Naked in College

Letitia Chai giving her thesis presentation at Cornell. from Facebook

There’s an old saying about how one can overcome anxiety when speaking in public, “Imagine your audience in their underwear.” I speak in public often but have never resorted to this tactic (perhaps because most of my presentations are done in church and such thoughts would be inappropriate.) This last week a student at Cornell University went the opposite direction. She gave her thesis presentation wearing only her underwear and asked the audience to join her.

The story is that Letitia Chai, the aforementioned student, was about to give a practice presentation of her thesis in the class “Acting in Public: Performance in Everyday Life”. As she was preparing to deliver her talk the professor commented on her attire (she was wearing very short cut-off denim shorts) and asked if that was what she was planning on wearing for her final presentation. The question did not go over well.

Ms. Chai was taken aback and offended at the perceived criticism of her appearance. She took particular umbrage at her teacher’s suggestion that her appearance was making a statement that might detract from the points Ms. Chai was trying to make. Ms. Chai stormed out of the class. A few minutes later she returned to the room and took her spot in front of the class, wearing only her bra and underwear. She later wrote how proud she was that she had stood up for “every person who has been asked to change how they look to make other people feel comfortable.”

Her story resonates with me for I had a similar conversation with a female medical student a few years ago. The student, by far one of the best I have ever taught, showed up to the office in a tight fitting blue cotton t-shirt along with white denim pants and a matching blue belt. The outfit was undeniably “cute” but it looked like something a young college student would wear on a date. It was not what would I considered professional attire. I pointed this out to her.

“You are a young woman,” I told her, “and you are asking people to trust you with their lives. Look the part.” I told her it would be easier for people to take her seriously if she was dressed seriously and that when she came to my office to see my patients I wanted her to dress as if she was interviewing for a professional position.

To her credit she received the feedback in the spirit is was given. Each day thereafter she wore either a dress or slacks and blouse. She oozed professionalism and carried herself with class. While nothing about her knowledge or skill set had changed, the perception others had of her did. It was a growth experience for her.

Over the years I have had similar conversations with other students, employees and even my children. My message is always the same. Like it our not, what we wear sends a message. Our jobs get easier when the message sent by our appearance aligns with what we hope to communicate. If we want people to think we are professional, we should dress professionally. As a physician I want to do everything I can to convince people I know what I am talking about, I do not want to give them any reason to dismiss what I say. Unlike Ms. Chai, I intentionally change my look in order to make other people feel comfortable. I do this because they are more important than I am.

This is true in every area of my life. When I give advice to a patient, it is the patient’s understanding that matters. When I deliver a sermon in church, the intent is for the audience to receive what I am saying. When I am called to the hospital to meet with a family about end of life care, it is important they believe I am an expert in the ethical issues we discuss. In each of these settings I choose my wardrobe carefully. I always where a dress shirt and tie in the office, always wear a collared shirt in church and always wear a conservative suit when I meet with families. Communication is never easy; there is no reason to make it more difficult by dressing inappropriately.

It appears this is a life lesson Ms. Chai has yet to learn. 

- Bart

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The Most Important Part of Church

A patient came in recently who I had not seen in a few years. I have known him for quite a while as we met 10 years ago at a church we attended in Irvine. We weren’t particularly close back then but he apparently thought enough of me to select me as his physician. 

As we had met a church it seemed appropriate to ask how things were going at the church he attended. He shared that they had switched churches recently and that he was now going to a different church in town. Ironically, it was a church my family had attended 15 years ago.  When I asked him why they had changed to this church his answer was a common one, that his kids were comfortable in the church's youth group.

After the visit I found myself pondering how it is that people choose a church. The common answers I have heard over the years include style of music, size of the youth group, and "relevant" or entertaining teaching from the pulpit. An answer that I have never heard is the one that should be the most important- church doctrine, the specific beliefs taught from the pulpit.

In the last few years I have seen firsthand the impact bad teaching can have on a congregation. Not too long ago I  heard a pastor in town demean the struggles some Christians have with their faith. "If reading the bible is a chore, if prayer is a struggle for you, you do not know God," he proclaimed. His casually false teaching made it difficult for people to speak truthfully about their struggles. Patients who attend the church have told me stories of having their faith questioned if the shared of any personal challenges. Guilt and shame have at times taken the place of grace.

A well known North Orange county pastor recently came to the conclusion that the Bible wasn't fully accurate. He shared with his church and his online followers that the Bible was written for specific people at a specific time and place in history, and that much of it no longer applied. I know some of his young followers took his words to heart. They "discovered" that the parts of the Bible that spoke of sexual purity no longer applied to their lives.

