Bedsores

A little more than a year ago, I moved far away from my beloved family and mountains to attend medical school in Pennsylvania. The first months, in particular, were harrowing, and all my time here has had been challenging. The other night, though, I found myself feeling particular trepidation because, in January, I will begin work in the hospital. I will replace the endless parade of powerpoint slides with patients–living, breathing, ailing, suffering humans who need our help to get well. The burden, as you might imagine, can seem daunting and the expectation is almost worse. I include here an e-mail written to my parents that night, slightly edited for presentation here, but hopefully remaining true to the urgeny of my feelings that night; I would appreciate the thoughts of anyone who has ever scaled a peak that, beforehand, seemed nearly insurmountable:

My sadness last night, I think, is part of a larger nerrvousness that is slowly growing within the class: the clinics are looming large and have begun to convince us that we know nothing (what, I’m supposed to remember EVERYTHING I’ve learned in the past year? Right….); we don’t know nothing, of course, but we know relatively little, it seems. I think beginning work in the clinics is kind of like beginning a mission: you look ahead of you to this vast expanse of undiscovered territory and realize you have no concept what the journey will really be like. Sure, you can ask people who’ve been there for advice or at least description, but even their answers further persuade you you have never been on a trek even remotely like the one on which you are beginning to embark. So you pause at the edge of the desert, draw in a deep breath, check your pack one last time, and wonder whether you really have the wherewithal.

The big difference, or so it seems, is a mission provides a whole cadre of companions (including literal companions as well as local ward members and mission leaders) who want nothing more than your success. Rumor has it, though, that the clinics are filled with interns who are too tired to care too much about your success, residents who are too far removed, attendings who are much too smart, and collegaues who are much too competetive, so that, at the end of the day, I wonder if anyone in the hospital will really be looking out for my welfare or if I will be engaged in some weird version of that TV show “survivor” (which I’ve never seen, but which apparently involves a group of people “voting” off the island one less-astute member of the team daily).

All of this, of course, comes on top of a schedule that would make a sailor cringe: surgery, for example, has you at the hopsital a 4:30 AM for prerounds and not leaving until 8 or 9, five days a week, plus some weekends. Then, on top of that, you are supposed to study for difficult upcoming exams (the dreaded “shelf exams”) not to mention studying for being “pimped,” a new term to which I’ve only been recently introduced: it refers to a higher-up, usually an attending, asking you questions, point blank, to see if you know your stuff. I’ve described the sometimes miraculous way in which answers have been brought to my memory during difficult medical school classes up till now; in the hopsital, though, any given day can bring up any given organ system which means anything we’ve studied in the past year–it’s all fair game for being pimped. In fairness, fourth year students say not to worry because no one expects you to know anything when you begin, anyway; still, while you’re obviously not expected to know everything, they must expect you know something, probably a good number of somethings, I mean you’ve been going to Ivy League medical school for a year and a half, and you passed the classes, right? Even worse (horror of horros) what if I have one of my fellow students on my team and, when I don’t know the effect of parathyroid hormone on calcitonin secretion is primary hypoparathyroidism, my collegue graciously (not) steps in and provides the explanation as if he were repeating his phone number.

The irony about the last paragraph is that we had a meeting with many of my fellow-students on thursday night and just about everything I’ve expressed here floated palpably in the air, like smog. Everyone’s eyes were darting about like squirrells’. Everybody is pawing nervously at the starting line, simultanesouly dreading and longing for the beginning of the race–we sense how hard its going to be but also know intuitively it must be better to get in there and dig our fingers into the dirt than to stand at the desert’s edge and fantasize about phantom know-it-all students.

