Why don't you get an education and a job?

This week I am teaching a course in health disparities where medical students pick a group of people who are afflicted with disproportionately poor health outcomes and tackle the reasons why that is and think about what can be done to get rid of the disparity.  The course always leads to very interesting discussions because so much of the material is an epiphany to both the students and myself.  For the students, they see that so many of the things they thought were "just the way it is" are actually the intentional products of a rigged social system.  For instance - any student who has ever walked into a dialysis unit has observed the high proportion of black patients receiving treatment.  It's just the way things are.  They are taught that blacks have disproportionately bad outcomes from hypertension (like kidney failure and the need for dialysis) for a variety of reasons - genetic, secondary to access to health care issues like poverty, being uninsured, etc.  What they find out when studying health disparities is that in other countries, blacks don't have a worse outcome in hypertension than whites. They only do worse in America.

What is it about being black in America that makes them do worse?  Well, when you put it that way, you realize we know the answer.  Slavery, Jim Crow, The War on Drugs, Red-Lining, Mass Incarceration - America never lets Black people forget that their race is a problem.  Being Black in America means existing in a state of chronic stress.  It is, in a thousand different ways, a killer.  So is being female and constantly having your legitimacy challenged in the work place while also being constantly reminded that your beauty is your only measure of worth.  So is being gay or trans or Hispanic or anything other than mainstream.  Why do young black men die at 3.5 times the rate of white men who live in the same city?  Because our society makes life a literal struggle for anyone who is not white, male, educated and well off.

The reality of this situation really struck home for me when the students and I were discussing the plight of the homeless population in America.  I'd given them an article to read - Malcom Gladwell's Six Million Dollar Murray.  In it, Gladwell talks about how there are really very few chronically homeless people in this country - but even though there aren't many of them, they cost the health care system an enormous amount of money.  The Murray in question cost the State of Nevada six million dollars one year (fell over drunk, hit head, bled into his brain, causing a multi-month stay in the hospital, etc) in medical bills.  The very same Murray actually does well when he works with a social worker and has help managing his money and finding an apartment - but those services are only provided temporarily and when they go away Murray goes off the rails and inevitably ends up in either jail or the hospital.  It would cost Nevada a lot less than six million dollars to simply provide Murray with help and housing permanently.  So why don't they?

We don't provide people who are struggling with life with the help they need because our society has a problem with people getting something for nothing.  As in - why am I working three jobs when that guy is getting everything for free?

There is this very strong sense in America that we get what we deserve, and we get that through hard work.  If you see things this way, it seems completely unfair that someone who has opted out of making an effort just gets things handed to them.  It's politically very difficult to obtain funds from the taxpayers for programs that aid the homeless for this very reason. It seems like we are giving things to some people for free that others are struggling mightly to obtain for themselves.

I could go on about how difficult it is to be homeless, and talk about all the different reasons there are that some people have a much harder time finding and keeping gainful employment than others, and talk about how cheap it would be for everyone concerned to end homelessness as opposed to the crisis management approach we have now, but I don't think any of that changes anyone's mind.  Because what, in the end, I am really asking people to have is compassion. I am asking everyone to believe that people are trying as hard as they can to cope with life, and some are better at it that others but that everyone deserves to have access to the things that dignify them as human beings, and a place to live is one of those things.  And there is a real resistance in many people to deciding to adopt a position of compassion. 

This resistance to an attitude of compassion has always been a mystery to me.  In a nation where the predominant religion is Christianity, why isn't there more charity and understanding for the plight of our fellow man?  Is it that hard to understand that people are differently abled and that some people need more help than others?

This is where I had my epiphany.  The problem isn't that Americans are "I got mine so screw you" jerks.  The problem is that most of us live in fear of being homeless ourselves.  Not in an existential way that you could see a therapist about.  In a real way.  It is a real fear.  It is reality.

When people tell me that it is unfair for them to work three jobs when some homeless guy gets stuff for free, I focus on the lack of compassion towards the homeless guy.  But why don't I consider the question of why in the hell anyone needs to be working three jobs?   Having to work three jobs is crazy.  Having to work three jobs is a desperate attempt to stay afloat.  Having to work three jobs is killing yourself in order to live.  Working three jobs is what you do when you are frightened that you're about 2 steps to losing everything.  No wonder there's such resentment towards having some of your tax dollars go to someone else.  You're barely surviving yourself.

