i’m here. where are you?

Don’t you hate it when your doctor’s late? I do. Well, okay, I don’t hate it. I understand that it happens… but it makes it very tough to plan the rest of your day around your appointment.

Welcome to my world. Me, a newly licensed MD, and what have I done? Two days into practice and I’ve already joined the dark side. Both days, I was running over an hour late. And that was after skipping lunch and bathroom breaks. Basically, I went straight from 9am to 7pm, room to room, no stops. Then I was doing charts and paperwork until 11pm. Who knew there was so much paperwork involved in family medicine! No wonder family physicians burn out.

I know what you’re thinking… "You’re a new grad! Of course you’re slow!"

Yes, I’m new at this and yes, I have to work on seeing patients faster. Also, I’m working at an office where I don’t know any of the patients. But… well-established and experienced doctors also routinely run behind – so it’s not just me. I’m an aggravating factor but am not the sole cause.

Why does this happen?

Sometimes, it’s because 15 minutes just isn’t enough. Each appointment is generally booked for 10-15 minutes but if someone comes in with a page long list of problems, that may not be enough time. Or, sometimes, you see one person’s name on the schedule but when you enter the room, the whole family is there and they all have problems that need to be discussed. Other times, you’ve timed the visit perfectly but it turns out that there’s yet another problem that the patient reveals just as you are ready to leave the room: the “door-handle” problem (because your hand is already on the door handle). You’re supposed to check for these at the beginning of the visit but some of them still manage to elude discovery. And of course, there’s the visit in which someone comes in and breaks down into tears… that’s when you know 10 minutes will definitely not be enough.

So as you can see, running a timely schedule is not so easy. Patient education can take care of some of that – "one appointment per person", "come back next week to discuss the rest of the problems", "tell the receptionist that you need a longer visit", etc… but even with that, I have not yet mentioned the two biggest enemies to an orderly office: the fit-ins and the drop-ins.

Fit-ins are people who call the same day for an urgent appointment. Drop-ins are the people who don’t call first and just walk in the door. The receptionist says, we don’t have time to see you, and they say, well, I’ll wait here until you do! These people need to be seen, so they get crammed into the schedule. On a really bad day, you start with four people booked, two people are fit-in, another two show-up, and before you know it, you’re at 8 people per hour… and naturally, you start to run late.

Solution?

Book fewer patients per hour and leave empty slots in the schedule for fit-ins and drop-ins. The problem then is that all the other appointments get pushed further and further back, making the earliest you can get in to see your family doctor for a non-urgent appointment 2-3 weeks from now. That’s what they call a "full practice", i.e. a practice that is no longer accepting new patients. Most practices are full. No wonder nobody has a family doctor any more these days.

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Addendum ~ Day 3 report:

Today I ran relatively on time and was out of the office by 7pm! A good improvement. Quite miraculous actually! The key was (as predicted), leaving empty slots in the schedule.

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More information ~

Incidentally, I heard a CBC program on this very topic (long wait times) on Sunday. It’s called White Coat/Black Art.

http://www.cbc.ca/programguide/program/index.jsp?program=White+Coat%2C+Black+Art

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Statistics Canada 2004:

A total of 14% of Canadians, or 3.6 million people, are without an FP. Of that number, 1.2 million have searched unsuccessfully for an FP. "It’s a significant number," said Marc Hamel, a senior analyst at Statistics Canada and the survey’s chief. The other 2.4 million Canadians have not been looking.

http://www.cmaj.ca/cgi/content/full/171/2/124-a

I’m on palliative care this month. I’m not sure how it’s going to be. You don’t get to be a patient on a palliative care ward unless you’re dying. I nearly cried at least five times today… it happened twice in front of patients’ families, twice in front of staff and once in the stairwell on my way to the parking lot. I only managed to hold in my tears by biting my lip and by repeatedly telling myself to be detached. Is this healthy?

Finally, couldn’t hold it in anymore and started crying when I got to my car.

It’s hardest when the patients are young, or when they remind you of someone who is close to you. Who would want to do this for a career, you ask. Actually, some people love palliative care. They find it very rewarding to be able to make someone comfortable in their last days, and to be able to help the families through this stressful and momentous time. I’ll let you know what I think at the end of the month. It’s only the first day.

