Comments on Elder Home Care

Ah, the end of another illustrious week. I spent this week removing my cadaver's heart in anatomy, cutting it open and learning (what seemed like) every single blood vessel in the region of the chest (thorax) that lies in between the lungs, called the mediastinum. We learned a lot of other stuff, too, and the crazy part is that we could have gone into much deeper detail. I am doing an injustice by merely commenting on how fascinatingly complex the human body is, on all levels, from microscopic to macroscopic, there are SO many things going on. I love it. I think the most exciting thing in anatomy, this week, was being able to hold a human heart in my hands and actually trace the route that blood takes as the heart pumps. I've been taking my stethoscope periodically and listening to my heart in different places to hear all the valves as they open and close, which is the lub-dub you hear on a stethoscope. (nerdgasm)

Other things I did this week include lots of ultimate frisbee, studying, and an afternoon of house calls. The house calls were really cool, we visited two different elderly patients in north Philly, and checked up on them to make sure they have the appropriate health care support systems in place to keep them in their homes as they manage all the illnesses that come with growing older. I wrote a little essay as a response to my experiences, which is included below. Disclaimer: I only had 250-300 words to work with. I ended up using ~430 and I still didn't have enough space to get all my feelings out. At the very least, here's a limited representation of what we saw at the first patient's house. (I've edited it a little bit since I last wrote it, to give a more complete picture of what I saw.)
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As we exited the car and walked up the steps to Mr. S’s house, I abruptly realized I had no idea what to expect to see inside. Even though we had just been briefed on Mr. S’s situation, I was not ready for the moment when I finally laid eyes upon this 99 year-old man who was expected to die within the year. I walked in prepared to absorb everything, to be able to fill out my visit checklist, but most of all I wanted to soak in the real essence of the home visit so that it would be imprinted in my memory.

The checklist has us fill out a functional assessment of Mr. S’s ability to perform specific ‘instrumental activities’ of daily living (interaction with the outside world) and ‘activities’ of daily living (taking care of oneself). We observed that Mr. S is blind, almost entirely bed-ridden, incontinent and possibly progressing into a more lethargic state and deteriorating mental health – all of which means that he is largely incapable of initiating any interactions with the outside world (though many people come to him, which will be touched on shortly), he cannot prepare his own medications, needs a lot of assistance to get out of bed and move to a chair a couple feet away, can eat tender food but needs help guiding the utensils to his mouth, and depends on others to bathe and clothe him. All of these conclusions are based on what I've gleaned from his situation, and not from actually spending time with Mr. S. For me, the most striking part about entering his room was seeing him in his bed and realizing that he would almost never leave that bed for the rest of his life. As his situation dawned on me, I felt encumbered by all the things this man deals with from day to day and found myself wondering how he views himself.

Despite all of these challenges Mr. S has an incredibly large, varied, and most of all, loving, support group. He depends on 24 hour care, and has a total of 3 home health aides that come in shifts to perform a myriad of functions: a hospice nurse who helps with medication and other assessments, a social worker, church members who volunteer time to help him out, neighbors, and a number of dedicated family members (which is amazing, considering that Mr. S has no children). All of these people are here to see that Mr. S can achieve his goal of dying at home. It's weird to think about caregivers as allowing someone to die, but the ultimate point is that he will be comfortable and happy til the very end. Evidenced by how many people love him, Mr. S is clearly deserving of all this respect. (If not a 99 year-old, then who is?) The community support that is around to ease Mr. S into his final days is truly a humbling and grand effort.

There were a number of things that hit me as I experienced that home visit. Perhaps the most surprising (pleasantly surpising) was how much the community loves Mr. S. It made me realize how integral a community can be in the life of an individual. Though this experience made me think a lot, I am obviously only starting to understand home-care. Nevertheless, I can see that it definitely depends on a strong support network like the one I saw on my first visit. It's good to see that home care can be a viable (and we found, cost-effective) alternative to a nursing home, hospice or hospitalization.

Well, that's all for today. Time to go celebrate this 'free' weekend, because the next one will have exams looming over my head!

Respect

My thoughts this week have all been about respect.

Throughout my entire life I've been more or less aware of being respectful, and have come to the conclusion that every person deserves respect until proven otherwise - so I always listen carefully when addressed, and always seriously consider how my actions affect others. Most of the time this philosophy works out just fine, and I have meaningful conversations with others. Yet now I have been thrust into a professional world where the hierarchies are becoming more and more defined, and I fear that the day will come when I have to sacrifice being exceedingly respectful so that I can (conceivably) seek the truth or effect the very best patient care. (One very important message here is that I know I am not infallible, and I hope that I can be humble and remain acutely aware of my limitations, and dependence on the expertise of others.)

Example: Enter histology lab. We have a replacement instructor because Dr. Ochs is out giving a lecture to the second year med students. Our group gets started and we're chugging along until Dr. X (I'm not naming him because the point is not to call out specific people) comes by to talk to us about the optic nerve as it exits the eyeball. I will try to spare you the details, but basically we got to talking about how the area where the optic nerve leaves the retina (back of the eyeball) is the cause of the blind spot because we have no sensory cells located there (to make room for the nerve). Dr. X points out that this spot is called the 'fovea', which immediately sends up red flags in the back of my head, because the 'fovea', as I have learned it, is actually the area of the retina that contains the most sensory cells, and is why the center of our visual field allows us to read and see really well. Quite the opposite of a blind spot, the fovea is like our 'seeing spot'. Responding to Dr. X, I voiced my concern in a very non-confrontational way (with the hopes of allowing him to reconsider what he had said), I said, "Oh, hmm, that's odd. I thought the fovea was the center with the highest concentration of photoreceptors, and not the blind spot?" At this point, I can faithfully say that Dr. Ochs (and many other Penn faculty) would have consulted the internet in pursuit of the truth, if they disagreed with me. Dr. X, however, maintained his erroneous statement by repeating it to me a number of times and as a result I felt helpless, like I couldn't respond - like it might be too confrontational, or 'punk-like' of me to maintain my point. Plus, I was starting to doubt a very fundamental fact in my brain, because 'if this professor claims otherwise, I must be wrong...' So I said nothing and tried to agree with him.

