Deck Them Halls

I've usually had a very Grinch-like attitude toward Christmas, finding it hard to muster up any enthusiasm for the holiday. For as long as I can remember, Christmas has been about driving up to my grandmother's house and eating a meal of turkey and rice pudding with my tiny Canadian family, people who I already see every week.

After the meal, we settle down in the living room and unwrap presents that we actually bought ourselves before handing them over to the gift giver a couple days prior to Christmas. I always do my best to feign surprise and slap on a smile while someone snaps pictures.

But this year I decided to rediscover the Christmas spirit. I was inspired to this end after flipping my journal over to the very first entry: December 25th, 1999. I had scribbled over five pages with excited musings about all the wonderful things about Christmas; the contents of my stocking, gingerbread cookies, my new N64, etc, etc.

Yearning to feel the Christmas spirit once again, I threw myself into holiday activities. I went to two Secret Santa parties and then carolled for charity in a beautiful Victorian neighbourhood in Dundas. The families in those Dundas homes would open the door, look at us suspiciously, and then break out into smiles when they realized we wanted to sing for them. It was almost always a happy response. In return for "Silent Night" or "Jingle Bells", they would take our information pamphlets, donate money or even, in one case, serve us giant fresh pretzels from their oven.

I also decided to put the "surprise" back into gift-giving, which involved a very successful trip to Walmart. One hundred dollars and eight cents later, I had a box of dark Swiss chocolates and "Chicken Soup for the Christian Soul" for my grandmother, a set of cherry candles for my mom, a warm fleece blanket for my sister, and special collectors' DVD box-sets for my uncles. My dad normally refuses gifts, but I bought him a box of cashews anyway. I wrapped each gift nicely and included a hand written card - although they were pretty simple, they didn't fail to delight.

Unfortunately I can't say that my own presents were much of a surprise: a gift certificate to Chapters, a fat check, a sweater, socks and a $40 pen that exploded all over my hands. And yet I'm still glad that I put serious effort into injecting some spirit into the holidays. Because, in the end, Christmas is what you make of it. It could be a cold and lifeless affair, or it really could be the most wonderful time of the year... even for an ex-Grinch like me.

Our Own Worst Enemy

Medical school was supposed to be stressful and exhausting, but my experience at McMaster hasn't borne that out so far. Even though my schedule is typically packed with tutorials, clinic time and studying, I’ve always managed to find pockets of time to relax and socialize.

It helps that McMaster has taken strides to encouraging a work/life balance in its curriculum. Even the keynote speaker at this year's medical student conference, Dr. Marla Shapiro, talked extensively about her belief in self-care through the framework of her experiences with cancer.

But there are tough times on the horizon. During their residency, perhaps the toughest part of a physician's career, a resident will likely do a 28-hour shift. If you think it seems a bit unreasonable to allow an inexperienced doctor to suture cuts while being extremely sleep-deprived, then you’re not alone. The province of Quebec has capped the maximum shift rate to 16 hours, citing the fact that exhaustion chokes off cognitive and motor functions.

As far as I’ve gathered, the 28-hour shift doesn’t actually serve any true medical or educational purpose. Instead, it’s a rite of passage into the medical profession that has continued on for generations (up until recently, it was actually 36 hours instead of 28 at many hospitals). This “rite” is borne out of the traditional conception of a physician in the West as being infallible to normal human weaknesses like stress and fatigue. Before the era of House and Grey’s Anatomy, doctors were routinely portrayed as being all-knowing father figures who could handle any emergency that came their way.

Dr. Ben Casey: surgeon, hero

and manly man. A fairly typical

TV doctor in the early 1960s.

But these views have rapidly changed over the past couple of decades as evidence has shown that doctors have a relatively high rate of suicide amongst professionals. Looking at my classmates and myself, I realize that we’re just as vulnerable to burn out as anyone else, and it’s easy to see the negative effect of exhaustion on the provision of care. When we’re physically and mentally exhausted, our emotions become blunted and we’re less able to empathize with our patients. We miss the nuances and subtleties in patient communication, or we just become too tired to even care. 

