The next installment of my Thursday afternoon community experiences (i.e., “LACE”) brought me to the Sheltering Arms Day Center, a suprisingly modern and professional-looking building tucked away in a corner of an old residential neighborhood.

They describe themselves as “a nonprofit organization committed to the health and well-being of older adults and their family caregivers,” with a particular emphasis on providing services that help such senior citizens live safely and independently in their own homes.

I was fully expecting to walk through a typical nursing home, but was delighted to see something a little different.

First of all, this isn’t your typical nursing home. You can’t drop off your grandparents and expect them to live the rest of their days there.  It’s a day center – in fact, it’s Houston’s first dementia-specific adult day care facility, designed specifically for those with Alzheimer’s disease and other forms of memory loss.  It’s also well-furnished with several different areas, each serving a different purpose.  There’s an outdoor patio for parlor games, a rest & relaxation room with loveseats and an impressive aquarium, a kitchen not unlike one that you might see on TV, and even a theater fully equipped and decorated by the Houston Texans!  However, we were told that the patrons were discouraged from spending too much time in the theater since they could just as easily do that in the comforts of their own home.  Instead, all of the activities and events during the day are focused on social interaction and working on activities of daily living – things that improve the functional quality of life for adults with dementia.

And apparently it is quite popular.  At least thirty people were in the main room playing bingo with the students and it seemed like everybody was having a jolly good time.  Some patrons had more advanced dementia than others so conversation was sometimes not as spontaneous, but in general there were smiles all around my table.  I met a 90-year-old gentleman who told me he had Alzheimer’s disease and as such he would have a hard time remembering my name.  I admire his insight, since having done a rotation through mental health services before, I know how difficult things can get for a patient with advanced dementia or a psychiatric diagnosis.  He told me how he had worked for a geophysics company for most of his life, which took him all over the United States as well as to Guatemala and Canada.  When I asked him which location was his favorite place to live, he said, “Well I guess it would have to be Canada, since I met my wife there.”  Good answer, ol’ chap.

Unfortunately, he never won a game of bingo, even though every single bingo ball was called that afternoon (to help everybody win at least once).  I only started talking to him halfway through the game, so he must have missed the crucial calls that would have given him a bingo.  Regardless, he received a piece of chocolate for his participation which he promptly offered to me.  When I refused, he chuckled and said, “Oh all right – I’m going to enjoy this right now then.”  He deftly unwrapped the chocolate piece, popped it into his mouth, and gave me a warm wrinkly smile.  My thoughts went back to my own grandmother, who probably would have done the exact same thing.

There’s the child to whom I explained how to properly wash his hair to alleviate his scalp itch who then said to me, “I don’t think I know what you’re talking about, but if you tell my mommy, we’ll figure it out.”  There’s also the child who was getting her immunization shots but couldn’t stop sobbing no matter how firmly she shook her head no when asked if she was scared.  Then there was the child with pneumonia who told me she didn’t want to be sick anymore while making the most adorable sad-puppy-dog face.

But only recently have I noticed that the elderly patients I see also have endearing qualities that make my interaction with them all the more pleasant and enjoyable.  One of my patients while I was on the Cardiology service last month had chronic abdominal pain among several other things, and despite his best efforts to cheer up whenever I visited him, he was physically a human version of Eeyore.  His slow waddle, his deep sighs, even his cadence of speech reminded me very much of everybody’s favorite old grey donkey.  He wasn’t as pessimistic as Eeyore tended to be, but his mannerisms were spot on.  I’ll never forget the time he told me he felt very cold sitting in his room at which point he drew his blanket up to his neck and sat there looking at me with his big droopy eyes and his pouty expression full of wrinkles.

