tag:blogger.com,1999:blog-89804533003335113302024-02-07T00:41:11.059-05:00Feel the Road.A medical student's quest for clarity, balance, and fulfillment.Melissa Marotta Houserhttp://www.blogger.com/profile/16888355366191460693noreply@blogger.comBlogger63125tag:blogger.com,1999:blog-8980453300333511330.post-52920934628677974422011-07-21T15:40:00.005-04:002011-07-21T16:31:39.143-04:00Finally 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.<br /><br />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 <a href="http://increaseandbreathe.blogspot.com/2009/07/meaning-something.html">July 2009 blog entry</a> on this encounter:<br /><br /><span style="font-style: italic;">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.</span><br /><br /><span style="font-style: italic;">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.</span><br /><br /><span style="font-style: italic;">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 </span><span style="font-weight: bold; font-style: italic;">rehearsing her coping mechanisms in advance of encountering challenges</span><span style="font-style: italic;">, of developing an </span><span style="font-weight: bold; font-style: italic;">arsenal of experiences to draw upon that demonstrate her strength and confidence.</span><br /><br /><span style="font-style: italic;">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.</span><br /><br /><span style="font-style: italic;">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.</span><br /><br /><span style="font-style: italic;">This was what I had trained for; this is what I had trained myself for.</span><br /><br /><span style="font-style: italic;">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, </span><span style="font-weight: bold; font-style: italic;">actively constructing her own experience.</span><br /><br /><span style="font-style: italic;">She smiled and took my hand.</span><br /><br /><span style="font-style: italic;">And I knew that I could and would never practice medicine in any other field besides primary care.</span><br /><br />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.<br /><br />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:<br /><br /><span style="font-weight: bold;">"Well, you see, I simply can't come on Thursdays. Thursdays are the day I ride my horse."</span><br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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 <span style="font-style: italic;">have </span>to think straight (since they're not likely to do so): the thinking is already done for them, by them, in advance.<br /><br />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:<br />"Instead of vomiting, I could draw a picture."<br /><br />Again, I wanted to bawl.<br /><br />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.Melissa Marotta Houserhttp://www.blogger.com/profile/16888355366191460693noreply@blogger.com0tag:blogger.com,1999:blog-8980453300333511330.post-55074839604722006362011-02-28T15:26:00.010-05:002011-07-23T07:56:28.627-04:0010 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. <a href="http://increaseandbreathe.blogspot.com/2010/03/milestones.html">When I began third year</a>, 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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><span style="FONT-WEIGHT: bold"><br /><span style="FONT-WEIGHT: bold"><span style="FONT-WEIGHT: bold">1. My job is to learn medicine; being useful is an occasional collateral benefit.</span></span><br /></span>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.<br /><br />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.<br /><br />And in the end, you <span style="FONT-STYLE: italic">are</span> useful. You're useful because you have time and motivation to translate "medical" into English for patients. <a href="http://increaseandbreathe.blogspot.com/2010/03/time.html">You help people understand</a> 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 <a href="http://increaseandbreathe.blogspot.com/2010/03/learning-to-listen.html">listen</a>. 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.<br /><br /><span style="FONT-WEIGHT: bold">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.</span> <span style="FONT-WEIGHT: bold">And I sure as heck wouldn't do that.</span><br />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.<br /><br /><span style="FONT-WEIGHT: bold">3. Hospitals are negative places. </span><br />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<span style="FONT-WEIGHT: bold">.<br /><br /></span>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.<br /><br />Community hospitals have fewer people indeed -- and specifically, fewer (if any) residents. A study in the journal <span style="FONT-STYLE: italic">Academic Medicine </span>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.<br /><br />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.<br /><br />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.<br /><span style="FONT-WEIGHT: bold"><span style="FONT-WEIGHT: bold"></span><br />4. Jadedness is not predetermined.</span><br />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).<br /><br />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.<br /><span style="FONT-WEIGHT: bold"></span><span style="FONT-WEIGHT: bold"><br />5. "Sometimes, you just want to go home."</span><br />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.<br /><br />One late afternoon, he turned to me and remarked in a profound-sounding tone: "Sometimes, you just want to go home." Tru dat.<br /><span style="FONT-WEIGHT: bold"></span><span style="FONT-STYLE: italic"></span><br /><span style="FONT-WEIGHT: bold">6. There is more than one way to demonstrate one's survival skills.</span><br />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.<br /><br />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, <a href="http://increaseandbreathe.blogspot.com/2010/09/d-e-d.html">fear</a>, <a href="http://increaseandbreathe.blogspot.com/2010/09/this-is-not-ok.html">deprivation</a>. Some of the longest days, <a href="http://increaseandbreathe.blogspot.com/2010/09/breaking-numbness.html">the saddest moments</a>, 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.<br /><br /><span style="FONT-WEIGHT: bold">7. Looking forward to something good is one thing; counting down the minutes to the end of something bad is another.</span><br />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 <a href="http://increaseandbreathe.blogspot.com/2010/03/expectations-revisited.html">how miserable and dehumanizing</a> 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 (<a href="http://increaseandbreathe.blogspot.com/2010/08/choices.html">whatever I was doing</a>), 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.<br /><br />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.<br /><br /><span style="FONT-WEIGHT: bold">8. It's tempting to reflect only on the bad moments and gloss over all the good ones.</span><br />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, <a href="http://increaseandbreathe.blogspot.com/2010/03/thursday-march-11-2010-2331.html">complain a lot</a>.<br /><br /><span style="FONT-WEIGHT: bold">9. Feeling uncomfortable/awkward really can become the new "comfortable." </span><br />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 <a href="http://increaseandbreathe.blogspot.com/2009/09/own-your-awkward-not-to-mention-your.html">own it</a>.<br /><br /><span style="FONT-WEIGHT: bold">10. Feeling <a href="http://increaseandbreathe.blogspot.com/2010/02/enough.html">adequate</a> is a good thing, not an entitled one.</span><br />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 <a href="http://increaseandbreathe.blogspot.com/2010/04/permission.html">to feel competent</a>.<br /><br />I just spent three hours preparing a friend now starting <span style="FONT-STYLE: italic">her</span> 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.<br /><br />I have tons more to learn, and will always have tons more to learn -- but right now, things are going exactly according to plan.Melissa Marotta Houserhttp://www.blogger.com/profile/16888355366191460693noreply@blogger.com1tag:blogger.com,1999:blog-8980453300333511330.post-35174551501982181052010-09-26T09:52:00.004-04:002010-09-26T10:24:48.123-04:00Breaking 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.<br /><br />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.<br /><br />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."<br /><br />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.<br /><br />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.<br />I'll never forget the gray color her skin took, as she dropped her jaw in horror.<br /><br />Then, only then, did my own tears flow.<br /><br />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.<br /><br />I need to keep this pain in mind every single time I deliver this kind of news.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />"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."<br /><br />I say goodbye, find a supply closet, and bawl.Melissa Marotta Houserhttp://www.blogger.com/profile/16888355366191460693noreply@blogger.com0tag:blogger.com,1999:blog-8980453300333511330.post-55306756422576463932010-09-16T22:22:00.004-04:002011-07-23T08:00:28.366-04:00D-E-A-DOvernight 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.<br /><br />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.<br /><br />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...<br /><br />... until tonight.<br /><br />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.<br /><br />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.<br /><br />I offered her paper and a pen. She began to scribble, slowly. I translated aloud, spelling the letters as she wrote.<br /><br />D ...a....e...d....d...p...u...d...e...d...<br /><br />This went on for five minutes. She kept tapping the pen in frustration every time I misread a letter.<br /><br />D...a...e...a...d.<br /><br />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.<br /><br />"Dead."<br /><br />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.<br /><br />"I can't read what you're saying -- maybe we can talk later?" said my resident.<br />I wasn't sure if he was dodging the issue, or truly couldn't see what I saw.<br />"I think she just spelled out d-e-a-d..." I said, softly.<br /><br />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.<br /><br />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.<br /><br />"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."<br />Blank stare.<br />"Is that what this is about? The tube?"<br />She shook her head no. I had no idea where to go from here.<br />"In the hospital, it's very common and normal to feel depressed and scared and hopeless. It goes away, it gets better..."<br />Blank stare.<br />"Your family -- do you remember them coming today?"<br />Shook yes.<br />"How about we wait for them to return tomorrow so you can talk with them?"<br />Shook no.<br />"Have you spoken with them before about your wishes?"<br />Shook yes.<br />"Are you close with your family?"<br />Shook yes.<br />"So how about we wait til tomorrow - maybe the tube will be out and you can speak freely..."<br />Shook no. She pointed again to her tortured letters on my notepad.<br /><br />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.<br /><br />And I didn't know what on earth to do about it.Melissa Marotta Houserhttp://www.blogger.com/profile/16888355366191460693noreply@blogger.com0tag:blogger.com,1999:blog-8980453300333511330.post-6058250048661885082010-09-13T21:16:00.004-04:002010-09-13T21:48:43.449-04:00My First Death.Rule #1 of a medical student on a surgical rotation: Never walk into an OR without first meeting the patient.<br /><br />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.<br /><br />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.<br /><br />"Go see that, Melissa!" my preceptor said. "That'll be definitely more interesting."<br /><br />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.<br /><br />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.<br /><br />I slid up against the side of the wall. This was not my world. I didn't want to engage.<br /><br />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.<br /><br />"She has no carotid pulse!" someone called out.<br />"That's your indication for ACLS."<br />"Beginning chest compressions now..."<br /><br />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.<br /><br />"This is useless - when do we call it?"<br />"Another 2 minutes..."<br /><br />Two minutes later, they stopped. I didn't hear anyone call the time of death. I just left.<br /><br />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.<br /><br />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.<br /><br />"I'm sorry for being quiet. I've never seen anyone die before."<br /><br />He asked me if I were ok, was truly kind and supportive. And I truly was ok.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />But instead, I cried just where I was.Melissa Marotta Houserhttp://www.blogger.com/profile/16888355366191460693noreply@blogger.com0tag:blogger.com,1999:blog-8980453300333511330.post-27998310086378116162010-09-06T16:34:00.002-04:002010-09-06T16:40:14.854-04:00This 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.<br /><br />And then there's the smell of burning flesh, singed from the cauterizer. That, I pay attention to. It's grounding, somehow.<br /><br />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.<br /><br />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?<br /><br />And yet, here I am: hard-pressed to recall any moments of my life as miserable as this one.<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />The resident, the one with the scalpel in hand carving up segments of bowel, had been awake just as long as I had.<br /><br />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.Melissa Marotta Houserhttp://www.blogger.com/profile/16888355366191460693noreply@blogger.com0tag:blogger.com,1999:blog-8980453300333511330.post-62966992760521003082010-09-02T09:54:00.003-04:002010-09-02T10:16:12.307-04:00A 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).<br /><br />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.<br /><br />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 <span style="font-style: italic;">wanted</span> 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?<br /><br />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.<br /><br />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.Melissa Marotta Houserhttp://www.blogger.com/profile/16888355366191460693noreply@blogger.com0tag:blogger.com,1999:blog-8980453300333511330.post-15228756619991744662010-08-31T06:49:00.003-04:002010-08-31T07:04:17.315-04:00A 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.<br /><br />I think there's plenty of stuff that just "happens" that I'd do well to capture, to hold onto.<br /><br />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.<br /><br />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:<br /><br />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.<br /><br />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."<br /><br />BAM. Just like that. A completed story, begun and wrapped up all in a few hours.<br /><br />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.Melissa Marotta Houserhttp://www.blogger.com/profile/16888355366191460693noreply@blogger.com0tag:blogger.com,1999:blog-8980453300333511330.post-32734660053068951662010-08-23T20:32:00.004-04:002010-08-23T21:17:28.826-04:00View from the TopIn my former life (of five months ago), a huge chunk of my world revolved around climbing - literally, and figuratively. Largely, I've carved out <a href="http://increaseandbreathe.blogspot.com/2009/07/synergy-balance-and-purpose.html">my sense of a place in the world</a> through defining the metaphor of <a href="http://increaseandbreathe.blogspot.com/2009/02/practicing-commitment-part-i.html">committing</a> to uphill terrain, tapping into significantly deep motivating forces to stay the course, and reaping <a href="http://spintastic.blogspot.com/2008/08/conquering-hills-on-off-bike.html">the benefits of conquest</a>. I've defined by concept by expending so much effort to coaching people to do the same.