At a conference I once attended, a doctor recounted a story about a particularly gruelling clinic shift. After working for 20 hours straight, he had finally fallen into a nap when a patient called in with chest pain. The doctor, who was exhausted, brushed it off as indigestion (the patient had a history of this), even though he knew there was a possibility that it was a heart attack. After waking from his nap several hours later, the doctor panicked and called up the patient, half-expecting him to be in serious trouble. 

Fortunately it was indigestion after all. Was the physician at fault for not getting up? Absolutely. But at the same time, it's also true that the medical system put him in a position where it was very easy to miss a critical diagnosis. Are our resources really stretched so thin that we can’t afford well-rested doctors?

Sadly, in this regard I think that doctors are their own worst enemy. There's still a strong attitude within the profession that we should be totally resilient to stress, that we should be able to provide care but never have to accept it ourselves. In reality, even though we made it through the gruelling admissions process of medical school, we're still vulnerable to burn out.

Ultimately, a well-rested doctor is so much more capable of communicating with patients and synthesizing information, skills that are essential to accurate diagnosis. By learning to take care of ourselves, we become better care providers. While med schools may be holding more lectures on stress management, deeper institutional reforms are needed to make a real difference. 

Sweet Surprises

Standing in the maternity ward room last week, I couldn’t help but wonder whether I’d been assigned the wrong patient. My task was to perform an abdominal exam on someone who’d just delivered her baby, and yet the woman lying in front of me had a hugely distended abdomen. There shouldn’t still be a baby in there, I thought.

She suddenly opened her eyes and wearily looked me over.

“Hi,” I said nervously, “Are you Ms. So-and-so?” She nodded. Yep, right patient. Pressing my stethoscope against her stomach, I heard all the normal bowel sounds. Wait, was that the baby kicking?

As it turned out… no, no it wasn’t. Behind me, a nurse wheeled in a small bed with a tiny newborn happily perched in its centre. The mother broke out into a tired smile. “That’s my son,” she said proudly.

Surprise! A woman’s uterus remains enlarged for days after she delivers the baby, before it eventually shrinks back to its normal size. The uterine muscle inside becomes so thick over the course of the pregnancy that it could probably mug an old lady on the street.

Day in and day out, medicine has never failed to surprise me since I started here at McMaster. Now that I’ve wrapped up my first semester or “foundation”, I can only look back at the last three months and marvel at all the weird yet wonderful things I’ve seen and done. It’s been the most intense period of my life, a rollercoaster ride through success, failure, exhaustion and jubilation with a healthy dose of surprise.

First of all, I’m really surprised about how much I’ve enjoyed working with patients. Before entering med school, I kind of assumed that I would branch off into a more research or teaching-based specialty with minimal patient contact. The thought of having to drain pus-filled abscesses, suture wounds and do prostate exams on a daily basis didn’t seem particularly appealing.

And yet I’ve come to love being in the clinic. Yes, it’s messy, stressful and endlessly frustrating, but it’s also invigorating to be in such close contact with the human experience; to share in people’s lives and stories while feeling like you’re in a position where you can actually help. The cases do tend to get repetitive, but for every one hundred episodes of diarrhea and headache, there always seems to be that one case that touches you. 

Recently, a four-year-old boy came into the clinic with a cough and fever. With a short thatch of red hair and big, expressive brown eyes, he instantly reminded me of Puss in Boots from Shrek. But unlike the feisty cat, he was polite and clearly very smart, describing his symptoms in great detail. At the end of our interview, I asked him what he wanted for Christmas.

“Ummm, I asked Santa for Cars 2 [a movie].”

“Nice… Anything else?”

“And some Hotwheels cars, and…”

“And?”

“And a Jeep,” he said earnestly. His dad laughed.  

“So I take it you like cars a lot?” I asked.

