Do You Decry Your Doctor's Dyslexia?

The same op-ed section from the Boston globe that I quoted in my earlier post "Medicine Hates Moms" contained the following question from Janet James of Lunenburg, MA:

"Should students with dyslexia and attention disorders be allowed into medical school?"

The comments section under "Medicine Hates Moms" has taken an interesting turn thanks to a thoughtful, articulate reader who got me thinking about medicine and learning disabilities, particularly about the issues raised by James's question above. A lot of my thoughts on the subject can be found in that section, so I won't rehash those here, except to say that I think a lot of people erroneously equate "disability" with "inability," and I think this does people with learning disabilities and ADHD an injustice.

I'm interested in medical education and curious to know more about people''s thoughts on this. Please feel free to comment on the subject if you'd like, but please, please, please, in the wake of having had to delete a comment already due to obscenity and extreme disrespect, I ask that folks refrain from being acrimonious, disparaging, contemptuous, condescending, obscene, or insulting, even if offering criticism. Please express your opinions graciously, whatever they may be - with passion and even indignation if you feel them, certainly, but never without respect for fellow-readers and writers here.


In particular I'm interested to know

-Do you know professional people with learning disabilities?

-Do you think people with learning disabilities should be excluded from any particular profession? Why/why not?

-What about neuropsychological disorders?

-Where do you draw the line in terms of excluding people with shortcomings from the medical profession?

-What measures are appropriate for predicting whether someone will be a good physician or not? Or IS a good physician or not?

Learning to Play; or, Two Steps Forward, One Step Back II

I think a capacity for silliness or playfulness is important. I find that people who don't seem to have one either are miserable or tend to make other people miserable, or at the very least extremely annoyed.

In med school I wrote a contemplative poem about my cadaver. That was not playful. But the little verse below, also penned during medical school, was meant to be, another self-check to make sure I wasn't taking everything so seriously all the time. In the wake of my recent ranting and raving, I include it as a way of stepping back and lightening up a little.

Ode to a Mitochondrion; or,

a medical student's homage to Ogden Nash

Cristae, cristae curling 'round,

In your matrix have we found

A clue to evolution's jaunt?

Are you an endosymbiont?

:)

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My son started taking violin lessons with my daughter's best friend's mom. Naturally when he brought home his little rental violin we all wanted to try it. No one sounded as screechy and awful as I did. It was pitiful. Best of all was our little boy, who produced a rich, mellow tone from it right from the start. I asked his teacher how this was possible - we had all been expecting to have to plug our ears during practice time to get through the squeaky beginning phase - and her explanation was eye-opening. Without a relaxed grip on the bow, it can't vibrate against the strings properly, and you get that awful scraping noise, whereas if one just eases up a little and "goes" with it - "goes with the bow," as it were - a nice tone comes out. The moral of the story is I am way too tense, and I need to learn to be more like my child who, despite a bit of an anxious nature, is still relaxed enough to be open to his experiences and just let the music flow through him. Maybe that's what's meant in part by "the kingdom of God belongs to such as these."

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That being said, I have to confess my annoyometer registered a pretty high reading this afternoon when I was dealing with someone from a local oboe reed manufacturer on the phone. This manufacturer charges $4.00 for delivery even though the same box sent through the mail by another manufacturer shows postage for MUCH less (like, by about 300%). Already this was irritating the first time I ordered from them. At that time I asked if I could pick the reeds up in person because I live so close by. They agreed, and it turned out the pick-up spot was two streets over from my house. Today I called and asked if I could do the same, and the woman made reluctant noises before saying finally, "We really don't like to do it that way."

"Why not?!" I asked, unable to imagine a powerful enough reason for her to object to such a sensible arrangement.

"Well, it's just coordinating everything..."

"But there's nothing to coordinate. The last time you let me know when they were ready, and I walked over, opened the front door, and picked them up from the foyer."

"Well...we like the orders to all to go out at once."

Eventually she agreed I could come on foot the two ridiculous little blocks, not worth $4.00, and pick up the reeds on Monday, but this whole exchange struck me as silly - not the kind of silliness I was advocating when I first started writing this post, but the ANNOYING kind, the kind of bad PR that makes you never want to call the company back or order from them ever again.