I went home that day and looked up the fovea. I re-confirmed that I was correct, and then sat there with a bad feeling in my stomach. Even though this was a debate about a very inconsequential fact in the lab, and shouldn't bother me much, I wonder if similar situations will occur later in life when there's more on the line. The imbalance of power and overall knowledge between student and teacher may inevitably cause me to bite my tongue when I know the correct answer. In the previous situation, an attitude of (perhaps excessive) respect kept me from speaking my mind - I expect my professors to be correct, yet I had learned something that contradicts them. I have not yet found a resolution to this kind of problem, but in looking back on this experience I think that one thing I could have done to mediate the problem was to innocently suggest to check the internet to 'further my understanding of the retina'. That way, Dr. X will realize his error and (hopefully) not feel like I'm calling him out. It's not the best resolution, but at least we can be on the same page at that point.

Clearly I have a lot more to think about when it comes to disagreeing with professors and mentors.

Switching gears, I want to talk about respect for the dead. We started anatomy on Monday of this week, and that obviously set in motion a number of poignant topics to think about. As we cut into our cadavers for the first time, I inevitably started thinking about the man who gave up his body for science so that we could learn. It's amazing how important his donation is, and interesting to think about how we, as students, have to rationalize the fact that we are poking around inside the body of a 90+ year-old man who had a rich and full life. This is a man who lived through the Great Depression, World War II, Vietnam, The Cold War, and many other important 20th century events. On our table lies the body of a man who might have an extensive family in which he was the patriarch, or he may have lived alone. He might have been rich or poor, liberal or conservative, religious or atheist. He has lived an infinite number of possible lives that I will never know about. Instead I know him as the cadaver - and by viewing him as a cadaver it is much easier to dissect his body because we distance ourselves from his humanity. But that is not really how we should do things, we should remember his sacrifice and praise the life he lived, lest we become totally desensitized to the reality of anatomy lab, that these cadavers come from real people. I don't know how I can fully appreciate this man's life, but as a sign of respect to him and anyone who knew him, I want to end this post by saying that I will be eternally grateful for his amazing and selfless donation every day I come into anatomy lab. Every day I will remember to thank him for letting me learn his anatomy. I can guarantee this kind of respect and wholeheartedly feel it for the rest of my life as I continue developing my professional career.

Beginnings

Well, here it goes, the first post in a haphazard blog about life in medical school. I can't guarantee that it will be interesting or funny, the only thing I can promise is that it will be the truth, from my heart. I guess I should start by talking about beginnings. (It's really my only chance to do so, you can't talk about beginnings in the second post and be taken seriously.) Now's the time to talk about the start of med school, how I got here, and what I might do with my life. Actually, I might save the 'future' stuff for later, because I have no idea what to do with my life. That'll come later, they tell me.

So I've been living in my apartment for about two months and after the initial shock of being co-responsible for everything here (endless internet hassles, cockroaches, mice, no more meal plan) I have settled in and things are going surprisingly well. After spending four years in the semi-city that Nashville is, I'm glad that I finally have a chance to live in a large downtown urban area. Disclaimer: I love Nashville, but it's not what people think of as a metropolis and it doesn't have the history that Philly does. Furthermore, it's great to be in the northeast... despite all the earthquakes and hurricanes that greeted me during my first month here.

But enough of that, we're here to talk about med school ('med school' is synonymous with 'life', by the way). Every day I am in awe of the amazing things that occur at Penn. Whether it's the research, patient population, our curriculum, or various educational programs and extremely brilliant mentors available here, I can already tell that this is a place that will provide the tools for me to become whoever I want.

One example of the caliber of mentors at Penn: I just got home about 30 minutes ago from a talk by Dr. Richard Shannon, the Chair of Medicine at HUP (Hospital of the University of Pennsylvania) at an internal medicine interest group meeting (I was lured there by free Indian food). He told us about his past, all of the great successes and significant failures that got him to where he is now. (Originally in this post I had written out all of the things he told us, but a lot of it was personal, and I should probably not betray his trust here on the internet. Suffice it to say that he has experienced successes and failures of equal magnitude, yet his drive and determination have caused more success than failure.) The important point is that one must have experience and wisdom to be successful, but one only gains meaningful wisdom from failure. Dr. Shannon's drive and conviction were palpable throughout the talk, and listening to him made me realize how much a typical person could be limited by self-assigned limits of willpower. Hopefully I'll remember Dr. Shannon next time I don't feel like waking up for class, or putting in the extra time to learn something new...

Now, I don't necessarily aspire to be a Chair of Medicine at a top ranked teaching hospital, but his words will inspire me to achieve excellence in any path I end up taking. I paraphrase his message, 'the key to success is committing yourself wholeheartedly to every detail in order to improve your work in every way,' which reminds me over and over how important the details are. It's hard to find the drive to commit yourself to those minutiae, but I suspect it is easiest when you do something that you love. I will eventually find my true calling, but right now I vow to commit myself to a lifetime of learning and growing, as well as maintaining excellent physical and mental health, and most of all to approach every day with a positive outlook and energy.

Well, that's enough for one day, I think. I'll be back next week.

Mark

P.S. The writing will get better, I promise.