The most important concert

I never had the joy of having a ‘typical’ grandparent until I became a part of my husband’s family. Both my mother’s parents died early, she was only 24 and my older siblings barely remember her. My father’s mother went through a lot in her life and combined with her frail health condition, she wasn’t able to act like a stereotypical grandmother* .
However, my in-law grandmother really plays the part, in the sense that they stuff you with food, ask questions about every aspect of your life and offer lots of unasked for but valuable advice. She is the kind of person who really grows onto you and it’s never a pain to visit her because you know that that afternoon will be memorable.
My grandfather was a musician and a theologician, until he had several strokes that left him almost unable to communicate or play his instrument. I never knew the kind of person he was before the strokes, but even now his very strong and loving personality remains. He hated the home he lived in, they put on the TV all day and had them listen to Dutch popular music, while my grandfather had always loved classical music. We’d given him an ipod with classical music but he was dependent on the nurses to turn it on for him, so he rarely got to listen to his preferred music genre.
So of course, I really wanted to play the harp for him, but I didn’t want to just play some celtic tunes on my bardic but I wanted to play the Handel concerto. That is the most classical piece I know and I felt that only that would be worthy enough for such a first-class musician as he had been. On a 27-string harp the Handel is quite a challenge. I’ve tried it for fun but there are some spots where you can’t change the octave and it just doesn’t sound right. Bringing my 34-string harp wasn’t an option because we don’t have a car, so I resigned to the fact that it would be quite some time before I could let my grandfather hear what the harp sounds like.
A few weeks ago, we were planning to visit my grandparents in their new home, but I also had to take my bardic harp along for a band practice session in another city later that day. I hadn’t planned on ‘giving a performance’ but of course I couldn’t let that thing sit in its case…
All the things they say about playing for people are true. It isn’t about playing the correct notes, it isn’t about complex music, but it is about touching people, telling a story and forging a connection. I first played some celtic tunes to warm up, then I made a go for the 27-string version of the Handel. While it was certainly interesting, it didn’t really go as intended. Sometimes I had to stop and go back, sometimes I sort of hesitated. I hoped he’d show recognition the piece of music or maybe show that he liked it. No response, even though he was sitting a few feet across.
So I started improvising a bit over the idea of the Baroque flamenco, the menuet part, then some flamenco-inspired thing – and I don’t know what happened but I noticed that my grandfather had noticed the music and was listening very intently. I was suddenly very aware of his breathing and his awareness. I continued to play, most of this piece works rather well on a 27-stringed harp – and I could still feel the tension, his attention.
The baroque flamenco has a cadenza, where you really build up suspense by tapping on the harp sound board – and then you play a few notes in the high register, still keeping the tension –
Anyway, it worked. I finished the piece and I looked at him and he looked at me and I knew I had accomplished my goal, connecting through music. While it was very profound and moving for me, it wasn’t like there was a huge silence, the moment lasted maybe a few minutes.
This is what making music is all about, and apparently, you can’t force it, it just happens when you least expect it. Sometimes I am really intimidated by all the fabulous professional harpists with their superior tone control, they really can tell a story with their music – but some aspects of this are also available to amateurs, as I discovered that day. Actually, in hindsight, I think that this experience really has a lot in common with what I experience with a patient a while ago! I never felt like I was a very spiritual person, but the spirituality seems to find me

* Regarding my paternal grandmother: I’ll cover this in a blogpost in a while, I discovered that she indeed deeply cared about her grandkids, even though she did not always show it to us in an obvious way.


Skill development

A couple of years ago, I was really worried by the whole ‘qualified and competent’ principle in the law that governs medical actions. Here, the law is that certain professions are allowed to do certain procedures (venipuncture, physical exam etc), but only if you are both ‘qualified’ (either a doctor/nurse/midwife/dentist or under supervision of one) and ‘competent’ (having had the correct training). The second part underlines your own responsibility in this, if you do a procedure that you are allowed to do but haven’t been trained in, you can’t hide behind your qualifications if something goes wrong. I certainly didn’t want to do things I was not allowed to, being quite scared of the disciplinary process that was drilled into us during lectures.

Now it’s quite amusing to read about my somewhat naive concerns. In medicine, there’s a lot of see one, do one, teach one going on. Atul Gawande writes about it in his book Complications and it is true: sometimes, patients serve as guinea pigs for medical students to learn procedures. I’ve contributed to it myself during my final internship by asking the medical students on their internal medicine rotation to draw blood for me on my patients. I remember how important it was for me to get lots of opportunities to draw blood in order to build a routine – and now I was passing on that privilege, knowing that sometimes, patients would have to be stuck twice (or more) to obtain a blood sample.

