During this time of third-year, much of our class is embroiled the tough decision of what to do with our lives, for the rest of our lives. It's a question I've been wrestling with myself, and although my decision is postponed for a few years, I still wonder what I want to do with myself when I grow up.
I was running by some of ideas with Dr. Allan, one of my mentors, and I started to talk about some of my concerns. "I really liked surgery," I said, "but the lifestyle seems so terrible." I told him about the long hours we had, even as students, and our attendings and residents who were overworked, tired, and who seemed to constantly lived in the hospital.
Dr. Allan surprised me by suggesting that deciding a career based on lifestyle was a bit of a fallacy. "A lot of the people you see working those long shifts," he said, "have other things going on. If you want to make balancing work with other aspects of your life a priority, you'll make it work. If you want to live on the beach all day and still make tons of money, that probably won't work out-- but I think people have more control over their lives than they realize."
In many ways, this was a shocking message, and despite how awesome of an advisor Dr. Allan is, I couldn't help but approach it with some skepticism. Really?
After all, a great portion of medical school is dedicated to the idea that we have no power, and more so, work is absolutely paramount. Often, we don't know where we're going the next day, or how long we'll be there. Although we're still students, we work long hours and weekends, at least compared to many of our peers on Wall Street or in other industries, but they normally don't have to go home after a long shift to study. On some rotations, skipping meals and subsisting on granola bars is the norm. We even hand off our life decisions to the machine, the Match where a computer determines our residency placements and the next decade of our lives.
Even our student evaluations forms have a section where we are rated, on a scale of one to five, on whether or not a student "consistently places patient needs before personal needs." Our evaluation forms place a clear message that we should no longer expect our personal needs to be paramount-- doing so would detract points from your grade.
Now that I'm no longer on the wards, I find myself a few pounds lighter, out of shape, less in touch with my friends and family, and perhaps unsurprisingly, with a ton of personal issues that I've piled up over the year. And, unfortunately, I find that I can't only blame the system. The reality is that to some degree, Dr. Allan was absolutely right-- for myself, I realized that it was often easier to take care and think of others than myself.
After all, what do my petty problems compare to my patient lying on the floor, with a mystery illness that we had no idea how to treat? Or the kid in the ER who we're admitting for suspected child abuse? Or my buddy Mr. Galloway, who is likely to be dead in a few months thanks to a challenging liver cancer? Or even the simplest of cases in the hospital-- ear infections, pneumonias, broken ankles, at least these are issues that have clear, easy prescriptions. These are problems and issues that are either prioritized or concrete and easily fixable. Either way, they are problems that are worth more of my attention than my own.
These days, I find myself flooded with loose ends, personal things to ponder and think about, and relationships to restore and develop. I used to blame the hamburger machine of med school, but at the same time, I can't help but realize that I, too, share much of that blame. Sometimes, being selfish is the most difficult task of all.
Tuesday, February 16, 2010
Saturday, February 13, 2010
February 13, 2010
I'm having some incredible trouble focusing-- I was supposed to study, but instead I find my mind wandering, replaying memories and thoughts from the past year. I tell myself it's because of Lunar New Year Eve, and in many ways I feel grateful to be born into a tradition that celebrates two new fresh starts a year, forcing you to reflect on how time has progressed.
On the other hand, it might also be my lack of clinical duties at the moment. As a medical student, so many things happen to us so quickly, and we're so busy that we don't have much time to really process or digest our experiences. Everything is a blur, up until the moment you finally stop to breathe.
***
"We're taking a field trip," my upper level resident said, rather abruptly. I looked at the other students a tad nervously, and we've definitely never taken a field trip in the hospital before. "In fact, it's a taste test."
We followed her into the elevators, and up to the pharmacist's office. On his desk were a pile of small syringes, each filled with brightly colored fluids of different shades. There were a few cups of water, and, improbably, a bright red M&M dispenser. He didn't have much in terms of introduction. "Ampicillin," he said, handing each student a syringe.
I squeezed a small amount of fluid onto my tongue, and watched the other students gag and reach for water. Apparently, I didn't have the taste receptors for it, but I remember a sickly sweet, almost alcoholic sensation on my tongue.
We repeated this process for several antibiotics, a corticosteroid, and who knows what else. It was a bizarre scene-- all of us in our white coats, taking shots of medications interspersed with palate-cooling drinks of water. "The cefalexin is delicious," someone said. I remember a sweet brightness, with notes of citrus and berry. And then there was the Cipro, which has a taste difficult to describe without profanity. Everyone was gagging, one classmate reached for the trash bin, and the water didn't seem to help. I found myself wishing, oddly, that we had shut the door. Instead, I reached quickly, desperately, for an M&M.
