The Story Continues

After getting somewhat acclimated to residency, I've been carving out time to write again.  For this new stage of my life, I've set up a new blog called The Growth Curve: Ruminations of a Pediatrician in Training.  Check out the blog here and the facebook page here

Well, it happened.  I graduated in May.  And with a walk across the stage, the beast that had defined the past four years of my life was over.  The end was relieving, confusing, even anti-climactic, but I didn’t really recognize the effect that my time in medical school had had on my loved ones until my dad told me the following story: The day after my graduation, he was at the gym doing his usual workout when he noticed that he was feeling exceptionally happy.  He thought for a while and then realized that it was because “med school couldn’t hurt you anymore.”

It did hurt me, perhaps because I fought so hard against it or perhaps because that is simply the nature of an undertaking so full of rigor and challenge.  These years held experiences so incredibly positive that I would never want to change them: the privilege, of course, of earning my M.D.; the added time spent with my mom and dad and Bijou, with leisurely weekend days at my childhood home and quick visits we called “puppy fixes” dotted throughout intense periods of study; our wedding and the start of marriage for Tay and me; the rediscovery of and re-engagement with my interest in writing.  These were all tremendous things.  And yet the rest, in fact the bulk of the everyday, is something I’d prefer to move on from and forget.

A few weeks ago, Tay and I took a cruise to celebrate my graduation and our second wedding anniversary.  We traveled up the coast of Maine and Canada, eventually sailing down the St. Lawrence River to Montreal.  Near the end, we stopped in Quebec City, where we had vacationed the summer before med school began.  It is one of our favorite destinations, but in addition to the joy of once again strolling through the city, it was there that I felt a distinct ending.  It was like the two visits – one right before medical school, the other right after – were the ends of purse strings that, when pulled tight, walled off the pouch of time in between.

I am signing off from this blog now.  Medical school is over, and though I will continue to write during residency, I must first give thought to the trickier ethics involved in my new role as physician and decide what form my next endeavor will take.  I thank you for your support, patience, and readership.  I look forward to sharing the next step as it unfolds.

With great love and gratitude,

Rebecca MacDonell-Yilmaz, M.D.

The Hardest Thing

During my last week of medical school, a physician I had recently met asked me what had been the hardest part of it all.  I thought for a moment, both to sort my way past the obvious pop-up replies, such as Anatomy or The sheer volume of information to be learned.  But once I began to speak, the answer - for my experience, at least - became clearer.  And as I rambled, I made my way toward a truth that I hadn't fully realized until that moment.

The hardest thing, I said at the start, was that there are so many things that I love in life other than medicine.  I truly love medicine, and I am thrilled and honored to have the privilege of doing its work.  But I also love to read.  And write.  And run, travel, knit, ski, do yoga, speak French, watch movies, catch up with friends, and spend time with my family.  The devotion required by a life in medicine spares little time for any of those things, let alone all of them.  The biggest challenge for me was trying to maintain the most important aspects of my outside life while striving to master the ocean of information laid out before me, a task difficult enough even without distractions.  

There was always a tug-of-war: steal some time to read or write, then feel guilty as I hurried to catch up in my studies.  Ignite a reactionary resolve to dedicate every minute to medicine, then burn out and be forced to take a break, thus setting off the guilt again.  I spoke and wrote ad nauseam about the holy grail of "balance," and I pictured the road to this goal as an ascent of evenly-spaced steps.  Once I had worked one outside activity into my life - say, by devoting an hour most days to exercise - I would integrate another, perhaps allotting some time for reading before bed.  Then, I reasoned, I would (while keeping up with my classes) juggle in a third and perhaps a fourth such activity.  The only way I could explain my repeated failure to reach what seemed a perfectly reasonable goal was my own ineptitude.

As I spoke, my words carried me to the revelation that had previously evaded me.  The hardest thing, I concluded, had been the constant, punishing pursuit of a balance that was impossible to achieve.  Suffering in the service of an arbitrary and artificial goal of my own invention.  I only recognized it at the very end.  But as I stand at a new beginning, I hope to remember it.

