The wisdom of an older generation

I was talking to one of the Asian attendings in the hospital a few days back, and he was giving me the first generation perspective, where I was offering back the second generation perspective, and he pulled me aside in the hallway and leveled with me.

"These people in the Midwest, they're friendly. They seem nice, but don't be fooled into thinking you're one of them, because no matter how much you act like them, all they see is your skin and your eyes."

This isn't the first time that I've heard this. It's a rallying cry for first generation immigrants. I used to think that this was paranoia or misunderstanding, but as I've gotten older, I've realized that it's true. I'm not white. I'm not one of them.

Even though I love the Midwest, I'm thinking about the East or West Coast, somewhere where it's a little more normal to be Asian, because as much as I like to think that I'm just another guy, I'm the Asian guy. And it's not that people are trying to lynch me, but it's a very subtle recognition that I don't belong here.

Loved

My family visited for Thanksgiving, and my GI system has forgotten what it's like to eat nothing but Asian food. I'm gassy and my stomach is a mix of hungry and bloated. I haven't slept in my own bed in days, and I haven't had a moment of privacy except in the hospital of all places.

Still, I miss them now that they've left. I'm not a very communal person. I'm very hermit-like. So it's not my thing to hang out with random people. But family, family loves you, and it's always bearable to have family present. Family does little things like make your bed with hospital corners, or vaccuum, or make you dinner after a tough day in the hospital.

Family listens to your troubles and is always rooting for you. It feels nice to feel loved. There really is no substitute for that. My mom wants me to date and get a girlfriend, but I reserve the right still to be picky, because it's quite a wonderful thing, to be loved, and I don't want to waste that.

Thankful

I guess that Thanksgiving is supposed to be the time when we say what we're thankful for. And people in their blogs I'm sure wax philosophical about what thanks means and the ways which we give thanks. Here's what I'm thankful for: turkey, parents who feel the compulsive need to clean, having enough money that even the craziest black Friday sales aren't worth waking up for, not having to work on Thanksgiving, and svelte women that wear tight shirts. Thanks.

Transference

While I was reading another blogger's discussion about malpractice, I realized that there are certain things that are true about a lot of situations where people threaten litigation.

In my experience thus far in residency, the most common occurrence where litigation is threatened is the angry family, where no malpractice has been done. It's just an irate family, entirely unsatisfied with perhaps even the best of care.

I've had families where we diagnosed small cell lung cancer, and simply that piece of knowledge prompted the family to yell at me for 40 minutes, threaten to sue me personally, my residency, the hospital, and the nursing staff.

And this is just my observation, and probably not that generalizable, but the worst of them seem to be families with guilty consciences. Maybe they didn't love their father like they should've. Maybe they should've visited mom at the home more often. Maybe they shouldn't have yelled at their sister and called her a whore before she went into a coma.

And transference is a bitch, because it's so easy to shift all that guilt and self-loathing to the doctor. He's the lightning rod, and it's easy to dump on him. He should've done a better job, worked harder, developed godlike powers to miracle heal. And you know, sometimes, I don't mind.

So, I try to work with families and get them to understand things, because it's important for families to see, especially in terminal situations, that I am also in up to my armpits. Families need to see that someone else cares. Because for all of medical technology, we have little power over disease, and even less over life. I had one patient who just wanted to die at home, and I could not even give her that.

Most families are fine, despite the worst outcomes. I've had grim discussions with families who shed their tears and thanked me for telling them it was okay to pull the plug. And it's touching to see a patient's family who loves him enough to let him die.

But to those families who feel the relentless need to find fault with everyone involved, and blame doctors or nurses or the whole profession (excepting those where we have earned such blame), please realize this: what we can do with medicine, what we can offer is not playing catch in the backyard or teaching to ride a bike. We can't offer family vacations or Thanksgiving gatherings. We can't save everyone. We can't turn back time. We can't forgive you.

Feel free to yell at me all you wish, but please remember that all the yelling in the world won't make you feel whole inside. I know that for sure.

That holiday between Halloween and Christmas

I just wanted to wish you all a happy Turkey Day tomorrow, and mention one thing that's been bugging me, and it's been getting worse every year. People keep celebrating Christmas earlier and earlier, to the point now where the day after Halloween, everyone's got Christmas decorations up. It seems like no one remembers how to celebrate Thanksgiving.

First off, Thanksgiving is the best American food related holiday that we have. But more importantly, what it means. It's a chance for us every year to give thanks for what we have and spend some time with loved ones. It's an important day, and people are so eager to skip over to Christmas.

So if you're one of those store owners and you've been playing Christmas music in the malls and grocery stores this November, screw you, you bastards. You've made my shit list. Just because there are no catchy Thanksgiving songs doesn't mean that Christmas gets to come any earlier this year.

Happy turkey day!

Aaaaaaaaaaauauuuuuuggggghhh

Dammit, dammit, dammit, dammit, DAMMIT

I'm rich

I've discovered during my residency that there are several residents with wives and children (as in multiple offspring) and they seem to get by okay. Compare this to me, where I have a car payment, an apartment payment, and not much else. I'm rich.

