Thursday, July 21, 2011

Finally inspired.

It's not that I haven't done anything fulfilling in the past 5 months. Much to the contrary. Fourth year has been intellectually and emotionally fulfilling, beyond all belief. I learned how to manage scary things and be in scary places. I learned how to talk with people about death -- their death. I learned how to actually, legitimately perform brief interventions in psychotherapy. I returned to the clinic where my love of rural family medicine began. At times, I struggled (when least expected, really); at others, I felt so profoundly gratified. But I just never really felt like writing about any of it. It's just one more thing to do -- as though simultaneously preparing for my Boards, writing my residency applications, planning my wedding and subsequent epic travel (all of which will happen within the next five weeks) wasn't enough.

I almost wrote a few weeks ago, though. I've been recruiting patients for a clinical trial I am doing next month, and I received a phone call from a woman who had seen my advertisement. I recognized her name instantly. Because exactly two years ago, she made me feel like I could actually one day be useful to a human being. To excerpt from my July 2009 blog entry on this encounter:

I spent 2.5 hours with this woman. I asked her to talk about what it was like to wake up and move about, and dress and eat and get about her day. I asked her to talk about what it was like to leave the house, to interact with her family. To go food-shopping, to attend church. To process the world around her. To communicate with her doctors, her therapist. To feel alone, discouraged, purposeless. Hopeless.

And along the way, we tapped into issues that I wondered whether they'd seen the light of day before -- her anxiety about how she communicated with imprecision, about remembering certain key things in her day. I didn't know how to manage her meds; she probably really did need all 20 of them. But I knew about her anxiety. I've not had any training -- but I knew EXACTLY what to say, how to prompt her to evaluate her thought process.

Everything out of my mouth was fluid and confident. I knew that I knew what I was talking about, and I just did it. And she did it. She engaged the questions I asked her, engaged the concept of asking herself questions, of rehearsing her coping mechanisms in advance of encountering challenges, of developing an arsenal of experiences to draw upon that demonstrate her strength and confidence.

As each word passed my lips, I line-item compared it to those that have spouted during Spinning rides, blog posts, car rides, and all of the other opportunities I've given myself to practice, inadvertently, for this one moment.

As I deliberately carved each word to empower this woman to motivate herself towards change, with the exact same words that I'd used for so many literal and figurative hills for myself and others, I was so mindful of how directly I was speaking to myself just as intently as I spoke to the woman before me.

This was what I had trained for; this is what I had trained myself for.

I made her a list to take home with her of three skills she had developed and practiced during our time together. Her ammo against her depression that was all of her own active creation, to help the meds work better. Her way of reminding herself that she was in charge, actively constructing her own experience.

She smiled and took my hand.

And I knew that I could and would never practice medicine in any other field besides primary care.

So when I heard this woman's voice on the other end of the line, I flashed back to how truly fulfilled I felt when I wrote all that. I remembered, specifically, about the "list" I referenced. I had assigned her homework that day to go home and ride her horse, which she hadn't been able to bring herself to do for several years but once enjoyed. It was an exercise in "acting opposite" to her mood.

We made arrangements that she would come in to speak with me. But unlike the downcast, tearful woman I met two years ago, here she was with a bright, sunny straw hat making legitimate eye contact. She consulted the planner book in her purse before committing to schedule her study visits with me:

"Well, you see, I simply can't come on Thursdays. Thursdays are the day I ride my horse."

I bit my lip to keep from bursting into tears. I was so proud of her, this woman I hardly knew. And I told her so.

Now flash forward to yesterday. Back at clinic, I was asked to go see a young woman with complicated psychiatric illness who had begun to exhibit some self-destructive behaviors, who had expressed an interest in my study. She didn't qualify for participation, but I thought it might be a good opportunity to practice some of the skills I'd be actually using during study visits -- figuring it was worth a shot to try to help her. Went in, introduced myself, did a little bit of an intro pitch to diaphragmatic breathing, etc. Then I demonstrated her how to practice it, same as I would show someone on a Spinner bike. No big deal. Demonstrating to her how to rest her thumbs on her navel and let her fingertips expand across her lower abdomen so that she could gauge how well she was expending her abdomen on inhalation, I noticed how intent she appeared to learn this "skill." She looked up at me, wide-eyed and timid, with an expression on her face that seemed to be asking for approval.

The dynamic was foreign to me, in a clinical setting at least. I felt some combination of guilty, horrified, and overwhelmingly useful (as in, more so than I really should have been able to be useful) and sad. Sad because the way this girl was relating to me, more reminiscent of a young child, was the result of so many things gone wrong: her neural wiring, her life circumstances, her poor, poor coping mechanisms.

