Aequanimitas

William Osler's most famous essay was titled "Aequanimitas" on the importance of imperturbability.

"In the first place, in the physician or surgeon no quality takes rank with imperturbability, and I propose for a few minutes to direct your attention to this essential bodily virtue. Perhaps I may be able to give those of you, in whom it has not developed during the critical scenes of the past month, a hint or two of its importance, possibly a suggestion for its attainment. Imperturbability means coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril, immobility, impassiveness, or, to use an old and expressive word, phlegm. It is the quality which is most appreciated by the laity though often misunderstood by them; and the physician who has the misfortune to be without it, who betrays indecision and worry, and who shows that he is flustered and flurried in ordinary emergencies, loses rapidly the confidence of his patients...

A distressing feature in the life which you are about to enter, a feature which will press hardly upon the finer spirits among you and ruffle their equanimity, is the uncertainty which pertains not alone to our science and arts but to the very hopes and fears which make us men. In seeking absolute truth we aim at the unattainable, and must be content with finding broken portions. You remember in the Egyptian story, how Typhon with his conspirators dealt with good Osiris; how they took the virgin Truth, hewed her lovely form into a thousand pieces, and scattered them to the four winds; and, as Milton says, "from that time ever since, the sad friends of truth, such as durst appear, imitating the careful search that Isis made for the mangled body of Osiris, went up and down gathering up limb by limb still as they could find them; We have not yet found them all," but each one of us may pick up a fragment, perhaps two, and in moments when mortality weighs less heavily upon the spirit, we can, as in a vision, see the form divine..."

I pondered on this essay today, on a day of transition from medicine internship and anesthesia residency. While I would not say that imperturbability is the utmost virtue of a physician, I see its qualities and they fit that of an anesthesiologist; we have to, in rapidly changing, critical situations, remain calm and even-headed. Everyone looks to the captain who, in the raging storm, carefully guides the ship home. I also really like the second quoted paragraph because residency thus far has taught me that we know little about the human body, health, and disease. There is a long way to go and through this journey we may pick up on small slivers of truth here and there, and it is our job as a profession to try to make sense of these pieces.

Intermission

There's a short week-long intermission between intern year and residency (we finish on the 24th and residency starts on the 1st of July) where the hospital is staffed by new interns and old residents; as old interns, we spend the week rehabilitating (and perhaps thumbing through other career plan guides). Right now, I'm on a break with friends (from other residency programs in the same transition period) and it is such a breath of fresh air. What a wonder how a few days can change the way we feel. How much free time we have now! I can't even figure out what to do with all of it. We sink back into old routines, familiar hobbies, comfortable conversations. Occasionally, thoughts, diatribes, reflections of residency poke through but for most of us, we want to hush that side of our lives as we know things will start back up soon. For me, anesthesia residency orientation begins tomorrow.

Eulogy

During intern year, I have taken care of many patients who passed away. For some, I called the time of death, comforted family, squeezed the patient's hand. I called the coroner, wrote the death note, called the attending. Other patients passed away after I left service; for some, this was unexpected, and for others it was a matter of time. These patients are harder to recall - after I leave a service, my working memory gets filled with a new set of patients. But occasionally, I run into my succeeding co-interns and ask about shared names and learn of what happened. Yet other patients have made it out of the hospital, and some die at home, occasionally on hospice, occasionally not. Over the year, I have seen many patients with terminal illnesses and learned a lot about end-stage heart, lung, liver, neurologic, and oncologic diseases.

This is a post in honor of them. These are the patients who submitted themselves to my care as a new doctor. They are patients who shared their final moments, fears, and sorrow with me. They are patients who opened up about what they want at the very end, who struggled with me at fighting overwhelming illness, who may have suffered by my hand. For some who kept up a fight, I asked them to undergo tests, painful procedures, medications with harsh side effects. For those who stopped aggressive care, I asked them to yield to the grief of closure and saying goodbye. I thank these people. It is a rare thing, to be present at that time in someone's life (or death), to be trusted, to make decisions that feel so much gravity. It would be so easy to omit such reflection at the end of the year - to just scamper off to parties in the sunset - but I would be remiss if I did not say: I've struggled with the concept of death and dying for years, and during this internship, I had to confront these issues with patients, and I thank them for allowing me to do so.

What We've Accomplished

One year ago, all of us in concert got a new degree. I am sure we had in our minds some expectation of what this degree would mean, and I dare to venture that intern year did not fulfill our hopes of medicine. This is how pre-meds imagine medicine, what their essays describe: a career in which every day is different, unexpected, challenging, thought-provoking, and intensely meaningful, a job that focuses on precious patient interactions in which a physician guides a grateful and scared human being through a difficult time in their life, a work highlighted by high-level discussions of scientific merit, an occupation where all components of the system mesh perfectly so that the doctor is only called upon when his highly refined skills are necessary, and in which every action the doctor makes has resounding and reverberating consequences of Good.

