Any discussion in metaphysics serves only to entertain in my drunkenness among good company. However this is the night before Thanksgiving and I have nothing I'd rather do than get this out of my head.

Problem: Am I truly free to do things as I will them; or have I been predetermined to do those things (whatever mechanism one proposes for predetermination)?

Most of the time, the focus is on the human being and his/her perception of the capacity to make a decision. The arguments for each side (free will versus predetermination) quickly based on the perspective taken. If the choice (or illusion of choice) is seen through human eyes, free will seems like a plausible reality. On the contrary, the viewpoint of God or an absolute order of the universe could support predetermined natured of our lives.

In my extensive research (of 5 minutes on Google), I have yet to come across anyone who questioned the assumption of separate entities. Who is God? What is a human being? What is an absolute order? The first question belongs to the theologian. The second to the sociologist, anthropologists and other -ologists. The third question posed to physicists. There are no clear answers on these questions in year 2007.

Right now I have the choice of going to bed or stay in front of this computer, but I am going to stay in front of the computer. I have exercised a choice in options. However, whether that action (or inaction) was a result of free will or predetermination depends on the definition of Who "I" am. If "I" am an entity of single human unit which decided not to go to bed, then the action was the result of exercise in free will. However if "I" am an entity composed of countless molecules subject to laws of physics, then perhaps the seeming single action of "staying in front of computer" was a predetermined output of a predetermined input. Neither answer alone is satisfactory in explaining the phenomenon of causation of "my" action just now because ownership of this action is not clear. Even if one were to accept the two seemingly contradictory perspectives, the reality is not any more understandable or acceptable.

Eh, of course, I am not going to stay up and try to define who I am. That would take too long.

One thing is certain though. If I define myself too strongly (or with too much certainty), I will create more dilemmas about metaphysical nature of my experiences. The practical application of this intellectual exercise is very clear: be damn unequivocal about the self if any semblance of harmony is desired.

11/21/2007
-Wilbur

Do you remember the first time you did something? First day of school. For example, the first date with someone special, first time at work, or first time traveling abroad. For me these times were both exciting and scary. I usually have these same thoughts, 'I'm really happy to begin something new, but what if I mess up?'

Zay was my first patient as a medical student. I was excited to finally be on the hospital ward. At the same time, I was also scared that I might make a mistake. What if I tell her something not true? What if I tell her something that upsets her? What if I hurt her during physical exam?

On that first day, we talked for an hour. Zay in her blue hospital gown sitting on her bed, and me in my yellow gown in a chair. She told me about her life with CF (cystic fibrosis) and the lung transplantation. How she had to come to the hospital this time because she wasn't feeling well.

She also told me about other things about her life. How she had worked as a town manager. How she had traveled to Paris and would like to go back sometime. How she cared for others. How she cared for herself. Every morning for the next three weeks, I woke up Zay up apologetically to see how her night went. Listen to her lungs. Talk about how the day might go. And both of us leave each other with our fingers crossed as a quick prayer of sorts.

Soon I became comfortable being Zay's reporter for the team. I would tell the team, "Miss Lawson had no acute events overnight. Her temperature was 36.7. Respiratory rate 16" and so on. I even learned how to treat bronchiectasis and pneumonia. Advair, albuterol, atrovent, saline nebs, supplemental oxygen, tobramycin nebs, and antipseudomonal antibiotics. What was initially a mumbo-jumbo really started to make sense to me in two weeks.

For this opportunity to learn, I am grateful to Zay.

Grateful, too, for being patient with me when I took too long to listen to her lungs and heart. For putting up with my own anxiousness towards her well being. For allowing me and my teachers to do the best as a team. To trust us and thereby allowing us the satisfaction of being the caregiver of someone who deserved the best.

I am still very scared for my other patients, 'What if I forget to ask an important question? What if I overlook an important lab value?' I worry quite a bit when someone gets a fever; I think about Zay. Her fever was the sentinel event to her passing.

Zay makes me careful. She helps me to remain human when I find it difficult to face the suffering of another human being and through her example, find redemption and comfort in our inevitable human nature.

I am in debt for the beautiful experience of getting to know Zay personally and of partaking in her life though briefly. I hope to pay off the debt of her spirit as I continue to live this life and dream of traveling like Zay often did.

Here's to you, Ze-Ze; I hear Paris is a beautiful place this time of the year.

To begin this story, I have to confess that my opinions on cultural sensitivity and sensibility are biased because I was once a migrant myself. Having experiences the stereotypes and prejudices - not all of which are negative - I am sometimes overwhelmed at how crude and insensible my fellow students could be toward another human being because they did not understand the psyche and social apprehension people of different cultures hold.