Both of the churches led by these pastors have been "successful." They are well attended and the pastors are loved and praised by their church members. In spite of their apparent success I fear for them. To be successful in God's eyes requires pastors two accurately proclaim God's word. Doctrine matters. Correct theology is important.

I know this is important because it was important to the Apostle Paul. When he penned letters to the pastors he trained, when he instructed them on the things to which they needed to be faithful, sound doctrine was high on the list. Several times in his letters he mentioned the importance of correct teaching. He was clearly aware that a faith filled with new believers would be susceptible to error. There was a significant danger that the tenets of the faith could be altered or lost. In this environment faithfulness to the truth was essential.

The importance of sound doctrine remains to this day. A faith without consistent beliefs is not a faith worth believing in.

Unfortunately Paul’s admonitions about sound doctrine have lost emphasis in many churches. The focus is on acts of service and self improvement instead of on right thinking about God. As important as good deeds are, the reality is that if our theology is not correct we are nothing more than a social club. Why we do what we do matters. What we believe matters. We cannot be people of faith if we do not even know what we believe in.

-Bart

Life, Death, and a Little Boy Named Alfie

Alfie Evans died today. You may have heard his story. He was in a coma for over a year. His parents wanted life support continued, but a court ruled otherwise. His story and passing illustrate the challenges all physicians face in dealing with death. Here are my thoughts-

I deal with death on a regular basis. All doctors do, but in my role of Ethics Chairman at my hospital I often have end of life discussions with dying patients and their families. All of these conversations are difficult. I am only called to assist when there is conflict between physicians and families that cannot be resolved or when families cannot agree on how to proceed.

The most common consultation requests are in cases where doctors have concluded that there is nothing more to be done and recovery is impossible, yet families believe hope remains. When they believe additional treatments and life-prolonging interventions will only prolong death and increase suffering doctors recommend stepping back and allowing natural death to occur. Families often believe that letting go is the same as actively killing someone and thus cannot accept the doctor’s recommendations. When these impasses cannot be resolved, they call me.

I have been involved in dozens of these conversations. While each situation is unique they all share common characteristics. Foremost among them are differing views on death and what it means to be alive.

Doctors, in particular critical care physicians, see death all of the time. They see the signs of its coming and recognize its inevitable progression. They know the signs of recovery and survival, and in fact search for these signs relentlessly. They long to cure and heal but learned early on in practice that there are some battles that cannot be won. When recovery and restoration are no longer possible they turn their attention to the good that remains, the ability to provide comfort and dignity as a fellow human being passes from this life.

The families of patients sometimes see things differently. They see someone they love lying in a bed, someone they cannot bear to lose. They know death happens but they cannot believe or accept that it is happening to their loved one at this time. They have heard and read of miraculous recoveries and have profound hope in the power of love and the will to live. They “know” that at any moment things could change, that their family member could return. Even if full recovery isn’t possible, the chance of one more smile, one more word, or one more touch seems worth fighting for.

This hope for a miracle can lead them to see hopeful signs where no hope exists. Reflexive responses such as grimaces, grunts, and the movement of a headare evidence that “she is still in there!” or that “he can hear us!” The grasp reflex, present after only four months of development in the uterus, is interpreted as a reassuring squeeze, instead of a primitive reflex that means nothing at all. These false signs of hope become the evidence that doctors are giving up too early, proof that the fight should continue.

Love, compassion and mercy compel physicians to speak truth in these circumstances. When this truth is not accepted people like me are often the final messenger. My suit and tie and title of Ethics Chairman provide extra gravitas to words others have spoken and communicate a level of seriousness and concern families need to hear. Referencing our shared promise to “Do no harm,” I remind families that prolonging suffering and futile care are things we cannot and will not do. There are times when there is a moral and ethical imperative for physicians to compassionately say, “No.”

These conversations are always difficult but they are times when the burden is more bearable. When the patient is a nonagenarian victim of a massive stroke, bed bound and ventilator dependent, there is a higher degree of clarity. We know that death is only a few years away for the healthiest of 95 year olds, which eases the fear of error. Conversations with multiple patients near the end of their lives give us confidence that it would be cruel to artificially force someone to a prolonged death tube-fed and non-communicative in a nursing home.

The younger the patient is the more difficult these conversations become. There is a dramatic difference between saying goodbye to an elderly grandparent and saying goodbye to one’s little boy. The natural fear and intense emotions that come with a dying child can overwhelm the coping mechanisms of any parent. Desperate desire and gargantuan grief, when combined with the false signs of hope often displayed by a vegetative patient, make it impossible for some loving parents to let go.