I assure you, internship could not feel more different. At times, we feel that we didn't do anything of particular significance. Our day to day activities are laden with the banal and trite. We seem to be learning more of the system rather than medical knowledge. More of our time is spent doing nonmedical stuff than medical stuff. Our schedules, lives, and free time are dictated by our programs. We have no flexibility, no freedom. And this system feels stifling. Where is our creativity now? Where do we find time to try new things, learn to cook, read a novel, write a blog, dance, see friends? And not only that, our day-to-day activities so rarely make us feel like a doctor, and this is insult upon injury when our job confines our spare time.

But now, sitting on my high perch at the end of internship, I propose that this is only transient. What have we but to be optimistic, especially with this deep sense that we've already invested four years of medical school for this. Residency gets better from here on out. Life opens up, it blossoms. And these "Dark Ages" - as one of my friends calls it - they are something we assimilate and learn to accept. I've, after all, learned something. I can't really say what it is exactly, and it probably doesn't have a place on the syllabus handed down from on high, but I think it's worthwhile. I've come into this system, learned to play by the rules, figured out its keystones and stress points, and made a bit of it my own.

How It Feels

Image of Tibetan plateau taken by Karrin Sheldon, shown under Fair Use.

One Year

It has been a year of internship, a year of pneumonia and urosepsis and failure to thrive and COPD exacerbations and chest pain and GI bleed and altered mental status. It has been a year of daily notes, midnight admissions, social work rounds, wrestling with the fax machine (I have more confidence putting a central line into a patient than reliably sending a fax), calling the operator, negotiating with consultants, falling asleep at noon conference. It has been a year of poor nutrition, worse exercise, absent sleep, distanced friends and family. It has been a year of building self-confidence, of perceived last-minute saves, of crying with patients and families, of obscure diagnoses, of late-night troubleshooting.

It is a year of small victories, a year where I finally learned my antibiotics, where I feel confident that I can keep a patient alive overnight until help comes in the morning, where I've learned how to put a needle into a person, where I've built a library of heuristics in my head so that I have a list of diagnoses within minutes of seeing someone. We are always told, "learn how to tell if someone is sick versus not sick," a feat that sounds easier than it is but something I think I've learned. It's been a year of growth.

It is the kind of year where in a week, I'll start saying, "Back in my day, I worked 30 hour shifts." It's the kind of year I'll never want to repeat again, but one where I'll look back and understand as one of those curiosities and perhaps necessities of residency.

End of the Year

And suddenly, like dawn, we have arrived and the world is bursting with light. There's only a week left of internship, the purported "hardest year of residency," and emotions are mixed. I'm tired, exhausted. But not unhappy. I don't think I'm bitter or jaded yet. I feel a little calloused, like I don't have enough energy to expend on emotion. But slowly color seeps back into life. The day is warm and light when I leave the hospital. And work isn't bad; I like thinking and seeing people and occasionally doing procedures with my hands. I love talking to my cointerns and sharing the incredulous or noteworthy or satisfying. The end rumbles near and there are a few celebrations marking it - an intern barbecue with awards for each intern ("Most likely to turn a note into a novel," "Most likely to get called by medical records for delinquent charts," "Most likely to be mistaken for an attending," "Most likely to think they are an attending") and an end-of-year banquet with baby pictures of all the graduating seniors. But these events are strange, almost curtailed since not everyone shows up (we have to, after all, continue staffing the hospital).

Perhaps I expected more. Shouldn't this moment be accompanied by fanfare and balloons and brash music? Shouldn't it be full of pomp and circumstance? Or does it go quietly, this transition from one year to the next, an induction rite into the hallowed traditions of medicine? Do we, like a band of travelers for a year, shake hands and depart in all directions now that we've arrived at our destination? I've gotten to know my co-interns in critical situations under stress and sleep-deprivation. I've come to trust their intuition and judgment (and I quietly protect my patients from those I don't trust). What happens next year when we disperse into further crannies of specialization?

It is an odd feeling, reaching the end. It feels good, like I've accomplished something. The world is opening up. I don't think I need any artificial celebration, just a quiet moment of reflection, a rare breath of relief in this monotony of exhaustion.

Bedside

"Time with the patient will remain the currency of medical care." - Leon Eisenberg

I recently admitted a patient from clinic whose medical problems I understood simply by looking at the chart. While he was being transported from the clinic to the hospital, I wrote most of my admission note. Upon hearing the sign-out from the attending, I knew what our plan would be. But when I saw the patient, I pulled up a chair and chatted with him and his daughter for half an hour. Much of it was that the service was slow and I had time to do so. And it was such a breath of relief. It felt good. The best part of my day is talking to patients, and in an era where medical care is limited to 15 minute office visits, patients like this luxury.

