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.

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.

Amputations

I never thought much about amputations. They are common surgeries, most often related to uncontrolled diabetes, and seemed routine and unremarkable to me.

I've had the experience of witnessing several amputations while in my surgical service, all diabetes-related. Each time it surprises me with the sense of loss that comes with the amputation of a toe, a foot, a leg. I had never really considered the emotional impact of losing a limb. To be honest, I sort of thought that amputation resulted from a lack of self-control; the inability of the patient to monitor their glucose levels and make changes. Not to say that anyone deserves this sort of pain, but it seemed like a correlation between sugar and limb loss equaled a well-documented and preventable consequence. And then I had a black foot staring at me from a sterile blue-shrouded operating table.

I looked at it, and it looked at me, and I thought about all the things it had done for that person over the course of their life, how it was part of the patient. Bodies last longer than people, and it's natural to think that the body remains intact throughout ones' life. The operation to remove it reflects the difficulty, the tense dichotomy of this separation. It is a very physical removal- powered bone saws, strong manual bone cutters, and large scissors coarsely separate the limb from the proximal tissues. Nothing is pretty, edges are not delicately sewn. The necrotic tissue is essentially ripped from the living person.

And then you are left with a toe sitting on the OR table; a foot without an owner. You look at it and think "that was just attached a moment ago. Now it's just sitting there." You think about the extension of the person that it was- a baby's tiny toe, taking a first step, running, stubbed, swimming, carefully painted- and the gaping hole that is left from the amputation reflects the loss of something that helped shape a life. It always seems wrong to me to bandage up the stump without the limb, like the surgeon forgot something.

Even as these surgeries seem in contradiction with life, they are performed so people may live. A missing foot is a small price to pay for the excision of gangrene. There is a picture of me (on my second birthday) and my grandfather, who looks absolutely enamored with his granddaughter. He died a few months after this picture was taken. After hearing about my emotional reaction to the excision of a limb, my dad sent this picture to me. He gently reminded me that this precious moment with his granddaughter would not have been possible if he hadn't had the operations to remove a diabetic gangrenous foot and leg.

This is the glory and curse of the surgeon: you either cure or kill. The operating room is the fastest place in the hospital to make a difference in the long term prognosis of a patient. It's not for me- I like ongoing relationships with (awake) patients- but I can appreciate the meaningful work of the surgeon.

Grandpa Irv and a (very) Little Doc, May 15, 1986

Slice n' Dice

I am lame.

On the first surgery of my first day in the OR, I got faint and had to sit down. I am so embarrassed even to write that here. And it was on a simple tumor excision- no big deal! This wooziness from a girl that was a phlebotomist in college, thinks emergencies are interesting, had a relationship with a cadaver (named Phyllis!), and enjoys nothing more than the gory display of childbirth. Granted, I had just recovered from a pneumonia, and have a propensity towards hypoglycemia if I don't eat every two hours, but I don't think that was it. I think it triggers something in me when I see a sign of life in the patient on the table. When they become a person, and not a body, it freaks me out.

Normally I am okay with surgery. I stand there, assist, do what I need to do, and have lunch afterwards. In fact, I'm usually hungry in the operating room. As far as I can tell, the only times I have gotten woozy is when I connect the parts to a whole. I was fine with c-sections, except one time when the patient began complaining of pain. The thought that she could feel the pain of my knife instantly made me anxious and dizzy. A hysterectomy is a removal of a part, akin to replacing the air filter in a car. That's the level of attachment that I have towards the body. But one time, I was assisting on an open hysterectomy and saw the iliac artery, pulsing just beneath my tools, and right away I was nauseated. Of course I know that the person on the table is alive, and this is normal anatomy. However, I think that a sign of life- pain, a pulsating artery, the woman today who was talking to me about western movies- these force the connection for me between patient and body, person and pain.

