My Grandpa’s Socks

This post was initially featured on In-Training

Whenever I go to the hospital, I wear my grandpa’s socks. They looked distinguished on an older man, but a little childish on a me, a 25-year-old medical student. I’m okay with that. Feeling like an overdressed kid on Easter helps to balance the overwhelming pressure of becoming a physician.

I still see Pop sitting in a chair with his silver hair that was too strong to fall out during chemo. He’s half smiling, with a slight eyebrow raise. Even just thinking about him, I can smell that nostalgic mixture of moth balls and Polo cologne. While one elbow rests on the armrest, his fingers fiddle with a small scrap of paper he always seemed to have. He has one leg crossed over the other, his pants halfway up his shin to display his timeless socks that match his timeless sweater. They were usually wool, sometimes cashmere, solid or a traditional argyle, in classic shades of navy, maroon and grey. Noticeable, yet subtle, they represent maturity, humility and composure. Pop, like his socks and outfits, always seemed so together. This is the Pop I knew.

Then there’s the other Pop. The one I only heard hushed, whispered stories about. This man is belly up, sprawled out on a diving board. Iron weights dangle off his ankles a few inches above the surface of his backyard pool. As the breeze rustles the tree leaves, the winter sun casts a paltry spotlight on a suicidal alcoholic. My grandpa. Pop.

Pop set high expectations for himself.  He had to be strong, independent, and successful.  He hated the idea of burdening anyone else with his issues, so he swallowed whatever life threw at him. He wanted to be perfect.

With these heavy expectations, Pop, like all of us, had to cope. Opening up or asking for help wasn’t an option; it would have exposed the fact that he couldn’t handle it, whatever “it” was. At first, drinking eased his self-imposed pressure. Eventually, it yanked him into a self-destructive cycle, ripping away the curtain of security that hid his inability to live up to his ivory tower ideals. Unable to meet unrealistic standards, he felt like a failure. Failing, in his eyes, was a waste of life. So, he tried to end his.

Full of pills and alcohol, with weights tied to his legs, he waited on the diving board, hoping to pass out, fall forward, and sink to the bottom of the pool. Luckily, he passed out and flopped backwards.

I don’t just wear Pop’s socks, I wear his demons, too.

Like him, I fear failure. Like him, I want to be perfect. Like him, when faced with high expectations and left to my own devices, I feel the pull towards isolation and the self-destruction. Not wanting to expose my weaknesses or be a burden, my gut tells me to put on a smile, shove down the uncomfortable emotions, and white knuckle through the hard times.

The last time I talked to Pop, he was nearing the end of a steady, but peaceful decline. After overcoming the suicide attempt, a collapsed lung, pancreatic cancer and a heart attack, his body was finally giving out on the last of his nine lives.

As I sludged my way up to lecture, I tried to keep it together. My hood covered my tear streaked face, my silence covered my trembling voice. I walked extra slow, savoring one last chance to get one last lesson.  Today, he opened his textbook on life to the chapter about A Bronx Tale, one of Pop’s favorite movies.

“Jack,” he said, “the saddest thing in life is wasted talent.” My talent, according to Pop, was my potential to become a good doctor.  I would waste that talent if I followed in his footsteps, suppressed my internal struggles and walled myself off from support. Those behaviors, he told me, brought him to the diving board that day. Connecting, stepping out of his own head, and opening up to others helped keep him from going back.

Talking to Pop was like getting the answers to a test you didn’t know you were going to take.

Now, a year later, as I’m trying  to come into my own as a physician, I doubt myself and fear failure everyday. The mental, physical and emotional demands of medicine compound these insecurities in a culture that often refuses to acknowledge they exist.  The high-achieving, overly independent atmosphere pushes students to prop up a pristine, image of strength, competence and unwavering resilience. I wish it was that clean on the inside.

Amidst the long hours, competing demands and big tests, we struggle to find time to pee, let alone process the inner turmoil that comes with grieving families, dying patients and tracking our own fulfilling path in medicine.  On top of that, none of us want to admit we can’t handle it. All the good doctors seem to be emotional fortresses. Most of our classmates, too, at least on the outside.  No one really talks about the trying times, so they must always be fine.

Not me. What about you? What’s the cost of this culture of silence?

No single experience captures the trial by fire that is medical education better than the age old practice of “pimping” — the diarrhea-inducing time when an attending physician pelts you with a series of obscure, “read my mind” questions in front of all of your peers and superiors. The questions rain down until you get one wrong. If you’re lucky, it stops there. If you’re not (you usually aren’t), the pelting continues until you become a babbling mess that can’t decide whether to shrink into submission, cry or simply soil yourself. Meanwhile, everyone externally cringes for you and internally wipes the sweat off their forehead because they aren’t under the lonely spotlight.

