Stepping Up To The Plate

Recently, I’ve started shadowing a fantastic geriatrician. In my first blog post, I talked about being more engaged when shadowing as a medical student. Now, we’ve learned how to take an HPI and perform most of the basics of a physical exam, so we actually get to interact with the patients directly to practice these steps. However, I’ve been struggling with the idea that while it’s an honor to be learning in such an amazing teaching hospital, as a first-year medical student I really haven’t learned enough to be of any real help to the patient – I’m just going through the motions of what I learned in class. The real physician comes in right after me and basically re-asks the questions I’ve asked and performs the relevant steps of the physical exam herself. I mean, I understand that this learning step is necessary so that we know enough one day to help our own patients, and that the patients we talk to now gave consent for us to “practice” with them, but these patients are real people, and they’re here right now to see the physician to get real help. I’m just hindering that process without bringing anything to the table.

I was especially anxious about this idea the second time I shadowed the geriatrician (I’ll call her Dr. G). I followed Dr. G into the room and she explained to the patient, Mrs. T, that I was a first-year medical student (“she’s brand new!!”) and that I would be asking her a few questions. Would that be okay?

I remember that Mrs. T’s daughter was also there, and she said, “Oh,” in a way that sounded disappointed to me. I suddenly realized that my first mistake was to follow the physician directly into the room, because it put a kind of pressure on the patient to say “yes” to letting me practice on her, the alternative being that she would have to say “no” to my face. I wanted to back out of the room in case Mrs. T felt uncomfortable that I was there, but it was too late. I just stood there in a white coat that was too big and smiled in a suitably polite way. Look at this brand new, harmless face.

Before we had entered the room, Dr. G had explained to me quickly all the things that had happened to Mrs. T since her last visit here, including an incident of low blood pressure listed in her records.

I could tell right from the start the Mrs. T didn’t want any nonsense. I started off by asking her how her health had been lately (start broadly, I had learned). When asked what brought her in today, she said, “I don’t know, I set up an appointment and you guys asked me to come in today.” That’s fair.

Then I asked her about how they’d told her she had low blood pressure at one point, and how her blood pressure was lately. Any dizziness or fainting recently? At this point, Mrs. T’s daughter cut in. “Her blood pressure? That was so long ago – it must have been at least a year ago! Of course it’s normal now.” Oops. I guess that visit had been longer ago than we had thought.

I continued to ask the questions that I had been taught to ask. “So how has your health been since your last visit? Has anything changed? Anything you might want me to tell Dr. G about?”

Finally, Mrs. T seemed to want to tell me something. “Yes, you see, I get really tired easily from walking or raising my arms now, and it wasn’t happening before.”

I perked up. I knew what to ask next. “Can you describe what you mean? Do you get short of breath?”

“No, it’s not that I can’t breathe, it’s my arms and legs. They get tired, you know, when I walk up some stairs or if I’m trying to comb my hair, like this.” She put her hands behind her head to demonstrate.

Should I press further? If this was her main complaint, I wanted to make sure I understood what she meant. “Okay, so do you feel pain when you do those motions? Do you get sore?”

Mrs. T started to get exasperated. “No, no, it doesn’t hurt, I just get tired.” Then she paused and stared at me, as if realizing that I was rather incompetent. “Haven’t you ever felt tired before?”

I didn’t know what to say. I laughed a little, then cut it short in case she thought I wasn’t taking her seriously. I hurried to explain, “I’m asking all these questions because I want to know exactly what this tiredness is like, so that I can explain it to Dr. G.” In addition to learning how to ask the right questions, we have to learn how to respond appropriately to every comment a patient makes. You have to show that you’re empathetic, without pretending to know how the patient feels (how would you know?), and you have to laugh at all the right times, nod at all the right times, and say “that must be difficult for you” at all the right times.

Anyway, I started struggling to think of what questions I should ask next, without knowing her full medical history and for fear of asking questions that would waste her time. What I should have done was ask about her social surroundings: how things were at home, who she lived with, how her day-to-day life was, if she was able to take all her meds, all things that are extremely important for geriatric patients. But in the end, I left the room after what I felt was too short an amount of time, thanking her for talking to me and promising that I would bring Dr. G with me.

After Dr. G came back in and asked Mrs. T all the questions I had just asked but in a better way, I observed that Mrs. T started opening up more about what other things had been bothering her recently. At the end of the visit, Mrs. T even stood up and hugged Dr. G. I was in awe at how much Dr. G cared about her patients and how much they loved her back. At the same time, I was feeling a little like an extra on a TV show. On your cue, you walk across the screen, maybe do a little something, say a few things, and then off you go. Back to the real show.