And, yes, at least I hope, there is still the reason we came here. On Tuesday night I traveled with Dr. K (a retro-hippy with a gnarled sprig of gray hair who wanted to know “how did Salt Lake end up with a democratic mayor?”) to visit a 96-year-old man who is nearing death. This African American fellow had fluid accumulating inside his belly (ascites) and his heart is failing and his vision’s going. His hearing is out unless he puts in and cranks up the hearing aids. He just left the hospital after a month there and now no one is sure how far the insurance will extend–at some point, his family may have to let him go. He lied on his bed, haloed by the tacky crawling flowers typical of seventies wallpaper, and moaned occasionally because of his bedsores. He spoke with the doctor and told us how he’d been doing great till about a month and a half ago: two months ago he was still riding his motor scooter to go fishing over across the Delaware.

“Fishing?” I asked–“you like fishing?”

“Yes, son, ya ever do any fishing?”

“Oh yes, in Utah: browns, and rainbows, and cutthroats. What about you? What do you catch?”

“Anything that bites.”

“That’s a better answer than the one I gave.”

“I once caught a twenty-five pounder; I’ve even caught sharks off the coast of Florida, you have to use a net, they’ll break any line you put out there.”

And now we had connected–Alaska, Florida, trout, sharks, fishing, nets, hooks, worms, lines, mountains. Stories and memories came gushing forth:

“And those little girls,” I asked, “what were their names?”

Mr. C. looked a bit puzzled–he knew he should know the answer but he couldn’t remember his granddaughters’ names (each was about five years old).

Finally his daugher volunteered: “Mr. Johnson, ask him what he calls them.”

“Mr. C, what do you call those pretty little girls?”

“Sugar-momma,” came the reply, without hesitation, in a voice as sweet and gritty as brown sugar.

Later, when we had to turn Mr. C. over for examination, we brushed his bed sores and he howled in pain: “oh, it buhns, it buhns lak fahr, lak fahr.” So I put my hand on his shoulder and stroked him, cooing: “it’ll be alright, shhhhhh, it’ll be ok, you’re alright:” and, again, we connected, this time the energy flowed from my hand to his shoulder, imparting, silently, the kind of comfort that only comes from human touch.

The moment was beautiful and mixes a sweetness with the trepidation I feel as I approach clinics–this is why I came, right? I just wish I wasn’t quite so nervous.

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Published in: on October 9, 2006 at 3:51 pm  Comments (22)  

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  1. That’s a great story. It reminds me of last season on LOST. Jack, the doctor, never perfected the “bedside manner” approach to medicine. He was trying to get Sawyer, who had been shot in the shoulder and was semi-conscious from a raging fever, to swallow a pill. But it didn’t work. Finally, Kate (one of the main reasons I watch the show… ahem) sat behind Sawyer to prop him up, rubbed his forehead gently, and spoke softly in his ear to encourage him and prompt him to try and take the pill. She then gave Sawyer the pill, and presto change-o, he swallowed it.

    Sure, it’s fictional, but it illustrates how much easier medical administration can be when, as you put it, there is that “human touch”.

  2. That was great. My seemingly insurmountable peak, was of course, motherhood; and it still is. First off, I never thought I’d make a good mother. Don’t know why. Maybe it was irritability I noticed when I’d hear a whining, crying or kid having a temper tantrum in the next isle at the supermarket. I’d always think, “Shut that kid up!” When I was in my twenties, I was afraid to hold my newborn nephew for fear of dropping him. I just never had a feel for babies, period.

    Then as I got older, and more spiritual, I realized that I had a LOT to offer a child of my own, but I still had serious trepidation. Right before I met my husband, a GYN actually told me that I could not have children. On top of that, I was previously married for 8 years and never got pregnant. I was relieved and disappointed at the same time.

    Okay, that sets the stage. In walks my future husband and before we married, over and over, I made him understand that in all probability, I could not have children. He accepted me as is, we married, and we had lots of fun…! All the while, my husband had a very subtle smile on his face every time the topic came up and I, again, reminded him that I couldn’t have kids.

