Wednesday, September 29, 2010

Teachers and Students in Medicine

                                              Knowledge (statue in Turkey)

All hail to the teacher. And yet what has become of the student? The ignominy that resides in hubris leaches out slowly and steadily into our reality. We the teachers now expressively ensconced on the upper rung of the ladder given grief from the publish-or-perish-world conspire to manipulate data to suit the world’s thirst for knowledge. We the teachers face the glut of questions answered with the thin veneer of specialized words that mean nothing and impart nothing. We the teachers hatched into a world belaboring to achieve fame and recognition lose sight of the young student that puts out his or her hand and asks, “May I have a little more sir!” This little person with a brain that is a sponge for knowledge is left threadbare with patches of knowledge, a confusion of ideas and a dose of cynicism that will fit the mosaic of a future reality.

What is it that inspires a teacher must undoubtedly inspire the student. And yet if the inspiration is drawn purely from a function of self-advancement, then all hope for the fundamental grant of imparted knowledge becomes riddled into the fabric of misappropriated facts. It is from this misunderstood and fragmented knowledge base that the mind of the student must grow and encompass and learn to practice in the minefield of human-diseased indignity. How can they, in all likelihood, ever accomplish such lofty goals?

I remember those days when I was a student. They were heady days long in the hour and short on time. There was a constant barrage of questions and answers, some answers were short but paved the way to search for more details while others were to the point needing little exposition. The battle of wits continued between the student and a bevy of very smart, considerate, careful and thoughtful teachers. These were the old guards. Their purpose was to educate and create the models from which new knowledge would sprout. They felt pride in calling someone their student. Their pride flowed in the words “my student.”  We were their calling card.

But most of that is gone now. Today the race to produce circumvents all such glory. The race is all. There is nothing but that race. The teacher walks into the lecture hall rushed for time, gives out a test and sits down at the desk to contemplate his own issues. Remarkably, the students have come to know that never is any time to ask questions. Just listen keep quiet and maybe skip classes and then cram by rote from the textbooks before an exam and graduate with a degree. Some students yearning for better grades espouse the cause of the teacher and become embroiled in the “scientific trials,” only to become what the teacher is.

And there in lies the problem, a perpetuity of this distress. What insights might the student have gathered from the textbook about the clinical nature of his understanding about medicine? He might as well have seen the TV show House, MD and come to a conclusion that irreverence to others including patients and their families is the hallmark of being a physician as long as you can call for every diagnostic test and probe and biopsy any and all organs of the body to determine the malady which, I might add may be determined in large measure with a simple art of history taking and thorough examination. Yet, House MD an actor with no knowledge of medicine and far less as a sympathetic human being, watched by millions as a recalcitrant intellectual, is idolized as a hero. My, My what have we come to? And no you don’t have to become a Sherlock Holmes and trespass into someone’s home to determine there is mold to realize that a fungal pneumonia is a possibility in an immuno-compromised host. It all stems from a dysfunctional nature of thinking. The very essence that makes us humans has been slowly and quietly through mechanisms of studying the study habits and measuring the measure of accomplishments or deifying a phenomenon of teaching that lasts a season of endearment, we have lost and tripped onto this societal debacle.

When did it all go so different that now we need to analyze “how to teach?” and “how to learn” There are countless articles and books and magazine reviews about the art of learning. There are empty words that skim the surface of intelligence amongst the discussants who sit with their noses turned up high and their brows touching their hairline or if not, wrinkling the elegant bald scalp that gives them the air of arrogance, but through all this chicanery, does nothing for the students. Words like “Metacognizant” and “Concept Map” and “Mind Map,”  resound in the circles of these ivory tower individuals that have become so bloated from self that their ballooned faces have turned their eyes into slits from whence they cannot see.

