Ramblings on healthcare, medical education, and life with a spinal cord injury

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I Almost Cursed Out an Attending Physician

Hey there. Been a while, huh. Almost a year to the day. I’ve thought about writing more over the past year, as my goal was to document experiences I’ve had as a medical student living with a disability. And I’ve even got several drafts of things I’ve written over the past year that never got finished. It’s certainly been a busy year, but it hasn’t been without time to breathe.

In order for me to get things done, they have to make it to my massive task management list. It’s something I review regularly and it’s the only way I can get anything done. More about that at a later date, but the short of it is, I’ve decided to set a regular deadline for myself to write something here every few weeks. It’s something I really want to do, and that doesn’t seem an overly-impractical goal. Granted, who knows if I’ll be able to pull it off. But that’s the plan. So without further ado, here’s the first.

In late February 2011, I started my third year of med school (M3) with a couple months on neurology and psychiatry. One morning while writing a patient note during my psychiatry rotation, an internal med doc sat down next to me. He said, “Hello!” in a familiar way.  I had no idea who he was, but he sure seemed to know me. The man asked, “you don’t remember me, do you?”  I looked at him somewhat quizzically and shook my head. He said, “one morning, crossing the walkway…” And I knew exactly who he was.

I’ve written in the past about the strange interactions I’ve had with people – but that was mostly about people telling me I need a bell (I don’t), or that I should get a speeding ticket (I don’t go THAT fast), or that I’m quite adept at moving “that thing” (and you’re quite good at working those shoe “things” you have, thanks). One story always stuck with me, but I haven’t written about it before.

One morning I was hurriedly rushing to class at 7:50am, trying to be there by 8:00am. I took my normal route, which happens to pass through one of our teaching hospitals. As is the case for me, I was in my own world. I approached a walkway that had a slight incline, and started to go up it.  As I moved forward, someone asked if I wanted help.  I politely said, “no, thanks.” I wasn’t struggling, and it only takes 5-10 seconds to get up the full length of the incline.

The person again said, “here, let me help you.” And I again declined the offer, albeit not quite as politely as before. But the person persisted, and started to grab on to the back of my chair to push.

Now, imagine you’re walking up a ramp. Imagine someone asks if you need help, asks again after you decline, and then picks you up and starts to carry you. You’d be pretty ticked, right? You might even feel your personal space had been invaded.

I grabbed my wheels and squeezed my hands tightly to lock them in place before turning and angrily telling the person to stop, as I’d said several times I didn’t want help. I came very close to cursing at the guy, as this was very invasive on his part, but better judgment prevailed and I avoided it. Finally, he got the message.

And now, while entering my patient note into the computer two years later, here was the same person sitting right next to me. Wearing a white coat. Oops. Good thing I kept my tongue in check that morning.

We talked for a few minutes, and he told me how the brief, chance interaction early that morning, coupled with a story he saw on TV later that evening about an individual living with a disability, changed how he views and interacts with people living with a disability. He realized that, although well-intended, forcing assistance on people wasn’t the right idea. He realized that a big part of living with a disability is being able to retain control over the aspects of one’s life that one actually can still control. And that when people force help on you, it serves to take away certain parts of that.

He felt quite a bit of remorse for how he’d acted that morning, which was even evident two years later. And we ended up having a nice chat. We’ve since run into each other around the hospital any number of times, and it’s worked out to have been a positive experience for all parties. And every time I see him, I think how happy I am that one summer morning, I didn’t unleash a tirade that would have made a sailor blush.

You never know when you might cross someone’s path again.

Edit 2011-07-06: This post was recently selected by Doctor Fizzy for inclusion in Grand Rounds. To new readers, welcome! Have a look around and I hope you’ll come back and stick around for a while!

June 10, 2011   1 Comment

Memorializing a Gift in Death

One of the quintessential medical school experiences is gross anatomy. It’s one of the things people frequently ask about, and it’s possibly the one single experience that causes the most apprehension amongst newly-minted students. That first exposure to a cadaver is one that nobody will ever forget. Unzipping the protective vinyl bag, curling back the large sheets of plastic, and being confronted with the somewhat rubbery skin of somebody’s embalmed remains is at once both intimidating and awe-inspiring.

We’re first instructed to locate structures that can be felt externally, which begins to ease the transition to an increased comfort with the person who will teach us most about the structure of the human body. Feeling skin and bony structures, cool to the touch, is a good way to start. Eventually we must pick up a scalpel and make the first incision, opening the layers of skin that, up until now, have been all many of us have had any kind of close contact with on another human being.

Stories often circulate of the occasional student passing out upon their first experience in gross. Others may become light-headed or need to take a break. It goes to show how significant this experience is in the many rites of passage in medical school. Nobody in our lab fainted, although I’m sure there was some apprehension that was not vocalized – we were all new to each other at that point in the year, and I’m sure some were guarded.

Often, the apprehension that precedes one’s first foray into the gross lab is gone shortly after that first experience. Replaced instead by a growing familiarity and sense of purpose, and the realization that there is nothing to be intimidated by. Our purpose is clear: we are there to learn, and that is what we do as time goes on.

