Free Association Post!

It has been a while since I’ve last posted. I’m having a hard time pinning down specific things to talk about, so I figured I’d just let fly with the gestalt in my head.

I’ve been thinking about some of the memorable patients I’ve met over the course of the year. Single, earthy, elderly grandfather taking care of his two grandchildren. The girl who shot herself in the head, and the doctor who told her family. The really nice guy with inoperable pancreatic cancer. The other really nice guy who had the courage to joke about having his leg amputated. The sister and her mentally retarded brother who live together with her boyfriend, somehow making things work. The little girl with leukemia that we tried to send home for her birthday, but came back the next day to stay for four months. The man who lived in utter squalor at home with terminal cancer, that we kept in the hospital for two days against his will. The cancer patient who tried to leave AMA, trying to curse the doctors through his trach tube. The man who asked me when I’d be a doctor, and if he could be my patient. The woman that I tried to “give homework” to overcome her agorophobia by driving her son to school . . . and she succeeded. The 23 year old girl with a rare and terminal liver cancer. The little girl that we coded for two hours. The little boy with prune belly syndrome who smiled all the time.

I’ve been thinking a lot about surgery lately. About making it my career. I figure for some people, working 40 hours sucks because it’s just a job, and they spend another 40 hours chasing their hobbies and their passions. But if surgery is my job, my passion and my hobby. . . maybe that’s not so bad. I was told I was a low-average applicant, and I will need to do some solid work in the next six months or so if I want a shot at a good surgical residency in California. I am thinking that perhaps if I do surgery, I won’t necessarily get what I want, but maybe I will get what I need.

I have spent the last two Saturdays at the student run clinic I used to help direct. It’s amazing how far I’ve come since I was there a year and a half ago.  It’s kinda awesome realizing I have something to offer/something to teach.

My parents bought me this huge (for me) full size bed that I am luxuriating in each night.

I have started fencing again each Monday. It’s been so long, but the joy in that activity is still there. After practice this week, I went to dinner with some of the fencers afterwards. We all turned out to be grad students in one discipline or another. Was great to relax and be socially awkward in front of people who couldn’t care less.

Advice to First Years

About six months ago, a good friend of mine was just starting as a first year at my medical school.  In an attempt to be a good friend/good third year, I thought I’d jot down a list of pithy tidbits of “wisdom” I had accumulated over my two years here.  Some of this is specific to my medical school, but I feel like a lot of it is generally applicable.  Enjoy.

1.  If you are scared, everyone else is scared too.  They just aren’t showing it.

2.  Don’t fall into the trap of not seeing past your own nose (to use the Marry Poppins term).  If you’re stressed, then everyone else is stressed too, and small gestures to acknowledge that and to help other people through difficult times will be incredibly appreciated.

3.  Nobody expects you to learn it all.  Learn what you can, and move on to your next task or else you will get bogged down and miss the big picture.

4.  Don’t worry if you can’t see a ‘big picture.’  I’m a third year, and I am only now just beginning to pull the pieces together.

5.  Do what you have to do to learn best.  If that means skipping all the lectures and learning from syllabi and recordings at home, do it.  If it means sleeping all day and studying all night, do that too.  You are responsible for your own education, so use or cast aside the tools the school gives you to achieve that end as you please.

6.  Get your hands on a copy of First Aid for the USMLE Step 1, and peruse it as you go through your classes.  One of my biggest regrets in my first two years was studying for my classes, and not for the boards.  No one cares what percent you get in your class (so long as you pass [my medical school is just a pass/fail system]), but a good number of people will care what score you get on the Step 1.  Also, some classes at [my medical school] are not the best organized, and First Aid can really help summarize complicated and badly taught concepts.  And finally, if it is in First Aid, you should know it.  Use First Aid to help you learn for your classes, but also use your classes to learn what is in First Aid.

6.5.  What will get you a good score in your class is not necessarily what will get you a good score on Step 1.

7.  Make sure you take some time for yourself.  Everyone says this, and it’s true.  I played frisbee almost every Friday for two years, and I think I am mentally and physically better for it.  Plus, no one cares how good you are, and it’s a good chance to hang out with your classmates while not in school.

8.  Medall [our med school listserv] is for important stuff (and ultimate frisbee emails).  Like a good surgeon, think twice, email once.  Cuz once it’s out there. . . it won’t be coming back.

9.  Take time to get to know your classmates.  Everyone has an amazing story, and everyone is worth taking some time to meet.  And so if a classmate is sitting alone during lunch or break or at a party, take some time to meander over and exchange a few words.

