Spelunking

During orientation week of my first year of medical school, one of the deans spoke to us about the rigors we would face. He used the typical analogies – this is a marathon, not a sprint – to encourage us to find our own balance and make time for things like exercise and visits with family. But sometimes, he warned us, sometimes, we would need to "go into the cave and get it done."

I went into the cave in July. After finishing out third year with my surgery rotation, celebrating Tay’s and my first wedding anniversary, using my vacation week to move to a new apartment, and absorbing the news of my dad’s prostate cancer diagnosis, I had three weeks to prepare for Step 2 of the United States Medical Licensing Exam, a 9-hour, 352-question multiple-choice extravaganza of clinical knowledge and reasoning on which a passing score is required for graduation and which score can have a sizable impact on one’s residency prospects. So, after the first week of study, I packed my bags and took myself to Vermont.

Possibly more harrowing than preparing for the test was the prospect of living in near-total solitude for fifteen days. It’s quiet up there in the summertime. Other than going out for runs and walks and the occasional foray to the grocery store, I wouldn’t be interacting with anyone. It’s funny how, back in the days of bad roommates, I couldn’t wait to live on my own, was bursting at the seams to establish my own domain. Now I’ve lived with Tay for four years. I wasn’t sure how I would do with so much time and space for my wandering thoughts.

Fast-forward to the day the scores were released and Tay, knowing I would put off looking at my score for weeks if given the chance, took charge and looked at it (just like last year) and you will know that I learned a good bit of medicine up there. But I also learned a number of things about myself that feel somehow both arbitrary and important to know:

-I can change my own tire, though I might need a little help loosening the lugnuts. Apparently I paid attention to my dad’s lesson that day in the driveway more than ten years ago.

-I’m still kind of afraid of the dark, or at least of going to bed knowing I’m alone in the building. (Yes, even in Vermont.) I never thought I’d be so comforted to hear what I’m pretty sure was drunken Czech floating over from two balconies away.

-I have no idea if I’m allergic to bee stings, and suddenly this hole in my knowledge grew to seem incredibly egregious as I considered the potential consequences should I happen to be stung by a bee and happen to in fact be allergic and happen to feel my throat closing with no one nearby to call 911 or give me an emergency tracheostomy…. Witness the limitless creativity that results when I off-load my test anxiety onto every aspect of normal life.

-I might consider getting a [small, subtle, classic and classily-placed] tattoo, assuming I can decide on a design that I will love for the rest of my life and get over my fears of getting Hep C.

-Finally, the lesson with actual ramifications: Writing will always soothe me. It will always inspire joy. Even when I’m alone in my cave of concentration and solitude, balancing the desire to close the curtains against what was likely a firecracker but could be imagined as a gunshot (stop laughing) with the need to let in the comforting sounds of boisterous Eastern European revelry (apparently they did not think it sounded like a gunshot), writing will do wonders. It might be a poem - which is how I calmed myself the night before my exam - or an essay contemplating the decision to ink or not to ink. I might not initially feel that I have much to say, or that saying it deserves precedence over the ever-expanding list of other things I "should" be doing. But if I can just let myself start, or get myself to start, it will carry me through every time.

Experience

You know you’ve gotten the hang of third year, of functioning on rotations, of being a good “clerk” (that term that appears in the written descriptions of your role on each service but that you’ve never ever heard anyone actually use in reference to you), when you arrive at the hospital at 5:15am to find out which patients you’ll need to present on rounds, which will begin at 6am. You’re already planning how you will log into the electronic medical record system and quickly scan your patients’ lab values for anything abnormal or notable and copy their vital signs and I’s and O’s (in’s and out’s, which is just what it sounds like – a record of the quantity each has taken in and excreted throughout the past 24 hours) right onto the page you already snagged from each of their medical records on which to write your note (no reason to waste time and pen-strokes jotting numbers onto scrap paper first and then transcribing them into the note when by now you know exactly how far down in your note to write them, leaving enough space above to record the overnight events and the patient’s status this morning) before scurrying off to examine the patients themselves. You’re aiming for only one computer log-in this morning - it’s so irritating to have to go find a computer and watch seconds tick by as it processes your username and password for a second time after you’ve seen the patients and have realized while scribbling your notes that you forgot to pull up the report of that chest x-ray that one of them had overnight.

You punch in the first patient’s medical record and squint at the abbreviation indicating her location in the hospital. Instead of the expected series of three numbers preceded by an N or a P for the North or Potter sections where most of the surgical patients reside, next to the name you see ADMH05. Huh?