While we are told the age and cause of death of these, our first patients, we are not told their names. The process is intended to be anonymous, to ensure the respect and dignity due the donors and their families. So instead, many students name the cadavers. These were people who led full lives, and giving them a name, rather than just saying “our body,” helps to make the whole process more personal. These aren’t animals or science experiments we’re peering into, they’re people. I’ve worked in two separate anatomy groups, in different classes, and have learned a great deal from both Alfred and Herman.

Along with the names sometimes come stories of the lives people led. Alfred had tattoos that appeared to be of a military origin, so given his age, we came up with stories of him flying planes in the Korean War. And things he had done since then. Alfred led a good life, was a good man, and had some incredible experiences.

A few days ago, Case held a memorial service for the families and friends of those who donated their bodies to our education. These were people who chose not to be buried or cremated, but instead to have their remains preserved and then torn apart by young, eager students. People who, even in death, have continued to give. One can only imagine that in order to bequeath such a donation, the donor must have been incredibly selfless.

Despite looming end-of-year and board exams, a lot of the students came to the service to honor and remember those who had died, and convey our gratitude to the loved ones who were not able to bury those they cared so much for. Seeing those people, after spending an entire year in the lab, was truly stirring. If those who lay on our tables had not been real enough before, they could not be more so now. The lives of those we memorialized had ended, but their spirit continues to live on, through the people they loved, and now, through us and through every patient we will be able to treat because of what we learned from them. Seeing the attendants of the service was every bit as memorable and humbling as that first step into the lab. Probably even more so.

As my first year of medical school draws to a close, I think back on how much I have learned scrutinizing Alfred and Herman. This experience is neither replaceable nor quantifiable. Every time I locate the anterior scalene, palpate the sternal angle, examine a radiograph, or dissect the connective tissue around a mass or vessel, it will only be possible because of what I have learned and practiced in gross. Every patient I treat, every student I teach, every patient those people treat, and so forth. It quickly becomes clear just how exponential the reach becomes.

So to Alfred, Herman, every other anatomical donor, and all of those who have sacrificed so that we may learn, I thank you with all my being. In death, you continue to live on and have single-handedly touched and benefited more lives than any of us could ever imagine.

May 18, 2010   1 Comment

Is Medical Education Too Black and White?

Studying medicine while also living with a chronic medical condition provides somewhat of a unique perspective on how disease and various conditions are presented. And recent material we’ve covered has given me pause to consider how things are taught.

The curriculum at Case Med is based heavily on the concept of problem-based learning (PBL). Which means we do a lot of work in small groups (roughly eight students per group, with one faculty facilitator). On Monday morning, we receive two cases. Each provides a narrative describing a particular fictional patient, their signs and symptoms, some imaging and potentially a diagnosis. We spend about an hour per case in our small groups working through the details, discussing elements we need to learn more about and how we will focus our individual research about the cases in question. On Wednesday, we reconvene and discuss the first case, Friday the second case. Small group is augmented by lectures that serve to provide some formal guidance as to the physiology and pathology with which we are presented, a sort of springboard for our small group research.

I think this is an incredible way to study medicine, as it forces us to learn how to learn, which will be infinitely more essential in our future careers as physicians than having memorized the entire list of signs of interstitial lung disease. To be sure, the ability to recognize common conditions and their presentation will be necessary to do our jobs. However with collective medical knowledge expanding at a phenomenal pace, even more important is the ability to quickly and thoroughly assimilate details about something with which we are unfamiliar. But I digress.

Recently, we had a case that was intended to guide our learning of the diaphragm and the accessory muscles of breathing, as well as the various phases and intricacies of the process. Because the diaphragm is innervated by spinal nerves C3-C5 via the phrenic nerve, but the accessory muscles are variously innervated by nerves at the thoracic and lumbar levels, the case we were presented with involved a patient with a spinal cord injury around the level of C4-C5. The idea behind this being that the patient would have at least moderate function of the diaphragm, but no use at all of the accessory muscles. Being able to discuss the topic in depth requires an understanding of all of the various muscles, what they each contribute to the process of respiration, and how they are impacted by a neural deficit.

However, during the course of the case, no mention was made of the classification of the patient’s SCI: complete or incomplete, or what the ASIA level was. Unfortunately, without this information, it becomes a lot more difficult to fully ascertain how the patient would fully be affected. As the case was not intended to be a neuro case, going into great detail on the ASIA scale or all of the other items impacted would be inappropriate. But without understanding at least that there can be tremendous variance in how patients are impacted by spinal cord injuries, it becomes impossible to really know this patient’s situation.

Of course, I’m in a unique position and am acutely aware of these differences. I’ve had to learn it as I’ve lived it, and as someone living with an incomplete SCI, I’ve learned just how bafflingly variant such an injury can be. Some muscles may function perfectly fine, while others that are controlled by nerves higher up the spine are more poorly innervated than those further down. It’s impossible to predict the items that will be affected in an incomplete SCI, which is why patients comparing functionality between ourselves can be nigh on useless.

