I'm exhausted. Physically and emotionally exhausted. I exist on cereal, soda, and however many gluten-free snack bars I can stuff into the pockets of my white coat. I haven't exercised in a week. I haven't slept adequately in two. My feet are on fire, accompanied by 1+ pitting edema up to the mid-tibia. My vasculature, my brain, my soul -- all of them resisting the reality of my new life.
I stopped dreaming that My First Patient was going to die. Not because he necessarily got better (as alluded to in my previous post, "getting better" = upgrading to lifelong dialysis -- so I guess, yeah, he got better). But because I'm now helping to also take care of My Second Patient, and I simply don't have the emotional resources to obsess over two people. How do people have practices? How do people have children?
My Second Patient is an elderly woman with congestive heart failure, chronic kidney disease, hypertension, and a slew of the other usual suspects, and came in on Monday with progressively worsening shortness of breath and fluid buildup. Our job is to a) help her breathe better, and b) figure out whether to blame the kidneys vs. the heart vs. some other entity. Three days later, she still can't breathe too well (even on oxygen!), and we haven't been able to get rid of much fluid with diuretics.
The worst part is that she lives 2 hours away (this is the closest big hospital), far away from her husband or anyone else who can be here to hold her hand. So I do.
I am so attached to this lady that it's sick. I've come thisclose to snuggling her. I also came thisclose to slapping my senior resident who marched into her room yesterday, leading our amusing-looking pack of lapdogs, poking and prodding her while spouting frightening jargon. When I returned to her room later to "translate" (from Medical to English), her eyes were red and moist. She had been crying.
I, too, am tearful often around this lady. Not because we have the "intimidated, confused, and alone" thing in common, which we do. I get tearful because she makes me feel like I might actually one day be a decent doctor. When I am forced (by my conscience) to explain test results and treatment plans (presented completely differently than the residents do: "today we're going to do x to you" doesn't exactly do wonders for one's locus of control) at the level of some fuzzy grey zone between sub-technical and respectful-lay (perhaps resembling Wikipedia-level medicine -- i.e., how most medical students learn anything that makes sense), I appreciate that I don't suck at it. I get nonstop practice at tetering on that fine line between "neutral" and "non-neutral." Everything matters here. Your tone, your facial expressions, your body language. The moments you create for people might actually be some of the only human interactions for the day. Their singular insight into "what's going to happen to them" that day, or ever. These moments matter. You can't butcher them or rush them. Or skip them (as My First Patient was about to be whisked off to the OR to have a catheter placed for dialysis, I asked whether any of his real doctors had told him. I nearly puked when I heard the answer.).
Today on rounds, my attending called out a senior resident for his ineffective nonverbal communication skills. It was a resident I actually like, who is actually pretty gentle and friendly with patients -- doesn't interrupt, is pleasant and reassuring. But my attending called out for the way he interviews patients while standing up, towering over them, with his arms crossed against his chest. I was very moved. Moved because FINALLY, for the first time on this rotation, someone called attention to everything I've been complaining about since I got here. Somebody finally said this wasn't ok. But the thing was, the resident didn't take this feedback constructively. Instead, he argued of the merits of "asserting one's self" with a patient, setting boundaries, "letting them know how it is." He didn't drop the "c bomb," but I thought he was going to.
"There's room for compassion sometimes..." he began. "But sometimes you just need to let the patient know that you're calling the shots."
This is who they leave me alone with, to teach me how to be a doctor.
My attending didn't bother to argue. I assume he chalked it up to a lost cause. But since he still had the floor, he continued.
"Sometimes you don't need to say anything at all. Sometimes you just listen. Everyone has a story."
One of the upshots of a) knowing relatively little about what's wrong with really sick people and how to fix them (or at least how to apply the stuff I know), and b) having relatively few responsibilities besides showing up early, hanging around late, and undergoing the various humiliating rites of passage associated with third-year med student life, is that I have all the time in the world to figure out other ways of being useful. I've found that my 'usefulness niche' is to listen to people's stories -- to look them in the eye, smile, and shut the hell up.
It's amazing what people tell you when you shut up.
I've created a construct of "listening quotient" -- how much listening will I do during any one enounter. The LQ is calculated on the basis of several factors: a) the look in a person's eyes -- are they scared? are they lonely? are they confused?; b) has any other human being interacted with him or her lately?; c) if I were in his or her place, how much and in what capacity would I want me there?; d) what is my purpose: data acquisition, comfort/assurance, interview practice, etc?.
Today, for example, I was tasked with performing a rectal exam on My Second Patient. I'd never performed an unsupervised rectal exam before, nor had I performed a rectal exam on a patient who didn't show up for an annual physical expecting to have one. I entered her room, and found her short of breath and distressed after experiencing an adverse drug event. Seriously? A rectal exam in the middle of this? Game over. So because I had the time, and because I did genuinely want to understand what she had experienced (so that I could relay it back to my team), and because I wanted her to feel like she had been heard, and because the LQ earned by knowing that I was about to impose discomfort, awkwardness, and potentially pain, we chatted for a good half hour before I explained why we were recommending (if it were ok with her) that I perform a rectal exam. I apologized profusely, etc. etc. about the nature of the exam, and helped her to roll over into the most appropriate (and comfortable, as I can attest via my experience as a patient) position. As a 400+ lb. woman, it was a challenge to attend to her modesty, comfort, and self-consciousness while helping her get into position. I'm not sure that I did a good job. And when it was all over (post-tissues: I ALWAYS give tissues; my doctors never did), we chatted again for another half hour. The blood I saw on my sample earned an even higher LQ, anticipating what I might one day have to tell her.
Tonight before I went home, I went in to check on My Second Patient. We went over some of her test results (good), and the plan for the next day (hopeful). She told me that her husband was visiting shortly (great!). And then, all of a sudden, she started bawling. I touched her arm.
"I'm so scared..." she said. My hand remained on her arm. I said nothing.
"Thank you. You make me feel so much better. You come with me to all my scary procedures, and you teach me about what's going on."
It's amazing what people tell you when you shut up and listen.
Wednesday, March 17, 2010
Snapshots from Week 1 on the Wards
I had so much to reflect on from my first week of inpatient medicine, so much I wanted to capture and document here in a format that I could look back on, a format that would keep me honest. But I didn't. Instead, I ranted to my roommates (I'm living in a dorm with four other med students, right across from the hospital), I ranted to my boyfriend. And I emailed my preceptor at the clinic.