Because in America you need to pay.  You need to pay for health care.  You need to pay for child care.  You need to pay to get help when you are aged. You need to pay for a bloated defense that's fighting multiple unwinnable wars.  You need to pay for private school.  Hell, you need to pay for public school.  You can only take vacation if you can afford not to get paid for the time you spend away. You have to choose between your job and spending time with your new born baby.   You need to pay for every single one of your basic needs.  You're only as free as your wallet can afford for you to be.  And there is a very sparsely woven safety net.

If our social safety net was better - if we didn't all feel as if we were just about to drown ourselves - would we be more open minded about offering help to those of us who need a little more help to live life?  If we felt that our society supported us by helping with education, child care, time off, health care - if we felt that society helped us live in a dignified way, could we afford to be more compassionate? 

"Give a man a fish, he eats for a day," I hear people say. "Teach a man to fish, he eats for a lifetime."  True enough.  But we're in a drought.  The river is shallow and the fish are dying.  We will all benefit if it rains. 

The Lady in The Van

I recently saw a Trailer for The Lady In The Van, which stars Maggie Smith in the titular role.  I'm excited about this movie, which is based on the diary entries Alan Bennett made about the woman who lived in his driveway.  I was very touched by the story when I read it back in medical school - so touched that I visited Alan Bennett's driveway when I went to London in 2007.  Here's my journal entry about the day I did that.  

Day Three 2007.  Camden Yellow

My alarm goes off at 8:30, but I find it impossible to get up.  I don’t end up leaving the hotel until almost 11, and the first order of business is to go back to the National Gallery and exchange my Italian Catalog for an English one.  My request stupefies the clerk and she has to get her boss to help her.  Then it’s on to the National Portrait Gallery, which is right around the corner.  I pass the Edith Cavell memorial, which bears the inscription “It is not enough to be a Patriot, I must have bitterness and hatred in my heart for no man.”  I should probably find out who Edith Cavell was, if she’s going to go around saying extraordinary things like that.

Still annoyed at the lack of organization at the British Museum, I go straight for the audio guide and Gallery One, which begins it all with the Tudors.  I meet my friend Hans Holbein^[1] again, and take in the really amazing portraits he did of Henry VIII, Sir Thomas Moore (who taught me, via A Man For All Seasons, that it was possible to be just as big of a pain in the ass by being very, very good as it was by being bad, thus opening up many possibilities for me in life) and Cardinal Wosley.  There are some gangs of school children about, being quizzed by their teacher:

Teacher: (Pointing to a full length portrait of Queen Elizabeth in her youth, red hair aflame) Who’s that lady there?

Children:  Queen Elizabeth!

Teacher:  And what was she famous for?

Children:  She was the Queen!

Teacher:  And what about this man?

Children: Francis Drake!

Teacher:  And what did he do?

Children:  Sailed ‘round the world!

Teacher:  And who’s that fellow over there?

Children:  Sir Walter Raleigh!

Teacher:  And what was he famous for?

Children:  Cigarettes!

There was also a lot of amusement when these children encountered a portrait of Sir Francis Bacon, the comedic aspect of having cured breakfast meat for a last name more than apparent to them.  I find myself comparing the portraits of people on the wall to what they looked like in the Hollywood films that have been made of their lives.  I have to give whoever does the casting for HBO credit for how much the Earl of Southampton in their mini-series on Queen Elizabeth looked like his portrait in the National Gallery.

 After the Tudors I lose interest in both the portraiture style and the subjects.  It’s all painted in that Fwenchy Rococo style that I don’t like.  I dutifully look at all the portraits, but I don’t care about any of them.  It isn’t until the men start looking like George Washington (I now know this is called the “Regency” Period) that I begin to see familiar names again, particularly men of science, like Jenner and Faraday and Darwin.  Speaking of films, I find William Wilberforce, whose portrait is only partially finished, and next to him his friend, Pitt the Younger.  Wilberforce does not look particularly like the actor who played him in Amazing Grace, (Ion Gruffud) but Pitt the Younger does (Benedict Cumberbatch, I no longer wince at the tweeness of this name, as you can see). 

Placards tell me that this person’s or that person’s portrait “caused a sensation” or “raised ire” when it was hung.  Silly people, it’s just a picture, I thought.  Then I arrived at the modern portraits and after being lulled by nice paintings of Alan Bennett and David Hare and Tom Stoppard (all acceptable) I came upon one of Sienna Miller and really, I had an urge to rip it from the wall and smash it on the ground.  Some one please, please tell me why that woman is famous.  Similar reactions to Rupert Murdoch, Richard Branson and the vile Anita Roddick.  Also all the cricketers and footballers who have portraits hanging – come on, National Portrait Gallery.  Have standards. 