The problem is, their reeds are REALLY good, and I still haven't gotten to the point of learning how to make my own. Sigh...that's the trouble with getting attached to a brand. The only thing worse than your favorite pen or ice cream flavor or lip gloss getting discontinued is it remaining available but at the hands of people you don't really want to deal with!

First lesson of the fall is next week. Between my travels and my call schedule, not to mention my kids' activities, I may have to start from square one. This summer oboe hiatus has gotten pretty worrisome. I can feel my gains slipping away. I need to remember the lesson from my son's violin: I gotta just relax and go with the flow.

Medicine Hates Moms

Speaking of opening old wounds...I need to vent about Sophie Currier's battle against the National Board of Medical Examiners.

A few days ago an article in The New York Times told the story of a medical student, Sophie Currier, who requested accommodation for her need to express breast milk for her child during her board exams. Her request was denied because breast-feeding doesn't constitute a condition covered by the Americans With Disabilities Act.

Never mind that a mother's act of nourishing her young is one of the most natural and important activities in the world.

Never mind that doctors are duty-bound to inform patients and the public that "breast is best," at least in early infancy.

None of this matters, you see, because there are rules about how you're supposed to be as a medical student or resident, the most revered one being that if you're weak, you don't deserve to be involved in medicine. And if you've chosen to be a mom and a physician, in many medical minds, you're weak. Because now they'll be asked to actually acknowledge and be considerate of your needs instead of treating you like chattel - what a pain!

What else makes you weak, in the world of medical training?

Needing 8 hours of sleep every night. Needing to eat breakfast, lunch, and dinner and not gulp it down in 15 minutes. Needing bathroom breaks. Needing to take sick time off. Needing to sit down during rounds because you have multiple sclerosis or are nine months pregnant with sciatica. Being pregnant. Having children and needing reasonable time away from work to care for them. Having a learning disability. Having a physical disability. Not knowing how to do something without being taught. Not knowing answers to esoteric questions. Sometimes, even taking time to be kind to patients.

What makes you earn the coveted phrase of praise, "strong work," during medical training?

Being fast. Being slick. Having an assertive personality. Always knowing the answer, or at least expounding upon it with confidence even if you don't know what you're talking about.

I need to get off my chest some incidents from my own training that Sophie Currier's story brought to mind.

Comment from the chief resident in OB/Gyn (no less!) as she walked into the residents' lounge while I was discreetly, under a blanket, expressing milk for my son: "Anyone can just walk in here and see you, you know. You really shouldn't be doing that in here."

Underlying messages I heard in her hostile tone: Breast-feeding should be hidden from view. Women shouldn't bring their motherhood into medical territory.

Comment from a female faculty member in the presence of my pregnant friend: "It's irresponsible for women to have children during residency."

Message: medicine is more important than your family. You should rearrange your "normal life" around medicine. Women shouldn't bring their motherhood into medical territory.

Catcalls from surgery residents as I was expressing breast milk behind closed doors in the surgery call room: "Do it out here! Come on!"

Message (albeit facetious): even if you're doing something sacred, like being a mother to your infant child, ultimately to us you're just an object for our entertainment or use.

Request from me to the chief resident in surgery during an operation for which I was holding retractors: "May I scrub out to pump some breast milk for my son? I'm in a lot of pain."

Resident: "You really need to stay and finish the case."

A few minutes later: "This is really hurting a lot and I'm losing some milk onto my scrubs. I really need to scrub out."

Resident: "Oh, all RIGHT."

Message: well, forget about getting a fair or decent evaluation for the rotation. Oh yes, and please don't bring motherhood into medical territory.

Warning from OB anesthesia fellow to me: "When there's a lot of down-time between epidurals, you need to be careful what you're seen doing. Stick to reading anesthesia. When people see you addressing birthday party invitations for your kids...it doesn't look good."

Me: "Because that's somehow more offensive than sitting around and watching baseball or action movies, the way the guys do between epidurals?"

OB fellow: "I know it's not fair, but that's just the way it is. It's ok for them to do that, but it's not seen as ok for you to do activities that belong at home. I'm just trying to warn you about the way people see things in this department."

Message: Women shouldn't bring their motherhood into medical territory. It's WEAK (see weakness criteria above).

