. Mrs. Tran lay on the bed relaxing, with a peaceful disposition, as if she were awaiting her turn on the massage table. Was this a spa or a hospital room? Her husband stood by her side, holding her hand, and frequently spoke kind and encouraging words to her. The nurse was on the other side of the bed, monitoring the status of her IV lines and epidural.

My resident and I left the morning’s chaos at the door, and dropped to the pace, feeling, and volume of Mrs. Tran and her delivery. We introduced ourselves, asked if it was okay if I assisted with the delivery, and questioned if she was feeling ready to push. After a look to her husband, a smile, and two answers in the affirmative, we prepared to deliver the baby and she started pushing. She pushed almost effortlessly for ten minutes, after which a beautiful baby girl transitioned from life in the womb to life outside. The joy mom and dad felt was palpable. As my resident and I cleaned up, I thanked God in my heart for the opportunity to experience in my small way of this important family bonding moment–what I had come to call “a family glue moment” by the end of my rotation.

Still basking in the idyllic feeling from Mrs. Tran’s delivery room, I was snapped back to reality as I reached the L&D deck. A woman I’ll call Linda had brought herself to the L&D triage unit, which is basically the Emergency Room for pregnant women, because she felt like her baby was moving less than it had been previously. My resident connected me to the Certified Nurse Midwife (CNM) who was managing the triage assessment, and she said she would love to have me help with the patient.

I began reviewing Linda’s chart, and soon my heart broke. She had been seen several times in prenatal care, so we already had a fair amount of good information to help us assess her and the baby. But it was also clear that she had numerous personal and health risks that we needed to check out. Now in her mid-30’s, she had a complicated pregnancy history, though we didn’t have much detail; she was in an narcotic addiction recovery program, and was currently taking the medication that helps with that called Methadone; and while stable now, she had recently had problems with being homeless. Perhaps the point where these problems started was in her childhood, when she had been the victim of sexual abuse and had turned to and was victimized by prostitution and drug abuse for many years thereafter.

The chart made it clear that Linda was making great efforts to stay off drugs and out of legal trouble so she would be permitted to keep her baby. And on that day, it was the job of me, the CNM, and the whole hospital system to make sure that she and her baby were healthy and safe.

The CNM introduced me to Linda and asked if we could get a better idea of her history and how she and her baby are doing. Linda agreed, and she shared that she had actually had two deliveries in the past. One was in Florida to twin girls that were born prematurely, helicoptered to another hospital where they could get life-saving care. After they were placed on the helicopter flight, she signed the adoption paperwork and never saw them again, because of her legal and personal state. Her other birth was to a boy in New Jersey, with whom she was able to spend a couple of days before putting him up for adoption as well. Even though Linda shared with me her story with the callous of a woman who had experienced life-shattering traumas, it was evident she still harbored sadness. It was also clear the great efforts Linda was taking to try and be a good mom and to be able to keep her this baby.

After further discussion, an ultrasound, and other tests, we were able to reassure Linda that her baby was moving well, that she and her baby appeared healthy, and that she could return home. Linda thanked us for the care and attention we gave her and her baby, and began preparing to go on her way.

After my encounter with Linda, two verses from a hymn in my Church’s song book came to mind:

Who am I to judge another
When I walk imperfectly?
In the quiet heart is hidden
Sorrow that the eye can’t see.
Who am I to judge another?
Lord, I would follow thee.

I would be my brother’s keeper;
I would learn the healer’s art.
To the wounded and the weary
I would show a gentle heart.
I would be my brother’s keeper–
Lord, I would follow thee.

(“Lord, I Would Follow Thee”, LDS Hymnal #220)

Leaving the hospital later that afternoon, I felt grateful to have been able to participate in my small way in the care of my sisters, Mrs. Tran and Linda. While reflecting on how one brief day had provided opportunities to help women who were on opposite ends of the socioeconomic and social determinants of health ladders, the image of Harvey Dent and “Two Face” came into mind.

Image result for harvey dent good guy

 

 

 

 

 

On one hand, I appreciated the role of academic medicine, and how as an institution, in its ideal though imperfect form, it strives to care for all people regardless of background; on the other hand, I was troubled at how familiar Linda’s story had become to me by the end of my third year clerkship rotations–that of traumatic childhoods, struggling families that too frequently break, the long-term health effects of terrible, selfish acts committed by others, the harmful minute-by-minute influences of one’s community and environment, and a society and healthcare system that rather than being one step ahead is more often than not is two steps behind.

We all know medicine is imperfect and needs major overhauls. And it’s not just medicine–the recent killings by police, the recent killings of police, the increased frequency of mass shootings (to name a few)…it makes one wonder, where is the hope? Rather than try to unpack each of these issues in this post, and without touching on all of the approaches that need to be taken to fix these issues, let me focus on one thing that has been on my mind.