Two weeks later, the same resident brought us down to the microbiology lab. There, we received a tour and waved hello to the staff. We learned about what happens after a lab is drawn, and the people who dedicated their careers to hunting and growing microbes. One tech passed around a series of a petri dishes, where we wafted odors of bacteria up to our noses. Each microorganism had a different smell-- odors of rot and decay, dust and mice, and the surprising sweet grapes of pseudomonas.
Later, I peered down at a series of cells through a microscopic in a darkened room, a series of cells glowing bright red and yellow and green against the darkness. The thought that I was seeing light reflected off antibodies attached to viruses was thrilling. Before, a virus seemed almost like a fantasy, a child's story of invisible animals comprised of nothing but a membrane around some nucleic acids (they sometimes wear coats). By seeing the light, even the most fantastical organisms became real.
These field trips, held in the final weeks of my third year, had the weird effect of making everything I was doing with my patients seem as real as the glowing viruses.
I found this unexpected. For all its powers in the applications of science, medicine has this odd way of making you forget the reality of the situation. I found it a weird paradox that even in clinical medicine, when the patient is literally right in front of you, it's still so easy to distance yourself. In many ways, having just a little bit of decreased empathy is adaptive. It makes it that much easier to draw their blood, cut open their skin with a scalpel, and it's an easy way to let you sleep soundly at night, knowing that the patient you just admitted is likely to be gone in the morning. You distance yourself because it's the easy thing to do, and when you see a series of drama after drama, sometimes the troubles of others becomes mundane.
In the preclinical years of medical school, the opposite occurs. Although we do a good job of making sure we had the occasional patient contact, at the end of the day the majority of your time is dedicated to books. The diseases seemed almost theoretical, esoteric even, as the effects of the diseases in the real world are often muted out by the science. I remember there was a dramatic shift in the class when one of the patients who came to speak with us about cystic fibrosis suddenly died a few weeks later. She was young, energetic, a hero. I found myself oddly upset, perplexed as I didn't really know her at all. Instead, after coming home to my apartment, I stared at my pile of books, wanting to cry for a girl I barely knew.
Now, I'm forced again to study nothing but my books, reading about diseases I've seen. I flip through the books to realize that for many pages, I see faces of the patients I've met, the stories I've collected, the connections I've made to the lives behind mere names of diseases. I wonder where they are now, and whether are not if we really made a difference in the end.
Yet for many sections, there are words on the page but my memory is blank. These are diseases I have yet to see, and they remain so on the page, only barely real. I spend my days treating artificial patients projected onto a computer screen, patients whose problems are solved by multiple choice. It becomes easy, again, to forget that what I'm learning affects actual lives. In many ways, I already crave being back on the wards. I wish I had the sweet taste of cefalexin in my mouth, reminding me that it's the mastery of both theory and practice that ultimately makes the magic of medicine.
On the other hand, it might also be my lack of clinical duties at the moment. As a medical student, so many things happen to us so quickly, and we're so busy that we don't have much time to really process or digest our experiences. Everything is a blur, up until the moment you finally stop to breathe.
***
"We're taking a field trip," my upper level resident said, rather abruptly. I looked at the other students a tad nervously, and we've definitely never taken a field trip in the hospital before. "In fact, it's a taste test."
We followed her into the elevators, and up to the pharmacist's office. On his desk were a pile of small syringes, each filled with brightly colored fluids of different shades. There were a few cups of water, and, improbably, a bright red M&M dispenser. He didn't have much in terms of introduction. "Ampicillin," he said, handing each student a syringe.
I squeezed a small amount of fluid onto my tongue, and watched the other students gag and reach for water. Apparently, I didn't have the taste receptors for it, but I remember a sickly sweet, almost alcoholic sensation on my tongue.
We repeated this process for several antibiotics, a corticosteroid, and who knows what else. It was a bizarre scene-- all of us in our white coats, taking shots of medications interspersed with palate-cooling drinks of water. "The cefalexin is delicious," someone said. I remember a sweet brightness, with notes of citrus and berry. And then there was the Cipro, which has a taste difficult to describe without profanity. Everyone was gagging, one classmate reached for the trash bin, and the water didn't seem to help. I found myself wishing, oddly, that we had shut the door. Instead, I reached quickly, desperately, for an M&M.