I’m writing a play.

Yes, you heard correctly… I am writing a play.

Am I insane? Am I delusional? Maybe. The thing is, everyone in my residency program, and probably across the country, has to do a research project… some kind of scholarly activity that is related to family medicine. Now, I could have gone with the usual favourites — surveys, chart reviews, literature searches — but instead I decided to do an interdisciplinary arts project.

"You’re writing a play for your research project?! How is that research?"

In the past, interdisciplinary arts projects at UBC have included a film on teenagers in inuvik, poetry on life as a medical professional, a photographic essay on medical care in tibet, a narrative on working in africa, and even visual art. Nobody has yet ventured into the playwriting field. Ironically, there are two of us this year who have taken on the monumental task.

I had my first taste of life as an artiste yesterday during a playwriting workshop that my supervisor kindly invited me to. I had to submit my work, it was read out, and then –horrors– I had to receive feedback on it.

Writing creatively is different from writing academic essays. It’s much more personal, and you become very attached to the work. Thus, when I heard the comments on my work, I felt simultaneously grateful, puzzled, sceptical, antagonistic, violated, ambivalent, nervous, and inspired. It was frightening. Here I was, among very intimidating company… and I had the audacity to present myself as one of them. I felt like an impostor. In the group, we had playwrights who have written shows that are regularly produced, non-published playwrights who have written multiple works, authors, actors… and most people there had at least two post-secondary degrees in liberal arts, if not more. These people were brainy, and my science background felt pretty useless in their midst.

The feedback, of course, was supportive and constructive. There was no bashing or crucifying, but still I never expected it to be so difficult to receive these comments and to force my mind open wide enough to process them. I have a strong vision of what I want my play to be, and while some of the suggestions fit, others did not… at all. I left feeling overwhelmed, wondering if my choices were the best ones, and questioning if the suggestions that seemed so astray might actually benefit the final product… and in the process began building in front of myself a huge mountain. I started to panic about the size of this seemingly insurmountable barrier, about all the work I have yet to do (Research day is in June), and about whether or not I’m going in completely the wrong direction.

My mind must have been working overtime, because I woke up this morning with ideas spinning around in my head. I had somehow figured out overnight how to deal with some of the jarring comments that I received yesterday. I feel better now. The changes will make the play richer, and have given me new direction and inspiration on how to continue. The tasks left to do still seem herculean, but I’m forcing myself to think of only a small bite at a time… or else I may get overwhelmed again and consider throwing in the towel and doing a nice safe literature review instead.

I was surprised at how hard it was to take feedback. I’ve never had any problems receiving feedback as a medical learner, or even on any of my university academic essays. I guess when you write creatively, it’s like exposing a part of yourself… your inner thoughts. I felt incredibly vulnerable. Yet, despite my ranting, it was definitely worth it. I heard my monologue read in different voices, and more importantly, I was able to move people and resonate with their experiences… which, of course, is why I write. Nobody writes for a vacuum. I want my play to be produced and seen. I want it to educate… I want people to walk out of the theatre with a better understanding of illness, whether it be theirs, their relative’s, or their patient’s. So I will continue to write, I will continue to offer myself up for criticism, and I will continue to work on prying open that mind of mine to make room for new ideas… because in the end, when I finally get there… it will all be worth it.

I’ve found myself repeatedly on my soapbox in the last little while explaining why I don’t want to see the new BodyWorlds exhibit at Science World. I guess it’s because as a medical professional, I am supposed to revel in such stuff… muscles, bones, et al., and yet even though I have a free ticket (valid weekdays only) — which incidentally I have misplaced — I am not even sure if I want to see it.

For those of you not in the loop, BodyWorlds3, as they call it, is the new sexy exhibit at Science World that features over 200 real human specimens preserved by plastination, a method developed by Dr. Gunther von Hagens (what an *ideal* name for a scientist). Apparently, it features whole body plastinates, individual organs, transparent body slices, and healthy and diseased organs. It’s a great educational opportunity, and yet I find myself recoiling from the dramatic images of muscles and bones on skinless bodies splattered across the newspaper ads.

