He had been divorced for many years. Admittedly, I initially felt awkward and a bit intimidated with our arrangement.
This man is old enough to be my father… and I’m a trainee… and he’s seeing me for therapy…?
The moon waxed and waned many times behind the blanket of grey clouds overhead. I progressed in my education; he became more self-reflective. We both learned from each other.
As Winter melted into Spring, his face brightened.
He had met a woman.
“I haven’t felt this way in a long time,” he said. A smile crossed his face as he looked at his feet. His sheepishness was cute.
“She’s got a great sense of humor. I laugh so much when I am with her. She’s beautiful. And very nice,” he continued, more to himself than to me.
“But I’m scared,” he confided. He rubbed his forehead with his calloused hand. “I’m scared of commitment. I don’t want to get hurt.”
He sighed.
“… which is totally normal,” I gently commented.
“Right. That is normal,” he repeated, looking up at me with that sheepish smile on his face again. His body began to quiver and, soon, his face was in his hands as he laughed at the situation, at himself, at this thing called love.
28 Apr 2008 | 2 comments.
Rest in Peace.
I didn’t open the envelope immediately because I noted that the medical school was the sender.
(Medical schools start soliciting alumni for money when alumni are still residents—and I am certainly not independently wealthy enough to start engaging in that level of philanthropy.)
When I finally sliced the envelope open, I was surprised to see that it was from a surgeon. He has a distinctive, memorable name that accurately reflects his warm character.
My surprise blossomed further when I saw that the letter was addressed specifically to me (versus “alumni” or “graduate”) and was signed with a fresh signature (versus a pre-printed signature).
It is uncommon for anyone to receive a personally signed letter these days, whether from surgeons or not.
I gasped audibly when I read the letter:
Many of you have undoubtedly already heard of the recent death of [Popular Surgery Attending]….
Actually, no, I hadn’t heard about his death.
Popular Surgery Attending was my attending for one week. It was my first month as a third-year medical student and surgery was my first rotation.
I was terrified.
Popular Surgery Attending didn’t smile much and he was reticent, but he was relatively young, handsome, and, my, he was clearly devoted to teaching. Here we were, completely naive medical students quivering in the month of July, and Popular Surgery Attending got straight to work. Though he could probably discuss the basics of hemodynamics in his sleep, he delivered his patter with serious enthusiasm. He instilled just enough fear to command respect, but consistently demonstrated affability so we felt comfortable enough to ask our novice questions. He didn’t yell at anyone in the operating room; he didn’t throw things; he didn’t condescend to any staff or students. His focus was entirely on the task at hand and, when appropriate, he would invite and welcome the curiosity of the students and residents.
The surgery residents loved him. They called him “sir” because they wanted to, not because he asked them to. Privately, they fondly addressed him by his nickname, which was the first syllable of his multi-syllabic last name, preceded by “The”.
I’m currently in that stage of life that is marked with generativity. Friends are getting married and starting families. Peers are embarking upon or settling into careers. I’m not sure that we’re exactly in our “prime” (we’re not supposed to recognize that until it has passed, right?), but we are all active. We have the good fortune of standing in the salad dressing aisle of the grocery and experience the overwhelm associated with staring at the eight kajillion types of salad dressing before us.
We have many options.
Those people who have helped us get to this stage in our lives shouldn’t be dying. They shouldn’t already be dead.
There will come a time when I shall be attending more funerals than weddings, when I shall be thinking more about the past than musing about the future. It’s so easy to be anywhere but right here, right now, though, in truth, right here, right now, is all we actually have.
And those moments can pass so quickly, sometimes without our acknowledgment.
Only when I am sufficiently tired am I able to clear my head enough to realize that my time here is finite. My thoughts are indulgent: What do I want to accomplish with the time I have? What’s the best way for me to fill this finite resource? Those are such luxurious questions; many (if not most) people don’t have the time to wonder about such things. They’re too busy trying to get everything done, all of those obligations that may not be theirs.
It is challenging for most of us, while alive, to rest in peace.
27 Apr 2008 | 3 comments.
When to Stop?
I’m still not sure when it’s time to stop.