The hope is in each one of us to grow, change, and influence the world around us for good. Let me apply the case of Harvey Dent to our current discussion: is Harvey Dent all good, or is “Two-Face” all bad? One reason his character strikes so close to home is that we subconsciously realize that we are all like him: looking good and trying to do good in our best moments, while appearing monstrous and almost unrecognizable in our worst ones. This is why we extend compassion and understanding to Dent so easily, for we all recognize the wort of us in ourselves as well. Hence the relief we feel at his death, because we are glad the darkest side of him is no longer around to wreak havoc. Perhaps this is also why we accept Dent’s portrayed martyrdom as a hero in exchange for Batman’s antagonizing sacrifice, because we too want to be remembered for our good deeds rather than our destructive ones.

The analogy can be extended to our spheres of influence in clinical medicine, and our day-to-day contributions to society. In similarity to Harvey Dent, each of us who fulfill a role in clinical medicine–big or small–is responsible for tremendous acts of individual care: lives saved, diseases prevented or cured, hearts and minds strengthened, along with many more examples. On a personal note, my orthopedic surgeon gave me my ankle back after I had a traumatic fall and fracture five years ago. Each time I step onto a soccer field or run around with my kids, I wonder at how my mobility could be very different without my surgeon’s knowledge of mechanics, bones, and pins.

But let’s not allow the “Two-Face” within each of us to hide behind the martyred Harvey Dent. How do we feel when caring for a Trump supporter? When the door to the resident workroom is closed, what are we saying about our patients, and perhaps more importantly, in what spirit are we saying it? Are we pushing ourselves to engage in those kinds of conversations that promotes understanding with others, including our patients, who look, think, or act differently than us? I went back to President Obama’s speech he gave at the Dallas Police Officers’ Memorial Service to grab the bit where he says we need to have difficult conversations about race and other issues with those outside of our circles. But reading through it, his moving remarks are connected to the Harvey Dent analogy, the socioeconomic determinants of health issues brought up by Mrs. Tran and Linda’s stories, and our individual responsibility to change ourselves and strive to make change around us. It’s long, I apologize, and I know it was considered by some to be a controversial speech, but it’s too important to not highlight. Recall that this speech was given at a memorial service for slain police officers in Texas. I’ll let him do the talking, and close using his pleadings (bold added for emphasis):

“We can’t simply dismiss [the black community’s calling attention to persistent inequities in how they are treated compared to their white counterparts] as a symptom of political correctness or reverse racism. To have your experience denied like that, dismissed by those in authority, dismissed perhaps even by your white friends and coworkers and fellow church members, again and again and again, it hurts. Surely we can see that, all of us.

“We also know what Chief Brown has said is true, that so much of the tensions between police departments and minority communities that they serve is because we ask the police to do too much and we ask too little of ourselves.

“As a society, we choose to under-invest in decent schools. We allow poverty to fester so that entire neighborhoods offer no prospect for gainful employment. We refuse to fund drug treatment and mental health programs.

(APPLAUSE)

“We flood communities with so many guns that it is easier for a teenager to buy a Glock than get his hands on a computer or even a book.

(APPLAUSE)

“And then we tell the police, “You’re a social worker; you’re the parent; you’re the teacher; you’re the drug counselor.” We tell them to keep those neighborhoods in check at all costs and do so without causing any political blowback or inconvenience; don’t make a mistake that might disturb our own peace of mind. And then we feign surprise when periodically the tensions boil over.

“We know those things to be true. They’ve been true for a long time. We know it. Police, you know it. Protesters, you know it. You know how dangerous some of the communities where these police officers serve are. And you pretend as if there’s no context. These things we know to be true. And if we cannot even talk about these things, if we cannot talk honestly and openly, not just in the comfort of our own circles, but with those who look different than us or bring a different perspective, then we will never break this dangerous cycle.

“In the end, it’s not about finding policies that work. It’s about forging consensus and fighting cynicism and finding the will to make change.

“Can we do this? Can we find the character, as Americans, to open our hearts to each other? Can we see in each other a common humanity and a shared dignity, and recognize how our different experiences have shaped us? And it doesn’t make anybody perfectly good or perfectly bad, it just makes us human.

“I don’t know. I confess that sometimes I, too, experience doubt. I’ve been to too many of these things. I’ve seen too many families go through this.

“But then I am reminded of what the Lord tells Ezekiel. “I will give you a new heart,” the Lord says, “and put a new spirit in you. I will remove from you your heart of stone, and give you a heart of flesh.”

That’s what we must pray for, each of us. A new heart. Not a heart of stone, but a heart open to the fears and hopes and challenges of our fellow citizens.” (President Barack Obama, June 12, 2016)

With love,

Spencer

 

** all images taken from either Google Images or Bing

ID: 17 year old Hispanic female who attempted suicide with Tylenol, now medically cleared and admitted for psychiatric evaluation

Dear John,

I have wanted to write a letter to you, an 18 year old man I have never really met, since I had the privilege of meeting Diana, your ex-girlfriend, during her admission to the Child and Adolescent Psychiatric Services program.

My intern Will and I found Diana settling into her newly assigned room. She was wearing a faded navy sweater two sizes too large for her frame. We introduced ourselves and asked if she would accompany us into a nearby room so that we could talk comfortably. As we walked in the hallway, she tied her freshly washed hair into a bun and pulled up her enormous hood. No longer could I see her deep brown eyes that were hazy with unfallen tears.

