The setting was Copenhagen, Denmark, circa 2004. The weather was cold and I shook in my thin Juicy Couture jacket, but young me was determined to take as many photos as I possibly could to add them to my photo album back home (despite no Facebook/Instagram/Snapchat for my #Europetravels). I snapped everything: castles, ballrooms, delicious desserts, random people and trees. As I was packing my suitcase up to return to the United States, I was pretty satisfied with what I had taken. When we came home, however, I realized that I left my disposable camera in the backseat of a tour guide bus. I was naturally upset but, after further thinking, I was happy for the opportunity to take pictures of so many incredibly cool things and places.

The point of this story is that, in our day and age, photography is a stressor rather than something enjoyable to capture memories. Every Instagram shot, every Snapchat caption, every new Facebook profile picture — these are things that we strive to make appear “natural,” as if none of us are taking an embarrassingly long time to think up something witty or come up with a creative pose. It was much simpler back when photography wasn’t for the world but for our own happiness. It’s been used to connect with others, as a way to represent a subject’s life, and as an avenue to explore culture and the world around us. Given, too, the abundance of mental health benefits associated with photography, I wanted my next project to harken back to the “good ‘ole days.”

A few friends and I decided to spend our afternoon out in the great city of Cleveland, taking pictures of whatever we felt like, be it food, buildings, nature or weird things. We would reunite in a few hours and share both our pictures and the story behind each one. Once we split, I immediately went on the prowl for “artistic-like” photo ops, starting at the park. Unfortunately, the only things I encountered were yapping dogs that wouldn’t sit still, runners irritated with an obstructed sidewalk and a lot of people staring at me in confusion as I awkwardly tried to take photos of “interesting trees.” The next place I went was the upscale mall. Pictures of random people would probably result in my expulsion from medical school, so I figured I could take pictures of interesting products. Alas, even there I struggled. I found that there are few ways to take an ~artsy~ photo of a purse, and there is a reason mall food is not lauded for either artistry or taste. Discouraged by this failure, I went back to my car fully aware I had maybe thirty minutes or so before we met again — and I had little more than pictures of angry animals and too-expensive clothing on my phone.

And that’s when I realized I had been going around this completely the wrong way. The point of this whole activity was not to manufacture something artificial but to portray the world like I saw it. I wasn’t there to make the perfect Instagram shot or be the world’s best photographer — my goal that day was to have a great time exploring the city of Cleveland behind the lens. I failed to capture my own objective, despite coming up with the idea in the first place. With that in mind, I felt much relieved as I drove to the sight of our meeting place.

I know this sounds clichéed, but as my third year of medical school draws to a close, I realize that my photography adventure is pretty similar to my third year. I entered both activities with certain expectations and a determination to “play the part” of unique photographer/smart and capable MS3 who knows exactly what she’s doing. In both, I racked up way more mistakes than successes and felt pretty down on both ends. But, when I realized that the whole point of my MS3 year was to learn, not necessarily to already have all the answers or have the perfect assessment and plan, I felt better about myself and my performance greatly improved. Perspective, like a good photographer’s, is important for everyone.

Oh, and my favorite shot? In terms of artistry or capability, it was the worst, most blurry shot I’d taken that whole day. But seeing a random guy dressed up in a sheep costume going to Starbucks made me laugh and here it is. Hopefully you’ll laugh too.

Mind Your Mind

A very important topic is that of mental health in medical practitioners, notably medical students. According to a study in the Student British Medical Journal, 30 percent of medical students report having a mental health condition — with a majority of 80 percent stating the level of available support was poor or only moderately adequate. This column was born from these alarming statistics and aims to stimulate conversation on mental health in medical students, from providing suggestions on how to maintain one’s mental health to discussing the taboo and stigma surrounding conversations on mental health in practitioners and students, and how to eliminate it.

The post Adventure #17: Behind the Lens appeared first on in-Training.

