Another day, and another senseless act of gun violence.
I sat down tonight to start writing about my experiences working as a locums primary care physician in the heartland of America and the Indian Health Services.
There’s a lot to write about, in terms of the myriad of chronic diseases facing this population and the stressed healthcare services that’s trying to care for them.
Cancer, heart disease, diabetes, tobacco abuse, alcohol abuse, obesity etc etc.
I forgot about one particular epidemic until I received a push notification on my phone about the shooting in Lafayette, Lousiana.
Another city, different from where I’m working but still uniquely American, trying to persevere through violence perpetrated by some who believe was just a person. Other’s who will attest he’s a person who culturually and perhaps legally was allowed to obtain an unneccssary appendage of violence.
In tragedy, the natural tendency is for people to come together.
When it comes to tragedy from gun violence, we seem to grow further apart as a nation, debating the merits of a vestigial amendment. This too, another uniquely American reality.
Another shooting and another night of mourning.
Empathy is a big topic in medical education. How do we teach and nurture it in the next generation of doctors? Personally, I’ve noticed that students and residents with personal experiences as a patient often “get it.”
I’ve had a few personal experiences as a patient and I think it’s helped me gain perspective. Fortunately none of my experiences were life threatening, but one them did leave a big impression.
In the fall of 1991, I woke up on one morning with a strange sensation. I had difficulty speaking and drool was intermittently falling from my mouth. I wasn’t in any pain and I remember finding the experience unusual and funny. My father had already left for work and with the situation unclear, my mother sent me to school with an appointment for our family physician later that day. I was happy to go and didn’t want to miss school early in the year. I remember later that morning, despite how my mouth felt, I volunteered to read a section of my social studies text book. I always considered myself an adept reader, but that day I sounded incomprehensible. I even remember the quizzical look on my teacher’s face after my attempt. I quickly realized I would have to hold back my enthusiasm for education for 1 day until my doctor could fix my ailment.
My family practice doctor was a nice Indian gentleman with silvery grey hair. I remember vividly that his office was also his only examination room. Right next to his large, expensive wooden desk and leather chair, was an examination table, up against a wall lined by his innumerable degrees. It felt like I was being seeing in his home rather than in the sterile exam rooms I’ve grown accustomed to. I don’t recall the details of the visit, except that he had diagnosed me with Bell’s Palsy, given me “steroids,” and a consultation with Neurology. As a teenager, I found this amusing but my parents were extremely concerned. They were so concerned that any run of the mill neurologist wouldn’t do. We had to find someone affiliated with one of the major teaching institutions in New York City.
We were lucky to get an appointment the following day. After an hour long subway ride, we were in front of a neurologist who was affable, intelligent but also eccentric with hair that only had chance encounters with a comb.The details from this part of the story are foggy. All I really remember is the concern on my father’s face after the doctor advised that we immediately go to the emergency room. For reasons that I don’t recall, my neurologist was concerned about meningitis.
My inpatient story began like many others in the ER. The most vivid memory had to do with lumbar puncture (LP). My father consented for me, as a pleasant male ER resident explained the procedure and how pain would be minimal and to expect some post procedure headaches. I remember laying on my left side facing a wall 6 inches from my face with my arms clutching my knees close to my chest. With my bottom and back exposed, I felt the warm anesthetic burn its way through my back, while the rest of me shivered in the cold room. My father had to wait outside for what seemed like an eternity. The resident was talkative and friendly but I found it hard to focus on anything else besides my fatiguing arms and lower back. I recall several attempts at him guiding the needle to find the sweet spot. It didn’t hurt but the repeated pressure and prodding of the apparatus was unnerving. After several minutes, the physician proclaimed success and asked me what color did I think the fluid was. I guessed red. To my surprise it was serenely clear.
I woke up the next morning with a terrible headache and nausea. This was definitely much worse than the actual lumbar puncture. I couldn’t enjoy the view from my window overlooking the East River while the smell of the hospital food made me that much more ill. Despite that, I was happy to see my eccentric neurologist who walked in like the Pied Piper with several medical students in tow. They stood around me, in a semicircle with their shiny white coats, smiles, enthusiasm and words of encouragement. The neurologist demonstrated his cranial nerve exam to the students with my Bell’s palsy playing a central role. The student’s marveled and I felt really special. I wish I could say this was that sentinel moment in my desire to be a physician and medical educator. But honestly, at age 13 although I fancied being a doctor one day, my real priorities in life were baseball cards and video games.
The days that followed were less about my Bell’s Palsy and more about a nasty pathogen. Although the results of my lumbar puncture were negative, the Varicella Zoster virus (Shingles) reared its ugly DNA. First it was having a party under the covers of my ear canal which many years later and only in medical school did I learn to call it Ramsay Hunt Syndrome. Soon after, it had found itself on the tip of my tongue in what turned out to be an extremely painful aspect of my illness. I could barely eat for the next several days. To this day, I’m not exactly sure if the steroids that I initially took triggered the Shingles or whether it was the Shingles itself that precipitated the Bells Palsy. Either way, it was a terrible and frustrating combination of events.