In the interview room we oriented ourselves in a small triangle: Diana and me on a couch together, Will in a chair across from us. His voice was gentle and questioning was focused, “Diana, do you know why you are here?” She withdrew her hands into the giant cuffs of her sleeves and brought her knees to her chest, hugging herself. No one said a word for 10.. 15.. 20 seconds. She brought her right hand to her face, covering her mouth with a giant sleeve. 30.. 45… She sat still. A minute passed — that trick we were taught, to be comfortable with silence, didn’t seem to be working. It was Will who eventually broke, “Diana?” Muffled and cracking but without hesitation, “I took the pills because I couldn’t take it anymore.” “What was it that you couldn’t take?” he followed up. Slowly but a little louder,

“He hit me again.”

I could see the navy blue sleeve that was covering her mouth grow darker with tears, mucus, and saliva.

This was my introduction to you, John. I know it is an unfair and biased way of meeting you, but this was it.

Will asked what happened. Diana answered in an even tone.

“I had just gone to lunch with a friend so I didn’t respond to his text right away… So when he dropped me off, ’cause he drives me home after school… He was upset ’cause it took a long time ‘til I texted him. Just before he pulled in front of my house, he hit me on the leg. Punched I guess. And when I got home I just went into a daze and went to the bathroom then my room. I texted him that it was over, I opened the bottle, and I swallowed however many pills there were. And that was it. My mom found me and I guess you guys know the rest.”

And she was right, we did know the rest of the medical course. The arrival at the emergency department by ambulance, the trends in her liver function enzymes and blood clotting factors, closely monitored to evaluate for signs of acute liver failure. But that’s all we knew. Her trauma, your abuse; we were ignorant, and she the only expert in her experiences. So Will pressed her for more information. He conducted the formal intake interview, running through the necessary check-off list of SIGECAPS, family situation, access to weapons, etc. She responded with yes, no, I don’t know, or other similarly short answers. He then asked, “Do you feel hopeless?”

Diana sat back in the couch and pulled her hood off her head. She dropped her knees and lowered her hand. It looked like she suddenly grew before my eyes, spine lengthening two or so inches — now maybe even fitting that gigantic sweater. She wasn’t hiding anymore. She was not shrinking herself now. Something in her was alerted in that question.

“I don’t actually want to die. I don’t know if I wanted to die then. No, I don’t think so… Nothing was even different about that day. But uh yeah, I have hope. The only reason I told anyone what happened in the first place is I realized that if I don’t, he’ll just do it to another girl.”

John, Diana’s reason for maintaining hope was the possibility of ending your cycle of gender-based violence. Here we were, trying to unpack our patient’s traumatic experiences of intimate partner violence, to which one in ten U.S. high school students are subjected [1]. And Diana’s source of hope was not for herself but for another girl; Diana was protecting a sisterhood whose members were unknown but connected to her.

Will wrapped up the interview efficiently, assessing quickly that her suicidality had a specific trigger; there are increased depressive symptoms and suicide attempts among women who experience intimate partner violence [2]. He thus became eager to schedule a family meeting in which strategies of preventing a future suicide attempt could be discussed. It felt somewhat rushed, but what in medicine these days isn’t? Will turned to me and asked, “Nicole, do you have any other questions?” Any other questions. As if I could think of just one i he forgot to dot or t he forgot to cross.

“I have a few. Diana, is it okay if I stay behind and chat with you for a bit while Will meets with our supervising doctor?” She said, “Sure” and I felt grateful she was willing to humor me.

I turned our conversation around and we talked for half an hour about where we were from, what we wanted to do when we grew up, what it is like to be older sisters. We laughed at the way we each liked each others’ hair but not our own, and how the things we cared about as freshmen in high school seem so silly now. And when it felt like we could no longer ignore it, I turned to her and said that she is a fierce young woman, that this abuse was not her fault, and that her internal strength is obvious to me, someone who had just met her.

She said, “I know it is not my fault,” as she lifted her sweatshirt and pushed up her basketball shorts to reveal thighs covered in various hues of pink, red, purple, and blue. I remembered that you hit her again, that this incident was only unique in what happened afterwards to bring her into the hospital, not in the physicality of it.

“I know it can’t be. But I am ashamed. I feel ashamed I let this happen to me and that now my mom knows and how much she has cried. I hate to see her cry and I just don’t want her to cry anymore.”

I can’t even begin to imagine the pain a mother must feel to know that her daughter has been hurt, despite all motherly attempts to shield her. But again, I was humbled by Diana’s foremost concern for someone else. Her shame was rooted in the pain she believed she was causing her mother. In reality, John, you were the one hurting Diana’s mother.

She had an uneventful, which is to say good, remainder of her hospital course. I would check in with Diana daily and watch her self-confidence grow. She looked forward to family meetings during which time she’d hold her mother’s hand as a Spanish translator updated her on the status of the police report, restraining order, and insurance coverage. With Latina women less likely to formally report intimate partner violence than white women [3] (though this could actually be mediated by women’s economics given minority women’s disproportionate poverty burden [4]), I felt all the more inspired by Diana’s decision to seek action. She was nervously excited about going back to school because she had missed so many classes, but was in communication with her teachers who seemed understanding. When it was time for discharge, we hugged and I said goodbye to one of my youngest teachers. I can’t believe how much Diana taught me about female resiliency.

