Life and Death

There are two givens about life. You are born, and you die. And medicine intersects these points. I prefer to be on the birth end of the graph. Being part of the process of a new life in this world is joyous and rewarding, and preferable to me over caring for the end. But obstetrics is the only specialty that traverses these two givens, that can unite them in a matter of minutes rather than years. We hear about life and death situations a lot, in terms of making a decision to save someone's life. But what if you have two lives to save?

Babies are born, and some babies die. It's terribly sad, but not unexpected. With what needs to happen for any baby to born healthy, it is truly a miracle that it ever happens. And it isn't surprising that sometimes things don't go right. More precarious is the balance of a healthy baby and unhealthy mama. I've only seen this a few times. One instance that sticks in my memory is of a young woman, twenty-five weeks pregnant, unconscious as an oscillating ventilator forced air into her swine flu-filled lungs. She couldn't get well with a parasite (baby) grabbing every extra molecule of oxygen she had. And so the decision became- do you deliver her for the possibility of saving this mom of a three year old, this wife and daughter, and risk a probable death of her baby? Do you watch her oxygen saturation decline in the presence of a happy, reactive fetal monitoring strip? Do you keep her alive for a few more weeks, using her body as a physiologic NICU incubator for her baby, and see what happens? This is what was opted for, and she was delivered two weeks later. Last I heard, her baby was doing well and she was newly pregnant again- a good ending for a tough call.

I saw another instance of this today. A young woman, exactly my age, came in to have her prenatal ultrasound. We looked at her uterus, measured her little boy, watched the happy flutter of his heart and his kicking feet. Swinging the ultrasound around for a cursory quick glance of a normal ovary revealed a large, nodular mass lined by enlarged lymph nodes. Most certainly an ovarian tumor, a highly malignant mass nestled against her growing child. Life and death, adjacent, growing silently together. Would this tumor be all this baby knew of his mother, both in the womb and growing up in her absence? Would the mother watch her baby's fluttering heart grow still as she underwent treatment in hopes of removing the cancer? Is there a chance of them both being okay, a chance for her existing daughter to keep her mother and gain a brother?

Medicine is imprecise, a collection of educated guesses from educated people, and that's the best you can do. And somewhere amid these calculated thoughts, there is a person. The nature of medicine is caring for fellow humans in times of difficulty, and it seems reasonable that the physician would grieve along with their patients. But they also need to learn to let go of the summation of patient pain to preserve themselves and their practice of medicine. It seems to be an unspoken competency in medical school, a skill untaught and hard-learned for most. A skill I am still learning, and expect to learn better in any field of medicine, especially obstetrics.

My First Baby

Here is the (long overdue) account of my first baby. Not one that I carried in my own body, but one that I cared for and delivered. The baby that changed my career as a doctor.

I thought I wanted to be a gastroenterologist. My background in clinical nutrition led me to an interest in the GI tract and how nutrients were absorbed and how nutrition affected health. Throughout my first two years of medical school I planned on become an internist and subspecializing.

And then I delivered this baby.

I was poised at the woman's vagina, easing the head, one shoulder, two shoulders, a body, and feet out of her body, clutching the newborn tightly against my too-big surgical gown. And my first, illogical, thought was "wow, this baby is really warm." Which was really stupid. Of course the baby was warm- he came out of a toasty uterus, insulated by his mother. But the first thought of a student doctor is often an expression of something that should be obvious, but just has not yet been experienced. It was a surprise to me when I first held him.

This has been kind of a funny story to friends, family, other patients, myself...I think in part because it illustrates that doctors start as children in medicine. We have these first experiences and have normal human reactions to them, instead of calculated medical answers. I think being a student gives you a unique perspective too, for your first delivery to coincide with a mother's first birth, where you share in the newness of this experience together. After that point, you are on unequal footing; the doctor and the patient, but as a student, you appreciate things along with the patient.

And I loved it. That feeling of cradling the warm, slippery baby and the happiness of laying the infant on his mother's belly was one of the greatest joys I had ever known, and ultimately changed my career in medicine.

It's a Man's, Man's World

My pants fell down today.

