The .Plan

One of the things I liked about my internal medicine and surgery clerkships is that there was a lot of doing going on. It was exhausting, having to stay at the hospital until 7 or 8 most days, but the doing is what appealed to the doer in me. Draw blood. Get the x-ray. Cut here. Stick that here. Pack the wound. Unfortunately, of course, there was also do a rectal and get a guaiac.

I thought that medical school would give me an opportunity to assemble a collection of stories about being the kickass medical student who brilliantly made a diagnosis that had left my senior attendings stumped. That didn’t happen, really. But medical school did provide plenty of occasions to meditate on my shortcomings. Not all of us are saints. Especially those of us who harbor punitive thoughts towards a comatose crack dealer who ran over a mother and her two children. Those of us who get impatient with the crying woman who is dying of AIDS whose husband has finally decided he can’t stick it out. Those of us who get frustrated with the diabetic teenager who just can’t seem to get it into her head that if she doesn’t take her insulin she’s going to end up back in the hospital next week, for the 4th time in two months.

I was reminded yesterday of Eric Schlosser’s book, Fast Food Nation: The Dark Side of the All American Meal, and I think the Iowa Beef Packers/IBP company provides a decent illlustration of what it means to be obsessed with time. The speed of the production line determines the beefpacking plant’s profitability, and as a result, the line speed in the typical plant has doubled in the past two to three decades, from about 175 to nearly 400 cattle per hour. Human suffering is but a secondary concern, if it is of concern at all. Hundreds of workers flashing sharp knives, making the same cuts over and over again, with power tools, power saws, power belts, and the slippery floor and watch out for the next carcass and there goes the finger–

“The chain never stops,” Rita Beltran, a former IBP worker told me. “I’ve seen bleeders, and they’re gushing because they got hit right in the vein, and I mean they’re almost passing out, and here comes the supply guy again, with the bleach, to clean the blood off the floor, but the chain never stops. It never stops.”

That’s not good. It’s disordered.

Donald Redelmeier of the University of Toronto and Rob Tibshirani of Stanford published a neat paper a few years ago entitled, “Are Those Other Cars Really Going Faster?” [link to PDF document]. They constructed a computer simulation of two-lane traffic where the cars had a target speed of 100km/h and accelerated if there was a gap in traffic and slowed down if the gap narrowed. And what they found was kind of interesting:

We found that the second lane could be mistakenly perceived as going faster because a driver generally spent more time being overtaken than passing. No combination of assumptions or parameters reversed this asymmetry… Together, these findings suggest a roadway illusion — namely, that the next lane on a congested roadway appears to be moving faster than the driver’s current lane even if both lanes have the same average speed… human psychology may make losses appear more salient than the corresponding gains, causing the joy of passing to feel less intense than the frustration of being overtaken.

And, of course, this beautiful paper would not be complete without a properly geekful conclusion: “Our findings suggest that naive attempts to rush may be misguided without a careful understanding of queuing theory” [emphasis added].

Sweet.

While I think queuing theory is interesting, I don’t know that studying more queuing theory would be the appropriate treatment when diagnosed with the reality of the human condition (per Romans 7). Sometimes you just need to engage in activities that sing the praise of slowness. Like trimming chicken thigh fat. Or running up a hill. Or watching hard-boiled eggs magically turn into lu dan.

What I found most odious about internal medicine and surgery was not that I kept getting chewed out by Dr. Onders for not knowing 15 possible complications of splenectomy. It wasn’t sticking my index finger up more arse holes than I care to remember. And it wasn’t even never having time to eat and always having to stuff my face while on the move.

What I hated most is that there was so much existential suffering that we simply ignored — or punted to psychiatry — in the name of cost minimization and volume maximization. Every patient got her 5 minutes (in surgery, 2-3 minutes) of chit-chat in the morning, and then whoosh we were off to see the next one. If the patient — or, God help us, her family — required more than, say, 8-10 minutes of handholding and sympathetic nodding, as we left the room we would each roll our eyes at the audacity of this squeaky cog in the well-oiled machine.

Although it was always kind of painful to observe a patient’s eyes plead his unresolved uncertainty or unaddressed concerns, it was even more painful to watch myself change from a timeful creature into one obsessed by time. As if spending a summer plodding along on southern California highways hadn’t already illuminated that dark corner of my character.

We were impatient with our patients.

Could there be a more succinct recapitulation of the disorder in American medical practice (or of the disordered values in this doctor’s life) than that?

The hours are much nicer on the inpatient psychiatry ward. Typically, we get to go home by 5:00 every day. But although our time is much less harried, the days do seem much longer than the days on the medicine or surgery ward, because one is confronted with a different kind of suffering entirely. My patients aren’t coughing up brown gunk, or lying deathly still because of an agonizingly painful peritoneal infection, or running out of breath because their hearts are not pumping properly. But they are wasting away. You can’t see it on a chest x-ray, you can’t cut them open and remove the infected tissue, and you can’t just give them a pill that will let them pee out the excess fluid building up in their bodies.