I think the modern portraits I liked best were the ones circa the Bloomsbury era – Joyce and Wolfe and Strachey.  Quite a few were done by Dora Carrington, and I really liked them.  I didn’t see many portraits from the thirties, forties, fifties and sixties because that wing was blocked off – there were installing something.  I’ll have to be back, because I missed Wilde and Orton, whom I must see.  There was a whole wing devoted to Diana, from which I heard sobbing emanating, so from which I fled as quickly as possible when I discovered what it was, eyes squinted so I wouldn’t see any of it.  I escaped unscathed.  I didn’t mind Princess Di when she was alive – I thought she was pretty, I thought Prince Charles acted like an ass, it was awful how she died.  What I can’t stand is this carrying on ten years later.  She wasn’t Gandhi, people.  Get over it.^[2]

I eat lunch at the National Portrait Museum Café.  I should know better by now, but they had a ham and asparagus quiche that looked very nice, so I had that, with a coffee.  It was repulsively salty.^[3]  Also, I was really hurting.  All the stooping to read placards and inspect the art had taken its toll and my back was hurting in a place it had never hurt before – right in the middle – so I had to find something to do that didn’t have anything to do with a museum.  I got on the tube to Camden Town.

My trip to Camden has been a long time coming.  It starts back in college, where I became enamored of the British Diary, ostensibly private ephemera written so obviously to survive for posterity - a human contradiction that I loved.  In medical school I read Alan Bennett’s diary and discovered The Lady in the Van.  The Lady in question was an elderly misfit who drove her station wagon into Alan Bennett’s driveway in Camden Town one day and lived out of it from there for decades.  Being British, he simply stepped around it every day.  He let her run an extension cord from his house out to the van, bought her groceries, and wrote about her in his diary.  He didn’t like her – she was a pain in his ass, her van stunk, and she would frighten the guests (he seemed to relish this, especially when she scared the shit out of Vincent Price) who came to his house.  She liked to put coats of yellow house paint on her car because it was a papal color and she was a devout Catholic^[4], so there were drips and draps of yellow paint everywhere.  Alan Bennett’s fairly famous, by the way.  He wrote the play The Madness of King George and got his start with the Beyond the Fringe comedy group, where his cohorts were Peter Cook and Dudley Moore.  Imagine a homeless guy taking up shop in Woody Allen’s vestibule. He'd call the police.  But Mr. Bennett just sort of bore this lady in his driveway the way you’d bear a bird’s nest in a tree on your property – a random act of nature, which he dealt with in a humane, patient and all together English way.  So in prep for my trip to London I reread the Lady in the Van parts of Bennett’s diary, trying to triangulate on exactly where his house was.  I narrowed it down to the house across the street from #63, Gloucester Crescent.  

I really couldn’t go back home without making this little personal pilgrimage, so I figured now was as good a time as any.  When I came up out of the tube, I found myself on Camden High Street, and it was quite a scene.  The streets were bustling with 20 year olds, every shop seemed like a place where you could either get a tattoo or a vegan meal, and anti war signs were plastered on every surface.  Unmistakable and comforting signs of a nearby University, I became quite enthused and was I was temporarily distracted from my pilgrimage by the temptation of a denim skirt with Che Guevara's visage silk screened onto its butt, which was for sale by a dreadlocked sidewalk vendor. It seemed very much like something I needed and I barely tore myself away.

Gloucester Crescent was quiet and residential.  Incredibly, I appeared to be the only person there on a pilgrimage to the yellow spots of paint on the curb outside Alan Bennett’s house.  I walked all the way up it and all the way down the road, taking it in.  The row houses were very nice – clearly, you’d have to have a lot of money to live in one.  I could see in through some of the windows and the insides were very luxe.  The street and the yards were very grungy and grimy, though – very Hyde Park, if you know what I mean.^[5]  I remembered the astonishment of my mother and father the first time we visited Hyde Park after I was at college – they couldn’t understand why educated, well paid people would live in such squalourous settings, where you had to keep one hand on your pocketbook at all times and everything you owned was covered in soot.  Needless to say, I felt right at home.  I found the faded yellow spots of paint, and rejoiced.