Soon after I began medical school, I found myself hungry for stories — despite (or perhaps because) I had essentially no contact with patients. I read pages of internet forums for people who suffered the diseases I was painstakingly learning from unwieldy textbooks, trying to absorb through the screen what it felt like to have recurrent blisters all over your body, what it meant to lose sensation in your feet or control over your bowels, or how it affected you to know you were going through menopause 25 years too soon. Everyone who has ever Googled a health concern (read: everyone) knows that Internet forums on health can be alarming at best and alarmist at worst. And, while this held true, the forums were also saturated with a gentleness towards the newly diagnosed or suffering.

In these preclinical years, each practice question I did began with a patient vignette (a 56-year-old man with an extensive smoking history walks into the office complaining of increasing shortness of breath) that sent me down a path of imagining the lives these patients led. As the subtle clues in the question stem pointed me towards the diagnosis of lung cancer, I felt such sorrow — guilt, even, as the man and his doom were conjured purely for my own learning.

When I finally made it to third year — the year that deserves all the clichés thrown at it: the promised land, the whirlwind, the rollercoaster, the “most fun you never want to have again” — my patients captivated me. I wrote down their words, their curiosities, the emotions they tucked away, hidden inside fists inside pockets until the exam room door closed and they could finally uncrinkle their palms and let them drop. The privilege of catching some of them in my own outstretched hands was nothing short of remarkable.

One man walked in with the chief complaint of “palpitations.” Once he sat down, it became clear that what he really wanted to do was discuss his wife’s recent cancer diagnosis — an English teacher, he quoted Hemingway off-handedly to give color to his fears (“It is awfully easy to be hard-boiled about everything in the daytime, but at night it is another thing”). He called me at the office later that day to recommend a favorite Faulkner short story.

One 88-year-old woman, in the hospital for the sixth time in as many months, pulled out her makeup as I asked her how she was feeling that morning. She was wearing a hot pink bathrobe, New York Times crossword in her lap. “Sweetheart!” she winked at me, “Grab me my brush, will you? I can’t be seen by all of these handsome young fellows in a state like this.” Later, the doctor explained that her only real shot at a cure was a major surgery. He could guarantee a long recovery time but couldn’t guarantee success. She waved him off, eyes gleaming, and reapplied her lipstick.

A father promising never to drink again after his new diagnosis of cirrhosis with devastating earnestness. A lovely woman who, during an episode of psychosis, attacked a neighbor with a rolling pin. An 18-year-old, 39 weeks pregnant, who didn’t have any prenatal care because the fetus’ father was killed shortly after conception and she just couldn’t bear the ultrasound reminders. A 12-year-old girl steadily interpreting her father’s stories of torture. A man realizing minutes before his operation that the surgeons were planning to remove his entire tongue; the way he looked at his wife after this dawned on him. A group of friends giggling at a friend who split his lip during a skateboarding accident.

I accumulated these moments, holding them as sacred — or at least near it. But as the year progressed, I got tired. I wrote less; my journal took on a new identity as a coaster on my night table. I read less. I asked less. I noticed less. This happened slowly, and then seemingly all at once. I practiced the skill of directing the conversation with patients to efficiently get the information I thought I needed and, in the process, became less tolerant of meandering stories — the stories they needed to tell. Late in the year, I performed my first chest compressions on a 14-year-old girl, her softness startling to the heels of my hands. After the doctor pronounced her dead, I went to the bathroom in anticipation of tears, but none came.

This spring, I reported for duty in the emergency department. I was tired, coffee in hand in preparation for the night shift. A man rolled into the CPR room, obtunded, with no obvious source of his altered mental status. As is customary, he was surrounded by a flurry of people in motion: hooking him up to the monitors, performing a physical exam, administering supplemental oxygen, undressing him. I slipped off his right shoe, which, to my chagrin, housed six small cockroaches — “water bugs,” as I’ve learned to call them in the south. As one skittered towards my leg, I smashed it, reflexively, with the Timberland in my hand. The commotion in the room screeched to a halt. There was another shoe to remove, and a pair of pants too, but no one was moving.

