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Wellness Section Newsletter - September 2006, Vol 10, #4

Wellness Section

circle_arrow Join Us for the Annual Section Meeting in New Orleans!
circle_arrow Co-Editor's Corner
circle_arrow Core Readings in Wellness for Emergency Physicians
circle_arrow Defining Moments
circle_arrow Acute CVA: An Emergency Physician's Personal Story
circle_arrow Happiness...
circle_arrow More Core Readings in Wellness for Emergency Physicians
circle_arrow Council Resolution Review
circle_arrow Learning Spanish on the Fly

Newsletter Index

Wellness Section

Join Us for the Annual Section Meeting in New Orleans!

The Wellness Section will have its annual meeting on Sunday, October 15, 2006 in conjunction with Scientific Assembly 2006 in New Orleans.

The meeting is scheduled for 5:00 pm – 6:30 pm in Room 399 of the Ernest N. Morial Convention Center. Be sure to check the schedules on site, as meeting times and location are subject to change.

The section is accepting nominations for Newsletter Editor and Chair-Elect, with the elections to be held at our section meeting during Scientific Assembly in New Orleans. Please submit your interest to staff liaison Marilyn Bromley at

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Co-Editor's Corner

Julia Huber, MD, FACEP

Greetings! While preparing this issue of the wellness newsletter I have received notice that we are now going online! If you are new to the newsletter and are just "surfing," please take a close look at the sections entitled "Core Readings in Wellness for Emergency Physicians," compiled by Richard M. Goldberg, MD, FACEP. His summaries are concise, and the readings both scholarly and informative. Also, take a quick look at the article by Diana L. Fite, MD, FACEP, which is a reprint from the AAWEP newsletter. If there was ever a plug for the Wellness Booth at the national ACEP convention, it would be hers.

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Core Readings in Wellness for Emergency Physicians

Whitehead DC, Thomas H Jr, Slapper DR. A rational approach to shift work in emergency medicine. Ann Emerg Med. 1992;21:1250-1258. 

In an extensively referenced paper, the authors discuss principles of circadian rhythm and sleep physiology, as well as the adverse physiologic and psychologic consequences of circadian disruption. Such consequences have been documented in the public health literature and include many of the following: chronic fatigue syndrome (up to 80% affected); chronic sleep disruption and deprivation (average 4.5 hours sleep daily for shift workers); increased rates of depression, mood swings, and divorce; increased incidences of gastrointestinal and immune disorders, as well as infertility; higher rates of drug and alcohol abuse; chronic hypertension; increased cardiovascular mortality (risk worse than smoking a pack of cigarettes per day); increased rate of work-related accidents and errors; and increased risk of accidents driving to and from work. These considerations become increasingly important as the average age of emergency physicians continues to increase. The ability to sleep during the day deteriorates with age, and older workers are less tolerant of shift change.

Certain circadian principles are key to an understanding of the physiologic disruptions associated with shift work. Circadian rhythms have both endogenous and exogenous components. The former refers to the biologic clock pathways residing in the hypothalamus. Human beings have a 25.1-hour circadian clock, a time interval that is constant and predictable. The exogenous component is driven by external time cues, the most important of which are the light/dark cycles that are instrumental in setting the circadian clock.

Considerations of sleep physiology are also important in attempting to devise a rational approach to shift work. Sleep occurs in four discrete stages. Stages three and four, also known as delta or slow-wave sleep (SWS), have been thought to be vital in regulating physical recuperation and maintenance of the immune system. The bulk of SWS occurs early in the sleep cycle.

Based both on circadian principles and recent findings in sleep physiology, the following recommendations for dealing with the problems of shift work have been developed:

  1. Night shifts should be scheduled either in an isolated fashion or overextended, consecutive periods (eliminates partial resetting of circadian rhythms).
  2. When using rotating shift schedules, do so in a clockwise direction (less disruptive of circadian rhythm).
  3. Take measures to enhance the comfort and quietness of the sleep environment.
  4. Start the awake period with a hot protein meal, switching to complex carbohydrates at bedtime. Avoid use of caffeine and alcohol at bedtime.
  5. Use bright light in the emergency department at night (7,000-12,000 lux) or 10,000 lux for two hours upon awakening in order to entrain circadian rhythms more rapidly.
  6. Napping for two hours before going on duty has been shown to increase alertness and ability to perform complex cognitive tasks, possibly due to the additional SWS obtained.
  7. Do not try to live a day-shift lifestyle working nights. Avoid taking on day-time responsibilities.

