Author: Leigh Goodrich

Leigh is a second-year medical student at the University of California, Irvine. She is passionate about bringing health care to the underserved, both at home and abroad. As part of the student-run Outreach Clinic, she teaches a class for high-risk Spanish-speaking patients with uncontrolled Diabetes. She also volunteered in rural Panama this summer, partnering with the non-profit organization Floating Doctors to serve indigenous communities. Hopefully, writing and working with our medical student network will be another step towards global health advocacy. In her free time, Leigh enjoys traveling to new places, meeting new people, discovering new ice cream shops and writing about it all.

Categories
Emotion Empathy Reflection

Notes from the Road: A Letter to my Future Self

Think back to the very first time you ever drove a car alone. You were probably sixteen, freshly-printed license in hand, putting a foot on the gas pedal for the first time with an empty passenger seat. No parent telling you to check your mirrors, no driving instructor reminding you to keep your hands at ten and two. That first drive was a rush of freedom and excitement, but also of fear.

You probably don’t think about that drive very often, and certainly not every time you get into a car. There are moments in life that seem so incredibly momentous you think you’ll never forget them. But, as time goes by and distance clouds the memory, you have trouble remembering exactly how you felt. You can remember the sequence of events, the people involved, the way you described your feelings at the time, but it becomes more and more difficult to recreate the unique combination of emotions that flooded and overwhelmed you at that precise moment in time. That moment you swore you would never forget….

Ultimately, we never know what lays on the road ahead, what might become routine in a medical career, or what combination of emergencies we might become desensitized to. So I’m writing this down to put into words something that I struggle to articulate, but something I think is worth remembering vividly.

This is my way of putting down a mile marker, of recording my experience, and all that comes with it – I hope you find a way, too, so that at the end of the drive you can see how far you came.

 

Dear Future Self,

Today you saw a patient die.

Today was the fourth day of your first clinical rotation in the hospital and today you saw a patient die.

You saw a patient die, briefly. It was just long enough for you to think she was really going to die, permanently, and then she was resuscitated back to life.

This woman was responsive, albeit uncomfortable, just a few hours beforehand. And now here she was in an operating theater undergoing an emergency C-section for a ruptured uterus. She lost her pulse.

Chest compressions. Pushing epi. Giving her blood.

But she came back- she didn’t die permanently.

As her blood pressure plummeted and the anesthesia team noted weaker and weaker pulses, there were a million things running through your head. When they lost her, though, all those voices in your head went silent. You became numb, as time seemed to slow. These are the things you will forget, and these are the things you should remember.

You were so scared.

Everyone in the room seemed confident, following protocols and executing each step in a methodical and calm way. You felt terrified. You couldn’t believe what you thought you were about to witness. While you tried to stay outwardly calm, you were inwardly panicking. You felt the blood rush from your head to the pit of your stomach. You felt nauseous, flushed. But you mostly felt immensely sad and scared for her and her family. She had come into the hospital with nobody, and you couldn’t bear the thought of her leaving with nobody. You couldn’t handle the thought of her dying alone, in her 30s, in an emergency procedure her family could have never predicted.

You felt so powerless.

There was nothing you could do. You realized there was also a limit to what anyone could do in that moment. Even the attendings, even the best doctors, faced the reality of this woman dying. Remember how you thought to pray in that moment, how even though you aren’t religious, you prayed. You wondered if the doctors were silently praying too, even as they called the code and ran through their crash protocols. Were they whispering to some greater power to help them save this patient? Did they also, in this moment, feel powerless?

You were so impressed by the team.

You become accustomed to seeing well executed medical care. Sometimes it’s hard to appreciate because you are in such awe of what you are witnessing that you almost can’t believe it. You forgot, until this moment, how much of a privilege it is to watch and work alongside people who are uniquely trained to be the absolute best at their jobs. You watched as the OB and the anesthesiologist communicated clearly and coordinated care. As the patient continued to bleed, both teams prepared for an emergency C-hysterectomy. The scrub techs and nurses moved swiftly, efficiently, anticipating directions and keeping meticulous record of everything happening in real time. The entire OR buzzed with an energy that was never frantic, even at the direst point, yet still never completely free of tension, even with the closing stitch. This team thrived on that energy.

