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And the Oscar Goes to "Surgery: The Movie"

We only spoke for sixty seconds, a chance meeting at the breakfast line on the last day of a conference. It was an intense minute of conversation, though, as we had met exactly one year earlier on the sun-lit streets of San Francisco. We realized then that we were both actors going through medical school, him a film actor, me a stage actor and we were eager to compare notes. When we met a few days ago, the parallel path that linked our stories became even more aligned as we both happened to have just completed our Surgery rotations. "What did you think?" he asked eagerly. "I liked it" I said. "So did I!" he responded with enthusiasm before I had barely completed my response. "It felt familiar didn't it?" I probed "The Operating Room is like a . . ." "A movie set!" He completed my sentence. I was actually going to say stage as I thought of the lights, the roles, the robes and rituals, but his reference point sounded interesting and I listened for more. "First, all the "techs" (nurses, students) set up the "set/OR", then the "talent" arrives (fellow or attending) when everything is ready to "shoot" (cut). I would love to have heard more, but the program was beginning and we parted to find our seats. But my partner in crime was right, surgery is in many ways, a movie . . .

You the medical student start off as an extra. You are careful not to step into the spotlight in the center of the operative field. This is the domain of the "lead actor" (the attending surgeon). Then you have to be careful not to be in the space of the "supporting actor" or first assistant (fellow or resident). Just when you think you have successfully found your place, you bump into the "props table", the sterile collection of instruments carefully prepared by the "props master/scrub nurse." Sometimes the best place to watch an operation is in "the wings" behind the curtain with the "stage manager/anesthesiologist." These are the silent controllers of the action doing things the "audience/patient" never really sees like calling light cues or maintaing adequate sedation. And yet, they are crucial to an effective "performance." As the extra, being in the OR can feel like a thankless task. Long operations are a test of focus and patience and are also a time when many decide on their specialty . . . or at least eliminate one. The most you might do in some operations is cut the suture with a pair of scissors. But for some, and I include myself here, there are those moments when the extra does a little extra, and can make even a long operation somehow worth it. The long silence is broken with a question about the operation that leads to an insight, or the offer is made that is both terrifying at first but ultimately most satisfying, "Would you like to close?" With surgery, you move from the "table-readings" to the stage or the set and you perform with eyes on you including the residents, the nurses and the anesthesiologists. But you take the leap anyway, stumble, fall and try again. It is not for everyone, but for some . . .  Like strange early morning movie shoots, surgery rotations have demanding hours that include rounds at 6am, operations, clinic, floor work, rounds again and all the patient care in between. At some point we all must ask, "How much do I want this?" or even "Do I want this?" like the aspiring performer who must also persist despite daunting odds. 

*** Different colored tears***

But like most metaphors, this one reaches its limit. Surgery is not a movie. Mistakes can't simply be edited. The sacred threshold of the body is crossed and can't simply be cleaned up with make-up. Lives truly are at stake and are changed on a daily basis. And despite the fact that the surgery is "rehearsed" and there is a surgical plan, some moments can't be prepared for . . . as I found out when I went on my first organ procurement while on the Transplant service. I jumped into the car, joined the fellows as we rushed off to pick up a newly available liver. We arrived at the hospital of the donor and then a few moments later they wheeled him in, a four year old boy. He looked like he was peacefully sleeping. But he wasn't. He had been brain dead for several hours. All breaths now were external, all heartbeats created, all life illusory. It was a difficult sensation when I first saw him. I could only imagine the anguish of his parents; and yet, there were another set of parents sixty miles away feeling the swell of hope for the first time as they awaited the new liver for their sick child. They were crying different colored tears. This whole encounter felt surreal and sacred to witness. I was not expecting the fellow to say "Jonathan, come and do the final closure." It is not unusual for medical students to help close the final skin of an operation. But this was different; this patient was not going to wake up. I felt that my suturing here was not just the sealing of a incision, but felt almost like a funeral rite. I remember thinking, "I just want this to be neat, in his honor." Six hours later,  his liver was in another little boy, and a life was changed. 

Now, not every day on surgery will be this dramatic or poignant, but that day was. Like in a movie or a play, victories and failures in surgery are all too visible and that's hard and exhilarating. Surgery is simultaneously bold, yet vulnerable, assertive yet humble, or at least should be. 

And so, the operation and the performance end, the lights go out, the patient and the audience leave the room and the actor and the surgeon watch after them and silently think, "I hope what I did changed that person for the better . . ."

What Will Happen? Dealing With the Challenge of Uncertainty.