Two weeks later, the same resident brought us down to the microbiology lab. There, we received a tour and waved hello to the staff. We learned about what happens after a lab is drawn, and the people who dedicated their careers to hunting and growing microbes. One tech passed around a series of a petri dishes, where we wafted odors of bacteria up to our noses. Each microorganism had a different smell-- odors of rot and decay, dust and mice, and the surprising sweet grapes of pseudomonas.
Later, I peered down at a series of cells through a microscopic in a darkened room, a series of cells glowing bright red and yellow and green against the darkness. The thought that I was seeing light reflected off antibodies attached to viruses was thrilling. Before, a virus seemed almost like a fantasy, a child's story of invisible animals comprised of nothing but a membrane around some nucleic acids (they sometimes wear coats). By seeing the light, even the most fantastical organisms became real.
These field trips, held in the final weeks of my third year, had the weird effect of making everything I was doing with my patients seem as real as the glowing viruses.
I found this unexpected. For all its powers in the applications of science, medicine has this odd way of making you forget the reality of the situation. I found it a weird paradox that even in clinical medicine, when the patient is literally right in front of you, it's still so easy to distance yourself. In many ways, having just a little bit of decreased empathy is adaptive. It makes it that much easier to draw their blood, cut open their skin with a scalpel, and it's an easy way to let you sleep soundly at night, knowing that the patient you just admitted is likely to be gone in the morning. You distance yourself because it's the easy thing to do, and when you see a series of drama after drama, sometimes the troubles of others becomes mundane.
In the preclinical years of medical school, the opposite occurs. Although we do a good job of making sure we had the occasional patient contact, at the end of the day the majority of your time is dedicated to books. The diseases seemed almost theoretical, esoteric even, as the effects of the diseases in the real world are often muted out by the science. I remember there was a dramatic shift in the class when one of the patients who came to speak with us about cystic fibrosis suddenly died a few weeks later. She was young, energetic, a hero. I found myself oddly upset, perplexed as I didn't really know her at all. Instead, after coming home to my apartment, I stared at my pile of books, wanting to cry for a girl I barely knew.
Now, I'm forced again to study nothing but my books, reading about diseases I've seen. I flip through the books to realize that for many pages, I see faces of the patients I've met, the stories I've collected, the connections I've made to the lives behind mere names of diseases. I wonder where they are now, and whether are not if we really made a difference in the end.
Yet for many sections, there are words on the page but my memory is blank. These are diseases I have yet to see, and they remain so on the page, only barely real. I spend my days treating artificial patients projected onto a computer screen, patients whose problems are solved by multiple choice. It becomes easy, again, to forget that what I'm learning affects actual lives. In many ways, I already crave being back on the wards. I wish I had the sweet taste of cefalexin in my mouth, reminding me that it's the mastery of both theory and practice that ultimately makes the magic of medicine.
Thursday, February 11, 2010
February 11, 2010
There have been so few postings on here because, apparently, people have begun to find out about this blog. Suddenly, the simplest post becomes even more nerve-wracking. It's even harder when you realize that the people you write about may actually be reading this thing.
It's a question of confidence, really.
In thinking about my extraordinary inabilities to actually post on this blog, I realized that much of medical school has been about the development of confidence. And not necessarily by increasing competency, but rather, we're taught at the minimum to portray a phenotype of outward confidence.
This lesson is often taught in one of the rituals of teaching in medical school known as "pimping"-- when the resident or attending physician asks a series of questions where the student must answer on the spot. Much has been written about its efficacy (and pitfalls), but in the proper hands of an experienced physician-teacher, pimping works very well in engaging the student and transferring knowledge.
The secret un-spoken lesson that is taught, however, is that sometimes you need to exude confidence even in the face of complete uncertainty. One of my attendings was very explicit about this fact, embodied in his sometimes-not-so-gentle ribbing of students who would answer his questions awkwardly or in the tone of a question. In the OR, he might ask, "What innervates the section of the foot I'm cutting?"
"The superficial peroneal nerve?" you might answer.
"I don't know, you tell me!" he might reply. Or, he might ask why you're asking him. Or, he might just blatantly accuse you of answering his question with another question. You quickly learned to give the answer in a direct tone, even if you didn't have the least bit of a clue as to what he was talking about.
One day on rounds, we had started to joke about these almost-cheesy responses to our answers, he suddenly explained himself. "When you walk into a patient's room to tell them they have cancer," he said, "you can't be wishy-washy about it. Even if you have no idea what's happening, you need to be confident in your plan."
At that moment, I couldn't help but think about how I would personally respond if my physician gave me bad news, filled with "ums" and hints of uncertainty.
