The Pro-Psychotics

Prelude: As seems to have become a habit of late, I am again cramming all of my month’s blog posts into a matter of days.  Although in theory I suppose I should rejoice in what appears to be my dedication to spending more time living life than writing about it, the truth is this blog is important to me and my personal reflective process, so in practice, I think I simply need to concentrate on posting more consistent, but shorter posts.

Let us see how long this can last…

A little while ago I was at the hospital with the privilege of shadowing the Esophageal Clinic, consisting of four doctors who jointly saw patients one after the other, providing a superb level of patient-centred care that I had yet to witness firsthand in Montreal.

The team consisted of a gastroenterologist, a general surgeon specializing in the thoracoabdominal region, a thoracic surgeon, and a surgical resident specializing in minimally-invasive surgery.

Four extremely talented and competent doctors in one room meeting one patient at a time, spending, in one case, an hour explaining all the options to deal with a particular patient’s achalasia (i.e., difficulty getting food to pass from the esophagus into the stomach).

It was incredible.

I believe the patients are referred to this clinic only if their case is particularly difficult, and I think the idea is that the team of doctors comes to an understanding of each patient together, and offers the best options based on the situation.  For some, maybe all that can be done at the moment is a nitric oxide prescription to try to increase gastric motility.  For another individual, perhaps there are a range of options (from Heller myotomy to balloon dilatation of the lower esophageal sphincter).

I appreciated that the team discussed each individual before seeing them, so that they can provide a professional, united front for the patient.  Each doctor took turns taking the lead at different moments, and they supported each other while joking with each other as well.

In particular, I appreciated that they always asked this: “If you could only choose one symptom that you want to improve after today, what would that be?“

I thought it was a beautiful question for so many reasons.

For one, it made care tangible.  Because many of these patients were referred because their diseases were particularly challenging to treat, many of them had multiple illnesses and symptoms that were bothersome.  To focus on the chief reason why the patient came to the clinic today meant that they could focus on trying to improve that one symptom, and perhaps continue forward in a stepwise fashion when the patient comes back in three months.  I think this piecemeal plan is rightly cautious and likely prevents the risks of overmedicating while allowing for better understanding of the nature of the individual disease based on how each treatment helps or fails to.

Perhaps more importantly, though, I think that understanding the principle symptom helped the team much better understand that patient’s perspective.  There can often be a great difference between what is physiologically wrong with someone’s body and how that problem manifests in and bothers the individual patient.  So for example, physiologically, there may be a sizeable diverticulum in one’s esophagus, but if the top concerns of the patient have nothing to do with the diverticulum, is it worth the risk of surgery to remove it?

It was eye-opening to hear firsthand how the same mechanical problems in the esophagus can create such a range of symptoms depending on the patient’s life circumstance.

In short, in our first year of med school, we were assigned to describe what the difference is between the “disease” of a patient and the “illness” in the individual.

For one of the first times since starting medical school, I genuinely believe that I see that difference influencing the action of practicing physicians.

And it gives me tremendous hope.

I was walking home after getting take-out from my favourite restaurant close to the corner of St. Catherine and St. Mathieu when I saw a public transit bus stop right in the middle of the intersection with no signs of moving.  I thought maybe the bus had somehow ran out of gas right in the middle of the intersection, but that seemed unlikely.  I then saw all the people gathered around to watch, and I feared maybe the bus had hit someone.  I dislike it when people stick around to watch accidents, but I thought maybe I could help, and I also wanted to ensure my personal safety, and let’s face it I was also curious, so I tried to survey the scene quickly to see what was going on.

I finally saw a young lady of Asian descent lying in fetal position on the side of the road with someone supporting and holding her head in place.  It turns out the bus driver stopped the bus in the middle of the intersection to ensure that the lady had some room to breathe without fear of being run over.  I watched from across the road and I literally froze.  I felt so ashamed as I stood there, motionless, wanting to go across the road and help, but I had no idea what to do.  I had no idea what I could do.  I racked my brain before I fell in shock at the realization that up to this point, we haven’t learned very many practical skills.  I didn’t know what I could do for the patient lying on the side of the road, when it really mattered.