The function of teaching is to educate the student with the known knowledge. This knowledge is not abstract. The basic building blocks are the firmament of Anatomy and Physiology. From there the Pathos that inhabits the human body can be understood. From the knowledge of Embryology a branch of Anatomy becomes the building block of childhood disorders dealing with malformations such as the 

Tetrology of Fallot and Dextrocardia. Equally, knowing the basic understanding of the Kreb’s cycle can help in the understanding of hypoxemia and its effect on various organs and from there to the acid-base disorders that do ensue. It is not the temporary, the latest, the trendy knowledge wrapped in a euphemistic term called "evidence." It is the deep unchanging rule of nature. It is fact.

Similarly understanding the cell growth cycle and the proliferation of the cells into daughter cells hastens the knowledge of how malignancy starts and spreads and how medicines like chemotherapy counteract this wayward behavior. From there the students can garner knowledge of the cell surface receptors that line every cell surface and respond to the various antibodies, hormones or specific chemicals and through knowing this reward themselves with the understanding of the intra and intercellular pathways that motivate the cell to grow, divide and multiply.

The building blocks to “know” medicine are essential to the gaining of a foothold into the reality of disease. Knowing and citing literature about esoteric and unusual medical cases may seem smart and lofty but it isn’t. It is true that the knowledge and understanding of diseases keeps changing like the shifting sands of time, yet the basic mechanisms of health remain constant. Build a strong foundation and the structure shall survive a large measure of time. The gifted Sir William Osler, MD was one such teacher that touched the pinnacle of educating students.

               Sir William Osler, MD

Physiology teaches us the mechanisms of normal activity of each organ and the combined pool of organs within a system. Since most organs are interconnected with vasculature and neural supply they, the organs talk to each other via chemical and neural circuitry. An assault on one is an assault on the entire soma. Learning about heart failure is not about learning the thousands of medicines that keeps the contractility of the heart muscle, nor is it about the extra fluid buildup that needs to be purged. What it is, is the knowledge of heart muscle’s decline from impeded vascular supply or overworked fatigue or age and the congested channels that flow into it, the organs that get flooded with extra blood and become dysfunctional with the excess fluid within their tissues. 

The liver so congested cannot process the food hence the patient loses his or her appetite. 

A continuous congested liver leads to bile-flow stoppage which shows up as jaundice and equally in that chain of events, the inability of the congested kidneys from filtering the excess blood from its waste-products leads to acid-base disturbance from the electrolytes, leading to acidosis. This excess acidity creates a damning effect on the blood factors contained within this humor, which can ultimately lead to a disseminated intravascular coagulation that can cause spontaneous bleeding from any site and can be fatal. It is from here to there to everywhere! 

So the vehicle that transports the “waste” is equally important as the heart that pumps the blood, which is  as important as the liver that filters the food products and makes the blood factors that keep the blood in a congealable state. In essence the cumulative damage from a single organ mishap leads to a multi-organ dysfunction. It is in this measure of understanding that the furtherance of knowledge is achieved. The connectedness of it all!

                         The Doctor by Luke Fields

Once the basic building blocks are firmly entrenched the nuances of each block can then be enhanced with additional information. Knowing the information without the basics is impressive when mouthed but in reality does little for the patient’s health or the physician’s advance in understanding.

So students of medicine, that we all are as physicians, must renew our association with the building blocks now and again to keep ourselves in the loop of understanding.

And teachers of medicine remember the time you are spending with the students is more important then the hours spent citing literature to your cohorts. If you are after fame, remember that the student will echo your name throughout his life. The Galley proof that is held in your hand that makes you expand your chest will soon be placed in a heap; forgotten. It is better to be a giant upon whose shoulders the student learns to stand on and see where others fail to, then an empty suit that hollers and demands silence but gives little in return for that demand. If you are after educating then you are the teacher the student will walk with in lockstep.

Can teaching be mandated and in the same vein can learning be forced? The answer is obvious to all. No and no. Where a student desires to learn and a teacher is passionate to teach the combination can have far reaching benefits for the student and the society in general. It is the passion that emanates from the deliverer of the message and the desire that resides in the receiver, which makes for a great future. It is a powerful reach into the expansion of understanding that is devoutly to be wished. 

