3rd Year of Medical School.

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Neurology.

  • How did I feel when I got home?

As my last rotation, the taste of fourth year right around the corner was always on my tongue. But I put my head down, kept myself busy, and confirmed three things: 1) Neurologists are badasses. 2) I feel something deeply powerful with stroke patients (go figure) 3) I love critical care. For my 2 weeks in the Neuro ICU, I was probably in the hospital for 95% of it – sleeping for a few hours in the call room until the next organ harvest operation, central line placement, or stroke page. I loved placing central lines, popping through the dura for my first lumbar puncture, or emergently rushing a patient to the OR – this chaos is my ebb and flow.

  • Did I feel excited to look up the illnesses and diseases in the patients I was caring for, or to study for the shelf exam? Was there diversity in the conditions being treated?

I was surprised to find how interested I was learning about neurology. I truly think neurology is the last frontier in medicine. There are still so many questions to be answered, so many diseases without treatment, and so much we still don’t know about that squishy pulsing thing in our skull. I loved the way neurology forces you to localize the pathology on-the-spot, and truly think your way through the diagnosis. But my lessons came from the most unexpected places as well- such as working with an expert in multiple sclerosis who opened my eyes about the extent of financial swindling with pharmaceutical companies. Then there was my Sharon. She was the equivalent of my Mr. Castillo on my vascular surgery rotation. A young woman with fire in her eyes and enough vibrance to light up a room. My intern and I, only saplings in our medical training, sat down with her husband and daughter to spread the cards of her critical situation. We consulted every service in the hospital trying to figure out what was wrong with her, but ultimately despite hundreds of labs, imaging, and biopsies, we didn’t have an answer for her husband’s hopeful eyes. She had been in the hospital for a week. That’s when I got the page. I remember how awful and bizarre it was talking to her- reassuring her – for those few seconds we had as she bled into her brain. I pretended like I wasn’t crying and refused to break her gaze, repeating,”Jim is coming, hold on okay? He’ll be here. Hang on.” Dozens of people flurried around us and the corner of her mouth gave her little smirk like she always did, right before her brain sagged beneath it’s fascial tent. With my third year wrapping to an end, I know that moment will be carried in a chunk of my heart forever. I will never forget that beautiful soul, or any of the amazing patients who shared their stories with me and let my unexperienced hands poke them at all hours of the night. I was lucky enough to honor every clerkship during my clinical year, and I can honestly say that staying interested in every aspect of medicine and taking complete ownership for my patients were not only the keys to my clinical learning, but also to helping me avoid burnout. I’ll admit- often my intrigue in neurology was usually only sparked if it directly related to the patients I was treating. But that little spark of intrigue is all it takes. So I run with it.

  • How much direct patient contact was there? 

So much. I loved the critical care aspect, and the slower pace of outpatient clinic and getting to actually spend time with patients.

  • What were the humdrum aspects in the patient population or workflow that would have to be tolerated for the rest of your life?

Non-epileptiform seizures.

  • Does this specialty address one of the leading causes of death in the world?

Yes, definitely – cerebrovascular disease. Our treatments for it still suck, though.

  • How easily can motivational impact be integrated into a career in this specialty?

So easily. I feel pretty confident in saying now that this could be integrated into any specialty in medicine.

  • Does this specialty focus on preventing problems or fixing problems?

I’m not sure how to answer this, because I don’t feel like we currently do a very good job at either of these. But as I said, I think neurology is medicine’s last frontier. We just need someone to unravel it.

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A Priori.

An EMG test helps determine if muscle weakness is from nerve injury or muscle damage.

In resting muscle, it should be quiet.

In active muscle, it should fire rapidly like a machine gun.

Inhale. Needle in. Eyes down.

Waiting.

Then, we heard it.

Slowly, it emerged from the silence. That dreaded, faint signal beating from resting muscle.

Eyes closed.

Sinking.

He had been healthy a few months ago. But Amyotrophic Lateral Sclerosis had chewed away the nerves, leaving islands of muscle without any connection back to the body.

Despite losing all neuronal input, the muscles in our body keep searching for them.  Forever emitting a lost telegraph signal. Hoping.

Sit up.

Wiping.

Plaster smile.

After all, stranger

we’re only satellites

sending out signals

waiting for someone-

fucking anyone-

to receive us.

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Family Medicine

  • How did I feel when I got home?

Similar to the satisfaction of unfastening something too tight. I would race home from clinic and burst through the front door to be greeted by those two little chunks of sun.  I’d bask in the warmth and the light of those two small humans, soaking up their innocence and honesty and curiosity while they melted my heart like a stick of butter. It was like remembering what the sun felt like after a long and relentless winter. I slowly refueled my empty battery packs. I stroked their back a minute longer after they fell asleep. I squeezed them tighter before letting them go. I made silent wagers with the universe to pull in the reins for a few years, please stop them from growing so fast. Somehow, everything else on the rotation paled in comparison.

