Category Archives: General Thoughts

Clinical Detachment and a Bridge in Brooklyn

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Another day, another mass shooting in America. And last night’s is close to home.

At 8:30 p.m., our house phone rings. Must be one of our parents or spam (they’re the only ones who call our house line). I look at the caller ID – it says “Michigan State.” Because I’m faculty for MSU’s med school, I’m on the list for their emergency system’s warning calls. I answer, and the computerized voice begins: “There are reports of shots fired on Michigan State’s East Lansing campus…”

I tell Doug. He pulls up the police scanner app on his phone, puts it on speaker, and we listen. It’s real.

Multiple casualties. They’re requesting all available emergency medical support.

We have three children. A subset of their friends are our children. We have friends. A subset of their children are our children. We have friends whose children are friends with our children. Those children are our children. Our sons are in their 20s and we live in the metropolitan Detroit area. You can do the math – this is close to home.

I call the kid down the street, a junior at MSU. He doesn’t answer. Of course not. Kids don’t talk on the phone. I text him: “There’s a shooting on your campus. Are you ok? Call your parents to let them know you’re ok, and then text me back.” Two minutes later I text him what we’ve heard on the scanner about the location of the shooting. And I implore the kid to call his folks and me. Three minutes later I’ve somewhat lost it and text him something to the effect of “Jesus Fucking Christ, call me.” That does the trick. He responds. We talk. He’s safe.

At this point, I’m in my clinical detachment state. Doctors have to have this psychological skill or we wouldn’t be able to do our jobs. Everyone, medical or not, employs this defense mechanism at times.

Youngest son and girlfriend are home with us, middle son in Ann Arbor, eldest in D.C.

Family group chat is going. We try to figure out whose kids, whose siblings, which friends, are in East Lansing. I’m no longer trying to message known East Lansing kids first to have them contact their parents – I’m reaching out to parents directly, even though I know what it will do to them if they hear from me before they hear from their children, because I would want to know if my child were there. Some parents have heard. Some haven’t. At some point, it’s late enough that they all know. Our/our kids’ most direct connections are safe.

Clinically detached.

Listening to the scanner.

Texting in family group chat. Detached, but listening for tone, observing, watching for evidence of any danger sign in psychological state of offspring. Watching, listening to offspring/significant other in my house, observing body language and facial expressions, listening to tones of voice. Watching and listening to my husband, who hasn’t stopped listening to every word on the scanner.

Talking to other parents. Clinically observing tones of voice. Figuring out who needs to hear what words as they process the situation of texting with their children who are locked and barricaded in buildings on campus.

Watching news briefs. Detached.

Listening to the scanner. Clinical.

That scanner, though.

Detached. Clinical. Listening to the radio conversations between dispatch and the rescue response teams. Listening. Observing. Drawing parallels, as I am wont to do, to medicine.

It’s all about communication. It’s all about objective information. It’s all about being methodical. And yet the communication is fragmented – so many moving parts, reports from all over the place. The theoretically objective information is overwhelmed by the subjective tainting of terrified humans. The method takes time, it is not instantaneous.

I am detached, clinical. Observing, considering, interpreting, and synthesizing information, trying to make sense of it.

Sons are scouring internet. Mostly Twitter. Texting in our group chat. D.C. son, who lives in a sea of helicopters, is incensed that the shooter is still at large and that there isn’t chopper support. Engineer son is incensed that all campus security cameras haven’t been used to triangulate and locate the shooter.

But there is helicopter support. It’s not on the scanner channel available to us (much of police communication occurs on encrypted channels inaccessible to the public). There is analysis being done on what has been captured on the cameras.

The scanner channel we’ve got access to covers communication between a central dispatch and rescue response teams. But at this point, there are hundreds of police officers from campus police, city police, state police, police from not only the local county but other surrounding counties as well, the FBI, all on campus, all coordinating to ensure students’ safety, to secure buildings, to question witnesses, and to find the shooter. We are hearing one part of that.

The rescue teams are checking out all of the areas of reported shooting. And Doug is keeping track of all of the reported locations – at least ten buildings on campus if not more. But most of the reports of shooting turn out not to be actual shooting. The dispatcher will report that people heard gunshots at building X, and there will be a response from a team at that building saying they’re there, and nothing is going on, that all is quiet.

But there are 50,000 scared students. A door slamming can sound like a gunshot. If you hear something, you report it. We hear the dispatcher relay a report that someone saw someone throw something into a trash can. An explosive device? A gun? A sandwich wrapper?

There are multiple reports of people with guns. Of course there are. It’s dark. People are looking out of windows. There are tactical units of law enforcement everywhere, carrying guns. Is one of the sightings the shooter?

It’s like practicing medicine.

As a doctor, I have a person in front of me. One whole person. With a lot of parts, a lot of systems. And a family. And friends. And perhaps an imperfect memory of his symptoms. Or an interpretation or a descriptive term that differs from a specific medical term.

