Heart Failure - Failure to Thrive

by Michael Greger, MD and United Progressive Alumni

[ Medical School Resources | Appendices | Discussion ]

I. PEDIATRICS - August 18-September 26

Failure to Thrive

I arrived in Maine today, my first time in the state. Eastern Maine Medical Center is a Tufts affiliate, and supposedly the best place to do pediatrics. It's in Bangor, the home of Stephen King, complete with moose crossing signs, Paul Bunyan postcards and billboards for lobster ice cream. I'm a long way from home.

The hospital is hugged by a wide sparkling river. Unfortunately, the building's only smokestack obscures my view of the water. We live in a make-shift dorm which connects right to the hospital. A classmate complains about the grime in the bathroom, but all I care about is the kitchen - no stove, no sink for that matter. Stuck with the cafeteria, I leave all my cookables in the car.

I drive Susan to the bus station. She boards a bus home. I watch her go and think about how bad a time third year is to be starting a relationship.

I put away my clothes. It feels like college, but the shirts have collars. I just throw all the ties in a drawer. It was Thoreau who said, "Beware of all enterprises that require new clothes." I sit at the edge of the bed and lay out all the toys I brought for the kids. For tomorrow. I lie down and lay awake.

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All authority of any kind, especially in the field of thought and understanding, is the most destructive, evil thing.
- Krishnamurti

My year's biggest fears center around the rigid hospital hierarchy. Authority and I don't get along very well - since kindergarten, actually. I had a habit of "talking back" to teachers, principals, adults. I cannot stomach the arbitrary power - what to do, what to wear, where to be. Because I said so, they would say.

I read that, "Medical school isn't really geared towards teaching students. Even in the clinical years, there is more emphasis on learning the caste system than in learning medicine."[7] "Medical school," my brother said, "It's not a job - it's an indenture." Martin Shapiro writes in his book Getting Doctored, "All too willingly, [medical students] submit before the authority of the institution of medicine, submerging themselves in it, but inescapingly forfeiting part of their own identities in doing so."[8]

Not me, though. I vow not to sell out. Not to give in. To refuse to be treated less than human, to stand up against injustice, to stand up for myself. "To thine own self be true" - Shakespeare.

In my readings I find out that such idealism is common among beginning third year students. A quote from an article in the Journal of the American Medical Association (JAMA): "To say that a junior clerk* is idealistic upon entering the floors is tantamount to professing that one's spouse is an acquaintance - it is a glorious understatement."[9] "Youthful idealism cannot last," another doctor wrote in JAMA. "This is true in medicine as in a monastery, the military, or the ballet."[10]

* "Junior clerk" is another name for third year medical student. My Webster's tells me the root of the word "clerk" is akin to the Greek word klan meaning "to break."[11]

Frederick W. Hafferty, former chair of the Medical Sociology Section of the American Sociological Association:

Although generations of students have embarked on their medical training tightly clutching the vow 'it will never happen to me,' early ethnographic studies, early autobiographical accounts of medical training, and long-standing concerns held by the public about impersonal and unfeeling physicians stretching back almost 40 years underscore the power of a process that is: (a) built around the altering of values and perceptions, (b) operates in a largely invisible and nefarious manner, and (c) embeds rationales in this process so that newly acquired norms, values, and identities appear unproblematic and 'just,' as well as objective, unbiased, and commonsensical to insiders and insiders-to-be.

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We start the year without orientation, without an explanation of our role or responsibilities only to be yelled at later for not knowing what to do. LA Law's Jimmy Smits in the (terrible) 1989 movie "Vital Signs" had one good line. "Third year," he said, "is like being an 18 year old rookie being called to pitch the seventh game of the World Series - blindfolded."

