Tag Archives: medicine

The Fatherless

Disturbingly common question and answer when I’m taking a medical history:

“And what about your dad, does he have any medical problems?”

“Well, I never really knew my dad, so I’m not sure.”

Lord, help us.

“Father of the fatherless and protector of widows
is God in his holy habitation.
God settles the solitary in a home;
he leads out the prisoners to prosperity,
but the rebellious dwell in a parched land.”
-Psalm 68:5-6 (ESV)

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People like people

There must have been at least ten of us all crowded into her room. She seemed very sick, and she probably would have rather kept sleeping. I felt bad waltzing in with my classmates to startle her, but our attending physician didn’t seem to care.

“How are you feeling today?” He said it cheerfully, as if he were seeing an old friend for the first time in awhile.

She whispered that she was feeling a bit better than yesterday. A few of us said hello, and she nodded slightly.

The doctor asked her to lean forward. She did so–painfully–and he moved her gown aside to expose her back. One by one, we placed our stethoscopes over her lungs and listened for a few moments while she breathed. By the time it was my turn, she seemed more alert.

“That’s a pretty shirt, sweetheart,” she said to one of my female classmates. The girl was a little surprised, but she smiled and thanked the old woman. Our attending physician then began explaining what we were hearing–I think he had a chest x-ray and some other data on the computer, but I wasn’t really paying attention. The woman had woken up a bit more, and she was now curiously looking around the room. She seemed relaxed.

“Okay?” said our physician.

My classmates nodded that they had understood whatever he just explained, but I was watching the old lady, who was now reaching across her table for a small plastic bag full of Dum-Dum Lollipops. She picked it up, and extended her the bag with a smile, the IV lines dangling from her forearm.

“Want some candy?”

We all smiled, and a few of us took a lollipop. As we walked out, the lady settled back into her bed, and she seemed more peaceful than she’d been before.

I’ve seen this often. Unless they’re very ill, people who are at first tired and sick often perk up when a troop of medical students walks into their room. I don’t think they’re startled; I think they just like company. People like people–strangely, it took me until college to realize this. So for the past few years I’ve been trying to talk to strangers and new people, because everyone seems to appreciate the attention. I’m not very good at it yet, but I’m getting there.

“The second is this: You shall love your neighbor as yourself. There is no other commandment greater than these.”

And the scribe said to him, “You are right, Teacher. You have truly said that he is one, and there is no other besides him. And to love him with all the heart and with all the understanding and with all the strength, and to love one’s neighbor as oneself, is much more than all whole burnt offerings and sacrifices.”

And when Jesus saw that he answered wisely, he said to him, “You are not far from the kingdom of God.”

Mark 12:31-34

[Just FYI, none of the patients I talk about are real–they’re composites of various patients and people I’ve met over the past four years or so.]

Me. A timid, white-coated kid with fake patients

No, no, I should use a deeper voice to sound more authoritative…

“Hello. My name is Ben, I’m a second year medical student. Today I’m going to ask you a few questions about your problem. I’ll also conduct a physical exam, and then I’ll consult with my attending physician. So, why did you come to see us today?”

Maybe that was a little too formal? And when should I ask the patient his name?

I was sitting in bumper-to-bumper traffic, practicing to myself. Today in school I had to see three “patients”. These patients are actors, and when the interaction is over with, the actors stop acting and offer us criticism on our communication skills. My number one criticism from all three patients?

Lack of confidence. An uncertain demeanor. A little timid.

Last year, when I did this same exercise, the patients said I performed swimmingly. The difference between one year ago and today is that for the past year, I’ve been constantly cramming knowledge into my head. Last year, I was full of self-confidence for one reason: no matter how much thinking I did, I just couldn’t think of any reason why I might be wrong. Now it’s entirely different. The more thinking I do, the more and more I doubt my initial impressions.

But patients don’t want a timid, uncertain doctor, and this kind of doctor won’t give patients the comfort they need when they’re ill. I may have an exquisite line of reasoning. I may be friendly, professional, and composed. But somehow, I need to convince the patient that I do, definitely, beyond any shadow of a doubt–know what I’m doing.

Of course, I won’t really know what I’m doing for another six years. Eventually, I’ll make accurate, lighting-fast diagnoses without even lifting a mental finger. Eventually, I’ll back up my confidence with competence. Until then, I guess I’ll just have to fake it.

Why I’m going into primary care medicine in an HPSA

On Tuesday, I found out that I have been accepted into the NHSC scholarship program. This means that the government will pay for the remainder of my medical school, and in return I’ll spend at least three years working as a physician in a federally designated under-served area. Of course my wife and I were ecstatic.

To have my schooling paid for is an extraordinary privilege, and as with all privileges, I wonder whether I deserve it. Only within the past few years have I been involved in community projects and service. I know many, many of my medical school friends who have done more meritorious and more service-oriented activities than me. The best I can say for myself is that I wrote my essays and my application as honestly as I could. If they chose me, it wasn’t because I made stuff up! I have a hunch I was chosen mostly because I’m from a high-need area, and I’d love to go back. Whatever the reason, I’m excited. I look at this not so much as a recognition of my merit (I don’t have much), but as a challenge to work hard, serve people in any way I can, and make certain I’m a “good investment.”