That department later tried to claim on written evaluations that I was a weak resident because my fund of knowledge was inadequate. I wrote back with a copy of the results for a standardized (read: objective) test of our progress that we had to take periodically, pointing out that my scoring above both the national average AND that hospital's average for OB anesthesia seemed to belie their claim: one cannot be simultaneously ahead of one's peers and behind them. After that they left my "fund of knowledge" alone but they tried many times on subsequent evaluations to claim deficiencies which I felt I did not have, and which I rebutted in writing with concrete examples. The bottom line was that I knew what I was doing and my patients were well-cared for. I am glad that stupid fight is behind me.

I passed all my boards, written and oral, on the first try, despite a diagnosed learning difficulty for which I couldn't get accommodations because I had done well enough in school and on past standardized tests. Clinically, I am careful and competent; my patients can trust me. I got through my training with two kids who are happy and healthy. I nursed both of them, not as long as I wanted to, but as long as I could. I was able to nurse my first child longer than my second, who was born during medical school; I was unable to express milk for him as regularly as I needed to during the rotations described above, and to my great sadness, my milk dried up early. (Message from the medical world: your physical and mental health, and that of your children, is not our concern - but excel in providing for the health of others nevertheless.) I wonder if medicine will ever pull its head out of it proverbial derriere someday and take measures to actively support mothers in their task of learning to become good physicians. It's too late for me, but I hope changes come, both in terms of breast-feeding education, which should be part of high school health curricula, and for women entering medicine now. If Sophie Currier's story is any indication, there's still a long way to go.

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Addendum, c. 9pm: I found examples of anti-Sophie-Currier posts, for instance at Parlancheq and at Don Surber's blog, that made me realize the breadth and depth of ignorance, sarcasm, and hostility that exists over women professionals, doctors, and nursing mothers out there. Posts like these sound like they're written by authors who have absolutely no idea what taking the boards is like, and/or no idea what nursing entails. To authors that fit this description I say the same thing I said on a recent post to people who pass judgment against Mother Teresa without having lived an equally generous life. To those who actually know what they're talking about, from experience, but still find Sophie Currier's actions objectionable, I would say I can understand why using litigation to make a point as well as to effect reform might be off-putting to some, but I also hold that the medical profession has been unfriendly to family life, for both men and women, long enough and could use some very real and lasting changes, and perhaps a swift kick in the pants once in a while. (Incidentally, for the MANY people who have asked on other sites why she can't just pump the milk before the test, I have to ask: what is she supposed to do when the milk rapidly reaccumulates, as it would in any healthy nursing mother, and causes extremely painful engorgement during the first couple of hours of the exam, with another seven hours of testing to go, reaccumulating milk all the while?)

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One more thought by Dr. Nancy Terres of Boston, from the Boston Globe op/ed section on boston.com: "It is one thing for the healthcare system to endorse a health behavior such as breast-feeding, but quite another to change our own behaviors to make the goals possible for our patients. As a representative of the medical establishment, the NBME is sending the message to the public that we as healthcare providers are not all that serious about our health recommendations."

It takes energy and conscientious effort to do the right thing. It'll be hard for anything about the system of medical training in the U.S. to change without personal transformation, insight, compassion, and courage from the individuals running the show - those who are "teaching" the residents and controlling credentials. I hope it's not too much to ask.

Wound Care

Not too long ago I had to counsel a family about a surgical procedure their loved one needed in order to have a chance at survival but which, at the same time, she might not survive. I told the family I needed to place a breathing tube for the surgery but that I was also unlikely to be able to remove it afterward. Our conversation was long and quiet but intense, and in the end I could offer no better news for them. "Thanks for explaining it to us, doc. You do what you gotta do." What I was able to do for that patient was very little. She survived the surgery and was in guarded condition when I left the hospital for the day, but she died later that night.

There's a lot that's hard in medicine. The hours. The demands. The stresses. These are merely exhausting or frustrating, but confronting our own impotence - that has something else to it. Something really humbling, a kind of sadness.

So why do it? Why did I? How did I end up in med school at all?

I was an English major in college, and a good one. I loved to read great books and write good papers. I was into music and dance, medieval and Renaissance history, ancient languages, modern languages, scripture exegesis, art history. I dabbled in theater and even performed the role of Connie in A Chorus Line. Later I would get interested in social psychology and anthropology. In short, I was a humanities student through and through, not an ounce of the science geek in me, nor the aptitude of one. I was fascinated and awed by science - especially molecular biology and astrophysics - but I had no facility with it. If I managed to get through a science class at all, it was with a lot of tears and sweat.

