In medicine it is really better to have learnt and lost...

When I climbed up the two flights of stairs to reach the anatomy floor, the distinct pungent odour of formalin tickled my nostrils and as I looked up I found my eyes transfixed by a fresco of a human skeleton standing nonchalantly with a skeleton under his/her (I still don't know if that skeleton was a male/female :) )left hand with the words that would soon become a part of my life; "In anatomy it is better to have learnt and lost than never to have learnt at all." Obviously, I didn't realize how profound this statement was because I hadn't been confronted by anything like learning human anatomy. I later realized that no matter how much we studied in medicine not just anatomy, there were always going to be things which we would forget; things which we wouldn't use for years on end; concepts which would change everyday and life would only become more complex. I realized that a lot stuff we were studying was not going to appear on tests; would not affect patient care; would not make a difference to anyone but we studied it anyway! Then there was all that stuff which was going to make all the difference; stuff which was going to change lives and that was the kind of stuff you didn't want to ever forget. Unfortunately you realize a lot of this only in retrospect. This theme carries on to residency as well. I really wouldn't want to forget any of the stuff I am learning, reading, hearing everyday but if you don't use it; you lose it. The joy of understanding a concept and applying it probably surpasses any other; but what happens to all the other stuff? I hope I can keep learning for the joy of learning but at the same time not lose heart if I forget something but study it all over again like I will never forget!

I have a consult for you...

My beeper goes off at 3:30 pm and as I answer the page; I am hoping it's not a consult when my brain is trying get home but then the voice says, "I have a consult for you..." Hmm, why didn't you call me up earlier I wonder as I start scribbling some details. So, I go see the consult. I get paged again while I am gathering information on my consult patient and this time it's a voice from the ER and the voice says what I didn't want to hear at 5 minutes to 4; "I have an admission for you." Hmm; so here I am. I really enjoy seeing patients; they are a huge part of who I am. Then why do I feel like someone should've called a consult earlier or that I shouldn't be getting an admission so close to my time to sign off? I love what I'm doing; then why do I feel that tinge of resentment when I get paged late? Shouldn't I jump with enthusiasm at every opportunity I get for learning and applying what I have learned so far. There are a few things which I realized as I was thinking about these times...one was that when you are mentally prepared to go home or call it a day; something which upsets those plans just happens to create a little resentment; or if you had plans to do things which were part of life apart from being a physician; then you get a little upset or if you're just really tired; or if it just hasn't been your day and you want it to end sooner than later or if you just want to go home! But life as a physician will always be about those moments which can never be planned for. That is both the joy and bane of being a physician; you can have a life and you can have a life but whatever you do; the very essence of your existence will be in being a physician first. The late consults/admissions are perhaps meant to prepare us as residents for the world at large; to accustom us to the uncertainties of being called upon at any time; of having plans postponed; of having to cancel birthday celebrations; of having to miss some important moments in our families; of being there and yet not being there because you're really needed more somewhere else...
Then is it cool to feel the resentment? Nope. Obviously, it's easier said than done. Being able to maintain that eagerness to learn and the drive to give it your all irrespective of the time of day; irrespective of your situations is what being a physician is all about. Someday, I'll get there; for now my beeper can keep going off whenever I'm needed whether it's to save the world or just give my opinion; I'm in training and will take it all in my stride!

When your best is not enough...

I am currently training at a university hospital which not only has a busy Neurology service but happens to a big referral center for complicated cases. I am seeing patients with some of the most bizarre presentations which are defying known diagnoses. It's great to be doing all the things by the book, then thinking outside the box and knowing that you gave it your all. But what if that didn't work? What happens when your best is just not enough? You fight back anger and all emotion and let your patients know you tried. What makes it worse is that they know it too. They know it all too well, that you fought till the end for them. What makes it worse is when they console you; when they say, "I know doc, you tried your best but what's got to be will be." And I can't help but think that it doesn't have to be this way! It's just not fair. Some of the worst diseases strike some of the best people; people who have been living by the book of good health and should have been promised longevity because they were so honest and unwavering in their approach. It just makes you realize that we still don't have the answers to the question; "When I did everything right, why did this happen to me?" A lump arises in my throat every time a patient asks me this question and all the marvels of modern medicine just fade away and all humour fails to dissolve the pain. Why is my best not enough to let someone dream on; to let someone live on and not die an untimely death?