The emergency resident beside me murmured, with a tenderness that almost broke me, “This poor man.”

She was right. Of course — this poor man. That should have been the first thought in my head too. Empathy. Understanding. Hell, moral outrage: How can our society tolerate the fact that one of our fellow humans is in such dire straits that he is living with a roach infestation on his actual person? But not once during the commotion did any of these thoughts cross my mind — instead I felt dismay, disgust, exhaustion. What was wrong with me?

These kinds of failures sting the worst. I’d always taken comfort in the fact that — even if I had struggled with a concept, botched a dissection, done poorly on an exam — at least I had my humanity. At least I gave a shit about people. And now, maybe I didn’t even have that.

I had a moment of clarity during the witching hour of that night shift. Empathy is a muscle you have to exercise just like any other. It is a choice. It’s something you have to study and practice and sometimes fail at and always try again. Putting on my little white coat doesn’t automatically transfer to me all the traits the best doctors have: empathy, compassion, warmth, kindness. I have to actively commit to working at these, every day with every patient. This is hard — so much harder than I expected when reading online health forums as a first year. It’s much easier to follow the path of least resistance, let the idea that emotional distance is required — to best serve the patient, to protect your own sanity, to get your freaking work done — edge out the reason I went into medicine in the first place.

I fail. All the time. But I’m trying, and I’m going to work to keep it that way.

The post The Ways We Fail appeared first on in-Training.

As a medical student in the transition from pre-clinicals to clinicals, I felt incredibly privileged to have the opportunity to interact with patients and finally be a part of the health care team — this is what I came here for. During this transition, I also came to realize that you can look at a patient solely through the lens of a clinician, but doing so will undoubtedly cause you to overlook the human being who is your patient. Clinical medicine is so much more than a textbook coming to life; it is about the fragility of life, the inevitability of death and everything in between.

Shortly after beginning my third year of medical school, I witnessed a code blue that hit close to home. It was a patient with chronic kidney disease who was on hemodialysis — just like my mother. The intensity was palpable as the team rushed to the dialysis unit. Although there were at least 10 people in the room, there was only one who really mattered in that very moment. Of course, as in any life or death situation, the minutes felt like hours. It was loud and chaotic until it became painfully silent — a silence unlike any I had ever encountered. Despite the team’s best efforts, the patient did not make it. The silence lingered for a short while, marking the harrowing realization that the patient was gone forever.

Afterward, the team quickly debriefed. To my surprise, no one showed any emotion. “She was a dialysis patient with end-stage renal disease — it’s not like she was going to live much longer anyway,” said the senior resident. My heart sank. When he looked at this patient, he saw chronic kidney disease and all of its co-morbidities while failing to see that patients are so much more than their constellation of signs and symptoms. However, I saw someone’s parent, spouse, sibling and fellow human being whose life was cut too short. While all he could see was the patient’s clinical morbidities and statistically poor prognosis, I saw a life that lost all its potential in a matter of minutes. I could not help but think of the holidays, birthdays, anniversaries, and family gatherings that would never be the same for a family who lost their loved one too soon.

As intelligent and clinically adept as he was, it was evident that this resident had lost sight of the importance of humanism in medicine. It was then that I knew I had my work cut out for myself. While this simply may have been his coping mechanism, it was certainly not a habit I wanted to pick up. I could not allow myself to minimize the loss of a life, to become so utterly jaded or to let my compassion slip away. While some might argue that becoming desensitized to losing a patient is the only way to cope with repeated losses, such suppression of emotions may be responsible for the staggering burnout and depression rates noted among medical trainees and professionals.

It is both fascinating and terrifying that we can easily lose sight of how compassion is at the very core of what it means to be human — even if just for a split second. Now that I have completed my third year of medical school, I have come to realize that type of morbid sentiment is commonplace in medicine. Sometimes I reflect on that day wondering “what if the outcome had been different?” and how much that would mean to this family; I can almost see an alternate ending without the enduring silence.

