Internal Struggles

You know it's a good day when you wake up before your 5:30AM alarm on a Sunday and make funny little popping noises with your mouth - just because it's fun - as you head into the shower to get ready for a day at the hospital. Then again, there are the days when you stagger toward the bathroom in the dark and accidentally drop your retainers into the wastebasket, then have to kneel on the cold tile floor to dig for them because you've already taken off your glasses and refuse to turn on the light just yet. I had a lot of both types of mornings during my eight weeks on Internal Medicine.

On the first day, I wanted to quit almost immediately. The nine third-year medical students doing the Internal Med clerkship at my hospital during July and August had an orientation session for an hour and were then sent up to the floors to join our teams on rounds. I received the briefest of introductions to the team and then was swept up into rounds, feeling completely overwhelmed and unsure whether to try to participate (and if so, how) or to try to be as unobtrusive as possible. I became sure that I would be completely unable to function in this setting and that my performance would score far below expectations, and that this was absolutely not what I wanted to do for a career. There was no way I would be able get through this one day, I suddenly knew beyond a shadow of a doubt, let alone the eight weeks of Internal Medicine and the remaining two years of rotations.

Yes, fine, roll your eyes. I made it. It's just that I'm not good with change. I always hate the first day of school/work/anything because I just can't take the uncertainty. What should I do and how will I learn how do it and when should I do it? What is the schedule? (Oh please, God, let there be a schedule!) What I always want to know is, Is this how things are going to be? And if I can't know all of that right up front, can't someone at least show me where the bathroom is and tell me when I'm allowed to eat lunch??

You can measure how comfortable I am in a situation based on how many times I use the bathroom. None of us peed on that first morning, I think. Because really, how do you ask the attending or senior resident, "Excuse me, may I take a quick bathroom break while you continue with the whole healing-and-saving-lives thing? And if you don't mind my asking, where might I locate said bathroom?" You don't. You just figure it out, make a mental note whenever you pass a door with that relieving symbol on it, and stop drinking anything at breakfast, or, for that matter, throughout much of the rest of the day, at least until you get a better sense of when you might be able to run off quickly to relieve yourself.

Eight weeks is a long time to work 10- to 12-hour days 5-6 days a week with a lecture for your lunch “break.” I guess you could say it builds character. I did indeed figure out how to make myself useful, and at times I would like to think that I actually contributed to patient care. I definitely struck up some good relationships with my patients, and the feedback I received was, for the most part, quite good. I think it’s safe to say that internal medicine will not be my field of choice. It’s obviously an important field, training most outpatient adult providers, hospitalists, and those who go on to further subspecialize in cardiology, gastroenterology, hematology, etc. But there aren’t enough procedures for me, not enough laying on of hands other than for the daily palpation of a patient’s abdomen and the quick check for edema in the ankles. There also isn’t enough decisive action for my taste; many times the internists call consults from specialists and then decide which recommendations to follow. They monitor blood pressure and electrolytes and watch out for infections. But mostly, at least in the hospital, they coordinate and deliver care to damp down the latest exacerbation of a chronic illness that will not be cured upon completion of the patient’s hospital stay. Patients with COPD will still have COPD when they leave; they will just be able to breathe a bit better than during their most recent attack. Until we see them back again the next time.

Although it’s not for me, I’m glad that I started out with Internal Med because it gave me a great base on which to continue building my clinical knowledge and skills. But I’m really glad it’s over.

Whoa-oh, we're halfway there...

At the end of second year, I had about a month to study for Step 1 of the United States Medical Licensing Exam. All medical students must pass it in order to continue on to clinical rotations. In 7 hours and 322 computer-based multiple-choice questions, it tests the basic science knowledge gained in the first two years of medical school: anatomy, physiology, pathology, pharmacology, biochemistry, etc. If you fail, you cannot continue on to your next rotation until you retake and pass the exam. If you pass, you do not have the option to retake it in the hopes of earning a higher score. (In some ways I feared passing with a low score more than I feared failing.) Step 1 is a serious source of stress for second-year medical school students starting around March. While still covering new coursework in our classes, we began pre-studying, or getting ready to study (e.g., making flashcards, revisiting old notes, buying far more review books than one could ever hope to read). And freaking out.

I entered the boards studying period with a carefully-crafted plan. I made a schedule on an Excel spreadsheet outlining which topic would be covered on which day, and how I would spend the hours of each day. I emailed this plan to my parents so they would know what I was doing and also know what times of day would be appropriate to call. My plan made me feel safe and equipped to tackle the beast that is Step 1.

The first day went very well. I started with immunology, a topic that I had especially enjoyed learning and was eager to revisit. I covered the appropriate section of my review book and completed the planned number of questions. I reviewed my flashcards for immunologic drugs in the evening and went to bed at my set bedtime feeling quite good.

