Colchicine

Colchicine is an old drug. Extracted from meadow saffron, it was described in De Materia Medica by Pedanius Dioscorides, published in the year 1. I mean, 1 CE (or AD, depending on the nomenclature). I first learned of this drug in biology as it binds tubulin and serves as a classic test question on microtubules and other proteins. But from a medical standpoint, it's not a pleasant drug. Occasionally used for gout (and the very rare familial Mediterranean fever), it causes pretty severe diarrhea. The doses at which it's useful are pretty much the doses at which it's toxic; I once heard, almost jokingly, that you titrate the dose of the drug up until the patient complains about the diarrhea more than the gout (an unpleasant image I know, but what can I say - you're reading a medical blog).

In any case, the story of colchicine is quite interesting. It's been around for centuries and that's why it was dirt cheap at 9 cents a pill. We have known for decades that it is efficacious for treating flares of gout. Colchicine has been used for so long that it existed before the Food and Drug Administration was around. Recently though, the FDA determined that even medications that existed before the FDA should be FDA-approved. Thus, one company came up with a lucrative and ridiculous idea. They ran a clinical study to show something we already know - that colchicine is useful for gout - and then applied for exclusive marketing rights for their version of the drug (which is the same active ingredient as all the generic versions). The FDA decided to approve that company for the exclusive production of colchicine, and as a result, they immediately raised the cost from $0.09/pill by markup of 54 times to $4.85/pill. Furthermore, they sued to get the generics off the market, even though we've been using the generics for decades without problems. How absurd is that? The cost for state Medicaid programs is estimated to increase from $1 million to $50 million without any discernible increase in the quality of health care delivered. This is why our country is in trouble.

Image of colchicine biosynthesis is from Wikipedia, shown under Creative Commons Attribution Share-Alike License.

A Day in the ICU II

Throughout the day, code blues and "e-teams" are called. Code blues, as popularized in the media, signify a medical emergency, usually from someone who has stopped breathing or who has lost their pulse. "E-teams" or rapid response teams are called when a patient seems to be doing a lot worse and requires more help. Although we expect each code to be a life-or-death situation, the truth is, they vary a lot in acuity. No one can ever be faulted for calling for more help, though. As the intern, I grab the transport box - a portable monitor with EKG leads, oxygen saturation, and a blood pressure cuff - as well as the medication suitcase and run to the scene. Our job as interns is to do chest compressions if indicated. It's a little scary and definitely gets the adrenaline going.

Otherwise, the afternoon is set aside for "work" until afternoon rounds where again, the giant team reassembles to discuss all the patients. Instead of formal presentations, afternoon rounds is focused on any events or new information acquired during the day and the problems the call team should focus on overnight. Then the giant team disperses, leaving only the on call intern, resident, and fellow to man the fort.

Evenings tend to be busy on call. With a full house of 14 patients, we can be kept occupied the entire night, especially if anyone is unstable. Sometimes a few more patients come in, either late surgeries, e-teams or codes, or emergency department admits. If there's a medical student around, I'll take time to do some teaching; otherwise, I'm triaging and prioritizing to-dos for all the patients and making sure they make it through the night. If we're lucky, we take a break for dinner; the VA sends us patient food which is not very appetizing - but it means we don't dawdle at dinner.

Evening rounds (yes, the day is pretty much made up of rounding) occurs with the fellow. We usually bring a computer around and go over any pertinent issues and goals overnight. While at first, I balked at the amount of rounding that happened every day, I realized that it's necessary for the ICU. Patients and their disease states change so quickly and dramatically that we have to keep everyone on the same page. After evening rounds, the fellow usually takes home call, and the resident and intern try to wrap things up before going to sleep.

I usually hang out in the unit until early morning. I get notes done, then do some reading and studying, and make myself available as nurses have questions and concerns. If I'm exhausted and think the unit is stable enough for me to get an hour of sleep, I go around from bed to bed asking if the nurses need anything. I bring a portable computer to my call room so I can have labs and vital signs immediately from bed. The sleep is hardly refreshing but its much desired and so if I'm lucky enough to get some, I'm entirely grateful for it.