Anyway, I wanted to post something today, so here is a slightly-modified version of my application essay. I think it’s fitting for this post:

I was 17 when I first considered working as a physician in a medically under-served population. My friends and I had driven to central Idaho to go backpacking. When we were driving down a dirt road in the forest, a small fallen tree glanced off the side of the truck and lacerated my friend’s neck, throwing him to the floor of the truck. He was injured and we were scared, but it took us nine hours to get him to a medical facility. The first physician’s office we found was closed, with a sign on the door saying the physician came only once a week.

My initial idea to become a physician faded as I considered a career in physics, but I decided to become a doctor when I realized I wanted to work with people. It’s hard to describe why I’m interested in primary care medicine in particular. I’ve always been interested in pretty much everything—I’ve gone from physics to biochemistry to medicine–so the type of knowledge required in primary care is very appealing to me. I’d much rather learn a little about everything than a lot about a few things. I want to see a lot of different patients who have a lot of different problems. But I’m perhaps most excited because primary care physicians are needed, and I want to be needed in my career.

Over the past few years, I’ve become more interested in medically under-served populations. During one summer, I trained as an EMT-B near my home to gain some experience before applying to medical school. I remember one call on the ambulance where we spent two hours round trip to pick up a lady and take her to a city where she could get medical care.

Having grown up in a rural area, I’m interested in serving rural populations that need physicians, but I’ve also spent the last six years near the city. For about a year before I started medical school, I helped out at a free clinic for people without insurance. The clinic was about an hour away through traffic, so I only made it once or twice a month to volunteer, but I’ll always remember pushing the gigantic rolling files of paper medical records—a very physical reminder that even in urban areas, there are a lot of people without adequate medical care, whether because of language or economic barriers.

For med students, debt stifles idealism

Forget the youthful idealism you started med school with, real doctors need to look out for number one. This constituted about 50% of a talk I attended over lunch the other day. The speaker was talking about the need for doctors to be politically active not only out of concern for our patients, but also out of concern for ourselves. He was interesting, but I disliked the amount of time he spent talking about physician income, the cost of malpractice insurance, Medicare reimbursement, and money in general. It’s not that I think these things are unimportant–I think they’re terribly important–but these things aren’t why my classmates and I are in medical school.

Originally, when I decided to go to become a doctor, it was because I wanted to do missions work and help people in desperate need of medical aid. I’d still love to do this eventually, probably part-time or over a short term, but I haven’t yet taken enough steps toward missions work to be headed in that direction.

I am, however, headed in the direction of having a tremendous amount of debt–about $250,000. My wife routinely reminds me about what a huge sum of money this is. The loan repayment calculator at finaid.org estimates I’ll need a salary of at least $181,000 and ideally $345,000 to repay this loan. The more often I look at my loan statements and my financial aid “award,” the more pressure I feel to make a lot of money. How can I care for my wife if I don’t? How can we have a family?

If there’s anything that squashes the idealism of young medical students, it’s the need to acquire the realism of a working physician.

The 2009 AAMC Graduation Questionnaire found that the average education debt of medical graduates in 2009 was $156,456. The loan calculator suggests that a graduate with this amount of debt ideally should be making $216,000 to repay this loan. The OOH from the US Bureau of Labor Statistics states that primary care physicians have a median annual income of $186,044. (The median salary of “specialists” is $339,738. And we wonder why we have such a shortage of primary care physicians.)

My concern about debt increases with each semester, and if I bring it up among my friends, the main response I receive is that we should quickly do away with that topic and move on to something else. Likewise, I’ve found there’s no better way to ruin an evening with my wife than to bring up the subject of student loans. (Without a doubt, reducing tuition costs would encourage more students to enter primary care.)

It’s not that I didn’t look carefully at the numbers before I started. For one thing, the loan calculator above assumes that paying anything more than 20% of “discretionary income” for loans is “financial hardship.” I grew up in a lower-middle class family, and I’m pretty sure that if I’m making $150,000 a year then I can afford to pay a bit more into my loans. If I do choose to go into a specialty, I really shouldn’t have any problem at all.

That being said, I applied for an NHSC scholarship last spring. This is a government scholarship that pays for medical school if you agree to practice primary care in a medically under-served area for a certain amount of time. I’m currently waiting to hear whether I’ll receive an award this year. Since I prefer to go into primary care anyway, this would be a pretty sweet deal for me. I would likely make significantly less money than the average physician, but I would also have a very manageable amount of debt. While this isn’t the missions work I dreamed of in high school, it’s pretty close, and there are a lot of people in the US who are in desperate need of medical care.