After a day or two, I started to stall out a bit. Sometimes I misjudged how much time I should spend on a certain study task and realized later that I had left too many things to accomplish in the afternoon. Sometimes I took a long lunch break, like when one of my sorority sisters was in town. Sometimes I just didn't feel like studying and my brain rebelled, spitting out poetry instead of medical facts.

Over Memorial Day weekend, Tay and I moved up to Vermont, where we would spend the entire month of June. I had high hopes that the change in scenery and decrease in distractions would allow me to really buckle down and stick to my rigid schedule. On the first night, we unpacked everything and I set up my study station, with everything organized just so.

It was a good decision to study in Vermont. I followed my schedule reasonably well, with breaks on most days to go for runs through beautiful scenery. Tay was fantastic about taking care of all of the grocery shopping, food preparation, cleaning, and quizzing me nightly on my drug flashcards corresponding to the organ system I had studied that day. Given the isolation, putting on nice clothes and going out to lunch became ridiculously exciting. And every now and then, with much encouragement and reassurance from Tay, I put down the books and took a night off from studying to go out for a burger and a beer, do some last-minute wedding prep, or just watch a movie.

Of course, there were darker times, too. It's exquisitely difficult to quit for the day when you have not accomplished what you hoped to, and know that tomorrow will likely yield too few hours in which to accomplish its assigned tasks, let alone to catch up from today. And that each time you are seeing each topic is the last time you will see it before the exam because there is too much to even cover fully once, let alone repetitively. These were the forces that kept me slogging along past my bedtime and - a rarity in my life - unable to achieve restful sleep. I reached a new stage of being worn out: the bags under my eyes grew such that there were actually two levels of bags. Tay and I referred to this as "double-bagging." My goal became not to be fully rested - that would take weeks - but to be down to single bags leading up to the exam... and our wedding.

I wish that I had blogged about this experience earlier, so as to actually capture the mix of tension, fear, frustration, and exhilaration as they coursed through me. It's hard to fully revisit and describe the apprehension, the feeling of Oh God I'm not studying hard enough... if only I could concentrate better and for longer... why didn't I study harder over the past two years... this is ridiculous, how can they expect anyone to know all of this stuff... what if I actually can't do this? when I know my score and have progressed through months of clinical training so that the boards are a distant memory.

One of the things I do remember is this: that sometimes, even while in the depths of worry and frustration, I would stumble across a connection so great that it made me want to cry. Often the knowledge imparted during the first two years of medical school feels like thousands of facts, each existing in its own little space with no relation any other, each to be memorized individually. And then somehow, either through a practice question or an explanation in a different review book or even just seeing the information again and seeing it in a new light, I would suddenly understand that these bits were not individual entities but part of a broad mural exhibiting and explaining one disease. Sort of: Oh, that causes that... and then they lead to that. Ohh-ohhhh! It felt like all of the facts were tiny dewdrops sprayed out separately in space, but with closer inspection I began to see the fine threads of the spider's web to which they were all stuck, that actually formed numerous links between them.

I took the exam outside of Burlington on June 21. Tay and I had planned go out in the city afterwards, but I was too exhausted; he picked me up, drove me to get my pre-wedding spray-tan, and then we went back to the condo to see Mom, Dad, and Bijou, who had arrived that day. I am rarely super-confident when I leave a test, so I refused to even speculate that I had likely passed. However, I felt that I had prepared well and that during the test I was focused and really "on."

Scores were released on July 14, but I refused to check mine for a few days. Finally, on Friday of that week, I came home from the hospital and Tay insisted that I check. I cried. He cuddled me, then pointed out that I was being a two-year-old and was no longer actually producing tears, just whimpering. (True.) Finally he logged onto the website for me. He stared at my score for a moment and my heart dropped; then he turned the screen toward me. I shrieked, we embraced, I called my parents, and then we went out for dinner.

And I reached the halfway point. From there I could begin to count down to the end of med school.

Owning It

Surprise, I'm back to blogging!

Third year has kept me busy, and I actually have quite a lot to share, stretching way back to the boards in June. Don't worry, I have several posts planned - you know, to keep things nice and organized - but I wanted to put up a quick post as sort of a lead-in to the ones to follow.

I came across this great quote in a Runner's World article the other day that completely captured a feeling I've been having about medical school. The article was by Peter Sagal, the hilarious host of NPR's Saturday news quiz show, Wait, Wait, Don't Tell Me (and, apparently, a darn good runner). He wrote about the final 6.2 miles of a marathon (which is 26.2 miles in total), and how, no matter what, they are especially difficult and painful. He quoted Paul Carrozza, founder of a Texas running shoe company, who offers this advice: "Stay in the moment. And remember. . . once it's over, you'll own it forever."

