Dusty Old Books

A special box arrived today from my parents, one I'd been waiting for all week.


I quickly opened the box after I got home from work but slowly examined the contents, pulling out one fragile book at a time.  I studied the titles, waved dust away as I turned pages, and noted the name inscribed in delicate calligraphy inside the front cover of each.  The earliest book dated 1892; the latest 1928.  I reviewed some of the content within, surprised at how well the facts and drawings correlate with our body of medical knowledge today.  There's no telling when they were last opened.  


I cannot tell you, though, how much I would have loved to have a conversation with the owner of these texts.


The name so carefully penned in her Practice of Medicine, Obstetrics, Diseases of the Brain and Nerves, Handbook of Physiology, and Dr. Potter's Quiz-Compends Anatomy books is Dr. Forrest Phillips Fleener ... my great-grandmother.


One of three women graduating in the Hahnemann Medical College Class of 1910 in Chicago, Dr. Fleener became licensed to practice general medicine in Illinois, Iowa, and Texas, before settling down with her practice in and around New Sharon, IA, a few miles from where I grew up.  My grandmother, Forrest's only child, told me that her mother would travel the local countryside, exchanging medical services for fruit and meat if her patients couldn't pay cash.  She died in her early fifties from a diabetic coma, leaving a few remembrances of her livelihood behind.  


I never knew a great deal about the only person in my family to be in medicine before me, and sadly, I know little still.  Nonetheless, I am grateful for what I do know.  For my white coat ceremony when I started medical school, my parents had my great-grandmother's class photo framed as a gift to me.  Forrest has never been far from my sight since --- she hung over my desk while I studied into the late hours in Iowa City, traveled with me to Reston, VA, where she resided on the wall in my AMSA office, and has now settled in Seattle.  I am quick to talk about her when friends come over to visit.  Her story, her experience, her legacy are a source of pride and inspiration for me.  


And, now, I have seven dusty, old books to add to my growing collection of medical antiques.  But so much more important than the knowledge contained within are what they have come to represent --- Dr. Fleener's perseverance, potential, and pioneering spirit.  I remind myself that if she could succeed as a doctor 100 years before her great-granddaughter ... then surely I can, too.  

Tough Questions

To say I love my outpatient clinic at this point in the residency game would be a bit untruthful.  Is the paperwork challenging?  Yes.  Is it hard to switch gears from the hospital to the clinic?  Yes.  Do I get frustrated at my slow speed?  Yes.  Will it get smoother?  I sure hope so ... at least that's the rumor I hear.

But what I love about clinic are my patients.  For the first time, I am gathering a group of people that come to know me as their doctor and who I have the great honor of learning their life stories.  I take all kinds --- the young, the old, the sick, the healthy, the rich, the poor, the stressed, the calm, those in physical pain, those in psychological pain, those with sordid pasts, those with fortunate pasts.  No longer do I simply stand in for other providers or see patients as an academic exercise ... I am the doctor with all the responsibility, fear, and concern that comes with it.

I met for the first time last week a patient unlike any other.  I walked in to his room, introduced myself, and sat down across from a man with thick glasses and a full, salt-and-pepper beard, wearing perhaps the loudest Hawaiian shirt I've ever seen.  He sized me up, grinned, and proceeded to open his notebook, full of meticulous lists of blood sugar readings, cholesterol values, and correspondence with his previous resident.  He flipped through a couple of pages until he found what he was looking for --- a list of 12 questions he had written for his new doctor to answer.

"Well, sir," I began, attempting to apply my slowly-developing skill of agenda setting.  "How can I help you today?  I'd love to make a list of your concerns, so I best know how to use our time today."  

"This is the problem with medicine today ... you only have 15 or so minutes each time.  We never have time to discuss all that I'd like to.  But, we have to start somewhere," he said, tracing over his list with his finger.  I scooted my chair a bit closer so that I could peer over the top of his paper.  He casually slid an envelope over his questions.

"Oh, I'm sorry," I apologized.  "Would you prefer I didn't look at the list?"

"Actually, I do," he explained.  "Or else, you jump to answer what you want to but not what's important to me."

Fair enough, I thought.  Any hope of guiding this interview rapidly dissolved.  I placed my pen on the desk.  If I could get to the end and understand better how the two of us would communicate and relate moving forward, then that would mean success.