Get five people reporting “dizziness” and get five different phenomena being reported. Feeling of room spinning? Feeling that you are spinning? Feeling lightheaded as if you are about to faint? Feeling “off balance”? Feeling a little “fuzzy”? What was tossed into that trash can above?

Did the dizziness start last week? The patient in front of me is adamant that it did. His wife is certain it’s been going on for a month. His daughter never heard him complain about dizziness, but right now she feels like she is going to pass out. Is something serious going on with her right in front of me?

Figuring out what’s going on. Clinical. Observing. Detached enough to stay objective, to see what’s in front of me and find the answers and find the problems, and at the same time looking and listening closely so I can connect and communicate and help.

Diagnosing and assessing and planning. History, family history, social factors, lifestyle, physical exam, laboratory testing, imaging studies. All take time. If a family member only focuses on one, it looks like we’re not doing anything and why is it taking so fucking long to figure out what’s happening? And no one is talking to anyone else! No one knows what’s going on!

But we are talking to one another. It takes time. We’re all caring for multiple people and multiple families and coordinating with multiple departments. Information comes at different times, and one piece may come for one person while we’re looking at a different piece for another person.

The coordination and communication logistics are mind-boggling.

Detached. Clinical. Seeing how the moving parts in East Lansing are analogous to the moving parts in my own profession. Seeing the reactions of those outside of the active team, those who have no control over the situation and who feel that lack of control to their core. Their fear. Their anger.

We hear on the scanner that the shooter has shot himself as officers approached him. We hear that officers are doing CPR on the suspect. A short time later, there is another briefing – confirms that the shooter is dead. And three of the people he shot are dead. And five are in critical condition. There will be more details later. The investigation is ongoing. There is no further physical threat.

It’s one a.m. and I’m exhausted. I’m clinically detached. I hold Doug as I try to fall asleep. You know that little jerk awake that sometimes happens as you’re falling asleep? That happens. But the jerk involves a scream. I’ve never done that before. It wakes Doug up. I apologize.

I have no idea what actually happens with my sleep last night. My exhaustion this morning is overpowering. And whatever tossing and turning I did has pulled a muscle in my neck.

There is more information today. All of the dead and critically injured are students. Two names of the victims have been released. The shooter has been identified – a 43-year-old man with no (as yet known) affiliation with the university.

I’m clinically detached.

Our neighbor kid gets back home this morning. I see his car, knock on his door, and hug him. He knows one of the deceased people.

I’m clinically detached.

A 43-year-old man has killed three people’s children and critically injured five other people’s children.

I’m clinically detached.

Putting ice on my neck makes it worse.

I’m clinically detached.

Another day in America, another mass shooting.

I’m clinically detached.

And if you believe that, I have a bridge to sell you.

To Play or Not To Play

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In last night’s Monday Night Football game, Damar Hamlin, a 24-year-old player on the Buffalo Bills, made a tackle, stood up, and collapsed on the field in cardiac arrest. CPR was administered, a defibrillator restored his heartbeat, and he was taken, still unconscious, to the University of Cincinnati Medical Center, a level one trauma center. As of this writing, he remains in critical condition and there has been no information released as to the cause of his cardiac arrest.

The lack of an official diagnosis, however, does not stop speculation, including my own.

There are a number of possibilities high on the differential (the list of potential causes). Vascular injury (injury to a blood vessel – for example a severed artery, or a ruptured aneurysm) can occur spontaneously or after a forceful blow. A spinal cord injury can occur with a forceful collision, and a severe, high (neck-level) injury can lead to cardiac arrest. An issue within the heart itself can lead to cardiac arrest – a heart attack (blockage of an artery that provides blood to the heart muscle) or a problem with the electrical conduction system of the heart can cause the heart to stop.

Mr. Hamlin was running fast to tackle the ball-carrier. The ball-carrier was running fast as well, and his shoulder hit Mr. Hamlin’s chest as they ran full-force into each other, and you can see effects of the rapid deceleration forces on their bodies as you watch video of the collision. Mr. Hamlin stood up and quickly collapsed.

Because of the timing of his collapse in relation to the collision, and because emergency medical personnel were able to get his heart to resume beating, I think there’s a significant possibility that his cardiac arrest was caused by “commotio cordis,” a phenomenon where a blow to the chest occurs at exactly the wrong time in the heart beat electrical cycle and can lead to ventricular fibrillation (fibrillation is a disorganized electrical firing of the cardiac electrical system which stops the normal, coordinated electrical pattern, and instead of an organized, coordinated, functional heartbeat, you end up with ineffectual random, uncoordinated contractions of cells that do not create a functional heartbeat – were you to touch a heart in ventricular fibrillation, it would feel reminiscent of a bag of worms). A physical blow actually creates an electrical impulse, and this impulse can affect the heart’s electrical cycle just as an electric shock from a damaged electrical cord or downed power line or a lightning bolt can. It can be caused by a baseball or soccer ball to the chest (the sport it occurs in most frequently in the U.S. is baseball), a punch or kick to the chest, a fall onto the chest, etc. at a very specific time when the heart’s electrical system is resetting itself for the next beat. It is rare, because of the specificity of the timing in a tiny window.