Then, Dr. G asked Mrs. T, “Well? How was our student today? Did she treat you okay?” I felt unexpectedly nervous. But Mrs. T turned, opened her arms to me and said “Come on over here!” She hugged me and kissed my cheek, then said, “Every time I come to this hospital, I always feel so welcomed. You all treat me so well.” It’s almost ridiculous that I’m even writing about this because the hug was such a small event and I’m sure it wasn’t an uncommon occurrence. But both Dr. G and Mrs. T will never know how much it meant to me to be included like that. I am part of the team, if only for this afternoon, I thought happily.

What I realized is that even though we’re not even close to the diagnosis and treatment step of the job yet, we still have an important role as first-year medical students. First of all, we represent the hospital system as a whole. If even the students at the bottom of the ladder genuinely care about the patients’ well-being, then it must mean that the entire team is truly invested in their care. If the patient has a bad experience with a medical student, they might leave the session thinking, “I had a bad experience at this hospital today.” We aren’t just background characters in this regard, because we have a real responsibility to present ourselves well.

Second of all, once in a blue moon you get to actually do something for the patient. I can’t tell you how excited I was the most recent time that I was shadowing Dr. G, when one of the patients suddenly turned to look at me directly. “Honey, do you think you could get me a little bit of water? I’m actually quite thirsty right now.” I almost leaped out of my chair in my hurry to oblige. Where had I just read that by the end of medical school, we’ll all be very good at getting patients water? I felt so happy that I was able to do something for the patient while I was there, no matter how small it was. Maybe I shouldn’t mention that I then proceeded to walk back into the wrong patient’s room without knocking and, mortified, had to ask a nurse which room Dr. G was actually in. That’s from my bad sense of direction, which is a whole other story altogether.

Stepping Up To The Plate

Almost Bilingual

As an Asian-American, I’ve become increasingly aware of how the culture I was brought up in has shaped who I am, how Taiwanese culture has melded into my everyday life. My family recently celebrated Lunar New Year together, and I helped my mom prepare all the traditional foods we would eat the night before, including various cakes (fa gao and nian gao), fish, and vegetable dishes (chang nian cai), to ensure we would have a prosperous year. However, when celebrating Thanksgiving in November with my friends, I had to Google “Thanksgiving dishes” to figure out what I could cook for the potluck, because I didn’t have much experience with “traditional” American Thanksgivings. The other day, I was watching Chopped, a cooking competition TV show, and became very indignant when even the judges were bashing on how Thousand Year Egg tastes. Some of the contestants tried to fry the egg, and the contestant that got the most compliments made a mayonnaise out of this delicacy – how outrageous!

I realize that my previous examples are all about food, but that’s not the only area of my life affected. Another major part of who I am is my bilingualism. Growing up in the states, I attended Chinese school and always spoke Chinese at home, so I am comfortable with verbal Chinese. However, my literacy level is probably that of a first grader, and when I speak, it’s still obvious that I’m not a native speaker. This year, I’ve had the unique and amazing opportunity of working on the board of a free clinic that serves patients who predominantly speak Chinese. I always assumed that as a physician, I would tell my patients that I spoke both English and Chinese, and that I could accommodate them if they were more comfortable speaking (Mandarin) Chinese than English. I figured to get there, I would just have to study up on medical Chinese vocabulary. However, my experience as a med student volunteering at this free clinic has helped me realize that since Chinese isn’t my dominant language (even though it was my first language), the situation is much more complex and I would have to make a lot of progress before I could lay such claims.

I’ve learned how frustrating it is to come up against a hard roadblock in terms of communication, to be on the edge of saying something but not finding the right words. I’ll give an example. I was listening to a patient who recently moved here from China talk about going to a community center for tai chi. I perked up. I wanted to say My parents do tai chi as well, because I just wanted to make some light conversation. But what was the verb for “doing” tai chi? Later, I remembered how to say it – da tai ji quan. But at the moment, the mental translation didn’t happen on time, so instead I said nothing and smiled. Besides, it’s not like the comment would have made a difference in the outcome of the visit. But that’s what I’ve found disappointingly difficult on many occasions: making casual conversation, witty banter, or joking around in Chinese to make the patients feel at ease. Without feeling completely at home while speaking the language, I’m unable to have the relaxed, back-and-forth conversations that I could have in English.

