17 August 2010

Medicine....the microcosm.

This is not about Cameroon.

But I did write about medicine when I was in Cameroon. The other side. The public health side, but the hospital as well, the TB ward I wandered in and out of everyday, talking with the patients as we ate dinner on the verandah overlooking the sunset over the rainforest. (I haven't yet seroconverted). The ectopic pregnancies. The children with malaria-induced anemia who survived sometimes. The children with AIDS. The children with kwashiorkor.

The first two diagnoses I learned to make before medical school: kwashiorkor. pediatric AIDS.
In Kenya, I learned marasmus - I saw that once in Cameroon.
In Cameroon last summer, I learned Kaposi's sarcoma.
(these are not things I would learn to diagnose in the US. Not without 4 years of medical school, at least 3 years of residency, and probably a few years of fellowship).

I wrote about medicine then.

And now, I'm a third of the way into my third year. This is neither significant nor insignificant. To sum up, there are a few practical things I know how to do. (and if I was on a plane and a woman went into labor, and there was no Ob/gyn, midwife, ER doc, or 4th year med student interested in Ob, I would be slightly/somewhat competent to run the thing/do it with help). There are a few procedures I can do. There are a few things I know about, a few things I know how to treat, and a few things I can take a stab at diagnosing. Few.

But a lot of the time is spent following people, blindly, grabbing at things to learn, and being "pimped" - ie asked questions about anything at all that is somewhat related to medicine, at any time during the day, and being expected to be able to expound upon the answer.


Trying to be useful/being told I'm completely extraneous. Learning and doing amazing things during the day and having incredible interactions with patients - and showing up to random call in the ICU or elsewhere where there is truly nothing for me to do and no one available to facilitate that/help teach.

So that's third year. We rotate through everything and are expected to figure out what we want to do with our lives.

The question is...what if medicine, or medical school, isn't the answer?

Medicine: the microcosm.

My world has become very small. My world, in a day, is each patient, what matters to that patient, that patient's health/life in toto, and what I can do to affect that. What I know and what I don't know. I am fully present in each encounter (does this change? is that what the being jaded/disconnected means, later?) - the doctor-me. My patients, for the most part, don't have insurance. This means they don't get shit. Essentially. It means I can't refer them for things they need, they may not be able to buy/take the medications I prescribe for them, and how the hell are they going to get that many days off work to come to all these appointments, or get surgery, or whatever, if those are even options.

These are the things that make me irate, everyday, about the inequalities in health in this country, everyday, and how so many things mean, functionally, that health (and health care) becomes a privilege and not a right.

The severely depressed patients who start crying when I ask them if there is "anything else" they want to talk about, after listing all of their somatic health problems. We sit there, for a long time. We talk. (This is my luxury. As a student, I do have the time. I don't have 4-6 patients scheduled per hour). That they feel safe enough with me, that they trust me enough to tell me these things - that they may not have told anyone before - is good. It means that maybe I'll be good at this part of my job, at least.

But this happens multiple times/day, I get home, it's been 10-16 hours (or more, or a little less) of this, and I can't focus on the larger problems of the world. I'm not sure I even know what they are anymore. I can't/don't read the news, or barely. Sometimes I'll listen to BBC Global news on the commute. Sometimes. But the days are hard, mentally, physically, emotionally - especially that last part, which differentiates it from a lot of jobs/grad school that I can think of - and I don't know how much space is left for the world. I care. My "purpose" - as I needed one - to stay in the US between med school interviews and starting med school was volunteering with the Obama campaign, in Chicago. (and then going to work in Kenya). I went to NH for Kerry. I've never had a deep grasp/understanding of any of this, or any scholarly insight, or pretense to know much at all. But I still care about politics as they affect people, and as they interact around the world - knew the most in Peace Corps, probably, listening to the global news every night and discussing politics with people in my village who knew more about the European government than I ever did.

For major natural disasters - tsunami 2004, Katrina 2005, Haiti now - in the selfish sense - I get frustrated that I still have no skills, am stuck in school, and can't go where I want to be useful, and could be as more hands. But I'm in school. Now, I know there's cholera in Pakistan. (health-related, again). So i think of what I know about cholera. About what I could do, now? Doesn't register.

My world has narrowed. Science looking through the microscope. Astronomy looks through a telescope, making a microcosm of the macrocosm.

I didn't want to look through a microscope anymore. I decided not to be a scientist. I used to revel in the worlds under my eyes, at that magnification - mitochondria, open to me, most primary of organelles. Nuclei I could see imploding. And it was - is - a privilege to be let into that world, as well.

But medicine feels constricting. My view of the world, of everything, has narrowed - I see health care, inequality, the economy on a person-to-person basis - granted, it is a lot of people. And granted, on the human level is how things matter and how they are understood.
But the debates, the politics, the philosophy, the events, the turnings of things, the torments, the natural disasters - there are headlines, sometimes, but otherwise I might be months behind.

