Showing posts with label humility. Show all posts
Showing posts with label humility. Show all posts

Saturday, November 27, 2010

Who has inspired you?



I am a physician in no small part due to the influence of one individual. My Grandmother, LaNere Gilligan, always told me that I would be a great physician, and as we all know, it is very difficult to doubt the truth of our grandmothers. From as early as I can remember, she told me that I would become a physician, and that I would be a good physician. I never doubted what she said, and really never wavered from this idea, this goal.

She came from a much more practical time in the world. She was born in 1916 , Woodrow Wilson had been nominated during the Democratic National Convention, and WWI was raging in Europe, the United States was not to enter until one year later. She was the youngest of five, a child of the depression, for whom her parents died when she was young. She grew up in Austin Texas being raised by her eldest sister. She met my grandfather in Junior High and dated him through college. They were married in 1939. She studied nursing a Seaton School of Nursing in Austin Texas, and practiced as a nurse for many years. Many things influenced her life, and subsequently mine, but her time during the depression and her life as nurse were the things I remember the most.

From the Depression, she gained a sense of frugality. She always planned for the worst, expecting that things could decline as they had done when she was young. This frugality was something that my Grandfather had never known, he was the son of a drag-line operator, and his father always had work in the coal region of Indiana. LaNere, knew hunger, and knew early that she was an extra mouth to feed, one that was not yet able to pay her own way. This drove her toward self-sufficiency, and in that time this meant secretarial work or nursing.

Nursing was very different in the 1930’s, as was medicine. It was a time when great discoveries still lay ahead, penicillin had only come to light in 1928, and the use of certain advance surgical techniques (electrocautery) were just beginning in surgery. It was a time a paternalistic medicine. She learned her craft during this time and it influenced her interactions with physicians from that point forward. She was of an age that did not question the physician, right or wrong that was the time. She learned many skills from this environment, one of which was to encourage behavior she wanted indirectly, and this she used to great effect on me, in my youth, as she molded me into a physician.

This influence came in many forms, from the first anatomy book at an early age (pop-up), to a Gray’s Anatomy for Christmas. She encouraged exploration and investigation in all things, there was never a wrong answer, just a conclusion that needed more work. As well, there was the need to ensure the well rounded nature of her young pupil, indeed of the young physician. Lessons hard learned from an earlier time had to be passed on, and an appreciation for the lives of others must be instilled. These she did without my even knowing or seeing. Understanding of our shared past, from whence we came (the family history as it were) should be learned so that you would be grounded for the future.

As with all things, the time comes when those who influence our lives pass on from our view. Their care and concerns, the lessons learned are instilled deeply in our lives, so much so that they live on within our hearts and minds. The influences they have laid upon us are so subtle and so deep that we can hardly see where they end and we ourselves begin, they simply are part of who we have become. These influences carry us forward and help make us who we are. So, on this day, as I reflect on the life on LaNere Gilligan, one of the most influential people in my life, I send my thanks to her for all that she taught me, for the unending support and for the steadfast belief in what I could become even when I doubted myself. May I always act in a manner befitting this legacy, as may we all.


LaNere Gilligan (Thornberry) June 5, 1916-November 27, 2010

Sunday, October 25, 2009

On not knowing everything………


We make decisions every day, most of them without any consequence at all. What are you having for lunch? Going for vacation? Getting your friend for Christmas? These decisions may take a lot of our time, but the outcomes do not usually make a large difference in our lives. What happens when the decision has greater implications? What happens when your decisions may impact the health and welfare of others? How comfortable are you with the unknown? When you clearly do not know something does it make you uncomfortable? Does it make a difference if this is public or private ignorance?


In medicine we often have a chance to review these thoughts as we go in to the ‘office’. As a family physician, often you are seeing the undifferentiated, the patient who has not been seen before for the problem at hand. These patients could have anything, and often do. This is the heart and soul of family medicine, and more than anything else, it is this aspect of the profession that I often find the most difficult in the long hours of the night.


When students ask me what they should do for a living, I often ask them how much tolerance they have for the ‘gray zone’ of family medicine. By the time that they have spent six weeks with me in the hospital and clinic, I usually have a good feeling for their tolerance of the uncertainty that caresses every action of your day. Those with minimal tolerance are encouraged to pursue specialties where, to quote one of my local dermatologists, you can ‘know more and more about less and less’. This whittling of the number of problems that you are responsible for allows you to focus in on a subset of problems and become expert in these diseases. You learn to recognize the intricate variability of a presentation of each of those diseases, learning the common and uncommon presentation of ‘your special illnesses’. When a patient arrives in your office with a consultation, your role it to determine if this patient represents one of these diseases or not, provide advice on the management of the disease if it is in your realm, and if the patient does not have anything in your specialty identify what they do not have and return them to the referring physician. As a family physician, these patients are often back into you office with a long list of what they do not have and you are back to square 1.2 where you restart your diagnostic processes again, the gray zone of uncertainty has returned.


Students who truly relish the gray zone, exhibit significant comfort in the zone, and are willing to work hard to develop tools to improve their work in this zone become the rural physicians of old. These folks work on ‘gut’ instincts at times taking a chance on a hunch when the data is not always there, but the feeling that you have is undeniable. This is a skill that some are born with, but most develop over time as a side effect of lessons learned. These lessons come through every patient that passes through our clinic, every specialist report that lands on the desk, every specialized test that you have ordered. What is important is how you supplement this instinct, and that is something that has changed over the last years.


In 1996 I worked in a small rural clinic at Dugway Proving Ground in the west desert of Utah. I had received the minimum training needed to not be outright dangerous to people, but I had hardly received what would be called sufficient training. In this location I performed the duties of a rural family physician, taking care of any and all that came through my doors. In my examination room I kept a copy of the Merck Manual so that I had the best compact source of information to assist me with the diagnosis and treatment of my patients. It served to help me fill in the large gaps in my knowledge base as I saw my patients, and I often took it off the shelf while the patient was sitting on the table. I knew what my limitations were, and had no difficulties letting the patients know that my fund of knowledge had definite limitations. This was one of the driving forces behind my desire to expand my knowledge base, complete my training, and my enthusiasm for on-line evidence based medicine.

In order to work well in a rural clinic and do so without waiting years to develop the fund of knowledge that comes from practice, you must have a series of tools at your disposal to help you shrink this zone of uncertainty. For my part, DynaMed, PubMed, and ePocrates serve as my peripheral brain. They help fill in the gaps in my knowledge base, remind me of things I once knew, and help me to become a better physician. Despite these tools, there are still times when you find yourself faced with patients for whom you simply run out of good ideas. These patients are the ones who haunt you as you sleep.

As a family physician, even the presence of these tools may leave you with a patient for whom you still do not have an answer. These are the patients that drive you to study more, to deepen you fund of knowledge. These are the patients that leave you with a feeling of inadequacy as you pull on your hair at night trying to figure out what may ultimately be unknowable. In a rural setting, this absence of knowing can eat at you as you see the patient routinely and feel you inadequacy tugging at your sense of self. What is left is often something very different than you might want something somber and reflective as you look back on the day a thoughtful player in this world.






The beautiful flame fractal on this page came from the following website