    To make a really long story short, my eventual pregnancy was “very short” for us. We found out when I was almost 7 months along, I was immediately put on bed rest, our baby came 6 weeks premature. How’s that for service? I/We had no time, really, to adjust to the idea of having a baby/family. I was happy that I would have a little one, yet I was very, VERY scared. I enjoyed the bed rest, though!

    Everything happened so fast we had no time to prepare. But, then God sent us angels. They came from everywhere, bringing gifts, advice, their own stories and shoulders to lean on. They came from our new church, people we didn’t know, bringing gifts to us every Sunday we walked in for mass, or church function. They came from our new neighborhood; again, we didn’t know anyone except two people. They brought new and used clothes and major essentials for a new baby. Of course, they also came from family, providing new items, hand-me-downs, etc. We didn’t have to buy a single thing. Our baby slept in a cradle that is the family heirloom. Well, I could go on, but you get the picture.

    When things seem insurmountable, God works His wonders. Now if I could just have faith from the outset, I’d be much better off, mentally, physically and spiritually. I am reminded of a favorite hymn, “Be Not Afraid.” Do you know of it? “Be not afraid, I go before you always. Come follow me and I will give you rest.”

  3. Connor–

    Thanks for your comments; I have never seen that show, either, but it sounds like they have the right idea. There is something near magic in the power of human touch.

    Dragonmommie–

    Your commitment to motherhood will make you a great mother, children can tell how hard their parents are trying.

    It also sounds as though the course of your becoming a mother has already been filled with miracles. Your congregation, in particular, seems wonderful–it sounds as if they understand Christ’s admonition to “lift up the hands that hang down, and strengthen the feeble knees.”

  4. Our congregation is wonderful. I failed to mention that most of it is Hispanic…all different countries, so there was/is a tremendous language barrier, but we are bridging the gap through our faith and that is a miracle, too.

  5. Thanks to dragonmommie for sharing important, wonderful, and miraculous lessons. And to Tyler for sharing the story of Mr. C and his Sugar-momma girls. I believe the greatest part of our growth comes in the last 10-15% of the effort we give. But, so often we fail to make it there. Dragonmommie, Tyler, and Mr. C., though, show us there are still people willing to put forth the effort to do so.

  6. I have never experienced anything like you speak of here. I think this is probably where some of the most meaningful learning takes place!

  7. Tyler, Your talents are going to be tested during this period in your life. You have learned much and you have many great things to offer. You will pass this test in life with flying colors. Just as you have passed every other hurdle that life has thrown at you. I have the utmost confidence in your talents and I have the utmost confidence in you. You are going to be really good at this. You have all the tools and your superior judgement will never fail you. I have faith in you. Enjoy this great learning experience.

  8. Barb–

    I agree I will learn much; often difficulty facilitates learning.

    BeesjNKJ–

    A very wise man once drew for me a graph which showed that 90% of the blessings (in that case, we were talking about missionary work) come with the last 10% of the work.

    Snarkey–

    Once again, you have proved yourself to be very un-snarklike. I am not sure if you make me less comfortable with your tirades against what I write or with your compliments of my character–I would think you were a mystery acquaintance of mine observing me and then commenting on my behavior without my knowledge. Your compliments, however, certainly prove that not to be the case. Or, at least, they remind of Mark Twain’s prescient comment: “the reports of my demise are premature and greatly exaggerated.”

  9. Heck Tyler, even I cant be “snarkey” 24/7. That would require too much work on my part. I just want you to know that Im here to boost your spirits should they ever need boosting. Really, Tyler I am a huge fan of yours. Who knows someday you might be the MD doing a prostate exam on me. If that happens I want to be on your “good side” if you know what I mean. Seriously Tyler in the next couple of years you are going to be tested to all of your physical and mental limits. I want you to succeed and I know you will. Some days you will be the bug and other days you will be the windshield. And then other days it will be like you are in a kennel of hungry German Shepard dogs and you will be wearing “Milk Bone” underwear. Or will they be Milk Bone “garments?”

