Breaking the Numbness.

Another day in the SICU. Another code. Another death. This time, I knew the patient; yet, just like last time, I felt nothing as the end of his life was pronounced.

The scene was pure chaos. Multiple people calling out orders for IV boluses of potent medications to break the man's arrhythmia (ventricular fibrillation, with intermittent runs of what looked like the ever-frightful Torsades de Pointes), other medications to support his non-existent blood pressure. An attending physician who appointed a chief resident to "run the code," yet persisted in overriding his decisions. So many people calling for equipment and labs and answers. So many alarms beeping. The heaving sighs of chest compressions, interrupted ever so often by calls to "clear" before the defibrillator attemped to convert the man's heart back to sinus rhythm. And failed, over and over and over again.

A needle placed into the sac surrounding the man's heart revealed that it was filled with blood. Cardiac tamponade. The pericardial sac was drained, but his arrhythmia continued to be unresponsive and his pulse never resumed. After 43 minutes, the attending made the call that we would not be able to revive him. "It is 6:57pm. Mr. A. is deceased."

My eyes glossed over. A chill passed through me. But in a moment, it was gone. I helped wipe up the blood, and discard all the equipment - all the usual things that happen after an intervention for a living patient. The man's motionless, cold body looked no different than that of any other patient in the ICU. I left the room feeling just as unrewarded as I've left every room on the unit -- no more, no less.

A few minutes later, Mr. A's wife arrived to the ICU. A frail, petite woman in a wheelchair, she was escorted into the room where her husband's body awaited her. I never saw her face, only her side profile in the distance as a nurse told her what had happened as she opened the door.
I'll never forget the gray color her skin took, as she dropped her jaw in horror.

Then, only then, did my own tears flow.

I think and talk and write a lot about empathy, the importance of "inhabiting someone's existence" - truly trying to understand the multiple facets of their lives, their values, their influences. I don't think I've ever experienced true empathy but for the moments where I imagine what it would be like to receive the news that my soon-to-be-husband has died, or is dying. Every organ in my body twists up and squeezes. My ribs stiffen, preventing my heart from filling and beating as it should. I get cold and light-headed. Everything around me feels purposeless. In that moment, there is nothing worth living for.

I need to keep this pain in mind every single time I deliver this kind of news.

The difference is now that the pain isn't permanent. It feels real as can be in that moment. But then I return to the rest of my day. I move on to the next patient, a 28 year old who suffered an aortic dissection the day after he married his college sweetheart and spent 18 hours in the operating room, receiving practically the entire blood product supply of our state. I've been checking in on him throughout the day, watching his unstable blood pressure and persistent blood leaking into his chest tubes, feeling the coldness of his limbs and the weakness of his pulses. He's intubated and unresponsive, the same as he's looked all day.

But when I enter his room this time, his new bride is by his side. She strokes his hair and whispers into his ear. My eyes brim with hot, burning tears all over again. I look up at the ceiling to drain them, afraid that the young woman may see.

She asks me questions about how he's doing, what the beeping alarms and numbers reflecting his cardiac and renal function mean. I bite my tongue inside my mouth to stay focused as she speaks, as even my lip is to much of a give-away.

She bends closer to her new husband, resumes stroking his face beneath the twisted cords of his endotracheal and feeding tubes. This time, I hear her as she speaks to him.

"You're so strong to fight this. You have so much to live for - we have so much to look forward to in our new lives together."

I say goodbye, find a supply closet, and bawl.

D-E-A-D

Overnight call in the surgical intensive care unit. Arguably one of the scariest places in the hospital, the SICU consists of 30-something rooms with sliding glass doors lining the perimeter of a huge cluster of desks and monitors and collections of tubes and people and chaos. Most of the patients within each glass cubicle are hooked up to 2-10 different foreign bodies: central and peripheral IV lines, arterial lines, Swann-Ganz catheters, nasogastric tubes, drains, chest tubes, endotracheal tubes attached to ventilators, a dozen different kinds of ports of which I still don't know the names. Most of them are so heavily sedated that they do not even grunt when you poke and prod them, lifting their gowns to inspect their oozing wounds and measure the output of their bodily fluids. They're kept alive with positive pressure ventilation and potent vasoconstrictors to support their blood pressure. They're monitored more closely than anyone else in the hospital - besides the doctors (who actually do check on them repeatedly), they are cared for by ICU nurses, who are exceptionally smart and demonstrate more dedication and compassion than anyone around.

Still, I hate it here. I am so viscerally uncomfortable, the minute I punch the combination code to enter the SICU fortress. Every time I hear something beeping, my stomach curdles and I want to go home. This is why I requested to do a 27 hour shift here: to own my discomfort, immerse myself in the overwhelming chaos. And maybe, just maybe, learn a little bit about how to take care of the sickest patients I'll ever meet.

I've spent most of the day being just as useless as on my other surgical rotations - tagging along and lurking behind hardworking residents. But I'm actually learning a ton. I'm already far less overwhelmed by the mysterious collections of "things" to which people are attached, and things that beep. It's been a relatively smooth day...

... until tonight.

I accompanied my resident to see an 86 year old woman whom we intubated earlier this afternoon, who was now coming off of her sedation and beginning to appreciate the circumstances of her world. She was not pleased. Pulling at her breathing tube, moaning, gesturing to us to take it out. My resident explained that she needed it to breathe for now.

Out of the corner of my eye, I saw her tapping her bed - waving, almost. I asked her if she were trying to tell us something. She nodded.

I offered her paper and a pen. She began to scribble, slowly. I translated aloud, spelling the letters as she wrote.

D ...a....e...d....d...p...u...d...e...d...

This went on for five minutes. She kept tapping the pen in frustration every time I misread a letter.

D...a...e...a...d.

My heart sunk. I knew exactly what she was trying to write now. Should I continue? What if I were right? Or worse - what if I were wrong? I ignored my predictions. I dared not suggest it, just in case -- how scary and rude and horrific for her to hear this if it had not already been on her mind.

"Dead."

I read it, silently. Now there was no mistake. I couldn't ignore it -- now it was in plain sight. She was truly communicating to us that she wished us to withdraw support, right here on my little scrap of paper. My eyes glossed over. Chills down my spine, down my left leg.

"I can't read what you're saying -- maybe we can talk later?" said my resident.
I wasn't sure if he was dodging the issue, or truly couldn't see what I saw.
"I think she just spelled out d-e-a-d..." I said, softly.

Our patient began to tap fervently and nodding her head. We both stood there, frozen. I didn't know what my role was supposed to be at that moment. I hadn't even introduced myself as I tagged along with my resident into the room. I didn't know her, I didn't know her family. I didn't belong here. But here she was, telling us that neither was she. We had something in common.

I don't know anything about ventilators and central venous catheters and fixing people who are dying. But I knew a little bit about being scared in a hospital.

"I know you're scared. The breathing tube is just temporary. It comes out soon, as soon as your blood tests come back normal to make sure you're safe."
Blank stare.
"Is that what this is about? The tube?"
She shook her head no. I had no idea where to go from here.
"In the hospital, it's very common and normal to feel depressed and scared and hopeless. It goes away, it gets better..."
Blank stare.
"Your family -- do you remember them coming today?"
Shook yes.
"How about we wait for them to return tomorrow so you can talk with them?"
Shook no.
"Have you spoken with them before about your wishes?"
Shook yes.
"Are you close with your family?"
Shook yes.
"So how about we wait til tomorrow - maybe the tube will be out and you can speak freely..."
Shook no. She pointed again to her tortured letters on my notepad.

I hurt for her. She was so hypovolemic that her eyes were tearless. Mine made up for hers, I guess. I was at a loss. I understood her. I understood her loud and clear.

And I didn't know what on earth to do about it.

My First Death.

Rule #1 of a medical student on a surgical rotation: Never walk into an OR without first meeting the patient.