Surgery is a different mindset than medicine. As my attending said today: "In medicine, you help people live with their disease. In surgery, you either cure or kill." The more I thought about it, the more I thought he was right. There is something to be said for being a mechanic, for leaving everything you got on the table, and walking away. It's not for me though. Those signs of life that make me dizzy- I think that happens because I love patients, because I connect and empathize with them. I don't think I'd ever feel fulfilled having a practice where the patients were primarily unconscious. Plus, its hard on you physically- to stand that long, under those bright lights, with your bladder exploding and stomach grumbling. I'm kind of dreading the next month. And I'm hoping that I can breathe my way through those moments where I catch a glimpse of human pain, and maybe even learn something about being a good surgeon.

California Dreamin'

I had a young patient in the hospital last week that I went to round on, and met her mother. She was a young Hispanic woman, anxious and obviously trying to do the best she could for her daughter. She said that she had recently moved here, and I asked where from? She said Arizona. Making conversation while I examined her baby, I said my school was out by Phoenix, and what brought her to Visalia? She said "I can get much more assistance programs for my kids here- it doesn't make sense for me to live anywhere else. My whole family moved here because in California, we can get so much free stuff."

Her honesty took me aback. I've said before that I can't judge anything as right or wrong, black or white. To an honest and educated person, things are always shades of gray. I cannot- and will not- comment on what my thoughts were at that moment, because what I truly think is that things are much more complex than they may seem. And my opinion is not really relevant anyway. This was just a conversation that surprised me, and demanded some thought. And I wanted to record it here because I thought it might provoke some thought in others.

Soldiers: The Silent Underserved

I loved my elective rotation in a family practice in Orange County. The office was decorated nicely, the exam rooms had winged armchairs instead of standard-issue medical office chairs, the office staff was a close-knit group, and the temp was a cool 67 degrees. It was exactly the kind of practice I'd like to have in the future. I saw many patients there, ranging from newborn to elderly, and enjoyed the various presentations of illness unique to a diverse family practice. One patient in particular was memorable, a young man serving in the Army.

The first thing I noticed about this guy was that he called me "Ma'am." It almost made me giggle- he was about my same age, maybe a few years younger, and I wasn't even the real doctor. He was clean-cut, polite, and respectful, wearing a t-shirt that I recognized as military fabric, similar to the ones my husband wears that are leftover from his years in the Air Force. I asked him what brought him in, and he held up his pointer finger, which was an ominous black color with red marks streaking up his forearm. He said a black widow had bitten it five days prior, and he had tried to lance the bite to relieve some of the pus, but it was getting worse. I asked him what he used to try to drain the area, and he replied "a steak knife, ma'am." Ouch.

I called in the doctor I was working for (clearly this was over my head), and she told me she had never seen a black widow bite before. Unfortunately (or fortunately?) I had already seen many, because in the community I serve, grape-pickers come in after a full-day's work with several bites on their fingers and back from the spiders falling down their shirts from the tall grape arbors. I had seen this because I work with underserved pickers. I never expected this active-duty military member to be more medically underserved than the illegal farmworkers.

The best idea was to refer him urgently over to the orthopedic clinic, given the likely systemic manifestations of the bite and the underperfused finger, but he couldn't go over there due to insurance limits. (When telling this story to my husband, he stopped me here and said, "TriCare" and rolled his eyes). Apparently the military insurance, TriCare, denies unapproved specialist/emergency visits, unless there is an "impending loss of limb, sight, or life." This was getting close enough to loss of limb that the doctor was uncomfortable, but couldn't get the visit approved. He had only come to the office today under direct order from his sergeant.

We gave him antibiotics, and she let me drain the pus using a scalpel (not a steak knife). He was a tough guy, but I knew it was hurting him. He left with strict instructions to come back in the morning to have it looked at again (Yes, Ma'am).

I was appalled. Here was this young man, putting his life on the line, and he was in danger of sepsis and loss of a finger because of insurance regulations? He should have absolutely the best insurance available, able to show his military ID card at any medical facility and receive care, no questions asked. Antivenom should have been given on day one, not palliative care on day six. This doesn't seem to be a topic civilians know much about, but I believe that if a feature article was run about it in a prominent newspaper, taxpayers would demand better medical care of our military personnel. I think this system compromises the medical well-being of the thousands of people that are responsible for protecting our country's safety. My own husband cites it as the main reason that he chose to leave the Air Force and reenter society as a civilian.

