ahh

sorry its been so long since I’ve last written anything. Last semester ended with my head buried in biochemistry, christmas apparently came, and now I’m back to the grind in physiology. Life has been challenging (insanely hard), intellectually stimulating (absolutely confusing), and nothing less than beautiful in its complexity, all while being constantly being outrun by time.
I have some updates on my life, but, more importantly, some things to think about.
More to come…

Transition

I found myself looking in the mirror last tuesday.  I thought I looked different, but didn’t feel so.  To tell you the truth, I didn’t feel anything, I just chuckled at myself.  I’m not sure why that was the reaction.  Maybe it felt natural, but why should it have?  Maybe I’m just not one for entitlement.  Whatever the case, I was staring at myself, in my white coat, stethescope around my neck, collared shirt and sweater underneath.  On a most elemental level, thats not me. But it was. It is.

I know it is because the Friday before, Nov. 16, I found myself sitting on the board of the Temple University Hospital Ethics Committee with our guest, Dr. Rita Charon of the Columbia University School of Physicians and Surgeons, an M.D., Ph.D who was also scheduled to give the Keynote speech later that evening at our White Coat Ceremony.  Who do they see that allows me to even be sitting amongst such accomplished academics?  I felt like a forgery or authority.

Nonetheless, I got to listen to the creator of Narrative Medicine, an entire field devoted to the narration of the physician’s experience;  whether on a basic relfective level, the level of a factual account, one of inquisition, or even to the point of phenomenological examination.  I can imagine it sounds cheesy compared to the precision and complexity requisite to the tradition of the medical sciences.  How cheesy, adding the humanities and art into medicine.  All those useless humanities courses taken in college just “to get them out of the way.”  How absurd, humanism in medicine…

The College of Physicians and Surgeons sends their students to the Metropolitan Museum of Art on assignment.  I know my father would be furious if I was a student Columbia Med spending my time meandering the exhibit halls of the Met.  What for?  Purpose.  Why.  Purpose, setting the structure for all that we do, leaving no space to just do (though this is an entire other digression that I will not delve into at this moment).  Our job as physicians is to be observant; we are trained to see and absorb as much information at a visual level (in addition to others) as possible.  Go look at a Picasso.  What do you see?  What can you abstract from abstract art?  What is there?  Art in Medicine, training the eye to pierce the surface, to navigate what is present, and, more importantly, what is not.

In my previous entry I spoke about exceeding in life on a structure not traditional to “success”.  Exceeding through creation.  Dr. Charon carved out an entire new field of Medicine herself.  Awards and Ribbons eventually go to waste in storage boxes.  She created something.  She made medicine a part of her life, the other part a Ph.D in English, and found a space where the two fused and precipitated a field that more and more students and physicians alike are yearning for.  I have a passion (if you cannot tell by now) not for balance, but for harmony, between philosophical inquiry and medical science, which for so long have been mutually exclusive entities.  A heart and lung tansplant surgeon was at the meeting, and he expressed the same yearning.  Here is a man trained to the highest degree, a master of his craft, who finds himself no longer interested in the dynamics of procedure, but in the non-physical interior of the patient.  What has he truly done to help his patients?  He may have fixed some machinery, but telling by his tired, deep-set eyes, he may have come to a reality that most of his efforts are in vain if he cannot read what is hidden in the deepest corners of patient’s persona.  A void science cannot fill. How scary.

I found Dr. Charon after the ceremony and thanked her, still feeling funny in my starched coat.  She put her hands on the lapels of my jacket, here eyes piercing mine, looking into me as if she knew me all my life.  She fixed the collar and said, “Look at you, you’re there.”  I’ll never forget that moment. It was a verification, a confirmation of my place in the field.  The ceremony itself had no real effect on me, but at that moment, her words elicited a reaction so visceral I can still relive it today with the utmost clairvoyance.  A pure mental marker in my life.  Absent from then until forever, but ever so present in my everyday.

In the Midst of Life

I wrote in an earlier post about the preservation of consciousness while living the everyday, which, I believe, requires a limitation of participation so that we may “smell the roses”, so to speak.  So that we may have that moment of clarity, full awareness of time and place in that very moment; a mental landmark in the day.  Inevitably, taking such a momentary hiatus requires we “step back” from reality, disengage, and perhaps, become invisible for a moment.  I believe that I’ve rediscovered this conundrum in a different form; one that questions freedom in the face of invisibility.

