Apr 28, 2010

Dress Shopping

In high school, I loved to shop for dresses. Prom, homecoming, winter formal, Sadie's....my mom and I would head out to Macy's or Jessica McClintock to pick out something really special. Often this would happen before I even had a date to these dances. The date was negotiable; the dress was not. We'd spend the day checking out the racks of dresses and even though the styles and materials changed over the years, the dresses always fell into the same categories:

Category 1: The dress looked great on the rack, but not on me
Category 2: The dress was neither attractive on the rack or on me
Category 3: The dress looked good, my mom liked it, but I wasn't in love with it
Category 4: The dress didn't stand out on the rack, but looked fantastic on me

Sometimes I walked in thinking I knew what I wanted, and left with something completely different that I loved. Other times I left with what I thought I was looking for. Each time, it was a fun adventure.

It's the end of my third year of medical school. I'm starting to ask for letters of recommendation for residency, set up "audition" rotations, and look at programs. I'm setting up all these things like I know what I'm doing, but I don't. I have to figure it out soon, though. It's almost time to pick a specialty. Rotations are set up so students can "try out" all the different disciplines of medicine, and see what they want to do. And strangely enough, it reminds me of dress shopping.

I knew some disciplines were not for me. They were a category 2 dress, a specialty that I knew wouldn't fit and it didn't. I never had aspirations to be a general surgeon, and I would have rather done just about anything than stand next to the OR table for a seven hour abdominal surgery. Radiology is a wonderful diagnostic tool, but the darkroom put me to sleep. Neurology was painstakingly meticulous and gave me a headache.

Category 3: I did wonderfully in family medicine. The attending physicians and patients loved me, and I scored the highest score in my class on the family medicine board exam. The high score actually created some anxiety, because I wondered if I was so clearly dispositioned to this specialty, shouldn't I go into it? I did like it, but I didn't love it.

Category 1: Internal medicine was like one of those dresses that looks fab on the rack and then adds fifteen pounds to your hips. You had high hopes for it, but then can't peel it off fast enough. I was sure this was going to be my specialty; a springboard for internal subspecialties like oncology and gastroenterology. Instead, addressing multiple chronic (and often preventable) diseases in medically complex patients became a draining task, bringing me a sense of weariness instead of the reward of knowing I helped someone. It is an important specialty, one of the backbones of medicine, but I was ready to unzip it and move on.

Category 4: Pediatrics and ob/gyn were time-consuming specialties that I thought I might enjoy, but would certainly not pick as a career. Crying kids held little appeal to me, and I was not particularly interested in women's health. But trying them on was like slipping into a great dress- curves in all the right places without being too tight, a gorgeous color and on sale. I felt like I easily molded into the role of obstetrician, into a kind pediatrician talking with a scared mom. It wasn't a tense stretch, it was just a gentle extension of my own personality, of my own strengths and skills.

So I'm left with two dresses that fit well, a scenario that often happened in the shopping trips with my mom. Sometimes we bought both, if I had occasion to wear them; perhaps perinatology, a mix of obstetrics and newborn care, would be a good choice. Other times we put them on hold and went out for lunch, returning to buy the one that stuck the most in my head. That's another option- just finish up my rotations now, and return to my thoughts in August, assessing which specialty has persisted out of all the disciplines.

I'm don't know yet. I'm still out to lunch. Hopefully it will be become clear soon, or maybe there is nothing to become clear. Either specialty fit well, and I could be a good doctor either way. I need to let go of the idea that there is only one "right" choice. I'm just not sure yet.

For now, I think I'll order dessert.

Apr 23, 2010

The Oranges of Wrath

I grew up in Orange County, CA. Back in the 1980s, it lived up to its name. Every spring, my life was punctuated by the sweet smell of orange blossoms that heralded summer fun. By the time I was eight or so, that smell was gone, replaced by the smell of multimillion-dollar new construction. That orange scent always stayed with me though, bringing forth happy memories of my childhood.

