Flows

The flow of medicine is strong. The seemingly endless stream of patients pours through the hospital and  clinic doors, into the rocks, and babbles back out again, both water and rocks forever affected by their  co-percolation. Some in the stream find themselves stuck in eddy currents, returning to the same place  over and over, while others are on a more laminar journey, perhaps meeting rocks only once or twice along their voyage  through the stream. We, as medical students, are small stones placed haphazardly into these streams, shaped both by our fellow rocks and by the water that flows past. For most in the stream, we have a  negligible effect, while for others, we can augment their journey quite drastically.

These metaphors are starting to hurt my brain, but, since I’m currently in my surgery clerkship, I’m going  to stick to my guns. As a shy third-year student from the Midwest, I have an incessant need, perhaps to  a pathological degree, to preserve the flows into which I’m placed. In some ways, this is an educational  advantage, in that I’m extremely motivated to learn quickly enough so as to not stick out like a boulder  in a brook. In other ways, though, this mindset can make it difficult to have the courage to make waves  when waves need to be made.

The presence of the flow was most tangible during my family medicine clerkship, while at a busy  suburban clinic that provided care for upwards of 25 patients per day. A single mistake with a  prescription or one missed question during my interview could add several minutes to the ever-present  log jam at the end of the day. And the lack of residents to buffer my ineptitude from the precepting  physician only added to my neuroticism.

By the end of the second week, I started to feel the jagged edges of my stone begin to smooth, and  flow through the clinic started to feel more natural. Patterns in the stream emerged and I found myself  able to conduct some appointments almost completely autonomously. Recognition of my progress by  my preceptor was quickly followed by genuine feelings of accomplishment, pride, and fulfillment.

Then came Mr. Sparrow. He had been in the Marine Corps for the better part of a decade, working his  way up to first lieutenant just in time for the Gulf War. Halfway through his first deployment, he was the  victim of a grenade explosion during a live training exercise, leaving shrapnel embedded into the left  side of his torso. Some of the fragments were subsequently removed, but others were deemed too  dangerous for operative intervention and remain in place today. He was quickly shipped home and  promoted to captain before retiring from the military and returning to civilian life.

As a consequence of this injury, Mr. Sparrow has a constant gnawing pain in his left abdomen and hip  area. He was originally followed at the VA hospital for several years but started to see my preceptor a  few years ago at the recommendation of a mutual friend. A quick look at his medical record revealed a

gradual, but steadily increasing dose of narcotic pain medications since his transfer to the clinic. Although this regimen might sometimes be appropriate in certain circumstances, the concerned voices

of past professors, recent pain research (Chou et al., 2015), and media coverage (Volkow & McLellan,  2016) floated into my thoughts.

After interviewing Mr. Sparrow, I went over his medication list with my preceptor, just as I had for most  of the patients we’d encountered together. That familiar feeling of flow resurfaced when I pondered  whether or not to raise the question of the patient’s narcotic usage, although this feeling was a little  different. I wasn’t particularly worried about disrupting the clinic schedule with a simple question about  medication dosing. Instead, I was concerned about the flow of our teacher-student relationship and how  it might be affected by the perception of a medical student questioning the decisions of an established  community physician.

With some mustered courage and careful wording, I broached the subject of alternatives to Mr.  Sparrow’s current pain medications. My preceptor’s response validated my initial feelings, and he agreed  that it was an appropriate time to have that conversation with Mr. Sparrow. After the appointment, we  had a discussion about the difficulties of preserving flow in balancing patient relationship expectations with concerns about long-standing medical care. He also noted that, had I not rocked the boat, so to speak, he may have let that situation continue unchanged for another couple of appointments.

As I strive to incorporate myself into the beautiful flow of medicine by taking my shape and minimizing unnecessary disturbances to the stream, I will forever remember that my presence in that stream does indeed serve a purpose and that, at times, I may be the rock in the best position to make a few waves.

References:

Chou, R., Turner, J., Devine, E., Hansen, R., Sullivan, S., Blazina, I., Dana, T., Bougastos, C., & Deyo, R.  (2015). The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic  review for a National Institutes of Health Pathways to Prevention Workshop. Annals of Internal  Medicine, 162(4), 276-286. doi: 10.7326/M14-2559

Volkow, N. & McLellan, A. (2016). Opioid abuse in chronic pain – misconceptions and mitigation  strategies. The New England Journal of Medicine, 374, 1253-1263. doi: 10.1056/NEJMra1507771