Dramatic irony, part 1

This afternoon, I spent an hour interviewing a 70-year-old retired lawyer who had been brought to the hospital for "confusion" and "unpleasant vivid daydreams." When I first met him, he said to me, "Well, it's been a fascinating trip so far. I didn't know that all this stuff is going on, that delusions like this can happen to people." He then elegantly launched into a nonsensical explanation of recent events, from being lost in the snow in Vermont with only strange innkeepers in sight, to being kidnapped and brought to Japan, where he was given hospital socks. As I struggled to keep him on track and progress with the interview, I felt frustrated with his verboseness. Listening closely, trying to make sense of his eloquent speech, I realized that his words added up to nothing more than nightmarish delusions. He, too, has been struggling to make sense of these experiences: "I've been trying to analyze why these things are happening to me... I feel better since they've mapped out a game plan, [which is] to bombard people with reality." Later, he failed a simple neurocognitive assessment. A picture emerged of an intelligent, educated man using those reserves to compensate and mask a significant decline.

As the interview seemed to be going on forever, we paused for a neurology resident to do her exam. I watched as numerous Parkinsonian features were revealed: bradykinetic hand movements, perseveration, increased muscle tone, shuffling gait. After, I stepped out of the room to ask the resident her thoughts. "We're thinking Lewy body dementia," she said, a diagnosis that goes along with Parkinsonism. I felt excited at discovering something new, the chance to diagnose, glad to have stumbled upon a neuro exam for a disease I hadn't seen before. A hypothesis shared only between the resident and me, not yet voiced to the patient himself.

I stepped back into the room to finish my interview. Towards the very end, I asked the patient to describe his mood at present. "One hundred percent better!" he said, and smiled. "I actually think I have a chance now of being able to do things again, of going back to how I was. I was really worried about Alzheimer's, but the CT and MRI came back totally benign!" I choked up. Minutes later, I stood up, thanked him, shook his hand, and left the room.

Albany update

Just marched down Central Avenue in Albany with a mixed race crowd chanting for a more just and peaceful policing system. We started in Arbor Hill, the broke and black part of Albany where so many of our patients live. For a start, I felt safe in a neighborhood where I have been told never to feel safe. (That's been an effort of a local family doctor here, to get people out in the neighborhood and feeling safe.) People came out of their apartments to cheer, men joined in as we passed, cars stopped and honked in support. Just as I feel empowered by my white coat to join in where I might have been shy in the past, the rally seemed to empower this neighborhood; or perhaps the neighborhood, empowered, created the rally. I passed one patient's street and then another. I was so moved by the crowd chanting, marching with both hands raised, that for several blocks I was silent. But I am not a tourist: my grandmother drove black families to the polls to vote for JFK in 1960. As medical students, we work with people and care for patients whose communities face injustices and challenges that many of us don't face personally. I want to be able to look my patients in the eye and let them know that I know and I care about what's going on outside of the hospital. To demonstrate that people in a position of authority want change too. Last winter I attended my first rally ever, marching down Michigan Avenue in Chicago with Students for a National Health Plan, feeling awkward and ambivalent. Yet trying something once makes it so much easier to try it again, sets off a chain reaction.

My patient woke up

For the past three weeks, I have been following an elderly male patient. First in the ICU, where he was delirious, in and out of consciousness and often nonresponsive. I spoke to his daughter, who told me that before his 75-day-and-counting hospitalization, he had been an independent man who used to come to her house daily to walk and watch TV with her dog. She was concerned that with so many transfers between and within the hospital, his providers had lost sight of his baseline, and only knew him as the extremely ill, nonverbal, mildly disheveled patient before them. In fact he suffered quite a loss of independence and dignity.

Today I met him on the floor (out of the ICU, in a regular surgery ward), and I introduced myself. I often feel the need to be careful when revealing to a new patient just how much I know about them from reading the chart and speaking to others; I don't want to appear to be a stalker. In this case, the patient was lonely, and soon the encounter became intimate. He asked which daughter I'd talked to. We talked briefly about how long he'd been in the hospital. Without prompting, he burst out, "I feel depressed" and "I'm scared," a phrase he kept repeating. When asked why, if perhaps he is afraid that he won't get well, he said, "I don't know." I was scared knowing he was scared.

"Rule out suicidal ideation by knife emoji"

On crisis call the other night at the local psychiatric hospital, we were asked to evaluate a girl brought in by the police, with her mother's urging. She had run away and was rumored to have threatened suicide. Apparently, she got in a fight with her mother over an alleged Facebook post in which she posted a "knife emoji" and said she was going to hurt herself. She denies having ever posted it and her mother never actually saw the post. We did not think she was suicidal, so I can joke about it. Kids these days.

The really tragic underlying story is that her mother has been trying to get her outpatient counseling services for a year, that counseling services were ordered by in-school supports, and that it never happened. In between the girl has been kicked out of school; it took a day waiting in crisis for an evaluation to finally connect her to badly needed services. Imagine the difference for a family of means trying to connect their kid to services. It was telling to me that the mother said proudly of her son, "He's doing well. He's 17 and never been arrested."

For fun, let's compare local 2013 high school graduation rates:

Among the top performers were suburban districts such as Niskayuna, with a 96 percent graduation rate in four years and 2 percent dropout rate; Voorheesville showed a 94 percent graduation rate and a 3 percent dropout rate. 

Less-impressive results were found in cities with higher concentrations of students living in poverty, including ethnic minority youngsters. In the Albany school district, the graduation rate was almost 54 percent, with a 21 percent dropout rate. Schenectady had a 65 percent graduation rate and a 20 percent dropout rate. 

(Times Union, http://www.timesunion.com/local/article/Graduation-rates-up-5574062.php)

Where do I even begin?