<br /><br />In my former life, I derived so much comfort and confidence from this construct. Conceptualizing challenges in my world akin to <a href="http://spintastic.blogspot.com/2009/05/translating-life-on-bike-off-bike.html">particular stretches of road</a> that I know how to endure and sustain by bike <a href="http://spintastic.blogspot.com/2009/09/own-your-discomfort-75-minute-profile.html">despite discomfort</a> has given me the sense that I really <span style="font-style: italic;">can </span>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.<br /><br />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.<br /><br />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 <a href="http://spintastic.blogspot.com/2009/06/do-it-yourself-ride-triumph-over.html">demonstrate his ability to survive</a>. But he also does it for the perks along the way -- the epic views from 4000+ feet, the neat wildlife, the breathtaking sunsets.<br /><br />Tonight, I got my breathtaking sunset.<br /><br />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.<br /><br />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 <a href="http://increaseandbreathe.blogspot.com/2010/03/expectations-revisited.html">stuff like this </a>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.<br /><br />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 <a href="http://increaseandbreathe.blogspot.com/2009/04/burden-of-generosity.html">cutting off a human head in gross lab</a> all over again: just another day in the life.<br /><br />That just <a href="http://increaseandbreathe.blogspot.com/2009/09/shoulds-and-should-nots-of-awkwardness.html">shouldn't</a> be.<br /><br />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.<br /><br />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... <br /><br />In an instant, it all becomes worth it.Melissa Marotta Houserhttp://www.blogger.com/profile/16888355366191460693noreply@blogger.com0tag:blogger.com,1999:blog-8980453300333511330.post-27979330231872531472010-08-20T16:34:00.003-04:002010-08-20T19:03:46.964-04:00Choices.Sometimes you make choices that you're not particularly proud of.<br /><br />My choice to not make time to write about <span style="font-style: italic;">any</span> of the incredibly formative life experiences I've had over the past four months? Not my finest.<br /><br />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-fianc<span style="font-size:100%;"><span class="alternate_name">é</span></span> about a particular event that writing a "second processing" feels forced and chore-esque as opposed to cathartic.<br /><br />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.<br /><br />I did make some good choices recently, though.<br /><span style="font-size:100%;"><span class="alternate_name"><br /></span></span>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 <span style="font-style: italic;">not.</span> It was the one thing, in that moment, that I could do to be useful, to contribute. It was my job.<br /><br />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.<br /><br />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.<br /><br />Calling upon my <a href="http://increaseandbreathe.blogspot.com/2009/11/taking-moment.html">framework for evaluating new phenomenon</a>: Where did this come from?<br /><br />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 <a href="http://spintastic.blogspot.com/2010/05/touching-lives.html">connect with them</a>. It comes from, from the minute I wake up, already wanting to go home.<br /><br />Do I like it? Not one bit.<br /><br />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 <span style="font-style: italic;">myself </span>to do so either. The hours, the stressors. The excuses.<br /><br />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.<br /><br />"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.<br /><br />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.<br /><br />"Oh, no problem! A little while on the ventilator doesn't sound that bad," said my patient. "I'll go for surgery!"<br /><br />"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.<br /><br />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 <span style="font-style: italic;">effectively.</span> We failed.<br /><br />I stayed behind.<br /><br />"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."<br /><br />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 <span style="font-style: italic;">have </span>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 <a href="http://increaseandbreathe.blogspot.com/2009/08/power-privilege.html">powerful direction</a>; 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.<br /><br />This profound responsibility, which should humble and thrill me, now frustrated me. I was tired. I was hungry. I was discouraged.<br /><br />The optimistic smile on my patient's face brought tears to my eyes. And right there, I chose to check out. <span style="font-style: italic;">This </span>wasn't my job.<br /><br />But it should have been.Melissa Marotta Houserhttp://www.blogger.com/profile/16888355366191460693noreply@blogger.com0tag:blogger.com,1999:blog-8980453300333511330.post-72190720773121234712010-04-13T17:02:00.002-04:002010-04-13T17:47:51.755-04:00Permission.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.<br /><br />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.<br /><br />I wasn't especially motivated to <span style="font-style: italic;">think</span> 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.<br /><br />For all my talk of mindfulness, I was -- in a sense -- completely mindless.<br /><br />And the days sort-of felt so. Though I attempted to approach this rotation with <a href="http://spintastic.blogspot.com/2010/04/dangers-of-not-training-for-something.html">a specific set of structured goals</a>, 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.<br /><br />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.<br /><br />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:<br /><br /><span style="font-weight: bold;">"You need to give yourself permission to feel <a href="http://spintastic.blogspot.com/2009/10/building-confidence-on-spinner-with-45.html">confident</a>."</span><br /><br />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 <a href="http://increaseandbreathe.blogspot.com/2009/09/own-your-awkward-not-to-mention-your.html">anxious</a>, permission to feel <a href="http://spintastic.blogspot.com/2009/09/own-your-discomfort-75-minute-profile.html">uncomfortable</a>, permission to feel (and outright be) <a href="http://increaseandbreathe.blogspot.com/2009/09/shoulds-and-should-nots-of-awkwardness.html">awkward</a>, permission to feel <span style="font-style: italic;">something</span>. 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.<br /><br />"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."<br /><br />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.<br /><br />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.<br /><br />"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 <span style="font-style: italic;">them</span>."<br /><br />I'll try.Melissa Marotta Houserhttp://www.blogger.com/profile/16888355366191460693noreply@blogger.com0tag:blogger.com,1999:blog-8980453300333511330.post-87660115571251415902010-03-25T15:04:00.005-04:002010-08-23T21:21:31.287-04:00Expectations, 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.<br /><br />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 <span style="font-style: italic;">no</span> 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.<br /><br />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 <span style="font-style: italic;">not</span> 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.<br /><br />Now we know that he has IgA nephropathy <span style="font-style: italic;">and </span>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 <span style="font-style: italic;">does</span> change is what happens next. This combination of IgA nephropathy and ANCA vasculitis is often fatal. When this guy left my care, he had <span style="font-style: italic;">no </span>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 <span style="font-style: italic;">anything<span style="font-style: italic;"> </span></span>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<span style="font-style: italic;"> </span>about<span style="font-style: italic;"><span style="font-style: italic;"></span></span> to learn.<br /><br />And when I really started to appreciate this last night, I was the one bawling. My <a href="http://increaseandbreathe.blogspot.com/2009/01/expectations.html">expectations</a> were violated, too.<br /><br /><br /><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div>Melissa Marotta Houserhttp://www.blogger.com/profile/16888355366191460693noreply@blogger.com0tag:blogger.com,1999:blog-8980453300333511330.post-25865187711709568452010-03-17T22:22:00.002-04:002010-03-17T23:51:09.722-04:00Learning to ListenI'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.<br /><br />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 <span style="font-style: italic;">children? </span><br /><br />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.<br /><br />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.<br /><br />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.<br /><br />I, too, am tearful often around this lady. Not because we have the "intimidated, confused, and alone" thing in common, which we do. <span style="font-weight: bold;">I get tearful because she makes me feel like I might actually one day be a decent doctor.</span> 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.).<br /><br />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.<br /><br />"There's room for compassion sometimes..." he began. "But sometimes you just need to let the patient know that you're calling the shots."<br /><br />This is who they leave me alone with, to teach me how to be a doctor.<br /><br />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.<br /><br /><span style="font-weight: bold;">"Sometimes you don't need to say anything at all. Sometimes you just listen. Everyone has a story."</span><br /><br />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.<br /><br />It's amazing what people tell you when you shut up.<br /><br />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?.<br /><br />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.<br /><br />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.<br />"I'm so scared..." she said. My hand remained on her arm. I said nothing.<br /><br />"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."<br /><br />It's amazing what people tell you when you shut up and listen.<br /><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div>Melissa Marotta Houserhttp://www.blogger.com/profile/16888355366191460693noreply@blogger.com0tag:blogger.com,1999:blog-8980453300333511330.post-51776162043558791802010-03-17T22:17:00.004-04:002010-03-17T22:22:02.443-04:00Snapshots from Week 1 on the Wards<div><p style="margin: 0pt;">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.<br /><br />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.<br /><span style="font-family:'Times New Roman';"><b><span style="font-size:100%;"> </span></b></span></p><p style="margin: 0pt;"><span style="font-family:'Times New Roman';"><b><span style="font-size:100%;"><br /></span></b></span></p><p style="margin: 0pt;"><span style="font-family:'Times New Roman';"><b><span style="font-size:100%;">Thursday, March 11, 2010 -23:31.</span></b></span></p><p style="margin: 0pt;"><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;">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.<br /></span></span></p><p style="margin: 0pt;"><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;"><br /></span></span></p><p style="margin: 0pt;"><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;"> </span></span></p><p style="margin: 0pt;"><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;">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.<br /></span></span></p><p style="margin: 0pt;"><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;"><br /></span></span></p><p style="margin: 0pt;"><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;"> </span></span></p><p style="margin: 0pt;"><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;">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. </span></span><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;"> </span></span><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;">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…)<br /></span></span></p><p style="margin: 0pt;"><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;"><br /></span></span></p><p style="margin: 0pt;"><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;">Most nights, I dream about him dying.<br /></span></span></p><p style="margin: 0pt;"><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;"><br /></span></span></p><p style="margin: 0pt;"><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;"> </span></span></p><p style="margin: 0pt;"><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;">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. </span></span></p><p style="margin: 0pt;"><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;"> </span></span></p><p style="margin: 0pt;"><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;"><br /></span></span></p><p style="margin: 0pt;"><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;">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.</span></span></p><p style="margin: 0pt;"><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;"> </span></span></p><p style="margin: 0pt;"><span style="font-family:Arial;"><b><span style="font-size:100%;"><br /></span></b></span></p><p style="margin: 0pt;"><span style="font-family:Arial;"><b><span style="font-size:100%;">Saturday,March 13, 2010 -11:30</span></b></span></p><p style="margin: 0pt;"><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;">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.</span></span><span style="font-size:100%;"><br /><br /></span><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;">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).</span></span><span style="font-size:100%;"><br /><br /></span><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;">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. </span></span><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;">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.</span></span><span style="font-size:100%;"><br /><br /></span><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;">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?</span></span><span style="font-size:100%;"><br /><br /></span><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;">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.</span></span></p><p style="margin: 0pt;"><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;"> </span></span></p><p style="margin: 0pt;"><span style="font-family:Arial;"><b><span style="font-size:100%;"><br /></span></b></span></p><p style="margin: 0pt;"><span style="font-family:Arial;"><b><span style="font-size:100%;">Monday, March 15, 2010 -- 20:12</span></b></span><span style="font-size:100%;"><br /></span><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;">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).</span></span><span style="font-size:100%;"><br /><br /></span><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;">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. </span></span><span style="font-size:100%;"><br /><br /></span><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;">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.</span></span></p><p style="margin: 0pt;"><span style="font-weight: normal;font-family:Arial;" ><span style="font-size:100%;"> </span></span></p></div><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div>Melissa Marotta Houserhttp://www.blogger.com/profile/16888355366191460693noreply@blogger.com0tag:blogger.com,1999:blog-8980453300333511330.post-55028672925893971452010-03-09T20:45:00.002-05:002010-03-09T21:26:00.813-05:00Time.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.<br /><br />"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.<br /><br />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.<br /><br />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.<br /><br />"Be careful about giving patients too much information," cautioned my intern today. "You might make them anxious."