Other articles of interest on this topic as it relates to emergency physicians include:

  1. Kuhn G. Circadian rhythm, shift work and emergency medicine. Ann Emerg Med. 2001;37:88-98.
  2. Thomas H, Schwartz E, Whitehead D. Eight- versus 12-hour shifts: Implications for emergency physicians. Ann Emerg Med. 1994;23:1096-1100.
  3. Smith-Coggins R, Rosekind M, Hurd S, et al. Relationship of day versus night sleep to physician performance and mood. Ann Emerg Med. 1994;24:928-934.

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Defining Moments

An original work by Jay Kaplan, MD 

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Acute CVA: An Emergency Physician's Personal Story

Diana L. Fite, MD, FACEP
Past Chair, AAWEP Section

(Reprinted with permission from the author and from AAWEP newsletter editor Lily Conrad, MD.) 

I wanted to write about a personal medical problem that I unexpectedly experienced recently, in the hope that reading about what happened to me would stimulate others to pay more attention to their own health.

I suspected that I had developed some hypertension, given occasional abnormal readings at the dentist office, which I attributed to nervousness and led to the dentist just telling his staff not to bother with taking my blood pressure in the future. Always insisting that my family get medical care, my husband was taking ace-inhibitors, so I tried a few and developed angioedema. Clearly in my mind it seemed that I was not really supposed to be taking anything, and I figured that I’ll get serious about making sure my blood pressure is okay when I’m a bit "older" and having problems. After all, I still have kids at home and I do not feel old (53 years old).

On June 7, after a busy, hard night in the emergency department, I was leaving a bit late and needing to rush to get to an outlying town where I was to be the defense expert witness in a malpractice trial. After driving about ten minutes, my right arm suddenly felt a little weak for a brief moment. I knew immediately what was up, but I tried to pretend that I had strained it and decided to ignore it. Suddenly the car was weaving all over the road because I was holding the steering wheel with my right hand (cell phone in my left hand). I threw down the phone, grabbed the wheel with my left hand, turned into an empty parking lot of a school, and kicked my right foot off the gas pedal with my left foot so I could stop the car. I quickly pulled down the visor to smile into the mirror, and sure enough, the right side of my face did not move at all.

My head did not hurt anywhere, and I was fully alert, so I was relieved to assume this was not a hemorrhagic event. It was hard to retrieve my cell phone with a now completely paralyzed right side, but I finally twisted my left side enough to grasp it, and called 9-1-1. I had not anticipated that my speech would be so slurred that it was incomprehensible, because my thought processes were clear. But indeed it took several minutes to get the dispatcher to understand my problem and my location. Fortunately, I had been the past medical director for years for the EMS service in the area, and they all knew me once they finally understood me.

Upon arrival the paramedic reported the blood pressure as 280/140, and I could not even move a toe on the right side. I tried to act calm (I was scared to death), and requested to go to Hermann Hospital, a designated stroke center, and home of Dr. James Grotta who is world-renowned for his advocacy of tissue plasminogen activator (tPA) treatment for ischemic strokes. Plus I am on staff there in the emergency department and it meant so much to be where I had physician friends. Sure enough, Dr. Grotta showed up, and I was a candidate for tPA, and received it well within the three-hour window from the onset of the stroke.

Thanks to thrombolytics, prayers from many special people, and most importantly thanks to the grace of God, I have fully recovered. It took a few days to recover all function, which was just long enough to teach me how devastating it would be to have a permanent disability, and to remind me how easily we take for granted that we will be able to work as long as we need and want to. I have been given that precious second chance, and I will never ignore my health again. It makes me feel ill to relive the stroke and to remind myself over and over again that I could have prevented this from even happening. Many physicians told me that because of what happened to me, they checked their own blood pressure for the first time in years, or that they made appointments for a check-up with a physician. And that is the message I want to give.

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Elaine A. Thallner, MD, MS, FACEP

(Reprinted with permission from the author and also from AAWEP newsletter editor Lily Conrad, MD.)