Today, I broke that rule. And it's probably the one reason I'll be able to sleep tonight. If I'm able to sleep tonight.

I was assisting my surgery preceptor with an elective surgery for a man with end-stage renal disease who needed better vascular access for dialysis. Was it the most fascinating thing in the world? No. Was it cool to see named vessels in a real, live person? Definitely. But then the phone in the OR rang, alerting us to an emergent case of a women presenting to the ED with a ruptured abdominal aortic aneurysm. See also: the scariest thing in all of medicine, wherein people bleed to death into their abdomens and/or their pericardial sacs.

"Go see that, Melissa!" my preceptor said. "That'll be definitely more interesting."

I didn't want to go. I knew I wouldn't be useful. I knew I'd be overwhelmed. I knew I wouldn't have met the patient before she was intubated and put under general anesthesia. I figured, however, that any other medical student would have loved the opportunity to observe the surgical management of a ruptured "triple A." I figured that I'd be an idiot for passing it up.

So I went. I gently opened the OR door -- and then *BAM* was blown away by the sights. There were 30 people, scrambling all over. Blood everywhere. Lots of monitors beeping. Surgeons calling out orders, calling for equipment and instruments. Organized chaos, if you will.

I slid up against the side of the wall. This was not my world. I didn't want to engage.

After a few minutes, the EKG alarm started going berserk. I recognized the pattern from televsion. The patient was in SVT. In my head, I silently reminded myself what drug to give her. Immediately thereafter, I heard the anesthesiologist announce that he was giving the patient this very drug. But the alarm continued to sound -- crazy fast beats, all over the place. Then, they slowed.

"She has no carotid pulse!" someone called out.
"That's your indication for ACLS."
"Beginning chest compressions now..."

I watched in horror. The surgeons continued to frantically attempt to stop the gushing blood from her aorta while the anesthesiologist rhythmically moved up and down behind the blue curtain separating her abdomen from the rest of her. I could only imagine how much force was being generated into her chest.

"This is useless - when do we call it?"
"Another 2 minutes..."

Two minutes later, they stopped. I didn't hear anyone call the time of death. I just left.

I felt numb. Kind-of like when I suctioned a demised embryo. I didn't feel anything, except the feeling that I "should" be feeling something.

I left the room. I saw my preceptor in the hallway a few minutes later. He started teaching me about the statistics of AAA ruptures and cardiac arrests and fatalities, and how the present situation had a 90% chance of occuring. I was silent. I realized that this perhaps projected disinterest.

"I'm sorry for being quiet. I've never seen anyone die before."

He asked me if I were ok, was truly kind and supportive. And I truly was ok.

Until an hour later, when I learned that this woman presented to the ED while her husband was being evaluated elsewhere in the hospital by a neurosurgeon for his own brain aneurysm.

When he came out of his appointment, after dealing with his own very scary reality, he would receive news that his wife was dead -- the very last thing he could ever have expected.

Then, I felt something. I felt a cold sweat break out, a deep ache in my stomach. I imagined what that might be like, and I felt like vomiting. I felt like crawling up into a little ball and bawling.

But instead, I cried just where I was.

This is not ok.

The sweltering OR lights dilate the vessels in my head and make me woozy. I alternate between being so overheated that I can barely stand upright, and with freezing chills from my sleep deprivation and the intermittent unbearably cold air conditioner. My face shield is fogged from my breath, my mask perpetually threatening corneal abrasion with its proximity to my fatigued eyeballs. The bottoms of my feet burn mercilessly from standing in place for 4.5 hours. I focus moreso on my duty to flex and extend my knees periodically to prevent venous pooling (and, accordingly, prevent passing out) than my duty to learn anything about surgery.

And then there's the smell of burning flesh, singed from the cauterizer. That, I pay attention to. It's grounding, somehow.

It is 10:30am. My shift was supposed to end at 7am. I've been here overnight, been awake 27 hours, and am scheduled to be back again in 8 hours. Sleep, studying, quality time with my fiance (who's been away for almost a month), and everything else that is supposed to comprise my "balanced" life is all supposed to fit in there. Yet, here I am in the OR, passively observing a 4.5 hour colon resection - with a field of vision more obstructed than the colon itself.

Ironically, this was quite possibly the one operation to which I was most looking forward to seeing on this rotation (I think the gut is amazing, and lots of my patients when I was a GI clinical research coordinator had colon resections by protocols that I only vaguely understood). I'd been able to spend time with the patient pre-operatively, who reminded me very much of a man I took care of in Maine on my medicine rotation (of whom I was very fond, who afforded me opportunities to build confidence and to be truly useful). So here we were, his abdomen sliced open with his oozing loops of bowel spilling out of his body - with so much promise to make him well! Perfect, right?

And yet, here I am: hard-pressed to recall any moments of my life as miserable as this one.

The back of my calf has a strange, sharp, throbbing pain. I am convinced that I have a DVT. I visualize it, ruminate over it. I imagine part of it breaking off and embolizing through my patent foramen ovale (a congenital hole in my heart that I conveniently learned this spring that I have), travel to my lungs and kill me. I try to make a Top 10 list of things about my present "learning opportunity" that are better than this scenario, and I truly can't come up with more than two. I instantly appreciate this as crazy. I become angry that this situation has driven me to think so irrationally.

Four times, I fall asleep while standing up. Once, I nearly fall onto the Mayo stand, the sacred base of sterility where all the instruments are kept. I resort to stepping side to side, or up onto and down from the step stool they've given this 4'11" medical student to be able to see over the surgeons' shoulders. I still can't. All this, and I can't see a thing.

The surgeon and the resident were too tired to teach me anything or engage me in any way. I wasn't being useful, I wasn't learning anything, and all I wanted to do was go home and snuggle my fiance and fall asleep for the rest of my life. And if that couldn't happen, I thought the DVT to pulmonary embolism plan was a good back-up.

The resident, the one with the scalpel in hand carving up segments of bowel, had been awake just as long as I had.

I "get" all the arguments about continuity of care, and how frequent hand-offs make for communication lapses that compromise patient care. But if the man with the scalpel feels half as dysfunctional as I do right now, there's something very wrong.

A blast of sunshine.

I'm post-call for the third day in a row. I've been awake for the past 20 hours, and have only slept 9 hours since Monday. I only have 4 hours off today before I have to leave for work again (see also: only 4 hours to sleep/study). But I aaaaaaabsolutely have to write before I attempt. (It's pretty nice to genuinely feel motivation to write again).

Since beginning night float, there's a new character in my life: the morning attendant at the hospital parking lot. I've never been LEAVING the parking garage at 9am before, so I've not previously made his acquaintance during my two years here. He looks about 70 years old, wears a big wicker cowboy hat, and always has a huge smile on his face. But that's not all. He doesn't just take your ticket and parking fare; rather, he chats you up about your day and your life outlook, and tells a select relevant anecdote. Literally, one spends 5 minutes at the parking window - even with traffic backed all the way up. And it's, like, the best 5 minutes of the day. You have to remember how many factors exist that drastically reduce the probability of my enjoying ANYTHING at this moment: I'm exhausted. I'm grumpy. I'm hungry. I miss my bed. I miss my fiance. But after this insanely long, totally context-inappropriate encounter with this character, I am glowing. I smile the whole drive home. I smile the whole way from my car to my apartment, and up the stairs. I'm still smiling now.

And the thing is: in my old life in NYC, this would never fly. In my old life, the old me wouldn't even have wanted this to fly. Five minutes to chat with a stranger about a gift his son bought him 20 years ago in Montana, and where he bought it, and how he sent it to him across the country (today's topic, for example) while I've been up 20 hours and haven't eaten in 12, and know that I only have 4 hours off between now and 24 hours from now?