 

Walking back to my hotel it occurred to me that I hadn’t had anything warm to eat all day.  I stopped and looked in the window of an Indian Restaurant on Gloucester Road and the owner of it came out and basically pushed me inside.  I ordered some Samosas, Garlic Naan, and Saag Paneer.  The waiter was not happy with my order and wanted me to order some rice or some lentils.  I didn’t want any of those things; I just wanted my old standbys.  Another waiter stopped and asked me if I was Chinese or Japanese.  For Christ’s sake, even in England.^[7]  “Japanese,” I tell him, and he chatters some words at me which are truly incomprehensible.  I’m sorry – I know I don’t speak Japanese, but I can say hello, and how are you and all those things people might be taught as phrases.  I look at him in dumb confusion.  He chatters at me again in Indian-accented Japanese.  I have no idea whatsoever what he’s saying.  “Not Japanese,” he pronounces, and moves on, seriously pissing me off. 

The Japanese speaking Indian man arrives later with my Samosas.  “Very good with mint sauce,” he tells me, pointing to the tub of mint sauce and then my Samosas.  “Yes,” I say, but he’s whisked himself away.  I put some mint sauce on a side plate and dip my Samosa into it.  The waiter reappears at my elbow.  “Please, try the mint sauce, Madame,” he scolds.  Before I can show him that I am eating it with the mint sauce, he is gone.  Minutes later he reappears, picks up the tub of mint sauce and pours it himself onto my remaining Samosa, shaking his head in disgust.  I take out my notebook in order to write this extraordinary string of events down for later documentation, and immediately the service becomes rather amazingly better.  My main course arrives, accompanied by a “tasting plate, compliments of the Chef,” a sweet Mango Lassi that I didn’t order and I am asked what I would like, for free, for dessert.  At first I think maybe the owner saw how rude the waiter was, but as he’s allowed to go around and be rude to everyone else in the restaurant, I end up with the realization that with my notebook they think I am a restaurant reviewer.  So I am obliged to tell you that Memories of India in Gloucester Road is clean and bright, but the service is challenging and the food is mediocre.  It is hot and filling, though, and they give you stuff for free.

---

^[1] Because I have seen his iconic portraits of Henry VIII all my life, I took Holbein for granted at first.  I looked at the portrait and I saw Henry VIII, corpulent of flesh and ego.  But the more of Holbein’s work I see on this trip the more I start to look at these paintings and see not the queens and kings and noblemen but Holbein himself.  The paintings lack the dramatic spotlighted three-dimensional fleshiness of a Caravaggio, or a David.  They are flat, open, straightforward, powerful.  There is no allegory here.  Henry VIII doesn’t need allegory – he just needs to be, and that frankness is what Holbein captures in his subjects.  Most of the artists who mean a lot to me are more contemporary, but by the end of this trip I had developed a serious reverence for Sir Hans.

^[2] Stephen Frears’ The Queen explores the notion that the English Public’s reaction to the death of Princess Diana marks a moment during which everyone realized that the EP had in fact undergone a distinct change.  Gone were the stiff upper lips of the generation that had survived the Blitz and defeated the Nazis.  The EP was now soft, weepy, sentimental – American.  Oh, the horror.  I agree completely.  Buck up, English Public. 

^[3] The quiche, not the coffee.  Although I wouldn’t have been surprised if it had been the other way around. English food is extremely dependable in its ability to revolt one’s tastebuds. Always Eat Ethnic in London – that’s my advice. 

^[4] And because she was crazy.

^[5] I speak here of Hyde Park, Chicago, the neighborhood that the University of Chicago is in.  It’s a small strip of lakefront land between two of the worst ghettos on Chicago’s south side (when Martin Luther King Jr spoke of Chicago’s “silver lined ghetto,” Hyde Park was the silver).  Having grown up there, most of Chicago is stamped with the identities of my parents, but Hyde Park belongs to me. 

^[7] No travel story of mine exists without at least one encounter that involves curiosity about my ethnicity.  This is a well-known fact.

Today, on World AIDS Day, I remember Glenn Walker.  That's his real name.  It's important.

I met Glen when I was an intern on the HIV ward at University Hospitals in Cleveland in 1993.  It wasn't called the HIV ward - it was called the SIU - the Special Immunology Unit.  Which didn't fool any of us, of course.   I have very distinct memories of this space, because it was where I made my bones as a doctor.

Glen had no T cells, and was frequently in the hospital.  He was pleasant enough, but he had terrible AIDS related dementia.  He wandered around, getting into other patient's beds and eating other patient's food and sauntering onto the elevator and winding up 3 blocks away, barefoot and panhandling for smokes.  You had to keep your eye on Glen.  And of course he was seriously sick quite a bit of the time, as well, which sent his dementia into the fog of war, where he hit us and fought us and there was real anger in his usually placid eyes.