What needs to be done, needs to be done now!

I was telling one of my patients that they need to quit smoking and perhaps the best way to do it would be cold turkey; pick a date and kick (the) butt! He obviously had tried numerous times and had failed. We didn't even go into the details of his attempts to quit. This important piece of advice was only a small part of my extensive interview with him and I already had more patients waiting to be seen. I wasn't the first doctor asking him to give up a habit which had only caused him harm.
So many things I ask my patients to do, are easier said than done! I might be persuasive, authoritative, gentle or even nonchalant in my approach to giving patients advice. I might be timely in my approach or very untimely. How many of my bad habits have I been able to kick by the very same approach I ask my patients to adopt? They aren't heroes who can change the ways they think and act at the drop of a hat even if it means it’s a question of life and death; and what if it is more preventive than therapeutic; does that make it easier to postpone your plan to change? How do I tell my patients that this process is going to be tough and they have to stick it out? How do I tell them that I will be there every step of the way on their good days and bad days when they're raging a battle against smoking/ drinking or any other addictions when truly I am not going to be there with them every moment of their emotional turmoil. It's their families and friends who will be; people who have been affected by the process of their spiral down will be the people who will help them climb up step by step. Of course I'll be there to check on them once in a while. So, it’s only more important to speak to the patients and their support systems at the same time; so they’re both prepared, so they both understand.

But what needs to be done needs to be done. Why are things easier said than done? Why are habits so hard to break? Why are good habits so difficult to form and sustain? It's not always a lack of motivation. It's sometimes about timing. You need to receive or give good advice at the right time, be able to strike the right cord and at the right time. But sometimes you nor your patient have the luxury of time. So, do what needs to be done as honestly and as urgently it needs to be done and hope and pray that it works.

Moving on...

Dignity in death as much as in life is perhaps what we all want. How do we ensure that we die as well as we lived? Coming to terms with one's own mortality becomes easier when you see death up close everyday as a physician. We all know that as we come so must we go. What makes us fearful about death is perhaps not knowing what lies beyond but isn't that true for life as well? Do we really know what's going to happen next? You can plan and plan to be prepared for surprises.
When I see loving family members from generation one to four paying their little old grandma a visit, holding her hand and kissing her good bye; I know that even in her coma she's not that scared anymore of the inevitable and yet unknown. When they decide to make her comfortable and let us know that it was what she wanted and that she had a long and fulfilling life, I know that grandma is feeling proud of her legacy to the world; children she raised well; children who have loved her well and ensured that she passes on as effortlessly as she brought them into this world; holding her hand just as she held theirs and taught them how to walk and move on. Life comes around in a full circle. A warmth from the tears I am holding back and the ones they are shedding fills the room. We're thankful to grandma for making it easy for them; for making it is easy for us as her doctors...she must've been a brave woman to decide what she wanted her death to be like; she made her choice so we just followed. And then I can't help but wonder, how do I want to die? I get paged and the thought vanishes from my head; guess it's another thought for another day but sooner or later I'll have to decide; if I want it my way!

What is true learning?

The motivation for learning has changed. It had to. Every single thing I learn now can change someone's life including mine. The differentials, the treatment options, the management plans...it's a sense of ownership; a sense of responsibility beyond scores, ranks; the stuff that makes you want to make a difference, the stuff that makes the difference. There's so much and there's finite time. When there's no time to lose, how can I stop? Medicine is changing every moment but where are we headed? Prolonging life by the years but are we really adding quality to those years? What I learn today, will it be passé tomorrow? What I learn today, will it stand the test of time? What would I have to unlearn? What would I have to relearn because the human memory fails me? What will keep evolving, what will perish; wish there was some way of predicting.
Medicine is as much an art as a science. Let me not sacrifice art for science and let me not forget to objectify. Either way the more I practice the more I will learn and perfect my ways. Yes, some I will learn, and some I will forget but no matter what I will be a better person for I learned. A part of me will change perhaps forever; I guess that is what true learning is all about. Changing and learning how to change and how to be that change. Perturbing as it might be, making my peace and anticipating that my sense of peace will change too. And knowing well that I am not alone in this process, I can't be more thankful to those from whom I learn; my patients, my teachers, my books and lives...mine and that of so many others!

