Tuesday, June 14, 2005

big place, lots of smart people

two weeks into this NIH thing. it's still a bit odd to be in a clinical place where everyone is wearing sandals, but the relaxed atmosphere is really cool compared to the dictatorial arena of medicine california-style. who would have thought i'd have to fly to the stodgy ol' east coast to see pedicured toes in the ICU? i'll keep my danskos on, thank you.

the one thing that does get me is the complete separation in medical research between the patient as subject vs. the patient as person. last week, we had a patient come in for a diagnostic procedure. all patients at NIH are here because of a study, which is why it's only a hospital-ish environment. i'm working in neurology, and our procedures always seem to have such creative torture elements, especially the minimally invasive ones. like the EEG: hold completely still for an hour after i stick 30 electrodes to your head and intermittently put a strobe light 3 inches in front of your eyes and make you hyperventilate until you're *this close* to passing out.

it's well-known that when you're giving someone a painful procedure, they're likely to have an emotional response to it. sometimes it's anger and they scream at you to stop this fucking test right now and sometimes they just start crying. since most neurological and musculoskeletal diseases are of the chronic, completely shitty variety, i'm not surprised anymore when my patients have a response like this. i always feel terrible for contributing to their emotional landfill with yet anoher test.

this procedure was a painful one. both my PI and i talked to the patient about mundane things to distract her, but she started crying softly. she mentioned recent stress and depression three times within a short period of time. the bells went off and my medically infantile mind sprang to action with the proper way to handle this situation. for once, i know exactly what to do!, i thought.

so because of my past experience in the mindfuck that is neurology, the year of essentials of clinical medicine in which we were taught to smile warmly, nod at the right points and reassure when needed, and my obsessional need to make everyone feel better, i asked this patient if she was seeing anyone about her sadness and stress. when she said no, i asked her if she would like to see anyone for this. she again said no, thanking me for asking but saying she'd be ok.

these same questions that got me a commendation from my standardized patient on my "sincere empathy", got me a friendly redirection later by my PI.

she was very nice about it, and placed it within the frame of "i know they teach you guys to do this in med school and residency", but clearly she wanted me to know that one does not delve into these questions in medical research unless they pertain to the particular study at hand. then, just like our running class joke about behavioral science goes, i felt shame.

i've had it hammered into my touchy-feely, dirty hippie osteopathic brain that we've got to treat the whole patient, emotions and physical maladies alike. but in clinical research, we measure a variable that becomes a figure in a paper for Experimental Brain Research. we're not there to treat, diagnose or prescribe, only to collect data.

and it bothers me. i saw my research fellowship to be an opportunity to blend together the things i love most about medicine- sometimes you get to see patients, and sometimes you get to figure out what makes them sick in the first place. i wrote in my cover letter that i was interested in a career that had elements of clinical and scientific medicine. in short, i wanted to gorge myself in the doctor's buffet.

who says you can't pour some syrup on your bacon?

it's been reported for years that the population of physician-scientists is declining so precipitously that soon it'll all be PhDs answering our burning questions about diabetes and heart disease. this is lamented and the reasons behind it are pondered- this article says it's because medical school admissions committees aren't taking the more scientific applicants anymore. they want to make more humanistic physicians, so those who have tons of research experience but little clinical exposure are not favored as much as those who have the converse.

when i was talking to my best friend sarah about how crappy it felt to have to disconnect from patients all suddenly, she said "well, you might not have been able to help that one person feel better, but you're potentially helping thousands of other patients by learning more about their diseases". it's an argument given by many physician-scientists as the precise reason why the more humanistic people should consider careers in research medicine. while i agree that it is vital to the future of medicine to figure out how to lure more people into research, it doesn't make it any easier when there is no mention of it in our day-to-day studies. i can only speak of my own school, but there is a complete absence of talk in regards to academic or research based career tracts there. of course the administration is very happy i received such a prestigious (god, i hate that word) fellowship, and we do have a small but thriving biomedical research club. but with so few research labs on campus, and constant quips from professors and clinicians on how we'll all become primary care doctors (by far my favorite DO-specific fallacy), i don't see how any of us can really foster our interest in this part of medicine. how are we supposed to want to do something that is currently at odds with our own conceptions about our profession and moreso, something that we aren't even told about?

and then when we do get the odd exposure to research, we don't get to hone that part of ourselves that wanted to become a doctor in the first place. i'm caught between the two things i like a lot, and neither one seems able to encompass the other.

so why not give more exposure to medical research within medical school (especially osteopathic institutions), and within that, find a way to create a bridged atmosphere for both patient and doctor during medical research. one that manages to let the patient get their actual immediate issues addressed and still fulfills the requirements for adequate, accurate data collection.

now that would be as rad as syrup on bacon.


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