A Day in the ICU I

Usually I get to the ICU at 6:45. I get sign out from the interns and residents who were on the night before and quickly run the list of patients, especially if I'm on call and have to know who's really sick, who could potentially leave the ICU, etc. I go see my assigned patients and make a plan for the day. As I think about the changes in management for each patient, I remember one of my ICU attendings at UCSF who decided that every patient should have one (and only one) "big move" for the day. Were we trying to take the breathing tube out? Should we broaden antibiotics? Can we put in a central line and start vasopressors? Of course, some patients require more aggressive management and some could easily handle multiple changes in their plan, but I took this to heart. ICU patients are complicated, and changing too many variables can muddy the picture and lead to unanticipated consequences. So for each of my patients, I come up with my "big move" for the day.

We round at 8. The ICU is filled with portable computers on wheels and most of us take one as we go from bedside to bedside. The computers allow us to pull up X-rays and put in orders for each patient in real time. At first, I didn't like the computers as it felt a little impersonal, everyone's faces aglow behind the screens, but now I realize how much more efficient that is. As a large team of 6 (weekend) to 14 people, we discuss each patient in depth and formulate the plan for the day. We get the post-call intern and resident out as soon as possible. Some attendings set aside time to do dedicated teaching.

I alluded to this on a previous post, but patients are really diverse. Most medical patients are admitted because of cardiopulmonary instability; they are failing to breathe and require a ventilator or they are actively bleeding and have poor blood pressure or they have a widespread infection with hemodynamic collapse. Sometimes, we have neurology patients with strokes requiring close monitoring. Our post-operative cardiac patients are often on lots of drips (IV medications that deliver an infusion over time), our post-operative ENT cases have tenuous airways that may close off with swelling, our post-operative general surgery cases are often liver resections with large fluid shifts and blood loss. The range of cases is really fun and really educational.

Morning rounds usually lasts 2-2 1/2 hours, depending on the acuity of the patients. Then we get as much "work" done as possible; we call our consultants, we put in orders, we adjust lines, we intubate and extubate people, we write our notes. Then we have a daily lecture on a core ICU topic such as pain management, end-of-life issues, ventilator settings, pulmonary artery catheters, or post-op cardiac surgery. Although the unit is excruciatingly busy, it is wonderful that we have time set aside for learning. The fellows and attendings usually cover issues during our lecture.

The Passing

An unfortunate accident, and a man loses nearly all his brain function with no meaningful chance of recovery. Artificially supported, the room hums with the sigh of the ventilator and the beeping of alarms. The blinds are shut and blankets are pulled up high. We talk in hushed voices and bow our heads. Finally, the family decides that it is time to withdraw care. I am on call the day he passes, and the medical student and I enter the room. I take my time, and listen to the family, listen to their heartbeat, listen to their breaths. I look at the patient; I want them to know it is okay to look at someone who has died. I offer tissues. I speak clearly, and genuinely, for this man has affected me as a caretaker. I am sorry for your loss, I say. I meet everyone else who has been central to this man's life. I hear their stories and squeeze their hands. Then, I must do my examination. A little sheepishly and with a preface of formality, I say his name and shake his shoulder. I apologize to the patient as I shine a bright light into his eyes. I watch for chest rise while my hand is on his wrist, still warm. Then I take my stethoscope and set it on the chest. I hold that position for a moment, close my eyes, hold my breath. Then I look up at the family and again, offer my condolences. I tell them that now is the time for them to reflect. I tell them that I have housekeeping to do, things like asking for an autopsy, contacting the donor network, notifying the coroner. But I will do these things later, because now is the time for the family to be wife, brother, son, daughter, friend. I tell them that they must take care of themselves. And then I end as I have decided I will always end when I declare a death and there is family: with a poem. I haven't found the perfect poem yet, and so I choose Yeats because that is one of the two poems I have memorized. For me, poetry is healing, art, humanity, transcendence. I do not know if the family felt the same way, but I needed some healing, art, humanity, transcendence. I indulged myself, and they thanked me for that.

HAD I the heavens’ embroidered cloths,
Enwrought with golden and silver light,
The blue and the dim and the dark cloths
Of night and light and the half light,
I would spread the cloths under your feet:
But I, being poor, have only my dreams;
I have spread my dreams under your feet;
Tread softly because you tread on my dreams.
-William Butler Yeats

The VA

To all of us in training, the Veterans' Administration has a special place in our hearts. The patient population is mostly older Caucasian men, a demographic that makes up a lot of "bread and butter medicine." At the VA, we learn not only to take care of common adult internal medicine conditions such as hypertension, hyperlipidemia, diabetes, COPD, and smoking, but also all of these diseases in conjunction. This is a good contrast to tertiary care centers like Stanford and UCSF which get referred patients with rare or complex diseases. The veterans themselves are a wonderful group of patients to work with. They understand how training works and actively contribute to our education as residents. I really appreciate their service to our country and find their stories fascinating. The VAs in San Francisco and Palo Alto in particular are beautiful and that also makes me happy.