I’ve been in medical school for almost 4 months now, or perhaps more descriptively, for a lifetime’s worth of experience and headache.  The density of the overall events in my everyday are staggering, and by the mere nature of this whole process, are beginning to swallow my presence in the normal everyday social structure I used to take part of.  I feel like I’m disappearing.  I feel free.

So how free are we to do what we want?  I’m taking this from a moral standpoint, the very fabric that tethers our human relationships.  When submersed in the everyday social structure, that of friends and family, our options and actions are restricted by our obligations to those around us.  Sure, we say we are free to do anything, but is freedom in the off-handed option to say so, or is it in exercising that option?  I find that my life is taking a turn that will sever many of the already anemic interpersonal relationships I have now, perhaps labeling me as selfish, but its a path I want to take.  I find that there are those people who die before they’re forty, capping their human potential in exchange for mere financial survival, those who have perfected mere survival in a life of luxury, though still mostly dead in the water when it comes to any sort of substantial existence, and then there are those who live on the periphery of the normal social constucts.  There are those who live their lives by exploiting every opportunty given to them, regardless of how society regards the activity, and excel on an entire different construct.

Maybe that is what we all strive to be, yet, held back by the “reality” of our lives.  Maybe I am selfish in wanting to take this path.  But, when educated everyday on what compromises the integrity of biological life, it seems completely absurd not to go forth and do so.  Heidegger once said death is “one’s most own”, which lead to a philosophy professor of mine to tell me “once we are born, we are old enough to die.”  How absurd. How true.  Like I said earlier, I feel free.  Though, I feel more lost than ever.  There is such a salient mental weight I find myself carrying around everyday; something to the effect of “this is not enough”. 

I know this entry seems rather disjointed, and perhaps vague, but thats the idea.  I still can’t put my finger on it either.  Like a thread with too many ends, I can’t find the one that tethers the entire thing together.

Hitting the brakes

I sawed a human head in half today.  First, my lab group and I disarticulated the head (i.e. popped the skull off the vertebral column), then proceeded to take a saw to the midsaggital plane of the face.  I don’t know if there will ever be a time ever again where I will question, due to such a frontal assault on my reality, the constitution of a “human” who is no longer living.  There is nothing like watching bone dust settle into the cranial cavity or feeling it wander into your nostrils that makes you think of a cadaver as anything but human.

This discussion has been floating about in our class; though it is not so much centered on whether or not the cadaver is human is in fact human, but is our natural objectification of the cadaver indicative of our future encounters with patients?  That is, is the numbing process really taking place, and if so, how quickly.

I’m not interested in that.  Its a bit self-centered, something to be conscious of, but nevertheless somewhat inevitably going to happen to some degree.  Perhaps its the distance, the lack of personality, that is the key to keep going.  Overt emotional investments seem to be anchors that prevent a doctor from being a doctor.

I’m really after the first part, the label that is automatically applied to the cadaver; that s/he is in fact human.  Is the cadaver human?  Isn’t the word cadaver an immediate, perhaps subconscious, predisposition towards objectification?  Its one we seem to overlook.

We can take the classic philosopical definitions of a “human” and apply it here.  For the Aristotelians, the human is a “rational animal” always in pursuit of actualizing his/her potential.  Rationality seems to be the key here, where the cadaver is incapable of anything of the like.  In addition, Aristotle talks of “human becomings”, as we are never fully actualized as humans, always attempting to harmonize the intellectual, moral, and passionate faculties natural to the human life, trying to find the medium that allows a certain ascent towards Eudemonia.  This is in contrast to say a rock, a thing, which is always and completely itself, that is, fully actualized.  A cadaver is, and for now, can and only will be a cadaver, no longer given the space for conscious fluctuation.  Not human.

One could also argue for the utilitarians on the point, as such a sacrafice benefits a greater good in knowledge, and by extension, the impact of the student in their subsequent careers.  We may put the deontologists at ease, since Kant is one to stand that consciousness, and the a priori reasoning we are capable of, is the criteria by which we are human.  The cadaver, therefore, is not.

