She was the most terrifying surgeon in the hospital.

In an age where white coats were to be worn only by men, she walked fiercely into medicine anyway. She took the sneers and barking from senior physicians but she held her chin held steady. Back then, medicine was not a woman’s game. With each step she climbed, she tacked on another piece of armor and she grew stronger. It toughened and polished her, and she was built into the indestructible surgeon she is famous for today.

I have watched chief resident’s fingers tremble beside her. I have watched fellow surgeons, renowned and respected in their own right, fall silent as she stepped into the room. Scrub nurses, usually bustling and preparing while chatting with the circulator,  stand alert with fingers poised and eyes glued her hands, anticipating her next move. Medical teams in the hospital, young doctors visiting from out of state, senior doctors trailing the end of their careers – they all know her name.

For weeks, we had stood shoulder-to-shoulder in silence as she performed many of the biggest surgeries known to medicine. The infamous Whipple procedure – a grueling 8 hour minimum- was her favorite. Her fingers seamlessly twirled around the surgical instruments, and I longingly watched as she carefully cut open the belly, clamped arteries, and unsheathed the pancreas. I stood perfectly still, often for over 10 hours, with my hands carefully planted on a corner of sterile draping. Others had warned me: “She prefers medical students to simply observe. Whatever you do – don’t grab anything.”

Yet something in me resonated with her. There was the smallest hint of a smile in the corners of her mouth under her mask when her eyes met mine. I recited my patient presentations I had spent hours memorizing for her clinic and could see a flash of approval in her stone cold expression before she spun on her heel to enter the patient’s room. Then one day, she handed me her suture. That day in the OR, I was taught the sacred ritual. She began to signal for me to cut her sutures with the slightest flicker of her fingers. One day, I nearly tripped over my own feet in shock as she stepped back from the operating table and silently waved for me to assist the chief resident in stapling the bowel in half.

She was like no one I have ever met. During my last day on her service, she unwrapped the ice cream sandwich socks I had bought for her and she squeezed the breath out of my ribcage. And I will never forget the words she told me:

“Hailey, you are a surgeon. I can see it in you. Do what you are.”

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Ice Cream Sandwich Socks.

I remember this.

I was standing in the operating room. It was the first time during my surgery clerkship I had scrubbed into a surgery. I stepped to the table on the patient’s left side, his face hidden behind blue drapes. His abdomen was open and exposed, orange with iodine, with a careful incision line marked on his midline. I placed my gloves carefully on the blue sterile field. Warm, nervous breath insulated the skin beneath my mask.

The surgeon swept into the room, hands and arms still dripping. His work is legendary. Specializing in melanoma, his work targets the most aggressive of skin cancers. His ground-breaking injectable virus is killing melanoma cells, and his research has shifted perspectives in oncologic therapy.

He approached the operating table and they raised it to meet his towering height. I climbed onto a step beside him. Nurses in blue gowns and masks whirred in preparation around us, bustling with sterile instruments hot from the oven. I could hear the anesthesiologist adjusting the tubing flowing from the patient’s mouth.

“Are you ready?”, he asked, glancing at me from behind his lenses. He knew it was my first case on the service.

Until that moment, medicine had always pulled me. I figured it was my father having life stripped away from him as his brain cells shriveled with ischemia. Or possibly it was my mother’s bruises, constantly coating her body like an ever-changing mood ring. Maybe it was the lack of stable family structure during my childhood years, a love and caring that I found was needed by the patients at the hospital.

But as I stood above the table, watching fingers twisting silk sutures and seeing the separation of the pearly fascial layers, I remembered. My body remembered. I had a visceral reaction to it, with tears and a twisting in my stomach, remembering something I have never known.

 

Scrape.

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.

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.