Image of Palo Alto Veterans' Administration (where I work this month) shown under GNU Free Documentation License, from Wikipedia.

Quotable Quotes

Late night shenanigans from the ICU.

"Where do you get your medications?"
"From FedEx."

From the on-call ICU fellow: "If I don't pick up my cell phone, just twitter me with your pager number. I'll get it."

Open versus Closed ICUs

Intensive care units come in weird flavors. The patients admitted to a medical-surgical unit can be pretty diverse. Some are post-operative from large liver resections or bypass procedures or neurosurgery. Some are COPD exacerbations or heart failure or metastatic cancer. The diversity and breadth of cases can be overwhelming, and it's compounded by the fact that every patient is sick. The best doctor for each patient might be different. Shouldn't surgeons handle the post-operative patients? Shouldn't medicine handle the heart attacks?

ICUs have struggled with this dilemma since they were developed. In an "open" ICU, when a patient is transferred into the unit, he has two primary teams that write orders: the team that transferred him up and the ICU team. Thus, a patient who has a valve replacement can have medications prescribed by both the cardiothoracic surgeons and the intensivist. At the other end of the spectrum, a "closed" ICU means that when a patient is transferred to the unit, all the care and responsibility for that patient is transferred to the intensivist. When the patient leaves, then the care and responsibility is transferred back. In this model, if the intensivist needs help from the surgeon or cardiologist, he consults them for recommendations. The strength of this model is that there is less room for confusion or miscommunication between multiple providers.

The truth is most ICUs are some hybrid or combination of these two. Here at the Palo Alto VA, medical patients are exclusively handled by the ICU (thus a "closed model"); we write the admission orders, decide the plan, and have the clinical responsibility for the patient. Surgical patients are "comanaged"; both the surgical and the intensivist teams write orders, and ideally, we communicate so that we do this in sync.

Unfortunately, this doesn't always happen. We don't round in conjunction with the surgeons and the plan they decide occasionally conflicts with the plan we decide. Sometimes when patients are complex and haven't been fully deciphered, we run into the problem of too many cooks in the kitchen. This is not uncommon in medicine; I've had many patients in which consulting services disagree. However, it can sometimes make life in the ICU difficult.

I actually prefer the system we had in the surgical unit at San Francisco General Hospital. There, patients are comanaged as well, but the boundaries are clearly delineated; the intensivist makes the plan with regards to the ventilator, sedation, and access. For everything else, they are a consulting service. If we write an order to start aspirin, we have to be cleared by the primary surgical team to do so. This has its complications as well; the ICU team is at the bedside 24/7 and when an emergency happens, we may have to start medications that are out of our scope before we can get approval from the primary service. However, the clarity of each team's responsibilities helped define each patient's goals for the day.

In the end, I'm not sure how best to organize an ICU. Somehow, we must encompass a multidisciplinary group of specialists to care for these complex patients. But we also must designate roles, whether a single primary caregiver or a well-delineated team approach to prevent us from stepping on each other's toes.

Colors

Image of Indian pigments on sale is shown under Creative Commons Attribution 2.0 License, from Wikipedia. Although it is pretty much unrelated to anything else on this blog, I really like it as it reminds me how much color is in the world and that some days, I have too much black-and-white in my blog.

Poem: Thirty

Thirty

Thirty past, this witching hour
colors converge and voices take flight
and a dream-not-dream apple
stares me down; how red you are
the fruit whispers
and I can't tell what's real
or not, fixating
from phantasm to phantasm
the blinking cursor, the shape
of a lightbulb, the way while is spelled.

Thirty hours past, even your jokes
are hilarious, even your stories
of a slight with your husband
sends me to tears.

As if sleep were some currency
from which we build our walls
and as the face's arms tumble 'round
we delve into the treasury of time
start pawning sense for endurance.
Eyelids falter and moats run dry
as the reminders of what's proper crumble
and societal barriers dissipate.
We're left with a distance far less vast
prompting me to lament in verse
why I couldn't control the yelling
or cheering or sobbing.