Playing God!

I find it difficult at times; to come to terms with how we predict prognosis in critically ill patients. There aren't any formulas to calculate the duration of survival and quality of life (QOL) with accuracy which take into account a patient’s personality or their will power to improve or their dreams, hopes and aspirations. A lot of perception, personal experience and surrogate decisions determine continuity of aggressive care. I find it difficult to say that if a 95 year old comes in with a massive intracerebral bleed and is comatosed; he shouldn't undergo surgical intervention perhaps because the likely complications and risks far outweigh the benefits in somebody who has perhaps lived their life. How do we know that someone has lived their lives; how can we be so sure that they didn't have unfinished business which they wanted to take care of before passing on; what I may perceive as poor QOL they might be perfectly at peace with and would want to live irrespective of how dependent they become. Perhaps, as doctors we need to enable patients and families to see beyond emotion; to see the physical, mental and emotional turmoil which lies ahead.
Medical treatments are fraught with dangers and letting well alone sometimes is the best strategy. You want to do the best for your patient and you want to be mindful of when it is best to let go and when you should go that extra mile. But the subjectivity of this process creates conflict. I have seen some patients who seemed to have no hope for survival do really well and others who I felt would pull it off with that extra push spiral down. When patients or their families talk about miracles, I don't want to be a naysayer because I don't know how these miracles happen but they sometimes do. I want to be able to give them hope but don't want them to lose all semblance of reality for I am perhaps; their only connection with reality in their time of impending loss of a loved one. I wish there was a better way to do this. Sometimes, I wish I didn't have to play God because I am so not!

Seeing is believing!

Sometime ago I met a very engaging, cheerful young lady three years after her stroke enrolled in one of the FES trials. We walked with her through her journey thus far. Being a swimmer and a marathon runner prior to her stroke put her in an advantegous position as she was a quick learner who worked very hard and knew the importance of regular exercise. As our instructor Mr. B pointed out she was someone they would have to ask to stop pushing herself so hard and slow down. She doesn't even live in this city but comes down for her therapy sessions four times every week. She was happy with her progress. When she related that she had developed an aphasia along with her weakness, I was amazed because she was speaking so normally! I have always known that a lot depends upon how much patients want to get better but since I hadn't seen many patients outside the acute inpatient setting, it was heartening to see reamarkable recovery and a testimony to will power. She had 5 implanted electrodes in the muscles of her rigth leg which weren't being used presently. I saw her work her way to almost normal components of gait with the help of FES. Having experienced the unpleasant sensations of FES, I was amazed to see how she was using it so effortlessly and beautifully! She would break into an easy smile with a compliment from Mr.B about how well she was doing and knew exactly when she wasn't doing a good job. I liked the way she was tuned in providing herself feedback! No wonder she was doing so well!
She told us about her brother who was in medical school and wanted to become a neurologist as well. As we parted ways, she wished me luck. I couldn't help but thank her for teaching us so much in just a couple of hours!

Shocking move!