From an article published in JAMA:

We throw students and interns into the pool and expect them to dog-paddle in July, sidestroke in September, do the crawl in December, and butterfly in April. [This] system of laissez-faire/sink-or-swim is outmoded and amounts to educational malpractice.[12]

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I read a lot about third year - the horror stories. What's the difference between a third year medstudent* and a piece of shit? The line goes. You don't go out of your way to step on a piece of shit.[13]

* Medstudent is common hospital parlance for medical student, just like medschool for medical school.

From the Journal of Medical Education: "Starting third year is like going to a foreign country... analogous to prewar Germany with many fiercely warring provincial duchies, and you are a simple pawn.... You don't speak the language, you don't understand the customs, and the natives are not necessarily friendly."[14] "Our nonmedical peers, family members and friends are appalled at how we treat one another," writes one doctor. "They are aghast at the mean-spiritedness, fierce competition, back-biting, shaming, blaming, and rationalizing that increasingly characterize our medical centres."[15]

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I had a prophetic dream about pediatrics before the year even started. I was a third year student on call, sleeping in a room to watch over a sick child. I am awakened by the child who is wheezing. He cries that he is having trouble breathing. I jump up and start to run out to get a nurse, but then I stop. I figure I need to collect my wits and figure out what to say. "Noted progressive loss of respiratory function in child." I rehearse that for a moment then start down the hall. Damn, I stopped again. I can't just say that. I forgot the kid's name. It would sound better if I started out like, "John Smith started to experience trouble breathing at 3:15 a.m." I don't want to sound stupid. I ran back. OK, copied the name, marked the time. Said it over to myself one last time. Smooth.

I again ran out to grab the nurse. Wait. I can't just say that; what the hell does progressive respiratory loss mean? They're not going to accept that. I ran back to quantify. One one thousand. Two one thousand. OK. OK. "Christopher Regland awoke at 3:15 a.m. complaining of an shortness of breath. Respirations 25 with expiratory wheeze." Oh, beautiful. Oh, shit. What's the kid's age? And the room number? Got it. Got it. Ran for a nurse, gave my schpiel, rolled off the tongue. The nurse runs to the room, and of course, child dead.

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I lost 6 pounds in the first eight days.

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My mom warns me to choose my battles. I had a feeling though, that the battles were going to choose me.

There is an atmosphere of deceit. We are told to tell the parents that the reason we are the third person to ask the same questions and perform the same physical exam - pressing on all the same sore spots - is because we are making sure nothing is missed. Bullshit. The veneer of this-is-in-your-child's-best-interest is nothing more than you-and-your-family-will-be-respected-only-so-far-as-you-can-be-exploited as tools for our education. Self-interest disguised as selfless service.

I have yet to see truly informed consent, the keystone of medical ethics.[16] The process usually consists of, "Sign here; it gives us permission to take care of you." In the recent medical literature informed consent has been described as, "securing the cooperation of patients for procedures [physicians]... wish to pursue." Even more critically: "'Consent' does not exist. Instead what we find is 'acquiescence,' the absence of 'objection,' or occasionally a 'veto.'"[17]

"Later in the day," one doctor writes in an anthology called Bedside Manners, "we had a Russian patient who didn't speak English. Giving him informed consent... oh boy. So I clutched at my throat to indicate risks of death. And I fanned myself rapidly to show hot flushes. I don't know whether he got it or not. That just goes to show you what a lot of bullshit this informed consent business is."[18]

My first week here I'm finding that I'm lucky if I'm introduced as a "student doctor" (as if I take care of students). Most of the time I'm "Dr. Greger" (No, I want to say to the patient, your doctor just lied. To your face).

For more on this common deception - calling students "doctors" - Appendix 1

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He is young, five maybe. I don't really know him as a person; he is a teaching exercise. I am instructed to tag along with the team - my first spinal tap.

We start to carry him away in our white coat sleeves to the "treatment room." He's sobbing; you can tell he's been crying for a long time. The mother asks to go. She is told, "We'll be back soon, everything's going to be OK." What he meant was, "If you do that then you'll find out that we're using your son as a pin cushion." And if the resident was truly honest, he'd have to continue, "We respect your autonomy so much that we're not even going to give you the opportunity to decide whether you want a medical student tapping your child's spine - not to mention that it's the student's first time."