I'll paste those emails here, more raw than I'd be able to re-create. His responses were what was epic about the exchange - but I think it's probably poor form to post someone's emails on the Internet, unbeknownst to him or her. But here's at least my end, for me to remember.
Thursday, March 11, 2010 -23:31.
Life is ok here. Slightly less disoriented as the days go by. Getting pretty good at writing notes, functioning on little sleep, and mildly to moderately competent at presenting without sounding like an idiot. Oh, and yesterday I found out that I passed my Boards.
I started my first rotation on Monday. Renal. Everything very interesting but exhaustingly sad and frustrating. Even the people who “get better” don’t actually really get better. It's almost like there is a drop-down menu: 1) dialysis now, 2) dialysis later, 3) death.
My first patient is the sweetest, nicest old man. I spend most of my day with him and his wife (a nurse), translating all the minutiae of his treatment plan (they totally care, and nobody ‘gets’ that they really, truly want to know every single thing that’s going on). They’re so scared, and they experience a greater sense of control by having specific data points to track. But all the data gets worse every day. Prior to a few months ago, he had no renal problems at all – and suddenly, he’s days away from dialysis. Diagnosis is still undetermined (repeated a biopsy today) – but he might actually have Wegener’s. I didn't know people actually got that. His renal function gets progressively worse, his sugars are skyrocketing from all the steroids he’s getting, and he has incidental lung findings that might be consistent with IPF (you taught me about how bad that on my last day at clinic; my first patient wasn’t supposed to actually have it…)
Most nights, I dream about him dying.
While I was at a lecture today, he had an ischemic cardiac episode (ST depression on ECG, initial biomarkers were negative but it was probably too early). I later found out he had to call 3x before anyone came to him. He had told me about overnight chest pain on pre-rounds this morning (which he later explained felt exactly the same as this episode), and my team unanimously concluded this was anxiety when I presented to them. Then, this happened. I felt horrible. I was too wimpy to advocate for him; I merely reported facts and didn’t dare express my differing opinion – even though, technically, this is an environment where I could have.
My residents frequently comment on what a great case this is for me to see as a student – an ANCA-positive vasculitis with possibly related lung findings (my one useful contribution to life was to suggest testing for anti-GBM antibodies, since that commonly but unfamously can show up ANCA-positive). But it doesn’t feel great. It feels awful. Every time he asks me if he’s going to get better and stop getting infused with all the poisons we’re giving him, and I have to find some horrible way to balance realism with whatever we’re waiting on for x day, it’s just awful. Important learning experience and preparation for what is to come, of course, but awful nonetheless.
Saturday,March 13, 2010 -11:30
Yesterday was a good opportunity to focus on all the non-"know how" parts of medicine, and to feel useful that way. It was a really scary day for my patient -- tunnel cath placement and start of plasmaphoresis and dialysis (all of which were decided last-minute, so he hadn't psychologically prepared for it). I had time to spend the whole day with him and talk about his fear, intervening/translating when various characters communicated sub-ideally (including eeeeeevery resident here, who all either spout nonstop jargon or deliver all news at the level of a first-grader; no middle ground). I hope I'm not naïve in thinking that piss-poor communication skills are not soley the result of time pressures that I don't yet have.
It's good that I'm literally forced, all day long, to practice educating him and his family at appropriate levels for all of them, and framing horrible test results and horrible treatment options (my new gripe that may prove to top "compliance" the longer I'm here, is the whole "we're going to do x to you today" without bothering to create even an illusion of perceived control).
I've been spoiled in spending so much time watching you communicate about difficult issues so expertly. But I forgot how instructive to watch how NOT to handle something, too - and attaching what I learn to this emotional memory, I hope will last. For example, we were recommending cyclophosphamide (communicated as "we're going to start you on cyclophosphamide" without a discussion of what it is or its risks) -- and the wife's eyes bulged out of her head. She clearly recognized the drug name and assumed her husband had cancer and that we weren't telling them, so started asking vague questions so as not to alarm her husband. The resident could have cleared this up so quickly, but didn't pick up on what the issue was instead was awkward and vague and ending up scaring the hell out of them. I don't think I'll ever forget that, the importance of inhabiting people's responses to be able to anticipate future response. I've been able to ask these folks all sorts of questions about their reactions to various events and interactions. I won't ever be able to spend an hour on that after clerkship - but hopefully I'll remember to ask at all.
I'd like to be at a place where I don't get tearful when I come home every night and show up to the hospital rehearsing my coping mechanism for finding him dead. Does this get easier?
In other news, today I saw the chalky blue-grey skin changes of amiodarone that I memorized and regurgitated for Boards but had never even seen a photo of. Seriously not ok.
Monday, March 15, 2010 -- 20:12
Today I pissed my supervising intern off by asking if I could call for a (free) dietary consult to teach my patient (who is actually getting better!!!) about how to adjust to his new restrictive diet. "It's too much information." A complete misread on who this guy is. He wants information. He wants to understand. He gets anxious without being able to have any expectations, or at least accurate ones (bonehead covering attending over the weekend told him he could go home today, without determining that plasma exchange isn't done as an outpatient here - Imagine his disappointment to learn that it's actually an entire week extra).
On the flipside, I'm now helping to take care of a new patient who's at a totally different level of what she understands and wants to understand. 78 year old woman, very much of the "doctors do no wrong, I entrust myself completely in all of your hands" mindset. I'm sure that I'll learn a lot about how differently I'll likely communicate with her than with the first guy. It's a tricky balance between making people feel comfortable and safe vs minimizing the fact that their kidneys are shutting down. It's entry-level "giving bad news" practice.
In other news, I independently diagnosed a real person for the first time. It was a result of relying on a flawed heuristic (I'd read someone's memoir a few weeks ago about missing ischemic colitis in a little old lady with a GI bleed) instead of legitimately knowing that the other potential causes I did know about were more common. It was the first time I had an original intelligent contribution within the borders of the state of Maine, and it didn't even earn a "good thought" (universal validation of medically intellectual legitimacy, of course). It was more "let's order a lactate to humor the silly medical student to make her feel like part of the team." I was kind-of furious at myself about how proud I was to be right, especially since I arrived at it completely unscientifically. But as a wise man once told me: "tis better to be lucky than to be good." I probably butchered that, sorry.