He was doing as well as everyone thought he would ever do: Though he insisted that the Ku Klux Klan was stalking him and stealing his thoughts, he was no longer breaking into churches for sanctuary. Though he was still drinking large volumes of alcohol to help mute the taunts of the Grand Dragon, he was drinking less—now just a couple of six-packs of beer most days of the week. Though he rarely experienced moments of subjective peace, he at least looked that way most of the time.
He and I got on well. A kind fellow, he was polite during our conversations. Initially, however, his discomfort was painfully apparent.
“How are things going?” I asked.
“Fine,” he blurted before I had finished saying the word “going”. He looked down, alternatively tapping his feet. Looking back up, he then asked in a stilted voice, “How… are you?”
As the weeks passed, he expressed more of his frustration with the Ku Klux Klan and his own thoughts. Though psychotic, he was clearly bright.
“I try to ignore the Grand Dragon. I know he can’t hurt me,” he bitterly commented. “I think I’ll find peace in the church, but I know it’s not a good idea to go back there. I don’t want to end up in jail again.”
But the moment he acknowledged that his reality may not actually be accurate, he slipped back into the comfortable shoe of fear.
“I hate them! They tried to break into my room last night. I don’t have anything in my room to block the windows except for my table and chairs!” he grumbled. “I can’t stay in Seattle anymore.”
The medication that he was taking was helpful, though perhaps not as helpful as the social connections he was slowly creating in his community. I encouraged this, even when he attributed his improvement to the medication.
“You’re experiencing a notable side effect,” I told him one day. “This could have long-standing effects on your body and I want you to stay healthy for as long as you can. Would you consider changing medications? These are the things that could happen….”
And, after I delivered my soliloquy, he simply commented, “Okay.” He furrowed his brows, perplexed, before adding, “I feel like I’m doing better on this medication, but okay.”
I unwittingly betrayed his trust. He did not do better on the other medication. He disappeared for days on end. Churches routinely called the clinic to report him as as trespasser. He went to jail. He began to wear multiple layers of black clothes in an effort to hide from the Grand Dragon. The tartly sweet aroma of cheap alcohol wafted out of his mouth when he spoke.
He looked terrible. He felt terrible, too.
“The Grand Dragon never leaves me alone and now there are crosses burning in my bones and I can feel the flames crawling along my bones and my muscles are bursting into flames all the time and the showers don’t help not even the cold showers and as much as I pray Jesus does not save me from the Klan and the stations of the cross do not protect me from the stations of the Klan radio that send flames to my body to burn in Hell forever and ever AMEN—”
I worried.
I shared my concerns with him.
“Do you feel like you’re doing better, worse, or the same compared to two months ago?” I asked.
“Worse,” he sullenly replied. “Much worse.”
We agreed to yet another change in medication.
“Fine,” he mumbled, his irritation apparent.
To his credit, he continued to visit me, though he initially made his frustration clear.
“I’m not going to talk to you today,” he said gruffly. “I’m not going to talk about the voices, I’m not going to talk about the Klan, I’m not going to talk about the church. I have nothing to say.”
Surprised and humbled, I nodded. “Okay,” I said quietly. Though I claimed frustration, it was nothing compared to his distress. What else could I say?
We sat in silence.
“The Klan keeps harassing me,” he suddenly said. I could then hardly keep up with what he was reporting: “The fires continue to burn in my bones and I am worried that I am getting shorter because my bones can’t regenerate after the flames eat up the calcium….”
The weeks passed. And his discomfort slowly disappeared.
After greeting me one day, he said, “I’d like to work. Maybe I can do recycling.”
“I think that’s a good idea,” I replied. “What prompted you to think of that?”
“I want to keep my hands busy. I want to work. I want to show the judge that I’m trying to do good,” he said. “If I’m working, I don’t pay as much attention to the Klan. And people then don’t think I’m so weird.”
Inside, I sighed. The agony of realizing that you’re so different from everyone else….
Everyone was telling me that he was doing better. He hadn’t broken into a church in months. He no longer discussed his perceptions of the Klan. He was taking showers on a regular basis, his clothes were cleaner, and he now shaved daily. He was talking more with his peers and drinking a six-pack of beer about every other day.
Objective improvement, right?
“Compared to a few months ago, do you feel like you’re doing better, worse, or the same?” Nothing but the medication had changed.
“Better,” he instantly replied. “Better. But the medication is like a sugar pill. Is it doing anything?”