  • Did I feel excited to look up the illnesses and diseases in the patients I was caring for, or to study for the shelf exam? Was there diversity in the conditions being treated?

Absolutely. Family medicine is incredible in that sense – the breadth and diversity is as far-reaching as the eye can see. I ended up keeping a list of all the patients I wanted to go back to check their results, look up their weird symptom, or see if the specialist agreed with my diagnosis. I saw a woman with metastatic cancer who’s tumor had pushed it’s way through her abdominal wall – visibly protruding and angry for all the world to see. I saw a woman who was rapidly losing her ability to move her muscles, leaving some of the finest research hospitals in the country scratching their heads. I saw a woman with nagging pelvic pain after her appendectomy (she forgot to mention the stormy black and purple bruising spreading across her belly), who quickly re-visited the operating room. I saw where medicine heals and where medicine falls short. I saw the expansive gaps in our health care system in which we have plugged with glue and gum,  when it should have been gardened with diet, exercise, and mental health. I saw the incredible miracles that medicine can provide, tacking years of life onto patients knocking on death’s door. Overall, I loved finally being able to drink in the minutia of America’s ‘bread and butter’ diseases. Turns out, I still love medicine after all.

  • What were the main feelings I encountered while working with the patients? The medical team?

An overwhelming sense of belonging. I listened to patients spill their entire lives with me – their relapsing meth addiction, their embarrassing odor, their breaking marriage, their battle against their disease. They let me scrutinize their skin, push my hands on their belly, feel for lumps in their breasts, stick needles in their joints. They shared words of wisdom distilled from years of seeing the inner workings of the health care system. I didn’t feel frustrated with patients, as I had envisioned myself feeling while coaxing relapsing diabetics and narcotic shoppers. Instead, I felt the same connection that drove me into medicine in the first place – that same window into the human experience.

The medical team felt more like a true team than I have ever experienced. The medical assistants and I grew so close you’d think we’d all grown up on the same street. They helped me finally settle on a prom dresses, filled the clinic with treats for my birthday, covered my back when I slept through my alarm (granted, I slept until 1pm, for which their is no excuse other than my body had literally tried to enter hibernation). Then the incredible physician I had the fortune of working with – I had requested him specifically after I had cared for one of his patients with newly diagnosed mesothelioma (“I just moved here and my new doc picked up the cancer on my first visit!”). I filled a small notebook with observations and clinical pearls during my short time with him – but what impacted me most was seeing the way he interacted with patients. Upon entering the patient room, he would greet them with the same warmth of visiting family, and would quietly sit back, cross his arms, and listen. Sometimes patients would talk for nearly ten minutes, but he never interrupted. He simply listened, quietly nodding and observing. During the entire encounter, he spoke less than most physicians do during the first few minutes. And yet – he was able to narrow in on their diseases with unbelievable precision. He has caught more missed diagnoses than I can even describe. Nearly every patient I interviewed would tell me, without any prompting, how “I just went in for my annual physical” and “he thought he felt a lump/heard a murmur” or “he said he just didn’t have a good feeling about it” and BAM – they were diagnosed with cancer, underwent open heart surgery, or admitted to the hospital for a weird fungal infection. This happened every single day. He was the most remarkable influence on me – instead of dismissing symptoms as I had learned to over the past year, he actually listened to the symptoms I was dismissing and worked them up. During my short experience with him, we sent countless patients to the children’s hospital for bizarre illnesses I had read about in textbooks, to the operating room for “a little heartburn”, and we even sent a patient with newly diagnosed lung cancer on imaging to the cancer hospital for the first time. I can only hope to retain half of the wisdom he imparted on me, and even a sliver of his skill as a physician.

  • How much direct patient contact was there? 

So much. So, so much – and I couldn’t have been happier. Except if their had been a scalpel in my hand.

  • What were the humdrum aspects in the patient population or workflow that would have to be tolerated for the rest of your life?

Do-cu-men-ta-tion. And well child checks, ugh.

  • Does this specialty address one of the leading causes of death in the world?

YES. In every possible way. I think family medicine is ultimately the answer to most, if not all, of our health care problems. Unfortunately, I am too damn selfish to relinquish my time in the OR.

  • How easily can motivational impact be integrated into a career in this specialty?

SO EASILY. This seems so ridiculously obvious that I’m not even going to answer it.

  • Does this specialty focus on preventing problems or fixing problems?

Both. See prior statement.

 

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So do it. Decide. Is this the life you want to live? Is this the person you were meant to be? Can you be stronger? More compassionate?  Decide. Take a deep breath – your heart will try to lodge itself in your throat. Brace yourself. Here it comes – the headlong dive into the deep.

