Boggy seems the absolute worst physical exam finding ever. It is. It’s awful. In fact, I’ve used it as an insult. Stop being so boggy, Kristen. You’re being a boggy uterus, Kristen. Stop it.
Honestly, I think that’s all this post needs to be.
And by the way, internal medicine is way cool. I may or may not have had a patient on my service with a hemoglobin of 1.9. That’s low. That’s really low. I get goosebumps thinking about hemoglobins that low. HEMOGLOBINS.
I need some sleep.
This blog has been silent for sometime. Think of it as a good thing, if you care at all about me. There is a time in every tasty and proper meal when the voices are silent and the utensils tinkle, erratically opposed to the regular, rhythmic grandfather clock. It means the food is pleasing and nothing else is necessary. Think of this past quiet time as that. And then the meal ends and dialogue opens. So here we are, near the end of the meal.
You’ll notice I’ve stopped this habit of uncapitalization. I don’t disagree with the idea behind it, but in the end it seemed more like a novelty than a novel thing. People who write poorly hide behind novelties like long words and adjectives and superlative. If you’re to write poorly, I say do it bold.
So a gentleman should know himself. What does that mean? I don’t know, but it does seem like something nice to write down and look at. It’s a good sentence. I’ve been listening to a lecture on hinduism over break by this man Mark Muesse. His last name is a mystery to me, as is this idea of being hindu still, but he likes to look at the subjects of sentences, attempting to define or redefine. He would ask what I meant by knowing, knowing himself that either I would give the true meaning of “to know” and have to reword my sentence, or give an incorrect definition of the word. In truth, I don’t really think we can ever know ourselves. Maybe I can know the me that exists inside. The true soul of myself, I could know that. After all, I know my intentions very well (or do I?), and what is a soul more than intentions, volitions? So I know what I intend. I know my own ends, I create them. But the means, the method by which I carry out my intentions are a mystery. Put another way, if my intention is a point at the end of a very long maze and the method is the path of the maze, I stand as a soul at the end, waiting for my body to catch up, hoping it goes about things in the right way.
This is turning into a poor metaphor, but I’ll keep going.
Moving on, an example: It’s clear to me that I need to light this candle. This is my intention, my aim, my end. Because I have the will, I see the match next to the candle and light it. I have accomplished my end, and my body has finally met my soul at the end of the maze. But along the way, who knows what has happened. A friend, also in the room, is red and pacified because that was her match and I didn’t ask to use it and she wanted it herself. Another friend is concerned because there was a bottle of lighter fluid just next to the candle and I didn’t see that and we all could have died. There are parts of the maze I never saw, not from my perspective. But they could from theirs. Maybe they’ll tell me what they’ve seen, maybe they won’t. Maybe I’ll never know.
So I suppose in the end, that’s what I mean by knowing thyself. Look through the eyes of your neighbor. And that’s what I want to do as much of as I can in twenty twelve. I’ll fail miserably, but I’ll try. I’ll try because a doctor must know himself all the more, as his end has on either side an audience of sometimes hundreds, each watching every turn in the maze.
i don’t consider myself an accomplished conversationalist. i speak like an antelope swims. there are plays i call during discussion which might lead the unfortunate other half to a diagnosis or two. verbigeration is probably the worst habit.
but, i’ll be darned if i don’t try, and try a gentleman must.
organic conversation is useless to a clinician. if what comes of a clinical interview would have come naturally to the patient in any other conversation, what’s the point? no, a clinical interview is not a chit-chat. a good clinician can make it seem that way, but underneath the bouquet is a very intense instrument. to be stupid, but to be able to obtain information effectively, is to not be stupid. to be brilliant, but to be unable to draw relevant information from the patient is to be stupid. this is a house rule. this is the verbal reasoning part of the MCAT. this is the seemingly esoteric course on “the patient-physician relationship” we’ve all taken at some point.
a clinical vignette has always been printed in front of us. it’s been given. the process to obtain that vignette has been assumed, but should it be?
september, as it were, seemed an uninspiring month for me. it was hot. pollen coated everything. and, worst of all, it induced this sickness of excuse making that, even now, you experience the residuum of as we reach the most wondrous and exciting month of them all. october, we were meant to be.
october is psychiatry rotation, halloween, my birthday, leaves changing, perfect temperatures, football– i can go on.
about this gentleman quote: i was speaking with a friend recently and that exchange was what inspired this selection. i found myself at a party following the end of surgery block (yesssssssssssssss.) and this person who shall remain anon asked, “are you a gentleman?” to which i replied in that endearing, befuddled, poorly articulated way i tend to speak, “well, i, um, absolutely? not.” despite this bumpy journey, i think i actually arrived at the correct answer. maybe. it seems that no one is The Gentleman, in the truest sense of the word. gentleman is an ethos, an ideal, not meant to be attained, only pursued. it’s like drawing a square and calling it a square. obviously, it’s wrong to call that square a square because a Square in the truest sense is impossible to recreate in the physical world. four perfect angles are conceptual, not real. i can think a Square, but never draw one. in much the same way, i can think a Gentleman or Physician but never write of one. unfortunately these ideals and their accompanying ethos are not meant to be held, only seen and observed.
but even still, as a gentlemanoid or pseudo-gentleman, one must do one’s best. and so before leaving the house, the gentleman tries his best, combing his lethal side part as well as possible, notching his tie to the best of his ability, and minimizing halitosis with a good and proper mouthwash.
vital and fragile, this one. so, so important it will surprise you. i knew a physician once, who knew another physician who knew a regular human without superpowers who became sick. sick human goes to physician to become unsick. physician finds the reason for sickness and shows disgust on his face. sick human leaves office, embarrassed. next, sick human becomes septic human, now needing an emergency room.