Tuesday, March 9, 2010
Time.
Status-post second day as a third-year medical clerk, and never have I been so conscious of time as a limited resource. There's not enough time in the day to see enough, read enough, eat enough, sleep enough -- even pee enough. Even when I have "free time" to do things reminiscent of My Old Life (the one from two days ago), I don't do them. Something's different.
"They" told us that everything becomes different now. All that matters is "our patients" -- the ones that were mentioned so infrequently during Orientation last week that I actually forgot (for at least a few hours) that I'd interact with any. Then, you show up and get thrown into this crazy, chaotic world of beeping alarms and White Coats walking around and spitting out numbers, minimizing human interaction wherever possible. The detachment is palpable.
A few hours into my day yesterday, though, I was told about a new patient coming into the Emergency Department after being sent in by his doctor urgently after discovering insanely elevated blood levels of potassium and creatinine. I was told he'd be "my" patient, and was later told to show up at the ED and interview "the guy in A8." I've gone into rooms to interview patients before: I could do this, I figured. So I found my way through the labyrinth of my new world, walked right in, sat right down, and... everything became different.
Over the past 36 hours, "the guy in A8" really has become "my" patient. I arrive at 5:30AM to check on all his labs and examine him. I present his updates to my team. I write up notes for his chart, write medication orders (seriously?), and spend most of the day with him and his family. I pop into his room periodically to give him "life updates," as I call them - what's going on with various tests, medications, and how the team is thinking about solving his case at x point. Because you know what? NOBODY ELSE IS.
"Be careful about giving patients too much information," cautioned my intern today. "You might make them anxious."
In addition to textbook resolution of his hyperkalemia, my patient was given insanely high-dose IV steroids yesterday to treat his mysterious kidney disease (which, in actuality, may be something that House throws out on his differential every episode but that we were taught in school that nobody actually gets...). Today, the team suggested adding another insanely potent immunosuppresent: a cancer drug, cyclophosphamide. Silly post-USMLE Step 1 jaw-jerk reflex goes off about the only thing I know about cyclophosphamide: that it can cause fatal hemorrhagic cystitis, and should be given with another drug called Mesna to inactivate its dangerous metabolite. Shot down. Silly med student. I pushed the issue with two interns, an attending, a pharmacist. I'm paranoid that this was my one opportunity to be useful, and I couldn't "sell it."
"So, we're going to start a new drug on you," says the intern to My Patient. I shudder. We're just going to do x to you. Not 'recommend.' No 'what do you think?' - no 'is this ok with you?'
"What is it?"
"It's a drug that shuts down your immune system."
"What's it called?"
"Cyclophosphamide."
Patient's wife (a nurse)'s eyes bulge out of her head. I instantly detect that she recognizes the drug name and thinks that her husband has cancer, and that we're not telling him. I try to intervene. Intern obfuscates with vagueness. My patient interrupts.
"Do I have cancer?"
Finally, it occurs to me how to explain that different drugs are used for multiple purposes. Everyone quiets down. But I deeply regret those 2.5 minutes where these lovely people felt in the dark about their lives. There was no need for it.
I continued to obsess over it, until I alleviated my hang-up by finding an article that documented that cyclophosphamide is the standard treatment for what we think he might have. I printed it. I don't know whether they cared what it said. But I did know that they cared that I knew they were scared and confused.
Tonight, it's time to leave. I tell the intern that I'm going to tell my patient that his cyclophosphamide first dose is coming tonight. That's when I was cautioned about the perils of keeping people informed about the whats, whens and whys of introducing toxic cancer drugs into their bodies, without thorough discussion of side effects. I did it anyway.
"Am I going to have to take this forever?"
I can't protect my patient from his kidneys or his medicines, or the cold alienation of his surroundings. I don't know whether my presence in his room contributes any real difference. I've never wanted to fix someone so badly. I hang onto his every little detail that comes out of his mouth, hoping that I'll catch some subtle little detail that everyone else blew off. I exaggerate the things I hear. I've been reading for hours about reactivated rheumatic fever. Nobody gets that. But then again, nobody gets what everyone thinks he has...
People say that the value of the third-year medical student is how much time we have. Unlike actual doctors managing dozens of patients, all of my energy and cognitive resources are invested in one man. I technically have oodles of time to indulge my tangents. But when you think about a round, little old man lying alone in a hospital bed -- caught in a balance between his kidneys trying to kill themselves and the toxins we gave him threatening to kill him first -- there's never enough time in the world.
"They" told us that everything becomes different now. All that matters is "our patients" -- the ones that were mentioned so infrequently during Orientation last week that I actually forgot (for at least a few hours) that I'd interact with any. Then, you show up and get thrown into this crazy, chaotic world of beeping alarms and White Coats walking around and spitting out numbers, minimizing human interaction wherever possible. The detachment is palpable.
A few hours into my day yesterday, though, I was told about a new patient coming into the Emergency Department after being sent in by his doctor urgently after discovering insanely elevated blood levels of potassium and creatinine. I was told he'd be "my" patient, and was later told to show up at the ED and interview "the guy in A8." I've gone into rooms to interview patients before: I could do this, I figured. So I found my way through the labyrinth of my new world, walked right in, sat right down, and... everything became different.
Over the past 36 hours, "the guy in A8" really has become "my" patient. I arrive at 5:30AM to check on all his labs and examine him. I present his updates to my team. I write up notes for his chart, write medication orders (seriously?), and spend most of the day with him and his family. I pop into his room periodically to give him "life updates," as I call them - what's going on with various tests, medications, and how the team is thinking about solving his case at x point. Because you know what? NOBODY ELSE IS.
"Be careful about giving patients too much information," cautioned my intern today. "You might make them anxious."
In addition to textbook resolution of his hyperkalemia, my patient was given insanely high-dose IV steroids yesterday to treat his mysterious kidney disease (which, in actuality, may be something that House throws out on his differential every episode but that we were taught in school that nobody actually gets...). Today, the team suggested adding another insanely potent immunosuppresent: a cancer drug, cyclophosphamide. Silly post-USMLE Step 1 jaw-jerk reflex goes off about the only thing I know about cyclophosphamide: that it can cause fatal hemorrhagic cystitis, and should be given with another drug called Mesna to inactivate its dangerous metabolite. Shot down. Silly med student. I pushed the issue with two interns, an attending, a pharmacist. I'm paranoid that this was my one opportunity to be useful, and I couldn't "sell it."