<br /><br />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."<br /><br />"So, we're going to start a new drug on you," says the intern to My Patient. I shudder. <span style="font-style: italic;">We're just going to do x to you. Not 'recommend.' No 'what do you think?' - no 'is this ok with you?' </span><br />"What is it?"<br />"It's a drug that shuts down your immune system."<br />"What's it called?"<br />"Cyclophosphamide."<br />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.<br />"Do I have cancer?"<br /><br />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.<br /><br />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.<br /><br />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.<br /><br />"Am I going to have to take this forever?"<br /><br />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 <span style="font-style: italic;">thinks </span>he has...<br /><br />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.<br /> <input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div>Melissa Marotta Houserhttp://www.blogger.com/profile/16888355366191460693noreply@blogger.com0tag:blogger.com,1999:blog-8980453300333511330.post-87485091328944755172010-03-02T00:02:00.003-05:002010-03-02T00:39:49.742-05:00Milestones.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."<br /><br />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 <span style="font-style: italic;">have </span>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.<br /><br />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 <span style="font-style: italic;">any </span>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.<br /><br />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 <span style="font-style: italic;">imagined</span> a year ago.<br /><br />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 <span style="font-style: italic;">completely</span> foreign to my inpatient experiences to date (see also: my "<a href="http://increaseandbreathe.blogspot.com/2009/09/own-your-awkward-not-to-mention-your.html">Operation: Own Your Discomfort</a>" trips with my preceptor this Fall). <span style="font-weight: bold;">I felt like I kind-of, sort-of, just-a-little-bit... belonged there.</span><br /><span style="font-weight: bold;"><br /></span>The first day was concluded with my first patient interview as a third-year student.<br /><br />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.<br /><br />"I heard a little bit about your experience from Dr. X. What has it been like for you?"<br /><br />Twenty thoughtful minutes later, I found myself discussing this man's use of <a href="http://increaseandbreathe.blogspot.com/2009/02/so-many-symbols-so-little-time.html">narrative</a> 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 <a href="http://increaseandbreathe.blogspot.com/2009/05/power-of-structure.html">structure</a>. His way of establishing control in the face of chaos.<br /><br />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.<br /><br /><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div>Melissa Marotta Houserhttp://www.blogger.com/profile/16888355366191460693noreply@blogger.com0tag:blogger.com,1999:blog-8980453300333511330.post-60998687120297985702010-02-25T07:03:00.009-05:002011-02-28T23:23:21.460-05:00"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.<br /><br />But the fact is, whatever I write not only <a href="http://increaseandbreathe.blogspot.com/2009/09/shoulds-and-should-nots-of-awkwardness.html"><span style="font-style: italic;">should be</span></a> "enough" - but will be. That's what the past two months have been about.<br /><br />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 <a href="http://increaseandbreathe.blogspot.com/2008/12/slicing-sawing-feeling.html">dissecting cadavers and doubting my self-worth</a>. 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?<br /><br />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 <a href="http://increaseandbreathe.blogspot.com/2009/03/promise-to-stop-procrastinating.html">studying enough</a>? Am I <a href="http://increaseandbreathe.blogspot.com/2009/12/2009-year-of-commitment.html">reflecting enough</a>? Am I <a href="http://increaseandbreathe.blogspot.com/2009/07/synergy-balance-and-purpose.html">balanced enough</a>? Am I <a href="http://increaseandbreathe.blogspot.com/2009/05/power-of-structure.html">structured enough</a>? Am I <a href="http://spintastic.blogspot.com/2010/01/2010-ride-and-year-of-focus.html">focused enough</a>? Am I <a href="http://increaseandbreathe.blogspot.com/2009/06/coming-full-circle.html">open enough</a>? Have I <a href="http://increaseandbreathe.blogspot.com/2009/04/burden-of-generosity.html">earned enough</a>? Have I re-earned and <a href="http://increaseandbreathe.blogspot.com/2009/11/changing-narrative.html">re-earned</a> and <a href="http://increaseandbreathe.blogspot.com/2009/08/power-privilege.html">re-earned enough</a>? Am I <a href="http://spintastic.blogspot.com/2009/06/trusting-your-judgment-evaluating.html">confident enough</a>? Am I <a href="http://increaseandbreathe.blogspot.com/2009/12/too-quick-to-dismiss.html">self-critical enough</a>? Am I <a href="http://increaseandbreathe.blogspot.com/2009/09/acceptance-loneliness-or-accepting.html">self-forgiving enough</a>? Do I <a href="http://increaseandbreathe.blogspot.com/2009/02/spiritual-care-at-hospital-feb-6-2009.html">feel enough</a>? Am I <a style="font-weight: bold;" href="http://increaseandbreathe.blogspot.com/2009/06/over-time-ive-come-to-accept-that-i.html">"present" enough</a><span style="font-weight: bold;">?</span> Do I <a href="http://spintastic.blogspot.com/2009/09/to-intervene-or-not-intervene-that-is.html">connect enough</a>? Am I <a href="http://spintastic.blogspot.com/2009/02/inspire-yourself.html">inspired enough</a>?<br /><br /><span style="font-weight: bold;">Am I </span><a style="font-weight: bold;" href="http://increaseandbreathe.blogspot.com/2009/07/meaning-something.html">prepared enough</a><span style="font-weight: bold;">?<br /><br /><br /></span>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 <span style="font-style: italic;">exactly one year</span> from <a href="http://increaseandbreathe.blogspot.com/2009/02/living-dream.html">the first time I drove out to meet them</a> (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 <span style="font-style: italic;">course</span> 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 <span style="font-style: italic;">course</span> we would drive through the snowy, winding hills to pay house calls -- just like on <a href="http://increaseandbreathe.blogspot.com/2009/03/stepping-into-role.html">my very first day shadowing</a>. Of <span style="font-style: italic;">course</span> we would even see patients in clinic that I remember first seeing on that same first day. Of <span style="font-style: italic;">course</span> 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 <span style="font-style: italic;">course</span> 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 <span style="font-style: italic;">once</span> -- 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 <a href="http://increaseandbreathe.blogspot.com/2009/02/practicing-commitment-part-i.html">commitment</a> to improvement of all kinds.<br /><br />And when I walked out that door, I thought about what the executive director told me on my first day there: <span style="font-weight: bold;">"In medical school, I always felt like an imposter... until one day, I didn't."</span><br /><br />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.<br /><br />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.<br /><br />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.<br /><br />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 <a href="http://spintastic.blogspot.com/2010/02/game-on-ride-mindset.html">my entire approach changed</a>. I no longer feared Step 1. I no longer dreaded it. It was one big, epic "<a href="http://spintastic.blogspot.com/2010/02/game-on-ride-mindset.html"><span style="font-weight: bold;">GAME ON!</span></a>" -- the pursuit of success and conequest, not merely the avoidance of failure. There's a difference. And it matters.<br /><br />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 "<a href="http://spintastic.blogspot.com/2009/09/own-your-discomfort-75-minute-profile.html">endure.</a>" It's <span style="font-style: italic;">just</span> how I coach people on the bike: directing one's attitude, choosing to perceive <a href="http://spintastic.blogspot.com/2009/06/do-it-yourself-ride-triumph-over.html">challenges</a> as "opportunities" to demonstrate SOMETHING (strength, discipline, control, etc.) as opposed to something to suffer.<br /><br />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. <span style="font-style: italic;">My</span> mind wandered to snapshots, memories, of where or how I learned something. It was like <span style="font-style: italic;">Slumdog Millionaire.</span> 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 <span style="font-style: italic;">knew</span> I'd seen. BAM. This happened over, and over and over again.<br /><span style="font-weight: bold;"><br />For the first time in medical school, I felt like I knew -- and was -- "enough."</span><br /><br />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, <span style="font-style: italic;">Every Patient Tells a Story</span> (Lisa Sanders, M.D.). I've had so many thoughts and <a href="http://increaseandbreathe.blogspot.com/2009/11/taking-moment.html">moments</a> 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.<br /><br />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. <span style="font-weight: bold;">It's just a matter of defining, and redefining, what that means.</span><br /><br /><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div><span id="leoHighlights_iframe_modal_span_container"><div id="leoHighlights_iframe_modal_div_container" style="border: 1px solid black; position: absolute; visibility: hidden; display: none; width: 394px; height: 40px; z-index: 32768; background-color: white;" onmouseover="leoHighlightsHandleIFrameMouseOver();" onmouseout="leoHighlightsHandleIFrameMouseOut();"> <div id="leo_iFrame_closebar" style="position: absolute; top: 0px; left: 0px; width: 394px; height: 40px; z-index: 32768; background-image: 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</script></span><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div>Melissa Marotta Houserhttp://www.blogger.com/profile/16888355366191460693noreply@blogger.com0tag:blogger.com,1999:blog-8980453300333511330.post-82534757968155127242009-12-31T16:42:00.001-05:002009-12-31T16:46:12.709-05:002009: The Year of CommitmentSince meeting the love of my life, I write far less. After all, I have an alternative mechanism for reflecting and processing -- perhaps not achieving the same level of splicing my reality or deleting content from RAM as does the process of writing, but rewarding in different ways for different reasons. It's a balance: still a work in progress. But there is one rigid, inflexible, much-anticipated written ritual for which I *must* carve out time: my New Year's decree.<br /><br />During the last week of each year since 2005, I open my electronic file of New Year's Resolution documents. I review each and every one of them, taking the time to re-inhabit where I "was" when I wrote them. What was important to me? What did I believe? What did I dream? How did I relate to the world around me? Who was I? What has endured, and what has changed? Then, I take stock of these previous goals in the context of the present: Did I achieve them? Did I fail? Why or why not? And does it matter, to the Present Me? And after reviewing and re-evaluating every single resolution I've ever set, I carve out an action plan for the year ahead -- informed by my previous values, achievements, failures, and lessons, transformed into the context of my present values.<br /><br />On the eve of New Year's Eve 2009, I can reflect with confidence that I kept each and every one of <a href="http://spintastic.blogspot.com/2009/01/new-life-policy-blog-more-study-less.html">this year's resolutions </a>(for the second consecutive year, at that). They were informed, thoughtful, and behavior-oriented. I didn't aim to "be" a certain way; I aimed to "do." And at the time that I set out these "doing" aims, I had specific, step-by-step actions carved out to prepare and enable myself to do so. It was the best resolution-setting operation I'd ever undertaken, faciliated by preparing a <a href="http://spintastic.blogspot.com/2009/01/new-years-empowerment-ride.html">"New Year's Empowerment"</a> Spinning ride that proved to be the most [permission to be arrogant self-granted] creative and important contribution I've ever made as a coach.<br /><br />Building on 2006 ("The Year of Change" - leaving my stimulating/rewarding career after appreciating how significantly it drained my creativity, self-advocacy, and ambition), 2007 ("The Year of Discovery" - dabbling in new experiences from which I abstracted no meaning until the year was over), and 2008 ("<a href="http://increaseandbreathe.blogspot.com/2009/01/putting-it-all-together.html">The Year of Putting it All Together"</a>), I embarked upon 2009 with goals of establishing a sense of feeling "complete." Assembling the missing pieces, acquiring the opportunities and experiences I sought to learn from, and charging forward along an ever-evolving path. Along the way, I tapped into the metaphor of a <a href="http://increaseandbreathe.blogspot.com/2009/02/practicing-commitment-part-i.html">red blood cell undergoing hematopoetic differentiation</a>: influenced by "growth factors" along the way, maturing and developing in a certain direction, accelerating on its journey without possibility of going back. In effect, 2009 became "The Year of Commitment." <span style="font-style: italic;">(Only fitting that I would meet the love of my life two months from said year's conclusion, of course.)</span><br />In 2009, I carved out an existence that completely fused the values and experiences that were important to me as a physician-in-training, a coach, an athlete, a writer, a human being.<br /><br />I learned how to <a href="http://spintastic.blogspot.com/2009/05/translating-life-on-bike-off-bike.html">apply my experiences in one realm of life to another</a>, to find synchronicity and meaning and <a href="http://increaseandbreathe.blogspot.com/2009/07/synergy-balance-and-purpose.html">balance</a>, and to <a href="http://increaseandbreathe.blogspot.com/2009/07/meaning-something.html">connect with</a> and <a href="http://spintastic.blogspot.com/2009/07/practical-applications-of-life-on-spin.html">inspire the same in other people.</a><br /><br />I learned <a href="http://www.blogger.com/im%20going%20to%20make%20a%20ride%20about%20this%20http://spintastic.blogspot.com/2009/05/im-going-to-make-ride-about-this.html">how to use my tools</a> and resources to <a href="http://increaseandbreathe.blogspot.com/2009/05/power-of-structure.html">structure my experiences</a> exactly as I need them.<br />I learned that by putting aside my perceived <a href="http://increaseandbreathe.blogspot.com/2009/09/own-your-awkward-not-to-mention-your.html">awkwardness</a> and inadequacy and enduring but a moment (ok, a looooooong moment) of <a href="http://spintastic.blogspot.com/2009/09/own-your-discomfort-75-minute-profile.html">discomfort</a>, I can and will <a href="http://increaseandbreathe.blogspot.com/2009/02/living-dream.html">achieve exactly what I want</a>.<br /><br />I learned how to <a href="http://spintastic.blogspot.com/2009/06/trusting-your-judgment-evaluating.html">critically evaluate</a> how I measure up to my own standards, and <a href="http://increaseandbreathe.blogspot.com/2009/09/shoulds-and-should-nots-of-awkwardness.html">when to re-evaluate those standards</a> in the first place.<br /><br />I learned how important it is to me to be "<a href="http://spintastic.blogspot.com/2009/03/training-for-something.html">training for something</a>," to be pursuing improvement - even f<a href="http://spintastic.blogspot.com/2009/03/6-hours-on-spin-bike.html">or the satisfaction of improvement alone</a>. I learned how critical it is to <a href="http://increaseandbreathe.blogspot.com/2009/09/acceptance-loneliness-or-accepting.html">define "improvement"</a> on a case-by-case basis.