 

 

When Love Stays

The following is an excerpt by Bianca Sparacino (more of her writing here):

“When love stays, something inside of you stops fighting. It lays down its arms and finally rests.

When love stays, your heart stops holding its breath and lets out all of the heaviness that surrounded it’s need to guard and dismiss anything that came close to holding it.

When love stays, you start to understand why it had to leave in the first place.

When love stays, you have to understand that it is going to be by your side, it is going to fight with you — no matter what. You cannot flee from it.

I know, I know — it is difficult —  but you must believe in love, the way it believes in you.”

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Psychiatry.

  • How did I feel when I got home?

I got a glimpse of what life was like before medical school again! Not only was I sleeping more than I have in the past 3 years, but life in general slowed down for me – I actually got ready in the morning, prepped tupperware lunches, and went snowboarding for the first time in years. I learned a lot about mental illness, addiction, and the biochemical imbalances that can push us off the deep end, and I know these problems really do permeate every field in medicine and I’m going to encounter them on a daily basis in my practice. I also realized that psychiatry offered a similar aspect that surgery did. There’s a saying I’ve heard that claims, “Those who don’t go into surgery end up going into psychiatry.” At first, I couldn’t wrap my mind around this. What could these two specialties possibly have in common? For weeks I tried to piece the two together and it wasn’t until a psychiatrist finally explained their similarity to me: both are extremely invasive, and both expose the taboo: the rawness of the human experience. Both fields throw the windows wide open, forcing you to stare inside the very essence of life.  Just like surgery, there were days that left me sitting stunned in my car – feeling awestruck by the beauty and the pain. But surgery’s twin sister was so drastically different in countless other ways. People walked slower. Talked slower. Smiled at each other in the hallways – instead of that look when you spot a surgical resident – like seeing a deer in headlights.

  • Did I feel excited to look up the illnesses and diseases in the patients I was caring for, or to study for the shelf exam? Was there diversity in the conditions being treated?

I tried my best to dive in and soak up everything I could, to learn the intricate details behind anti-depressants, opioid detoxification, socioeconomic factors impacting hospital care. But the truth is, I found myself feeling bored really quickly. For the majority of the time, the work felt passive: “How’s your mood today? Is the medication working? Should we try a different one?” There was definitely the few patients who were the exception to this  rule- and I was able to witness the enormous impact psychiatry can have in helping someone suffering from mental illness. But overall, I was constantly hungry for more. I kept finding myself turning back to surgery – looking up various topics in surgery, getting my name on more surgery papers than ever before, and sneaking back to the OR to close flaps or see traumas. I was grateful for the pause that psychiatry offered – a break in the grind, a chance to breathe – but in the end, I knew it was just that. A pause.

  • What were the main feelings I encountered while working with the patients? The medical team?

The medical team was AH-MAZING. My attendings became some of my absolute favorite people I’ve encountered in medical school so far, and honestly made me take a long, hard look at the stone cold personalities in surgery and truly come to terms with it. These attendings, in stark contrast, were overwhelmingly supportive and complementary, allowing me to take ownership of my patients, propose treatment plans, and write all of the notes. I’ll never forget the day the social worker was on the phone explaining members of the treatment team when she added, “and then Hailey, she’s the medical student on the team.” It sounds ridiculous, but being listed as a member of the team like that has not been a common occurrence (we’re not listed at the nurse’s station, on progress notes, in team meetings, etc). After all, it’s like you’re not really part of the team – you’re just a temporary transplant who only requires a formal introduction when standing face-to-face with the patient or about to put your gloved hand in their abdomen. But in psychiatry, I truly felt like I was fully embraced as part of the team.

As far as the patients I encountered, honestly a lot of my patients blended together in a blur of depression, anxiety, and detoxification. But then there were the select few who deeply impacted me and made me realize the fulfillment that psychiatry – in it’s finest moments – can offer. It was the young man presenting with his first psychotic break from schizophrenia, who became “my” patient – the patient I sat on the floor with and persuaded to agree with treatment, the patient who drew me a picture every day, the patient who left the hospital remarkably symptom-free with anti-psychotic flowing through his veins. It was my patient who stabbed himself in the chest in a suicide attempt, but miraculously missed every vital structure and left with only a handful of stitches. It was my pregnant patient withdrawing from heroin. It was my patient who, after hours of deep conversation, finally disclosed their suicide plan after discharge to me, and all of the ups and downs that followed: clever suicide attempts, riddles and games (“it’s all a game of chess”), and lastly, my letter (“checkmate”). In the end, psychiatry was both blissfully relaxing and an emotional whirlwind – with a tiny bit of crazy scattered in between.