I was listening to the lungs of a patient, and she had a toddler, about waist high, who tugged on the drawstring of my scrub pants to tell me something. They puddled on the floor, leaving me to examine my patient in my pink polka-dot panties.

How professional.

Nobody wants to be caught with their pants down. Particularly not in an audition rotation where you are trying to prove competence and professionalism to possible future colleagues. Given that I look young to begin with, a look exacerbated by no makeup and a daily ponytail, I try to make sure that I give a professional presentation in both a tailored dress and manner. Pink polka-dots were not the look I was going for.

I dropped my stethescope and snatched up my pants, silently cursing the bastard that invented "unisex" scrubs. They are the suggested uniform of the wards, and required to enter any surgical procedure. They are an ugly green two-piece set freely dispensed from the ScrubX machine in the hall. They say "unisex" but are clearly designed by a man for a man. First of all, no woman would pick that atomic booger color. Secondly, they don't fit.

I have the option of scanning my badge and pressing "10" for a size small uniform, and "12" for a medium. I can press "10" and get pants that are huge on the waist, yet hug my hips so tight that it brings the rise and hem of the pants four inches above my socks. I can press "10" and recieve a shirt that is so big that when I bend over, you can see my belly button through the v-neck. Or, I can press "12" and get a pair of pants that easily slides over my hips but has twenty extra inches around the drawstring waist and a rise halfway down to my knees. You can see my toes through the v-neck in that shirt. Usually I opt for the "12" since I don't like things tight on my hips nor unintended capri pants, but this choice leaves me vulnerable to rogue toddler pantsings.

Men do not have these problems. They walk around confident, broad-shouldered and tall, scrubs draped gently over their physician physiques. They look like doctors, not girls wearing their father's scrubs.

I do have some scrubs that fit me. I spent about $100 a pair, and they were worth it. Designed for a female doctor, they look like clinician scrubs, not nursing scrubs, and fit every curve and height. I look like a well-polished version of myself; the tailored female equivalent to the uniforms my male colleagues wear so easily and for free.

But I can't wear them in outside of ambulatory care. Any procedure requires a hospital-issued uniform where its sterility can be verified. With almost half of new doctors being female, this "unisex" policy is dysfunctional for nearly a majority of physicians. In ob/gyn, there were only 7% female physicians in 1970; today females make up 80% of incoming obstetricians. Yet most women look like I do, uncomfortably sandwiched or swimming in an ill-fitting professional uniform.

Medicine is still a man's world. Scrubs designed for a man's form are issued to women. I've sat in many doctors lounges filled with only males, making women driver/shopper/insert your stereotype here jokes over lunch, seemingly oblivious to the fact that I was there. Ugly, fat men that I have done hernia assessments on pull down the underwear and tell me to be careful, don't get turned on during your exam down there. Surgical instruments fit in a man's hand, not my small fingers. If a toddler pulled on a man's drawstring, their pants would stay up.

Aside from offensive jokes and patients with too much self-esteem, I genuinely think that our male counterparts are oblivious to the day-to-day difficulties that face a female physician. I'm sure they don't think how uncomfortable it is for pants to pull around your widest part all day, or for a male patient to leer down a gaping top. The tide of medicine is still changing; since older physicians are still in practice, females make up only 30% of doctors despite nearly equivalent numbers of males to females in medical school. And perhaps some of these challenges will change when the gender of the work force evens out. In the meantime, I think of James Brown's 1966 song...

This is a man's world

This is a man's world

But it wouldn't be nothing, nothing

Without a woman or a girl

Disorientated

I don't know what day it is. Hell, I don't even know what time it is. I was driving around at 7 today, genuinely wondering if it was 7 am or pm. The sky is a mellow blue at both instances of seven o'clock and either way the moon is up, so I just wasn't sure. Even though I have been driving to this hospital for two weeks now, I still turn my GPS on to get there from my motel. Normally I'm good with directions, but this rotation has turned my head around.