In trying to learn so much medicine, I am both forgetting other things and narrowing the scope of my new knowledge, my brain and what can fit. Only so many synapses at a time. It's gotten slower at recalling anything outside of this.
My world is narrowing, I'm a dilettante at everything else I do or try to do, and suddenly it's hard to remember what to talk about outside of medicine, health care, patients, frustrations and exhilarations in the hospital.

Medical school isn't hard. It isn't intellectually difficult (or, right now, intellectually stimulating). There's a lot of rote memorization - brute force memorization. Treatments, dosages, differentials. You have to act fast. You have to recall fast, to know everything, but you aren't, often, thinking about it. In emergent situations, at least, there isn't time. In other situations, there is, but in 15 minutes you're still supposed to take history, do a physical, decide on an assessment and plan, carry it out with the patient, write about it, and do the fifteen billing forms. And then move on.

Medical school isn't hard. Anyone could do it, once you're determined enough to get through the years and years and years of hostile hoops they set up for you. The tasks just meant to see if you have the endurance, really, to make it through. In a week of med school, we cover a semester's worth of college curriculum, in general. It's not hard. It's just fast, condensed, and focused. You have to want it to get through it and all the years of training afterward.

And to try not to let it swallow you whole.



  1. Anonymous4:02 AM

    There are different depths of laughing. A giggle at a slapstick joke is the lightest. A bit more weighty, there’s a chuckle at wit or dry irony. In the mix with the ironic laugh are bitter and cruel laughs, knowing laughs and laughs of a thank-goodness-its-not-me variety. After that bunch is a laugh at something said so plainly and so true that its very obviousness and plainness is funny. But past the belly laughs, past the head laughs and laughs of relief is a laugh that maybe could be called a soul laugh: one which simultaneously says my God life is incredible and my God we humans are such curious creatures, a laugh which denies a solopsistic existence. It’s in that last way that I laughed out loud when I finished reading your post.

    There is something violent about the narrowed world that specialization and a career demand of us, isn’t there? Was the project of a liberal arts education, the sensitivity to topics both in private and public life that we dedicated ourselves to cultivating, some sort of an ironic or anesthetizing joke? Did they know all along we would ultimately wind up vocational and “too busy”?

    I don’t have your writing knack or ability with metaphor. I’ve experienced moments and feelings so similar to what you’ve written about so well that a laugh slipped out and now I have to describe.

    My thought was not “what if medical school is wrong,” it was the exact opposite “what if I should have gone to medical school.” My work is/seemed impersonal, stripped of a human counseling component, thinking only in broad and abstract terms about problems. Yes, I feel sure my work has some bigger impact, and better decisions, better thought out policies and processes, subtly and gradually better the world (I believe that), but I don’t directly touch anyone’s spirit or, in six shades of literalness, anyone. Science, including medical science, seemed/is that neglected interest and part of me, the dilettantism my under-stimulated intellectual part craves. The opportunity to uncover the secrets of humanity that a knowledge of the body’s working allows and the understanding of the fundamentals of the universe, the various worlds that science illuminates, I miss science. So I read science in my spare time. Sometimes. When I have the energy. I will never be able to respond to "is there a doctor in the house" and no familly will feel deep relief and gratitude as a result of my work. My writing struck/seems to me to be too literal, lacking in style; I tried to self-study poetry (Langdon Hammer has a really good bunch of lectures free online).

    Ultimately, I didn’t drift into my career. I have a knack for what I have a knack for it. The imperatives of life are present. Es muss sein.


  2. A -
    You say I "write well" and yet I cannot come close to matching this. Today, in particular today, was a good day for me-in-medicine. Tomorrow maybe not, and the next, and the next. It's one of the possibilities. And at its core, it is about touching people - literally and metaphorically and emotionally and invasively - but after years of training, a lot of that filters out. It seems. At the end, it's a job, a job that you've been working towards for - what - 6? 8? years on my side, already, counting pre-med years, possibly the rest of college, applying and interviewing, school now. It demands a lot, and there is a reason for that. It is life and death, sometimes. And doctors are revered as gods, more because we/they play gods, and sometimes act as if that is earned or appropriate. And sometimes it's culture. And sometimes it's the ultimate intervention, that did save something, someone.
    A good part of what doctors do is glorified bandaging, or changing bandages on chronic wounds, which may get a little better, sometimes a little worse, but never fully heal.
    With medicine, it's one person at a time. With public health (are you referring to that? my bias) or policies... it's many people at a time. In lower SES populations in particular, and others in general, biomedical health is one piece of the larger problem - you won't fix something without fixing social situations, economy, rights, etc, etc, etc.
    And science does a good job of looking to others like it's the ultimate vanguard. THIS is intellectualism, THIS is JAMA, NEJM, etc. The words most people don't understand and are afraid of - science-speak. It's no more intellectual, difficult, or daunting than any other subject you delve into. Nothing is one or the other - from my perspective, at least, with a BS in Creative Writing AND in Biology, you need a good balance of both.


    This is only one way to try to do good.