Should be a Facebook Quiz: What Medical Specialty Are You?

Thanks to FreshMD, who works in a refugee clinic and writes a wonderful blog, I decided to take the University of Virginia Medical Specialty Aptitude Test while waiting to see if the surgeons are doing an appy tonight or not.

The results? Drum roll, please...

Anesthesiology is, indeed, one of the top 5 things I should have considered as a medical student embarking on choosing a specialty. It came in at #2 behind dermatology, of all things - a specialty I never really felt attracted to.

I remember when I took a similar test in medical school offered by GlaxoWellcome, I was SHOCKED to see that my top result was anesthesiology; at the time I thought I was headed for a career in pediatrics. I didn't know enough about anesthesia going into medical school to even have the specialty on my radar screen.

I guess the people who design these things know what they're doing...or maybe it's the power of suggestion?

The one other specialty I could see myself practicing would be neonatology which, as one of the neonatologists I know once said, is in many ways a cousin of anesthesiology. But that wasn't on the UVA test.

Inside the G-20

One nice thing about living in anonymity in a sleepy little Boston suburb, remarked my husband facetiously this morning, is that when a high-ranking U.N. official comes to your house for dinner, he doesn't need an armored car.

Our friend had glowing reports from his colleagues about our president at the G-20 Summit.  "He's not just intelligent," he said.  "The man is talented.  It was he who was able to bring conflicted heads of state together to the table for dialogue during the summit.  We haven't seen that kind of leadership in years."

That's because that kind of leadership takes vision, motivation, and skill as well as intelligence and talent.

Nice to know we've finally elected someone who can interact productively on the international stage.  Believe it or not I don't agree with all his views, but I do think we need an effective communicator (and thinker) out there, especially in times like these.

A Doctor at Calvary

Among the Catholic High Holy Days, Palm Sunday has always been my least favorite.

Ordinarily I cherish liturgies in which we can enter fully into story and ritual, and really inhabit a transcendent moment.  But for years I've resisted the liturgy of Palm Sunday.  Who wants to enter into the story of a tortured political pawn, especially in the role of the crowd clamoring to crucify him (the traditional role for the congregation during the interactive reading of the gospel on Palm Sunday)?  It's so unspeakably awful; the last thing I want to do is wallow in it.

Part of my aversion stems from having read the gruesome book A Doctor at Calvary by French surgeon Pierre Barbet, (literally) a blow-by-blow analysis of the physiologic sequelae of

 Christ's Passion.  I read it in high school.  Perhaps I shouldn't have.  But even back then, years before I realized I would eventually gravitate toward medicine, the vulnerability and complexity of the living and dying human body had me mesmerized.  

Even now, years later, it's hard to be confronted with the Passion narratives without the thought of Christ as a doomed patient who suffered a fate worse than death before finally dying in one of the worst ways imaginable.  I'm amazed he had the presence of mind even to recite psalms as he did.  If he had been taken down from the cross and brought into my O.R. for resuscitation, I don't know if we could have saved him.  The only thing going for him would have been his NPO status.  He would have had significant fluid losses thanks to the Roman flagrum; his electrolytes would probably have been off-the-charts; he would have been hypoxic and hypercarbic from the slow suffocation caused by hanging on the cross; he probably had a hemothorax or hemopericardium restricting his cardiac output in an already shock-prone or shock state.  Maybe intubation, large bore access, blood transfusion, inotropes, and pressors would have helped, as they do help some trauma patients.  Maybe.

To be honest, I can get distracted identifying with what I imagine to have happened to him.  The excruciating agony of nails being hammered through bone.  The muscles cramps. The claustrophobic sense of panic at being pinned to something in an uncomfortable position. The unrelenting pain of head wounds, scourge wounds, bruises from beatings.  The asphyxia.  I can't get past these very physical, physiologic things.  The theology holds no meaning and no promise for me in the context of such brutality inflicted by human beings on a fellow-human being. 

But today, at Mass, a ray of light got through.

My parish put together a liturgy today that was, in a word, beautiful.  It was the farthest thing from drawn-out and morbid that a Palm Sunday mass could be.  The opening procession was joyful, with liturgical dancers moving up the aisle waving palm fronds and creating the festive atmosphere described in the New Testament for Jesus' entry into Jerusalem.  Then we went straight from the first reading, one of the Suffering Servant Songs in Isaiah, to the Gospel narrative.  

The true gift within that liturgy was the way the Passion according to St. Mark was presented.  We are privileged to have in our congregation a talented and accomplished man named Michael Corso who has learned the Gospel of Mark by heart.  By heart.  He can recite the entire gospel from beginning to end.  Rather than having a bunch of mediocre readers reading the gospel parts from the podium, our pastor asked Mickey to narrate the Passion according to St. Mark from memory, dynamically, while members of the Boston Liturgical Dance Ensemble (with whom I've been privileged to dance on occasion) enacted graceful tableaus of the various scenes in the narrative.  