I didn't learn much that changed my direct medical care. But I listened to how the patient's disease was affecting him. I asked about his social history (though I had read the note from our transplant social worker) and inquired about his 3 marriages, his immigration from Cambodia, and his financial situation. I stopped worrying about time-constraints and just enjoyed the presence and role of being a doctor. It's the end of intern year - time to unfetter myself from being bogged down by scut and to take care of people.

NPH

One of the more common forms of insulin is "NPH." But how many of us know what NPH even stands for? We write for it all the time, but I doubt more than a handful of residents actually know why it's called NPH. "Neutral Protamine Hagedorn" is named after Hans Christian Hagedorn who obtained the rights to insulin. He then discovered that the effect of insulin could be prolonged by adding protamine (the same protamine used to reverse heparin, which incidentally is from trout semen). However, this only worked if the insulin formulation was pH 7. Hence, Neutral Protamine Hagedorn.

Image of insulin is in the public domain, from Wikipedia.

Transplant in Art

I always found this to be odd and I really don't know what to say about it, but it's a painting from the 16th century showing "legendary transplantation of a leg by Saints Cosmas and Damian, assisted by angels," shown under Fair Use, from Wikipedia.

Tenuous

The patients on hepatology are incredibly tenuous, especially those who are pre-transplant with end stage liver disease. It really reminds me how central the liver is in so many organ systems; dysfunction can lead to renal failure, gastrointestinal bleeding, susceptibility to infections, confusion, hypotension, and other adverse consequences. One small thing can tip a patient from stability to instability. I became acutely aware of this when one of my patients with end-stage liver disease had a small bowel obstruction and became dehydrated. This may have been enough to send him into hepato-renal syndrome and make him dialysis dependent. Many of my patients are at high risk of going to the ICU if they pick up even a minor infection or have a mild setback in their course. Even though hepatology is a floor service, it's a high-risk population whose disease states make patients so vulnerable to everything.

START

I start my anesthesiology residency in less than a month. The transition is quite scary; soon my entire role will change and instead of admitting older gentleman with chest pain and shortness of breath (which started off scary but now seems straightforward), I'll be putting people to sleep and become fully responsible while a surgeon takes a knife and cuts into them. The medications are different, the environment is unfamiliar, the vocabulary changes, the procedures are new. In talking to other anesthesia residents, the learning curve at the very beginning is incredibly steep.

Luckily, Stanford anesthesiology came up with their solution to this problem. The department has a START lecture series to ease us into anesthesiology during our intern years. Although we are scattered among many different programs for our internship, the program uses internet-based technologies to keep us connected. We learn about each other through message forums, we watch monthly lectures on core basic anesthesia topics, we take quizzes to gauge our knowledge, we have question and answer sessions. Although it only takes an hour or so each month, I feel that it's really helped me feel like I'm part of the starting anesthesia class this coming July.

Protectiveness

What I've noticed on this rotation is that everyone is so protective of both pre- and post-transplant patients. Since organ transplants are so high stake and often involve chronic diseases, patients' families have learned all about the process and advocate strongly for their loved ones. Most of the time this is great. Families work with doctors, they help patients get to their appointments, they are invested in patient education. They know the history well, they take meticulous details, they ask relevant questions. Doctors, too, are incredibly invested in their patients. On this service, we are far extremely conservative. We keep patients in the hospital longer, we prescribe antibiotics "just in case," we order tons of labs.

But on the other hand, this sort of behavior can be detrimental. I've had a few patients where families try to control the care so much that they are harming their loved ones. They lose the objectivity of what's going on, and their personal beliefs spill over to patient care. They request procedures that may be dangerous, insist on medications that aren't indicated, ask for tests we wouldn't normally send, and decide on code statuses which may be inappropriate. This is very scary because it's hard to persuade dedicated family members who've been by the patient's side through the transplant process. Likewise, physicians who are too protective of patients can cause their patients harm. Keeping a patient in the hospital when they don't need to be here can lead to nosocomial infections. Drawing blood for unindicated tests leads to iatrogenic anemia and higher costs of care. But in the end, we are very protective of these patients for whom we've invested so much time, care, money, tests, and an organ.