Here’s another example. I was speaking to a visiting physician from China with some of my peers during a Medical Chinese session, and she was talking to us in rapid Chinese about the differences between physician compensation in China and in the U.S. I can tell you right now that I understood very little of the conversation. How frustrating – though I may not always be able to respond with completely well-formed thoughts, I can understand everyday conversations in Chinese with little trouble. But here, she was using vocabulary that I had never heard before in my life. I was on the edge of comprehension, but I experienced so many lapses in understanding that I couldn’t piece together exactly what she was saying. It’s a weird feeling, understanding all the sounds of a language and yet not comprehending. It’s very different than, say, if I were to listen to someone speaking Russian, because I have no idea what their vowels sound like, how some of the syllables are even formed, and what kinds of inflections they use in speech. To me, hearing a very technical conversation in Chinese is like when those programs play a sentence in English backwards and suddenly the whole thing doesn’t makes sense anymore. I ended up trying to stay engaged, but I could rarely make meaningful contributions to the conversation.

Being bilingual on a basic level also means that I’ll never be able to create an even playing field with someone who isn’t comfortable with speaking English. Whichever language we choose to speak, one of us will not be able to fully express ourselves. What this means is that at the free clinic I’ll be writing down in English the symptoms the patient is describing in Mandarin Chinese before the interpreter has translated it, or I’ll nod along as the patient is talking. We have an excellent Cantonese interpreter, but since the dialect is different, she once was at a loss for how to translate “numbness” from English to Mandarin. I quietly suggested a phrase, and the patient looked bewildered. Why is this interpreter here if the medical student speaks Chinese? There was a great piece about the issue of doctors believing they can communicate with patients in another language called “The Danger of Knowing ‘Just Enough’ Spanish” that really stuck with me. I know I can’t go without an interpreter, because if there’s even a small gap in the translation, a lot could go wrong.

Still, I don’t think it’s impossible that I can one day speak Chinese in the medical setting well enough to at least make my patients feel more comfortable. I have had two primary care physicians that advertised that they spoke Chinese, and my mom was talking to me about how she liked one much more than the other. “It’s strange, they’re both American-born and their levels of Chinese-speaking are the same,” she commented. I think one factor was that one was much more enthusiastic to talk to us in Chinese, even if she spoke with an American accent, whereas the other was more abrupt and business-like. Beyond learning medical terms, I want to keep practicing speaking Chinese in my everyday life so that I can break out of that shell of reluctance when speaking with patients. It’ll be an active process of learning instead of a passive one, but communication is key in a doctor-patient relationship. If I can make even a small subset of my patients feel more at ease talking to me, then I think the process will be worth it.

Almost Bilingual

Crazy Thoughts

For a reading workshop during our MS1 symposium, we read “The Use of Force” by Dr. William Carlos Williams, who was a physician that was more well-known as a poet. The short story was first published in 1938 and describes an encounter between a pediatrician and a little girl with diphtheria. The child is not cooperative during the interaction, and he ends up prying her mouth open forcefully to get a look at her throat. During our discussion of the story, which included a group of first-year med students led by a psychiatrist, I believe that we all agreed that we didn’t like the way the physician treated his patient, and that we were glad the encounter was a fictional story. We then had a conversation about different motivations when working with patients and whether there were more appropriate ways to deal with ingratitude. However, something about the character’s narration of his inner emotions resonated with me, which made me pretty uncomfortable. It’s not that I’d ever been gripped by fury and violence when interacting with a patient before, but there was a specific incident in my memory that had emerged when I read the story.

During the summer of 2014, I was a volunteer at a children’s development center in Taipei, Taiwan, working with children with cerebral palsy and other neurological disorders. Every day, I played with the kids, helped them when they had difficulty eating lunch, and guided them through various physical therapy activities. I was specifically assigned to a very sweet 4-year-old girl, Jackie. Our main goal at the center was to maintain or improve the kids’ mobility and cognitive abilities. As an example, every morning I would grip Jackie’s arms and walk her from the toilet to the sink, making sure that she put one foot in front of the other instead of seizing up or getting her legs tangled. The whole process took about 20 minutes – I quickly learned how incredibly patient every teacher there had to be during my few weeks there.

One day, I was getting ready to change Jackie’s diaper before their post-lunch nap. I usually had her lie down on the mat, but I had seen other teachers sit the kids down for short periods of time. One of the teachers suggested to me that I could cross her legs, so that she could practice balancing and sitting up for the amount of time it took me to cross the room and get her a fresh diaper.