You’ll do the other patient first, you decide, scanning the chart for his history and what surgery he had so you have some clue where to focus your brief examine and pointed questions. When you finish his note, you ask a nurse which area this cryptic bed location indicates, and she tells you it’s the Hoag building. Excellent; you know just how to get there. You run down three flights of stairs to the first level, where all of the building’s sections interconnect, and head up to the 5th floor. You scan the large board across from the nursing station, but the patient’s name isn’t listed.

You check with a nurse – there’s no such patient on this floor. She gamely checks the computer, translating the location code as Potter rather than Hoag, so back downstairs and over to Potter you go. You find the right section, find the patient, and find out that the patient is hard of hearing. Trying not to rush, you remind yourself to keep the pitch of your voice low rather than high because high-pitched hearing is usually what goes first. You ask the patient how she’s doing, whether she has any pain and if she’s peeing and pooping without problems. You grab the chart and copy down the vital signs, then run back over to the North building to finish writing your notes.

At which point you realize that you don’t have the I’s and O’s for this second patient. The residents are going to want this information on rounds, which will start right at 6:00am. Which is five minutes from now. There’s no getting around it; you need the numbers. “I couldn’t find them” won’t cut it. You log back into the computer, but they’re not listed there. You hesitate for half a second, then turn and dash back downstairs, back over to the Potter building, back to the patient’s chart. You flip through the sections of the chart until you find the I’s and O’s, copy them down, then run back to the third floor of North. It’s 5:58. You have time for two more sentences of your note and one deep breath. And then it’s time for rounds, and you’re ready.

Ice Queen

A few weeks ago, I found myself stuck in a conversation of my least favorite sort. I was taking an end-of-year-three exam that involved different scenarios with actor-patients, each with his or her own presenting symptoms, history, and physical exam findings from which I would need to riddle a diagnosis or at least the next diagnostic steps I wanted to take. Having finished one such encounter with time to spare, I sat quietly in the hallway that connects all of the exam rooms, staring alternately at the ceiling, the floor, and my lap so as to avoid giving the impression that I might be attempting to communicate answers with other students via eye contact or facial expressions.

The man proctoring the exam stuck up a conversation with me, asking what area of medicine I planned to pursue. I explained that I hope to do a residency in pediatrics, followed by a fellowship in pediatric hematology/oncology. Then I braced myself.

I am well accustomed to people’s responses. Even before I shifted my focus to pediatric oncology, I had spent ten years planning to treat cancer patients of some sort, and so I was used to people’s facial expressions – which landed somewhere along the spectrum between slightly troubled and downright aghast – and their comments. Wow, that’s tough and, I don’t think I could do that and even, Won’t you be really sad?

But this man decided to take it even further. He chose to pontificate. Grimacing, he began, “Wow, that’s got to be really hard. To do that, you have to have no emotions at all; you really must be made of ice.”

Over the years, my response to the usual expressions of dismay has evolved. Previously, I was so uncomfortable with the discomfort of others that I grew almost apologetic, my voice rising in uncertainty as I explained the reasoning behind my decision as if imploring them to agree with me. Then I grew slightly more confident, presenting my thoughts earnestly, feeling the importance of making others understand my point of view. Now that I am inching closer to my goal – and to my thirtieth birthday – I just get pissed.

I agree that oncology of any sort is rife with challenges, and treating kids with cancer is another ballgame that most people can’t imagine. I’ve had plenty of doctors in other specialties tell me stories from their experiences in pediatric oncology during medical school. They describe situations that I find myself wanting to run towards even as I fake-sympathetically nod and cluck at how terrible the field is. I even realize that I could still change my mind. But what I can’t deal with is people who judge and criticize others’ career choices just because that area wouldn’t work for them. Do you want to know the truth? I really couldn’t stand surgery. There is not a cell in my body that so much as whispered of an interest in it. But that’s just me. Not only do I understand that others may disagree vehemently, I am thoroughly glad that they do, because we need surgeons and it would be best if the people who do surgery actually liked what they are doing. I’m really glad that some people out there enjoy it, because it means that I don’t have to enter a field that I don’t like. (Same goes for lawyers, engineers, accountants, etc.) I’d just like to politely suggest that they show the same deference for my career selection.

As much as I would have liked to walk away, I was stuck. I couldn’t exactly quit the exam midway through, nor could I excuse myself and go speak to one of my classmates, so I nudged us along to another topic. He asked where I planned to practice, and I gushed about Tay’s and my love of New England, adding that we are avid skiers. He asked if I had skied out west, and I said no, not since I was about four. And then suddenly there we were, back in judgment-ville. “You’ve never skied out west?! And you call yourself a serious skier??”

