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…

 

 


Oncologyclinic.gif

Somehow, the internships just zap my mental energy, after an entire day in the hospital I don’t feel the wish to struggle on the Händel anymore. I’m still working on the folk pieces, of course, because I’ve scheduled lessons on them, but as it will be a while before the next lesson, all semblance of regular / focused practice has come to a halt… My big harp has gotten quite out of tune after being neglected for a while… I wanted to tune it again but the tuner just broke on me (no idea how! Changing the batteries certainly didn’t help and it were new batteries which worked fine in other appliances).

Today was just like watching a bad .gif over and over. The attending with whom I was working did oncoloy clinic and while all cancer is bad, cancer in the head/neck region is especially bad. It basically eats your face and the only treatment is to remove everything it can get to – so then you will hopefully be cancerfree but also missing half of your lower jaw if you are unlucky. And I thought end stage colon / breast carcinoma was bad, but imagine a tumor sitting near your brainstem and there’s nothing they can do about it so it’s a matter of time before you become basically brain dead…

Fortunately, I didn’t have to say anything so I just sat there on my stool (the doctor gets the real chair) and watched as the attending patiently explained everything to the patients and their families. Halfway someone would inevitably being crying and then everyone except the doctor was crying – and of course, as a med student you should be professional so I was pinching myself discreetly to not to join in. And that over and over, just like a .gif where you already know the ending – they came in not really knowing the diagnosis / implications or perhaps they knew but it didn’t sink in yet  and then the news is broken to them and you almost hear the shattering of their plans and dreams…

But then there is the doctor, who leaves room for a silence, offers a tissue, asks a few questions… And the room is filled with a bit of hope – even while there is no hope, the doctor is there and will stick to their side until the very end.

This is what continues drawing me to medicine, even though I sometimes wonder whether I can be a good doctor as an introvert. Being there with and for someone in the worst parts of their life and hopefully being able to help them through it… And even when they don’t make it, knowing that you were there for them, that you really took the time to listen to them and reassure them, guiding them through the storm…

But I wonder whether I’ll be strong enough to avoid being knocked off my feet.


Triplets & CT: a story of love and hate…

It’s been a while! I’ve accumulated several posts with that very same opening sentence – I’ve started several drafts, then decided I didn’t really know where I wanted to go with the post and eventually, I sort of let them be. I’d like to write meaningful things about my journey in medicine, but I can’t share the most interesting stories because they’re much too recognizable. I think it just takes time – when I’ve seen more patients, I can merge stories and change details more efficiently. Also, every post about medicine eventually ends up with me contemplating depressing things like death and suffering and is it all worth it and if there’s a God (which I sort of think there is), why would he allow so many innocent people to suffer — there are a lot of questions that I’m trying to find anwers to, while also trying to learn something about medicine. So I think I will let these stories stew and brew for a little longer – but that doesn’t mean I can’t write about the harp, does it? :).

During internships, the harp is really my escape, my way to focus on something entirely different than patients and medicine and trying to cram all kinds of facts into my head. I can’t always work up the energy to actually practise – doing more than playing through a few pieces – but when I manage to, I can really get into a flow.

As this year is the last internship year that is slightly compatible with having ‘a life’, I’ve started taking folk harp lessons with Cheyenne Brown. There are a lot of teachers around here that can teach you to play classical music, but there are few who really know what folk is – the rythms, the ornaments – the art of making a rather simple melody sound like it’s a virtuosic piece – which is related to the art of touching people’s hearts by just playing a  ridiculously simple arrangement. It really takes skill and musicianship to make such melodies come alive.

Any classical performed will agree that you can’t properly play a piece if you’re just playing the notes. Unfortunately, due to a lack of good folk teachers (and lack of exposure to folk performers), in the Netherlands, a lot of people ‘just play the notes’, reducing folk music to something that’s only suited for beginners. I even fell into the trap of thinking that folk music was ‘too easy’! Fortunately, I was cured of that mindset by Youtube movies and harpist-friends who were really into folk!

So, I started doing workshops – some specifially geared towards the harp, others more focused on ensemble playing (arranging tunes for a group etc) – but I noticed there were certain things I just couldn’t do. Like triplets. I’ve gotten loads of advice, even a few informal private lessons with a folk harpist, but I was never really able to do them.

I still can’t do them. I love them, but I hate them as well. I’ve overcome most hurdles – there was a time that I just couldn’t do four-fingered chords, a time when I couldn’t understand how to do syncopatic chords – but eventually it clicked and I was able to do it. However, I still can’t do triplets properly, they become strange muffled ‘things’.  Having regular lessons with a folk teacher is a really good incentive to practise them daily – but it’s VERY frustrating that I don’t seem to make any progress. I can sort of ‘fake it’ by playing the tune at full speed, but in my fingers, I feel it’s still not quite right.

It’s entirely different from trying to learn the Händel concerto. There it’s just guiding my fingers into the right shapes, memorizing the patterns and then building up speed (which also takes LONG but at least, there’s progress if you work on it diligently). The quality of my triplets seems to worsen when I try to analyze what I’m doing and what’s not going right. So then I stop trying to analyze it and I force myself to just practise it and hope it gets better…

Perhaps it’s a little bit similar to what I’m going through with learning medicine. There are some things that you just can’t understand, you only need to trust that it will be alright in the end, that the hard work will finally pay off…

Here’s a little recording – the harp wasn’t totally in tune and the tempos are a little bit off, but I wanted to share what pieces I’m practising for the folk lessons.


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