I am not the only one who cringes at the thought of these anatomical displays. BodyWorlds and its imitators have been surrounded by worldwide controversy and debate. Still, they remain immensely successful and have attracted more than 18 million visitors on three continents and grossed an estimated $200 million (Boston Globe, 09/07/2006).

According to the organizers, all the bodies from BodyWorlds are from donor volunteers. However, a simple google search reveals a history of multiple legal challenges as well allegations — investigated but not proven — in at least four countries that von Hagens has purchased cadavers from grave robbers, prison wardens, bribed medical examiners, and other unsavoury characters (Boston Globe 09/07/2006, NPR 08/11/2006). While donation forms and death certificates have appeared to be in order, there is no clear paper trail since the bodies are made anonymous during the plastinization process. Furthermore, science museums are not research institutions, and their ethics reviews are not up to the standards of those at universities and hospitals.

Even more ethically questionable is another exhibit called "BODIES… The Exhibition." Knowing, perhaps, that they couldn’t win the ethics battle, they gave in and admitted defeat. Organizers freely admit that the cadavres in BODIES — all from China — did not come from willing donors. These "unclaimed" bodies from a country with a questionable history of respecting human rights have led to accusations that they are the bodies of executed prisoners. Other critics say that at best those bodies probably belonged to people too poor to have been buried properly. For these reasons, many venues will not display the BODIES exhibit.

Finally, such success has led to imitators, notably a San Francisco exhibit in which bodies were prepared improperly, which closed after the bodies were found to be dripping silicone and fat (NPR 10/08/2006). Yes, I agree. How pleasant.

Aside from the ethical issues surrounding the recruitment of cadavres, the other big qualm I have with these types of exhibits is the entertainment/freak show aspect. According to the same NPR article from 10/08/2006, von Hagens "readily admits to a showman side." Apparently, he sent a questionnaire to volunteers who have signed the donor form asking them provocative questions… Would they consent to their body parts being mixed with an animal’s, to create a mythological creature? Would they agree to be "transformed into an act of love with a woman or a man?" Even the few photos I’ve seen so far on the internet show evidence of this desire to shock and entertain. For example, the photo in the Boston Globe article shows a skeleton with some muscles attached. However, what really stands out are the cartoon-like eyeballs in the skull. It looks like a bad parody of character from the Roger Rabbit movie. Is this really necessary? Doesn’t it seem disrespectful to the donor to transform him/her into a character worthy of a freak show? Is this artistic sensibility, as they have been calling it, or is it just very bad taste in the name of "edutainment" (i.e. education + entertainment)? The Wikipedia article on BodyWorlds describes a few other controversial poses: a man carrying his own skin, a man on horseback holding his brain in one hand, the horse’s brain in the other; and a man kneeling in prayer, holding his heart in his hands. I’m sure proponents argue that these poses make the exhibits more accessible to the lay population. On the other hand, there’s nothing like sensationalism to create a buzz, which inevitably leads to profits.

Arguably, there are other times when we have bodies displayed in museums (eg. mummies and other remnants of ancient civilizations). However, even mummies are given the respect they deserve with tasteful displays in elegant galleries. Would the donors have consented if they knew how their bodies would be displayed?

Even if it is ethically acceptable for dead bodies to be dissected and then paraded around in a travelling exhibition, those bodies should be treated with respect. When the exhibits resemble those in a bad wax museum, then the show begins to look less like science and more like, as the Chicago Tribune put it, a sideshow "exploiting the dead for profit".

People have said to me — "you’ve gone through med school, you’ve already had the chance to see this stuff, we haven’t, and it’s just not the same reading it in books." First of all, I would argue that most of the visitors to the exhibit probably haven’t ever actually taken the time to open an anatomy book. However, I would agree that it’s definitely not the same seeing dead bodies in person versus in a textbook.