During the course of discussing this case, I tried to mention a few times the concept of complete versus incomplete, and reinforce the idea that incomplete can be a vastly inconsistent diagnosis. And people in my group seemed to either already be aware, or they came across it in their research for this case. But in talking to friends, it was clear that other groups didn’t seem to be aware of the concept and some students were under the impression that such an injury is simply binary: all or nothing. You’ve either got full functionality, or none.

Nothing could be further from the truth.

Which got me thinking. If the extreme variability that is central to even scratching the surface of an SCI wasn’t covered, what about other conditions? And as I began to focus more on how other conditions are presented to us, I started to realize that many cases are presented as “here is syndrome X, and here are the associated symptoms.” No mention is made of how variable something may be, or the depth of different manifestations.

I discussed these thoughts with some classmates, and many of them shared the feeling that it seems medical education may be a bit lacking in regard to the spectrum with which various ailments appear. Perhaps this is considered an implied undertone to everything we learn. Perhaps it’s something we’re assumed to pick up in third and fourth year, when we’re immersed in the clinical aspect of medicine every day. Perhaps it’s something we’re assumed to learn at some other point in time.

Whatever the case, my own experiences have made me more acutely aware of such variance than I otherwise would have been when considering anything that we study, as have those experiences done for several classmates of mine. Which in the end, I think, makes us all more versatile and adaptable as a result.

April 23, 2010   3 Comments

I Don’t Need a Bell for My Wheelchair

So I was reading over a blog post by Eva, about how people react to her approaching in her wheelchair.  Her blog is very interesting, and she has a camera attached to her chair, often recording the odd interactions she has with people. In this case, the women reacted appropriately – she just moved her cart out of the way, didn’t make any inane comments and didn’t make a big deal out of it.

If only everybody were like that.

Her post reminded me of the countless times I’ve had similar interactions with people and the poor judgement they’ve expressed in commenting or reacting. It’s a subject I’ve pondered writing about a lot in the past, and she’s provided the spark with which to do so.

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April 12, 2010   3 Comments

Patenting Your Genes

Before I begin, a caveat: I am not a lawyer, and my comments do not reflect a foundation in scientific law.  They’re purely opinion, unless cited, and should be treated as such.

I had an interesting discussion with some friends recently over the concept of gene patents. If you hadn’t heard, U.S. District Judge Robert Sweet in NY struck down a patent that had been granted to Myriad Genetics for the BRCA1 and BRCA2 genes present in many cases of breast cancer.  (The NYTimes has also covered this quite well).  He stated that regardless of the form of DNA being used, the fundamental bit of data is still human DNA, something that occurs in nature, and something that is inherently not patentable.

This is huge.

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March 31, 2010   2 Comments

Walking Progress Updates

Rather than add a new post every time I want to add new stats on walking, I decided to make a separate page that will contain graphs showing my progress walking.  If you look on the left navigation menu, you’ll see a new link for Walking Progress.  I’ll update the graphs on there at least once every few weeks, and at the top of the page will be the date on which the page was last updated.  And there’s been some decent improvement since the last time I posted the graph.  So check it!

December 11, 2009   3 Comments

Screening Mammography

Far be it from me to attempt to solve a complex matter like the current debate on screening mammography.  I’m a first-year medical student and haven’t had extensive experience treating patients dealing with cancer. But the climate of the current debate is troubling for a number of reasons, not the least of which being the knee-jerk reactions many people are having that fail to take into consideration a lot of the science behind it all.  I’ve been talking about this with a lot of people lately and figured I’d share some of my thoughts on the matter.

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November 27, 2009   1 Comment

Hi from Cleveland

Well, I never thought it would take this long to resume writing here, but apparently it has. I’ve mentioned in the past the intention to somewhat transition the blog to a discussion of not only my recovery, but also life as a medical student. So this is the first step in that direction. In addition to progress updates on my recovery, I’ll discuss topics I find interesting or relevant that are related to healthcare, as well as certain experiences I’ve had as a medical student. Updates will be shorter, but hopefully more frequent than they used to be (the past six months excluded, of course). There have been plenty of topics as of late that I’ve wanted to write about, from healthcare reform to cancer to H1N1.

But first, a much-needed progress update.

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November 18, 2009   1 Comment

My Other Life

Just a quick post.  As many of you know, I’m leaving the computer security/UNIX/development world for medical school. But since that will surely still be a big part of my life and I wanted to document some things I’ve been working on, I setup a new, separate blog to post random technical bits.  If you’re so inclined, please check it out! :)

http://bitdrop.st0w.com

May 19, 2009   2 Comments

I Broke My Knee

That’s right, I broke my right knee. Let me tell you the story. A few weeks ago (just after I last posted, so about three to four weeks), I was walking on the walker with a PT and Richie, one of the aides. After about thirty or forty feet, my right knee buckled and Richie caught me. The right knee had been feeling a bit strange prior to that, but nothing so unusual that I was worried about walking. After catching me before I had the chance to hit the ground, I sat and rested for a bit while collecting myself.

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April 15, 2009   5 Comments