Three lives abruptly altered in a matter of minutes. For Henry, a hard working 65 year old engineer, it was a walk in downtown Ann Arbor that turned into a stroke taking half his mobility with it. Would he be able to build again? For 88 year old Angi, it was a doctor’s office visit that turned into a swirling sensation that led her to the brink of death two hours later. How long would her daughter get to be with her mother? For Alexi, it was the morning of his son’s wedding when he lost consciousness following a stroke, only found because he was late for the wedding. He doesn’t speak English. In fact, he can’t say anything right now. Will he speak in any language again?

Uncertainty. It’s an uncomfortable state. Medicine attempts to decrease uncertainty with percentages, trends, labels and precedents. But ultimately, nobody really knows what will happen. This week has been paradoxical in that the sickest and the oldest patients have actually turned out to fare better than those seemingly less afflicted. Again, uncertainty. So I have wondered this week, what is the healthiest approach to uncertainty? Is it to battle it with information, data and analysis? Should we constantly try to decrease uncertainty? I saw several strained expressions of family members this week eager for the doctors to answer what they should expect. Will Henry work again? Will Angi leave the hospital? Will Alexi speak? It would seem that the humane thing to do is to eliminate uncertainty, but that is often not possible. Then what? Platitudes? Well meaning but ultimately hackneyed sentiments like “Hang in there”? What is the best response to uncertainty?

I think uncertainty, though uncomfortable, can achieve something worthwhile. It can put our focus squarely on the present. We may not know where we’re headed exactly but the right now can be attended to. Angi’s daughter wanted to know if her 88 year old mother would make it. She listened stoically as the doctors explained what they were up against. I was impressed with her resolve given the intense, high stakes setting of the emergency room and the grim details of her mother’s condition. All of a sudden, her mother reached out her hand shakily, unsure of where her daughter was. Her daughter rose to grasp it and held it against her face. A few seconds later, tears streamed down her face and onto her mother’s hands. It was the expression of someone who did not know how much time she had left with the person who brought her into this world. By this point, the docs and residents were busy working on the next steps in her care as was appropriate. I felt I had to go to her. I approached  Angi’s daughter, laid my hand on her shoulder and just looked at her. I wanted her to know that she did not have to be strong at that moment. That it was OK to simply respond with whatever she felt. She looked at me appreciatively. I still have so much to learn in medicine that it’s kind of ridiculous. But I hope I will always recognize when such gestures are needed. If uncertainty is to be confronted, it should never be confronted alone.

A few days later,  my team and I were walking past Angi’s room. We all had a double take as we saw her sitting in a chair chatting with her daughter, both beaming. The story could have had such a different ending. We still don’t know where Henry and Alexi’s stories will lead, but uncertainty also means possibility. And so, who knows?

The Oral Tradition: Third Year Begins

Finally, it's here. After two years of syllabi, slides, tests and exams, the theoretical becomes practical; the stories are now spoken, the patients are real.

"Third Year is an oral tradition" is a phrase I'll never forget from one of the doctors who interviewed me at UC San Diego two years ago. She meant that now, the spoken word, the story, interpersonal communication takes center stage. This is the stage of medical school that I have been waiting for and after my first rotation, it has not disappointed. Let's begin . . .

An Adventurous Life: My First Patient

She had a sly, smile about her, like she was always thinking mischievous thoughts. Her movements were careful and measured. She was 84 years young and one of the first patients I talked to [to protect the privacy of all patients I refer to, I'll simply call her "Amanda"]. I thought I had her story all figured out, probably a life-long resident of Ann Arbor, coming in for check-up. How sweet. And how wrong! Amanda, it turns out had been all around the world as a nurse including Africa. I could tell in which era by the way she referred to Tanzania as Tanganyika (the colonial name). Her escapades included evacuating her entire family from a war-torn region of the Congo in about twenty minutes and driving across the border. But the stand-out moment of the appointment was when she bust out in Swahili and said that medications were "bei kali" (expensive). The last thing I was expecting to do at this appointment was chat in Swahili. Once again, my presumptions about labels and first assumptions were questioned. And that was just my first morning!