At first you thought Glen was sweet and tragic, but after a few middle of the night tussles where you had to call security and affix him to his bed with leather restraints, his continuous efforts to be up to something got irritating.  Glen was a pest.  No nursing home could deal with him and even if we could dupe one into taking him, he'd be back with a fever in no time.  He was ours, always, like a permanent 3 year old who was never going to grow up and go to school.  With Glen around, there was never going to be any peace.  We smiled at him, and he smiled back - but we cursed him underneath our breath.

One day during morning report when I was a senior resident, we saw something big fall past the 3rd floor window of the conference room.  Rick Bailey went to the window and looked down.  "It's Glen Walker," he said, only slightly surprised.

Of course it wasn't Glen Walker is what we all thought.  Rick was a prankster.  But of course it was Glen Walker - of course it was.  He'd snuck into a bathroom and stood on a toilet and climbed out a window and fallen 4 stories.  He landed on his feet, shattering his ankles.

The first thought we had:  Glen in a wheelchair with two huge casts will be easier to manage.  Which he was.  The second thought we had:  "Glen No-Walker."

I knew it was wrong, but I sort of forgave all of us for calling him that, because black humor is about the only way you make it through a month on the Special Immunology Unit.   Until Glen Walker died, and his family sent us the program from his memorial service.  On the cover was Glen in full health, looking nothing like the 90 pound wasted man I knew.  And inside was a paragraph about how he had gone to Julliard, where he'd gotten a degree in piano performance.

What a rare and precious thing it is to have that kind of talent.  The ignominy of how we treated him at the end of his life still causes me to feel intense shame.  How could we not have known?  How could we not have asked?  How could we not have reminded ourselves that Glen used to be different - a whole man, same as us?

Well, its a thing.  He was alone, with family in a far away city.  His disease took away his mind and so you could argue there was a good reason we didn't feel his humanity the way we should have.  I'm not sure he noticed.  Nevertheless, I today I remember, as I frequently do, standing at the nurse's station where someone had taped up the program and being startled when I realized whose picture I was looking at.  I remember how sorry I was when I read about who he really was and realized he hadn't been a real person to me.

I really am sorry, Glen.  I'm sorry about everything - but mostly that I never got the chance to hear you play. 

Amen and Amen

Today, for the first time in about 30 years, I talked to a "Professional Christian" (i.e., pastors a church for a living) about my experience in an evangelical church and felt neither judged or proselytized. He seemed genuinely curious about how I interpreted things like faith healing and speaking in tongues then, and how I think about them now, and about the continued disgust I have with organized religion and the continued respect and wonder I have for the teachings of Jesus. It was a really wonderful conversation.

One thing that always spoke to me about Born Again Christianity was the idea that you did not need a pastor or priest or pope to tell you what to think about God. You read the Bible, and you thought about it, and you had a direct relationship. That said, it always seemed like the church never the less had some really hard line ideas about the right and wrong conclusions to reach, which is where the friction was for me.

I feel the message of Christ can be found in many places - in other religions, in other belief systems, in human interactions. It's all over the place, if you have eyes to see it. I feel like the New Testament helped me see it, and other people get to these Universal Truths through other religions or life practices.  I don't think you're going to Hell if you don't accept Christ as your savior. I think you're in for a terrible time (at least on Earth, if not beyond) if you don't get to those "Universal Truths" somehow - but I chafe against the idea that there is One Right Way.

The other thing about the church was that I took what I thought Christ was trying to say very seriously (because it seemed like you were supposed to - we're talking about going to Hell, right?)  and I tried very hard to meet the challenge of finding the way of peace, turning the other cheek and embracing people on the fringe of "polite society." And maybe this is adolescent of me, but no one ever seemed to notice that in the church I went to. I was trying to do what I thought were the most important things but it turned out there was a lot of other stuff that was more important to the church. The people who were held up as examples for the congregation were the rich, the beautiful, the powerful - but never, ever it seemed - the ones who were honestly engaged in the god damned struggle. (Pun intended).  The church preached to me that I was going to hell unless I was a Christian, but seemed to flaunt the opposite of the teachings I read about in the Bible on a regular basis.  Something was very wrong.

I will never forget the time in high school when I saw one of the teens at my church verbally and physically intimidate one of my favorite teachers in the hallway of my high school. I was shocked at the language she used towards her and the way she yelled and called the teacher a bitch, and lunged towards her. They were having a dispute about a failing grade, I gathered. Shortly after I turned the corner, she walked away, but she saw me and I saw her. That Sunday, the pastor was praying and speaking in tongues, and he said that Christ had spoken to him and told him to recognize the young people of God in the church, and he brought that very same teen girl (the daughter of one of the deacons) up to the front of the church and put a sash that said "Christian Teen" around her.  She smiled and the congregation praised God.

