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I’m drowning in organic chemistry and lab reports right now, so this week’s post is both late and brief. But it’s about viruses, and there seems to be a biology-classes consensus that viruses are way cool. Not only that, but this virus is one that attacks other viruses. Is it a force for good? For evil? For nerds? Who knows? Regardless, this discovery of the Organic Lake Virophage (OLV) makes for three total virus-eating viruses that have been discovered to date. Pretty neat.

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There are four turquoise recliners positioned in a semi-circle in the planned parenthood recovery room. I mention this because when someone says “recovering from surgery,” even a minor procedure, I always imagine hospital beds before anything else. Certainly I wouldn’t picture the sort of armchairs you might find positioned across from a wide screen TV in someone’s living room.

On a slow day we’ll see as few as two or three women, so the four-chair set up works out perfectly. On busy days, though, it always seems like there should be some backup. The procedure itself takes very little time, but it’s unpleasant and the women are often still in a lot of pain as they’re settled into their recovery chair. It seems like it would be an easy thing to shut out the world around you and just lose time as you wait for the discomfort to subside. The nurse in charge of the room will sometimes ask them if they feel up to heading home, but I’ve yet to see anyone at the clinic actively push a patient to clear out or make room for another.

The interesting part is how that’s never really been a problem. For all the days I’ve been there, I’ve only ever seen two girls who had to wait for a recliner, and both seemed to be in a minimal amount of pain. (Some women go through the procedure more smoothly than others; some walk out ready to face the world while others can barely make it from the procedure room.) Usually, though, busy days end up perfectly spread out; as one new girl hobbles into the room, another is gathering her things ready to make her way downstairs. Its only on slow days the girls seem to linger. They curl up in the chairs, close their eyes or text on their phones for long stretches of time before feeling ready to pull themselves upright again.

I mentioned this to the nurse one morning, how I always excepted things to take so much longer on days when we had twelve or fourteen women moving through and yet I always seemed to be leaving the clinic at the same time.

“You know, you’re right,” she said. “It’s like they sense that someone else needs the chair.”

It seems like personal sacrifice for the greater good would be the last thing on the minds of a group of women going through such an emotionally and physically difficult experience. I don’t know if it’s conscious or not; if they actually think to themselves, “Oh I’d better get moving before someone needs this chair,” or if something about the energy of the room is different on a busy day that keeps things moving along. Either way, I find the phenomenon intriguing and am curious to see if the pattern holds.

 

I’ve feared it, I’ve bemoaned it, I’ve ignored it — but the time has finally come. I’m going to start studying for the MCAT.

MCAT, for anyone who might not have been obsessing about this for the past six months, stands for Medical College Admissions Test. It is required for admission into every reputable medical school in the U.S. In an age where the GREs and the SATs are increasingly disparaged as in inaccurate measure of intelligence and are slowly disappearing from undergraduate and graduate applications, the MCAT exam continues to haunt the dreams of pre-meds nationwide.

There are four parts to the exam; biological sciences, which include biology and organic chemistry, physical sciences, physics and inorganic chemistry, a verbal section similar to the SATs or GREs, and a writing section that is graded separately on a bizarre scale of J-T. Each of the other sections is scored out of 15 points, for a total of 45. As far as I’m aware the maximum score is mythical; most students who get into medical school score in the 30s. One former postbac scored a 42 a few years ago and it’s still spoken of with a reverent tone.

I’ve never been much of a fan of standardized tests. I barely slept the night before I took the national exam for massage therapy, and that was pass/fail. The MCAT is like the mother of all final exams; the anxiety of every chemistry, organic, physics and bio test combined with a splash of fear that my verbal skills will desert me in my time of need. Let me put it to you this way; if I were offered instead to be jabbed with hot pokers for the four hours of the exam and be assured a reasonable score I’d probably do it.

Since the start of the program, the MCAT has existed in the back of my mind as a vague worry, but the full-fledged fear didn’t kick in until we were sent home with our study guides right before winter break. You know those three hundred page paperback SAT/LSAT/GRE study guides? That’s what I was expecting. Instead I was sent home clutching a four-book boxed set; the kind that comes in a cardboard case so you can keep them all together and then wrapped in plastic so none of the volumes can slip out.

The moment I returned to my apartment the study guide went up onto my bookshelf and remained there, untouched, for the duration of break and the start of semester. Other students talked about peeling the plastic wrapping off or starting in on a section or two; my study guide and I just eyed each other distrustingly as we went about our business.