This time I didn’t shy away. “What can I say?” I shrugged, meeting his eyes without faltering. “I'm an Eastern skier. I love to ski the ice.”

Sundays

I recently saw a TV commercial that extolled the merits of Sundays. I don’t even recall what product it advertised, just that it talked about how all good things seem to take place on this particular day of the week. To which I would respond: whoever wrote that commercial has clearly never been in a long-distance relationship.

For those whose love stretches across county or even state lines, Sunday is a toughie. It starts out well, usually with a leisurely sleep-in, maybe a nice brunch over which to recount the fun of the past thirty-six hours or so. This can be followed by an afternoon outing or perhaps snuggling on the couch in front of a movie. But inevitably the hands on the clock move too quickly and excitement and joy are edged out by concern over whether one’s contact lens case made it back into the toiletries bag and just how many minutes of togetherness can be eked out while leaving enough time to reach the airport or bus terminal or highway. Even before the last kiss, a pre-emptive loneliness sets in.

I have a friend who took such Sunday good-byes so hard that she sometimes had to call in sick to work on Monday. Happily, she and her then-boyfriend are now married and living together in Boston. One of Tay’s former coworkers, a Turkish physician, once spent six months training in the US while her husband, also a physician, continued his job in Istanbul. They missed each other so much that he made the 10-hour flight to see her four times during that half-year.

Tay and I, no strangers to the commuter relationship, breathed a sigh of relief back in 2007 when we finally moved in together up in Hanover, NH. When I was accepted to Stony Brook he moved down to Long Island with me. We thought that we had put the days of too-frequent good-byes and prolonged absences behind us.

Yet here we are, doing it again. I am spending my eight-week surgery rotation at a hospital about 35 miles from home, and given that my alarm starts my day at 4:30am, I opt to stay in the free student housing across the street from the hospital, returning home on weekends. It could be worse; at least we get to spend every weekend together, as well as the occasional weeknight when he drives in to have dinner with me and stay in the cramped twin bed from which we can hear the rumbling of trains and announcements from the nearby station throughout the night. Neither of us sleeps well, but we don’t sleep any better being apart.

When Friday arrives, each moment of traffic that eats away at my precious time at home is torture. Our rituals after my arrival hearken back to our early days: we go out to dinner – a luxury that we normally wouldn’t allow ourselves weekly - and it seems we can’t talk quickly enough to spill out everything we wish to recount from the week apart. (Despite multiple phone calls daily.) Saturdays are the best, as we find ourselves well rested with still more than 24 hours stretched out before us. But then Sunday dawns once more, and the usual frustrations of trying to cram in grocery shopping, cleaning, and all of the other to-do’s that can be pushed off no longer is complicated by the struggle to fit in that brunch. That outing. That extra snuggle time.

So I disagree with the commercial. For some of us, Sundays don’t contain everything pure and wonderful. Unless you count the fact that every Sunday night puts us that much closer to the end of the next week, when we can see the one we love once again.

It's Only Kind of a Funny Story

First, I’d like to make a film recommendation: go rent It’s Kind of a Funny Story. It’s the story of a teenager who inadvertently ends up in the psych ward due to the trials and pressures of adolescence. It’s funny and it’s got heart. (It’s also got Zach Galifianakis, or Alan from The Hangover.)

But in reality, the psych ward isn’t all that funny. I spent four weeks there during my psychiatry rotation, and it saddened me far more than I had expected.

Yes, there are crazy people there, to put it crassly. But these are the sickest of the sick, people who are suicidal, homicidal, psychotic, or are so impaired that they are unable to care for themselves. So they don’t get better quickly, if at all. It is kind of exciting to see a textbook case of schizophrenia for the first time, complete with voices, paranoia, and bizarre behavior. But when the person is still hearing voices coming from the heating vents two weeks later and drinking mouthwash to make themselves throw up the medication because they believe the doctors are trying to poison them, it’s just heart-wrenching.

An episode of mania in a person with bipolar disorder can be amusing, too, for the first few minutes; my team treated several, and some believed that they were being stalked by millions of people, and that these people were also stealing all of their belongings. The patients jumped from idea to idea with no connection between them, leaving me with whiplash after each interview. Yes, they said some hilarious things, always with a completely straight face. But when I heard some version of the same stories day after day, despite increasing doses of medication, it became clear that these were people who likely would be unable to function on their own in society for long periods of time. They had their physical health, but their minds were seriously impaired.