Back in the day, I went to anatomy because I needed the knowledge, not because I enjoyed it. I went into health care because I like to see people alive, not dead. I found it emotionally disturbing that all those bodies in metal boxes used to be real people, with real lives, and that we were now cutting them up. Furthermore, the preservation method was quite fragrant (to put it nicely) and the stench would stay in your skin and hair long after leaving the anatomy lab. It makes me shudder just to think about it. After a while, you just become desensitized in order to cope. I bought myself a textbook with photos of cadavres, and I much preferred to study from the book. Yes, my friends, the book was better than the real thing.

So, to those of your who can’t wait to see the exhibit, go buy your tickets soon, because I’m sure it’s going to be a hit and may even sell out. I continue to have ethical qualms about the whole thing. Am I going to go? I still don’t know. I haven’t decided yet whether BodyWorlds is education, bad ethics, or just bad taste. Most importantly, I’d really rather not be in the company of 200+ dead bodies. It’s disturbing and just plain spooky.

More info:

• Further photos are in the Boston Globe’s photo gallery
• The NPR 08/11/2006 is quite interesting and includes a side story on how the creator of the BODIES exhibit is an errant disciple of von Hagens. They are now fierce rivals
• Philadelphia Inquirer article, March 12, 2006
• and of course, all the links within the text are all interesting articles

Venice is like eating an entire box of chocolate liqueurs in one go.

-Truman Capote (American Novelist)

White swan of cities, slumbering in thy nest

So wonderfully built among the reeds

Of the lagoon, that fences thee and feeds,

As sayeth thy old historian and thy guest!

-Henry Wadsworth Longfellow (American poet)

Venice once was dear, 

The pleasant place of all festivity,

The revel of the earth, the masque of Italy.

-Lord Byron (English poet)

This was Venice, the flattering and suspect beauty - this city, half fairy tale and half tourist trap, in whose insalubrious air the arts once rankly and voluptuously blossomed, where composers have been inspired to lulling tones of somniferous eroticism. -Thomas Mann (American novelist)

Venice - The only place where you can get seasick by crossing the street. 

-Anonymous

Venice would be a fine city if it were only drained. -Ulysses S. Grant (18th US President)

Streets flooded. Please advise. -Robert Benchley (American Humourist), telegram from Venice to his editor.

I wasn’t really sure what to expect from Venice. Everyone, it seems, has an opinion — which, as you can see from the quotes above, may range from rapturous to disgusted. The concept is absurd. Who in their right mind would build a city on a lagoon? Yet, perhaps it is just this absurdity that keeps us so mystified and tantilized by Venice. I’d been warned about the dank smells, the tourist traps, and the crowded streets, but from my first moments of arrival into the city aboard the vaparetto (water-bus), I was completely enchanted. I felt as if I had stepped into both a fairy tale and a time capsule.

Venice is built around a large central canal, called the Grand Canal, from which a multitude of smaller canals fan out to weave through the city. To get where you want to go you either take a boat on the Grand Canal or you walk. The streets are too narrow to allow for any motorized vehicles except on the fringes of the city. These paths form a maze of narrow alleys that wind over footbridges and between buildings. Just when you think you’ve found your way, the lane will take a sharp turn over a bridge, taking you in the wrong direction, or even better, it will come to an end, leading you right into a canal. Maps are only semi useful as many of the streets are so small they are not even named on the maps. The ones that make it on the map may be labelled incorrectly or not at all, or the street name (usually painted on building wall) may be faded and indecipherable. Generally however, if you don’t mind wandering a bit, you will find your way, thanks to reassuring signs that point to common landmarks. Getting lost is part of the fun, and finding the destination gives you a great sense of accomplishment (especially if the rest of your family has no idea how you did it).

The architecture of the city is amazing. Buildings rise miraculously out of the water, and the ride along the Grand Canal treats admirers to an endless parade of magnificent palazzos in Byzantine, Gothic, and Baroque styles, complete with impressive arches and proud colonnades. Although some are restored, most of them sit quietly, gleaming in their ancient grandeur while showing ample signs of age. The abandoned doorsteps at the water’s edge, now dusted with seaweed, wait patiently for guests to arrive, their marble stones continually caressed by the lapping waves from passing watercraft. The opulent entrances to which they lead are equally neglected, sealed off with planks of wood or rusty gates, and flanked by dark windows. Yet, somehow, they manage to maintain their air of elegance, easily conjuring up images of soft satins and rustling silks; of noble guests stepping off the ornate gondolas into the foyer; of banquets and balls; and of the famous Venetian carnivale masks and costumes.

