Pediatrics: An Inspiring Rotation

Although pediatrics has not felt as relevant as other rotations, I've certainly had a lot of chances to be humbled and amazed by the parents I meet.

"Lupita"

In the outpatient clinic I worked in, my preceptor had me shadow for well child visits. One afternoon, I followed him into a well child check, only to see no child in the room...only a middle-aged woman sitting in the corner chair. She and the pediatrician began to speak and I slowly began to understand what was going on.

This woman was adopting a distant relative's child, "Lupita" after discovering that Lupita and her siblings were being neglected. Raised in a small town in south Texas, the children were left alone often and had to choose which children ate at meals. Lupita didn't speak English very well and didn't know what grade she was in. The woman said that at home, Lupita talked nonstop to whoever was around her and ate voraciously, almost choking on a sandwich in her haste to eat it. Drug use and deportation played a role in her mother's absence.

Lupita came in after the pediatrician had received all this news. She was a grave child, obeying the doctor in everything she could understand without smiling or showing any embarrassment that a girl her age would typically show. She spoke freely but only when spoken to. In her hand, she held a little charm, and when I asked her what it was, she opened her hand and showed me a plastic star the size of a die. "Mi estrella," she said simply.

I was very amazed by Lupita's new adoptive mother. This woman was also planning to adopt Lupita's baby brother, who was still in Mexico. And when my preceptor asked, "how do your twins feel about all this?" I was completely amazed. Pray for them!

"Aaron"

In the same outpatient office, with a different preceptor, I saw a follow-up with eighteen-year-old "Aaron" on a stress fracture. Aaron was a young adult with autism and a lot of sensory overload. He was in a post-high school program designed to teach adults to ride public transport, interview for a job, and use a basic skill set in an employment setting. He had come in with his mother, who I learned (and could see by difference in race) was his adoptive mom.

As the doctor conducted the history from his mother, Aaron would constantly interrupt: "what's going on? I don't understand," or "I have something to say. I'm going to explode. I still don't understand," and his mother would quietly redirect him or ask him for input. She was very skillful at letting Aaron talk as much and as constructively as possible, while also advancing the discussion of his painful foot.

During the physical exam, however, the doctor had to palpate for swelling and tenderness to palpation (an X-ray was inconclusive), and the pain began to be more than Aaron could communicate. Unable to say "stop it" fast enough, he screamed loudly, then began to cry. The doctor stopped and we stepped out of the room for a time, while Aaron and his mother re-grouped.

After a few minutes, we came back in. "Aaron wants you to know he's embarrassed," his mother said gently, "but he wasn't prepared for you doing that today." The doctor nodded, apologized to Aaron, and the interview went on. It reminded me of a video I'd seen about a nonverbal girl with autism (at right and also online: Carly's Cafe). It was as if Aaron's world was too overwhelming, and processing it took so much time that he couldn't ask the doctor to stop pressing, and the pain and the inability to stop it became very distressing.

Throughout, the mom was a calm and loving help to this young man who she was barely helping to function. At one point in the interview, she became tearful when she talked about Aaron "falling through the cracks." Where would Aaron be without this woman? This is another story of someone I'll not forget easily, someone whose generosity was humbling.

"Helen"

I just finished the week of newborn nursery time that's sandwiched between the other weeks of pediatrics. I rotated through the NICU and saw some very incredible moms there, too. I spent some time talking with one in particular, "Helen," who had delivered two preemies. Her first child was born at 28 weeks and she spent months in the NICU fighting lung problems and sepsis. While her baby used IVs and NG tubes, Helen pumped breastmilk from the day he was born, hoping that when he was mature enough he could take it. It was a nightmare, she said, something "I wouldn't wish on anyone." Fortunately, her son is now caught up in growth and milestones, and has no residual CNS effects except some possible learning disability.

During her second pregnancy, Helen received weekly progesterone injections (thick, oily, slow gluteal IM shots) and underwent cerclage, but still went into labor at 28 weeks. After trying every drug her MFM had to offer, she started a terbutaline drip at home and stayed on bedrest for six weeks. Helen told me she has a propensity to contact dermatitis and the indwelling needle for the terbutaline drip was a constant irritant in her leg during that month and a half. And at some point every week, she would go into labor again and the terbutaline dose would have to be increased in the emergency room.

"Was it worth it?" I asked.

"Oh, absolutely," Helen said emphatically. "My daughter was born at 36 weeks, and it was so worth it to have her that much farther along. Oh, absolutely." This woman has her priorities in beautiful order. The generosity of soul of these mothers astounds and humbles me!