This guy is SO good at his job. He makes every moment count. I'm sure that I'm not the only one whose entire day is brightened by his presence. I may be exhausted and I may be living according to a completely absurd, largely unreasonable life schedule -- but I'm hereby going to do my very best to be this kind of presence to at least one person every day.

My fiance has talked of how content he'd be to work an oft-underappreciated, underpaid job like this. He says he'd be really happy to work in the service industry as a McDonald's cashier or Starbucks bartender, or a school janitor: he's talked specifically of encounters like I've described -- "moments" of unexpected connection, the opportunity to brighten someone's day like none other. The elitist and realist in me, mindful of both of our massive student loans (and their obstructiveness to our having a comfortable life and starting to have children within a few years of getting married) and the discrepancy between societal (and my) expectations of how he'd use his very expensive, private university-earned Master of Business Administration degree, compels me to be vehemently opposed to these thoughts. I feel guilty about that sometimes, even though he's only half-serious to begin with. I suppose it's a good thing that my realism balanced his enlightenment -- but it's still a good reminder, today, to focus on those "moments" that can literally change the course of a human being's existence. At least for the moment.

A Night of Fulfillment.

New life policy: Blog entries need not be deep, philosophical analyses of life as we know it. If I'm actually going to continue to write when a) my husband-to-be is NOT away on a three-week hike, b) I'm on rotations like my current one, when I am allotted 4-6 TOTAL hours of free time per day (which I'd perhaps like to designate to sleeping), c) when I lack motivation to fulfill even the most basic life functions, I can't require myself to invest the amount of cognitive and emotional energy in my posts that I usually do.

I think there's plenty of stuff that just "happens" that I'd do well to capture, to hold onto.

Tonight was my first day of my surgery rotation -- I'm on "night float," covering the emergency surgical services for the next ten days. I work 6pm-9am every day, and my free time is broken up by random, inconvenient lectures. So I really only get to sleep for 4 hours each day, at random hours of daylight. I wasn't stoked.

But tonight was AMAZING. I interviewed patients in the emergency department with confidence, found that my brain was able to work most of the night (except 4am-6am: the end of the shift was unbearable and a complete waste of learning time -- I was just fighting to stay awake!), and had a particularly rewarding encounter:

20-something year old boy presents to the emergency department as if right out of a textbook. Sudden onset periumbilical pain that, over the course of hours, migrated to the right lower quadrant. Accompanied by nausea. Felt worst on bumps on the car ride to the hospital. Extremely tender; positive rebound. Classic appendicitis.

I took the patient's entire history, and spent 20 minutes getting to know him and his family - primary care-style. We talked about their lives, what he's studying in college, what he likes to do with his free time, what his concerns are. An hour later, I was scrubbed in to assist with his appendectomy at 2:45AM. Then, I was at his side in the post-anesthesia recovery unit, assuring him that he was "all fixed."

BAM. Just like that. A completed story, begun and wrapped up all in a few hours.

This almost NEVER happens. So many undetermined details, so much never discovered. Always so much pending. Mostly, that's ok. But this sort of rewarding, feel-good, warm-and-fuzzy connectedness and closure? Awesome.

View from the Top

In my former life (of five months ago), a huge chunk of my world revolved around climbing - literally, and figuratively. Largely, I've carved out my sense of a place in the world through defining the metaphor of committing to uphill terrain, tapping into significantly deep motivating forces to stay the course, and reaping the benefits of conquest. I've defined by concept by expending so much effort to coaching people to do the same.

In my former life, I derived so much comfort and confidence from this construct. Conceptualizing challenges in my world akin to particular stretches of road that I know how to endure and sustain by bike despite discomfort has given me the sense that I really can do anything. But more importantly, it gave me the sense that I really LIKED to climb. Not just because of how awesome it was at the top; it was always moreso that I was proud of the process.

And then, I stopped. I stopped climbing, literally (I avoid my bike - despite three Centuries under my belt and no accidents in a year, I've again begun to fear falling or make other excuses why I don't want to do this "thing" that was very recently my favorite thing ever) and figuratively. I don't seek out adversity in efforts to demonstrate my strength; I avoid it.

My fiance is a third of the way through a 270-mile hike across the entire length of Vermont. With nothing but 35 lbs on his back, he sleeps on wooden planks with mice crawling all over him every night. He, too, likes to demonstrate his ability to survive. But he also does it for the perks along the way -- the epic views from 4000+ feet, the neat wildlife, the breathtaking sunsets.

Tonight, I got my breathtaking sunset.

On the last day of my Ob/Gyn rotation (nearly daily 4:30AM wakeups, total awkwardness all day long because of completely undefined expectations from supervisors, frustratingly useless all day long), I watched my fourth birth: a beautiful baby girl. I cried through my mask. The baby's father bawled, which made me cry more. He stroked his glowing wife's head and snuggled her close. It was one of the most beautiful moments I've ever had the privilege to witness.

I started my third year clerkships with nephrology, where the goal was to situate people on either a road to dialysis or to death. Often, their end destinations were reached. It was depressing and awful, and I instantly decided that I hated hospitals - just because stuff like this actually happened. Turns out, this was largely an artifact of being on the service that takes care of the body's most important organ at a tertiary hospital that cares for the sickest of the sick for the whole state (and a lot of the state next door). Even so, the majority of my third year has been more about preventing imminent death than promoting health and wellness.

On Internal Medicine, none of the people I helped take care of are actually going to get better. Their hearts were failing; their livers and lungs were not far behind. On Gyn, I helped surgically reduce cancer loads from uteri, ovaries, and pelvic walls of women for whom the cancers would largely grow right back. On Ob even, I saw more suction dilation & curettage procedures for spontaneous abortions (miscarriages) than I saw live births. I even performed the suction of an embryo myself. I felt nothing. It was like cutting off a human head in gross lab all over again: just another day in the life.

That just shouldn't be.

It's hard not to get caught up in all the suffering and sadness without the energizing balance of primary care preventive health efforts. Even obstetrics is a chaotic, scary world where so much can go wrong in an instant. A shoulder can get stuck. An umbilical cord can rupture. An amniotic fluid embolism can launch, flying straight to the lungs or the brain. You never know that someone is going to be ok, until they're ok.

But then there's a clearing. Through the wet, mucky branches, we glimpse a moment of perfection -- a tiny new life entering the world. She is peaceful and perfect, the reward of intense dedication and commitment. Not mine, of course. But the fact that I have the opportunity to be present for the most special day in people's lives -- for a moment, to share the greatest joy they will ever know...

In an instant, it all becomes worth it.

Choices.

Sometimes you make choices that you're not particularly proud of.

My choice to not make time to write about any of the incredibly formative life experiences I've had over the past four months? Not my finest.

When I started this blog, it was to serve as a forum for self-reflection: to process, in real time, the subtleties of the thoughts, experiences and exposures that shape my world for better or for worse; to evaluate my choices along the way. Most of the time when I don't write, it's because I'm satisfied with the way I superficially process it as it's happening or, more frequently, because I'm too emotionally exhausted after telling my now-fiancé about a particular event that writing a "second processing" feels forced and chore-esque as opposed to cathartic.

But there's also something about the environment of medical training that makes me want to detach from thoughts and emotions alike. Something that makes me want to stick it in my back pocket, be glad it's done, and move on. Something that makes me just a little bit afraid of owning it, lest that give me the opportunity to regret it.

I did make some good choices recently, though.

