No Words

The Virtues of Appropriate Fear

Anesthesiologists shouldn't "scare" easily but they should "scare" appropriately. That is, an anesthesiologist needs to be able to keep functioning under stress, with as much calm, composure, and efficiency as a situation will allow, and call for any necessary help without reservation in the face of danger; but he or she also needs not to be so cavalier or arrogant as to be dismissive of extremely tough clinical situations, or be in denial that such situations are, in fact, frightening and dangerous.

Three examples of the latter come to mind - situations which have always commanded, and forever should command, a clinician's humble and healthy respect: 1) the potential need for intubation of a pregnant woman 2) the neonate, infant, or child in distress and 3) possible airway loss in a patient whose jaw has been wired shut.

In the last several weeks we had in our recovery room a patient whose clinical situation and appearance after surgery were something like this (this is the closest comparable illustration I could find on Google Images, from this paper in the Journal of Oral and Maxillofacial Surgery):

His lower jaw (mandible) had been secured to his upper jaw (maxilla) with a combination of wiring and elastics, and by secured I mean fixed SHUT. After surgery he was kept sedated for comfort and the breathing tube he had in his windpipe through his nose was kept in place.  The swelling of his cheeks and lips was severe, and any doctor, nurse anesthetist, or nurse who saw it would have had, as I've outlined above, what I like to call a "healthy respect" for the state of his airway. This is a potential life-threatening nightmare waiting to happen. When you are on call for the night and a patient like this is in the PACU waiting to be transferred to ICU you hope to God, even if you're not sure God exists, that all goes well and the breathing tube stays where it's supposed to. Fortunately he was transferred to the ICU in stable condition, and the night passed without incident.

As did the next night.

On the third night of his ICU stay my beeper went off at about one in the morning with a stat call to the ICU. I talked to one of the nurses on the phone and she said, "It's the oral surgery patient. He bolted forward and self-extubated."

I ran to the ICU and found this young patient grey as a storm cloud, with a low heart rate and, according to the monitor, the lowest oxygen saturation I'd ever seen in someone who wasn't dead. The covering night physician for the ICU, two respiratory therapists, and four or five ICU nurses were around the bedside getting equipment ready and assisting each other with resuscitation maneuvers.

"What do you need?" one of them said.

"Cutters," I said immediately, followed by, "Suction. Scope. Meds."

I immediately starting cutting the jaw securements, thinking all the while, "The oral surgeon's gonna kill me, but oh well." Fortunately a video laryngoscope was at the bedside and I was able to insert it into the patient's mouth and within a few seconds visualize the epiglottis and glottic opening clearly. The breathing tube had indeed slipped out and was dangling behind the arytenoid cartileges.

"Do we have any nasal RAEs in here?"

"What's that?"

"Never mind. Magills."

Someone handed me the bent forceps we use to advance nasally placed tubes through the vocal cords. Fortunately for us the patient's youth and vigor meant that even with sedation he was attempting to draw breaths, and with the laryngoscope blade lifting his epiglottis, these breaths were actually helping to improve his oxygenation even with the breathing tube dislodged.

I maneuvered the tube just to the entry point into the trachea, then manually advanced it in. With the breathing tube back in place his oxygen saturation came back up to 100%.

Once we felt the situation was stable we all took a deep breath, then called the oral surgeon, who came to the hospital immediately and re-secured the maxilla and mandible.

Honestly? I was SCARED. But you know what? I was supposed to be scared. There's a bad kind of scared that paralyzes you and makes you incapable of thinking clearly and doing what you need to do, and a good kind, the kind that removes any possibility of complacency or denial that something bad is happening right in front of you (pompous Downton Abbey doctor, anyone?).

We need to de-stigmatize the word and idea of fear a little bit and realize that not all kinds of fear are harmful or bad. Some fear is healthy and can actually protect people.

The Other Side of the Drape

My son had been having episodes of belly pain right around his belly button for several weeks. I watched and waited. Between these bouts of mild abdominal pain he was completely fine - healthy appetite, active, happy. But I had a feeling something was brewing. I was waiting for the other shoe to drop. The disease finally declared itself: several nights ago his belly pain was severe and unremitting. He was in tears. He couldn't sleep. The pain had shifted a little bit to the right. Sometimes walking made it worse, and when I examined his abdomen, pressing on the area and abruptly letting go increased the pain. Yet he was also able to tolerate the pressing, and to hop up and down on either foot. Still, I was pretty sure of what he had. It was time to take him to the hospital. Appendicitis.

"Where would you rate your pain on a scale of 1 to 10?" asked the E.R. nurse at our local hospital.

"Um...6.5," my son answered. His dad and I had to chuckle. This ultra-mathematically-precise answer was so in-keeping with his personality.

Some community hospitals evaluate and treat appendicitis in children but many refer patients directly to Children's Hospital, as ours did. I was glad of this; it's a terrific hospital, with complex, well-oiled systems which include not only health care delivery but also family and child supports. But I was also a little nervous. I had learned to anesthetize children here, and the training process had been demanding. I didn't know what it would be like to be on the other side of things.

My son and I walked into Children's just after midnight. It should have felt like home turf in a way, but it felt utterly foreign. We were led straight into an exam room. A strikingly beautiful pediatric resident came to interview and examine my son and did the same exact physical exam I had done at home. His peritoneal signs (i.e. symptoms that suggested an irritated abdominal lining) were even less prominent in the emergency room, and he had no real fever and an only slightly-elevated white blood cell count. I was concerned that the doctors there would lean toward discharging him, but I had a strong feeling we needed to be there for the long haul. The pediatric emergency medicine fellow came to see him as well. She repeated the questions and the exam. I can see now why this process can be irritating to family members who may not be familiar with training institutions. Can't the senior people just get the info from the junior people? Why do they have to ask the same questions and repeat the exams over and over? The answer is that doctors have to practice seeing with their own eyes, touching with their own hands, and knowing with their own inquiries. They can't just take someone else's word for what's going on with any given patient.

At 3:15 we went up to get an ultrasound of his abdomen. The radiology fellow seemed to be the serious, soft-spoken type (or maybe he was just quiet due to the time of day?), focused, with a cerebral air and a gentle manner. I watched as he scanned my son's belly, right kidney, left kidney, bladder, mid-abdomen. He pressed hard several times on a spot just to the right of my son's navel, and each time my son would wince or say "ow." After 45 minutes the fellow said he was 90% sure it was appendicitis, but it was hard enough to see the tip of the appendix that he was going to recommend a CT to confirm. "Usually it's a point of pride for me not to have to jump to CT confirmation, but in the interest of certainty I think I need to swallow my pride and send you guys to CT just to be sure." I was already sure, based on everything that had happened, but I respected the self-effacing and careful way he was willing to place my son's well-being ahead of his own professional "image" which, in my opinion, wouldn't have been

diminished anyway.

The E.R. nurse wheeled my son back to the exam room in the emergency department to await the next step. When we arrived he thanked her for transporting him. With a look of amazement she turned to me and said, "Who has such nice manners at four in the morning with belly pain?" I was so proud of him for staying sweet and patient despite his fear and discomfort.