This appears to have been the case with the parents of Alfie Evans, the 23-month old infant who died today in a hospital in England. Alfie had a degenerative neurological condition that resulted in severe development delay (he never progressed beyond the level of a 2-month old child). His condition led to severe seizures when he was 6 months old. MRI scans and EEG tests demonstrated significant brain damage was already present at the time of his first seizures. He was placed on a ventilator and a feeding tube was inserted. In spite of aggressive medical treatment the neurologic condition and resultant epilepsy progressed and caused continued damage to his brain tissue.

Over the course of the last 17 months extensive medical testing and analysis was done on little Alfie. Although it was evident to physicians early that recovery was not possible they continued to explore every available option. Ultimately, when later MRI scans showed that brain tissue was decreasing and being replaced with fluids, the medical team reached the appropriate conclusion that continued care was futile. While they could not know with certainty whether or not Alfie could experience pain it seemed clear that if he couldn’t experience pain it was because he had no meaningful brain function remaining. Worse, if he could experience pain, he would experience it with no hope of recovery. Neither option supported continued care. It was time to let him go.

All of this was presented to the family and the doctors said it was time to withdraw life support. The court documents articulately describe his parent’s response-

“The Fathers core dilemma, from which he struggles to escape, is that whilst he recognises and understands fully that the weight of the evidence spells out the futility of Alfie’s situation he is, as a father, unable to relinquish hope.”

Alfie’s family could not let go. A careful review of the case reveals the innumerable obstacles they faced as they struggled to process the tragedy and how they should respond. Alfie was their only child, and they were just 19 and 20 years old. They received an overwhelming amount of outside input from uninvolved parties, some of whom seemed more interested in personal agendas than they did in their suffering. The parents were trapped in the middle of a hurricane of opinions and emotions with no way of escape. It was ultimately the courts who determined the path that would be followed. The decision was made for them. Alfie was removed from life support and died this morning.

Much has been written about Alfie’s case, most of it focused on the issue of parental rights regarding decisions to continue care. I will leave those arguments to others. For me, Alfie and his parents demonstrate a reality that is a part of all medical care. Patients and families are often forced to make decisions they are not equipped to make.

When these circumstances arise it is up to physicians to love, serve and support the patients under their care, to do good whenever possible. When that is no longer possible, to do no harm.

Bart

If you are interested in the details of the case, I recommend you read the judge's decision. You can find it here.

Needed: More Small-Town Doctors

It was a rainy day on the island of Kauai. Sunbathing was not an option, and neither was swimming or snorkeling. The ocean water’s typical clear blue color had been replaced by an unappealing shade of brown. Stranded away from the water we resigned ourselves to wandering through the stores in the Kukuiula Village shopping center near Poipu Beach.

After meandering through stores selling beach themed home goods we wandered into an art gallery that featured photos of scenic locations from around the Hawaiian Islands. I did not recognize many of the images in the pictures and asked the proprietor, a woman who appeared to be in her seventies, where some of them were taken. She answered my questions and then asked some of her own, the standard tourist questions of “Where are you from?” and “Where are you staying?”

After hearing our answers, she volunteered that she had moved to Kauai over 20 years earlier and still felt like she was new. She told us of the small town nature of the island (there are 27,000 permanent residents, only about 2000 of whom live in the Poipu area), and how everyone knew everybody else. She mentioned that there was only one department store on the island and that everyone wore the same outfits because they all shopped at the same Macys.

As there was no one else in the store and she seemed to be in the mood for conversation, I decided to ask her what life was like living on the island. In particular I asked her about the quality of medical care. “It isn’t very good,” she replied.

She told us that the only up to date mammogram machine was on the southwest side of the island, nearly an hour’s drive away from the hospital and over 2 hours away from the village of Hanalei. The hospital on Kauai was not very advanced. It was equipped to handle common conditions and emergencies but was not staffed for more complicated cases. Her husband had been diagnosed with pancreatic cancer a year earlier and had needed to travel by plane to Honolulu for treatment. Their medical care was comparable to that one would find in rural America.

The best part of their health care was their family doctor who had provided their care since they arrived. He was kind and compassionate. She shared that she was concerned about the future of their medical care because he would soon be retiring. She then told us a story of her doctor that helped us understand her fears.

A few years earlier her brother and his best friend had gone out fishing on her brother’s boat. They were about 8 miles off the coast when they hooked a massive fish that weighed over 200 pounds. The friend worked to reel it in while her brother went to get something with which to hit it in the head so they could pull it into the boat. Metal stick in hand her brother called to his friend to pull the fish in a little closer so he could reach it.