Fifteen years later, both the orange blossoms and I have been transplanted to the Central Valley, and that smell is just as good as I remember. However, the scent of oranges now brings a reminder of the long work of harvest. Before living here, I never had an appreciation for the human demands of orange picking. It's expected that delicate fruits such as peaches and strawberries have to be carefully handpicked, often justifying their high prices. But oranges are hardy and plentiful- couldn't they be shaken from the tree like their neighboring crops of walnuts? No. This Valley is covered in thousands of acres of orange groves, each tree bringing forth a harvest of hundreds of oranges...and they all have to be laboriously picked, one by one.

The ladders lean precariously against the leaves of the tree, wide at the base and narrow at the top, and the workers wear a sack that will eventually be filled with about one hundred pounds of oranges. They advance up the ladder, filling the sack, reaching for the oranges in the middle of the tree, and then come down the ladder to place the fruit in crates that hold 400 pounds apiece. Too many times I've seen a worker that's been left hanging by his arms as the ladder slipped, with 80 or so pounds on his back. Fascia tears, creating hernias, shoulders dislocate, rotator cuffs strain, vertebrae compress as the picker falls and his sack falls on top of him. But the fruit needs to remain clean and the day finished for the worker to receive their pay, so back up the ladder he goes. I see him several days later in the clinic or ER, when he has a day off, after his hernia has strangulated, his arm hangs limply at his side, and he can't walk.

John Steinbeck wrote about this same ordeal in his 1939 book, the Grapes of Wrath. He writes about pickers who are starving, who work for almost nothing because its still better than the alternative, which is nothing. The Dust Bowl has abated, but the premise has not. Despite the establishment of a minimum wage, workers (especially illegal ones) have pay that is contingent on productivity and doesn't reflect the overtime worked. The creation of food stamps relieved hunger, but I wonder if it galls the pickers to pay at the store for the all-too-familiar fruit. Maybe available healthcare is better, but mass amounts of toxic pesticides used create high rates of cancers, lung problems, and birth defects. I should see only a few cases of DiGeorge syndrome, a rare type of immunodeficiency, in my entire clinical career. Instead, I've seen six cases in four months.

I still love the pungent, spring smell of orange blossoms. But now the happy memories of early childhood comes with an awareness of the effort and sacrifices made for these fruits. In saying grace, I used to thank God for our food, and the hands that prepared it. Now, I thank Him for the hands that picked it.

Apr 8, 2010

Role Models

The job of the physician is to promote health. Whether it be in treatment of disease, palliative care, mental well-being, or health promotion advice, patients look to doctors for answers. They really want to know how they can become or remain healthy. Part of the unspoken advice to the patient is in the physician's own appearance, the choices they enact in their own lives. After all, they are the ones with the wealth of knowledge; they beyond all others are enabled to maintain a healthy lifestyle.

I was in the hospital cafeteria the other day, chatting with a group of local physicians. Here's what I observed:
The cardiologist was holding a plate of fried beef chimichangas, french fries, and ranch dip
The pulmonologist was smoking
The gastroenterologist was eating meats loaded with nitrites
The internist was morbidly obese

Looking at this group of well-educated people, I sarcastically wondered where the dermatologist was? In the tanning bed? I mean, come on. Not only were these poor choices for anybody, but the infraction was directly related to the physician's line of work! Of all specialists, the pulmonologist knows the detrimental effects of smoking, the internist sees the ramifications of obesity, and so on.

I think physicians have a higher obligation to care for ourselves, not only for our own health but as an example to the patients we care for. The "do as I say, not as I do" philosophy is a contradictory and ineffective message to patients. After all, if doctors are making these choices with the knowledge and resources they have been afforded, why should a patient be motivated to make a change? The first line in the Hippocratic Oath is "first, do no harm." But being a poor example of health not only harms physicians, it has the potential to harm patients as well. Making lifestyle changes is hard. It's even more difficult with the professional demands of physicianship. However, I see this as an opportunity to serve patients; a demonstration that healthy choices can be made despite long hours, mentally-draining work, and personal obligations. The physician can be a role model in not only their treatments and advice, but in their own life.