Joshua Stein

Monday

“Before you leave today,” said my surprisingly tall, bearded resident, “you should introduce yourself to the patients on our service so that they will know who you are tomorrow morning when you pre-round.” I didn’t yet know what pre-rounding was, but I presumed it was similar to pre-boarding an aircraft, a practice reserved for people (medical students) who require extra time to perform routine tasks. “After you introduce yourself, pick one patient to follow. You will be writing notes on that patient every morning and presenting on rounds.”

It didn’t take long to meet our patients, many of whom exhibited little interest in exchanging pleasantries. There was an elderly man suffering from late-stage Parkinson’s dementia. There was a patient with schizophrenia experiencing a COPD exacerbation. Then, there was Mrs. G, who was admitted for immune thrombocytopenia. She was a retired teacher who spent her time volunteering at her church and caring for family members. She smiled warmly when I introduced myself as “Joshua the Medical Student” and announced that she would take good care of me during her stay. She asked me what year of school I was in and whether I had decided on a specialty. In turn, I asked about what brought her to the hospital and if there were any concerns I could communicate to the real doctors. She was kind, appreciative and outwardly healthy; a rarity in any hospital. She was my first patient.

Tuesday

When I woke up Mrs. G the next morning at an impolite hour, she was just as friendly as she had been the previous afternoon. “Good morning, Joshua.” At this point she was the only person in the hospital who actually knew my name. Her smile wrinkled her cheeks and the corners of her eyes in all of the ways that Botox, fillers, and face-lifts seek to reverse.

“My platelet count is up today. I can feel it,” she told me as I was preparing to leave the room and start working on my note.

“I hope you are right. We should have the results in about an hour. I will see you again soon, Mrs. G.”

When the results came back, they confirmed what our patient already knew. Her platelet count had risen high enough that she could be discharged from the hospital. “Med student!” my resident beckoned, rekindling my hope for anonymity, “Go tell Mrs. G about her platelets. Enjoy giving your first piece of good news — it’s not going to happen often.”

“How did you know your platelets were up?” I asked Ms. G, curious if there was a physical exam finding that could have tipped me off.

“Praying and believing, Joshua.”

We talked about her discharge as I wrote down a few questions to bring back to the resident and intern. We wished each other well. She told me I was going to make a good doctor and I told her she lifted everyone’s spirits on the floor.

An hour later, in the middle of grand rounds, I saw my resident and intern simultaneously look down at their pagers and begin the purposeful strut of the white coat warrior. They didn’t look at me, but I followed nonetheless with long, fast strides and sturdy eyebrows splashed with concern for the patient, anger at the disease and resolve. Like many genuine clinical skills, the walk can’t be taught via textbook, PowerPoint or YouTube.

Observe. Imitate. Repeat.

When we arrived at her room, Mrs. G looked scared by all the serious faces. She smiled half-heartedly and unevenly when instructed to, and failed to keep her arms raised with her eyes closed. The wrinkles on one side of her face were absent. The number of people in the room increased exponentially. The stroke team converged, pointed, murmured, and peppered the nurses and doctors with questions. “When…? When exactly!? How sure are you?” I took out my shiny new clipboard, flipped over a sheet of paper and started scribbling furiously, hoping that enough details could somehow halt the momentum of her illness. I blended in with the wall, standing still as the white-coated herd rolled her out of the room.

Wednesday

Mrs. G was transferred to a nearby tertiary-care hospital better equipped to evaluate and treat her stroke. From that point on we had no information and no way to access her medical record. There was no way to know if she was alive, severely disabled, or had experienced only a TIA that could resolve by the morning. The next day I asked my resident if he had heard anything about our patient. “No,” he told me, “but call the hospital and see if you can find out what happened. Tell them you are a resident.”

For the first time, I neglected a direct order from the tall, bearded one who would be writing my clinical evaluation. I pondered excuses ready to deploy should he ask me for an update. “They can’t provide protected health information over the phone,” or “The intern figured out I was a med student and promised to smother me in my sleep if I ever wasted her time again.”

Friday

The first week steamrolled my spirits sufficiently to make me question the veracity of the television doctor shows that led me to medicine. We had to restrain our Parkinson’s patient so he would stop pulling out his nasogastric tube. The man with schizophrenia yelled at me in the hallway calling me “retarded” when the doctors refused to give him opioids. I wanted to tell him that we don’t use the “R-word” anymore, but it seemed beside the point. When I left the hospital at the end of my first week on the wards, I still hadn’t called. I felt ashamed at my solipsism; that Mrs. G’s condition was a tragedy for me. I didn’t want to face the possibility that my first patient, the first person in the hospital to remember my name, might never be the same.

On my walk home, the bearded one sent the text message I had been dreading for the past three days, “Any news on Mrs. G?” I froze, tried to type, and then turned around. For the first time, I imitated the walk, unburdened by comparison with the real doctors sharing a corridor. Thirty minutes later, I was at our nearby referral hospital asking for directions to Mrs. G’s room. “Prayer and believing,” I told myself as I squinted at the confusing, color-coded signs.

I found her room, put on my white coat, knocked gently and stepped inside. Mrs. G looked at me, sat up in her bed and gently remarked, “Hello, Joshua. What a wonderful surprise.” Then, she smiled her big, crinkly smile.

Reflection

Nearly a year has passed since I met Mrs. G, my first patient, who I had the privilege to encounter several more times as part of a longitudinal clinical clerkship. Her recovery and our relationship helped buoy me through some of the most challenging months of medical school. Since then, I have been struck by how many patients relish their role as educators for medical students. When a student asks permission to learn from a patient, the roles of caregiver and care-recipient become reciprocal. We trainees have an opportunity to develop true partnerships with our patients, which, as Mrs. G taught me, can sustain student and teacher alike.

in-Training
in-Training - the online magazine for medical students

Kate Bock

For the smaller challenges of medicine, like fitting an entire person’s pertinent medical status in the half-inch gap between names on the patient list.

Listen to “Dotting I’s” here or below.

Review of Systems

Medical students’ place in the hierarchy of medicine means we are routinely restricted in what we can (or should) say. That taboo list includes our own transformation — despite being only one of thousands impacted by medical education, all too often we are left alone to process how it changes us. Review of Systems is a series of down-to-earth slam poems by Kate Bock, putting words to the unspoken process not just of learning medicine, but of becoming a doctor.

in-Training
in-Training - the online magazine for medical students

Ajay Koti

Part One

This was not what the manager had in mind for her evening.

An eccentric clientele was par for the course in her occupation. Low cost motels like hers tended to attract all sorts, and she took little interest in involving herself. Late-night traveler en route to some final destination — tenant. Thin, itchy man with wiry veins, eyes sucked back into bony skull, track-marks — tenant. Homeless or otherwise down on his luck — tenant. Each was provided a key to a seedy room with a vibrating, quarter-operated bed, a tube television complete with eight channels but no remote, a tattered Gideon Bible next to an even more tattered phonebook, moth-eaten lampshades and mothballed linens. Vagrants, petty criminals, nomads, the unlucky — all tenants at this godforsaken place on the godforsaken outskirts of this godforsaken small town.

The manager didn’t much know or care which category the godforsaken tenant at the end of the building belonged to. Maybe one. Maybe all four. Anyhow, it didn’t much matter. She was involved now, and that required timely eviction of the old woman at the end of the building. If she was still alive, anyway.

The old woman checked into the cabin a couple of weeks ago, making her stay a couple of weeks longer than most. She arrived with bad teeth and a duffel bag and a younger man with a Rolex. The man identified himself as her son — or was it her nephew? Anyhow, it didn’t matter, the manager never got involved — paid in full for the next few nights, the manager escorted the woman and her bad teeth and duffel to the cabin, and drove off in a sedan that accounted for two years of salary.

That was the last time she saw the man or the old woman, and now the rent was overdue and a blood-curdling stench thrashed the scent of mothballs and contemptuously spat its fumes through the gaps in the door-frame.

No, this was not at all what the manager had in mind for her evening.

She had already found the coroner’s number in anticipation of the inevitable but the old woman, as it happened, was not dead. She was merely ill — violently, graphically ill, at the expense of the motel room’s already dilapidated décor. An ambulance plucked her from the squalor of her cabin and deposited her at a hospital where, dazed and disoriented, she was admitted to the internal medicine teaching service.

At least that’s how I imagine things went before I had the chance to meet her.

Part Two

Delirium is a bread-and-butter presentation. The differential writes itself — stroke, infection, intoxication, electrolyte imbalances, shock, organ failure. The intellectual exercise this invites was practically invented for medical students, even if the final diagnosis (dehydration secondary to gastroenteritis) and its treatment (fluids) were relatively mundane. So it made sense that a medical student just starting an internal medicine rotation would be assigned to such a classic presentation. “Plus, I think she has some kind of unusual social situation,” said the supervising resident as she rifled through her list. It would be the understatement of the year.

I’ve made passing references to my Messiah complex before, so it will come as no surprise that the phrase “unusual social situation” was music to my ears.

The tenant really did have bad teeth — crooked, yellowed and gray, with black empty spaces where the missing ones were (or weren’t). Her duffel, impossibly overstuffed, was slumped over dejectedly in a chair. Scattered across the table were orange pill bottles, each of them empty, each of them stamped with a different pharmacy logo — the only clues the overnight team had to guess at her medical history, which included bipolar disorder.

The tenant appeared to have made a miraculous recovery in the twelve hours since her admission. Fully oriented now, she set her sights on mockery. She made short work of my short white coat and grinned toothlessly as she cracked wise about the “humorless” doctors who she met in the emergency room. “‘They’re all mad here,’” she said, quoting Lewis Carroll.

“Mad” seemed an apt word, I thought, as I perched on a stool at her bedside. The tenant was a riot. She spoke ceaselessly, breathlessly, eloquently, lengthily, tangentially. Each attempted probing of her “unusual social situation” was rewarded with short non-answer answers and then she began her magic trick. It goes something like this: first, she locks her gaze on you, and it is altogether unsettling because she is not looking at you, but through you, past you, beyond you and beyond now. And her black eyes are like shark eyes — wide, dark and lifeless, and the room shrinks around you, and those black eyes grow and swallow you up until you are falling into them, through them, down into the rabbit hole of her mind. You plummet endlessly and her voice tells you about her life in Brooklyn, her life in Europe, her life as an accomplished academic, her life with a few different husbands, her life with a man named Wayne and her life with her cats.

Just as you realize that you are through the looking-glass, that this rabbit hole has no destination, she releases you, and the hospital room materializes again: it is the present again and her pine-colored hair is matted across her forehead again, her eyes are brown and twinkling again and she smiles yellow and gray and cracks a joke at your expense. Again.

As you might imagine, this made communication challenging. We still didn’t know who the tenant really was, where she came from, who was responsible for her or why she was living out of a cheap motel. We were at the tenant’s mercy, and answers to our questions came drip-by-drip in incremental disclosures. The drips filled a basin near to overflowing, and in its reflection her dull black eyes shimmered and swam and uncovered a sinister reality about the man called Wayne.

First, Wayne was her son who was looking after her for the last year (or so). It was he who had dropped her at the motel, apparently just the latest in a string of hotel stays that he arranged. Then, Wayne was her nephew, who, incidentally, had full control of her finances. Finally, Wayne was revealed to be a stranger she met in a restaurant who became her lover. These, and other revelations, raised serious concerns for the possibility of elder abuse and our team made appropriate reports.