<br /><br />I learned how to optimally <a href="http://increaseandbreathe.blogspot.com/2009/06/what-i-learned-during-my-first-year-of.html">learn from my experiences</a>. Nothing is by accident. When I feel <a href="http://spintastic.blogspot.com/2009/04/best-day-of-my-life-on-bike-and-off.html">proud</a>, or <a href="http://spintastic.blogspot.com/2009/06/do-it-yourself-ride-triumph-over.html">strong</a>, or <a href="http://increaseandbreathe.blogspot.com/2009/04/empowerment-of-fear.html">afraid</a>, or <a href="http://increaseandbreathe.blogspot.com/2009/06/ineffective-self-efficacy.html">incompetent</a>, it's all for a reason. It's my job to identify that reason, internalize it, incorporate it into my processing of all future incoming stimuli, and to call myself out on it when I <a href="http://increaseandbreathe.blogspot.com/2009/12/too-quick-to-dismiss.html">identify prospective challenges</a> to upholding a given "life policy."<br /><br />I learned how to splice and shape <a href="http://increaseandbreathe.blogspot.com/2009/11/changing-narrative.html">a story to tell myself</a>, an edited version of reality that means more than its composite details.<br /><br />And above all, I learned to experience myself as <a href="http://increaseandbreathe.blogspot.com/2009/03/stepping-into-role.html">committed to a journey</a>. A journey that <a href="http://increaseandbreathe.blogspot.com/2009/05/flaneuring-to-purpose.html">evolves every day</a>, a journey with no specific requirements other than to persist. I've ranged from <a href="http://increaseandbreathe.blogspot.com/2009/02/so-many-symbols-so-little-time.html">blind optimism</a> to epic doubt, to a (reasonably) quiet confidence that e<a href="http://increaseandbreathe.blogspot.com/2009/06/coming-full-circle.html">verything is exactly as it is "supposed" to be</a>. And I've come to appreciate that, as <a href="http://increaseandbreathe.blogspot.com/2009/08/power-privilege.html">harsh the reality</a> of privilege that comes along with it, it's a pretty sweet journey indeed.<br /><br />So now what?<br /><br /><span style="font-weight: bold;">2010 is the Year of Being Present on my journey. </span><br /><br /><span style="font-weight: bold;">What does it take to "be present?"</span><br /><br /><span style="font-weight: bold;">I will listen better, without anticipating or interrupting. </span><br /><span>In my 2008 reflection document, I praised myself for becoming a better listener and dedicating myself to improvement to that end. I may be more perceptive now, I may ask more thoughtful questions - I may have a better sense for what I don't know and need to know in order to inhabit one's existence. But I'm not a better listener. I anticipate too much, think too much, track too much. Interrupt too much. In 2010, I will shut up and listen.</span><br /><br /><span style="font-weight: bold;">Since I anticipate interrupting myself every 30 seconds, I will establish a mechanism for re-focusing</span> .<br /><span>It's the same as I coach people to do in Spinning classes -- closing one's eyes, finding one's breath, and tapping into some detail -- any detail -- until the connection takes hold.<br /></span><span style="font-style: italic;"><br /></span><span style="font-weight: bold;">I will establish a reliable system for managing my commitments while protecting my RAM.</span><span style="font-weight: bold;"> RAM is reserved for medicine.</span><br /><span>A predictable side effect of my 2009 resolution to "take action on new ideas within 24 hours of conception" (vs. sitting on them forever) is that I made a lot of internal commitments this year -- all of them meaningful, all of them rewarding. All of them time- and energy-consuming. Most of them exhausting. While I'm proud of myself for structuring a reality where I actually DO the things I think about, I need to be more mindful of my resources. I'm getting older: I have less energy, I need more sleep. I need more (as my boyfriend says) "nothing box" time. Instead, I consume all available RAM tracking these grandiose projects I start (and am committed to -- commitments are commitments, and entirely unbreakable no matter what). Since all available RAM is spent tracking work to do, there is no RAM available to actually DO the work. Hence my perpetual state of "pending." This is not to say that I get nothing done. I get more done in a given day than most people do in a month. But I have so many projects looming that inspire so much anxiety for no reason. If I would just DO them, they'd be complete. I already made time to devour a great book earlier this week: "Getting Things Done," by David Allen, which advocates a practice by which I lived in late 2006: keeping EVERY thought I had on a 8x14 legal pad, structured according to context and priority. I was far more productive, creative, and peaceful -- and I lost my keys far less frequently. I've already dumped my "pendings" of all realms of my life onto a legal pad, absolving my dorsolateral cortex from having any responsibility for any of it... until I actively seek it out. </span> <span style="font-weight: bold;">In 2010, I will protect my RAM and use it to be "present."<span style="font-weight: bold;"><span style="font-weight: bold;"><br /></span></span></span><br /><span style="font-weight: bold;">I will complete data analysis, write up, and publish my Psychological Effects of Heart Rate Training study.<br /></span><span>'Nough said. The procrastination has reached levels of absurdity.<br /></span><span style="font-weight: bold;"><span style="font-weight: bold;"><span style="font-weight: bold;"><br /></span></span>I will blog more.</span><br /><span>This is a separate mechanism for "dumping" content from RAM. If I don't, I do not have the capacity to think the way I need to be able to think.</span><br /><br /><span style="font-weight: bold;">I will be more reasonable, realistic, and flexible in my self-negotiations</span>.<br /><span>Blog entries do not need to be novels. Data analysis for 226 subjects x 10 entirely open-ended questions does not need to be done in a single day. Articles do not need to be theses. I just need to DO things. The only way to enhance self-efficacy to DO things is to... DO things.</span><br /><br /><span style="font-weight: bold;">I will conquer new athletic exploits to build confidence and calmness.<br /></span><span>This was one of the most important things I learned in 2009. So, must keep going. Legitimate transition to clipless pedals on my bike. First sprint triathlon in August 2010.<br /></span><br /><span style="font-weight: bold;">I will learn to appreciate that right now is "enough."</span><span style="font-style: italic;"><br /></span><span>Commitment to continuous improvement is a great thing. That's why I have "Kaizen" tattooed on my back, after all. But here, now, this moment... by the end of 2010, I will find a way for complete satisfaction with the present to mutually coexist with the pursuit of something more.<br /></span><br />Here we go.<span style="font-style: italic;"><br />2010: Best Year of My Life...<br /></span><br /><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div>Melissa Marotta Houserhttp://www.blogger.com/profile/16888355366191460693noreply@blogger.com2tag:blogger.com,1999:blog-8980453300333511330.post-45822537464831041832009-12-09T22:13:00.006-05:002009-12-15T10:29:59.457-05:00Too Quick to Dismiss.<span style="font-style: italic;">"Don't blink if Shaquille O'Neal is on the Orlando Magic."</span><br />Nothing.<br /><span style="font-style: italic;">"See? He didn't blink. He's completely aware of what's going on."</span><br /><br />A mother's desperate way of explaining her universe. The only way she could make sense of the fact that her first-born son lay before her in her living room, hooked up to a bunch of tubes and things that beep, after blowing off the back of his head in a kerosene explosion accident.<br /><br />"<span style="font-style: italic;">Blink if you know we're here."</span><br />Nothing.<br />"<span style="font-style: italic;">Blink for us..."</span><br />Nothing.<br />30 seconds later, a random blink.<br />"<span style="font-style: italic;">See? He's right here with us. He's going to wake up any minute now."</span><br /><br />She has been saying this for three years.<br /><br />When I met this family on <a href="http://increaseandbreathe.blogspot.com/2009/07/meaning-something.html">a house call over the summer</a> that I made with my "med student hero," I felt physically ill from my inadequacy. What this poor soul was describing to me was, on its face, ridiculous. I'd never before seen how destructive hope could be, the desperate clinging to shards of nothingness. Nothingness that fueled a life of profound sadness, struggling, pain. Alcoholism. It was not my place to squash that hope. But when they asked me to <span style="font-style: italic;">reinforce</span> that hope, I felt guilty and helpless. That wasn't my place either. I couldn't find a way to come up with the perfect response that neither squashed nor validated something I believed to have no scientific basis. (Fortunately, my colleague did, which I reflected on in the above-linked post).<br /><br />In the five months that have transpired, we have discussed this family at the clinic time and time again. EVERYONE has experienced this as I have -- this sad, toxic hope that caused nothing but disaster for this family. EVERYONE has dismissed the mother's claims of all these "signs" of alertness, her attributions of brain stem reflexes to actual volitional movements. There was no QUESTION that these "signs" were completely random. EVERYONE was seeking the same balance that had eluded me. So when my preceptor invited me to accompany him and the clinic's neurologist to make another house call to this family, I was particularly interested in learning how these two REALLY smart, REALLY thoughtful physicians of whom I think the world would communicate with these parents. What could I learn from their magic?<br /><br />We drove out in the snowstorm. They'd turned the wood stove, and left out pieces of stale cheese and crackers for us -- more food than I'd bet that any of them had eaten all day. I was humbled by their generosity. We exchanged small talk and then followed them into the living room. There, he lay - exactly as I'd left him five months ago.<br /><br />Right away, she launched into her familiar routine. Basketball trivia. Blinks/no blinks. Mouth opening. Tongue protruding. All of it completely random.<br /><br />"<span style="font-style: italic;">Wiggle your left pinky."</span><br />She reached for his hand. The neurologist encouraged her not to prompt the effort. Nothing.<br /><br />Then, it moved. The left pinky.<br />I silently gasped.<br /><br /><span style="font-style: italic;">"Wiggle your left index finger."</span><br />It moved. It really moved.<br /><br />My preceptor's eyes started to bulge.<br /><br />Just as we started to get caught up in reversing course on our assessment, the air was filled with more random reflexes. My doubt returned. As we started to leave, the father asked his son to wave goodbye.<br /><br />AND HE DID.<br /><br />Seriously. He picked up his left hand, and waved it. That's not a reflex.<br /><br />We said goodbye and returned to my preceptor's truck. We sat there for a few minutes in silence.<br /><br />"I always wrote them off...." my preceptor began. "Yeah, yeah, he blinks on command... right...."<br />He shook his head.<br /><br />I was comforted by how mutually shocked we all were. These two people have seen INSANELY much -- and yet, they were just as unnerved as I was. This changed everything. This man was aware, and may have been aware for quite some time.<br /><br />This also means that he can feel pain. Everything now was different.<br /><br />My thoughts rewound back to a few weeks ago at clinic. My preceptor had asked me to go in and take a history from a new patient, with a goal of learning her entire life story in 10 minutes and coming back out to present to him before we went in to see her together. As if that were not unrealistic enough, this woman was ALL over the place. Probable schizotypal personality disorder -- seeing crazy patterns where they did not exist (as though I should talk!): her hand hurting every time she ate ice cream (due to the fat clogging her veins); her eye vessels bulging on command; her toe hurting every time she used a computer; her dire need to have all sorts of serum tumor markers checked because of a TV show she saw. And she was also certain that she was developing Alzheimer's disease (at the age of 35) because she kept losing her keys. I tried to get as much information as I could about her concerns -- founded or not, the things that were important to her needed to be important to us. I tried to reassure her about cognitive overload compromising the dorsolateral cortex (working memory), recommended a great book I thought she'd find interesting. She seemed to like that, and got back to talking about the ice cream clogging her veins.<br /><br />At some point, I gave up. I went out to present to my preceptor. I began with the disclaimer that my history was absolutely useless, and that I had been inept at reigning in her tangential rantings. I prepared him for what he was about to experience. We returned to the exam room.<br /><br />Within a few minutes, the woman launched into opening arguments for her Alzheimer's diagnosis case.<br />"Do you ever lose consciousness?" my preceptor asked her.<br /><br />Oh my gosh. He was asking about seizures (i.e., a legit medical problem). I hadn't asked about any pertinent positives or negatives to support (or fail to support) a legit medical problem. It hadn't OCCURRED to me to do that. In the context of a medical interview, it actually hadn't occurred to me to ask medical questions. I was mortified. It hadn't occurred to me that this woman actually had anything wrong with her. I'd already written her off in my mind as a complete hypochondriac, which is NOT mutually exclusive to actually having a legit medical problem.<br /><br />Really? *I* did that? For all my talk of inhabiting a person's existence, inhabiting their underlying fears and doubts and anxieties, REALLY?<br /><br />Mortified.<br /><br />Afterwards, I confessed my lapse to my preceptor. He laughed.<br />"Yeah, that happens...."<br /><br />I don't want it to happen. That's not good enough. It's not okay.<br /><br />But having experiences like this at this point in my training is important. Important reminders not to get sloppy. Not to discount, dismiss.<br /><br />After all, I've now seen a man in a persistent vegetative state wave goodbye.<br /><br /><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div>Melissa Marotta Houserhttp://www.blogger.com/profile/16888355366191460693noreply@blogger.com1tag:blogger.com,1999:blog-8980453300333511330.post-73836345112731057782009-11-19T07:59:00.004-05:002009-11-19T15:48:02.891-05:00A Burden.I walked into the room, and I wanted to snuggle him. Before me sat an 84 year old man, dressed to the nines with a tweed blazer, corduroy pants, black loafers and white socks. Beside him sat his son, a burly construction worker whose pained, glossy eyes penetrated my soul.<br /><br />"Dad's memory isn't what it used to be," the son told me and my preceptor. He spoke softly and gingerly. The old man looked straight ahead, unfazed. "He gets confused."<br /><br />As the interview unfolded, we learned of a life in isolation. The man lived alone in a trailer, which he kept immaculate. It's all he had. He was disconnected from his world -- he couldn't hear well enough, see well enough, process well enough to engage. His son did all he could, and they both knew that it wasn't enough.<br /><br />We assessed the pressing medical issues and developed plans for the next steps to evaluate his memory, vision and hearing difficulties. We said goodbye, and approached the door.<br /><br />"Should I bother keeping on?"<br /><br />My preceptor stopped dead in his tracks. Slowly, he turned to face his patient.<br /><br />"Absolutely. You have to. You have so much to live for. We're going to work together to get through this. I'm here with you."<br /><br />My eyes glossed over.<br /><br />"Sometimes I don't know if it's worth it. I can't do what I'm told. I'm stupid. I'm useless," he whimpered. "I'm such a burden on my family."<br /><br />It was a textbook list of "common concerns" of which I'm supposed to be mindful when interacting with older people. Except it was real, delivered through desperate, painful, hopeless sobs. And I didn't know what the hell to do about it.