The Huggability Index

During the final year of medical school, in addition to completing the remaining required clinical rotations and exploring a variety of electives, students undertake a complicated process aimed at securing a position in a residency program. Upon graduating from school, they will hold the M.D. degree and officially be doctors; however, given the vastness of modern medicine, further training is needed. Students may apply for residencies in surgery, internal medicine, pediatrics, obstetrics and gynecology, family medicine, dermatology, radiology, emergency medicine, ophthalmology, neurology, and various other fields.

The process begins in September with the submission of a standard application that includes the student’s education history, transcript, Board examination scores, extracurricular activities, personal statement, and letters of recommendation. (The preparation of the application begins months earlier.) Students submit applications to a varied number of programs. The number depends on the field to which the student is applying – how many spots are available nationally and whether it tends to be highly competitive – the strength of the student as a candidate, the student’s geographic preference, and just how worried the student is about securing a position.

After reviewing applications, programs issue invitations to interview between October and February. Traditionally, students accept every interview offered early in the season. Later, once they [hopefully] have the security of having garnered many interviews, they cull their schedules for the most desirable programs, cancelling their appointments with hospitals in which they have less interest. At the end of the interview season, students submit an electronic list of the programs that they have visited, ranked in order of preference. (They may choose to leave programs off the list, thereby guaranteeing that they will not train there.) Every program also submits a ranked list of the candidates whom they interviewed. A computer runs both sets of lists through an algorithm and spits out one program for each student. For some students, no program is assigned and they must then scramble to secure a position in a residency program that did not fill, often in a different state and even a different field than they had desired. The entire process, from application to algorithm, is known as The Match.

It’s a nerve-wracking process, this Match. There is the waiting for interview offers, and then the waiting to find out where you will train. But in between, there is the strain of not only putting your best self forward over and over again, but of trying to weigh the programs that are weighing you. Are the residents really as happy as they seem? Do the teaching methods favored by the program correlate well with your preferred learning style? Will you see a high enough volume of various diseases and patient populations? Does the program have a good track record of sending graduates on to fellowship training? How well is the program regarded in the field – how well will it prepare you for your career and how much strength will it lend to your curriculum vitae? What is the culture of the program and how closely do its values align with your own?

And which of these factors is the most important?

Early on in the process, I was awash in confusion.  I had a clear geographic preference (New England, centered around Boston). There are a number of impressive pediatrics programs in the area, with wildly different reputations, and with reputations that vary depending on whom you ask. I wanted the best for my education. But after four years of largely unhappy grinding, feeling that what I want out of life was at odds with what was being celebrated all around me, I wanted a place where I would feel comfortable, where both my love of medicine and my loves outside of medicine would be embraced. After each interview, I reflected on everything I head learned about the program and tried to rank it with respect to the programs I had already visited. Tay gently pushed me to explain my rankings, trying to help me process my thoughts, and sometimes there was no clear-cut answer as to why one program stood out compared to another; it just felt better. Over time, the intangible qualities that I sought in a residency program evolved into something I called The Huggability Index. On the surface, it was a basic measure of whether or not I had felt the urge to hug anyone I met on interview day, and if so, how many people I had wanted to hug. (I didn’t actually embrace anyone; I just noted the feeling.) Some programs scored high. Others garnered negative numbers. Still others were somewhere neutral in the middle.

The program that I ultimately ranked the highest brought out a flood of emotions. When the program director addressed that day’s group of applicants, I immediately felt the urge to cry and then vomit. Cry because everything he said about why he had come to lead this program and the wonderful quality and balance of life that he found there were exactly what I had been seeking. Vomit because I realized that I had one chance to make a strong impression, to make it happen, and that chance was today. (Again, I held both of these urges in check.)