"So, we're going to start a new drug on you," says the intern to My Patient. I shudder. We're just going to do x to you. Not 'recommend.' No 'what do you think?' - no 'is this ok with you?'
"What is it?"
"It's a drug that shuts down your immune system."
"What's it called?"
"Cyclophosphamide."
Patient's wife (a nurse)'s eyes bulge out of her head. I instantly detect that she recognizes the drug name and thinks that her husband has cancer, and that we're not telling him. I try to intervene. Intern obfuscates with vagueness. My patient interrupts.
"Do I have cancer?"
Finally, it occurs to me how to explain that different drugs are used for multiple purposes. Everyone quiets down. But I deeply regret those 2.5 minutes where these lovely people felt in the dark about their lives. There was no need for it.
I continued to obsess over it, until I alleviated my hang-up by finding an article that documented that cyclophosphamide is the standard treatment for what we think he might have. I printed it. I don't know whether they cared what it said. But I did know that they cared that I knew they were scared and confused.
Tonight, it's time to leave. I tell the intern that I'm going to tell my patient that his cyclophosphamide first dose is coming tonight. That's when I was cautioned about the perils of keeping people informed about the whats, whens and whys of introducing toxic cancer drugs into their bodies, without thorough discussion of side effects. I did it anyway.
"Am I going to have to take this forever?"
I can't protect my patient from his kidneys or his medicines, or the cold alienation of his surroundings. I don't know whether my presence in his room contributes any real difference. I've never wanted to fix someone so badly. I hang onto his every little detail that comes out of his mouth, hoping that I'll catch some subtle little detail that everyone else blew off. I exaggerate the things I hear. I've been reading for hours about reactivated rheumatic fever. Nobody gets that. But then again, nobody gets what everyone thinks he has...
People say that the value of the third-year medical student is how much time we have. Unlike actual doctors managing dozens of patients, all of my energy and cognitive resources are invested in one man. I technically have oodles of time to indulge my tangents. But when you think about a round, little old man lying alone in a hospital bed -- caught in a balance between his kidneys trying to kill themselves and the toxins we gave him threatening to kill him first -- there's never enough time in the world.
Tuesday, March 2, 2010
Milestones.
One year ago tomorrow, we were assigned to flaunt our brand new White Coats and prance around the cardiology floor of the hospital and impose ourselves onto some unsuspecting patient. Our task was to go through the motions of interacting with a human being whilst wearing said new coat, to experience how the symbol translates into real life. The problem was that we didn't have any useful clinical purpose. The assignment wasn't "go and see Mr. Smith, take a history and do a physical." Rather, it was "go and see Mr. Smith and practice talking to him." See also: "Go wake Mr. Smith up, disrupt his restorative post-surgical sleep and ask him to tell you his life story (for the umpteenth time) for no reason other than for your practice interacting with a real person, despite your complete inability to contribute in any way to his life."
I couldn't make his heart pump stronger. I couldn't get him out of the hospital and back to his real world any faster. He didn't have an overwhelming desire to unburden himself of his innermost concerns. He wasn't looking for anyone to listen to him and support him. He just wanted to go home, and I could do absolutely nothing to further that end.
I didn't belong in that hospital. I didn't belong in that coat. I was an imposter, completely disconnected from any of the privileges of existing under those conditions. I knew it before I walked into Mr. Smith's room that I would feel awkward and guilty for draining his resources without serving any purpose of any kind. It was an experience of profound uselessness that scarred me, inspiring a borderline-pathological, obsessive sensor to evaluate my contributions to any patient who has allowed me to learn from him or her ever since.
Exactly one year later, imagine the irony of beginning my third-year clerkship. Yesterday, I drove and moved myself to Portland, ME (a feat in and of itself: my car was so packed that I couldn't see out the back OR side windows... that I made it here alive without rendering irreparable harm to myself or others is pretty mind-blowing) to start my new life. And this morning, I strutted into the hospital - garbed in White Coat, of course - with a confidence that I could not even have imagined a year ago.
Day 1 of orientation was pretty chaotic. Lots of info, lots of hallways, lots of disorganization. But as I walked those hallways, I felt something completely foreign to my inpatient experiences to date (see also: my "Operation: Own Your Discomfort" trips with my preceptor this Fall). I felt like I kind-of, sort-of, just-a-little-bit... belonged there.
The first day was concluded with my first patient interview as a third-year student.
Assignment: "Go see Mr. Jones. Don't take a history or perform a physical exam. Just talk with him about what it's like to be in the hospital." The same exact assignment from a year ago.
"I heard a little bit about your experience from Dr. X. What has it been like for you?"
Twenty thoughtful minutes later, I found myself discussing this man's use of narrative to construct a meaningful experience of his frightful events (cardiac arrest, followed by an induced coma). With each rendition of his story, he recounted, he felt more and more appreciative for his life and the people around him. He selected his details, framed their context and consequence -- all of it shaped exactly as he needed it to be. His story was his coping mechanism, his structure. His way of establishing control in the face of chaos.
As his words fell upon my eager ears, I was surprised at how natural it felt -- it felt just like interviewing a patient at clinic, as I'd done so many times before this year. Granted, he was not in acute distress. I don't think clearly or feel comfortable/confident/anything remotely positive whilst in the presence of someone in acute distress: this is definitely going to be a challenge, and one that simply did not present itself today. But for now, in the moment, I felt like I truly did belong.
I couldn't make his heart pump stronger. I couldn't get him out of the hospital and back to his real world any faster. He didn't have an overwhelming desire to unburden himself of his innermost concerns. He wasn't looking for anyone to listen to him and support him. He just wanted to go home, and I could do absolutely nothing to further that end.
I didn't belong in that hospital. I didn't belong in that coat. I was an imposter, completely disconnected from any of the privileges of existing under those conditions. I knew it before I walked into Mr. Smith's room that I would feel awkward and guilty for draining his resources without serving any purpose of any kind. It was an experience of profound uselessness that scarred me, inspiring a borderline-pathological, obsessive sensor to evaluate my contributions to any patient who has allowed me to learn from him or her ever since.