Venice is a popular tourist destination, and even in May, at the beginning of tourist season, the crowds have begun to settle in for the summer. Herds of tour groups stampede past as they try to hit all the attractions in a single day. They mill at meeting points, following their leader who is marked by a bobbing flag. The crowds, however, tend to stay in the tourist areas, and you only have to turn a corder or two to find a deserted alley, complete with peaceful bridge and quiet canal. The transition from choas to quiet occurs within seconds.

I loved my time in Venice. It captured my imagination, pulling me back in time and tugging on all my romantic tendencies. The city defies logic, with buildings that grow out of the water and ribbon-like canals that embrace them. It’s amazing that the architecture has survived the weathering of centuries (>400-800 years) and that the buildings have not yet sunk to the bottom of the lagoon. I loved being surrounded by water, even if it was sometimes dirty, a little salty-smelling (what do you expect, it’s sea water!) and very occasionally fragrantly stale. The water is the blood of the city. You can’t love the city without loving the water.

Despite its detractors the city will continue to be a legend that lives on. Its legacy of romance and mystery attracts and will continue to attract tumultous hoards of artists seeking inspiration, adventurers, and curious visitors. It’s definitely caught me in its web. I look forward to the day when I can once again dive into the spell of this city of water.

• took a photo from inside a red telephone booth (no sign of the ministry of magic)
• went to the parthenon gallery in the british museum (very good website, by the way), somehow completely missed the rosetta stone and the caryatid — must go back
• saw the Queen and Prince Philip exit the british library and go into their car!
• zipped through the national gallery of art
• walked by the Big Ben and the "eye of London" ferris wheel
• saw the canal from Bride and Prejudice
• felt carsick on the double decker bus
• found a Tintin store in Covent Garden — great but pricey
• got sprinkled with rain (tomorrow i bring an umbrella!) — weather is very temperamental

It was interesting to visit the parthenon gallery in the british museum after seeing the real temple in athens last year. Perhaps the sculptures "belong" in greece beside their original home, but i must admit that they are well presented in the british museum… much more nicely than in the little museum on the acropolis. The sculptures taken to britain have also been better preserved than those left behind. It’s a huge gallery… a long room of marble flanked by columns to simulate the temple, with pieces of the frieze running down the length of the room, and what’s left of the east and west pediments at either end of the room (these were sculptures decorating the outside of the temple).

more to come

p.s. check out http://yvetteishere.blogspot.com — i will post more fanciful things there

I haven’t written for a while… I know. I’ve been annoyed at the inclusion of ads on this site. Banner ads at the top of the page, I can accept. However, an ad right in the middle of the page masquerading as part of the entry is unnecessarily intrusive. I’ve been looking at other options… but the features aren’t as good. The key features that I like about friendster are that it allows me to put my entries into categories, and that it allows me to put photos wherever I want in the entry. The big problem, other than the ads, is that the friendster server is often quite slow. Anyways, I’ll keep you posted. Thanks for checking back

So, if I haven’t been writing, what’s been keeping me busy you ask. Well, I was at home on call one dark Friday night, and I happened to turn on YTV. It turns out Friday evening is YTV’s Bionix line-up which consists of translated Japanese anime. My previous experience with anime had been Sailor Moon which was immensely popular back in the mid 1990s. It was a cute but silly show about a girl superhero whose powers were drawn from various talismans. It even made it into a Barenaked Ladies song.

The show I encountered that Friday night was called Fullmetal Alchemist. I was drawn into the story of two young brothers and their quest to learn "the science of Alchemy" in order to regain their mother’s love. Their quest develops into a vow to recover their bodies when their experiment backfires leaving one brother with two artificial limbs, and another brother with his soul attached to armour (it’s strange but just go with it).