And John, while I am very clearly an ally of Diana, I also consider myself your ally. This is why I have wanted to write you a letter for so long.

You grew up in a world that prioritizes mens’ desires over womens’ rights. Masculinity is revered and central to growing boys’ and mens’ identities. And this maleness is predicated upon obtaining all that is presumably yours, by any means possible. A woman’s disobedience is thus not only an affront to your control, which must then be reasserted when challenged, but also to the core of your identity. This is the gender power dynamic ingrained in our society. You internalized it. And then you externalized it. So now we have “met.”

John, I am angry because of your gender-based violence and society’s complicity and tacit approval. Despite this anger, like Diana I too have hope. I hope that you take responsibility and own the abuses you committed against Diana. I hope you are able to see that your expectations of a partner were gendered, and that you took inhumane steps to obtain that which you assumed was yours. And I also hope you see that you were wrong in part because society is wrong, and that you have the obligation and opportunity to change it. I hope you see this daunting task as a collective responsibility. Because in actuality it is our duty to upend and redefine masculinity, and I hope you join me.

In solidarity,

Nicole

[1] Gressard, Lindsay A., Monica H. Swahn, and Andra Teten Tharp. “A first look at gender inequality as a societal risk factor for dating violence.” American journal of preventive medicine 49.3 (2015): 448–457.
[2] Devries, Karen M., et al. “Intimate partner violence and incident depressive symptoms and suicide attempts: a systematic review of longitudinal studies.” PLoS Med 10.5 (2013): e1001439.
[3] Kaukinen, Catherine. “The help-seeking strategies of female violent-crime victims the direct and conditional effects of race and the victim-offender relationship.” Journal of interpersonal violence19.9 (2004): 967–990.
[4] Barrett, Betty Jo, and Melissa St Pierre. “Variations in women’s help seeking in response to intimate partner violence: Findings from a Canadian population-based study.” Violence against women17.1 (2011): 47–70.

Originally posted at femd.

This is wack

High Fructose Corn Syrup is straight up sugar crack

You and you and you all best believe that!

I saw you take that one liter soda off the rack

Put it right back

Because obesity will sneak up and attack

In the 1980s, crack plus black pushed an entire community back

That was wack

But in 2016, it’s the same story, Jack

Minority communities running rampant with the Big Mac

Or the box with jumping Jack

Or a King who makes it your way like he’s got ya back

But the BMI is so high you can’t even see your back

Or your arteries are clogged with that nasty plaque

You might as well get ready for a potentially fatal heart attack

I can’t even believe that

Then they put the blame on them because they can’t make it around the track

And not on the multiple resources that they lack

This is so wack

I’m not taking what I said back

CDC got all the statistics in a stack

Piled so high, they are falling off the rack

And every year, they will continue to increase until we act

This is wack

No, I’m not smoking crack

Or throwing that liquor back

The only thing coming out of my mouth is fact

In 1977, McGovern tried his best to get us off this track

But all the lobbying food industries (junk, diary, meat, salt and sugar)……..that entire rat pack

Came out the woodwork and they all clapped back

For them the profit is gold and your life don’t mean jack

My hand can’t get to their faces fast enough to smack

I’m so over the effectiveness we lack

In “trying” to bring the nation’s health back

With dietary guidelines that need a whole lotta feedback

With hospitals vending every type of snack

Children television advertising all kinds of junk and crap

Foods that glow in the dark and create dental plaque

and never ever ever ever grow mold like that

This game needs a new quarterback

A totally new plan of attack

because to be quite honest

At this point, this is just BEYOND wack

And I am not about to just sit back

And watch lives unnecessarily fall through the cracks

I don’t find it too hard to tell folk to tone down the fat back

And the oreo snack pack

But you got have the relationship and the tact

Or your patients will be out the door with their knapsack

And the American and global culture need a comeback

They need to have the desire to want to bring health back

We should be hunting down chronic disease like a wolfpack

I want folks to get their lives back

And if that means I might catch some flack

Come at me homie because research has got my back

Akesson et al 2012 in particular can tell you that

Most heart attacks disappear if the burger gets put back

Monetary and political interests need to fall the hell back

And the power of the people and their interests needs to come back

Mic drop

Now tell me can you handle that

 

Marsha-Gail Davis, MS4

 

 

I am too nice for general surgery

People often tell me I am too nice for general surgery. That I don’t fit the culture. But over the past few years, I have seen some of the greatest acts of compassion performed by my surgical colleagues and today, I’d like to ask you to challenge that stereotype. 

No one wants to have surgery. The day you are told you need a surgery, whether for gallstones, appendicitis or a newly discovered tumor, is often one of the scariest in a patient’s life. To allow another human to put you to sleep, paralyze you and cut into your body, entering portions of your self that you have never seen or felt with your own hands, and then sew you back together requires complete trust. So what kind of doctor would you like to see in that scenario? What qualities would you like this person to possess? 