Actually, venepuncture is taught quite well in medical school – first on a plastic arm, then on a fellow student, then during one afternoon at the outpatient lab where patients are asked if they will allow the medical student to draw blood. So before I unleash a student on a patient, they will have done the procedure 5-6 times at least. For starting IV lines – another common medical student task – they were less well prepared, having done it once or twice or maybe thrice if a kind resident let them during the junior clerkships. However, most hospitals offer a kind of crash course, in which you get to place IV lines in the OR, so again, by the time you enter the ward, you’ll be somewhat familiar with the procedure.

However, a very important procedure, obtaining an arterial blood gas sample, isn’t taught in medical school at all. I was shown once how to do it during my week-long rotation on the Pulmonology ward. When the next ABG had to be drawn, the resident asked me to list the supplies, the steps and how I would explain it to the patient – then she sent on my way – give it a try, if it isn’t succesful, come and get me. Are you sure? I have never done this before. Yes, I’m sure you’ll do fine!

I went to the patient, explained the procedure, conveniently leaving out the fact that this would be the first time ever that I did it. Fortunately, I got my sample in one try. The week after, I coached another medical student through the steps, even though I’d done it only twice by then.

Did I throw away my principles? I could have refused and demanded more training. And still I trusted in my own ability and obeyed the order  given to me. Well, that’s not completely true. I trusted in my resident’s assessment of me. I knew the theory, I just had to gain the hands-on-skills. The point is, like Gawande also argues in his book, there is only one way to learn a procedure: by doing it. Until you actually try it, you can’t learn. Of course I always got help if necessary. Really. I’ve asked an attending to repeat my blood pressure measurements on a patient (the most basic of basic tasks) because I wasn’t sure of my readings. I felt really embarrassed but I knew I couldn’t stand the feeling of maybe having made a mistake.

Eventually, I also realized that someone needs to do the job. As a medical student, it’s easy to get your supervisor. I often went to get them when I couldn’t feel a vein, then I didn’t even try. As the supervisor, you need to call anesthesia to place an IV line, so you better try it at least a couple of times before you start the process of enticing them to come to the ward. So I’ve slowly grown used to starting a procedure even when not completely sure because if you won’t do it, eventually, it will be very difficult to get someone who will.

I haven’t touched much on the most important perspective: the patient’s view of all of this. I’ll come to that in later blog posts, but a vital aspect of medicine still is knowing your limits. I still hold myself to a ‘two tries’ limit – if I can’t place an iv/draw blood/ do an ABG in two tries, I’ll get help. But I will allow myself the space of thes two tries. Gradually, I noticed that I was now able to place IVs in more difficult to see veins – apparently, by taking the time and trying, I slowly built my skills repertoire.

For me, learning how to become a doctor was a big lesson in how to deal with uncertainties and my own insecurity. This example of ‘skill development’ is intended to illustrate one aspect of that learning process – and especially how difficult it is to stick to your principles in the daily reality of clinical practice. Some people become a confident doctor-persona overnight, in others it takes a little longer. And, most importantly: doctors aren’t saints. Doctors aren’t perfect and the process of how to learn isn’t perfect either. But we try, we go on, because we have to -personally, I couldn’t imagine doing something else than helping people.

For those who were curious: I finally learned how to do intramuscular injections during the primary care internship in year five. I don’t think that half of the vaccination was supposed to leak out after I’d removed the needle, but the doctor’s assistant who supervised me, pronounced it as a correct vaccination. I did two more injections, now supervised by the doctor herself and that was it.

And then I consolidated these skills by vaccinating a boatload of unsuspecting first year medical students during my social medicine internship. ‘You’ve done this before, haven’t you?’  ‘Yes’. ‘Great! Here are the vials and here are the syringes. I’ll stay for the first few injections to see whether you’ll be alright.’

I remember how a very insecure looking woman vaccinated me during my first year while an elderly man watched – an exact mirror of the situation I was in. Before she actually injected me, she practiced the ‘throwing a dart like movement’ a few times. I remember being a little bit put off but I didn’t dare to comment. In hindsight I think she was also a social medicine intern who hadn’t had much experience with intramuscular injections… :)


Role model

(..) I was wondering  – you’re rather small, well, I’m not very tall either, but I’m always wondering, you’re so young, and the whole mandatory trying to draw attention to yourself thing during the coschappen, I always wonder what makes young people pursue medicine.