The pediatric resident came in again to let us know they were in talks with the surgical team to see if the surgeon wanted to wait for CT confirmation or go straight to the O.R. based on the exam, labs, and ultrasound. We waited another hour after she left. My son confided, "Mommy? I'm worried about the surgery." I reassured him there was nothing to worry about: we were in one of the best hospitals for children in the country, perhaps in the world, and I trusted the surgeons and anesthesiologists there to take good care of him.

What reassured him most, however, was actually meeting his surgeon, a man who will be on my love-forever list for making my son feel instantly comfortable and for saving his life. We forget, when we are involved with several appendectomies a week most weeks out of the year, and it's one of the most bread-and-butter operations performed, we forget that these operations literally save patients' lives. Without them, patients risk dying. As my consent form read, "Alternatives: none." Our surgeon didn't want to wait around for a CT. He agreed with me. Everything pointed to appendicitis. He was going to bring my son to the O.R. to take his appendix out.

The surgical resident came to have me sign the consent form. By this time word had gotten around that I was an anesthesiologist, and that I had done some of my training there. Every new person who introduced himself or herself to us mentioned this to me. I had to smile when the surgery resident ACTUALLY USED HIS STETHOSCOPE and listened to my son's heart and lungs. He truly would not have been breaching any care standard if he had deferred the heart and lung examination at this point in the process - we were going to the O.R. regardless of what how heart and lungs sounded - but I appreciated this gesture.

We were transferred up to the O.R. holding area where my son changed at last into a hospital gown. His belly pain had been waxing and waning throughout the night, but now the pain was increased and holding. "Now that we're taking it out, it's making its last stand," he said good-humoredly through his pain. To my delight the pediatric anesthesia fellow on-call that night was a friend and former colleague of mine, and the anesthesia resident on-call was someone from the program that had trained me, which made me feel very comfortable because I know those residents are HAMMERED into doing the right thing for their patients from the first day of training. I knew these two, and their attending anesthesiologist, would all take very good care of my son.

And now came the hardest part: waiting. Waiting sucks. It was six in the morning. Even though all I wanted to do was sleep, I could only doze off for about twenty minutes. I wandered aimlessly through the parents' lounge. I watched the slice of sky between buildings outside the window change from black to grey to light blue as dawn broke over the city of Boston. Over an hour later the liaison called into the operating room for an update, and the specimen still hadn't been taken out of my son's body. I found that a little worrisome. Another colleague who was working in a nearby ICU stopped by to visit me after his morning rounds. Facebook friends were sending volumes of good wishes. I felt incredibly uplifted and supported but every clock tick was like something poking me to remind me that all was not yet well. It was like waiting for a plane to land and fearing that something might still happen.

Finally after about two and a half hours the surgeon came out to tell me they were done and my son was in recovery. The appendix had not perforated but it was one of the nastiest he had seen in years. It had been walled off under scar tissue from my son's body's attempts to defend against its brewing trouble, hence the equivocal nature of his peritoneal signs. The appendix was snaked back up behind the liver and toward the side, and it was large and gangrenous. They had had to widen the umbilical incision in order to be able to get it out. The surgeon showed me a photo (shared here with my son's permission):

That's when it hit me. My son could have died. Without this guy, and the other members of the surgery and anesthesia and nursing teams, or if we had been dealing with this 150 years ago, my son likely WOULD have died or at best gotten very, very, critically ill. ICU ill. It's a chilling and humbling thought.

My son did very well. He was lucky to have a room to himself when he went up to the floor. My husband and I got a tour of the place, which was clearly designed to be as family-friendly as possible, and every time we walked by his doorway my son would give us a sweet, wan smile from his sick bed. We watched "A Bug's Life" and "The Princess Bride" while my son had some Jello and mac-n-cheese and I had salads from Au Bon Pain, which at children's is a 24/7 operation. I had to go home for the night to rest for 24-hour call the next day, but my husband stayed with our son overnight and was able to take him home the next morning. My son never once forgot to say "Thank you" to his caregivers whenever they did something for him. Before I left for the night he even thanked me for bringing him to the hospital. I am grateful for his sweetness, and for the wonderful individuals who saw us through his first major ordeal. We owe them all a debt that I can only repay by trying to be for my patients what they were for us.

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Addendum 3/14/12: My son's thank-you note to his surgeon.

Haunting Music

Today in the hospital we were all surprised to hear strains from a harmonica playing "Somewhere Over the Rainbow," "Silver Bells," and other gentle favorites in the preoperative holding area. It was a patient playing in his stretcher - hospital gown, I.V., and all. Hearing soothing music played live in a setting in which such a gift is completely unexpected is indescribable. When he came out of surgery he played again. We could hear soft harmonica music from the area in the recovery room reserved for people who are going to be fast-tracked home. What a beautiful visitation for our not-so-hallowed halls. I have permission from "Harmony Hank," as I'll call this patient, to share this memento of those moments here. On rare occasions, magic does happen in the hospital!

***

There are some works of art that have captured my heart forever and will always be on my list of favorite or "most influential" works or "works I love most."

Then, among these, there are those I cannot, cannot, cannot imagine my life without. They have taken root inside me and are woven into my permanent intellectual and psychic fabric. I cannot shake them. They are part of me. They haunt me. They possess me like spirits inside.

Liszt's Piano Sonata in B minor, which I've recently been re-obsessed with in light of an announcement that Philippine concert pianist Cecile Licad will be performing it in Boston next month, and which I happened to look up TODAY only to learn that it premiered ON THIS DAY in 1857, is one of those latter works.

For me it will always be inextricably intertwined with Frederick Ashton's ballet Marguerite and Armand, and frankly if I didn't know better I would have thought, listening to the music, that Liszt had written it specifically for Alexandre Dumas fils' story The Lady of the Camellias, the subject of Ashton's ballet. I like to think Liszt did have this story in mind; the play premiered in Paris in 1852, Verdi's opera La Traviata opened in 1853, and Liszt composed the sonata in 1852 and 1853 and published it in 1854. Coincidence? Moreover he had been romantically involved with Marie Duplessis, the inspiration for the character of Marguerite Gautier, between 1845 and 1847. Surely the Lady of the Camellias was at least an indirect inspiration to the Sonata in B minor?

Ashton describes seeing the ballet unfold in his mind upon hearing the sonata on the radio. One might say that because he was a talented choreographer he was able to fit the ballet to the music, but once you see the ballet, you realize that it's also the other way around: the sonata follows the story EXACTLY. The best Youtube version I could find is between time index 42:55 and 1:12:30 of this Youtube upload of the documentary Nureyev: I Am a Dancer. Fonteyn and Nureyev, for whom the ballet was created by Ashton, will always be THE Marguerite and Armand, to my mind. Sylvie Guillem may have had more acrobatic technique, but she didn't have the soul for it. Tamara Rojo, though, who recently danced the role in London, may have been able to bring both qualities together - flawless technique and mature artistry. I'd love to see her Marguerite.