a face can be useful in practice. when arranged properly, it can express a sense of empathy, sadness, happiness, intelligence. in this way, face can be counted as a boon to the medical doctor. in other ways, it can be our undoing. if a sense of propriety and/or wherewithal are not kept close and constant, the face undermines our professional image and can hinder an otherwise open relationship between the patient and his/her healer. doctor faces should only belie an underlying feeling when that is beneficent.
i am torn on this post. i’ve always felt authenticity should be the default position for a practitioner not knowing what to do. this post disagrees. it just happened, you decide whether to nod up-down or left-right.
also, i should say the august 2011 edition of reflections has been published and printed. if you’d like a copy, just email me at acoehler@iupui.edu and it shall be done.
the last day of surgery came and i hadn’t performed a nasogastric tube insertion for all of the 5 weeks. undespairing and full of a courageous spirit i enlisted the help of an unnamed classmate to perform the act on me, so that i might not only understand its process, but empathize with the victim. eh hem, patient.
so here it is, in video form. it was a strange experience. i felt it all the way to the back of my throat, and then no longer. it makes sense, as you don’t feel food the entire way down to your stomach. because of this, i don’t think we’ll ever know if it actually made it to my stomach, one can only imagine. also, you’ll hear during the video a peanut gallery laughing about a basilar skull fracture. google nasogastric tube and skull fracture. then, you’ll see why they were so concerned.
i haven’t felt like posting for quite a while. i won’t give you some reason that sounds like busy. now, these days, this day and age, here, with as much technology, there is no reason not to get something done. it’s a matter of choice. people do what they feel like doing. on surgery rotation, there aren’t as many opportunities to make choices, but they do still exist. my choices recently are of recurrent themes: sleep, eat, read, stare, nap, stare, hold retractor, shut mouth, open mouth, give incorrect answer, give correct answer, say “i don’t know,” don’t faint, stand still, stop hands from shaking. at any given moment over the past few weeks, if you were to look at me from the outside, i’d bet on the inside, i would be making one of those choices. sleep depravation will do that. you’ll still function just fine, but the span of choices you would remotely consider making narrows considerably. eat, sleep gets bigger and bigger in your mind. stuff like writing, pondering, making anything becomes remarkably small to the point of disappearing.
all this is to say, it’s difficult to maintain your sense of self amidst a heavy assault on the soul. most become very labile, or the opposite. but few, few residents, staff, medical students, withstand this war of attrition and salvage a sense of propriety. they say thank you when something is done for them. they smile at you with a correct answer. they smile at you with an incorrect answer. they have patience.
this is good, but this should not be the outlier. we’ve come this far because of an unusually high set of standards, unyielding. this should extend into our interactions with others. i’ve snapped at others more over the past 5 weeks than any other time in my life, save maybe one other. it’s not a relief to yell at another person, make snide remarks. it’s not satisfying, like any other indulgence.
so be nice.
yes a physician should be able to speak a sentence. in english. clearly.
this is not an anti-FMG post. i don’t think i could handle a post like that. my opinions are like long blades of grass. if you look hard enough, they’re there, and they’re defined, but a puff of wind will bend them. a child could break them.
i think this post is more about being a human being. we’re only as much as we can convey to the outside world. a thousand mute einsteins could all be in a room full of science and nothing new would happen that day. the same number of articulate monkeys would build something, probably a poo-flinger. case in point: planet of the apes. the point of this is to say a gentleman is fluent in thought. when a thought pops in about this or that, the gentleman knows how best to translate it, verbally. the physician should be of the same sort. the minute you become a 3rd year, you realize the value of effective communication. brilliant 3rd years are made low by mediocre 3rd years with a sense of what information is important.
also, be a round, symmetrical human being. a physician at a party should be able to speak intelligently about things beside the spleen. in office practice, the majority of social contact you have will be non-physican. you have 70 or 80 years to live. be a human being. it’s not just about getting top marks anymore. some of us are 1/3 of the way through with life. i have fonder memories of standing on top of the wallace monument outside sterling than getting top score on some test, some time, some where.
the explanation today has little to do with this quote. writing it, i was under the impression of every sentence being supremely poignant and quippy. i was mistaken. on to the content:
of course the knowledge a physician holds is much different from that of the layman, but my experience with cardiothoracic surgery over the past several weeks has given indication that there is something more going on. both a physician and a gentleman must have this information, but how s/he reaches for it is a sequence far denser. anyone can be an encyclopedia, and when presented with the right question, will answer it correctly. this is deductive skill. but the question isn’t always obvious. when you look at a bowl of spaghetti, there is chaos, not mona lisa. one must induce the right set of ideas onto this chaos, find the proper questions, and then answer them.
labs are not presented by system or pathology. patients don’t provide symptoms grouped by problem. both a gentleman and a physician must imagine reality into something orderly, confirm that imagined thing with labs and tests, and finally tweak that imagined thing with procedures and treatment.
it’s all a grand guess. any error along the way can send you after imagined reindeer when in reality it’s a bloodthirsty alpha lion. and then what?
medicine administers success and Failure in very large doses. it’s difficult to swallow, but a gentleman/medical student just has to. too much success in your mouth can distort words– track upwards to distort thoughts. even worse than distortion, it can petrify brains, holding a good medical student still while okay colleagues pass good to better. failure is not like this. the right amount of failure in your mouth acts to filter thoughts and words very carefully. it can change altogether the way you think and speak into something new and grown. failure is fertile soil for careful thought and reflection.
i feel like yoda. there won’t be another post like this…i’m no good at being yoda.