While there is no way to choose our patients’ outcomes, we can certainly choose to be empathetic and compassionate regardless of their outcomes. Medicine without empathy and compassion is not medicine at all. I wholeheartedly believe that being an exceptional clinician and a compassionate human being are by no means mutually exclusive — rather, they are inextricably intertwined. If we allow ourselves to feel, to empathize and to mourn our patients, we will undoubtedly be better clinicians. Needless to say, I am committed to coming out on the other end of my medical training just as compassionate, if not more, than when I started this journey for my future patients and for myself. After all, I like myself a whole lot better when I am a little more human.

The post Compassion in Medicine: Looking Beyond the Patient’s Illness appeared first on in-Training.

An intern, a fellow student and I are walking back from our final lunch talk. We board the ‘S’ elevators to get back to our wards, and, as we get on, a young girl is sitting on the elevator floor holding her mother’s hand with her grandmother standing next to them. She is blocking the way, so her mom asks her, “Sweetie can you stand up? The floor is yucky.” However, as we watch her, three of us quickly realize that something isn’t right. She doesn’t move. She doesn’t respond. She doesn’t even blink. For the first time, I understand what it means to stare into space. “Are you okay, sweetie?” asks the intern as we start to ascend. She is completely unconscious, looking into nothingness. I start to feel the adrenaline. “I don’t think she’s okay,” remarks the intern.

The doors open as we arrive at the hospital, and I immediately start running towards our ward. A family — parents and two or three kids — is trying to buzz into the ward, and they’re standing in front of the card reader. “Excuse me,” I not-so-calmly remark, pushing them out of the way to scan my card. The doors start to open, and I walk in stopping to turn around to check behind me. Sure enough, there is the mother with the daughter in her arms, intern close behind, and the child’s grandmother with hands on her head, saying, “Oh my God. Oh my God.”

I keep walking forward and instinctively shout “Can we get some help?” In the corner of my right eye, the two women sitting in the nurse practitioners’ office stand up in sync. At least two or three other nurses run out in front of me to meet the little girl. I try to communicate the situation to them. “Four-year-old found unresponsive in the elevator.” I don’t really know if she is four, I don’t even know if she was completely unresponsive, but the words were spilling out of my mouth. “Take her in here,” says one nurse pointing to an empty room. “Start a code!” someone shouts. They lay her in one of those over-sized cribs, and a flurry of activity happens in the next two minutes as I stand in the back of the exam room.

For the longest time, I had wondered what a code looked and sounded like — it’s almost mesmerizing. The constant ‘ding-ding-ding’ and the blue flashing lights above the door as though shouting, “All eyes on us.” In front of me, nurses were scrambling to attach monitors, obtain vitals, and understand the situation. The other student in the elevator comes and hands me the mother’s scarf. I hold it in the back of the room. Someone else gives me a box which I have no idea what to do with, and place it on the counter to the side of the room. I quickly realize the best way I can help in this situation is to get out of the way. I leave the room and stand with a few others who are preparing for the coming drama. Overhead we hear, “Attention hospital staff, code blue, center tower, room 435.” Boom.

From the left, in rush physician assistants and nurse practitioners from the pediatric intensive care unit. From the right, anesthesiologists hurry down the hall. Behind me, two security guards walk in with a gurney ready to move the patient. One by one, other interns, residents and fellows show up panting from running upstairs thinking one of their patients was coding. There are dozens of people both inside and outside of the room, and I shakily try to describe to everyone what’s going on currently. The other medical student on our team walks by nonchalantly almost oblivious to what is happening. Everyone seems confused, but inside the room, a symphony is taking place.

In the backdrop of that constant dinging, they resuscitate the girl, and it becomes apparent that she will be okay. “We’re not needed here,” says the attending anesthesiologist, and her team takes off to the right. Most people standing around begin to return to their work — different descriptions of what happened moments before filling the air. “I was just sitting there, letting a family in, and suddenly a medical student comes in screaming,” remarks one nurse.