After I was sure that Jackie was sitting up on her own, I went over to the area where all the kids’ backpacks were kept. There, I knelt to reach into the back of the cubby and grabbed one of her diapers. Timmy, a boy with Angelman Syndrome, had just walked in holding his nanny’s hand. He had dark, curly hair, and was wearing an orange bandana around his neck. He was always very fashionable and smiled at everyone. But he also had cuts and bruises all over his legs, and the teachers were always scolding him for recklessly careening across the play area. He turned to me with that joyful smile on his face, and I smiled back.

Then I turned, ready to head back to Jackie with diaper in hand. Suddenly, I realized that she had toppled to one side, still in the same spot that I had sat her down. Her legs were still crossed, but they were now in the air, and her head was resting on the ground. All around her, the teachers were busy changing the other kids’ diapers, and no one had noticed that she had fallen. She wasn’t crying or yelling. I have no idea what she was feeling inside – perhaps she was frustrated to be in such a predicament, or perhaps she was patiently waiting for me to come back.

Either way, I had a sudden, horrible, mad urge to laugh. And I have no way of explaining why. There was nothing about the situation that I found funny, and I immediately rushed across the room to pick her up. Luckily, she was unscathed and I changed her diaper with no further incident. But still, right before I flew into action, there was that singular moment where I almost – but did not – burst out laughing. Was I sleep-deprived? Was I desperate and frustrated, and somehow, the combination of emotions and exhaustion had produced this very inappropriate reaction in my brain? Retrospectively, I’m not so sure. I do know that I’m very glad it didn’t happen, and that to everyone else nothing appeared out of the ordinary.

Still, I want to address this completely irrational impulse I had in the moment. It’s the only time I’ve been so disturbed by a feeling that I can describe surely as wrong, and yet nothing really happened. It brings me back to the story that we had read. The physician in Dr. Williams’ short story did end up violently prying open the patient’s mouth, in a sense succumbing to the eagerness for aggression that had been cumulating during his visit. Meanwhile, in ordinary everyday life, I’m sure that physicians do sometimes experience emotions or feelings that are not optimal or even appropriate, whether it be tears welling up when talking to a patient, or feeling frustration toward a patient for their lack of understanding, or fear of failing a patient while reassuring them. Sometimes they might be confused or even repelled by what they are thinking to themselves. But they don’t show what’s happening internally, and perhaps compartmentalize those thoughts to be able to continue acting as a physician.

I guess my question is, when a feeling that seems inappropriate occurs and we “compartmentalize” it, where does it go? It’s very likely that we will never again address the fact that we had that feeling, and instead, act like it never happened. Is it okay for me to not ever acknowledge that I had almost laughed at Jackie, the girl who trusted me to take care of her, when she had fallen, and to speak about my time with her fondly?

We stress the need for empathy in doctors constantly, because it is of course a core characteristic that anyone going into med school needs to have. We are also taught that to make mistakes when treating a patient is inevitable – which is why we should learn to ask for help and learn from what we did wrong. We talked in our ethics class about how in surgery, moral mistakes (mistakes of judgement) are perhaps more grievous than technical errors. But I wish there were more discussion about what should be done in the case where a mistake never manifests itself physically and is rather a mental one – an error of the psychological kind. While our moral restraint ensures that these thoughts stay internal, I still believe that we should encourage discussion so that our moral compasses stay on the right track.

Crazy Thoughts

The First Step

I want to write about what I think is the first big mistake I’ve made in medical school – that is to say, the first mistake that made me stand back and think, should I be doing something different? I’m not talking about mistakes like thinking I can study all of histo the morning before an exam, or setting my alarm to 6:30 PM instead of 6:30 AM. While those are certainly mistakes that I’ve made more than one time and should probably stop making, they’re not the kind that made me question whether I could be wrong about my approach to life in a broader sense.

It happened while I was shadowing one day. The patient (I’ll call her Mrs. B) was there with her husband, and they were both in their mid-30s. She was sitting in a wheelchair, with thin tubes coming out of her nostrils, connecting her lungs to the oxygen tank next to her. What struck me was how engaged she was in what the doctor was saying, and how many questions she asked about what was next. Mrs. B had a manila folder full of papers on her lap (I hate how papers fall out of those folders so easily), and would ruffle through them to point to specific items she had questions about. Every time she had to reorganize the papers in her hand, she would end up breathing heavily, her body already desperate for oxygen after the physical movement.