I would like to share with you some thinking about happiness. The "pursuit of happiness" was important enough to our founding fathers to put into the Declaration of Independence. The subject was selected for a book club discussion that I recently hosted about the book, Authentic Happiness by Martin Seligman, PhD, a University of Pennsylvania professor well known in positive psychology. The book club participants were classmates in my Organizational Development master’s program that I recently completed, a course of study heavily informed by positive psychology. My writing is a merging of the ideas presented in the book, the book club discussion, and my thoughts. The Book Club itself formed because a group of students recognized the intrinsic value in conversation, wished to stay connected with each other after graduation, and wished to continue learning.

My curiosity about this subject was piqued in medical school as a first year student 25 years ago. A psychiatrist explained to our class that we there because we needed to ‘compensate’ for some deficiency in our childhoods that compelled us to ‘over-achieve.’ He cited statistics on our overwhelmingly negative experiences thus far (‘victims’ of alcoholic or dysfunctional parents) and statistics predicting our future negative experiences (depression, divorce, dropping out, etc). These comments stuck in my memory to be tested many years later. I remember wondering if most of us were there simply to do something meaningful with our lives in the best way we could imagine at that time. Over a decade later, my husband and I adopted children and again I was curious about the underlying assumptions that were made: our presumed need to ‘compensate’ for some deficiency. And we thought we just liked kids!

In medical training, we are trained to look for what is wrong (a ‘disease-model’ of thinking). Mental health literature overwhelmingly studies dysfunction; why not also consider "best-function?" If we allow ourselves to see what is right and good, our lives and the lives around us become enriched. Basically, we see what we look for. Aren’t our lives better if we look for goodness? For example, I recall days walking from my office to the ED in Philadelphia and passing ghetto homes with razor wire topping the back yard fences. One day I noticed that someone had planted beautiful flowers. I never saw that small backyard or that neighborhood in the same way again and wondered about the person who planted them. We can choose to make unlikely connections by engaging in unplanned conversation. Several years ago, while sewing up a young man’s face (about 80 sutures as I recall), I decided to try to relate to this person (I was looking for a challenge that day). What I saw at first was a young man just released from prison, tattoos, baggy pants, attitude galore, and a real tough actor. Putting aside my assumptions about him, I simply told him that he was brave for moving ahead with his life after what must have been a difficult few years and then asked him what he was planning for himself. The next 45 minutes while suturing his lacerations were actually amazing. I learned a lot about his hopes and dreams and I think the conversation helped him begin to identify his strengths and what was important to him. In that time, he also completely changed my assumptions about him from ‘thug’ to a young man with hope and vision. He returned several hours later to thank me for listening to him, for not asking him why he had been in prison, and even tried to give me money (which I asked him to spend on his girlfriend instead). He reminded me of how infrequently we chose to look for goodness and of the possibilities unleashed when we do. For me, this approach gives meaning to my clinical duties. As a parent, these unplanned conversations often occur in the car, while folding laundry, or putting dishes away.

So, what is happiness anyway? Seligman offers a simple formula for happiness: H=S+C+V. "H" is our enduring level of happiness; "S" variables are not under our control, our genetics and set range; "C" is our life circumstances and sometimes under our control; and "V" are the factors under our voluntary control. Positive emotions are past (satisfaction, pride, contentment), present (joy, pleasure, flow), and future (optimism, hope, trust, faith). He suggests ways to increase positive emotions about the past, present and future. For example, gratitude and forgiveness increases positive emotions about the past. Savoring and mindfulness increases positive emotion about the present. And optimism can be increased by learning how to dispute pessimistic thoughts. As one example, I can have a terrible shift and still feel ‘happy’ by feeling gratitude for living in the US, having an education, a job, my health, my family, etc. and I can be optimistic about my future. Seligman challenges one to consider the difference between having a pleasant life, a good life, and a meaningful life.

Why is happiness important? Increased happiness has been correlated with better health, longevity, marital success, work satisfaction, promotions, productivity, and higher income. Happy people are better able to deal with bad events and are more altruistic. When we are happy, we have more energy; we are more open; more creative, more patient. We are better parents, teachers, doctors, and partners. We can teach our children (and our residents and others) so much about happiness and fulfillment by simply honoring their strengths and asking them to define what kind of people they want to be. For example, I no longer ask my children, "How was your day?" after school; instead, I reframe the question positively: "What made you feel proud today?" or "What act of kindness did you notice today?" Instead of "What do you want to be when you grow up?" ask them "What is the best person that you can imagine being?" You will be surprised at the wonderful things they share with you and the speed with which they solidify their values (informed by your values, of course).