Exactly one year later, imagine the irony of beginning my third-year clerkship. Yesterday, I drove and moved myself to Portland, ME (a feat in and of itself: my car was so packed that I couldn't see out the back OR side windows... that I made it here alive without rendering irreparable harm to myself or others is pretty mind-blowing) to start my new life. And this morning, I strutted into the hospital - garbed in White Coat, of course - with a confidence that I could not even have imagined a year ago.
Day 1 of orientation was pretty chaotic. Lots of info, lots of hallways, lots of disorganization. But as I walked those hallways, I felt something completely foreign to my inpatient experiences to date (see also: my "Operation: Own Your Discomfort" trips with my preceptor this Fall). I felt like I kind-of, sort-of, just-a-little-bit... belonged there.
The first day was concluded with my first patient interview as a third-year student.
Assignment: "Go see Mr. Jones. Don't take a history or perform a physical exam. Just talk with him about what it's like to be in the hospital." The same exact assignment from a year ago.
"I heard a little bit about your experience from Dr. X. What has it been like for you?"
Twenty thoughtful minutes later, I found myself discussing this man's use of narrative to construct a meaningful experience of his frightful events (cardiac arrest, followed by an induced coma). With each rendition of his story, he recounted, he felt more and more appreciative for his life and the people around him. He selected his details, framed their context and consequence -- all of it shaped exactly as he needed it to be. His story was his coping mechanism, his structure. His way of establishing control in the face of chaos.
As his words fell upon my eager ears, I was surprised at how natural it felt -- it felt just like interviewing a patient at clinic, as I'd done so many times before this year. Granted, he was not in acute distress. I don't think clearly or feel comfortable/confident/anything remotely positive whilst in the presence of someone in acute distress: this is definitely going to be a challenge, and one that simply did not present itself today. But for now, in the moment, I felt like I truly did belong.
Thursday, February 25, 2010
"Enough"
Mmm. To unify the epic events of the past two infinitely-eventful-yet-blogless months: quite the daunting task. Starting this entry whilst sitting in an airport on layover awaiting a connecting flight home, part of me is sub-motivated to write at all. If I don't write, after all, I can't craft a mediocre product.
But the fact is, whatever I write not only should be "enough" - but will be. That's what the past two months have been about.
The last time I went two months without documenting the formative events of my world, both drastic and subtle, was Fall 2008 when I was dissecting cadavers and doubting my self-worth. Then, no matter how widely I opened my mouth to catch as much of the violently explosive stream of water gushing at me from the Hose of Medical Education, I couldn't learn or see or do or be enough. How on earth was I going to internalize enough information to earn the privilege of caring for a human being? To inspire trust and confidence?
Over the past 1.5 years, this theme of doing "enough" has been well borne out in my writings - and certainly in my thoughts. Am I studying enough? Am I reflecting enough? Am I balanced enough? Am I structured enough? Am I focused enough? Am I open enough? Have I earned enough? Have I re-earned and re-earned and re-earned enough? Am I confident enough? Am I self-critical enough? Am I self-forgiving enough? Do I feel enough? Am I "present" enough? Do I connect enough? Am I inspired enough?
Am I prepared enough?
Three weeks ago, I had my last day at the rural clinic where I've spent > 10 hours a week for the past year. Ironically, my last day was exactly one year from the first time I drove out to meet them (my first solo Interstate drive -- which, looking back on that post from the age of fake-driverdom, was such a big deal!). And just as that day forever changed my life, so will this one. My anniversary/departure rang of true synchronicity. Of course it would also be the day of a full staff meeting, where I got to bid adieu to everyone en mass (and receive the warmest of applauses) - where my hero would present me with a symbolic gift of the legendary William Osler's original "The Principles and Practice of Medicine" (1901), citing one of Osler's famous quotables acknowledging how much he learns from his students. Obviously, I cried in front of the whole clinic staff. Obviously. Of course we would drive through the snowy, winding hills to pay house calls -- just like on my very first day shadowing. Of course we would even see patients in clinic that I remember first seeing on that same first day. Of course I would have built-in opportunities for reflection, according to specific parameters, on how much has changed (my shift in the confidence:awkwardness ratio; my appreciation for being useful in some capacities) and how much has remained the same (how inspired I am by the energy of this place, these people; how fulfilling it is to connect with people, to understand the context of their family and community, to build on that understanding over time). Of course I took epically rewarding opportunities to thank my mentors, with great specificity, for what they have contributed to my world. I wrote to the clinic's executive director how it had been my dream to get accepted to medical school in Vermont, only to have access to meet him and see this clinic once -- let alone have the opportunity to actually train here, let alone for a whole year. I wrote to my PA mentor how invaluable it was to have someone so gifted so deeply and passionately believe in my ability to "do this" before I believed it myself. I wrote to my direct preceptor that I will spend my life working to match his balance of unfailing compassion, mindful self-reflection, and commitment to improvement of all kinds.
And when I walked out that door, I thought about what the executive director told me on my first day there: "In medical school, I always felt like an imposter... until one day, I didn't."
Beyond the hundreds of thousands of tangible and intangible things I've learned through this opportunity over the past year, beyond the influences of the energy and personalities and experiences, what made all of this all the more rewarding is that I created all of it. It didn't merely "happen." I found them, I sought them out. I decided very early that the more time I spent there, the more I would learn. Do I study books as much as other people? No. Is that bad? Maybe. But the difference is: the stuff I learned at clinic, I actually remember.
Which brings us to Influential Life Event #2. Last week, I took Step 1 of the United States Medical Licensing Exam. 6 hours of torturous convoluted questions on the basic sciences, genetics, and vague clinical correlations. Preparing for it has consumed my existence for the past two months -- particularly my "brain space" for self-reflection, self-nourishment, and self-other good things requisite for successful human functioning. I've spent most of the past month in particular glued to my kitchen table (across from my equally miserable roommate, preparing for the same exam) taking thousands of practice questions, displacing relevant and irrelevant knowledge with every extra factoid encoded, doubting my self-worth. Frustration, boredom, distraction were wicked breeding grounds for high-level procrastination. It was easier to make Spinning rides about some variant of the process than to actually engage in the process.