The show has heart… it touched me and I’ve been hooked ever since. Fortunately for me, it was early on in the series so I have been able follow the story properly from the beginning. It’s always annoying to start a show in the middle of the season. The "alchemy" in the show involves the ability to transmutate objects from one form to another, and is probably more magic than science, but who cares as long as it’s cool!

It turns out that Fullmetal Alchemist or FMA as it’s called is one of the most popular anime series in Japan and in the US. The manga, or Japanese comic, written by Hiromu Arakawa is also very popular.

But the story goes on.

When I admitted that I liked FMA, one of my anime-obsessed friends directed me to the YouTube site (www.youtube.com). This site is amazing. Anyone can post videos of anything. We have everything from old television shows (Saved by the Bell, Jem, She-ra) to home videos of crazy people singing karaoke.

Some of my favourites are:

• Yoda rap (yes, it’s Yoda rapping with storm troopers) http://www.youtube.com/watch?v=l49Qt-LoSH8
• Shamu (you think it’s a simple kayaking video and then…) http://www.youtube.com/watch?v=n23_IsU4Uic

The other thing this site has is an excellent archive of fan-translated anime. Since I still haven’t figured out how to use BitTorrent to download files, I was delighted to find so much pret-a-regarder (ready-to-watch) anime. I didn’t want to ruin the ending of FMA, so I picked another series called "Scrapped Princess" to watch. It was about a princess who was thrown off a cliff (i.e., scrapped) at birth because of a prophecy predicting that she would destroy the world upon reaching her 16th birthday. She was, of course, rescued and the story follows her as she flees from her pursuers. The premise did become a bit strange at times, and there were unanswered questions at the end, but overall it was a lot of fun to watch.

Here’s the brother… pretty cute for an anime character, eh?

Anyways, the latest show I’ve been watching online sporadically is Read or Die. This one is about a girl who absolutely loves to read, to the point of being ridiculous. She always has her nose in a book and will go to extreme limits to retrieve a book. It turns out she is a secret agent for the British Government called Agent Paper and has superpowers which involve the ability to change paper into whatever she requires, including weapons. This requires her to carry a suitcase of paper with her wherever she goes! It works, so far at least.

Here are the links to youtube:

• FMA episode 3, the first one I watched. It’s a little different because this one has been dubbed by fans instead of through the official channels:
  • http://www.youtube.com/watch?v=8O_Irdg9e8k
• Scrapped princess episode 1, part 1:
  • http://www.youtube.com/watch?v=qA-IyD0PodM
• Read or Die mini movie episode 1:
  • http://www.youtube.com/watch?v=X2YIsiLjrMU

Resolution is sometimes mediocre, but the best part is that there are no commercials! Thanks for reading. *hugs*

I’ll try to write something medical next time.

There’s an *interesting* dictum in medicine that doctors love to throw at unsuspecting medical students and residents: "see one, do one, teach one." Does that sound scary to you? It’s still rather frightening to me. What’s even more surprising is how often they actually expect us to rise to the challenge based on these words.

I, on the other hand, subscribe to the "see many, do many, then teach one" theory. I like to know exactly what I’m doing before I jump into something. This, however, creates problems.

First of all, it turns out that the best way to learn something is by doing it. So — sometimes you just have to swallow, grit your teeth, and have a go at the procedure (on an usually unsuspecting patient). It’s not dangerous, as there’s a preceptor nearby, but it definitely makes the procedure go much more slowly. Usually, it’s also less elegant! The staples might not be perfect, a stitch might have to be cut out, or another needle might be required for a second try.

Another problem is that some procedures just don’t come up that often. I am in a short, two year residency. If I wait until I’ve seen twenty nerve blocks before I try one, that’s nineteen less times that I could have practiced my nerve block, and additionally, I might only see twenty in my two years — and then I’m out in practice and stuck.

Finally, even when procedures do come up, the hospitals are swamped with other learners who are fighting you for the experience. Usually the resident who is there first or the most senior resident will get to do the deed. The medical students and lower year residents are often relegated to the mere sidelines. I write because this morning, I had a delivery "stolen" from me. The preceptor I’m working with this month had a woman in labour, and this morning, just as I was waking up, he called me telling me to rush in as the baby was well on its way. So I hopped out of bed and rushed through the morning traffic to the hospital only to find that a second year resident was already all gloved and gowned and standing in my spot! It’s frustrating, not only because I had "dibs" on that baby, but also because I need to do more deliveries if I’m ever going to be competent. Anyways, so I added another baby to my "observed" list instead of my "done" list.