The mother insists, however, to be with her baby. She takes him from us, coos at him, wipes hair from his sweaty face. One of the doctors rolls his eyes. Once in the room we take him back to lay him on a metal table. We order mom to fold up her child. She is to bend him into a fetal position, head to knees. "Tighter," she is scolded, "tighter." "Do you want someone else to do it?" No, she shakes her head. Now she's crying too. The little boy is on his side facing away from us. The room is filling with people.

* The tiers of the hospital hierarchy are confusing. After four years of medical school you get an MD, but to practice medicine you still have to complete at least a year of a residency which - in all - can be 3-5 years long. An intern is a first year resident. The "real" Doctors are called "attendings"; they are the attending, supervising physicians. So the kick-the-dog hierarchy, as far as I can tell, starts at dean, then department chairperson, attending, resident, intern, nurse, fourth year student, third year student, professional support staff, nonprofessional staff, and then last - and treated the least - the patient.

The resident whispers an apology to me. With the mother in the room he's going to have the intern do it. "I don't want to make it look too suspicious." But it's August and the intern has only been a doctor for a month*. "Have you done any of these?" The resident asks the intern. The mother looks up at the hushed tones, eyes darting to each of our turned faces. The intern said that he had. The resident reminds us, "See one, do one, teach one."

The intern carefully snaps on a pair of sterile gloves. The child's back is prepped with iodine. The sponge is cold and the curled child sobs faster. It's obvious that the intern doesn't know what to do with the tray of needles and bottles in front of him. The resident sets him up. The mother looks worrisomely about.

The needle is four inches long, and so thick that a metal stylus has to be inserted inside the needle so as to not core out a column of flesh. The intern feels along the bony ridge of the child's spine - position is everything. The five-year old - I wish I knew his name - starts to squirm. "Hold him still!" the resident yells at the mother. She tightens. He places the needle on the skin between two knobby vertebrae in his lower back. I tug on the sleeve of the resident and point to the unopened vial of lidocaine on the table. He looks up at the mother, but her eyes are fixed on the needle. "Shush!" he responds under his breath.

The intern pushes the needle into the boy's back. The child screams; mom and I cringe. She holds him tight, squeezing him open to us. Tears roll down her cheeks. "It'll be over soon," the resident states. But he's wrong.

The needle is inches into the child's spine. The intern anxiously yanks out the stylet, hoping for a drip of amber fluid - cerebrospinal fluid - signaling he's tapped the right place. Nothing comes out. The stylet goes back in as he repositions the needle. Again, nothing. The child is moaning. Frustrated, the intern pulls the whole needle out. A drop of blood appears at the hole.

Resident and mother look nervously at each other. The intern feels again with his fingers, trying to gauge position. He grabs for the needle again and makes a new hole. The kid is panting and whimpering. The mother closes her eyes, squeezing out two more tears.

The second attempt fails too. The resident no longer seems to care what the mother thinks. "Try a different angle," he instructs the intern. "Hold it like this." Each try takes minutes - needle in, stylet out, wait for fluid, stylet in, reposition, stylet out.... Nothing in hole number three. I learn later he was sticking the needle in the wrong place.

On the fourth try, the intern was so flustered he accidentally just sticks the stylet into the child's back, without the needle. I looked around the room. No one says anything. When the intern realizes what is wrong, he acts as if it was part of the procedure, a studious look on his face. "Get me a pair of gloves," the resident ordered to a nurse. The resident dug hole number five.

And still nothing. "We'll just have to try again later," the resident says nonchalantly as he snaps off his gloves. Mom grabs her child towards her. "No," she cries, hardly able to breathe. "I want my doctor." The resident throws his gloves to the floor and walks out. We follow in line like ducklings, leaving the nurses to deal with mom and the mess.

