There is absolutely nothing better than an entire week with patients. After an intense month of biochemistry, I was more than happy to be at hospitals and clinics, even if it meant getting up very early and being dressed semi-professionally. Now, for the first time, my white coat actually merits a good wash (I swear it’s not just me being me and wanting it to be extra clean and extra white…it really, really has some stuff on it that is – ahem – not dinner table conversation). The week-long mini-course, “Clinical Foundations of Medicine,” was a break from the routine for first-year medical students. We still had lecture, but it was on all of my favorite things: health care economics, law and policy, doctor-patient relationships, alternative medicine, and epidemiology.
I could tell you one hundred anecdotes from the various sites I visited, but I will stick with the highlights from each. At the HIV/AIDS Resource Center (HARC), I was struck by how differently I saw things after talking with the employees. Though I’d read all of the statistics before, it is very different to watch clients walking in and to talk with the manager about the percentages of people who are of color, who are men, who are homosexual or who are homeless. I was also somewhat sad, though not surprised, to learn about how limited HARC’s outreach and education efforts are at the middle- and high school level. It turns out that these limitations stem from the state’s public education funding that has abstinence-based sex-ed. On the other hand, HARC apparently does a great job in Ann Arbor with their outreach events at Aut Bar and Necto.
Moving on to my “senior visit” at an assisted living facility, I was delighted with the ninety-five-year old woman I interviewed. Seeing as my grandparents are some of my favorite people in the entire world, it’s no shocker that I loved every minute of my conversation with this fiery, opinionated old woman. She repeated a few of her stories, but was generally quite sharp and even witty. She did phenomenal imitations of the other senior citizens in the home, cupping her hand to her ear and pretending to be more deaf than she was and going on and on about how inane she found bingo. Sometimes I could barely keep up with her mockery and sarcasm. After a few questions about her medical history, it became clear she would much prefer to talk about her farming family and her political opinions. I’m not sure I want to go into geriatrics, but when you spend enough time with the lucid elderly, you realize that they are fascinating people who crave substantive conversation. I was particularly fortunate this week to talk to a senior who was from Finland, who had dated ski-jumpers, who ironed her brothers’ pants before they “went girling,” who called her husband her “helpmate,” and who referred to political debates as “simply horseshit.”
Besides the joy of hearing stories from another century, there is the simple truth that senior citizens are older and wiser. There is meaning behind their words when they tell you that the secret to life is finding the joke in anything serious. At various points in the conversation, she expressed this in different ways:
“Don’t let the little things get you down.”
“Most problems don’t amount to a hill of beans.”
“Laugh and the world laughs with you…cry and you cry alone.”
“Enjoy life. Go out and make it interesting. Don’t sit around waiting.”
I found myself thinking about a book I just finished, Expecting Adam, which is written by an ex-Harvard professor about her experiences while pregnant with a son who would have Down syndrome. In the epilogue, Martha Beck describes her son’s incredible ability to find humor in the most difficult of situations.
“There are many times when I see the pain on his face as he struggles to communicate…but just at that moment when Adam’s frustration is most intense and I expect to see him fall into rage or despair…he’ll take a deep breath, as though he is letting the frustration slide off his shoulders, and begin to laugh. This is not the laughter of an idiot. It is the laughter of a person who chooses to see humor in his own discouragement, and to me it is not only intelligent but wise.”
Humor, it turns out, is a raging epidemic in many clinical specialties. Perhaps this is doctors’ way of dealing with the pain and suffering that is surrounding them throughout the day. Sometimes, it can seem a bit crass and inappropriate, but most of the time the patients appreciate it, too. In otolaryngology (ear, nose, and throat) I saw many patients who were greeted like old friends by their physician. There were jokes about how the doc loved smokin’ too but decided he’d rather not get cancer, there were those who referred to local anesthetic as “Canadian local” and then proceeded to talk about their favorite liquor, and there were imitations of prissy female doctors in other not-to-be-named specialties.
The final clinic I went to was with an allopathic doctor (MD) who used to work at UM and now has a private practice in partnership with an osteopathic doctor (DO). I could go on forever about how much I enjoyed her office. As I entered the clinic with my medical student partner, we turned to each other and whispered that our living rooms were not as well decorated as their exam rooms. There were the standard tables and beds, but also comfortable chairs, stenciled quotations, and peaceful paintings. I’d been eager to see how this particular physician integrated her knowledge of standard allopathic medicine with complementary and alternative practices. The immediate and obvious difference is in the time spent with patients; during my two hours at the medical center, I spent half an hour talking to the doctor about her approach, 75 minutes with one patient, and then 15 minutes debriefing. The clinical appointment was an intake evaluation and was thus particularly long, but 75 minutes is not unheard of. The focus is on knowing the patient as a complete person and listening to their full story. The particular women we saw was clearly someone with a complex assortment of complaints that were related to both her physical and psychological state. Knowing the intense anxiety and sadness that was present in her personal life helped explained some of the physical manifestations. The patient felt she was being taken care of and she respected the doctor’s time; she had come with a list of specific questions and had done quite a bit of research on her own. She was well-educated and knew how to do some research into conditions on her own, but was still willing to listen to the doctor’s evaluation.
There was also extensive opportunity for “reading between the lines.” As we got to know the patient better, it was clear how much she was struggling and it was increasingly evident when she was holding back information. For instance, when asked about her drinking habits, she answered quickly and then abruptly changed the subject. When talking about this part of the appointment in private after the patient had left, the doc explained that she had ordered liver enzyme analysis in the labs she wrote up and that she wanted to wait to press the issue further until she had established trust with the patient.
I was blown away by the comprehensive nature of the physical examination. The doctor even did a few basic manipulations often performed by physical therapists in order to re-align the woman’s hips. Interestingly, there are many “chiropractic” maneuvers that are considered mainstream if done by a physical therapist. This dichotomy also exists – to a certain extent – with the use of heat ultrasound for injury treatment. At this medical center, they address a range of physical, emotional, and neurological problems in patients of all ages. I think what most impressed me was their openness to using either “standard” or “alternative” techniques depending on the individual patient and what would work for their particular needs and lifestyle. They use everything from x-rays and blood tests to massage and psychotherapy to bioenergetics and homeopathy. I came away with incredible respect for their ability to straddle the allopathic and osteopathic worlds.
What a week! I should now go pack up my dry-cleaning and get ready for tomorrow: a normal Monday back in jeans in the lecture hall.