Today, I went to the hospital to talk to an elderly lady who I’ll be following this month.  She has a history of seizures and cerebrovascular disease, and may be suffering from multi-infarct dementia, a diagnosis describing a step-wise cognitive decline with each subsequent stroke or infarct in the brain.  She was under multiple layers of blankets while I was examining her, and when it came time for me to look at her feet for any sores or swelling, I was having trouble exposing her lower legs.  As I was fiddling around with the many blankets, I muttered that I couldn’t quite get to her feet.  In a childlike voice, she then said, “Where’d they go?  My feet disappeared!”  I let out a chuckle, and when I finally did pull her feet out from underneath the blankets, she started wiggling her toes madly and shouted out happily, “There they are!  Whew!”

I guess some hide and go seek games never grow old.

The Downside to Monthly Rotations

Well, they are all leaving in two short days, to be replaced by a completely new team with only the medical student (i.e., me) to provide some semblence of continuity of care.  Fortunately, presenting the patients to the new team isn’t such a big deal to me; rather, it’s the unknowable dynamics of the new team that worries me the most.  Will the attending be as nice as the previous one or will he pimp the living daylights out of me on rounds?  Will the fellow be just as helpful, or will he scut me out like no other?  Can I rely on my intern for guidance when there’s a huge question mark over my head, or will we both be equally clueless?  Just as important – will rounds be efficient yet thorough, or will they be excruciatingly long?  These are a few of the concerns that run through my mind before starting rotations or switching to new services, and yes, I realize this classifies me as a bona fide worrywart.

But I have to make the case that most, if not all, medical students have similar thoughts.  Any person entering a new situation with a significant number of unknowns would feel the same way.  And that’s exactly what makes it so exciting – just as there is the potential to fail miserably (depending on your level of pessimism), there is an equal or greater potential to succeed (dare I say wildly so, depending on how optimistic you are).  How awesome would it be if everybody fell into their roles on the team with ease, and if there was no such thing as a rocky start?  I’d love to see our new team be a well-oiled, finely-tuned life-saving machine right from the get-go.

Fortunately, my coping mechanism is to set aside all these fears and “go at it” with “all I’ve got.”  Cliché?  Perhaps.  Facetious?  I’d beg to differ.

Words To Live By

In memoriam of this short-lived week that the team had together, my attending offered me some parting advice.  For the longest time, he said, he had been taught three basic maxims to guide his thoughts and actions:

1. Be nice to others.
2. Work hard, play hard.
3. The expeditious conversion of any arrhythmia, lethal or otherwise, into sinus rhythm will always provide the best outcomes for cardiovascular morbidity and mortality as well as overall quality-of-life, no matter what anybody else thinks or says.

Truer words have rarely been spoken.

Before I continue, let me disappoint and stop what seems like will be an insightful and informed perspective on the role of pharmaceutical industries in a physician’s practice.  It’s so common to hear medical personnel talk about Big Pharma as this evil-doing monster that uses direct-to-consumer advertising (DTCA) and physician detailing with fancy gifts and extravagant dinners to deprive people of their sound clinical judgment and brainwash them into prescribing unnecessary drugs.  Sure, I agree that advertising in any shape or form may have some effect, subconsious or otherwise, on a clinician’s thinking, but that doesn’t mean that the presence of pharmaceutical industries in the hospital is morally reprehensible either.

But I am going to suspend this debate until I start working on my MPH because right now, it is incredibly fascinating to set aside all those articles and opinion pieces I’ve been reading all these years and to actually witness this interaction firsthand.  How is my perception of certain medical products and therapies going to change?  How are my clinical decision-making abilities going to evolve after a few hosted dinners?  Will that cool pen with the recommended dosages conveniently written on the barrel really make me consider using that drug more often?

And so I present to you the first two exhibits of what I like to call “pharma phun” – the exploration of this ongoing controversial issue not from an academic standpoint, but from the skeptical yet somewhat impressionable mind of a budding clinician-to-be.  No boring breakdowns of industry-physician dynamics or economic analyses of advertising.  Just some looks into this crazy world that is being a physician.

“Ye cannot drink the cup of the Lord, and the cup of devils”

Mug of Knowledge? What happened to my coffee?

Um, I think I’ll pass…

Mom, this candy makes me feel weird...