Acknowledging that our American society is losing connectivity, that we rarely engage in conversation (without distractions or multitasking), I would encourage you to read this book along with some friends, neighbors, and colleagues and start a conversation.

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More Core Readings in Wellness for Emergency Physicians

Richard M. Goldberg, MD, FACEP

Benson H, Beary JF, Carol MP. The relaxation response. Psychiatry. 1974;37:37-46.

Benson, Herbert. The Relaxation Response. (New York: Harper, 1975). 

These two landmark publications were among the earliest that explored the physiologic basis of mind-body dynamics. The authors reviewed data to support the hypothesis that an integrated central nervous system reaction, "the relaxation response," exists as an innate protective mechanism to counter the harmful bodily effects of stress. They discuss a variety of experimental evidence suggesting that a locus within the anterior hypothalamus can cause hypodynamia of skeletal muscle, decreased blood pressure, decreased respiratory rate, and pupillary constriction when stimulated. The same or similar changes, which are directly opposite to those of the flight-or-fight response, have been described during the practice of a variety of meditative techniques, including prayer, transcendental meditation, autogenic training, hypnosis, progressive relaxation, Zen, and yoga.

These findings have important implications for emergency physicians. First, there is a scientific basis for the concept of "mind-body medicine." Additionally, the "relaxation response" appears to be a physiologic pathway capable of being accessed by a variety of consciously applied techniques. An example of a simple technique is described in detail, and includes a mental device (sound, word, sight, or phrase on which to focus), a passive attitude to one’s flow of thoughts, a comfortable position to minimize muscular exertion, and a quiet environment:

  1. Sit quietly in a comfortable position.
  2. Close your eyes.
  3. Deeply relax all your muscles, beginning at your feet and progressing up to your face.
  4. Breathe through your nose. Become aware of your breathing. As you breathe out, say the word "ONE" silently to yourself.
  5. Continue for 10 to 20 minutes. When you finish, sit quietly for several minutes with your eyes closed and later with your eyes open.

Do not worry about whether you are successful in achieving a deep level of relaxation. Maintain a passive attitude and permit relaxation to occur at its own pace. Ignore distracting thoughts by passively accepting and not dwelling upon them. Return to repeating "ONE."

With practice the response should come with little effort, and can be an effective means of stress reduction, useful before, during or after duty hours.

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Council Resolution Review

Mitchell B. Cordover, MD
Council Representative

As the Wellness Section Council representative, I’m presenting the proposed resolutions for this year with the hopes that interested section members will take the opportunity to comment on them. I am eager to represent your position in the Council, but I need to hear from you to do that. While my poor frayed e-mail inbox may sag under the weight of your enthusiastic response, please let me know where you stand on the issues outlined below. Write to

I have not included every resolution here. Some are purely administrative or are distant from our shared interest in physician wellness. I have included everything that I think reflects on physician practice or which may be controversial. A tentative list of resolutions has been sent to the Council representatives, but some resolutions are still in the works. When they are complete, the final proposed resolutions will appear on the ACEP Web site. Some of these will represent important strategic decisions for the College, and I encourage you to look them over and let the Council know what you think. My commentary, if applicable, is in italics. 

Resolution 16(06) - Universal Basic Health Care
Purpose: ACEP encourage its members to join the Archimedes Movement & adopt policy that supports the vision to "maximize the health of the population by creating a sustainable system which reallocates the public resources spent on health care in a way that ensures universal access to a defined set of effective health services."

This seems like an extension of a resolution last year for the College to support a national single payer insurance system. (The resolution was referred to committee.) The Archimedes Movement is an organization in Oregon that aims to develop grass roots support for a health insurance system proposed by their governor. It foresees local input into the design and priorities of such a system. Its tenants are universal access to certain key services and minimized costs. The governor’s proposed system was a reorganization of the state’s medicaid rules. They were overruled, but resulted in productive negotiations for wavers from CMS. 

Resolution 17(06) - Restoration of ED On-Call Services
Purpose: ACEP appoint a task force to address restoration of ED on-call services under the principle that emergency care is an essential public service with stated criteria.

