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The Stanford-Boston connection

My New York Times op-ed discusses the care of VIP patients and the problems with a hospital class system.

When we torture our patients

(The following piece also appears on the physician blog site, KevinMD.com)

Today, a patient attacked me. A nurse got kicked. Another punched. I was gouged to the point that blood was drawn. The patient was neither intoxicated nor psychotic. Rather, she was a meek 92-year-old grandmother, and she was terrified. It took five of us to hold her down, as she summoned the strength of a woman fighting for her life.

Linda is an elderly woman with moderate dementia. She is blind and nearly deaf, and she speaks no English. Normally, she is quite pleasant. She lives in a nursing home where she has several friends and gets along well with the staff. Although she is forgetful about day-to-day events, she frequently tells stories of her past. She loves having visitors.

In the days leading up to her hospitalization, Linda had begun acting strangely. She accused staff of conspiring against her. She even cursed at a friend. Then, she had a seizure. By the time EMS arrived, the seizure was over, and she was confused. She refused to go with them. What were they to do?

She arrived to the emergency department on a stretcher with her hands bound. A small old woman, she appeared harmless. We tried speaking to her in English; she replied in her native tongue. We called for an interpreter and attempted to contact her family. Using the interpreter, we explained that she was in the hospital and that we were here to help her. She spit vulgarities at us. When we unbound her hands, she suddenly sprung into action, punching and kicking. She screamed at the top of her lungs — a scream saturated with fear.

We were forced to hold her down against her will, jab a needle into her arm, and inject her with a medication to calm her. She did not respond to the medication right away, and we tied her to the bed with four-point restraints. She continued to thrash and shout.

Of course, there are many reasons why an elderly patient might have a seizure. We needed to act quickly to look for the cause and treat her appropriately. As soon as she appeared sedated, we attempted to obtain a blood sample. Again, she went wild. We gave her more meds. Finally, we were able to do the work that we needed to do — checking labs, scanning her head, etc.

The situation I encountered with Linda is more extreme than typical, but it represents a common scenario. Few will disagree that in special circumstances physicians need to treat patients against their will. In particular, we may do so when a patient is deemed to lack the cognitive capacity to make decisions for him or herself. Linda was delirious, and she lacked capacity. For that reason, we did what was necessary to treat her. But what was necessary was torture.

Admittedly, using the word “torture” is hyperbolic. We had no malicious intents. We were working in Linda’s best interests. But let’s put semantics aside and try to understand the situation from her perspective.

Linda has dementia. She is blind and nearly deaf. She was forcibly taken from her home by people she did not recognize who spoke a language that she could not understand. She was tied down to a bed and stuck with needles. In her frail mind, the only way to understand this situation is as an attack on her life. To her, it was torture.

The mere thought of torturing a patient makes me queasy. My rational mind immediately objects to the use of that word. I had no desire to hurt Linda. Quite the contrary, I desperately wanted to help her. But in order to help her, I allowed her to experience a terrible situation.

I did not torture her, but she surely felt tortured.

Is this alternate phrasing clever doublethink? Am I simply protecting my conscience? I suspect that I am. I have to. If I do not, how will I be able to go on treating patients like Linda?

When I tell Linda’s story to friends outside of medicine, their response is, “That’s horrible!” When I tell the story to young physicians, their response is, “That’s too bad.” Older physicians simply respond, “That’s life.”

Inevitably, physicians become desensitized to these experiences. It is not because they have lost their humanity or their compassion. Rather, these unfortunate situations are simply part of the job.

Linda is better now, but it’s only a matter of time before she gets rushed back to the hospital for some other reason, likely to go through the whole ordeal again.

That’s life.

#writing

Hope has a cost. Hope is not comfortable or easy. Hope requires personal risk. Hope does not come with the right attitude. Hope is not about peace of mind. Hope is an action. Hope is doing something.

Chris Hedges

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In an effort to be a more responsible scientist, I wrote this article for my home town's newspaper. GMOs have been a hot topic, but most of the debate has been fueled by misinformation and lies.

#writing

My Uncomfortable Truth

Remember your humanity, and forget the rest. ~The Russell-Einstein Manifesto

The American healthcare system is a paradox of triumph and failure. We lead the world in medical innovation, yet we lag behind in cost, quality, and equity. During my last month of med school, I sat with a group of graduating students to discuss this challenge. As students, we had directly confronted the shortcomings of modern healthcare. As the next generation of physicians, would we do better? Could we do better?

The group consisted of several accomplished individuals, each destined to be a leader in medicine. Nine specialties were represented, ranging from family practice to neurosurgery. The conversation was insightful and impassioned, but there was an underlying tone of caution. We used delicate language, exchanging glances of a mutual understanding. Eventually, someone noted what we all were thinking. The discussion was starkly different from what it would have been if we were first year medical students. We had changed.