So I thought that I might try to teach her some coping mechanisms. One of the best things I learned on my outpatient psychiatry elective a few months ago was a component of cognitive behavioral therapy, a tool called Coping Cards. The idea was that you teach people, while they're not in crisis mode, to brainstorm coping actions or thoughts that they can look to during a crisis -- so that they don't have to think straight (since they're not likely to do so): the thinking is already done for them, by them, in advance.

I encouraged this girl to come up with a list of five actions she could immediately complete as an alternative to forcing herself to vomit when she got anxious. Without questioning me, she started rattling off a few things she could do to distract herself. I explained the concept of Coping Cards, handed her a few blank index cards that I started carrying around in my white coat pocket lately -- just in case I ever got to do this. And, again without questioning this foreign concept, started writing -- in a handwriting style and content consistent with the other regressive qualities I'd observed -- the following:
"Instead of vomiting, I could draw a picture."

Again, I wanted to bawl.

I didn't know if I was actually accomplishing a darned thing. But even getting to practice this skill that I didn't think most people even knew about, which I only knew about because of a very specific opportunity I sought for myself, with the promise of doing so much good with something so simple -- felt almost as good.

Monday, February 28, 2011

10 Lessons from Third Year.

Third year of medical school: the hailed carrot dangled before medical students throughout the country, *the* motivation to get us through the grueling hours in the anatomy lab, tedious biochemistry lectures, exam after exam after exam. When I began third year, otherwise known as clerkship year, 365 days ago tomorrow, I was as excited as anyone. I wrote about how I finally felt like I "belonged," like I was going to be useful, like it was going to be the adventure of a lifetime.

My roommate during first year (one of my "med school heroes" who used to be in the class above mine before taking a year off to complete a prestigious fellowship, and will now graduate with me) has prepared me for every step of medical school along the way. She told me what basic science classes were going to run me into the ground and make me want to drop out. When she started clerkship and hated every minute of her first rotation, she told me that, too. But somehow, I thought my life would be different. I was somehow going to be "above" the misery. I was Little Miss Balanced & Well-adjusted. Whatever.

Still, I structured my third year schedule according to what I expected it to be. I expected my surgical block to be the most painful, grueling and/or torturous, so I scheduled it for the summer so as to maximize my daylight (and, accordingly, my mood). I expected that block to be *less* horrible if I'd already completed an inpatient internal medicine rotation and, like, learned how to take care of sick patients (anticipating that they would *not* teach me that on the surgical rotations, somehow assuming that I'd know that already), so I arranged to do my medicine/neurology/psychiatry rotations first. Ob/gyn and surgery came second (yes, summer). I deliberately scheduled the rotations at which I figured I'd suck least and enjoy most -- pediatrics, family medicine, and outpatient internal medicine -- at the end, so that I'd end the year on a high note of confidence, optimism, and still-wanting-to-practice-medicine-ism.

You'll note that I haven't blogged in five months. Since I only blog when I'm emotionally distraught, I guess this means that I planned well.

As I sit here today, I am happy and content. I feel like I've learned what I needed to learn this year, with a clear idea of the experiences and exposures I want to have during the remainder of medical school. I feel balanced and at peace with myself, where I am, and where I'm going. But I don't want to forget, for a second, how utterly and completely miserable most of this year was -- along with the very specific insights I've developed about why this was all so.

And, so, I will write. I will write about what I've discovered about the process of medical training, the intersections of my idealism with real clinical practice, and about myself. Some of it won't be pretty. All of it I'll want to remember.

1. My job is to learn medicine; being useful is an occasional collateral benefit.
I spent first/second years with this obsessive, pathological preoccupation with being useful. I'd feel guilty for every worthwhile clinical experience I'd have, feeling like I did nothing to earn the generosity or trust of the patient who made themselves vulnerable solely for the purpose of my learning, and had no way to in any way alleviate the burdens of the folks at clinic who'd spend hours teaching me things, slowing down their day. My friends told me to stop. My mentors told me to stop. I couldn't stop. I... had... to be... useful [insert withdrawal tremor]. When I couldn't be useful as a medical student, I *had* to find ways to be useful in other realms of my life, whether that be coaching cycling groups for free, or signing up to mentor a 12-year old, or joining this or that committee, or any number of commitments I've taken on over time to get my "usefulness fix." And still, the pursuit of usefulness would continue indefinitely. Why? Because with all those little tastes of "the good stuff" comes the belief that pure, unquestionable usefulness is just around the corner.

Until clerkship year. Clerkship year, the residents make it abundantly, unambiguously clear that you are *not* useful. Your job is to wake patients up at 5AM to ask them if they've had bowel movements or passed gas. Your job is to carry around 40 lbs worth of gauze, scissors, and other random supplies (even though there's a supply closet within a 2 minute walk of any place you'd ever be). Your job is to read the minds of everyone peppering you with vague, impractical questions. Your job is to fulfill all of the random expectations that everyone has for you yet refuses to tell you about even when you ask multiple times. Your job is to finally "get" that you're not in any way useful to the team, and that you're best off finding a new goal for yourself. Like learning stuff. More on that next.