And then it was over, the patient made it through.

You came back the next day, your fifth day in the hospital, and nothing had changed. Nothing but you, because you felt different. For a few days, those moments of panic and powerlessness replayed on an endless loop in your mind. Those moments of shock and fear and overwhelming emotion.  And you should remember this day, those terrifying moments, because those are the moments that come to define us.

Sincerely,

-Your Past Self

 

Featured image:
road by Victor Camilo

Categories
General Opinion Public Health

The Policy on Policy: Why Medical Students Need to Learn About Healthcare

A 27-year-old woman is woken up by a sharp, stabbing pain in her lower right abdominal quadrant. She feels feverish, nauseous and weak. If you’re a medical student, you want to get a thorough history and test for a positive Murphy’s sign or rebound tenderness. You’re thinking it sounds like appendicitis. If you’re a doctor, you want to examine the patient and consider an appendectomy as a treatment option. You’re thinking of all the cases of appendicitis you’ve seen, and how well your education prepared you to diagnose and treat this condition. Except, none of that happens if this patient is never seen by a doctor. None of that happens if this patient instead, uninsured and unemployed and alone, decides to wait it out because it seems like her only option. None of that training in diagnosis and treatment makes any difference if that patient doesn’t have access to the care that could have saved her life.

The issue of healthcare policy is complicated, and oftentimes controversial, especially when presented in the framework of a political debate. As healthcare providers, however, the issue becomes less of a political one and more of an ethical one. The reported number of uninsured Americans ranges from 29 million1 to 45 million2, with tens of thousands of preventable deaths caused every year by lack of access to care3. That could mean a young woman dying of sepsis when her appendix ruptures, or an inmate asking a parole board to keep her in prison so she can continue to receive cancer treatment, or any number of similarly startling stories being told every day, across the country, about people who we know how to treat if we’re just given the chance.

A good resource for information on healthcare policy is the Commonwealth Fund’s 2014 analysis of our healthcare system compared to 11 other industrialized countries.3 The U.S. spends the most on healthcare per capita each year ($8,745), yet has the highest rate of potentially preventable deaths (96 per 100,000 people) and the highest infant mortality rate (6.1 deaths per 1,000 live births). Given the state of our broken system, it seems strange that medical students are essentially unaware of these issues until they enter the working world. Why are we not exposed to the struggles of healthcare policy in medical school? While it is certainly true that students are already saturated with information, it seems there are few subjects more universally applicable to graduates than learning about the system they will be working in.

To get an expert’s thoughts on the matter, I spoke with T.R. Reid, a leading author and journalist in the field of health policy. His bestselling book, The Healing of America, explores foreign models of healthcare and how we can learn from those systems to reform our policies at home. He currently serves as the chairman of the Colorado Foundation for Universal Health Care, which has recently placed an amendment on the 2016 ballot that would create the first state-initiated universal healthcare system by opting out of the Affordable Care Act.

 

Why do you think it is important to teach health policy in medical school?

The United States has the most complicated, the most inefficient, and the least equitable healthcare system of any rich country. Doctors are graduating into it and they don’t know what a mess it is… I think we need to prepare doctors for what they’re going to face. The second reason is, as a country, we need to fix our healthcare system. It’s ridiculously expensive, it leaves 33 million people uninsured, and the impetus to change has to come from doctors.

Health policy can be very broadly defined. What is the most important element of policy to incorporate into medical education?

The most important point is that a decent, ethical society should provide healthcare for everyone who needs it… In almost all other rich countries, healthcare is considered a basic human right and if you think about what a human right means, a human right is something the government is obliged to provide for you. You have a right to an education. You have a right to vote. If you get charged with a crime, you have a right to a fair jury, a fair judge, and a defense lawyer. We provide that because we’ve decided those are basic rights that every American ought to have. All the other countries say that’s also true for healthcare. If you’re sick and need medical care, you should get it and we have to provide it. The United States has never made that commitment… If you don’t make the basic moral commitment to provide healthcare for everybody then you end up with the American healthcare system, where some people get the world’s finest care in the world’s finest hospitals with no waiting, and 33 million people barely get in the door until they’re sick enough to go to the Emergency Room.