Of course we had changed.

As first years, we were brazen and quixotic. We were more than ready to throw away the status quo and succeed where our predecessors had failed. Now, as newly minted physicians, we were utterly, almost nauseatingly, realistic. The naivety of inexperience had been stripped from us, and buried in that conversation was an unsettling seed of cynicism. Although we hoped for success, we were quick to list the ways that our efforts might fall short. Our words were soaked with the pragmatism that had been bludgeoned into us (perhaps by necessity) during two years of clinical training.

The clinical years of medical school are infamous for transforming happy students into bitter physicians. The pre-clinical years that precede them are often referred to as the “pre-cynical” years. In one large survey, 50% of students reported feeling burned out, and 11% reported suicidal ideations. Those who make it through medical school with their enthusiasm, hope, and humanism still intact are not home free. The same experiences that serve to erode such characteristics are encountered day in and day out for the rest of one’s career.

In just two years, my classmates and I went from having our heads in the clouds to being irreversibly grounded. How will we change after another two years? Ten years? Twenty? I am forced to ask a scary question. Which of us will eventually succumb to the ugly reality of medical training? Could it be me?

I used to think that I was immune to cynicism. I am a hopeless optimist who has been accused of being “annoyingly positive.” While some debate whether the cup is half full or half empty, I respond, “I can’t believe I have a cup! Cups are awesome!” How could anyone with this outlook ever become jaded?

I now understand that my positive attitude is not a shield. I am not special. No physician begins his or her career planning to become despondent. The process is insidious, and we are all at risk. It is hard for me to admit that fact. To concede my own susceptibility feels like a step towards defeat. Certainly, it is more comforting to pretend that I am impervious. But no challenge is overcome by seeking comfort. In fact, we should relish in the discomfort that we feel when we confront our weaknesses.

Indeed, our vulnerabilities are a deeply meaningful aspect of our humanity, and nothing is more important to the practice of medicine than humanity. Unfortunately, it is easy to lose sight of this fact. In the setting of modern healthcare, physicians are made to feel like mere cogs in a machine. We spend more time with paperwork than with people. We are pressured to be efficient and pragmatic. On a daily basis, our best is not good enough, and it often feels like the system is working against us. Inevitably, we have moments of exasperation and discontent. In the instant when we feel disempowered, cynicism creeps upon us.

Instead of hiding these feelings, we should accept them as valid, reflect upon them, and remind ourselves of our fallibility, our humanity. If we approach our patients, not as a physician approaching disease, but as one human caring for another, the frustrations of our medical system melt into the background. As humans caring for one another, there is always hope that we can do something good and meaningful. We are never disempowered. Perhaps that which we wish to protect – our humanity – is best preserved when left exposed and vulnerable.

#writing

Be kind whenever possible. It is always possible. ~Dalai Lama

Dalai Lama

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My college essay

Nearly 12 years ago, I wrote the following essay and submitted it as part of my college application. After spending four years on my bachelor's degree and seven years on my M.D. and Ph.D., I am finally ready to begin working on this promise. I've felt guilty for the past several years for taking so long to finish school, but my mother has supported me 100%. I know that in the end, I'll be able to help many more people than if I had taken a shorter route. If I ever do anything good for anyone, please thank my mother.

...

Prompt: What is one of your dreams, and how did it originate?

My whole life, I have lived in apartment buildings. In fact, I have lived in seven of them. At a young age, I became used to moving frequently. As I grew older, I began to realize how hard these transitions were for my mother. She and my father separated before I can remember, and my father vanished from our lives. My mother has done the best she can to provide for my two sisters and me. She works multiple jobs while, at the same time, caring for her family as both a mother and a father. I have never encountered anyone who works as hard as my mother does for her children, but no matter how hard she works, she never can make more than ends meet. Any money she saves, she eventually spends on her children. My mother always puts her children before herself. She has put her dreams on hold in order to help her children achieve their own. One of my dreams (I am reluctant to call it a dream because I am sure it will become a reality) is to one day buy my mother a home of her own.

Living in apartments, landlords control much of our lives. The same pattern always evolves. My mother tries to live in one place as long as she can, but when the rent is raised too high, we move. In one case, we were forced to move before my mother could find another place for us to live. We lived in a shelter for a while. I was only six at the time, and I actually enjoyed living in the shelter. It brought my family closer together. I did not realize the hardships it caused my mother. She hated living there. She hated not being able to provide for her children. When we finally found a place to live, my mother promised that we would not move again for a long time. She worked as hard as she could but was unable to keep that promise. We moved again a year and a half later.