Somehow, free will is entangled
with it all, and as each hour saps
more from me, I feel less myself.

Healthcare Reform

At UCSF, I heard a completely packed lecture on health care reform by Mark McClellan, MD, PhD (economics). He is really quite an accomplished person who has served as Deputy Assistant Secretary of the Treasury, member of the President's Council of Economic Advisers, senior policy director for the White House, Commissioner of the FDA, and administrator of the Centers for Medicare and Medicaid services. The room was overflowing; we had rows of attendings standing on the stairs and in the back; not a seat was empty. He discussed the motivations for, legislation of, and challenges to effective health care reform. This was really educational for me; although I've read the lay press on the new legislation, he elucidated why things were the way they were and why there are so many concerns about the financial viability of this recent bill. However, I realized the health care reform bill is only the first step in regaining control of this exponentially worsening mess. It won't staunch the financial hemorrhage as health care slowly overtakes the GDP, but it is a start. Indeed, it reminds me of the crisis with global warming; we are all trying to change our deeply ingrained habits, taking more public transportation, eating less meat, recycling, but when you look at the numbers, it's so discouraging. Nevertheless, we must try to change these things now to protect the future. Dr. McClellan talked about many things, and it was so interesting to hear a real expert on this issue.

Day One, Part II

Please see the previous post for Part I.

We admitted a patient from the emergency department, a gentleman with a severe COPD exacerbation who required emergent intubation. When he came into the ICU, the fellow asked me if I wanted to put in a central line. Central venous catheters, insertion of a "line" into the neck or groin isn't a minor procedure, but it was one I felt comfortable doing. Although I'd done central lines in the past, they were with quite a bit of assistance. Here, the fellow walked me through the steps but had me do everything independently. It worked. The adrenaline rush was surprising and thrilling.

I finally ate something at midnight. I realized I was exhausted: me feet hurt; my eyes were sore; I was thirsty and sweaty and gross. But the time had flown by so quickly. I was constantly multitasking, trying to juggle in my head things that needed to happen "stat," things I needed more help with, and things that could wait. The resident and I went around doing midnight rounds before sitting down to finish our notes. Documentation is the bane of the intern's life. I know how important and necessary it is, but at 2 in the morning, I was aching for some rest. When I was a medical student, I was appalled at how scant and bare some resident notes were; now I was writing these sparse notes.

Nothing prepares you to be an intern. I thought I understood an intern's life when I observed them as a student, but now in their shoes, I realize how fragmented, frantic, and scattered their life can be. At any point in time, I was multitasking half a dozen things; on my way to see one patient, I'd be sidelined to see another. Before I'd finish ordering a medication, I'd see a consultant I wanted to talk to. I'd type a sentence into a note before a family member would request to see a doctor. I had to be aware of and think about a dozen patients at once, and I had to be able to switch gears immediately. This is a skill I do not yet have, but I am sure it'll be one of the first things I develop as an intern.

Day One, Part I

I was on call in the ICU on my first day of internship. That terrified me. What do I even bring? I didn't know. But I showed up, learned about my patient (we started with just one, so that was reassuring) and rounded with the team, scribbling frantically on my list those things that I thought were important. That's the thing about being an intern. We're responsible for all the details, all the small things, and so I jot down any vague information that might help me overnight: their creatinine or their mental status or their wife's name. I figured that having more information is better than not, which overwhelmed me completely.

After a lecture, we started getting admissions. Luckily, I got the straightforward admissions - two thoracic surgery cases. But after afternoon rounds, I realized being on call is not easy. Suddenly, I inherited ten more patients to worry about. As my co-interns went home, they signed out their patients to me. I learned that interns never have spare time. I would sit down to work on a note, and a nurse would ask me to see a patient or the pharmacy would call about a drug or the lab would alert me to critical results. And though my instinct was to say, "I'm a medical student, let me ask the intern," now I was the intern. Most things I figured out myself, and I always had backup from my resident and fellow.

But then for a two hour span, the resident and fellow were called down to the emergency department to evaluate a potential admission. I scurried about checking on all the patients in the unit, making clinical decisions - albeit small - and recording these faithfully so I could report them. From time to time, I'd page my senior, but for the most part, I was practicing medicine. True, most of it was cookbook - repletion of potassium, administration of lasix, prescription of pain medication - but it was a really new experience. If I wanted something, it would be done. Furthermore, when patients developed new symptoms, I would go to the bedside and evaluate. I would determine whether I needed further workup or whether I could start empiric treatment. Or I would find that I was in over my head and grab my resident. But these decisions were mine to make and that was an immensely liberating and gratifying feeling.

