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Medication, Listening, and Searching

Well, when I went off to medical school, I thought I would pursue a career in psychiatry à la Robert Coles Handing one Another Along (2010). Much to my dismay when I got there, this didn’t seem to actually exist, no matter where I looked. I had good experiences on my psychiatry rotations as a student, and bad. I loved my mentor in pediatric psychiatry in Seattle, enamored of weather patterns and continually pressuring me like an incoming storm to decide on psychiatry, because there was such a great need. But then there was the attending on an inpatient rotation who thought it important to teach us, in his words, to manipulate patients. He told us to beware of their deception and demonstrated how to corner them into the desired behaviors. His statements landed like a well-aimed punch in my stomach after the middle-aged unkempt woman in her bathrobe and slippers shuffled out leaving us med students behind with our inquisitiveness- what’s wrong with her and how to do we help her get better? This was clearly not the stuff of understanding human nature that I sought. Interestingly, when I finally decided what to do, I turned literally in the opposite direction to anesthesia which involved, predominantly, putting patients to “sleep.”

Anesthesia was exciting, terrifying, exhilarating, and at times exhausting. I learned everything about the body, where it betrays us, the infinite ways it can get a new trainee in trouble, where it still causes the experienced professional a leap of anxiety in our workday. I was exposed to everything in training except how the experience of and meaning in our memories are an accumulation of who we are, and why this is important. It was all body little mind, except in so far as learning brain protective strategies for various procedures. We didn’t learn what makes us who we are, but I knew how to leverage autoregulation, mean arterial pressure, and cerebral metabolic rate for optimum tissue salvage. I learned how to manipulate heart rate, peripheral vascular resistance, pulmonary arterial pressures, coagulation parameters, urinary output, core temperature. And this seemed to me an appropriate application of manipulation. I learned about the impact of each medication on the body and on my proposed anesthetic plan, how heart failure or occult valvular disease had the potential to trip us both up. I also learned that the best laid plan didn’t always fend off catastrophe, and how to live with that tension over the course of a career. I learned which medications to be very wary of; theophylline, an old timey asthma med that we sometimes still see, any monoamine oxidase inhibitor (MAOI) which puts a straitjacket on old reliables for falling blood pressures in the operating room. This latter resulting in a potentially lethal interaction should we forget or become careless. How to navigate lithium under the fluid shifts of surgery and anesthesia and dependent on adequate renal function, so that dysrhythmia inducing electrolyte disturbances would be less likely to interrupt our day. I had a love affair with beta blockers. As I transitioned out of training I spent a career learning among the most enduringly difficult aspects of this specialty, getting along with and communicating effectively with multiple stake holders in the unfolding of an operation. I learned how to discuss reasons to cancel a surgery with a disappointed patient and a sometimes-irate surgeon. I learned to present end of life questions. I learned to be effectively commanding in emergencies. I learned to love and rely on my teams which made this highly complex system within health care function. Suffice it to say, our days could be complicated, despite one of my primary roles being to generally take patient consciousness out of the picture. I learned that every intervention has risks that must be weighed with the anticipated benefits and communicated effectively with people not trained in medicine. I learned to derive decisions based on a collaborative understanding for what an individual needs or wants, along with the inescapable realities. I became intimately acquainted with my limits of exhaustion.

Internship, the earliest training a newly minted physician engages and must succeed at to retain privileges, is where we first face the daunting reality of practice responsibility. Where ordering aspirin or Tylenol becomes a monumental decision- do we really understand how the medication works, what it might interact with, where it can harm a patient? What is their liver function, is platelet function already compromised? Most people don’t think twice about this, but most people don’t answer to a staggering depth of knowledge and responsibility. During all the sleep-depriving and stress-filled hours, sometimes quite rewarding, sometimes frustrating and utterly exhausting, there is an end goal in sight which is to become competent at the decision making required of a practice of medicine.

Although I decided to become an anesthesiologist with the appeasing notion that I would someday return to mental health, those thoughts fell away completely during an all-encompassing training and demanding career. So, when I decided it was time to revisit my young adult interests, I had to reacquaint myself with an old and long-lost companion. Having spent much of my growing up time as a solitary reader, my adulthood was rooted in action and interaction for a specific purpose. I was not someone comfortable with stillness. I did not immediately have room in me to be quietly present and un-preoccupied with the next move or impending disaster or a need for plan B or C, so quintessential of an anesthesiologist. I was certainly not comfortable with a lengthy and intimate exposure to uncertainty, disquiet, sadness. I was not someone primarily engaged in handing one another along, sharing space with an individual’s story, their feelings, the fallout of their unique experiences. All of this I had to learn.

But my skill set as an anesthesiologist has come in handy. It is comforting to hold a depth of knowledge associated with physiology, pathophysiology, enzymatic pathways, metabolism, med/med interactions, especially the potentially lethal combinations. Certainly, it is important to understand the limit of our therapies, what these can realistically offer, and to be able to communicate this information effectively. Medical intervention, including medication can lead to improvements, but nothing comes without some undesired impact or side effect. We can approximate nature with our medical therapies, but we can never mimic entirely what we were born with. Talking with people about the risks and benefits in an informed consent process, sharing knowledge and information while hearing individual concerns and the meaning behind these, is a critical process fraught with potential landmines. All of these are the purview of an anesthesiologist. I had to go back to graduate school to learn to be an effective therapist, however. I had to become a learner again, to learn to listen for other kinds of stories, to discover my capacity for quiet empathy. I had to learn the intricacies of being a journeyman in a collaborative process not exclusively dependent on my expertise, while exploring the root causes of the misunderstandings and agonies which make us human.


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