Did I study as much as other people? No. Did I make questionable choices of how I spent my time (i.e., packing up my apartment prematurely, snuggling with Scott, holding extra 2-hour endurance trainings for my riders, eating gluten and lactose, spending hours hanging out at clinic)? I'd argue that every one of those were good choices.
Why? I knew I didn't know everything, and would never know everything. Acknowledging that is less acceptance of mediocrity as I'd once surmised earlier in medical school; rather, it's setting reasonable, realistic, specific goals (i.e., to pass with a 20 point margin) and continue to invest in my big picture. I knew damned well that I knew a LOT. I knew a lot with great specificity. Not everything. Not even 50% of everything. But I thought that maybe, just maybe, I knew enough. And when I made that decision, suddenly my entire approach changed. I no longer feared Step 1. I no longer dreaded it. It was one big, epic "GAME ON!" -- the pursuit of success and conequest, not merely the avoidance of failure. There's a difference. And it matters.
It mattered on Game Day. Yes, there were tons of questions I didn't have the slightest clue how to answer. Yes, there were times where I muttered - literally, out loud - "are you kidding me?!" (ok, maybe I wasn't that polite/professional). But by and large, I saw a heck of a lot more opportunities to demonstrate the effectiveness of my preparation and knowledge base than obstacles to "endure." It's just how I coach people on the bike: directing one's attitude, choosing to perceive challenges as "opportunities" to demonstrate SOMETHING (strength, discipline, control, etc.) as opposed to something to suffer.
A lot of my friends told me that they "checked out" at times during the exam -- their minds wandering to skiing, to vacations, to sex. My mind wandered to snapshots, memories, of where or how I learned something. It was like Slumdog Millionaire. Sometimes it was a memory of a specific lecturer's memorable one-liner. Sometimes it was of my preceptor sharing a particular clinical pearl. But mostly, I had images of patients I'd seen at clinic. I'd read a question, admit that I either never read or never encoded this in an academic setting, sigh - and then all of a sudden, trigger a vision of someone and something I knew I'd seen. BAM. This happened over, and over and over again.
For the first time in medical school, I felt like I knew -- and was -- "enough."
I wanted to write about two subsequent life-altering experiences -- flying with my boyfriend to his hometown in rural North Carolina to meet 50+ of my future-in laws for the first time, and then reading an epically inspiring book, Every Patient Tells a Story (Lisa Sanders, M.D.). I've had so many thoughts and moments flying through my head that directly relate to the theme at hand. But I'm also supposed to be packing up my entire life into cardboard boxes and garbage bags, in efforts to move to a new state in 36 hours.
I've used this blog over the course of my training to date as a mechanism for processing important experiences, re-shaping and re-structuring them in a way that I'll want to look back on as evidence for what I've thought about and valued, documenting both the patterns that endure and evolve. When I fail to carve out time to write, I experience it as "cheating" myself out of an invaluable opportunity. But it's not like that. When I start clerkship (inpatient rotations) on Monday, I'm going to have hundreds of thousands of experiences that I'll want to "document" and reflect upon. I won't. The balance between "reflecting" and "living"/"doing" is an important one. Maintaining a sense that I am continuously evaluating "enough" is a truly high priority for me. It's just a matter of defining, and redefining, what that means.
But the fact is, whatever I write not only should be "enough" - but will be. That's what the past two months have been about.
The last time I went two months without documenting the formative events of my world, both drastic and subtle, was Fall 2008 when I was dissecting cadavers and doubting my self-worth. Then, no matter how widely I opened my mouth to catch as much of the violently explosive stream of water gushing at me from the Hose of Medical Education, I couldn't learn or see or do or be enough. How on earth was I going to internalize enough information to earn the privilege of caring for a human being? To inspire trust and confidence?
Over the past 1.5 years, this theme of doing "enough" has been well borne out in my writings - and certainly in my thoughts. Am I studying enough? Am I reflecting enough? Am I balanced enough? Am I structured enough? Am I focused enough? Am I open enough? Have I earned enough? Have I re-earned and re-earned and re-earned enough? Am I confident enough? Am I self-critical enough? Am I self-forgiving enough? Do I feel enough? Am I "present" enough? Do I connect enough? Am I inspired enough?
Am I prepared enough?
Three weeks ago, I had my last day at the rural clinic where I've spent > 10 hours a week for the past year. Ironically, my last day was exactly one year from the first time I drove out to meet them (my first solo Interstate drive -- which, looking back on that post from the age of fake-driverdom, was such a big deal!). And just as that day forever changed my life, so will this one. My anniversary/departure rang of true synchronicity. Of course it would also be the day of a full staff meeting, where I got to bid adieu to everyone en mass (and receive the warmest of applauses) - where my hero would present me with a symbolic gift of the legendary William Osler's original "The Principles and Practice of Medicine" (1901), citing one of Osler's famous quotables acknowledging how much he learns from his students. Obviously, I cried in front of the whole clinic staff. Obviously. Of course we would drive through the snowy, winding hills to pay house calls -- just like on my very first day shadowing. Of course we would even see patients in clinic that I remember first seeing on that same first day. Of course I would have built-in opportunities for reflection, according to specific parameters, on how much has changed (my shift in the confidence:awkwardness ratio; my appreciation for being useful in some capacities) and how much has remained the same (how inspired I am by the energy of this place, these people; how fulfilling it is to connect with people, to understand the context of their family and community, to build on that understanding over time). Of course I took epically rewarding opportunities to thank my mentors, with great specificity, for what they have contributed to my world. I wrote to the clinic's executive director how it had been my dream to get accepted to medical school in Vermont, only to have access to meet him and see this clinic once -- let alone have the opportunity to actually train here, let alone for a whole year. I wrote to my PA mentor how invaluable it was to have someone so gifted so deeply and passionately believe in my ability to "do this" before I believed it myself. I wrote to my direct preceptor that I will spend my life working to match his balance of unfailing compassion, mindful self-reflection, and commitment to improvement of all kinds.
And when I walked out that door, I thought about what the executive director told me on my first day there: "In medical school, I always felt like an imposter... until one day, I didn't."
Beyond the hundreds of thousands of tangible and intangible things I've learned through this opportunity over the past year, beyond the influences of the energy and personalities and experiences, what made all of this all the more rewarding is that I created all of it. It didn't merely "happen." I found them, I sought them out. I decided very early that the more time I spent there, the more I would learn. Do I study books as much as other people? No. Is that bad? Maybe. But the difference is: the stuff I learned at clinic, I actually remember.