Dark Diagnoses and Extraordinary Forms

I told you I needed to be more poetic, and this is the story I was trying to write when I realized some parts of human lives are too great for clunky prose.

A man came into the office, I saw him, and he left with a diagnosis that will either accompany him or hurry him along his walk towards death. And although he feared a diagnosis like that (or at least, his wife did), I truly don't think he expected to get it. His major goal of the day was to figure out what was wrong and fix it, so that he could get back to the way life was before his symptoms were bothering him. But instead, he walked out of the clinic with a dark diagnosis.

His 'dark diagnosis' is one of many that I store in a mental box in a corner of my growing art. Myasthenia gravis, multiple sclerosis, diabetes, some cancers, HIV/AIDS, hepatitis C, congestive heart failure, chronic obstructive pulmonary disease, etc. I am not the master of these diseases, but I am the one who sees the signs of them and shakily opens that slim black case and pulls out the corresponding diagnosis, handing it solemnly to the person as I introduce them to their unwanted companion.

Sorry for getting so very poetic so quickly.

Actually, I'm not sorry. All death is poetic. Prose isn't adequate for sacrifice, suffering, birth, death, heaven, hell, love, or God. All these things overwhelm the speech of ordinary life and we need the extraordinary forms of poetry or song.

And these dark diagnoses are a kind of death, because I must tell them, "Life is different now. I wish I had different news to tell you, but you can't go back to the way life was before."

"Now your body is not the instrument you knew it was: it won't obey you, you can't rely on it. Now you have to do special things and change the focus of your life."

I study this dark box often because these diagnoses have many effects and are chronic, debilitating, and common. Many times I had spoken with patients and they had said "and I have COPD" or "I'm diabetic." They already carried their darkness.

But I had never visited with someone, examined him, presented his case my preceptor, and heard that we must open that box. Hearing my presentation (which is made privately outside the patient's room), Dr. H's mouth fell open and he said with raised eyebrows, "You think maybe organ failure?" as if saying, "are you opening that black box?"

And I could have said, "Oh, no! Not that, not for him." I had though his symptoms were from a relatively benign condition. And I liked this patient. We were alike somehow, even though he was a huge man with the build of a sailor, a square jaw, and the bronzed skin and bleached hair of decades of work in the open sky. We had a good rapport. (Maybe because we were both choleric?)

But I instantly knew my preceptor was right: organ failure fit with the patient's story much better than my idea, although my idea was still on my differential. In that instant I swallowed my "No!" and answered aloud evenly and honestly, "I don't know, but..." and I continued with the presentation. I watched as every word I said corroborated Dr. H's diagnosis and the lid of that box opened wider and wider.

We walked into the room and I looked at the patient with different eyes. Now I recognized the signs of that diagnosis in him. Now I saw that he had a dark companion which he did not know about but I did. It was like I could see his future, and I saw that he would become a different man.

(Sadly or happily, this man didn't grasp the impact of that diagnosis. He was relieved to have a pill to start taking to fix the problem so that he could go back to work. Dr. H may have broken the news to him a little too gently for a man so choleric. But I won't go around asserting that I know how to break bad news better than a successful, experienced, and sensitive family doctor. I actually started to see the wisdom of Dr. H's approach: the patient may be more likely to come back for follow-up if he feels his goals were met. And coming back for follow-up is good for chronic and serious diagnoses. The impact of the disease might change based on how the patient fares in two weeks.)

And I can't help it: I have to draw a spiritual parallel because it's not actually a parallel, it's a true instance of what I'm talking about. We all have a dark diagnosis--much, much darker than anything in medicine's little box. The name for people with this chronic, hereditary, debilitating disease (the name for all of us): sinners. Our appetites are not the instrument we knew in Eden: they won't obey us, we can't rely on them.

And alone with this condition, our future is completely black: we spiral down gradually to eternal death or separation from God, who is all that is loving and good. But God planned mercy, prepared us for it, and executed it beautifully by sending a Physician (or, better), the Cure Himself.

And now we work out the cure in our own souls day by day. Now we have to do special things and change the focus of our lives. And since it is simultaneously a kind of sacrifice, suffering, birth, death, heaven, hell, love, and is altogether of God, it sometimes takes extraordinary forms.

Raining Grace

The other day I had my first day of the Family Medicine preceptorship. (Last semester I did an Internal Medicine preceptorship, and this semester I have Family Medicine. Same routine, same program: once a week for five weeks, I go into a physician's office and see patients and learn what I don't do well, and reinforce what I already do well.) It was awesome! But it didn't start out that way.

At TAC, it did rain once or twice a year for several days
in a row. It was so much fun.

It was pouring rain on the second day of a huge storm.

