Frozen precipitation is a rare phenomenon in Seattle. Because of the infrequency of snow, the city does not invest in appropriate equipment and supplies to ensure that the city shall continue to function despite the weather.
Practically, this means that the roads and sidewalks are not scraped or salted after a snowstorm. For a city that boasts many hills, this means that much of Seattle shuts down while everyone waits for the ice to melt.
There are homeless men who insist on sleeping outside, regardless of the weather. For those that do not sleep under freeway overpasses, inside abandoned buildings, or under the eaves of a storefront, they sleep in the woods. Sometimes they sleep under the trees; sometimes they sleep in the trees. Most of the time, I’m not really sure where they sleep.
When the sun finally peeks through the winter grey pall, the black ice transforms into sparkling water that trickles down the hills and into the rusting storm drains. The city emerges from its hibernation and soon, people are out and about, their hands shoved into the pockets of their puffy jackets and a few wild locks of hair sticking out from underneath woolen caps.
There are homeless men who navigate their way from the woods onto buses into the city. Though they do not own watches or other keepers of time, they somehow know when and where to appear for their appointments. They arrive willingly, cheerfully, often for nothing more than conversation and discussion about current events.
I’m not sure how these homeless men protect themselves from the frozen precipitation. Winter strips the trees of their leafy apparel and their naked branches offer little protection from the slushy snow and pebbles of hail. I’ve never asked them.
So when these men who regularly attend their appointments do not appear after a night of snow, I wonder. And then I begin to worry.
Should I blame myself for not previously offering to them the warmth and safety of my residence?*
Is my penance to take them home with me now, even if only in my mind?
* Not that I would actually take patients home with me—boundaries and limits and whatnot—this is more of a philosophical musing than anything else. It’s easy for those of us who Have to luxuriously indulge in the self-righteousness of worrying about the Have Nots.
16 Jan 2008 | 3 comments.
Why He’s Special.
I noticed the curtains surrounding the adjacent beds were gently swinging back and forth. Someone was systematically looking into each “room” of the emergency department (where each “room” actually resembles a stall surrounded on three sides by a curtain that sports a horribly tacky print). I continued to watch the (excellent) medical student conduct a (skilled) interview with the patient.
Suddenly, it was our curtain that was gently swinging back and forth. Mildly annoyed, I looked up to identify the intruder. As curtains do not muffle sound (contrary to popular belief), anyone walking past could hear that an interview that was unfolding within our drafty “room”. (The sound of an interview, of course, does not prevent interruptions, but it should, darn it.)
He had already removed his head and was now standing on the other side of the curtain. When my eyes alighted on the back of his head and his checkered shirt, I immediately recognized him. And then I heard him ask a passing nurse in that quiet, nasally voice of his: “Where is Mr. So-and-So?”
Ah ha! That voice belonged to no one else.
“In that bed over there,” she clipped.
“Oh. He moved!” said That Special Attending. Feigning a cough, I smiled into my hand. That Special Attending was on service! Perhaps I could catch him and say hello—
—but, patient care first.
“So, while you were interviewing that patient in the emergency room,” I babbled to the medical student and intern, “I saw an attending that I totally had a crush on while I was a medicine intern.”
They laughed, permitting me to elaborate. After sharing the name of That Special Attending, I continued, “I had the good fortune of working with him twice when I was on medicine. That’s a total of four weeks! He’s really smart, incredibly witty, very easy to work with, a fantastic teacher, and really good with patients. I totally fawned over him, especially on post-call days—I’d gush about him to anyone who would listen. The nurses made fun of me all the time.” Throwing my voice into falsetto, I mimicked my sleep-deprived ramblings: “He’s so smart! He’s so cute! He’s so charming! He complimented me in front of the whole team!”
The intern and medical student laughed even more, though clearly more at me than with me.
“… and he’s married and has kids,” I concluded. Their laughter turned into utterances of commiseration.
The opportunity was lost: The hospital was large. He had disappeared. We were inundated with our duties on call. And stalking attendings just isn’t a good idea.