He seemed to think for a moment. “Um yeah,” he replied with a giggle, as if only suddenly realizing his obsession.

Sitting the kid up on the examination table, I listened to his breath sounds with my stethoscope and found fluid in the lungs, an early indication of pneumonia. After I presented the case to the doctor and medicines were prescribed, the boy stuck out his hand.

“Thank you, doctor,” he said.  I shook his tiny hand before his dad whisked him off.

Despite being slightly concerned that I had just contracted an infectious disease through hand-to-hand contact (don’t worry, I hit up the Purell right afterward), I felt all warm and fuzzy inside. It was deeply satisfying to think that I played a small role in making this little person get better. And one day I’ll get paid to do this? I thought.

Small group learning

But perhaps my biggest surprise has been my fellow med students. Far from being stereotypical “Type A” personalities, the people I’ve met so far are generally relaxed, friendly and have great senses of humor. I spent most of my time this semester with my tutorial group, a team of eight students who study and train together every week. No matter how stressed or tired I felt on a particular day, I always felt cheered up at tutorial. We bonded through laughter, cracking jokes in between obscenely long discussions about death and disease.

Going into the Christmas vacation, I’m looking forward to a break from all the surprises and toward more predictable activites: sleeping in every day, eating lots of fat and going shopping for presents. Then I’ll be jetting off to the Bahamas with my mom and sister for a “self-discovery” program in yoga and meditation. To be honest, I only signed up because of the beaches and warm weather … I’m not sure how much more of myself there’s left to discover. But who knows? Maybe the greatest surprises are yet to come.

A Spark of Insight

I felt slightly terrified when my supervising doctor told me that I’d have to speak with his patient and wife alone. The patient, a man in his early middle age, had come into the clinic the week before complaining of dark urine and fatigue. A CT scan confirmed that he had advanced pancreatic cancer. Whereas he had been planning a vacation with his family only a short time ago, he would now be contemplating his own death.

Knocking on the clinic room door, I felt my heart pounding out of my chest. What do I say to someone who’s just been diagnosed with a terminal illness? After greeting the patient and his wife, a woman with long brown hair and a gentle expression, I pulled out my pad of paper and plunged into a series of biomedical questions: What colour is the urine now? Do you have any nausea? When is it worst? Every time there was an awkward silence, I would quickly fill it with another question.

When the interview was nearly over, I looked up and saw the man looking despondent while his wife just stared at the floor. I had completely and utterly failed to make any connection at all. I realized that I had kept cutting him off when his answers began to veer into the emotional. Even out of the clinic, I sometimes feel guarded when talking with people I don't know well, and yet here I was expected to talk to a total stranger about his impending death.

My heart pounding, I put aside my pad, looked the man in the eye and asked, “How are you personally coping with this diagnosis?” The man started to speak but then lapsed into silence, a silence that seemed to stretch on and on as the clock ticked loudly onward. What do I do now? Did I say something wrong? I wondered. But I shoved these anxious questions aside while my stomach tied itself into knots. 

After what seemed like an endless interval, he resignedly said, “I just don’t know what to do.”

I had suddenly made a connection. The man opened up after that, explaining how frustrated he felt to be diagnosed with cancer at such a young age. He described how he envisioned the final chapters of his life; he didn't want extensive surgery or chemotherapy, but rather to just be at home with his family. Whenever he would struggle for words, his wife (now engaged with the conversation) would help him out. By the end of our interview, I felt like I had gained a much deeper understanding of his suffering. In turn, I think he appreciated that someone just listened to him. 

By putting aside my script and connecting with the patient on a personal level, I saw him as being much more than a series of symptoms. I better understood his illness in the broader context of his life, an understanding that can help shape the course of medical treatment and improve the quality of care.  As time goes on, I'm becoming better at ripping up my script in favour of the spontaneity of genuine conversation. Maybe this conversation is more awkward and uncomfortable, but it is undoubtedly a much deeper source of insight than scripted responses could ever be.