On my psychiatry rotation in May, I chose to intervene in a child custody case. I chose to advocate for my patient, despite her history of severe mental illness and substance-induced violence, and chose to personally drive her and her mentally ill boyfriend an hour each way in my car to a hearing (after the hospital and child protective services refused to pay for a cab) that single-handedly enabled her to be able to keep her newborn son out of foster care and have a chance at supervised, safe recovery. I didn't necessarily think that she would be Mother of the Year; I didn't say that I did. My medical assessment of her psychiatric state, however, was that she was no more likely to make a bad parenting decision than hundreds of thousands of people who don't automatically get their kids put in child care -- and that she should at least have the opportunity to advocate for herself. My dramatic action (to seek the permission of legal services, my supervisor, and her supervisor to transport two homeless strangers, one of whom I was moderately fearful, in my own car) was the only thing that could have afforded her that. When I spontaneously offered, I didn't want to do it. I just felt that I had to. I couldn't not. It was the one thing, in that moment, that I could do to be useful, to contribute. It was my job.

On my internal medicine rotation in June, I chose to intervene in a patient's cancer evaluation. After I heard how pompously and jargon-esquely an oncologist explained my 93 year old patient's options to her, I chose to acknowledge that she understood 0% of her situation (including her option to do nothing). I chose how to re-present it to her, neutrally, and was fortunately able to find words that meant something to her. I asked her questions that helped elicit her underlying priorities and life values. Surrounded by 25 family members all crowded in the hospital room, I helped her frame the choice at hand (whether or not she wanted to know if she had cancer, based on whether or not she would do anything to treat it). My words found their place for each person in the room. There were tears and sighs and questions, so many questions. I patiently backed myself out of the equation, enough for her to make her choice clearly. I chose to hold her for the next hour as she sobbed on my shoulder. That was my job, too.

On my gynecology rotation, I didn't have a job. My role is ill-defined, and the circumstances of my environment contributed very little to any motivation to define it for myself. And I find that this very directly shapes the choices I make, new choices that I don't think I would have made before.

Calling upon my framework for evaluating new phenomenon: Where did this come from?

It comes from 4:15AM wakeups, 15-hour days where conscious patient interactions are limited to waking them up at 5AM (while they're supposed to be recovering from surgery), inquiring about their bowel movements, and forcing them to painfully contort their bodies to participate in a cursory exam that will be repeated an hour later by somebody else once I return with the rest of my overwhelming "flock" of white coats. It comes from how badly my feet burn after 9 hours a day standing in a freezing operating room, both temperature-wise and temperament-wise. It comes from the sterile, hostile surgical environment where the people entrusted with my development are more interested in advancing the tradition of 'education by humiliation' (which is actually preferable to hearing them mock and disrespect their patients' body habitus). It comes from being surrounded by overworked, exhausted residents who complain, talk dismissively of their patients, and are systematically forced to prioritize getting people out of the hospital over even attempting to connect with them. It comes from, from the minute I wake up, already wanting to go home.

Do I like it? Not one bit.

So on this rotation, I experienced almost the exact same situation as the previous one I described. But the players were different: a resident who in no way empowered me to take ownership of any of my experiences. The motivation was different: I didn't empower myself to do so either. The hours, the stressors. The excuses.

My resident explained my patient's options to her for evaluation of an ovarian mass that was causing her unbearable pain, which may or may not have been cancer: 1) do nothing, 2) drain it, which might be a temporary fix, or 3) have surgery, which would be a permanent fix. The trouble was that she had severe congestive heart failure, diabetes, hypertension (a significant risk factor for stroke), and severe lung disease. Surgery, for her, was a huge risk for death.

"Well, the thing about surgery is that you might not be able to get extubated... you might have to go on a ventilator for a little while," explained the resident.

Ventilator for a little while?! A little while, until her family may or may not have decided to take her off of it. A little while before death. That's a pretty important qualifier to include.

"Oh, no problem! A little while on the ventilator doesn't sound that bad," said my patient. "I'll go for surgery!"

"Ok, think about it some more - we'll come back this afternoon. See you later!" She and the rest of the team left, returning to the rest of their lives.

My heart sunk. My patient, who had no independent mechanism for evaluating her risk, was about to make what might be an irreversible choice. It would be her choice, of course, but based on things that we as her treatment team had a responsibility for communicating effectively. We failed.

I stayed behind.

"Mrs. W," I began. "You realize that you don't have to choose one vs. the other. You can try the low-risk option, the draining, and see if you get better. Then this way, you might not have to go through the dangerous risk of surgery."

I was leading her. I detected my own agenda, and I stopped. I didn't underscore the risks of surgery. I didn't underscore my concerns about all the reasons that she was more likely to die than not. I was a mere third year medical student; I didn't feel that I had the right to have an agenda. It wasn't my place to scare her. It wasn't my place to sit down and assume control over her life. The words I chose had powerful direction; however I chose to frame it and explain it, that's the way she would understand it. If I wanted to scare her, I could. If I wanted to make her understand, I could.

This profound responsibility, which should humble and thrill me, now frustrated me. I was tired. I was hungry. I was discouraged.

The optimistic smile on my patient's face brought tears to my eyes. And right there, I chose to check out. This wasn't my job.

But it should have been.

Permission.

A few days away from the end of my three-week rotation on the dementia unit. My attendings have been inspiringly warm and upbeat, I keep far more normal hours, and nobody makes me feel stupid. I wouldn't call the experience "rejuvenating" by any means; in fact, it's been a pretty dismal scene. So dismal that it only took me 14 hours before I completely wrote off my half-baked (but nevertheless present) ideas about dual residency in family medicine and psychiatry, once it became clear that I wasn't especially stoked about even my 15th hour.

I was tempted several times throughout this rotation to write. In theory, this was a "big deal" rotation for me (as a point of irrelevant trivia, I originally went back to school to do my pre-reqs and apply to medical school towards the specific pursuit of a career in psychiatry!). And there were quite a few "big deal" moments -- some painful, some overwhelming, some peaceful, some appreciative, some fearful, some outright absurd. But I wasn't motivated to write about any of it.

I wasn't especially motivated to think about any of it really, at least not meaningfully. When I spoke to my boyfriend by phone each evening, it was more about my curiousity about his dietary habits in my absence than about what it felt like to watch an old man drool and defecate on the floor. I rarely emailed with my mentor -- and when I did, it wasn't about what it was like to watch a room full of completely hopeless, barely functioning adults throw Dominoes at one another. When I fell asleep at night, I wasn't thinking about how helpless and incompetent I 'ought to' have felt about my inability to contribute anything to these people's lives. I wasn't thinking at all.

For all my talk of mindfulness, I was -- in a sense -- completely mindless.

And the days sort-of felt so. Though I attempted to approach this rotation with a specific set of structured goals, and though I fed off the positive energy of my attendings (who framed, for themselves, their role as more palliative than anything else), the day sort of ticked along according to a script. It was much like the rote, cursory scripts that many of the patients regurgitated with each interaction. There was very little connectedness; very little left with which to connect.

I had a good grasp for what was going on around me. My 3.5 years working in a psychiatric consulting practice before medical school left me with vague recollections of terms and drugs and phenomena --- things to which I've given absolutely no thought in the 4 years since I moved on from that particular job, but that surprisingly proved to be quite retrievable. I had the data points in mind, and tasked myself with learning how to manipulate that data into a usable form -- particularly as I imagined it playing out in primary care. It was a good approach, I'd say.

Today, I had my evaluation meeting with my attending. Turns out, he'd picked up on what I'd been doing. We talked about it. It was good. But when it came time to give me feedback on points for improvement, he said something I'd never expected:

"You need to give yourself permission to feel confident."

I've used the 'give yourself permission' construct quite a bit, for myself and for the athletes I coach, in a variety of contexts: permission to feel anxious, permission to feel uncomfortable, permission to feel (and outright be) awkward, permission to feel something. I've talked about the role of confidence in dictating my interactions with the world. But I've never combined them. It's always been about 'giving myself permission' to feel however I'm feeling, as a vehicle to reach confidence. There's a subtle difference.

"You know a lot," my attending said. "You know more than many of your peers. I see that. You need to decide to step up and use it."