After round one, I have to say that I’m only amused by Merck and GoLytely, perhaps a little disgusted by the latter.  My patients do drink GoLytely before certain GI procedures, and as for Merck…well, let’s just say the manual is a nice addition to my shelf.  Somewhere.

12:39 PM, December 6, 2007

I’m sitting in my room, idly clicking through the five websites that I religiously follow in a feeble attempt to delay studying for my impending final exams, when I get an email from some person by the name of “Shawna.”

Dear Dr. Hsu,

I’m writing because I thought you should know that you’ve influenced my blogging.

I’m a writer. To be successful, I have to be able to communicate at the level of whatever reader is likely to run across my content. Your blog does a brilliant job of that.

I first read your blog last year when I hit the “surprise me” link on wordpress. When I describe to my friends why I like blogs, I tell them about my experience reading yours. I have never had a desire to go to medical school, or to become a doctor. But, your experiences showed me a world that I never dreamed of.

My blog is about my dog, my life and my dream to live aboard a boat, again,  at sea, so content-wise, we couldn’t be more different. But, the opportunity to slice human experience with the same descriptive, matter-of-fact detail that you used helps me, when I’m feeling uninspired.

Thanks for the creative boost.  Best of luck with your studies and your career.

Shawna

Wow.  And this comes almost a full year after being inactive!  Shame on me for not keeping up with my blog like I had originally intended, and for not, at the very least, returning a courteous reply to her in a timely fashion!  Thank you, Shawna, for your words because now I have an excellent source of external motivation to help me pursue my online journalistic aspirations.  (Internal motivation is currently being sapped by the pressures and demands of becoming a medical professional…to be explained soon!)

Sometime in the morning, May 17, 2008

Having finished my three-month long Surgery clerkship the day before, I had just woken up from the first truly restful, worry-free night of sleep in what seemed like forever.  I had traveled up north after the Surgery shelf exam to (1) get away from the black hole of stress that is medical school, but more importantly to (2) visit my significant other for the weekend.  Sitting down with my breakfast in one hand and the computer mouse in the other, I fired up the Internets on my girlfriend’s computer.  There in the center of the browser’s toolbar – and taking up valuable real estate on the tiny 12″ screen – was a button bookmarking this very blog.  It was a quiet surprise that gave me pause.  How many times must have she clicked on that link hoping for something new, only to see the same post dated nearly two years ago again and again?  I remembered how excited I was when I first told her I was going to start my own blog and how interesting it would be to document my progress through my medical career.  I remembered how I called her when I had posted another update with another random story from class, however mundane it was.  And despite being so physically far apart at a medical school of her own, she never once nagged about keeping her up to date on all things me.

So here I am on a nice Sunday afternoon gearing up for Try #2 at this thing, with a whole new look and what will soon be a whole lot of new posts.  I do plan on making a few posts that will be dated in the past simply because there are some stories and lessons from my so-called sabbatical that I don’t want to forget.  Those will be appropriately tagged as “retrospective” so as not to disturb the space-time continuum of this blog.  But for the most part, I’ll continue with my ramblings, trying to keep things simple, and trying to keep myself humble.  Thank you for reading.

Someone once told me that the smell of formaldehyde acts as an appetite stimulant, and I think I replied that I didn’t believe it.  Today, after I got home covered in the smell of formaldehyde, I immediately went to the refrigerator and picked out some leftovers to heat in the microwave.  It wasn’t until I was actually eating did I stop and realize maybe there is some truth to that bit of trivia…

Non Causa Pro Causa?

I think a few of us chuckled when the professor started off with the fact that meiosis was all about sex, and since we’re all interested in that, we were going to have a good time.

The best part came when he put up a slide with the title, “Meiosis: Where, When and Why?” We went through the where and when with relatively little difficulty – “…in males, the male sperm are produced in human males in male meiosis…” – but when we got to the “why,” I think he almost got a bit misty-eyed when he mused, “Why? Well, we all know why. Sex is wonderful.”