Our collective guard was up now. Strong as our suspicious were, we had no proof of their veracity. Not that this mattered any — we weren’t the police, and it wasn’t our job to investigate. Plus, there was no way to separate truth from fiction, or at least fictionalized truth, in the tenant’s meandering stories. She didn’t seem all too worried herself. Once, after resurfacing from one of her rabbit holes, I pointedly suggested to her that Wayne was taking advantage of her for her money, and she narrowed her crinkled eyes into slits and shifted in bed and stared silently at me (or through me) for an hour of a minute and I was sure I crossed a line. Then she shrugged and mussed her matted hair and twinkled her eyes and grinned that ashen grin. “Maybe he is, maybe he isn’t; so what if he is, so what if he isn’t?”

Part Three

We rarely got a hold of Wayne and we stopped trying so hard once we found out about their relationship. The tenant talked to him every day on her cell phone and each day he promised her he would visit tomorrow. As reliable as the morning sunrise, Wayne was inevitably sorry he didn’t come yesterday but his back was acting up, and he was sorry he couldn’t come today because of an awful migraine. The next day, he would surprisingly not show up again, they would talk on the phone and he would apologize again that he didn’t visit yesterday but he had that awful migraine, and he was sorry he didn’t visit today but his back was acting up again. Or perhaps it was some other physical complaint. I chose not to remember.

Reality didn’t much care about Wayne’s ailments or our misgivings — it cared about discharge planning. The tenant’s presenting diagnosis had been satisfactorily treated, and she was medically fit to vacate her hospital accommodations, which charged a nightly rate approaching $2,500. Wayne was still her emergency contact, though not a particularly good one given how reliably our calls went to voicemail. Finally, we got in touch with Wayne; in a brief conversation that was equal parts terse and tense, he acknowledged he did not have the requisite documentation of his alleged POA status before leaving us with an obscenity, a click and a dial tone.

I counted this as a victory. The tenant wanted to be discharged into Wayne’s care, but she had been stripped of her medical decision-making capacity after not one, but two, consultations with the hospital’s psychiatry service. She would not get her wish; instead, we, the system, the medical elite, the protectors, the paternalists, would assert our wisdom and our will because, after all, we knew “best.” We won, and she lost.

So we tried again for family. After some initial reluctance, the tenant shared with us the phone number of an estranged son, which did not really belong to her son but to another person who knew him, and after some initial reluctance he shone a flashlight into the rabbit holes of his mother’s life. Yes, he knew all about Wayne. Yes, Wayne had control of her assets. No, this wasn’t remotely the first time she had been in a situation like this. I still remember how quickly the disbelief in his voice evaporated into weariness and exhaustion. Despite the years of trauma and the thousands of miles and an ocean between them, his mother was back in his life. He shared with us that it had been a turbulent childhood that continued as a turbulent adulthood, always in the churning wake of his mother’s poorly controlled mania and its consequences. Now those consequences had chased him across the globe through a telephone set, and he was falling into the rabbit hole of his own past, because no matter how hard you try, you can never really leave home. His mother was back in his life, and we had put her there. Resigned, he agreed to help make arrangements for discharge. It was another victory; we won, and he lost.

Part Four

We began the discharge planning in earnest and the tenant would outlast every other patient on the ward. I would care for patients with cellulitis, gastritis, pancreatitis, vasculitis and various other –itises, and each of them were diagnosed, treated and released while the old woman played Sudoku and poked at green Jell-O trembling on her lunch tray. She quickly fell out of the formal rounding ritual: she was no longer a patient, but a tenant. The hospital had become an extension of the motel, just another place where she spent her days alone and abandoned in the depths of her rabbit holes.

I kept going back to see her, stealing away during those lulls in the afternoon, when the day’s work has largely been completed but it’s too early to go home. Each day when I arrived at her room for one of our chats, she would greet me with a “Finally, there you are!” before picking up wherever we left off. We talked about everything from her career in academia to the Syrian conflict. We talked about life in her New York apartment building, where she would share anti-depressants with neighbors — “just like lending a cup of sugar.” We talked about how Donald Trump would never, ever, ever become president. We talked about humorless doctors, and she made me promise never to become one. We talked about the kindness of strangers upon which she had always depended. Then her eyes would open up into rabbit holes.

She was captivating, whip-smart, with a wit that cleaved clean to bone. I fought to stifle laughter as I witnessed her expertly eviscerate a consultant with jokes that flew up over his head and out into the sky. We spent hours talking over her three-week hospital stay, she became more of a mystery to me. The lines between mental illness, eccentricities and performance art had not been merely blurred — they had been beaten into submission, and I got the feeling she liked it that way.

I was preparing to leave one evening around 6:30 when I remembered I promised the old woman to stop by before I left, to continue our afternoon conversation. Coat and bag in hand, I walked to her room at the end of the ward, acknowledging a well-dressed bald man who nodded hello in the hall and wore a sweater-vest and a Rolex, promising myself I wouldn’t stay too long. I nearly collided with the tenant’s nurse as I entered the room; “That’s Wayne,” she said.

“Really?” I stepped back into the doorway and looked at the shrinking figure heading away from us to the elevators. I thought for a moment. Then I walked after him.

I was not (and am not) the police. Whatever crimes he may have committed, visiting someone in a hospital was not one of them. Whatever crimes he may have committed were also immaterial, because, as I said, I was not and am not the police. So, I had no delusions of grandeur about meeting Wayne: I was motivated more by curiosity, a desperate sense that if I didn’t talk to him, my mind would have conjured up some imagined confrontation that would have paled in comparison to the real thing. I’m not sure which motivation is worse.

I caught up with Wayne by the elevators, just before he pressed “Down” to go down, and out. He smiled, I smiled, I extended my hand, he clasped it with both of his, I regarded the Rolex on his wrist, the beads behind his spectacles peered forth, he thanked me for taking care of his “aunt.” I asked if he had any questions, he said no but thank you, that he had to be going, he smiled, I smiled, he let go of my hand and got on the elevator and went down, and out.

Part Five

In the end, the tenant’s son came through. He arranged for her to stay with extended family. Her last day in the hospital was also my last day on service, which conferred a sense of poignancy that I still struggle to put into words. The forces of Nature, the Universe or Chaos itself directed our paths to intersect, and I am certain my life has been better for it.

So I perched on a stool across from the woman with the twinkling eyes and the matted hair and the bad teeth and the duffel bag, just as I had three weeks earlier when we first met, and I commented on our diverging paths and how this was goodbye.

She just stared at me quizzically, blankly. Then her gray toothless smile flashed and she extended a hand and I took it. “It’s been a pleasure,” she said. “I think we’ve made tremendous progress.”

“Progress?” I asked, standing.

“On you, of course!” she cackled. “Now sit down, and let’s talk.”

And her eyes opened up.

Author’s note: Part One is partially fictionalized for creative purposes. All names have been changed or omitted in the interests of privacy, and certain facts have been excluded owing to the sensitivity of the subject matter.

M.D. or Bust

Numerous studies have documented that medical students lose empathy during clinical years, becoming jaded and pessimistic. This has been linked not only to diminished enjoyment of our work, but also to worse patient outcomes. My goal is to sustain the humanistic values that drive so many of us to medicine, so that, instead of being quelled by cynicism, our idealism can be refined by wisdom.

in-Training
in-Training - the online magazine for medical students

Photo Credit: Pexels.

“Be a duck,” became my mantra throughout medical school, so much so that my mother had it printed onto a canvas and has it hanging on a wall at home in my honor. As a medical student you might think I would be more interested in having the prowess of a lioness, the elegance of an eagle, the speed of a cheetah or the energy of a dolphin. A duck, as most envision it, does not have much appeal; except, however, when swimming. The quote that led me to emulate the duck is Michael Caine’s, “Be a duck, remain calm on the surface and paddle like the dickens underneath.”

Just picture the creature, awkward as it may be, waddling alongside a pond, but once in the water, gliding on the surface. Submerge your view into the pond to see the intensity of its counter-current circulation powering those legs back and forth, propelling the duck forward. The act appears so different with this change of perspective. As a new third year student I “waddled” into my first rotation and after a few months, both patients and mentors complimented my glide.

On my medicine rotation during third year, my team was paged to the emergency department (ED) for an admission.

To give some context, as you may be new to this, oftentimes (in my limited experience) when the inpatient team is paged to the ED for an admission, the resident reviews a long checklist of questions in the electronic medical record while the medical student whizzes through history-taking. Only then do they two step out to have the medical student present the case to the attending physician with occasional interjections from the resident. Finally, the attending engages in a brief conversation with the patient to review either party’s unanswered questions and discuss the plan. The reset button is tapped and it starts all over again for the next patient. A great duck, my attending in this story, trained me with a different method.

We arrived in the ED, the patient’s name tickling my mind. The attending quickly recognized the patient as an elderly woman with a complex rheumatologic disease whom we’d cared for a few weeks prior. He entered the room with the team and gave a hearty hello with a proper handshake and reintroductions. Rather than starting with the classic, “What brings you in today?” he began with questions I had not heard before, “Are you comfortable, dear? Warm enough? Would you like an extra blanket? Can we get you something to drink?” With her response he rose from his chair and left the room. I quickly followed him, trailing behind his abrupt departure, and in a moment we returned with a blanket and a beverage for our patient. She was grateful, after hours in the ED, to be warm with quenched thirst before beginning our conversation.

This is merely a glimpse into this attending’s approach. What he exemplified, and I hope to emulate, was that he was gliding on the surface as he engaged patients, staff and trainees, but paddled furiously to generate differentials, complete paperwork on time, work on systems improvement, follow up on cases, stay current with literature, teach and more. He also believed, as I always have, that some of the earliest lessons learned in life are some of the greatest lessons to learn in medicine; that is: to remember the manners your mother taught you.

Treat everyone with respect, be friendly and approachable, bring positive energy, get to know your support staff and nurses and genuinely greet those who clean the linens, transport your patients or bring them food. Every single individual at the hospital is essential to patient care. The more friends you have in a hospital, the better equipped you will be to serve your patients – and the more people who will help you learn to glide through this incredibly complex and overwhelming system. Do all of this while calm on the surface, but paddle like the dickens underneath: study hard, exercise, eat well, map out concepts, prepare for rounds, do your assignments, be there for your loved ones and cherish your classmates. Your short white coat is a symbol for everyone to know that you are a novice and that you are working hard to stay vertical some days, never mind become the brightest clinician you can be. Be like a duck, but don’t frazzle your feathers.

The post Transitioning to the Clinical Years: Be A Duck appeared first on in-Training.

I spent the first week of my outpatient experience in Internal Medicine working with the nurses at Hospice of the Red River Valley in Fargo, ND. Besides being incredibly nervous to begin my third year of medical school, I was anxious about what I might encounter on my week at Hospice. I was naive to end-of-life care; I was under the impression that Hospice was emotionally distressing, that all patients were dying from cancer and that there was little that providers could offer patients besides Ativan and morphine. My week with Hospice fortunately rid me of those misconceptions. These brief stories emphasize the small details that ended up having a profound impact on me.

Monday:

Each Monday, nurses met to discuss what had happened with patients over the weekend and to plan their goals for the week. As nurses and I filed into the conference room, I listened to them catch up about their personal lives, talk about their children, laugh about their too-short weekend at the lake and groan about chores like laundry and grocery shopping. I’m sure this banter occurs in offices around the world on Monday mornings, but the simple energetic chatter began to unravel the preconceived notions I had about Hospice being nothing but sad.