<br /><br />My preceptor left me alone with the man and his family, tasked with administering a Mini Mental Status Exam (MMSE). I've seen it done several times in my forensics life and had a lecture on it in school last year, but I'd never administered one before. I was nervous.<br /><br />I sat down at the desk beside him, touching my sharpened #2 pencil to the first question. Breathe. Ready. I looked up at him. His eyes were glossed over, looking at me helplessly as if he wanted me to fix him. I didn't know how.<br /><br />I ransacked the archives of my brain for prototypes of experiences like this one: discouraged person looking for answers he or she expected me to have. No, not that one. Not that one. No. No. No. Yes. Flash back to the day after Thanksgiving last year. One of my Spinning students in New York confided to me after class that she was struggling with an eating disorder. She felt helpless, and thought that I might have some magical insight to end her suffering. The responsibility of being trusted to share in her burden was heavy, painful. I felt inadequate. I couldn't erase her challenges; I didn't know how. But then I had a moment of clarity. I wasn't supposed to "fix" this. I was in control of how I defined my function, and I could choose a useful one. So I started asking questions designed to help this young woman frame her challenges within the context of her goals, and to identify the cognitive structures that helped and/or distracted her. Maybe it didn't make a difference in the long run. But for at least the next 10 minutes, she felt empowered to fight. And that was enough.<br /><br />"It sounds frustrating to feel like you can't remember the things people tell you..." I began.<br />His eyes held my gaze.<br />"Have you ever tried repeating back the things people tell you, to hear the instructions in your own voice?"<br />He looked confused.<br /><br />I simulated a conversation with the man's son.<br />"Dad, come over Sunday at 12pm."<br />"You want me to come over Sunday at 12pm?"<br />"Yes."<br /><br />I explained how there are different pathways in the brain that are responsible for processing things we hear vs. generating speech -- and that some people's brains work differently, and are better at some pathways vs. others. I told him that, as a medical student many years his junior, I need to engage the other pathway in order to remember stuff. He smiled. So we practiced a few more rounds with his son, and I could feel the anxious fog start to clear.<br /><br />I started the MMSE.<br />"What year are we in?"<br />"Year?"<br />"You know, the date... the year?"<br />"Huh?"<br />"2000 and..."<br />"Oh. 1002. I mean, 1007."<br /><span style="font-style: italic;">Gulp</span>.<br />"Ok, what state are we in?"<br />"Vermont."<br />"GREAT!" I exclaimed, far too enthusiastically. I was so eager to validate him.<br />"What county are we in?"<br />"County?"<br />"You know, the part of the state..."<br /><br /><span style="font-style: italic;">Silence.</span><br /><span style="font-style: italic;">Dread.</span><br /><span style="font-style: italic;">Frustration.</span><br /><br />His eyes squinted, and he slammed his fist into his forehead.<br />"I AM SO STUPID. Stupid, stupid. I don't know anything. What am I going to do?"<br /><br />I touched his shoulder.<br />"I understand that you're frustrated... because you expect yourself to be able to do this stuff. But a lot of people don't know their county. You don't ever have a cause to think about it in your daily life. And the thing is, the part of your brain that handles attention is affected by how frustrated you are. When you get frustrated, it doesn't work so well. So maybe if you try to be more patient with yourself and take your time, your recall will kick in. Take a deep breath and..."<br />"Washington County." he interrupted me.<br />"See? Perfect."<br />"You're right. It's really 'in there.'"<br /><br />The rest of the exam continued. Word repetition, number counting, backwards spelling, instruction following. Most of it pretty dismal. Occasional episodes of forehead-slamming, lip-quivering. I felt awful; he felt worse.<br /><br />The last step is to copy a figure of interlocked pentagons. I expected this to be painful for him. I told him that I think it'd be painful for me -- that this test is designed to assess many different domains of function, that some people just simply aren't "spatial." He began to draw.<br />"No... this isn't it."<br />"That's ok. Try again."<br />He tried again.<br />"Just one more... I can do it this time."<br />"Go for it."<br />And he went for it. Twelve more times.<br /><br />When he finished those damned pentagons, he looked up at me and smiled triumphantly.<br />"See? I did it."<br /><br />The pentagons weren't exactly pentagons. But there were 10 angles, and the shapes sort-of touched. It wasn't exactly what anyone would hope for. But from the look in his son's glossy blue eyes, it was good enough. Enough to affirm that there's nothing else I'd ever want to do with my life.<br /><br /><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div>Melissa Marotta Houserhttp://www.blogger.com/profile/16888355366191460693noreply@blogger.com2tag:blogger.com,1999:blog-8980453300333511330.post-46428372866460332492009-11-08T01:21:00.004-05:002009-11-08T12:42:58.637-05:00"Changing the Narrative"We're all telling ourselves a story. This is not so much reality as it is the deliberate choices we make about how to respond to reality. <a href="http://increaseandbreathe.blogspot.com/2009/09/acceptance-loneliness-or-accepting.html">Splicing it, spinning it, shaping it.</a> Owning it.<br /><br />That's what this blog is, really. Forcing myself, despite the burdens of time and resources, to tell myself the evolving story of my road to 'doctorhood.' It doesn't have a beginning, a middle, or an end exactly. But, so far, it's a pretty sweet story.<br /><br />I wrote some time ago about <a href="http://increaseandbreathe.blogspot.com/2009/02/so-many-symbols-so-little-time.html">story-telling in patient care</a>, and how I saw narrative medicine -- the thoughtful, collaborative weaving of the themes and values that make up the broader context of a person's life (of which their illness is only one part) -- as a major influence in the way I hope to one day care for people. The symbols, the irony, the various devices to layer awareness and reflection -- all designed to empower people to heal themselves through the tools that doctors, patients and the characters of their lives all work together to develop.<br /><br />Narrative medicine, of course, is just as powerful a vehicle for me as a trainee -- and will continue to be, for the rest of my life. Writing allows me to construct and reconstruct the formative events of my world, to give them meaning -- to frame it all in a way that teaches me as I go, and will continue to teach me as I look back upon it. Tapping into recurrent, intersecting themes is comforting for me -- the power and confidence of consistency is enormously gratifying. Last year, I had a "thing" about what I called "<a href="http://increaseandbreathe.blogspot.com/2009/02/practicing-commitment-part-i.html">practicing commitment</a>" (which is how my immunology course director used to describe the process of building confidence in coming to a diagnosis and standing behind it -- which I extended to apply to EVERYTHING that ever happened...). I found my "champion" symbol in the hematopoetic stem cell (en route towards various paths of differentiation -- unlimited possibilities, yet unable to turn back the farther along it proceeds). I practiced "<span style="font-weight: bold;">practicing commitment</span>" as an athlete, as a coach (HOW many <a href="http://spintastic.blogspot.com/2009/02/practicing-commitment-part-ii.html">training sessions have been specifically themed around commitment</a> -- to a specific intensity, to a specific challenge, to a specific breathing technique, to an awareness -- over the past year? Hundreds. Commitment for the sake of commitment, even. The idea of demonstrating one's ability to husband all of one's resources upon a specific task -- how gratifying that can be.), as a medical student. As a human being.<br /><br />As it turns out, we revisited hematopoesis last week in school. As slides of myeloblasts and lymphoblasts, and dozens of genetic translocations that result in their failure (that I'm magically supposed to encode for life -- or at least, for my Boards) flashed before my eyes, I was comforted by associating these "characters" with the way I conceptualized my life story. Or something like that.<br /><br />Ironically, this coincided with quite a few epic developments to said "life story."<br /><br />First, the process of TELLING it. At clinic on Wednesday, I had a fascinatingly subtle discussion with my preceptor about self-narrative. I am so lucky that I have a mentor who spontaneously slips into casual evaluations of self-narrative (what?!). His premise was how it's futile to deny how much of the stories we tell ourselves are inextricably linked to our biases, our expectations, and our dreams. We project aspects of our stories onto other people; we see what is consistent with what we want to see -- what we tell ourselves that we're seeing. I wanted to tell him that he was wrong. I wanted to tell him that I was confident in my objective analysis of reality at all times. But he wasn't wrong. I reconciled my dissonance relatively quickly. I came home and told Scott "my story," and heard his. In so doing, I 'owned' every single one of those projections, biases, and distortions. And it was a pretty sweet story, indeed.<br /><br />The week continued. It was Primary Care Week, so I had the opportunity to attend a bunch of family medicine-related talks and interact with a number of characters who are starting to make quite the impact on me. I also set myself up to attend another family medicine conference, this one the Vermont state professional organization. I'd attended this group's meeting last year, as my first introduction to the community I'd come to experience as "my people."<br /><br />Yesterday, I met with my advisor (one of the coolest human beings on earth). I found myself comfortably, casually recounting the past 6 months of my life. When summarized and editorialized (i.e., crafted as a story), I felt really "together." Even recounting my flop of a study (that I'm SERIOUSLY going to work on this week!) felt pretty good. He was amused by all of my masochism (i.e., three Centuries, deliberately seeking out awkward/unbearable/AWFUL experiences in order to <a href="http://spintastic.blogspot.com/2009/09/own-your-discomfort-75-minute-profile.html">get comfortable being uncomfortable</a>). He observed my hyper-self-awareness (which I didn't exactly have the sort of relationship where I really should have felt comfortable reflecting at the level I was reflecting -- but I suppose he experienced my candidness as refreshing). Our discussion left me really proud of the story I'd pieced together. It may not have felt so fluid in real time -- but the version that lasted was a useful one.<br /><br />Then, last night I went out to the clinic to have dinner with my preceptor, the PA who treats me like a daughter (she MET my mother a few weeks ago - it was pretty epic), and another friend. We got to talking about prostate exams (I do them all the time, unsuccessfully -- my fingers are too short!) and pelvic exams (I've done four now...) -- both of which I haven't been formally taught how to do at school, yet am regularly invited to practice at clinic. While I can comfortably discuss my history of anxiety and panic attacks, my love for my boyfriend, and my self-narrative style with my preceptor -- what I blurted out next was somehow outside of my comfort zone. <a href="http://increaseandbreathe.blogspot.com/2009/08/power-privilege.html">I've written about it a ton</a>. But blog fodder is not necessarily "say out loud to your hero"-appropriate.<br /><br />"I feel so guilty every time I do a pelvic exam. I feel like I haven't done anything to earn this privilege. There's no reason that someone is being so generous. So I just want to get in and get out and get them done with being vulnerable to me. I don't spend time really learning."<br /><br />With no more than 5 seconds passing, my preceptor responded:<br />"<span style="font-weight: bold;">So change the narrative. Tell yourself that this patient made this choice because they wanted you to learn as much as you possibly humanly can -- and it's your job to honor that underlying basis for her choice."</span><br /><br />Whoa. This man is BRILLIANT. That is an entirely crafted, distorted narrative. It's a version of reality that gets me to adapt my behavior, my attitudes and my emotions. It's a version of reality that's TOTALLY going to work for me. Is it exactly true? No. Is it false? No, actually. Is it more true than it's false? Yes. Is it going to make me a better doctor? Damned straight.<br /><br />So, today was the conference. I woke up with a reprise of my lung-hacking cough. I had no appetite. My GPS got me lost. There was a country song on the radio, and I found myself kind-of LIKING it -- just because it seemed so movie-esque to be driving down a dirt road as the sun rose, en route to a symbolic event to mark "my future."<br /><br />Turns out, I was the only medical student there. I didn't know anyone. I was awkward. Irony: it was held at the hospital where I deliberately accompanied my preceptor those nights over the summer, for purposes of "owning my discomfort." HA. I owned my discomfort for 9 hours today!<br /><br />I didn't want to network. I just wanted to crawl in a hole and not be alone and out of place. But, at intervals, I changed the narrative. I was confident. I belonged. I had useful things to say. So I started... saying them. I met a handful of people who were really eager to encourage and support me. I talked with someone I'd heard speak a year ago, who really inspired me -- and there she was, eating lunch with me. There was another character, a junior doc, who probably recognized a lot of my young, naive, overly eager idealism. She inspired such comfort that I was able to ask her genuinely useful questions, and learn a ton from her experiences (i.e., elective choices, geographic options, etc).<br /><br />Then, I had an idea.<br /><br />A board member from the national umbrella organization for this state chapter was there, giving a talk on the future of family medicine. He started off with statistics about how very few people are choosing to go into family medicine and how it doesn't pay as well as x and y and z and blah blah blah. He then went into all of the mechanisms for reform under way, but completely omitted a discussion of efforts to increase the workforce (which tons of other speakers address). The difference is that this guy didn't expect a medical student to be in the office. But you know what? I <span style="font-style: italic;">was</span> a medical student in the office. And suddenly, I felt compelled to be useful.<br /><br />I spent 45 minutes during this talk plotting my next life event. My heart was pounding, unresponsive to breathing techniques. My legs were twitching. My vision started to blur. <span style="font-style: italic;">Own your discomfort. You don't need to make the anxiety go away. You just need to own it and keep going. You practiced this</span>.<span style="font-style: italic;"><br /></span><br />"Any questions or comments?"<span style="font-style: italic;"><br />Show time.</span><br /><br />I raised my hand and in front of 60+ strangers, introduced myself as a second-year medical student for whom there was a 0% chance that I would do anything else with my life besides practice family medicine. I offered that I didn't know if my perspectives were useful, but that I felt compelled to speak up as the only student in the audience. I wanted them all to know that the reason I'm so committed to family medicine is because of experiences I've had with people like themselves -- the stories, the intangibles, the generosity of making time to give me the opportunity to learn from them and their patients. That I know they're busy and overworked, but that they should know that the time they make is invaluable to the future of family medicine -- that it means so much, that it goes so far.