Internal Medicine.

  • How did I feel when I got home?

 Happy. Most of the time, I felt validated and confident about the work I had done that day, and I had enough time and energy after work to get things done or to do the things I enjoy. I had a sense of purpose and meaning. I also found my mindset shifting – my thoughts more frequently trailing into questions about the meaning of life, why we do what we do, and how we can better ourselves.

  • 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?

Yes and yes. I loved learning about the intricacies of the signaling pathway from the brain to the gland atop the kidneys to determine if my patient was in septic shock or adrenal crisis – or both. I loved reading New England Journal articles about empyemas and when to refer to my patient for surgery, or scouring the literature to understand why it might be better to re-start the blood thinner in my patient with a bleeding stomach vessel sooner than later. Weaving symptoms together and teasing out the abnormalities in the blood work in order to arrive at the right diagnosis felt like solving a mystery, and I think I was good at it. The diversity of the conditions that hospitalists are expected to know is enormous – often I would think to myself, “but they can’t know everything” – but they did.

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

The patients made me feel connected. I often cared for them from the day they arrived at the hospital until the day they left, and I loved that sense of short-term continuity in the acute inpatient setting. The outpatient care setting was (if I’m being entirely honest) – repulsive in many ways. But I loved the continuity aspect. The medical team made me feel respected, encouraged, and supported. They listened to my reasoning through various diseases I was considering could be affecting my patient, and why I wanted to pursue one treatment over another. They often complimented me on my knowledge about my patients and my ability to maneuver in the hospital setting, and I felt like my hard work was appreciated.

  • How much direct patient contact was there? 

As much as I wanted. There were times while I was in the physician’s workroom, typing up progress notes or printing research articles, and I realized that was not what I should be doing. Great doctors aren’t molded over a keyboard. So I would spend a fair amount of time sitting in patient’s rooms and hearing about their experiences in Afghanistan, or in the darkness of the radiology reading room pointing at the bright structures on my patient’s scans. I realized that work is a sliding scale,  a balancing act. If I wanted to spend more time in clinical experiences and at the bedside, then my documentation time and the quality of my notes would be sacrificed. I was okay with that, it made me happy.

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

Pages of tedious paperwork. There has to be a more efficient system for documenting treatments administered and medical decision making. Long rounds didn’t bother me as much as I thought they would. I felt like the patients who greeted us in the room deserved that time. They were likely having one of the worst experiences of their life, and they were the reason I endured years of grueling coursework. The least I could do was spend more than 5 minutes in a sterile hallway outside their door discussing their illness and how we were going to help them. Too often, we brush past the surface and never step deep enough to see the exposures and co-morbidities  fueling the disease we see lying in the hospital bed, or to appreciate their values that should guide how aggressive we are or aren’t with their treatment. I can see myself feeling like the time-consuming aspects of internal medicine are “chores” – until I pause to remind myself of the deeper meaning of medicine. It’s not always fixing people.

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

Yes. That is the essence of internal medicine, really. Heart disease, hypertension, diabetes, and a little splash of renal failure.

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

I would argue that there is no better specialty for the role of motivation in having the largest impact on patient health.  I think there is beauty in the short-term encounter of the inpatient setting. You, as a physician, haven’t struggled with this patient before. They are new to you. You are new to them. You are a fresh page, and this is the chance for a new beginning. The perfect opportunity for an intervention. They are out of their normal routine, a stranger in their environment, isolated and stripped down to their rawest self in a hospital gown – without labels or reputation or distractions. They have the chance to peel away their layers and stare their humanness in the mirror, to ask themselves for forgiveness for damaging their body, and to see the need for a change.

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

Both. For the patients caught early, there is the opportunity to alter their disease course and to avoid yearly hospitalizations. For the patients reeled in later with a roaring storm of imbalanced drugs in their bloodstream, or soggy lungs filled with bacteria, or intractable headaches due to an un-solved mystery, there are always new problems to fix.

I see the beauty of life –  in all of it’s distressing disguises.                                                     I see the unfolding of human spirits.                                                                                        I see the core of what lies within us.