The resident can't believe her audacity to refuse to let him have his way; how dare she advocate for her child. This meant the attending physician would actually have to come in from home. The resident placed the call. Minutes later, the attending stormed in and started yelling at the mother. You could hear him down the hall - maybe as a lesson to the other parents, I think to myself. Our turn was next.

Our first mistake, he told us, was to let mom in the room in the first place. When I started to protest, I was taken off the case. Further, I was forbidden from talking to anyone in the family - for my own good, of course.

I didn't get to say I was sorry for how we treated her son. Or how we treated her. I didn't get to tell her that she was right. And I didn't get a chance to stop her from apologizing to everyone the next day.

Unfortunately this scenario is the rule, not the exception. See Appendix 2a.

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Tufts offers a 9 hour course in Ethics in the preclinical years which include about 2000 hours of instruction.[19] Half a percent.

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This morning my Glasgow* was a little shaky. Responsive only to harsh alarm clock.

* The Glasgow coma scale rates depth of coma in part based on responsiveness to a hierarchy of stimuli.

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I am told Maine is beautiful. I realize today that I have not been outside for six days. Someone on the elevator this morning complained about the weather. A shaming flash of anger - you think I get to go outside? It was raining. I'd do anything to be out in the rain. Would I do anything to be out?

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The head of the pediatrics department keeps winking at me. No, I'm not like you. He has a sign in his office, NO WHINING (WHINING with a slash through it). And he's a pediafuckintrician! It took me weeks to understand that my smile was independent of him.

Michelle Harrison, in her book A Woman in Residence, wrote, "Staying sane in school meant saying to myself, 'I'm not like them. I do care. I am different....' But those thoughts also left me very isolated. I walked a thin line between what I believed I should be doing as a human being and what my role as medical student required."[20]

A very thin line. See Appendix 3a.

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God only knows, I don't,
What keeps me laughing.
The stem of a flower
moves when the air moves - Rumi

I force everyone to smile at me. I'm amazed at how far I can get with a sticker on the forehead; I am transformed into a clown guru. From my fluorescent orange hippo to my plush purple platypus, on every white coat button hangs a beanie baby clone, in every button-hole a stuffed animal's foot is stuffed. From fuzzy pink rabbit ears on my head to plastic rainbow slinkys trailing at my feet. And it's not even really for the kids.

True it's for everyone. True it tones down The Coat. But mostly it's for two reasons. One, I am not like you. Nor you, soul-snatcher, I am me. Not another white coat, and certainly not another MD. I'm me, damn it. And this means I don't care if you think I'm silly; it means I don't care what you think.

And two, wherever I go, whenever I look up, people are smiling at me. I infect smiles from hallway to elevator; they can't help it. It doesn't matter that they're just smiling at my coat. The world interfaces with me with smiles. And so I smile back. All day.

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It's the non"professional" hospital staff with whom I have most bonded. They're not even used to being looked at in the face. To the team at the information desk downstairs I am the "sunshine doctor."

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My early mornings are spent meditating on the employee gym Nordic Track, eyes closed, half asleep, rhythmic. I listen to my walkman with goose bumps, inspiring to the songs of the civil rights movement. This little light of mine; I'm gonna let it shine. Let it shine. Let it shine. Let it shine.

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I remember my first interview for medical school. It was at Cornell. I had asked if the school offered a nutrition course. "Nutrition is superfluous to human health," the interviewer replied. He was a pediatrician. I should of just gotten out while I had a chance.

People off the street may know more about nutrition than doctors. See Appendix 4.

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Food in Bangor? Chinese menu in the Bangor yellow pages: "Vegetarian Delight (served with pork fried rice)."

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Arguably the most influential pediatrician of all time, Dr. Spock wrote Baby and Child Care, the second-best-selling book in U.S. history, next to the Bible. Active to the point of civil disobedience during the Vietnam War, he remained true to his motto "Pediatrics is politics" to the end.[21] Before he died at age 94, Spock advised in the edition published posthumously that all children be raised vegan - no meat, dairy or eggs.