I directed the group of residency applicants into the hallway and launched into my usual greeting. As I followed them in (all wearing dark suits, of course), I looked up and who should I see walking towards us?
Unlike two days prior, I didn’t feign a cough this time. I smiled broadly at That Special Attending and waved hello as I continued to speak with the applicants. He waved back, a stethoscope swinging from his neck in front of his checkered shirt, and walked past us.
As I concluded my greeting, I turned around and saw him walking back towards us. He grinned at me, his face full of mirth.
“Are you an attending now?” he warmly asked in that nasally voice of his.
“No,” I answered, unable to suppress the smile that was now dancing on my face. “I’m still a resident, giving these applicants a tour.”
He smiled at them and remarked, “This is a good hospital for psychiatry.”
“It is the crown jewel!” I concurred.
“It is the crown jewel,” he said, chuckling at my buoyant enthusiasm.
“This is That Special Attending,” I said, responding to the confused looks on the faces of the applicants. “He is one of medicine attendings here.”
“Hi,” he said. They all politely waved at him.
“He’s wonderful,” I continued.
“Ah, thanks,” he said, a bit embarrassed, a smile playing on his lips as he looked at the ground.
(Sometimes my enthusiasm can be a bit too buoyant, I suppose.)
I directed my attention back on the applicants, tacitly asking the permission of That Special Attending to depart. He graciously took the cue.
“Good luck,” he said to the group, his fingers fidgeting with the bell of his stethoscope.
“It is very nice to see you,” I said, my face still aglow with a bright smile. It wasn’t merely a pleasantry; it was an honest remark.
“It is very nice to see you, too,” he said, flashing that toothy grin at me. He paused and waved good-bye before retreating down the hallway. I shepherded the group in the opposite direction.
Though his admirable character, intellect, and charm are endearing, I don’t think those aspects sufficiently explain my affection towards him.
I am fond of him because I enjoy who I become when I am around him.
14 Jan 2008 | 3 comments.
Reflections from a Sunday Evening.
Faith and good works versus insight and behavior change. My college roommate and I occasionally bickered about faith and good works. She was raised Catholic and I, Protestant. (If we weren’t bickering about this, we were bickering about transubstantiation. She believed that people indeed consumed the body of Christ at Communion. I believed that people were drinking grape juice or wine and eating a very dry cracker.)
“Paul makes it very clear,” I argued, “that man is saved by faith alone.”
“James makes it just as clear,” she responded, “that faith without works is dead.”
“Good works stem from faith. Theoretically, if one believes, one will naturally engage in good works.”
“But without good works, there is no evidence of one’s faith.”
And around we went. The point of disagreement was trivial. She and I both knew that we were both maintaining the schism between the Catholic and Protestant churches. Ecumenism is overrated. Martin Luther would have proud.
(Though I do not qualify to join The Brights, my faith is not what it once was.)
A similar disagreement occurs within psychiatry. There are those that believe that insight alone will result in behavior change… and then there are those that argue that insight alone does not necessarily result in behavior change and thus, one must also explicitly address behaviors.
For example, someone may enter therapy and eventually learn that the reason why he cannot enter intimate relationships with anyone is because (wait for it, wait for it…) of his childhood experiences. Whenever he shared his concerns and worries with his parents, they informed him that he worried too much, was weak, etc. and punished him with public and private ridicule. He subsequently lived his life in a guarded and stoic fashion, which garnered him success in his professional duties, but not with women.
Fine.
Just because he understands this, though, does not mean that he is now going to sashay down the street, hand out his business cards to every woman he passes, flash a bright smile, and ask the recipients to call him if they are interested in joining him for dinner. Some would argue that, if his goal is to participate in an intimate relationship, insight is not necessary: He simply needs to change his behavior. Thus, the therapist might instead coach the patient to increase the type and amount of contact he has with women, develop and hone skills in social interactions, and take action, even if he feels anxious to do so.
Fine.