[insert long pause and forlorn gaze at the screen]

That awkward silence was long enough for us to laugh nervously not once, but twice, as well as give some applause for this man who was obviously in love with the intricacies of meiosis (or otherwise). When his mind returned to the classroom, he smiled, shuffled around a bit, and stated with conviction, “And because it’s wonderful, we reproduce.”

Not that we reproduce because we have an interest in furthering the species or anything like that! He then went on by saying that it supposedly doesn’t have anything to do with “that crazy thing going on in our minds,” because that’s “put there by evolution.” Um, now I have no idea what he’s saying.

And all of a sudden, every single woman became very available…

A few minutes later, he elaborated a little more on the “when” of meiosis with a nice overview slide. He glossed over gametogenesis in the male and in the female, and we weren’t really concerned with his minor slip-ups since by that time we knew we were going to double-check his lecture notes against the textbooks later.

But when you get something that is near and dear to a certain gender very wrong, you can’t let it slide. “Meiosis occurs in the ovarian follicles” – good so far. “Oogenesis starts in the embryo and continues all the way through maturation…” – ok, fine. “…and it ceases at the ages of 35 or 40 when all those eggs are used up and depleted” – all righ….WHAT??? Depleted at 35-40?!

As the rest of us were left in shock by this shortened timeline, one of my friends was perturbed enough to raise her hand and rightly set the onset of menopause somewhere closer to the ages of 45 and 50. Some would probably argue you’d want to have had children by around 35 anyway, but I don’t think there are a lot of women out there who would gladly welcome menopause a full decade or so earlier!

Speaking of unlucky, one of my tankmates (I guess that’s what you’d call the people who share the cadaver with you) is observing a Jewish event by fasting for the entire day, from sundown yesterday to sundown today. He can’t eat or drink anything, including water – a true fast. What a way to kick off anatomy lab! I was worried for him at first, but he’s a pretty sturdy guy, and he got through the first day of anatomy without any major problems. I probably would’ve been rather dizzy and fairly incapacitated if I had to do such a thing. Mad props, yo.

We dissected the posterior and anterior thorax muscles today. We cut the trapezius and reflected it to expose the teres major/minor, rhomboid major/minor, supraspinatus, infraspinatus, and levator scapulae. Anteriorly, we cut and reflected the pectoralis major to access the pectoralis minor and the serratus anterior. Unfortunately for us, our cadaver had very poor musculature and so all the muscles were very thin and not very well defined. The muscles definitely didn’t look as impressive as they were in Netter or Rohen, but they were all there!

One thing I found puzzling was that the entire anatomy lab was carpeted, instead of having a hard or bare floor. With all the formaldehyde that dripped from the tanks and the pieces of tissue falling everywhere (yes, very pleasant, I know), I don’t know if carpet was the best choice. Then again, you don’t have to worry about slipping on a wet surface, and I guess you don’t need to clean the floors as much (can’t really see how dirty it is). As long as my feet are in my comfy Crocs, then I’m all set.

Next week in anatomy lab: the infamous brachial plexus!

And if he asks you in front of the entire class the following question: “Where can we find this fine structure? In microvilli, centrioles, or cilia?”

For your own sake and dignity, SAY “CILIA!” Don’t do as I did, and guess microvilli and then centrioles before arriving at long last to the correct answer. At least the class applauded me for my efforts.

Positively elegant.

A businessman, on his way to a conference in a big city, was driving through a rural part of the country when his car broke down. The tow truck brought him to the closest town and while the car was being repaired, he decided to go find something to eat.

The mechanic suggested, “Try the family restaurant just down the street. Chicken tongues are their specialty.”

“Chicken tongues?” the man wondered, but seeing as he needed some sustenance for the remainder of the trip, he walked down to the restaurant where he sat down at one of the tables.

The waitress greeted him warmly and said, “Thanks for stopping by – I sure hope you’re hungry, because the next batch of our delicious chicken tongues is just about ready!”

Slightly disturbed, the man replied, “Um, that’s just about the craziest thing I’ve ever heard. I’m pretty sure I want to pass on the chicken tongues. I have no desire to eat anything that’s been in a chicken’s mouth!”

“I’ll have an egg.”