05 December 2010

Having Patients

       It’s a possessive thing. They are my patients, and I’m their…well…sortof doctor, for lack of a better word. But in my clinic (yes), we run it exactly like intern/resident clinic. I do history and physical, assessment and plan, discuss this with the patient, do education, etc, counseling, etc, then I go write up my note, write out the prescriptions, fill out lab sheets/imaging/referrals (if I want that), then I present to whatever attending is present. We go over the plan, they mostly sign and maybe change a few things, then we go see the patient and I re-explain everything, add/modify if there are changes, and that’s it. My patient. My patient gets a follow-up appointment with me.

            Or, did. It’s been six months (this is a different sort of medical school program that I’m doing…but…not terribly relevant right now). This was the first week I referred patients to people other than me, made them appointments with “other” doctors (as in, the others are doctors. I’m not lying. My patients know I’m not a doctor, not yet. But they see me as one, because I am providing the care).

            I remember the first time a patient asked me how I was, after I started in with my usual ‘how are you doing today,’ etc. It meant a lot. And it’s happened with most of them now. It means that…it’s not a one-sided relationship. Over time, I’ve learned and thought about how much of myself to share. Personally. No one’s asked me questions I didn’t feel comfortable answering. And of course I know eons more about them. But I’m there, too, and they want to know how I am, how much later I’m working, and to tell me that they like my shoes (the latter, actually, has happened several times).
            I remember the first time a patient hugged me. I wasn’t sure how I would feel about that at first. But…again, it’s always been appropriate. And it always comes out of an overwhelming…relief, sense of partnership, sense that they’re not alone in this and that someone is supporting me. There’s the patient’s wife who asked if she could hug me – she’d come in close to tears, so much going on, so much to manage with her husband who was so sick with so many different things. I helped, in small ways. And it was one less thing for her to worry about. Now, she hugs me everytime, as does her husband, and I look forward to seeing them and hearing about how their family is doing. They’re sad this is ending – and so am I. So am I.
This is where medicine is different – there aren’t that many jobs that are emotional, not that I know of, outside of healthcare fields. I not only know the story but I’m involved in it, involved in trying to improve it, shape it, and just being there to listen when there’s no one else to do that at the moment. I don’t know if I realized quite how much trust patients put in their doctors – not in all doctors, I guess. So many times it’s “have you been able to talk to anyone else about this?”

“No.” (says the patient).
“Do you think you could?”
“I don’t know/I’m not sure.”

Is it because I’m “objective”, “anonymous”, HIPAA compliant? Yes. And I am. But I also carry all of the stories. And I look forward, in each encounter, to learning more about how they enfold.
I was jubilant – out-loud, YES!!!! – in the residents’ workroom in clinic, the other day, seeing my patient’s lab values online. Cholesterol DOWN. It meant that, together, we’d done the right thing. Same thing when handed a chart with my patient's vital signs of the day - NO MORE HYPERTENSION! I go in beaming. (There are, of course, the flip-side stories. Not to write about today, though. Not today).

(No particular reason for the above. Just that...wildebeest are cool. Kenya, Maasai Mara, 2008). 

It’s funny, I wrote a blog post on a now-so-defunct-blog-I-don’t-remember-the-address with a similar title to the above. Six years ago, my first clinical experiences. College. I’ll repost that, just because it’s an interesting contrast. And a number of things are still true. I may start doing that with a few other things, actually. I’ve been writing about medicine for years. I’ve been writing about the conflict, this tension, for years. Some things will never change.

This is the beginning of that post:

“Patients are a virtue”

And this will be dedicated to them.  A few in particular, who have brought up these issues.  As preface, I've been shadowing a doctor in the city for the past few months.  One afternoon a week, I go in to the hospital…and follow him. In essence.  I'm in on the patient exams (except for the few- maybe three, or four- who haven't felt comfortable with a student there. understandable).  I've worked with the practice assistants too (PAs here, though in TX that means Physician's Assistant. very different), bringing in patients from the waiting room, getting height and temperature, starting to fill out their charts. etc. clearly I can't do much in the practical sense, not being ah, qualified, or even in medical school. 
Why am I there.  This particular doctor (RC, simplest to name as he signs his emails) was my professor a year ago for a course that was supposed to be "Literature and Healing." It turned into a poetry workshop, because he was the visiting poet for the year and the demand for his poetry workshop was so high that the admins decided he should have two workshops and no class. Disappointed, yes.  I had arranged my entire course schedule around that one class (and Thursday, 5-8 pm- ain't easy).  But more than that, I had wanted to take a course- any course- with him. To spend any amount of time with him.  Why?  He's the reason I'm still in science.  He is, in short, my hero.
My hero.  At the beginning of last year, I was so frustrated with science- with the curriculum- with the people- with the outlook- that I was very seriously considering dropping it altogether.  Giving up on what I decided ten years ago would be my life's work, and pursuing literature, alone.  OB (poetry advisor, teacher at the time of poetry workshop), knowing this dilemma, gave me a book.  RC's book, essays and some poems, describing his experience with medicine, why he became a doctor, and what it was like.  Reading, I was re-inspired.  His words made me remember why I loved science in the first place, why I did it, and what joy it could bring.  Besides reigniting my passion for research, he showed me that the fusion is possible- he is a physician (internist) and a poet, and pretty damn good (and renowned) at both.  (except for the research I would like to do), he, in essence, has done and is doing with his life what I aspire to do with mine.  He's doing it well.  And the man offered me, a year ago, the possibility to work with him at the hospital and share his experiences and get a feel for the "clinical aspect" of things.  I would have been crazy to not pursue this offer avidly.  As I did.

And my first-draft med school application essay (the fake one, the one I had to send to the pre-med board at college when I interviewed with them three years prior to applying and just prior to Peace Corps....). I wrote about shadowing Dr. Rafael Campo (the “RC” of above. I played at HIPAA with everyone’s names before it was cool…), physician-poet-mentor….
 This paragraph is from that:

Dr. Campo's clinic treats general adults, but he focuses on Latino patients and patients with HIV/AIDS.  I was astounded by the trust and confidence each patient gave him, but I was even more taken aback my Dr. Campo's personal relationships with them, no matter how long it had been since the last visit.  Each case—even the routine checkups—was truly unique, as each patient was unique.  He, as I aspire to do someday, seeks to heal not the illness but the person, to lovingly read each distinct narrative and respond to its artistic demands.  His Latino patients, no matter how fluent their English, opened their tongues a bit more loosely to describe in vivid color each symptom and episode.  One man's cholesterol and subsequent leg pain increased after a visit home to Peru, where we deduced his dietary changes may have caused the problems:  "you know, doctor, what the family feeds me at home!"  I chatted eagerly with another patient, trying to remember bits of my high school Spanish, and thoroughly confused him when I insisted I had a sixteen-year-old hija (daughter), when I meant to say hermana (sister).  "You look young" he smiled at me, indulgingly, his illness taking a backseat to the doctor he loved and his bumbling new assistant.  I marveled at the couple, husband living with HIV, wife sero-negative, who walked in with mountainous folders of information, ready to wrestle and harness science as it manipulated their daily lives.  Sitting silently in each exam, I soaked up the humanity with the medicine, greedily. 

It may be an “easy way out,” posting things I wrote six, no, six and a half, and five and a half years ago. My knowledge base has changed, certainly. I am, now, becoming a doctor, and in terms of getting the degree, pretty far into the becoming. This is two-thirds through the third year (of four). But, younger, less knowledgeable, a good deal less Spanish, I wasn’t wrong.

For now.


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