The Whipple in the Unit

Most of my [15] readers are medical students in your first two years. As you go through school, you will meet wonderful physicians who will mentor you and inspire you and remind you of why you’re here in the first place on those occasions when you get discouraged and forget the reasons. You will meet others who will tell you to get out while you still can and who seem to have lost sight of what a privilege it is to work in this field. Consider the differences between the two as you watch them from a short distance. You have much to learn from both. Below is a brief letter I wrote to a surgeon I worked with during my rotation (obviously NOT a letter I would ever send—just a way for me to get my thoughts down on paper. I often write letters I never send). Without caring at all about my education, he may have actually taught me more than any other person I met over the course of 12 weeks.

I wonder what you looked like twenty years ago. I wonder what you wrote in your personal statement as you applied to medical school and what you said in your interviews when asked “Why medicine?” I wonder if you looked a lot like me.

I think you did. I think your journal looked a lot like my blog. I think your heart was moved by patients’ stories, just like mine is. I think you tried to use your patients’ names instead of diagnoses—that you took the time to sit down on their beds in the mornings and ask about their grandkids. I wish these things weren’t true. I’d like to think you were always the miserable person you are now—the person I dread being in the OR with. The thought that you were once like me makes me shudder. What happened to you? Will it happen to me?

This morning you said “Tell me about the Whipple in the Unit.” I started my presentation in the ceremonious way I’ve been taught: “Mr. O is a 49-year-old man post-operative day 1 status post Whipple procedure for adenocarcinoma of the pancreas…”—you interrupted me. “You can skip all of that. You’ll often find that I refer to patients as ‘the Whipple in the Unit’ or ‘the Thyroid on the floor,’ and if you think that makes me sound like I don’t care about my patients…you’re exactly right. I don’t.” You laughed. I didn’t. I didn’t know how to continue.  “Just skip to vitals, labs, and outputs,” you said with annoyance in your voice—“Tell me only what I need to know.” At least you were honest. But I bet it wasn’t that long ago that you read every note in your patients’ charts, eager to get the whole story and to know them as well as you could. I bet it wasn’t that long ago that you had a heart of flesh instead of a heart of stone.

Maybe you never did. Maybe you were always like this—but what can I learn from that? It is far better for me to imagine you as compassionate and enthusiastic at my age and to be fearful of whatever changed you. It is far better for me to see you as a glimpse of what I may someday become if I do not tread with care. If I imagine that you looked like me, I will spend my years in medicine watchful and wary of things that make me look like you. If I ever see your likeness in my reflection, I hope that I will hang up my white coat forever—for the sake of the Whipple in the Unit and the Thyroid on the floor. 

Time-Out

I like rituals. I like ceremonial things. I like routine and structure. For this reason, so much of the interaction between a physician and patient appeals to me. The acquisition of the History of Present Illness, the recording of the Past Medical History, and the head-to-toe Physical Exam look the same in almost any institution. Documentation varies in method, but not in substance—the SOAP note following a patient encounter has the same format whether dictated, hand-written, or typed. The traditions of Pre-Rounds, Table Rounds, Morning Rounds, and Grand Rounds have been preserved by time, and the Patient Presentation that occurs during rounds will always be an art form.

 Just as the clinics and wards have their traditions, so does the operating room. The Morning Scrub; the Gowning and Gloving of the physician, resident, and student; the sterile Preparation and Draping of the patient…and then my favorite: the Time-Out. It’s hard for me to pin-point why I like it so much. The Time-Out is simply a tradition where we take a break between the completion of preparations for the case and the first incision, in order to discuss the patient, the staff, the procedure, and any concerns. It’s when we take a few seconds away from all of the standardized procedures to remember why we’re here in this operating room at this specific time with this specific human being draped in blue. It’s an opportunity for every person present to be acknowledged by name and purpose, and a time for anyone to express concerns about any aspect of the operation. It’s designed for the safety of the patient to make sure all participants in the operation are on the same page—but I like it because it is sometimes the only thing about a case that differentiates it from the one before and after it. For those brief moments, we mention specifics about our patient—the name, age, sex, and relevant medical concerns. After that, it’s just another laparoscopic cholecystectomy or just another appendectomy, either of which look a whole lot like the ones we did before and the ones we will do again. The Time-Out is a tradition that itself fights against the monotony of tradition—it makes an operation a personal, individualized event.