Overall, I enjoyed the four weeks. I disliked not touching my patients and it was a little bit strange to need keys to let myself through the double doors onto the ward, but the hours (roughly 8AM-4PM) and autonomy (leading the team’s daily interview with my patients, taking full responsibility for calling patient’s families for further information and writing detailed daily chart notes) were great. I even had fun studying. But I quickly realized that, while I found it fascinating to read about the various diseases and symptoms that can affect one’s mind and personality, I could only feel frustrated and sad when I interacted with people actually dealing with them. It seems that pediatrics is still the field for me.

On Idols and Not-So-Idle Thoughts (Part II)

Gynecologic Oncology – it was what I had dreamed of doing for ten years. I had spent a summer working in that field, and lost a loved one to ovarian cancer, so this wasn’t idle fantasy. The very reason I had chosen to do my ob/gyn rotation at this distant hospital was because it was home to one of the leaders in the field, and I desperately wanted to work with her.

I did get that chance, and it went well. Embarrassingly, we have nearly the same build and haircut, so on the day that I worked her office, multiple staff members noted, loudly and repeatedly, that we looked like twins. Just what this renowned surgeon wants to hear, I cringed, that she looks like a lowly med student. It was especially awkward for me because I had previously stated to family and friends that I wanted to be this woman, and here it looked like I was imitating her. Of course, she had no way of known about my prior reverence for her, so she probably didn’t view me as a creepy stalker. Another student told me later that she had actually spoken highly of me. (Yay!)

I did like gyn onc. But I still wasn’t sure I liked it enough to endure four years of the ob/gyn residency necessary to get there. So maybe, as Tay gently suggested, the important part for me was the oncology, not the ob/gyn. I had loved peds onc; in fact, I had often caught myself fantasizing about my career in the field, only to reprimand myself: You can’t do that, you’re going to be a gynecologic oncologist, remember? What’s more, I felt sure that I would enjoy the years of the general pediatrics residency that would precede an oncology fellowship. I loved the kids. I loved the parents - dealing with them, calming them, explaining things to them. I loved that the medicine incorporated all of the body systems, rather that just one as was the case with ob/gyn. And the more time I spent in gynecologic surgeries, the more I recognized that my favorite part took even before the anesthesia was administered: talking to the patient, explaining the procedure, answering questions.

On the surface, then, it might look like a simple decision. But I spent nearly the entire rotation torturing myself with endless ruminations and unanswerable questions. If I wasn’t going to be a gynecologic oncologist, then who was I? How well did I know myself? What else had I been wrong about? (And having been wrong, in and of itself, wasn’t my favorite thing.) My soul ached. I felt like I was failing. I felt like I was losing my identity. I felt like I was letting people down.

It took many long talks with family and close friends, as well as a good hard cry one night as I drove back home for the weekend. Through the rain I picked out the sign for the cemetery where one of my favorite people in the world, the one whose life was claimed far too early by ovarian cancer, is buried. Through my tears, I realized, finally, that choosing a different field and abandoning my personal vendetta against the disease that stole her away, would not be letting her down. She would probably even be proud of me for wanting to help kids with cancer… and for figuring out what I really want and going after it.

One other factor eased my decision. Last summer when I attended a medical writing workshop, I met a physician-writer whom I came to greatly admire. She had written a book chronicling her experiences in med school (sound familiar?), and it was one of the things I read at night to try to distract myself from my daily worries.

I enjoyed her stories and related to many of them. Then I came upon the chapter describing her decision of whether or not to go into Ob/Gyn. What, now? I knew that this woman was a pediatrician; had she once been less than sure about her path?

In a word, yes. I read faster and faster in disbelief as she gave words to the turmoil that raged inside me. She, too, had imagined a career helping women. She, too, liked parts of her ob/gyn rotation (truthfully, I think she liked more than I did). And yet, she, too, yearned to have a career with slightly more flexibility in order to allow her to develop her blossoming writing career. And she, too, agonized over the decision, lamenting the confusion she felt about her very identity and even admitting to questioning whether she wished to practice medicine at all.

Today, this woman is a successful pediatrician, wife, and mother, and she is also one hell of writer. And from the bit of time I spent with her, she’s an incredible person. And a happy one.

So I have a new career path and a new idol to go with it. I also feel a new sense of in-tune-ness with myself and what is important to me in life. I finished my ob/gyn rotation successfully and set up my fourth-year schedule with lots of electives in pediatrics. And I haven’t felt that knot in my stomach since.

On Idols and Not-So-Idle Thoughts (Part I)

Obstetrics and gynecology was my carrot throughout the first few years of medical school. It dangled in front of me, the reward for those years of grinding, crushing study; for giving up so much of what I loved in life along the way. Third-year rotations in general served as a general type of carrot – after all, seeing patients had to be better than hours hunched over textbooks – but as the first few rotations proved less than inspiring, ob/gyn hung promising on the horizon. I had scheduled it for January and February; I would start out 2011 on the right foot.

