People : Dysfunction

Kyoto Japan, July 2007

man with clear blue eyes
what lies behind them
who knows, even he can’t tell

*

When anyone at my job apologizes for some sort of dysfunction, I smile and think about my time working at San Francisco General Hospital (now also known as the Zuckerberg). It was there that my perspective of function was constantly in flux, and made me think about balance very differently--both for patients and for myself.

During my month on the wards at San Francisco General Hospital, I scaled the wide spectrum of dysfunction. Everything at the hospital is at least slightly broken, and a good number of things are very broken. If you’re able to get on the internet on one computer, it’s likely that it won’t print. If the computer prints, its screen likely intermittently freezes. Each phone requires individual insight into its needs: one might need to be held for five seconds before any dial tone will appear, another’s ring will be lost if you’re not consciously listening for its low-pitched sound. On the floor with the sickest patients, the orders for drugs, lab tests, and patient care can only be written by hand, this floor being the one in the whole hospital not linked to its computer system. There’s no longer hot food available in the cafeteria for dinner, because the one person who manned the grill went on maternity leave and there was no one to replace her. Things are tenuous, a word I understood but never experienced until learning medicine at the General.

Patients there are often described as tenuous, their situations being unstable and fragile in many dimensions—medically, socially, mentally. These people constantly face the tipping point of chronic wear and tear, and each time I learn a new face I wonder when its screen will freeze on me.

As anyone will tell you, it is an incredible opportunity to meet people so different from you, who are living in such different spaces. It blows my mind that as people in their twenties who’ve spent most of our lives sheltered in school, we are in charge of taking care of these people who hold so much world. It seems intuitively a little wrong, but maybe there’s meaning to be created in this meeting of people. I try to absorb some of our patients’ realities, but it can be hard to do this and stay balanced. My body, which has its own steady supply of idiosyncrasies, didn’t really know how to equilibrate all the things that are slightly or immensely off-center about these people.

Being with them, I realized that staying balanced means living on a different fulcrum. I wrote the haiku above about a patient of mine who was deemed by psychiatry, neuropsych, and medicine to lack capacity to make decisions for himself. He was described, accurately, as cognitively impaired due to years of substance use. When he left the hospital one day against medical advice, he was found the next day lying on the floor of his apartment covered in his own feces. So he was taken back to the hospital and kept there, medically stable but labeled as unable to make the decision to leave, unable to take care of himself at home. While I agreed with all of this judgment, he often surprised me with insights that maybe only someone without capacity could give. When asked about how he felt about being in the hospital, he looked at me with eyes you’d think were widened if you didn’t know that was just his baseline diameter. “Well, it’s kind of an interesting problem. Because I’m sick, but I’m also not sick.” It was more true of a one-liner than any of the descriptions I gave of him on morning rounds on our patients. The General is humbling and moving in the way it reveals dysfunction to be someone’s natural function, and I think it’s changed where I lie on the scale.