I watched, as time seemed to stand still, at the woman on the other side of the road, to make sure that she was well taken care of. Someone was holding her head and someone else had just put on purple latex gloves and looked prepared to get involved and help the young woman.  I figured that the patient either had a seizure or a car accident, and when I saw that she was able to move her right hand and her right leg (she was lying on her left side), I felt a bit of relief.  When I heard the ambulance siren traveling towards us, I finally felt that the situation was in control, and I left the scene.

I literally froze across the road because I wanted to help.  I didn’t walk across the street because I didn’t know how to help.  In a way, it perfectly captured where I am in my medical career: filled with the sense of duty, obligation, and desire to help, but not knowing enough to do so.  To be fair, I later asked one of my medical mentors, and she told me that there really wasn’t much I could do for the patient in that particular situation without any tools, but still, I felt a bit in limbo and it was not a good feeling.

My first year of medical school is about to end in two weeks, and I really can’t believe it.  It has been one of the best years of my life, and I have my med school colleagues, theatre friends, and significant others to thank for that.  I’ve been fortunate enough to have had a lot of time to enjoy Montreal and all that it has to offer extracurricularly, but the accident that I saw reminded me that I am here, ultimately, first and foremost, to become a doctor.  We’ve had one year of lectures, and we have another 4 months to go in the fall, but after that, we will be in the hospital every day, and it will be time to step up.

The accident that I saw reminded me that I never want to feel so helpless ever again.

The only way to do that is to make sure that when January comes, I will put all of me and my focus into learning those skills that will make me a great medical doctor for my patients.

I simply can’t wait.

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Warning: Certain details in this post concern a disease and may be a little bit graphic in description.  Reader discretion is advised.

We had an interesting discussion in class once, about whether as medical students we should try a watered-down version of the liquid concoction that patients drink to clear out their bowels before a colonoscopy. There were opinions on both sides, and mine generally sided with those who believe that as doctors we can’t possibly experience every procedure to understand what it might feel like for the patient, and even if we did, the experience may actually make us less empathetic.  One of the doctors admitted that he tried the solution and found no ill effects, so he really couldn’t relate to why his patients kept complaining about it!

That class, though, made me consider the importance of experiential learning – when is it appropriate?  And useful?

While it may not always be true that you have to experience something to understand something, sometimes it may help.

In med school, we are often told that our job is:

“To cure sometimes,
to relieve often,
to comfort always“

Truth be told I had some sense of what those words are getting at, but I think I didn’t quite understand the whole picture.

That is, until a recent bout of sickness.

I think it was a combination of stress from shows and school, the viruses and other microbes that had been stewing in me all winter, and my immune system constantly being weakened by the unfamiliar cold of Montreal that had finally given me the worst flu I had ever experienced in my life.

I felt so sick that I didn’t want to eat (which is as serious as a symptom can get for me, because that’s one of my primary methods of enjoying life), and then I felt chills and headaches so bad that I couldn’t even get up to walk 2 minutes to the pharmacy to get drugs that might have helped.  The worst of it, of course, is that I didn’t have people who could take care of me, and I had never really learned how to take care of myself during an illness like this.

I remember doing my research online to confirm that my symptoms were definitely caused by influenza viruses, and then I knew that the flu would be gone in five days, so my main plan was to just wait it out (with fluids, rest, Advil, etc), without going to the doctor, because he would tell me to do the same thing.

I took as few drugs as I could for the flu symptoms, both because I couldn’t make myself go buy them and because I didn’t want to spend the money.  I knew that I just had to wait five days.  It’s nothing, right?  Absolutely nothing.

Boy was I wrong.