If commotio cordis is the cause, the fact that he had immediate CPR and defibrillation gives him the best chance of a positive outcome, and I very much hope that this kid is ok (and yes, he’s a man, but he’s the same age as our middle son, so to me he’s a kid).

In medicine, we are always weighing risks and benefits. Risks of differing treatments. Risks of not treating something. And we all do this in life in general. We assess which potential risks are worth which potential benefits and we live our lives accordingly.

Which brings me to the topic of playing football in general.

I love watching football. The beauty of the strategy, the athleticism and skill of the players, the teamwork, the meticulous planning and also the changing of plans in response to unexpected situations, the constant action – when you know what’s going on, it’s a remarkably fun sport to watch.

I hate watching football. I hate seeing players’ heads jerk sharply when they collide with another player or hit the ground.

I won’t watch professional boxing. I appreciate the skill needed to be a professional fighter. I appreciate the work that needs to be put in, the fitness level, the practice. I cannot ignore that the goal is to knock your opponent out. The objective is to cause a degree of head injury that renders your opponent unable to stand for a full ten seconds. The intent is to harm. I cannot, will not, condone this as a sport.

But in football, the goal is to move a ball across a goal line (or through goal posts). The intent is not to harm. The intent is to move a ball. The intent is not to render your opponent unconscious. But the effect, even if not the intent, can indeed be harm.

I hate CTE (Chronic Traumatic Encephalopathy) – the condition that comes from repetitive sub-concussion-level head hits (or even non-head hits – when you slam into a tackle dummy bag and your body stops, your brain continues to move and hits the inside of your skull, and if forceful enough can then snap back and hit the other side as well) and/or repeated concussions. It’s a progressive brain disorder which can eventually lead to dementia. It occurs mainly in people who participate/participated in sports with repetitive collisions (e.g. boxing, football). It occurs with hockey and soccer as well.

Concussions suck. Spinal cord injuries suck. Knee injuries certainly aren’t desired.

All three of our sons are athletic. All three of them wanted to play football in middle and high school. I told all three of them “no.”

Our sons are athletic. Our sons are not big. Basic physics – when a small guy and a big guy run into each other, the small guy is going to take a lot more force in the hit.

Would they have had fun playing? Yup. Would they have learned things they wouldn’t have learned elsewhere? Yup. Would there have been other potential advantages? Also yup. Were these benefits to my kids worth the repetitive collisions? In my calculations at the time, nope. And if I were to have it to do over, my answer would remain “no.”

But every time I watch the Michigan Wolverines play, I’m watching other people’s children take those risks, and I really enjoy watching. I kinda suck as a human, if you think about that.

But here’s the thing: We allowed our kids to do plenty of things that involved not-insignificant risk. They all ski. They all did track and cross country through high school (dehydration and physical exhaustion are not benign, and runners certainly frequently experience injuries). They all did martial arts (in a dojo where you worked with “partners” rather than “opponents,” and where respect and safety were emphasized, but I’m not an idiot – I am well-aware it was not a risk-free activity). There are plenty of folks who would not allow their kids to take on the physical risks of skiing or of martial arts, but they enjoy watching the competitions in the Olympic games – I don’t think these people are unethical for accepting a risk for others they don’t accept for themselves. We all have our level of risk tolerance, and for so many things, even if the risk isn’t worth it for us, we can appreciate those things (think air shows, or gymnastics, or car racing).

So when one of my friends asked me if I think Damar Hamlin should retire from the NFL after this, assuming he recovers fully, and if the cause of his cardiac arrest was a piss-poor-luck timing of impact and not an underlying cardiac condition, I honestly cannot answer. His risk of continuing to play would be the same risk of brain injury that all players assume, and that I would not want my children to assume.

And the cause of his collapse may be something else. We don’t know yet.

I would like to see football evolve so that there is less collision. One may ridicule me here, but two of our boys played flag football, and it’s a great game. We have technology that we could adapt with sensors on uniforms to make football more of a two-hand-touch type of game. It would be different. But a new football could evolve that would keep much of the strategy, athleticism, and esthetics of the game and mitigate some of the more catastrophic risks.

Note that I said “mitigate” and not “eliminate” risk. To live is to be at risk. But risk mitigation allows us opportunity to do more. A freak accident can happen anywhere, with any sport, and in life in general, but we can set things up so that there are fewer accidents expected.

Risks. Benefits. Intent. Mitigation. It’s a lot to think about.