We went to a nursing home to visit an elderly woman. The nurse briefed me on her status: she had dementia, weighed 85 pounds and was bedridden. She had declined further over the weekend, and the nurse predicted that she was mere days from dying. I introduced myself to her a few times. Each time, she was newly delighted; she clapped her hands, exclaimed that Anna was a beautiful name and complimented me on my lavender blouse, gleefully remarking that we had similar tastes in clothes as she tugged on the lavender sweater she was wearing. But her glee was short-lived before she was suddenly crying and yelling, “I’m sad, but I don’t know why!” She shed only a few tears before she became quiet and pensive, looked at us very seriously, and said, “I love you all.” She appeared very graceful at that moment, and it left me wondering about her life, her personality, her essence. I was entirely perplexed about these wild mood fluctuations. Why did she teeter so precariously between cheerful, anxious, sad, and terrified? I read more about dementia on the Alzheimer’s Association website: “People living with dementia keep their essence and spirit, although many will experience major personality changes…your loved one can show rapid mood swings from calm to tears to anger.”

Tuesday:

We visited the home of a 93-year-old woman with COPD. It was a hot July morning, well over 80 degrees by 9 o’clock, but she had the heat set to 80 degrees in her home. Perhaps she watched the sweat drip into my eyes as I removed my cardigan, because she quickly but unapologetically explained that an aide was coming to give her a bath later, and she hated when it was cold in the house after her bath. I couldn’t argue with that. Under the cardigan, I was wearing a blue skirt past my knees and a white collared shirt with my name tag pinned to the front pocket. She told me she liked my ‘uniform’ and compared it to the dresses she remembered nurses wearing in the 1930’s when she was a child. I laughed in embarrassment, because I really liked that outfit (which wasn’t a uniform)! She was frank, but she was lighthearted and so kind. She must have somehow sensed my intrigue with her demeanor, because she explained to me that she was ‘this way’ (self-described as stubborn, but a ‘softie’) as a result of over 40 years of teaching gym class at a grade school.

Wednesday:

On the drive over to the patient’s home, the Hospice nurse briefed me on her status: the patient was a recently retired nurse, she had colon cancer with peritoneal metastases, had recently undergone colon resection and had gotten a wound infection along her abdominal incision. We were going to clean and dress the wound. We got to her condo, and she showed us into her pastel colored bedroom where she had a plastic bin meticulously organized and filled with gauze, tape, antifungal cream, etc. She closed the bedroom door behind her to keep out her inquisitive cat. As she climbed onto her bed, she excitedly told us about her granddaughter’s recent visit from Washington, motioning to a framed picture of a toothy toddler that rested on the nightstand. As the nurse cleaned and dressed the wound, I contemplated how great it was to come into her home where we could change her dressing in her own bed, surrounded by pictures of her family.

Thursday:

We went to the Memory Care Unit of a nursing home to visit a couple of patients. A music therapist was there on her weekly visit. She played guitar while the aides handed out tambourines, wooden blocks, and kazoos to the patients. One of the patients we visited was known for being gruff—when we met with her before the music started, she cursed at us and told us to leave. Once she was outfitted with a tambourine, we saw a different side of her. She closed her eyes, smiled wide, and sang along; she stood and danced with one of the nurses. The aides and nurses who knew her said they had never seen her act like that. The Hospice nurse I was following cried.

Friday:

The man we visited had amyotrophic lateral sclerosis. He was lying in bed wearing checkered pajamas with a BiPAP mask secured to his smiling face. As I checked his vitals, I noticed a nearly illegible note scribbled in purple crayon on thick construction paper taped to the wall next to the bed. I could barely make out the words, “I want Grandpa to have hope.” The child who wrote that had more insight than I did. I was concerned about the man’s lab values, his respiratory status, and of course his comfort; but I’m not sure I would have considered his mental and spiritual well-being had this child not literally spelled it out for me. The smile that refused to be subdued by his BiPAP mask assured me that he had hope.

If my false notions about Hospice were challenged by the friendly conversation of the nurses on that first day, they were all but shattered after five days of meeting people with uplifting spirits, loving families and hope. Contrary to my misconceptions, Hospice was emotionally enriching, patients were living and coping with their illnesses, and there was much that providers could offer patients besides medication. In fact, the majority of our days were spent simply spending time with patients. Sure, we refilled medications, asked about symptoms and checked vital signs, but this introduction to my clinical years of medical school would be a memorable lesson in hope.

The post A Lesson in Hope appeared first on in-Training.

Sunrise on the psych unit.

A tentative, yawning flicker, a wash of tired fluorescence, and the hallway shudders to life—or something approximating life anyway. Bluish light cascades down greenish walls, rushes over the carpet and crawls under door frames into the rooms beyond where it meets the golden brilliance that beats upon the narrow gap in the wall that calls itself a window. The doors creak open, and the sunbeams spill through the glass, reaching at shadows that live here, before fading against the electric light. The shadows, and the shadows’ patients, trudge into the hallway, wearing thin the fibers of their socked feet, the silence replaced by the rhythm of their shuffling over the stained carpet.

Night shift signs out to day shift in the staff lounge as patients emerge from their rooms, hair wrapped in towels, with toothbrushes clenched in their jaws. Most had an uneventful night. Most slept poorly. A handful were tearful, another handful were belligerent. Francine showered, changed her clothes, and even cracked a joke — moreover, her eyes had finally stopped screaming, a harbinger of good things to come.

Leon was status quo. Flat. Withdrawn. Reclusive. Selectively mute. Leon was borderline catatonic, which was a modest improvement from how he initially presented weeks earlier — full-blown catatonia. My attending suggested I start seeing him myself. This was either a desperate attempt to shake up Leon’s routine or to brick-wall my not inconsiderable — and wholly unearned — ego that had developed over the past nine months of third year clerkships. I was in the home stretch now — mere weeks from achieving the esteemed title of “fourth-year medical student.” It’s the little things.

So, I saw Leon first. More accurately, I saw Leon’s roommate first. Upon my entrance, he fervently shook his head in a No-I’m-Not-Leon sort of way, his dreadlocks thwapping against each other, giving the appearance of a tornado on a human head. He left, the sound of thwapping diminishing in the corridor, leaving me alone with the shadow on the cot and the person casting that shadow.

Leon’s body was postured in a series of right angles — most notably at his neck, which pointed his head facelessly into his lap, which remained downward as he limply took my hand in an awkward finger-handshake. I pulled up a chair.

Later that afternoon, my attending and I reconvened in an office designed to give the local fire marshal chest pain. Hands interwoven over his rotundity, he stared blankly at me as I presented my conversation with Leon. I didn’t get as much as a smile when I revealed that Leon had actually spoken to me after weeks of near-silence to the entire ward staff. Not one iota of acknowledgement for a feat that should have earned me a Nobel Prize — or at least an early dismissal from the ward.

“Okay. Go ahead and see him again tomorrow,” he said, smearing a check mark on his list.

Sunrise on the psych unit.

Leon and I sat quietly in the shadows of his room. It was our tenth straight minute of silence — I had been speechless after the first five. Leon had changed since yesterday — from minimal eye contact to no eye contact, from soft-spoken fluency to complete opacity. Even the right angles of his posture seemed more pronounced. In the standoff, my mind began to wander. I could envision my attending shivering in schadenfreude-infused laughter, making one too many references to Icarus.

I began ransacking my brain for ideas. Maybe Leon wasn’t a morning person. Maybe he was just toying with me.

Or maybe it was my opening question asking how he was feeling that raised his guard. Leon had been selectively mute with much of the ward staff — interactive until they began asking about his mental health; then, the walls would come crashing up. My attending, who greeted me with resignation rather than mirth, agreed and encouraged me to keep seeing him. He spared me the Greek mythology reference.

For the next several days, Leon and I sat in silence. Ten, twenty, thirty minutes, exchanging nothing but a handshake. It was only then, when I had all but given up on interviewing him, that I finally began to notice some small details. I noticed that we were the same age, our birthdays only a few weeks apart. I noticed the comic books and John Green novels strewn — mementos from home. Most importantly, I noticed the table in the corner, past his downward gaze, past his shadow, where dozens of origami, painstakingly folded out of Kleenex, were piled upon one another. Cranes and swans, roses and carnations. Crude but beautiful. When I complimented them, Leon gave me one of his crumpled flowers. Marker ink colored the petals, bleeding into the tissue.

The next day, Leon sat and folded into right-angled silence in preparation for our not-talk. I gave the silence fifteen minutes. I stood, pushed my chair back — its legs scraped the tile with a bored snort — said “Let’s go for a walk,” and promptly walked from the drab of the darkened room into the drab of the darkened corridor.

A few tense moments held the weight and anticipation of an hour and were interrupted by the soundless padding of sock feet on carpet. My shadow was joined by another. I looked over at him to exchange a knowing smile to complete the cliché, but his chin remained pinned to his chest; I made eye contact with his hairline.

As we started walking, Leon maneuvered by peripheral vision, sidestepping patients and staff without once interrupting his staring contest with the floor. We passed the attending in the hallway, and he smiled before rolling his eyes.

Leon and I did laps around the ward each morning and most afternoons. Along with morning sign-out, med pass and group therapy, our walks became part of the ritualized life on the unit. At first, the silence followed us like a shadow; but after a few days, Leon began engaging me. It was small talk, mostly about our respective families. Even the vaguest reference to his mental health resulted in a complete shutdown. Our walks were a nice change of pace, but nothing had really changed for Leon — he remained guarded, paranoid, withdrawn and mostly mute. I felt less like Icarus and more like Sisyphus, pushing a boulder up a hill relentlessly, perhaps even pointlessly. All I had to show for it was a growing origami bouquet.

Leon had endured week after week of inpatient hospitalization and multiple medication trials without much of a change in his symptoms. After spending some time on a waitlist, my attending told me that Leon had been accepted for transfer to a long-term residential facility.

“What would he get there that he isn’t getting here?”

My attending shrugged. “Not much, it would just be cheaper than a hospital bed.”

A reasonable and wholly unsatisfying answer.

“Think he’ll get better?”

“He might. He might not. He’s still pretty sick.”

This time I shrugged. “I suppose he wasn’t getting much from us anyway.”

“Yeah … at an absolute minimum, he got a few good walks.” He smeared a checkmark.

Sunrise on the psych unit.

Or just before it, anyway. I arrived on the unit early Monday morning to find the hallways still dimmed. Leon and his shadow were gone now, discharged to more intensive long-term therapy a week earlier. I dropped in the staff lounge to ditch my bag and catch a bit of staff sign-out when the bulletin board caught my eye.

Posted were a series of thank-you poems, adorned with drawings of flowers and vines. An origami tulip was scotch-taped alongside a post-it note: “Leon did these for us!”

I left the lounge and walked into the hallway as it flickered awake. The patients walked into the corridor in sock feet, and I listened to the sounds of sunrise on the psych unit.

Note: All names and identifying information were changed to protect the identity of the patients.

The post A Third Year Opus — Chapter Four: A Walk on the Ward appeared first on in-Training.

“There must be a better way to make a living than this!”

Slam.
Silence, except for the persistent heartbeat.
The beat of the ticking time bomb, the dying heart.
It beat uselessly, against flapping intima, seeping vessels
Blood oozing and clotting and weeping everywhere.
An aortic dissection – a dissected body
Laying open, uselessly repaired.
Hand over hand squeezed dripping laps into the cell saver
For hours
Warm blood waterfalling over my student hands while
Seasoned surgeons grafted against a ripping aorta
A stranger, wandering and confused, memory meandering.
Surgeons thought it was hopeless,
Left no other choice.
Intimal flaps flipping across valves, blood pressure bottoming
To the operating room they went
Middle of the night
For hours
Sutured in a bright new aorta, came off bypass
Every needle puncture gushed. Coagulating, bleeding.
Defeated, surgeon threw down instruments, stomped from the room, exclaiming.
Slam.

It lingered.
Resident crossed to other side of the table, handed me the needle.
Fresh flesh, best practice.
Heart still beating, close the chest.
Blood still oozing
First time suturing
First patient dying
Under my hands, must approximate edges
Not too big of a bite now
Family waiting, don’t butcher him
Nurses impatient, huffing and cleaning
Resident critiquing
Hands shaking, not breathing, patient still dying, patient still bleeding
Flat line.

