Wednesday, March 28, 2012

Taking life as it comes


Two of my patients refocused my attention on living in the moment this week.  In a week when we were bombarded with information regarding planning next year and the next 4 years of our lives post medical school and into residency, I needed to be refocused on the here and now.

The day I turned 28 I had a conversation with an 82 yo patient my team was caring for;

“Ive been in the hospital a few weeks now. I have a problem in my lungs.” He told me how he used to smoke and drink back in the day, and now he’s just taking it as it comes.  “That’s all you can do”, he said.  He told me he’s 82 years old and has lived a good life.  Life is about giving and taking, he’s given all he has to give and now he’s just taking it as it comes.  Mr. B told me lots of people say you shouldn’t smoke or drink, but they die young sometimes too.  "You never know what’s going to happen, so you have to just take life as it comes."

Sand Dunes of Northern Michigan

The last day of my internal medicine rotation at this hospital I decided I'd spend my free afternoon sitting with a patient I had grown fond of;

Mr.N was severely demented, not oriented to person, time, or place, but every once in a while he had these breakthrough moments where I felt like we were connecting.  Each morning when I woke him up to accomplish my duties of finding out how he was feeling and completing a physical exam, he would pop his eyes open and smile "well hello there, good morning to you too!" Throughout the exam he'd  usually babble things I couldn't piece together- "how do you feel today sir?" "I feel wonderful, hot diggity dog- do you see that over there I'm going to get it!" Together we would laugh, maybe not about the same thing, but hey we were laughing!  Perhaps we couldn't cure his end stage lung cancer, and perhaps he didn't know what was going on, but he was happy and we could help him laugh.  This afternoon when I came in just to talk to him, I let him ramble about the most obscure topics and just put my hand on his as he laughed.  After a few moments he turned to me with a look of intention and started to cry. "I have been looking for the way all this time, and because of you I have found it."  Together we sat in silence for a few moments as he cried and I held his hand.  I'm not really sure what was going through his mind at that time, but I know that somehow an emotion was evoked merely by the presence and touch of another human being.

This week the NYTimes ran a piece on the effect of human touch and presence on the emotions of another human being.  Several studies have proven that mere touch and empathy can be as effective or even more so than the use of traditional pharmacological methods.



Wednesday, March 14, 2012

A reflection on death and dying in the hospital


I almost met death today. He was looming in the air. I could feel his presence leave right before I arrived in the morning and linger after I left in the afternoon.  It wasn’t me he was visiting but I still felt blown away. 

When I first arrived to the hospital my resident greeted me in a chipper voice, “good morning- have you ever pronounced someone dead? Want to come do it.” Sure it was 6 am, seemed like a perfectly normal way to start your day!?! So off we went through the tortuous halls, up and down the stairs until we reached our destination.  The moment we walked in the room I was reminded of my cadaver, how I was able to cope with knowing she was dead because she looked so dead and felt so dead.  I always thought it was the formaldehyde they shot through her veins prior to our first meeting.  But here I was meeting this man for the first time, and he was formaldehyde free, only a short while since his life had ended and yet he looked just like the expression “you look like you got the wind knocked out of you”.   Pale and glazed over, I did not have to feel for his pulse to know his soul had left his body.  We did our ABCs (Airway, Breathing, and Circulation check), closed his eyes, called out the time and marched on to attend to those patients whose life was still present.

Hospitals are funny places- are they there for people to heal? No I’ve learned they are more a place of stabilization- make sure the patients are not in any acute danger, ship them out to heal at home under the care of their GPs, and hope that someone will be home with them for the healing process.  This concept was a surprise for me, it wasn’t what I had hoped or imagined.  I find I have such difficulty letting patients go without a clear diagnosis, prognosis or solution.

We rounded on half of our patients in the morning and left the more long-term cliental for the afternoon.   After my afternoon slump  (that often occurs post prandially during our lunchtime lectures) my team shuttled off to round on the afternoon patients.  Outside the room of the first patient a resident filled us in on his overnight activities and what the plan of care was from here out.  “Ok shall we go see him?”  The attending asked.  One behind the other we filed into his room and surrounded the bed looking down at him.  “So how do the tests look?” the patient asked.  “The tests came out alright, the cancer has remained stable.” “Oh that’s great news, I’m so glad to hear it.  So where do we go from here?” “Well sir, your cancer is pretty far along, the treatment we could give you now would only be palliative- it would help with some of the symptoms you have been having but it won’t cure the disease. “ “Well I want to continue the treatment, if everything looks good right now we might as well keep trying to fight it.” “Ok sir, we can continue to give you the chemotherapy, but I think its important that you understand the cancer will not ever be beat, just slowed a little bit.” “ You know you are the first person who has said this to me, everyone has beat around the bush and no one has been honest about my prognosis.” “I’m sorry, I’m sure this is hard for you.” “It’s alright”. And then we moved on to the next 3 patients, having similar conversations with each of them.  Shuffling from one to the next no one spoke in between, we just delivered the bad news and moved on- leaving the patient alone in his room.   

After seeing all of the patients our attending went back to his office and we (students and residents) went back to our team room.  Everyone started working away on the computer to get things done.  “I’m sorry I know you guys are working- but I’m having a hard time with processing what just happened.” “What do you mean?” “I mean how do you guys deal with telling so many people they have terminal cancer? It’s really sad.” “I guess we just become callous to it, don’t really internalize it and move on with our day.” Oh ok.....(is that really what I'm supposed to do?)