Again, I hope this kid is ok. And I hope all the players get the professional emotional support they need.

A Birthday and Anger and Resolve

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Today I turn 53 years old. I do not want to celebrate. I will politely thank the people who post their kind wishes on my Facebook wall, but I will not have a “great day.”

This birthday, I and my siblings and my friends and my children and their partners/future partners and potential future grandchildren face fewer rights and more danger than what has been the case in this country for the past 50 years.

My head is still swimming. I alternate between rage and more rage. There is so much harm from medical misinformation regarding “abortion.” It is difficult to know where to start. But I will start.

In many states, women have completely lost their rights to privacy and bodily autonomy.

Women will die.

Doctors’ jobs of saving the lives of their patients have been criminalized. Women are already being denied appropriate, life-saving medical care. Sepsis kills. A miscarriage in process but not completed is a set-up for life-threatening infection. Doctors now have to wait and watch until fetal cardiac activity ceases or the mother has already gone into shock (and has a far smaller chance of survival) to do what needs to be done.

Women will be forced to bring to term, deliver, and watch the prolonged suffocation deaths of their children with horrible chromosomal and other congenital defects – they will be forced to allow the brain of the fetus to develop maximally so that it will have the greatest ability to suffer as it is born and dies over hours or days or weeks due to lethally underformed lungs.

Couples will be denied fertility treatment. In vitro fertilization (IVF) will no longer be an option.

Women who are pregnant when they are diagnosed with hormone-sensitive cancers will be forced to allow those cancers to grow and take hold and spread.

Couples who are carriers of lethal genetic diseases will not have the choice to do IVF and implant embryos without the lethal diseases. They will have the choice only of not having children or of risking the intolerable.

Those impregnated with twins who develop twin-twin transfusions will be unable to choose to save one. They will both be condemned to death.

Women who have miscarriages have already been investigated and charged. There will be more of this.

The religious zealotry of the few is being imposed on those who do not share in that empowered minority’s beliefs. Politicians who have no idea what they’re talking about are forcing their medically ignorant, religiously-based lay-opinions on others.

That the intrusion into privacy, that intrusion into a doctor’s office, that intrusion into the health and well-being of others trying to make the best decisions possible for themselves and their families in unthinkable situations, is infuriating and unconscionable.

And even if the act is illegal, as my eldest has pointed out, rape is now, in effect, in several states, a legitimate means to reproduction.

Yes, there are states that protect against this. But many are working their hardest to make their states as intrusive and controlling and harmful to women as possible. And there are folks openly working to make this hateful, harmful, intrusive, controlling repression national policy.

It is not a “happy birthday.”

My college roommate knew not to wish me a “wonderful day.” Instead, she hoped that I would be surrounded by people I love and that I could enjoy the beautiful weather. I am indeed surrounded by people I love, and I appreciate the blue sky, cooler temperature, and gentle breeze.

I will absorb the energy of that love, of that sunshine, and of that wind, and I will let it fuel me as I fight alongside the vast sea of others for my own basic rights and the basic rights of the people in every state in our great nation.

Today I do not want to celebrate, but I will use the symbolism of today to vow to make my presence on this planet a presence that makes this world a better place.

An Early Snow in a Long Year

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Snow.

Snow falling and swirling and sticking and coating the ground, the trees, the leaves.

Yes, the leaves.

The leaves are still here. It’s not their time to go yet.

They’re beautiful, these leaves. A perfect rainbow of greens, yellows, reds, and browns, varying from tree to tree and even branch to branch. Lush verdant deciduous holdouts along with evergreens, punctuating pumpkin orange, gilded flax, opulent burgundy, burnt sienna, and toasty brown canvases, with a smattering of gray, newly baring branches thrown in.

The depth of the hues, the strength of the crunch underfoot, the bright smell of the pine needles, all speak to the coziness and comfort of autumn.

And right now it’s all coated in snow. Bright white, fluffy, cold snow. A blanket of winter, foreshadowing what will soon be here to stay for a while.

But it’s not time yet.

The colors peek through.

I stop repeatedly to take pictures with my phone, trying to capture the sounds, the cold, the smell of wood burning, but there aren’t enough pixels to conjure on the screen what is aroused in my senses.

The excitement and rapid heart rate as we trudge down the path along the river, slipping and catching ourselves on the little hills, the brief stab of nervousness as a branch cracks somewhere overhead and my husband and I speed up our steps – this also doesn’t come through in the digital images.

Not even the colors come through.

The brightness. The persistence. The depth. The tone.

What shows on the thumbnail looks black and white. The camera won’t extract the complete information. The snow is dominant, unrelenting within the portrait.

I try different angles, different positions, different directions, different locations, managing to get a few shots where a hint of the pigments show through, though never coming anywhere close to what I see outside of the viewfinder.

And I think about the snow.