I get there before it is light. Sometimes I leave after dark. Sometimes I sleep during the day and go in at night. I am so beyond tired that I don't even feel tired; instead it manifests in a mild nausea and progressive confusion. This experience reminds me of training for deep diving, to prepare for the nitrogen narcosis that occurs at depth. With many extra atmospheres of external pressure, nitrogen solubilizes in the blood and decreases oxygen supply to the brain, and tasks that you could do at surface in 9 seconds now takes 14 at depth. A divemaster will show you this deficit and prepare you that even though you feel completely normal, your capabilities are affected by the external pressures.

Even though I feel okay, I am aware by objective measures that my cognition is not sound. My GPS tells me to turn right, and I turn left, and then am surprised when it says "recalculating" because I think I've gone the correct way. I do a patient's history and physical in Spanish, and then come out and write parts of the note in Spanish, because the conversation is in my head that way. I don't seem to realize that the English-speaking chief resident isn't going to know what I mean when I write "no tiene sangrado" on the intake form. My dad thinks he's been disconnected from me on the phone when he asks a simple question, because it takes awhile for me to formulate an answer. I'm making up words that make sense, such as the neologism of being "disorientated."

A lot of these skills are tested in what's called a Mini Mental Status Exam, or MMSE. We give to patients who are elderly, confused, psychotic, or otherwise just not making sense. It's a baseline measure of basic orientation and cognitive skills.

I'm sure I have a much better chance of failing it than whomever I am giving it to.

These external pressures are real, and even if I don't feel them consciously, I am narcosed by the environment, just like diving. I'm sure this is not the best idea for patient care. Would you want someone operating on you that had been working the last 84 hours with irregular sleep? Probably not. But it's an hazing of doctors into the fraternity of medicine, a tradition of each generation of doctors initiating the next. It's traditionally thought that this creates a stronger doctor that is capable of practicing good medicine despite all circumstances, but I have to doubt that. And I question the role of the older physician in this process. A divemaster demonstrates human deficit in the face of uncontrollable external pressure and teaches each student to recognize it and compensate for it. The doctor-divemaster takes young physicians to depths to try to prove that skills can overcome human reality. My sense is that this is not good for the new doctor, and certainly not in the patient's best interest.

Que hora es?

(Not) Paging Dr. Nobody

I'm starting the first rotation of my fourth year tomorrow. The night before a new rotation, I always have jitters. It's like the first day of school rolls around every four weeks- new teacher (doctor), new classroom (office), new classmates (office staff, nurses, etc), new location. But this one is different. It's my first "audition" rotation, which means it is an out-of-town rotation at a place that I hope to do residency. There are only two for ob/gyn in Phoenix, where we'll be living because of my husband's doctoral program, so I really need it to go well. I always have "sunday-night" anxiety before a new rotation, but this time I am alone in an unfamiliar hotel room, white coat pressed and stethescope polished, counting down the hours until 8 am.

I wasn't sure why this one bothered me more than others. Obviously the stakes are high- I desperately want this program to like me, and for me to like them, since since there are only two residencies in Phoenix. But I think it's more than that. In this hospital, there are attendings, fellows, residents, interns, other students. It's associated with a large academic university. It's planned down to the last four page memo emailed to me last night, with a reminder to bring fifty bucks with me to pay for my badge so I can work. In my hospital- wait. I don't have a hospital. I have a collection of low-income clinics that serves high volumes of underserved patients. My school is a thousand miles away. Planning is scant, since I am part of the school's first class and the rotations are arranged the month, week, day before they start. And I'm intimidated that I am finally going to a "real" medical school hospital, where I perceive other students to be better trained than me. I'm nervous about being in a place where there are tiers of doctors to be hard on me, and to prove myself to.

For most students, this is a standard experience. And every time I wish my school was "regular", that I had gone somewhere else where I would be more used to a traditional, well-planned curriculum, I think about what I got to do in my second and third year. The feel of a warm, slippery baby that I eased out of a mother's body, instead of a handful of paperwork. The unique pressure to make a clean abdominal incision, instead of peering over some other student's head. I wrote prescriptions, chart notes, did patient visits and counseling on my own, made changes in meds. I put in IUDs and did pap smears and colposcopies, rather than just being responsible for cleaning the sticky mess at the end. I told a mother her baby had died. It was an underserved area with too much work, and I was given responsibility beyond my formal education level, with the expectation that I would grow exponentially in skills and knowledge.