I heard what he was saying. I'm exceptionally timid. I try to stay out of the way, kinda dance around in the questions I ask, never ever contribute my opinions. I'm obsessed with not looking stupid. I don't "take control" of the management of the patients I follow, because I feel like it's not my job. And very specifically, that's what feels most awkward about being a clerk. I don't get to practice making decisions. I didn't think it was my place. In a lot of cases, it's not going to be.

I asked him for some strategies for framing this issue, as I recognized it as stemming from a greater issue - a reinvention project that will go on indefinitely, I expect.

"Do it for your patients. Speak up not for yourself, not to impress your supervisor. But do it for your patients," he said. "Don't be afraid to be wrong. Just do it. Do it for them."

I'll try.

Expectations, revisited.

My second patient started bawling today, clutching at my hands and pulling me close. She's being discharged today, truly no better than when she walked in the door 1.5 weeks ago. She was bawling, she explained, because she's going to miss me.

My eyes welled up. I wished her well, thanked her for the privilege it has been getting to know her and help take care of her, thanked her for everything she has taught me. She cupped my chin and told me that I'm going to be a great doctor, and that she'll keep me in her prayers. I tilted my head up to drain the tears, to no avail. I needed to leave. I wished her well again, and left. I felt useful and proud and all the other things you'd think one would feel after a moment like that. But I also felt so profoundly sad. My patient isn't well, she's not going to be well. I spent 5 hours tracking down all her specialists for follow-up and jumping through hoops to get her portable oxygen to take home with her -- and after all of it, she's still not well. And I'm not well because of it. She has no concept of how unwell she is -- because neither her real doctors nor I did anything to frame it for her. Her expectations are entirely dependent on the words that leave our mouths.

Yesterday, we got biopsy results back from my first patient. He was discharged Monday with the label of a disease, a 10% understanding of that disease, and an absence of discussion about its prognosis. Not because this gap wasn't identified; it was truly because nobody really knew. But then the biopsy results came back, and it was not what we told him that he had. Instead, he actually has one of the first things I wrote on my initial assessment note the day I met him (based on a silly "flag fact" that I internalized during my Step 1 exam prep - if a question steam says that someone gets kidney disease 10 days after an upper respiratory infection, it is always implicit that they have IgA nephropathy -- and therefore, any question asked thereafter needs to operate with the presumption that the patient actually has IgA nephropathy). Nobody talked about IgA nephropathy, because of a really unique lab finding that he had - pointing to a specific category of diagnoses (an ANCA-associated vasculitis). Nobody read my note. When I asked a question about a particular lab test that would point to IgA nephropathy, I wasn't confident or articulate enough to explain what I was thinking. I let it go. Clearly, I reasoned, my thoughts were unfounded. I didn't step up.

Now we know that he has IgA nephropathy and the other diagnosis. There is no treatment for IgA nephropathy. He needed treatment for the other diagnosis, which he continues to receive. The treatment would not have changed. What does change is what happens next. This combination of IgA nephropathy and ANCA vasculitis is often fatal. When this guy left my care, he had no expectation that this was even on the table. Nobody talked about prognosis for ANCA vasculitis; it's so variable. But for optimistic people, the absence of specific cautions implies a reasonably positive expectation. So when this guy eventually hears from his primary nephrologist that he has this other disease process that he's never heard one word about after 2 weeks in the hospital, what will he think? He'll feel crushed. Alone. Mistrustful of the competence of those taking care of him. Not because anything is different, except his expectations. We didn't help shape his expectations - and those developed of his own devices are so drastically different from the reality he is about to learn.

And when I really started to appreciate this last night, I was the one bawling. My expectations were violated, too.

Learning to Listen

I'm exhausted. Physically and emotionally exhausted. I exist on cereal, soda, and however many gluten-free snack bars I can stuff into the pockets of my white coat. I haven't exercised in a week. I haven't slept adequately in two. My feet are on fire, accompanied by 1+ pitting edema up to the mid-tibia. My vasculature, my brain, my soul -- all of them resisting the reality of my new life.

I stopped dreaming that My First Patient was going to die. Not because he necessarily got better (as alluded to in my previous post, "getting better" = upgrading to lifelong dialysis -- so I guess, yeah, he got better). But because I'm now helping to also take care of My Second Patient, and I simply don't have the emotional resources to obsess over two people. How do people have practices? How do people have children?

My Second Patient is an elderly woman with congestive heart failure, chronic kidney disease, hypertension, and a slew of the other usual suspects, and came in on Monday with progressively worsening shortness of breath and fluid buildup. Our job is to a) help her breathe better, and b) figure out whether to blame the kidneys vs. the heart vs. some other entity. Three days later, she still can't breathe too well (even on oxygen!), and we haven't been able to get rid of much fluid with diuretics.

The worst part is that she lives 2 hours away (this is the closest big hospital), far away from her husband or anyone else who can be here to hold her hand. So I do.

I am so attached to this lady that it's sick. I've come thisclose to snuggling her. I also came thisclose to slapping my senior resident who marched into her room yesterday, leading our amusing-looking pack of lapdogs, poking and prodding her while spouting frightening jargon. When I returned to her room later to "translate" (from Medical to English), her eyes were red and moist. She had been crying.

I, too, am tearful often around this lady. Not because we have the "intimidated, confused, and alone" thing in common, which we do. I get tearful because she makes me feel like I might actually one day be a decent doctor. When I am forced (by my conscience) to explain test results and treatment plans (presented completely differently than the residents do: "today we're going to do x to you" doesn't exactly do wonders for one's locus of control) at the level of some fuzzy grey zone between sub-technical and respectful-lay (perhaps resembling Wikipedia-level medicine -- i.e., how most medical students learn anything that makes sense), I appreciate that I don't suck at it. I get nonstop practice at tetering on that fine line between "neutral" and "non-neutral." Everything matters here. Your tone, your facial expressions, your body language. The moments you create for people might actually be some of the only human interactions for the day. Their singular insight into "what's going to happen to them" that day, or ever. These moments matter. You can't butcher them or rush them. Or skip them (as My First Patient was about to be whisked off to the OR to have a catheter placed for dialysis, I asked whether any of his real doctors had told him. I nearly puked when I heard the answer.).

Today on rounds, my attending called out a senior resident for his ineffective nonverbal communication skills. It was a resident I actually like, who is actually pretty gentle and friendly with patients -- doesn't interrupt, is pleasant and reassuring. But my attending called out for the way he interviews patients while standing up, towering over them, with his arms crossed against his chest. I was very moved. Moved because FINALLY, for the first time on this rotation, someone called attention to everything I've been complaining about since I got here. Somebody finally said this wasn't ok. But the thing was, the resident didn't take this feedback constructively. Instead, he argued of the merits of "asserting one's self" with a patient, setting boundaries, "letting them know how it is." He didn't drop the "c bomb," but I thought he was going to.

"There's room for compassion sometimes..." he began. "But sometimes you just need to let the patient know that you're calling the shots."

This is who they leave me alone with, to teach me how to be a doctor.

My attending didn't bother to argue. I assume he chalked it up to a lost cause. But since he still had the floor, he continued.

"Sometimes you don't need to say anything at all. Sometimes you just listen. Everyone has a story."

One of the upshots of a) knowing relatively little about what's wrong with really sick people and how to fix them (or at least how to apply the stuff I know), and b) having relatively few responsibilities besides showing up early, hanging around late, and undergoing the various humiliating rites of passage associated with third-year med student life, is that I have all the time in the world to figure out other ways of being useful. I've found that my 'usefulness niche' is to listen to people's stories -- to look them in the eye, smile, and shut the hell up.

It's amazing what people tell you when you shut up.

I've created a construct of "listening quotient" -- how much listening will I do during any one enounter. The LQ is calculated on the basis of several factors: a) the look in a person's eyes -- are they scared? are they lonely? are they confused?; b) has any other human being interacted with him or her lately?; c) if I were in his or her place, how much and in what capacity would I want me there?; d) what is my purpose: data acquisition, comfort/assurance, interview practice, etc?.