Another time, I was on my pediatrics emergency rotation and I had been waiting all night for the treatment room to be available so that I could do a lumbar puncture on a baby (i.e., take a sample of the fluid around the spinal cord by sticking a needle into the baby’s back — no, it’s not as bad as it sounds). Anyways, the room was finally free and we were getting ready to start when the entire pediatric team from the ward traipses down into the ER and starts discussing which of them is going to do the lumbar puncture. I told them politely that we (my staff and I) were planning to do it and their senior resident hit me with: "well, we’re doing it because we’ll be taking care of the patient on the ward." My goodness. Now nomally, I’m a nice person, and as a medical student, I probably would have said — fine, I’ll take the next one but their antagonistic, possessive attitude made me stop and stand up for myself. I told them: "Look, you’re in a five year pediatrics residency. You’ll see tons of lumbar punctures in your five years. I’m only here for three weeks and this may be the last one I see for my entire residency. If I work in a rural area, I may have to do the next one on my own." Thankfully, my staff stood up for me and said, "Yvette has been waiting all night to do this procedure." Staff outranks resident so I won. It was quite satisfying, actually, to win that battle, even though it was probably only because my staff backed me over the peds resident. Sometimes family medicine residents don’t get as much respect as the "specialty" residents (we’re at the bottom rung of the ladder). It’s not fair because often we need the procedures as badly as they do. I appreciated that she treated me as an equal player in the patient’s care.

Anyways, the procedure went well and I got the fluid on my first try. What a sense of fulfillment! Maybe the "see one, do one", theory isn’t that bad after all.

I cried the other day. In front of the patient. In front of the patient’s family.

I couldn’t help it.

I’m only human.

There’s a perception that the doctor should be strong, should be objective. Is that what patients want? Would they rather have a doctor who is emotionally detached? Who sees the patient only as a problem to be solved? I guess most importantly, people want a doctor to be competent, and then secondly, one who cares about them as a person. How do emotions play into this? Is it possible to care about patients without becoming somewhat emotionally attached to them? Does a stronger connection to the patient interfere with patient care by taking away objectivity? Should health professionals become desensitized, diagnosis-producing machines? Do families want to see that you mourn their loss with them, or would they rather have you there as a stabilizing, emotionally detached support? And then of course, regardless of what the benefits are to the patient and the family, being intensely emotionally involved in every case would become immensely draining over time and lead to early burn out of the caregiver.

I’m in surgery now. It’s a busy rotation with early mornings, late nights, and ridiculous 36 hour stretches in which I don’t leave the hospital. About a week and a half ago, I met a woman in her 60s who had been battling cancer for over 10 years. She was a bright woman, definitely a fighter, and always ready to put on a brave front despite adversity. She came in for a procedure to help with her nutrition but as sometimes happens, the stress of being in the hospital and the stress of the anaesthetic, was too much, and she caught pneumonia. Pneumonia… just a simple lung infection and presumably treatable in our day and age with our miraculous antibiotics. However, in the elderly and in people with a high disease burden, pneumonia can be a death sentence.

The most difficult aspect of dealing with my feelings around this patient was how quickly it all happened. One day, we were standing by her bedside, discussing how we could best help her malnutrition, and four days later, the intelligent and witty woman was barely able to communicate with us. She was very scared going into the OR. She asked me to hold her hand while she went to sleep. It was very important to her to have someone provide comfort during that time. I remember she kept squeezing my hand. She was so scared and yet what could she do but proceed. If she didn’t, she would slowly starve to death. Surgery. It was supposed to be a simple procedure. Nothing is ever simple, especially not in a person who is already very sick.