"Let's see here," he paused, studying me carefully.  "Why were you chosen to be my doctor?"

He seemed relatively satisfied when I told him I had very little to do with this decision; his previous resident had graduated, and he needed a new one.  I'm one of two new Harborview residents; the coin flip could easily have gone to Daniel instead.

"What can you do for me?"

I only hoped I didn't appear as deer-in-headlights as I felt.  

"How do you feel about organ donation?"  

With his multiple chronic diseases, he was pretty sure that his individual organs wouldn't be useful but perhaps his body might come in handy for science.  He wanted to begin planning for this now, just in case.  Given that he lives in a shelter and does not have a cell phone (but does have a rentable mailbox), we determined the best way to send information and questions back and forth between visits was to revert to old-fashioned snail mail.  The donation question was the first of three that I agreed to write him once I found the answers.  

"I want you to know that I like to have copies of all my labs and that I do better when I have access to information and when my situation is explained carefully to me."

"Very reasonable," I reassured him.  I glanced surreptitiously at my watch.

"I know, I know," he said, crinkling his eyes.  'You're very busy.  But just one more question for you, doctor."

"Yes?"

He leaned forward and looked at me intently, "Do you treat my cells, or do you treat me?"

"Pardon?"

"Let me state this a different way.  Are you concerned about my cells and individual disease processes, or do you care for all of me as a whole?"  

I sat there for a moment and chuckled slightly, a wide smile slowly spreading across my face.  I wish more patients were like him, curious, thoughtful, and philosophical.   I answered frankly.  

But what an absolutely brilliant question.

A Good Death

We simply don't talk about it.  We become uncomfortable and change the subject, avoiding the inevitable.


As a society, we often box any discussion of our certain demise and tuck it away, out of sight, and we hope, out of mind.  We tend not to think about or discuss our wishes with the ones we love, and when a diagnosis looms, we desperately search for a cure, a surgery, a magic pill --- little of which bring solace or fruitful resolve.


In my own family, regrettably, I've born witness to unhealthy deaths, not so much the death itself but all that follows.  Misunderstanding over the past and confusion over the present with regards to particular family proceedings have left me sad and hollow, all so very unnecessary.


And, so when a good death comes along, I am somewhat stunned and appreciative for the opportunity to take part.


As a medical student, I volunteered briefly for Hospice, sitting with patients at odd hours wherever they were in their final days and hours, visiting with them and their families.  I became comfortable with the physiologic changes at the end of life --- increased need for pain relief, air hunger, and spiraling vital signs.  But I never was faced with being the one to tell a patient's family that their loved one was dying and that medical intervention is futile, at best.  Recently, however, one of my favorite patients gave me that opportunity, teaching me immensely in his final hours.


As a medical team, we had known for a while he was sick, and we were frustrated because we didn't have a solid explanation as to why he was so sick.  We all loved him and his stories, his photos, and his jokes.  He never wanted to be a burden.


On the morning he began to decline rapidly, I called his son and asked for him to come.  I don't know when he will die, I said, but I suspect it will be soon.  After I finished caring for my other patients, I took over for my attending physician to wait until his sons could arrive.  Both she and I did not want him to be alone.


Thankfully, my pager was silent for those forty-five minutes as I sat with him and held his hand.  One of the nurses brought me an e-mail message from a family member that his eldest son from several states away was on his way and asked me to relay the news.  I started to and broke down.  After about ten minutes, I regained enough composure to tell him what it said.  Although he could no longer respond, I told him how much I enjoyed his jokes and that his younger sons were on their way.  But mostly I sat quietly at his side.  It was the best doctoring I've done to date.


That afternoon, after his sons arrived, the palliative care team, my attending physician, and I visited at length about what was happening --- his disease, his death process, his wishes.  A remarkably frank and refreshing conversation, we were all on the same page in terms of making sure their father was comfortable and free from pain.  We encouraged them to say what they needed and wanted to say and to do the best they could to take care of themselves through this.  But mostly, we shared stories.  We learned from his boys about his upbringing, the morals he passed along to his sons, and their family traditions and forgiveness.  As one of his doctors, I had come to know my patient through his labs, tests, and symptoms, but that afternoon, I gained a much greater understanding of the incredible person he was, both before and while he was sick.  I gave his sons my number in case they had questions and gave each of them a hug before I left.