And the word snow.

When we “snow” someone, we’re duping them, fooling them, even betraying them.

I think of the snowflakes themselves, their intricacies, their points, their spikes.

And I think of the spikes on a virus.

And I think of a coronavirus, falling everywhere, blanketing the earth, hiding the colors, hiding the brightness.

I think of how it’s duping us, fooling us, betraying us, causing us to turn on one another, hiding our humanity from one another, leading us to think in black and white, us and them.

I’m a child of the northeast. I know snow.

And I love snow.

To love snow, you have to know it well. You have to know that its freshly fallen beauty belies its frigidity. You have to know how to dress to protect yourself from frostbite and hypothermia. You have to know when you’re going to need to shovel, and when it’s going to melt. You have to know when it’s the right consistency to make a snowball or a snowman, a snow angel or a snow fort. You have to know how to slide down it on a sled or on skis or how to walk on top of it in snowshoes. You have to know when it needs to be raked off the edges of your roof so that your roof doesn’t collapse and so you don’t get ice dams. You have to know when it’s too deep to be safe to walk through and when it’s falling too hard to drive. You have to have shelter. And you have to have good boots.

You have to know, no matter how deep it piles up, or how dirty is gets along the road, that it will, without fail, give way to spring, to new leaves, to new life.

Snow is a disguise. A cloak.

A mask.

It covers the dirt. At first glance, it’s just pretty. The first coating obscures its power, its destructive potential.

It covers the still living leaves, making the branches hang heavy, threatening to break them all and managing to break some.

It weighs the leaves down, concealing the depth and intensity of their hues, knocking some of them to the ground weeks before they would have drifted down of their own accord.

But even though the pictures refuse to show it, we can see the colors as we walk through the woods. When we’re there, when we’re in it, we can see what’s there.

We have to stop and look. We have to place ourselves there. If we are not physically there, we have to extrapolate from the photos taken by others. The cameras cannot manifest the sounds, the smells, the tastes, the temperature, the emotions, or even the true colors, so we need to go further – allowing ourselves to enter the photographs with our souls, breathing the cold, crisp air in our minds.

We are still here. We are still beautiful. The youthful greens, the peaking yellows, oranges, and reds, the aging siennas and browns. The firs and the maples, the spruce and the oaks, the pines and the beeches and the ashes and the elms and the birches. The leaves and the colors and the depths and the branches of humanity.

With apologies for the triteness of my analogy, for now facemasks are our boots, physical distancing our shelter, and vaccines will be our jackets. They are how we will manage.

Our housemates, Zoom, Facebook, telephones, and neighbors and friends outside on the lawn are our skis and our sleds. They are how we will thrive.

More snow is coming. Know the snow. Know what’s under it – what’s hidden, what looks dead, is dormant, resting, waiting. Know how to manage the snow and how, as best as possible, to protect against its damage. Know how to thrive in it.

Grieve what the snow breaks that is not reparable.

And know, always, that the snow will melt, and that we will emerge in all our colorful splendor.

Live DocThoughts 3/24/20

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Due to technical difficulties, I did last night’s live talk on Facebook on my personal page. I will do another tonight (8:30 P.M. Eastern time), also from my personal page – while on Facebook, search for “Abi Schildcrout”. You can choose to “follow” me if you want my public posts to show in your feed. I do not accept friend requests from people I don’t know.

Last night’s talk dealt mainly with public health and societal issues related to COVID 19. Tonight’s talk will deal more with personal/individual issues related to this outbreak. From my Facebook description for this evening: “Body, mind, “soul.” Will touch on Advil/NSAIDs, ACE-inhibitors, steroids, asthma, high blood pressure, and other chronic conditions and how they play into this, disinfection/self protection, differentiating health/medical bullshit from non-bullshit, “self care” – staying at optimal health and staying sane during this time, and elevating our selves and others so that this crisis brings out our best. If this gets to be too much for one session, I’ll continue these subjects tomorrow. I plan to do this nightly as long as people are interested and as long as I’m helping.”

You will be able to view the videos after the live talks are over, but they won’t be interactive for Q&A as they are in real time.

Please let me know if there is anything in particular you’d like me to touch on during these talks.

Stay healthy. Stay home. Stay away from others.

M-ing My Own B – Or Not

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Sometimes I suck at minding my own business. Usually I’m pretty good at it, but it’s harder for me when I really care about someone. And unfortunately (or fortunately, which is how I generally look at it), I really care about a lot of people.

So sometimes I open my big mouth.

When I do it in a way that I know risks crossing a line, it’s because 1- I know what I’m talking about, 2- I genuinely believe that disseminating the information has the potential to make an impact on someone’s life/health, and 3- I care about the person enough that the risk of pissing them off is outweighed by the potential that the information/suggestion will do good in that person’s life.