Behind the Smile: Later That same Day

You would never know how much she had been through. A young patient is supposed to be essentially healthy, perhaps dealing with strep throat or a bad cold. In her 18 years, Carla (not her real name) had already had complications from orthopedic surgery, seizures, pneumonia and multiple other issues (or co-morbidities as we like to call them). Today, though it was not her physical issues that were on her mind. She is a vocal performance major in college and panic attacks have been part of the picture for her as well. As she described the challenge this presented for her, I saw an opportunity to interject. Having been given the go ahead from my preceptor, I told Carla about my own background in the performing arts and how the relentless expectation to perform at a high level and constantly being on the spot can wear on you. I shared how it takes stepping back and getting back in touch with what attracted you to the art in the first place, tapping back into the simple joy of performance, before the competition, the expectations and yes, the rejections. As I talked, Carla's mouth dropped. She was clearly not expecting to hear this perspective in the doctor's office (even though this was an Integrative Medicine visit). She had the expression someone gets when they feel someone understands their dilemma, not in a cerebral way, but in a "I've been there" way. I do wonder, though, who got more therapeutic value out of the encounter, her or me. I miss theatre, acting and performance. So when an an opportunity within medicine presents itself in this way, the resonance within me is vibrant. I feel the relationship element within medicine and theatre collide and it makes a glorious sound! 

A central theme of my entries is story. I am now at a point when I hear stories on a daily basis. My first month of family medicine has been revealing. I've learned that there is so much more going on in people's lives than you would ever think.

I just read a great play "Dead Man's Cell-Phone" by Sarah Ruhl. In the play she quotes Charles Dickens from "A Tale of Two Cities." in which he describes each human life as a "book of secrets." We each have a limited time to read each other's books, and then the books close. The process of learning and sharing secrets can be unnerving, so we package each other with labels and assumptions because otherwise, who knows what we may find . . . but if we do dare to open the book without presumption or preconception, then along with anything unsettling we may discover-because that is real- there is also a richness of experience in each life that is revelatory, challenging and often inspiring. And so, I await my next story . . .

[My goal in third year is to post at least once a week since there is so much more patient contact now. Neurology begins tomorrow- next post in a week!]

Through a child's eyes . . .

Once again, a poignant moment occurred when hearing from a patient rather than in the classroom. Of course, it should not surprise me by now that I don't get flashes of insight when reviewing the five different causes of diarrhea. I'll spare you the "running" commentary. Sorry for the pun, just had to get that out . . . Ok, I'll stop.

This time we were hearing about a 14 year old kid whose life changed when he learned that he had a blood disorder that would require a bone marrow transplant. We were taken through his story by his doctor, who recounted how the boy's biggest concern was whether he would be out of hospital in time for his senior prom. It was at this point that the doctor shifted in his seat, looked right at us and said pointedly "This is the difference between kids and adults (and why I love working with kids). Kids worry about living; adults worry about dying." This loaded statement got me thinking. Is the transition to adulthood about moving to an "anything but that" worldview? Giving a speech becomes about NOT looking stupid. Interacting with others becomes about NOT embarrassing yourself. Working about NOT losing your job. Parenting about NOT having your kids misbehave. Living about NOT dying. While kids think maybe I can jump that far; I'll try it. Maybe that kid wants to play. Popcorn right after cake? Sure!

It's an easy cliche of course, to talk about the disinhibition and creativity of children versus the social straitjacketing of adults but if life is to be lived fully it's worth looking at those who might not yet have forgotten how to do that. If adulthood is about having a much deeper and richer knowledge of everything of that can go wrong, why grow up?

Of course as doctor, I will have to consider what CAN go wrong. I owe my patients that information. But hopefully I can also imagine brightly everything that can go right and convey that to my patients so that they can believe that they will not only not die, but live.

Looking back . . .

So it's been ridiculously long since my last post so it's hard to know where to begin. I suppose I should talk about what stood out to me this semester. I thought perhaps I would approach this task Seinfeld style and mention some random things and then tie them all together in an unlikely but real narrative. So here we go:

Rose between teeth, low notes, breaking bad news, good acting, empathy, relationship, humility, fragility, memory loss, creative writing. Ok, this list is getting longer than I planned.

On their own, theatre and medicine capture my imagination, albeit in different ways. Every so often , they intersect and then I truly feel like--need some cheesy song lyrics here--like . . . "I'm flying without wings" Thank you Ruben Studdard. That happened this semester when we assembled at the Michigan League to participate in dramatic enactments of breaking bad news to patients or their families. The scenarios involved a professional actor working with each group to be the "receiver" of bad news. I was "banned" from being the representative "doctor" from our group because our instructor did not feel that having TWO actors demonstrate the issue was ideal. I understood where she was coming from. I thought about offering to play the role of a medical student who was not an actor before medical school but that was getting a little much . . .