I shrugged. I wasn’t sure.
But that was subjective improvement, right?
“Do you still experience the Klan harassing you?” I carefully asked later. It’s generally considered ill form to confirm the delusions of others, though I have certainly endorsed them in the past.
“Yes!” he replied without hesitation. “The Grand Dragon sometimes won’t shut up at night; I try to sleep and he continues to preach at me like I am the biggest sinner that ever lived….”
His face contorted with frustration and anger.
“How difficult is it for you to ignore the Grand Dragon?” I asked.
“He tells the Klan to torture me, he does, he does,” he continued. He never answered my question.
So I’m still not sure when it’s time to stop.
Indeed, his condition had improved clinically and he himself suggested that he was feeling better. And yet, there was still so much that could change. He was still tormented, he was still uncomfortable, and he was still psychotic.
When do we decide that this is the best that there is? How do we make that decision? Who makes that decision?
How can we know what is medication-induced and what is not?
A change in medication can result in clinical improvement… or, as he and I had already experienced, worsening of symptoms. How do we decide to take that chance?
How do we assess risk versus benefit?
How do we know if we are overestimating or underestimating the good judgment of others?
What exactly are our goals? What happens if the goals of the patient are unfeasible? What happens if my goals are unfeasible?
Just how do we know that we are providing the best care possible for our patients?
And how do we justify to ourselves and to our patients that the best care we can offer has actually hugely disappointing results?
I shan’t post anything for the next few days. Life will be offering competing interests.
23 Apr 2008 | 4 comments.
Pick-up Lines.
The barista had bright blonde hair—the kind that is more white than yellow—and blue eyes that resembled shiny blue marbles. Intentionally smudged black eyeliner surrounded the periphery of her eyes.
She smiled at me, though only with her mouth. Her eyes, though stunning, simply looked at me blankly.
Nearby, a man, who was probably twenty years her senior, was staring at her. He shifted his weight from one foot to the other, impatiently trying to capture her attention. He opened his mouth and said, “So like I was saying—”
“What would you like?” she asked me, ignoring him. She had blinked sharply when he spoke, as if she was flinching. She kept her blue eyes on my face.
“A tall chai, please,” I responded, also ignoring the man.
She told me the price and I fished out some bills for her. She smiled at me again (and still, only with her mouth) as I gently plunked the change into the mostly empty tip jar.
“So like I was saying—” the man said again.
The barista turned her head and looked at him. She looked nervous, but she was smiling. “Yes?” she prompted.
“Wow—look at those eyes,” the man breathed. His voice had softened. He stopped moving and put his hands into his pockets.
Her limpid blue eyes steadily looked at his face.
“Did I just hear a refrain of violins?” he finally asked, a hint of playfulness in his voice.
“Wha…?” the barista said, feigning innocence. The tone of her voice betrayed her discomfort; she wasn’t reciprocating his advances.
As I walked to the other end of the coffee bar, I smirked to myself. Oy… a refrain of violins?
Earlier that morning, a particular someone had directed a pick-up line at me: “If I were a derivative, I would lie tangent to your curves.”
That one made me laugh out loud.
20 Apr 2008 | 1 comment.
I Could Start a Blog!
One of my duties over this past academic year was to schedule speakers for a weekly academic conference for the department. In addition to recruiting speakers, I have also had to advertise the conference to (1) inform people of the conference topic and (2) increase the likelihood that people will attend the conference.
I never thought advertising would be part of my job.
Admittedly, I have pursued the task of advertising with gusto. The e-mail distribution list is large and, to my pleasant surprise, people I do not know have approached me (or otherwise hit the “reply” button) and complimented my announcements. Many people apparently find them colorful, witty, and entertaining.
That’s nice.
In fact, some people have actually told me that they have saved my e-mails to bring them cheer on dreary days.
That’s really nice.
Today, someone approached me and said, “When you graduate, I’ll miss your e-mails. They’re the highlight of my week.”
“Oh,” I said, a bit embarrassed. “Well, I can ask the person who is taking over my job to continue the silly tradition.”
“It won’t be the same, though,” he said. A woman standing next to him nodded. Suddenly, her face brightened and she blurted out, “You can start a blog!”
Heh.
18 Apr 2008 | 3 comments.