One day, after my shift, I’m sitting at a coffee table in the hospital, trying to decompress after getting the intellectual noogie of a good pimp. This one came too soon after the death of a young man, husband and father I was caring for. As I obsessive-compulsively bite my nails, my mind jumps between ruminating on the barrage of questions I just got wrong and wondering what more we could have done for that man and his family.  I’m rattled, festering in my own head, and feeling like a failure.

“You all right?” my friend asks as she walks up. She looks just as tired and a little less beaten down than I am.

I want to be strong and perfect like I’m supposed to, so I start reply with, “Yeah, I’m fi–.” Before I can finish, she cocks her head to the side and gives me a look of unbridled disbelief.

“Oh shut up. Come on.” She is unapologetically direct and unrelentingly caring.

I laugh. “It’s that obvious, huh?”

As she flops down into the seat next to me, I unload the last three weeks on her. Moments of grief and frustration, along with the wonderful ones that reinforce the reasons we go into medicine in the first place.

She does the same, recounting the patients who touched her life and the veritable storm that opened up during her Powerpoint presentation on “Diagnosis and Treatment of An Itchy Anus.” Her supervising physician decided to turn a grammatical error into a personal attack on her attention to detail. “What other mistakes will you miss?” he asked. She, too, feels like a failure.

I make a pitiful attempt at a joke about butts, and even though I swing and miss, it at least helps us laugh off some of the absurd aspects of this whole medical student thing. In our self-organized therapy session, we realize we have the same vulnerabilities, fears and insecurities. We’re not alone in this.

I think of the last conversation I had with Pop. This is why I wear his socks. To remind myself to break the silence. To remind myself that we settle our inner turmoil with the support of others. Most importantly, to remind myself perfection is neither a realistic human quality, nor one worth seeking.

“I needed this,” she says. I nod in reply.

Three hundred to four hundred physicians kill themselves every year. One in four of medical students suffer from depressive symptoms, and it just gets worse in residency. Refusing to ask for help, self-doubt, unrealistic expectations of perfection, and loneliness are at the core of these painful stats. We all agree that something has to change. But medicine is a big ship that takes a long time to turn. I’m not sure we can afford to wait for a top down cultural shift to start the conversations around the fundamental highs and lows of the medical student experience. The conversations that remind us we’re not alone.

Every time we choose to swallow the difficult emotions, we waste an opportunity to support ourselves and our colleagues.  If we refuse to connect with and understand our own emotions in emotionally trying times, how can expect to connect with our patients’?

As his health deteriorated, Pop loved to discuss with me his echocardiogram results, medication changes, and fluctuating prognoses. ”My East Coast Doc!” he’d say when I answered the phone. “As your career goes on, you can think of me and all my woes.” He’s referring to the heart failure, the pancreatic cancer and the lung he damaged falling off a ladder.

I told him I would always think of him.  And I do. Every time I put on his socks and go to the hospital, I think about Pop and all of his problems. Just not the ones he hoped.

The Weekly Roundup: A Newsletter Series on Medical Humanities, Leadership, and Personal Development

Since the beginning of 2017, I have been sending a weekly newsletter that features articles, videos, podcasts from around the internet, medical literature, and anywhere else I dig up thought-provoking work.

Below is a sample of what comes in the Round-Up, which will find its way to your inbox on Sunday evenings.

If it interests you, feel free sign up. And if it looks like something a friend or loved one would enjoy, please pass it over to them.

Alright, here’s your sample of the Weekly Round Up:

Design Matters with Debbie Milman: An Interview With Gail Bichler

In this podcast, Debbie talks to New York Times Magazine design director, Gail Bichler, about magazine design and the role of the magazine cover in the digital age.

Despite the surface-level lack of connection to healthcare and the humanities, Gail talks much about being a part of a field during a time of extreme transition, and sticking to a craft despite overwhelming scrutiny and criticism. We all face these challenges in one way or another.

Bichler’s career trajectory, including how she navigated her rise to a fulfilling position, has universal lessons on approaching life’s unplanned turns, leveraging your skillsets, and embracing the one constant in life: change.

Doctors want to give their cancer patients every chance. But are they pushing off hard talks too long? By Bob Tedesch

The cancer therapy market has recently seen a rapid growth in novel drugs that make up the new field of immunotherapy.

While its efficacy has been revolutionary in a number of cases and has provided an especially valuable lifeline for late-stage patients who have run out of options, there is a growing concern that the treatments offer an escape route for physicians who do not want to have the difficult conversation about palliative care and hospice.

