Basketball and Medicine

A few months ago, my husband and his brother took me to my first professional basketball game.  Prior to this, the last basketball game I had attended had been to watch from the corner of my eye as my middle school boyfriend and his teammates trekked up and down the court, facing the team from a neighboring district, as my girlfriends and I gossiped and giggled.  At this more recent game, my husband and brother-in-law laughed at my reactions to the barely-clothed dancers who gyrated during extended time-outs and at the way that my interest was only piqued by the Big Wheels race for children held on the court at half-time.  The rest of the time they spend in detailed analysis with one another while I gazed around the arena and daydreamed.

But one of the things that really struck me was the treatment and behavior of the players, the way that a man about to substitute for his teammate would rise from the bench, pull off the T-shirt layered over his jersey, drop it to the floor and step out onto the court without giving it a second glance.  The job of retrieving it fell to the ball boy or some similar team employee, who would scurry quickly to grab it before retreating back out of the limelight.

I grow irritated when people don’t pick up after themselves, and even more so when they expect others to do it for them.  I scold my husband for this repeatedly, when he leaves that day’s tie on the shelf in our entryway, having shed it the moment he walked through the door, or his shoes one in front of the other, in the exact position that he stepped out of them, along the hallway leading to our bedroom, as if they had begun to walk themselves back to their home in the closet but hadn’t quite made it to their destination.

The subtext that I read from such actions is that the perpetrator views himself, or his time, as more important that someone else’s, and that it is appropriate for that other person, who holds a lower position, to cater to the first.  And I began thinking about similar situations that occur in medicine, the way that doctors, and attending physicians in particular, have many tasks completed for them, tasks that wouldn’t necessarily cost them a lot of time, but that just make their lives a little bit easier.  For example, in hospitals that still utilize a paper medical record, each patient’s chart is often bookmarked, allowing the attending to open it to the next blank page rather than having to rifle through it before beginning the day’s progress note.  In other places, the page for the day’s note is removed from each patient’s chart, and once the notes are written, the pages are filed back in their proper places – by someone other than the attending.

These are small courtesies, to be sure.  They don’t occupy a large portion of the day for the person who performs them, nor would they occupy a large portion of the attending’s time.  Some would argue that physicians who have completed four years of college, four years of medical school, and at least three years of residency potentially followed by fellowship have earned exemption from certain more menial tasks.  Perhaps I am too early in my training to share this feeling of entitlement, but I am uncomfortable with any special accommodations that stem from status alone.  Certain divisions of labor are appropriate and necessary for the flow of an organization; ball boys, not the players, should retrieve balls that have traveled out of bounds in order not to delay the progress of the game.  Similarly, nurses administer vaccinations to children at the end of my clinic visits, which allows me to move on to the next waiting patient.  But I do feel that, when I am an attending physician, I will not be too slowed by the need to flip through the chart to find a blank page.

I recently came across a charming blog post entitled “Physicians: Learn to pick up the proverbial poop.”  The author describes his experience being a clown in the circus and seeing the elephant tamer, the man with the highest status in the show, helping to pick up the elephant droppings after the performance.  He draws from this a lesson that can be applied to physicians, managers, and any professional operating in a hierarchical setting: when leaders indicate through their actions that no task is beneath them, they set an example and promote a culture of teamwork from which everyone will reap benefits.

I haven’t been to any basketball games lately.  And I am certainly far from being offered any of the courtesies reserved for attending physicians.  But my irritation at these seemingly innocent yet powerfully charged distributions of tasks has made me determined to pay closer attention to my treatment of coworkers in different areas of patient care and of medical students – of anyone who could potentially feel compelled to show deference to even a junior physician.  I appreciate their respect, and hope that we all demonstrate mutual respect for one another, but I don’t deserve special treatment.  We may have different tasks, but we’re all in the business of caring for patients together.

The Haircut

There are things that I do slowly and things that I do quickly.  Take running, for example.  I’m no sprinter.  I move at a plodding pace, with plenty of time to take in the scenery.  Then there is speaking.  Once during high school, I launched into an oral presentation in my history class only to be met with laughter after about seven seconds.  I stopped cold and glanced uncomfortably at the teacher, wondering what foul word had inadvertently escaped my lips or what article of my clothing was incompletely fastened.  When she was able to contain her own chuckles, she explained: “Becky, you need to slow down.  I can’t even begin to write that fast.”