In my last year of college, while I was writing my English thesis, I took an EMT class for fun. Should I have or shouldn't I have? I ask, facetiously, because in the middle of that course a voice in my mind said, "Uh-oh. I think I want to be a doctor. I love taking care of people, and using clinical skills and science to do it." Here was science that had the breath of life in it! Physiology, the logic of the body, was a tantalizing intellectual pleasure. I wanted to learn all I could about it, and use it to be of service to people. The first (and, intially, the only) person I admitted this to at the time was the man I would eventually marry (at a time when we were "in neutral," between fitful bouts of dating). His reaction then is what it still is: whole-hearted, affirming, faithful support. We would wind up marrying and starting a family before I ever set foot in medical school, but set foot I did, for better or worse.

I wasn't always going to be an anesthesiologist, though. I was going to be a pediatric specialist and spent most of my electives in medical school preparing for a life in pediatrics. I took a special course in an inner city hospital in New York on the evaluation of victims of child abuse. I was attracted to the field of medical genetics because of its integration of child development, in which I had a master's degree, and counseling, and I had the chance to spend several stimulating weeks at the National Institutes of Health learning the ropes in its division of medical genetics. They wanted to hire me as a resident and fellow, in fact, but sometimes life takes its own circuitous path. Choosing anesthesia involved a "voice in my head" kind of moment too: after mask-ventilating a child for the first time, I knew I wanted to be the doc that was doing that every day. So here I am.

Sitting here on the eve of the anniversary of 9/11 I realize that though my life was left intact by those dramatic moments in our history, I was not entirely untouched by those events. When the planes hit the towers I was in New York, completing another elective in medical genetics at Mount Sinai Medical Center. The first nail in the coffin of my dream of becoming a medical geneticist was hearing one of the medical geneticists comment, "Should we go and help? Oh, wait, we can't really...unless they need IVs or something..." I was bothered by that. I wanted to be a doctor who COULD help in that situation, and even though I knew the ongoing care given by medical geneticists to their patients was irreplaceable to those patients, I also knew how abstract it could be, and I realized I wanted to be able to see the help I was giving. I'm a lot like Doubting Thomas in many ways.

Academic activity was suspended that day, but all fourth-year medical students were asked to assemble in one place and offer assistance if needed. Someone had the presence of mind to make a note of anyone who was multilingual. It was all for naught, as we now know: there were few if any survivors to help, and rescue workers needing medical attention would go to hospitals downtown, where some of my classmates were on rotation, not uptown.

That day was the most intense example of what for many physicians is one of the worst aspects of medicine: its limitations. When I look back on the times in medical school or residency that left me feeling utterly disconsolate, I remember moments when I or the clinician next to me would have to say some variation of "I'm sorry, but there's nothing I can do."

I recall a beautiful young girl who had been maimed somehow and who came to the orthopedist's office with the hope of restoring some function to her arm, the upper part of which had been shattered and faultily repaired in some foreign country. She couldn't lift her arm to the side, so when I asked her to extend it she had to unfold it in a broken-winged sort of move. The orthopedist was using my imperfect Spanish to communicate with this lovely girl and her mother, and I felt stupid, frustrated, and helpless telling them we couldn't do anything for them.

Another time in the ear/nose/throat clinic I examined an African American woman with downcast eyes whose eardrum was blown wide open.

"How did this happen?" the ENT fellow asked.
Her bottom lip started to quiver. "My boyfriend..."
We remained silent, hoping to give her space to tell the story.
"We got into a fight..." Large tears started to roll down her cheeks.
"He hit you," the fellow said quietly.
"Will I be able to go back to my job?"
"What sort of work do you do?"
"I'm a..." The woman was laboring to suppress a sob, but couldn't. "I'm a telemarketer."
"Oh," said the fellow. His manner was serious but gentle, like his voice. "The injury is quite severe. We could attempt a surgical repair, but I can't guarantee that surgery would help."
"But it don't feel right. Can't you do nothin'?"
"I'm sorry..."