10.  As an addendum to 9, LOOK OUT FOR EACH OTHER.  Medical school is very hard on the self-confidence and self-esteem.  One never knows when a kind word or gesture can reach through someone’s funk to brighten a gloomy day.

11.  DO NOT BE AFRAID TO ASK FOR HELP.  Medical school is quite possibly one of the hardest things you will ever do, and I cannot express just how stupid it is to think you can do it by yourself.  It takes courage to admit you need help, and NOBODY will ever hesitate to lend you a hand, a set of notes, a sympathetic ear or a shoulder to cry on.

12.  And as a corollary of 11, never, Ever, EVER ignore someone’s request for help.  And remember, people can ask for help with more than just their voices.

13.  When the helicopters rumble overhead, I like to pause and think about the doctors in the hospital getting ready to receive their patient, and how someday that is going to be me.

14.  The lobster bisque isn’t bad at the cafeteria.  Italian wedding and the clam chowder aren’t bad either.  And make sure to get the extra bread that comes with the soups.

15.  Medical school will take you outside of your comfort zone.  Whether that is hemisecting your cadaver’s pelvis, feeling out of your intellectual depth, or trying to do a blood draw on an IV drug user, you will feel uncomfortable in medical school.  That is a good thing.  I think one can learn a lot about themselves when they are out of their comfort zone.

16.  There are some amazing views to be had from the 14^th floor of the hospital.

17.  Don’t forget your big and great-big sibs.  They’ve been through this before, and will have lots of tips, tricks, and a healthy dose of perspective to offer you.

18. You came to medical school because you wanted to be a doctor, but that is easy to forget if all you do is study.  Take some time to volunteer your time at the student run clinics, and to remember the altruism that brought you here in the first place.

19.  Take some time to reflect once in a while.  I keep a blog for some stuff, and a written journal for others.  This is a crazy experience, and taking some time to think about it not only helps put it in perspective, but also helps you get the most out of your experiences here.

20.  There are a fair number of bull-crap classes and small group sessions in medical school.  Don’t let yourself get bogged down in worrying about them, but don’t let them upset you for wasting your time either.  There is usually a point to the maddness, even if it could be made in 5 minutes in a lecture, rather than an hour in a small group.

21.  Carm will always have candy and a kind word for you.

22.  Take some time to shadow in the hospital.  You will be shocked at how different it feels to be part of the medical institution now, rather than just volunteering at its fringes.

23.  If you go to lecture, I highly recommend having at least one scrabulous game with your classmates going during class time.

24.  If you have a significant other, don’t forget that because you are working your ass off chasing down your dream, you have less time to spend with your boyfriend or girlfriend.  Your medical school experience is a sacrifice for them too.

25.  If you can get involved with the trauma study later in your first year, do so.  It is a great chance to get a watered down idea of what call is like, and to see some of the ‘highlights’ of the Emergency Room.  Plus they give you money.

26.  Get a copy of BRS Physiology.  Physio is a huge and hugely important subject, and BRS Physo helps greatly to keep you oriented, and serves as a good place to get simple explanations of complicated topics.

27.  Consider getting a copy of Lipencott’s Illustrated Reviews: Biochemistry.  Biochem is very confusing, and if you are more of a self-studier, it can be very helpful.

28.  Take lots of pictures.

29. Once a month, all the stores in [my city] are open waaaay late, and there are tons of free samples, live music, art on display, etc.  It’s a fun little promenade and good chance to see what normal people do with their spare time.

30.  If you cannot be friends with everyone in your class, at least find it in yourself to be civil.  You never know when you might find that person in your next small group, doctoring group, or third year rotation.

31.  Never forget that it is an honor and a privilege to be doing what you are doing.  Things might get hard, but before you complain, you should ask yourself “Is there anything else in the whole wide world I would rather be doing at this moment?”

32.  Medical school is about helping each other out; it’s about kind words, nice gestures and shared notes.  There have been times beyond counting that my class has carried one another through rough patches.  Be loyal to your class, because you will be getting through medical school together.

33.  And finally, enjoy yourself.  You will be working very hard, but don’t forget you are living your dream.  You will belong to a group of amazing people working very hard to learn how to become a doctor.  How much cooler can it get?

Soul Points

It has been a while since my last post, but it’s my lunch break here at the psych clinic, my med-student colleague has left early, and my next patient isn’t supposed to show until 1pm.

Psychiatry is a funny clerkship (and a funny profession). Most other specialties in medicine focus on physical, quantifiable parameters of the body; your weight, your blood pressure, x-rays, sodium level, and so on. Psych on the other hand is much more interested in how you feel, think, and behave; qualitative things that require a certain rhetorical flair to portray fully. Psychiatrists need to think about how their patients make them feel. If the patient makes you feel sad, then it lends credence to the thought they are depressed. If they make you feel annoyed, then perhaps they are borderline. If you are entertained, perhaps they are slightly manic.