My last distinct memory of this event was the day of my discharge. Like any patient, especially a restless teenager, I couldn’t wait to go home. The night prior, the IV line placed in my ante-cubital fossa gave out and a night float intern haphazardly (after several attempts) placed a new line in my wrist. Probably 6 to 8 hours after that, this too infiltrated and started to cause pain. My family and I rang for assistance. As minutes turned to what seemed like an hour, pain became agony as a huge bleb formed at the site, stretching my skin while likely causing pressure on the carpal tunnel underneath. I squeezed my mother’s hand as hard as I could and squinted my eyes trying to endure the pain. I’m not sure how long I waited, but I remember the catheter being pulled and the immediate relief that came right after. A large fluid filled blister was left behind on my wrist. I was allowed to go home with instructions not to manipulate the blister. Of course one day it did pop, leaving behind exposed underlying tissue that I took care of myself for several days. Luckily it never got infected, but it did leave behind a scar that I still possess today.
There are a few other tidbits to the conclusion of this story. I parleyed the illness into a new video game system from my parents. The scar on my wrist gave me a tiny bit of “street cred” with my teenage friends. I quickly lost that “street cred” when I regained my ability and confidence to read out loud in class (4-6 months later). I missed over a week of school and when I returned, I got a lot of hugs from girls who would otherwise ignore me. And I remember my class portraits that year. I had an ugly crooked smile to match my ugly multicolored shirt. Most importantly, it was a vivid experience that’s given me perspective and a story to share in my life as a physician and medical educator.
When I first met Izzy (name changed) he was a portly elderly gentlemen with an effervescent and jolly personality that lit up the clinic every time he visited. His most recognizable feature was his voice. His lifelong hobby was singing opera, as a tenor. The first time I discovered this, he belted out a few lines that echoed through our entire clinic. It was marvelous and since that moment, I always made sure my medical students and residents not just saw him, but heard him as well. He was a spectacular patient and person.
A few years from our initial encounter, I found myself wandering the halls of the hospital with 2 medical students. They were 2nd year students looking for patients to practice taking histories and doing physical exams. Earlier that day, I received word that Izzy was admitted. Though this was unfortunate for Izzy, it was fortuitous for my fledgling doctors that such a great patient was available to talk to. And not surprisingly, despite feeling unwell, Izzy with his wife by his side, welcomed my students openly.
I stood off to the side of the room, while my students peppered him with questions for over an hour as they tried to piece together his medical history without much experience and medical expertise to fallback on. They learned about his vocal talents and though he wasn’t well enough to sing on that day, Izzy was quick to point out how his voice swept his wife off her feet when they were in college. I thought I knew everything about Izzy from our several appointments together, but these medical students were able to illicit a entirely new story from him that even I was unaware of.
My intrepid students were taking a travel history when they discovered his wife was originally from South America. He reminisced about the last time they went to visit her family which was about 4 to 5 years prior. He fondly recalled staying near a seaside town, enjoying the fresh ocean air and wonderful local cuisine. The only thing he didn’t enjoy about this trip was going further inland to visit in-laws living in more mountainous areas. He recalled getting sick during that part of the trip, blaming it on some bad food and lack of sleep. His wife reminded him that he almost passed out a few times that week from feeling so unwell.
After almost 90 minutes of questioning, doing a physical exam and sharing lots of laughs, my students and I left Izzy to go debrief on everything we had talked about. There was just an incredible amount of things to learn from Izzy. We were able to weave together his history, his physical exam, basic pulmonary physiology, and pathology to explain what had happened. I described to the students that Izzy was suffering from pulmonary fibrosis and explained some of general facets of this illness including impaired gas (oxygen) exchange and just the progressive reduction in his lungs’ abilities to perform . We reviewed oxygen disassociation curves and the effects of altitude and oxygen saturation. In light of his diagnosis, it became clear why with his reduced lung function and thinner mountain air, Izzy felt so ill on his vacation. This was probably one of the first signs of his illness until later when it became sadly obvious his opera singing days were coming to an end.
With every patient, there’s always something to learn and Izzy’s story was no exception. For me, when I look back at his story, I began to appreciate medicine as something more than doctors treating individuals with specific diseases affecting affecting well defined anatomy through different but predictable mechanisms. Medicine, as a science has surprisingly very abstract human qualities. At times, it can be funny, or sad, thrilling, uplifting, unpredictable and often dramatic. When an opera singer that relied on powerful lungs got a relatively uncommon condition affecting those same lungs, medicine got my attention that it also has a knack for irony.
Health insurance is an extremely high priority issue for most Americans. It is the sensible thing to attain, whether it is to ensure wellness or treat illness that might otherwise derail a lifetime of hard work. But my family member’s reward for obtaining health insurance wasn’t good health but rather a glut of potentially wasteful and dangerous medical care. As we continue to expand health insurance in an attempt to cover all Americans and provide them access to care, we have to continue efforts towards curtailing health care that is not evidence based, wasteful and only serves to fulfill the American dream of providers and drug companies while taking advantage of hard working naive citizens.
It’s easy and convenient nowadays to take a few minutes to rally against the “Anti-Vaxxer” movement. With the recent measles outbreaks, there’s no shortage of articles, memes, jokes and cartoons to share on blogs, Facebook, Twitter etc. But I’m going to throw a very small teeny tiny microscopic bone to the Anti-Vaxxer camp. I will do so with the disclaimer that as a primary care physician I think vaccines are an extremely important part of good health. Anyone that doesn’t see their value, is misguided and perhaps misinformed.