They desperately want to live normal lives. Who takes pleasure in building a hedge of razor wire around his house to keep out the FBI agents who are after him? Who wants to be in the situation of trying to get her police chief to discipline her physically abusive 2nd husband (who is a police officer in the same department) only to see the entire department defend him, suppress all of the evidence, and drive her out after a 6-year court battle, during which she remarries, only this time to an emotionally abusive alcoholic 3rd husband whose abuse drives her to the point of spending 6 months carefully researching different ways of killing herself? Who can stand listening to the disembodied voice of an abusive ex-boyfriend who yells hurtful things at her through other people, only to discover that the only way to stop the voices is to have sexual intercourse with the people from whom they emanate? Who likes being addicted to heroin and going through the all-too-familiar cycle of shame / abstinence / hunger / binge / disgust / suicide, for the 8th time?

The doer has a hard time watching and listening. He wants to do something. But that’s not how healing occurs when you can’t just stick in a chest tube and drain what needs to be drained. Our patients do get better under our care. But healing requires more than a chest tube; it requires understanding, and understanding requires listening.

To know in what way others are suffering demands an exhaustive understanding of what makes them the individuals they are — when they feel themselves whole, threatened, or disintegrated as well as their view of the future, the past, others, the environment, and their aims and purposes. Given its almost infinite complexity, this may appear impossible; after all, we usually do not even know these things about ourselves…

To know others to the degree required for the depths of human compassion requires a knowledge not only of the empirical facts of their existence through time, but also of their values as displayed in their presentation of self, their speech and their behavior. Their purposes and their aims become known in the retelling of the past and their moment by moment choices and behaviors. Finally, to know others as the whole persons they are demands an aesthetic sense of wholes and parts — in the moment and over time. Since, in suffering, disruption of the whole person is the dominant theme, we know the losses and their meaning by what we know of the person who confronts us.
–Eric Cassell, The Nature of Suffering and the Goals of Medicine (Oxford University Press, 1991)

Ay, there’s the rub. Not only is a virtuous sense of timefulness in short supply among those of us who are not saints, psychiatric practice is receptive in nature. And that’s why the next 6 months are going to feel like a really long 6 months. Stanley Hauerwas, in his book Suffering Presence: Theological Reflections on Medicine, the Mentally Handicapped, and the Church, has written persuasively about how the physician’s primary task is to be present to the patient in his suffering and alienation — but, to which I respond only two weeks into my intern year, does it have to entail so much discomfort?

So this is what was keeping me awake…

Fire department spokeswoman Helen Fitzpatrick said the fire started on a large dock at 1801 Fairview Ave East at about 1:22 a.m., which is at an old National Oceanic and Atmospheric Administration wooden pier containing creosote. Flames quickly engulfed the pier and spread to a nearby ship.

A tower of smoke that could be seen for miles billowed from the waterfront and drifted across I-5 throughout the early hours of the morning and several houseboat owners were evacuated due to the thick smoke.
–“Firefighters Battle Massive Blaze on Lake Union”, KOMO News, July 5, 2006

Now my apartment smells like smoke. Unfortunately not the nice, satisfying, post-kalbi grilling smell.

After she heard the rumble of firetrucks outside, Hammock opened her door around 2:30 a.m. and saw smoke “so heavy, you could barely see the white lights on the engine (of firetrucks),” she said.

“People coming up the street were saying, ‘We can’t get home.’” At one point, she heard emergency officials use a loudspeaker asking residents to evacuate. She also saw embers falling from the sky.
–Brad Wong, “Four-Alarm Fire on Lake Union Prompts Evacuations and Detours”, Seattle Post-Intelligencer, July 5, 2006

From XKCD, the “webcomic of romance, sarcasm, math, and language”:

The approach of a wife, in the words of a blind man:

Consider Tracy’s sound. I like to. The other day, when she finished shopping, she returned to fetch me from a bench… Although I didn’t see her coming, I thought I recognized her footsteps, so I stood up. “How did you know it was me?” she asked, placing my hand on her elbow.

The leather was unfamiliar. A new coat. Had I not identified Tracy by her footsteps, I still would have known her by the feel of her elbow, even when dressed in this new, smooth texture. I would wager everybody has known the body of a lover to this degree. Touch is enough, and I doubt it’s a party trick specific to squinty folks.

“Nice coat,” I said. “I guessed it was you by the way you walk. Your boots make a certain music when you move. Just sounds like you.”

…When Tracy passes me in our house, her fragrance doesn’t arrive in advance. Perhaps that would smell needy, even clumsy or brash. But as soon as Tracy nears me, the faint sweetness of her air unfolds. The notes are singular, a subtle mingling of her own scent with that of her perfume. Then, the full effect reaches me — and this is the important part — the moment she passes. Those are the erotics of smell and space. Different notes twirl in the air after her. They make me want to turn my head. I want to look.

What a pleasure and a pain it is.
–Ryan Knighton, “Seeing the World Through my Wife’s Eyes”, New York Times, July 2, 2006