  • Advocacy for statutory and regulatory revisions to EMTALA requiring that physicians with hospital privileges participate in ED on-call coverage as a condition of their participation in Medicare, coupled with federal commitments to provide the necessary planning, funding, and professional liability. [There has been some discussion on the council web about this, some saying that the "hammer" approach will have unintended adverse consequences. Others suggest that it is the only consistent way to get coverage, and that, like EMTALA, people will settle into it.]
  • Continued advocacy for the principle that all EMTALA-mandated emergency and on-call services should be granted malpractice liability protection under the Federal Tort Claims Liability Act (HR3875);
  • Support for federal legislation to allow hospitals and physicians to collaborate in regional and community ED on-call coverage arrangements under the auspices of their local community EMS agencies without violating federal antitrust laws;
  • Support for federal legislation that directs the Centers for Medicare and Medicaid Services to establish pilot programs for the development of coordinated, regionalized, and accountable ED on-call systems including but not limited to - regional transfer coordination centers, regional on-call purchasing groups, and fee-based funding for specialty care transfers. [There has been some misgivings, reflected in resolutions below, that this policy could be used for financial reasons, to the detriment of patients. Others suggest that the system works for psychiatric transfers, and would guarantee access.]
  • Advocacy for the principle that all federal and state regulated commercial payers be required to reimburse non-contracted ED on-call physicians at the physician’s usual and customary fee for services to their enrollees, or if the payer believes the physician’s charge is excessive, at the lesser of the provider’s charge of the 50th percentile of usual and customary charges in the area of service based on a validated database of physician fees;
  • Efforts with major stakeholders to develop a model dispute resolution methodology to determine fair value compensation for physician participation in ED on-call rosters
  • Support for the study and adoption of ED on-call coverage requirements as a criterion for establishing specialty workforce targets and service commitments by all organizations involved in the planning and development of our nation’s future medical workforce;
RESOLVED, That ACEP appoint a task force to study and recommend a comprehensive national plan to restore emergency department on-call services that addresses all pertinent elements of the on-call crisis,

Resolution 18(06): Availability of On-call Specialists
Purpose: ACEP petition government to perform actuarial studies to determine the Education/Training Account for all licensed physicians and that those physicians repay this subsidy by either "playing" by serving on-call or performing other public service or "paying" into a fund which would be used to reimburse on-call physicians. [This would effectively provide an incentive for young physicians to stay on the on-call list, and establish a fund of federal funds to pay on-call specialists.]

Resolution: 20(06): Psychiatric and Substance Abuse Patients in the Emergency Department
Purpose: ACEP evaluate principles and promote talking points to respond to issues related to psychiatric and substance abuse patients in the ED. That ACEP evaluate guiding principles for states and chapters to respond to issues related to psychiatric and substance abuse patients presenting to the Emergency Department including issues related to adequately providing community resources for care, support for emergency physicians treating these patients, and promote talking points to facilitate local and state level efforts to respond to the needs of this patient population. [This resolution is preceded by a long explanation in the "whereas" section of the problem of psych and substance abuse patients getting inappropriately brought to and getting stuck in the ED for lack of community alternatives.]

Resolution 21(06): Selective Triage for Victims of Sexual Assault to Designated Exam Facilities
Purpose: ACEP supports the selective triage of victims of sexual assault to designated sexual assault exam facilities; the collection of forensic evidence (performance of evidentiary examinations) by specially educated and clinically trained personnel; and the development and funding of additional SANE/SART programs. [Does this raise questions of admissibility, testimony credibility, patient convenience and cost? "Supports" v. "Advocates"?]

Resolution 24(06): Emergency Department Leadership
Purpose: ACEP develop a policy statement stating ED medical director\chair have sole oversight over medical practice in an ED. ACEP work with hospital organizations to establish a standard ED leadership model which supports an emergency physician as the primary leader of the practice of EM. [Discussion mentions the problem on non-ED people having operational authority of an ED, including ED operational budget management, policy setting, staffing requirements, and ED patient flow directives.]

Resolution: 27(06): Responsibility for Admitted Patients
Purpose: ACEP create a policy stating that the ultimate responsibility for admitted patient's care rests with the admitting physician. […regardless of the location of a patient within the hospital]

Resolution 28(06): Psychiatric Bed Availability
Purpose: ACEP study the issue of psychiatric bed availability and the EMS impact to determine the national scope of the problem in order to look for solutions.

It is interesting to note that there are no resolutions this year that directly impact the subject of physician wellness. None-the-less many of these address issues that affect job satisfaction, longevity, and other issues of concern to us as a section.