According to my husband, my quick speech is related to my tendency to jump quickly to conclusions, a habit that consistently irritates him.  He speaks, then I counter with a rapid-fire assertion that what he has said is untrue or should be done differently.  After a testy “if you’d let me finish,” he provides the key piece of information that negates exactly what I have just said, after which I huff that he should really offer up the important points sooner.

Not long after we moved back in together after having spent the better part of a year living apart for work reasons, I found him in the guest bathroom of our apartment giving himself a haircut.  For years he has eschewed the idea of paying a barber when I – and over the previous year, he – could easily shear his thick dark hair with an electric clipper.  A shorter blade attached for summer, a longer one for winter; what more, he reasoned, could he need?

“Hey honey,” he called out as I passed by.  “Could you come here and fix the back?”

He wanted my help?  How nice!  From my approach I could see the area that he had missed.  It would be difficult for him to see the locks that sprouted from the back of his head, still so long in comparison to their newly trimmed neighbors.

“Sure,” I agreed enthusiastically, stepping into the room and taking the clipper from his hands.  With one smooth motion I raised it to slash away the renegade patch.

“What are you doing!” he cried out at the exact moment that I realized what I had done.  “I said the back!”  He pointed to what I held in my hand: the clipper with no blade attached, set to buzz anything in its path.  He had been asking me to clean up the stray hairs that always remained at the nape of his neck.  I had been right: he couldn’t see the few too-long strands that had remained higher up in the back.  And so he couldn’t have been asking me to cut them.

“How bad is it,” he asked without inflection as I stared numbly at what I had done.  Any glimpse of his scalp appears shockingly white against his dark hair; a small scar form a fall down the stairs as s child already marks a bright apostrophe against a field of black.  Now an entire bald patch glared back at me.

I stalled, searching for some way to hide it, to make it better.  To at least prevent him from seeing it for a little longer.  With eerie calm he asked me to get my hand mirror.

After he saw the result, he sighed, put down the mirror without a word and left the room.  I heard the shower in the other bathroom ignite.

I set about clearing away the clippings scattered across the floor, my insides churning with disbelief, self-reproach, regret.  Eventually the water stopped but I was surprised when, not long after, I felt his arms wrap around me.

“I don’t care about the haircut,” he said softly.  “It’s stupid.  It will grow back.  But I care that you don’t stop to listen.  That’s what you need to work on.”  I turned and hugged him back, nodding into his shoulder.

In a few days it would be a funny story.  Months later it still lingers as a cautionary tale.  But I’m fortunate that there are also things that my husband does very quickly.  He is fast to forgive.  And his hair is fast to grow.

The Parent Trap

Parents: one of the most oft-cited reasons by physicians in other specialties that they chose to keep their distance from pediatrics.  And one of the factors that convinced me that the field was right for me.  In the personal statement for my residency application, I waxed poetic about how much I enjoyed the task of explaining things on two levels – to the parent as well as the child – even when differences in understanding, values, and culture posed additional challenges.  To me, parents were just another appealing aspect of the field.

So of course I had my first made-me-want-to-scream parental encounter early in my intern year.

It wasn’t that the parents were overly rude.  And it wasn’t that their child’s case wasn’t serious.  It was that they first wanted the medical team to alter our treatment plan because the very well-established standard of care for this particular illness simply did not mesh conveniently with their lifestyle.  Then, once I had discussed at length with them the disease and rationale for this treatment and they had decided to go ahead with it, they needed every detail put into place rightthisverysecond.  Why, they wanted to know, was I still standing there talking to them?

When I finally had a spare moment in the resident workroom, I paced in agitation as I vented my frustration to the senior resident who oversaw our team.  How could people be so entitled?  How could they try to deny their child the only proven treatment for a serious condition, and then, once on board, demand immediate service as if they were the only family in the hospital? My senior listened patiently, his grin a mixture of amusement at my impassioned recount and a caution that I should get used to this. The chief resident, who had peeked her head in the room to check on the day’s progress, ducked out then returned with a can of green Play-Doh.  “For stress relief,” she said as she slid it across the table in my direction.

A few phone calls and electronic order entries later, I trudged back up to the patient’s room armed with the news that the treatment would commence far earlier than anticipated and their discharge home would thus be expedited.  I found the patient sleeping while the mother barked into a cell phone.

She spoke tersely, enunciating each syllable.  She looked up at me and rolled her eyes as if we two represented an alliance against all that was stupid in the world.  “No, I said three round-trip tickets.”