No one was upset with my mother for breaking her promise. The apartment she found was wonderful. It is the nicest place we have ever lived. The apartment we live in now lacks in comparison. We each had our own bedroom, we were allowed to have a dog, and we even had a backyard. For a while, it began to feel like a real home. We lived in this dream apartment for only three years. When we moved, I resented my mother for making me leave the one “normal home” I had ever had. I did not realize how hurtful I was towards her. Not once did she make me feel like I was being selfish, but I was. I now understand that she loved that apartment more than I did. Leaving it behind, my mother felt like she was losing her last opportunity to settle down. Since then, we have moved twice. The apartment we live in now is dark and cramped. We have lived here for four years now, and to some extent, it has begun to feel like a home. I know my mother wants to move, but she would never say anything.

Though she is by no means soft spoken, my mother rarely speaks about her own wants and needs. She is too busy worrying about the wants and needs of her children. However, when she does talk about her longings, she always mentions owning a home of her own. She sometimes says to her friends, “You see this one?” referring to me, “He’s the one who’s gonna make it. But when he does, he’s gonna buy his mother a house. Isn’t that right, Shoa?” I always nod with a smile. My mother makes these comments jokingly, but I take her words seriously. I have many dreams of my own, but I also have a dream for my mother. She has been continuously weakened by the sacrifices she makes for her children. Still, she keeps pushing on. For giving me more than I could ever ask for, I want to give her the one thing she has ever asked for. I am going to buy my mother a house, so that she can finally settle down.

#writing

In defense of cosmetic surgery (sort of)

I think it’s time for a good old fashion rant. Let’s hope I don’t get myself in trouble...

In the last few days, a series of images appeared on the internet, each depicting a 2013 Miss Korea pageant contestant. The images are displayed in a comparative fashion, tagged with such captions as, “Are these all the same person?” Social media sites have been flooded with posts of the photos along with words of shock and disgust. A clear message of judgement echoes through Facebook and Twitter. Some comments are as simple as “Ew,” or “lol koreans.”

I take issue with this self righteous outcry for two reasons. The first is simple, the latter somewhat complex.

The simple reason is that these girls do not look that much alike! Yes, they are thin, young, Asian women. Yes, they have practiced smiles, thick eyebrows, and dark eye makeup. None of those features are the result of surgery. Admittedly, they share the same jaw lines and thin nasal bridges, the result of mandibuloplasty and rhinoplasty. But if you allow more than a glance, you’ll notice some have pointed noses, others round. Some have prominent nasolabial folds, others flattened. Etc, etc. How many, though, have taken the time to examine the faces for their individuality? Instead, we quickly scan the images already wanting to see similarity, eager to join the bandwagon of judgement.

And that brings me to the second issue.

The rapid explosion of mob mentality is disturbing. I’m sure many out there simply want to express the sentiment that we should question a culture that so strongly encourages conformity. We should discourage social pressures that drive women to extreme measures for the sake of aesthetics. Yet, I’ve seen very little thoughtful discussion. Rather, nameless internet users have rallied together to judge and mock these girls whom none of us know. We as a society have become desperately hungry for moral authority, and yet, we lack the contemplation, introspection, and reflection that is fundamental to moral character.

If we are to judge those girls, let us also judge ourselves. We’re fine with people piercing their ears and dyeing their hair. Tattoos and colored contact lenses are a rising fad. Wrinkle creams and teeth whitening are a must. We yearn for assimilation through fashion, music tastes, and food preferences (it was all about cupcakes for a while, but I guess now it’s macarons). We are just as guilty of conformity and vanity.

Some may rebut that the above examples are benign. Taking your daughter to have her ears pierced is far less extreme than changing the shape of a nose. But in America, we’ve embraced elective medical procedures as well. ~55 % or male infants are circumcised. And how many kids undergo multiple orthodontic procedures for that perfect smile? You may think that braces are only used for health reasons. In reality, orthodontists assess the need for intervention based on a definition of dental health that includes “social acceptability” (their words, not mine). Others use more flowery language to describe dental health as, “the absence of negative impacts of oral conditions on social life and a positive sense of dentofacial self-confidence.” When we feel our childrens’ smiles may be socially unacceptable, it is perfectly within our cultural norms to perform arch expansions and tooth extractions.

I’m not saying that we should deny our children braces, and I have no intention of promoting cosmetic surgery. I’m just worried that we have become exceedingly quick to judge others while remaining thoroughly reluctant to judge ourselves. Are we really so comfortable ridiculing people whose stories we have not heard, whose culture we are not a part of, whose names we don’t even know?

#writing

You are here, and it is now

It’s Saturday morning. Or Sunday. It could be any day.

A stranger, full of life, sits in your passenger seat. She inspires you. The windows are rolled down, hiding from the playful winds that taunt your hair. The indifferent sun slowly burns your skin; you're unaware. As you inhale deeply, the aroma of coffee is confused by the scent of perfume.

The ocean dances on the horizon, and the perfect song comes on.