Transplants III

There's a lot of great intellectual meat in transplant medicine. Even from a basic science standpoint, the immunology of the body's recognition of self and not-self is fascinating. How do you coerce the body to accept an organ from someone else yet still recognize cancer and infections to fight them off? How are host defenses modulated, and what happens to this process over time? After transplant, we have to maintain a delicate balance between preventing rejection of the organ and safeguarding the rest of the body against malignancy and microbes. But our tests for this are poor; much of the time, we have to biopsy the new organ to determine whether there is rejection. There's so much room for transplant research. Why can't we create targeted drugs to prevent self-harm while preserving immunologic defense? Why can't we identify markers to better characterize rejection without invasive procedures? Do we actually know what's going on when we stick someone else's liver, kidney, heart, or lung into a patient's body?

Even from a macroscopic medicine point of view, transplant medicine has lots of nuances. A post-transplant patient suddenly has a host of new medications all with significant side effects. The whole process ages a patient; suddenly cancer and opportunistic infections become more likely, patients develop diabetes and coronary disease, chronic medical problems are exacerbated. On the one hand transplant medicine is extraordinarily specialized, but on the other hand, it is simply general medicine for a specific population.

Transplants II

The social history matters in organ transplantation. We spend a substantial amount of time assessing if a patient has the right social milieu for a transplant. They need to be free of drugs, drinking (especially in liver transplant), and smoking. They need to have good social support. I recently did a transplant evaluation on a person who had a positive urine toxicology for methamphetamines. Unfortunately, this meant that he could not be listed, and would have to contract to stay clean for 6 months with random urine screens prior to being listed. It was devastating to the patient, especially because he needs that organ to live. But these are the rules within which we operate. Organ transplantation is a major surgery, and afterwards, a lot of commitment is necessary to take one's medications, follow up in appointments, work with rehabilitation, etc. This is essential; post-transplant loss to follow-up is loss of that organ. And so we try to ensure that our transplant candidates have the family and friend support they need to succeed afterwards. But all of this social stuff raises interesting questions. Do richer people have better social support and use fewer drugs than poor people? What about certain ethnicities? Or people living in specific geographic locations? While these rules don't necessarily represent discrimination, they may be more severe on some demographics than others.

Transplants I

Transplant medicine is fascinating. It has generated its own world with its own rules, organizations, and protocols. Although we get maybe an hour lecture on transplants in medical school, the truth is, before I talked to transplant physicians or worked on this rotation, I didn't know what the process involved. How does one qualify for a transplant? What evaluation is done beforehand? How does one get listed and what determines who gets an organ when one becomes available? What does the surgery involve? How do people do post-transplant? One could easily go through medical training without delving into the specifics of those questions. And the truth is, it's not absolutely necessary. The transplant process is so complicated that it necessitates a certain specialization in that area to navigate the system appropriately.

Even the solid organs themselves - lung, heart, kidney, liver - have different protocols. And I have no idea how bone marrow transplants (or even other oddballs like corneas and skin) work. But it's fascinating to think of the ethical and organizational dilemmas that fit in. Who should get an organ? The person who waits the longest? The person who is the sickest? The person with the most money? The youngest? What factors should exclude someone from a transplant? Age? Drug use? Drug use in the past? Having a spotty social support system? And indeed, when an organ becomes available, is it better to use it on someone close by (presumably optimizing the organ quality) or should it be shipped to a surgical team far away to someone who needs it more?

Who makes such decisions? Doctors? Patients? The general population? Organ transplant recipients? Potential organ transplant recipients? What organizations are formed to fairly allocate organs? Who funds such organizations?

Even aside from the medical mumbo-jumbo, transplantation - the use of a scarce resource in a population that desperately needs it - is an enormously weighty topic. Hopefully, this rotation exposes me more to the nuances of the political, societal, and cultural aspects of organ transplantation because even though I'm not particularly going into the field, I find it so, so interesting.

Team T

My last rotation is "Team T" which is the liver and kidney transplant service. Although at many hospitals, liver patients are seen by the general medicine service, here hepatology has a primary admitting service. We see all pre-transplant liver patients and post-transplant patients who have nonsurgical problems. We see all post-kidney transplant patients as well. It's a great place to learn about common liver diseases such as hepatitis, cirrhosis, spontaneous bacterial peritonitis, ascites, hepatic encephalopathy, and liver cancer. There are some oddball diseases such as primary sclerosing cholangitis and primary biliary cirrhosis as well. The patient acuity can be fairly high; sepsis, coagulopathy, and renal failure are common comorbid conditions, and patients bounce in and out of the intensive care unit. We also perform a lot of procedures such as paracenteses. It seems like it will be a pretty educational rotation.

The rotation is 6 days a week, admitting from 7:30-5pm. Anyone who comes in out of those hours is admitted to medicine overnight and transferred to us the following day. The census caps are slightly lower than medicine caps with 8 patients total rather than 10, a reflection of the time-consuming nature of procedures and pauci-ICU patients. The service is run by a hepatology fellow and attending. Although there are no overnight calls, it's considered a wards rotation. We'll see how this month goes.