As for the sonata, my favorite recording of it is still Alfred Brendel's from 1981, but Andre Watts played a stunning version in Tokyo in 1988, and Evgeny Kissin's is amazing too. The piece epitomizes the Romantic period. It's almost PAINFULLY emotional and unapologetically melodramatic. But it also expresses what we mere mortals have no words to express, and sometimes we need that kind of intensity, especially in a world that holds the UN-emotional - rational and the scientific - so dear.

What is Death

I've only had to declare death a couple of times. Once in a three-year-old and once in an adult. In each case the heart had stopped beating. Death was clear.

Brain death is tougher to cope with, both clinically and psychologically. I imagine it would make anyone want to say, at some point, "Are you sure? Are you really sure? How do you know? How can you be sure?" Some times when brainstem function is gone and seems clearly irretrievable, there remains a good, strong heartbeat. Strong. Vital signs vigorous.

At one point this month, as I often do around Halloween, I was watching an old episode of the T.V. Show Ghost Whisperer. I enjoy ghost stories. I think whether or not one believes in a soul that can live on after bodily death, ghost stories can be interesting and appealing because everyone can relate to the feeling of being haunted or wanting to haunt. Even the impulse to visit places we haven't seen in years is this kind of gravitation toward haunting. The place still haunts us, and we want to return to haunt it for bit.

In this episode the main character, who is able to see and speak to spirits, receives signs and visions from a man whose body is in a coma but whose soul longs to break free and move on. His family is reluctant to remove life support, so he remains tethered, unable either to wander as an earthbound spirit or cross into a realm of peace that lies beyond this world. Every time I walk into an ICU I think of this episode. Even if ghosts and spirits don't exist, how can we know whether some remote corner of a patient's consciousness feels this sense of being trapped, tethered to ventilators and tubes?

If a family makes a decision to release their loved one and permit the life-giving gift of organ donation, I think of how painful it must be to leave the bedside for the last time. I've heard the sobbing of parents and siblings as I've waited to bring a brain-dead person to the O.R. for organ removal. I've watched a woman tearfully thank the doctors and nurses on her way out of the ICU for the last time as she leaves her sister in our care. I've looked down at someone younger than myself, thinking, "Your life was just starting," and felt sick and sad. Yet the automatic drill sergeant in my mind kicks right in: Not now. No time for feelings now. You have a job to do. Make sure all the families waiting for new beginnings today have the best, most well-cared-for organs you can help this patient provide. But I feel sick, I want to say. I want to cry. No. No sick. No cry. You do what you have to do and cry later. So that's what I do.

Anyone who wonders why an anesthesiologist would be needed for organ donation by a brain-dead person clearly has no grasp of what an anesthesiologist's job is. An anesthesiologist's job is to keep a patient's organs well-perfused and well-oxygenated. Usually this is synonymous with keeping a patient alive under anesthesia. In this special case, it means keeping the patient's heart and lung functions stable so that the donated organs can continue to give life in another or several others. I won't lie and say this type of case feels just like any other, even like just another cardiac case. It doesn't. It's strange. The patient is dead in the ways that matter most to his or her loved ones but alive in ways that will matter to others. Dead but not completely dead. I am taking care of a living shell of someone. A body that is dying and that eventually will come to a full stop.

For the anesthesiologist that moment comes when surgeons cross-clamp the aorta (and, if the heart is being removed, cut the heart out). After that, we can just walk out of the room. For the transplant surgeons it's just the beginning; after about four hours of harvesting they must rendez-vous with the organs and recipients at their respective medical centers and keep operating for eight or ten more hours, this time to put the harvested organs into hopeful people who have been waiting for this new start. For us, though, it's time to turn off the machine and leave the patient behind: the only time we ever leave a patient unattended in the room. This always feels eerie and wrong, but after all, what is there to do, when there is no beating heart left, no circulation, no breathing? And at some point, there is an almost-palpable change in the energy in the room. The person does indeed become a shell, with none of the vibe given off by a living individual.

Afterward all sorts of thoughts swirl around. What if that had been my loved one? Or me? What would I have wanted done, or done differently? I had ice cream last week. I hugged the person I love most in the world last night. This person will never do either again. I want to see Florence again before I depart the universe. I want to make croissants from scratch. I want to hear my son play the Bach Double Violin concerto, which he's starting to work on. I want to laugh really hard at a play with my daughter. What else should be on my bucket list? The thoughts just keep coming, when there's time and space for them, and Mr. Mental Drill Sergeant no longer needs to keep me task-oriented.

Organ removal is even more humbling, I think, than cardiac surgery. It's a concrete reminder of our own fragility and our tenuous hold on life. Lately I've been researching my children's ancestry on their father's side as well as mine, and as I go back and back and back many generations, and see birth dates and death dates and marriages - all huge events when we go through them, but mere drops in the ocean of time when you see them listed over the years - I can't help but think of how paradoxical it is that we are so small and insignificant, yet so dear and so meaningful. I also realize that what we pass on in terms of ideas and good actions is so much more important that what we pass on chromosomally. Our lives are so brief, then death comes for us all. There's no avoiding it. This moment is all we have.

Time to go and make the most of it.

9/11

images by Reuters, Doug Kanter, Shannon Stapleton, and Joe Raedle

Moving Beyond Mammy: Why I Strongly Disagree With Some Criticisms of The Help

I read Kathryn Stockett's novel The Help two years ago, when it first became a literary sensation. I loved and was astounded by it; it quickly became one of my favorite books of all time, among novels like Harper Lee's To Kill a Mockingbird, Barbara Kingsolver's Prodigal Summer, Natalie Babbitt's Tuck Everlasting, Marilynne Robinson's Gilead, Mark Salzman's Lying Awake, and now also Sara Gruen's Water for Elephants. It was unexpectedly very personal for me. I grew up in a society where the privileged have help, the help wear uniforms and eat in the kitchen and call their employers their "masters," and in some families the kids are taught "not to get too friendly with the help." I was lucky, though, and had someone like Constantine (portrayed by Cicely Tyson in the photo above): a woman I bonded with who's like a second mom to me, who's now been in our family for forty years and whom I love with all my heart, and who I know loves me with all of hers. Because of her I learned that love transcends a lot of barriers people can try to erect in various situations.

My brief mention of The Help in a blog post from when I first read it in 2009 summarizes the major themes that made me like it so much: "story and story-telling, truth and lies, having a voice and keeping silence and secrets, writing and how it transforms both writer and reader, and the true meaning of dignity and of significance." It's also, one of my friends adds, about "the power you get over your own story when you break the secrets and silence." She and I read it as READERS, I might even venture to say students of literature - but not as scholars of history. For this reason, critics who have blasted both the book and the movie for (supposedly) failing to be true to the historical times in which the novel is set, and for not focusing on Black History and the sufferings endured by Blacks in the South in the 1960's, have irritated me profoundly. The book was not written to be a documentary about the Civil Rights Movement. It was written to be the story of the intertwining lives of three very different, complex, and compelling women. Novels are about CHARACTERS and novel writing is and should be entirely focused on who those characters are and how those identities drive what happens to them.