I don't know what happened to this guy. I wasn't in the office the following day (another doctor was on call), but I still wonder about him, and hope that everything healed well with no loss of function. Especially since the affected finger was his trigger finger- important for an Army man. I hope everything is okay, but I'm doubtful. If it did heal, it's because of his staff sergeant's orders and his own immune system, not because of care provided by the military. And that's a shame.

Babyfinder.com

I adopted all my animals. Either they were from the pound, browsed for on petfinder.com, or someone didn't want them anymore. In any event, they joined the family. While I know babies are a lot different than dogs or cats, this was my only personal exposure to adoption.

A few weeks ago, while attending to the NICU babies, I noticed one that didn't seems sick and wasn't getting visitors. She was labeled a "boarder baby" on my rounds report. I asked the attending what that meant. He said "it means that she was born and her mom gave her up for adoption. She's just staying here until we can find a home for her." He turned away, and then turned back suddenly. "Hey, do you want her? She's really cute. She has a little heart murmur, but that will probably close within the first year."

I was surprised. I thought that finding a baby to adopt was a huge, prolonged process, and maybe it is. But they were looking for a home for this little one right away. What struck me as funny was the way the baby was presented. All of the animals I adopted had a similar advertisement. The only thing missing for the baby was the "free to a good home" sign, a cardboard box replacing the isolette, and maybe a listing on a website like babyfinder.com.

I told the doctor I wasn't really looking for a baby right now, but I hoped she finds a good home. The doctor looked disappointed and said he understood. And then he turned to one of the nurses and said, "Hey. Do you know if Susie's still looking to adopt? We've got a cute one here." She must have been adopted, heart murmur and all, because when I came back a few days later, she was gone.

Then I started working in pediatric gastroenterology, and saw the most medically fragile kids I've ever seen. I loved it- the challenge of keeping these kids thriving, comfortable, and developing as normally as possible. I loved the challenge of talking with the parents about every aspect of their complicated kid's medical health, and enjoyed the rapport that was built between the patient, parent, and physician of this pediatric subspecialty. I marveled at these young parents' ability to care for their kid and be so knowledgeable about the multiple medical problems they had. They knew much more about their child's care than I did as the medical student. Premature crack babies with a short gut due to resection of necrotizing enterocolitis, feeding tubes, Down syndrome, epidermolysis bullosae (where the kid was wrapped in head-to-toe sterile gauze because of the deep blistering), kids in strollers with oxygen and parenteral nutrition on board, little girls with Crohn's disease, rare metabolic defects, and everything else- these kids needed care. I would sit there and observe, wondering, how do these moms do it? They are happy, invested and knowledgeable about their complicated child's care. Every minute of their lives is consumed with this kid, and they accept it as a part of a full life.

What ultimately came to amaze me was that the most complex kids invariably came with an adoptive parent. The crack kid? The nice lady in front of me wasn't the one who had smoked crack while pregnant. She was the one that accepted the kid after the prenatal damage was done. The kid with cystic fibrosis? She sat breathing noisily on her adopted mom's lap as her adopted grandma fussed over her. It was absolutely amazing- the unquestioned commitment that these parents had to their kids, kids that sometimes had preventable problems due to another adult's irresponsibility.

I think when most people look for a pet, they want to adopt a young, healthy animal. But these moms had committed to kids with disabilities, with lifelong special needs. How much of a commitment is a dog, really? Fifteen years? Compared to a lifetime commitment for a child. It was one of the best lessons that I got out of the rotation. And I hope that the little boarder baby, wherever she is, was adopted by a mom such as this.

My Drowning

Today is Tuesday. It happened on Friday. Usually I use writing as a tool to think about what I've seen, make sense of problems, and move on. I am writing today because it has taken me this long just to sort out this situation well enough to write about it.

