Treatment of the Heart

As the daughter of Persian immigrants, my life has been a somewhat messy, chaotic blend of the Persian and American cultural lifestyles. In my daily life, I transition between speaking Farsi on the phone with my mom and chatting with my friends in English, shopping at Ralph’s and then running over to the local Persian grocery to pick up specialty cooking ingredients, and listening to a blend of Persian and U.S. pop music ritually.

I was raised in a particularly white, homogeneous suburb in the Los Angeles area. My pediatrician, from when I was born through when I left for college, was named Dr. Sadd. (In my head, I called her “Dr. Sad”; I wasn’t very found of her.) All the physicians in the small practice were white, and all their patients were predominantly white. Dietary recommendations never satisfied my mother’s Middle Eastern palate, and I was told I had hirsutism–a syndrome of excessive hair–though all Middle Eastern children have hair crawling up their arms and legs and faces, and any one who claims they don’t is either a liar or a genetic mutant.

I didn’t visit another physician until I began shadowing a Persian cardiologist, Dr. Rizi, several years later in college. After my first day, it became clear his patients were predominantly Middle Eastern, and, in fact, almost every consultation was conducted entirely in Farsi, already a stark contrast with my previous experience in internal medicine. On a regular basis, families–grandmother, mother, and son–would attend appointments together. It was as though I had stepped into Little Tehran. After my second week, to my surprise, Dr. Rizi introduced me to patients as the “brilliant student from Duke” and the “intelligent aspiring doctor.” The patients, in turn, seemed delighted to meet a Persian shadow student and inquired great detail regarding my academic endeavors and future plans–all in Farsi, of course. The older women gazed at me with a glint in their eyes that suggested I reminded them of their younger selves. The older men looked at me admiringly, no qualms about enduring stress tests and echocardiograms under my watchful eyes. I was taken aback by how easily I was welcomed into their lives and their enthusiasm for sharing private aspects of their consultations with me. The message was clear: I was one of them.

I wondered if the experience would have been the same had I not been Persian. Would Dr. Rizi have introduced me as his protégé to his patients, clear paternal pride in his voice? Would the patients have been so eager in turn? The language barrier would have been an immense challenge, for one. I appreciated the sense of community, but upon reflection, I feel like this implicit judgment of my capacity as a pre-medical student, though positive, was far too hasty. Though I can’t express how much I enjoyed my shadowing experience, at times I wish I had worked harder to gain Dr. Rizi and his patients’ approval, proving my intelligence rather than seemingly being accepted on the basis of my cultural heritage.

Final Paper Brainstorm

For my final paper, I’m very interested in examining the representation of female doctors in modern fiction, and (if this wouldn’t be too much to take on) compare and contrast this with the representation of male doctors in similar works. Stereotypically, women are thought to be warmer and more empathetic than men. I’m wondering if this will hold true with respect to the relationships that the female doctors have with their patients and how they feel internally about the life of a doctor, as well as the ways in which they view their patients (i.e. do they feel closer to them? Can they empathize or sympathize to a greater extent? Or do they detach themselves emotionally?) Another interesting topic might be physician burnout, especially considering the societal pressure placed on women to raise a family and to excel as both doctors and mothers. While I was originally inspired by Memoirs of a Woman Doctor, I’d like to confine these stories to those of individuals living in Western societies. I think it would be interesting to then examine these fictional representations in relation to memoirs written by both male and female doctors, but again, I’m not sure how feasible this will be until I actually start writing the paper. The only problem I foresee is that, after an initial search for sources, I haven’t found any particularly compelling texts with female doctors as the protagonists (but lots with female medical examiners). I’m going to keep searching though!

Goal-Oriented Behavior

It’s impossible for me to imagine a day where, as a physician, I burn out. I doubt any pre-med student can. We’re all eager, driven, and, in many ways, naive. We all have one ultimate goal in mind: becoming a doctor. However, along the way, we have many smaller (but, in the moment, seemingly major) goals in mind that become the focus of our lives. For instance, the first step in the process is getting accepted to college. After that, we become absorbed in our academic schedules as pre-medical students: taking general chemistry, then organic chemistry, then molecular biology, then genetics and evolution, and then, finally, biochemistry. Every semester is about earning good grades in those courses, as well as becoming involved in clinical and research-oriented extracurriculars. Those are the goals. And in junior or senior year, the goals expand to include preparing for the MCAT. Do well in your classes, and learn the material well, so you can achieve a high score on the MCAT. And THEN, you apply to medical school, an extended process in and of itself. And if you’re so lucky as to be accepted to medical school, the cycle starts all over again, but you take the USMLE in place of the MCAT and apply for a residency position instead of medical school.