Even if the time course of an illness is well delineated based on past evidence, such as in the case of the flu, while you experience the disease, it can be the most horrific experience of your life.  Even though I knew it would be over soon, I was so frustrated during those few days that felt like eternity, because my headache and hot/cold flashes prevented me from being able to sleep, and my illness completely annihilated my desire to eat.  Despite my belief that my mind could control the situation (i.e., mind over matter), I became very depressed and so frustrated because I knew I needed to eat and sleep to recover, but I could not do it, no matter how hard I tried.

And then, of course, it got worse.

I started getting bumps on my lips.  At first, it was just one little bump, and it was annoying, so I kept breaking the blister every time it would form.  Little did I know, but I think that blister was actually a cold sore, and by bursting it repeatedly, I let the herpes simplex viruses get out and about.  The result was that one little bump quickly turned into, and I’m not joking here, fifty bumps all over and around my lips.  I thought maybe I needed to go see a doctor at that point, but I felt so hideous and so lethargic because of the continuing course of the flu that I had even less desire to go outside.

I knew that the majority of the general population is carrying this herpes virus on their lips, but the reason why we don’t all have cold sores all the time is because our immune system is strong enough to suppress the symptoms of the virus.  Unfortunately for me, my immune system was under severe attack by the influenza viruses, and thus, it allowed for the opportunistic expression of the herpes virus on my lips.

I thought maybe I just needed to wait it out until my immune system fought off the influenza virus, then the cold sores would naturally resolve themselves.  Thus, my strategy remained the same: starve out the diseases.

Unfortunately for me, everything just got worse.  I continued to feel horrible from the flu, and the cold sores on my lips got so bad that my lips were just bleeding everywhere all the time, with pus and constant inflammation.  And worse yet, my gums and other oral mucosa were starting to get inflamed as well from the virus.  I didn’t know the virus could affect the inside of my mouth as well as the outside.

I felt awful and looked hideous, and I didn’t know what to do.  I felt so helpless, and thinking that it would all be over soon did not help me at all.  In fact, there were moments when I thought I would never get better.  I was no longer thinking logically.  I was no longer able to detach myself and think like a medical student.

I had completely become the patient, and it was only then that I finally admitted that I needed help.

I went to a walk-in clinic and waited for hours with bandages all over my mouth to try to cover up how awful I thought I looked.  I finally saw a doctor, and he prescribed valacyclovir for the cold sores.  He said that this medication is preventative so I should have seen someone earlier instead of waiting until this stage in the viral infection.  The funny thing is that I knew that fact already, and yet I still couldn’t motivate myself enough to go see a doctor before I felt like I absolutely had no choice.

Ultimately, and thankfully (knock on wood), I made a complete recovery, and I ended up, surprisingly, learning quite a few lessons about medicine.

My experience with the flu taught me that symptom management is extremely important.  Regaining functionality despite having the disease is what it’s all about (even if the disease is supposed to be short-lived).  When we can’t do things that we normally take for granted, like swallowing, life’s joys, including singing and eating for me, are greatly diminished, and that is extremely detrimental to a patient’s mental health, which further impedes recovery and healing, no matter how short the disease trajectory.

A really “mad case of the herp” – on my lips – taught me that part of what’s damaging is a disease’s attack on someone’s self-image.  My lips were like mountains of pus and swollen yellow on red, cracked canvas.  I couldn’t look myself in the mirror without cringing, and again, it did not help my recovery in the least.

Even though curing a disease is nice, and sometimes it’s possible, the most important lesson I learned as a patient is that the journey matters.  No matter how long or short the time a patient spends with a disease, how the patient is treated in the meanwhile – how they look and feel during the disease – makes all the difference.

Even if we think we know the endgame of a disease, the uncertainty is devastating, and the wait, as I found out, can be deadly.

And that’s why our goal as doctors is to relieve often and comfort always.

But the biggest lesson out of all of this?

I need to find me a GP in Montreal, ASAP.