A four year old boy drowned. In a pool, in the middle of winter. He had been dead, was resuscitated by the paramedics, and was brought to meet me and the attending pediatrician in the ER. As I put the bagged oxygen mask over his mouth, I wondered if he had been eating a blue popsicle before drowning? No, I realized, his tongue was that color because he was so cold. Reaching out to touch his baby hand was like holding a refrigerated chicken wing. His eyes were brown, dull and unseeing, under his closed eyelids. His temperature was 85 degrees, and his lungs were filled with water. Listening to them was like ascultating an aquarium. He wasn't getting enough oxygen, even with the bagged oxygen mask, so we needed to intubate him. The ER doc tried first, pushing the tube down his throat. As the ventilator was turned on, his stomach distended with air. His heart rate dropped down into the 30s, and bagging was resumed. However, the bagged oxygen mask was now cracked, and he was losing oxygen and his heart rate was falling. The doctor gave the laryngoscope to me to try, and I opened his mouth, visualized two tiny vocal cords, and pushed the tube in. Pool water sprayed out, soaking my shirt and face, and the monitor alarms went off. In the few moments it had taken me to intubate, he had gone into asystole.

Asystole. Pulse zero. Respirations zero. These are all medical terms to describe death. The death of a kid that had been a normal little boy a few hours ago, and was now cold and lifeless under my shaking hands. The doctor shouted, "He's going to die!" and my stupid brain wondered "Isn't he already dead?"

The attending and I talked with his parents, explaining what had happened, and invited them to come see their son. As I watched mom kiss around the intubation tube, and dad touch his son's cold, dusky feet, my heart broke for these parents that turned away from their child for a minute and will now live with a lifetime of guilt. A couple of tears slid down my face as I watched these parents desperately try to reach their son, and grapple with the realization that he was not there.

My lungs were clear, but my heart was drowning. How long would it be before I forgot the sweet detail of this child's face? How could I not wonder if I could have done something better? When would I see other children as they are, rather than thinking about how they would look drowned like this little one? After all, he was a healthy boy a few hours ago, with a chest that heaved with exuberant play instead of the force of a ventilator. Why was I the only one that seemed to be bereaved by the loss of this child?

My friend June, who has been a wonderful nurse for longer than I've been alive, offered some perspective. Some doctors build protective clamshells around themselves, shielding them from experiencing patient pain. Sometimes this dissociation is necessary in order to care for someone in great distress. But to be too far removed is a disservice to patients and their families; patients need doctors who are there for them in the most difficult of times. She also reminded me to be gentle with myself. All of the distress and grief I experienced over the loss of this child are some of my best attributes; they indicate a caring and empathetic nature that ultimately will benefit my patients. It also indicates that my self-awareness is set correctly, because questioning and analyzing situations like this is the way to maintain a humble and teachable spirit. However, that does not mean that these situations are easy on me.

This is not an easy job. I never want to wear those chlorine-soaked scrubs again. Suddenly I don't like my stethescope, because it allows the amplification of human suffering into my ears. I don't know how to move on and forget about this kid that was the most awful situation I've ever seen.

All of these events form a collage of who I will be as a physician. With experience, I'll learn how to reach an equilibrium where the pain and triumphs of my profession are balanced with the rest of my life. And I'll know that while this experience will stay with me the rest of my life, there is a new patient outside my door that deserves every bit of the best care that I tried to give this little boy. It's not right for grief to cloud my focus on the next patient, because there is always more need to be met.

People say medical school is hard. What they don't say is that the academics are extensive, but attainable. What you really wrestle with is the ability to develop meaningful doctor-patient relationships. To emotionally engage with someone that is in pain is burdensome, but a privilege. Doctors have the unique opportunity to be part of peoples' lives in exquisitely intimate moments. I think most people would say that they go to medical school to "help people." This is probably partially true, but I think it goes beyond this. I think the desire to become a doctor stems from a deep yearning to offer people a part of us; the ability to treat illness but also relate to them in a time of difficulty, to meet needs that are seen and unseen. And I think if you do it right, you come away with more than you ever gave.

Pediatrics Warrior, not Prisoner of War

I was dreading my pediatrics rotation. From what I could see, it involved barfy, sniffly, whiny, drippy, crying, germy children whose little ear canals are impossible to examine and whose heart and lung sounds are indistinguishable from their wailing. I figured that February 8-March 7, 2010 would be a black hole in my medical schooling; the doctor equivalent of torture training by the military for the possibility of being a POW. And that's what I would be: a POW in the pediatric community clinic.

What I learned today is that this is the picture of outpatient peds. Inpatient is different. And I LOVE it.