“I don’t feel very good,” the friend said. Then he dropped dead on the deck. Her shocked brother radioed the Coast Guard and started CPR. It took a while for the Coast Guard to arrive, too late to do anything for his friend. The Coast Guard took his body away. Her brother returned to the harbor alone. Waiting for him on the dock was his family doctor. The doctor had heard of the tragedy, and concerned for her brother’s state of mind had driven to the harbor to meet his grief-stricken patient.

As the woman told the story it was clear that she had not been surprised by the kindness of their physician. His caring act was what they had come to expect from him, standard practice from their small-town doctor. While this behavior was normal for her physician she knew that it was a level of kindness that could disappear now that he was retiring. She did not know if she would ever find a physician who cared for her that much, a physician she could trust to be there when she needed him.

Her story has stayed with me. I repeatedly find myself reflecting on the power of this small-town physician, the healing and comforting power of relationship and friendship, the importance of simply being “there” when needed.

I think of the times I have been able to care like that, the patients I have known over the last 25 years who have allowed me to be a part of their lives. The house calls made, the phone calls answered, the stories told and the tears that were shared. So often what mattered most were the moments shared, not the medications prescribed.

Our society is moving away from these relationships. Medicine is now practiced according to a set schedule. Interactions with primary physicians are often limited to the hours of 9-12 and 2-5, Monday through Friday, if scheduled in advance.  After office hours and on weekends patients get the stranger in the Emergency Room or the Urgent Care Clinic. The feeling seems to be that people need a doctor, that seeing their doctor is not all that important.

The woman’s story, and my experience, suggest this is not true. There is more to good medical care than knowing medicine. Truly excellent care requires knowing the person who is receiving treatment, a truth small-town doctors know and the rest of us need to learn.

- Bart

The Night I Became a Doctor

I didn’t know what to do. The location of the young woman’s pain was consistent with appendicitis, but the level of pain wasn’t. The classic exam findings of marked tenderness, worse when pressure rapidly removed, and a firm abdomen, were absent. Her blood work was normal, and she didn’t have a fever. I did not think I could justify taking her to the operating room, but I wasn’t comfortable sending her home either. I had only been a doctor for a few months, so I did not have much experience to draw on.

It was 1990 and the medical profession hadn’t yet figured out the value of CAT scans and ultrasounds for diagnosing appendicitis so all I had to go on was my head and my hands. I felt badly that the patient had me for her doctor and worried that I would make the wrong diagnosis. I remembered that the symptoms of appendicitis typically increased over time so I admitted her to the hospital with the plan of checking her every few hours. I figured that the pain would either get better or get worse, and that time would prove to be the best diagnostic tool. I was confident that the answer would come within a few hours. It didn’t.

Six hours later nothing had changed. She still had pain and tenderness over the appendix, and nothing else. I knew enough to worry but did not feel like I knew enough to make a decision. I nervously decided to call the surgeon on call and ask him for advice. He was the Chief of Staff for the hospital and had a reputation for being a no-nonsense jerk with a tendency to yell at stupid interns, but he was the man who would be doing the surgery if surgery was needed. I was afraid he would be bothered by my call, but it was 11 PM and I was pretty sure his mood would only get worse the longer I waited, so I called his answering service.

He returned my page within minutes. In typical intern fashion I launched into a detailed explanation of the patient’s history and physical examination. I had barely begun my story when he interrupted me. “Do you want to take her to the operating room or not?” he demanded. Taken aback, I attempted to explain to him my uncertainty. He wanted nothing to do with my lack of confidence.

“You’re the doctor, I’m the consultant. Be a doctor. Make the call. You say the word and I’ll do the surgery. If you don’t want to do the surgery then hang up the phone and let me go back to sleep. Make the call.”

His words were like a punch in the stomach. It was time for me to “grow up” and be a doctor. The fact that the evidence wasn’t clear was irrelevant. A decision had to be made and it was up to me to make it, right then and there.

I made up my mind as I spoke my reply, “If it was my wife, I would want her in the operating room.”

“I’ll call the OR,” he answered.

A little over 30 minutes later I was standing across from the surgeon as he made the incision in her abdomen. I watched as he reached in with his gloved handed and gently worked to bring the appendix into view. It was not in its most common position. It was swollen and infected but it was tucked behind the cecum in such a way that the cecum blunted the pressure of examining fingers. It would have ruptured before the diagnosis became clear. Waiting would have brought harm.

As he prepared to remove the appendix the surgeon looked up at me. From behind his mask he said, “You made a good call.”

I have never forgotten his words, for they have meaning beyond medicine. I learned a life lesson that night. Sometimes there is no one to turn to but yourself. We can’t always wait for things to be clear. Sometimes being a grown up is about making the best decision we can in the moment and learning accepting the consequences.

- Bart

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