No one should presume to tell an author, "Your character should have done this" or "done that." Only the author knows her characters well enough to know why those characters do what they do; she then opens up their lives to us in moments, and we can get to know those characters, but not with the intimacy and authority to be able to dictate what their actions should have been. Any such criticisms are projections by readers, which may be out of keeping with the characters' identities and completely untrue to the world of the book. And that, right there, is the problem: people with an axe to grind couldn't accept a CREATED world, the world of the novel, but rather wanted it to be the world as THEY would have it or depict it.

I read the Open Statement to Fans of The Help by Ida E. Jones, National Director of the Association of Black Women Historians (ABWH) and a review by journalist and University of Georgia professor Valerie Boyd, who wrote Wrapped in Rainbows: the Life of Zora Neale Hurston. I sincerely respect the fact that they know much more than most of us about African American history, and I appreciated being educated on perspectives that might not have occurred or been familiar to me, but I couldn't agree with many of the statements they made. Some of them annoyed me because they missed the point, and because by being so ready to criticize the work - perhaps even before reading the book or seeing the film, like some of their commenters, and perhaps because it was not written by a Black woman? - these critics willfully obviated the possibility of appreciating its many gifts.

The ABWH statement asserts, "Portraying the most dangerous racists in the 1960's Mississippi as a group of attractive, well-dressed society women, while ignoring the reign of terror perpetuated by the Ku Klux Klan and the White Citizens Council, limits racial injustice to individual acts of meanness." What a short-sighted attitude. Stockett clearly did not set out to portray "the most dangerous" racists or write another Mississippi Burning. It's unfair to paint her as intentionally "ignoring" the more violent aspects of the 1960's simply because her novel is about the moments behind closed doors, about diaries and journaling, about words on pieces of paper. I thought that was the very beauty of her novel - that it's about these non-spotlighted things. Does EVERY author who chooses to write about Black women have to have a scene in her novel with a burning cross? Is that a requirement? I thought the special thing about this book WAS its focus on the tiniest moments - it's about the little things that aren't so little. The WHOLE POINT of it is that racism isn't just in KKK violence but ALSO, and perhaps even more insidiously, in the fake smiles of the well-dressed hypocrites and the not-so-hidden sneers of day-to-day interactions.

I also COMPLETELY disagree with the description of any of the characters as "asexual, loyal, contented caretakers of whites." There are no Mammies in Stockett's book - just real-seeming, complex women with courage and heart. Each African-American woman in the book had an identity and a personality. There aren't well-developed male characters, but I think it's because another big POINT of this book is the power and impact of WOMEN's relationships with each other - the focus was, rightly, on Skeeter, Abilene, and Minny.

Many object to the fact that a Black male in the book is an abusive alcoholic. This, too, I find immature: the need for only positive portrayals when a given negative element is important to the story. Do people really think just because African Americans suffered for years, and continue to suffer in many ways still, that there were no wife-beaters among them, as there were among Caucasians, back in the 60's? Do all writers have to walk on egg shells and give terrible traits only to white people in their novels? This kind of reverse racism demonstrates some pretty stunted growth. The literature of my own culture suffers from similar post-colonial tensions. Poor us, it cries; look how the Spaniards raped and enslaved and colonized our people, and after them, the British and the Americans. We have to highlight how evil the white people were, and how long-suffering and noble we are. Give me a break. We have to tell the stories as the stories are - that's what writers DO.

At some point, the literature of a people has to move beyond the need to be perpetually and repeatedly social justice literature. Literature should ultimately be about story first and foremost - story and character. I don't think a story about any group is necessarily obligated to speak for "The Experience" of that group; a writer has to be true to the characters she creates, and those characters may NOT be at all representative in the way historical scholars would understand "representative," whatever that means. I thought the women in The Help were all worth "getting to know" for all their different strengths and faults - a sign of good writing and a story worth reading. In the end I always approach novels as being about the novel's characters, NOT about Black people in Mississippi or Native Americans in New Mexico or Haitians in Haiti. In this particular book, the message of having the courage to tell one's story, to use writing as a way of asserting voice, to paint oppressors of any kind as ultimately ridiculous, and to work together in friendship for justice despite danger, comprised such a valuable STORY that I find politicizing it really unnecessary and unhelpful. The characters are strong, courageous, humorous, imperfect, loyal to EACH OTHER, and different from one another. What's so Mammy about that?

There were many other points made in the aforementioned pieces and the comments they generated that inspired only incredulity and disagreement in me. Boyd's soap-boxy review The Help: a feel-good movie for white people can't even leave the anti-white venom out of its title. If a white person wrote something entitled "A Feel-Good Movie for Black People" there would be a public outcry. I am neither a white person nor a Black person and I certainly did NOT feel good about the pain I read about and saw on the screen, but like one African-American woman journalist who left a comment, I felt very good about the love I saw between women friends and the way the women "ultimately save themselves by telling their stories." Boyd's sweeping generalizations and judgments - that Black people would never confide in white people, that no white person would be remarkable enough to earn Black women's trust, that Skeeter was ONLY motivated by ambition as a writer and not by genuine compassion for the Black women working as domestics in her town, that this novel should have encapsulated the experiences of all maids working in Jackson in the 1960's AND been a portrayal of the larger Civil Rights Movement AND (unrealistically) shown a white woman breaking some kind of mold to confront her only circle of friends with their behavioral ugliness - reveal the bigoted stereotypes and narrow view of white people in her own mind. She's supposed to be this accomplished journalist and scholar - yet she can't rise above what one commenter aptly described as "petty grandstanding."

I honestly think a lot of people out there are just plain SORE that a white woman would DARE tell stories from Black women's point of view AND do such an amazing, vivid, compassionate job. Sour grapes, I say. They need to move beyond judging something for what they WANT it to depict and judge it instead by what the author actually set out to do - get into the small moments, the pouring of tea in kitchens and changing of diapers in the nursery, explore the daily moments and relationships in the lives of three characters: Skeeter, Abilene, and Minny. This is what novels do. They are not Civil Rights documentaries. Stockett didn't want to write a novel about the lynching of innocent, persecuted Black men; she wanted to write about courageous, funny, gifted, strong, inspiring women and their friendships, obstacles, trials and choices. I think her incredible writing and her portrayal of these characters has honored women of all races, and she should be praised and thanked for it.

But please don't be like the intellectually lazy commenters under Boyd's review who don't feel like thinking for themselves and have decided instead, based simply on her tirade or other negative hype, to hate The Help already and not bother to read the book or see the movie. Have a little cultural integrity and responsibility and experience the work for yourself, then decide. It deserves that much, if only because it has us all thinking and talking.