My school says this is the benefit of their new, unique curriculum- that students will really be used to care for patients, and will learn more as a result. There weren't other students or residents- just me and the doctor- which is a much different relationship than the model I will be entering tomorrow. I worry that the doctors above me will see it as their right and duty to humiliate me, be hard on me, and overwork me with busy work that they don't want to do, but I more worry about opportunities that will pass me by as a senior student. I don't get to deliver the baby, because that's the privilege of the second-year resident. I get to scrub in on a surgery, but not touch. Now that I've had a taste of these things, I think it might be frustrating and boring to be sidelined. At this hospital, I'll be a nobody, a not-even doctor.

I'm hoping despite these probable outcomes that I will like the program and make a good impression. Despite the usual anxieties- I hope I find the place, can I bring a lunch? will I get to eat it? What time do I go home? Will they like me? Will they give me good patient opportunities? How can I be a good student for this rotation?- there are new ones, more permanent and worrying ones. Will they like me enough to offer me a position for four years of training? Can I compete in an MD residency as a DO student? What are they looking for in a potential resident? What if I don't like them?- a horrifying thought since that eliminates half of the local programs. How can I show them that I will be a good doctor, that in some situations I have already been a good doctor?

T- 12 hours and counting...

Patients(ce)

Patients take patience. On any day, interaction with a high number of people can be trying, especially for an introverted personality like myself. But patients are uniquely frustrating in that many of their disease processes are self-induced. This becomes difficult to manage in an outpatient setting, where patients have the capability of making lifestyle choices. By the time they reach inpatient status, the problems are sometimes beyond repair. I've had many such cases this week in the ICU, and have been struck by how preventable they all could have been.

Besides the typical obesity/hypertension leading to heart disease, and smoking leading to pneumonia and pulmonary complications, there has been some interesting cases of causality casualties. Here are a few examples from my last couple days:

• A young man so obese that the weight of his chest wall compressed his own lungs to where he couldn't properly oxygenate his blood. He needed a tracheostomy and a gastric tube and placement in a long-term care facility to lose enough weight to be weaned off of the trach.

• Two teenagers with multiple gunshot wounds to the chest following a gang fight.

• A Jehovah's Witness dying from complications of low hemoglobin post-surgery. She would walk out of the ICU if given a few units of blood, but instead will die within a day or so from heart failure from her steadily dropping hemoglobin.

• A patient with severe aortic stenosis who declined a valve replacement for years. Now she has consented to the surgery, but her heart is four times a normal size from the pressure exerted on it from the stenosed valve, which makes her a poor surgical candidate. Even if she were to survive the operation, her heart is too badly damaged to expect any change in prognosis.

• A young mother, brain-dead from an overdose of cocaine, meth, marijuana, and other drugs. She was brought in after crashing her car with her baby daughter in the backseat.

• A woman who wrote an alternative-medicine book on radiation poisoning, who failed to follow up with her doctor after he told her the treatment for her lung mass was radiation therapy. Now she is in the ICU with a lung completely filled with tumor and metastases to the liver and brain, causing intracranial bleeding. She didn't even want the CT scan that yielded that information. She died a few hours later, only 58 years old.

It takes a lot of patience to manage these situations; to explain to a family member that choices their loved one has made has caused irreversible damage. Families sometimes displace anger over the uncontrollable nature of the situation onto the doctor, and that takes a lot of patience to work through. You force yourself to be patient and thoughtful with the treatment, because it is unmotivating to try to heal someone who made such damaging decisions. You try to be patient and kind with yourself, acknowledging the frustration and discouragement that comes with an easily preventable death.

One thing I am learning quickly upon entering doctorhood...patients require patience.

Intensive Care

For the past 2 1/2 weeks, I've been working in the intensive care unit. I love it- each case is interesting, there is a lot to think about in terms of medical management of multiple organ systems, the nurses are very knowledgeable, there is a wide array of procedures to perform, and the hours are good. One of the things I've particularly liked about it is the communication skills that it takes to do the job well. I hadn't thought of this as an important requirement for this specialty; after all, a lot of the patients are completely unresponsive. What I forgot about was the families.