I think the hypocrisy of that moment was probably it, for me. I believe that Christ speaks to people, but probably not the ones who brag about it. And I think he says stuff to me all the time - not as a voice in my head, but just sort of stuff that's there for me to see and hear if I have the eyes to see it and the ears to hear it that day. Edgar Cayce, a famous American mystic, once said that an angel had revealed to him the meaning of life, which was to do whatever you needed to do to become a worthwhile companion to God. That has always made a ton of sense to me and I think I do try to do that by finding ways to appreciate what's in front of me (and fail a lot, but that seems to be how it works).

It wasn't until today that I was reminded, in talking to Wes, that that ethos I've adopted as an adult actually is very connected to what I started out to do when I was a teenager sitting in a room of people whom the Spirit Had Moved wondering if it was really the Holy Spirit who had stopped by or rather a form of the mass hysteria I'd read about in my abnormal psych book.

Have I actually been a rather religious person all along? Wes says I'll have to tell him, because I'm the only one who knows.

On the Value of Humanities in Health Care, or Surfing the Waves

Caveat - I extoll the virtues of an undergraduate degree in English Literature in this post to the point that it may seem I am saying that the only good doctors are former English Majors.  While in some ways I do think that, I'm willing to concede to a broader point - that an interest in and a study of the humanities is vital to good doctoring. 

This week I had the great pleasure of participating on a panel which spoke to a group of pre-health undergrads at Northwestern University about the value of an undergraduate education in the Humanities.  I was invited to sit on the panel by my medical school classmate, Paul Checchia.  Paul and I met during the first week of medical school in Lindegren Library when we were both trying to check out All The Books, because the first wave of being a humanities major (in our cases, English Majors) in medical school had hit us.  

That first wave is the obvious one: what was review for many of our classmates was new material for us.  I remember standing in the gross anatomy lab slowly realizing that there were many holes in the base of the skull through which nerves ran.  It made sense – how else would the brain extend into the rest of the body? – but these holes had names – crazy, hard to remember names.  I said something about this only to find that my lab partner had a master’s degree in Anatomy.  He already knew all the names.  He went to a bar that evening and watched the ball game.  Me?  I studied.  

That first wave was pretty bracing, but it wasn’t a surprise to me that I was going to have to study in medical school.  I think it was only in retrospect that I realized how much more I had to cram in than some of my classmates.  I also realize it was only like that for a few months.  We were all in the realm of knowing nothing very quickly, which brings me to the second wave, which was the wave that buoyed us up.

It is my sad (but somewhat gleeful) duty to inform you all that the realm of knowing nothing, which you reach at some point during the first year of medical school, is where you shall remain for the rest of your life.  There will be times you think you know something, but these times will be followed by stark illuminations of the exact dimensions of your delusion.    Knowing nothing makes medical students really crabby, because they have tried so hard for so long and they are used to achieving things and not used to having doubts about their abilities.  It is really awful to score 100% on your microbiology final and then walk into a hospital, see a patient who doesn’t speak English with a high fever who is crying uncontrollably with two babies by her side and not know the first thing about what might be wrong with them or what you might be able do about it.  It is disconcerting to be someone who researches oncogenes and then walk into a room where a patient is dying of cancer and wants to discuss physician aid in dying.  One begins to wonder what the point of all that studying was. 

And that is the wave that lifts up the humanities major.  It is not news to someone who has read Beckett that very important events in life may feel profoundly meaningless.  It is not a shock to someone who has played in an orchestra performing a Beethoven Symphony that something can be blindingly beautiful and devastatingly tragic at the same time.  Someone who has acted in Hamlet understands that the same person can be both very good and very bad.  A student of history is not confused when she discovers that her African American patients don’t trust the medical system.  Students of the humanities are primed to encounter the incredible spectrum that is the human condition.    They are comfortable with ambiguity and with all sorts of perspectives and points of view.  Through the humanities, they have experienced a myriad of worlds unseen.  When they finally see it in person as medical students, it’s not strange.  It’s familiar and comfortable.  It’s home.

Patients notice this comfort.  They start saying things.  “Thank you.  No one ever bothered to explain that to me before.”  “ You talk to me like I am a person.”  “Please remember to be like this when you are a doctor.  Remember to be real.”  “Thank you for not treating me like shit.”    Doctors notice students who seem to just naturally belong in the clinical setting.  “Good Clinical Acumen.”  “Fantastic rapport with patients.”   And my favorite: “This student just somehow ‘Gets It.’”