The View from my house when I lived in Puyo Ecuador.

Saturday, March 10, 2012

Wisdom of the Sages- Rosemary Sage Sweet Potatoes Beets + Garlic

For those of you who follow the news, you might be aware of the current battle in congress over contraceptive access.  I recently wrote the following Op-Ed that was featured in Mother Jones about 2 weeks ago, so I thought I'd share it with you- and of course a recipe to accompany :)

 A few weeks ago, I had a conversation with the Democratic staff of the House Oversight and Government Reform Committee.  They were looking for a medical student to testify at an upcoming hearing on contraception—would I be that student? 

Ultimately, the Committee chose to invite a student at Georgetown Law Center as their witness—but neither of was given a chance to address the Committee.  Chairman Darrell Issa refused to seat Sandra Fluke because, in his view, the hearing was “not about reproductive rights but instead about the administration’s actions.”  The hearing was quite clearly a reaction to the Obama Administration’s decision to require church-affiliated organizations to provide insurance coverage for contraception.  Ms. Fluke would have been the only woman on the panel.

I suspect that, even if I had been invited, I would not have had the opportunity to address Congress.  But if I had, here is what I would have said:

Mr. Chairman, Ranking Member Cummings, and Ladies and Gentlemen of the Committee—

It is a privilege to sit here before you and be able to address you, the men and women who make up the membership of this committee.  As I look beside me, however, it must be recognized that I am the sole female on this panel—a collection of witnesses you have asked discuss access to medication that is only prescribed to women. 

If this hearing had been called to discuss the issue of access to erectile dysfunction medication and the panel here consisted solely of women, I would have also argued that your decision was, at best, irrational.

My gender notwithstanding, I hope to present two rational, evidence-based arguments in support of our responsibility to assure that women have access to contraception.  There are other arguments we could discuss, but these two highlight the absurdity of obstructing the use of certain classes of safe, effective medications.

First, contraception provides this country with measurable health and economic benefits that have nothing to do with sexual activity.  Although they are called “oral contraceptive pills” (OCPs), synthetic estrogen and progesterone are now among the most widely prescribed medications in America.  Is that because more women are sexually active?  No.  It is because these medications have helped millions of women with a diverse array of medical concerns.  They are now prescribed for acne, endometriosis, polycystic ovarian syndrome, and as a means of protecting women who are particularly at risk for certain diseases such as ovarian cancer.  The health risks involved when access to these drugs is blocked is very real.  For example, without OCPs a woman with polycystic ovarian syndrome is exposed to unopposed estrogen, placing her at higher risk for endometrial cancer. 

Along these same lines, from a public health standpoint, OCP prescriptions allow more women to attend school and work without having to use previously used sick days for debilitating premenstrual cramps.  By denying women diagnosed with dysmenorrhea (painful cramps) or menorrhagia (excessively heavy blood flow) the option of birth control pills, we deny them the current gold standard for treatment.  All evidence suggests that health care providers should use these tools to treat female patients.  In a nation that has invested such a large portion of funding—about two percent of our annual budget—towards medical research, it is unfortunate that some would ignore this research-based conclusion. 

Second, although we may disagree as to the benefits of family planning, we should all recognize that, in this country, it is a doctor’s obligation to present a patient with a wide range of reasonable medical choices. 

I recently completed a rotation in the nursery of a nearby hospital whose policy is not to offer contraceptives to women.  As I was discharging new mothers—most of whom were immigrants, or poor, or both, with little idea of where to go and what to do after they and their newborns left our care—I was not able to present them with a fair range of options. 

Many studies have shown that it is beneficial for women to use some sort of birth control for the first year after delivery.  Becoming pregnant any sooner puts the mother, her current child, and the future infant at risk for adverse health outcomes.  I struggled to bite my tongue as these mothers left without this important medical advice—information that I freely and routinely provide to other patients at other hospitals.   How could this hospital, whose goal is to provide the best healthcare to its patients, deny these women that information?

Regardless of where you stand religiously on the use of contraception, as medical students in the year 2012, we are taught that it is our responsibility as healthcare professionals to provide “patient centered care.”  We have moved away from the paternalistic view of “doctor knows all,” to presenting the evidence and options to patients in order to come to healthcare decisions together as a team.  Without presenting the full spectrum of available options, we are reverting back to a paternalistic view that physicians (or politicians) “know” what is best.   That view, in my opinion, is wrong.

-       Yonit Lax
MD Candidate | Class of 2013
The George Washington University
School of Medicine and Health Sciences 


Photo Courtesy of Planned Parenthood: The Chosen Witnesses at the Hearing



Wisdom of the Sages- Rosemary Sage Sweet Potatoes, Beets + Garlic

This is absolutely delicious, I make it often to accompany meals or as a snack for the week.  The whole garlic roasted together melts in your mouth and the sage gives it a perfect edge.


Ingredients: ( 3- 4 servings)

Pre-cooking
3 Sweet Potatoes cubed
3 Beets cubed
6 Whole Cloves of garlic unpeeled
1 bunch of Sage
Handful of Rosemary
Olive Oil - just enough to coat

Instructions


1) Preheat Oven to 425
2) Line a baking dish with parchment paper
3) Mix together all ingredients
4) Bake for approx 45 minutes



Rosemary-Sage Sweet Potatoes Beets + Garlic
(Sorry if they seem scarce, I may have picked at these before taking the picture....oops)