The effect was stunning, meditative, and haunting.  Although the church was packed with children, you could have heard a pin drop as Mickey, putting his whole heart and soul into the recitation of the narrative, moved among the dancers and across the front of the congregation, sometimes stepping into the role of a disciple or of Judas.  Such a bold way of presenting the Liturgy of the Word could, in less sensitive or less professional hands, easily have degenerated into "cheesiness," but this parish is blessed with fine, talented people who have incredible vision and skill.  

My family and I were there, at the foot of the Cross, transported - not wallowing in guilt or horror as the long reading of the Passion accounts can sometimes lead us to do, but rather truly present in a transcendent moment, one filled with reverence and with compassion for the participants in the story.  Ultimately this kind of liturgy points to the heart of what Catholic faith should be:  reverence for the humanity and intrinsic dignity of the other. 

It was a Palm Sunday to remember.

The Sociology of Blog Hits

Every time my son comes to peek at my blog over my shoulder he asks, "Can we look at your map?"  He loves Clustrmaps.  I agree with Paul Levy that it tends to grow less useful with time, but I can't help but enjoy the visual appeal of it.

My husband took a look not too long ago and remarked, "Look at your dot distribution."

"What about it?"  I asked.

At first all I saw was a distribution of readers of English-language blogs:  lots of dots in the United States, Europe, the Philippines, India, South Africa, Australia, New Zealand, and Canada.  

But when my husband started pointing out places where there were very few dots - notably almost the entire African continent, the cradle of humanity - a different picture struck me.  Industrialized nations showed a plethora of dots; rising economic powers like Brazil had a moderate number of dots; and countries with struggling economies had few dots relative to the populations in those nations.  

I checked out a couple of French-language blogs on Africa just to see if the overall picture was different, but it was disappointingly similar. The Clustrmap seemed to be a geopolitical snapshot that connected computer access, language proficiency, and blog-reading.  Perhaps I am making too much of this, and it's attributable simply to a greater interest in blogs in Europe and North America?  

We're living in the information age. Technology has connected the world more extensively than before, with faster-than-ever communication.  Yet lots of people are still out of that loop, either by choice or by circumstance. Most of us can't imagine life without reading and writing, but the use of literacy to convey ideas rather than just information is a privilege we're fortunate to be able to enjoy. It's a sobering reminder that the opportunity and freedom to do all this pondering and blogging is a luxury, a gift.

Just Another Night

Someone's coding in the ICU.

The patient's been coding off and on all day.

I strongly believe that in most situations we should get to know our patients as best we can. Faces. Names. Fears. Hopes.

On occasions like these, though, we often can't know. We show up because a disembodied voice over the loudspeaker announces the code or calls for "rapid response team, stat." We've never seen the patient before. We don't know his or her name.

Nor, I would argue, should we be expected to take the same approach we would for other clinical care situations. A code is not the time or place to be holistic. A code is about numbers and lists. Blood pressure is 50 over 30. Heart rate dropping to 20, 10, zero. Patient with a history of cardiac disease, asthma, and gangrene or sepsis or bowel obstruction or trauma. The patient does become, for a tense, crucial moment, an amalgam of data points.

And we NEED those data. I would argue that people like me - who do feel pain when others suffer, and cry over individuals and their stories, and long to hold people's hands and offer comfort - need those numbers to occupy center stage during a code and obscure for a moment the identity of the dying person, so we can concentrate on the resuscitation. Names, faces, memories, personal connections - these can be a dangerous distraction.

I watch the monitors while the chest compressions are being performed and the epi and atropine are being injected. I am looking for those numbers to change, willing them to go higher. They are our guide and our visible goal. When someone is dying in front of our eyes, the hard realities of math and science keep us grounded and focused; they're both the bad news and the ally.

A code is the only time I allow myself such calculated distance when taking care of patients. I need that mental space. It's important.

After the code team gets the patient back, the other elements of taking care of the patient return in a rush of feeling. Relief. Concern. Sympathy. Even fear, after the fact.

Walking toward the call room I see the walls of the main entrance from a large window in the corridor, feel the weight of the hospital around me. Outside, traffic is slow; the town is winding down. What must we look like to passersby? Just a pile of bricks and stone, housing the sick? But in here lives are changing. In one window there might be a nurse pounding on someone's chest, trying to defy death. In another, a mother weeping tears of joy over a baby just minutes old. In yet another, an anesthesiologist looking out at the world, missing her family, and thinking of a patient who's hanging on to life by a thread. An ordinary night at the hospital, in other words; just another night.

Diagnosis: Writer's Itch

I've just returned from a wonderful medical writing conference.  Intense and exhausting, but informative and inspiring too!