I was incredibly impressed with our assigned actor, Courtney. I know the focus was on the breaking bad news scenario, but I couldn't help but take in her acting as well. She was sincere, vulnerable and bold all at once, the elusive trifecta of every acting performance. We talked afterwards and it was powerful. I told her about my interest in the brain and she revealed how she used to work with traumatic brain injury patients and how her acting background enabled her to become whomever these patients needed her to be. It was an extraordinary conversation as I felt acting and medicine meet in the medium of compassion and empathy. Little did I know that a few weeks later I would be given a seemingly impossible assignment on a very similar theme:

For our "Giving Voice" Creative Writing Elective, we were asked to create a piece of writing based on an interview with a patient with memory loss. How do you talk to someone about their life when they have forgotten a lot of it? This task reminded me of one of my favorite courses to teach "Departures from Realism." This course dealt with a genre of theatre, Absurdist theatre, in which no clear narrative or character was apparent. These plays could be frustrating for an actor because nothing seemed to make sense, but that of course was not really unrealistic. Life can be absurd and fragmented and contradictory. And I think it was this openness to the unstructured that allowed me to collect my patient's story in bits and pieces and created a much more satisfying arc, emerging without prescription or heavy handed linear direction. We shared our stories with each other and I was impressed, yet again, by the sensitivity and artistic sensibility of those who chose to take this class with me. I cannot escape the connection; the patient, the actor and the doctor are united by the story, except that the story may be elusive or difficult. How then is it discovered? I found I had to assure my patient first that I really did care about her story. Two, that the hidden is worth looking for and to acknowledge that yes, we may not come up with much. In this case, I heard a story fit for any play-- cross country travel, family drama, an unexpected accident and personal reinvention.

Hmm, I didn't get to that rose between the teeth or those low notes . . . a story for another day?

Bad News . . .

This week in medical school we had what I can now call without qualification the most moving and powerful session of my entire medical school tenure so far . . . in some ways I am hesitant to write about it because I'm not sure I can do it justice in print. But I'll try.

The session was entitled "Breaking Bad News" and focused on the difficult interaction that we will all have as future physicians breaking bad news to patients. My concern with such sessions is that they  can be full of platitudes and well-meaning, but somewhat packaged, attempts to comfort a hypothetical patient. This was anything but . . .

After a solid introduction by one of our faculty, we were introduced to two parents, both of whom received devastating health news about their children. The first parent was a mom who learned by genetic testing that her child would be born with Down's Syndrome. The second was a man who found out that his 8 year old son had an aggressive form of leukemia. Their entire stories were compelling but I want to focus on two moments:

For the mom, the moment of truth was the decision on whether or not to maintain the pregnancy. At one point, she asked the doctor what she would do. I have wondered about this scenario before. Is the doctor's job to be neutral and simply give the most helpful information or is there a place to share personal opinion about the choice one would make? The doctor said she would not continue the pregnancy. The mom was ultimately offended by this. She felt the doctor should have been neutral . . . and yet, she asked. So there is also the tricky issue of the patient's contradictory impulses; they are human after all. Bertolt Brecht, the German theater practitioner, spoke of "embracing our contradictions." The doctor, it seems, must somehow lead and follow the patient at the same time! She kept the baby and he is now a vibrant 4 year old. She spoke of how the experience changed her, giving her an almost supernatural patience with other people and appreciation of others and difference.

But what really got me was the man's story. Let's call him Cliff. Cliff had an 8 year-old Matt (not real name) who was diagnosed with leukemia. The story was tragic as Matt ultimately did not make it. But what was extraordinary was a moment Cliff described where his son was in a coma and he had a chance to go up and speak to him but did not. His best friend insisted on going to talk to him and there was an immediate change in heart and rate and oxygen saturation. Matt succumbed not long after that. Cliff was devastated that the doctors did not tell him just how serious Matt's condition was when they induced his coma. He struggles with how badly he wanted to speak to his son one last time and how he wished he could have done what the best friend did and just speak. Watching Cliff describe this story was incredibly moving. It was pure, human emotion. No attention-seeking here or self-indulgence, just a man daring to relive a devastating moment and sharing that with us so that we could learn. At one point, Cliff said "You have no idea how powerful you are in this situation." By this point, I had tears rolling down my own face. Some of this reaction I know was being a parent myself. Anything affecting kids has always hit me harder since having Christian and Cameron. But I was also just moved; I felt so privileged to hear this man's heart. Our faculty member described these moments as "sacred" and that is no understatement.

The only problem with such sessions of course is that it is extremely hard to transition back to the nuts and bolts of textbook content! You just want to process . . . and maybe that's what I'm doing now. I want to use that power that Cliff referred to wisely and empathetically. Nothing else I am doing matters as a physician if I miss that.