Medicine has a surprisingly rich history of radical activists, see Appendix 5.

From an interview in Redbook, Dr. Spock on medical students:

[The sociological study] showed, discouragingly, that the level of interest in patients as people was high on entering medical school, went down precipitously during the four years of school and the years of internship and residency and reached a low point at the start of practice.... Unfortunately, when departments of psychiatry tried to teach students in the third and fourth year of medical school about people's feelings - including their own - they found that many students had already developed such a deeply impersonal attitude that it was difficult or impossible to warm them up.[22]

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The bathrooms in the hospital are segregated. There are bathrooms marked "Patient's" and bathrooms marked "Nurse's." Worse - the two OR locker rooms; one's marked "Doctor's" and the other is marked "Women's."

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Why do all the surgeons look like drill sergeants?

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Brennon is old enough to realize that life is draining away. In fact, he seems older than all of us. His body is slowly giving up; it's starting in his joints. I don't think he can walk anymore. Friends from school visit. His parents want to take him home. I try to imagine the storm that is raging in his mind.

Childhood leukemia cure rates approach 85% these days. Brennon is in the 15. He's been through it all - the chemo, the radiation, the transplant. And now he's just Brennon. Terminal care, Do Not Resuscitate. Which means I don't have to poke him, or wake him up to ask how he's feeling. It means it no longer has to be doctor-patient (did it ever have to be?). And so we have a symbiosis. I make his day with daily comic book drops and he makes me feel consequential.

Confronting the death of one child, I force myself to think of the millions more. Appendix 6a.

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There are little black ants all over my dorm room carpet. When I concentrate I can see them everywhere. And see the struggling one I just stepped on. So when I step I pretend they're not there. I am above them and as long as I don't think, I don't care.

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I used to be a different person every year. I used to grow, not shrink.

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The frosted metal of the elevator door reflects back only the headless, faceless blur of a white coat.

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Fall and surgery are coming; it's going to get cold soon. I go back to Boston for the weekend. Fogged, sleep-deprived, I don't even feel part of the world anymore. People bustle around me. "In solitude the lonely man is eaten up by himself, among crowds by the many" - Nietzsche.

The leaves are changing; the breeze sounds different. The hospital starts to seem safer. I have a regimen, a schedule. Life outside is complicated - too many questions, people freezing in the parks. In the hospital I'm insulated.

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My life is not my own. I miss doing things that matter. I want to be happy because - not despite.

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I hear stories. These students dropped out after failing the boards; this one lost it and got expelled; this one just went back to his family in Shanghai. About ten percent of medical students drop out every year. Why do we stay? Why do I?

Why do you stay in prison
When the door is so wide open? - Rumi

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The swollen river around the hospital knows how fast it needs to go, while I rush and rush and rush and rush. How long will it take to regain the slowing of my life?

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Today I looked at my watch and had three hours to myself! I am on the toilet setting sapphires in earrings for our eight month anniversary. Time, it seems, is of the essence.

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The high point of my week should not be feeling wind in my face. Do I want a tree to feel that good? Last night I sneaked from call to a toy store to buy Brennon a suction dart gun and was transfixed by the waving of weeds in the parking lot breeze. It shouldn't take something like this to notice something like that.

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The first two words a doctor used to describe a new patient today, before age, gender, "chief complaint," - certainly before name - were "no insurance."

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I feel like an anthropologist in a strange world; a fake jotting down notes.

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The wall above the desk that I'm never at is covered with cards and pictures from friends. One contains a quote from Edna St. Vincent Millay. "You are loved. If so, what else matters?"

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A supermarket stop between clinic and hospital to fill Brennon's food coloring request. I flew up and down the aisle in full regalia, slinkys dragging. I bent to give stickers of rabbits holding flowers to a little girl. It's the first time I've seen smiles on a checkout line.