How do you pull a blog back from the brink? Let's start by explaining how I got here.

In addition to having a precious few free hours a day as a third year, working with real patients every day is an intensely personal experience. There is so much to process; over the past few months I've found it easier to do that with just the people to whom I am closest. Then there's the fear that I won't convey as well in writing interactions that have meant so much to me on the interviewing or observing end. Finally, how do you end a glimpse into someone's decision-making with a trivial recipe for kale salad?

Over the past few months, I've learned to feel ownership over my patients, to follow them daily in the hospital and try and make myself useful to them regardless of whether a note needs to be written or not. It's the luxury of being a med student that we have time to do this. And in practicing this, I've begun to feel for this handful of patients, worry about them on the days when I'm not there, become very upset when I hear about a miscommunication. Medicine takes you into the most intimate moments in strangers' lives, from a family meeting in which an elderly couple turned down palliative surgery in favor of home-hospice, to planning next steps after a miscarriage, to intrusively asking a patient whether he wants to die.

Last week I met a man who was a survivor of the earlier AIDS epidemic, diagnosed with HIV in the mid-80s and told at 22 that he would have five years to live. He buried all of his friends from that era, grew close to his family, and only a few years ago stopped taking all medication because he had grown tired of it. I felt so strongly for him, felt so privileged to be in the room interviewing him. Over the past few months I've been reading a nonfiction book, My Own Country, by Dr. Abraham Verghese, about the AIDS epidemic in rural Tennessee as experienced by an Indian-trained, African-born infectious disease doctor. I can only see that book as increasing my interest in this patient.

As I've written enough, I think I will link to this recipe from the New York Times, which looks delicious and inspired my lunch for tomorrow: Apples from Thanksgiving Start to Finish. My adaptation was a quick chopped dinosaur kale, sliced apple, Cabot farmhouse cheddar cheese, toasted walnuts, and a mustard/balsamic/olive oil/black pepper dressing.

On pulmonary outpatient clinic, part 2

Last night marked the last TGIF yoga class from the teacher who has been there since well before I started med school. It was a momentous occasion: I've attended this class every single Friday night that I've been in Albany over the past two years. Friends have changed, apartment has changed, schedule has changed, I've changed, and this yoga class has been there the whole time. It reminded me of when I finally moved away from Boston, I realized that the most consistent companions I'd had over the six years post-high school (besides my family) were not my friends or my co-workers but the kids I babysat for every week. These are background patterns I take for granted.

It was an unexpectedly sad and amazing week on pulmonary outpatient clinic. For the first time in my career as a med student, I was fascinated and impressed by the rare cases as opposed to the mundane: nocardia pneumonia with a healing abscess, acquired pulmonary alveolar proteinosis, two patients both alive and well five years after diagnoses of lung cancer with brain metastases. In the past I've felt that the rare cases, while "cool," don't reflect what we really need to learn to manage most patients, nor do they encourage empathy for the suffering person. I'll take this as one more instance in which I'm becoming culturally more similar to the rest of my profession.

Friday ended with a pair of sisters--fairly young, fit and healthy-looking women in their early sixties (one thing I've learned this week is that my "healthy-looking" sensor can be way off)--sitting before me in the exam room. One of them was just diagnosed with lung cancer in May and had the entire right lower lobe of her lung removed in June. She was now suffering from bloody pleural effusions and her sister was there with her to learn how to drain the fluid at home. What a mental shift that must have been for both of them: one previously healthy to sick and missing a huge piece of lung; the other now taking on a caretaking role. Both seemed to be taking it in stride: cheerful, matter-of-fact, not grossed-out, hopeful yet concerned about prognosis. I was so impressed.

So this week was tinged with endings, both of the new-beginnings kind and of the beginning-of-the-end kind. Let's be thankful for the former.

On pulmonary outpatient clinic, part 1

I've heard that respiratory failure is one of the more painful ways to die. In renal failure, once you're off dialysis, toxins build up in your blood and you slip into a coma, going gently into that good night. In respiratory failure, you are hungry for air: it's a set of diseases that causes anxiety.

Similarly, then, patients living with lung disease live actively with their disease. They sense it, feel it, accommodate it, fear it around the clock or spontaneously here and there. Cystic fibrosis, asthma, emphysema are debilitating conditions around which patients may define themselves. This morning I met a very healthy appearing young woman, dressed nicely for her office internship, ready to start her college semester next week. On exam she seemed totally fine: no cyanosis, no clubbing, perhaps some very brief end-inspiratory wheezes but no extraordinary breath sounds. You would not pick her out walking down the street. Yet she has cystic fibrosis, a very treatable form, and when I told her I'd once met an older lady with CF during a lecture, she said, "An older woman? That's good to hear!" Raised with CF, treated with a drug only made available in 2012, she lives with a sense of her own mortality. She is comfortable enough with her mortality to allude to it in a comment to me, while I look at her and see a healthy person, and deny to myself the possibility of serious illness.

All of this to speculate as to why I've found the physician-patient relationships over the past week (shadowing in pulmonary) so profound, even as compared to a previous weeks in cardiology and endocrinology. It could just be the particular physician, but it could also be that hypertension and even type 2 diabetes are relatively silent diseases (for diabetes that's a questionable statement that certainly depends on the patient and how much insulin affects their daily living, but those in denial are able to live in denial, it seems). Over the past few days we've had patients cry in the office; express joy and gratitude over improved asthma; dismay over worsening, untreatable emphysema. My attending lingers with his patients, dreamily reminiscing about his intern days, thoroughly explaining the mechanisms underlying symptoms or treatments. I think it keeps them coming back, improves their disease self-maintenance. How privileged to be a fly on the wall for conversations that have been years in the making.