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Internal Medicine.

Nurses and technicians suction to the walls as we pour from of our corner in a flurry of coffee, papers, pagers, and white coat tails. We stand outside patient rooms in a methodic ceremony of speedily reciting dates, numbers, and medications encompassing the sleeping patient behind the door. Our huddle exchanges less than a hundred words to dictate which orders to write and which direction to turn from here. A brisk walk inside, possibly a handshake or an introduction or two, regurgitation of plans, glob of sanitizer, swarm out. The entire process takes about twenty minutes.

When I first heard her case, I knew it wasn’t an infection. As a 3rd year medical student,  I just get patted on the head with a taste of “oh, little medical student, you’ll learn to stop reading into these silly small things”. They slapped antibiotics on her chart with a note to “reassess in the AM”. Days passed. Fevers kept spiking. Her creatinine kept climbing. 80% of her kidney function was gone by the time they ordered the kidney biopsy.

When results came back, they looked at me as if I had been cheating the system.

I remember the staff would groan at the mention of her name. But I secretly loved how she would take out her notebook each time we entered and scribble down every word we said. Inside, I completely understood her demand to be heard and pleas to not be dismissed. They had called her “a crazy narcissist who loves playing the sick role”. After the biopsy results, I spent hours carefully printing articles about her condition, highlighting the answers she had begged us to answer. I scoured her chart until I traced the inciting event back to a single telephone note documenting a course of antibiotics for a dental procedure and emphasized the importance of her avoiding this drug class in the future. Her greatest fear was being treated, for the side effects it might entail. She cried and told me about her son with a rare genetic disease. For her, the possibility of psychosis as an adverse effect was not just inconvenient or frightening. It was her son’s life on the line. It meant risking a lapse in time where she couldn’t adjust the dose for him right away, or tell the babysitter what to do when his blood sugar plummets spontaneously, or help him clear his secretions plugging his airway.

“I knew from the minute you all walked in the door, you were the only one who still had their eyes open. You were the only one listening to me.”

Six.

Medical school is sucking the life out of me.

I know I’ve loved medicine before. I know I could never love anything else like I love medicine. But it feels like a tarnished, battered marriage – one I used to truly feel butterflies for, but now I’ve been spit on and bruised one-too-many times to feel that way again without some serious digging in the rubble.

My first rotation in 3rd year started off as a fantastic explosion of pure bliss – rounding with attendings who sat on the edge of the bed, held patients’ faces as they cried, who spun me around the pathways of cancers and diseases. I felt like a dry sponge that couldn’t soak up all of the new and exciting information fast enough! Things have changed now. A bald man with squinty eyes extinguished the electricity and left a floor without white coats or discussions about plasma cells and hospice. The white coats get draped over chairs, we sit in a room to “round” on patients, and I find myself feeling drained after a mere 8 hours of work – when before I would be too giddy to sleep after an 18 hour shift. Typing notes into patient charts, calling orders, juggling readmissions – is this my medicine? It can’t be. My medicine knows my favorite note and sings it right into my heart space. My medicine opens my eyes to how beautiful this world is and thrives on breath sounds and a gentle touch and the skipped beat of a rushing around the corner.

This?

This is not my medicine.

Come back to me.

I have studied for 124 consecutive days, without a single day off.

19 more to go.

I miss my family. I miss feeling like a good friend to someone. I miss not doing flashcards while I’m walking. I miss SLEEPING IN dear god I miss sleeping in.

For 2 years I wondered how I would be feeling in these moments right before STEP 1. I am feeling shockingly calm – probably because I’ve been anticipating it for so long. I feel burnt-out, yet somehow I still have fuel. I feel skeptical about the exam – I find myself scrutinizing every short simplification stamped into FirstAid, imagining the question-writers wringing their hands devising clever ways to trick us. I guess I just don’t know what to expect, and I don’t know whether all of this work will pay off.

But at the end of these 5 months, I will have accomplished my goal I set for myself – by far the most difficult task of dedication and resilience I have ever encountered.

I know, without a doubt, that I am capable of anything.