 As beautiful as traditions and standard procedure are, sometimes they are not possible. Sometimes we improvise. Recently, a child with aspiration pneumonitis and resulting multi-organ failure began to rapidly desaturate in the pediatric ICU. The operating room staff quickly mobilized and moved upstairs—the child was too unstable for transfer down to the OR for a procedure that would provide a detour pathway for her blood to receive oxygen since her lungs weren’t doing the job, even on full ventilator support. So we brought the operating room to her. Her parents and siblings stood by her bedside while pediatricians, surgeons, nurses, technicians, and students filled the room. I counted 33 people in the room. Her well-worn blanky sat draped on the arm of a chair next to her hospital bed. There were fast food bags stuffed in the trash can by the door. This looked nothing like an operating room, yet here we were.

 The unconscious toddler’s father looked up for a moment and freed his hands from the strawberry blonde ringlets he had been running his fingers through while the room filled. He pulled his two older daughters aside. “This is the real deal,” he said. “This is the last thing they can do to save her. Do you understand?” They nodded. “You have to be strong for each other. You have to be strong for your mom. Can you do that?” They nodded again, tears silently pouring down their faces. “Go get some food, and your mom and I will find you in a few minutes,” he finished. They left the room, and he returned to the bedside to tear his wife away from her little girl. That exchange between a man and his daughters stuck with me. This is the real deal…you have to be strong for each other. A Time-Out. A purposeful moment for refocusing in the midst of high-speed chaos. Our own Time-Out followed closely behind. Once the parents had left the room and the sterile field had been created, the nurse called out our tiny patient’s name, her medical record number, her sex and her age. She stated the name of the procedure we were performing and the names of the staff members performing it. At the end of the Time-Out, instead of asking “Are there any concerns?” she simply said, “Of course, concerns are many. This concludes our Time-Out.”

 That little girl is still alive. Every day we check on her multiple times. Every day, new concerns arise. One day, complications in her care led to somewhat of a debate between critical care physicians and the surgery team about what the next best step in her management would be. Four doctors circled up in her room, discussing the little girl as if she were a malfunctioning monitor, and not a tiny person whose vital signs were being read by one. “We have to get her sats up so we can turn the ventilator settings down—her lungs need to rest or this whole thing was pointless,” one said. “Yes, added another, but you’re not going to like any of the numbers on that screen if she has a stroke during the procedure.” They continued…”She’s too sensitive to tolerate anything else right now. She’s in multi-organ failure.” I heard her mother gasp to hold back a sob.

 I walked over to her parents, knowing they had heard every word. A wall behind them was decorated with pictures of a lively young girl who looked so different from the one who had been in a medically-induced coma for days. “I love looking at all these pictures,” I said quietly from behind them. I was surprised when they turned suddenly to face me. They beamed as they told me the story behind every one of the photographs. They were relieved for the distraction that I offered…relieved to have a reason to stop listening to the conversation about their daughter’s medical problems and to tell someone about who she is instead. It was another Time-Out, and I was thankful that they took the opportunity to focus on the child they were fighting for, even when it looked like they might be losing the game. They soon left to eat, and their departure was followed by our own Time-Out and another procedure to improve the flow of her blood as it bypassed her lungs. It was successful, and her vitals are improving as her lungs are resting. There are likely still more Time-Outs available for this family—and they will likely need to use them in coming days and weeks.

 For another family I encountered recently, there are no Time-Outs left. Their teenage son attempted suicide and was ultimately successful. His parents blame themselves. His young siblings don’t understand. We didn’t even get our own Time-Out when we were fighting for the life that he didn’t think was worth fighting for—we don’t in cases like that when we’re racing against the clock with monitor alarms sounding all around us like referee whistles and onlookers’ foghorns and scoreboard buzzers. Game over. I can’t stop thinking about it.

 So I’m thankful for OR Time-Outs. They are simultaneously a part of this process and a break from it. They can bring focus where there is chaos. They increase the safety of our patients. They remind us of who our patients are and of what we’re doing with them. And outside of the operating room, I know that families have their own versions of Time-Outs. They encourage each other to stay strong. They know the person we’re operating on better than we ever will, and they can sometimes only survive the intensity of this whole process by dwelling on who that person is, not on the medical problems that threaten to overwhelm them. They are there for each other, helping each other maintain sanity even when the odds are stacked against them.