ICU

I start out at the VA ICU. The details are fundamentally important to me, though I'm not sure how relevant they are to readers. It is a 15 bed unit with both medical and surgical patients. The ICU team is huge, made up of 4 interns, 3 residents, 2 fellows, and 2 medical students along with the attending, pharmacist, and dietician. We're the primary team for all medical patients and we comanage surgical patients. Every day we have about two planned surgical admissions from the operating room, usually cardiac, vascular, or thoracic cases. The medical admissions are pretty diverse, from neurologic catastrophes to heart attacks to COPD exacerbations. About half our patients are intubated and half are on vasopressors. Interns are on call every fourth night; residents every third.

At least I feel comfortable in this setting. Compared to San Francisco General Hospital where I did my ICU rotation as a fourth year medical student, we have fewer patients but more responsibilities. Luckily, that rotation taught me about ventilators, drips, and lines. We have lectures every day, but learning is really experiential. The patients vary in how complex and sick they are, but I have good oversight and supervision. Hopefully I'll also get a few procedures in. It'll really be a trial by fire, and as it's the first of five call months in a row, I hope I don't get worn out too quickly.

Poem: Intensive Care

The dilemma on call is whether to sleep or not. Sleep is fairly unsatisfying; I'm constantly interrupted by nurses, the bed isn't too comfortable, I worry about my patients. But what do I do if I stay up? It's too late to concentrate on reading papers. I catch up on emails. Procrastinate. Write a poem or two. Here's today's poem, written in a call-delirium. I don't know what my reaction will be when I reread it in the morning.

-
Intensive Care

I wonder what it's like to wake up in hell.
Naked, cold, wrists bound
in a regression to slavery.
Beat me hard enough with drugs
and I'll surrender the numbers you crave.
What a sight it must be
to see my chest rise and fall
and feel the ventilator
pry me open like bellows.
I can't even see;
I have no idea where my glasses are,
and I can't ask for them, or speak,
or gesture. What is it like
to wake up to an auditorium of faces,
students, nurses, pharmacists, doctors,
physical therapists, dieticians, social workers
in the blinking lights and artificial night
they try to create here.
The TV is on; it's in a different language
and all I do is stare.

I'm Really Back at Stanford

There are some things that strike me as very "Stanford." During orientation, we were invited to internal medicine's grand rounds and the speaker was Anna Deavere Smith, a professor of the drama department at Stanford for a decade before she went to NYU. Now, she's going around the country performing a play called "Let Me Down Easy." She's a recipient of the MacArthur "genius" grant, nominee for the Pulitzer Prize and two Tony awards, and winner of numerous other awards. Only Stanford would invite someone completely outside of medicine yet utterly amazing to be at medicine grand rounds (UCSF did have a narrative medicine speaker Rita Charon, but she was an MD).

It was amazing. She performed from two plays which were constructed from interviews. She took on the persona, voice, mannerisms, and words of the people she interviewed including patients, medical students, residents, and professors like Dr. Watson (of DNA fame). It was poignant, hilarious, moving, and breathtaking all at once. Although we were in Braun auditorium where I had my first class at Stanford (Chem31), it became a theater with the beauty of her performance.

I think this generation of medical students is most in tune with the patient experience of health care. We haven't become jaded or exhausted or angry; we empathize with patients, we are the recipients of a new movement to teach us to be compassionate, patient-centered advocates. But this grand rounds taught me way more than anything else. She portrayed a Texas governor's feelings about alternative medicine and cancer, a privileged practitioner's emotions at Charity hospital after Hurricane Katrina, an appalled medical student working with a rude resident, an orphanage director who took care of dying children. These performances by a master actress drew tears. I thoroughly enjoyed it and found it to be not only a reminder but a beautiful lesson in approaching patients as whole persons.

Stanford Medicine's 2010 Intern Class

Just kidding. Perhaps a Grey's Anatomy or House image might be more apt - we'll see as the year unfolds.

Image from Wikipedia, shown under Fair Use.