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A family physician who returned to McGill for a 30-year reunion told us a few wishes that are fulfilled by becoming medical doctors.  Really, though, it’s more like three needs of ours that gets fulfilled:

1) The Puzzle-Solver.  Just like House, M.D., medical students are, by nature, curious creatures who like to understand and explore the human body, figure out illnesses, and navigate the uniqueness of human beings and our diseases.

2) The Fixer-Upper.  We like to help.  And feel needed. =).

3) The Soap Opera Star.  Have you seen Grey’s Anatomy?  It’s all about drama.  As doctors, we will have the privilege and responsibility of knowing intimate details about patients that very few, if any, others know, including close family members.  Medicine deals a lot with life and death considerations, serious repercussions, ethical dilemmas, and the complexities of interpersonal relationships, so it can be an intense career in those ways, and that’s sometimes just what we crave.

In short, medical students are individuals with needs, desires, and issues.  And we deal with our issues the only way we know how: by becoming doctors. =D.

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Ladies and gentlemen.  You know what’s beautiful?  You know what the most elegant and delicate and precious organ system in your body is?

I didn’t think so.

Well, let me tell you: it’s your gut.

The GI tract has its own brain – one hundred million neurons!  Many more neurons than the spinal cord.  I’ve seen a segment of a GI tract excised from an animal, and it keeps contracting for hours!

The brain and the heart are pretty boss, but the brain only runs on glucose, and without the GI tract regularly taking up sugars, the brain has to start using ketone fuels that it does not like, so the GI tract can hold the brain hostage.  As for the heart, well, did you know that there is increasing evidence that keeping your teeth clean is the number one way to reduce heart disease?  Bad dental hygiene results in bacteria that gets into the blood via the gingiva in your mouth and travels directly to the heart where they just goes wild.  Didn’t know flossing mattered, eh?

Then there is the fact that the gut knows to not destroy all the bacteria that live in it, allowing for protective, commensal bacteria that prevent opportunistic infection and produce essential nutrients for us.  It is absolutely awe-inspiring how our regulatory T cells can identify this commensal bacteria via intracellular NOD receptors and suppress immune responses, thereby allowing for absorption of nutrients instead of constant, chronic inflammation as a side effect of relentlessly trying to destroy these good gut microbes!  Emaciation (i.e., abnormal thinness) can be a symptom in some HIV patients because they lose T cells in their gut that are regulatory, and thus the patients lose the ability to recognize what bacteria is safe and good for the body, so the body attacks these commensal bacteria and the result is an inability to absorb nutrients.

The gut is just beautiful: a selectively-permeable barrier that keeps us all alive.

This is without even mentioning how elegant the pancreas is.

Anyway, all this just because I wanted to say: Gastrointestinal Tract (I use full names when I’m being 100% serious), I love you.  I couldn’t live without you.

Cue music.

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People who know me may know that psychiatry has been my field of choice since before day one.  I’ve opened up my options recently to include neurology and internal medicine, potentially, but I had ruled out surgery pretty early on.

Well, some of you already know what happens next in this story… I visited the Operating Room for the first time as a med student.

Now, I’m sure a lot of you have read about med students’ first experiences in the OR, and how it blew their minds.  Thus, to be different, I am going to simply write a Top 10 List of lessons learned on my first day in the OR:

1. The vending machine of awesome – a vending machine dispenses scrubs.  You pick the size and out it comes, like a candy bar that you can then wear.  End of awesome story.
2. The chillest people ever – no joke.  The surgeons, anesthesiologists, nurses, and students were all joking and pretty relaxed before the first surgery started (and still chatted periodically during the surgeries).  I know there can be intense times in the OR, but it was really refreshing to see just how cool these people can be in the face of such great pressures – I think it’s a necessary strategy to be successful in that stressful environment.
3. Living the medical video game - I’m sure almost everyone has heard that laparoscopic surgery through tiny holes that are minimally invasive to the patient means that you use cameras and tools inserted into the body to essentially do your work through a tv screen like you would play a video game.  Everyone may have heard about such amazing procedures being done nowadays, but until I watched it in real-time, I really didn’t appreciate how incredible this technology is, and how skilled surgeons need to be when they use this technique.  The simple spatial location, alone (i.e., which part of the tv screen means which side of the patient), is difficult enough to navigate.
4. A surgeon is an athlete – There is the old stereotype that surgeons are all jocks.  This stereotype may not be true, but certainly surgeries require a level of athleticism that not everyone may possess.  Standing for surgeries that are hours-long is difficult enough – at the end of my one day in the OR, my back and neck were quite stiff – but I was sweating like crazy over the stress of just holding one instrument still for a few minutes.  The tension placed on the tool I was holding was immense – I could only imagine the strength I would need to use if I had to use the tools to actually pull and operate on parts of a patient’s body, and for hours at a time without a break.
5. The thrill of the scrub scrub - When you scrub in, you wash your hands a couple of times with soap to your elbows and dry them off, which is expected, but then you use this awesome antiseptic solution that you just rub on your hands and forearms until it just dries out on your skin like alcohol sanitizers.  Then you are officially sterile, and now enter the OR where a scrub nurse helps you into a scrub gown and gets you to spin around in it (clockwise…I think…I never got the turning right), before helping you get into your gloves.  The whole procedure made me feel quite special – I mean, someone had to help me into special clothing, which then gave me rights that no one else had if they didn’t scrub in! – but I later realized that there was a reason why a scrub nurse had to help us into the gowns…it’s not just to boost egos…
6. The privileges of scrubbing in - After the scrub-in procedure as described above, you are sterile, so you can touch the patient!  I didn’t know how big a deal this was, but everyone in the room kept emphasizing that I could now touch the patient!  Pretty great times.
7. The responsibilities of scrubbing in - The joys of scrubbing in and being able to touch surgical equipment and the patient were quickly followed by the realization that touching anything that wasn’t sterile would mean that I then became contaminated.  Case in point: some unidentified solution hit my forehead during surgery, so naturally I wanted to wipe it away with the back of my glove before it went into my eye.  Little did I know, as soon as I touched my forehead, about four people yelled at me for becoming contaminated.  I then had to scrub in all over again.  It was then that I realized that that was the reason why sometimes nurses would dab sweat off of surgeon foreheads during surgery.  It’s because it’s the only way that sweat is leaving that face (outside of it dripping down the face and onto the floor…).  Another interesting tidbit includes the fact that the surgical gown is only sterile until your waist, so your hands have to be above your waist at all times, which is why surgeons hold their hands up in front of their chest after scrubbing in.
8. The power of the scrub – When you wear scrubs in the hospital, delightful old ladies sitting next to you in the cafeteria will talk to you about their personal medical history and give you many details that they normally wouldn’t tell a stranger. People also seem to stare and look at you differently when you’re wearing scrubs, but that may simply have been because I still look like I’m in my late teens, so people were confused as to why this boy was playing hospital…
9. I belong – I had absolutely phenomenal mentors and teachers, who taught me so much, treated me delicately (but not too delicately), let me help and used me as part of their team, and made me feel like I belonged in the hospital and that I had purpose there other than to distract them from their work.
10. Being seduced by the OR - I stood for 8 hours, had a 20-minute lunch, the most I did was hold an instrument still, and I was still utterly exhausted by 5 PM… But lo and behold, at the end of the day, I was so physically drained, but so mentally energized.  Being part of this active, observable healing process obviously inherently holds some type of addictive magic that I have yet to understand…

In short, psychiatry and neurology are still my main potential options, but the biggest lesson learned today?

Never rule out surgery.

In Physician Apprenticeship, which is a fantastic program in medicine that pairs small groups of us with senior medical students and a practicing physician (we have a wonderful general surgeon as our mentor), the point is to have meaningful conversations about the human aspects of being a doctor outside of medical facts and diagnosis. I see it as a safe place where I can discuss my fears, frustrations, and struggles with the medical program, and learn from the amazing stories (both rewarding and horrifying) of my senior colleagues, which show me what I get to look forward to: once we get through these lectures, we get to go into the hospital and actually practice medicine and contribute to saving lives.