<br /><br />I didn't stutter. I didn't cry. I didn't have a panic attack. And a few people came up to me afterwards and thanked me.<br /><br />I got in my car and drove off, literally, into the sunset. I put "Who Knew?" by Pink on repeat for 45 minutes straight. Not because the lyrics mean anything to me -- but chords just kept striking the absolute perfect 'place' for me. I was tearful. Proud. Self-enamored. Peaceful. I even drove the speed limit the whole way home.<br /><br />'Who knew' that I'd be telling myself THIS story? Or any of the stories that have directly led up to it? Every story of the experiences I sought to prepare me to do what I did today. The uncomfortable bike rides, the embarassing questions, the deliberate exposures to looking like an idiot -- just to get good at it.<br /><br />Who knows what I'll be telling myself next?<br /><br /><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div>Melissa Marotta Houserhttp://www.blogger.com/profile/16888355366191460693noreply@blogger.com0tag:blogger.com,1999:blog-8980453300333511330.post-19286889700048210182009-11-02T12:33:00.003-05:002010-08-26T07:39:58.847-04:00Taking a moment.It was right out of a movie. I met someone. And I fell in love. *BAM* And just like that, I have a whole new life. I've had this epic, cheesy, ridiculous over-the-top grin on my face for three straight weeks --glowin' on right through depressing renal pathology, indistinguishable hematologic cancers, and even a personal adventure with likely H1N1. (When I stopped hacking up my lungs long enough to have a conversation, a friend of mine accused me of glowing so much that I was emitting vitamin D). I'm just so utterly, ridiculously friggin happy.<br /><br />Is my attention suffering? Maybe. Is my schoolwork suffering? Nah. Are my priorities skewed? I don't think so, either. Am I still making time for the things and the people I hold important? By and large, yes.<br /><br />But there's one change that I don't think I'm okay with. I've not been writing.<br /><br />In my last entry (a month ago!), I reflected on a concept in Jeremy Spiegel's book, <span style="font-style: italic;">Mindfulness for Medical Students</span>, about how to own one's changes -- reflecting on them in real time, incorporating them into a larger context of "self" without being derailed towards another <span style="font-style: italic;"><span style="font-style: italic;">version</span></span> of self that is inconsistent with one's original goals and values (as sometimes happens to doctors in training). Most of what Spiegel advocates, I've been doing for a while. But after internalizing his perspectives, I developed a framework that I decided would work for me:<br />1) "What's new?"<br />2) "Where did it come from?"<br />3) "Do I like it?"<br />4) "Is it consistent with my goals and values?"<br /><br />In my last entry, I took the concept of "riding Centuries" -- this thing I apparently now "do." I identified these dramatic undertakings as a direct consequence of my perceived inadequacy as a future doctor -- and my strategy of deciding that if I could dedicate myself towards continuous improvement of a concrete, measurable task of riding a bike for 100 miles, that I could build the confidence I need to dedicate myself to the less concrete, more unnerving, ridiculously high stakes goal of learning enough to be responsible for a human being's life. Does riding three 100-mile rides in an 8-week period mean that I'm going to be a better doctor? Of course not. But do I think about it under conditions of extreme self-doubt and awkwardness? You'd better believe it. So this change -- do I like it? Damned straight. And is it consistent with my goals and values? It's, in fact, the most precise embodiment of my goals and values that I've ever practiced.<br /><br />So, now "what's new?" Me, the writer with a huge chunk of her self-concept staked within the domain of self-reflection, self-awareness, written expression, and the active "remodeling" of life experiences, stopped writing.<br /><br />"Where did it come from?" There's only x amount of time in the day. There's only x amount of energy. I've made an active choice to redirect that time and energy. I've never been happier with the results of my choices. But my happiness has come at the expense of choosing not to write.<br /><br />"Do I like it?" I don't think so.<br /><br />"Is it consistent with my goals and values?" One of the reasons I'm so happy in my new relationship is that I've been accomplishing almost ALL of what I accomplish by writing, just differently. But there's something very specific about reflecting in written form, creating a record of my life experiences (that I really do go back and re-read within a new context, afforded by another week or month or six months' perspective) that I really cannot, and will not, do without.<br />I think.<br /><br />Over the weekend, I had an experience that I knew that I would never forgive myself for not making time to capture the way I've captured so many moments that have led up to it.<br /><br />I attended a family medicine conference in New York. I shouldn't have been there. My fever had resurfaced and I felt terrible. Just as I was prepared to retire at 7PM for the night (lame...), I decided to take another lap at the residency fair. I'm not applying to family medicine residencies for another several years. There was no need to. But I was curious. I was curious about a program somewhere near my new boyfriend's hometown in rural North Carolina. So I strolled over, and started chatting with a third-year resident about her experiences. I was quite impressed.<br /><br />And just as I started to walk away, a gentleman who -- no joke -- looked exactly like my preceptor at the clinic where I train (Irony: my preceptor trained in North Carolina) started talking with me. I told him I was from NYC, and shocked at how much I love Vermont, and how this has taught me to be open-minded about the experiences that will bring me a sense of rewardedness. He began to speak of what makes him feel rewarded as a family doctor...<br /><br /><span style="font-style: italic;">"I'd been taking care of a woman for 35 years. One day, she came to me and said that her husband wasn't doing well. I went over to their home to see him. I said I'd be back in 3 hours -- but by the time I arrived, he had completely decompensated.<br /><br />I told her that her husband wasn't going to make it through the night.</span><br /><br /><span style="font-style: italic;">She was frantic. She started talking about needing to call this daughter, and that daughter, and this daughter and rushing him to the hospital.<br /><br />'No,' I told her. 'There's no time for that. Here's what we're going to do. Call one daughter... and then ask yourself: What would your husband want right now? How would he want to spend this time?'<br /><br />'He'd want me to hold him,' she said.<br />'Then go do that. Go into your bedroom. Close the door. And just hold him.'<br /><br />And that's how he died.<br /><br /><span style="font-weight: bold;">Moments like that.... that's why I'm a family doctor. Life is a collection of these moments, these lessons you'll never forget, where people allow you into their spheres of values -- and it's your job to help them make choices that reflect those values."</span><br /><br /></span>My eyes brimmed with tears. I told him that, for what it's worth, that this moment was going to be one of those lessons that I'll never forget for the rest of my life.<span style="font-style: italic;"><br /><br /></span>After we parted, my immediate response was to go find somewhere to write. I didn't. I had H1N1. I went to sleep. But not before sending a text message to my new Alternate Reflection Mechanism. I felt at peace.<br /><br />When I returned to Vermont and shared this story in person, my reflection had a special quality to it that was a "moment" in and of itself. A moment I didn't need to document on a blog (but apparently am, anyway). A moment that stood on its own as the version I'd remember, that I'd call up when I needed it. A moment that would last forever.<br /><br /><span style="font-style: italic;">"I'm going to be here to share in these life-altering moments with you. And I'm going to make even more of them."</span><br /><span style="font-style: italic;"><span style="font-style: italic;"><br /></span></span>I may be okay with not writing so much, after all...<br /><br /><span style="font-style: italic;"><span style="font-style: italic;"></span></span><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div>Melissa Marotta Houserhttp://www.blogger.com/profile/16888355366191460693noreply@blogger.com0tag:blogger.com,1999:blog-8980453300333511330.post-65870864782357305262009-09-27T23:12:00.011-04:002009-09-28T11:47:04.020-04:00Acceptance & Loneliness... or Accepting Loneliness.Amidst 1600 people, I felt very alone. As I crossed the finish line of my third Century (100-mile) bike ride yesterday, passing a receiving line of cheerers calling and waving signs bearing 1599 other people's names, my eyes brimmed with tears. My stomach knotted with dread. Dread that this moment really <span style="font-style: italic;">was</span> all there was going to be -- that whatever feeling I had in that moment -- call it pride, call it accomplishment, call it emptiness -- needed to be enough. <span style="font-style: italic;">I</span> needed to be enough. I wasn't sure that I was.<br /><br />As I stretched and iced my assorted musculoskeletal re-injuries on the shores of the Atlantic, I thought about what this sad, lonely, anticlimactic moment was supposed to teach me:<br /><span style="font-weight: bold;">* Another step of discomfort-immersion? </span><br /><span style="font-weight: bold;">* Practice in distinguishing between 'thoughts' and 'feelings,' and practice accepting the latter? </span><br /><span style="font-weight: bold;">* Keeping me honest in appreciating that this part of my life (i.e., riding Centuries) that I associate with PURE internal validation really isn't completely devoid of external influences?</span><br /><span style="font-weight: bold;">* Practice accepting that experiences can be powerful and influential in addressing </span><span style="font-style: italic; font-weight: bold;">some</span><span style="font-weight: bold;"> of my needs, without requirement to meet </span><span style="font-style: italic; font-weight: bold;">all</span><span style="font-weight: bold;"> my needs? </span><br /><span style="font-weight: bold;">* Prompting me to re-evaluate and re-define my concept of "inadequacy" in a more realistic, compassionate way (i.e., if one can feel "inadequate" after riding 100 miles on a bike, one has an unfair definition of the word)?</span><br /><span style="font-weight: bold;">* Practice accepting that my spectrum of "continuous, incremental improvement" does not require that every experience "n" is forever trumped by an "n+1?" Or that "improvement" doesn't always need to be measured on the usual scales (i.e., "faster than last time," "prouder than last time," "more joyous than last time") but can qualify as improvement all the same: "more insightful than last time," "more compassionate than last time."</span><br /><br />And when I thought about that moment's potential utility -- for all of those reasons -- I felt less alone. More appreciative that, although this moment was drastically different from how it was "supposed" to be (or how I expected it to be), perhaps exactly as it <span style="font-style: italic;">needed</span> to be.<br /><br />This was supposed to be my first Century, an organized ride out of Hampton Beach, New Hampshire up and down the coast of New Hampshire and parts of Maine and Massachusetts. I'd rented a beachside suite for a weekend getaway with three friends -- they'd hang on the beach while I rode, meet me at the finish line, and then we'd all have the next day together. Two deviations, right off the bat:<br />1) This was no longer my first Century. I've done three, in an eight-week period: <a href="http://spintastic.blogspot.com/2009/08/my-1st-century-check.html">The first one</a> was an accident. <a href="http://increaseandbreathe.blogspot.com/2009/09/own-your-awkward-not-to-mention-your.html">The second one</a> was a pseudo-spontaneous desperate (and successful) act to conquer some unresolved anxiety.<br />2) My friends bailed, last minute.<br /><br />So after taking my pulmonary exam on Friday, I set off for my solo adventure to Hampton Beach. I'd been up since 5AM after cramming til after midnight the night prior, so staying awake behind the wheel was a major, caffeine-fueled feat. I spent the drive thinking about why I was doing this. I wasn't excited. I was exhausted. I was driving to a random tourist trap to stay by myself in a random motel, and ride 100 miles for no reason. But was it really "for no reason?" No. At some point, this meant something to me -- so it was a matter of reminding myself what that was.<br /><br />By the time I pulled onto the beach -- literally -- I had some idea. After a series of surprisingly calm navigation of confusing one-way streets, I dumped my gear off at the motel (a comfortable, AWESOME suite right on the water) and headed for the sand. It was 60 degrees but as sunny as could be -- and, yet, there were no human beings around. I had an entire beach front to myself. I walked barefoot back and forth for an hour, thinking about what I wanted out of what sure to be a very strange, very random trip.<br /><br />This included my plans that night to read a book I'd borrowed from my roommate: "The Mindful Medical Student: "<span style="font-weight: bold;">Staying Who You Are While Becoming Who You Want to Be</span>" by the psychiatrist Jeremy Spiegel. Upon initial skimming, this seemed to be documentation from someone-who-legitimately-knows-what-he's-doing of precisely "what I do all day with my life to preserve sanity." He even has a chapter on synchronicities -- that is, finding and exploring connections between seemingly unrelated concepts (i.e., my whole friggin' life purpose) -- and describes it as an adaptive extension of pattern-recognition (i.e., a major skill for medical diagnosis). Validation. Nice.<br /><br />I literally devoured this book from cover to cover the night before the ride. Dr. Spiegel's premise is that medical schools focus on technical content of medical education, while lacking training in the equally important skills and processes for self-reflection, exploring strengths and weaknesses, and coping with the uncertainty, ambiguity, and unease that are inherent to the practice of medicine leaving many a new doctor unable to navigate the challenges of their new world, and wrapped up in new identities that depart from their underlying character and values. I am fortunate that this will most certainly NOT be my problem. I've been preparing for this for years, even before medical school, because I anticipated this exact issue arising. I've been reading gazillions of physician and patient-written memoirs, thinking and writing a ton -- developing a whole arsenal of thoughts, and a structure for <a href="http://increaseandbreathe.blogspot.com/2009/07/synergy-balance-and-purpose.html">evaluating and balancing</a> them over time. I'm also beyond fortunate that my program does include "life development" as a component of our curriculum. Though I appreciate that I am in a better place of <a href="http://increaseandbreathe.blogspot.com/2009/02/so-many-symbols-so-little-time.html">self-awareness </a>than this book's intended audience -- and I rejected some of the author's pseudo-over-the-top psychodynamic interpretations of self-evaluation (the fact that I can filter in selective sources of inspiration vs. filter out others is an important skill that I readily appreciated!), it was gratifying to read endorsements of what I do and think and write about to keep myself grounded in the moment, and document my evolving perspectives on which to look back over time. I link to previous posts on this blog, and my other blog, to keep myself honest. I'm comforted by my own consistency -- but the structure is built in to allow myself to process, evaluate, and "own" my changes, for good and for bad.<br /><br />Amongst other themes he discusses (that perhaps I'll write about another time), Spiegel talks about undertaking "quasi-spiritual quests" to evaluate one's evolving identity. <span style="font-style: italic;">Do you recognize yourself? What's new, and do you like it? Where did it come from? How does a present conflict relate to conflicts of the past?