That sentiment reflects the reason that I will likely attempt a marathon someday, and also the feeling of accomplishment and worth-it-ness that I am beginning to sense lies at the culmination of these four years.

Stay tuned for details about my transition to the clinical years.

It's Always Sunny . . .

I always swore I wouldn't plan an outdoor wedding. I knew myself too well. I was well aware that, throughout the months of planning, my visions of sunlight sifting through my veil to sparkle on the surrounding greenery would be have to jockey for position with crazed checks of the weather forecast. I didn't want to build a fantasy only to have it crushed beneath the white plastic flaps of a hastily-erected tent.

And then somehow during my engagement to Tay, the worrywart melted away, leaving a zen bride-to-be I nearly didn't recognize. We planned a ceremony that required blue skies not only for the twenty or so minutes the nuptials would last, but for enough time to transport the entire wedding party and all the guests up and down the chairlift. In May we decided to bank on June 26 - of the following year - being sunny.

Why was I so comfortable with this scenario? Risk-averse, double-no-triple-check-everything me? At that point, my calm was due to the fact that we had a back-up plan that would also be beautiful. We decided that, if the weather were inclement, we would marry in front of the huge windows in the Gate House Lodge, where the reception was slated to be held anyway.

In the month leading up to the ceremony, I was guilty of frequenting weather.com every day or two. I watched the little illustrations in the forecast toggle between a little yellow sun and a gray cloud emitting miniscule raindrops, but my observations were colored more by interest than emotion. I was honestly just curious to see down which aisle my father would escort me.

By now, however, the reasons for my composure had shifted. Sunshine or thunder, mountaintop clearing or base lodge or even a private room somewhere with just a few witnesses, I was about to marry Tay. There are no words to express how happy I felt to join my life with his.

Wedding Weekend (yes, it's a proper noun in my mind) arrived with a flourish. I took the boards and Tay and I cleaned up the mess of books and study materials that had littered the condo for the previous three weeks just in time for my parents' arrival. The last-minute details that required only a few words to describe turned out to require more than a few hours to complete; we stuffed welcome bags, affixed tiny crystals color-coded according to entree selections to seating cards, tied bejeweled ribbons to paper lanterns, and met with the videographer and wedding planner. On Thursday a shipment of 300 pieces of baklava arrived from Turkey, compliments of Tay's father. In addition to blessing us with their presence at our wedding, my parents' close friends the Hacketts, who had traveled from Arizona, gamely rolled up their sleeves and helped us form an assembly line. We packaged the baklava into favor bags tied with silver and purple ribbon and affixed little cards highlighting the charities to which Tay and I had made donations in our guests' names. (They also gave me the huge gift of revealing that, in fact, my blog has a wider readership than just my parents and Tay. Thank you so much, Mr. and Mrs. Hackett!)

The rehearsal the day before the wedding occurred up on the mountain in bright sunshine, which lasted throughout the welcome dinner. Descending the stone steps on the side of the lodge to be met with so many loved ones from so many different times and places in our lives was surreal, almost confusing. The party lasted until Castlerock Pub closed, then spilled over into Clay Brook hotel for a few more hours of revelry.

June 26, 2010, dawned with tentative sun and emphatic reassurances from all around that the weather would cooperate. A jog with some of my closest college friends, followed by hours of hair, makeup, and estrogen-fueled fun in "Salon 106" (as my hairdresser, Richie, dubbed my hotel room) helped me to remain calm. When raindrops began to spatter the pavement visible outside my window as I sat in a high chair having my makeup applied, my stomach relaxed a bit. At least now we had an answer.

In yet another uncharacteristically calm and spontaneous moment a few days prior, I had agreed to change our rain location to Timbers, a restaurant with breathtaking woodwork that we frequent whenever we are at Sugarbush. Conveniently attached to the Clay Brook hotel, it allowed the bridal party to simply walk through the halls of the hotel to reach the foot of the aisle. As we drew near the entrance to the restaurant, I glimpsed Tay before I even registered the music or the guests, and the tears lasted from approximately that moment through my first dances with Tay and with my dad at the reception.

Most of the rest of the experience was different than most people had predicted: Tay and I actually ate our dinners, we visited with every guest during at least once (but in most cases, several times) during the weekend's events, and the night didn't fly by. It was not a blur but a series of moments that were alternately breathtaking, exhilarating, and serene. And of course, no one other than our family and wedding planner could have predicted the fireworks at the end of the night. :)

My husband and I have now stolen away for a few honeymoon days. We are spending the long weekend at a bed & breakfast in Newport, Rhode Island. It includes gourmet breakfasts and daily wine & cheese as well as a resident bichon frise. With an uncharacteristic lack of interruptions and to-do lists, we are enjoying one other's undivided attention and the inviting conglomeration of shops, eateries, and architecture. We are married and we are happy. Oh, and the sun is shining.