Don’t breathe; don’t let them see you cry.
First patient dies
While you piece them back together
You feel the heart stop beating.

Initially published in the 2017 edition of Penn State College of Medicine’s humanities journal, Wild Onions.

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“Where are you from?”

A question that I am asked many times during the course of my day. But the answer has never been clear nor concise.

I was born and raised in Dhaka, Bangladesh. I came to the United States, at age 18, for my undergraduate education and my parents immigrated after my freshman year of college. They settled in Atlanta as we had family there. After college, I lived and worked in New York City and finally moved to Burlington, VT for medical school.

When someone asks the question, “Where are you from?” I find myself weighing these three options – Bangladesh, New York City or Atlanta. But it is hard for me to decide which one to choose.

I feel more American than Bengali. I view the world as a new American. I am ill-informed about the Bangladeshi society, art, politics, media and even the cricket team. A lack of basic cooking skills has also meant that I rarely indulge in Bengali cuisine — something that is central to Bengali culture. My loved ones all live in the US and they all have American concerns. This may be the ultimate example of acculturation, appropriation or assimilation, but I now rarely identify with my native land.

New York has been the obvious choice. My formative years were spent there. My personal, emotional and intellectual growth is directly linked to the people, culture and the politics of this state. But I have only spent four years in the NY metropolitan area and a little over two years in the city proper. I have no roots in the city. I was very much like the millions of transients who take up residence in exorbitantly priced tiny apartments in search of an authentic and quintessential NYC experience. I feel like a fraud when I claim NYC as my land of origin – as if I was feigning it to look hip and sophisticated.

I have never laid claim to Atlanta. My entire family now lives there year-round but I hesitate to call it home. Having only spent two to three weeks at a time in ATL and knowing only half of the tourist attractions in the city, I remain oblivious to what makes the city and its people tick.

As uneasy as this convoluted sense of belonging makes me feel, what truly puts me ill at ease is the need a lot of people place on knowing this information.

There is the innocuous “Where are you from?” and then the probing “Where are you from?” The person who asks the latter question seems to always know the answer, always expecting me to conform to their image of who I am. The nurse who doesn’t believe I am from New York City – “You don’t sound like you are from New York!” The technician who is incredulous that I am from Atlanta — “You are not a southern boy.” And the doctor who seems perplexed when I state to be from Bangladesh — “I thought you were Indian!”

But it is always difficult to tease apart which “Where are you from?” question is being asked. As I thought about the distinction between the two, I came up with what I thought would be the perfect answer. It was a pithy answer, similar to the answers everyone else would give. It wasn’t the whole truth but it wasn’t a lie either. And it kept me from having to continuously retell and explain my immigrant experience to strangers. It also allowed me to judge which of the two questions was being asked.

Q: “Where are you from?”
A: “I am recently from New York.”

I have routinely used this tactic as I changed services and hospitals regularly as a third-year medical student. This approach is not 100% effective. But it has been surprising to note the number of people who have very similar replies to my answer.

Q: “But, where are you really from?” Or,
Q: “Where were you from before New York?” — As if it is hard to believe that a South Asian can also be an American.

I have decided that people who have the above reply are asking the probing version of the question.

What I cannot understand is why this information is so important. There is the obvious answer, that it allows people from the same place to form a connection, it provides a sense of kinship. It can also be used to stereotype people and endow a person with many characteristics and qualities, no matter whether they deserve them or not. It helps people to categorize others into neat little boxes and helps us make sense of the world. And the more nefarious reason is that this information allows someone to feel superior about their standing in life while simultaneously making someone feel inferior.  There can be a multitude of other reasons why this question is so important. I am not oblivious to how race, gender, socio-economic class and perceived citizenship status among others play a role in why this question is asked. Nonetheless, it is astounding how something so mundane is used to codify and summarize people.

Identity issues are not exclusive to medicine. In the current political climate, identity is fast becoming a polarizing topic. I chose to believe that medicine was different. That the intellectual and compassionate nature of this work separated medicine from the typical fallacies of the majority. Somehow the white coat was able to create a true meritocracy. However, we still remain members of a greater society and in that world, race, gender, class and sexual orientation matter. The hospital is not exempt from the daily struggles of America. And this has been an important realization.

If you, the reader, were one of those people using the “Where are you from?” question to establish kinship, to find commonality between strangers — I propose that we use a different question. Maybe,

Q: What is your favorite color?
Q: What kind of books do you read?
Q: What do you like to do in your free time?
Q: Are you a dog or a cat person?

The post Where Are You From? appeared first on in-Training.

First year of medical school:
Don’t remember much.
MD/PhD students, you know what I mean.
Learned how to use a stethoscope.

Second year of medical school:
Everything a blur except
Step 1 introduced me to my friends
melatonin, Benadryl, Ambien
And my best friend
Lunesta.

Third year of medical school:
First clerkship: Ambulatory.
First time I saw a patient by myself!
It took an hour and a half!
Attending happy?
Attending not happy.

Second clerkship: Neurology.
Oh Neuro.
So hard to “localize” my feelings about neuro.
Where is the lesion, Thomas? My attending would ask.
Because that’s very important!
Right…

Third clerkship: Pediatrics.
First time I made a patient cry.
Also the first time a patient made me cry
Actually no, just kidding.

Fourth clerkship: Internal medicine.
I matched into IM.
Enough said.

I am going to skip OB/GYN and Psych.

Seventh clerkship: Surgery
A surprisingly enjoyable clerkship
But maybe that’s because I did ophthalmology.
Just kidding. Surgery was fantastic.
Until the day I stepped on the suction cord.

Emergency medicine:
Where I learned chest pain = troponin, EKG, CXR, D-dimer, CBC, CMP, U/A, LE Doppler, abdominal U/S, troponin
Oh, and of course CTPE

Anesthesia:
For some reason I was always paired with the same resident.
She only had two weeks left before she finished residency,
So of course her favorite thing to say to me, every morning, was:
“Oh, Thomas, I can’t. I can’t. I can’t.”
And then I tell her,
“You can you can you can.”
But what I was really thinking was,
“We can’t, we can’t, we can’t.”

Time out from medical school, research year:
Wow! Look at this graph! It’s looking good!
P value? 0.06.

F**k!
All of my mice died.

I can’t, I can’t, I can’t.

Longitudinal primary care clinic:
First patient of the night!
Just going over her problem list on EPIC, I saw the following:
Asthma, HTN, HLD, morbid obesity (saw that coming), pain in LLE, GERD, depression (easy, SSRI), Diabetes type 1.5 (what?), rheumatic mitral stenosis (uh oh)
And that was only the first patient of the night! And her EPIC problem list.
Plus, she checked in at 4 p.m. for a 6 p.m. appointment.
And she’s scheduled to see me for a good, solid 15 minutes.

O.M.G.

Fourth and last year of medical school:
Beginning of my medicine sub-internship:
On my IM sub-I. I got a page! From the care coordinator, whew.

I got another page, from a nurse, saying “come to pt room N.O.W.” I grabbed my stethoscope and ran to the patient, whom I was cross-covering for the night, and whom I did not know and had never met. Nurse was now telling me, patient was blue in the face, and desatted to the 70s.

O.M.G.

The respiratory therapist was also in the room, and as soon as she saw me, she said “Patient is okay now, I gave her NTS.”

Now, I didn’t know what NTS was, but I knew it saved the patient. So I didn’t ask any questions.
I went up to the patient, and pretended to listen to her lungs even though I had no idea what I was doing or what had just happened.

Fast forward to the end of my sub-I:
I got a page. It was from a nurse. “Ms. M is not looking well, she’s very somnolent,” it says. I ran to my patient Ms. M. She had severe CHF and COPD and she was barely responding to me.

O.M.G.

But this time I knew what to do. I called my senior.

I suggested that we get an ABG immediately to check for CO2 retention which I suspected was causing her somnolence.
(Okay, I suggested a VBG and my senior said no and told me to get an ABG, but that’s not the point).

The point is, the ABG confirmed severe CO2 retention, and we treated that by transferring her to the MICU.

Towards the end of my sub-I, on that day, I thought I could do this.
I could be a good doctor.

Soon I will be sitting at Commencement,
Having traveled the long road from a mild dork
To a Medical Doctor.

To all of my amazing classmates and
The incredible, persevering medical students
About to graduate from all over the country,
Who simply refuse to not take another exam

I am going to say to you all,

We can, we can, we can.

The post Transformation from md to MD appeared first on in-Training.

***

Summer

It didn’t take long for the truth to come out. We had just completed our second week of medical school, the anticipated “Week on the Wards” in which each student was matched with an attending physician in an experience that officially marked our transition from layperson to health care professional. “From now on,” our deans told us at orientation, “society will see you as a doctor. Sometimes you may not feel like one, but that is what you are becoming. This week marks the beginning of that transition, which will continue in the months and years to come.”

That Friday afternoon I sat with a group of women at a table outside the medical school to debrief. The air was thick with the heat and humidity of a southern summer, and though we hadn’t known each other for long, the jarring nature of a new experience and numerous hours spent sitting through orientation lectures lent us the illusion of intimacy. We compared notes from our assignments: one person had observed surgeries at the VA, another had been on internal medicine at the city’s public hospital. I had happily followed the infectious disease team at the esteemed children’s hospital. We chatted about the long hours and our attempts to explain to residents and nurses that yes, we are technically medical students, but no…please, please don’t expect us to know anything yet. We recounted highlights, interesting cases and the intimidating thrill of the fact that we had really made it to medical school.

I don’t remember who said it first: “I’m not sure I want to do this anymore.” The bold honesty rang out among the hum of positivity. We hadn’t yet started classes, and the uncertainty was beginning to surface. “I don’t know,” she continued. “It was cool to be with the doctors, but… I’m just not all in. I almost wonder if I should get out now before it’s too late.” A few others nodded in agreement, laid out their own misgivings like offerings. I had spent each lunch break that week on the phone with my then-boyfriend wondering aloud if I’d made a grave mistake. “What if I don’t want to do this anymore?” I’d asked him. “I should have done nursing,” I said one day, and the next day, “maybe I should have been a teacher.” Now, my classmates and I remembered our past jobs: consulting, farming, research, advocacy, education. The positions we’d worked hard to move away from suddenly seemed alluring, and we wondered why we’d left. One week earlier we had learned the term “escape fantasy” from a faculty physician, and we discussed our own premature escape fantasies, feigning humor to disguise anxiety. We imagined alternate futures, populated by versions of ourselves that seemed, already, to be slipping out of reach.

***

Autumn

As the seasons turned, we began to learn the language of medicine. We studied words for things we’d never known to name, to appreciate nuance in what had once seemed straightforward. Simple squamous, cuboidal, transitional, columnar. I’d never known our casings to be so complex. We began to match symptoms to processes and processes to pathologies until we could, by autumn’s end, try our hand at diagnosis. Our small group sat with printed copies of chief complaints, lists of vital signs and associated symptoms. We learned to craft a differential, a list of diseases that could cause the suffering described in these fictional patients. It felt like a game: we would try to find a possibility in every category, imagine the many biological stories that could be occurring inside bodies we would never see. Our untrained minds ran wild with ideas.

Though the art of crafting a list of differentials was new, the concept felt familiar. I had been turning over a list of my own possible paths in the back of my mind since the summer. The categories I populated were not based on organ systems; instead, they represented people, places and professions. I nurtured some steady fantasies: working as a teacher, a social worker, a nurse. These were the horses, my most likely differentials. Occasionally I would entertain zebras, imagining my life unfolding as an ecologist, a journalist, a park ranger, a cook.