What changes do you foresee in the next ten years, or how do you think the current healthcare landscape will change by the time current medical students are actually in practice?

In the first place, I’m absolutely certain that we will get to universal coverage in our country and I believe we’re going to do it at a much lower cost than what we’re spending now. I’m quite optimistic that we’re going to improve our system. I think that’s going to happen… I don’t think we’re going to get there nationally. I’m convinced the way we’re going to get there is state-by-state…That’s how we got to interracial marriage, that’s how we got to same sex marriage, that’s how we got to female suffrage, that’s how we got free public education. It all starts in two or three states, the rest of the country sees that it works, and says ‘let’s do that’… The reason I’m confident in this is that we’re about to do it in Colorado. We got the initiative on the 2016 ballot. When people see a good idea working in some states, they copy it. Colorado is going to prove to the country that this can work, I hope.

As you’ve been campaigning in Colorado for universal healthcare, have you noticed that misconceptions about socialized medicine are still pervasive in public opinion? Does this influence people’s level of support or questions they raise?

The notion of limited choice and long waiting times in Canada is an issue for us…Our critics say ‘they’re going to bring Canadian medicine to the United States.’ Well, Canada covers everybody, they spend half as much as we do on healthcare, they have significantly better population health, they live longer, they have lower rates of neonatal mortality. But they still keep people waiting. I think it’s wrong to say we’re going to put the Canadian system here but that is a powerful argument…My answer is in fact Australia and South Korea have exactly the same model and they have shorter waiting times and broader choice than the United States.

In your book you examine foreign models of healthcare in detail and you described in a 2009 article in the Washington Post several ‘myths’ the American public believed about health care abroad4. Do you think American misconceptions have changed at all since the passage of the Affordable Care Act?

I think Americans still don’t like socialized medicine. Even if they don’t know what it is, they know it’s bad. That’s still true. Many Americans think other countries have limited choice and long waiting times, which is true in some countries, but many countries have broader choice and no other country has the kind of in-network, out-network business that our insurance companies have created. No other country does that…American companies and device makers say government intervention stifles innovation. I think there’s no question that in other countries regulations drive innovation. Cost controls drive innovation because they have to innovate to make their products cheaper.

If medical students are interested in health policy, how can they get involved and learn more, especially as things change?

The best way is what several medical schools have done, which is to put into the curriculum a course on health policy… I say this to every medical school dean I ever meet, ‘you ought to have a course on health policy’ and many of them say ‘I wish I could do that’ or ‘I’m thinking about it’ but some say ‘I’ve got four years to teach the entire human body and everything that can go wrong with it, don’t get me into that mess. It’s beyond our jurisdiction.’

Final thoughts?

Everybody who is sick should have access to healthcare in the world’s richest country. We have to fix this system and your generation of young doctors is going to be a powerful force for change.

 

Sources

  1. CDC National Health Interview Survey Early Release (2015)
  2. Institute of Medicine, National Academy of Sciences (2009)
  3. Commonwealth Fund (2014)
  4. Reid, T.R. “Five Myths About Health Care in the Rest of the World” (2009)

Featured image:
Healthcare Reform Initiative Announcement by Maryland GovPics

Categories
Narrative Reflection

Little Flickers: How Medicine Truly Connects Us

“See the little flicker?” the doctor asked, as she tilted the ultrasound screen and pointed to the tiny movement. The patient leaned forward, squinting, trying to decipher the gray and black pixels that showed she was now a mother. “That’s the heartbeat,” her doctor explained. “Right there,” she pointed again, this time zooming in even further. The patient nodded as she tried to contain her excitement. She smiled with one of those tight-lipped grins as her eyes widened, as if joy was actually bursting out of her. Her husband chuckled at her wild expression and squeezed her hand. “It’s okay,” her doctor said. “Be excited! This is exciting!” And with that word of permission, the expecting mother squealed, just a little, and calmed herself again. “It’s our first, you know, and my sister just had a girl and I wanted our kids to be able to grow up together and we just didn’t know if it would happen this fast, and,” she paused to catch her breath. “Sorry, I just can’t believe we get to start buying baby stuff!”