Functional Electrical Stimulation (FES) is a technology which can make weak muscles move by stimulating them via electrodes which could either be implanted or be placed on the surface. A little box is used to supply current and change its amplitude and frequency. It's the power of electricity at work for you and I was very excited to experience this technology first hand, quite literally!
My heart skipped a few beats when I saw our instructor's fingers move after she let 3 ma of current run through a few muscles of her right hand. Now it was my turn. I was a little apprehensive and very excited. I had been told that the current might feel funny, almost like parasthesias and even painful. One set of tiny surface electrodes and I was ready to experience electricity! I began feeling parasthesias with a very small strength of current and before long my fingers were moving; moving at their own will. I felt pain in a few tiny muscles of my hands and we decreased the signal intensity.
Then I wondered, I was experiencing this pain for such a short duration. People with stroke or SCI who undergo therapy have to go through these unpleasant feelings repeatedly and work with it to regain functional motility of their upper or lower extremities. Of course, there are many who will have some impairment of sensation and perhaps can tolerate higher intensities of current by virtue of their impairment but it still seemed like one had to be strong to endure and prevail.
My mom says this often, "There's no gain without pain”. I wondered about how much pain is enough; how much endurance will get you to where you want to be; how much patience one must have... I wondered about that amazing Creator who planned these moves and about the power-house our neurons were a part of. Every little synapse, every molecule of neurotransmitters at work every single moment of our lives; making us think; making us move; making us fall in love; making us do things we thought we were incapable of; making us feel pain; making us the people we are; is part of the incredible magic of nature and the Creator! We are trying to replicate nature and restore function in the way it was created. I like the idea but wish it was less painful and that we were using this technology more widely.

Walking; what a gift!

As part of my neurorehab rotation, I experienced first-hand two techniques for gait-training. They are both research tools currently but have showed promising results to help people with hemiplegia and SCI (spinal cord injury) walk and walk better.
I had only seen a few pictures of what I was going to experience. The first equipment I was hooked up to was a gait-robot called the “Lokomat”. By hooked up, I literally mean hooked up! The machine comprises of a treadmill, three different computer systems, works on electricity, has weight suspensions and sockets which house straps for your ankles, knees and hips and the machine fits snugly on your pelvis to stabilize it. The process of taking the first step involves a lot of preparation. There are all these measurements which must be taken before one can actually work on the robot. There’s a lot of trial and error before the right fit can be established. As Mr. L, the very patient therapist and researcher was going over the fitting process which took a good 45 mins, he explained how since patients are usually hemiparetic/ paraparetic, they could easily tire out before the measurements are completed and that might be the end of their session! It might even take a few sessions just to get the fit right! One of the motor-learning principles which seems difficult to achieve is to be to get a movement as close to normal is one of the principles the robot works on. The way the robot works is by making your joints moved in a co-ordinated fashion to mimic normal gait and with training, the amount of work done by the machine is decreased and the amount done by the patient is increased. Walking is not really about strength but about co-ordination and hence, there’s enough hope and means to make people who do not have 5/5 power in their lower extremities walk normally.
Getting on to the treadmill with all the gear as if I was about to sky-dive was almost surreal. So, once you're on the robot, you are actually suspended in air by way of weights. As I "stood" suspended in mid-air, I almost felt like a super-hero! Not until, the robot actually started moving my legs, did I realize that this was for real. Mr. L would keep checking if I was comfortable or not or if something didn't feel right. I was trying to tell the difference between the robot-generated gait and my normal walk. The weird thing is that besides having attended a brilliant anatomy lecture on gait by Dr. SRK in my first year of medical school, I hadn’t really thought about walking and so, understanding the subtle differences was quite difficult! To think that so much of evolution got us from a quadripedal gait to a bipedal gait only seems fair when you admire the complexity and the number of muscles involved in making sure you get to your destination whether it's Mt. Everest, the moon or your refrigerator! Walking is just one of those things we take for granted, which we never think consciously about unless we are in pain. It's an amazing feat of co-ordination, endurance and almost beautiful when you think about the principles! Perhaps, today was yet another reminder to not forget to be grateful for all things we take for granted. I was almost ashamed to think of the times I've complained about walking or taken the easier way out by driving or hailing a cab! It's a gift we use every single day and what a thoughtful gift it is! Kudos to researchers and therapists trying so hard to give this simple, elegant gift back to patients who will only feel so much more independent once they can stand up on their feet again.

What hurts more; what heals faster?