Psychiatrists have this uncanny ability to cut through a person’s outer layers (onions vs cakes anyone?) and seem like they are looking into your soul. Much like the Jedi, they can’t so much read minds as they can read emotions. This is unsettling enough watching your superiors use this power with patients, but it is truly disquieting when they turn that piercing gaze on you (think Frodo and the eye of Mordor). What this all means is that their critiques of your performance during the clerkship tend to be very incisive, and not a little bit painful. They seem to be able to find your insecurities and bring them to light, in an attempt to “fix” them. This is a painful thing for a student, knowing you are flawed, feeling shitty about it and trying to hide it, only to have your boss drag it out into the light and examine it under a microscope. People say that good critique is painful, and if it is one thing that these guys do, they seem to give good critique.

And so I get to what all this has to do with the title of my little entry (in a round about, or as we would say “circumferential,” manner). I’m not going to lie, I have had a couple of really crappy weeks during my first month of psychiatry. I think I was finally reaching that part of third year when, for want of a better phrase, I was running out of soul points.

What are soul points? Well, it’s kind of an extension of wins and losses. The way you get them is by doing good, self-affirming (or just fun) things. A patient tells you that you’re going to make a good doctor. Someone notices your hard work. You get in a good game of ultimate frisbee. You lose soul points when bad things happen; you watch the unsuccessful code of a 10 year old girl, or participate in another unsuccessful code of a 17 year old girl who shot herself in the head. When you worked for 2 months setting yourself the challenge to honor a clerkship, and don’t. When you have to help keep another human being in the hospital against their will . . . for their own good. When your supervising psychiatrist tells you that you that he thinks you have made one too many inappropriate comments during rounds. When the world singles out a vivacious person doing good work to get sick and die for no particular reason.

Talking about some of this with a fellow third year, I swear to god I nearly cried. Tears in my eyes and everything. That’s probably the closest I’ve come to crying in front of somebody in five or six years.

People generally say that third year and internship are the two hardest years of medical training. Those two years are long, and they nibble away at your soul-points without offering much time or many chances to replenish them. I think one starts to “burn out” when you run out of soul points to absorb the random shit flying at you. Once you run out, then it’s all body blows; you can’t muster the enthusiasm, optimism, idealism or any of that life-zest anymore because everything gets to you, and it beats you down.

I know soul-points is kinda a funny name for the concept, and truth be told it’s more or less just a sardonic nod to the elephant in the room. Rather than not give it a name, or give it a less melodramatic (and thus more credible) one, I feel like like this way there is some degree of acknowledgment both of the problem’s existence, as well as some degree of defiance; that is hasn’t gotten so bad as to sap all humor.

I’m feeling much more myself now than I was a week or two ago. But the point stands all the same; they weren’t kidding when they said third year was going to be hard.

Like a Moth to Flame

The last three weeks of my surgery rotation (on the trauma/emergency surgery service) have been by turns mind-blowing and terribly sad, exhausting and exhilarating.

I think that the range of those emotions are well summarized on one of my call days about a week ago.

Trauma call starts when you get to the hospital (~5am) and ends when you leave the next day after rounds and conferences (~10 or 11am). As a result, you spend about 30 consecutive hours in the hospital. While on call, your team is responsible for evaluating all the trauma-related patients that come into the ER in that time, as well as the emergent surgeries that cannot wait until the next morning (appendicitis is probably the best example). Being a medical student, I am responsible for nearly nothing (cutting clothes off of injured patients and holding retractors are not exactly a highly trained skills) but it affords a front row seat to events.

Anyhow.

The day started kind of slow, but I saw that my favorite third year resident was on that night with me (he likes to get the medical students involved in working patients up, enjoys teaching us and tries to let us know when patients are headed to the OR) so I figured that boded well. Over the course of the night, I got to scrub into four separate operations; two laproscopic cholycestectomies (removal of the gall bladder with cameras and tiny little grabby hand things without making big cuts into the abdomen), a laproscopic appendectomy, and an incision and drainage of a breast abscess.

I’m not gonna lie, there is something amazing about laproscopic surgery; you are looking at this person’s insides . . . from the inside!! You poke this little camera in there, and you can pan around and see all the major organs hanging out in your abdominal cavity. And using that and some little grabby things, you can do some basic surgeries like removing the gall bladder or appendix. I wish I could better express the wonder of it all, seeing peoples insides on a TV screen that I (they let me direct the camera!!) control. And there is something very satisfying too, about seeing and examining the patient in the emergency room, ordering some quick tests, making a diagnosis (not me, but just watching the process is pretty sweet) and then forming a plan that involves literally cutting the problem out with your two hands and some tools.