I looked at the screen again, at the little flicker of light, at the little piece of white against black that would someday have a lot of “baby stuff” foisted upon it. It was one of the earliest pregnancies I had seen on ultrasound – in fact, I had only seen one other scan done at the same gestational age. It was striking how identical this scan was to the first one I had seen, months earlier. The screen had looked exactly the same, with the crown-rump length of the tiny embryo measuring the same, with the same shape of black fluid around white tissue. I thought back to that day, to the tiny portable ultrasound screen so far from home. Instead of an antiseptic outpatient OB/GYN clinic in temperate California, the first scan had been done on the dirt floor of a little hut in Central America.

It was a typical clinic day in rural Panama – humid, muddy, with lines of patients waiting to be seen. Working over the summer with the non-profit organization Floating Doctors, I saw many pregnant women come to clinic for prenatal care. Traveling to indigenous island communities, where most patients have no other access to health care, we would set up makeshift clinics and see as many patients as possible. It is common for women in the Ngobe communities to have as many as ten kids; oftentimes they start having children when they are teenagers themselves. Unsurprisingly, there was a lot of prenatal ultrasound scanning to be done.

When I saw this particular patient, whose ultrasound was done so early in the pregnancy, the crown-rump length was the same as the patient’s I would see months later at home. This woman was 32 and had five children. Her youngest, a two-year-old girl, leaned on her mother’s chest as I scanned, taking a pause in her whining to stare at the screen. She didn’t understand what it was, but her mother squeezed her excitedly anyway as I pointed at the little flicker, the unmistakable heartbeat. Even though they already had a big family, even though it was miserably sweaty sitting on the floor in our little ultrasound hut, and even though the toddler was getting fussy, this woman had the unmistakable grin of sheer excitement.

Talking to the pregnant women in Panama, either during the scan or translating during the physician checkup, I imagined the lives these babies would have. It was an easy thing to think about, seeing so many children running around and playing as their parents waited in line. The kids were a handful to organize; it was no easy feat keeping them far enough away from the clinic to avoid distractions, but close enough to organize whole family visits when it was their turn. They played muddy games of soccer or baseball, chasing each other around and asking us for highly coveted stickers. They were so full of energy, so happy and so free. The mothers usually didn’t find these games as amusing as I did; they were exhausted, overwhelmed, and just trying to get the visits done so they could go home. I can’t begin to imagine the strength and resilience it takes for those mothers to care for so many children, and oftentimes other family members, with such limited resources and support.

There was a mural painted on the side of a school in one of the communities we visited. The mural was a giant world map, not particularly accurate in terms of scale or geography, but vibrantly colored and decorated. When I saw it, I thought it was quite fitting, as I was working in a team with students and doctors from all over the world, living in a country I had never been to before, speaking a foreign language every day. When I thought about its place in the community, however, I began to wonder what it meant to them. These villages are isolated, by geography and lack of transportation and resources. The children who seemed so free to me would most likely find it difficult to leave their small village, if they ever wanted to. I wondered what they thought of that colorful map on the wall, whether it was an abstract concept of the world beyond their borders, or whether they dreamed of a truly unrestricted future. The child back home in Orange County, of course, might dream of just the opposite – wishing the world were not so vast and intimidating, wishing the world stretched just to the end of the block, where everything in between was familiar and safe.

These are the things I wonder about, the things that keep me thinking about certain patients long after they’ve left. These are the things that connect patients, at least in my mind, despite the vast differences in their lives. Ultimately, the job in medicine is to focus on the patient, or the ultrasound image, but it’s not always easy, or in the patient’s best interest, to tune out the context.

We are trained to look at that little flicker of a heartbeat, measure its rhythm and pace, and watch as the baby grows and the flicker gets stronger. We are trained to look at every patient, every heartbeat, the same – without bias, without judgment, without assumptions. At the same time, we can’t ignore the world around us, the world that we are working in and the world that our patients live in. We can’t ignore the fact that differences between two patients’ cultures, communities and access to resources may make them seem worlds apart. But mostly, we can’t ignore how strikingly similar we all are at the start – just little flickers of black and white, so simply alive. Maybe if we try to remember that, all the differences we see every day will become just parts of the mural – not terribly accurate, certainly open to interpretation, but mostly just a beautiful mess of color.

 

Featured image:
Panama Clinic, courtesy of Leigh Goodrich