HE SAW MY PAIN! He was the first doctor to acknowledge that the coschappen grading process might be very difficult for shy-er people. I didn’t really say anything in his presence, I just observed, but when all the patients had been seen, I was subjected to a crossfire of questions. Where do I see myself in ten years? Why do I study medicine?

I met this very empathic surgeon during my surgery internship. He was the first and only one to ask the questions that actually matter. Of course, during the admissions process you write a little eassy on how you’ve always dreamed on becoming a doctor, but you don’t know anything about the reality of doctoring. Now you are on the brink of becoming one yourself and you find that you had never really put any thought in BEING that doctor and WHY. I just struggled on, trying to stand out in a class full of extraverted peers.

That afternoon I spent doing clinic with this doctor – ‘doing clinic’ entailed sitting on a stool and maybe palpating someone’s abdomen and taking a blood pressure – was an afternoon full of bad news. I never realized that that is a huge part of a surgeon’s day.

One patient stood out in particular, a a cheery fellow in a wheel chair who had been dropped off by a caretaker. He did not know why he was there, he just smiled a lot and said he already felt a lot better now, all the studies and tests had been quite uncomfortable but he was glad it was over.

We’d spent five minutes reviewing the chart before he came in, and this too, would be bad news. Advanced colon cancer, an urgent resection offered the only chance of curation, buteven then the prognosis would be very bad. The surgeon hesitated a little, but then plunged forward and delivered the bad news as sensitive as he could. They say a lot about callous surgeons but this man certainly wasn’t like that. He got up from his comfortable chair when our patient started crying, went over to his side of the table, and crouched next to our patient’s wheelchair. Quietly, he asked, what are you most afraid of right now?  – and took the time to hear our patients fears and worries.

To provide some perspective, the surgeon decided to introduce our patient to a colleague of his, who specialized in the specific operation that our patient would need. We were already behind schedule, but the surgeon didn’t want this man to leave without any notion of what was going to happen next. So we knocked on the door of the other surgeon, asked him to come with us and see the patient.

The contrast between these two men couldn’t have been bigger. This was a typical surgeon, big, muscled, loud. Of course we are going to fix you, sir! he bellowed and continued to spout well intentioned nonsense. You will be out of the hospital in no time, maybe in time to still catch some of the summer! Then he patted our patient on the head and left. Our patient was quite flabbergasted. Am I going to die now? he asked.

After the patient had left, the surgeon asked me what I thought. This had been one of the first bad news conversations I’d ever witnessed, so I was glad to be able  to share some of my emotions – I was very touched by how our patient took the news. I felt very bad for him, how he had come here expecting good news and then being hit with a sledgehammer.

No, what do you think?

I wanted to start talking about the patient’s feelings again, but he interrupted me.

Don’t you think that [colleague] was completely inadequate? He’s a surgeon, loud, expressive, while this man needed a calm reassurance.

And then he looked at me and asked me how I was doing, as an introverted person in the middle of a group of extraverts. I’m afraid to say that I lied and said I was doing fine. At the previous clerkship I had shared my feelings with our clinical facilitator and it came back in my grade in a very nasty way, everything I had shared in all honesty, wanting to become a good doctor, was used against me. So naturally, I now knew that I could trust no one and I just smiled and said that I loved medicine and that everything was fine. He didn’t take that for an answer, he asked me why did I go into medicine? Why do I love it so much? At the time, I just tried to give politically correct answers, but now I realize the lesson he was trying to teach m. Don’t try to become someone you aren’t, become a doctor because you want to. Otherwise you won’t make it, otherwise it won’t be worth the constant struggle.

I’ve worked with a lot of doctors throughout the years, but he was the only one who really recognized what I was going through, most likely because he himself was introverted. He didn’t say anything, just looked at me and wished me good luck on my journey of becoming a doctor. Now I see the truth and wisdom in his words and I am grateful for it, that he took the time to talk with me, one of the many, many medical students they see every day.


A glimpse of heaven

We thought he wouldn’t make it to the afternoon when we visited him in the morning. We, a cloud of white coats, gathered around his bed. The attending took his hand and looked him in the eye for a long time. He sighed. There is no way to translate his words into concise English, but he said the equivalent of ‘You’re very ill. We are afraid that you will not live for much longer.’. They shared a moment together, he, the oncologist who helped and guided him the past few years, him, the man whose body was now really failing him. He didn’t say anything but it was clear that he understood.

I had the responsibilty of caring for him during his last hours. Before this internship, I would have never felt up to this, but somehow, pieces just fell into place and I could finally become that doctor I wanted to be, the rock in the storm.