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Today I watched a baby get strapped down to a Circumstraint. And get brutalized. Not awake enough to be angry, I'm just disgusted.

Circumcision is one of the most controversial subjects in pediatrics. Appendix 7.

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I wish I were in a forest. I want to walk barefoot on the moss; I want to feel human all the time.

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From A Woman in Residence: "It's when you know there is no relief that coping becomes possible. Maybe that's the secret of how I survive."[23] If I do survive this year it will be because I asked every patient if they were thirsty and because I got them a drink.

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Just a year, I hear. How many do you think I have left? We only have so many breaths. "Enjoy yourself. It is later than you think" - Bernie Siegel.

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I tell friends and family to stay healthy. I've seen the next generation of doctors and it ain't pretty.

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When I got back from the comic book store today for Brennon, a classmate asked, "Did he give you money?"


A few classmates are doing their Ob/Gyn rotations in Maine. They think it's OK to practice pelvic exams on anesthetized women. After all, it's a teaching hospital. "When you're on Medicaid," one classmate tells me over lunch, "of course you're going to have less rights." I wonder if they started out this way.

Personality changes in medical students - Appendix 8.

My fellow classmates recoil in fear to uncapped needles, but scoff at the cleaning person who complained that we left an uncapped razor in our bathroom. I hear the excitement and enthusiasm with which my classmates describe the saddest horror; no death is "neat." Their self-esteem and life's meaning is tangled up in procedures, trivia oneupsmanship and approval from "superiors."

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I smile as I remember something I made in kindergarten. I had gotten out my crayons and made a book called Dumb Doctors. The first page, if I recall, is me sitting on a doctor's table being told that the blood draw would feel no worse than a mosquito bite. The next page had me strapped into a chair with a gargantuan blood-sucker and the caption, "Yeah, maybe a 12 foot mosquito!" Remember, Mom?

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I whimsically wonder to this day whether my love for spicy food can be traced back to my second grade teacher's cayenne peppering of my tongue for talking too much. I can still remember the knot in the wood of the door in the principal's office I stared at while he beat me with a ping-pong paddle.

Pediatricians and family physicians continue to condone corporal punishment. Appendix 9.

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Everyone around me has a story, something I could learn. I don't care, though, I'm so tired I'm nauseous.

Then I met an angel in the hall named Tracy, an RN turned traveler. I don't have time for the trial superficial niceties period of new friendships; I'm in survival mode. I pour out my heart to everyone and see which ones don't run away from real feelings. She said I was a beautiful human being. I said, "I try." She said, "That's why."

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Missy had leukemia - now in remission thanks in part to yellow bags of methotrexate that follow her as she rolls around the floor. When I fall to my knees she runs to hug me. I sit on the floor and we play you-look-in-my-ear-I-look-in-yours. She drew a smiley face on my hippo and named the stethoscope beanie rooster "Elvis." She paints me pictures and signs them "FROM MISSY." I paint her nails and she paints mine - a lovely purple-brown. I wore them to rounds this morning.

My senior resident took me aside. "Your fingernails are getting in people's way," he said. Huh? "The attendings are complaining; this is a conservative profession." Defensively, I tried to explain that I didn't paint them myself, mad that I even felt the need to explain at all. He knew. He knew that she had done it. He replied, "Medicine is also an anti-emotion profession."

She gets to do my toenails tonight.

There is a "general disdain for normal emotion in many residency programs."[24] Appendix 10a.

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The next day, head down, I went to Missy's room. "I'm sorry; the doctors made me take it off." I held up my hands to show her. She inspected my hands and with great indignation said, "If you can't wear it then I'm not going to either!" And she made me acetone hers away too. Solidarity from an 11 year old.

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Medical school is such a regression from the freedom of undergrad. It's like back to high school - junior high even. "Medical school faculties," writes the director of medical education of the American Psychiatric Association, "tend to regard students as people who are out to beat the system, so they set up a regressive, elementary-school format."[25]

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I want a residency where you can stick your tongue out at the attending.

