Maureen Miller – Entry 2
The morning after Steve Jobs died I went to a morbidity and mortality conference at the NYU Department of Surgery. An M&M conference, a ritual within the specialty, is rich in theatrics. I see it in drawn breaths and twitchy forearms and PowerPoints that whoosh content. The gravity of the event merits the flair. Senior residents present cases to the chief of surgery. Their bosses, the attending physicians, dissect each other’s decision-making in the hope that the intellectual process will improve outcomes. Complications, of course, arise. Our job is as medical students is to attend, which is to say we remain attentive. We are there to follow the conversation and keep the details of, say, the surgical oncology case histories clandestine. It is not unlike a MacWorld lecture.
On my way out to the wards my white coat pocket got caught under the plate that had held my apple Danish. I exhaled. My paperwork, my medical pocket reference texts, and my housekeys gave out. I gave up and flailed onto the detritus. The lean iPhone 4 I bought just two months ago came to skit along the floor until its back fractured into a stellate lesion that made it look as if it were glass smushed to planned obsolescence by white coat dead weight. It is, or was, black. That phone has dropped a lot of calls so far, so I wasn’t too keen to go to the Genius Bar after work to fix it. I’d stayed up much of the night watching Steve Jobs coverage, which reminded me of the employee at the Genius Bar who ran the diagnostic on my new phone signal and told me they had done all they could do.
The iPhone 4 that broke me was the product of a similar incident on my internal medicine rotation two months ago. I was getting out of a cab very early in the morning when the black 3G I had been using for a while fell out of the white coat pocket. Maybe I am unable to contain myself to it as medicine expands: Faculty remark all the time on the number of Apple products they see on their services, as if these things expand the medical hivemind. So my white coat contents have since thinned, and my case presentations have become simpler. Back then, though, all of two months ago, I was still green enough that I pronounced cachexia like the cereal. My patients wasted inside the wards as my coat billowed outside me.
Since I began my clerkships in June my teams have followed about twenty cancer patients in end-stage disease. I have not been able to track down what has happened to most of these patients in the weeks since. By now I would imagine that ten or more of them have died.The patients at the M&M conference expired. Danielle Ofri, a Bellevue internist and New York Times contributor, once wrote about how doctors avoid the word “died”: They pass. (http://well.blogs.nytimes.com/2011/05/26/doctors-and-the-d-word/).
Jobs reminded me of William Halsted, the father of modern American surgery who first experimented with aseptic technique at Bellevue. It is difficult to like either Jobs or Halsted, and impossible not to be charmed by either, either. Halsted had no interest in passive constructions. He cut the breast and closed the hernia. Like Jobs, Halsted was an opaque figurehead on the academic fringe who eviscerated colleagues in order to retreat into his own thought process and triumph. Their ascetic minimalist philosophies are somehow more human than they. Yet I wonder if either died under the care of a medical minimalist. I do not know enough about their medical teams to say. Halsted died in the hospital he built after a complicated postoperative course. Jobs, cachetic, grew his company. We do know that the public mourning periods that followed their deaths evoked their visions rather than their gall. So I have come to think as a result of that and other moments on the wards that a death with minimal complications—in other words, dying well—is the best service we can provide to our patients. Sometimes a minimalist medical approach is the best way to promote human dignity.
The white coat is the constant through the indignities of our medical training. It gets stained, and we trade it into a basement laundry. In these small ways, work within an institution makes us harder, so much so sometimes that we may strain to reduce ourselves enough to think outside of it. Can one think different in a uniform? Steve Jobs couldn’t, and neither did William Halsted, so they made their own: Jobs had the turtleneck, and Halsted made up scrubs. Their professional accomplishments, however undignified in practice, invests us with the desire to aspire to create service that suits us. In ten years, will we wear a white coat to clinic? Some infection control specialists think not. When we think different our clothes start to change, and some wounds that separate us close.
Maureen, I just read your Occupy/Health Care article, and I wanted to thank you so much for writing it and for being you! It’s really inspiring and makes me so happy to know how passionate and committed you are to both mindful medicine and outward reform, thank you!!!