Sunday, September 5, 2010

Being a Physician

She had recently celebrated her Emergency Board Certification. After completing her 12-hour shift, which had consumed two extra hours of paperwork and transferring of patient data to her peer, she had finally left the hospital at 1 AM. It was a clear still night; the stars were out in their full majesty. Somewhere in that 25 miles of car ride between work and home, her eyelids grew heavy with fatigue. And then there was a veteran rheumatologist moderately obese from the love of Cheeseburgers who had just completed his “patient-rounds” in the hospital and had made his way back to the parking lot. He felt tired that evening, so instead of starting his car and rushing back home, he wanted to just sit in silence in his car for a moment, to luxuriate in the oft desired but mostly elusive of life’s benefits; respite, unfortunately for him that moment never ended.

Those arduous moments of loss have a pungent vulnerability to them. They sting your senses and dissolve the cloak of aloofness. They come too close for comfort. The sun was still beneath the horizon although the faint echoes of the reddish hues were just beginning to stream the sky. I walked lockstep with my surgeon friend. It was a chilly morning, cloudy with doubt and question of rain and the fine misty breath of my friend dissipated quickly as he spoke of his late night encounter with a ruptured aneurysm. He rubbed his hands while we walked in through the automatic doors together and said, “You know, I think I will go to the ER, I don’t really feel that well.”  Twenty-four hours later after a three vessel bypass he was recumbent in the intensive care unit watching the flickering nonsense on television.

It is a strange life we have, I thought. Strangely attractive for the lofty goals to help human survival and banish misery, and strangely repulsive for the loss of self and banishment from living. So the following day when work had depleted all sense of personal thought and subjugated the sense of loneliness, I made my way to the hospital to care for my patients. It was a cold and chilly day once again but a beautiful clear blue sky as a rejoinder to the recent past. Things were looking up? I thought.

“I walked five steps today.” He said, with a tremulous voice bordering on great joy. He was an elderly man laid up for all the wrong reasons. Medicine was a labyrinth of chutes and ladders for him. He would make the arduous climb to slowly feeling better and then something would eject him down the chute. It gave him comfort to have this modern day vision of healing around him while he lay in the hospital bed. This was not a path he chose and neither was this the environment he preferred; yet there he was concealed behind the dubious smile of doubt and concern. Lets call him Joe.

“So Doc?” Joe asked with that quintessential cliffhanging question that lingers on the edge of the tongue barely able to roll of it. I knew where he was going with this daily dose of salutation. “Well Joe it will be a few more days.”

“I was afraid of that.” He said, his smile vanishing behind the obvious layer of despondency. I had barely turned to withdraw myself from the room when he asked, “Will I ever be back to myself again?”

I held that question for reasoning a bit longer than I normally would. “Depends Joe, what you mean by that. Are you referring to your thirties, forties, fifties, sixties or your current seventies?”

“Forties would be good but I know you are no magician.” He said, again the smile back on his face.

“Back to where you were functional and all before you came in. That is very possible provided you keep that smile and follow along with my advice.” I don’t know what made me say that to a dying person, but there it was all laid out. The sound waves had crashed against both our eardrums and the promissory handshake and a mental agreement between two parties was hammered out. Although the very premise of such a promise was out of frame with reality I had uttered it and we had both committed it to memory. Even though life and death are extreme colors within the same spectrum, he, unfortunately had by circumstance and age, been granted a passage to the “undiscovered country from whose borne no traveler returns.” But there it was a promise spoken, assimilated, accepted and expected.

Time dilation did take pace as I searched and broke some spines of books and journals that had never been opened in the hospital library. Day after tedious day, the ordeal of finding the right peg to fit the circular hole became a trying ordeal and an emotional drain. Somewhere in there the consequence of reality disturbed the manufactured realm of fantasy. I continued to cheerlead. He needed my best and I was not going to disappoint him. I felt he could see through my limits and yet he played along. Then on the sixth day of searching, I discovered this obscure letter to the editor in a medical journal describing a similar patient in a nearly identical situation. I discussed that with Joe and his family, the ramification of such a trial of medication. He agreed whole-heartedly saying, “I trust you doc.”