However, he didn’t die that day. And not the day after either. Family members from all over the country visited, said their goodbyes. He was surprisingly lucid, at the beginning we thought that maybe there were some signs of delirium but these receded. I began to feel some hope again, despite the odds. But on one morning, I read in the file that the patient was now barely able to wake up.

Being a ‘sub intern’, my patient load was lighter than that of the residents and I was able to check in on my patient every couple of hours. We never spoke of much, I watched him silently for a while to see if there were any signs of distress and then tried to wake him to ask him if we could do anything to make him more comfortable. This little rather one-sided conversation would last a few minutes and then he would fall asleep again and I could turn my attention to the family members.

There is always a kind of holy atmosphere in the room of a dying person, a silent anticipation of what is going to happen. I can’t describe it in words but it’s a very powerful atmosphere which makes me pause every time. It’s the atmosphere that is created when someones soul is preparing to depart their body. Do I belive in the ‘eternal soul’?  From a theological and scientific viewpoint, I don’t. I can’t. But with this specific patient I experienced something that transcends simple answers.

He had now been dying for almost twelve hours. The family was getting restless, asking me how much time there was left, couldn’t we do something to speed it up (the patient was now entering the phase where the brain sort of disconnects from the body and sometimes forgets to breathe). I answered their questions to the best of my ability – we never know ‘how long it takes’,

Dying is a really strange process. Sometimes, it happens in an instant, but sometimes, it’s a long and drawn out journey – sometimes, it feels almost equal with a birth but then in reverse. ‘Letting go’ takes a lot of energy, it’s certainly not just a passive shutting down of bodily function. So I’m honest with family members and explain to them that ‘the last part of life’ doesn’t just ‘happen’, it is an active process, and as a family, it often helps to talk to the person, to touch them, because hearing is the last thing that stops. And of course, this takes a toll on the family, and it is important to urge them take care of themselves, take breaks, go home to sleep for a while – but we can never ‘predict’ the moment of death. ‘Euthanasia’ is completely out of the question as that has to be requested by the patient themselves. In case of refractory symptoms, we can administer painkillers or other symptom-directed therapy, and in rare cases of terminal anxiety, we can administer a sedative. But usually, when a family asks me to ‘speed things up’, the patient is already oblivious to what is going to, far away on their journey to the next life, and is is their discomfort that prompts the question.

As usual, I also tried to ‘contact’ the patient. I remember vividly how I was almost afraid to speak to dying patients when I started working on this ward, as if I’d disturb them, but I learned by example of a great oncologist that patients usually really appreciate the care you show them (or they will just continue to sleep). I softly touched his hand and said his name. I did not expect a reaction but I wanted to try anyway.

He opened his eyes. Hi, he said. Hi! I responded enthusiastically, maybe a little inappapropriate for this situation, but I was so surprised that he actually spoke that I said the first thing that came to mind. He returned my gaze and we shared a moment of silence.

It felt like hours. I don’t know what happened, but I was suddenly connected with my patient on a level that I have never experienced before. We saw each other, he saw me and I saw him, and it felt like we belonged, like it was exactly right. There were no barriers, there was no doctor or patient, we just were.

I was suddenly jolted back to the present and I had to struggle to control my emotions. My patient had gone to sleep again, the crackling sounds of his breath filling the room. I didn’t say much but I think everyone present could see how touched I was.

What happened? I don’t know, I think I got a glimpse of heaven. I’ve read a lot about near death experiences and how they can also be felt by observers – this felt like it. The odd thing is that I can hardly put it into words. It was just a moment but it was so much more than that. It was like coming home, arriving after a long journey and seeing that this is your place. Nothing changed during the mere seconds that this lasted, but I felt like I had been somewhere else, in a very bright and light place.

I will always cherish this experience, this gift from my patient. I think it’s the best gift ever. It’s a glimmer of hope in the very dark and bleak reality of the oncology ward.


These shiny letters

Suddenly I’m a doctor. There’s not much to it, it took a signature of the preceptor of my last internship and that was it. On paper, I was a doctor. The decision was sealed by the Board of Examiners and then I had to take the Doctor’s Oath (modified and modernized version of the Hippocratic Oath). And THEN I became doctor for real. Or did I become a doctor when I registered myself in the national registry and got my personal identification number? Or maybe when I first introduced myself as ‘Doctor [Surname]’. Or maybe I’m not a doctor yet, because no patient has called me doctor yet since I graduated.

When DO you become a doctor?

I thought I would know by the time I finished medical school, but I’m still not really sure. Part of this has to do with the fact that I’m in clinical research now – of course, if I’d gone on to work in the clinic, a lot of people would have called me their doctor by now. Now I’m mostly the ‘researcher’ who tries to convince people to donate some extra blood.
On the other hand, the insecurity and the scariness of the fact that you’re responsible for someone’s health never goes away, not even when someone certified that you can now independently take a lot of clinical decisions.