It's the sort of day that merely serves as an extension to the night before. Unplanned and yet expected. A day composed of experiences rather than events. Each second is fleeting until you allow yourself to notice its passing. Moments like this one are the substrates of dreams. They are like those deeply realistic illusions that you either cling to or run from as the dream slips away. But you are not dreaming.

Within the vastness of time, a single day is infinitesimal. Of the billions of people milling and seething across the globe, you are but one. In the grand scheme of things, this moment may as well never have happened.

But right here, right now, the grand scheme is irrelevant.

#writing

Few will have the greatness to bend history itself. But each of us can work to change a small portion of events. And in the total of all those acts will be written the history of this generation. Each time a man stands up for an ideal, or acts to improve the lot of others, or strikes out against injustice, he sends forth a tiny ripple of hope. And crossing each other from a million different centers of energy and daring, those ripples build a current that can sweep down the mightiest walls of oppression and resistance. Robert Kennedy, as quoted by his brother Ted

http://youtu.be/dvo-7YrMoK0

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Content, execution, intent. The best TED talk I've ever seen.

"From this distant vantage point, the Earth might not seem of any particular interest. But for us, it's different. Consider again that dot. That's here. That's home. That's us. On it everyone you love, everyone you know, everyone you ever heard of, every human being who ever was, lived out their lives. The aggregate of our joy and suffering, thousands of confident religions, ideologies, and economic doctrines, every hunter and forager, every hero and coward, every creator and destroyer of civilization, every king and peasant, every young couple in love, every mother and father, hopeful child, inventor and explorer, every teacher of morals, every corrupt politician, every "superstar," every "supreme leader," every saint and sinner in the history of our species lived there – on a mote of dust suspended in a sunbeam." ~Carl Sagan

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Dance everywhere.

The Value of Dedication

Do something wonderful. People may imitate it. ~Dr. Schweitzer What is the most important book you’ve ever read? Can you name one that has impacted your life more than any other? Until recently, I could not. The problem was not one of indecision or lack of options. I simply couldn’t remember the name of the book. It was the story I read as a child that first steered me towards a career in medicine. I remember first picking it up and holding it in my hands. I’ve always remembered the cover vividly. But I could never remember the title. Finally, thanks to the omniscience of the internet, I’ve tracked down that unnamed story. One day in third grade, my teacher arrived with a stack of books. They were biographies written for children. Each one was about an important figure in history. Our assignment was to choose one and do a presentation for the class. Immediately, I eyed the book with Albert Einstein on the cover. I didn’t really know what Albert Einstein did or why he was important, but I knew he was smart. Maybe even the smartest person ever. I rushed to get in line to choose a book. I was hopeful; there were only a few kids ahead of me. The first chose George Washington. Respectable. The next chose Thomas Edison. The light bulb guy. Whatever. My stomach sank as the girl in front of me picked up the Albert Einstein book. I was left deflated. I pawed through a pile of titles with names and faces that meant nothing to me. As a childish effort to console myself, I chose the one other book with the name “Albert” on the cover. It was “The Value of Dedication: The Story of Albert Schweitzer.” I had no clue who he was. Before third grade, I was an overactive, imaginative kid with no real focus. I got into a lot of trouble. Like many kids, I wanted to be a doctor. I also wanted to be a scientist, an astronaut, a spy, a ninja, a robot. The list goes on. I wanted to be everything that my family was not: educated, respected, important. By the time I was eight, I had already lived in four different apartments and had been homeless once. I was used to being teased. I was a cunning liar, able to deceive my friends about where my father was or where I lived. Whatever I might say about my future was really no different than the claims I made about my past and present: pure fantasy. The story of Albert Schweitzer resonated with me. I may have been an immature nine year old boy, but I was familiar with the concept of disparities. I had first hand experience. I considered Martin Luther King Jr. a hero. I had a poster of him on my wall. We had books about him at home. But to a child, MLK is almost magical. He changed the world with his speeches that no one else could give. It was like he had a superpower. To me, Schweitzer presented something different. Schweitzer addressed disparities through his profession. Through his everyday work. Simple, quiet, persistence. He was not special. He was an ordinary physician. He was tangible. He presented a portrait of a man I could become. After reading the story of Albert Schweitzer, for the first time, I envisioned a future for myself that was not just fantasy. For my presentation, I dressed up as Schweitzer and shared my (his) dream with the class - a dream for a world where we are all brothers and sisters, where compassion drives our work, where we universally care for those most in need. At the age of nine, I decided I would become a physician. Twenty years later, I’ve finally arrived. Not at my goal. Rather, at my starting point. Still carrying that dream and unwavering dedication.

#writing

Progress is more plausibly judged by the reduction of deprivation than by the further enrichment of the opulent. ~Amartya Sen

Amartya Sen, Nobel Prize winning economist

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For all the knowledge, grandeur and beauty of the universe, the world is only as large as what is encompassed by your mind.

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