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Addendum 8/18/11: for an articulate, balanced, scholarly critical essay on what The Help could have done better, with a concrete and appropriate LITERARY example, check out this wonderful NPR piece by W. Ralph Eubanks: "Eudora Welty's Jackson: The Help in Context." He gracefully avoids undermining his own credibility by not lapsing into shrill, knee-jerk invective and thus successfully invites readers to open their minds and think critically - presumably the desired effect of any good critic.

8/29/11: Another thoughtful critical piece that makes an excellent point.

To Bare Or Not To Bare

Topless sunbathing is widely accepted in France, where we've spent a lovely vacation visiting my husband's family. Our recent day trip to a beach on the northern coast sparked interesting conversations between my daughter and me and between my husband and me.

On one hand, I think the relative absence of Puritanical sexual repression in Europe, as compared to the United States, has provided some advantages. People are accustomed to seeing bare breasts on billboards and other media from a young age. Breasts therefore need not be objects of shock value or secret, horny fascination. Women are allowed to be comfortable with their own bodies - as they should be - and men allowed to be comfortable with women's bodies in multiple ways without having to be so obsessively titillated by the one aspect of them, their sexuality.

On the other hand, I value modesty. I think there's something to be said for being feminine and even sexy without needing to bare all, for keeping private parts private (and thus in some way sacred, and meant for reverent care) and preserving the meaning of intimacy. My husband pointed out, though, that two-piece bathing suits are already immodest; what's the big deal with doing away with the top piece? (He is, of course, half European.) My young daughter, on the cusp of womanhood, sounds torn between two cultures; she was a little shocked at how easily modesty was abandoned here in France, but also admired young women for their confidence in their bodies regardless of body type.

Not long after our trip to the beach I read the current National Geographic article about child brides in India and Yemen. So much in that article dredged up a lot of anger in me - at how girls and women are still seen around the world as possessions or goods for use, whose worth is directly associated with the integrity of their hymens, whose appearance or even presence is often blamed for what is really the uncontrolled lasciviousness and misogyny of the males around them. Are men all over the world really so incapable of controlling their basest tendencies? Really? Can't the rape just STOP already? What is WRONG with people?

In my mind the jury's still out on topless sunbathing. Where it's commonplace and culturally comfortable, there doesn't appear to be a down side, and there may even be many positives. Women's efforts at extreme modesty elsewhere don't seem to quell the animal frenzy that leads to their victimization by stupid, irresponsible, and worthless men. Perhaps if the whole world would just relax about the human body we could all just step back, appreciate it, and take good care of it.

Why I Hate Birth Plans

Recently on a physicians' forum I came across a tragic story about a home birth gone bad. The doctors on the forum were mercilessly critical of the individuals involved, but I couldn't disagree with them. Their tone may have crossed the line from anger over the tragedy into disrespect or even cruelty, but I can't say I blame them entirely - there's a part of every conscientious physician that does get enraged over what's perceived to be preventable catastrophe, and sometimes venting the outrage in private (which this forum was supposed to be), among others who understand, can release some of the tension raised by the story.

There seems to be a wide chasm between expectant women who distrust or perhaps even hate doctors and doctors who see themselves as the protectors of human safety and life and who thus sometimes see such mothers-to-be as close-minded, willfully uninformed, and even selfish. From the physician's point of view, a) "natural" isn't synonymous with "safer;" b) pregnancy causes physiologic changes that can sometimes pose real dangers to mother and infant - DANGERS, not just inconveniences or discomfort; and c) a rigid "plan" for birth is nonsensical in light of the possibility of unplanned concerns necessitating prompt and sometimes life-saving intervention.

Don't get me wrong; I firmly believe in women's right to express PREFERENCES and to have those preferences respected as closely as possible when safety allows. Of COURSE I would never insist on placing an epidural in a woman who preferred to give birth without one. But I resent the kind of pseudo-feminist culture that creates guilt or a sense of "failure" in women who feel they would like an epidural to relieve childbirth pain. I've heard it so many times; a tearful woman saying "I'm a failure" because natural childbirth became medically assisted childbirth. No woman should ever feel BAD about bringing a new life into the world. That, and the social signals that engender it, I definitely resent.

And despite the title of this post, I don't actually hate birth plans. I had one myself. I scrapped it in the end and decided to just trust in the process, and take things a step at a time, and actually have face-to-face conversations with my caregivers, but I did draft one. A birth plan that is meant to clarify preferences is a good thing. A birth plan, written or spoken or just held in one's mind, that is meant to be a binding contract for a physician, come hell or high water, is stupid and ultimately, in my opinion, wrong. The priority should be the baby's and mother's SAFETY, not the parents' "birth experience." If the so-called birth "plan" interferes with safety, it has to go, and any parent who insists on adhering to it under such circumstances doesn't deserve to be a parent. What I hate about certain birth plans is the unspoken attitude or culture behind them that seems to declare that nothing is more important than the mother's "birth experience." This is irresponsible and wrong.

So when a screaming doula verbally abused an obstetrician colleague of mine recently for going to stimulate a baby who was cyanotic and was making no respiratory effort - and when I say screaming, I mean I was three doors down attending to someone else and I could hear her yelling at my colleague at the top of her lungs - I felt the same anger that the physicians on the forum were feeling over the home birth disaster. My colleague was doing her JOB, protecting the baby's life and ensuring the mother's safety, according to standards that have been carefully studied, and here was this medically untrained woman interfering with this physician's care and potentially threatening the life of the child by screaming at the doctor that clamping the cord and stimulating the baby were against the parents' wishes. The baby's safety didn't seem to matter; it was all about the parents' wishes. THAT kind of ignorant, selfish "care" is completely inexcusable, yet in certain circles is glorified and touted as advocacy of women's rights and empowerment of mothers. There's nothing empowering about medical ignorance, stubbornness, or selfish adherence to a dream of a birth experience contributing to a child's death.

Here's what I would want all expectant mothers to know about giving birth at our hospital. Pregnancy may be natural, but it can also be dangerous. If you show up at our door, we're going to bend over backward to protect you and your baby, but we're going to do so according to the high standards of safety to which we've been trained to adhere. Please tell us what you prefer, by all means - we do want to create as wonderful a birth experience for everyone as we can - but we also have to put safety above EVERYTHING. We would be bad doctors, and morally culpable people, if we did any less.

_________________________________________________________
ADDENDUM:
See also this well-articulated critique by an ob/gyn:
BIRTH PLANS: WORSE THAN USELESS.

Anesthesia v. The Joint Commission, Part II

Yesterday's post mentioned that the leaders of this country's most important anesthesia organizations had sent a letter protesting several inane mandates that were being imposed or about to be imposed on anesthesia providers by the JCAHO.

This letter, requesting written confirmation that we anesthesiologists and anesthetists could keep our current, safe practices rather than switching to the suggested idiotic, less safe practices, was sent last December.

Now...let the back-pedaling begin!

JCAHO's response arrived at the American Society of Anesthesiologists' desk just about a month ago, and our anesthesia group has been abuzz about it this week.

