The Fraud Police (and other ramblings about self-doubt)

(I realize that is not the most enticing title there is. I don’t have a better one just now, and, as this is about honesty, I can’t really make up a title with no connection to the article:)
Every now and then, as a doctor but I suspect in any other profession, I have moments of “what am I doing here, who the heck gave me permission to do this, why am I in charge?”. I think about it from time to time, but, as I was listening to Amanda Palmer’s The Art of Asking (read it!) yesterday while drawing fern motives on my crutches (random occupation number…. I’ve stopped counting), she happened to mention the exact feeling. She calls it “the fraud police”, the fear that someone might come and call you on your bullshit: how are you qualified to be in this role, to do that or say this? Who gave you the authority?
I constantly go through this. And not necessarily with the -minority – of patients who are angry, for various reasons, about the health system you happen to be working with, or angry about something completely unrelated, or just belligerent, but as a result challenge every decision you make, contradict the advices, etc… Those are fine, and useful: you are reminded you must absolutely stick to evidence, and, usually, you try to go and find why they have lost trust in you or what you represent. They are a sort of welcome detergent, if you like.
The more troubling ones  – maybe not at first glance – are those who come to you in search of absolute certainties. Whatever the question, they don’t want a balanced answer, they don’t want an “I don’t know”, they will trust whatever you say but you have to have an answer.
And, so many times, over and over. you don’t really have it. Whether the question doesn’t have too much consequence, like, “what is the cause of this cough?” (that is, once you’ve eliminated the possible serious causes, often you just know it’s nothing serious, which is not really the greatest possible answer), or “but when am I going to die?” – and again, most of the times, there is no certainty.

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Brave strange brain: Mr B.

Mr B comes to the consultation with this glazed look of barely being there, as if there is a thick glass sheltering him from reality. And that is probably what he hopes for, because his reality is not a pleasing one.
Mr B has the monotone, almost robotic tone you often recognize in people suffering from the same affections, the great and frightening potpourri we call psychotic disorders. He says a few words, but has learned not to say more than that: people don’t believe him.
Mr B has come from Russia many years ago, but it is impossible to know what he has lived there, his past is a shut door – maybe even for himself.
Mr B suffers from paranoid schizophrenia.

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Mrs K and what makes a good woman…

(Now how do I always manage to get a song stuck in my head just by trying to find a title for my daily ramblings)

Anyway, I wanted to talk about Mrs K.

She is just one of the people I’ve come across in the last months, working in an outpatient psychiatric consult aimed partly at the migrant and asylum seekers population. And yet that is as unfair as any introduction can be, she is a lot more than that. She is about 8 years older than me, a small, always elegant woman with expressive eyes. She has come from Turkey, with her husband and two children, and has arrived in Switzerland a few years ago after spending about a decade in Germany, and in the end being deported back to Turkey. So now they are trying to find a place in Switzerland, and are, even after so many years, still waiting for a final decision, a permit. Which means they don’t have the right to work, don’t have the right to leave the country, don’t have the right to much.

She was engaged at 14, married – that is, culturally married, but that is the only one that really has an impact – at the age of 15, and had her first born at 16. By that time, she had had to go to Germany to join her husband  – it is an arranged marriage, in case you were wondering, who is a lot older than she is, and gave birth in a foreign country, not understanding anything the doctors and nurses said. She says those first years of marriage were the most unhappy of her life.  But she isn’t one to let things go without a fight. She learned German – despite her husband not wanting it, fearing it would make her – and rightly – too independent. She raised her first than second child.

And now that they are in Switzerland, she is learning French, and is so good and motivated at it that she managed to secure a place in a private and expensive course, that her teachers pay for her because they thought it would be such a waste if she couldn’t continue to learn.  She doesn’t see it as an accomplishment. Rather, she sees it as yet another source of stress (other that the conflicts with her husband, her fear of her sons not being integrated at school, the constant threat of receiving the news that they are expelled from this country, and a few others), because she absolutely doesn’t want to disappoint the people at her class that allowed her to pursue her education.  She values education more than anything. She has a clear view of what makes a strong, real woman: it is a woman who works, doesn’t depend on any man, and until she has found work – no matter what her husband thinks or allows her to do – she won’t consider herself strong, independent. 

