Listen To Your Patients Please Even When They Can’t Talk

Eleven years ago, on August 7^th 2002, after a day of outreach with the Baby Steps team at Marcus Garvey Park in Harlem in honor of Breastfeeding Awareness Month, I called my significant other.  An unfamiliar voice answered his cell: “Ray went code blue.  Who is his doctor? Do you know if he takes any medicine?”  Code blue, code blue, my mind played the words back to me over and over as if they didn’t register the first time until I caught my breath and finally uttered, “Oh my God, it’s Dr. Patel on 125 St.  He takes Coumadin...” 

Eleven years later, I am in an ambulette on the same highway leading to New Rochelle that I traveled alone on that day which would change my life forever.  The day my faith was tested beyond measure, the day I was given strength I never knew I had.  Only this time I am not alone.  We are riding together, me & Ray, strapped in an ambulate, and the equipment in the back is bouncing up and down making a huge racket.  By far, taking these scary rides (which I don’t have to do) is probably the greatest sacrifice I make for Ray.  All the other stuff I do as his primary caretaker, I don’t mind.  It’s funny too because throughout the years people have always told me “Ray is so blessed to have you.”  No, no, you don’t get it, you have it all wrong, I am the one who is blessed!  I am the lucky one!   

Ray suffered traumatic brain injury secondary to cardiac arrest, which occurred while he was working out at a gym.  He lost his memory, his childhood, his adulthood and many of his inhibitions.  Ray lost his career and many “friends.”  He lost a lot of material things and eventually after a series of TIAs the strength of his legs, leading him to be dependent on a wheelchair.

Two days before our annual cardiac appointment in New Rochelle with Dr G, the doctor that was a huge part of saving his life, I participated in Ray’s annual care plan meeting at the nursing home (TBI floor) where he lives.  One of Ray’s challenges every day is speaking; let’s just say that it takes him some time to “warm up.”  In fact, I never call Ray before 12pm unless it is simply to tell him to get ready or that I will be there soon.  But for some reason the nursing home didn’t consider this.  They set the meeting for 10:30am.  

Good thing Ray & I spoke about the meeting the day before during a trip to the South Street Seaport in lower Manhattan.  The only thing we had on the agenda to discuss was his menu.  More diversity needed.  Perhaps some veggie burgers or eggplant parm to supplement the daily tofu, rice, veggies and salad. 

Ray had JUST started physical therapy two weeks prior to this meeting.  Dealing mentally with his brain injury took many years.  No matter how graceful, happy & good-natured Ray is, he hasn’t been ready to deal with his physical limitations until now, more than 10 years after he first started using a wheel chair.  Getting him to agree THIS TIME was easy because he was ready.  Getting the nursing home to remind him to come down every day was another story.  Good thing I’m back from school.  Good thing I’m done with STEP 1 now because I have to stay on top of them. 

Finally it is the PT’s turn to report.  “Ray has been in PT for almost a month now and will be discharged next week.  He is not making any progress.”  Just like that.  No consideration of Ray’s efforts.  No consideration of his feelings.  Nothing strength based said.  Not one positive thing.  I look at him, see his face and know inside that his heart is breaking.  “Excuse me (my voice is cracking.  My voice is expressing the hurt I can see on Ray’s face), first of all, Ray has only had 8 sessions.  He keeps track on this pad of the days you come to get him and the days that you do not.  This is the FIRST time he has EVER been in PT at this facility in almost 10 years.  He deserves a chance.  He wants to walk.  He should have never been given a wheel chair to start with. When he came here in 2004, he was using a cane, not even a quad cane, a regular cane.  Plus, Ray can walk.  He walks with that quad cane but his left leg is weak.  Show them baby how you can walk. .........”  Ray looks at me and I can tell this is not the right time.  But there is so much pressure in the room and everyone is looking at us.  “Baby, they are going to discharge you from PT.  Show them that you can walk.”  Nothing.  The PT looks at the head nurse and asks, “Have you ever seen him walk?”  “No” he says.  “Has anyone here ever seen him walk?”  “No.”  “No.” “No.”  “No.” “No.”

The meeting ends with no performance.  No more than 5 minutes later, Ray’s warm up is complete and he is talking to me: “JT, they don’t even want me down there.  There is no encouragement to walk.  There is no one there to encourage me.  I want to get stronger JT so I can walk but honestly the way they treat me makes me feel like I don’t even want to be down there.  I will just do it in my room.”   “Ok baby I get it.  I know.  I am so sorry.  I can’t believe they said you made no progress.  They are wrong.  You have to show them Ray.” 

Ray agrees to talk to the social worker and show her that he can walk.  Once the social worker arrives, Ray gets up and starts walking with his quad cane, across the room six times, talking as he is walking, “All I want to do..... is have... the opportunity......... to exercise ........so I can ........walk....... again.  I need to..... strengthen....... this leg......  Why do they........ want to....... cut me off?  I just want........ the chance...... to walk.”   “Wow,” the social worker says, “I’m going to get the director of PT.”  Half an hour later, the director shows up and the social worker says to her “Ray can ambulate.”