And in the end, you are useful. You're useful because you have time and motivation to translate "medical" into English for patients. You help people understand what's going on amidst the chaos, to give them a way of feeling like they have any sort of control over anything. You keep people informed about their lab results or the chest x-rays nobody told them they were having. You walk them around the floors, you help them use their incentive spirometer. You answer their family members' questions. You listen. You stop feeling compelled to prove your usefulness to yourself, finally, because you don't even want to think about how utterly terrifying a patient's experience in the hospital could be without a 'useless' medical student.

2. Showing up to a clinical experience without a specific set of learning experiences in mind to seek out is like showing up to the gym without a HR Monitor. And I sure as heck wouldn't do that.
I had an epiphany after my first three weeks of clerkship that I should be treating every day like a training session. From there on out, I had a checklist of specific things I wanted to get out of x rotation -- stuff I'd ask about, stuff I'd try to see, stuff I'd read about. A "To-Learn" List, if you will. It gave me a sense of purpose, structure, and meaning to my day. I don't know how people get through a day without doing this.

3. Hospitals are negative places.
Imagine you're sick. Really sick. You're sick enough to have to be in a hospital, where flocks of strangers wearing MRSA-covered white coats are coming in and out of your room, speaking in acronyms and jargon (to one another, barely saying two words to you) that you question whether it's even English. You get your blood drawn at least every day (then people are surprised that you're anemic), if not more frequently. You get whisked off for chest x-rays that nobody told you that you were having (let alone presented as a "recommendation" for you to accept/refuse). There are beeping alarms and monitors, and the person on the other side of the curtain is coughing so loudly that you're sure he's going to blow out his lung. You spend all your time on a hard-as-a-rock tiny twin bed with scratchy sheets and pillowcases. The only thing noisier than your room is the hallway outside your room. And then there's the silly, awkward medical student waking you up at 5AM (after you finally fell asleep at 4), asking you how you're feeling.

I've been through four hospitals now as a medical student. I used to be deeply afraid of and uncomfortable in inpatient settings; this is no longer the case. Instead, I just strongly dislike them. Two of the hospitals I've been through were small, community hospitals (as opposed to large academic tertiary care centers) that had fewer white coat-clad people scurrying about. It felt more peaceful there. Less chaotic. When it comes time to apply to family medicine residency programs this summer, I will surely keep this in mind.

Community hospitals have fewer people indeed -- and specifically, fewer (if any) residents. A study in the journal Academic Medicine in Sept. 2009 showed that empathy levels in medical students drastically dropped during 3rd year. I wonder if being around overworked, overtired, miserable people who complain about their jobs, their patients, and their lives all day long has anything to do with contributing to a sub-empathetic environment. Hmm.

The only residents who seem to actually tolerate, if not enjoy, their lives are pediatrics, anesthesiology, and family medicine residents. I'm glad I decided to become one of the latter.

On the rotations where I worked directly with attendings (obstetrics, family medicine, outpatient internal medicine, and outpatient pediatrics), I a) learned more; b) woke up every day actually wanting to show up to work; and c) didn't spend the whole day counting down the minutes until its end. It's hard to tell whether it was being around more uplifting life characters vs. being specifically out of the hospital vs. practicing primary care. I suspect it's a little bit of each.

4. Jadedness is not predetermined.

On my family medicine clerkship in rural Vermont, I had the opportunity to work with one of the most inspiring people I've encountered in my training to date. She was compassionate, kind, and empowering towards her patients. She was *exactly* how I want to be "when I grow up" (as one would expect, collecting various stylistic approaches along the way is a selective process -- picking and choosing "how to be" and, often more importantly, "how not to be" -- but with this mentor, she was literally completely masterful in every situation and inspiring in every way).

She was a relatively new attending, only a few years out of residency. I asked her how it was that she made it through residency without becoming jaded and cynical and awful. She told me that all I had to do was keep noticing the "awful," processing it with the people around me, and just being myself as best I can. In part, that's why I'm writing this entry.

5. "Sometimes, you just want to go home."

My obstetrics preceptor who, while having his share of shortcomings (namely, dictating overly legalized, defensive notes as he saw patients often without actually interacting with the patients -- just having them listen to what he said into the dictaphone; note to self: don't do that), was a super-smart, super-impressive character who had a lot going for him. He was a gifted surgeon and, despite his very strange and off-putting interactional style, somehow had the adoration of all of his patients. While I have no plans to model his style, I did find myself inspired by his ability to balance all of the different realms of his life. He was a competitive mountain bike racer and golfer, flew planes, was an elite pianist, stuff like that. Still, he was up on all the latest research and seemed to read everything out there in the world. He worked hard, stayed late, was meticulous about details. There'd be nobody who would ever question his work ethic or dedication.