 Now for my own Time-Out: I bought my daughter a sprinkled donut with hot pink icing and chocolate milk on my way home from work this morning, simply because I’m glad she’s alive. If we’re blessed with healthy families (and jobs where we don’t work too many weekends), we have a total of something like 1000 Saturdays to spend with each of our kids from the time they’re born until they leave for college. That’s not a big number, and the game could change at any time and leave us with a smaller one. I know that we’re only given so many Time-Outs, and none of us can know exactly how many. Like a suspenseful football game, lives can change in an instant. Team members can be benched, the margins can close, and there may be no more chances to be coached or refocus or change plans. So right now, in this moment, I remember who I am: First, a wife; then, a mother; then, a student and a friend. I remember who’s in the game with me—my husband, my two little girls, my extended family, my patients and colleagues and friends. I remember my value and my purpose in serving those beside me, and I commit to do it well so I have no regrets when the final buzzer sounds. I examine my heart and my life’s work, identify concerns, and address them appropriately. This has served as a lengthy Time-Out for me, and I hope it has for you, too. Now get back in the game. In the words of the OR circulating nurse, “This concludes our Time-Out.” 

M&M

“When one prevents one’s emotions from overtaking one’s rationality, it is called reason.When one prevents one’s rationality from overtaking one’s emotions, it is called compassion.When one can do both, it is called wisdom.”

—Ancient Chinese Proverb

 The surgery department holds its mortality and morbidity conference (known as “M&M”) every Thursday. At this hour-long meeting, attending physicians, residents, and medical students meet to hear and discuss presentations of surgical cases that involved some complication leading to an adverse outcome or even the death of the patient. We were all told at orientation that we must dress professionally for these meetings. At the beginning of the year we all did. I’m the only one who still does—the lone pencil skirt in a sea of blue scrubs. On one hand, I understand—it’s somewhat of a scramble to get back into scrubs in time to make it to the OR by the first case after the conference. On the other hand, I’m not sure that personal convenience should matter so much when we meet to discuss real people whose lives were adversely affected or even ended because of decisions we made. It’s easy to forget what we’re talking about when we sit in Lecture Hall 1 eating kolaches and gourmet donuts while we drink Starbucks coffee, all provided by the surgery department. Meanwhile, upstairs there are 20 NPO patients who have placed their lives in our hands. We talk about what happened to our patients and the resulting complications, and the last line on the “hospital course” slide of the power point often says “The patient expired” after some number of days. There’s that word again. Donuts are easier to swallow when we speak of death that way and talk about patients without using names.

 I learn more from these conferences than I could ever learn in the OR. The residents always give the presentations, and they usually defend their decisions and the decisions of the attending surgeon on the complicated case. Throughout the presentations and even more at the end of each one, those decisions are challenged by other attending physicians who have been surgeons for years—many for most of their lives. The discussion that ensues reveals so much about the “art’’ of medicine (the aspect of it that’s not clearly delineated in a textbook or journal), the whirlwind of real-time decision-making, and the clarity of hind-sight. Participants often show confidence in their thoughts and abilities, commitment to patient care in their discussions of evidence-based medicine, and occasionally even humility in admitting mistakes. They almost always show a desire to know more and practice better. Even though the words we use to discuss our patients are often too “sterile” for my taste, these conferences remind me that these doctors care about their patients—they just express it in a different way than I would. Maybe that’s part of why I’ve decided that surgery isn’t for me. I don’t fit in here.

 Regardless of the medical fields we go into, most of us will struggle with the apparent conflict between rationality and emotion, and most of us will strive for the wisdom to balance reason and compassion, as well as confidence and humility. We often come closer to achieving that balance through lessons we learn from mistakes than through the thrill of success. My hope is that we will not forget that our patients are real people who allow us the opportunity to make those mistakes, and that we will honor them for that gift with our care right now and with our discussions later on. And that maybe we’ll dress up when we have those discussions and stop complaining about the coffee being cold…that we would focus less on our own reputations and more on the lives we’ve sworn an oath to protect, less on being right and more on being wise. 

The Debt

Below is an essay I wrote for a contest. It didn’t place, but it does express my heart.

To my first patient:

You startled me with what you said when I walked into the room.

“Sometimes I feel like I’m a big hunk of meat dangling from a tree, and all you kids in your little white coats are hungry coyotes trying to get a piece of me.”