  10. Snarkey,

    Only you can leave me shaking my head wondering why anyone would think so highly of me and then leave me shaking my head wondering how anyone could actually write something like that in the space of one paragraph–and apparently be sincere in both comments.

  11. Well I tried to add a little humor to that last post. Often during tense situations in doesnt hurt to add a little levity to relieve tension. I think maybe I failed at my mission.(?)

  12. Don’t worry, Snarkey, you had people smiling.

  13. Im glad to hear that Tyler. Humor is a gift from the Creator.(Notice I didnt say “Heavenly Father.) When Jesus was on this earth he was just as human as you and I. Jesus laughed, Jesus cried, and believe it of not, Jesus even passed gas.

  14. Tyler: I read your stories on Times and Seasons and enjoyed them. I will speak here as one of the “interns who are too tired to care too much about your success”.

    Several thoughts come to mind as I read your post. First, it is nice to hear your optimism about your role as a med student and your compassion for your patients.

    It is an interesting balance in medicine. Balance is a requirement. I have a senior on my medicine team that is almost always spot on with her assumptions and diagnoses of patients. We work on an admission and after a few moments looking over the labs and the history she has a comprehensive problem set, differential diagnosis and plan worked out. She is quick, intelligent and hard working. However, she is unable to communicate well with the patients.

    On mulitple occasions, as the intern, I have received thanks from patients for my care and attentiveness and talent. In reality, I am taking credit for the intellectual gains made by my senior while the patients value my interpersonal interactions with them.

    Other physicians I have interacted with are very personable and very kind, but they don’t keep up on the literature in their field and are rusty and even wrong in their assessments and treatments.

    What is the right balance? A complete physician–in western medicine–must be book smart or he/she will kill people. However, books smarts don’t come close to making a good physician.

    I wonder when you said, “it’ll be alright, shhhhhh, it’ll be ok, you’re alright”. How is that statement to be taken. If this patient is as sick as you say then he will die in a lot of pain over the next several months. Maybe ‘it’s alright’ means he will be eternally well. Maybe you could sense his eternal worth. Or perhaps, things won’t be okay for him–physically, emotionally or spiritually. That uncertainty of outcome gets to some physicians and they aren’t able to make your comment with the same certainty and hope.

    Last comment (sorry to make this so long in my first comment on your blog). Clinicals are hard but not. Every student approaches them differently and every student shines and fails to differing degrees. Here is my two cents (maybe I am an intern that cares).

    No one in the hospital is there solely to teach you. It is a privilege for us (students and interns) to be with upper level residents and attendings as they let us into their thought processes on how to treat patients. Medicine is often an art and it is like being allowed into the studio of an artist in the most intimate moments of creation. DO NOT expect those above you to spoon feed you the answers. If you have a patient with a certain disease you should figure out everything you can about the patient’s disease, pathology, treatment etc before you start interupting your higher ups with your questions. This serves several purposes. It allows you to really learn the material. You look smarter when you do ask a question (better grade, better letter of recommendation and entrance into the residency and field of your choice). The bottom line of this paragraph is this: don’t ask questions that you can find the answer for yourself. Ask questions that aren’t found in the textbook. Ask questions that evidence your understanding of the desease that you have studied.

    Second point. The privilege of sitting in on the decision making of the doctors above you requires something from you in return. Yes you paid a lot of money in tuition, but if you tally the time put in by the doctors with–hour for hour–you didn’t pay that much…So one of the few things you can do is make the lives of those above you easier. Come very early. Pre-round. Write down the vitals correctly. Talk to the nurse about what happened the night before. Look in the soft chart and find every medicine that they are on. Do this for every patient, every day. Do the busy work that is important to the managment of the patient that you can actually do yourself. Then when it comes time to do the parts of the patient care that you can’t do yet (you know, diagnose, treat etc…) you will have everything on the table for those decisions to be made. Those above you will be more efficient, appreciate you more, grade you higher, be more willing to teach you and you will be more intimately acquainted with your patient.