I find myself telling the PT director what a physician mentor recently taught me during rounds on the NICU “Medicine is as much an art as a science.  You simply can’t treat everyone the same.  You say Ray has made no progress but really your conclusion is based on the wrong assessment. Your assessment of Ray was on the parallel bars with two people holding him. He can’t walk like that.  He needs more freedom to have proper range of motion.  So you see now that he CAN walk with a quad cane, which is actually more advanced than you thought....”

Ray was not discharged from PT.  In fact, we went out the very next day to buy him a new pair of sneakers.  

USLME Step 1

Saturday July 20, 2013

I am sitting in my 6 x 12 tile room in NYC.  The warm air from both a window and square plastic box fan is blowing on me from both sides.  This tiny room with a single bed, closet, small desk & dresser represent an important part of my journey, not always comfortable, but necessary.  This is where I lived while studying for the USLME Step 1 exam.  

Any medical student aiming to practice in the USA will tell you that Step 1 is the most important exam of their life; everyone has a story of the stress they endured to study for this exam, which ultimately culminates in a three digit score that will largely determine one's fate as a doctor.  

The stakes were no different for me as I finally sat for this exam on May 17, 2013 at the Westbury Prometric center on Long Island (where I grew up), after canceling it twice.  What WAS different is that I am 43 years old & never prepared for a standardized exam (besides my social work licensing test).  As you get to know me you will come to understand why I never took the SAT, GRE (took it but did not study) or MCAT exam.  For now, I will just say that victory over Step 1 (praise God) & my passion to make a difference in the world of medicine prompted me on this sweaty, Saturday morning to continue the blog I started right before my 40^th birthday. 

I came back to New York from the small island of Sint Eustatius ("Statia") in the Dutch Caribbean in March 2012.  I never got to walk in my basic science graduation because I had to leave early to secure this room. 

My plans were to take a Kaplan course in July after reviewing all of the videos & my Step 1 exam shortly after.  My NBME practice scores, however, told me something very different; I had a long way to go.  My first practice test score after Kaplan was a measly 163, only 3 points higher than than my first comprehensive basic science NBME during medical school.  A low NBME score with almost every arrow pointing in the wrong direction was discouraging but I had to remember how far I had come already.

At age 35, with zero science background, I was accepted into a post-baccalaureate premedical studies program at the City College of New York.  At that time, I was a social worker directing the Baby Steps Home Visiting Program in Harlem and living in my first "real" home, a one BR prewar coop I bought in the Riverdale section of the Bronx.

A lot of medical students know early on that they want to become a doctor; I didn’t figure that out until I was 35.  As a kid who spent a lot of time sick  in hospitals, I did want to be a nurse early on though made little advancements toward that goal.  When I finally got to college and looked at the career books, I narrowed down my choices to Speech Pathologist, Nurse or Social Worker.  I wanted to help people, like my guidance counselor helped me get accepted to college even though I was a terrible, mostly absent student.  I looked at the science requirements for both nursing & speech pathology and said, “I can’t do that.”  Social work it was. 

As the director of Baby Steps and a community faculty member for Harlem Hospital’s community pediatric residency program, I meet weekly with mostly IMG residents who rotated through our program & conducted home visits to Baby Steps families.  The linkage we built between the hospital and the community inspired me to pursue medicine as a 2^nd career.  I started at the beginning with basic math and took 1-2 courses a semester until I completed all of my premed requirements.  I even signed up for tutoring for the first couple of courses, which helped me gain a lot of confidence since studying science was all new to me.  There are lots of little (and very big) stories that occurred during this time, which I will get to in future posts!   

Back to NYC, post Kaplan, 2012... armed with my new Hunter College Alumni card (I received my MSW from Hunter College in 1994), I trucked with my new, big bag (a graduation gift from my brother Billy) through 3 subways each way every day to reach the Hunter College main library on Lexington Ave. and 68th Street.  In my bag were the usual suspects: my dependable MacBook Pro, my falling apart 2011 First Aid which I eventually replaced by the color 2013 FA, Pathoma & my embarrassingly barely read BRS physio book (my very worst friend which I was trying to make amends with), external hard drive, head set, glasses (I never needed glasses until I got back from medical school) plus some fruit, water & 1-2 peanut butter & jelly sandwiches.  

Hunter College has a huge 7-floor library, which was undergoing renovation during my study time.  You have to take the 7th floor elevator to the 3rd floor and transfer to another elevator to reach the very bottom quiet floor, which is where I lived eating peanut butter and jelly sandwiches & drinking Vitamin water (I joked that this was my health plan) + Pathoma + FA for almost a year.  During this time, I was also completing coursework and an internship for an online Master’s in Public Health (MPH) and doing intermittent consultant work at a hospital in the Bronx.    

About three months ago, a fellow US medical student asked me how it was that I started medical school at age 40.  When I gave him a short, highly edited version of my journey, from wayward- barely-graduated-from-HS-youth to social worker to MD student, he simply said, "You are unorthodox."  I smiled and thought, "If he only knew."