Role Model

As I am relatively new to the attending physician role, I am still getting used to the idea that my students and residents are watching me.  All the time.  Whether I am consciously teaching them something or not.  I put a great deal of thought and preparation into the didactic talks that I give them, the teaching points to bring up on rounds, and the formal feedback that I deliver.  But I am starting to realize that there are many dimensions to the team’s education that are more subtle.

When I am leading a team of residents and medical students, I am supervising their patient care.  They are absorbing knowledge about clinical judgment, the management of the diseases that we encounter, and integrating their scientific foundation with practical applications.  However, they are also learning the art of dealing with uncertainty and with the infinite variety of humanity.  I feel a responsibility for their clinical development and also their moral awareness. 

While I am on the inpatient wards, or in the residents’ clinic, everything that I do or say communicates something about being a doctor.  My tone of voice can convey respect or exasperation.  When I speak about disagreeing with a colleague, I can be collegial or unprofessional.  I am modeling attitudes for my learners, which may be subconscious to them (and to me) but nonetheless influential as they are growing into their doctor identities.

Sometimes it is hard to avoid mixed messages.  When I stay late at the hospital with my call team, I show them dedication to the job.  But do I also undermine the ideal of work-life balance?  When I admit to not knowing something, does it shake their confidence in me?  Or can we use the opportunity to look it up and promote life-long learning?

Even my lifestyle choices are under scrutiny.  My team knows what I get from the cafeteria or what I bring in for meals and snacks.  It actually motivates me toward healthier eating.  If I spend all day counseling others about their diet, I had better practice what I preach.

It is exhausting to be constantly alert, not only to the high demands of patient care but the role of teacher as well.  I need to keep in mind that my team of doctors-in-training is learning a science and an art at the same time.  They are figuring out how to apply clinical knowledge, analyze data, keep up with advances, interact with people, improve systems, behave professionally, balance their work and personal lives, and countless other complex tasks. 

They are learning through observation.  I must keep all of this in mind, as they are observing me.

Death Scenes

My favorite death scene in literature is that of Kurtz in Conrad’s “Heart of Darkness”.  I am also fond of its parallel in the film “Apocalypse Now”, which is evocative in its own right.  Though not exactly a death scene, I greatly appreciate the death-discovery of Nastasya Filipovna in Dostoyevsky’s “The Idiot”.  That fine novel also includes my favorite fake-out death scene of Ippolit’s failed suicide. 

The winner for best-death-scene-in-a-short-story goes to Kafka’s “In the Penal Colony”.  This is one of my favorite short stories in general, with its fascinating combination of horror and mystical experience.  It speaks to the insight (or lack thereof) derived from suffering.  I have not seen any film adaptations of this story.  If my readers have, I hope they will let me know.

I also enjoy the seemingly random, senseless deaths of Vonnegut.  They are not exactly death scenes, as many of them occupy only a sentence or two.  They speak to the absurdity of life and death, but at the same time reflect a deeper humanity.  Each death is marked by a “so it goes” that strikes me as not quite as dismissive as it first appears.

What makes a literary death scene great?  I am sure that much has been written on this topic.  I simply offer my personal opinion.  I look for a death that is appropriate to the character, a fitting culmination of that person’s arc.  It must be dramatic and memorable.  It must express something in the human condition beyond that individual, something that all of us can understand, whether it repels or attracts us.

I often have occasion to contrast these literary achievements with “real life” death scenes.  Most of us probably wish for as little drama as possible in our own deaths.  A peaceful, dignified passing.  An expected death is preferable in a way, as it allows us to prepare, reconcile with others, plan for those who will survive us, and say goodbye to loved ones.  We may not be especially concerned with the human condition in general, but we do wonder what our own lives mean and what the next stage in our journey might be. 

As a doctor, I have witnessed quite a variety of “real life” death scenes.  Young people, previously healthy, with sudden, shockingly unexpected deaths.  Older people, well prepared and ready.  The drama of heroic efforts to resuscitate cardiac arrests.  The peacefulness of hospice deaths.  The despair, rage and turmoil of grieving loved ones.  Reconciled loved ones, singing hymns and comforting each other.  It is never as neat and tidy as it seems in books. 

Many of us will have no say in how our personal death scenes are written.  There is plenty of unpredictable risk out there.  But there are some things that we can do.  Avoid life-shortening behaviors.  Make advance directives, so that our end-of-life wishes will be known.  Reconcile with loved ones now, before it’s too late.  Reflect on mortality, faith, and the meaning of our lives. 

Guest post

Check out my guest post on KevinMD.com: Social Media's Leading Physician Voice.

You look too young to be a doctor

I walk into a clinic exam room or to a hospital bedside and introduce myself.  The patient looks me up and down and declares, “You look too young to be a doctor!”

There are many variations on this scenario.  Some patients state it as a question: “Are you sure you’re the doctor?”  Some try to guess my age, incorrectly.  Others simply give me a quizzical look.  I interpret it (perhaps over-interpret it) to be a judgment on my youthful appearance.  Behind it, I also see a judgment on my competence and authority.

I sympathize with the patient’s predicament.  He or she is coming to the doctor with a medical complaint or condition, seeking diagnosis, treatment and advice.  It may even be a life-threatening situation.  It is important for the patient to have confidence in the wisdom and experience brought to bear on the case.  I try to understand the patient’s vulnerability but, at the same time, I am bristling at the superficial prejudice that casts doubt on my credentials.

Another layer to my defensiveness is the impression that my female appearance is also working against me.  Although female doctors are becoming more common, it remains a challenge to gain equal status in a traditionally male-dominated profession.  I am sensitive to any suggestion that I am less worthy of the doctor role than my male counterparts.