Throughout that day I wanted to hug an inordinate number of people: the director for asking about my writing [I had used my writing as the focus of my personal statement, as a sort of litmus test for the programs; would they still be interested in someone who didn’t submit a statement that was some variation of Why Medicine Is The Best Thing Ever? Would they be not only interested, but encouraging as I made it clear that I had no intention of putting my writing on hold during my training?] and for every thoughtful and huge-hearted sentiment that he shared about the patients he cares for, his enthusiasm for the colleagues he works with, and his philosophies about educating new physicians. I wanted to hug the residents for their enthusiasm, warmth, and candor; my interviewer for being the most laid-back yet respect-inducing interviewer I had ever encountered, and for having really cool music playing in the background while happily discussing both public health and the many wonderful reasons to call New England home; and pretty much the entire institution for being fantastically child-friendly. Yes, many hospitals are decorated with children in mind, but this one exudes a warmth that I have felt in few others.

In the end, my choice was easy. Waiting to find out the contents of the envelope with my name on it was excruciating.

But once I opened it, there were hugs all around.

I’m going to become a pediatrician, and I'm going to do so at Brown.

Return to Iowa

Three years ago, when my writing project kicked off, I went to the University of Iowa - a writer's Mecca - to attend a workshop. I was nervous and excited and overwhelmed. (I wrote about it here: http://beckymacd.blogspot.com/2009/06/done-and-done.html) And I vowed that I would go back again.

Last week I did, this time for a conference devoted to writing and the art of medicine. Three days of panels and workshops on topics ranging from the ethics of writing about patients and family members to how we can write about death and dying to the options in the world of self-publishing to how writing can help us as clinicians to take better care of our patients... and keep ourselves well, too. There was even a how-to session offering tons of information about getting started as a physician who also writes (and gets paid for it).

You can imagine how freaking excited I was to be there again, among like-minded people who don't give me a funny look when I say that I'm a medical student writing a collection of essays on the side.

The last time I was there, I was unsure of myself, wondering if I really deserved to be there alongside real writers. This time, I dove right in. I stood up and read an excerpt from one of my stories in front of a crowd of more than fifty people. I eagerly shared the words I scribbled during on-the-spot writing exercises in various workshops.

There was another difference, too. Three years ago, I felt so compelled to extract every single sliver of potential fabulousness out of the weekend that I went a little nuts. I hoofed it all over the town, lugging my ginormous then-laptop on my shoulder, determined to visit every single little bookstore and boutique (there are lots) lest I miss one possible winning experience. I felt compelled to be on the move the whole time, because what if I failed to make the most of my time there? What if I was doing it all wrong?

Last week, I visited one store: Prairie Lights, my favorite independent bookstore from my last visit. In fact, I went there twice. The rest of the time I spent doing whatever I needed to do at a particular moment. One morning I skipped the first conference session in favor of some more sleep and a run. I didn't go out to any restaurants that looked like they just had to be experienced. In fact, one night I brought a Quizno's sub back to my hotel room to visit with Tay over Skype. And after I heard the US Poet Laureate speak (because, really, how could I skip that?), I ditched the evening reception in favor of heading somewhere quiet... to write.

Bath Salts

I was visiting my cousin’s family in Texas when I remembered bath salts. In the bathroom by their guest room, the shower has a recessed shelf on the end farthest from the showerhead, a place to put shampoo, soap, or a little something decorative. The shelf held an assortment of colored bath salts in jars, arranged all nicely. As I stared at it while rinsing my hair, I kept thinking, Those are so pretty! So very pretty!

It turns out that I had forgotten about bath salts. Not forgotten to buy some or to set them out in my own apartment, but forgotten they even existed. This happens quite frequently, I’ve learned, when you go into the cave. (See http://beckymacd.blogspot.com/2011/09/spelunking.html.) Because you’re working so hard to block out all of the distractions, you end up blocking out the good stuff, too. A friend in architecture school – which sounds far more grueling than medical school – forgot about plants, that they exist and look really nice when people have them in pots around their houses.

As I showered, I resolved to pay more attention to the little things that bring me joy and revitalize my life. Of course I failed miserably for a few months. But then I asked Tay to get me a peppermint foot lotion for Christmas, a product I had eyed for years and alternately assumed I would lack the time to use and forgotten about. It now sits on the bedside table, moisturizes my skin and makes it smell pretty, and makes me happy whenever I look at it.