I met some amazing people there. I was privileged to be in a small workshop among talented writers who are also incredibly dedicated clinicians.  There's nothing like finding like minds who share your passion for something (and encourage your growth in that endeavor).  It's so much easier, moreover, to learn from others in an atmosphere of respect rather than an atmosphere of contempt.  We've agreed to continue trying to support each other's writing through a virtual writers' group.

I even got up the courage (despite my intense aversion to public speaking) to pitch an idea for a book in front of a ballroom full of people, mostly other doctors.  I figured if I could do a mock oral exam in public, I should be able to survive a 90-second pitch. It went surprisingly well (despite the fact that I actually signed up for the "pitch" activity without having originally planned to do so).

Writing is my true love, but I didn't have the courage when I was younger to try and pay the bills with it, so I applied to medical school.  Now that I've immersed myself in a conference that has allowed me to blend my love of writing with my love of medicine, I feel re-energized.  I want not only to keep writing but also to write more.  That's to be expected, of course, with any good retreat or conference; there's an initial surge of fervor in the afterglow.  Let's see if I can keep the pilot lit.

***

Here's a passage from Michael Chabon's Maps and Legends that recently took my breath away:

"I could adduce Kafka's formula: 'a book must be an ice-axe to break the seas frozen inside our soul.'  I could go down to the cafe at a local mega-bookstore and take some wise words of Abelard or Koestler about the power of literature off a mug. But in the end - and here's my point - it would still all boil down to entertainment, and its suave henchman, pleasure. Because when the axe bites the ice, you feel an answering throb of delight all the way from your hands to your shoulders, and the blade tolls like a bell for miles." 

At first I wanted to say, Wait!  Entertainment and pleasure aren't everything!  What about insight?  Then I realized even insight is a reward once-removed:  insight brings exhilaration, which is, in the end, just another form of pleasure - which the language in Chabon's sentences definitely inspired.

Oh, to write like Chabon, or McEwan, or Kingsolver.  At the conference an idea was brought up about mastery: the idea that 10,000 hours of practice are required before a person can claim expertise at something.  Why do I have the feeling that good writing is different, somehow - a little more precarious?  I do think writing more makes you write better, but not necessarily with greater ease, if Hemingway's statement about sitting at a typewriter and bleeding is any indication! I guess that's what keeps people who love to write both challenged and inspired.  The quest for that "truest sentence" never really ends.

Sick

I am sick.

Yesterday at work my eyes were so swollen and my cough so toxic-sounding that even the surgeons were sympathetic. My head hurt. My throat hurt. My joints ached. My nasal passages were so congested I had to breathe through my mouth all day. Sick, sick, sick.

What on earth was I doing at work?

The answer is simple. Doctors don't call in sick. Or, I should say, doctor rarely, rarely call in sick.

We are held to a very high (unspoken) standard of dedication to duty. We are expected to put the comfort of others before our own, our patients' needs before ourselves. If there's work to be done, we are simply expected to DO IT. No right to "go on break" at regular intervals, like some other health care professionals. No lunch if it's too busy. No sleep if there are cases to do at night. And yes, no sick days.

The week after I broke my arm during internship I was back at work, performing my duties with the other arm. No extra time off. No strong painkillers allowed. My boss once hobbled around with a walker after a foot fracture. I've put IVs into my colleagues at work so they could keep functioning. Patient care first, at almost all costs.

There's a stigma attached to calling in sick. You'd better be practically DYING if you do. Even if half your guts are on the floor, you still get a version of the snippy, skeptical, "Oh, OK, MAYBE that's true, so I GUESS we can find someone to cover for you" at many places - by "vibe" if not by verbal utterance.

There are other unspoken judgments that accompany sick calls. That's WEAK, Doctor. Can't you suck it up? Are you as dedicated to your patients as you pretend to be? And now you have to tax your colleagues to do YOUR work FOR you? Weak, weak, WEAK.

I am counting my blessings: I am on call tonight, which means at my current place of work that I don't have to be at work until 3 p.m. So I slept last night and slept in this morning and will rest in bed all day until I have to report for duty. My mother-in-law graciously came over to get my kids off to school.

"Can't you call in sick?" She asked.

"No," I replied, perhaps a little resentfully, blowing my nose.

"That's crazy. You look terrible. Won't your patients get sick too?"

"I can avoid breathing on them and touching them ungloved. One advantage of my particular specialty."

"It's still crazy. You're sick. You should be in bed resting."

"But I'm on CALL. The only thing worse than calling in sick for a regular work day is making someone else do your CALL for you. Doctors don't call in sick, Maman. It's just not DONE. There are patients to take care of, and with two docs out on vacation, we're a little overstretched as it is. "

Doctors don't call in sick because they feel they can't. It's not culturally acceptable - and that's a culture code that's very hard to break, or to change.

But maybe with enough orange juice, Tylenol, and a squirt of phenylephrine into my nasal passages, I'll be better by this afternoon. Fingers crossed.