March 28, 2016

Health : On Feet

A fair warning: this post is about feet.

Before medical school I was interested in pediatrics, and when I started medical school I became interested in geriatrics.  People say that the two fields can be similar. At either end of the age spectrum, some aspects of caretaking and quality of life become more important than the straightforward numbers of blood pressure and cholesterol levels that medicine likes to track.  I once went on home visits with a geriatrician, where she met patients in their home.  She noted things that I could never examine during a conventional visit where the patient comes to you, like the temperature of the home ("the patient is wearing many layers, presumably because there is no working heater").

She also noted things that I could theoretically examine during a conventional visit, but had never thought to, or if I did likely never had the time to do so--like the patient's feet.  "You can really tell if the patient is well taken care of by his feet," she explains.

These days most doctors in primary care forgo the physical exam in a routine visit, because it offers limited information and takes extra time in an already confined space of time.  We never routinely check a patient's feet.  The exception would be patients with diabetes, who 1) lose sensation in their feet due to nerve damage, so they don't feel cuts and wounds in their feet, 2) receive poor circulation, so it's harder for these wounds to heal, and 3) have weaker immune systems, so these issues can rapidly become bad infections.  You don't have to be in medicine for very long to see countless cases of foot amputations due to diabetic infections.

But outside of this group of people, I ignore feet even more than I often ignore the rest of the physical exam.  At least I know I'm choosing to skip the heart or the lungs.  The feet, I don't even register as being absent. Our culture makes it easy, feet being commonly perceived as, at the very best, not something to hide, but never something to uncover. Even in our scientific training as medical providers, we learn in anatomy to be delicate and intricate with our dissection of the hands, and most often leave the feet untouched.

It makes me consider what my own feet would say about my self-care.  I've noticed that some people, even very active people who spend a lot of time barefoot or booted outdoors, effortlessly have feet that look like they've never had to take a step. I've inherited my dad's feet, in that they very clearly reflect what I put them through.  My dad spent most of his life in America on his feet, standing for fourteen hours straight behind the cashier of his convenience store or stocking products.  For Christmas one year I bought him a small stool to sit on while he ate his meals at work.  Before that, there was only one chair behind the cashier, and he didn't use it because he didn't want to eat his meals in front of his customers.  So he would go to the back of the store to eat, and I had to find a stool small enough to fit in this space.  Other years for Christmas my brothers got him increasingly upgraded shoes with good support, and in retrospect I realize how much we tried to take care of him by taking care of his feet.  From all the standing he developed very thick, coarse skin on his heels and the balls of his feet.

These days and in this generation of computer workers, we talk about how bad sitting is for our health and encourage standing desks. Back then I remember wishing my dad could sit more, rest his feet more.  I don't think it particularly bothered him during the moment.  He ignored his feet during the years of working, but when he retired, he went through a period of soaking them for hours and moisturizing them afterwards. I haven't seen him do this for awhile.  From my own experience, I think it's because it might be too late to reverse the years.

My own feet are very sensitive to the elements, in that they show a lot of wear.  The roughness that develops actually makes me able to put up with a lot, so I tend to put them through more than I should.  I don't tend to feel much discomfort in the wrong shoes or terrain.  I received my feet woes from the luxury of having hobbies (mainly running, hiking and rock climbing), not from physical labor like my dad.  Because you don't wear socks with climbing shoes and because they are very tight, if you have sensitive skin like mine, thick callouses develop on the knuckles of your toes (do toes have knuckles?) and the heels crack and nothing good comes from walking around gyms with other sweaty bare feet.

The few times that I've gotten pedicures, the women at the salon are horrified. Sometimes they ask me directly why my feet are so messed up, and I'm used to this Asian directness from my mom (who once said to me while washing my bra: "You have VERY small breasts, even for a Vietnamese woman"). Sometimes I overhear them commenting to each other in Vietnamese, not realizing that I can understand them or that I'm well familiar with this strategy of speaking about people in front of them without their knowledge, this being the only reason for my brothers and I to communicate to each other in Vietnamese.  Sometimes I want to explain to them that this is why I'm here to get a pedicure, that if I knew how to take care of my own feet I wouldn't be there.  If I were in a movie I would say this in perfect Vietnamese and they would look at me with surprise and respect and enough embarrassment to make me feel okay about my own but not enough to make me feel bad.  But in reality my Vietnamese is simple, and I don't know how to express the surprising number and breadth of emotions that feet elicit.

Now in rare cases when I have a few extra minutes during a visit or when I'm already performing a physical exam and it's relatively convenient, I'll look at a patient's feet. Knowing how difficult it can be to express what a person carries day to day, and how our outer selves respond to that, I feel that at least for a moment we've drawn attention to something neglected and important.

As I've accumulated ways to better care for my own feet, I realize what a luxury it is to even consider this part of self-care, that most of us rarely think of it despite how much our feet do for us.  I can say with certainty that for our clinic patients, the part of their body that withstands most of their weight occupies minimal thought amidst a collection of other more pressing concerns.

On our part, I feel that one of best ways of caring for others in the major ways that they need is to sustain minor ways of caring for ourselves. To that end, I make sure to wash the soles of my feet and in between toes in the shower, use a loofah to scrub the knuckles (or whatever they are called) and the heels, and moisturize them before bed. I register and absorb the luxury of attending to an essential need, and try to remember both this simplicity and difficulty when caring for our patients' bodies.

                                                                    Mirror Lake, New Zealand. December 2009

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