I would hope for a physician who understands the fear that exists pre-operatively. My patient came to clinic one week prior to his surgery, a pancreaticoduodenectomy, or whipple, for pancreatic cancer. His initial imaging work up had shown a questionable liver lesion, so he had already had a diagnostic laparoscopy with a liver biopsy which luckily returned as benign. He went on to complete two weeks of neoadjuvant chemoradiation, which he tolerated remarkably well. So here he was to discuss his surgery. He had worked as an engineer his whole life, and wanted to discuss every detail. How long is the surgery? How will I feel when I wake up? Where will I recover? How long will I be in the hospital? When will I be able to eat? Will you update my family? How quickly will I be able to see them after I wake up? His questions shifted from surgical logistics to the wellbeing of his family. The surgeon I was working with remained until every question was answered. He drew pictures, he reassured the patient, he provided comfort to his wife and he got further and further behind in his clinic schedule. But in that moment, as that patient prepared for the scariest day of his life, he was 100% his. 

I hope that my surgeon is thorough. Our patient was asleep and prepped on the table for his whipple. My chief resident and I opened the belly and began to explore the abdomen for any metastatic disease. Now remember, this patient had already had negative liver biopsies one month ago. So our suspicion was low. But we felt something on the liver that wasn’t quite normal, so we sent a biopsy to pathology. We then proceeded with the first part of the operation, a cholecystectomy. Our attending scrubbed and we continued the case, mobilizing the duodenum and dissecting out the pancreas. 

The phone rang in the OR and it was pathology. “Calling regarding patient X, medical record number 159375. We have results from a liver biopsy. Biopsy shows metastatic adenocarcinoma.” The OR was silent. All hands stopped moving in the belly. “What? How is that possible? We have benign biopsies from a month ago”. The pathologist “we know, and we compared to those samples and this is definitely metastatic disease. Can you send more tissue?” “Yes definitely, we will send a second biopsy”. So we went back to the liver, to another place that didn’t feel quite right, and sent another sample. 

And then we waited. 

The phone rang. “Hello this is pathology, calling regarding patient X, medical record number 159375. We have results from the second liver biopsy. This also demonstrated metastatic adenocarcinoma.” 

So what does this mean? We are already in the abdomen, should we just do the surgery, we have already started? No. All we can do now is palliative procedures. The prognosis after a metastatic pancreatic cancer diagnosis is 3-6 months.  All we can hope to do is to make him more comfortable. So we performed a gastrojejunostomy, bc as the tumor grows it will obstruct his duodenum, making him unable to eat. Hopefully this will allow him to keep his digestive track open for longer. And we performed a celiac plexus block to help alleviate abdominal pain he will certainly develop soon.

I would like a physician who is honest, even when it is painful. After closing, our attending went down to speak with the family, his wife and daughter, and explain what we found and the prognosis. Our patient wheeled to recovery. After an hour, his family joined him in recovery, knowing his new diagnosis, while he lingered in the post op twilight. 

Later, we returned to the bedside to tell our patient that we could not complete the surgery. His wife held his hands and he looked to our attending for hopeful news. He explained that we took another liver biopsy when we got in and that it returned as metastatic cancer. I watched my patient’s eyes as it began to register. His shoulders tightened, he looked to his wife and back to our attending. Tears welled in his eyes. His wife squeezed his hands and cried and told him she loved him. He did not ask questions, he just was. My attending squeezed his arm and we left him with his family. 

We walked back to the floor in silence. Each of us lost in that family’s pain and their love.  

Unfortunately, this is not the first or the last of those conversations that my attending has experienced. He has dedicated his life to pancreatic cancer and caring for patients as they face a terrifying diagnosis. 

So I ask, is he too nice? Is the pediatric surgeon operating on your child, too nice?

These are the surgeons that I have worked with. And these are the physicians who have shaped me, inspired me and taught me that compassion exists in every specialty, even general surgery. I hope that none of you will fall into the trap of believing these stereotypes, and you will be too nice for all specialties. 

Taylor Coe
MS4

The Role of the Healthcare System in Eliminating Institutional and Structural Oppression

I am black, I am a woman, and I am visibly queer. In most aspects of society, my compound minority status limits my opportunities. Fortunately, I am also a third year medical student. This grants me both an enormous amount of privilege and an astounding platform. Through my experiences and my identities, I have been tasked with an unknowable amount of responsibility. I spent much of my preclinical years learning how to use my voice. I checked my peers, educators, and facilitators on their micro-aggressions. It became a perpetually exhausting duty. I reminded myself of the fact that these teachable moments were opportunities and not obligations.

Mobilizing within the national #WhiteCoats4BlackLives campaign has allowed my passion for breaking down barriers and promoting social equity to keep the fire burning within me. The culture of medicine is traditionally unforgiving. Even those students, residents, and physicians naturally gifted with emotional intelligence lose sight of their humanity. Healthcare providers have a responsibility to be advocates for patients. I hold these things to be both truth and self-evident.

I have often felt lost in the white supremacist culture of medicine. I am no longer sheltered in the safe environment of the School of Medicine. I have been in the “real world”, witnessing encounters in broken Spanish, disparaging remarks about patients with poor health literacy, overt paternalism in lifestyle counseling, and abhorrent bedside manner toward patients of color. I am acutely aware of my place in the hierarchy of medicine, and detest my complicity in a system that keeps so many people out.