But what happens after you become a resident? The cycle ends. Not only do you stop “learning” in a classroom setting, as Ofri pointed out, but you’ve essentially reached the end of the road. All these smaller, miniscule goals fade away. Before, I’d always thought that this would be blissful, but after reflecting on this process through our discussions this week, I’ve started to think that perhaps it won’t be. What keeps me going on my hardest, most trying days is knowing that if I push myself just a little while longer, I can achieve one of those more finite goals I had set for myself at the beginning of the school semester or year. To be frank, accomplishing goals, checking items off of lists, has always been immensely satisfying to me. So I wonder: what will be my goals once I have achieved my current dreams? Obviously, treating my patients as effectively as possible will be at the top of my list, as well as staying current with developments in the field. But what about my life goals? 

I suppose this is a transition that all professionals must make, but the change is particularly amplified in medicine in part because we’re students and in training much longer than most others. I’m not sure how to resolve this issue, but I do think that picking up or maintaining a hobby, such as playing a sport or a musical instrument, might help. And as we’ve discussed already, communication is key for expressing frustration and relieving stress. I hope that, in the end, I enjoy my job to the extent where I won’t need a goal to motivate me if I must deal with a tough case or a noncompliant patient.

Empathy in Medicine

I shadowed a cardiologist at his practice a couple of years ago, and the experience was my first foray into the clinical environment. The doctor I shadowed was an exceedingly compassionate man, evident in the respect and patience he showed all his patients and their families. He had established long-term relationships with most of his patients, only further proof to his excellence of not only technical but also emotional skill. He knew the details of all the lives of his patients. He might ask Mr. J, “How have you been doing since you lost your job?” or Mrs. A, “How is your mother doing in Iran? Has she come back to visit again?” I think he’d spend so much of the consultations discussing his patients’ family, career, and life events because he cares about their stress, not just because of its influence on cardiac health but also because his investment in the satisfaction and quality of life of his patients.

The stress tests were probably the hardest part for me to watch. Because they’re designed to max out the heart function of each patient, they’re difficult for anyone is unfortunate enough to have to do one. (Side note: perhaps part of my bitterness stems from remembering how much I hated doing lines and other sprinting exercises in tennis practice in high school…I suppose this might be a bit of empathy in and of itself?) I struggled to concentrate on the patients, especially the elderly men and women, as they clutched the handles and strained to keep up with the treadmill or bike. The doctor shouted out words of encouragement, but for some reason, they sounded hollow to me–I assume because he has had to do this so often that it has lost its novelty for him. I could hardly watch, yet stress tests are nothing when compared with the abundance of painful medical procedures that other patients must endure. How can doctors emotionally handle administering such procedures on a daily basis? I still wonder this.

One of the most striking visits was by an older male, a chronic smoker. I could smell the smoke even outside the room, down the hall from where the patient was seated. As Dr. R explained to me, he was a long-time, non-compliant patient. No matter how hard he had tried to convince him to quit smoking, he wouldn’t listen. When we walked into the room, I saw a man who looked to be about 80 years old, with an oxygen tank at his feet, wrinkled skin, gaunt and hollow-cheeked. I found out later he was only in his 50s. Dr. R asked him, as he always did, if he would consider quitting smoking–the patient flatly refuse. Dr. R didn’t push it after that, but he did ask his wife how she was doing caring for him and joked around with them a bit.

I think what made Dr. R a great physician was the quality of his patient interactions, through which he learned about his patients’ cultural and familial backgrounds and displayed his genuine concern for their emotional health. His greatest test was treating the non-compliant patient, and he was able to do so gracefully: Dr. R’s persistent effort to reopen the discussion on smoking, his concern for the patient’s wife, and his desire to put them at ease all point to his desire to connect with his patients and to comprehend their emotions. But no one’s perfect: at a certain point, I believe you have to learn how to shut out the pain before it consumes you, and I’d like to think this he had adopted this strategy for dealing with stress test administration.

The Wrong Motivation?

Since I began taking this class, and especially as we’ve been reading and discussing Arrowsmith and Memoirs of a Woman Doctor, I’ve been pondering what the “right” reasons are to pursue medicine and the relationship between one’s motivations and their ability to be a “good” doctor. My first impulse (and that of most) is to answer this question with empathy: I’d personally hope that my doctor aspired to help alleviate the suffering of others and was keen on getting to know and understand his patients. However, strikingly, the protagonists of the aforementioned novels distinctly did not enter medicine for these reasons. For both, it seems that pride and respect more strongly compels them, much more so than altruistic reasons. But in and of itself, does this necessarily mean that they’ll be “bad” future doctors? Martin, yes: he quite obviously lacks, and fails to develop, appropriate bedside manner. But our unnamed narrator shows traces of empathy and concern for her patients, starting in medical school (33-34), during her training when the dying mother gives birth (36-39), and, notably, in the countryside (45-47). Therefore, if a doctor shows capacity for empathy towards his patients, does the initial spark that drove them to medicine really matter?