That night, before I left the hospital, I stopped by his room to say good night and goodbye.  His sons had gone to stay with family.  I squeezed his hand and told him how much I enjoyed taking care of him, how great a job he did raising his sons, and that he could go, whenever he was ready.  He died early the following morning, comfortable and at peace.


A few days later, the attending physician, medical student who had cared for him, and I attended our patient's memorial services at a small city park.  Over fried chicken, macaroni salad, and Hawaiian punch, we laughed, looked at pictures, and celebrated.  I stood up to share a few words and thanked his family and friends for allowing us to attend.  I marveled at the healing around me --- his sons from two marriages who had never previously met were getting to know another, and the ex-wives hugged and welcomed family.  Out of pain and loss came almost palpable rejuvenation and mending.  And being able to witness it all was beautiful, to say the least.


I am grateful to him, my funny patient who was always ready with a compliment, a smile, a story, a man who had the conversations he needed to have as his life drew to a close and made certain his boys knew how much he loved them.  One of those patients I will remember for the duration of my career, he taught me what it means to live a good life ... and how to live a good death.

Next Time Call a Nurse

My roommate and dear friend Ramona is about the most brilliant, passionate, and genuine woman you will ever meet.  She has a penchant for adventure, designing crazy costumes, and playing interesting sports.  She recently joined a kickball league and plays regularly on Thursday nights at Gasworks Park with friends from around the city.

One night earlier this summer, as I slept soundly post-call, I was awakened by the following, somewhat urgent, crescendo whisper / hiss outside of my bedroom door, "Dr. Hughes ... Dr. Hughes ... Dr. HUGHES ... are you awake?"

I stumbled to the door and opened it.  "Yes, Ramona?"  I replied, rubbing my face.

"I'm bleeding!  Come look!"  

I followed her in to the bathroom to find her left knee scraped and dribbling blood, her left elbow, gingerly frozen at a 120-degree angle.

"What happened?"  I asked, a bit more awake.

She proceeded to explain that following a huge kickball win, she jumped in the air in celebration and landed on a curb, tumbling off to her side.  Nearby skateboarding youth rushed over to assist, but she soon was up and hobbling home but now a bit concerned as to what she should do.

I squinted my eyes at her knee.  "Wash it up.  I'm sure it'll be fine," I said.  "Now bend your elbow ... does it hurt?"  I asked, completing the briefest of exams in my stupor.  My parting words before crawling back in bed were something along the lines of ice it, rest it, and go to bed.

The next evening, Ramona reported that she did as I said and iced her elbow at work.  When her boss, a lawyer and a nurse, walked by and asked what she was doing with the ice, Ramona told her the entire story and that she had already been to see a doctor.

"Really?" her boss asked.  "Who did you see?"

"My roommate's a resident ..."

"Well, did she tell you take ibuprofen?" 

"No ..."

"Ramona!" she laughed.  "Take ibuprofen whenever you have an injury like this ... and next time, call a nurse!"

So, naturally, whenever Ramona has a medical question for me these days, I never forget to remind her of one important aspect of her treatment.  And, in fact, it's the first thing I mention ...

"Ramona," I say, "Don't forget your ibuprofen!"

 

She said, "You need to find a different outlet for your writing."

I have found note-writing to be, at best, an onerous task, one that I'm afraid I'm going to have to learn how to like.  Given today's medical-legal documentation standards and necessities, there's no escaping it.  And there's no escaping that I need to become faster at it. 


I don't like to leave a shoddy note in a patient's record and tend to review and rewrite portions of it before submitting the final version.  I discussed this recently with one of my family medicine attendings in clinic, and she smiled and told me, "You prose writers will simply have to find a different outlet for your writing."  


Hence ... my return to blogging.  Let's see if this time around it sticks a bit better than before!  Now that I have a few weeks of residency under my belt, I have plenty of interesting fodder to share and reflect upon.  I hope you enjoy reading the stories as much as I have enjoyed experiencing them. 


But, for now, it's time to sign off ... a few patient notes are waiting to be finished.