I am calling for academic medical centers to promote equality and equity for all people, regardless of race, color, religion, creed, sex, sexual orientation, gender identity, documentation status, health literacy level, education level, military status, first language, English fluency, HIV status, socioeconomic status, housing status, and past or present drug use. I am calling for academic medical centers to stand up to institutionalized, personally-mediated, and internalized forms of oppression. I am calling for academic medical centers to stand for health equity and intersectional justice.

Healthcare providers and health care systems should not contribute to or perpetuate any form of oppression. It is our duty to Do No Harm.

“I will maintain the honor and the noble traditions of the medical profession. I will not permit consideration of race, religion, nationality, ideology, or social standing to intervene between my duty and my patient. I will maintain the utmost respect for human life and its quality.”
Hippocratic Oath, Modified Geneva Version

I am calling for action.

White Coats for Black Lives http://www.whitecoats4blacklives.org/
Medical Students for Justice https://meded.ucsd.edu/index.cfm/groups/ms4j
Vanessa Ferrel on LinkedIn https://www.linkedin.com/in/vferrel

by Vanessa Ferrel, MS3

“I don’t want to bother my doctor”

The fourth year of medical school provides a little extra time for catching up with loved ones. I’ve been traveling during the holiday season, and I’ve been fortunate to spend a lot of time with family this year. We carve turkeys, swap stories, and count our blessings. My little brother got married. My sister-in-law is pregnant. Grandma just turned 85. Frequently, I get asked a few medical questions over dessert. “I’ve been coughing in the mornings … my doctor said my blood pressure is still too high … do you think I should be worried? … I don’t want to bother my doctor with this, it’s probably nothing.”

It’s that last statement that sticks with me. “I don’t want to bother my doctor.” We’re going into medicine so we can answer patients’ health questions, address their concerns, and help them make treatment decisions. We’ve spent time acquiring knowledge so we can share it with people who are sick, scared, and hopeful that we have answers. So why do my family members hesitate about their health issues? Why wait for an infrequent, informal meeting with a family member who is a medical student instead of scheduling an appointment with a physician? I suppose there’s the advantage of my being immediately available at the dinner table – no scheduling, no driving, and no waiting room. A lot of the problems they mention, however, aren’t new. My loved ones describe chronic symptoms that they struggle to minimize rather than asking doctors for help. I wonder how often my clinic patients minimize their own symptoms. I think about times I’ve interrupted, rushed a personal story, or shelved a patient’s concerns “for a follow up appointment.” How often do my patients avoid making these appointments because I’ve made them feel like they’re bothering me?

In 2016 I’m going to try to be more approachable in my patient interactions. If I listen first and make patients’ perspective a priority, then maybe visiting the clinic can feel more like a comfortable dinner conversation. Ultimately, it’s about lowering the barrier to picking up the phone and finally making that appointment.

“Your patient wants to leave against medical advice”

We realized that it was our patient’s 38th birthday during morning rounds. She had a history of drug and tobacco use and poorly controlled blood pressure. She had already had a heart attack and stroke in her twenties. She had come in with slurred speech and right leg weakness and was found to have an intracranial hemorrhage and a blood pressure that was through the roof. She had not been taking her blood pressure medications. She was a single mom with three boys aged 4, 8, and 11. The 11 year old was severely autistic. She was admitted early morning to the ICU for blood pressure medication and close monitoring.

After lunch, our senior resident made a quick trip out to a nearby bakery to buy birthday cupcakes and candles for the patient. Although the ICU staff vetoed the candles, the ICU nurses, residents, and students gathered to sing “Happy Birthday” to our patient and enjoy bites of cupcake. She was moved to tears by the gesture and eagerly showed us pictures of her three sons on her iPhone. “I’ve only been here 10 hours, but I miss my boys already,” she said. “Nobody wants to spend their birthday in the ICU,” said the senior resident.

Several hours passed. We had admitted another patient and completed our floor work when we got a page from the ICU. “Your patient wants to leave against medical advice because Child Protective Services wants to send her kids to Polinsky while she’s in the ICU,” explained the ICU nurse. Our senior resident found a note in the medical record from the social worker elaborating on the story. Two days prior to coming in to the hospital, she had brought her children to work and school staff suspected that she was drunk based on her slurred speech. When her three children did not show up at school the next day because she sought medical attention, the school filed a CPS report. She had not had any open CPS reports previously.

She had found a friend to take care of the youngest child while she was there, but a neighbor was only able to watch the two other boys until the late afternoon. The social worker found temporary placement for the boys at Polinsky, a shelter for children in emergency situations. However, our patient had apparently spent time in the shelter herself as a youth after significant abuse by her father. She was fearful that her children would be taken from her permanently if she did not get back home. She was anxious and wanted to leave against medical advice to take care of her boys. During all of this, her blood pressure, which had been stabilized, began to climb again and put her at risk for worsening hemorrhagic stroke.