Communicating with families is probably the most important thing the intensivist does each day. The doctor has to manage patient care, in some cases making them well enough to walk out of the unit, in others, providing a comfortable death. He does a variety of bedside procedures and stays on top of every electrolyte and troponin and ventilator setting. But that's not really the intensive care. Intensive care is for the family, not the patient. Intensive care is a clear and detailed explanation of their loved one's disease, treatments, changes in status, and prognosis. It's obtaining a compassionate and clear do not resuscitate order. It's putting a dying patient on morphine so the only discomfort in their death is felt by the family, not the patient. It's being willing to be the only doctor in the hospital to recognize when medical management has failed, and to make the judgement to decline further treatments that have little chance to improve prognosis.

This is a very unique role for a doctor. Our job is to fight death by treating the entities that lead to it. Acceptance of death equivocates failure. After all, many other professions are measured by outcome. Teachers are graded on how many of their students pass exams, retailers by how much they sell, lawyers on how many cases they win, preachers on how many souls they save. Doctors are assessed by how many of their patients live. This places far too much responsibility on the doctor for patient outcome, rather than a recognition of human mortality. It's true that some physicians are better than others, but none of us can alter or reverse all disease processes. This outcome-based measurement doesn't allow for a practice that by it's nature cares for those with poor prognoses.

Many beds in the ICU are occupied by dead people. The only thing separating them from the morgue in the basement is a ventilator, balloon pumps, medications to keep blood pressure up, dialysis machines, defibrillators, fluids, blood products, and a crash cart. The thing is, death is temporarily optional in most situations. If your heart stops, we can start it. Lungs don't work? No problem. I can keep a body warm and a heart beating until family comes to discuss end of life care, but I have I saved them? No. Dead but with a living body, patients are suspended in a sort of physiologic purgatory until families indicate their last wishes.

And this is where the intensive care really happens. You place a patient on "comfort care" measures- morphine so they don't feel shortness of breath or pain. You take out the uncomfortable endotracheal tube and allow them to breathe on their own. Dialysis stops, feedings stop, medications are withdrawn. They die within minutes, hours, or days, with no discomfort. The loved ones are the people experiencing pain, not the patient. They are the ones that need to be updated daily on patient status, repeatedly explained prognosis and options to, and reassured that their loved one is not in pain and no, they couldn't have prevented it. Comfort care is for the patient. Intensive care is for the family.

Thus was my situation this afternoon. A patient brought in this morning, down for hours at home following a cardiac arrest. Minimally responsive, with a poor prognosis, the attending had a conference with the family to explain these things and let them know that we would watch him for 72 hours to get a better idea of his neurological status and possibility of recovery. That afternoon, the attending left to place a difficult central line, and the patient's oxygen dropped from 96 to 30, pressure dropped, pupils were dilated and nonreactive, no response to sternal rub- all signs of neurologic death and rapidly approaching cardiopulmonary death as well. Since he didn't have an end of life directive (at age 44, who would?), it needed to be ascertained quickly from his wife and daughter what their wishes were. And there was no other physician there. So, I put my big-girl coat on and was the physician, kneeling next to his wife, explaining his new signs and that a decision was needed more prematurely than we had anticipated. It was my first time explaining an impending death in order to get a DNR status, and it was an intensive experience for me to explain his deterioration, to say that the prognosis wouldn't change much despite more aggressive life support, and to try to help the family believe that his death wouldn't be their fault, even if they elected to turn off the ventilator. It was an intensive experience to look into this patient's eyes- glassy, fixed, and dilated, and know that even though I was watching his heartbeat on EKG, he wasn't alive.

No matter what I go into, this rotation has great value not only in learning to think critically about many organ systems at once, but in developing finesse for talking with patients and their families about sensitive topics, including end of life care. It's good for me to see that a good outcome doesn't necessarily equal life. I am grateful to see that just because another treatment is out there doesn't mean it should be initiated. It's good for me to know that I am capable of having difficult conversations. I'm glad to be more exposed to and comfortable with death, accepting that it's a universal truth and that I as a physician can't change that truth. I know these realizations from the intensive care unit are reflective of the intensive process of becoming a doctor.

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.

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.