But by the second week of the rotation, I could no longer remember how it felt to live without a knot in my stomach.

Tay asked again and again for clarification of just what I was feeling. From what he could see, I had loved pediatrics and was just having a hard time adjusting to ob/gyn, likely due to a combination of: 1) residents who seemed to hate their lives and barely notice the students like myself who frantically followed them everywhere, trying to make sense of roles that were never explained to us; 2) my general aversion to change that reared up predictably at the start of every rotation; and 3) the fact that I was living in the free student housing, an hour away from my home with him, in an apartment that I would have shunned even when I was fresh out of college and scrounging to find a place that my embarrassingly small paycheck could cover.

(The best part of that housing was the skinny mirror in my bedroom. That and the bright pink striped shower curtain that had cost $8.99 at Target. Another plus was that the hot water didn’t always emit a scree like the sound the smoke detector would have made had it not been dismantled and disemboweled of its battery; sometimes a full five minutes could be spent in blissfully quiet pre-sunrise steam.)

I had met so many people – residents, attendings – who reminisced bitterly, “I thought I wanted to do ob/gyn... until I did my rotation!” This sentiment had frustrated me, with its negativity and with these individuals’ apparently easy dissuade-ability. I wanted to prove them wrong, to prove that ob/gyn could be liked, could fulfill what one hoped it would, could be a path charted at the start of med school (or even before) and followed without deviation. I didn’t want to be just another of the stereotypical women who had been all about women’s health until they realized how demanding the hours were or how catty the residents and then went running to something like psychiatry... family Medicine... pediatrics. I had been sure that one day I would look down my nose at them and announce that I, in fact, loved ob/gyn and found it to be nothing like the stereotype. So there.

Except here I was, hating every minute of every day spent at the hospital, and using up every minute spent outside of the hospital dreading my return to the wards the next day. I stayed up later than I should, lamenting my unhappiness to Tay over the phone, reading a few chapters of a book for pleasure and then feeling guilty about the indulgence; half fighting through the din of the ugly, noisy town in search of sleep with the other half always keeping an eye on the alarm clock, terrified I would sleep through my 5:30 wake-up. As a result, I was exhausted and cranky in addition to being frustrated and confused.

What was so bad about it? The residents, for starters. The younger ones – the interns – were all very sweet, but personalities seemed to go downhill as one climbed the ranks. I spent idle moments trying to pinpoint at what stage in their training the kindness was beat out of them. Teaching was rare; the few questions they asked ranged from those requiring magical mind-reading abilities and ones so ridiculously simple they made you wonder what you were missing. I once scrubbed in on a C-section and received only two questions: What is this? (pointing to the uterus) and Very good, now what about this? (holding up the fallopian tube). They were the only words spoken to me throughout a procedure in what is supposed to be a teaching hospital.

The lack of organization, for another thing. The rotation was ostensibly well-organized, with each student spending one week on each of seven services: Gynecology, Labor & Delivery, Nights (which was basically more labor & delivery but with horrible hours and less action… in other words, an atrocious week), Urogynecology, Reproductive Endrocrinology & Infertility, Maternal-Fetal Medicine (high-risk obstetrics) and Gynecologic Oncology. The problem was that the organization ended there. No one had any clue about appropriate roles for students, so they didn’t really give us any; we chased the residents all day, with no warning about when we might be able to eat lunch or use the bathroom or when we had to attend a meeting in a building several streets away. Multiple times, I nearly followed residents into the bathroom because they hadn’t told me where they were going – hadn’t told me anything at all – so I judged it safer to follow along than risk losing them. At other times, the residents would be busy and decline my offers to do anything to help, so I would be left literally holding up the wall, torn between trying to look available eager to help out and trying to look busy, like I wasn’t just standing there counting the seconds.

And then there was the actual medicine of it. Truth be told, I just wasn’t feeling as excited as I’d anticipated. Yes, I got teary-eyed at each birth (especially if the dad cried – that really got me), but that didn’t make me want to do it all the time. And the surgeries were interesting the first time I saw them, but with each repetition my interest dwindled. Once upon a time, I had been excited by the uterus and its neighboring organs, by the infections that could plague them, the tumors that could grow, the changes that took place monthly and throughout the arc of a woman's lifespan. But now that I was faced with them each day, I wasn't all that thrilled. I missed the heart and the kidneys.

Of course, as everyone reminded me, I had planned to subspecialize in oncology, so maybe it was ok that I wasn’t so excited about the general stuff. They suggested I wait to see how I felt during my week on Gyn Onc. So I tried to control my freaking out until then.