And an alliance was exactly what I wanted.  I found myself speaking with ingratiating sweetness, my tone all chirpy and won’t you please like me and can’t we please just get along?

I explained the next steps in the child’s care.  She listened, then began to apologize . . . that she needed to leave. It was just that this new development, this incredibly inconvenient illness and our stubborn resolve to treat it in this way were forcing some alterations in the family vacation and, well, I just knew how imbecilic those travel agents could be, didn’t I?  She was just going to have to go take care of the adjustments in person.  She would be back later that evening; maybe at that point we could start discussing discharge plans?

I listened in amazement to my own voice making one more high-pitched stab at pleasantry, remarking how lovely the trip sounded, how it would give her child something to look forward to and allow them all to put this illness behind them.

You want so badly for her to like you!  I realized as she nodded absently and I made my way to check on my other patients.  But why?  She had agreed to the best treatment for her child; wasn’t that enough?  Did we need to be buddy-buddy, too?  Would winning her approval of our plan, of our medicine, of me, somehow erase her maddeningly entitled ways and make everything alright?

Parents: one of the unique aspects of pediatrics.  Bane or boon, depending on whom you ask.  I had encountered dozens already, some of whom I had bantered with in a chummy rapport, some of whom had concerned me with their lack of attention to their child’s needs, but all of whom I had treated with professional respect and politeness, and whom I felt had largely accorded me the same.  None had infuriated me in this way.  None had tried my patience and thrown me so off-kilter, challenging my ability to keep my emotions restrained.

Yet, too, none had led me to such introspection, such an examination of my visceral responses.  As I peeled flecks of green Play-Doh from beneath my fingernails, I had to admit that none had left such a lasting impression that, despite its frustrations, would arm me for future such challenges.

And there will be many, many future parental challenges.  After all, it’s pediatrics.

Language Lessons

I meant to learn Spanish a long time ago.  The years between college and medical school seemed like a clear opening, although I found plenty of ways to busy myself.  At one point I signed up for a Spanish Word of the Day email service, and dutifully copied and pasted each day’s nugget of knowledge into a comprehensive spreadsheet.  It turns out, though, that you don’t actually learn anything if you never revisit said spreadsheet.

In the first semester of medical school, I jumped to sign up for an evening course in medical Spanish.  It was a hodgepodge of students with abilities ranging from no foreign language knowledge to a substantial recollection of college Spanish, as well as one who spoke fluent Italian.  After a few sessions spent gamely following along as the instructor attempted to wrangle us through a variety of exercises that suited no one’s ability and guiltily promising myself that the following week I would devote some time to my medical Spanish workbook rather than losing it under the mountains of anatomy atlases littered around my apartment, I politely withdrew.

When I began residency, my husband and I moved into an apartment halfway between the cities where we worked.  My husband traveled by train, while I drove twenty miles down the highway to my hospital. A coworker told me of a friend in a similar situation who had used CDs to master Italian during his commute.  Armed with new determination, I secured a library card and borrowed a 3-CD set of instruction in conversational Spanish.

On the drive to work the next day, I learned several greetings and introductions.  When repeating the examples offered by my faceless instructor, I proclaimed them with gusto.  I rushed ahead during translation exercises, the overzealous student shouting out the answers before the teacher calls on her.  The warm voice coming through the speakers told me I was doing muy bien.

That afternoon I attended my first session of residents’ clinic.  I was scheduled to only see a few patients while I learned to navigate the flow of the clinic and familiarized myself with its electronic medical record system.  After yet another day of feeling lost of and overwhelmed, I began to relax as I finished writing my notes.  I offered to see an additional patient in order to help finish the day’s work, and typed my initials next to the patient’s name on the large electronic schedule board in the doctors’ workroom before heading down the hall to meet the patient.  But when I walked into the exam room and introduced myself, a mother and her daughter stared back at me silently.  I tried again, but when the mother nudged the girl and said something rapid and incomprehensible to me, I sighed.

“Español?” I asked.  They nodded.  “No inglés?” I asked, just to be sure.  No, no inglés.

A nurse had already paged a translator, so I returned to the doctors’ workroom to wait.   One of the two attending physicians commented that it had been a speedy visit, and I explained the language barrier.  The two looked at each other.

“Do you want me to take it?” one asked.

“No, it’s ok, I’ve got it,” the other assured, rising toward the door.

Both spoke fluent Spanish.  The translator was cancelled and clinic finished soon after, with no help from me.