Today, for example, I was tasked with performing a rectal exam on My Second Patient. I'd never performed an unsupervised rectal exam before, nor had I performed a rectal exam on a patient who didn't show up for an annual physical expecting to have one. I entered her room, and found her short of breath and distressed after experiencing an adverse drug event. Seriously? A rectal exam in the middle of this? Game over. So because I had the time, and because I did genuinely want to understand what she had experienced (so that I could relay it back to my team), and because I wanted her to feel like she had been heard, and because the LQ earned by knowing that I was about to impose discomfort, awkwardness, and potentially pain, we chatted for a good half hour before I explained why we were recommending (if it were ok with her) that I perform a rectal exam. I apologized profusely, etc. etc. about the nature of the exam, and helped her to roll over into the most appropriate (and comfortable, as I can attest via my experience as a patient) position. As a 400+ lb. woman, it was a challenge to attend to her modesty, comfort, and self-consciousness while helping her get into position. I'm not sure that I did a good job. And when it was all over (post-tissues: I ALWAYS give tissues; my doctors never did), we chatted again for another half hour. The blood I saw on my sample earned an even higher LQ, anticipating what I might one day have to tell her.

Tonight before I went home, I went in to check on My Second Patient. We went over some of her test results (good), and the plan for the next day (hopeful). She told me that her husband was visiting shortly (great!). And then, all of a sudden, she started bawling. I touched her arm.
"I'm so scared..." she said. My hand remained on her arm. I said nothing.

"Thank you. You make me feel so much better. You come with me to all my scary procedures, and you teach me about what's going on."

It's amazing what people tell you when you shut up and listen.

Snapshots from Week 1 on the Wards

I had so much to reflect on from my first week of inpatient medicine, so much I wanted to capture and document here in a format that I could look back on, a format that would keep me honest. But I didn't. Instead, I ranted to my roommates (I'm living in a dorm with four other med students, right across from the hospital), I ranted to my boyfriend. And I emailed my preceptor at the clinic.

I'll paste those emails here, more raw than I'd be able to re-create. His responses were what was epic about the exchange - but I think it's probably poor form to post someone's emails on the Internet, unbeknownst to him or her. But here's at least my end, for me to remember.

Thursday, March 11, 2010 -23:31.

Life is ok here. Slightly less disoriented as the days go by. Getting pretty good at writing notes, functioning on little sleep, and mildly to moderately competent at presenting without sounding like an idiot. Oh, and yesterday I found out that I passed my Boards.

I started my first rotation on Monday. Renal. Everything very interesting but exhaustingly sad and frustrating. Even the people who “get better” don’t actually really get better. It's almost like there is a drop-down menu: 1) dialysis now, 2) dialysis later, 3) death.

My first patient is the sweetest, nicest old man. I spend most of my day with him and his wife (a nurse), translating all the minutiae of his treatment plan (they totally care, and nobody ‘gets’ that they really, truly want to know every single thing that’s going on). They’re so scared, and they experience a greater sense of control by having specific data points to track. But all the data gets worse every day. Prior to a few months ago, he had no renal problems at all – and suddenly, he’s days away from dialysis. Diagnosis is still undetermined (repeated a biopsy today) – but he might actually have Wegener’s. I didn't know people actually got that. His renal function gets progressively worse, his sugars are skyrocketing from all the steroids he’s getting, and he has incidental lung findings that might be consistent with IPF (you taught me about how bad that on my last day at clinic; my first patient wasn’t supposed to actually have it…)

Most nights, I dream about him dying.

While I was at a lecture today, he had an ischemic cardiac episode (ST depression on ECG, initial biomarkers were negative but it was probably too early). I later found out he had to call 3x before anyone came to him. He had told me about overnight chest pain on pre-rounds this morning (which he later explained felt exactly the same as this episode), and my team unanimously concluded this was anxiety when I presented to them. Then, this happened. I felt horrible. I was too wimpy to advocate for him; I merely reported facts and didn’t dare express my differing opinion – even though, technically, this is an environment where I could have.

My residents frequently comment on what a great case this is for me to see as a student – an ANCA-positive vasculitis with possibly related lung findings (my one useful contribution to life was to suggest testing for anti-GBM antibodies, since that commonly but unfamously can show up ANCA-positive). But it doesn’t feel great. It feels awful. Every time he asks me if he’s going to get better and stop getting infused with all the poisons we’re giving him, and I have to find some horrible way to balance realism with whatever we’re waiting on for x day, it’s just awful. Important learning experience and preparation for what is to come, of course, but awful nonetheless.

Saturday,March 13, 2010 -11:30

Yesterday was a good opportunity to focus on all the non-"know how" parts of medicine, and to feel useful that way. It was a really scary day for my patient -- tunnel cath placement and start of plasmaphoresis and dialysis (all of which were decided last-minute, so he hadn't psychologically prepared for it). I had time to spend the whole day with him and talk about his fear, intervening/translating when various characters communicated sub-ideally (including eeeeeevery resident here, who all either spout nonstop jargon or deliver all news at the level of a first-grader; no middle ground). I hope I'm not naïve in thinking that piss-poor communication skills are not soley the result of time pressures that I don't yet have.

It's good that I'm literally forced, all day long, to practice educating him and his family at appropriate levels for all of them, and framing horrible test results and horrible treatment options (my new gripe that may prove to top "compliance" the longer I'm here, is the whole "we're going to do x to you today" without bothering to create even an illusion of perceived control).

I've been spoiled in spending so much time watching you communicate about difficult issues so expertly. But I forgot how instructive to watch how NOT to handle something, too - and attaching what I learn to this emotional memory, I hope will last. For example, we were recommending cyclophosphamide (communicated as "we're going to start you on cyclophosphamide" without a discussion of what it is or its risks) -- and the wife's eyes bulged out of her head. She clearly recognized the drug name and assumed her husband had cancer and that we weren't telling them, so started asking vague questions so as not to alarm her husband. The resident could have cleared this up so quickly, but didn't pick up on what the issue was instead was awkward and vague and ending up scaring the hell out of them. I don't think I'll ever forget that, the importance of inhabiting people's responses to be able to anticipate future response. I've been able to ask these folks all sorts of questions about their reactions to various events and interactions. I won't ever be able to spend an hour on that after clerkship - but hopefully I'll remember to ask at all.

I'd like to be at a place where I don't get tearful when I come home every night and show up to the hospital rehearsing my coping mechanism for finding him dead. Does this get easier?

In other news, today I saw the chalky blue-grey skin changes of amiodarone that I memorized and regurgitated for Boards but had never even seen a photo of. Seriously not ok.

Monday, March 15, 2010 -- 20:12
Today I pissed my supervising intern off by asking if I could call for a (free) dietary consult to teach my patient (who is actually getting better!!!) about how to adjust to his new restrictive diet. "It's too much information." A complete misread on who this guy is. He wants information. He wants to understand. He gets anxious without being able to have any expectations, or at least accurate ones (bonehead covering attending over the weekend told him he could go home today, without determining that plasma exchange isn't done as an outpatient here - Imagine his disappointment to learn that it's actually an entire week extra).

On the flipside, I'm now helping to take care of a new patient who's at a totally different level of what she understands and wants to understand. 78 year old woman, very much of the "doctors do no wrong, I entrust myself completely in all of your hands" mindset. I'm sure that I'll learn a lot about how differently I'll likely communicate with her than with the first guy. It's a tricky balance between making people feel comfortable and safe vs minimizing the fact that their kidneys are shutting down. It's entry-level "giving bad news" practice.