As oncologist and palliative care specialist Dr. Eric Roeland said, “It’s almost in lieu of having discussions about advance-care planning, so [physicians are] kicking the can down the street.”

You may hear me talk and write about polarities often, and this is another example of another ongoing tension we have to grapple with in healthcare: Hope and Reality.

The magic lies in uncovering where each patient’s optimum lies and helping them discover how to leverage the upsides of both hope and reality. That may mean hospice, it may mean immunotherapy, and it will likely mean both at different times.

We have to walk with them and be open to course-correction. That may mean making mistakes, it may mean backtracking, and it certainly means being human.

The toxic antidote to goodwill by Seth Godin

What is it? Not caring.

That’s how we lose both the trust of others and a connection to our humanity.

Seth, in his unrivaled ability to pack heaps of meaning in few words, reminds us why the choice to care is perhaps the most important one we make.

A few months ago, I talked about something similar in a short piece I wrote called Heroes Don’t Have to be Talented. Check it out, it’s only a two minute read.

‘A feature, not a bug’: George Church ascribes his visionary ideas to narcolepsy
By Sharon Begley

Abnormal does not mean diseased. In fact, an abnormality in the brain may be the reason why some individuals have a keen capacity for exceptional insights.

World-renowned geneticist and one of the father’s of next generation genome sequencing, George Church, is a prime example and advocate of this idea.

Church has narcolepsy, which he attributes to his most creative thoughts about his research.

From the article: “Church said “almost all” of his visionary ideas and scientific solutions have come while he was either asleep or quasi-asleep, sometimes dreaming, at the beginning or end of a narcoleptic nap.”

We often think that we do patients a service by ‘fixing’ their differences or by decreasing their diversity and bringing them back towards ‘normal.’

Is “sameness” really “better?”

Do we undersell the benefits of diversity when we try to ‘fix’ people that aren’t broken in the first place?

How do our perspectives on medical diversity influence our views on cultural and social diversity?

These are the questions Church’s articles has me asking. What are you thinking?

Medical Students Fall Short on Blood Pressure Check Challenge by Jennifer Abbasi

A recent study on physical exam skills in medical students found that, of one hundred fifty-nine students from medical schools in 37 states who were assessed on an 11-element skillset on BP measurement, only one student demonstrated proficiency on all 11 skills. The mean number of elements performed properly was 4.1.

An article like this precipitates a variety of justifications for the student’s poor performance and a slew of criticisms of medical education.

Some blame the preclinical curriculum and a lack of preparation. Others blame the “hidden curriculum” that medical students see during their clinical years– the series of shortcuts and compromises that physicians must make due to the overwhelming time constraints of the modern medical system.

And still, there’s a third group who says, “who cares? We should be automating this skill by now. Why is medicine so far behind?”

As a proponent of bedside medicine, physical diagnosis, and the seemingly dying art of medicine, you can guess what my take is.

I’d like to hear from you. What are your thoughts? Is this worth worrying about? If so, what can we do to make it better?

Audacious Philanthropy by Susan Wolf Ditkoff and Abe Grindle

From the eradication of polio to the development of the 911 emergency line, to the economic scale of reduced-price school lunches, philanthropy has spurred some of most impactful social advancements. Yes, that kind of philanthropy- the nonprofits that operate to serve their customers, not their shareholders.

Yet, despite philanthropies’ storied past of moonshot successes, today’s list of breakthroughs sees few philanthropic organizations in its ranks. This articles seeks to examine how nonprofits and philanthropy can reclaim its place as a driver of innovation.

I will also add that, as J.D. Kleinke points out in Oxymorons: The Myth of a U.S. Healthcare System, the most cost-efficient, high-value hospitals are the non-profits (see: Kaiser).

Quote of the Week:

“This is an extraordinary time full of vital, transformative movements that could not be foreseen. It’s also a nightmarish time. Full engagement requires the ability to perceive both.”Rebecca Solnit, discussing hope in dark times.

That wraps it up for this week!

As always, feel free forward this to someone who may enjoy it and suggest they sign up by emailing me at jack@jackpenner.com, reaching out on Twitter (@JackPenner), or signing up below.

Best,
Jack Penner

Your Weekly Dose of the Art of Medicine

The latest articles on Medical Humanities, Healthcare Leadership, and Personal Development

Heroes Don’t Have to be Talented

A 68 year old man comes into the clinic for a late afternoon appointment. As is typical for him, he’s complaining of vague symptoms that seem like nothing more than those of an older man who doesn’t take great care of himself feeling the effects of…well…not taking great care of himself.

The resident responsible for his care goes through the history and checks a blood pressure in the man’s right arm.

152/103. High. Just like last time.

Then, the resident moves to check it in the other arm because his favorite med school professor hammered home the need to ‘‘always check a blood pressure in both arms. That’s just good medicine.”