Humanities majors are not somehow “getting it.”  They have made an active decision to “get it” – they have made a commitment to “getting it.” They are determined to “get it” and they succeed.  I read hundreds of medical school application essays that talk about dreams of becoming a doctor and helping people.  Well, to help people, you have to understand them and appreciate them and see the beauty in them, even when they are complicated and contradictory and different from ourselves.  And the people who have deliberately taken on that challenge – who have been willing to look what it means to be human right in the eye – well, these are the poets and painters and dancers and philosophers and historians and – well, you see where I am going.  These are the people who have chosen to pursue a foundation in the humanities.  

Doctors with strong backgrounds in the humanities have the ability to surf the magnificent third wave, which I suppose I might broadly label “empathy.”  A contradiction I think about a lot is the fact that all my medical students write these beautiful application essays about wanting to help and heal (and I believe that in some way or another they are all being very truthful when they write these things) juxtaposed with the fact that doctors are perceived by the public as arrogant, uncaring and obtuse.  How does such a wonderful group of intelligent young men and women get transformed into a bunch of brutish beasts?  The simple answer is that although doctors care, they don’t always know how to show it.  But let’s drill down further.  Why don’t they know how to show it?  What gets in the way of them showing it?

If you think about what’s behind the closed crossed armed body language, the use of jargon instead of plain English, the stony mien, the judgmental attitude, it comes down to two things.  Fear and anxiety.  Not fear and anxiety about their knowledge of science and medicine – remember, these people have studied like mad and passed metric tonnes of tests – fear and anxiety of interacting with other people.  And you can either embrace that feeling and display curiosity and search for connection, or you can shut down.  A grounding in the humanities gives you the courage to embrace the other, because you know that as nervewracking as that can be, it’s where the good stuff happens. 

Medical knowledge without true connection with a patient or a community is worthless.  You can’t just take science and paste it onto people because it’s for their own good.  I mean – you can, but it won’t work.  Knowing the diagnosis means nothing at all if you can’t partner with your patient to find a treatment that fits them.  Deciding to put up posters about cancer screening in a community where children go to school hungry is the epitome of the type of “not getting it” that is so rampant in the medical system. The ability to get past the fear and anxiety that happens when you encounter a person who is quite different in looks, world view, religion or social status and truly partner with them to solve a problem takes an expansive and curious nature.  That’s the attitude that studying the humanities inculcates, and it’s also the path to the kind of empathy that leads to healthier patients as well as healthier doctors.  

That’s the thing about figuring out how to surf the empathy wave.  It’s exhilarating.  You can really help other people out and use your knowledge to improve people’s situations.  Doing what you actually said you were going to do when you were 19 is extremely validating.  You’re making good on a promise you made to yourself when you were young and that is a life triumph that many people never achieve.  I actually think that I get more out of trying to have an empathetic stance with patients than they do.  The patient gets help with their problem.  That’s great, that’s what they expected, and that’s my job.  But I have to say I think I have become a much better person through my interactions with patients, and that wouldn’t have happened if I’d pursued a career outside of health care.

In health care, you can’t walk away.  Even if you really want to.  It’s your job to help whoever shows up in the ER, the clinic, the hospital.  You have to find a way to provide a healing experience for anyone who needs it, and that means you’re forced to find connections and ways to partner with people you’d normally never encounter or more importantly, actually go out of your way to avoid.  The guy who I know beats his wife since she’s my patient, too.  The prisoner shackled to the bed.  The woman who I admit to the hospital every month for the same self-inflicted problem.  I cannot choose to avoid them.  I must find a way to understand them.  That means I have to get to know them.  And because I have felt my profession obligated me to do so, I have realized a great life lesson:  we are all the same.  There are no “those people” or “people like that.”  There is no one you can’t understand, because they are you.

Medicine forces you to confront the fact that we are all in it together.  Some people find this frightening, and build walls.  Others find it liberating and validating, and do amazing work as physicians and healers.  I am no longer surprised that when I encounter a really happy, successful doctor I can count on finding out that they have a strong background and interest in the humanities.  I have gone from thinking that being an English major was something distinctive about me to knowing that it is the real reason I’ve been able to evolve into being a good doctor. 