Which brings us to Influential Life Event #2. Last week, I took Step 1 of the United States Medical Licensing Exam. 6 hours of torturous convoluted questions on the basic sciences, genetics, and vague clinical correlations. Preparing for it has consumed my existence for the past two months -- particularly my "brain space" for self-reflection, self-nourishment, and self-other good things requisite for successful human functioning. I've spent most of the past month in particular glued to my kitchen table (across from my equally miserable roommate, preparing for the same exam) taking thousands of practice questions, displacing relevant and irrelevant knowledge with every extra factoid encoded, doubting my self-worth. Frustration, boredom, distraction were wicked breeding grounds for high-level procrastination. It was easier to make Spinning rides about some variant of the process than to actually engage in the process.
Did I study as much as other people? No. Did I make questionable choices of how I spent my time (i.e., packing up my apartment prematurely, snuggling with Scott, holding extra 2-hour endurance trainings for my riders, eating gluten and lactose, spending hours hanging out at clinic)? I'd argue that every one of those were good choices.
Why? I knew I didn't know everything, and would never know everything. Acknowledging that is less acceptance of mediocrity as I'd once surmised earlier in medical school; rather, it's setting reasonable, realistic, specific goals (i.e., to pass with a 20 point margin) and continue to invest in my big picture. I knew damned well that I knew a LOT. I knew a lot with great specificity. Not everything. Not even 50% of everything. But I thought that maybe, just maybe, I knew enough. And when I made that decision, suddenly my entire approach changed. I no longer feared Step 1. I no longer dreaded it. It was one big, epic "GAME ON!" -- the pursuit of success and conequest, not merely the avoidance of failure. There's a difference. And it matters.
It mattered on Game Day. Yes, there were tons of questions I didn't have the slightest clue how to answer. Yes, there were times where I muttered - literally, out loud - "are you kidding me?!" (ok, maybe I wasn't that polite/professional). But by and large, I saw a heck of a lot more opportunities to demonstrate the effectiveness of my preparation and knowledge base than obstacles to "endure." It's just how I coach people on the bike: directing one's attitude, choosing to perceive challenges as "opportunities" to demonstrate SOMETHING (strength, discipline, control, etc.) as opposed to something to suffer.
A lot of my friends told me that they "checked out" at times during the exam -- their minds wandering to skiing, to vacations, to sex. My mind wandered to snapshots, memories, of where or how I learned something. It was like Slumdog Millionaire. Sometimes it was a memory of a specific lecturer's memorable one-liner. Sometimes it was of my preceptor sharing a particular clinical pearl. But mostly, I had images of patients I'd seen at clinic. I'd read a question, admit that I either never read or never encoded this in an academic setting, sigh - and then all of a sudden, trigger a vision of someone and something I knew I'd seen. BAM. This happened over, and over and over again.
For the first time in medical school, I felt like I knew -- and was -- "enough."
I wanted to write about two subsequent life-altering experiences -- flying with my boyfriend to his hometown in rural North Carolina to meet 50+ of my future-in laws for the first time, and then reading an epically inspiring book, Every Patient Tells a Story (Lisa Sanders, M.D.). I've had so many thoughts and moments flying through my head that directly relate to the theme at hand. But I'm also supposed to be packing up my entire life into cardboard boxes and garbage bags, in efforts to move to a new state in 36 hours.
I've used this blog over the course of my training to date as a mechanism for processing important experiences, re-shaping and re-structuring them in a way that I'll want to look back on as evidence for what I've thought about and valued, documenting both the patterns that endure and evolve. When I fail to carve out time to write, I experience it as "cheating" myself out of an invaluable opportunity. But it's not like that. When I start clerkship (inpatient rotations) on Monday, I'm going to have hundreds of thousands of experiences that I'll want to "document" and reflect upon. I won't. The balance between "reflecting" and "living"/"doing" is an important one. Maintaining a sense that I am continuously evaluating "enough" is a truly high priority for me. It's just a matter of defining, and redefining, what that means.
Thursday, December 31, 2009
2009: The Year of Commitment
Since 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.
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.
On the eve of New Year's Eve 2009, I can reflect with confidence that I kept each and every one of this year's resolutions (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 "New Year's Empowerment" 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.
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 ("The Year of Putting it All Together"), 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 red blood cell undergoing hematopoetic differentiation: 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." (Only fitting that I would meet the love of my life two months from said year's conclusion, of course.)
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.
I learned how to apply my experiences in one realm of life to another, to find synchronicity and meaning and balance, and to connect with and inspire the same in other people.
I learned how to use my tools and resources to structure my experiences exactly as I need them.
I learned that by putting aside my perceived awkwardness and inadequacy and enduring but a moment (ok, a looooooong moment) of discomfort, I can and will achieve exactly what I want.
I learned how to critically evaluate how I measure up to my own standards, and when to re-evaluate those standards in the first place.
I learned how important it is to me to be "training for something," to be pursuing improvement - even for the satisfaction of improvement alone. I learned how critical it is to define "improvement" on a case-by-case basis.
I learned how to optimally learn from my experiences. Nothing is by accident. When I feel proud, or strong, or afraid, or incompetent, 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 identify prospective challenges to upholding a given "life policy."
I learned how to splice and shape a story to tell myself, an edited version of reality that means more than its composite details.
And above all, I learned to experience myself as committed to a journey. A journey that evolves every day, a journey with no specific requirements other than to persist. I've ranged from blind optimism to epic doubt, to a (reasonably) quiet confidence that everything is exactly as it is "supposed" to be. And I've come to appreciate that, as harsh the reality of privilege that comes along with it, it's a pretty sweet journey indeed.
So now what?
2010 is the Year of Being Present on my journey.
What does it take to "be present?"
I will listen better, without anticipating or interrupting.
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.
Since I anticipate interrupting myself every 30 seconds, I will establish a mechanism for re-focusing .
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.
I will establish a reliable system for managing my commitments while protecting my RAM. RAM is reserved for medicine.
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. In 2010, I will protect my RAM and use it to be "present."
I will complete data analysis, write up, and publish my Psychological Effects of Heart Rate Training study.
'Nough said. The procrastination has reached levels of absurdity.
I will blog more.
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.