However, one must have some insight to engage in behavior change, or the desired behavior just won’t happen. For example, this man in question may not require knowledge that his difficulties stem from his punitive parents, though that may certainly help him realize that his childhood experiences may not be valid in his contemporary life. It is helpful for him to realize, though, that perhaps the reason why he avoids contact with women is because he has underlying beliefs (regardless of origin) that women, across the board, do not find him attractive. What is the evidence for that belief? If the evidence is scant, then he may learn that he cannot believe everything he thinks and can challenge this thought through behavioral experiments that may ultimately demonstrate that, indeed, women like him.
And around it goes. Faith and good works? Insight and behavior change?
Should there be any surprise that there exists controversy in both religion and psychiatry?
The ways parents wound their kids. We’ve all said or done unkind things to our parents: Perhaps we told them, as adolescents, that they were THE WORST PARENTS EVER. Maybe we’ve stolen money or other valuables from them. Told them hurtful lies. etc.
The injuries, however, obviously do not flow in that single direction. The power differential that exists between parents and children can increase the magnitude of these injuries that children bear to heartbreaking proportions.
I refer specifically to those parents who beseech their children, “Please help me kill myself,” or “If you don’t do well in school, I will kill myself,” or “If you really loved me, you would help me commit suicide,” etc.
Augh!
Consistency and predictability. There is comfort in consistency. Once patterns are established, the need to consider other options (some of which may be distressing) is limited. However, if there are deviations in a pattern, this results in an aberrant piece of information that requires reconciliation.
Reconciliation requires effort. Furthermore, the justification process may insist that people completely reevaluate their worlds (or, more accurately, the perceptions of their worlds). To realize that the world may not actually work the way one thought is distressing. This mental conflict can be called “cognitive dissonance”.
Because cognitive dissonance is usually uncomfortable (physically, mentally, emotionally), people will often change (or really not change) to resolve this situation. For example—going back to the concept of faith—some people who already adhere tightly to circumscribed ideas about God may rigidly exclude any information (such as evolution) they learn to decrease the likelihood of experiencing cognitive dissonance. Because they may have invested so much time, energy, and resources into their perceptions of the world, introducing information that contradicts this world view may invalidate their existence and purported purpose in life. To incorporate differing information, whether valid or not, may require an agonizing reassessment and, really, who wants to feel agony?
(Think mid-life crisis.)
Thus, polarization is an appealing option. At least in that situation, there is consistency, there is predictability—and the path is clear as to how one ought to proceed. The sense that one is doing “the right thing” brings security. Ambiguity and uncertainty cannot offer nearly as strong of a support or anchor.
And, to be clear, we all do this. We all believe things—whether in people, things, science, medicine, religion, philosophy, arts—that may not actually have any basis in anything, but they help us lead our lives with a little more comfort. We believe that they offer stability and thus, we trust.
13 Jan 2008 | 3 comments.
An Open Letter to a Man Who is Probably Now Dead.
Dear Sir:
I’ve thought about you recently. I’m not sure what prompted this lately, though I have noticed that I think about you every six to nine months.
I’m pretty sure that you’re dead now. There’s no way I can know this with any certainty, though I at least know that you have not died in the hospital. (I confess that I had looked up your hospital records several times within that first year after we met. I no longer do this because I don’t remember your first name, though I do remember your last name. That is how I addressed you.)
I was an intern and you were my patient. You had HIV. We met in the ER. If I recall correctly—the details are hazy now—it was an unceremonious greeting. You were too confused and what you said made little, if any, sense.
In fact, I hold only three snapshots of you in my head:
- The image of your brain. The greyscale image revealed a large tumor there. That mass explained just about everything about your clinical presentation: Your thick speech, difficulties with walking, and headaches.
- You nearly falling to the floor. I had walked into the room and you were staggering about, your hospital gown hanging wide open and your arms flailing as you teetered towards the bed. Lucky for us both, you regained most of your balance when you grasped my hand.
- You sitting on your bed. You invited me to sit down next to you.
Though I remember you for many reasons—the heartbreaking condition of your health, your attractive face (you weren’t handsome, though there was something about your dark eyes and uneven smile that was appealing), the way you shouted at all of us—the primary reason I recall now is that you taught me the importance of being present and genuine with patients.
You were sitting on your bed. I couldn’t understand the words leaving your mouth; the tumor was affecting the nerves that power the tongue and throat.