In other news, I independently diagnosed a real person for the first time. It was a result of relying on a flawed heuristic (I'd read someone's memoir a few weeks ago about missing ischemic colitis in a little old lady with a GI bleed) instead of legitimately knowing that the other potential causes I did know about were more common. It was the first time I had an original intelligent contribution within the borders of the state of Maine, and it didn't even earn a "good thought" (universal validation of medically intellectual legitimacy, of course). It was more "let's order a lactate to humor the silly medical student to make her feel like part of the team." I was kind-of furious at myself about how proud I was to be right, especially since I arrived at it completely unscientifically. But as a wise man once told me: "tis better to be lucky than to be good." I probably butchered that, sorry.

Time.

Status-post second day as a third-year medical clerk, and never have I been so conscious of time as a limited resource. There's not enough time in the day to see enough, read enough, eat enough, sleep enough -- even pee enough. Even when I have "free time" to do things reminiscent of My Old Life (the one from two days ago), I don't do them. Something's different.

"They" told us that everything becomes different now. All that matters is "our patients" -- the ones that were mentioned so infrequently during Orientation last week that I actually forgot (for at least a few hours) that I'd interact with any. Then, you show up and get thrown into this crazy, chaotic world of beeping alarms and White Coats walking around and spitting out numbers, minimizing human interaction wherever possible. The detachment is palpable.

A few hours into my day yesterday, though, I was told about a new patient coming into the Emergency Department after being sent in by his doctor urgently after discovering insanely elevated blood levels of potassium and creatinine. I was told he'd be "my" patient, and was later told to show up at the ED and interview "the guy in A8." I've gone into rooms to interview patients before: I could do this, I figured. So I found my way through the labyrinth of my new world, walked right in, sat right down, and... everything became different.

Over the past 36 hours, "the guy in A8" really has become "my" patient. I arrive at 5:30AM to check on all his labs and examine him. I present his updates to my team. I write up notes for his chart, write medication orders (seriously?), and spend most of the day with him and his family. I pop into his room periodically to give him "life updates," as I call them - what's going on with various tests, medications, and how the team is thinking about solving his case at x point. Because you know what? NOBODY ELSE IS.

"Be careful about giving patients too much information," cautioned my intern today. "You might make them anxious."

In addition to textbook resolution of his hyperkalemia, my patient was given insanely high-dose IV steroids yesterday to treat his mysterious kidney disease (which, in actuality, may be something that House throws out on his differential every episode but that we were taught in school that nobody actually gets...). Today, the team suggested adding another insanely potent immunosuppresent: a cancer drug, cyclophosphamide. Silly post-USMLE Step 1 jaw-jerk reflex goes off about the only thing I know about cyclophosphamide: that it can cause fatal hemorrhagic cystitis, and should be given with another drug called Mesna to inactivate its dangerous metabolite. Shot down. Silly med student. I pushed the issue with two interns, an attending, a pharmacist. I'm paranoid that this was my one opportunity to be useful, and I couldn't "sell it."

"So, we're going to start a new drug on you," says the intern to My Patient. I shudder. We're just going to do x to you. Not 'recommend.' No 'what do you think?' - no 'is this ok with you?'
"What is it?"
"It's a drug that shuts down your immune system."
"What's it called?"
"Cyclophosphamide."
Patient's wife (a nurse)'s eyes bulge out of her head. I instantly detect that she recognizes the drug name and thinks that her husband has cancer, and that we're not telling him. I try to intervene. Intern obfuscates with vagueness. My patient interrupts.
"Do I have cancer?"

Finally, it occurs to me how to explain that different drugs are used for multiple purposes. Everyone quiets down. But I deeply regret those 2.5 minutes where these lovely people felt in the dark about their lives. There was no need for it.

I continued to obsess over it, until I alleviated my hang-up by finding an article that documented that cyclophosphamide is the standard treatment for what we think he might have. I printed it. I don't know whether they cared what it said. But I did know that they cared that I knew they were scared and confused.

Tonight, it's time to leave. I tell the intern that I'm going to tell my patient that his cyclophosphamide first dose is coming tonight. That's when I was cautioned about the perils of keeping people informed about the whats, whens and whys of introducing toxic cancer drugs into their bodies, without thorough discussion of side effects. I did it anyway.

"Am I going to have to take this forever?"

I can't protect my patient from his kidneys or his medicines, or the cold alienation of his surroundings. I don't know whether my presence in his room contributes any real difference. I've never wanted to fix someone so badly. I hang onto his every little detail that comes out of his mouth, hoping that I'll catch some subtle little detail that everyone else blew off. I exaggerate the things I hear. I've been reading for hours about reactivated rheumatic fever. Nobody gets that. But then again, nobody gets what everyone thinks he has...

People say that the value of the third-year medical student is how much time we have. Unlike actual doctors managing dozens of patients, all of my energy and cognitive resources are invested in one man. I technically have oodles of time to indulge my tangents. But when you think about a round, little old man lying alone in a hospital bed -- caught in a balance between his kidneys trying to kill themselves and the toxins we gave him threatening to kill him first -- there's never enough time in the world.

Milestones.

One year ago tomorrow, we were assigned to flaunt our brand new White Coats and prance around the cardiology floor of the hospital and impose ourselves onto some unsuspecting patient. Our task was to go through the motions of interacting with a human being whilst wearing said new coat, to experience how the symbol translates into real life. The problem was that we didn't have any useful clinical purpose. The assignment wasn't "go and see Mr. Smith, take a history and do a physical." Rather, it was "go and see Mr. Smith and practice talking to him." See also: "Go wake Mr. Smith up, disrupt his restorative post-surgical sleep and ask him to tell you his life story (for the umpteenth time) for no reason other than for your practice interacting with a real person, despite your complete inability to contribute in any way to his life."

I couldn't make his heart pump stronger. I couldn't get him out of the hospital and back to his real world any faster. He didn't have an overwhelming desire to unburden himself of his innermost concerns. He wasn't looking for anyone to listen to him and support him. He just wanted to go home, and I could do absolutely nothing to further that end.

I didn't belong in that hospital. I didn't belong in that coat. I was an imposter, completely disconnected from any of the privileges of existing under those conditions. I knew it before I walked into Mr. Smith's room that I would feel awkward and guilty for draining his resources without serving any purpose of any kind. It was an experience of profound uselessness that scarred me, inspiring a borderline-pathological, obsessive sensor to evaluate my contributions to any patient who has allowed me to learn from him or her ever since.

Exactly one year later, imagine the irony of beginning my third-year clerkship. Yesterday, I drove and moved myself to Portland, ME (a feat in and of itself: my car was so packed that I couldn't see out the back OR side windows... that I made it here alive without rendering irreparable harm to myself or others is pretty mind-blowing) to start my new life. And this morning, I strutted into the hospital - garbed in White Coat, of course - with a confidence that I could not even have imagined a year ago.

Day 1 of orientation was pretty chaotic. Lots of info, lots of hallways, lots of disorganization. But as I walked those hallways, I felt something completely foreign to my inpatient experiences to date (see also: my "Operation: Own Your Discomfort" trips with my preceptor this Fall). I felt like I kind-of, sort-of, just-a-little-bit... belonged there.

The first day was concluded with my first patient interview as a third-year student.

Assignment: "Go see Mr. Jones. Don't take a history or perform a physical exam. Just talk with him about what it's like to be in the hospital." The same exact assignment from a year ago.

"I heard a little bit about your experience from Dr. X. What has it been like for you?"

Twenty thoughtful minutes later, I found myself discussing this man's use of narrative to construct a meaningful experience of his frightful events (cardiac arrest, followed by an induced coma). With each rendition of his story, he recounted, he felt more and more appreciative for his life and the people around him. He selected his details, framed their context and consequence -- all of it shaped exactly as he needed it to be. His story was his coping mechanism, his structure. His way of establishing control in the face of chaos.