Interdisciplinary Ethics Day

Last Saturday, I had the pleasure of attending an interdisciplinary conference between first year law, medical, social work and physician assistant students.  They examined and discussed this case:

http://www.npr.org/sections/health-shots/2015/01/08/375659085/can-connecticut-force-a-teenage-girl-to-undergo-chemotherapy


As it is every year, the discussion was very interesting.  I was struck again about how quickly you can differentiate the law from the medical students - you can do it within a few seconds of hearing them speak.  These are students in the first few weeks of their professional studies - and they already wear distinctive mantles.  This conference (usually held on the first truly beautiful Saturday morning of fall - a tragic thing for all of us) always gives me a lot to think about.  I try not to say too much during the goings on, but here's what I sent off to the students today on the subject of consent, capacity, and doing the right thing. 



1.       Objective Criteria for Determining Maturity – several people made mention of using some objective criteria to decide whether a patient was mature enough to make medical decisions.  Something like that would be useful, but nothing like that exists.  It’s hard to define what we mean by “maturity.”  Any attempt to objectify it becomes arbitrary.  Part of the issue is that the ability to make a decision for one’s self depends not on age or maturity so much as what the decision at hand actually is.  I may not trust a 5 year old to make a decision about chemo, but I would let them decide what to eat for dessert, for instance.  But I wouldn’t let a baby decide what to eat, because they might literally eat poison if it was brightly colored.  And so on. 

Close to the maturity issue, I think is the issue of Informed Consent.  FYI, you can break this down into a few specific questions.  Does the patient have the ability to understand the information they need to make the decision?  (So they need to be able to listen/look/think and also to communicate back by some method their understanding).  Second, can they tell me the consequences of their action?  (for instance, “You (the doctor) are worried that I will die of infection or sepsis in less than a week if I do not take this antibiotic.”)  If the answers to these questions are yes, and you don’t think the patient is being coerced by outside forces (a controlling family member, etc) – then the patient has decisional capacity.  As you can see, if you are very young, you may not meet the first criteria, and if you are delusional you might not be able to fit the second.  However, it’s decision specific.  A patient may have the ability to make some decisions but not others. 

If a patient has decisional capacity, they get to make the decision, even if you think it’s a terrible decision.  That’s our right as autonomous humans.  BTW, law states that if decisional capacity is in question, two doctors need to weigh in and come to consensus on it.  It doesn’t state that it has to be two psychiatrists – although they are often asked to assess capacity/competence (“capacity” is the more PC term) because it comes up not infrequently in patients with significant mental illness.  Any licensed physician can assess decisional capacity. 



2.       Protecting Patients from their own Regrettable Decisions.  I saw a trend for the law and medical students to come down on different sides on this.  Apart from the question of letting patients make bad decisions is the issue of how hard we should try to convince them to decide otherwise.  This process is part of that mysterious “art of medicine” that you hear doctors talk about.  You’ll never read about how to do it or where the line is in doing it in a book.  You will deal with the impulse to do this with almost every patient.  So, here are my two cents. 

Your ideas on this will change as you practice.  When I was a student/resident/new practitioner I tried very, very hard to get people to make what I thought was the best decision.  I think just about everyone who saw me doing this would have given me an A for effort.  The problem was that even though my effort was massive, the results were anemic.  The truth is, as a doctor, you can lean and lean and lean on someone until you force them to say “ok, I’ll do it your way.”  And they may actually do it your way for a while.  But then they’ll get out from under your thumb at some point, and guess what happens then?  They do what they want.  AND they no longer will come back to see you – because you and they, they have correctly surmised, do not see eye to eye. 

People need time to figure things out for themselves.  Sometimes they have to see things for themselves.  Educating someone about their problem sometimes takes many visits over long periods of time. Sometimes they need time to talk to other people and let things sink in, etc. etc.  There are very few times in medicine where people must follow your advice immediately.  So when people choose a course that I think is a mistake, I let them know that they should keep checking in with me to see how they are doing and then, if I think they have decisional capacity, I let them do what they want.  I have learned a lot about medicine this way, because many times something I thought was a terrible decision turned out to be a good one for the patient in the end. 



3.      No fighting.  If I can tell you nothing else, it’s that if you are fighting and arguing with a patient, you are doing it wrong.  I think if you really can’t disengage and in good faith live with a decision your patient is making, you should recuse yourself from the care of that patient.  I would tell you though, that when patients realize you’re still on their side even though you don’t love what they are doing, they really appreciate it.  Knowing that you support them without judging the way they are running their life often opens the door to them listening to you and trusting you more.  It’s through this kindness that patients will sometimes change their minds and consider doing something much better for themselves!