Granted, I love weather in general, and especially rain. I associate it with grace. (St. Scholastica and St. Therese are right!)

Yes, rain is plenty of fun if umbrellas and roofs are useful.
Not so fun otherwise. Exhibit A: Useless curb. Hatt

But having spent four years in a legitimate desert (with phenomenal artificial irrigation powers) I have forgotten how much it can rain at one time.

The curbs were useless. The little creek nearby was level with the sidewalk. No matter how acrobatically I tried to avoid the river flowing past my car, I knew I would still got a shoe full of precipitation.

All this when I'd like to make a good first impression by not walking in drenched and frizzled by heavenly moisture. So, on this day I was not so overawed by the grace of rain.

Whatever. I got in the car without dignity, my big poofy, soaking coat bunched awkwardly on the wet seat. I am so glad I have a truck! I drove through a small river as I got onto the main road. After I reached the highway, everything was very safe and I made my way to the hospital. In the lobby, I ran into another medical student: she was (as she always is) beautifully put together, with her white coat safely stored in a dry clean bag. Inwardly rolling my eyes at myself, I took off my ridiculous coat and rejoiced that my copy of Differential Diagnosis of Common Complaints seemed unhurt. In fact, I seemed generally presentable: my white coat (although not transported via hanger and bag) was dry and clean, and my skirt looked like a skirt, not the mop that I feared.

It was very easy to find the practice, and once I was inside a nurse led me back to Dr. H's office. The space about the same size as Dr. F's and was also crowded with paperwork and evidence of a busy life, but what a difference in first impression! This one was tastefully furnished with a large dark L-desk and credenza. The chairs matched and were handsomely upholstered. A green marble and gold desk pen set took center stage. The doctor himself was a rotund, older gentleman in a pristine and pressed white coat. Were it not for the laptop, desktop, and Keurig, I would have thought I'd been transported to the 1950s.

Dr. H was very busy that day and (because he was a good preceptor), so was I. It was a great day in the life of a soon-to-be-third-year! I saw six patients and felt confident to ask questions and examine them, plus form a differential diagnosis. The learning curve was extremely steep and fun to ride. And I think I actually made a difference, even if very small.

I became very glad that I was just getting over a wretched cough. Apparently, the same thing is going around, so I was able to ask the right questions because I'd just had all the symptoms. And St. Joseph of Cupertino must have been interceding for me, because all the patients had things I knew about, like rheumatoid arthritis. I'm sure that won't always happen, but I was glad it happened on this first day of a new preceptorship.

Going from room to room, talking with people, asking the right questions, examining them, and taking notes is so awesome. I love it. And having someone (like Dr. H) place their confidence in you is a really big help toward having confidence yourself. I felt like a junior colleague, instead of like a student. I was late leaving, but I couldn't imagine a better afternoon. It makes me really look forward to third year!

I guess it was raining graces.

Cool Stuff

Over my first preceptorship, I saw, heard, and felt a lot! This post has nothing to do with Catholicism, faith, holiness, dignity, or anything supernatural. It's just a list of amazing things the human body exhibits when something's wrong. If you're bored you should google some of these.

1. patient frustrated with the wait time (this is actually a not-so-amazing thing the human mind does when something's wrong...)
2. skin grafts
3. screws bulging under the skin of old internal fixations
4. inverted T wave on ECG (cardiac ischemia)
5. arcus
6. excessive bony transverse processes in cervical spine compressing nerve roots (shooting arm pain)
7. omega-3 FA deficiency
8. polycystic kidney disease
9. glossitis
10. puncture wound to foot
11. fibromyalgia
12. cherry angiomas
13. polypharmacy causing fatigue
14. sarcoidosis
15. Bell's palsy
16. possible new Ehlers-Danlos diagnosis?
17. diabetes mellitus (type II)
18. recurrent UTI
19. diabetic neuropathy: hyperesthesia in hands and feet, anesthesia in feet
20. pitting edema
21. enlarged tonsil (making the uvula deviate)
22. femoral bruits
23. hemiplegic migraine
24. mild clubbing

I also wrote my first two prescriptions! (I didn't sign them; that would be illegal...so maybe we should say they weren't my first two prescriptions. But the drug, dose, number, and sig were all in my handwriting!) Wow, what an experience.

Vibrant Catholic Culture in Exam Rooms is Awesome

Right now, my country is trying to shove my faith out of my work. How dare I bring my vibrant Catholic culture into the exam room? Recently, I was glad I dared to bring my vibrant Catholic culture in to see a patient.