And it’s hard to take the doctor out of a doctor. When a patient is sitting in front of me in an exam room, or when a medical advocacy client is talking to me about a health/medical/weight-loss issue, I have carte blanche to give my opinion. I mean, that’s why the patient is there, and that’s why my clients pay me. They asked for my opinion.

But sometimes, when something is revealed in a personal, not professional interaction, and my opinion wasn’t asked for, the doctor in me comes out anyway.

It actually comes out all the time – like most docs, I’m always analyzing, synthesizing information, asking ridiculous numbers of questions, and trying to find answers. That questioning is probably inborn and leads a lot of people to become physicians, and through the process of becoming a doctor it is honed into a sharp weapon of third-degree-interrogation.

And then information comes out that puts me in a spot of feeling compelled to offer unsolicited advice. So of course it’s my own fault.

Anyway, I was with a (relatively new) friend today, and what started out as normal small talk conversation about candy bars and fast food got Abi-ified into a little more questioning and resultant disclosure that this friend and his wife “really aren’t doctor people,” and therefore he had no idea about his blood pressure because he hadn’t seen a doctor in almost 40 years.

Which of course then shot my blood pressure up about 20 points as I swallowed and thought about 1- how doctors in general have done a horrific PR job and how a doc with a less-than-ideal bedside manner can turn people off from all doctors and how the corporatization of medicine is making that even worse and driving wedges into whatever tenuous doctor-patient relationship had been there in the past, and 2- what, as an internist, are my biggest worries when a middle-aged patient walks into my exam room who hasn’t seen a doctor in decades and what are the things most likely to kill him if we don’t check now and what is a person who’s not-a-doctor-person possibly going to listen to and would have the biggest potential impact of overall health, function, and longevity and if I say something to this person in front of me who’s not my patient or client am I going to annoy him or piss him or his family off and cause problems or if I say something could I maybe get him to consider getting just a few basic things checked and save himself and his family potential heartache or if I don’t say something will something awful happen that I could have prevented by not being chicken-shit and just saying something.

Yes, I always have that many thoughts at once. I should really learn to meditate.

But yeah, I said something.

In the few-second brain arc between his disclosure and my opening my mouth, I figured the things with the biggest bang for the buck would be checking blood pressure, screening for diabetes, and colon cancer screening. There’s more, but if I had to pick three, those would be the big primary-care-doc-office-visit items I’d hit first (at least without knowing any other specific medical history, and even with my incessant questions I do have an understanding of basic boundaries and don’t do complete medical interviews with my social contacts), so I suggested he consider seeing a doc to discuss these things and explained (minimally) why they were so important. If he were a woman, I’d have thrown in suggesting a PAP smear and a mammogram. And if I had thought fast enough, I’d have also recommended a flu shot and a tetanus booster and a few other immunizations (which, if he actually goes to a doctor’s office, the doc will suggest).

I assume he won’t listen to me. But maybe he will. I’ll zip him the name and office number of a doctor I know and trust who works near where this friend lives.

If someone with professional knowledge of building structures were in my house and noticed a crack indicating a loss of structural integrity, I’d want him/her to tell me so I could do what was needed to prevent my house from collapsing. If someone with a knowledge of cars heard that I changed the oil in my car myself so never took it in to the mechanic but I’d never checked any fluid levels or spark plugs or tire treads or break wear, I’d want them to share their expertise and tell me what I didn’t know so that I didn’t end up broken down on the side of the road in the middle of nowhere or in an accident because of something that could have been prevented or caught early and fixed.

I really don’t want to be a pain in the ass. But I do show my colors pretty openly, so if someone chooses to spend time with me then they are well aware of my pain-in-the-assness.  

Somewhat recently, I didn’t like the description of a complaint by another friend of mine when we were exercising. I pushed her to see her doctor immediately. I was a pain in the ass. And it turned out she needed cardiac bypass surgery.

So yeah, I’ll keep on being me – a pain in the posterior who asks a lot of questions. At least you know that if you’re getting unsolicited advice from me, I’ve spent some brainwaves agonizing over whether I should have said anything.

A Letter to a Young Writer

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So.

Doug and I have grown three pretty amazing people. Mostly by luck, but we’ll take credit for having introduced them to good music and the great outdoors, and for teaching them to cook and to change a tire.

One of the best side effects of growing these people is that they end up finding other amazing people and bringing them into our lives. They’ve brought us a nice bunch of extra humans to love.

One of these delightful bonus kids is Caroline, a brand-new college graduate with fantastic culinary, percussion, and theatrical skills. She is also a writer. Her latest blog post deals with sensitive personal medical issues and she does an excellent job of explaining the clinical aspects. Her account is raw and honest. She also touches on doctor-patient relationship and communication issues, and she has kindly given me permission to weigh in on these. (You can read her post here – you’ll want to keep that tab open so you can click through and read more of her posts later – she’s a great storyteller).