Amazing News!!!!

OK, second year is over and I'm studying for the Boards and the wedding is in less than a month and we had a super-fantastic engagement photo shoot last night and I did my final dress fitting this afternoon and we're moving to an exciting new apartment in July, and I really will try to catch up on all of that, but another amazing thing just happened that I need to share right now: I got accepted to attend a 3-day conference offered by the American Medical Student Association in Washington, D.C., that is all about writing in medicine!

A physician who helps to facilitate the poetry group that I joined this year (and who is an amazing surgeon, poet, and person; an idol of mine, really) forwarded some information about the conference to students interested in the humanities. The application deadline was 4 days away, but when I visited the website, I began writing my essay immediately; I couldn't believe that a conference geared so perfectly toward my interests even existed. (Check out the website to see for yourself; it's got Becky written all over it: http://www.amsa.org/AMSA/Homepage/EducationCareerDevelopment/AMSAAcademy/WI.aspx)

I am one of 24 students accepted, and I will be participating in the prose track. (The other options were poetry and journalism.) There are workshops and seminars and small-group sessions with peer feedback and critique. The only catch is that I'd have to miss a day and a half of my internal medicine rotation. I emailed the dean about 5 seconds after getting the acceptance email (and calling Mom & Dad, obviously), so I'll be waiting anxiously to receive her response.

Now if you'll excuse me, I have to go burst with happiness.

Open Letter to the Doctor Who Did My Physical Exam at the Student Health Clinic This Morning

Dear Dr. S---,

You walked into the exam room without knocking. You didn't introduce yourself. By way of greeting, you demanded, "What do I have to sign?"

I know that just checking to make sure I'm healthy enough to enter my third year of medical school and start seeing patients is probably incredibly boring and annoying; I'm sure it's not what you aspired to do as you to studied medicine. I know you can probably guess that I am in good health just by looking at my vital signs and overall appearance. But couldn't you have listened to all four of my heart valves rather than just three? And couldn't you have listened to more than two of the five lobes of my lungs? Yes, I am healthy, but if I weren't, you could easily have missed something.

What about the rest of the exam? Did you decide it was safe to assume I have no swollen lymph nodes, no tenderness in my abdomen, no abnormal reflexes, no back problems? Or did you just not care enough to do these things or to even say "Goodbye" or "You're welcome" as you flew out the door?

Maybe you had just finished with a difficult patient or maybe you were having a bad day. Either way, I want to thank you for signing off on my health form. Thank you, also, for reminding me exactly what kind of doctor I don't want to become.

Becky

It just got real

You know how sometimes you look forward to (or dread) something for so long that it feels like it will always be looming somewhere out there in the future, will never be right at hand, never really occur? And then one day it sort of smacks you in the forehead and announces, "Hello, I'm here! I'm happening!"?

I'm taking Step 1 of the medical licensing boards on June 21. My last class of the pre-clinical years (the last class before my intense month of studying for the boards) starts on Monday.

Tay and I are getting married on June 26. Invitations go out tomorrow.

Oh yeah, things just got real.

If you're like me, you think you'll have everything all worked out by the time that the thing you're anticipating actually rolls around; you think you'll have completely reviewed and re-mastered all of microbiology and pharmacology as sort of a pre-study before the real boards-studying commences, and that you'll have your ceremony all written and your abs all flattened long before the Big Day. Except then you look up and realize that your second year of med school wraps up in less than a month and your wedding dress has arrived at the salon and is awaiting its first fitting. And suddenly, these two huge events are right here, right about to happen. And it's a crazy, overwhelming feeling.

Just to be clear, I am thrilled out of my mind to be marrying Tay in less than two months. It's just that there are still many details I hope to attend to, putting the finishing touches on our ceremony and celebration. I'm also thrilled out of my mind to be finishing this year of school and moving on to clinical rotations. But Step 1 of the boards is the most important test that I will ever take (Literally. This puppy tests the entire body of knowledge from the first two years of medical training, and my score will be the most important factor in determining the strength of my candidacy for residency.) and the time remaining just doesn't seem like a fraction of what I need to tackle the entire mountain range of material, of which it currently feels like I know nothing.

But here we are. Less than two months left. It's time to stop thinking (lamenting overambitious study schedules that were left in the dust months ago and worrying about, well, all of this) and start doing. Do what I can each day and then go to bed with a clear mind so I can be well-rested enough to do what I can the next. Because the boards and our wedding are here. They're real and they are happening.

And I will be ready.