It’s a feel-good ending, until you consider that I have been on vacation for the past two weeks, sleeping in with no interruption from the alarm, reading ravenously, daydreaming about decorating a house or condo someday, and using peppermint foot cream to my heart’s content. The problem with realizing what you’ve been missing, and tasting some of it, is that you’re all too aware of what it is that you lose when you lose it again. Which I likely will when I resume my rotations. And I’m not looking forward to it.

Taking Space

This story begins in Paris, where I found myself one day about a month after college graduation. I had just wrapped up a trip during which I led and taught American high school students, who were now en route back to the US with another of the teachers. I was set to catch a flight to meet my parents in Rome the following day. With 24 hours in my favorite city, free of any obligations and with some money left over from my teaching salary, I had expected to be jubilant on this last day, roaming the city’s streets without a map, popping into tiny cafes and boutiques and daydreaming about the next time I would return. Instead, I found myself consumed with agitation and anxiety. I felt the need to run and escape, though I had no direction. An unpleasant incident had occurred the previous night, in which one of the teachers had made poor decisions that endangered a student, and although the situation had been resolved safely, my mind still swam with confusion, betrayal, anger, and disappointment that I had yet to process. So I stalked the streets distractedly until I realized where I needed to be, then made my way to one of two small islands situated in the Seine right near the city’s center and entered the cool cavernous sanctuary of Notre Dame.

I am not religious, and if I were, I’m pretty sure I wouldn’t be Catholic. Though I am only vaguely familiar with the faith – growing up, the little girl across the street always seemed to be wearing pretty dresses when she played in the driveway after church, from which I deduced that this must be one of the fancier denominations – I do know that organized religion is not, at this point in my life, something that appeals to me. Regardless, I felt a strong pull toward the cathedral.

I have made many visits before, each time falling more deeply in love with the stunning architecture, so I attributed the draw to this fondness and familiarity. I sat in a pew, thought hard and let my mind wander, focused on breathing and being.

***

This month, I am rotating in a partial hospital program, which is a treatment program for children who carry concurrent (and often connected) medical and psychiatric diagnoses. It is organized similarly to a school; the kids arrive and check in each morning, then return to their families for evenings and weekends. It can be very difficult, especially for kids suffering from anxiety, to always be around others and to participate in group activities and therapy. Thus, a child always has the option of “taking space.” This involves going to a separate room where he or she can remain - supervised by a staff member – until the feelings of anxiety or panic or being overwhelmed have subsided.

I’ve been thinking a lot about space and its importance in relation to different activities and even states of mind. I often get frustrated with myself for failing to integrate meditation into my life, until I look around my cute by small apartment and realize that there is no area where I would feel serene and calm (and not totally bizarre) sitting on my meditation cushion. In the living room with the TV towering over me? Nope. In the bedroom between the dresser and desk? Not so much. It’s the same reason that yoga performed on a mat spread out in front of the couch just isn’t as relaxing as that practiced in a studio with dimmed lights and soft music and a teacher and other students surrounding me. Different spaces have different distinct purposes and connotations, and while there is some overlap and fluidity, attempting to assign too many tasks to one particular space, or not having enough space in general, can be mentally and emotionally constricting. Which is probably why I am writing this in Tay’s large, bright, windowed apartment in Boston, where I only come to relax, and which feels vastly different from the spaces I use for studying and the tasks of everyday life.

When I look back, I have to laugh at myself because there have been many times in the past when I have fully - though subconsciously - appreciated the importance of space, such as when I chose to study for both steps of my board exam in Vermont. At the time I conceptualized the decision as "Vermont is a place where I am happy and not distracted," but I clearly needed to remove myself from my everyday milieu and the aura of stress that permeates the study areas at my school and even at my desk at home. I took space without even knowing that I was doing so.

In retrospect I understand that my pilgrimage to Notre Dame was not one of faith in religion but of faith in my need, although I didn’t explicitly understand it at the time, to take some space. I needed a peaceful, comforting place to hide out from the disappointments of world for a little while; to work out how I felt about what had transpired, to take a rest from the effort required to exist in the unpredictability of the the everyday, and to shore up my mental strength to re-emerge and face it again.