Many possible reactions come to mind, when a patient remarks on how young I look.  I imagine the critical retort: “Well, you look old and fat.”  Or perhaps the affronted listing of qualifications: “I’ll have you know, I completed my medical training at prestigious institutions!”  Or the harsh reality check: “I may look young, but I’m your doctor, so deal with it.”  Or the facetious admission: “You caught me!  I am actually a college student masquerading as a doctor.”  Or the sarcastic comeback: “Oh, how insightful of you to notice.  You are the first person ever to bring this to my attention.”  Or the self-doubting crumble: “I guess I must be too young.  Maybe I should give up and go home.”

I know that none of these responses is the correct approach.  Simply ignoring the patient’s remark seems inadequate.  I consider a positive spin, such as: “I work out and eat right to stay young.”  I usually go for something more self-deprecating (and truthful): “I can’t take much credit for genetics.  My whole family is skinny and young-looking.”

I move on quickly to talk about the patient, instead of myself.  I do my best to build his or her confidence in me through our interaction.  As we get to know each other, my physical characteristics become less important than my intellectual abilities and emotional engagement.

The important thing, for me, is to figure out what the patient needs from the encounter.  My ego is secondary to discerning the patient’s insecurity and overcoming any potential barriers to a therapeutic relationship.

Learning Languages

Learning languages has always been an interest of mine.  When I am going somewhere new, I try to gain at least a rudimentary awareness of the language.  I consider it a gesture of respect to greet people in their own tongue, especially when I am a guest among them. 

The process also feeds my own curiosity about other cultures.  Languages reveal ways of thinking.  In the quest to expand and deepen my understanding of humanity, new vocabulary and syntax provide a window on new points of view.  Learning a fair amount of French, German, and Arabic and a limited sampling of Bengali, Czech, and Turkish have been a fascinating challenge.

When I had to learn organic chemistry and pharmacology, I approached them as language acquisition.  Chemicals are words and reactions that connect them are syntax.  These sentences communicate knowledge and describe relationships.  Behind them, lies a worldview.  Elements form larger, more complex structures.  What goes into a reaction must come out again.  Processes are directional, occur along arrows, and are spurred by catalysts.

In the world of chemistry, there is building, balance, and progress.  There is also inflexibility, little room for the spontaneous or unexpected.  Descriptions are dry and rational, often lacking a creative flare.  However, even these names hold meaning beyond their surface.  Labeling the gain of electrons as “reduction” inspires a mental stretch and must be paired with oxidation in the necessary give-and-take of natural phenomena.

The names of elements evoke a history of achievement, discovery, and myth.  Many are named after places, such as Polonium (Poland), Ytterbium (a town in Sweden), Ruthenium (from the Latin for Russia), Hafnium (from the Latin for Copenhagen).  Others are named after people, such as Curium, Einsteinium, Mendelevium.  My personal favorites evoke characters in Greek mythology, such as Tantalum, Niobium, Titanium.

Consider also the step from chemical names to drug names.  Chemical names describe components and structure.  They suggest certain characteristics, bonds, and acid-base properties.   When marketing gets a hold of them, a transformation takes place that deviates wildly from the straightforward pathway of chemical composition.  Drug names can be trademarked, patented, and claimed for profit.  They are crafted to evoke feelings and associations in consumers.

When I was memorizing hundreds of these names, my main concern was how to tell Clonidine, Clozaril, Klonipin, Clorhexidine, Clonazepam and others apart and recall that two of these are actually the same compound.  Now that they roll off the tongue, I have a chance to step back and think about how they have shaped my own synaptic connections as I have assimilated them.  And to think about the meanings embedded in another new language.

Confidentiality

I have been reflecting on the issue of patient confidentiality in medical writing.  Cases shared for educational or research purposes are de-identified.  The standard approach is to use initials, not names, and change characteristic features, such as age or gender, if they are not directly relevant to the clinical question.

What about fiction set in clinical environments, in which patients and doctors are characters?  All characters bear some connection to the writer’s personal experience.  They are usually designed to feel “real”, in order to make their stories believable and to communicate some element of human truth.  How can a writer achieve this effect without making characters who are too “real”, traceable to the individuals on whom they are based?

Fiction is preceded by the caveat: any relation to actual persons living or dead is purely coincidental.  However, can we say this with confidence when our characters are influenced by actual persons and intentionally crafted to behave like them? 

Is there a higher standard for coincidence when the writer is also a doctor?  Medical professionals have privileged access to the lives of others and a unique perspective on the human condition.  This exposure can enhance our writing and give our novels insight.  However, much of our human contact occurs in confidence, in the context of private doctor-patient relationships.    Patients who tell us of their personal struggles and tragedies do so for therapeutic purposes, not to become the basis for fictional depictions of struggle and tragedy.

In some cases, we know which patients of ours inspired which characters.  If we are successful at de-identification in our writing, we are the only ones who can draw the connection.  In other cases, the link is obscure even to us.  Characters come into being without conscious attribution to someone we know.  They are composites of our experiences, the essence of many people rolled into one.

It is difficult to tell exactly how others will respond to or interpret our work.  I do try to imagine how my patients would feel reading my writing.  Would they see themselves in a universal sense, in the way that any readers identify with characters who are like them?  Or would they feel used, their personal details stolen or taken advantage of, because they see themselves in an individual sense?

If I suspect that a character or a particular scene would cause offense to a patient or family member, I change it.  Yes, I could exercise my freedom of speech and write whatever I want.  But I also take my professional obligations and privileges seriously.  I aim for my clinical and literary lives to complement each other, not conflict.  And even though my sharing of experiences is not for educational purposes, there is an intention to create something positive.