I was working in the office of a Hindu physician, many of whose patients were from south/east Asia. I felt out of place until I saw a patient who was much like me: white, Christian, and Southern. She was applying for federal disability income and had a long story culminating in her current deep poverty. She cried as she said "I'm indigent," but dried her tears as she repeatedly professed faith in God's will for her.

If my preceptor had seen this patient, the patient would not have gotten so far as to mention God's will. Because my preceptor is adept at getting clinical information quickly, she probably would have listened to a few sentences of the patient's spiritual situation, would have nodded and produced a true but not supernatural platitude in a tone of voice implying closure, and asked another question about the patient's disability. Because I I know the truth of God's providence and the ultimate purpose of this life, I could nod with real understanding and begin to pray earnestly for this poor woman.

I love it when cultural competence, a humanities buzzword, actually refers to cultures to which I belong. In other words, I love it when cultural competence is something I already have, instead of something I woefully lack because I am not brown and, alas, something I will probably never acquire because I am not a liberal.

But this experience goes beyond, "I'm so glad I am a Christian and was there for a Christian patient."

First afternoon in first preceptorship

My first afternoon in Dr. F's preceptorship gets mixed reviews. You may recall that it had a rocky start.

So, confession time: I really want to be a doctor. I want to put my stethoscope on people and ask them questions and think up some things that might be causing their problems! I want to get messy and make mistakes! My preceptor, Dr. F, has a different approach. She wants me to see a lot and transition slowly. So, I spent the bulk of my day shadowing, took one history, and performed zero physicals. That made me angry.

I admit, her approach may have been a result of the way I presented that one history. I know presentations are supposed to be brief recaps of longer interviews that a med student makes to a physician. This allows the physician to check the student's mental work: what did she think was important? What step did he take next? What is he thinking of for a differential diagnosis?

I boiled down the history too much, I'm afraid, and I left my preceptor with the idea that I hadn't taken a complete history. To my frustration, she did not ask me for more; instead, she went in and interviewed the patient again, obtaining the same set of details that I did and all the while interjecting meaningful injunctions to me about collecting details.

Ah, misunderstandings! How you art rife when there is a power disparity!

I hope next week is better.

Conflict Resolution: I...can't do it.

You might think that the oldest of seven children, a "talker" in TAC sections, and a leader in lots of student groups would have some conflict resolution skills. But in the past few weeks the need arose for conflict mediation with a superior (Dr. F) and I was completely ineffective.

Although Dr. F asked for my goals during the preceptorship and was no doubt trained by my course coordinators in what I could and should be doing, my afternoons with her did not resemble a preceptorship at all. 

We spent large chunks of time closeted in her office talking about spiritual things and her philosophy of medicine (very alternative). While spiritual things and alternative medicine are terrific, it grated on me to see time slip away when I knew that I should be seeing patients (or studying). Worse, the patient volume while I was there was very small--I only saw two patients this week, and that was representative of the past three sessions. Finally, I was not able to practice forming assessments and plans, since the patients I was seeing were being evaluated for federal disability and no treatment is ever given. Granted, she calls me in to show me pathology, like femoral bruits or xanthelasmas. But the primary purpose of the preceptorship is to hone H&P skills.

I tried several times to ask her whether I could see more patients. "I could go in and see this one while you see that one," I'd say, but she would gently coerce me to do what she wanted in an annoyingly nice way that she probably meant well. All of this made me really angry.

Upshot: I called the course coordinator and I'm being moved; I won't even talk to Dr. F again.

Ironically, we have a Professionalism class about "Communicating in Challenging Situations" on Monday. I was reading through the presentation just now, which articulated all the things that I experienced:

The Typical Physician [and, by extension, the med student] is...

• Compulsive [check]
• Perfectionist [check]
• Guilt prone [CHECK]
• Exaggerated sense of responsibility [check]
• Limited emotional expressiveness [check]
• Significant communication deficits [ouch]

Conflict arises when...

• Perception that another person is blocking our goals [exactly what happened]
• Another person is not acknowledging or understanding our beliefs or values [definitely contributed]
• Different expectations about roles, resources or outcomes [the root of the problem]

I wonder how a two-hour class hopes to teach us how to resolve such complicated problems. These are moments when I'm glad I went to TAC, where criticism of ideas happened daily and formal behavioral  feedback (don rags) happened twice a year.

I guess I'm no perfect communicator, but I trust that the rest of medical school and residency will shape me a lot.

Struck by Dignity

Another opportunity to think on my feet: I was told to see a returning patient who was following up on pain problem.

The patient told me about her pain and that she figured out what started it all: holding the phone with her head for hours while working around the house. At that time, a new relationship was beginning for her, and she would spend a lot of time on the phone. After a few more minutes of history, I asked her conversationally about that relationship.