One late afternoon, he turned to me and remarked in a profound-sounding tone: "Sometimes, you just want to go home." Tru dat.

6. There is more than one way to demonstrate one's survival skills.
A big thing that happened this year is that the athlete/coach part of me took a back seat. My long-time ankle injury persists, and cycling is really quite painful. I didn't do any distance riding (or much riding at all) this year, whereas a year ago I was banging out 100-mile rides to demonstrate to myself that I could "own my discomfort" and survive any challenge. I didn't have my fall-back "if x --> then y" construct of athletic mastery implying future clinical competence, which felt uneasy for a while (even though it didn't really make a whole lot of sense as a premise anyway). So instead, I had to focus on clinical competence itself. I read more, I asked more questions, I organized material in a way that was useful to me. In the end, it's not as disappointing to no longer identify as an endurance athlete.

Besides, I had a new kind of survival sport. The ob/gyn & surgery block. I remembered when my former roommate had done it the year prior, she told me that for her it was all about proving to herself that she could survive without sleep, proper fuel, proper self-care, etc. I reminded myself that this challenge for me, too, could serve that purpose -- I told myself every day that I was about to demonstrate a different kind of strength that I'd never before considered. Four months of daily discomfort, embarassment, fear, deprivation. Some of the longest days, the saddest moments, the grimmest outlooks. And pretty much as soon as it was over, I realized that it wasn't even half as bad as I expected.

7. Looking forward to something good is one thing; counting down the minutes to the end of something bad is another.
I spent most of third year counting down to the ends of each day, week, and month. It started out when I spent my first four months in Maine, on rotations I would have ordinarily enjoyed if not for my poor coping mechanisms for being separated from my now-fiance. Instead, I focused on how miserable and dehumanizing hospital medicine struck me, and told myself that life would be better if I could just get to June 18 (when I'd move back home). On June 17, I asked my now-fiance to marry me. Life became amazing. But after a short summer break, it was time to start the most grueling four months of third year. I told myself every single day that if I could just get to October 15, that life would become extra-amazing. I'd saved everything I expected to love til the end. Every single morning, I'd wake up and remind myself how many days there were til October 15. I'd drive to work in the pitch black dark, dragging myself even after three cups of coffee downed by 5AM, and huff and puff to myself about how soon October 15 would come. I reminded myself of all the horrible things I could be doing besides (whatever I was doing), and fantasized about my post-October 15 life. And when October 15 did roll around finally, it was completely non-anticlimactic. It was really as good as I'd hyped it to be.

But you know what? That was no way to live. I expect to only really have one month of the next 13 that I will dislike; however, residency is bound to contain several. I'd like to think that next time, I can take these experiences as they come, treat them as though they'd last forever, and learn to be ok with that.

8. It's tempting to reflect only on the bad moments and gloss over all the good ones.
I regret that I didn't blog about any of the positive role models with whom I've interacted this year. I didn't capture any moments of inspiration, or triumph. I didn't write about how good it felt to counsel patients with mood disorders and eating disorders, to reconnect with the specific population I went to medical school to help (or to remember that this was so). I didn't write about how rewarding it was that my dream clinic decided to allow me to carry out my dream study of which I conceived three years ago, and will finally have the opportunity to carry out in a few mere months. I didn't write about what it felt like to start believing patients in clinic when they tell me I'm going to be a good doctor. I did, however, complain a lot.

9. Feeling uncomfortable/awkward really can become the new "comfortable."
This personal project of mine, taken on as a second-year, ended up being exactly how I thought it might. Every time I felt or otherwise clearly behaved awkwardly, I would just tell myself I was awkward and... keep going. Over time, it didn't faze me. I could be awkward whenever I wanted, and the earth would continue to rotate. I could look stupid or silly or whatever and, still, life carried on. I didn't have to fix it or resolve it; all I ever had to do was own it.

10. Feeling adequate is a good thing, not an entitled one.
I used to feel guilty every time I appreciated that I didn't suck at something, as though that were a dangerous omen that I was becoming cocky and over-confident. Actually, it's a pretty healthy thing to feel competent.

I just spent three hours preparing a friend now starting her third year tomorrow. I cooked her dinner, and taught her the basics of how to function in the hospital: where to go, what to do, what to cover on 5AM "pre-rounds," how to write notes, how to present patients on rounds, how to survive in the OR -- things it took me a year to learn, yet could be covered in a few mere hours. I even taught her a few new clinical facts. I never thought I'd be in a place to explain this to another person, and to be confident that I was being helpful.

I have tons more to learn, and will always have tons more to learn -- but right now, things are going exactly according to plan.