Here’s to –

being fearless in not knowing.

being fearless in failing.

being fearless in the moment,

regardless of the outcome.

 

 

What I Set Out For.

I am officially 50% a doctor. Stepping into medical school I was always burning with the questions of what would fill my mind at the end of it all and how this journey would change me. Here’s the answer so far:

  • I learned how to use a stethoscope, recognize heart failure, what fibromyalgia is, and how to delineate sepsis from the flu.
  • I realized how much I can learn if I put my pen down and listen. I do not need notes or papers, because they will not be there when I’m taking a test or with a patient. I learned to write down nothing, to absorb and retain things in my mind instead.
  • We can practically hear the whirring of the machines constantly at work behind an eardrum, but we still know so little about what actually goes on in there. Yet we have careers built on knowing everything about the numbers on wall street, and we even have careers built on creating numbers to analyze those numbers – all for an imaginary financial system filled with imaginary symbols of things that don’t really exist. I find myself looking recognizing this contrast a lot – and I’ve learned to value the soft dirt beneath toes or the pulse in warm skin and the trueness of real things.
  • There is absolutely nothing more beautiful than this crazy world of medicine. We get handed the next link in this chain that goes back to Aesculapius standing in a Greece temple in 350 B.C. or hotels serving as hospitals in England in 1622, and something about that feels magnificent and sacred.
  • Sometimes I feel like medical school is just like being given a pair of x-ray vision-type goggles. You begin to see things others cannot. Vomit with black specks is no longer such. It’s upper GI bleed, possibly a curved bacterium that has burrowed in the small curvature of a stomach.
  • I think we are built from the tiny moments in our lives.  Riding the bus home, standing in line, the in-between gap before your next duty. I’ve realized the beauty of these grains of time.
  • I’ve seen where medicine can so easily help (a simple tube of cream to a patient with atopic dermatitis who has scratched their skin open during months of sleepless nights), and I’ve seen where medicine falls short (we don’t know what’s causing that, describe your worsening angina for me again, you have to get your blood sugar under control first).
  • It takes at least 3 wrong attempts in answering something before I even begin to really understand it.
  • There is something very broken with the education system, and I am an intent on changing that somehow. But that will be a story for another day.
  • Life sweeps you away the second you let it. If you didn’t solidify your beliefs and morals – like really tie those loose threads and secure them – life will unravel them faster than you can reach. Medicine is especially dangerous for it’s ability to smear white-black boundaries into a grey smog of right and wrong. Dig your roots.
  • I realized doctors are detectives, every word is calculated, and the good ones can extract the keys to a diagnosis in that 15 minute window because of it. The ones who never polished this skill, who can’t scratch past the surface, live in loops of increasing doses and idiopathic this or that.
  • I am just a thin membrane wrapping organs. An air bellow puffing wind. Nucleic acids fighting with each other. A thousand genes that were somehow read, translated, strung together, and folded correctly. Every single one of us – we are just a single oxygen molecule slipping off hemoglobin, an electron passing from inside to outside, a phosphate group popping on and off. T
  • I’ll admit I didn’t believe it, but you really can run on four hours of sleep and remember that entire book.
  • I realized that somehow I lived 23 years of my life without knowing much about the huge red pipe running down our back, or the different kinds of cells that bubble out of our bones each minute, or how every human on this earth created the same 9 holes in the exact same spot in the bottom of their skulls while they were asleep inside a belly.
  • I learned a lot about myself. I saw how hard I’m willing to push myself, watched myself make conscious decisions about who I choose to surround myself with, and read the things that my younger self had engraved into my subconscious.
  • I learned a lot about other people. A sentence I read years ago in a book with no cover has popped into my head a countless number of times, and each time it’s more loud and true: “We are all just satellites, waiting to be heard and received.”
  • I realized that emotions are organic. You can nurture them but you can never fault them.
  • Nothing lasts as long as you think it will. Little hands staying little. Pain. Bliss. Confidence. Certainty. Which brings me to my two goals stepping forward in the other half of medical school:
  • Be fearless in failure.
  • Be fearless in the unknown.

 

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Caterpillar Legs.