The highlights:

"Dear Anesthesia Providers:

...Your letter points out that if specially designed processes are followed to accomplish [the task of pre-labeling syringes], labeling a syringe first and later filling that syringe can be accomplished in a consistently safe manner. [REALLY?! YOU DON'T SAY...?! Is that why we've managed to do this for the last several DECADES?! Imagine that!]

...After discussions with the Joint Commission staff, it was decided that it is beyond the scope of this NPSG [National Patient Safety Goals] to detail all of the various safe and unsafe processes in which a syringe could be filled and labeled. The Joint Commission decided to leave the current NPSG as is, which requires all filled syringes to be labeled, and to remove from the FAQ the prohibition against prelabeling...

As a follow-up to the previous discussion, one exception does exist to the requirement that all syringes be labeled...As long as there is no break in the process, labeling is not required during the administration of spinal and epidural anesthetics and analgesics. [Why THANK you! But we already KNEW that, because to require something so USELESS and intrusive would be completely STUPID.]

...The issue of anesthesia professionals (or anyone for that matter) carrying a medication is left to the individual health care organization."

Thank you, JCAHO, for taking our concerns seriously and realizing the idiocy and lack of groundedness-in-reality of so many of your requirements. Keep up the good work. Maybe if you keep paying attention to what you described in your response as "a number of concerns" voiced by many medical practitioners from many different fields, you can make up for your deficiencies in clinical knowledge and practical imagination with responsiveness to those who actually live and work in the real world every single day.

[Photo source here.]

Anesthesia v. The Joint Commission

The following was written by a colleague who wishes to remain anonymous but whose permission I have to reprint it here. I think it expresses what a lot of people are thinking but can only admit in private.




Dear JCAHO (Joint Commission on Accreditation of Healthcare Organizations, a.k.a. "Jay-Co" to clinicians talking about you or, most commonly, complaining about you):


Over the years I have dealt with your incessant nitpicking by reminding myself that the regulation of institutions responsible for human lives is, in principle, a GOOD THING. I believe in safeguards. I believe in holding organizations to high safety standards. I believe accountability is important.


But over the years I have also wondered how it is that the bureaucrats that come to survey our hospitals can be so unimaginably clueless about the practicalities of patient care. Yes, perhaps they have had clinical experience in the past, are highly qualified (according to you), and have an alphabet soup of degrees after their names that purportedly validate their authority. Yet why do they seem unable to belie the stereotype of the out-of-touch, small-minded bean counter who has absolutely no idea how the real world of caring for patients really works?


You've already received a missive about this from representatives of all the major anesthesia organizations in the U.S., but I feel that their diplomacy diminished the forcefulness their words could have had.


I've gritted my teeth and had to accept the locked anesthesia cart you mandated in the obstetric O.R. despite the fact that if a pregnant woman were hemorrhaging TO DEATH and needed a true STAT C-section, the delay caused by having to retrieve the key to open the cart might actually KILL her AND her baby.


I've rolled my eyes at the various little rules you add each year, with the determination and scrupulousness of people whose mission in life is to add at least ONE new rule each year come hell or high water, even if on occasion one of your commands might, for example, be to get rid of the very form you made us adopt the LAST time you came.


But I cannot, cannot, CANNOT wrap my mind around the completely ASININE prohibition against pre-labeling my medication syringes and against the transport of medicines on my person for the sake of patient safety / emergencies, and the criticism of anesthesia practitioners for not labeling the STERILE syringes of a spinal kit when there is absolutely no discontinuity in the opening of the kit, drawing up of the medication, and injection of the medication into a SHARP OBJECT STABBED INTO SOMEONE's BACK which needs to be done as swiftly as possible once the patient's cerebrospinal fluid is observed leaking out of his or her spinal canal.


You would rather, as I understand it, INTERRUPT a procedure for the sake of a literally USELESS step, CONTAMINATE a sterile kit with a nonsterile label, and risk the injurious complication of arachnoiditis from the ink on a labeling pen, than have a spinal anesthetic performed cleanly, efficiently, and above all, SAFELY.


You would rather I draw medication up into an UNLABELED syringe, leaving it unrecognizable for a few seconds or its contents potentially forgotten, than allow me the opportunity to SAFEGUARD the drawing-up process by making sure my label and my medication vial MATCH. Pre-labeling, by the way, is an EVIDENCE-BASED safety practice, unlike your nonsensical and over-intrusive prohibition.


Most egregiously, you would rather a patient CODE AND DIE during transport than have me carrying with me the very interventions that might save that patient's life. And for what? For the sake of making sure pharmaceuticals are locked away, locked away, locked away? Who is protected by this kind of imbecilic medical tyranny?


The above satirical cartoon sums up in a few seconds why you appear to be almost universally despised by the medical community. Arguably no one is more obsessed with patient safety than an anesthesiologist, and we certainly know intimately the day-to-day practices that safeguard it. Perhaps, then, YOU should take a few mandates from US. You might subsequently find your recommendations and regulations actually having some lasting positive impact and earning something with which you might be unfamiliar: respect.


Sincerely,


An anesthesiologist somewhere in the U.S. who cares deeply about patients and their safety.

How I Spent "Judgment Day" 2011

If you knew, or thought you knew, when the world was going to end, would you change the way you live your life?

Would you spend your life savings and forego career plans? Would you take one last trip to see some places you'd always wanted to see?

I never believed in preacher Harold Camping's prediction that the Rapture would occur today. Even if Jesus himself hadn't said plainly that no one can know the day or the hour, Camping's calculations would still have held no merit, based as they were on a) a literal interpretation of the Bible and b) a calendar that failed to take Dionysus Exiguus into account. But I did follow some of the media coverage around this phenomenon with interest. It generated questions like, "What makes people willing to take such risky actions for the sake of one fallible man's ideas?" and "What would you change about your life if you knew it was ending - SOON?"

I was pleased to realize that the answer to the latter was "not much." I'd still go to work and do my job - but keep it part-time, or make it even MORE part-time. I'd still spend as much time enjoying my family's company as I could. And if today had really been our last day, I would have been truly happy to have spent it as we did today.

My husband and I had a long, relaxing lunch outdoors. The weather was perfect - sunny, breezy, dry, in the 70's. The food was delicious. Later in the day we went to a fair two towns over. I love small town fairs; they evoke simpler times, happy families, and friendly communities with something to celebrate. The best thing about this particular fair was the presence of a book tent, where my husband and I spent contented hours browsing through tables laden with used books while the kids enjoyed the games and rides outside. Back home I concocted some Thai-spiced burgers for a late dinner, and they were yummy. It was a day full of all the things I enjoy and the people I love most. If the world had actually ended, I would have counted myself blessed to have known such lovely moments.

Blog Anniversary - It Kinda Snuck Up On Me!

I can't believe this blog has been around for four years!

I know it's been much quieter lately, but that's been working for me. Not that there's anything too extraordinary going on in the rest of my life right now - other than the usual extraordinariness of my ordinary life. One day I am running to the emergency room to help with a potential difficult airway, anesthetizing a patient for abdominal surgery, or putting epidurals in expectant moms; the next day I have a cake decorating class, or a post office errand, or a movie night with spouse and kids. Life's got stresses, life's got joys, and I'm finding that this kind of balanced, un-remarkable existence is just what the doctor ordered (so to speak!).