Our attending's point wasn't that we should deceive our patients, nor misrepresent how much we knew. In fact, he encouraged us to be honest with our patients about our knowledge or uncertainty, but to be certain and confident in our mannerisms and the next steps we would take.
A similar lesson is found in our interactions with standardized patients, who are all real actors with fake illnesses in fake clinic rooms with hidden cameras. Every effort is made to ensure realism, but sometimes it's hard to forget you're being videotaped and that nothing is real. And in these simulation sessions, I found it horribly ironic that outside of our medical knowledge, what we're really being assessed for is our acting abilities-- and sometimes explicitly so. "I didn't feel you had any empathy for me," I once heard a standardized patient tell one of my classmates. "You either need to get some empathy or learn how to fake it."
The hidden lesson is many of these simulations is that we need to present ourselves in a certain manner-- one that is empathic, confident, and caring, despite what we're actually feeling inside. Of course, ideally we should be expressing these factors genuinely, but at an absolute minimum, we need to know how to fake them if the need arises.
In the past year, I've learned to be more confident despite my own ignorance-- becoming more confident of my own ignorance. I do genuinely care about my patients, but I'm also very aware of my own gaps of knowledge as a medical student. I stride into a patient's room confidently. "My name is Howard, and I'm a student doctor," I'd say. "I'm the lowest person on the ladder here, and I have the least amount of experience. But, I usually have the most amount of time. Feel free to ask me any questions you have, and if I don't know the answer, I'll find it out for you. It's my job to make sure that you know what's going on."
It's a question of confidence, really.
In thinking about my extraordinary inabilities to actually post on this blog, I realized that much of medical school has been about the development of confidence. And not necessarily by increasing competency, but rather, we're taught at the minimum to portray a phenotype of outward confidence.
This lesson is often taught in one of the rituals of teaching in medical school known as "pimping"-- when the resident or attending physician asks a series of questions where the student must answer on the spot. Much has been written about its efficacy (and pitfalls), but in the proper hands of an experienced physician-teacher, pimping works very well in engaging the student and transferring knowledge.
The secret un-spoken lesson that is taught, however, is that sometimes you need to exude confidence even in the face of complete uncertainty. One of my attendings was very explicit about this fact, embodied in his sometimes-not-so-gentle ribbing of students who would answer his questions awkwardly or in the tone of a question. In the OR, he might ask, "What innervates the section of the foot I'm cutting?"
"The superficial peroneal nerve?" you might answer.
"I don't know, you tell me!" he might reply. Or, he might ask why you're asking him. Or, he might just blatantly accuse you of answering his question with another question. You quickly learned to give the answer in a direct tone, even if you didn't have the least bit of a clue as to what he was talking about.
One day on rounds, we had started to joke about these almost-cheesy responses to our answers, he suddenly explained himself. "When you walk into a patient's room to tell them they have cancer," he said, "you can't be wishy-washy about it. Even if you have no idea what's happening, you need to be confident in your plan."
At that moment, I couldn't help but think about how I would personally respond if my physician gave me bad news, filled with "ums" and hints of uncertainty.
Our attending's point wasn't that we should deceive our patients, nor misrepresent how much we knew. In fact, he encouraged us to be honest with our patients about our knowledge or uncertainty, but to be certain and confident in our mannerisms and the next steps we would take.
A similar lesson is found in our interactions with standardized patients, who are all real actors with fake illnesses in fake clinic rooms with hidden cameras. Every effort is made to ensure realism, but sometimes it's hard to forget you're being videotaped and that nothing is real. And in these simulation sessions, I found it horribly ironic that outside of our medical knowledge, what we're really being assessed for is our acting abilities-- and sometimes explicitly so. "I didn't feel you had any empathy for me," I once heard a standardized patient tell one of my classmates. "You either need to get some empathy or learn how to fake it."
The hidden lesson is many of these simulations is that we need to present ourselves in a certain manner-- one that is empathic, confident, and caring, despite what we're actually feeling inside. Of course, ideally we should be expressing these factors genuinely, but at an absolute minimum, we need to know how to fake them if the need arises.
In the past year, I've learned to be more confident despite my own ignorance-- becoming more confident of my own ignorance. I do genuinely care about my patients, but I'm also very aware of my own gaps of knowledge as a medical student. I stride into a patient's room confidently. "My name is Howard, and I'm a student doctor," I'd say. "I'm the lowest person on the ladder here, and I have the least amount of experience. But, I usually have the most amount of time. Feel free to ask me any questions you have, and if I don't know the answer, I'll find it out for you. It's my job to make sure that you know what's going on."
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