As the days grew darker, we learned the art of dissection. I found myself in the medical school more than in my apartment and felt less at home in each. The longer I lived in Georgia, the more I cultivated visions of living in Colorado or California or Alaska, the late nights in anatomy lab tempered by distant ridgelines and the curves of coasts I’ve never seen. I envisioned alternate endings to my relationships, imagined staying with the love I’d left behind. I fantasized about leaving school, starting over. I practiced the lines I would use when explaining it to my family and friends. At first my mind’s wanderings were confined to the quiet of the evenings as I studied and lay down to sleep. But the meanderings metastasized until they clouded my mind during lectures, meetings, afternoons in clinic. The days became blurred by thoughts of a thousand futures unrealized, futures that had or had never lured me before.

***

Winter

I know now that I was never alone. Initially, the students who surrounded me seemed so sure of their decision to come here, to walk into those wards and begin becoming doctors. Perhaps some of them were. But for every person who seemed so convinced of their decision, another wore the weight of uncertainty, embarrassed, as I was, by their confusion. These truths came out slowly, on long days when we arrived at school before sunrise and left long after the cool night returned. We asked in low tones, “How are you holding up?”, aware of each other’s fragility. And always there was an air of guilt: we would explain our unhappiness while expressing our gratitude, acknowledging the paradox of displeasure and privilege. We sent each other photographs of signs reading “Now Hiring!” at coffee shops, clothing stores, and car washes with messages that both teased and tempted. When my family asked how school was going I simply told them I was working hard, though I never felt I was working hard enough. Well-meaning friends outside of medicine told me they couldn’t fathom committing to such a lengthy and arduous path. I laughed, silently thinking “neither can I.”

Many of us were drawn to medicine for its promise of flexibility, of open doors. As the year came to an end, we could almost hear the soft clicks of doors closing behind us. In a particularly low moment, a group of students admitted that they had wished for accidents that would render them unable to continue medical school but free them from the shame of consciously quitting.

It is a common question in medical school interviews: what would you do if you could not be a doctor? I had been warned before I heard it. “Tell them you’ll try again,” I was instructed. “Say you won’t give up.” But what had seemed like a threat during interviews now sounded like an invitation. What would I do? Many people who had struggled to answer that question a year ago now had countless replies, could name other plans and different paths that were often vague, but always somehow better.

***

Spring

The warmer weather brought a welcome change: the first stages of understanding. The words we had practiced pronouncing in September now rolled effortlessly off our tongues; the heart became connected to the lungs and the liver and the skin in a system that was still opaque, but increasingly elucidated. I no longer felt like an outsider in the clinic. Not quite a citizen, perhaps, but also not a tourist.

To study medicine is to study trade-offs, to become intimately aware of the costs of success. We learned early on that there are no perfect remedies; even our best medications have the potential to do harm. As we study pathology, it is clear that the crooked path of evolution has left us with bodies that thrive or fail depending on context. Our tendency towards salt retention has allowed us to survive in environments with limited resources; now it manifests as hypertension. Our appetite for sugar, so crucial in times past, leads to dangerous diabetes. And so it is with the most human of traits: imagination. Our capacity to envision alternate futures carries us through doubt and allows us to plan for the future. Surely this, along with our physiological adaptations, has sustained us through the harsh realities of many millennia. When uncontrolled, however, it can cause more suffering than salvation.  When our minds become restless and wander, lonely among ideas of various futures and fates, we must tend to them like the other cravings born of humanity’s past. We must honor and understand our imagination’s presence, and learn to discern true hunger from ancestral appetites thrown out of context in a modern world.

The journey ahead will feed our imaginations day in and day out. We must nourish our imaginations; it is what will allow us to see patients in new lights, to initiate creative therapies and to think beyond the confines of medicine’s established framework. On the hardest days, it will help us remember that things will get better. And it will, undoubtedly, cause us turmoil. I see this in older students, residents, fellows, attendings. I hear murmurings of “what if?”, some simply musings on lives unlived, some despairing statements of resentment or regret. I’ve seen simple musings become realities, when people choose to walk a different path away from medicine and are all the happier for it.

We live in a culture that celebrates certainty and encourages decision. We play into a myth that we know what we’re doing, and that the harder we had to work for it the more certain we must be. In reality, it is never so simple. Many of us are molded by misgivings: on good days, they are fueled by curiosity; on bad days, they are the sequelae of discontent. We live with the consequences of the choices we made, as well as the ghosts of the ones we did not. I sometimes imagine a world in which our résumés listed not only what we have done, but also the opportunities we considered but did not pursue, and the experiences we gave up in exchange for others. Are those experiences, pondered and passed by, not as intrinsically important to the people we have become?

A friend once told me that the extent of our serenity is measured by our ability to let go of the things that we are not meant to have. It is a difficult task, to let go with grace. And while we find occasion to practice letting others go, we seldom think of applying the same mercy to ourselves, of releasing our grips on alternate versions of our own lives.  It is an exercise in self-acceptance, in trusting the paths and process we each took, strategically or serendipitously, to arrive here.

***

Onwards

A list of differentials represents a beginning. It is the physician’s task to chip away at the list, to carefully consider each idea in the context of what we know and do not know and cannot know. We may order tests or treat empirically. Sometimes we will rule options in and out until we achieve a diagnosis; other times we may find a cure without ever fully knowing the culprit. In some instances, we might arrive at a conclusion only to look back, weeks or months later, and realize we had been wrong. We may start over, re-think, alter course.

And so it is with us. We are dynamic. We can rule in and out, employ processes of inclusion and elimination, change our minds and ideas and plans until, eventually, we find enough comfort and confidence in our decision to keep on moving forward.

The post Differentials appeared first on in-Training.

“No acute issues overnight for 402.”
“403: this guy kept me up all night!”

I was writing feverishly as my resident was getting the sign-out from the night team. I wrote everything down, not knowing which piece of information would be useful. After sign-out the Green Team usually met on the second floor of the Smith building. I was running to keep up with my resident while trying to jam the patient list with all the information into my white coat pocket. My coat was already weighed down by a clipboard, the purple book of Pocket Medicine, pens, highlighters, band-aids (for me and my patients), granola bars (for me, exclusively), a reflex hammer and my stethoscope. This was my first medicine clerkship and I did not want to make a fool of myself.

During the team huddle, I was assigned to Room 403, Bed 1.
“There is a lot you can learn from this patient. You should see him.”

I got the one liner and was off.

“41 year-old-man with a history of IV drug use with a 2-cm vegetation on his aortic valve who came in with new onset headaches.”

403’s nurse looked unhappy after a busy night. She mentioned that 403’s wife was in the room, and that his son had apparently visited last night. I knocked on the door and went in. 403 immediately woke up. His wife was still asleep in the armchair next to him. I apologized and introduced myself. As my eyes adjusted to the dimly light room I saw a bald, cachectic man lying with his head propped up on multiple pillows.

After the requisite formalities, I asked how the night was. 403 hadn’t been able to sleep. He had an unrelenting headache that none of the medications were helping. I didn’t really know which physical exams to do to evaluate a headache, so I pressed on his sinuses, haphazardly checked his cranial nerves, clumsily flashed my phone light directly into his eye and did the routine heart, lung and abdominal exam.

403 had tattoos on his neck, his entire torso and two full sleeves. It was intricate, colorful artwork. A wolf was prominently displayed on his left arm and a tribute to his mom was tattooed on his left pec. I listened to the heart and lungs. As I did the abdominal exam I saw “Aryan Brotherhood” written in prominent lettering across his abdomen. My eyes quickly inspected all the remaining artwork and hidden in the mish-mash of memorabilia, Celtic crosses and skulls, were swastikas.

Aryan Brotherhood is a white prison gang. Rules indicated that you had to kill a black inmate to join. They preached the two-seed line theory of Christian Identity that whites were the “true Israelites” and Jews descended directly from the union between Eve and Satan. Their “Christian Identity” theology had inspired a man to fire a submachine gun in a Jewish community center and another to shoot and kill a black state trooper.

His wife was looking at me. I stopped and stood up straight, making eye contact with 403’s wife. My heart was racing: this was going to end poorly. My head was split between fear and anger. I was preparing the most scathing of rebukes when she asked how her husband was doing. I exhaled, said he was doing well, and left.

I had focused on the indignities my mother and sister suffered for being Muslim. I remembered the times I was told to “be careful” because of the color of my skin. I didn’t care about 403.

My presentation was a disaster. I didn’t know what the morning labs were or what the cardiology note had said. My resident noted that the morning CT showed multiple emboli to the head, which could be causing 403’s headaches. We continued with morning rounds.

Nobody asked if I wanted to be off this case, nor did I request to pick up a different patient. So, I woke 403 up the next few mornings, our interactions devoid of emotion. Each day he would have the same complaint — severe headache preventing him from sleeping. I wouldn’t inquire further, and would rush out of the room as soon as I was done.

Two days later his son was in the room when I arrived. 403 wore a huge smile as he played with his son on the bed. His wife had brought homemade soup for the nurses. The day after, 403’s son tugged on my stethoscope. He was incredulous that I could listen to a heart with that device. He forced a smile on my expressionless face.

On rounds later that day, 403’s pain issues were brought up. My attending did not want to feed 403’s habit by prescribing narcotics. We hadn’t changed his medication in the past few days and had convinced ourselves that 403 was faking the pain. As we were about to move on, I spoke:

“Can we start him on scheduled Tylenol or Tramadol? The current regimen is not managing his pain.”

“Sure,” my attending said, dismissively. And we moved on.

That was one of the first times I had suggested a change in the management of a patient. It was months before I realized what I had done, and I am still unsure why I did it. Why did my third-year medical student-self think that this was important? Why did I advocate for this patient?

Of course, I had multiple theories. I was doing my job; I was helping out the nurses; I did it for his family; I did it so I wouldn’t have to make up a physical exam for headaches every morning. Ultimately, I did it because he was a person in pain and I had the ability to help. Our shared humanity allowed me to empathize despite my efforts to distance myself. For a bumbling third-year, that was the biggest takeaway.

“My mercy takes precedence over my anger.”

The post 403 appeared first on in-Training.

Dear medical students, I’m sorry.

You had just finished two years of didactic learning and couldn’t wait to feel like a “real” doctor. You were finally starting your clerkships, that is, finally working with patients and getting deep in the trenches.

You were bright-eyed as you pulled on your pristine short white coat. You got to the hospital at 6:15 a.m., 15 minutes early for the first day of your very first third-year clerkship in OB/GYN. You were so ready. Your medical school colleagues had told you what to expect: you would meet your new team of doctors that you would be joining, helping with the diagnosis of diseases and management of patients. Maybe they’d even let you assist with delivering a baby!

At last, you approached the workroom where you were told to find the residents. You prepared to introduce yourself — this was important because these people would be evaluating you and would be your peers for the next four weeks. You were so nervous because the room seemed so daunting.

“Hi, I’m the medical student!” you said with cheer and a big smile to the room.

Silence. No one bothered to look up from her computer as everyone furiously typed away.

Over the next few weeks, you always acted engaged and excited about all you were witnessing. You always knew all the details about your patients and, when asked “pimp” questions, were always able to answer them. Yet, sometimes everyone would rush out of the room without saying a word to you, and you wouldn’t realize what had happened until someone mentioned that room 230 just delivered. You once asked a great question about pre-eclampsia, but the resident just snapped at you. You were so excited to see your first C-section, but once you made it to the operating room, you felt so clumsy getting on your sterile gown and gloves because no one had time to tell you what you were supposed to do. Or, you would often just sit in silence in the workroom because everyone was too busy to talk to you.

