19 September 2010

... and sometimes there are miracles.

I think I wrote about both of these before.
The patient, not-so-slowly degenerating over a year to the point of losing function, losing vision, and starting to lose speech, who wanted to kill herself because she could no longer do anything he cared about. Who couldn’t do it because she can’t take the pills, by herself.
She’s getting better.
This almost never happens (at this level).
She’s getting better.
I go in, not often enough, but a few times a week. And, gods, she’s glad to see me. That in itself is miraculous. The doctor-patient relationship. Being someone to someone, but in a very different way than every other relationship in my life.

(addendum to the other, the patient with the wires in her heart. She survived. She went home. And if she has brain damage, after all that, it seems minimal. These are. Miracles. And by miracles I mean unlikely events that turn out well)

The only doctor I’ve ever really liked or felt like I had a relationship with, at all, was my orthopedic surgeon. Ironic, as they’re renowned for not having charisma, warmth, all the things we call ‘bedside manner’ (there has GOT to be another name for it. I’ll ponder that). But I saw him every week for months, then every two weeks, then every month, then every time (once? occasionally twice) per year that I was back from college. Then once, twice after Peace Corps. I think. I haven’t seen him in two years; perhaps I should stop by and say hello.

Orthopedic surgeon. By stereotype, jock-ish types who like to break things. And run a lot. And be really mean to residents. And be crazy in med school and only study in order to have stratospheric USMLE scores that have no correlation with either future promise in medicine/actually application of knowledge/ ability to be a good physician.

Orthopedic surgeon. He saw….forty patients per day? Perhaps. But the five minutes he was in the room meant something, and he was connecting for that time. You didn’t count it. It wasn’t short. It was real, he was there, and he was there. That’s what matters.

Dr L didn’t fix me. He tried. Twice. Things are put back together, then other tendons were moved around and remade, and then… well he told me before the second surgery that for some people it didn’t work even after three. That they were still in pain. (why he told me this directly prior to surgery, I’m not sure). And two didn’t fix it, but as there’s no guarantee that three would – there’s no point in reopening the thin white line that I think gives my wrist character.

He didn’t fix me.
But I read the records. I was seventeen, and in my medical records it mentions that I was filling out college applications and that’s when I had noticed how difficult it was to write anymore. It mentions that, a little later, I delayed surgery because of Academic Decathlon, and I didn’t want to schedule it until I knew if we were going to Nationals, or not. (not. but only by a few points). It doesn’t mock that. It states it. This is what was real in my life. The things that matter to me are written down.
They were not only listening but remembering.

In medicine, left is right and right is left. Things are organized according to the patient. That is our perspective in space. Looking at a person, their left faces my right. Same with x-rays. Looking at a CT or MRI, we look from the feet up. Seeing into a person from the ground to the sky. So, sometimes, now (and I was never very good at this) – I get it wrong with myself. I become my mirror-image patient and I’m confused. Directions are not according to me, anymore, or to my body in space. In the neuro exam, we test for the integrity of nerve fibers that judge position in space. Proprioception. Where is your body? Where are you….
and yet we, ourselves, no longer see ourselves – at least in the encounters – as our own point in space.

(as a sidenote, I once examined a patient who had lost his joint position sense. It’s fascinating and strange, almost unbelievable. We test by having the patient close his eyes and moves a finger or toe, at the joint, up and down. “Is it up or down?” we say. Sometimes we’re tricky and keep it neutral. This patient didn’t know. He didn’t know where his body was, when he couldn’t see it anymore.

I try to remember this. I don’t always write it, but I remember. It’s a great PR trick (I’d imagine) to remember clients’ families, their names, favorite hobbies, important things in their lives, etc. Schmoozing points. So maybe it isn’t all that different. Do I want them to like me? Of course. I want them to trust me, and I want to earn that – whatever that means. Be respectful of it. The shrewder docs who were in private practice (and love to tell me how much money I’m hypothetically losing, sometimes, by taking too long and not billing enough) say it’s because patients are much less likely to sue a doctor they like who made a mistake than one they were indifferent towards. Fine.

So why does it matter, then, that I remember the salient details and ask about them? Yes, I care. It also helps me remember the patient, file them in my head as a person and not just a disease attached to a face/name.
But why, other than the insecure need/want to be loved, like, appreciated, or the normal-human aspect of that, does it matter if they like me?*

* there's also the patient who told me her son calls me "the pretty doctor" (as opposed to her other, ugly doctors? ha....the real doctors....i never say i'm a doctor, but it's confusing, apparently, because to them i function as one. or, they think i'm a nurse)

Then there was the ophthalmologist. Dr R. I saw him a few times a week at first, then every week, every two, and a few months apart. It was an infection that (somewhat dramatic, but serious, as well) could have left me blind in one eye. Granted, this is without treatment/ or with much-delayed treatment, and being a person who is informed about health, has access to medical care, and has a job and life situation flexible enough so that I could see a doctor… I could do it immediately. And “immediate” meant the day after I woke up and couldn’t really see out of one eye. Not itchy, not painful, but everything blurred and just difficult to…see…at all. It took a month for normal vision to come back. At any rate, in those frequent visits, I lost my sense of squeamishness about eyes, and I started to connect with the doctor I saw as saving my vision. I remember him, still. He wore glasses. He thought contacts were part of the problem (for everyone), in general, and recommended (as did the US govt) that contacts shouldn’t be worn in Peace Corps. Little details. But he appeared in a poem, later that year*. He never saw the inside of my hand, manipulating and moving the delicate wires, like Dr L. He put green fluoroscein drops in my eyes, looking at arrays splayed through an opthalmoscope (spider webs, I picture, little fingerings). Bright green tears from the extra liquid. You can see into the brain through the eyes. (We learned that, last year. I’m amazed by medicine where you can see internal organs. )
At any rate.

* come to think of it, so did Dr L. Not by name, but a very vivid image of him in the OR as I drifted into a dreamless, timeless sleep.

Hands. Eyes. There isn’t much that’s more personal about how we see the world. Perhaps an otolaryngologist, if I lost my voice. A neurologist, if I couldn’t think anymore because of a mass lesion, an infection, something else blurring my vision, changing my sense of touch, of senses, of…everything. Perhaps a psychiatrist for the same reason.

Hands and eyes are easy symbols.

But it is everything. And there I return to what I do love about medicine, what makes me stay in the every 2-3 week episode of wanting to drop out and do something more, more, that isn’t micromanaging and expands my mind and my world rather than contracting it.

It isn’t the disease, it’s the person and how the disease process affects the person. How they feel it. (everything’s subjective). What else it means to them. How it affects daily life. How it affects their vision of themselves. (…and here, the grammatical structure breaks down).

To wit. “Written on the Body”, Jeanette Winterson. “Illness as Metaphor,” Susan Sontag. The canon.

There are things that vibrate in this world. To finding that….


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