Textbook time!

Late last week, one of my class reps sent out a survey from the class of 2010 (well, a third of the class of 2010) about second-year textbooks. Exciting! I definitely bought way too many books for first year, though, so I'm trying to hold off this time. The top-rated books for pathophysiology are subject-specific (Lilly's Pathophysiology of Heart Disease, Despommier's Parasitic Diseases), but I'm debating about supplementing with a general pathology book. Robbins, perhaps? Or BRS?)

Truly, though, I'm nerd enough to be looking forward to the start of second year. I went ice skating this weekend with some high school friends, one of whom is now a pharm tech. He was lecturing pharm to everyone who would listen -- basically, me. So exciting to think that in a year, I'll know everything he was talking about! :)

I mean, second year will probably be scary. More volume, more detail. That pesky little board exam in June. Building on previously learned material. Which I have pretty much completely forgotten. (Bones of the wrist? What? I only vaguely remember our rotund little professor with the sweat issues, standing in front of a slide of a giant hand and telling us a dirty mnemonic about Tillie's pants.) But also really cool! I mean, parasites! What could possibly be more interesting than that!

We have summer reading! Again! As BH, who is in math grad school (taking classes like "topological algebra" and "partial semi-differential hand-waving") said when I told her: "Buh?"

Last year's summer reading was on The Spirit Catches You and You Fall Down, a rather sad story of cultural clashes. It frustrated me no end, which I suppose was the point. We were supposed to discuss in small group but never actually got around to it, so my understanding of cultural competence, $60k later, is not really much better than what it was around this time last year. (I do, however, have a much better understanding of rotation of the gut, for what it's worth. Everyone has situs inversus.)

This year's summer reading is Mountain Beyond Mountains, Tracy Kidder's biography of Paul Farmer. I'm holding off judgment until I actually receive it (could be a while, given the Fourth of July shipping delays), but it should be an interesting read, if nothing else. I'd like to do international work eventually, and Dr. Farmer's kind of a Big Deal in the global health arena. It is gratifying to see that idealism can actually work.

Overtired and undermotivated.

I feel like I'm in over my head again and kind of want to shut the world out. Or at least the med school part of it. I just want to flit from one social engagement to another -- tonight I'm going to a play, tomorrow to a dance -- instead of being holed up in my room or the library wondering why, exactly, apical ENaC channels are so important. And because my heart isn't really in it, my studying is very unproductive. I stare at the wall a lot.

It snowed today, you see. Snowfall is always beautiful, but in New York the beauty is fleeting. Already, the streets have turned to brownish slush. I really wanted to make it down to Central Park to take pictures, but, like I said. Studying. Death.

Sometimes, I wonder if I'm missing out on life. I am living in the greatest city in the world, and I feel like I can't enjoy it because I have to study. And I know that these demands on my time will only get bigger as I move through the ranks of medicine.

*deep breath*

I am reading Jerome Groopman's How Doctors Think at bedtime, and it's wonderful. I wish that this, rather than The Spirit Catches You, had been our summer reading. The cultural dynamics of Spirit were fascinating and obviously relevant, but Groopman's book is more immediately applicable, I feel. Also better-written. Like Oliver Sacks, he revives the case study as a narrative form. Although it's billed as "how to avoid misdiagnosis," it's really just about listening to the patient and the patient's body. And zebras.

Agency

Yesterday I read Better: A Surgeon's Notes on Performance, by Atul Gawande. It was an excellent book, especially after The Spirit Catches You and You Fall Down. Both address problems in healthcare, but whereas Spirit is anecdotal and a little touchy-feely, Better provides facts to back up its claims. Most importantly, Better focuses on how doctors and nurses can improve things. Mainly, it seems, by giving themselves agency.

Agency is a funny sort of word. I first heard it in my first semester of college, in a class about Shakespearean comedies. I think it was the lecture about Much Ado about Nothing (great play, fantastic movie starring Kenneth Branagh, Emma Thompson, and Denzel Washington). It refers to the power to effect change. So, Hero ("Leonato's short daughter") has no agency in the events of the play. Instead of, say, Merchant's Portia, who does things like cross-dress as a lawyer, Hero allows things to be done to her.

Literary digressions are fun!