As I nervously washed my hands, I found myself smiling at your oddly poetic metaphor about life as a patient in a teaching hospital. I was a second-year medical student on the first day of my Internal Medicine preceptorship, and you were the first patient I had ever been left alone with. I felt more like a baby bird needing pre-chewed food than a hungry carnivore salivating over meat. I timidly navigated as you retold an eventful medical history that was punctuated with numerous wartime traumas, and I struggled to keep you focused and on course—you often spent more time discussing the battle itself than the resulting injury and subsequent surgery. Then I fumbled through a physical exam, trying to keep the conversation going so you wouldn’t notice my awkwardness with tools I wasn’t sure I remembered how to hold, much less use correctly. The entire two hours were painful, perhaps for both of us in different ways. When I thanked you for putting up with me and finally turned to leave, your parting words surprised me.

You whispered, “You’re going to be a good doctor.”

For some reason, my mind wouldn’t permit a simple “Thank you” in response. Did you not just experience the same two hours I did? Nothing about this encounter makes me a good medical student—much less a good doctor.

“I’m not sure why you think so, since you know better than anyone that I don’t have a clue what I’m doing,” I laughed—kicking myself internally for challenging your compliment, and longing for the safety of the hallway outside. Your reply was simple.

“Well, you didn’t treat me like meat. Have a good day.”

I’ve always heard that you never forget your first patient. I’m only a second-year medical student, and you were not even technically my patient. Even still, I will never forget you. Your sad definition of a “good doctor” has found a home in my thoughts as I consider my future career, and I have further defined it myself since then with a growing mental list of comparisons between a “doctor” and a “good doctor.”

A doctor says, “I have accomplished much”; a good doctor says, “I have much to learn.” A doctor boasts, “I know all about how to treat this disease”; a good doctor asks, “How can I best help this patient?” A seasoned doctor says, “Years of experience have made me an expert”; a well-established good doctor will always say, “I will never forget my first patient who was gracious enough to let me make mistakes—and the many patients who followed to make me the doctor I am today.” The good doctor recognizes that we owe a debt to these patients—and we must serve them in a way that honors that debt.

A doctor interacts with patients’ physical conditions; a good doctor interacts with patients’ humanity—their diseases, their hopes, their fears, their passions—the entirety of their stories, because we owe them that much. When I examine my own heart’s ambitions and consider my classmates, I realize that we likely all strive to be heroic doctors. Not all of us will be. But the odds that we will encounter heroic patients throughout the years are in our favor. I’m only a second-year medical student, and I already have. You, my first patient, are one of them. I may never do anything worthy of recognition, but if I can see deeply enough to take lessons from my patients’ battles—from the war stories that come from fights with your own bodies—perhaps I can be a good doctor, at least in your eyes. For some of you, this is all you ask—not for total healing from your own scars, but for the opportunity to leave a legacy through the marks you leave on me. These marks, if I allow them, will remind me of your stories and enable me to better serve those who seek my care in your wake.

What an insurmountable debt I owe. It is far more than the debt of an expensive education—I will someday repay that. The debt I will never break free of is the one I owe to you, my first patient—and to each one after who offers a body and a story to me as a living textbook. This indebtedness drives me to compassion and to offer my patients what you all deserve—the best medical care I can provide, as well as a heart that feels privileged to know you and is willing to humbly receive the gifts of your humanity. You are not a billing code. You are not a chart. You are certainly not a piece of meat. You are a person, just as I am a person—and as I seek to offer you all that I can, I hope you know that you have much to offer me. I eagerly accept what you so willingly give, and I thank you for it.

To my future patients:

As I practice medicine as your doctor, I promise to never forget the debt that I owe you for the gifts you give to me—for your trust, your stories, your secrets, and for the privilege of finding fulfillment in my career because of the fellowship that we share. I will give you my best in return. The day that I no longer feel indebted to you is the day that I cease to be a good doctor. May the sun never rise upon that day. If it does, I hope to have the dignity to entrust your care to another, for I will no longer be worthy of you.

Image by © Clearviewstock | Dreamstime.com – Books And Stethoscope Photo

When the Door Closes

Have you ever been bravely holding yourself together while inwardly fighting back tears—and then suddenly lost the battle of the brave face the moment your long-distance run started, or in the instant that the hot shower water hit your face? I cleaned off a young tough guy’s bloody face tonight in a trauma bay. His rough exterior crumbled when his mom entered the room. He let his guard down, and he was no longer the patient I had known for the last hour. I was suddenly wiping blood-mingled tears, and I wondered how well I really know my patients. How often do they cry in front of me? Almost never. How much are they hurting? Most of them more than I can fathom. If I can cry because of bad grades or exhaustion or stressed relationships, are they not crying so much more because of terminal diagnoses and lost opportunities and a sense of loneliness that I will likely never experience? I could provide the most superior care for my patients if I could treat them for who they really are—not just who they show me. The truth is, they don’t want to know the radiologist’s “impression” of the scan—they want to know if they will walk again. They don’t want to hear about the histological findings of a pathology report—they want to know if they are going to live or die. They are far more concerned about accomplishing their own ambitions and reaching their own milestones than they are about the orders and plans we write in their charts. And although they bravely answer our questions and nod their heads at our plans and politely chuckle at our awkward attempts to lighten the load of their situation with humor, I suspect that courageous smiles often give way to tears the moment the doors shut behind us.