Poem: Cenerentola

I'm still trying to write a poem a week, but the timing of the posts is a little erratic. This is based on my second night of call in the ICU.
-
Cenerentola

Midnight rounds alone
wheeling a computer from room to room
humming.

I flip through lists of patients
check new labs
ask the nurse if she needs anything.

I find a glass slipper
in one of the rooms, next to the vent
and wonder, what magic broke
this midnight

what transformation of man--
reduced to numbers, to breaths
and drips, and what sorcery
in beeping and alarm
we conjure in our efforts
to stave midnight mercy.

This is what a doctor must feel like
a fairy godmother
who sees conjuration
and hounds to reverse it
to tame that pumpkin
and shackle the curse
which has sent order awry.

These vials, syringes of epinephrine
they are our potions,
and as I stand at the bedside
conducting a symphony of humours
draining a little of this
infusing a bit of that
lulling to sleep, a spell of a thousand years
a milk that seduces--
These are our rituals
our tomes, our handbooks
the art in finding that one spell
that, like this slipper, fits.

Orientation

Orientation week went by in a blur. There are about forty of us so I had lots of new faces and names to remember. The class as a whole seems awesome and passionate; I really like the diversity though we noticed a predominance of Stanford graduates, people from Chicago, and guys names Jason. Social events like an evening at Gordon Biersch nibbling at appetizers and a welcome dinner at the chair's house allowed us to mingle.

I really like the program directors, chief residents, and staff. They're really personable and approachable, and as my world whittles down from a high school of 2000, an undergraduate class of 1600, a medical school class of 140, I find it surprising and refreshing when the program administrators know who I am (though now I can't hide behind the guise of anonymity). During our welcome, we got our much anticipated schedules - the contents of which will unfurl in this blog as I go from rotation to rotation. It'll be a solid year, fairly intense, but I'm excited about it.

We also had an orientation by the department of graduate medical education, getting our badges, going through employee health, learning about infection control practices, getting computer codes. Much of the week consisted of computer training, and that was somewhat frustrating. There are so many systems to learn, so many nuances and details, and each hospital has its own particulars. But we did have some fun sessions such as one on putting in central lines. They got chickens and we were able to practice using ultrasound and going through the entire procedure. This came in handy as I put in a central line on my very first day.

Break

The break between medical school and residency was about a month. It was fantastic. We are "real doctors" yet have no responsibility. I stayed for a bit in San Francisco and some time at home in Southern California. During my free time, I visited a host of museums like the Museum of Modern Art, Walt Disney Museum, and California Academy of Sciences (again). I spent time exploring the city, revisiting favorite places, and hanging out with friends (doctors!). I also moved down to Menlo Park in preparation for residency. Overall, it was a time for relaxing, recharging, and mentally preparing for this ordeal that I've just started.

I really will miss San Francisco. It is a fabulous city. It took a while to grow on me with its odd streets, lack of parking, hills and valleys, but now I'm really attached. Compared to the suburbs where I grew up, San Francisco has character. Its nooks, crannies, pink houses, and hole-in-the-wall places make me smile.

Happy Independence Day, everyone.

Image of SFMOMA shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Neurology

"I once dated a girl named vertical nystagmus."
"Did she make your head spin around?"
"Nope, but there were lots of ups and downs."

What I've Been Doing After Graduation

I don't do well with unemployment. I get antsy when I'm too lazy, and I need things to keep me busy and active. After graduation, I've kept up two vaguely academic exercises. I decided to volunteer at a UCSF event where elementary school students from underserved communities came to UCSF for a day. The event was to excite them about science and encourage them to pursue college. It was very similar to the MedTeach activities I did as a first year medical student. I got to teach 50 fourth and fifth graders about the anatomy of the heart. It was really fun and reminded me how much I enjoy working with kids and teaching. Fourth and fifth grade is a great time because the students haven't become "too cool" for science and yet have some insight into the human body and a working level of attention.

I've also been auditing the elective "The Mentoring Muse," taught by David Watts, a writer and gastroenterologist who runs the weekly creative writing workshops I attend. The course focuses on medical humanism and literature, using Dr. Watts' books as a text. We talked about how to listen, engage patients, interpret their stories, use silence, and approach moral boundaries. As a writer, I think words have immense power, meaning, and heft, and that as doctors, we have to recognize the significance of what we say and do. This course really brought me back to the pre-clinical realm when being a doctor was about being a doctor, before I got muddled with all these questions, facts, and dilemmas.