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Even the language is starting to get to me. The patient "denies" this or "complains of" that. Studies show that physicians treat patients' stories as, "subjective accounts with only tenuous links to reality." While "Physicians 'note,' 'observe,' or 'find'; patients 'state,' 'report,' 'claim' 'complain of,' 'admit,' or 'deny.'"[26] Robin Lakoff: "Language uses us as much as we use language."

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Life changes from disappointment, upon hearing I have no phone messages, to relief.

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Sir William Osler, professor of Medicine at McGill, Johns Hopkins, and Oxford Universities.[27] True, a eugenics advocate and true, he advised that all persons over sixty should be, "painlessly and unfussily exterminated,"[28] but there is a warming story of him attending to a dying child in the influenza epidemic of 1919, the last year of his life:

He visits our little Janet twice every day and these visits she looked forward to with a pathetic eagerness and joy. There would be a little tap, low down on the door which would be pushed open and a crouching figure playing goblin would come in, and in a high pitched voice would ask if the fairy godmother was at home and could he have a bit of tea. Instantly, the sick-room was turned into a fairyland, and in fairy language he would talk about the flowers, the birds, and the dolls, who sat at the foot of the bed who were always greeted with, 'Well, all ye loves.' In the course of this he would manage to find out all he wanted to know about the little patient...

The most exquisite moment came one cold, raw, November morning when the end was near, and he mysteriously brought out from his inside pocket a beautiful rose carefully wrapped in paper, and told how the rose had called out to him as he passed by, that he wished to go along with him to see his little lassie. That evening we all had a fairy tea party, a tiny table by the bed, Sir William talking to the rose, his 'little lassie,' and her mother in the most exquisite way; and presently he slipped out of the room just as mysteriously as he had entered it, all crouched down on his heels; and the little girl understood that neither fairies nor people could always have the color of a red rose in their cheeks, or stay as long as they wanted in one place. The little girl understood and was not unhappy.[29]

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I went home last weekend. The bus stopped in Portland and I got off to smell a little tree on the side of the road. My hand still smelled like latex. I crushed a cedar needle and have kept it in my white coat for whenever I need it.

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I am not home until I've smelled Susan's neck.

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In the book To Do No Harm, a doctor describes how, as a medical student, "The shock of realizing just how low I was on the rungs of the medical ladder (best described as a hole several feet below ground) hit me hard."[30] My own back hurts from this submissive gorilla-type bowing that I find myself doing. No more. La Bruyere: "A slave has but one master; an ambitious man has as many masters as there are people who may be useful in bettering his position."

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The chairman of the department had a talk with me. It seems a number of attendings are concerned. I am "Too enthusiastic." "Too dramatic." "Too sensitive." I think of Patch.

I was told by a fourth year student last year that I would do great in third year because I was so enthusiastic, but he misunderstands. It's not enthusiasm for life that they value (in fact quite the opposite), it's enthusiasm for them.

It's all in how you wear the slinky. Susan thinks they've just got slinky-envy.

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Missy is back for her last round of chemo. SOAP*. Assessment: 11yo girl finishing maintenance chemotherapy. Plan: Disney World.

* A SOAP note is a daily progress note broken up into four sections - Subjective, Objective, Assessment, and Plan.

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I made a pact with myself. Throughout third year I was going to wear a QUESTION AUTHORITY button on my coat. And I have.

I will be telling this with a sigh
Somewhere ages and ages hence
Two roads diverged in a wood, and I -
I took the one less traveled
And that has made all the difference.
- Robert Frost.

The new residents rotate onto the pediatrics floor. And the senior has a button too! People speaking their mind, wearing their hearts on their sleeves. And right on her lapel! I squinted. NO WHINING.

Four-pointed star

This Autumn morning - home - I pace the apartment. Windows open, cold feet on cold tile, lovely purple-brown toenails and a smile, because I'm still me.