NHSC is a wonderful government program, but it only solves a part of the student debt problem. If I’m awarded a scholarship, I can focus on caring for patients without worrying about loans, but my classmates will make their decisions with $200,000 weighing heavily on the scales.

And if I don’t receive the scholarship?

Well, I can only spend so much time calculating, talking to physicians, and looking up salary statistics. After I’ve done as much as I can, all I can do is trust the Lord to care for me.

Therefore I tell you, do not be anxious about your life, what you will eat or what you will drink, nor about your body, what you will put on. Is not life more than food, and the body more than clothing? Look at the birds of the air: they neither sow nor reap nor gather into barns, and yet your heavenly Father feeds them. Are you not of more value than they? And which of you by being anxious can add a single hour to his span of life? And why are you anxious about clothing? Consider the lilies of the field, how they grow: they neither toil nor spin, yet I tell you, even Solomon in all his glory was not arrayed like one of these. But if God so clothes the grass of the field, which today is alive and tomorrow is thrown into the oven, will he not much more clothe you, O you of little faith? Therefore do not be anxious, saying, ‘What shall we eat?’ or ‘What shall we drink?’ or ‘What shall we wear?’ For the Gentiles seek after all these things, and your heavenly Father knows that you need them all. But seek first the kingdom of God and his righteousness, and all these things will be added to you.

Therefore do not be anxious about tomorrow, for tomorrow will be anxious for itself. Sufficient for the day is its own trouble.”

-Matthew 6:25-34 (ESV)

The Art of Death

Awhile ago there was a display at my medical school titled “The Art of Pathology”. On display were pictures of human flesh–perhaps a microscope slide of a liver with fatty deposits, a section of a lung destroyed by smoking, or a heart with a large infarction.

I spent most of this morning looking at slides of diseased organs, and probably the last thing that might have gone through my head is “What a beautiful image.” Each organ had caused someone great pain. Then it had killed them. I don’t know much about art, but if art is something beautiful, then pathology slides and sections are most definitely not art. Pathology is death, and death is not beautiful.

Looking at pictures of dying organs is an impersonal way to learn medicine.I study alone, and while I’m studying things that are relevant to all of us, I don’t actually get to interact with any people. One image I saw this morning was of a massive infarct in the temporal lobe of a brain. I don’t get to comfort this person–I only get to see the aftermath. And the aftermath is gruesome. Whatever used to be in the infarcted section of the brain has been replaced by a huge, gaping hole. Even if, by some method, we could extract memories and thoughts from the connections and organization of neurons in a brain, we couldn’t extract any memories from this brain. There was just no structure left. Perhaps she lost function slowly as successive parts of her brain succumbed. Perhaps her memories blinked out of existence one by one, like in The Eternal Sunshine of the Spotless Mind.

Studying pathology is impersonal because each of us is more than just the sum of our parts. I am different from my body, because I am a soul, and God has blessed me with a body to interact with others and experience life. The difference between staring at books all day and seeing patients on the wards is that patients have souls. Patients can smile, cry, and express their concerns. But the world is tainted by sin, and our bodies–vessels for our souls–are dying. Pathology is happening in each of us, and eventually, one of our pathologies will kill us.

“By the sweat of your face
you shall eat bread,
till you return to the ground,
for out of it you were taken;
for you are dust,
and to dust you shall return.”
-Genesis 3:19 (ESV)

If pathology is art (I still have serious doubts), it’s because it reveals us as we really are–as dust. Slowly, imperceptibly, we’re broken down into dust, and eventually, we’ll return to dust. If we’re followers of the Lord, dust isn’t the end of us. As our bodies decay, our souls are perfected.

In Ephesians, Paul talks about our “old self.” If we’ve been renewed as Christians, we are new. The part of us that makes mistakes, that hurts people we love, that desires comfort more than service to God–that part of us is old, and God is working in us to destroy the old and build up the new. Just like our bodies, the “old self” is being destroyed. Death and pathology is God’s judgement on sin, and each of us will die. But this judgement is out of love. The parts of us we hate are falling away, and as we grow in closeness to the Lord, the new self grows in vitality. Once we’ve finally died and been made new, what more could we want? We’ll be with God, and in God’s presence “is fullness of joy; in [his] right hand there are pleasures forever.” (Psalm 16:11)

I tell you this, brothers: flesh and blood cannot inherit the kingdom of God, nor does the perishable inherit the imperishable. Behold! I tell you a mystery. We shall not all sleep, but we shall all be changed, in a moment, in the twinkling of an eye, at the last trumpet. For the trumpet will sound, and the dead will be raised imperishable, and we shall be changed. For this perishable body must put on the imperishable, and this mortal body must put on immortality. When the perishable puts on the imperishable, and the mortal puts on immortality, then shall come to pass the saying that is written:

Death is swallowed up in victory.
O death, where is your victory?
O death, where is your sting?

The sting of death is sin, and the power of sin is the law. But thanks be to God, who gives us the victory through our Lord Jesus Christ.”
-1 Corinthians 15:50-57 (ESV)