A sense of trust weighs heavy on the conscience. It has a way of redefining how you see the world. It provokes thoughts of success and failure. It energizes the spirits and with one turn of the screw pulls the plug. It fills you with promise as equally as it depletes the soul with worry of inability. It is the very essence of humanity based on kinship and yet it has a heavy ball and chain attached. It is the root of the bifurcated self and non-self.

The next morning after that “Hail-Mary” pass, I found him lying in his bed barely coherent with his left atrophied leg hanging over the bed-rail. His responses were barely discernable from known linguistics. The decline was dramatic. The torture of that decision had just begun to weigh in and would lead to a sleepless night of “shoulds and coulds.”

What drives us to spend countless hours advocating an imperfect science? To spend decades of life in the pursuit of learning a science that changes with every season like the colors of the leaves. Science is a constant river of knowledge that flows and remakes the shores of understanding, keeping the delicate sense of balance between right and wrong in constant flux. Ethics abound in the issues of nurture, care, compassion, and comfort and agony-sparing decisions made by the bedside, daily. All those years of experience in that complex grid of nature makes it no easier to fail against her fury.

What drives one to suspend sleep for the care of another? What makes physicians commiserate with the family faced with the difficult decision of life and death for their loved one? What makes a person shun the darkness before daylight and the darkness after sunset to work through and call it a “work-day?”  What makes a physician, eat on the run, sleep on a wink, surround himself/herself with the prattle of pain and grief and call it a life?

The rewards lie in the memories of smiles on faces. The comfort afforded and the lives saved from the brink of death. There is no other profession quite like a doctor’s that lives with the misery of his or her patient only to grant both the dignity of respect, virtues of comfort and in most cases a future.

Patients are like butterflies caught in a gale, confused, frightened and totally overwhelmed. To sooth, to heal and to allow them to circumnavigate the jagged rocks and swirling deep pools of nature’s wrath is hallowed ground.

The word physician relates to metaphysics and is derived from the adjective “physikos,” meaning nature. This nature’s dislocated confusion is remedied by the art and the right sprinkle of science by one such individual called a “physician.”

It is in the healing of the sick and the love of such an endeavor that those inflexible hours of demands compacted between unsocial timelines creating great personal stresses make the trauma to forge against another’s worth the while.

Getting back to our story of Joe; On the third day after the trial therapy Joe was found sitting by his bedside, eating a full breakfast that had alluded him for weeks.

“Doc how did you do it?” he asked as he rubbed his thumb and forefinger on his cleanly shaven chin. I had not. “You did it Joe. Your strength of character and determination.” I said.
“Doc it must be rough on you. Isn’t it?”
“No Joe, seeing you like this makes it all worthwhile.” I replied.

He wheeled himself under the concern of his transporter to the lobby to meet with his family under the banner of balloons and get well cards.

So Dear Joe, whoever and wherever you are, know this that the doctor tending to you has lost the virtues of societal living, worry-free comfort of his/her daily life so he/she can vouch for yours. His/her years of knowledge and experience are there to provide you with the best care and comfort modern medicine can afford. Limit not your thoughts with the media’s snippets of “good doctors and bad doctors.”  The media makes up things as they go along. Their vested interest is as long as the next broadcast and ratings. Diseases are not cured in an hour after subjecting “patients” to countless biopsies of every organ and diagnostic tests as shown on the TV program “House, MD” nor are the doctors crippled with reliance on narcotics with irascible demeanors. Physicians are humans who take pride in healing. Do not cross into the cynicism that plagues the politics of medicine, for many will disavow the goodness in medicine for the sake of personal ambition. Understand this that your physician is there for your healthy life. To him or her you are a person with a past, present and above all a future and that he or she will try, forearmed with the knowledge and the experience, to win the fight for you against the vicissitudes of what diseased your body. Your health is a testimony to his or her endeavor. Trust him/her and have faith in his/her abilities. Let your physician find the key to unlock the virtues of good health for you. It will make you both happy.
So for now Joe, “Live well!”