When something of ourselves rips or breaks, there is grief, a futile yearning for things to be as they were, unhurt, unchanged. Healing is an astonishing process, as is our capacity for it; but there is a melancholy aspect to it: we are forced to learn to live with scar tissue, with changed selves, and to accept that things can never be as they were before a blow was dealt, whether with words or ideas or fists or fortune. Perhaps in the end our scars are meant to teach us that while in some respects "there is nothing we can do" but let things be, and find new ways of accepting and transforming imperfection, it's also true that we can do more than we realize, especially when we recognize, get involved with, and learn from the wounded around us, and the wounded within.

The Limits of Viability

21 weeks, 6 days.

As far as I know, this is the gestational age of the youngest premature infant to have survived beyond birth. Amillia Taylor (not the infant picture here) weighed only 10 oz and was only as long as a pen.

This makes my 32 weeks back in the early seventies look like term.

***

The story I'm about to tell may elicit a strong reaction from some. I need to retell it because I it's an experience that has stayed with me, and the telling of it helps me understand, gradually. I don't want anyone to infer any opinions or judgments on my part; I'm not interested in sharing opinion right now. Just telling a story.

In my third year of medical school, during my rotation in OB/gyn, a couple was admitted for termination of the woman's pregnancy. The fetus, whose age I don't recall exactly but I believe was somewhere in the teens (for weeks of age), had Down Syndrome. I remember very little about the tasks I was asked to do outside the couple's room - perhaps a little shuttling of pain medication or fetching a sheet of paper for the residents involved more closely with the couple. Their privacy was maintained as much as possible.

A few images are branded into my mind from that day. I remember catching a glimpse of the couple just after the termination was completed, when the door swung open so the fetus could be brought out of the room. The man had his head on the woman's and they were sobbing quietly together.

A little later I remember passing the cleaning supply room and noticing that the fetus had been placed in there, for whatever reason. I asked one of the residents if it would be all right if I looked in on the fetus. Permission was granted and I went. I could not tell if the fetus was male or female - externally this was not yet visible. But I recall being able to see the heart beating through the chest wall, and feeling a mixture of disbelief, confusion, and helplessness because it took such a long time for the heart to stop.

***

During my intern year I had an unplanned "take your child to work" day because a snowstorm closed my daughter's day care center and she had to get dropped off at the hospital, where I was doing a rotation in the neonatal ICU. I thought it was kind of cute that she went on rounds with us in the less restricted unit, and thankfully the NICU attendings thought so too. She took it all in stride - the incubators, the eye covers on some of the tiny babies to protect them against the treatment lights for jaundice, her mom in a big blue gown and mask about to do a spinal tap or place an umbilical line. The attendings took turns playing with her and taking her to the cafeteria. It was the one time the high-stress environment of the NICU felt a little brighter for me.

***

I wish people wouldn't pass judgment on parents who ask for everything possible to be done to save their children.

I wish people wouldn't pass judgment on parents who ask that their children be left in peace if resuscitation appears futile.

I wish there were easier answers to the question of what is futile and what isn't.

***

Many thanks to Brian Hall for making the first image above publicly available on Wikimedia Commons, where the second image can also be found.

Composition and Decomposition

I remember being afraid as I stood in line waiting to enter the anatomy lab for the first time in medical school. What I can't remember is why. Dead bodies can't hurt us. Practically speaking, we can't really hurt them any more either. But I was scared. I was nervous about entering a room and seeing dead human beings everywhere.

But I needn't have been. The most beloved professor of anatomy at my school, Matthew Pravetz, made sure to teach us from the start that we could not approach our cadaver, our "first patient," as he reminded us, without deep reverence in our attitude, demeanor, behavior, and indeed in our hearts. Dr. Pravetz, also a Franciscan priest, brought the gifts of his spirituality into his work, and ours, without imposing any kind of religiosity on us. Every time he gave a lecture or demonstration, you could see his sense of wonder at the way every sinew and vessel in the body had developed; his love of the human body and faith in its sacredness permeated the course and set us off on the right foot toward becoming true physicians. That's a good teacher for you.

The following year, when it was our turn to help the new first-year students take that first step into the anatomy lab, I was stunned to find myself breaking out of my usual timidity and lack of self-confidence, carried away by my own excitement about anatomy and growing love of medicine. I remember trying to pass on some of what I'd learned, touching a cadaver's thorax and explaining what its "barrel chest" might have signified about lung disease in life, laying their hands on the chest so they could feel for themselves and no longer be afraid, as I had been. The medical school chaplain was there, standing by just to support us all, and later he took me aside and said, "Good teaching in there."