    So there it is. Know your patients really well. Don’t ask questions that you can look up yourself. Look up your questions before your attending asks them of you and you will shine.

    Good luck. Before you know it you will be an ‘intern who is too tired to care too much about the success of students on your team’.

  15. Paul F–

    As you intimate, you are obviously an intern who cares. I have to admit: I hoped someone who had been through the clinics would read this post and comment–thank you for taking the time to make such extensive comments, I really appreciate them.

    I will internalize your advice as best I can; I have a tendency to ask a lot of questions, so I will benefit from your suggestion that I keep my questions to the attending to only those I can’t answer on my own. I think knowing my patients well will not be as hard for me: if I am like either of the med students you describe, it is more the one who interacts well but doesn’t know his/her stuff. That is not to say I won’t study hard, or that I haven’t put in the work to get to know my patho (and other year 1/2 knowledge), it’s just that there is so much to know, sometimes I get nervous that I won’t know enough of it. Still, I’ve studied really hard and been able to do fairly well these first one and a half years, so hopefully I’ll be alright.

    Thank you again for the wonderful comment, I’ll keep you posted.

  16. PS: As to my comments while the patient was in pain: they had no real (at least conscious) philosophical significance. Quite simply, the man was in pain and I was trying to calm him down, hoping maybe to alleviate his pain a bit by showing I cared.

  17. Being on the wards is tough as a med student. There is no way around it. I don’t envy your position, but that’s not to say that you can’t enjoy yourself and care for patients well and get a good grade.

    Unfortunately the grading really matters. Especially if you want to get into a good residency (or even match in a competitive field). It sounds so counter-productive to tell someone not to ask questions, but there is just so much stuff to know that you may well be asking a VERY commonly known question and that doesn’t help you. Attendings are forgiving of medical students lack of knowledge to a point. However, if you think of human nature, how many people actually take the time to put themselves in another’s shoes. It isn’t easy to remember just how little a beginning 3rd year medical student doesn’t know. My tact was to always ask my co-med student in private any answers to questions about my patient that I hadn’t found about my patient (ie. what is kayexalate, why am I using it for this patient and what is it’s mechanism of action). If your co-med student doesn’t know, then you could go to a resident whom you befriended from medical school or while on a previous rotation and ask that person the question. That way you can get the really easy questions out of the way (how few ml should you have out of the jp drain before you pull it)?

    Uptodate.com, google and board review books are your friends.

    Good-luck. Your patients will appreciate you. You can really have fun on the wards by working hard and smiling a lot. Of course the surgeons may talk behind your back, yell and be rude, but they are just overworked and it’s hard to blame them for their actions.

  18. Some advice from someone who is recently on the far side of med school, internship, residency, and fellowship:

    As has already been stressed, your third year grades are your most important grades in med school. The hardest thing about the clinical year is figuring out who is evaluating you. As cynical as it sounds, you need to figure this out immediately on every rotation. You simply don’t have the time to be the personal and private slave of every overworked nurse, intern, resident, fellow, and attending in the hospital. Figure out who is grading you and play to them. At my med school it was a different person every rotation. Sometimes tests counted, sometimes they didn’t. Figure this out pronto.

    I agree to an extent about the “there is no obligation for them to teach you,” “it is a privilege for you to be there,” stuff, but only to an extent. Be aware that in many fields (and the surgical ones in particular) people don’t really care at all about you or your education. They care about the work you can do for them. Many will exploit you as much as you let them. Don’t be afraid to help and work hard, but always bear in mind that you are there as part of your education, not as a system of indentured servitude. Don’t be afraid to watch out for yourself. If you don’t, you could end up looking back on ten or more years of “scutwork” and wondering why you still don’t know any medicine.

    And finally, remember the old joke about doctors. What do you call the last person in your med school class? You call him Doctor. Most people don’t know one med school from another. Indeed, the more prestigious residencies and fellowships will be totally unknown to them. Unless you go into academia it just won’t make that big a difference. Just make sure that you end up in a field that you enjoy.