Having made this realization, I've been a little more liberal with my spending. I'm so used to my medical school days where I never knew when the money was coming, or how much of it I'd get. I'd put everything on the credit card and pray that I had $5 to buy ramen noodles for the month.

There really is nothing quite so humiliating as medical school. It's a process of taking away a person's self-sustinence, pride, relaxation, and joy, and replacing these things with fear, inadequacy, and rejection. In some ways, it might be considered torture by the Geneva Convention.

I'm glad to be done with medical school and earning a steady paycheck. I've wasted quite a bit of money on things, but sometimes, things make you feel a little better about life, like buying that camera I said I'd buy myself when I was a doctor, or living in my own apartment alone again, and very comfortable.

Pimping

My current attending loves to pimp, and he's good at it, and I know most people would hate that, but I loved it. It was fantastic fun. it's so refreshing to be put on the hot seat again. I'm asked questions by other attendings, but it's more collegeal than instructional. Should we increase fluids? Did you check a TSH? It's nice to get something more basic. What's the most common peripheral neuropathy? What's the sensory innervation of the thumb? What are all the diagnostic criteria for type 2 diabetes?

Believe it or not, there is an art to pimping and an art to being pimped. And there are attendings where your admission of ignorance is welcomed, and others where it is an invitation to disaster.

Personally, I really enjoy being pimped by the right folks, because when done well, it feels more like a conversation than education, and I'm sure Socrates would be smiling up in Heaven, if not for all that hemlock business and not believing in God and all.

For your benefit, here is a treatice on the art of pimping, published in JAMA.

Target heart rate

So, I finally decided it was time to start working out again. My apartment complex has an exercise center that's actually pretty comprehensive. I was surprised, and felt a little sheepish that it's taken me this long to make use of it.

I got on the treadmill, and using my m4d d0ct0r sk1llz, figured out my target heart rate. For those of you that are curious, your maximum heart rate is 220 - age. Ideally, cardiovascular exercise should occur somewhere between 60 and 80% of your maximum heart rate. That's why stress tests aim for 85% maximum, and why a stress test that doesn't achieve at least somewhere close to 80% is worthless.

Anyway, my target HR was between 140 and 160, roughly. Well, I achieved and maintained that HR on the treadmill at the blazing speed of 3.5 MPH. I think the girl running at 7 MPH next to me must've worked pretty hard to contain her laughter. And this is why I don't go to gyms.

A girl's pen

I was out with one of my friends, and I was showing off my latest purchase, my new Waterman pen.

me: This is my new Waterman. $50. Worth every penny.
friend: ... dude, is this a girl's pen?
me: ... fuck you.

The art of medicine

There are some things that other doctors look for when they want to find a good doctor. And it's not that guy that bitches about his patients and has MD on his checks and credit cards and on his vanity license plate.

When I'm looking at other doctors, I'm looking for that guy who loves the pathology. He gets excited about hypertension. He dreams of gallbladders. He can give a 20 minute impromptu lecture on nephrolithiasis. He knows his shit and he knows it because he loves it.

He fears the white coat. He doesn't splash his doctor title around like a piece of fancy jewelry. He respects the meaning of it, what it means to patients. Just being a doctor means a lot, a fucking lot, to people and he takes that responsibility seriously.

But I think most importantly, he understands that there's a science to medicine, and then there's an art. Science is all about data and studies and biochemical markers, and that stuff is great. Fantastic. But the thing about medicine is that you don't treat test tubes and beakers. You treat people. And in any field where you work intimately with people's lives, there's an art to it far above what science can offer.

Because there's no textbook on how to deal with that confrontational patient who's fighting your every move because she's lost complete control of her life and she's grasping for any amount of control that she can get, even if it's refusing her morning labs. There's no multiple choice test that will teach you when a 96y/o demented lady should get a PEG tube and when she needs Hospice. There's no lecture that can prepare you for telling a patient's family that he's going to die, not in a month or a week or a couple years but today, this afternoon.

After I did my first family meeting where I was the doctor, I was the one delivering the bad news, I grew up that day. Understanding the biochemical mechanism of neosynephrine doesn't make it easier to tell some poor lady's husband that it's the only thing keeping her alive.

And I sat there for what seemed like 10 minutes, not saying a word, letting the patient's family cry and sob, letting them grieve, and I knew that 12 months before, I would've blabbered on incessantly, but that day, a voice inside my head said, "Shut the hell up. There's nothing you can say that will somehow make death more palatable."

And so I offered tissues and a shoulder to cry on, and I had the nurse titrate off the levophed and neo. And I'll be damned if I didn't feel like a doctor that day. Because any idiot can read the studies and order the tests, but there's no randomized, double-blind, placebo-controlled study that can teach you how to be a caring human being. And sometimes that hurts, but it's a good hurt.

And the only word of caution I offer is this: at some point, you will realize that you've nothing left to give. You've poured yourself empty. And that's good, because it's then that you'll realize that you're not in the practice of medicine to give yourself. You give medicine. That's the art.