I can still see my cadaver clearly in my mind, down to the graceful loop made by her recurrent laryngeal nerve after we dissected it free from the other tissues in her neck. Some of my other fond memories of the anatomy lab are spottier, though I remember my three wonderful lab partners vividly. I remember a guy once had an itch on his nose but his gloved hands had just been handling the cadaver, so in desperation (and apologetically) he rubbed the tip of his nose on the shoulder of my scrub shirt as I walked by. I remember being alone late at night with my cadaver studying for an anatomy exam and being startled when a light turned on at the opposite end of the lab, followed to my great relief by a friendly classmate's voice saying, "It's just me!" I remember having no child care for one of my anatomy oral exams and handing of my then-one-year-old daughter to the group ahead of us as they came out of their oral so I could go in with my lab partners and take mine.

It was so great to come out of that exam and find my little girl waiting in the lobby with my kind-hearted classmates. A new, fresh little life, bright and sunny, just beginning her journey.

***

I started thinking about the ubiquity of decay today because of mushrooms. We spent the afternoon at the Adirondacks' natural history museum, The Wild Center, a small but beautiful museum in Tupper Lake, NY. Despite the fact that I have almost completely shed the "doctor" part of my identity during this vacation, I was happy to see this defibrillator situated halfway through one of their nature trails:

You'd think the highlight for me would have been the adorable river otters, or the natural history hands-on cabinet, or the live kestrel presentation, but no, the highlight for me was...the mushroom exhibit. I didn't know there were 1.5 million species of fungus in the world (compared to 4,630 mammals). I had no idea that oyster mushrooms are predatory. But I did know that morels are DELICIOUS as well as mysterious.

***

Speaking of morels, I have to give vent to the foodie in me and rave about the dinner we had last night at our amazing hotel. My husband and I have been trying for weeks to celebrate our anniversary with a nice dinner, and last night we had our chance: the Narnia movie was showing in the hotel's small movie theater, and our kids were more than happy to be dropped off while we had our romantic dinner for two. We were done with it in time to see the last battle scene with them - perfect!

I had some delectable morel risotto with a perfectly prepared halibut garnished with a frizzled wild leek and some small carrots, paired with a delicious Sheldrake sauvignon blanc. My husband had lamb. For dessert I had a strawberry "shortcake" assembled from candied ginger scones, whipped cream, and strawberries with sorbet and a dark-and-white chocolate stick on the side. YUM.

Yesterday the New York Times featured a story about a chef , Rebecca Charles, who was fighting for her recipes and restaurant design to be recognized as her intellectual property. I don't know much about the case, but I do think it's time for creativity with food to have its due. Creativity and composition balance out ever-present decomposition and the relentless law of entropy, and the necessity for all life to fall into the cycle of decay and renewal.

In a couple of billion years our sun will explode and take all of our achievements with it - human language, writing, architectural treasures like Chartres cathedral and the great bridges of the world, chemical engineering, great musical works, art, painting, inventions, medical technology, spiritual insights, movies and shows, all lessons and artifacts, not to mention relationships and unique individuals...unless we find a way not to lose these by then. For now, our creativity is what we have as evidence of our vitality and witness to our preciousness. Creativity in the kitchen included!

***

This recipe for Morel Risotto is courtesy of Phillip J. Speciale and quoted from www.thegreatmorel.com/recipes.html:

Ingredients
1 cup of small dried morel mushrooms, reconstituted and cut in quarters
1 medium sized yellow onion, chopped
2 cloves of garlic, chopped
4 Tbls of butter
6 cups of chicken stock
1/2 cup of Marsala wine
2 and 1/2 cups of arborio rice
1/2 cups of freshly grated parmesan cheese
1/4 tsp salt
1/4 tsp of freshly ground black pepper

Preparation
Pour broth in a medium size saucepan and heat to a simmer. In a slightly larger saucepan add the butter and sauté the garlic and onions for about 1 minute. Add rice and mix well coating the rice with the butter. Stir in the wine until it has evaporated. Stir in mushrooms. Add broth 2 cup at a time and stir until broth has been absorbed. Repeat until all the broth is used. When rice is tender mix in parmesan cheese.