Sensing her desperation and knowing the ramifications of her leaving in this condition, our senior resident started making phone calls. He called the social worker, who was on his way to our patient’s home to check on the children. There was no answer. He called the social worker’s manager and that person’s manager, hoping to find any way that someone could watch over her children. They stated again and again that Polinsky was the only option unless she had family that could watch them. The patient grew more and more anxious, her blood pressure was rising, and she was demanding to have her IVs removed and to obtain AMA forms so that she could leave to take care of her children.
The resident pleaded with her to stay, carefully reiterating the danger that she might be in if she left with poor blood pressure control: worsening hemorrhagic stroke and death. She indicated that she understood and was adamant about going back home to her children. She promised to take her blood pressure medications and return in the morning to the ED. She signed the AMA form and walked out of the ICU. I followed, attempting to dissuade her from leaving, while the resident tried one more time to talk the social worker into finding a neighbor or anyone else to watch the children. Despite our words and efforts, she found the exit and walked out of the hospital.

The senior resident was devastated. He had been giddy at the thought of bringing her cupcakes for her birthday early that day. He was terrified that she felt like she had no other option but to leave against medical advice to save her children from the experience of a temporary shelter. I was impressed by my resident’s persistence in attempting to find a compromise and by the social worker’s efforts to visit the home outside of work hours to make sure that the children were safe. It was a difficult reminder of the importance of understanding a patient’s social support system and its profound impact on treatment.

Long Distance

The distance between medicine and humanity, no matter how far we try and convince ourselves otherwise, is quite small.

After several small strokes and repeated infections, my grandfather was receiving care at a skilled nursing facility as his ability to speak and safely eat were no longer within reach. Such an image was one that was hard to imagine of a proud ex-marine that I had always perceived as invincible. Growing up with several thousand miles between me and extended family, I have grown accustomed to receiving text message updates or short calls with family happenings, and with illness such communication became more frequent. Texts would be brief, requiring careful interpretation and conveying much emotion like a modern telegram; “Gpa has started another round of antibiotics. Not sure what is going on,” or “just visited gpa, still unable to talk. He is getting quite frustrated.”

About two weeks ago, I got another message that seemed similar to previous ones; “Grandpa’s heart is racing, nursing home is taking him to ER now. Will update when I hear more.” My grandfather passed away shortly after being place on hospice several days following that text message. He was surrounded by those he loved for the last moments of a life well lived.

The cycle of ED visits, admissions, and subsequent discharge planning he experienced was something I understood, at least logistically, from my experiences in medical school. Although I had helped take care of many older patients nearing the end of their lives (even some whose wit reminded me of my grandpa), I had never really been privy to the raw emotion and fear of being a family member. Every word and gesture of those caring for a loved one mattered. I was instantly embarrassed about how I had emotionally distanced myself from previous patients in similar situations and will likely encounter again in my career as an emergency physician. With my grandpa, it was no longer an “older gentleman who was brought in from a SNF for tachycardia,” but rather a man I loved and whose fragile state caused my fathers voice to quiver when he spoke.

May we always remember as health care providers the necessity of compassionate care. Sometimes that may mean reminding ourselves that although our individual encounters with a patient and their families may be brief, each interaction fits into a narrative that is much bigger and messier than the precise clinical situation or chief complaint.

by Chris Evans, MS4

It’s around 9pm

It’s around 9:00pm- I’m heading into the last two hours of my shift in the emergency department. I’m seeing an Amish patient who presented to the ED with neutropenic fever, when a trauma arrest gets called overhead. I excuse myself from the room and head over to the trauma bays. The large room is packed with people- EM, trauma surgery, multiple medical students from both services, nurses, techs, pharmacy, RT… Everyone knows what to do- this is a familiar routine for a busy level 1 trauma center in east Baltimore. When my senior resident arrives, he announces to the room: male, mid 30s, multiple GSWs (gun shot wounds) to the head and chest, CPR in progress, 10 minutes out.

Thus far in medical school up until my fourth year, I’ve seen plenty of trauma, many codes, and a few traumatic arrests. So far, I had managed to avoid doing chest compressions. I’ve done my fair share of compressions from my prior days in EMS, and I thought my days of futilely cracking ribs were behind me. But our EM attending asks for everyone without a defined role to step out into the hallway to give us a little breathing room. So I assign myself a role and line up first for compressions.

The patient arrives in a less than stately fashion, with a medic attempting to continue compressions, another struggling to ventilate via BVM, all while the rest of the EMS crew are hurtling the gurney and patient down the hallway. Controlled chaos begins. As with any traumatic code, there are people securing the airway, performing the primary and secondary surveys, doing compressions, and obtaining IV access- all occurring simultaneously. I’m attempting to provide high quality compressions while my hands are slipping all over the chest due to the liberally applied ultrasound gel, while nurses are applying the pacer/shock pads to the same area that I’m doing compressions, while a resident is making use of all that gel with a cardiac echo. We’re all fighting for the same real estate on the chest.

But we aren’t able to resuscitate him. No sign of spontaneous cardiac activity on echo. Time of death is called after 20 minutes, and we all de-gown, de-glove, and try to lower our catecholamine levels as we head back to our patients in the main ED. As I step outside the trauma bay, I overhear our social worker asking for the patient’s name from the sheriff so that she can contact the patient’s family. It’s clear from her reaction that this was not just another patient. This was someone she knew.