It was exciting. Pediatric consults in the ER, waiting for the product of a difficult delivery, kids in the NICU and pediatric ICU, one room with cribs stacked side by side filled with babies with respiratory syncytial virus, all waiting with no pretense for the care of a quick-minded physician. It was just my first day today, but I saw more of a gamut of problems than I had ever expected; things that I figured I would read about but never see.

There was one little guy in the ER with a history of imperforate anus and dependence on saline enemas. He was backed up to the small intestine, with his large intestine so distended that it was putting pressure on his lungs. Looking at the xray, I asked "Does he have Hirschsprung disease?" The attending looked at me and said "You know, I think you're actually right. I can't believe no one has diagnosed him with that." He saw a pediatric gastroenterologist that afternoon and is now being treated. I was pretty proud of that (and glad to make a decent impression on my first day).

There was another little baby with Down sydrome, sick with pneumonia. He was cute as a bug, with a mom who was only 15 but really trying to do the right thing. One kid we saw today was in the ER with pneumonia, but I thought that I heard a heart murmur along with the junk in his lungs. On the xray, the little guy's heart was dilated to the size of a grapefruit, with a nice patent ventricular septal defect. There were a set of twins born at 25 weeks, that the 14 year old mom had gotten pregnant with them when her first child (a preemie born at 30 weeks) was still in the NICU! There were a set of parents in the ER with a kid who didn't look too sick, but on further questioning revealed that they had a three year old that had died the year before after being sent home with a respiratory illness, so were understandably anxious. Besides that little guy, there were another two dozen with respiratory illnesses (RSV) sick enough to be hospitalized. The pediatric ward was full, so kids were spilling out into the postpartum ward, the L&D, and even adult med-surg. One scene reminded me of third-world medicine: because of a lack of beds, they had put makeshift cribs in one room and clustered several babies with RSV in there. We rounded on them one right after the other, talking with different families, in different languages, but about the common illness their kids shared.

One kid was a particularly interesting case. This kid was about two, and had been born with hydrocephalus. He was followed in the NICU, and then discharged. Since then, he's bounced from PA to physician at different clinics, and NO ONE has addressed (or even mentioned) the fact that this kid's head can't fit through his shirt. He's now got a sodium level of 120, probably from a mass effect on the hypothalamus causing a SIADH syndrome. And yet, when we looked at the CT read in November, the radiologist said that is was unremarkable. Um, hello? This kid looks like he was fathered by the Elephant Man. His ventricles stretch almost the longitude of his midbrain and the hemispheres are asymmetrical. I'm a student, not a radiologist, and I could see that. The pediatrician called up a buddy he had in San Diego that was a neurosurgeon, and asked him to reread the CT as a professional favor. He needs a shunt, so he'll get connected probably with Stanford Children's Hospital now. I hope he gets taken care of.

Another interesting kid was one that both she and her mother had coded (died) during delivery. Both were resuscitated. Mom was okay, but this kid is completely vegetative. She's graduated hospice twice now (does that get a cap and gown?), and her life consists of just hanging on between infections. However, her parents are fighting about the DNR order, so right now she's a full code. Dad says it is against his religious beliefs to let her die; mom thinks it is kinder to her daughter to let her escape this medically sustained life. Interesting, the ethical dilemmas that come up in medicine.

I think this is a very different picture than I might get in another hospital. Sometimes the negligence of care is shocking. Other times, the care is good but the facilities are lacking. In any case, this is an area of great need. The doctor I'm with says that he sees things here that statistically he should only see once or twice in a career, and yet he has had several cases in the last few years. Kids with Edward syndrome (trisomy 18), DiGeorge syndrome, one rare metabolic syndrome (there are only 5 documented in the world), high rates of acute leukemia, and others that are considered medical "zebras" but somehow become "horses" in this community. He thinks its because of the generations of farming pollutants. Sounds reasonable. I don't know. Either way, I'm grateful for the experience here. And I'm very grateful to have discovered a love for sick children that I didn't know I had.

Poverty Is...