The Story

My favorite part about my surgery rotation is getting “consults”—usually Emergency Room patients who may or may not need surgery (my team decides). Why? I get to hear the story. I get to hear a little about a patient’s baseline, normal life, and a lot about the ailment that brings them to this hospital. I get to ask personal questions and learn secrets I would never write about, simply because I’m wearing blue scrubs and have a stethoscope around my neck. What a privilege. When I check on my post-surgical patients every morning before rounds, I ask them about their bowel function. I ask them if they had fever, chills, nausea, vomiting, chest pain, or shortness of breath overnight and if they tolerated their diet yesterday. I ask them if they’re in any pain. A lot of personal questions about their bodies, followed by intimate skin-to-skin contact. It seems so odd that I can invade them in this way without knowing anything about who they are—without knowing the rest of the story. It’s unnatural. I don’t like it.

We recently consulted an oncologist for one of our patients prior to signing her off to hospice care. He wasn’t this patient’s doctor—just providing his services in order to provide the hospice recommendation my team needed. At the end of the note in her chart where he described his conversation with her about her incurable cancer and her willingness to pursue hospice care, he wrote that she would be celebrating a milestone wedding anniversary in two days. There it was—he got more of the story. That’s the kind of doctor I want to be. I hope I never forget that there is more to each of my patients than whether or not they have pooped in the past 24 hours. They are made of memories and ambitions, milestones achieved and milestones hoped for. I hope I always remember to ask about these things. There’s a different kind of healing in these stories, but perhaps it is just as powerful as the healing that my team sends through their veins with pharmaceutical concoctions. It can heal me, too, and anyone else who cares to know the story.

Sterile Fields

There’s a knock at the team room door. A nurse enters. “Ms. A. has expired,” she says, as casually as if she were notifying us that Ms. A was asking for ice chips. Expired. Like a perishable food item. Our use of this word is just another way that we shelter ourselves from the terrifying fact that we are intimately acquainted with human beings. Our job is so much easier if we can just forget about the whole humanity thing and process our paperwork like quality control employees at a food market. It’s so much easier if we assign numbers to our patients instead of using their names.

“467 is in the operating room,” the nurses told me as I looked for the patient’s chart so I could file away a progress note. I realized that I didn’t know whether 467 was a man or a woman. I didn’t even know 467’s name. Meanwhile, 467 was downstairs in a sterile room where skin-to-skin contact is forbidden. 467 was draped completely in blue, with only the inches surrounding the incision site uncovered. Blue. The color of sterile things in the operating room. The color of anonymity. The color that allows us to forget that we’re invading the bodies of living, breathing human beings. The color of Ms. A’s lips as she died alone in her room.

Have our hearts become sterile fields? Sterile hearts make us safe, just as sterile fields shield our patients from infection—but everything within me wanted to take the gloves off today. I wanted to strip away the euphemisms and the numbers. She didn’t expire—she’s dead. He’s not 467—he has a name. We’re not operating on a blue sheet—we’re operating on a human.

May my heart never be “scrubbed in.”

A Time for Healing

A time for healing. If you told me as a college student what the name of my future blog would be, I would probably assume that it would be filled with touching memoirs about the daily work of a physician—healing others. But I’m finding that when I write (which I do far more often in private than I ever publicly post), I write not about the art of healing others, but for the purpose of healing myself. Writing is the cheapest and most effective form of therapy for me. It is the most powerful medication for this future doctor, and in reflecting through words I realize that my patients heal me as much as I’ll ever heal them.

What do I need healing from? Don’t I have it made? I’m married to my best friend. I have two perfect little girls—one three and one who is yet to be born. I am on the home stretch of my journey toward the two most coveted letters at the end of my name. And I am physically healthy, unlike every patient I have seen since I started my third-year clerkships. It would be so easy to just feel sorry for them and consider myself one of the lucky ones. And that’s what I need healing from.

I need to be healed from the illusion that I am not in need of healing. Join me. These are only semi-private rooms.