For the rest of the evening, I simply provided my presence for our dear social worker as she sobbed. I listened to her stories of how she helped raised her best friend’s son, who was now lying cold in one of our trauma bays. She shared the hardships and struggles that the patient had been through, and how he had grown into a fine young man. How great of a person his mother is, and how his mother is always there to help out all her neighbors. All his hit close to home.

Through my time in EMS, I had become well versed at dissociating from my emotions and focusing on the job at hand. Even so, I had learned to always take a brief moment to acknowledge the passing of a human life. I can’t pretend that witnessing such moments doesn’t affect me in any way. It is profound to stand at the cusp between life and death, to come face to face with one’s own mortality, and to witness the passing of a life, along with that life’s story. The patients that we take care of in the trauma bay come from all walks of life- young and old, rich and poor, of all ethnicities and backgrounds. Some are husbands/wives, sons/daughters, brothers/sisters, friends. Some have no next of kin at all.

But sometimes the most meaningful work we can do as physicians, especially when we reach the limits of our medical care, is to provide our presence. To let our patients and/or their families know that we are also fellow human beings. That we share in their joys, and share in their sufferings. That they are not alone in this world, even though their world just came crashing down around them. That we are there, that we are listening, and that we care.

That social worker later called me an angel and asked me who I was, how could I be so kind. I was taken aback because I wasn’t doing anything extraordinary. I was just being a fellow human, sharing in sorrow and mourning in grief. We all lose people that we care about. Death doesn’t discriminate. But helping someone along on the path towards resilience can be meaningful. As an ER doc, I’ll be there at those crucial moments in time. Delivering bad news is within our job description. But sometimes I’ll have nothing greater to offer than my presence as a fellow human being.

Words of Comfort

Katherine Lee, MS4 at UCSD SOM, GHHS Class of 2015
This story is adapted from “Solidarity Day” hosted by the UCSD Chapter of the Gold Humanism Society on February 10, 2015″

The story I’m going to share came to me more during my 4th year rotation on an acute care surgery service. But the story actually starts during my 2nd year after our First Lecture series when we read “Cutting for Stone” by Abraham Verghese. There is a surgeon in the story, Dr. Stone who’s lecturing to residents and students and asks: “What is the treatment administered by ear?” The auditorium is silent, no one knows the answer. His son, unbeknownst to him, is in the audience and answers: “Words of comfort.”

“Words of Comfort” stuck with me, and I thought that I would try to administer “Words of Comfort” as I went through my medical education. But you read the story, see these words…how does one actually administer “Words of Comfort?” I think I had difficulty doing this in practice. While I had seen many physicians and surgeons administering “Words of Comfort” to patients, I never quite felt comfortable doing as good a job as they did.

Then during my visiting rotation on this acute care surgery service, I had a really complicated patient, Nancy. Nancy was a 45 year old rectal cancer survivor and she came in for a routine follow up surgery and ended up suffering a serious complication, went into septic shock, had multiple organs that were failing, with waxing and waning mental status in the ICU. I came onto the service halfway through her time in the hospital. I’m a visiting student, still figuring out my role, and there wasn’t much I could do for her clinically, I checked her dressings, checked her ostomies, and flushed her chest tubes twice a day. Then I had to fit it in between my time in the OR and doing all of these things I have to do to make a good impression as a visiting student. I found it challenging to be true to this philosophy of words of comfort.

Then I realized a few days in, I was spending a lot of time with her, at least 15-20 min twice a day. I just started talking with her, telling her about my day, and while she never really responded, it made me feel better to try to comfort her.

I then also noticed her husband and daughter were there every day. They were there before I got there and still there after I left. I wanted to know the woman that inspired such faith and love from these people! I started talking to them and found that there was a lot of struggle about what to medically do with her. She had a large, extended family, and everyone was very opinionated. No one wanted to be the person to make that decision to end her treatment. They were also very religious, so maybe this was God’s will that she was here persisting in the ICU with the hope of getting better. I realized her husband and daughter were agonizing over what to do, troubled and despairing over having to lead the decision making. I couldn’t really do much except comfort them, “Nancy is incredibly lucky to have you and no matter what decision you make, you have been here and loved her and shared that love you have for her with me.”

Ultimately during my last week on the rotation, the family decided to end treatment for her. All during this time, I had learned more about her, she became a real person to me. Before they withdrew care, I stopped by her room that night to say goodbye, talk to her like I always did, flush her chest tubes one last time. Her husband gave me a big hug, and said back to me, “She too was lucky to have you.”

I guess I had always thought that “Words of Comfort” were words I give to comfort the patient or extend to their families and loved ones. But I never thought my own words of comfort would come back to comfort me. That was really moving for me. Then of course I go home and have half a bottle of wine and cry while I’m writing her discharge summary…

I had a moving experience with “Words of Comfort” with Nancy during this challenging rotation. What I sort of took away from this experience was that as a medical student I had multiple clinical duties to do for my patient, but it didn’t take that much more time to treat her like a real listening person even if she wasn’t listening. What I also took away was that “Words of Comfort” extend to more than just the patient, but also the family, and me because I cared. I’m hoping as I continue into my career to keep that in mind. Surgery is not an easy career and it can be hard to find connection when you have to be in the OR and have multiple other clinical duties. But a couple of minutes can mean a lot and come back to comfort you.