How harsh does this sound?  The other option is to act as many med students do; the cadaver is human, respect him/her, then paradoxically slip into objectification without even knowing it.  We speak to each other during anatomy using possessive pronouns when referring to the cadaver: “Come look at my brachial plexus if you want to see the musculocutaneous nerve.” 

From such a standpoint, we as students are less human than the cadaver, as we are doing the most inhumane things to it/him/her.  We removed a leg, bilaterally split the penis (thus causing referred pain, I might add), and today, split the head like a melon. 

Maybe, I think that if we are to understand the cadaver from the onset as non-human, then the moral dilemma (or at least the immediate internal hesitation), followed by the subsequent guilt, or lack thereof (since such a lack is such a frequent occurrence) may not be such a problem (though I think it should be, but that I will reserve for a whole other diatribe).  Its a blunt, intellectual bridge over the problem, as the previously stated “lack” only exists as one in the constructs of an initial human understanding of the cadaver. 

Is there anything to this?

Medschool: Week 3

I haven’t had internet in my apartment since I moved in a month ago, mostly because this illustrious internet company has managed to drop the ball in ways I can’t even begin to explain.  (The company’s name rhymes with “verizon”)… So, I’ve reverted to stealing ambient wireless signals in my apartment.

Anyhow, quick update; Started medical school proper on August 11th, walked into anatomy lab with sharp objects, and they essentially told us to just “have at it”.  In the course of 13 days of lab we’ve completed, in ridiculous detail, the vertebral column, spine, posterior triangle of the neck, back, upper limb, arm, forearm, hand, hip, thigh, leg, foot, thorax, and heart with all the accompanying neurovascular relations and common clinical occurrences respective to each of the said areas. Oh… and they threw embryology on top for good measure.  First test is Friday, August 29th.  Thats the day after tomorrow.  So what did I do after school today? I napped.

Here’s for something a bit more interesting.  Last Tuesday I met with my first patient at Temple University Hospital.  The day before, we had a lecture on Narrative Medicine in our “Doctoring” course, which took me by surprise seeing as they took a liberal arts approach to a clinical course.  After our first patient experience we had to reflect and write…

Waiting on the elevator to the 7^th floor, I started to think about this actual assignment. For my “Doctoring” course I’m supposed to go into a patient’s room and get to know him or her in a way that, I’m guessing, medical professionals don’t usually get to know him/her. We are doctors-in-training who are supposed to go in and not act like the stereotypical doctor. We are to ask for the details of no clinical relevance, to have a conversation outside of the abrasive medical truths that appropriate one as a “patient”, and perhaps, to get a bit personal. Maybe the initial, somewhat intrusive nature of a stranger at the foot of your bed is of the common clinical practice, but I appreciate the fact that this may be one of the final remnants of a relationship with a pure stranger that is not mediated by a patient chart.

And so I start sweating. I’m at the bottom of the medical totem pole, if it even goes down that far, in limbo between non-doctor and doctor. Not identified with the former, and lacking the professional air of the latter. I have no white coat, like I’m going to war without Kevlar, identifiable only by my TUID which I wear like a hospital ID forgery. Any anchor I have to credibility walked right out the door the moment she dropped us off in Mr. H.’s room. No, this isn’t awkward.

Mr. H. must have seen this. Even with acute pneumonia, he lay there, his right hand cupped behind his head, legs crossed, talking with his left hand. Smiling. Of course one of us rattled off, “How are you feeling today?” like an age old bad habit. Like when your nerves do all the talking on your very first date. He smiled again.

Retired now, Mr. H. lived right off Erie for most of his life. He lives alone, and worked at a furniture store moving and shipping pieces he’ll probably never be able to afford himself. I apologize. I’m not doing him justice. “An expensive furniture store, a big company.” At first shot it sounds trivial, however, his eyes lit up a bit, chest expanded, and chin raised when he said it. Even at one of his most vulnerable moments, when three medical students are doing some directed probing, lost in their own thoughts, Mr. H. was proud to share what he had done with his life. To explain what he did. To just talk.

For the next 10 minutes none of us could get a word in edge-wise. I quickly realized I needed to get out of my own head and just listen. Shut up, and listen. His left hand, scorched by life of manual labor, each crack and tributary a different story, waved in concert with his words.