And I remembered what was perhaps the main reason that all of my previous attempts at Spanish had fizzled: because it will take so long to ever finish, or even to make substantial progress, in learning a new language, especially when the task of learning medicine still looms large.  Because greeting a patient and exchanging pleasantries in another language isn’t the same as conducting a full encounter in that language and does not relieve my dependence on a translator.  Because these thoughts’ defeatist nature doesn’t make them any less true.

I skipped the Spanish lessons for a few days, but eventually tuned in again.  I don’t know how far this latest attempt will take me; perhaps it’s best to avoid dwelling on it, to just keep hitting “play.”  Last week I learned the colors.  I can say, “I live in a big yellow house.”  It isn’t true or even that useful.  But it’s something.

Stethoscopes and Poop

There are few places that can make an intern feel as inept as can the neonatal intensive care unit (NICU).   The medical care required by premature and very ill infants is unlike anything in the rest of pediatrics.  But before new residents can even begin to build a knowledge base, they must chisel through layer upon layer of the foreignness that envelops the place.  As the interns who rotated in the NICU before me repeatedly intoned, it’s just different over there.

A special language is spoken in the NICU, one awash with acronyms – GIR, HMF, PPHN – whose meanings are not easily intuited.  There is a distinct – and distinctly unique – format for presentations during rounds.  Add to these challenges the fact that the NICU is located in a separate hospital from the rest of the pediatric services, with a separate electronic medical record system, and it becomes clear why new interns find it so intimidating. Not to mention the fact that the babies there make our usual patients look like giants.

As I progressed through my first days in the NICU, I felt increasingly unmoored, drifting ever farther from the competence I craved.  It seemed that there was no time to learn, only to do, yet each task highlighted my ineptitude more than the last.  I asked question after question of the senior residents, the fellows, the attending physician, the nurses and nurse practitioners – anyone, which is to say, everyone, who had more experience than I did.

The best and worst parts were the deliveries.  The pediatrics team was called to the labor room or operating room each time a baby was being born that might need some extra support or resuscitation.  We were called for premature babies, twins, and triplets; for babies who had already passed meconium (the baby’s first stool) and so were at risk of breathing it into their lungs; for babies born to mothers who showed signs infection during labor.  Interns took turns responding to these calls, and were accompanied early on by a more senior member of the team.  Once we had demonstrated proficiency with the required skills, we responded on our own.

It was exhilarating and terrifying: the initial scramble to find the right room, never knowing just how far along the delivery would be by the time you arrived; the frantic gloving – or, for the OR, scrubbing – while checking the infant warmer to be sure that all the right equipment was available and properly functioning; the mental checklist, running on repeat, of just what equipment to use when.  And, of course, the ever-present possibility of being handed a baby that refused to breathe on its own.

As with everything else NICU-related, I asked questions.  I double-checked the indications for giving oxygen and for intubating to suction out meconium.  I even discussed Apgar scores – just how pink had the baby been at that first minute of life? – before committing them to the medical record.

But it was tiring, pestering people with so many questions.  I felt irritating, was even irritating myself.  And so, for anything that wasn’t directly related to patient care, I shied away from querying and began to make educated guesses.

I had begun to feel the first tinges of proficiency when I was called to the delivery room, accompanied by a nurse practitioner seasoned in deliveries.  We arrived just as the baby was about to, and rushed to check our equipment.  I grabbed the stethoscope dangling from above the warming lights and set it down on the table where we would soon place the infant.  I had seen others lay the instrument with its diaphragm on the table and the ear pieces hanging off, but this seemed arbitrary, more of a style thing, and so I laid it my own way, with the ear pieces curled up next to the diaphragm, right next to where the baby would soon lay.

The nurse brought the baby to the warming table and I dried him vigorously.  As she wrangled a hat onto his tiny head, I used a bulb syringe to suction the secretions from his nose and mouth.  He began to cry and, as many babies do, to poop.  Black, sticky meconium poured onto the table, oozing over everything in its path.  The nurse practitioner rescued the stethoscope just in time.  “That’s why we lay it like this,” she said, grinning as she straightened it to lay in the normal fashion, with the earpieces safely out of the meconium’s reach.

And so I went back to asking questions, not only in the NICU but also in every unit where I work.  I ask questions about medicine, about how things are run, and about whether there are better ways to do things than I have already found.  It’s exhausting.  But it helps me to keep learning.

And it also helps to keep the poop out of my ears.