I am currently doing a neuro-rehab rotation. There are two very striking things about this rotation. First, the duration for which some of these patients have been here and the other; seeing conventional rehab and innovative technologically advanced rehab at work together to enable people to do things which we don't think twice about like walking, eating, voiding, moving one's bowels etc. and fighting fiercely to be as independent as possible wrt their ADLs(activities of daily living). So far, I have essentially seen Motor rehab and not cognitive rehab. Motor rehab is supposedly easier as one might imagine but it is painfully slow, needs a lot of endurance both of the body and spirit not only of the patient but his care-givers as well. There's the SCI (Spinal Cord Injury) unit and there's the TBI (traumatic brain injury) clinic. Since it's at the VAH (Veteran's Affairs Hospital), I know each one of the gentlemen lying in their beds in the SCI unit with paraplegia (paralysis of both legs) or tetraplegia (paralysis of all four limbs) waiting for someone to feed them or dress their pressure ulcers or clean them up, served in the armed forces at some point in their lives. I have always admired people from the armed forces who I feel do selfless service for their countries and have always felt that their sense of pride about their country, their work and their being, their self-sufficiency and their discipline is what makes them who they are. I don't know what hurts these men of honour more, their physical or their psychological dependency on others. Does being a tough guy make it more difficult to come to terms with being dependent on others even for the most mindless, almost reflex things we all do day in day out? And because you're a tough guy, does sharing that pain become more difficult and does the internalization of so much suffering erode your self-esteem paradoxically?

What amazed me last week in my first, brief encounter with the SCI unit was some of these men who seemed to be made up of a different fabric! They were laughing, gleefully sharing their hunting/fishing stories, lifting their arms up (with a lot of effort) triumphantly and telling me how once they're in their motorized wheel-chairs, they can do anything or enjoying a hearty breakfast and actually wishing they could have more bacon! And watching them, brought all those thoughts I mentioned above to my mind again and I felt a sense of regret because here are people who knowing well the limitations of their bodies want to constantly challenge themselves and win; when they don't feel sorry for themselves then why must I feel sad? Then I wondered; if being a tough guy with a strong will-power makes you better-equipped to deal with such physical limitations and inspire people around you and show the world that you're unbeatable no matter what!

And then there were men who lay in bed with the saddest eyes I have ever seen; with tracheostomies, and stubborn non-healing wounds through which bones were playing peek-a-boo; with colostomies; suprapubic catheters and wounded spirits. Some of them have been here in the SCI unit for more than a year. I wonder when their wounds will heal or how much will they scar; I see some scars already with my yet untrained eyes. I can’t help but think which scars are uglier, the ones that show or the ones that don't but completely disfigure your spirit? Does paralysis of the body make you more dependent than the paresis of the mind? Which of these recovers faster and recovers more completely?

Being in the midst of such contrasting patients with similar physical maladies leaves me with more questions than answers, with more inspiration than despair.

Cold hands, Warm heart!

As physicians, I feel we are in a unique position to learn so much from people who are around and those were and those who will be! There are so many moments we experience everyday which warm the cockles of our hearts, which raise a lump in our throats, which bring tears to the brink of betraying how human we are; moments filled with anguish, pain, helplessness; moments which are so full of hope which make us believe that there will be a better tomorrow, that there will be a better answer, that there will questions which will make us think for the better...

There has been so much which I have experienced as a medical student, intern and now as a resident which has made me who I am and there's so much which continues to inspire me to become a better physician and a better person. I really want to remember all those fundamental life-changing moments as much as the subtle changes which are slowly becoming a part of who I am as a physician.

I don't know where to start but I guess I will start with every morning...
Every morning as an intern at SVH and now as a PGY2 at UH, there's something amazing I experience every morning; something which I had never experienced back home. My hands remain icy cold! I, of course try to warm them up but don't think I do such a good job of that. All my septuagenarian and octogenarian patients who are sleeping soundly under layers of blankets wake up to the sound of an energetic good morning and the touch of cold hands! Now I've started warning them that I am really sorry but that's the way my hands are...I can't recollect the number of times I've already heard this but I think I want to hear it over and over again as they laugh heartily and say, "Cold hands but warm heart!" And then I smile to myself and feel that was yet another great start to yet another promising day.