  19. Tyler, I just finally caught up with your site via the MA. All the links I’d found before pointed to what was an old version.

    I’m not a med student or a doctor, but I’ve been a patient (a *lot* lately). I know you’ll find ways to get your questions answered, to shore up your knowledge when what you need isn’t right on hand in the moment. I just, well, I wanted to ask you to try to stay human.

    I realize that you can’t turn your heart inside out for every patient, but, well, please still look them in the eye and treat them like living, breathing, feeling people. Please don’t let the process harden you, leve you jaded to suffering.

    Too many doctors have gotten that way–in so many fields.

    Simple eye contact, and even a smile. Taking a second to let the person speak; hearing, acknowledging, and demonstating an understanding of what the patient has expressed to you—these are all the priceless qualities of those rare doctors whom I feel really helped.

    Never forget that it’s the patient’s body, and that they’ve been living in it their whole life. Remember and respect that fact, and you will find patients will be more connected, more open, and more likely to give you the critical information needed to make the proper diagnosis.

    It’s easier to treat people when they are connected to you, when they trust you. They’ll only open their hearts to trust you if you remember to stay human, and to acknowledge that they are, too.

    We’re all brothers and sisters, y’know.

  20. Naiah–

    Thank you for the heartfelt advice. Such things seem natural to me now; I pray I’ll maintain those feelings as I progress through school, residency, and my occupation.

  21. Tyler,

    Very recently found your blog (story for another time) and have enjoyed the journey through it. I work as a charge nurse in a county jail, where I function unofficially as a mid-level provider, seeing patients in the daily sick call clinic. I thought you might appreciate the following excerpt from my collection of thoughts on working with inmates:

    When someone asks us for advice or help, and we put some effort, experience, and caring into responding to them, we rather expect that they will act on what we give them. An example comes from doing sick call at the jail. An inmate comes to me with a problem, I go through the pertinent questions to get some history, check vital signs, do a physical exam, and based on my assessment, get some medication prescribed. Then I am surprised the next day to find that the patient has decided not to take the medication, and is willing to just put up with the discomfort he is in. I confess, the thought crosses my mind “Why did you waste my time? Do you know how many years of study and practice went into being able to diagnose and treat you? Doesn’t it matter that I actually care that you are uncomfortable?”

    Then of course, there’s the comparison of me to Christ. I make mistakes and know I need to repent. So I go to the great Physician and explain my problem. He is patient and kind, listens to me describe how I got to where I am, and then, through His spirit, tells me what I need to do to be healed. Then for a little while, I do what was prescribed, because I want to be better. But for various reasons, I may go back to my previous behavior, which says in essence “I have decided not to take the medicine any more.” And when I do that, I have wasted the tears and the agony of Gethsemane and Golgotha, ignoring the effort, love, and suffering that went into Christ being able to heal me. But unlike me, Christ doesn’t have a tendency to write me off as not worth worrying about. He is always ready to heal me, as soon as I am willing to be healed. And so He provides an example for me to follow with my patients. I don’t need to judge them or write them off. I have to be ready to help them when they are ready to ask. And even if they repeatedly reject the treatment prescribed, they have the right to request to be seen again, and again.

  22. I have thought of you a lot through the years when I have had people that were important in my life on disability or government insurance go to medical professionals. When they have been treated with dignity, it has meant so much. I think everyone deserves respect.
    I know of someone who has had contrasting experiences of doctors who treated her as a valued person while others treated her in an antagonistic way. Granted the person may have brought some of it on themselves, I think that a professional should behave in a professional way. Of course, that is ideal.

    Still, I have been touched by many caring professionals and also Social Workers.

    I am grateful that I have never had to go on disability with my condition and am able to work. It is so scary to me to think of being viewed in such a way.

    All the best to you! Also, thanks for being nice to me in days gone by.


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