<br /><span style="font-style: italic;"><br /></span></span>Ok, then. What's new? I was about to ride my 3rd 100-mile bike ride in an 8-week period. THAT'S new. Apparently, I have become someone who "does" Centuries. Just as my self-concept behind the wheel of a car evolved to that of a "Real Driver," I had begun to conceptualize myself as as "Real Cyclist." That's a big deal. Do I like it? Hells yes. Where did it come from? That's another story.<br /><br />Most people in my life, including the people I train, don't understand why it's a big deal to me to ride 100 miles on a bike. It's not as crazy or "unrelatable" as it sounds. To me, riding my first Century represented a dramatic, epic triumph over an intimidating challenge that, while intellectually in-reach, was psychologically outside my comfort zone. But instead of comparable life challenges (i.e., becoming a competent physician), this was a challenge that I had <span style="font-weight: bold;">COMPLETE control </span>over conquering -- and for which my progress had measurable, objective feedback mechanisms: <span style="font-style: italic;">How much work could I do at 80% of lactate threshold (i.e., an intensity I can sustain literally all day long)? How much could I increase lactate threshold? How many beats could I lower my heart rate by altering my breath?</span> <span style="font-weight: bold;">Indisputable, objective feedback breeds confidence</span> -- confidence that I could apply to the rest of my life. C<span style="font-weight: bold;">onfidence that I can and will do the things I say I'm going to do, no matter how intimidating.</span> And confidence that came from training more intangible, immeasurable skills: <a href="http://spintastic.blogspot.com/2008/07/its-all-about-how-you-talk-to-yourself.html">language to coach myself </a>through discomfort, awareness of the interplay between my breathing, form and movement, the ability to focus and husband all of my resources upon a specific sub-aspect of a task.<br /><br />So after doing it once, why keep going? Because I could improve. I had complete control over improving my performance on this concrete task, <span style="font-style: italic;">unlike</span> my perception of control over improvement in my medical training. I read and listen and ask questions with intent motivation to one day be qualified to care for human beings -- sometimes incoming stimuli stick; sometimes they don't. I can see and try an exam skill or procedure a gazillion times -- sometimes it sticks; sometimes it doesn't. I take and occasionally create opportunities to build confidence -- sometimes I succeed; sometimes I fail. My performance is unpredictable. Practice makes anxious.<br /><br />As an athlete, my performance is measurable. I feel confident and strong and alive. On a bike, I can be the person I want to be and accomplish the things that mean something to me -- and in those moments, I genuinely believe that this translates to the rest of my world -- even if it doesn't. <a href="http://increaseandbreathe.blogspot.com/2009/04/you-are-what-you-think-about-all-day.html">In those moments, my perception is all that matters</a>. Contrary to public opinion, it is NOT difficult for me to please myself: in fact, some of my proudest, most memorable moments as an athlete were "mere" 30 minute periods of maintaining lactate threshold. Or there was another experience where I held 106% of lactate threshold for 10 minutes. 10 minutes! The woman who says she needs to ride 100 miles in order to feel "accomplished" cites a 10 minute experience amongst her proudest moments? Really? Yes.<br /><br />The difference with a Century, though, is its potential to influence my self-concept as a Real Cyclist. I wanted that confidence so badly, and I worked for it. It's "epic" enough of an experience that I associate as unique to a Real Cyclist. Lots of real cyclists don't ride Centuries -- but if you ride a Century, you're absolutely a Real Cyclist. I keep riding these things to reinforce this new part of my identity that doesn't quite seem real enough to last-- almost like I'm afraid it will melt away.<br /><br />One can't just up and ride 100 miles, though. It has to stand for something -- something that earns commitment, something that inspires <span style="font-style: italic;">some</span> feeling that goes above and beyond the normal span of routine, daily emotions. Dramatic efforts call for dramatic reasons, reasons that mean something dramatic. And so, as I took on this third Century, I decided to dedicate it to the themes of this book that resonated with me most. As though to permanently weave them as strands of my character, to protect them from fraying or unraveling against the mangling challenges that are to be my life. Yes, I'm entitled to a little drama: I 'do' Centuries.<br /><br /><span style="font-style: italic;"><span style="font-weight: bold;">Finding Meaning in the Ordinary</span></span><br />Off the top of my head, I can list more than 20 profoundly meaningful examples of synchronicity -- but I'd sound psychotic. And it doesn't matter. I believe in every single one of them, and that <span style="font-weight: bold;">perception of order and </span><a href="http://increaseandbreathe.blogspot.com/2009/05/power-of-structure.html"><span style="font-weight: bold;">structure is comforting</span></a>. The world makes sense when there are predictable patterns to pick out, an order to the universe. Medicine is that way -- and I never conceptualized any of this as "pattern recognition" as this book calls it. But as I prepared for this "ordinary" ride, I knew that <a href="http://increaseandbreathe.blogspot.com/2009/07/meaning-something.html"><span style="font-weight: bold;">it would have to mean something</span></a>. Like anything, it was a matter of deciding what I wanted it to mean -- and, as it would turn out, appraising what it <span style="font-style: italic;">did</span> mean... and appraising how the discrepancy between the two would affect me.<br /><br /><span style="font-style: italic;"><span style="font-weight: bold;">It's All in the Editing<br /></span></span>Spiegel suggests conceptualizing medical school as an iMovie -- that instead of collecting all the fragments in contextless chronological order, that one can edit them in real time into a useful form that is easily revisited over time. Thus, this conscious creation represents an evolving, maturing personal and professional self. That totally resonated with me. That's what this blog is all about. I capture stories for a context -- but by and large, it's not about the facts. It's about their meanings. The meanings are what are going to stick -- the influences upon which I will want to look back on and remember their roots.<br /><br />I thought about that as I rode, not only when I finished. As the breeze of the Atlantic tickled my ears and the sparkling waters interrupted my rhythmic, continuous breaths, I was mindful of actively blocking out everything else about that moment. My throbbing ankle, my kinked neck, my sore butt. I encoded the concept that, there I was, cruising along the Atlantic Ocean on a bicycle. And that right there in the moment, it was awesome.<br /><br /><span style="font-weight: bold;"><span style="font-style: italic;">An Arsenal of Comfort</span></span><br />Spiegel also writes about developing mechanisms for comforting yourself under stressful circumstances - stroking your own arm, telling yourself it's ok. I do a lot of that already. I've made it a point, over time, of developing an arsenal of tools to convince myself that I can endure a particular challenge (including, of course, accomplishing 100-mile rides). My latest tool comes from Century #2 -- the memory of the 85 mile mark (where I saw a road sign that told me it was 5 miles to Williston, a town 10 miles from home), when I bawled with intense pride and intrinsic reward that I would indeed triumph over my suffering and finish this overwhelming feat. At a few points since -- in "life," in training, and now here during this ride -- I told myself: "THIS is your Williston." Fascinatingly effective.<br /><br />I also found myself acknowledging my discomfort with more natural compassion than usual. Usually, I have to force it when I'm riding: "Stop being so negative!" (i.e., reprimanding myself for reprimanding myself). "I'm tired. I hurt. I hate this." <span style="font-style: italic;">Ok</span>. "I huuuuuuuuuuuurt." <span style="font-style: italic;">Ok</span>. <span style="font-style: italic;">That's ok. If you want to stop, you can stop.</span> "Hell no! I'm going to rock this. Go." More compassionate, and legitimately more successful outcome. This is just like I've been practicing in my medical training: acknowledging my discomfort, accepting it kindly, and keeping on.<br /><br /><span style="font-style: italic;"><span style="font-weight: bold;">"I'm Gonna Get Better At This, Too"<br /></span><span style="font-style: italic;"></span></span>I "celebrated" my (lonely, isolated, sad) achievement with a 10 minute stretch on the beach and a peanut butter/banana/rice cake sandwich. Then I promptedly biked another mile to my car, not-so-discretely changed inside of it, and hit the road. I'd done what I came to do: now I could go home.<br /><br />Cruising down the coastline, the cool saltiness breezing through my open windows, I smiled for the first time since crossing the finish line. As I pulled onto the Interstate, rockin' out to my empoweredly titled "REAL CYCLIST" mix with my shades on and my uber-scarred elbow out the window (another proud emblem of a "real cyclist," of course), the sunshine scorched my left cheek -- so strong that it bordered on discomfort. I drove on, though, and acclimated to the glow.<br /><br />People say that the discomfort of medical training (i.e., anxiety, inadequacy, incompetency, loneliness) gets better over time, too. That the more you do, see and feel, that you develop skills, intuitions and competencies. Part of me accepts this as a logical reassurance; part of me thinks it's bullshit. A <span style="font-style: italic;">lot</span> of me expects to never get good at certain tasks, no matter how many times I practice them. In moments of failure, success feels so far away -- so unattainable. And exposure to things I've not yet tried (i.e., no opportunity to fail) -- from emergency tracheotomies to routine IV insertion -- have bright red "this is NEVER going to be something you can do" warning sticker on their card catalog entry in my brain. But you know what? People said the same thing about driving and about biking -- and in those moments, those skills felt just as realistically impossible. But they happened, all the same. A year ago, I would never have CONCEIVED of any single occurence of the past 22 hours. A year ago, I barely knew how to drive; now, I drove 3 hours to create an epic, purposeful adventure for myself. A year ago, I barely knew how to ride a bike; now, I'd biked through 3 states for my third Century ride. I never expected basic competency, let alone comfort and confidence. For the first time in my life, I entertained the concept that medicine really would work the same way. If nothing else, my 22 hour adventure prompted me to appreciate <span style="font-style: italic;">that.</span><br /><br /><span style="font-style: italic;"><span style="font-weight: bold;">Uncertainty</span></span><br />When I arrived home, I mapped out the route I thought I'd taken (accounting for all my missed turns and accidental returns to civilization). I didn't remember 75% of the random turns I made but I included what I could. 80 miles. Could it be? Had I really not completed a full Century? I'd taken 7.5 hours (the others had taken me 8 hours, and were 107 and 105 miles respectively) -- but this was entirely flat (as opposed to the mountains of Central Vermont, which I climb slower), and I was obsessive about maintaining a faster cadence than usual on flats. Had all my stops asking random passersby for directions really taken up the length of time I'd have expected 20 miles to take me (1.25 hours)? It couldn't be -- no way. But then again, 20 miles is a huge gap to screw up on a map.<br /><br />Discomfort over uncertainty has plagued me for most of my life. <span style="font-style: italic;">What will I be when I grow up? What college will I attend? Will I get a job? Will I spend the rest of my life with this person? Can I really pick up and move to the far-away land of Vermont and be ok? How's this all going to pan out?</span> On one level, I've grown more comfortable with varying degrees of uncertainty. On another level, I simply have fewer uncertainties as I get older -- and, to some extent, avoid situations associated with long-term uncertainty.<br /><br />So how fitting it is to take this concept of the Unachievable Achievement, which allegedly exists for all of these reasons/sub-achievements independent of the achievement itself (that may or may not be even more important than the achievement itself), and let history bear that I have complete uncertainty over whether or not I actually achieved it. Talk about playing the irony card. And if I didn't really ride 100 miles, which symbolized all these great things, do all of those other reasons/sub-achievements still hold?<br /><br />That's why I wrote this post. After writing this, I cannot possibly answer that question with "no."<br /><br />If I had a specific need to accomplish the concrete task of riding 100 miles, maybe I accomplished it; maybe I didn't. I don't console myself with assurance that I've legitimately ridden 100+ mile rides twice prior in the past eight weeks, or with the promise of re-attempting this feat. It's not about that. It's about whether THIS one "counted" -- whether it meant something, something that will apply to the rest of my world and really, truly have staying power.<br /><br />But after all I've described... how could it not?<br /><br />I took this on to triumph over doubt, to impose structure on inflooding chaos, to build confidence amidst anxiety. I did that, and then some. It's not the facts upon which I'll look back; it's the meanings.<br /><br />Everything is in the editing. It's less lonely that way.<br /><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div>Melissa Marotta Houserhttp://www.blogger.com/profile/16888355366191460693noreply@blogger.com3tag:blogger.com,1999:blog-8980453300333511330.post-58751115057848140592009-09-12T13:52:00.005-04:002009-09-21T21:46:52.651-04:00"Own Your Awkward" -- not to mention your inadequacy, your anxiety, and your utter dread.<span style=";font-family:Georgia,";" >My current self-improvement project over the past few weeks has been to immerse myself in experiences that optimize my anxiety, discomfort, and outright dread. As I described last week, I am endeavoring to train myself to mindfully "accept" negative emotions without attempting to control them. <b>Active acknowledgment; passive acceptance. </b></span><br /><br /><div id="refHTML" style="font-family: Georgia,"Times New Roman",serif;"></div><div style="font-family: Georgia,"Times New Roman",serif;"></div><div style="font-family: Georgia,"Times New Roman",serif;">While the experiences I've been structuring for myself this week may seem quite drastic in the moment, they're actually quite subtle. In the true spirit of Kaizen, it's been the little things: Asking a question after class of an intimidating lecturer. Volunteering to interpret an EKG in front of 114 people (knowing full well that I would fail and embarrass myself). Accepting a task of injecting a screaming, kicking infant with a vaccine. Giving medical advice to a guy with heart disease about the proper way to use his nitroglycerine when he has chest pain. Asking my preceptor if I could accompany him, yet again, to the hospital late at night.<br /><br /></div><div style="font-family: Georgia,"Times New Roman",serif;"></div><div style="font-family: Georgia,"Times New Roman",serif;">What these opportunities have in common: 1<b>) I've not wanted to do them -- more specifically, I've wanted to NOT do them; 2) I anticipated that they would trigger my oh-so-familiar catecholemine surge, and its predictable consquences of physiological discomfort; 3) I recognized that exposing myself to situations that predictably inspire panic, to teach myself that it's not the end of the world to be uncomfortable -- with the expectation that, one day, it might be comfortable to be uncomfortable.