That was the happy intense part of the evening. The sad intense part of the night was a teenage girl who had shot herself in the head and was rushed via helicopter to the medical center. When a trauma comes in, all we get is a page on our pager telling us the rough severity (911 is the most severe, 933 is the least) and the time until the patient’s arrival. And so what usually happens is the trauma and ER teams are hanging out in the room, all gowned up and ready to go with nothing to do, not sure if it’s gonna be some big case, or someone who just got clipped with a bullet on the tummy (because it involves bullets and abdomens, they usually get coded the same).

The girl shows up with the paramedics with her head almost entirely covered with bandages. The first task in any trauma is to cut the clothes off the patient so it’s all out of the way. While this was happening, I could see blood oozing out of her nose, mouth and ears. The doctors checked the wound in her head, and immediately blood started gushing out of one of the bullet holes. It looked like someone had taken a pen and punched a hole in the bottom of a milk carton or something, the way the blood was coming out. They continued their evaluation of her, while trying to get big IVs into her to start giving her blood and fluid. Somewhere in the middle of that, her heart stopped beating, and she was coded for about 20 minutes. I was stuck in the middle of this whirlwind, and really the only useful things I could do was help pass medications and equipment, and clear off the piles of used packaging and bandages that pile up like snowdrifts.

They were able to get her heartbeat back, and she was quickly bundled off to the CT scanner to look at the damage to her head. The images came back showing ‘non-survivable injuries.’ All the same, she was hurried back to the ER (the ’sick’ and actually sick patients looking on from their gurneys as this little girl comes by on her bed) where they continued to give her blood and fluids. I helped the nurse and my R3 take down the dressing on her head, and pack it in an attempt to slow down the bleeding so she wouldn’t bleed out before her family and the organ donation people could get there. I don’t think I will forget the force with which my R3 was packing the wound; basically jamming bandage into the hole in her head. You could feel his frustration and anger. He packed the wound so forcefully, little bits of her brain came oozing out the sides and seeped into her pony tail. I helped wrap the rest of her head.

Her father and uncle arrived soon after, and I snuck into the small room with my R3 and the trauma chief where they were waiting with a social worker, and watched their reaction when he told them that her injuries were not survivable. Her father kept repeating that she was such a good athlete and student. It was one of the most emotionally intense moments I’ve ever experienced. She died a few hours later.

Over the course of the night, I snagged a grand total of 30 minutes or so of sleep.

I guess where I am going with all this, is that surgery is a brutal, beautiful, taxing (physically and emotionally) . . . and tempting field. Being in the operating room, and fixing someone with your bare hands and seeing them recover afterwards is a feeling hard to beat. There is a directness and a bluntness to surgery that I enjoy. Surgeons will tell it to you like it is. But on the flip side, there are a lot of surgeons who are hard-assed assholes. The hours can be insane. And it will take a long time to work my way up the seniority ladder in our 5-7 years of residency, before I am in a position to actually start acting like a real surgeon.

Kinda like a moth to surgery’s flame though, it’s appeal is hard to pass by, and I can see that making the decision to do surgery or some other path is gonna be a difficult one. They say that if you are going to choose surgery, you need to love the operating room. I think I do, but really can one actually be sure? I don’t know. I chose medical school because I thought that I would never be bored, because of the chance it afforded me to do good work and have real responsibility. I feel like surgery will do those things for me, but I balk at just how hard that path is going to be. But perhaps taking the harder road is worth it in the end. I don’t know, and I guess we will see.

And some words of wisdom from Grays Anatomy (from an episode themed, ironically, about responsibility):

“When did we become adults? And how do we make it stop?”

Wins and Losses

It’s been quite a while since my last post; internal medicine and now surgery have managed to pretty effectively swallow what life I had managed to have while on pediatrics.  But long story short, I really enjoyed myself on internal medicine, and now on surgery, I am getting a chance to see what the hype is all about.

Over the course of those rotations and especially now on surgery, I’ve come to form a theory explaining a bit of third year psychology.  In medicine, there are wins, and there are losses.  A win is when you do something good, like when a patient thanks you, you answer a pimping question correctly, someone notices/mentions your hard work, you put together a good presentation, and so on.  A loss is when you make a social faux pas (no, that’s not the intern . . .  he’s a chief resident), answer pimping questions wrong, are ignored, do something stupid, etc.