She told me it was great! They were finding so much in common and it was a great source of enrichment and joy for her. I could see that it lit up her face. Then, between sentences about how the relationship was flourishing she said, "now, I won't lie to you, it's not a man--it's another woman, and..."

I stopped hearing her for a few words, feeling as though I had been struck. Everything was so normal until that sentence. Now what do I do? Instantly I began to determine how I should receive this news: it is clear that this relationship is more than friendship and I know that homosexual acts are naturally disordered and spiritually harmful. But I am not this woman's doctor and am, in fact, a stranger and a medical student visiting the office for education. But will I give scandal if I calmly smile and nod? I am wearing a crucifix and am therefore a representative of Christ for this woman, who is surely observant enough to notice my necklace.

The patient was concluding, saying that she felt valued in her relationship. I decide to say true things but withhold the truth that is inappropriate to provide. "I am so glad that someone can make you feel the dignity you have as a person, can appreciate your worth," I said.

Her response was almost as shocking to me as the original admission. She was delighted! She said, "that's exactly it," and that I completely understood. She went on about her partner while I went off into thought. Untangling my thoughts later, I wondered:

1. This woman only found appreciation of her transcendental value in this relationship. This is terribly sad: everyone can appreciate everyone's human dignity...we don't need intimate relationships for this (although I'm sure this love is crowned with greater intimacy).
2. Is hunger for this appreciation fueling homosexual intimate relationships and the gay marriage drive? 
3. If there someone else made this woman appreciate her human dignity, her , would she ever want a homosexual relationship?
4. This woman is missing out on a unique element of marriage: self gift as a woman, to a man. There is so much more to marriage than simple (though profound) appreciation of human dignity.

The patient later told my preceptor that I was "an excellent human being" (I guess, the highest praise of the secular world?). I think I was at least excellent in one thing: I saw what she loved about being loved.

The Preceptorship Diaries

During second year, medical students at my school are placed one afternoon each week in a physician's office to learn to take histories, perform physical exams, create assessments and plans, and document their work at a tempo that resembles real life. (This replaces the lovely take-your-time atmosphere of the simulation center.) I became really excited: finally, a chance to play doctor at a real pace!

I knew that my preceptor, Dr. F, was an internal medicine physician. Further, I'd heard that she gave an informal talk on superfoods and was going to come talk to the Holistic Medical Society (which is actually a cool group, when it avoids the hippie commune end of the spectrum and adheres to good practice using all available wholesome methods). Her name was Indian.

Her office was adjacent to an acupuncturist's (later she told me that she was also certified in acupuncture). I entered and was asked to wait in the waiting room while she got off the phone. This was unusual for a medical student (usually, I'm told to come right back), but I sat among the patients and quietly waited the short time until I was called back. I noticed that this office, like Dr. D's, attracted people like the doctor: Dr. F's staff and clientele were more brown than, say, Dr. C's or Dr. A's.

When I was called back, Dr. F greeted me warmly and sat me down in her little office. She asked me what my goals were for this preceptorship, for which I was grateful. Next, she discovered that I studied philosophy and theology, and asked me for a favorite scripture. I mentioned the Song of Songs, and recited the verse that appears when my alarm goes off in the morning ("Arise, my beloved, my beautiful one, and come!"). She was charmed, and hinted that she might look up the book on Google.

While I was describing TAC, she learned that I was Catholic. She asked me, "what do you think of diversity?"

I answered honestly, if in an abbreviated fashion. "It's beautiful," I said. "I haven't always spent time in the most diverse environments" (TAC had one black student?) "but I realize that people's different experiences and cultures are enriching." This was true, and largely the product of my summer with Dr. D. I left other thoughts about diversity unstated: its ascent to a replacement for true exchange of ideas in this culture is strange at best, and relativist at worst.

Dr. F smiled slightly, but then looked at me squarely. "I meant difference in religion," she said.

For an instant, I was at a loss. I gathered that Dr. F was something of a pancretist: she had a large carving of a Native American medicine man on driftwood in her office, she wore a tiny rhinestone angel pin, she had a calendar displaying a Hindu god, she promised to look up the Song of Songs, and she was asking me this question.

I could not lie. "While I believe that my faith is the truth, I cannot and will not treat others without the dignity they have as human persons."

Boy, that was hard to say! A little wall went up in her eyes after the first clause, and her next sentence started in a tone most professors reserve for the correction of a wrong thought. ("Well, hypertension is associated with atherosclerosis, but this question is actually asking something else....") I'm not sure whether this preceptorship will go as swimmingly as I'd hoped. Time will tell.