I will be more reasonable, realistic, and flexible in my self-negotiations.
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.
I will conquer new athletic exploits to build confidence and calmness.
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.
I will learn to appreciate that right now is "enough."
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.
Here we go.
2010: Best Year of My Life...
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.
On the eve of New Year's Eve 2009, I can reflect with confidence that I kept each and every one of this year's resolutions (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 "New Year's Empowerment" 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.
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 ("The Year of Putting it All Together"), 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 red blood cell undergoing hematopoetic differentiation: 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." (Only fitting that I would meet the love of my life two months from said year's conclusion, of course.)
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.
I learned how to apply my experiences in one realm of life to another, to find synchronicity and meaning and balance, and to connect with and inspire the same in other people.
I learned how to use my tools and resources to structure my experiences exactly as I need them.
I learned that by putting aside my perceived awkwardness and inadequacy and enduring but a moment (ok, a looooooong moment) of discomfort, I can and will achieve exactly what I want.
I learned how to critically evaluate how I measure up to my own standards, and when to re-evaluate those standards in the first place.
I learned how important it is to me to be "training for something," to be pursuing improvement - even for the satisfaction of improvement alone. I learned how critical it is to define "improvement" on a case-by-case basis.
I learned how to optimally learn from my experiences. Nothing is by accident. When I feel proud, or strong, or afraid, or incompetent, 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 identify prospective challenges to upholding a given "life policy."
I learned how to splice and shape a story to tell myself, an edited version of reality that means more than its composite details.
And above all, I learned to experience myself as committed to a journey. A journey that evolves every day, a journey with no specific requirements other than to persist. I've ranged from blind optimism to epic doubt, to a (reasonably) quiet confidence that everything is exactly as it is "supposed" to be. And I've come to appreciate that, as harsh the reality of privilege that comes along with it, it's a pretty sweet journey indeed.
So now what?
2010 is the Year of Being Present on my journey.
What does it take to "be present?"
I will listen better, without anticipating or interrupting.
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.
Since I anticipate interrupting myself every 30 seconds, I will establish a mechanism for re-focusing .
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.
I will establish a reliable system for managing my commitments while protecting my RAM. RAM is reserved for medicine.
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. In 2010, I will protect my RAM and use it to be "present."
I will complete data analysis, write up, and publish my Psychological Effects of Heart Rate Training study.
'Nough said. The procrastination has reached levels of absurdity.
I will blog more.
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.
I will be more reasonable, realistic, and flexible in my self-negotiations.
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.
I will conquer new athletic exploits to build confidence and calmness.
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.
I will learn to appreciate that right now is "enough."
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.
Here we go.
2010: Best Year of My Life...
Wednesday, December 9, 2009
Too Quick to Dismiss.
"Don't blink if Shaquille O'Neal is on the Orlando Magic."
Nothing.
"See? He didn't blink. He's completely aware of what's going on."
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.
"Blink if you know we're here."
Nothing.
"Blink for us..."
Nothing.
30 seconds later, a random blink.
"See? He's right here with us. He's going to wake up any minute now."
She has been saying this for three years.
When I met this family on a house call over the summer 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 reinforce 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).
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?
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.
Right away, she launched into her familiar routine. Basketball trivia. Blinks/no blinks. Mouth opening. Tongue protruding. All of it completely random.
"Wiggle your left pinky."
She reached for his hand. The neurologist encouraged her not to prompt the effort. Nothing.
Then, it moved. The left pinky.
I silently gasped.
"Wiggle your left index finger."
It moved. It really moved.
My preceptor's eyes started to bulge.
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.
AND HE DID.
Seriously. He picked up his left hand, and waved it. That's not a reflex.
We said goodbye and returned to my preceptor's truck. We sat there for a few minutes in silence.
"I always wrote them off...." my preceptor began. "Yeah, yeah, he blinks on command... right...."
He shook his head.
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.
This also means that he can feel pain. Everything now was different.
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.
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.
Within a few minutes, the woman launched into opening arguments for her Alzheimer's diagnosis case.
"Do you ever lose consciousness?" my preceptor asked her.
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.
Really? *I* did that? For all my talk of inhabiting a person's existence, inhabiting their underlying fears and doubts and anxieties, REALLY?
Mortified.
Afterwards, I confessed my lapse to my preceptor. He laughed.
"Yeah, that happens...."
I don't want it to happen. That's not good enough. It's not okay.
But having experiences like this at this point in my training is important. Important reminders not to get sloppy. Not to discount, dismiss.
After all, I've now seen a man in a persistent vegetative state wave goodbye.
Nothing.
"See? He didn't blink. He's completely aware of what's going on."
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.
"Blink if you know we're here."
Nothing.
"Blink for us..."
Nothing.
30 seconds later, a random blink.
"See? He's right here with us. He's going to wake up any minute now."
She has been saying this for three years.
When I met this family on a house call over the summer 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 reinforce 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).
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?
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.
Right away, she launched into her familiar routine. Basketball trivia. Blinks/no blinks. Mouth opening. Tongue protruding. All of it completely random.
"Wiggle your left pinky."
She reached for his hand. The neurologist encouraged her not to prompt the effort. Nothing.
Then, it moved. The left pinky.
I silently gasped.
"Wiggle your left index finger."
It moved. It really moved.
My preceptor's eyes started to bulge.
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.
AND HE DID.
Seriously. He picked up his left hand, and waved it. That's not a reflex.
We said goodbye and returned to my preceptor's truck. We sat there for a few minutes in silence.
"I always wrote them off...." my preceptor began. "Yeah, yeah, he blinks on command... right...."
He shook his head.
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.
This also means that he can feel pain. Everything now was different.
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.
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.
Within a few minutes, the woman launched into opening arguments for her Alzheimer's diagnosis case.
"Do you ever lose consciousness?" my preceptor asked her.
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.
Really? *I* did that? For all my talk of inhabiting a person's existence, inhabiting their underlying fears and doubts and anxieties, REALLY?
Mortified.
Afterwards, I confessed my lapse to my preceptor. He laughed.
"Yeah, that happens...."
I don't want it to happen. That's not good enough. It's not okay.
But having experiences like this at this point in my training is important. Important reminders not to get sloppy. Not to discount, dismiss.
After all, I've now seen a man in a persistent vegetative state wave goodbye.
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