During the clerkships, there are a lot more losses than wins.  Sometimes a single win is all you need to give you the strength and the passion to bounce out of bed and zip to the hospital in good spirits for days, even if the previous days have been littered with losses.  But the problem is, sometimes the losses come in streaks, and you don’t have yourself a legit win for days and days.  You can’t do anything right, nobody cares about you, and it just sucks.  Those doldrums can be hard to see the other side of, and in all truth, if it were not for your classmates to help drag you through it, they can be darn near insurmountable.

In the ever so wise words of Firefly, “if you can’t run you crawl, and when you can’t do that you find someone to carry you.”

Remarkable People

I’ve been doing the outpatient portion of my pediatrics rotation for about two weeks now, and in the course of my time there I have had a chance to meet quite a cast of characters.

One particular family has stuck in my mind the last few days, and I felt it couldn’t hurt to spend a few minutes trying to do justice to (for want of a better word) their humanity.

The grandfather of the two kids was with them in the examining room.  Father was loooong out of the picture, mother was a deadbeat whose calls home would only serve to agitate her children, and grandmother had died several years ago from cancer.  The grandfather himself was a more elderly guy, looking almost like he had just walked out of Lonesome Dove with his ruddy, weather beaten features and bulbous nose.  He reminded me of gnarled tree roots; stubborn, old, strong and earthy.  He had on a sweat-stained American car company cap (the brand escapes me at the moment) with work boots and spoke sparsely with a low, gravelly voice.

The purpose of the visit was just a well-child check; regularly scheduled health maintenance for his grandchildren.  There were a lot of errands to take care of that morning he said, and he was sorry that they were late.  They had probably done over 2 hours of driving before they made it in to see us at 9am.  These well-child visits are important, but there are a lot of parents out there who skip them because circumstances, or their own dysfunctionalities prevent them from making it to the appointments.  Bringing his kids in to see the doctor that day, I got the sense of a man who was doing his best to provide for these kids who rightfully should have two normal parents, but instead only had him without even his wife to help.

The emotions I got from this meeting were a mix of admiration and respect for what I could feel was his dogged commitment to the kids that were now his, together with a melancholy for just how hard it must be for him to support and care for two growing children, having already done this task at least once before, but this time without his wife and the energy of youth.

But you could tell that he loved and cared for his grandkids.  You could see it in the way he’d gently tap his grandson on the head with papers in his hand, referring to him gruffly as ‘this one’ while underneath you could feel his pride that he was healthy and doing ok.  You could see it too in how he looked at his grand daughter and described her meeting her milestones, while she played with the toys on the exam room floor.  I could just imagine him waking up to make them eggs in the morning, before sending them off to school.

Not everyone is dealt a good hand in this life, and there are a lot of people who I think are more than happy to just fold and walk away when they don’t like the cards.  I have not experienced much adversity or want in my life, but I don’t think that prevents me from paying respect to those who choose to pick up a burden that many a lesser person would pass by.  I guess what makes this man so remarkable and striking, is how unassumingly he seems to have taken up the task of raising these children, how he has taken on the responsibility that by rights should have been his daughter’s.

I guess the moral of the story (if all stories do indeed have to have morals) is that there are a lot of astonishing people out there, and their stories are not always those that make it into newspapers or books or movies.  And to some degree, I wonder if that doesn’t make them all the more remarkable.

Unpredictability in Medicine

If there are any generalizations I can make during my four week long dabble in pediatrics, it is that in medicine, things are never certain, and that those things can change really fast.

It is sorta unspoken wisdom during your third year, that when your intern excuses you or tells you to go home, you say thank you and then haul ass outta there as fast as you can make yourself go, because no one knows what might happen next that could keep you in the hospital, turning your free afternoon into a late night.  A classic example of this is the hypothetical last minute admission (it has yet to happen to me in it’s full-on glory, but the scenario is not uncommon).  You and your team are puttering away in a Doc Box (apparently medical slang for “the room in which the doctors hang out and do their work when they’re not seeing patients”) taking care of little odds and ends on a quiet day, and then all of a sudden two kids are admitted from the emergency room, another is admitted straight to the floor and one of the patients already on the ward decides to get sicker.  And so, the slow day is quickly dashed.