On the last day of your rotation, all the residents rushed to Mrs. Smith’s room — her baby was starting to crown. It was a quick labor due to the fact that it was her third child. The resident ran to the drawer to look for sterile gloves, but there weren’t any. She sighed and realized that there would be no time for that. But then she turned around to find you with an open pack of sterile gloves in her exact size. You had run to grab them outside the room because you overheard another resident mentioning that the gloves needed to be restocked in that room at an earlier delivery.

Dear medical students, I’m sorry there were many moments when you were ignored. I’m sorry sometimes we — the residents — were so stressed out that we forgot to tell you to come with us to the delivery. I’m sorry that there was a really cool congenital lung finding on the CT scan but that I didn’t even bother to call you over when you were just sitting silently, just hoping that someone would acknowledge your existence.

I’m sorry I often came off as mean and snippy. I was just so stressed out by the pressure I was under keeping patients alive that it just came out that way. Add that to a lack of sleep and maybe even a lack of a real meal in five days. Residency is just so long and seems never-ending at times. It was never, ever personal.

Your time on the clerkship gave me the best histories and physical exams. You were always a welcoming ray of sunshine and optimism even if it didn’t feel that way. By the way, Mrs. Smith complimented you because you went back to her room a few hours after the delivery to check on her and see her baby.

I finally saw you in your long white coat the other day. And guess what? You were laughing and walking with someone in a short white coat. You looked over, saw me, and smiled.

Dear medical students, thank you for forgiving me.

Editor’s note: A version of this article was previously published on Student Doctor Network.

The post An Apology to Medical Students appeared first on in-Training.

The entirety of the third year of medical school is an act. If you want to be a good medical student, you are what your team wants you to be. Amenable, pliant, easygoing — even when inside you are a bitter angry little thing who’s tired of being pushed around. The paradoxically best and worst piece of advice I’ve heard about being a good M3: “smile, even when you’re not happy.”

The reasoning behind it is essentially this: medical students are tired, but everyone else is more tired. Smiling is, therefore, a way to be a positive emotional support to the team when you may be useless otherwise, and since residents are definitely stretched thinner than we are, smiling — or at the very least, not complaining — can be helpful to overall team morale.

I hated it. So much for all the talk about self-care and healthy coping — what’s the point of introducing all these methods of maintaining mental health when the core of being a successful medical student is to never express your stress?

Yet, as hypocritical as I found the advice, it was fundamental to my third year. For those who haven’t experienced it, clerkships can be a bit confusing — you’re switching sites every couple weeks, sometimes even daily. It requires constant social recalibration, between different residents, attendings and even entire hospitals and medical record systems. Interactions, expectations and your role as a student vary widely in each environment, but there’s one constant: you’re always being evaluated.

So I found myself smiling a lot over the course of my third year. I smiled when I felt awkward, angry, sad, happy, validated and everything in between. I smiled when I asked for a nurse’s help, when I apologized for making a mistake, every time someone asked me where I’m really from, when sometimes, all I really wanted to do was scream.

I didn’t do it for my team or the people around me — sorry, but being an emotional support for other people wasn’t my priority when I felt like a bundle of nerves most of the time. No, smiling was for me. It was my defense mechanism in the times that I felt thoroughly out of my element or was just trying to be professional when I knew my true emotions were quite the opposite. It was the mechanical voice of my social interactions’ GPS saying, “Recalculating. Recalculating.”

The third year is often considered the hardest year of medical school. The unexpected social isolation, the uncertainty of the medical student’s role, and just the sheer gruel of working sixty-plus hours a week in addition to studying for a shelf exam are only a few factors that make clerkships so challenging.

There’s also the constant exposure to humanity that can be simultaneously demoralizing and rejuvenating. We’ve seen things that we likely shouldn’t be exposed to, from the technical miracles of reconstructive surgery to the intimate tears and fears of humans confronting mortality. We’ve felt everything from frustration to glowing validation from patients. It’s an intense emotional rollercoaster and also an incredible amount of information to take in, let alone process, in a very compressed amount of time.

Many medical students experience imposter syndrome, characterized by “chronic feelings of self-doubt and fear of being discovered as an intellectual fraud,” with a recent study showing almost half of all female students experience this during their training. I felt this syndrome strongly throughout this year, but the self-doubt extended to my second-guessing absolutely everything, from social interactions to my own emotional reactions —  was I being too sensitive? Thinking too much? Is it an appropriate time to bring up an article I looked up, ask this question, point out this error?

Yet, truth be told, despite the challenge, third year was by far my favorite year of medical school. There’s direct and constant patient interaction, more hands-on opportunities, and honestly, just the sheer fact that I’ve grown to know more and as a consequence, the flow of medicine simply makes more sense. I feel more comfortable. I can be useful to a team. I can envision just what kind of physician I want to be, from bedside manner to parts of medication management. And in retrospect, all these realizations result from having the fortune to have enough good attendings and residents who became goals and mentors for me. More importantly, though, I had classmates and friends I could rely on. After everyone goes through the same rotations, there’s a strange kind of camaraderie that we reach, an understanding you come to after a communal trial by fire. Everyone exits with different experiences and different goals, but it’s hard to exit the year without feeling some degree of accomplishment.

The positives of third year don’t take away from its difficulties, and I don’t expect to be cured of imposter syndrome anytime soon. There is too much information to learn, too many diseases we collectively still do not understand. And as challenging as dealing with that feeling of inadequacy can be, it is also humbling. The growth of medicine as a field is rooted in an atmosphere of constant self-betterment.

So my only advice is this: smile — one day, it’ll be real.

The post Smile appeared first on in-Training.

Genre: Fiction

Synopsis:

A third-year medical student gets stuck in a stairwell on her first day of her surgery rotation. All she wants is out, but she meets a distraught mother of a patient and a seasoned hospital employee who remind her of the privilege of medical school training.

Content:

“No, no, no,” I repeated, first silently and then as a whisper, as I frantically pushed the elevator button.

The reliable elevator chime did not ring, and the button light would not stay on.

“Great. Fantastic,” I sarcastically muttered.

It was my first day, and I did not bring my stethoscope to Grand Rounds. I thought Grand Rounds was just a lecture of grandiose proportions. But, no. The senior attending physician looked right at me and asked me for my stethoscope. I froze. I didn’t have it. I thought my surgery rotation was supposed to be about blood and guts, scalpels and sutures. Why was this happening to me?

The reason I did not bring my stethoscope was because fourth-year students told me to travel light. They said that all you need are your scrubs, a pencil and some paper. In a split second, you may be running behind the trauma team into an operating room. Extra stuff would contaminate the sterile field resulting in the scrub tech effectively cursing your existence and dramatically rolling her eyes to theoretical Kalamazoo.

So now I had to go get my stethoscope to listen to God-knows-what — trust me, while I can reliably hear the lub–dub of S1 and S2, please don’t ask me to distinguish a diastolic murmur from an extra heart sound. As a newly minted third year, I’m not there yet. Guess I’ll take the stairs…

I entered the stairwell, and the pitter-patter of my feet rapidly hitting the steps ricocheted off the walls. I reached the next landing and pulled the door handle. It didn’t open. I swiped my badge, and the red light blinked twice in defiance.

Great, medical student access denied, I thought.

I rushed to the next landing and tried the door, only to receive the red blinks.

You have got to be kidding me. The next landing didn’t even have a keypad to swipe my badge. Seriously?

I looked down the spiral staircase and got nauseous just thinking about continuously descending, round and round, for 20 more flights. It didn’t help that I had not been to the gym in weeks.

Thank you, med school, for sucking out my spirit and making turning the pages of ginormous textbooks my most strenuous physical activity, I thought bitterly.

You are taking the stairs down to the lobby. Accept it, I chided myself.

I looked up at the quote painted haphazardly on the wall: “The hardest part of the journey is taking the first step.” How cute. The stairwell was a cheerleader in a previous life.

Soon the solo sound of my determined descent merged with another. It was the sound of jogging steps approaching and then receding. Approaching and then receding. Finally, I came face to face with the source. Her eyes were puffy. I wasn’t sure if it was from physiologic crying or a pathologic process.

“Don’t mind me,” she said as she passed me on her way up the stairs.

I stood still as she passed me again on her way back down. She was wearing a black tracksuit with a double white stripe down the side. Her worn sneakers matched her outfit, stripe and all. She looked exhausted, frightened and alert all at the same time. She stopped before passing me the third time and looked at my ID badge. She must have seen that I was a medical student because she began talking unprompted and without restraint.

It was her son, Gayel. They said he was in respiratory distress and had been admitted to the pediatric intensive care unit. And so, she was going up and down the stairs. Up and down to get the sight of his nose flaring out of her head. To remove the sight of his tummy muscles moving rapidly in and out as he struggled to breathe from her mind. He had turned blue. Her happy, smiling, pink bundle of four-month-old joy had turned blue right before her eyes. And that’s when she called 911. She admitted that, while she knew it was weird, maybe even twisted, it comforted her to lose her breath climbing stairs. All Gayel wanted was to breathe, and if he couldn’t, maybe she shouldn’t. When she stopped talking, I tried to NURS her. Pronounced like nurse, the mnemonic stood for name, understand, respect and support. I had learned this method in my touchy-feely clinical skills course. Our instructors recommended this method to effectively address our patients’ emotions.

“You seem overwhelmed, and honestly, I can only begin to understand what you are going through. You recognized that Gayel was in danger and sought help. That takes courage and initiative, and I’m proud of you for that. The doctors, nurses and health care team are here for you now. They will do their best to help Gayel to breathe normally again.”

“Thank you,” she mumbled.

We locked eyes for about five seconds. I’m not sure if it was a flicker of hope in her eye or maybe just a receding tear. She quickly turned on her heels and re-entered through the doors to the hospital floors. Rather than escaping the stairwell after her, I continued down the stairs. Descending the stairs was now a proven coping mechanism.

The next landing had French-style glass doors with the word “Laundry” printed in faded black block letters. I could see a woman pushing an industrial-sized cart filled to the brim with scrubs, identical to the powder-blue ones I had proudly donned earlier that morning. I waved frantically to get her attention, and she quickly came to open the door.

“And … you must be lost,” she said in the rich accent of a southern grandmother, her drawl wrapping me in a hug as her words lingered in the air.

“Hi, I’m Kamari. I’m a third-year medical student. I’m trying to get out of this stairwell and down to the lobby,” I blurted out.

“A medical student?” she questioned, in a tone mixed with both respect and disbelief. “Like, you’re going to be a doctor?”

“Yes. I am.”

“A doctor,” she said with a smug smile across her face. “Hi, I’m Donna. I’m one of the Santa Clauses who makes sure you get clean scrubs from the scrub dispenser on the fourth floor.”

I had never contemplated how it worked. The scrub dispenser was like a vending machine for scrubs: I swiped my badge and out came clean scrubs.

“You know,” she said in a hushed tone, “I am a scientist at heart. I was a maintenance worker in a factory for 18 years before coming to work for the hospital. In another life, I was an engineer.”

She chuckled more to herself than to me.

“Well, you better hurry along. You have things to learn. Lives to save!” she said. “And, honey, the stairs are the fastest way. You don’t want to get lost going through the Laundry.”

I thanked her before turning around and walking away.

“See you later, Doc,” she said proudly, as I continued my journey.

The last flight of stairs was bittersweet. I pushed open the door and was finally met with the hustle and bustle of the busy lobby. Patients and their families, nurses and doctors, all moving in scattered directions, some more purposefully than others. I was back to reality, but the stairwell left me feeling hyperaware of my surroundings. As a future physician, absolute strangers trust me with their fears and the intimate details of their lives. Others see me as an inspiration and are proud of me without even knowing me. While I had been counting down the years to graduation and stressing over the heavy course load of medical school, the stairwell redirected my focus.