Yet she has lived trough much more than I have ever lived through, and is probably a dozen times stronger than I am. But she says she admires me: the fact that I work, that I studied – she was pulled out of school by her parents at 14 to go marry her husband. 

She is probably more intelligent than any of us. She is determined, yet has touching ideals – she told me, the second time we met, that she would like to feel, just once, what it is to feel love for a man, a real passion, even though she knows divorce is not an option, and she is unlikely to  ever leave her husband.  She is a woman in every strong sense of the word. She doesn’t even resent her life, her circumstances, she isn’t bitter.  And she thanks me for my support. That is what I struggle most with: I feel I am the one who has learned a lot more, I am the one who was given support by our meeting. Because I will remember Mrs K. all my life: her tears, her smiles, and what she believes so strongly she isn’t afraid to go against her husband and her whole community to get it: Education. Independence. Freedom. Even love.

Heroes of our days are to be met in refugees camps. Heroes of our days don’t even consider themselves strong, but they are stronger than ever.

Read what unsettles you. Book review: Being Mortal, Illness, Medicine, and What Matters in the End, by Atul Gawande

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I may not read very diversely.

Scratch that.

I know I absolutely don’t read “diversely” (in any sense of the word) despite the fact I would like to believe I do, and often try to push my own boundaries. Often, that means, when I’m not picking a book by its’ cover, forgetting that most covers are now designed to resemble another book of the same genre you just bought, or books I know I will like, for comfort, or books by authors I’ve already read,… So, not so often then. And I used to be better at this: I would go to the library and pick at least 5 of the authorized 10 books you could borrow that would be books I knew nothing about, picked at random in shelves, because I read a few pages in the middle, liked the sound of the title, anything. Now I do it less frequently, probably because the number of authors and books I’ve discovered through this medium means there are so many books I want to read – that I already know of – that I don’t have the willpower to discover entirely new ones. Anyway, that is one of my 99 book related problems, you would say, and absolutely not related to this book in particular.

But it is a predictable choice, is what I should have said were I to use fewer words than this first paragraph ever needed: I’m a doctor (still sounds weird!), I’ve worked in palliative care, I’m interested in questions about end of life and the worth of living, and how to help those who face death at the best of my abilities. So I picked this book. See, not diverse at all.

And it is a very good book. First, it’s well written (If I were to be sarcastic I would add “…for a surgeon”, but that would be classical inter-medical-species bickering, and in any case one would argue that Gawande is now about as much an author as a surgeon.), and it is about an important subject matter, for “anyone about to age and die”, so a lot of us. It makes a great case for the importance of palliative care training of health care professionals in an ageing world, it studies the effects of the ageing population and what it means for the end of our lives, it gives individual histories of what people value at the end of their lives – underlining the vast array of what might be considered “a life worth living”, by people living them, which I’ve always felt should be the first thing you say when trying to discuss subjects going from whether or not people should grow old in hospices to whether assisted suicide should be allowed: What an individual might consider a life worth living depends almost entirely on that individual.

So it is everything I expected, and in that, it is a marvellous book, read it. (See, I can be direct when I want to).

I have no problems with it, only with myself, for, as comforting as it may be to read a book that is a mirror of your own certainties, it didn’t teach me anything, it didn’t bring me out of my comfort zone, it didn’t surprise me – it could have, had Gawande taken a firm stand concerning for example therapeutic measures to shorten the suffering of people dying, which he didn’t, and it is comprehensible that he did so, after all it is perhaps the trickiest subject you could talk about, and it wasn’t his purpose. So what I was saying before still holds: It is a great book and I would love for people to read it, I’m happy to have it in my bookshelf to pass it around, but I, myself, have only learned what I already knew.