Until then, Physician Apprenticeship is like a delicious taste of the world that we will get to be part of, the carrot that keeps us moving.

In our last meeting, we watched a couple of clips from the tv show ER (this is part of why I love this course so much: we get to watch tv!), and we discussed a couple of scenes at length.  One scene was a young resident spending hours of his personal time connecting with a pediatric patient who had cancer and was taking out his frustrations on his older sister, who seemed to be the sole caretaker of the young boy.  For me, the scene was about whether or not it was appropriate for the young doctor to take hours (during his time off) to play video games with the patient, bond with the patient, and eventually tell the young patient a very personal story about his experience with his own brother’s cancer, and how his brother lashed out against his relatives as well.

This simple clip opened up many topics of dialogue.  For me, I tried to articulate to the group that I don’t think that a doctor should be expected to do what the young doctor did, because the doctor’s goal was to mend the patient’s relationship with his sister, which didn’t directly treat the cancer (the way that chemo and other treatments can), so if every doctor was expected to heal families as well as the patient’s specific disease, then wouldn’t that take up every hour of a doctor’s day?  (Plus, wouldn’t psychiatrists then be out of jobs?!!)  I didn’t feel like it should be part of the job description for a doctor to spend all his free time with patients or wear the doctor hat all the time.

But my argument was, at best, incomplete.  I couldn’t quite articulate my intention without sounding like I don’t care about patients other than their disease.  The truth is, if you ask me whether I would have done exactly what the young resident did?  The answer would be yes without hesitation.  The reason why I want to go into psychiatry is because I believe in the power of perspective: how changing the way we think about a disease or situation changes everything about it.

A poignant example of what I mean is this 3-minute TED Talk by Stacey Kramer on the best gift she has ever received, and how perspective played a big role.

I believe that the ER doc was being a phenomenal doctor by trying to treat his patient’s poor relationship with his sister, because his relationship with his family and how much he lets his family support him affects everything from how willing he is to get treatment, to how adherent he will be, to what attitude he will face his cancer with, all of which have tremendous effects on how well the treatment will work.  In that light, isn’t the ER doc doing exactly what his job is as a doctor?  Well, kind of.  So isn’t that shooting myself in the foot?

Well, it took me a long time to clarify my frustration with the entire process, but finally, I think I realized that the issue for me is the difference between wanting to do something and being mandated to.  My frustration isn’t with what the ER doc did, or even with med school’s noble intent of producing doctors who care about patients holistically.  My disagreement lies with the method med school uses to try to teach empathy.  I finally understand that the reason I don’t think a doctor should be expected to do what the ER doc did is because a mandate like that would not produce effective doctors that actually care about the patient – only doctors that pretend to care for the sake of doing their job, which is arguably worse than a doctor who doesn’t try to fake it.  My issue with these types of classes in medical school is that (as a dear friend expressed to me) I don’t think we can teach empathy.  Ultimately, I have no problems with what the doctor in ER did, and I would have done the same thing if it meant being able to heal a patient holistically, but my biggest concern, now that I’ve had time to reflect upon it, is that these courses seem to strive to teach an intangible quality, and I fear that all we can accomplish is teach how to act empathetic and caring without the true substance or intent behind it.

Fortunately, I don’t think my classmates lack empathy (thanks, in part, to the change in the way med school interviews are done), so for the most part, I think these courses will help us refine and clarify our empathetic powers.  I guess my fear with watching and discussing these clips is that it will promote one ideal for what being a “good” doctor is like, and it will encourage us to act in certain ways just to impress or to “do the right thing” even though in our hearts we disagree with the action.  I think the key is to understand the ER doctor’s intention of healing the patient as an entire human being.  Once that is understood, I think the exact course of action that a doctor takes to heal a patient is an extremely individual choice.