It seems as though ‘being’ a doctor has a lot more to do with how you feel about it then any external factor or diploma. Interesting.

For the curious people: here in the Netherlands, there are two options, you can either start working in the clinic to gain relevant working experience, or you can do research (clinical, fundamental, any type counts). After a few years you’re in a position to apply for residency. I am blessed with a position where I can do both research and still do some clinical work as well. I don’t know yet what specialty I’d like to be in, so this is an excellent opportunity to do something I love while finally, finally being paid.


Dance technique & harp playing

This is a post I wrote after the Harp Friends Meeting Leerdam (May 2013). Lately, Tristan Le Govic is posting very interesting posts about the ergonomic / postural aspects of harp playing, and I thought it would be nice provide a learner’s point of view. 

As a dancer, It’s quite common to re take a level of dancing lessons or take lessons in a lower level than you actually have. There is no dishonor in this – you’re just showing that you’d like to go back to the basics and work on the foundations of your dancing. And as every teacher has something unique to offer, you might discover things about dancing that you’d never known before in a class for absolute beginners.

I’ve talked about this before, but I seem to have a weird sense of pride where it concerns harp playing, I never even thought about going to a beginners workshop, because, well I’m by no means advanced but I do know about basic placing, playing hands together etc? No need to waste time relearning stuff I already knew, right?

Then the Irish dancing workshop was cancelled. I was offered a place in a beginners workshop in Breton music by a teacher I love – Tristan Le Govic.

I first met him and his teaching style in Waregem. Just like there are few dance teachers who can really convey the essence of dance in a workshop, Tristan is one of the rare teachers who really grasps wat harp playing is about and can convey it perfectly. Listening to him and doing a workshop with him is like one giant aha erlebnis. So I knew, Tristan is doing this class and he is good so it will probably be a good review of basics and I might learn more about the Breton style – where that is concerned, I really am a beginner.

In the workshop, we learned an Andro tune. That’s a dance that is commonly played in the Dutch balfolk scene, so I’ve had a lot of lessons by various teachers on it. At first sight, the Andro is a very simple, repetitive group dance. However, you sort of need to relax and tense at the right moments to make it a dance. Actually, it’s a little bit like taiji quan, it’s a very decisive but relaxed movement. So it’s easy to learn but it’s hard to master, to make it a dance, being connected with each other as a group instead of going through the motions on the rhythm of the music.

Tristan also dances Breton dances, so of course, he taught us how to dance it. Perhaps it’s because he is from Britanny,  but Tristan indeed dances the Andro very well. And then there was a revelation. He applied the principles of the Andro to the harp.

You need the same kind of relaxed shoulders; even though it’s a movement done with the arms, you shouldn’t tense up. Same goes for the harp, you can’t play comfortably with your shoulders all tense. I had never thought to apply the whole body work of dancing to the harp, but it turns out that harp playing is also related to moving from your center /hara.

When dancing, you really notice that center- derived motion is not esoteric or abstract. If a leader doesn’t move from his center / lacks proper frame, you as a follower don’t understand what’s going on. That’s why some men get really good at leading in a short time – they naturally have either a frame or the necessary body awareness to create a frame. Everyone else is left struggling until they suddenly get it. That’s because a huge part of having a frame and properly transmitting movements of your center is to have proper posture – straight back, relaxed shoulders but a certain tension in the arms… And it’s not like our society really helps us to achieve a good posture. So generally, we don’t know about good posture – me neither. But Tristan showed how much this is needed to avoid uneccesary strain while playing.

I know that Alexander technique is often done by musicians but I never thought about the possible benefits for me, an amateur harp playing. But essentially, harp playing is about movement and all movements come from the center, just like dancing or pencak silat!


It’s been a while…

Almost six months later and I

  • started my last year of medicine. In less than a year I’m supposed to be a doctor!
  • am able to play through the first movement of the Händel concerto
  • discovered that my thumb placement in harp playing is TOTALLY wrong (I’m trying to get it right, but I’ve played the harp like this for 14-16 years…)
  • have changed from a ‘shy’ ‘introvert’ person into an ‘assertive’ person (according to my evaluations.) It could have something to do with the fact that this year, my performance is graded based on 1-to-1 observations of patient encounters instead of how I function in a group full of extraverted people during a 1-hour teaching session…
  • Still can’t stop procrastinating. Tomorrow, I’ll have to present something about psychiatry and it’s 20:30 already…

 

 


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