And here I was concerned about my stethoscope.

The post Stairwells and Stethoscopes appeared first on in-Training.

I’m careful to put my mask on as I enter the operating room and make way to the anesthetist’s station. I gather the necessary tools from the cart’s drawer and place them on the table attached to the anesthesia machine. I take the laryngeal mask out of its plastic container and prepare it to be inserted into my patient. The CRNA begins to sedate the patient as I wait patiently listening to the beep of the monitors and the radio play quietly in the background. Just as the patient drifts to sleep the anesthesiologist walks in and hastily approaches the OR table. I sigh as I see it’s the doctor who berated me yesterday for asking him where his colleague could be located.

He stands adjacent to me, watching me bag oxygenate the patient. To my surprise, he begins to help and instructs me as I work to make sure no air leaks out of the mask. I begin to thank him a few times as my focus narrows on making sure the patient is being oxygenated. The next thing I know, he is yelling at me again to stop thanking him. A bit shocked, I pause for a moment and wonder how someone can yell at someone for thanking them, and then grab the laryngeal mask and prepare to insert it into my patient’s airway. To my relief, I am able to insert it on my first try without any complications. Failure would have surely resulted in disparagement. Finally, I promptly connect the mask to the oxygen stream and my work is done. As I step back from the table I hear snippets of the anesthesiologist’s conversation with a scrub tech acknowledging how he has yelled at me twice now in the last two days.

The point of my story is to outline a scenario that many of us as students have probably experienced: being the target of a superior’s anger. This isn’t the first time that an attending or senior has treated me poorly and unfortunately, it won’t be the last. So how do we deal with, and prepare for, these inevitable encounters with our not-so-happy superiors? I’ve made a list of five strategies to keep in mind during these scenarios.

1. Take It With A Smile
If you happen to become the target of an angry attending, don’t get angry. Don’t retaliate.  Do your best to brush it off, move forward and take it with a smile. When you fire back, it only fuels the fire (no pun intended) and makes the situation worse. This may be hard for some people but I can assure you that responding with respect and not stooping to their level will make your situation much better than if you had escalated the situation. This is because by responding in a respectful way you effectively end the encounter and are able to move on with your day.

2. Stay Focused
If you become the target of a superior’s criticism, the last thing you want to do is step out of line and give them permission to condemn you. To avoid this you need to make sure you stay focused, show up on time, be polite, complete your assigned tasks and do as you’re told. In a way it prompts you to step your game up. The unfortunate reality is that some people displace their anger to people beneath them on the pecking order. A way to avoid this is to stay focused and to not give them an opportunity to criticize you.

3. If You Make a Mistake, Own Up To It
If it turns out the criticism is valid, even in a small way, own up to it. This shows your superior that you’re mature and it allows both of you to move forward. Most people will respect you more for owning up to your mistake. When you own up to your mistake, you are able to put the incident behind you and move forward with your learning endeavors.

4. Stay Professional
Avoid gossiping to colleagues. This is a good rule in general. The people you confide in may not understand the situation or may not have been there. It may cause them to label you as a gossip or worse, they may side with their colleague whom they know better. Talking about these confrontations at work is unprofessional and you should do your best to avoid it. That being said, if the situation troubled you and it helps you to decompress by talking about it, reach out to an advisor, counselor, spouse or friend.

5. Keep The End in Mind
You’re there to learn, so you should do your best to not allow a negative situation to impede your education. If possible, keep your distance from that particular individual and find someone who is willing to teach. The reality is that not all people want to teach and there will be people looking to take their anger out on inferiors. Whatever the reason, remember that you’re there to learn and that you should not let negative people influence that.

My goal is to give a short outline of what to do when we’re faced with confrontation from a superior. It is by no means exhaustive and I understand some tips are more obvious than others. I just want to offer the basics on how we can respond and thrive in the face of criticism from our superiors. In the end, my situation did not warrant a formal complaint to my school. If you believe that you were in a situation that made you feel uncomfortable and impeded your learning experience (after all we are paying a lot of money to be there) then it should be reported.  This will hopefully help prevent another student from having a similar experience. These situations are inevitable in any classroom or work setting and we will encounter them outside of the hospital as well. Just remember to take it with a smile, stay focused, own up to your mistakes, stay professional, and keep the end in mind.

The post The Victim of an Angry Attending: Five Ways to Deal with Criticism appeared first on in-Training.

In high school, I was obsessed with wearing only vintage clothing. After hours of painstakingly searching every clothing rack at Goodwill, I would find a well-worn baseball jersey or an elaborately bejeweled Christmas sweater. I felt a sense of immense pride in reclaiming someone else’s memories — their winning games, their holiday parties — in an attempt to express my “uniqueness.”

My mother found it ridiculous that I dedicated so many hours to purchasing useless articles of clothing (a point upon which I obviously begged to differ). In her defense, I wasn’t old enough to drive, and she was stuck sitting in the lobby of the thrift store for much longer than she cared to. “I have a closet full of old clothes,” she said one day. “Why don’t you just go there and take whatever you want?”

It had never occurred to me that my mother possessed anything that I would find to be of value. I went up to my parents’ bedroom to take a look. I discovered a walk-in closet filled with every piece of clothing my mother acquired since she first arrived in the United States from India. Long, flowy dresses with thick belts around the waist, oversized fuzzy sweaters with large shoulder pads … It was a gold mine!

As I went through each item on its respective hanger, I saw glimpses of my mother’s past: the first pair of pants that she put on after 24 years of wearing only traditional Indian clothing, the shorts my father bought for her to wear on their first trip to a public beach, a white dress with orange flowers that I recognized from a photo of my first Christmas. Each one carried a memory, a feeling. The apprehension of moving thousands of miles from her familiar life in India, the excitement of creating a family. Visiting her closet became a journey through her life, one about which she spoke very little and about which I had never really thought to ask.

I continued to return to her closet throughout high school and each time I came home from college. As I was getting ready to begin medical school, I found myself with so many questions. Which of these items holds her experience of landing in the United States for the first time? What was she wearing when she found out she was pregnant with her first child, when she began her internal medicine residency as a young mother of two?

What about what she was wearing on the day she learned that she had cancer?

Maybe it was a pair of jeans sturdy enough to shield her or a sweater cozy enough to comfort her as she took in the magnitude of the diagnosis.

“We are taking care of it. Everything will be fine.”

When my parents called to tell me the news, they urged me to complete my junior year of college and to continue my plans to study abroad. They assured me that “everything was under control.” I took their word for it and went on with my life thousands of miles away.

When I returned home several months later, it was clear that weeks of chemotherapy and radiation had taken a toll on both of my parents. My mother smiled weakly through tired eyes; she had lost a significant amount of weight and recently got a new haircut to mask her thinning hair. My father had put his life on hold to drive her to her daily treatments, cook meals and worry. They looked like different people; I realized that I had missed a significant chapter of their lives.

It was not until I was a third-year medical student on my surgical oncology rotation that I began to understand what their journey might have been like. Together with my attending, I sat down with families to deliver the news and outline the treatment plan. The energy of the room immediately changed as they realized that their futures were no longer what they expected them to be. Their shoulders sagged with acceptance, and their eyes grew tired as the doctor outlined the long road ahead. Family members cleared their calendars to make room for the daily appointments, the operations, the months of recovery.

I tried to imagine myself with my mother and father as they sat in a similar room with their doctor. Did he sit down? Did he hold her hand? Did he take time to go through her labs, images and biopsy reports? Did he answer each of my father’s questions, as repetitive as they might have been? What did they feel and say before they collected themselves and decided how to tell their children?

After my rotation, I went home and asked my parents to take me through their experience from start to finish. I was ready to go back in time and to walk with them through each step. They couldn’t give me very detailed answers. Years have passed, and those difficult days have blended together. They focused on the fact that she is here, and she is healthy. “You know, I had always been meaning to lose weight. And after going through my treatment, most of my clothes don’t even fit anymore!”

My parents keep those memories safely tucked away in a place that I don’t have access to and perhaps never will. The clothes that carry those memories are sitting in Goodwill somewhere, waiting to be part of someone else’s story. That chapter of her life has closed, and she now gets to embrace a new one.

And she has a new wardrobe to go with it.

The post Her Wardrobe appeared first on in-Training.

The very first patient I ever met on my internal medicine rotation was someone who hated being in the hospital. He took every opportunity in the following ten days to remind us that he was waiting to be discharged. He was sick of the nurses coming in at five o’clock in the morning to draw his blood. Sick of being woken two hours later to be given medication. Sick of being woken again for some student to timidly ask: would he mind a physical exam? Yes, he minded. He minded the teams of people coming in and out of his room at all hours, demanding to know if he was breathing better yet, pushing on his shins, and listening to his heart.

Every morning, we filed into his room wearing awkward yellow aprons and cold gloves. He would squint at each of us in turn through his remaining good eye and demand to know if he was going to go home that day. The answer, inevitably, was no. We were sorry, but there was still more fluid to take out of his lungs and legs. We would have to reassess the crackles in his lungs and the edema on his back tomorrow. And his reply, inevitably, would be to roll his eyes and sigh.

The first patient I followed was a lovely lady who had been experiencing shortness of breath for the last week. Was she having chest pain? Yes. Did it radiate anywhere? No. Did she have a cough? No. Any associated symptoms? No. Was she feeling better on the heparin drip? Yes. Any questions she had for me? Yes: when can I shower?

This was, I assumed, a very reasonable request. After all, she had come to the emergency room yesterday evening. After the stressful experience being hooked up to EKG machines and having a hundred clinicians ask her the same questions, she probably wanted to clean up. Surely one of the nurses could help her take a quick shower.

No, said the nurse who kindly stopped to answer my question. The doctor has to put in an order for a shower.

We didn’t put in such an order because she was still on her heparin drip. That night, she was diagnosed with extensive bilateral pulmonary emboli. She didn’t get that shower until nearly four days later.

I had never before contemplated the sheer lack of autonomy that came with the territory of being a patient. Would I like to be woken up at three in the morning for imaging only to be woken up again at seven thirty to be asked by some annoying medical student how many bowel movements I’ve had in the last twelve hours? Would it be okay if I peed into a bottle kept next to my bed for the next few days? Check in with the doctor every time I wanted to take a shower? And per doctor’s orders: a clear fluid diet only for the foreseeable future — that’d be fine, right? Not that I’d have any say in the matter.

As physicians, we rely on the lab tests to tell us things that our patients can’t. We not only want to measure the exact ins and outs — we want to control them too. We see patients at our convenience even if it means asking them questions when they are barely half awake. For the majority of these patients, this is a burden to bear for only a few days with the promise of discharge lingering in the near future. But for many other patients who have to stay in the hospital for weeks at a time, waiting for their medical condition to stabilize, this life could easily become unbearable.

I don’t have solutions. In the grand scheme of things, I’ve barely begun to see the problems. There’s very little I feel like I can do to help, but I keep reminding myself how frustrating hospitalization can be for patients. My contribution to their care is time: time to help explain a diagnosis, time to discuss families, pets, the best donut shop in Boston. I can reinforce the fact that this hospitalization is just one page in the long story of their life, and if I am very lucky, help reshape their understanding of their health into a form that will fit better into their personal narrative.

My patient asked to see the images that had been used to diagnose her pulmonary embolism. I won’t forget the way she scooted to the end of the bed to view the CT-PA I displayed on a computer for her. The shape of her lungs were reflected in her glasses as she silently stared down the tiny clots in her pulmonary arteries, visual proof of the battle she was fighting.

I won’t forget the smile on the first patient I met when we told him he’d officially finished his course of IV diuretics. Completely dressed and sitting at the edge of his bed — pulling on his shoes and, finally, ready to go.