I grew up in Orange County, CA. From there I moved to San Luis Obispo. I always had (more) than enough to eat, school supplies, and clothes that were not only warm but reasonably in style. I had never experienced poverty. Sure, I volunteered at the food bank, collected toiletries for the homeless, filled school backpacks with supplies and send toys overseas, but poverty was not part of my existence.

As a senior in high school, I went on a mission trip to Mexico to play with kids and build a house. My classmates were happily kicking around the soccer ball and drilling nails into a framework, but I remember watching all those kids running around barefoot in a field with rusty nails, and thinking that what they really needed was tetanus vaccinations. It was my first real glimpse into poverty, and gave me a sense of purpose for my future life as a physician.

Fast forward six years. I am now a third year medical student stationed in the central valley of California, my task to learn medicine while providing services to the underserved and poverty-stricken population here. What I've observed is a lot different than what I expected. I had thought that my time here would be a similar experience to that time in Mexico- working hard to provide something good for a family who would otherwise go without, and the people would recognize the service and be thankful. Instead what I've seen is two types of poverty. One is heartbreaking, one is frustrating.

Probably the worst representation of poverty that I've seen here is the car washes to raise money to bury a dead family member. The whole family sets up in a parking lot and depends on the money they raise to pay for the funeral. I can't imagine this grief; that you would be mourning your loved one while soaping a stranger's tires to earn money for a burial. Families of dying patients don't come to the hospital because they are picking fruit and will not make wages without a full day's work. Sometimes they die before their family gets there. Moms with babies, broken down on the side of the road. Parents that don't bring their kids to the doctor for fear of deportation. A man with six black widow bites on his back, from a day of grape picking (they fall out of the vineyards down the workers' shirts) who didn't come in for treatment until his shift was over. Families that share one apartment, one car, one social security number. This poverty is heartbreaking and deeply compels me to do the one thing I am able to do: provide compassionate and quality medicine.

And then there are the people that I tend to think of as selectively poor. A man who cannot "afford" his $4 prescription from Walmart, yet has a four pack per day smoking habit. People that demand that the doctor sign a disability form so they don't have to go back to work. Parents who use food stamps in front of me in line and then put their groceries in the back of their Cadillac Escalade with 26" spinner rims. A 17 year old with four kids whose frame of reference and way of life is to live on a government check. The woman at the clinic who is on MediCal, pays nothing for the $500 IUD I just put in her, and walks out chatting on her iPhone with a Coach bag slung over her shoulder.

I had expected my work here, even though I was in school, to be rewarding. And sometimes it is. But more often than not, I am confused by a population that drives a nicer car than I do to the swap meet on thursday morning, while I go to work. Some of my patients are appreciative of the care they have received, and motivated to make changes in their own health. Most of the time, however, the patients treat me like it is my duty and honor to serve them, and demand a lot in return for nothing. What I'm left with is a genuine desire to help those in need, with a disillusionment of needy people. I feel like my work here matters, but only to a few. I am tired of trying to make changes in people's health who only want Vicodin and a disability form signed by the doctor. I enjoyed working in practices where bills were paid by private insurance; where the patients asked thoughtful questions, were polite to me, and seemed committed to maintaining a healthy lifestyle.

I don't like myself for wanting to work with those above the poverty line. It seems like a failure, like I wasn't good enough of a person to reach out to those in need. But what I've experienced is that you give and give to people who are not invested in their own health and it is an unfulfilling experience for all involved. The truth is, public clinics have a hard time retaining doctors; they come for a few years (possibly for loan repayment) and then move on to a better life. I want to be a doctor who is excited about what I'm doing, who feels like my work has a purpose. I thought the greatest purpose of all would be in serving those who would otherwise not receive quality healthcare, but instead I'm left wondering what might be a better fit for me. In the end, all people need healthcare, everyone gets sick. It's just that some have better access to care than others. I am not content settling only in a comfortable practice with patients that pay their bills on time, but maybe there is a balance between this and the community health center. I'd love to have a practice that is a good fit for me and volunteer for Doctors Without Borders. Is this enough? I don't know. A comfortable, wrapped up ending to this post? There isn't one. Somewhere between my sense of morality, guilt, and desire for an enjoyable practice I'll have to figure out how and where I should practice medicine.