Sadly, though, my days of obliviousness had to come to an end. Spring break arrived and with it the last of obstinacy. Before leaving on break I steeled myself and ripped the plastic from the cardboard case. Figuring my course load would be enough to keep most subjects fresh in my mind, I extracted the chemistry and the verbal reasoning volumes and slipped them into my backpack beside lab manuals and textbooks.

It’s strange; going into the postbac I felt as though I were signing my life away. Even though I knew it was just the first step on a much longer journey, I didn’t really consider the fact that it would someday be over. Now I’m two months away from the end. Terrifying as studying for the MCAT may be, it’s exhilarating to realize how much closer to my goal I’ve become.

A cheerful start to spring break would be a little obvious, don’t you think? Instead, here is an article by Atul Gawande about hospice care:  http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande#ixzz1FvNCGNpM

The article is long, so here are a few excerpts that stood out to me. First on the role of hospice and the distinction between prolonging versus improving a person’s life:

“The difference between standard medical care and hospice is not the difference between treating and doing nothing, she explained. The difference was in your priorities. In ordinary medicine, the goal is to extend life. We’ll sacrifice the quality of your existence now—by performing surgery, providing chemotherapy, putting you in intensive care—for the chance of gaining time later. Hospice deploys nurses, doctors, and social workers to help people with a fatal illness have the fullest possible lives right now. That means focussing on objectives like freedom from pain and discomfort, or maintaining mental awareness for as long as possible, or getting out with family once in a while. Hospice and palliative-care specialists aren’t much concerned about whether that makes people’s lives longer or shorter.”

This second excerpt is about Stephen Jay Gould, who was diagnosed with abdominal mesothelioma, which statistically has a survival rate of about eight months:

“Gould was a naturalist, and more inclined to notice the variation around the curve’s middle point than the middle point itself. What the naturalist saw was remarkable variation. The patients were not clustered around the median survival but, instead, fanned out in both directions. Moreover, the curve was skewed to the right, with a long tail, however slender, of patients who lived many years longer than the eight-month median. This is where he found solace. He could imagine himself surviving far out in that long tail. And he did. Following surgery and experimental chemotherapy, he lived twenty more years before dying, in 2002, at the age of sixty, from a lung cancer that was unrelated to his original disease.

“I think of Gould and his essay every time I have a patient with a terminal illness. There is almost always a long tail of possibility, however thin. What’s wrong with looking for it? Nothing, it seems to me, unless it means we have failed to prepare for the outcome that’s vastly more probable. The trouble is that we’ve built our medical system and culture around the long tail. We’ve created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets—and have only the rudiments of a system to prepare patients for the near-certainty that those tickets will not win. Hope is not a plan, but hope is our plan.”

And finally, how medical science makes it impossible to give up hope completely, even when the outcome is all but assured:

“We imagine that we can wait until the doctors tell us that there is nothing more they can do. But rarely is there nothing more that doctors can do. They can give toxic drugs of unknown efficacy, operate to try to remove part of the tumor, put in a feeding tube if a person can’t eat: there’s always something. We want these choices. We don’t want anyone—certainly not bureaucrats or the marketplace—to limit them. But that doesn’t mean we are eager to make the choices ourselves. Instead, most often, we make no choice at all. We fall back on the default, and the default is: Do Something. Is there any way out of this?”

The overall message is that talking about death is difficult, but the skirting the issue only makes it harder in the end. Patients look to their doctors to guide them through the process of staying alive, not to help them come to terms with death. Meanwhile the doctors themselves are only human and they hardly want to be the bearers of bad news. Gawande describes getting caught up in the optimism of his patients, of questioning whether he has any right to destroy their tentative hold on hope . It’s easier to give in to that sense of possibility; the idea that this patient is the one holding the winning lottery ticket. It’s much harder to reach past that optimism and change the conversation from, “What do I do next?” to “Where do we draw the line?”

I take this article as a warning. Away from the immediacy of such a confrontation, I like to think that I would take a sympathetic but practical approach to talking about death. The trouble is, death is not practical and neither are the emotions that go along with it. The situation Gawande describes is all too familiar; that desire to turn away from an uncomfortable topic toward a more agreeable fiction. I could easily see myself unwittingly embracing the false hope of a patient determined to fight to their very last breath. It’s the stuff of great stories and no one wants to play the part of the doctor who gave up before the fight was over.

In the end, though, it is the doctor who needs to be the one who doesn’t succumb to the convenient fiction. Hope is a good thing in medicine, but false hope will make the reality that much more difficult to bear. I hope that by anticipating the difficulty I will face when talking about death, I can prepare myself not to shy away.