Picture Books

Being a medical student is a lot like being a toddler. A small child is exposed to so many new things each day, her world grows exponentially in a short amount of time. Likewise, each day I see new things and am exposed to new situations, forming a frame of reference for the rest of my career. We show babies picture books in the hopes that once they see an picture, they will be able to apply that knowledge next time they encounter that image. What else is medical school? I see something once or twice, learning the character of that disease, in the hope that next time I see it, I'll correctly diagnose that patient. Of course, I had a lot of books during my didactic years in school. But the picture books are formed during the clinical years.

Some pictures in my book:

The joy on a father's face when I hold up his baby for the first time

My first written prescription

A tiny 15 week old fetus with perfect fingers and toes, laying in my hands

The subtle differences between polyps, ulcers, cancers, and rashes

The waxy covering on a baby I just delivered

A young patient dying from incorrect treatment of neutropenia

Riding along for a home visit of a bedridden patient

A chest wall covered not with skin but with the surface of an extensive breast tumor, beginning to be gangrenous, and my hand holding her hand

A tiny heart beating on ultrasound

I suppose the nature of these snapshots is that they are something new; something different, shocking, heartbreaking or joyful. You remember them clearly to try to create a healthy experience, to fix something earlier than when you saw it before. There's a weight of these images; a responsibility to know them and learn from them. After all, these picture books form the foundation of a physician.

The Family Doctor

Every physician is a family doctor. I don't mean to say that they all specialize in family practice. On the contrast, the majority of physicians now enter subspecialties. My point is that every physician, no matter their specialty, ends up being "the doctor" in their family. Sometimes this is okay. There's not a holiday that goes by the someone doesn't want a mole looked at, a consult on pain or bleeding or GI trouble...whatever ails them. Usually I don't mind taking a look and giving an opinion, although sometimes it is tiresome. What I'm struggling with is where and how to draw the line between family and patient. I think the real issue is that there is no line to draw within myself. I am not a doctor from 9-5 (or 7-11, more realistically), and a daughter, a granddaughter, a niece, a wife on all the other hours. I've said it before, you are never "off call" as a doctor. It is a casualty of the training. You think and observe medically, every moment, without thinking about it.

This duality is something I haven't learned to balance yet. It can be hard both ways: for a doctor-daughter to be a family member while entrusting her parents' care to other people, and for a daughter-doctor experiencing human grief whilst being expected to care for and relay medical information to the rest of the family.

My dear friend lost her young fiance last weekend, after he collapsed during a half marathon. She said he had a massive brain hemorrhage. My friend heart breaks for her, while my doctor-friend mind wonders if he had an arteriovenous malformation, if the increased heart rate and blood pressure probably triggered the rupture of the aneurysm. There is no separation between these two thought processes for me.

So, I am learning to manage this new addition to myself. It is easier to go to the hospital and just flip through the chart, rather than pestering a relative for information that they don't have. On the other hand, if I find something abnormal, I feel compelled to do something about it, and maybe miss out on the richness of caring for someone simply as their granddaughter, their friend. It's hard as a doctor to trust the care of someone you love to another doctor. But you have to, otherwise you'll be exhausted of patients before you even step foot in your own office.

iRx: An Oncologist's Prescription for Treatment

Oncology allows room for the humanistic side of medicine. A lady presented today for a follow up on her metastatic uterine carcinosarcoma. She had been feeling very weak from her chemotherapy, and needed another treatment and a CT scan. She wanted to go to Monterey for two weeks over the as holiday to visit her son, but it interfered with her treatment schedule and she would have to come home early. The oncologist told her not to worry, and to come in when she got back for her treatment.

This recommendation was not on the treatment schedule published by the American Cancer Society, but it was on Mary's* treatment schedule. Why? She is 85 years old, with metastic cancer. A visit with her son may be the best medicine for her. Will her cancer progress faster given the treatment delay? Maybe. Will this be her last Christmas, either way? Probably. The oncologist knew this and governed her treatment accordingly.

This is what I love about oncology. You see a patient for a prolonged period of time, in a manner that no other practitioner experiences. You get to know what matters to them and their family. It is one of the few practices that you can stray from published guidelines and still remain in practice. You can make treatment decisions based on the person, not the disease.

Amid a practice of dying patients, success lies not in the prolongation of years, but in the improvement to your patients' health. And even though you know how it ends, there is great satisfaction in contributing to the well-being, both physical and mental, of these patients in their time of sickness.

*name has been changed

Grandma's Rules

My grandmother, who has spent 84 years on the planet, is wise. This is an excerpt from a letter that she wrote to me after my first patient died:

Rule #1: Sometimes patients die

Rule #2: Doctors can't change rule #1

Seems obvious, but to a young doctor who is committing her life to preserving health (delaying death?) this was a profound thought. An allowance of myself to do the best I can, but not to be expected to fix everything.

Thanks, Grandma.