  • How much direct patient contact was there? 

So much! I would say more than any other specialty. I loved getting to spend hours just talking with patients, hearing their stories, learning with them. I’m going to miss that.

  • What were the humdrum aspects in the patient population or workflow that would have to be tolerated for the rest of your life?

Borderline personality disorder and addictions. The former left me feeling absolutely emotionally drained. The latter left me feeling like there was nothing I could do and like I needed my own drink.

  • Does this specialty address one of the leading causes of death in the world?

Suicide is the second leading cause of death in young adults worldwide, so I guess it does in that sense. Otherwise, it probably does in many ways indirectly.

  • How easily can motivational impact be integrated into a career in this specialty?

SO EASILY! This was one of my favorite aspects of psychiatry! I loved feeling like I was helping to shift a patient’s path in life. I want to carry this with me. It’s easy to lose sight of this motivational potential with patients. I also loved the personalized descriptors used in the documentation of these patients and want to carry that with me as well – you never really see that in other specialties (like when my psych attending included “Appearance: well-groomed, eyelash extensions in place).

  • Does this specialty focus on preventing problems or fixing problems?

I would say fixing. But truthfully, I never felt like it did a great job at fixing them.

 

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When your favorite attending greets you with a present and pastries for your last day. 

PEDIATRICS.

Pediatrics.

  • How did I feel when I got home?

I felt more well-balanced. Although pediatrics was a steep learning curve for me (“Oh we don’t give cold syrup to kids this young?”), I really enjoyed the patients I was caring for every day. I didn’t mind staying late or waking up early, and I found a little more free time to balance my life outside the hospital with things that have been pushed aside with other clerkships. Outpatient peds clinic nearly converted me after a whole week getting spoiled with sleep and sauntering into the hospital at 9am. Almost.

  • Did I feel excited to look up the illnesses and diseases in the patients I was caring for, or to study for the shelf exam? Was there diversity in the conditions being treated?

Gahd, no. I mean, learning the basics of bronchiolitis and viral gastroenteritis will help me in any field I end up in. And hopefully, I can look a little less clueless when a stranger inevitably points to their kid and asks me what’s wrong with it. But in all honesty, I had to drag myself to study each night. I remember how eagerly I would go bouncing into a coffee shop to bury my head in a surgery textbook despite my exhaustion and spending all day in the OR, and it became increasingly apparent how different specialties truly pull at you. All in all, the kids were great – but asthma algorithms, growth charts, and counting wet diapers is not my jam.

  • What were the main feelings I encountered while working with the patients? 

I honestly love working with kids. Usually they are pretty healthy. Taking a social history is a breeze. They are pretty cute for the most part. And I feel like I’ve succeeded in life every time I finally get one to laugh at me. What I liked most of all about having pediatric patients was the absence of internal bias when treating them. There was never a lingering shadow of “metastatic cancer” or “2x CABG” weighing down our medical decision making. The kid is sick? Let’s treat them. I liked that.

  • How much direct patient contact was there? 

A lot. And I liked that. I miss interacting with patients and getting to hear their stories without having to hurry along to the next patient. And pediatrics was overall a slower pace with more time spent in patient interactions. “Tell me about how they first discovered your brain tumor.” “How were the first few weeks after bringing him home from the NICU?” “What do you want to be when you grow up?” I also really liked that physical exam plays such an important role in pediatrics. You see a bulging, red ear drum holding back a pocket of pus and prescribe some antibiotics – just like that. There were many times when a regular viral bronchiolitis turned out to actually be bacterial pneumonia after we noticed diminished breath sounds over a soggy pocket in their lung.

  • What were the humdrum aspects in the patient population or workflow that would have to be tolerated for the rest of your life?

Everyone always says the downside of pediatrics is having to deal with the parents. I actually didn’t mind the parents. I didn’t really mind the boring diagnoses either, such as conjunctivitis or strep throat, because that meant I just got to spend more time playing with the patients since the diagnosis was covered. I guess the aspect I enjoyed the least was actually the medical team. I often felt annoyed with the smatterings of protocols for seemingly simple diagnoses, and the pompous gloat of the medical team as they tinkered with them, knowing that somewhere in the hospital other medical teams were pulling patients from the brink of death – unclogging arteries of the heart, suturing ruptured vessels, removing angry gallbladders.

  • Does this specialty address one of the leading causes of death in the world?

Ultimately, yes. But not in a way that I see my own contribution to the world.

  • How easily can motivational impact be integrated into a career in this specialty?

Very easily, I think. The youth is our future, isn’t it?

  • Does this specialty focus on preventing problems or fixing problems?

A little of both, I think. But at the end of the day, I definitely didn’t feel like I was ‘fixing’ much.