Please respond as soon as you can. If you have any questions about the background of any of these, I can get them to you by e-mail. Send staff liaison Marilyn Bromley a request at

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Learning Spanish on the Fly

Jennifer Blair, MD

(This essay, originally titled "Bilingual Med," appeared in the Northwest Magazine of the Hartford Courant on August 17, 2003. Reprinted with permission.) 

The Simpsons can speak Spanish. You have to wonder if the American actors are bilingual, because Marge grates, Lisa pipes, and Homer complains so well that the joke inherent in their voices isn’t lost at all. I found this out during lunch at a medical clinic in San Sebastián, Spain. Doctors chewed and watched me, amused by my laughter. I just liked hearing the voices speak Spanish. I didn’t actually understand them. That was why I was in Spain in the first place.

My advisor comes from Mexico, and I’d asked him if he knew a clinic there I could visit, after I’d seen a Hispanic mother try to give birth with only one busy resident available who spoke some Spanish. I’d often tried out a little bit of Spanish with my patients, asking them the names of things, putting them at ease while waiting for the interpreter. But properly studying a new language is a big undertaking, and I’d dragged my feet in favor of other pastimes. The day the Hispanic woman gave birth, though, encouraged me. What with my passing familiarity and the similarity of Spanish medical terms to English ones (they both come from Latin), I could understand much of the exchange. I just couldn’t construct anything to say. Maybe a few days’ immersion would change that.

"Forget Mexico," my advisor told me, "you should go to San Sebastián." He’d spent time in Basque country, in northern Spain, and he sent a few emails to colleagues there, all the while singing the praises of its food, people, and landscape. Soon it was arranged. I spent a week as an observer in an urgent-care clinic there, trying to follow patients’ complaints and doctors’ questions; reading medical write-ups, looking up word after word in a little dictionary whose spine broke in short order. We had a good time. The doctors got a kick out of my cheerful willingness to blather in whatever Spanish I could scrape together, and I was thrilled if I could make out what they were saying.

The Spanish that natives speak is a lot faster than that resident’s high-school Spanish had been. I became an expert guesser. Trying to communicate in a foreign language when you know only a couple of hundred words is an art, particularly when you mislead people into thinking you know more by rattling off stock phrases with a decent accent. (Mimicry runs in the family: my uncle does a sidesplitting Richard Nixon.) People answer in much more detail than you’re prepared for, and you don’t want to disappoint them. You listen so hard your neck hurts. You watch their hands, their gazes, the expressions of other people in the room. You feel your brain processing about three seconds behind what is being said: first a string of gibberish, then the old 486 whirrs, then one or two words come forward, bright and clear against the static. Seconds tick by, but finally you think you know what he said, more or less. Often, you can then just nod and smile, but sometimes the speaker looks at you inquiringly, expecting a reply. You think of one – in English. You translate, butchering your original brilliant response to accommodate your miniscule Spanish vocabulary. You remember to conjugate: third-person singular, -er verb, past tense…But too much time has elapsed. The speaker has concluded that you didn’t understand, and helpfully repeats himself. Your fragile little sentence is swept away in the rush of words. If you’re lucky, he’ll slow down, rephrase, gesticulate. If not, you’ll say Sí or some other such inanity, and hope he won’t notice you’re clueless.

More than just the language was novel to me. Being European, the clinic itself was full of, as Pulp Fiction’s Vincent Vega put it, "little differences." Temperatures were taken from the underarm with mercury thermometers, rather than with the flash-quick eardrum cones we use here. Sheets weren’t changed unless they looked dirty – if two people with headaches had sat on them, they were left alone. Gloves were similarly not bothered with except where bodily fluids had escaped. On my first morning, I was given an enormous set of scrubs and ushered, reluctant, into an operating room, a place I had hoped never to have to enter again. I was led to a stool behind the surgeon, whom the nurse assured me had spent time in England and spoke good English. Not knowing how to protest that speaking English would defeat the purpose of my being here, I stood obediently, watching them sew in a heart valve – admittedly an impressive operation, but one with little linguistic yield. I had plenty of time to look around and notice that the surgeons’ gowns were made of cloth, not paper, and so were the drapes. No doubt they’d been sterilized, of course, but I was pleased by the frugality. (I did wonder what kind of fuss they would have made if someone were to contaminate a drape.)