As his words fell upon my eager ears, I was surprised at how natural it felt -- it felt just like interviewing a patient at clinic, as I'd done so many times before this year. Granted, he was not in acute distress. I don't think clearly or feel comfortable/confident/anything remotely positive whilst in the presence of someone in acute distress: this is definitely going to be a challenge, and one that simply did not present itself today. But for now, in the moment, I felt like I truly did belong.

"Enough"

Mmm. To unify the epic events of the past two infinitely-eventful-yet-blogless months: quite the daunting task. Starting this entry whilst sitting in an airport on layover awaiting a connecting flight home, part of me is sub-motivated to write at all. If I don't write, after all, I can't craft a mediocre product.

But the fact is, whatever I write not only should be "enough" - but will be. That's what the past two months have been about.

The last time I went two months without documenting the formative events of my world, both drastic and subtle, was Fall 2008 when I was dissecting cadavers and doubting my self-worth. Then, no matter how widely I opened my mouth to catch as much of the violently explosive stream of water gushing at me from the Hose of Medical Education, I couldn't learn or see or do or be enough. How on earth was I going to internalize enough information to earn the privilege of caring for a human being? To inspire trust and confidence?

Over the past 1.5 years, this theme of doing "enough" has been well borne out in my writings - and certainly in my thoughts. Am I studying enough? Am I reflecting enough? Am I balanced enough? Am I structured enough? Am I focused enough? Am I open enough? Have I earned enough? Have I re-earned and re-earned and re-earned enough? Am I confident enough? Am I self-critical enough? Am I self-forgiving enough? Do I feel enough? Am I "present" enough? Do I connect enough? Am I inspired enough?

Am I prepared enough?


Three weeks ago, I had my last day at the rural clinic where I've spent > 10 hours a week for the past year. Ironically, my last day was exactly one year from the first time I drove out to meet them (my first solo Interstate drive -- which, looking back on that post from the age of fake-driverdom, was such a big deal!). And just as that day forever changed my life, so will this one. My anniversary/departure rang of true synchronicity. Of course it would also be the day of a full staff meeting, where I got to bid adieu to everyone en mass (and receive the warmest of applauses) - where my hero would present me with a symbolic gift of the legendary William Osler's original "The Principles and Practice of Medicine" (1901), citing one of Osler's famous quotables acknowledging how much he learns from his students. Obviously, I cried in front of the whole clinic staff. Obviously. Of course we would drive through the snowy, winding hills to pay house calls -- just like on my very first day shadowing. Of course we would even see patients in clinic that I remember first seeing on that same first day. Of course I would have built-in opportunities for reflection, according to specific parameters, on how much has changed (my shift in the confidence:awkwardness ratio; my appreciation for being useful in some capacities) and how much has remained the same (how inspired I am by the energy of this place, these people; how fulfilling it is to connect with people, to understand the context of their family and community, to build on that understanding over time). Of course I took epically rewarding opportunities to thank my mentors, with great specificity, for what they have contributed to my world. I wrote to the clinic's executive director how it had been my dream to get accepted to medical school in Vermont, only to have access to meet him and see this clinic once -- let alone have the opportunity to actually train here, let alone for a whole year. I wrote to my PA mentor how invaluable it was to have someone so gifted so deeply and passionately believe in my ability to "do this" before I believed it myself. I wrote to my direct preceptor that I will spend my life working to match his balance of unfailing compassion, mindful self-reflection, and commitment to improvement of all kinds.

And when I walked out that door, I thought about what the executive director told me on my first day there: "In medical school, I always felt like an imposter... until one day, I didn't."

Beyond the hundreds of thousands of tangible and intangible things I've learned through this opportunity over the past year, beyond the influences of the energy and personalities and experiences, what made all of this all the more rewarding is that I created all of it. It didn't merely "happen." I found them, I sought them out. I decided very early that the more time I spent there, the more I would learn. Do I study books as much as other people? No. Is that bad? Maybe. But the difference is: the stuff I learned at clinic, I actually remember.

Which brings us to Influential Life Event #2. Last week, I took Step 1 of the United States Medical Licensing Exam. 6 hours of torturous convoluted questions on the basic sciences, genetics, and vague clinical correlations. Preparing for it has consumed my existence for the past two months -- particularly my "brain space" for self-reflection, self-nourishment, and self-other good things requisite for successful human functioning. I've spent most of the past month in particular glued to my kitchen table (across from my equally miserable roommate, preparing for the same exam) taking thousands of practice questions, displacing relevant and irrelevant knowledge with every extra factoid encoded, doubting my self-worth. Frustration, boredom, distraction were wicked breeding grounds for high-level procrastination. It was easier to make Spinning rides about some variant of the process than to actually engage in the process.

Did I study as much as other people? No. Did I make questionable choices of how I spent my time (i.e., packing up my apartment prematurely, snuggling with Scott, holding extra 2-hour endurance trainings for my riders, eating gluten and lactose, spending hours hanging out at clinic)? I'd argue that every one of those were good choices.

Why? I knew I didn't know everything, and would never know everything. Acknowledging that is less acceptance of mediocrity as I'd once surmised earlier in medical school; rather, it's setting reasonable, realistic, specific goals (i.e., to pass with a 20 point margin) and continue to invest in my big picture. I knew damned well that I knew a LOT. I knew a lot with great specificity. Not everything. Not even 50% of everything. But I thought that maybe, just maybe, I knew enough. And when I made that decision, suddenly my entire approach changed. I no longer feared Step 1. I no longer dreaded it. It was one big, epic "GAME ON!" -- the pursuit of success and conequest, not merely the avoidance of failure. There's a difference. And it matters.

It mattered on Game Day. Yes, there were tons of questions I didn't have the slightest clue how to answer. Yes, there were times where I muttered - literally, out loud - "are you kidding me?!" (ok, maybe I wasn't that polite/professional). But by and large, I saw a heck of a lot more opportunities to demonstrate the effectiveness of my preparation and knowledge base than obstacles to "endure." It's just how I coach people on the bike: directing one's attitude, choosing to perceive challenges as "opportunities" to demonstrate SOMETHING (strength, discipline, control, etc.) as opposed to something to suffer.

A lot of my friends told me that they "checked out" at times during the exam -- their minds wandering to skiing, to vacations, to sex. My mind wandered to snapshots, memories, of where or how I learned something. It was like Slumdog Millionaire. Sometimes it was a memory of a specific lecturer's memorable one-liner. Sometimes it was of my preceptor sharing a particular clinical pearl. But mostly, I had images of patients I'd seen at clinic. I'd read a question, admit that I either never read or never encoded this in an academic setting, sigh - and then all of a sudden, trigger a vision of someone and something I knew I'd seen. BAM. This happened over, and over and over again.

For the first time in medical school, I felt like I knew -- and was -- "enough."

I wanted to write about two subsequent life-altering experiences -- flying with my boyfriend to his hometown in rural North Carolina to meet 50+ of my future-in laws for the first time, and then reading an epically inspiring book, Every Patient Tells a Story (Lisa Sanders, M.D.). I've had so many thoughts and moments flying through my head that directly relate to the theme at hand. But I'm also supposed to be packing up my entire life into cardboard boxes and garbage bags, in efforts to move to a new state in 36 hours.

I've used this blog over the course of my training to date as a mechanism for processing important experiences, re-shaping and re-structuring them in a way that I'll want to look back on as evidence for what I've thought about and valued, documenting both the patterns that endure and evolve. When I fail to carve out time to write, I experience it as "cheating" myself out of an invaluable opportunity. But it's not like that. When I start clerkship (inpatient rotations) on Monday, I'm going to have hundreds of thousands of experiences that I'll want to "document" and reflect upon. I won't. The balance between "reflecting" and "living"/"doing" is an important one. Maintaining a sense that I am continuously evaluating "enough" is a truly high priority for me. It's just a matter of defining, and redefining, what that means.