Dear Caroline,

In your post, you share openly about experiences with very personal gynecologic issues, and in doing so you give other people the power of knowledge to seek help for themselves. You describe some interactions with doctors that are far from ideal, far from helpful, and which need to be addressed.

One can read what’s behind your words. Your title: “My Vulva is Melting (And Yours Might Be, Too),” was developed because of the shock/impact your physician’s specific word had on you. You put a picture of a slightly melting ice cream cone in the part of your story where you relay your doctor’s words. And you repeat the word “melting” a few different times. It obviously (and understandably) disturbs you.

Doctors learn a whole language of medical terms. We learn to speak precisely with this language. And then we learn to translate it back into language our patients can understand. Sometimes the translations leave something to be desired. What your doctor was describing is called “adhesions” – tissue can adhere to other tissue and become permanently attached. This is what your doctor meant. By trying to simplify medical terms, your doctor conveyed a confusing and upsetting image. Thankfully she was later able to explain what she had meant, and I am glad that she is helping you deal with your medical issues.

Several parts of your story hearken back to experiences with prior doctors, ones who do not seem to have been successful in positioning themselves as listening, caring, medical professionals who were in your corner. This is not to say that they weren’t, but they did not succeed in convincing you that they were.

When you describe an episode in high school in which mononucleosis caused gynecologic symptoms, you describe your doctors as not believing you (they were sure you had an STD even though you had told them you weren’t sexually active). You put a GIF in your post describing doctors as sadists who like to watch lesser people scream, and the caption of that GIF describes the physician doing a procedure roughly, as if to be punitive. It was humorous – you frequently use humor in your writing, and it’s humanizing and wonderful. But there are elements of truth behind much humor, and I worry that you thought a doctor was trying to hurt you or didn’t care that they were causing you pain.

I believe fully that this was your experience. And I highly suspect that this was not what was in the brain of the doctor.

My medical school class had 300 students. I knew most of them. One was an irredeemable asshole. The rest genuinely were there because they wanted to help people, but some didn’t have the best communication skills. I have found a similar pattern among the practicing physicians with whom I have worked. In fact, the doctor assholes are generally assholes to other doctors who they believe are not doing the right things for their patients. The overwhelming majority of doctors really do care about and want to help their patients, and they dedicate an enormous proportion of their lives to doing so. But sometimes they suck at parts of it.

Doctors are trained to look at signs and symptoms of a patient and synthesize everything they’ve learned in in-depth academic and clinical courses to come up with a differential diagnosis – a list of things that could be causing a patient’s presentation. Docs are taught that, in general, hoofbeats mean horses, but occasionally there’s a zebra. If it looks like a duck and quacks like a duck, most of the time it’s a duck. But not always.

If a doctor suspects an STD in an adolescent, it would be gross malpractice not to test for one, no matter what the patient says about risk factors, because missing that diagnosis could result in irreversible long-term sequelae, such as permanent infertility. Or severe systemic infection. And, for a variety of reasons, people frequently don’t give their doctors the full story (and a large proportion of sexually active teens deny sexual activity if they think their parents could find out). It’s simple to check and rule out an STD that could have potential devastating consequences. But that needs to be done in a way that respects the patient so that she feels she’s believed and listened to. “I know you told me that you’re not sexually active and I believe what you tell me. Because this looks so much like X, I’m going to test for it even though the fact that you’re not sexually active makes it very unlikely. I am looking for other causes, too, and I need to be complete.”

As far as the rough, painful specimen collection, there is of course a chance that the gynecologist was a sadistic asshole. But the far more likely scenario is that the doctor had not established trust and didn’t talk you through the procedure. I suspect it would have made a difference if the doctor had said, “Those ulcers are probably quite tender, so when I swab them to send some cells to the lab to figure out what it is that’s causing this, it’s going to hurt. I am using a soft, cotton swab, and I will be as gentle as I can be, but it may feel to you like I’m using sandpaper. I’m sorry that this is painful – I want to figure out exactly what this is so I can help you get better.”

In describing seeking help from a previous gynecologist for symptoms related to your new diagnosis, again there seems to be a deficit in communication. It seems that the doctor may have only been suspecting horses of making the hoofbeats, or at least the doctor didn’t let you know that other causes were being considered. It’s the doctor’s job to come up with the differential diagnosis, but sometimes it helps if a patient asks, “what else could this be?” – then you know what else, if anything, the doctor is thinking about.