But the main point is that agency, and a belief in one's own agency, is important. It underlies the ethical principle of autonomy. There's a lot of energy focused on the patient's autonomy, as there should be. For example, the Lees in Spirit lost autonomy in part because of their inability to communicate with the physicians. In many ways, the book is as much about their struggle to be subjects as it is about Lia's battle with epilepsy.

But there is also the autonomy of the physician. This seems to be gaining ground nowadays, with physician discontent with the insurance system in this country and with government/administrator involvement in how their practices are to be run. Better's kind of unique in that it addresses the autonomy of physicians, surgeons, and nurses to make choices about their practice of medicine. One chapter, which I personally found the most fascinating, deals with medical practitioners assisting in lethal execution, and their ethical and personal dilemmas about how far to go.

It's a great book, even better than Complications, his first. Go read it.

More on The Spirit Catches You

I finished reading The Spirit Catches You and You Fall Down a few days ago. First off, I mistakenly called the family Cambodian in my earlier post; they are Hmong. I didn't really know a whole lot about the Hmong before reading this book, and I still don't know a lot about them. Interspersed within the medical narrative were histories of the Hmong, who have faced persecution just about everywhere because of their refusal (stubborn or courageous, depending on your point of view) to assimilate into the mainstream culture. Anne Fadiman characterizes them as "scrappy."

But I begin to see why people on SDN are so frustrated with the way the parents behaved. They took the epilepsy meds and pretty much made up their own medication regimen, without informing the doctors. The kid kept seizing, and the result was painful.

What I don't understand is this: why did the parents, who were very mistrustful of Western-style evidence-based medicine, keep bringing Lia back to the doctors? In general, it seemed as though they loved the kid to distraction, but they were so ambivalent about her treatment: medicating her whenever they felt like it, skipping days, overdosing her. For a long time, this was not communicated to the doctors, either willfully or because of faulty (or non-existent) interpretation.

Some bleeding hearts might say it's politically incorrect to suggest that the parents purposely withheld information. But no. Politically (and factually) incorrect would be saying something like "All Hmong are dirty liars," which is just ludicrous. Don't confuse personal accountability with group stereotypes. In fact, the only criticism I have of this book is that Fadiman treats the Hmong like porcelain figurines. The doctors are very realistic -- some efficient and some effusive -- but the Hmong are long-suffering victims to the last man; no criticisms allowed. Although she devotes a lot of time to what the doctors could have done to facilitate communication, she seems almost afraid to point out that compromise is a two-way street and that the parents' confused stubbornness is just as much to blame as the physician's insistence on a biomedical treatment.

In the end, I found myself sympathizing with the parents but empathizing with the doctors. Lack of compromise can have terrible results.

Truth be told, I don’t really know that I deserve a blog. I don’t write as well as some of the medical bloggers out there, and I’m sure many of you already know what medical school is like. I don’t even start until August.

But I’ve already begun collecting paraphenalia, like a Netter’s Atlas. It’s sitting upstairs in its shrink-wrap; the thought of opening it is mildly frightening, like an acknowledgment that I’m actually going to med school.

We have a summer reading assignment (how very middle school) — The Spirit Catches You and You Fall Down, by Anne Fadiman. It’s frequently discussed on the SDN boards, where the fashionable position appears to be Cynical Pro-Establishment. One person, who shall remain nameless in the interests of anonymity (and because my memory kind of sucks), stated that as the Cambodian refugees sought out American medical care for their daughter, they should agree to do everything the Western way. I wrote my undergraduate thesis on power struggles in medicine, and so I am loathe to suggest that the balance of power in the physician-patient relationship be so fully given to either party. That seems like less of a solution to culture clashes, and more of a Tarzan-esque chest-beating competition. (”My medicine’s better than your medicine!” “Oh, yeah? Sez who?” “Sez me!”)

That’s not to say that I’m some kind of crazy hippie throwback. I happen to think that magnetic bracelets are in the same category as, say, Chinese tattoos, but I also think it’s foolish to discount centuries-old cultural practices just because they might be unusual. Case in point: Indians have used turmeric for years as a standard home remedy for everything from stomachaches to bruises. Somewhere along the line, the West wised up to this unassuming yellow powder, and a PubMed search for “turmeric” returns 499 papers in 2006 alone, examining everything from cancer to neurodegenerative disorders. Kind of impressive, eh? The moral of the story is: don’t ignore traditional remedies. Sometimes, just sometimes, the uneducated natives get it right.

Er. That was a bit heavy for a first post. I promise I’m not so serious all the time.