Immediately after the surgery, she didn’t have any problems… it was only a day or two later that her condition started to deteriorate and the pneumonia and infection began to take over. Once it took hold, she just didn’t have enough resources to fight it off, even with the help of maximum antibiotic therapy. Being in the hospital is risky. Every day you are there that you don’t need to be, you risk catching a nasty hospital antibiotic-resistant infection, or going through a procedure that might not need to be done. In obstetrics, we tell people who are safe to go home to leave, even if they are already in early labour. There’s plenty of evidence that staying around will only increase their risk of forceps, vacuum, or c-section delivery. It’s hard for doctors to suppress their need to "do something". New Yorker magazine writer Dr. Jerome Groopman has a book about how to deal with medical advice called Second Opinions. Despite having read it 5 years ago, I still remember that one of his chapters is entitled "don’t just do something, stand there." That’s right, not the usual saying but its reverse.

Everything happened very quickly… 10 days ago, she was still sitting up in bed, talking about going home. A week ago, she started to go downhill. Six days ago, she was no longer able to communicate. Four days ago, she was transferred to the palliative care ward where all her non essential medications were discontinued. Yesterday, she passed away. Her family promised to be there with her 24h a day, taking turns in shifts, and they were. They stayed with her, talking to her, holding her hand, not knowing even whether or not she could still hear them. I went to see this brave, once strong, woman just after she was transferred to the palliative ward where she was still holding on. Her daughter was by her bedside. She looked at me and said: "she just won’t let go," then turned to her mom and said: "let go mom, it’s okay — you’ve fought long enough… it’s time to let go now."

That’s when I cried.

Happy New Year! I’m on call again. Waiting for patients. Sitting here at the same computer in the nursing station. They *really* need a computer in the dr’s room.

Anyways… I’m surfing the web and what I want to write about today is this great site that my sister sent me. It’s at http://www.pandora.com — and they call it pandora: the music genome project. Apparently, this group has analyzed over 10,000 songs according to 400 or so dimensions or "genes" (melody, harmony, instrumentality, etc.) and then uses these attributes to find songs that you will like. You enter a song or artist into their website and it spits similar sounding songs back out at you. You can add multiple songs/artists to your "station" to create diversity and further guide the content by providing feedback after each song. It’s a cool name, a great concept and so far I’m liking it. You do need to sign up after listening to about 5 songs. It’s free if you don’t mind ads and there is also a paid subscription. I don’t think they’ve actually gotten around to putting the ads on yet, but it’s in the works. Enter "99999" for your US zip code if you don’t have one — it means unclassified and is often used for people without a fixed US address (or you can make one up, i suppose).

Upon searching the internet, I found lots of commentary about pandora with mixed opinions, ranging from people who love it to musicphiles (phile is from the greek word for love) who have concerns about commercialization and complaints about the lack of non-mainstream music. Pandora also hasn’t yet figured out how to include classical music in their database, but apparently so far they have four "genomes": the main pop/rock genome, the jazz genome, the hip hop/electronica genome, and the world music genome.

The main competing site that musicphiles like seems to be last.fm, which can be found at http://www.last.fm/

Last.fm works with the slightly different concept of building a listener profile for you and then matching it to "neighbour profiles." It will then play music that people with similar profiles to you enjoy. They call it "social music" — the analysis is based on human subjective preference as opposed to the more objective analysis of pandora. You can sign up for free, make an optional donation, or sign up for a paid account that will give you more control over your playlist. I haven’t actually tried it yet but it looks promising.

Other links:

• An interesting blog by DJ Alchemi with commentary on pandora, last.fm and other music sources http://alchemi.co.uk/archives/mus/does_music_have.html
• DJ Alchemi’s comment on last.fm — who decided to conduct a mini research study and collected data on 100 users to assess usage patterns for the service (research in your spare time! now that’s dedicated)  http://alchemi.co.uk/archives/mus/preliminary_ske.html
• PC World article on how to find online music http://www.pcworld.com/news/article/0,aid,123539,00.asp
• Associated press article from Nov 2005 http://home.hamptonroads.com/stories/story.cfm?story=95225&ran=117297
• More comments than you could ever have time to read from all sorts of people about pandora and online music (scroll past the ads) http://slashdot.org/article.pl?sid=05/11/29/151229&from=rss
• Lots more at Google

Let me know what you think… I love comments