Another example of unpredictability in medicine applies to diseases in individuals as well.  About a week and a half ago, I had just ended my two weeks on the Heme-Onc service, and was just starting my first day on the general peds wards.  My team and I were sitting in a corner, doing sitting rounds on our patients before we got up to see them.  It seemed like a rather routine morning (with no more than the usual amount of stress that comes from presenting in front of smart people who really don’t need you).  But then the interns’, the resident’s and the attending’s pagers all went off at once.  Trouble.  They snatched the pagers off their hips, looked at them, and without a word to each other they all jumped up and ran off in the same direction, with a terse call over a shoulder to follow them.  Big Trouble.  Us medical students could sense the electric tension in the air, and we fumbled with our knick knacks as we took off after the rest of the team.  We joined a growing stream of nurses, med students, house officers and attendings hurrying towards a single room, and heard the PA mechanically vocalize “Code Blue, (insert location here), Code Blue . . .” and it then dawned on us what was happening.

For the medically uninitiated, and those who have never seen an episode of Gray’s Anatomy, House, ER, or just about any other TV show or movie that involves a hospital, a code describes a set protocol that medical personnel follow when a patient, usually suddenly, develops a condition that is either imminently incompatible with life, or is a large shift in a negative direction from their baseline.  When someone calls a code, it is an all-hands on deck sort of operation, (theoretically) with a single person in charge, and a zillion other people trying to put in IVs, give drugs, administer chest compressions, setup defibrillators, check pulses and vital signs, fetch additional supplies, call for emergency imaging, and do whatever else someone more senior to you tells you to do.

Codes are hectic, scary, adrenaline drenched affairs.  Because just about the entire staff of the floor is attending the code, as a med student everyone else present is more clinically useful than you.  And so when someone calls out to go get more saline, or syringes, or make a call to radiology or fetch a portable computer, like three or four of us scatter off in all directions because we want to be of some help in this incredibly intense process.  In the end, for this particular code, it went on long enough that the residents and nurses were tiring from doing chest compressions, and so two or three medical students rotated in to take over.  Sadly, I remember this distinctly, for I was standing almost next to the doctor in charge, gloved up and with a face shield on getting ready to rotate in on the chest compressions, when he turned to the clock and said “Alright, I’m calling it now, at 10:10 am,” and all the frenetic activity in the room stopped.  People took off their protective masks and gloves and gowns, and started cleaning up.

And just like that, the entire floor of the hospital had gone from a quiet morning, to a full-on code for an emotional, time-bending two hours, and thence to a full stop.  My team and I were to be taking on care of this girl, and my intern had actually gone to see her early that morning.  But things change fast in medicine.

But not all the unpredictability in medicine is bad.  Just as patients can suddenly get worse, they can suddenly get better too. And I think that there are a lot of quiet random acts of kindness that slip in under the radar.  I started writing this last night but ran out of time (gotta get to bed by 10:30!) and sadly, I’m outta the verve that might have added another paragraph or two about some other unpredictable things that have transpired in those four weeks.  But it’s gonna be a long third year, so don’t worry.  I am sure there are going to be more stories.

This is Ourselves, Under Pressure (or First Week of Third Year)

Well, third year officially started about a week ago, and by all apperances it seems I am still here to tell the tale.  But no lie, this week feels like it could fill a month.  Last Friday we began orientation to third year, and Monday I had my pediatrics clerkship orientation (it’s my first rotation).  I am assigned to the team taking care of the pediatric hematology-oncology ward (read: kids with cancer) with (in rough order of seniority) another fellow third year, an exchange student from Japan, a fourth year, an intern, a second year resident and an attending.  There are only 8 or 10 patients on our service, so the Japanese medical student, and us two third years are responsible for ‘only’ one patient.

I use the quotation marks there because even now, a week later, we are still struggling to figure out such simple things as how to access the appropriate records and how to present in a manner that doesn’t provoke the wrath of our attending.  Needless to say, it’s a good day when, between my third year colleauge and I, we can find the elevator to get from one floor of the hospital to another (I’ve given up on finding the stairs).  And to make it all worse, our utter ineptitude slows the work of the team down to a pace cold molasses might surpass.  In the colorful words of my old high school soccer coach, we’re “as useless as tits on a bull” and for someone who desparately wants to be of use to those around him, it’s kina irksome.

But yeah, I think I’ll just tell you guys about what an average day looks like on our peds heme-onc service.

The day starts at 4:45am when my alarm goes off, so I can get to the hospital a little before 6 to pre-round (check up on, in medical-ese) on my single patient.  For the next hour or so, I check her labs, speak to her nurse, slip in quietly to actually see her and do a brief physical exam, then settle down to try and hammer out a progress note summarizing my physical, any new labs, the pertinent events from the last 24 hours and so on.  Taking that, I am theoretically then supposed to formulate a plan for my patient for the day . . . which usually turns into the clinical equivalent of a five year old’s attempt to design the Lourvre.  After that we meet with the night float team and hear their quick summary of the patients on our service.  Then at around 7:30 we practice our presentations with our intern, scurry off to Morning Report, where one of the pediatrics residents presents an interesting case seen recently in the hospital.  At 8 or 8:30 the attending arrives, and we round on our patients, updating him on the events of the last 24 hours for each of the patients.  These labs came back, patient X developed a fever, patient Y was admitted, patient Z seems to be tolerating her chemo well, etc etc.  Then we explain to him the treatment plan we’d like to institute for the day, and go visit each of the patients again with the attending.

