On the roof of the Metropolitan Museum in New York City there was recently a bamboo structure entitled Big Bambú, designed by artists Doug and Mike Starn. To me, the bamboo stalks running in all directions suggest vectors—line segments whose length is representative of the magnitude of a force and whose orientation is indicative of the direction of that force. They serve as visual reminders of the great number of forces at work in the lives of the patients I care for and in my own life.
A 60-year-old man comes to see me in clinic two weeks after a myocardial infarction, his first cardiac event. He has diabetes, is 40 pounds overweight, smokes 20 cigarettes a day, and never takes the stairs. My focus is on reducing his risk of another heart event, which could be his last. My mind's eye sees a single big bold arrow (vector) that represents the force that should be compelling him to do all he can to reduce his cardiac risk. I take for granted that this imaginary arrow is topmost in his mind as well—that he is fixated on the trauma of the recent elephant sitting on his chest and the ensuing cardiac catheterization. I imagine that the desire to prevent another heart attack will motivate him to change his bad habits. When he comes back six months later, still smoking, still taking the elevators up from the first to the second floor, with 10 more pounds in his belly, I cannot understand, and subtly (but probably to him, not so subtly) let him know my disappointment and displeasure.
Later, though, I consider how other forces in his life are counteracting the “health vector.” His just-divorced daughter has moved in with him and his wife, and she and her 10-month-old son are occupying his den. Two people in his department have been laid off; is he next? He doesn't exercise because his high school football knees ache when he walks; he has never considered a bike. His father died at 61; is this his genetic fate? These are all powerful forces that oppose the single “simple” vector in my mind. My patient's life is a tangle of competing needs, hopes, and anxieties. Big Bambú, indeed. My patient may be unaware—or he may be all too aware—of these competing vectors. Perhaps my role as a physician is to help him grasp that even if some forces cannot be eliminated, something can be done to decrease their magnitude.
Maybe forces of other kinds are at work in my patient's life. Perhaps my patient's energy is focused on writing a novel. He tells me he writes two hours before work and then from 9 pm to 1 am. His mind is on creating a realistic plot, not 30 minutes of exercise a day. Who is to say that this creativity vector is less important than the health one? And what about fostering a healthy home environment? My patient's loading of the dishwasher for his wife, who also has a full-time job, may supersede any trajectory toward better personal health. I need to understand that I cannot eliminate vectors—that life is complex, full of forces pushing in all directions and all vying for supremacy. There are times I cannot even be certain if a given vector is beneficial or not.
Before passing judgment on my patient, I should certainly examine the vectors in my own life. How are my eating and exercising affected by the stresses of too many patients in clinic on a Thursday afternoon? The death of a 45-year-old woman who wasn't supposed to die? If I react to these stresses by watching TV instead of going to the gym in the evening, how can I expect my patient to handle his stresses?
In my own life, I have come to recognize particularly powerful influences from the vectors of mentoring, epiphany, and habit. Awareness of these vectors may also be helpful in my interactions with patients. Mentoring in the attending–student or attending–resident pattern is unlikely with patients, but our patients look up to us, and our own habits and outlooks on life can be examples—good or bad! If I can come to understand my patient, I might be able to bring about an epiphany for him with regard to a risk factor. I once told a patient that smoking clogs his arteries just like calcium blocks a pipe. That patient tells me that this example was the epiphany that caused him to stop smoking. Perhaps I can help a patient develop a good habit, emphasizing that if he can, for example, exercise for 30 minutes every day for two months, it will become a habit, a positive force toward better health.
Some of the most powerful vectors in the real world work in concert. A sailboat runs fastest not when the wind is behind it, but perpendicular to it. I would maintain that a powerful and superior vector can result if we let the poem we've just read, the Degas exhibit we saw yesterday, the story a patient told us in clinic last week, combine with the force of our scientific training.
I would like to have a simpler world around me than that suggested by Big Bambú, but I would be hiding my head in the sand if I thought there were only two or three vectors influencing my thoughts and actions. While I can rarely eradicate a negative vector, I can reduce the magnitude of its effect. I can create trajectories and increase the strength of the positive ones already at play in my life. Maybe, with a little luck and good intentions, I can help my patients do the same.