It seems fitting, then, that I should celebrate with...

Berry-Basil Guacamole. An ordinary treat with an extraordinary twist.

This is my latest obsession. I had some at my in-laws' and fell head-over-heels for it. I really enjoy this kind of food adventure: take something rather ordinary (mashed avocado), and make it a little special with the unexpected ingredient, a not-your-usual combination of flavors. The strawberry-basil combo is, I must admit, kinda old news; it's been done a lot, as a salad, an ice cream, and even a cupcake. But I still consider it somewhat special.

Let me know if you develop (or have) a good version. Mine is just what you see above: avocados, strawberries, fresh basil, a little diced cherry tomato and onion, and whatever sprinkling of seasoning and citrus juice happens to be on hand and palatable at the moment. Best with my other latest obsession: Tostitos brand Artisan Recipe roasted-garlic-and-black-bean whole grain tortilla chips.

Happy Berry-Basil Blogiversary!

On Advocating For Patients

The following is based on an actual conversation from an evening on call. Some details have been changed.

Situation: Emergency surgery for a patient whose vital signs were unstable and whose mental status was deteriorating.

Doctor: "I have some quick questions before we enter the operating room, and I'll also need signed consent for the anesthesia."

Family Member #1: "Oh, I'm his health care proxy. I can sign that."

Doctor: "All right. Can you tell me about his medical history?"

Family Member #2: "You mean why we're here?"

Doctor: "No, I know that part, but I was hoping you could tell me about his major medical problems. Does..."

Family Member #1: "Oh, I don't know any of that. I'm just the health care proxy."

Questions:

What does the average person understand to be the role of a health care proxy?

What should that role consist of?

Can people really advocate for others whose situation they either are in denial about or don't understand fully?

Family Member #1: "My brother knows some of that stuff, though."

Doctor: "I was reading through some old records. He has high blood pressure?"

Family Member #2: "Oh, no, he doesn't have that."

Family Member #1: "No. Not that."

Doctor: glances at listed hypertension medication in the record

Family Member #1: "He's actually really healthy."

Doctor (puzzled, glancing once again at list of medical issues from previous hospitalizations): "Oh? I thought I saw..."

Family Member #2: "Yeah, he's healthy."

Pause.

Family Member #2: "He just has a little congestive heart failure and some emphysema."

Processing...

The physician ran down a list of specific questions, asking about recent hospitalizations, heart symptoms, frequency of inhaler use, mental status changes, and other medical information felt to be germane to the patient's care. In this situation, however, time was short - surgery needed to be performed as soon as possible. Not only was the information not readily available, but also the sources of information were largely unreliable. Such circumstances can have a significant impact on patient care. The doctor here is responsible for efficient and thorough information gathering and the performance of a proper focused physical exam, but time and available sources can be very limited in situations like these.

Plea: Please know your own medical history, and if advocating for another, know that person's issues as well as his or her medical management preferences. The best care is provided when clinicians have the best information available, especially during emergencies, and sometimes loved ones / proxies / advocates are our only source.

Another Pet Peeve: the Finger-Pointing

People blame anesthesia personnel for EVERYTHING. You name it, they blame us for it. They call us by the umbrella name "Anesthesia" and if there's a problem, it's always "Anesthesia's" fault.

Got into the room late? Blame Anesthesia. (Even though the anesthetist's been sitting at the bedside for twenty minutes waiting for the surgeon or the nurses to be ready.)

Patient craving ice cream when she woke up? Must be Anesthesia's fault.

No more coffee in the break room? It's because of Anesthesia.

Think I'm exaggerating? Spend a day in any O.R. in the country and count how many times someone says, "It's because of Anesthesia."

Why? Because it's easy to point the finger at the people / work / department you understand the least. The practice of anesthesia is poorly understood by people outside the specialty, so it makes the perfect scapegoat for EVERYTHING.

I recently heard about a conversation that exemplifies exactly what I'm talking about. My chief was explaining to some of the O.R. nurses what happened to a patient who experienced a known but uncommon complication from one of the materials used by the surgeon during the procedure.

"Yeah," my chief said, "X event happened after the surgeon put in Substance Y for that part of Operation Z."

One of the nurses replied, "Really? How did you [anesthesia] guys cause that?!"

The attitude is so ingrained people can't even detect the nonsensical nature of their own illogical utterances. *Sigh*

The practice of anesthesia looks easy but if people were to try it for a day I think they'd come away pretty spent. When the endpoint is a smooth course, with "nothing unusual happening," the expertise, planning, and careful execution are easy to take for granted. For the record: we prevent or correct many more problems than we cause. When you hear someone say, "It's because of Anesthesia," think twice. You're probably not getting the whole picture.

Sometimes It's Easier Not to Write

I've been neglecting this blog because I've had some recurrent feelings of annoyance lately, and I like to keep my unsolicited invective to a minimum. After all, when I see whiny complaints or bitter criticisms on other blogs sometimes all I want to do is roll my eyes and say, "Who died and made you queen?"

Still, I can't deny that I have some of those thoughts and feelings too. I got a lot of heat when I disclosed the behind-the-scenes frustration that sometimes gets vented "around the water cooler" about certain less conscientious members of the anesthesia and/or nursing staff at my workplace. Lately the same people have exhibited the same lack of professionalism, not around calling in "sick," but avoiding work while at work (disappearing between cases, not checking in with the person in charge before leaving, refusing to see a patient on rounds twenty minutes prior to the appointed departure time because "it's almost time to go," etc.). And the same loud, obnoxious people who have often pontificated about things they don't know enough to pontificate about have continued to be loud and obnoxious and under-informed.

Then there are the surgeons with narcissistic priorities. Some examples:

Dr. Narcissus: "Can you bring the patient to the recovery room without extubating him, please, so we can get the next case in faster?"

Our team: "No, that's not the safest way to conclude the anesthetic for this patient."

Dr. Narcissus: "What difference does it make, extubating there versus extubating in the O.R. with me having to wait around for turn-over?"

Us: "Extubation is safest in the controlled environment of the O.R. We'd still have to watch over and extubate the patient in recovery. It wouldn't save any time and we'd have less available anesthesia equipment outside the O.R."

Dr. Narcissus: "Bring it with you."

Us: "Huh? You don't seem to be understanding the relevant issues..."

or

Me: "I did something a little different for the anesthetic based on some studies in the British Journal of Anesthesia."

Dr. Contemptuus (looking at patient in recovery room and not understanding that he's actually doing better than expected): "Well, I don't think the patient read that study."

Me: "His pain score is already less than expected considering you cut him open from stem to stern."

Dr. Contemptuus: (shrugs)

Patient: (chatting comfortably with family, laughing, and telling jokes)

or

Me (through the nurse-in-charge): "I'm sorry, tell Dr. P I have to delay his case because I have a hemorrhaging pregnant woman who needs an immediate C-section to attend to."