The urgent-care clinic had a little office where the staff retreated during quiet moments between patients. The first morning, I set down my things stiffly, asking permission to eat the flaky croissant I’d bought before the bus ride. (I’d been too shy to eat it on the bus, afraid of breaking some societal rule and looking like a dumb tourist.) The doctor waved his hand in the air carelessly, and before long I learned that you could all but open a keg in that room. Nurses and doctors alike wandered in and out, popping mints, rolling and smoking cigarettes, surfing the web. Everyone went by first names and kidded each other like siblings. Sometimes people without white coats came in and were greeted effusively with kisses and how-have-you-been conversation. They would open their briefcases, take out some flyers, and, to my astonishment, deliver a two-minute spiel about a medication. Drug reps, those pariahs of the American doctor’s office, who usually have to bring lunch bribes to get anyone to listen to them, were welcomed in Spain like old friends. As soon as they finished their pitches, they resumed their social conversations with the doctors. They were not the corporate enemy. I’m still trying to figure that out.

The patients, too, were treated differently. The doctors showed the patients their X-rays, and explained the medical write-ups. Patients took both items home with them, which isn’t done here. There was a certain ineffable casualness. It wasn’t at all unprofessional, just less distant. The doctors didn’t shrink from laughing at the patients’ jokes; the patients didn’t hesitate to lower their trousers to show a rash on the thighs – there was no fanfare of drapery and chaperone. There was time for conversation. It was as though the exam were being done during an interlude to a party to which both doctor and patient would soon return.

Speaking of parties, here I must describe what it’s like to have lunch when you’re a doctor in a Spanish hospital, or at least in that one. There’s no tray-bouncing or soda machines or soggy paper plates. You go up to the cafeteria counter, where you are handed a menu. You tell the black-and-white-uniformed waiter what you want, then proceed to the doctors’ lounge and sit down at a long table with your fellow-doctors, most of whom are smoking cigarettes. An assortment of newspapers is available. Sometimes the TV is on, so you can watch news or cartoons. The waiter comes in and puts a plate, silverware, and long-stemmed wineglass down on the white tablecloth. You get bottled water, or wine if that’s what you ordered. After you finish your appetizer, generally a salad, it is taken away and your entrée is brought. The options are elemental, proteinaceous; either something involving meat, or something involving fish – an enormous fish, generally served intact and lying across the plate, spilling over both edges. Spaniards seem to like their food oily (once I watched a doctor all but empty a decanter of olive oil over his salad), so the fish lay in a little oily pool. It took some work to fork all the flesh off the bones. It was not untasty, just muy rico. What with the fish and the delicious, milky, sweet desserts (yogurt, flan, ice cream, or flan with ice cream), lunch could hold me till the next morning.

The pace at lunch was leisurely, so it was a good time for language practice. One day I was eating beside Dr. P., a handsome and jovial Basque who was fluent in Spanish as well (as are most Spanish Basques). His cell phone rang. He swallowed his fish and answered with a curt "Sí?" I couldn’t begin to follow what he said to his colleagues, so I paid attention to Lisa and Bart Simpson instead. When he hung up, he took a quick sip of water and turned to me. He told me that he had to go back to the clinic, and that I should feel free to stay and finish my dessert. That part I understood. Then he began to explain why he had to go. I listened carefully, as usual picking up perhaps one-quarter of what was being said. It seemed that a woman there – probably one of the nurses – had done something with some preserves. Ah, yes; the nurses in my father’s office sometimes bring in food from their gardens to share, and I figured he was going upstairs to snag a jar. (I was too busy constructing this hypothesis to realize how little sense it made.) I made noises of cautious comprehension, but my expression must not have satisfied him, because he repeated himself. Gradually he zeroed in on a word I seemed to be missing. "Romper," he repeated. My face was blank. Gamely, he took my dictionary and found the word. Romper: to break. Hm. Had one of the jars broken? Maybe someone had been cut. The doctor started again, determined not to let me smile and nod my way out of this one. He spoke more slowly. Something about a woman and her novio, her boyfriend. They had been making amor. This was getting racy. But then what was this about a preservativo? I looked it up. Preservative. Now I was completely lost.

In despair, Dr. P. made a hole of his thumb and forefinger, then poked his other finger in and out, looking at me pointedly. Novio – amor – romper el preservativo. Condom! It was a Helen Keller moment. He got up, wagging his eyebrows at me, while my cry of comprehension filled the room. After only a week in Spain, I’m nowhere near proficient, but that is one Spanish word I’m glad I learned from a doctor instead of a patient.

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