The hospital is not a place where only physicians and patients are the only people who exist and matter. The doctors and medical students provide a large part of the service, but without the nurses, food services personnel, pharmacists and other staff, we cannot function in our role at all. In the basement departments and hallways are people who work to pick up the trash, wash the laundry, clean up empty rooms of blood and feces and generally keep this a hospitable place. These most basic functions of the hospital are most often served by a Hispanic person.

Today during our physical diagnosis round with the chief resident, we came through the set of doors outside the 5th floor Women's hospital elevators only to be greeted by a foul smell in the hallway. A student blurted out rambunctiously, "Oh, man! What is that smell? It smells like trash!" It became immediately apparent to me the smell was coming from one of those large trash carts which was being pulled by a service staff - invariably a Hispanic gentlemen.

Another student next to me pointed in the general direction of the man and trash cart, "It's the trash!" The students, stimulated by the irony of wondering what smells like trash and finding out that there was a large cart full of trash, started laughing. The student who first asked the question laughed also because he found his own remarks to be silly.

I looked at the man again. He was a dark-skinned, short man. He was moving down the hallway but had stopped because of the noise we made. We had caught his attention in our childlike laughter. He saw us point at the trash. His face turned sour, then he looked away. Walked away.

Of course, I cannot say for sure what exactly he was thinking or feeling, but I can tell you that I have been in a similar pair of shoes in my life. I had worked along with Mexican construction workers. I befriended these guys and learned lay Spanish from them. Often when we would work, the American home buyers and American supervisors came to look at the house. When these people showed up, we felt that we were invisible or transparent. Our existence felts as an inconvenient but temporary measure to fulfill the needs and wants of these strange blue eyed creatures who somehow have a lot more money than we do. The people who can afford to live in the houses which we built with our sweat and blood. Whenever those people passed by me, they never said hello or looked at me in the eyes. I felt very, very small.

As I saw the man push the cart away from us, I became sad and enraged. I was sad that we may have made the service person embarrassed. I was enraged that my colleagues would be so insensitive as to point and laugh at a person who is providing a valuable service which none of us would be glad to do. Are we not supposed to be doctors? Are we not supposed to comfort people?

I have a tendency to antagonize people in these situations as I try my best to protect the people who have less capacities to protect themselves. I tried my best to convey the man's perspective to the students involved, but I wasn't well received. One of the students told me that she or he was laughing only because of the situation and not at the man. I decided to drop it at that point. I have still much to learn in the diplomacy of bringing the perspective of the disadvantaged side to the table without causing more friction.

However, the reader must understand. Our failure was not in the intention; we didn't have any intention except we let our mind run free where it shouldn't have. It was insensitivity which led to that one-sided situation. We should have recognized that we were in the presence of another human being who was carrying a cart full of dirty trash. Perhaps we would not have laughed so loudly or pointed at the cart. Maybe just a smile would have been enough for us. Maybe some of us could even have smiled at the person and nod our head in greeting - as we did for a Hispanic mother and child we saw just 40 second later.

This assignment was supposed to be a reflection on how culture affects patient care. However, the discrepancy between what I saw in the hallway today and what other students saw serve to show the real failure in cultural competency. In our training we are asked only to recognize cultural issues as they exist in the context of clinics and in whom we consider to be "patients." Perhaps such training serves the requirements of a prominent social medicine faculty or a Medicare requirement, but it does not address the fact that medical students and doctors treat people of lesser socioeconomic background with ignorance. We must not only remind ourselves to treat all of our patients with respect but also with everyone else we see daily. We cannot simply say, "we'll treat this group of people well because these are our patients but not the nurses or cafeteria workers." We must recognize culture everywhere.

I am sorry to tell you that I have been served much more by my immigrant background, my travels overseas, and by the drunks I've met than by social medicine class or the interviews with that patient from a privileged background. By my humble but frank account as a someone outside of the "main" culture, too many our students are culturally incompetent and insensitive. I won't have them take care of my family.

I am also sorry to say that we cannot teach equanimity; it can only be learned. For those of you other students, good luck. For you residents and attendings, I'm going to keep standing up for the migrants, poor people, the homeless, alcoholics, the service staff, and others for whom medicine serves only to increase the gap between the well and not-well. All I ask is that you don't berated me for being naive or idealistic during morning rounds when I stand up for a chronic pain patient.

Wilbur Larch

10/31/2007