It is here during rounds that we get pimped (so far pretty gently), reprimanded for not presenting data correctly, or chucked at for suggesting outlandish or grossly inappropriate treatments for our patients.  (By the way, ‘pimping’ in medicine describes the ritual of the attending asking questions of med students or other members of the team.  “Why did we order the magnesium levels on patient z?” “How much would you expect the hemoglobin of patient x to change if we transfused him with 2 units of blood?” etc etc.  Not the other thing.).  Because of our painful deficit in clinical knowleage, presenting skill and general medical know-how, rounds usually drag on until 12 or later, until we zoom off for (what has lately been) a ten minute lunch and return to sit for a Journal Club or some other noon-time conference that usually has materiel waaaaay over my medical student head.  Then the afternoon is spent ‘making things happen,’ calling consults, ordering labs and meds, and so on.  If we are lucky and do our work quickly, we update the attending again in the later afternoon regarding any changes . . . or we keep on taking care of the work we were suppposed to do, but because of the medical student dead weight, is still being worked on.  Then at around 5 or so the intern and resident excuse us to head home to study about the 10,000 things we didn’t understand, eat, maybe watch a Scrubs episode, then to bed to repeat the next day.  This goes on for six days a week.

I promise there is a lot more to all of these things than I am writing here.  Sick, sad children with cancer being pretty high on the list, as well as what it feels like to ostenibly take care of them, and to finally be in the hosptial.  I promise there is more to come in the future, but I think that’s all I can muster for now.  More to come.

Learning to Fly . . . But I Ain’t Got Wings

I’ve always had a thing for the view from the dining room in my parents house.  There is something appealing about sitting alone in the quiet, darkened room, with the lights stretching out below me.  It’s a good place to sit and reflect.

I’m headed back to school (well, more like my house near school, but you get the idea) tomorrow, with a little less than a week to go before my class and I officially start our third year of medical school.  The last several days at home, I have been visiting with the family and friends, tying up loose ends, getting knick-knacks that will (hopefully) help me in the coming year.  Got the car smogged, bought and setup the iPhone, found some comfy (bodily fluid resistant) clogs, ordered some books, that sort of thing.

It’s that same sort of fear and excitement of facing the unknown of a big trip; you kinda know where you’re going, but really have no idea what you’re going to find there.  You’ve done the best you can to pack, but no matter how carefully you’ve done so, you’re always gonna be running into a situation you didn’t plan for.  But that’s part of the thrill.  Nothing to be done for it but have confidence that you can handle (and enjoy!) those unforeseen curve-balls that are inevitably waiting for you.

It is generally agreed that third year is the hardest of medical school.  Making the jump from the relatively objective classroom learning I’ve been dong for the last 18 or so years of my life, into the hospital and clinic, where people’s impressions of you matter just as much what you’re carrying around between your ears.  But more than that, from here on out (in some form or another) we’ll be spending the majority of our time doing what we applied to medical school to do.  That is, take care of patients.  On one hand, that’s a totally thrilling thought.  Finally, we get to do what we signed up for!  But on the other, I think it can be quite intimidating.  I’ve wanted to be a doctor for so long, and now it’s finally Go Time.  But what if I’m bad at it?  What if, after all this work, I learn I’ve only got what it takes to be a mediocre doctor?  Worse yet, what if I find I don’t like it?  Because now, after all that hard prep-work, it’s time to see what we can do, and how well we learn the actual profession of being a physician.

And on top of all that self-doubt of whether or not we’re gonna end up making good doctors, there are the patients themselves.  My very first day of my very first rotation is to be on the pediatrics hematology-oncology ward.  In other words, I’ll be helping (in my very small and ineffective just-barely-third-year way) to take care of kids with cancer.  After months of studying this stuff from course syllabi and power points, I’ll be examining these (real!) children, and talking to their parents.  I am sure that some of these kids will get better . . . and I am sure some of them will not.  Most of the ascending third years I’ve spoken to have had at least one of ‘their’ patients die.  But on the flip side, they’ve gotten to watch a lot of their patients get better too.  I guess what I’m saying is, with things so much more personal and individual now, the whole emotional aspect of this business is gonna get kicked up about half a dozen notches.  And I suppose it will be interesting to see how we all deal with that.