I have to explain that I really admire when somebody is passionate about something, whether it be my classmates discussing the research they’ll be doing over the summer, or my friends talking about how much they love to run, or even overhearing somebody raving about a new recipe they want to try. I just love seeing people light up when they talk about something they’re truly interested in, and often I get so absorbed in what they’re saying that at the end I realize I’ve contributed very little to the conversation.

Looking back, I really hope that I wasn’t just staring at Mrs. B as she talked, because I was so taken in by how lively and forward she was as a person while talking about a disease that was in the process of killing her. It was an honor for me, as a first year medical student who could only tell you where the lung was and not much else, to be able to stand quietly in a corner of the room and learn from a patient many times braver than I was. I had my hands behind my back and was struggling not to move a single inch, so as not to disturb the intense level of energy and trust that had been established in that room. I thought that if I even rolled my shoulders to get rid of the ache that was creeping in, the patient, her husband, and the physician would all look at me in dismay because I had accidentally reminded them that I was there.

But then, suddenly, I was acknowledged. Mrs. B’s husband turned to me and asked, as if I had been involved the entire time, “So do you have any questions for us? We’re both teachers, as you might be able to tell, and we know that the best way you can learn is to ask us questions.”

What an amazing pair of people! I was so surprised, and I felt embarrassed for some reason. So I said, “Oh, no, I’m really just here to learn by observing. But thank you so much!” I mentally kicked myself immediately then, and I mentally kick myself now as I write this. I want to really think about why I felt like I had done such a wrong thing, why I felt so sure that I had let everyone in the room down.

A week before this experience, I had been shadowing in Interventional Radiology, and the resident led me along a hallway with thick, glass windows on either side. The windows looked in on the operating rooms, and the resident pointed a rack of lead vests out to me. “Please feel free to put one on and enter the room. You can see the operations more clearly then, since we do smaller procedures that might be hard to see from out here.” I nodded enthusiastically and thanked him, and he left to do the important things that residents have to do. But in my head, I thought, no, I’ll stay in this hallway so I can see as many different kinds of operations as possible. There will be other opportunities where I can enter the room and learn about the procedures more in depth. During that time, I felt that I had acted reasonably, and that this was the best way that I, as a med student of less than half a year, could learn about different aspects of specialties.

However, with Mrs. B, I was once again on the other side of glass window, peering in. This time, it was one that I had constructed myself by saying no, thank you, to learning more about the patient’s experience when she had offered. I thought that I had been actively engaged in learning while standing there in the room with the physician as she spoke to her patients, and yet I was politely removed, carefully keeping a distance under the excuse that I didn’t know enough yet and was only observing. What sort of image would that leave the patients with? That here was a medical student observing them as if she were still sitting in a classroom, watching a video of a doctor speaking to patients, rather than being there in the room, in real life, finally learning from experience after all the work she had put in to get to this point.

Flash forward a few months. The first-year med students at my school recently went through a team-building exercise where we were assigned into groups of 7-8 people, and we were recorded while we discussed items we would want to bring with us on a stranded lifeboat. There were so many things to consider – should we prioritize navigation and attempt to reach land? Or would it be better to try to survive as long as possible until somebody found us? Anyway, during the discussion I loved listening to my groupmates bring up movies they’d watched (namely, Life of Pi) or books they’d read and past experiences they’d had that justified their opinions as to what we should bring. We had an engaging and fast-paced conversation and eventually reached consensus. Afterward, when we watched the recording of our session, I was shocked to find that I actually hadn’t said anything, and instead had only laughed or agreed with what people said. But I had had such an amazing time! Did I really not contribute anything to our final product? I was again disappointed in myself, and felt similarly to when I had politely refused to ask Mrs. B any questions.

What I’ve slowly realized is that now that I’ve finally made it to med school and am realizing my dreams, it’s not enough to be involved as a listener, as an observer anymore. While it’s useful to absorb through listening and learning from talented peers, amazing physicians, and brave patients, that’s just not going to cut it if I want to engage with other people, if I want to truly participate in all the wonderful opportunities we have as medical students. This isn’t an inspirational piece because it’s all easier said than done, and I feel like it’s been a long, 6-month process of even realizing that I had a lot of self-discovery to go through. But I want to use this blog to document my thoughts along this journey, so that someday, maybe I’ll look back and think, “Wow, you finally made it.” But also so that maybe someone out there who’s feeling the same way will realize that they’re not alone. We all don’t know what we’re doing (I hope), but we’ll get there!

The First Step