Perhaps it is time to go back to the library and pick books at random. A lot of those were disappointments, of course, but as Gavande says: “the vital questions are the same: What is your understanding of the situation and its potential outcomes? What are your fears and what are your hopes? What are the trade-offs you are willing to make and not willing to make? And what is the course of action that best serves this understanding?” The important questions, at any time in your life, are indeed those. And one of my many fears is precisely not to learn enough, to build a fortress of certainties that doesn’t allow me to be unsettled any more, and, as Thoreau puts it “and not, when I came to die, discover that I had not lived“. So perhaps this book has thought me something in the end: go for what unsettles you, a little more frequently.

One more quote to convince you, if need be:

“Our most cruel failure in how we treat the sick and the aged is the failure to recognize that they have priorities beyond merely being safe and living longer; that the chance to shape one’s story is essential to sustaining meaning in life; that we have the opportunity to refashion our institutions, our culture, and our conversations in ways that transform the possibilities for the last chapters of everyone’s lives.”

Book review: Of microbes and men: Peste et Choléra (Plague and Cholera) By Patrick Deville

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This is a book my father gave me as a graduation gift for finishing my medical studies. If I knew him less, and he me, I might have taken offence in being given a book called “plague and cholera”, as a light-readable treat after 6 years of medical studies, but as it is I was right to suspect it would be a great read.

This is a novelization of a biography, or I suppose you could call it so, of Alexandre Yersin, a Swiss microbiologist, but also an explorer, a doctor, a part time cartographer and sometimes cultivator, a humanist of the turn of the 20th century, who is famous for discovering, and giving his name, to the bacteria that causes the plague, Yersinius Pestis. Continue reading

How do you tell the individual stories?

It’s been a while since I’ve written. Mostly because I’ve been too tired to function, once the days at work are over, those last two months. I’ve been working as a junior doctor in a walk-in clinic of pschychiatry, dedicated partly to the migrants and asylum seeker population, and otherwise to the “general ” population (whatever that means).
And there would be so much to tell, but it’s also what has kept me silent, in a way: how do you choose which story to tell? how do you pick one more than the other, how do you prevent a single story to become a generality, especially in a subject so prone to generalizations – or rather, two subjects prone to generalizations and stigma: mental health patients and migrants. So migrants with mental health issues, careful where you’re going…

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Have some news, have a kit kat. On the smallness of big moments

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Sunrise over Thorong peak

Yesterday, I climbed upto a 5416 meter high (every meter counts) pass in Nepal, starting before dawn, to arrive early at the top before the wind was too strong. So we walked, in the dark first, a small caravan of flash lights in the emptiness, looking at the stars slowly disappearing as the sky became clearer, and suddenly the sun  reached the peaks and the world was full of colors. It was one of those moments where nature is so splendid you whish you were an ancient bard, able to compose an ode to it, this beauty, this moment, you feel like it shouldn’t go unnoticed.

Afterwards, we reached the top, I almost lost a few fingers waiting for my companions to arrive, in the icy windswept pass, and we started going down in a growing sandstorm, back to a valley with a village, a good coffee, and a slow WiFi. There, mechanically checking my emails after 5 days of unconnected bliss, I discovered that I had finally received the confirmation that I had passed my final exams. I am now, officially, a doctor. I didn’t really know what to do with this news, to be honest. I went down to the “general store” of the village, and bought the closest thing to a celebration gift for myself I could find : a kit kat (and some toilet paper, less glamorous, that’s another story).

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Life to death, black to white, dawn to dust. On the middle ground where it’s so uneasy to stand.

Tales of the Undead

This is not about a zombie apocalypse, don’t worry.

Or do worry, because it’s not about a very lighthearted subject either. It’s about Ms B.

Ms B. Is a patient in our ward. She’s not supposed to be, because I’m in a Surgery unit, and she’ll never get an operation. She’s a very quiet old lady, always smiling. She has cancer, the nasty type. In fact, she has more cancer in her body than there are Starbucks in New York, probably. She arrived last week to the Emergency Room because, basically, her cancer is so eager to take over everything it digested her stomach and now there’s a hole in it. In a very non-scientific way, it means shit is everywhere. And there’s no way we can close the hole because it’s all cancerous and dead stuff around it and she’s not really fit enough for any operation. Continue reading