Dr. Puerilus: "I'm going to call the administration." He proceeds to do so AND to call my chief at home to LIE and say I asked him to come immediately to help with the C-section (only because the surgeon actually wanted to avoid the delay of his own, NON-emergency case).

Chief (to me, on the phone): "Hey, Dr. P said you really need me there. I'm on my way."

Me: "I don't. I never said that. In fact, I never actually spoke to him because I had to run up to O.B."

Chief: "Oh. You mean he made that up?"

Me: "Yup."

Pencil-pushing administrative nurse calling me to ask about delay of Dr. P's case: "I guess I shouldn't be distracting you with this while -"

Me: "While our patient's about to bleed to death and lose her child? NO, I guess you shouldn't."

Pencil pusher: "Well, he's just wondering when-"

Me: "We'll be able to start Dr. P's case once THIS LIFE-THREATENING EMERGENCY is stable."

CLICK.

It's not the clinical medicine that's the most stressful part of this job, though that can be demanding enough. It's the short-sighted PEOPLE.

I've cut back my hours and elected to spend more time enjoying life with my family. Life requires balance, and medicine tips the scales pretty forcefully. So we try as a family to keep the equilibrium. I recently took my daughter to her first Shakespeare play (The Merchant of Venice, with F. Murray Abraham as Shylock), a feminist theater festival highlighting women's rights abuses across cultures, and a wonderful performance of The Fantasticks in New York. My husband and I have had lunch a couple of times, been to the movies, spent some lovely quiet time talking. My son and I have had some time to ourselves. I wouldn't trade any of this to make more money; it's just not worth it. My family's love keeps me going and helps me remember why I need to keep looking past the little frustrations at work and focus on taking really good care of patients and those who love them.

Life in Medicine: A Reality Check

This was posted on a discussion forum for physicians. It's a draft of an e-mail from an anesthesiologist to a medical school applicant who has not been accepted to medical school and has subsequently written to him/her for advice. I've changed the name of the student in question to just "Student."

Many physicians on the forum commented, "I'll sign it too" or "Put it up for all of us to sign" or "You could almost certainly get every doc [here] to sign this" or "It's the truth. She should know the whole story."

The e-mail draft is reposted here by kind permission of its author. I think it's extremely thought-provoking and worth reflecting on, especially by any students contemplating applying or reapplying to medical school.

[Student],

Sorry to hear things didn't go as well as you would have liked this cycle. It is a difficult process and I too had a tough time getting into school. That being said the road is long, hard, filled with debt and financial uncertainty. The federal government and a series of large multi-billion dollar companies provide their CEO's 10's of million dollar bonuses on taking payments and distributing a small fraction of them for your services. This is typically deemed as "efficiency in medicine" but Ii can't exactly see any efficiency out of a $22.2 million dollar bonus to the CEO of AETNA. Everyone says "I can work hard" or "I can get through it", but when it comes down to it you get 8 years into it and you start to see for the first time and question why nurses are running the show at the majority of hospitals, why the lawyers are so "involved" at work, and how no one with an MD after their name ever gets educated about expense, cost, and reimbursement.

The interesting thing about medicine is that by the time you see what it really is you are already committed to it. The paperwork, insurance, and contract negotiations don't show up until you are already in your 30's. Insurance companies establish a team of individuals dedicated to finding reasons not to reimburse your services, fortunately residency and academic medicine protects you from a lot of this, but that soon changes. By this point most people find themselves >$100k in debt and feel that there isn't any other job they are qualified to do which provides some significant barriers to exiting. As a physician you are expected to be the first one in the door, the last one out it, and the ultimate individual responsible yet a body of administrators / insurance companies tell you what drugs you can and can't give as well as what studies you can perform.

To this a lot of people say "but I want to be a doctor and help people" but which type of people do you want to help? When some entitled patient walks in your door and complains about a $20 copay do you want to help them? Is your time not worth $20 after a decade of your life, $200k in medical school, $50-100k into college, and 3-7years of earning less than a first year nurse (out of a 2 year school) while you were in residency? How about when you are anesthetizing a 60yr old HIV positive heroine addict with no veins who thrashes when you attempt to put an IV in? Most people want to run away from that one, but someone has to help her and you happen to be the person on call.

Truth be told, [Student], there are lots of great jobs out there. Jobs where you can come out of college and earn a decent living with less sacrifice of your time, effort, and finances. Dental school is an excellent option. Dentists make anywhere from 150-300k/yr as a 3 day/wk General Practicioner (+/-call). The training involved is 4 years of dental school and 1 year of residency. Endontists make $500-700k/yr working 4 days a wk with 4 years of dental school and 2 years of residency (no call). Now why do they make more pulling/drilling teeth than you do prolonguing lives? You can thank the federal government for medicaid/medicare and the hippocratic oath for your moral imperative. There is nothing like a patient walking into the ER with a tattoo on their arm (tattoos are expensive ranging from $300-800 typically) complaining that they want a prescription for motrin because they can't pay for a bottle at the store (medicaid covers prescriptions written even for diapers). A dentist seeing the same financial complaint for a dental extraction would tell the patient to reschedule.

For a physician to make anywhere near 300k they would have to enter a top-competitve residency at a minimum of 4 years length with what is typically a significant call burden. The only specialties avoiding this are radiation oncology, dermatology, and radiology which have a lessened call burden. The time sacrifice also has social implications as a woman, most people don't like hearing this, but most physicians don't have more than 2 kids. By the time they have time to have children they are typically approaching advanced maternal age (AMA is age 35, residency typically ends at age 30 if no breaks were taken) and the risks start to outweigh the benefits.

Now do I hate medicine? No, actually I am fairly satisfied with my job. I get to take people who just met me then poison them with drugs to slip them into a coma so that they don't feel the lacerations, saws, and needles that we poke into them to raise their overall quality of life. Not only do i spare them the trauma of the experience, I off set my poisons with other drugs to keep the patient alive, well resuscitated, and from going off the physiological deep end. The job itself is amazing, unfortunately it is surrounded with lawyers, politicians, and white haired physicians pronouncing a "follow what i've said not what i've done" mantra while lining their pockets. This is then wrapped around the recent scandals of states equating an anesthesiologist to a CRNA, because 4.5 years of school is just as good as 12. I am actually quite fortunate to have no debt outside of what I plan on marrying into, but have friends with easily $500-600k in debt with the juice running (rates are currently 6.8% on loans). If i could spend all day in the OR and not have to hear administrators tell me about "hospital compliance training" or "annual compensation reviews" or "drug shortages" it would be heaven.

[Student], from what I know about you there were top grades at a good school but your boards were a little weak. You should look at this as a blessing and really review why you are drawn into this and investigate alternatives if you find those reasons wanting. One universal constant in medicine is that people applying to medical school and subsequent people applying to residency don't know a thing about what they are getting into. The only exceptions possibly family of a physician who is open about the experience. Be careful of blind leaps.