This resident swore to himself he was going to be the doctor who does it right. So, for this patient, and all his patients, he moves the cuff to the other side and takes the extra 45 seconds to check the left arm.

It reads 107/73.

90 min. Later, the patient is on the operating table as the vascular surgeon repairs his aortic dissection. 4 hours later, he’s still alive.

The resident ends up a hero, albeit an atypical one.

As Atul Gawande explains in The Heroism of Incremental Care, the physicians who plod through medicine’s sometimes dry but often invaluable fundamentals end up overlooked and undervalued.

The talented and the gifted – those who save lives with unwavering ease and composure– have their legacies etched into medical history and their portraits hung in hospital halls.  The world renowned trauma surgeon who pulls a child back from the verge of death with other-worldly dexterity. The brilliant diagnostician who keeps a family from losing its mother 45 years too early by identifying a life-threatening disease from the tiniest nuance in her lab work.

Heroism, by these standards, jolts into existence as a product of rare and unique abilities.

What would happen if we saw heroism not only as buzzer-beater brilliance, but also as the snowballing impact of choosing to make a difference when no one else will?

Opportunities for heroism would still arise when lives flicker between persisting on and becoming a memory. They would also grow out of all the seemingly minor moments when patients give us the opportunity to understand their joys and sufferings.

Who would the heroes be?

In an era of medicine when we face less time with patients than ever before, the title wouldn’t be limited to the talented, the gifted, or the brilliant. Instead, it would also go to those who practice the most basic and pure crafts in medicine- noticing, listening, and bearing witness. The ones who work in the space of trust and compassion that serves as the foundation for the art and science of medicine. The ones who step up to the bedside and into their patient’s realities.

Yes, the trauma surgeon and the brilliant diagnostician, but also the ones with the patience to always ask, “what else?” The ones who check a blood pressure in both arms, and listen to everyone’s heart and lungs because the touch of caring hands can be a medicine in and of itself.

Even though it may not save a life that time, and even though it’s the 15th time you did it that day, it’s the first time for that patient and it just may be the moment that matters most.

In other words, “Hero” would go to those who choose to make people feel how much they care.

Unlearning Certainty

The first two years of medical school come down to identifying an answer. The answer.

It’s always nestled among five choices, at the bottom of  a carefully constructed paragraph that includes all the information and buzz words we need.

Being a great first or second year student becomes of game of plodding through the cycle of memorization and regurgitation. We learn to see medicine as a series of singular issues that require nothing more than facts and textbooks, and come to believe that pure intellect will let us plow through patient problems with accuracy and efficiency.

Fortunately, medicine is an intricate, ongoing dance between science and compassion, in which we must not only memorize, diagnose, and treat, but also listen, connect and unpack. 

Clinical care that brings patients and physicians together does not stem solely from narrowing down answer choices and recognizing patient presentation patterns. It also unfolds out of recognizing the limitations of certainty and the importance human-to-human trust in healing the body and the soul.

We all have the choice to stop playing the game of certainty. To do less fact regurgitation and more patient engagement. If we do that, we might get a little closer to being the kind of doctor we thought we would be when we first got our crisp, overly starched white coats.

One who refuses to stop at being right and instead, also focuses on doing right. One who constantly circles back to the uncomfortable questions of “Am I sure about this?”,  “What am I missing?”, and “Are we meeting your priorities in your treatment?”

Once we hit the requisite threshold of facts, making the move from good to great depends less on what we know, and more on how often we choose to show up with the presence, attention and humility that keeps us forever curious.

What’s It For

Throughout medical school, we jump to “How’d I do?”

After all, feedback, grades, and evaluations are the engine of success for medical students. But, the answer to “How’d I do?” depends on another, more important question.

“What’s it for?”

When we skip that question, the one that defines the meaning and purpose of anything we do, we end up enrolling in a very specific rubric based on a set values that may or may not align with our own.

For students, every aspect of the curriculum comes with a finely tuned, bullet point list of precise objectives.

What if you’re not doing it for that?

What if you didn’t go to that patient’s room just to remove a few stitches, but also to give them an ear and a chance to feel valued and cared for? How do you define a job well done in that case? 

What if you aren’t in the radiology small group to answer every question right, but instead, are there to help your anxious friend build the confidence to read a chest x-ray in front of his peers.

It doesn’t matter if it’s not on the rubric. It can be on your rubric.

It can be a chance to bring more meaning, humanity, and personal touch to the lives of the patients and peers who share this path with us.

A chance to show up for someone, connect, and uphold the reasons we all come to medicine in the first place. To make a difference.

How’d you do?

I don’t know. That’s up to you now.