Moreover, can we definitively say that empathy is required to be a “good” doctor? In this case, I believe it depends on how we define a “good” doctor in the first place. Hypothetically speaking, what if a doctor possesses good bedside manner, without experiencing empathy, and is capable of successfully treating his or her patients? Wouldn’t he still be a “good” doctor? Personally, I’d say if a physician can put his patients at ease and heal their pains, then you really can’t ask for more. Lewis seems to suggest that this is true as well, one specific instance of this being when Silva cures Gottlieb’s wife. Saadawi, on the other hand, seems to be implying that empathy is essential to being a good doctor: while empathy first drove the narrator out of medicine , it also ultimately drives her back into it. I’m curious to see where her journey leads and how her renewed, enhanced empathy will affect her practice.

Physician or Renaissance Man?

As we briefly mentioned in class today, one of the most interesting characters in Arrowsmith is Dr. Gottlieb. He seems to represent a slew of paradoxical notions: renowned but reclusive, prolific but financially poor, critical but an earnest mentor. He rebels against the status quo of medicine and refuses to betray his scientific principles in order to pursue self-serving motives – for these reasons, he also seems to be the most admirable character in the novel. Initially, Gottlieb appears to be just as god-like as Martin believes him to be, incapable of error. Over time though, his faults begin to be revealed. Personally, I think one of the most interesting interactions in the book takes place during the scene where Silva comes to treat Gottlieb’s wife. Earlier, Gottlieb criticizes “ordinary” doctors, feeling that “there are too many of them,” and doctors who are uninvolved in research, “cur[ing] village bellyaches” (127, 126). However, when his wife falls ill, Gottlieb fails to heal her: “[He] had forgotten what he knew of diagnosis, and when he was ill, or his family, he called for the doctor as desperately as any backwoods layman” (130). He doesn’t know the proper dose of morphine to administer, and he relies on Silva to diagnose her (130-131). I found this scene striking because it showed that for all his haughtiness, he failed to fulfill his duties as a physician when the time came. Which begs the question, can we excuse this failure because of his intellect and distinction as a researcher? Personally, I believe that Lewis, while admiring of Gottlieb’s integrity and self-sacrifice, suggests that a doctor must be both a good physician and a good researcher in order to truly help others.

On the other end of the spectrum, we have Dr. Pickerbaugh: poet, doctor, and politician. He hardly spends time actually practicing medicine, instead obsessed with fame and glory. Lewis clearly doesn’t recommend abandoning medicine to become a politician either. Again, I think he’s suggesting a marriage between medicine and politics, specifically within the domain of public health, in order to advance medicine. Today, we’re lucky that many doctors are researchers too, and the field of public health has come a long way. Still, medicine’s continued problem is physicians’ lack of empathy for their patients. By reading novels such as Arrowsmith and writing their individual experiences, doctors might grow personally and begin to understand their mistakes (especially when it comes to bedside manner) as well as their patients’ perspectives.

The Good Doctor?

I was very intrigued by the short stories we read by William Carlos Williams and Ernest Hemingway and their take on the morality and empathy of doctors. The Williams, in particular, was shocking: the doctor enjoyed the idea of hurting the child and resented being called a “nice man” by her parents. He even admits that his primary goal in behaving so roughly with the child wa to satisfy his outrage more so than to protect the girl from diphtheria or the others in contact with her. I understood his exasperation with the girl, and maybe I shouldn’t admit this, but at times I was rooting for him to out-rough her, to beat her at her own game. Not because I condone child abuse in any way, but because I felt that the child had no right to resist the doctor (and her parents!) when all he wanted to do was to look at her throat. Which raises the question: where should we draw the line between trusting the patient to take charge of his or her own health, and when should we turn to the doctor to make decisions about the patient’s health for him or her? I can be very liberal regarding such matters: for instance, I believe in physician-assisted suicide. Still, despite my deep-seated childhood fear of the pediatrician and my continued hatred of shots, I find it incredibly difficult to empathize with the child. Williams seems to indicate a conflict between the doctor’s love for (and perhaps even admiration of) the tenacious child and his hostility toward her, but ultimately, it seems the latter wins out.

In the Hemingway piece, the doctor is portrayed much more favorably. However, engrossed in the technical details of the case, he all but ignores the suffering of the woman and instead is excited by the challenge presented by her ailment–similar to the aforementioned doctor in the Williams story. He doesn’t “hear [her screams] because they are not important” and feels “exalted and talkative” after the child’s birth, presumably because of his medical accomplishment, not particularly due to relieving the woman of her pain or bringing the child into this world. I believe that this again indicates a conflict between the doctor’s expected mission to serve others and his or her personal desire to gain fame or to win a competition of sorts.

After finishing the reading, I had a lingering question. I didn’t understand the husband/father’s role in “Indian Camp.” Why on earth would he commit suicide during his wife’s labor? Is Hemingway trying to suggest something about the doctor by association, and if so, what?