…

As he rounded out his story I asked him, “What would you advise us to do?”. Words always sound clumsy when speaking and swallowing at the same time. He told me that every time he’d been to the hospital he’s had good doctors that put him “back together”. He said, “You need to keep doin’ what you’re doin’, and keep goin, ‘cuz you need to put people like me back together so we can go on and live our lives.” A simple maxim it was, almost understated, and easily lost in the blue-streaked confusion of anatomy lab. It’s something that no one will tell you explicitly, nevermind as personally, in a pure academic setting. Nor should it be. Simplicity as such should only be colloquial, never to be stripped of its tone, its meaning, and set into a powerpoint.

Again, another smile.

Orientation

Its happened. I am really going through with this. I am writing this at the end of the second day of orientation, because frankly, yesterday happened without me. It just was. And I was there, but the entire thing seemed like a dream state; faculty and students engaging one another through intense gaze, sprinkled with colloquial niceties. The first dissection you do in medical school is of the students in your class. I never thought I would admit to this, but if you’re a medical student, you are narcissistic to some degree.

Its interesting to watch, and even more interesting to feel yourself secretly scowl at the people around you. That is, until you realize what you may resent in some of your fellow classmates (even before meeting them, I am sad to say) are the faculties within yourself that you once held dear. They are the very things that once made each and every one of us unique at our respective alma maters, from Princeton and Penn to Moarvian and Scranton. I’ve never seen such a quick dissolution of individuality in my life. Yes, each of us as students are individuals in our own respect, but as to the magnitude of what got us in the door of Temple, they completely cancel each other out.

I suppose I should find some solace in that fact. I now have the ability to remold myself, and for one thing, after talking to my fellow classmates, I’ve found that each have the drive to do so as well. But it is no longer to some further end (other than residency, but the numbers seem to govern that, not so much the complexities of human experience), but for the sake of a self-refinement. I’ve found that the second dissection one does in medical school is of the self; an almost panic-induced self-inventory. At least I hope everyone does this… it should be a momentary humbling experience, one that opens you up to the ability to respect the achievements and stories of those who will be sharing the next four years with you. For those who do not experience this, I suggest sitting down to allow yourself to be grounded.

Dr. Lyons, a prolific and extremely well spoken professor at Temple (who also interviewed me for medical school), shared a couple of thoughts with our class that first morning. I remember two of them very well. The first being the difference between “not knowing” and “ignorance”. Not knowing is not a conscious shutting out of information and experience, but more of an innocent lack, whereas ignorance remains double blinded. In one respect it does not know, but as a compounding factor, it does not care that it does not know when made aware due to some determination of necessity. I guess thats what I mean by the dissection of the self; to be successful in this field, one needs not only to become aware the s/he does not know, but must be comfortable with that fact. However, that comfort should be paired with an almost animalistic vigor to find out. This allows for one to open to the entirety of life experience. This is excellence.

The second thought. “Perfection is the enemy of excellence”. Dr. Lyons started with “life is demanding enough”, not as a prescription for getting what you need and want out of it, but that life demands enough from you without having to compound it with the stress of “knowing absolutely everything.” In this day of medical science it is impossible, and furthermore, a completely transparent and empty goal to be attained. Let the mindlessness of computer storage “know it all”. Which lead to his conclusion; don’t have a life in medicine, “have a life with medicine”.

Relief. Maybe this field is the right thing for me. Or, maybe against all probability, I managed to get the quack doctor buried in a University mislabeled for excellence in healthcare for the the underserved, and this is all a load of bullshit. Not likely. For anyone who has read the entry before this one (before I even stepped foot into the school), I wrote under Only the Weak, “I have no intention of being a doctor, its what I hope to do. I am still working on being human.” I am lucky to have found a school that understands the distinction between a life in and a life with medicine, between who I am, and what I hope to do. These two ideals are not at odds, nor are they mutually exclusive, but complimentary. I hope that one day they will still be identifiable as separate entities, yet intertwined to a complexity that rivals that of the human mind. It seems oxymoronic, but if you get the first distinction, maybe someday we’ll both discover what it means to live the second.