[7] Fugh-Berman, A. "Med School Blues: Year Three." Off Our Backs 17(1987):15.

[8] Shapiro, M. Getting Doctored Santa Cruz, CA: New Society Publishers, 1987:98.

[9] Jones, TR. "Speak No Evil: Physician Silence in the Face of Professional Impropriety." Journal of the American Medical Association 276(1996):753-754.

[10] Ibid.

[11] Webster's Ninth New Collegiate Dictionary. Springfield, MA: Merriam-Webster Inc, 1990:248.

[12] Stitham S. "A Piece of My Mind. Educational Malpractice." Journal of the American Medical Association 266(1991):905-906.

[13] Fugh-Berman, A. "Med School Blues: Year Three." Off Our Backs 17(1987):15.

[14] Ricks, AE. "Passing Through Third Year." New Physician 31(1982):16-19.

[15] Myers, MF. "Abuse of Residents." Canadian Medical Association Journal 154(1996):1705-1708.

[16] Williams, CT and N Fost. "Ethical Considerations Surrounding First Time Procedures." Kennedy Institute of Ethics Journal 2(1992):217-231.

[17] Silverman, DR. "Narrowing the Gap between the Rhetoric and the Reality of Medical Ethics." Academic Medicine 71(1996):227-235.

[18] Ballantyne, J. Bedside Manners An Anthology of Medical Wit & Wisdom Upland: DIANE Publishing Company, 1998:240/

[19] Swica, Y. "Teaching Medical Ethics at Tufts." Tufts Medicine 1998(Spring):40.

[20] Harrison, M. A Woman in Residence New York: Random House, 1982:2.

[21] U.S. News and World Report 30 March 1998:59.

[22] Spock, B. "Why Education Must Not Neglect Emotions." Redbook 1980(October):62, 67-71.

[23] Harrison, M. A Woman in Residence New York: Random House, 1982:2.

[24] Myers, MF. "Abuse of Residents." Canadian Medical Association Journal 154(1996):1705-1708.

[25] Coste, C. "Stress:The Dark Side Of Training." New Physician:38-39.

[26] Conrad, P and R Kern. The Sociology of Health and Illness New York: St. Martin's Press, 1990:325.

[27] Southern Medical Journal 84(1991):620.

[28] Gordon, R. Alarming History of Medicine New York: Saint Martin's Press, Incorporated, 1997:220.

[29] "The Lost Art of Medicine." Adbusters 1995(Summer):19.

[30] Reilly, PR. To Do No Harm: A Journey Through Medical School Westport: Greenwood Publishing Group, Incorporated, 1987:105.


Reader's Comments

I'm a veterinarian. Thank god it's not like this for us.

-- Stephannie Tallent, October 9, 2000
I'm also a veterinarian, and I'm also glad it isn't that way for us. In my profession it is routine, expected even, to hug and kiss our patients, to delight in their shining eyes and wagging tails, or to offer a special "yummy" as a reward for being "such a good patient." I hate to hear what the folks on the human side are put through, but it sure explains a lot about why so many doctors are the way they are.

-- Hillary Israeli, September 18, 2002
Hey, it sounds like you had a really rough go of the clinical years in medical school. I'm glad I'm reading this right now - as I try to choose where I want to live for a year or two before I go on to med school. I have basically lived on the pediatrics ward at a teaching facility for the past couple months and I would have to say that you could ALMOST stick your tongue out at last month's attendings!!!! We'll see :).

-- Ashley Crimmins, March 10, 2003
A heart-wrenching and sobering account, and so very different from my own third-year experience in pediatrics, where the attending brought Play-Doh to rounds, and I was praised for spending time getting to know my patients. For me, it's been a humanizing experience, as I've had the chance to work with some enthusiastic and wonderful people.
But I've seen the other side too, and had days where I feel like that. We're evaluated on our ability to communicate with patients and our compassion now.
Maybe, slowly, medicine is changing.

-- Nicole Boersma, March 28, 2004
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