The post Ready to Go appeared first on in-Training.

I was called to a code the other day.

Now, I should probably clarify: As a medical student, I don’t actually do anything (unless they really need people for chest compressions). In fact, I wasn’t even in the room.

But, outside, I got to witness the family as they stood in agony.

I couldn’t quite figure out who they were at first, but I immediately knew they were with this patient. One of the women had two small blood stains on her white sleeve. She didn’t seem to notice – she was too busy frantically trying to tell the nurse running for a tracheal tube that the patient already had a tube in his neck. The other woman shushed her. This woman was disheveled and smelled strongly of smoke, dressed in a pink sweatshirt and black pants. Her eyes glared as she paced. A nurse tried to guide them toward the Family Room, far from everyone running in the hallway. They refused. They couldn’t leave this man’s side.

Yet they had no idea what was happening inside the room.

The woman in pink questioned why there were people in the hallway and asked why we weren’t with the patient.

“They must be interns,” whispered the woman in white.

A chaplain arrived and she also encouraged them to walk to another room. Again, they refused. The woman in pink identified herself as the man’s wife. The woman in white remained unidentified.

I watched from the door as Anesthesia came and pushed through the herd of people to intubate the man. I saw the commotion as they all tried to don a gown, gloves and a mask. He was on contact precautions, though I didn’t know why.

The wife continued to pace. She eventually made her way in front of the door and peaked inside. She heard a nurse shout, “Pushing 1 of epi in 30 seconds!”

She whipped around to the chaplain, who stood nervously with the other woman.

“They’re giving him epi, that means he’s coding. Is he coding?” She nearly shouted in the chaplain’s face.

The chaplain softly explained that, yes, he is coding.

“So he’s dead!” Her eyes were full of rage. “Why didn’t I know he was coding? Why didn’t anyone tell me? Why didn’t anyone do anything sooner?” she seemed to scream internally.

Initially, a rapid response had been called. The family knew he was in trouble but not the extent. It wasn’t until a few moments later that a “Number One Emergency,” had been called and the family had been ushered out of his room. At my hospital, a “Number One Emergency” is equivalent to a Code Blue. But nobody knows “Number One Emergency.” Everyone knows Code Blue.

The chaplain drifted away from the family, seemingly to find more information. She probably just didn’t know what to say to them. I certainly didn’t.

I continued to watch both the code and the family. A nurse tried for a third time to guide them elsewhere. The woman in white choked, “I can’t. I can’t leave him.”

A phone rang from the inside of a white coat hung over a hand sanitizer dispenser on the wall. The wife was leaning against the wall with her head in her hands. “Why is there a phone ringing!?”

The woman in white quieted her. A nurse quickly took the phone when it rang a second time.

I wondered if I should talk to them, but I knew as much as they did. In fact, they probably knew more: I knew the medicine behind the code, but they knew the man. I didn’t know him at all, not even why he was in the hospital. I didn’t think there was anything I could do.

The wife finally began to cry. Her hands clasped together, she looked up at the sky and prayed, “Oh god, don’t do this.” My heart hurt for her, but I was at a loss.

Eventually, I walked away. I found my intern, who had looked up the man. She told me that he was in the hospital for tonsillar cancer and he probably aspirated blood, resulting in the code. I learned the next day that he made it to surgery, but nothing else.

As doctors, we are called to codes frequently. We’re in charge of everything that happens inside that room, but our vision is finite. We don’t see anything outside the room. We’re laser-focused on saving the patient and it’s too hard to have family inside: It’s far too unsettling for them and far too distracting for us.

Despite the fact that we have their best interest at heart, the family is in agony. They only know bits and pieces of what goes on as the person they love crashes before their eyes. And as all the doctors and nurses work tirelessly to save the person in front of them, the family outside can only stand aside and wait.

I was called to that code in case I was needed for compressions. But, instead of being in on the action or even witnessing the medicine itself, I witnessed this family at their lowest moment.

I know I will be called to many more codes throughout my career, working my way into the room and eventually to the top. But when I make my way there, I’ll never forget the anguish outside the room.

The post Outside the Room appeared first on in-Training.

As I entered the hospital to begin an Internal Medicine rotation, I was eager to make use of the array of diagnostic tests I had spent the past year analyzing in board review questions. The thought of, “Will this information change our care plan?” was not considered when the chance arrived to diagnose classic berylliosis in an elderly patient with lung disease and a history of work in the aerospace industry. As students, the opportunity to diagnose conditions we have read about in textbooks is thrilling, and erring on the side of restraint and reflection is often not our first response. Although the case is sometimes made to obtain a test “for the sake of learning,” uncritical ordering of tests may represent the beginnings of a more important issue: the unwitting embrace of medical overuse – that is, the provision of medical interventions where benefits do not outweigh the harms.

Daily labs are commonly ordered on hospitalized patients. While such tests may be indicated when patients are acutely ill and the clinical picture is unclear, there are many times when this is not the case. When a patient is stable and awaiting discharge, the plan from the previous day is often maintained, unaffected by the daily labs reported on rounds by a diligent student or intern. With countless other concerns related to patient care, I began to understand the appeal of “daily labs” and perhaps how it came to be so commonplace. The results were always there, but could be glossed over in stable patients. The practice made sense until I became aware of the unintended harms that can come from daily labs.

At the most basic level, daily lab draws means increased discomfort for patients. In addition, daily lab orders, which are intended to save valuable time and energy, require more of the team’s attention. Physicians must review the results of every test they order and are charged with the additional task of responding to unexpected abnormalities. Spurious results or unexpected changes, often reflecting clinically unimportant variations in human physiology, can lead us down a rabbit hole of further testing and cloud the clinical picture. Not only are health care workers impacted, but this seemingly benign practice is rarely regarded for what it truly is – an invasive procedure for which risks and benefits should be weighed. Patient discomfort along with the risks of bruising, thrombophlebitis, infection and hospital-acquired anemia should all play into the decision as to whether a given laboratory test is warranted. Additionally, the opportunity costs associated with time spent by nurses performing blood draws and the lab staff completing the tests are not inconsequential. With an estimated 750 billion wasted health care dollars spent annually in the U.S., the overall financial impact of this practice is considerable.

Some institutions have begun to tackle this issue. In 2016, Vanderbilt University Medical Center instituted a one-time twenty minute educational session on this topic for house staff on inpatient general medicine and surgical services. They taught about how to choose medical tests wisely and then provided each participant with weekly feedback on the number of labs they had ordered and their peers’ success in reducing recurrent lab orders. Health care providers were also given pocket cards to carry which detailed the financial cost of routine labs at their institution. This program was successful in reducing the number of routine labs ordered while also increasing the number of patient “lab-free days” without any negative impact on length of stay, ICU admissions, readmission rates or in-hospital mortality.

Other interventions have included adding a “labs needed for tomorrow” section in the daily progress note, as described in a study conducted at Massachusetts General Hospital. Clinicians were discouraged from writing recurring orders, and the new charting section provided a built-in check to encourage reflection about the necessity of each ordered test. The Royal Victoria Hospital in Montreal also instituted a “time-out” during evening sign-out as a period to actively engage in discussion about the lab work necessary for the next day. In the 14 months following this intervention, they were able to save $50,657 over the course of 985 admissions.

The mindset of health care providers also plays an important role in the overuse of health care interventions. An article recently published in JAMA Internal Medicine examined how different provider types view overuse of laboratory testing at Memorial Sloan Kettering Cancer Center. 54% of respondents reported that superfluous testing was done simply because they believed that their attending physicians wanted these tests to be done. Interestingly, 84% of attending physicians surveyed reported that they were comfortable cutting back on laboratory testing. This stark contrast illustrates how misperceptions of attending physicians’ expectations also contribute to unnecessary lab work orders.

There are many drivers underlying the overuse of daily labs in the hospital. They include inexperience of trainees, diagnostic uncertainty, time constraints, a lack of knowledge about cost and a culture of care promoting the idea that more is better. Although some institutions are beginning to address these issues, one area not commonly considered is the role medical students can have in shifting the culture of inpatient lab testing. A program at Medical College of Wisconsin trained third-year students to serve as “health value officers” and initiate team discussions about the value of the care being provided. This initiative led to a decrease in charge-master billing equaling an average of $53.80 per patient day and $269.10 per hospitalization. Perhaps more dramatically, 50% of faculty and 56% of residents surveyed said this experience would impact how they practiced in the future.

As students, we are responsible for fewer patients than residents and have more time to carefully consider the value of the lab orders placed for hospitalized patients. Acting as new members on a medical team grants students the opportunity to identify which clinical habits are driving overuse. By educating ourselves about the harms associated with over-testing and encouraging discussions about the value of the care we provide, medical students have the ability to ensure our patients receive the best possible care.

The post The Testing Epidemic appeared first on in-Training.

Some of my friends and family are really fascinated when I tell them I’m on my third-year surgery rotation. It is hard to convey how glamorous and inspiring it is, so I’ve written a short summary of a morning in the operating room:

7:30 a.m.: Wander around the operating room attempting to be helpful while patient is prepped. In actuality, be in everyone’s way as much as possible.

7:40: Scrub in to surgery. Fail to get your fingers in the fingerholes of the gloves.

7:42 – 7:52: Try to surreptitiously adjust your gloves without anyone noticing how stupid you look.

7:52 – 9:25: Try every possible position to get a view of the surgery around the other six people who are scrubbed in.

9:25: Give up on trying to see anything. Think about snacks.

9:48: Someone remembers you’re there, feels bad for you and hands you a tool! Something basic you can’t screw up!

9:52: Screw up anyway. Tool privileges revoked.

9:52 – 10:52: Think about snacks. Regret the coffee and garlic bagel you had for breakfast.

10:52: Accidentally brush the non-sterile pole with your sterile glove. Everyone rolls their eyes simultaneously; movement privileges revoked.

11:20: “Med student, what is this structure?” Attempt to visualize said structure in a two-by-two-centimeter hole from six feet away. Fail to visualize but make a wildly incorrect guess anyway — no matter how easy the question. Answer incorrectly until they give up on trying to teach you anything. Learning privileges revoked.

11:22 – 11:38: Think about snacks. Try not to think about how much your nose itches.

11:38: Note to self: “Rectum? Damn near killed ’em!” punchline does not go over well. Speaking privileges revoked.

11:40-12:40: Think about snacks.

12:42: Surgery complete! Attempt to help by putting diaper on patient. Fail to diaper. Diaper privileges revoked. Continue to be awkwardly in the way as much as possible until next surgery starts.

Looking back now as a senior resident, I can say the awkwardness is real. It’s hard. Being a “good medical student” involves being the perfect amount of present but unobtrusive, sharp but not a show-off, inquisitive but not questioning, caring but not too soft. This was never as obvious to me as it was during my surgery rotation. Though I’m sure for others, the awkwardness peaked elsewhere in their clinicals. At times, it is difficult, dehumanizing and lonely.

Each of us has a choice when we are no longer in the medical student role of how we respond to learners in the environment. You have the choice to turn the awkwardness around on the medical students whom you will supervise and make them suffer the same indignities. You can make them feel every bit as obtrusive and annoying as you were made to feel — you would not be alone in making them feel that way. Or, you can decide to recognize that theirs is not an easy role with a clear path to success. You can be supportive and appropriately kind. You can find reasons to notice their efforts and applaud those things that they do well. You can stand up for them when others look to be abusive. You can find the skills that need developing and give them the tools to be not just a good medical student, but a good doctor.

Barring all else, you can always warn them that coffee and a garlic bagel before surgery are a lethal combination.

The post The Glamorous Life of a Medical Student in the Operating Room appeared first on in-Training.