And that’s just the emotional stuff.  I got my beeper in the mail about a month ago, and I took it out of it’s wrapping and set it on the table (think about those weird car commercials with the stack of money and the googly eyes).  Me and you, I thought, we’re gonna be rather close companions for the next two years, and it is likely that it or one of its cousins is gonna be bothering me at inconvenient times for the rest of my career.  On many of the services, we’re expected to work six days a week, to arrive to take care of our pre-rounds at 6am and say ‘until you’re done’ (which, I am given to understand can mean anything from like 2pm all the way into the late evening).  And those are the nights we’re not taking call.  There’s a new computer system to learn, a constant stream of new teams with their different personalities, different wards, different nurses and different sets of expectations to get used to.  And every time you’ve got one just about figured out, it’s time to move on to the next.

This is going to be a crazy year, and I’m sorta disappointed that I feel this entry isn’t quite doing my roiling emotions justice.  All the same, I just want y’all to know this is some scary exciting shit, and there are sure to be more entries about it as things really get rolling.

Chasing That Golden Pretzel

My class and I are just now finishing our studying for/taking the USMLE Step 1.  This means time to party, drink a lot of EtOH (alcohol, for the medically uninitiated), sleep in, see old friends and do fun things . . . and then steele ourselves for third year beginning in a few weeks.

One of the big reasons I got into this business is for the intensity and challenges it offers.  I didn’t want a droll nine-to-five, and so I chose this.  But medicine is a big entity, and there are a lot of ways for it to be practiced.  The spectrum includes primary care doctors, trauma surgeons, psychiatrists and neurologists.  All involve caring for people, but each has its own unique way of doing so, with its own unique set of pros, cons and challenges.  Despite the fear of being too archaic (and populistically out of touch), I recall a quote from early Gray’s Anatomy, where the Asian intern (Christina?) declares that surgery “is the Marines!” arguing that of all the specialties, surgery is the most-est of all of them; the hardest, the most intense, the longest hours, the most taxing, the most rewarding.  Whether or not it’s true, I think it begs the question, how far does one chase that intensity, and how much of your life are you willing to surrender up to it in its pursuit?

I’ve always felt that if you are going to do something, no point in doing it half-assed.  But where does one draw the line?  When is it ok to stop clawing your way up to the next level?  The personalities that end up in medical school aren’t the ones that like stopping when things are “ok.”  They keep going until they’ve totally blown the goal out of the water.  But there can always be some other goal to chase, some intense adventure to seek.

For me the conundrum has presented itself as a choice between Emergency Medicine and Trauma Surgery as my future career path (granted I’ve had very little concrete experience with any field of medicine, but I’m gonna speculate anyway!).  I am afraid what choosing a career in Trauma Surgery would mean for the rest of my life.  Yes, I’d be the guy wielding the scalpel, cracking chests in the ER and sticking fingers into bleeding arteries, but at what cost to the other aspects of my life?  Would I still have time for a family, meaningful relationships, travel?  Can I still keep an identity separate from doing this crazy job, or will I sink so deep that I won’t even care if it becomes the only thing that matters in my life?

I feel that in Emergency Medicine, when you’re on you’re on, and when you’re off you’re off.  And it’s a schedule laid out months in advance.  You don’t work as many hours, and as such it isn’t as all-consuming as other specialties like Trauma can be.  It seems like it is much easier to keep a life separate from your work.

I don’t know.  At some point, one needs to be able to strike that balance between seeking the next challenge and being content.  I suppose it is an admirable way to spend a life, chasing one mountain peak after another, but it makes one wonder if perhaps there is more to life than simply seeking the most intense experiences you can find.  At some point, I feel like you’ve got to crest your last summit, look up at the next one and say, “I really don’t need to climb that next mountain.  Let someone else do it, I’m happy here.”  I agree that there is a thrill to the climb, to the struggle and the hard won success, and it can be addictive.  And I fear that that is a big trap in medicine.  One can become so involved in the challenges of your work, wanting to get better, to ascend to the next level, that you allow other parts of your life to languish.

And so on one end sits Emergency Medicine, with its ample excitement and consistent hours, and on the other Trauma Surgery, which offers crazy highs and lows, but also long and unpredictable hours which can threaten an independent life.

This really isn’t a fully formed entry.  It’s just me mulling about one of the upcoming choices and I promise you, it will likely not be the last blog on the subject.  Anyhow, hope you enjoyed it, and hopefully more to come in the future!