When you reported to that doctor that you had pain during sex, the doctor made sure to tell you to stop your partner if you were in pain. Your response in your piece (not to the doc) was the equivalent of “no shit, Sherlock.” Yup. It’s all well and good to advise a patient not to do something that causes pain, but if a normal activity causes pain, it needs to be evaluated thoroughly. A reported symptom needs to be addressed. Perhaps your doctor would have investigated further had you not politely let it go when you received a “’Doc, it hurts when I do this,’ ‘So don’t do this’” message – a request for more thoughts might have prompted more response. “I of course stop when it hurts. But it’s not supposed to hurt. I’m not doing anything rough or unusual. What are your thoughts about why I might be having this pain?” might help a doctor who’s overwhelmed with patients stop for a moment and really focus on the one in the room. (Please note – I’m not at all “victim blaming” here – it’s absolutely the doc’s job to do all this anyway, but doctors are under significant pressure and sometimes a gentle nudge goes a long way).

Your advice to your readers is to listen to their bodies and investigate anything that seems abnormal for them. You balance this with a caveat against self-over-diagnosis. I second your advice wholeheartedly. Advocate for yourself. Don’t walk out of your doctor’s office if you don’t understand what was said to you (by the way, I’d be happy to discuss ureaplasma with you), or if you don’t think your issue has been heard and addressed. There might not be an immediate answer, but there needs to be a plan in place to find the answer and address the issue.

I also highly suggest that those on their way to becoming doctors listen to these stories. They need to hear their patients. They should be writers themselves – understanding the importance of words, understanding the importance of pictures, and always thinking about how their patients may be hearing them.

Thank you, Caroline, for sharing your stories. People are learning more from you than you know.

Some People Don’t Listen

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My official medical advice is to avoid hot tubs. Always.

They’re germ soup. The temperature is perfect for bacteria to thrive and multiply. You can get some nasty skin infections from going in those things, it’s possible to get lung infections from pathogens aerosolized by all the bubbling, and heaven forbid you should get that water in your mouth.

Just say no. Period, the end.

So after my workout this morning, I got into the hot tub at the gym.

When you’re a doctor, you’re always weighing risks and benefits. You’re uber aware of risks. It’s such a bedrock of the years of medical education and training that it becomes ingrained, automatic, a reflex, to think of what can go wrong with any decision you make and how you could kill someone. You’re also weighing how any decision you make can help someone. It’s a balance.

Anyhoo, back to the hot tub.

I recently decided to kick my fitness routine up a few notches. I pushed it a little too hard, and a few days ago I pulled a muscle.

Nothing like doing that to make you feel old.

I rested it a couple days and got back to my workouts yesterday and today. And today’s workout finished in the pool. Right next to the hot tub.

My muscle was a little sore. And the pool was a little cold. And the jets in the hot tub were on. And I knew how good it would feel to get in that hot water and hold my sore muscle near a jet.

I thought about the likely bacterial level. And I thought about how I see gym personnel checking pH levels and adding disinfectant regularly in both the pool and hot tub.

I thought about potential skin infections. And I thought about the fact that I haven’t shaved my legs since two days ago so probably didn’t have any micro-nicks in my skin where bacteria were likely to get in.

I thought about potential lung infections. And I thought about the fact that I have a good immune system and healthy lungs.

I thought about the potential of accidentally getting any of that water in my mouth. And I thought about how easy it would be to keep my face out of the water, and that no one was splashing.

I got in. And put my sore muscle against the jet. And stayed there a good 10 minutes.

And damn, did it feel good.

And it stopped the soreness.

I got out, took a shower (I may or may not have soaped up a second time), got dressed, and went on with my day.

Glad that today I did not follow my own medical advice, and will let you know if I end up with hot tub lung.

New Year Wishes

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May your last few hours of this year be relaxed and happy, whether that be reveling with family and friends or snuggled up on the couch in pjs.

May your new year be filled with triumphs big and small.

May you have enough challenge that the above triumphs mean a lot to you.

May those who are mean to you develop recurrent hives.

May your teams win, unless they’re playing against the University of Michigan. Or unless your team is Ohio State or Notre Dame.

May your family members tease you about your teasable traits, and may you come back with your comebacks in the moment, not hours later in the shower.

May you find really good recipes that make kale, quinoa, and other stuff that’ll make you live forever taste good enough that you don’t want to die while eating it.

May you see a bunch of really good movies and read a bunch of really good books.

May your favorite Netflix series be renewed for another season.

May you spend enough time in the mountains or on the ocean or in the woods or on a lake or in the city or whatever floats your boat. Figuratively. I know mountains, woods, and cities don’t float boats. Well, Seattle and Venice float boats. But I digress.

May you breathe, love, and laugh deeply.

May the children in your life provide you with multiple moments you’ll tell their dates about in the future.

May your arguments change someone else’s opinion, and may someone else’s arguments change yours.

May you find physical exercise that relieves your stress and makes you stronger. Unless you’re on a Notre Dame or OSU team (see above) – then the stress relief wish holds, but not the making you stronger part.

May the people you spend long times in the car with enjoy the same music you do.

May you dance.

May you sing.

May you learn.

May you grow.

And again, because I cannot stress this one enough, may you laugh.

Happy New Year.

Love,

Abi