“I’m sorry—can you say that again?” I asked.
You repeated yourself.
“I’m sorry—I still don’t understand what you’re saying,” I said.
“I AM TIRED! TIRED! I JUST WANT TO REST!” you shouted, waving your arms around.
I recoiled, took a few steps back, and blurted, “I feel scared when you shout at me. Are you angry with me?”
You looked surprised, maybe a little hurt. You shook your head before mumbling, “No… no.”
And then you extended your hand. It was trembling.
At that moment, I felt shame: Did I make a poor assumption in believing that you were angry with me? Should I have kept my fears to myself? What was I hoping to accomplish with my remark? Was I alienating you?
Should I not have made the obvious explicit?
How I wished I could have taken those words back.
I instead took your hand. Your arm gently—though jerkily—pulled me to the bed. Implicit in your gesture was an invitation to sit down. So I did.
And we sat there. You held my hand while it continued to twitch and tremble. We may have had a conversation; I can’t remember. If we did, the content of the conversation was of little consequence, primarily because I still had problems understanding your thick speech.
I can’t know for sure what it is that you wanted to communicate to me. In my mind, I interpreted it as a sort of apology. Maybe you just wanted company. Maybe you were bored.
What you did not do, though, was punish me for my honest reaction.
Shortly thereafter, I rose from the bed and tried to remove my hand from yours. You would not release it.
“I have to go,” I said. “I have to see other patients.”
You mumbled something incoherent, though the expression on your face clearly communicated disapproval. Your fingers popped open and I was free.
The attending had told me later that your prognosis was extremely poor—maybe six months at most. In my selfishness, I didn’t want you to die—we had just met. You seemed like a nice guy. I wanted to see you in the future as a healthy, functional, nice guy.
And that’s why I checked your medical record thereafter.
I will never know if I ever crossed your mind after you left the hospital, though I highly doubt it. I was just one person in a long, white coat out of the dozens who you saw during your time in the hospital. You had other people in your life who reminded you of your days as a healthy young man and good friend, not as a patient with HIV who had a brain tumor.
Some people insist that doctors don’t think about their patients outside of work, or that they don’t care about what happens to them.
That you still remain in my memory and continue to affect the way I interact with patients is evidence otherwise.
Thank you,
Maria
10 Jan 2008 | 5 comments.
What’s In Your Bag?
There is a Flickr group dedicated to answering the question, “What’s in your bag?” The photographs generally reveal neatly arranged accoutrements—occasionally of expensive and stylish varieties—and may feature the bag within which these items sit. Presumably, these tangible things reflect individual intangible values and beliefs.
Whenever the homeless man came to visit, his hands—grimy, dark, with dirt underneath his short nails—clutched a dirty plastic bag. I asked him what items he had in his bag.
A sly smile crossed his face as he opened it. He inserted one hand into the bag; it crinkled loudly as he rummaged through the contents.
“Well…” he started, pausing for effect, “inside, I have a water bottle…”
He pulled out a quart-sized plastic water bottle, inside which swished water that was brown and murky. The cap, once white, was now smeared with dirt.
“… a razor…”
It was black with two blades. I thought I noticed rust on the outer blade.
“… antiseptic deodorant…”
He pulled out an unmarked container of deodorant—not the stick kind, the roll-on kind.
“Did you know,” he said, flashing a playful grin at me, “that this deodorant also helps heal small cuts? It works well for that.”
He continued to dig through the bag.
“… a toothbrush…”
He only revealed the handle. The bristle end he kept in the bag.
“… more plastic bags…”
His hand pulled out another crumpled bag.
“… and candy.”
With panache, he showed me a Snickers bar.
I asked him again if he wanted to replace any of the items. I was specifically thinking of his water bottle.
“No, no,” he emphatically replied. “I’m fine.”
Noting that he had consistently declined all of our offers for clean, intact clothing and new toiletries, I gently asked, “Can I ask why you don’t accept newer stuff to replace what you currently have?”
He closed up his bag and looked at me.
“Because I already have everything I need,” he simply replied.
8 Jan 2008 | 3 comments.