<br /><br /></b></div><div style="font-family: Georgia,"Times New Roman",serif;"></div><div style="font-family: Georgia,"Times New Roman",serif;">At the hospital on Wednesday night, I could NOT have been more awkward. I stuttered. I walked into things. I stood behind the nursing station while my preceptor checked labs on the computer, staring at the ground wishing that I weren't there looking like a moron. <i>Stop</i>. <i>Who cares that you look like a moron? Just stand there and look stupid. You're gaining SOMETHING in this moment just by being there. So just be there.<br /><br /></i></div><div style="font-family: Georgia,"Times New Roman",serif;"></div><div style="font-family: Georgia,"Times New Roman",serif;">I followed my preceptor across the hall to see our first patient. The room was dark. Before me lay a 42 year old woman who has been in and out of the hospital for the past 4 YEARS with uncontrollable vomiting and abdominal pain. Her moans slowed to heavy breaths as she nodded to answer my preceptor's questions. As she spoke, my eyes glossed over with warm tears. I froze. <i>What are you doing?</i> I'm frozen. I'm tearful. I'm awkward. I'm uncomfortable. I can't do anything to alleviate this woman's discomfort, or my discomfort. I suck at life. <i>No you don't. Your task isn't to do anything; it's to stand there. So stand there. Why are you uncomfortable?</i> I've never seen anyone in this much physical distress before. <i>This is what you're going to do for a living -- see people in physical distress and try to help them. Remember?</i> Right. So I then attempted to scan my brain systematically for the potential causes of this woman's discomfort. <i>What's in the abdomen?</i> Uhhhh... <i>Really? Can you really not retrieve the organs located in the abdominal cavity?</i> Uhhhh...<br /><br /></div><div style="font-family: Georgia,"Times New Roman",serif;"></div><div style="font-family: Georgia,"Times New Roman",serif;">It occurred to me that there are some things that I'm not going to be able to accept. I was somewhat ok with the concept that my brain didn't work while in the presence of a crying, moaning person in pain. I could, in theory, ultimately remove myself from that setting and think outside of her presence. But what I could NOT accept was how poorly I was communicating. I expected that I should be able to say SOMETHING -- ANYTHING. And I couldn't. As my preceptor left the room, I turned to follow him. The pit of uselessness in my stomach made me want to crawl into the corner and cry.<br /><br /></div><div style="font-family: Georgia,"Times New Roman",serif;"></div><div style="font-family: Georgia,"Times New Roman",serif;"><i>Say something. Anything</i>.<br /><br /></div><div style="font-family: Georgia,"Times New Roman",serif;"></div><div style="font-family: Georgia,"Times New Roman",serif;">"I'm sorry you're in so much pain..." I started.<br />She moaned.</div><div style="font-family: Georgia,"Times New Roman",serif;">"Please help me.... please help me.... can't someone help m..." she trailed off.<br /><br /></div><div style="font-family: Georgia,"Times New Roman",serif;">I placed my hand over her wrist. People tell me all the time about how touch is comforting. I didn't necessarily believe that my touch would do anything - but I figured it was worth a shot. Maybe it did, maybe it didn't.<br /><br /></div><div style="font-family: Georgia,"Times New Roman",serif;">"We're going to do everything we can to get to the bottom of what's causing your pain."</div><div style="font-family: Georgia,"Times New Roman",serif;">"Please help me.... please....."</div><div style="font-family: Georgia,"Times New Roman",serif;">"We're going to try to figure out what's causing this, and help you get better..."</div><div style="font-family: Georgia,"Times New Roman",serif;">"Please...."<br /><br /></div><div style="font-family: Georgia,"Times New Roman",serif;"></div><div style="font-family: Georgia,"Times New Roman",serif;">I could tell quite immediately that we could continue this inadequate cycle all night, and that the meek touch of my hand on her wrist and my empty commitments to diligence weren't going to achieve a blessed thing. Still, I allowed the cycle to continue a few more rounds, then capped it off with another "I'm sorry" and a goodbye. I have never felt so inadequate.<br /><br /></div><div style="font-family: Georgia,"Times New Roman",serif;"></div><div style="font-family: Georgia,"Times New Roman",serif;">I returned to the nursing station where my preceptor was documenting his exam. I looked down at the floor, saying nothing.<br /><br /></div><div style="font-family: Georgia,"Times New Roman",serif;"></div><div style="font-family: Georgia,"Times New Roman",serif;">When we left a few hours later, I stopped him at the door.<br /><br /></div><div style="font-family: Georgia,"Times New Roman",serif;">"Do you have any thoughts on how to prevent your brain from shutting down when you get emotionally affected? I found that I was so distressed in the room with that patient that I literally couldn't retrieve the contents of the abdominal cavity."</div><div style="font-family: Georgia,"Times New Roman",serif;"><br />He smiled.</div><div style="font-family: Georgia,"Times New Roman",serif;">"That's how I've spent my whole life..."<br /><br /></div><div style="font-family: Georgia,"Times New Roman",serif;"></div><div style="font-family: Georgia,"Times New Roman",serif;">We then had a fantastic discussion about preventing the limbic system from interfering with other higher-level cognitive pathways (he used the expression "going limbic," which I adored) and about my project of immersion in uncomfortable, distressing situations. He shared that this is exactly how he approaches his world: identify a weakness, and immerse entirely until it goes away.<br /><br /></div><div style="font-family: Georgia,"Times New Roman",serif;"></div><div style="font-family: Georgia,"Times New Roman",serif;">I write this 30 minutes from heading out on the greatest physical challenge of my life. I am riding my bike 50 miles to the house across the road from the clinic (where I stayed for the summer), staying over, and riding 105 miles tomorrow. Century #2 -- just because. Just because I 1) don't want to do it -- more specifically, I want to NOT do it; 2) I know full well that it will inspire terrible, terrible feelings of panic during certain instances (I'm clipping in with both feet for the first time; I'm riding terrain I've never seen before; I'm riding by myself through areas where there are no people for hours); 3) I see it as an opportunity to practice EXACTLY what I've been talking and thinking and writing about all this time.<br /><br /></div><div style="font-family: Georgia,"Times New Roman",serif;"></div><div style="font-family: Georgia,"Times New Roman",serif;">In my coaching life, I talk/write so much about identifying goals -- and more importantly, the REASON for these goals. I stress the importance of investing time at the front end to develop very clear, specific psychological fuel. That's why I'm writing about this ride BEFORE I do it, instead of after.<br /><br /></div><div style="font-family: Georgia,"Times New Roman",serif;"></div><div style="font-family: Georgia,"Times New Roman",serif;">In theory, there is no good reason to do this ride -- except for MY reason. I see this, symbolically, as something that is going to represent conquering something that is important to me. I could try to talk myself out of my discomfort. Or I could just BE uncomfortable -- and keep going anyway. And when I've done it, I will remember it for the rest of my life. Every time I stand at the foot of a patient's bed and can't do anything to help him or her. Every time I fear that I've made a fool of myself. Every time I think I'm inadequate or incompetent or weak.<br /><br /></div><div style="font-family: Georgia,"Times New Roman",serif;"></div><div style="font-family: Georgia,"Times New Roman",serif;">Completing this challenge isn't going to make me smarter or smoother, or a better doctor. It's just a structure, and an important structure. <b>Conquering this is giving me a framework to expose myself to what scares the hell out of me, accept my anxiety, and do it anyway -- thus demonstrating, once and for all, that challenges can be conquered INDEPENDENT of negative emotions.<br /><br /></b></div><div style="font-family: Georgia,"Times New Roman",serif;"></div><div style="font-family: Georgia,"Times New Roman",serif;">I have resources around me to make this (mostly) safe. My roommate has offered to come get me from "wherever," and I have resources around the halfway point. I'm doing the first 50 miles (the part of the trip I've never seen before) in sneakers. I have tools and physical fuel. My psychological fuel, of course, is a genuine belief that I will have an entirely different life outlook when I conquer this. I'm excited to KNOW that I've done this. I'm excited to talk about it in the Spinning class I'm teaching tomorrow night about triumphing over adversity.<br /><br />I'm excited to be in an uncomfortable situation and remind myself that I did this, for the reasons that I did this.<br /><br /></div><div style="font-family: Georgia,"Times New Roman",serif;"></div><div style="font-family: Georgia,"Times New Roman",serif;">So now, the only thing left is to DO this.<br /><br /><span style="font-weight: bold;">EDIT 9/13/09 4:10PM: I DID this. It was <a href="http://spintastic.blogspot.com/2009/09/own-your-discomfort-75-minute-profile.html">the most painful journey imaginable</a>. But also the proudest.</span><br /></div><input id="gwProxy" type="hidden"><input id="gwProxy" type="hidden"><input id="jsProxy" onclick="jsCall();" type="hidden"><div id="refHTML"></div><input id="jsProxy" onclick="jsCall();" type="hidden"><div id="refHTML"></div><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div>Melissa Marotta Houserhttp://www.blogger.com/profile/16888355366191460693noreply@blogger.com0tag:blogger.com,1999:blog-8980453300333511330.post-10333465791733623972009-09-03T21:30:00.004-04:002009-09-04T06:58:59.065-04:00The "Shoulds" and "Should Nots" of Awkwardness.It might be said that my protocol for interacting with my environment is a tad rigid.<br />Perceive stimulus --> evaluate stimulus --> decide how stimulus "should" be --> rationalize/negotiate/strategize cognitive construct to make stimulus match intention. Translated as: "<a style="font-weight: bold;" href="http://increaseandbreathe.blogspot.com/2009/01/i-think-therefore-it-is.html">Reality is the way I say it is</a>."<br /><br />Most of the time, this serves me well. I decided I "should" be able to ride 100 miles on my bike -- <a href="http://spintastic.blogspot.com/2009/08/my-1st-century-check.html">so I rode 107</a> (just a few miles shy of the Canadian border) and am primed to ride 110 in 3 weeks. I decided I "should" be able to do <a href="http://spintastic.blogspot.com/2009/08/i-need-16-more-responses-for-my.html">a study on an obscure concept </a>about which nobody admits to thinking about except me (even though it changes lives, and the potential to be applied to EVERYTHING), so I launched a survey that collected 230 responses from around the world. I decided I "should" be able to leg-press twice my body weight -- and, as of a week ago, I can. I decided I "should" be training at my fantasy clinic that I discovered in an obscure magazine article before I even interviewed for medical school -- so I, well, am. I decided I "should" spend tonight writing about my psychological strife instead of studying, despite having also spent the past 2 hours coaching people on a bike. Reality is the way I say it is, after all.<br /><br />Yet. when I decide that I "should" be able to get through stressful life experiences without anxiety or any negative emotions -- any emotions at all, even -- this intention is not only unsuccessful but it's absurd. When I experience a response that departs from my intention, I expend a TON of energy to shut it down and control it -- forcing reality, in some way, to be as malleable as it is in 90% of my life circumstances.<br /><br />So for the last few weeks, I've been trying to drop the word "should" from my vocabulary. As adaptive as it has been for some of the examples I've cited, its destructiveness has been way more profound. I "should" be useful at all times at the clinic, so as not to be perceived as a mooch off their energy and resources. I "should" feel more comfortable performing every single clinical examination I know about. I "should" sleep more, study more. Consternate less.<br /><br />Instead, I've been making an effort to "accept" reality as it is -- not in spite of my intentions exactly; just independent of them. I'm not very good at this process. I "accept" that part, at least.<br /><br />Last night, I was at the clinic really late seeing patients with my preceptor. Around 10PM, he announced that he had to go admit one of his patients to the hospital through the ED. I asked if I could accompany him. (See: <a href="http://increaseandbreathe.blogspot.com/2009/06/coming-full-circle.html">creating opportunities</a>). I told him that I had no legit hospital experience and that it made me anxious, and that I "should" get over this by exposing myself to it. He supported this plan. I think he's amused by my ready professions of what makes me anxious and what I intend to do about it. I think he's also quite perceptive about what makes me anxious. When I don't have a useful structure with which to organize incoming stimuli and/or I lack confidence about my abilities or decisions, these patterns quite predictably set me off. So he spent a half hour teaching me how to organize a hospital admissions note. He's so awesome.<br /><br />So, 11:30PM. EVERYTHING about my arrival was awkward. It took me 5 attempts to park straight. I caught my stethescope in my car door. Upon entering the ED, I felt the wave of "awkward, useless, why am I here?!" wash over me. Yes, that wave. I timidly avoided interacting with human beings until my preceptor introduced me, lest I be faulted for draining attentional or oxygen resources me.<br /><br />'I "should" not feel this way,' I thought.<span style="font-style: italic;"> This is a great opportunity, and you are ruining it by being ridiculous. Stop it.</span><br /><br />Then I remembered Operation: Acceptance.<br /><br />Yes, I am anxious. Yes, I am awkward. <span style="font-style: italic;">It's ok to be awkward. This is the first time you're in this situation. You're fine.</span><br /><br />My preceptor pulled up a CT scan of the patient we were here to see. 72 year old man with Stage 4 esophageal cancer -- which even a 2nd-year medical student knows is a really dismal thing. Though I often can't tell a heart from an intestine on CT, I knew exactly what I was looking at -- and it was bad. His esophagus had become completely obstructed by the tumor. Part of me felt confident that I knew what I was seeing; part of me felt guilty for possessing this knowledge.<br /><br />We went in to see the patient. His frail, bony legs stuck out beneath his hospital gown. His sunken face looked up with indifference. "I can't keep food down, Doc. It comes right up."<br /><br />That was the "real life" translation of what I had just seen on the computer screen. It aligned perfectly. I stood there, possessing knowledge that explained this man's world -- defined it, scripted it towards an ending that I could anticipate far more clearly than he could.<br /><br />I gave myself permission to freeze and mindfully observe how I felt about this moment, a preview of so many moments just like it that are to come. Observing each sensation, without interpreting it. I was awkward and useless -- and whether that "should" have been or not was irrelevant. I was training to be right there in that moment -- that heavy, painful moment -- accepting every aspect of my reality.<br /><br /><span style="font-weight: bold;">And in that moment, reality was ok.</span><br /><br /><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div><input id="gwProxy" type="hidden"><!--Session data--><input onclick="jsCall();" id="jsProxy" type="hidden"><div id="refHTML"></div>Melissa Marotta Houserhttp://www.blogger.com/profile/16888355366191460693noreply@blogger.com2