That was me. I had started a code. “Quite a way to end my last day,” I quip with the groups. While the rest of my team leaves for the office, I stay and wait to see what happens next. The little girl is loaded onto a gurney and slowly pushed away. The dinging from the alarms has stopped and has been replaced with a calm that seems to settle us down. The intern stands outside the room, and the patient’s mother and grandmother each come up and hug her. To me, they say, “Thank you for saving our girl.”

This is a moment I will always look back upon as my welcome to practicing medicine. Only a couple of weeks earlier at the orientation to my third year, I remember being gripped by the anxiety and panic for the coming challenges. I was worried about the hours, how much free time I would have, how I would plan my meals and how I would survive. This moment reminded me of what I have been working towards my entire life. Yes, the last two years had been hard and not overly satisfying. Still, at this moment, I was reminded of my life’s dreams: to be hands-on, to treat patients, to help in the emergencies if even if all I do is shout five words. I am going to be a doctor, and I am excited about it.

The post My First Code Blue appeared first on in-Training.

Though the white coat’s role in medicine today is complex — to some, a respected symbol of medicine’s history; to others, a antiquated relic of a paternalistic past — few medical students or frontline residents would deny this emblematic item one major utility: a source of pockets.

Dr. Abraham Verghese makes the eloquent case that the objects we keep with us for patient care can serve as important reminders against allowing the “currency” of medical care from centering on the computer rather than the patient.

Perhaps no third-year clerkship leans so heavily on white coat pockets as surgery. At the surgery clerkship at my medical school — as at many others — we students were expected to keep a ready and full stock of supplies. My white coat pockets were generally bulging full.

What was in my white coat pockets, Surgery clerkship edition:

1. Dr. Pestana’s Surgery Notes: An amazing review book for the surgery shelf exam — both thorough and concise. It’s conveniently-sized to fit into an inner white coat pocket and can also sneak into the back pocket of scrubs for quick reading between cases.
2. “Flushes”: 10 mL syringes filled with normal saline, useful for flushing lines or for washing wounds and wetting dressings.
3. “Fluffs”: 6 x 6-inch sponges, essential for general wound care. These took up a lot of pocket space, but we went through them by the box-full.
4. Square gauze in various sizes: Also used for general wound care and as dressings. We used the “4 by 4s” (4 x 4-inch) most often. I usually had at least two of the larger size.
5. ABD pads: Short for “abdominal” and used for larger wounds.
6. A shadow
7. Gauze rolls: Also used all the time for dressing wounds and holding bandages in place.
8. A book with clerkship requirements
9. Tape: In two forms: paper and a plastic-like version. The paper is softer on the skin but weaker. Two rolls could easily fit around the tubing of my stethoscope.
10. Stethoscope: Used countless times during the day for heart, lung and abdominal auscultation.
11. Identification (ID) reel: This was one of the most useful things I bought for third year as it let me extend my ID without unclipping it.
12. Extra ID reel: After I had one break during a heavy breeze walking between clinics, I had to use my tie clip to attach my ID to my coat. I’ve since lost that tie clip, but its gallant service has never been forgotten.
13. Hospital ID
14. Maxwell’s Quick Medical Reference: A great pocket guide with reference material. Even though the electronic medical record and my iPhone made the need for a reference book partly obsolete, it was still incredibly useful being able to look up common values quickly. I often used it to check lab values and remind myself of normal electrocardiogram (EKG) intervals.
15. Pens: I spent a lot of time finding the ideal pen for third year — it needed to be clickable for one-hand use and have a fine point for annotating printed documents. I finally settled on two: the Muji 0.38 mm gel-ink ballpoint and the Pilot G2 extra-fine ballpoint. They both served admirably.
16. Pocket flashlight: Used just as much for reading pages during the dark hours of early morning rounds as for checking pupils and throats.
17. Tissues
18. Metal tin with breath mints: Lots of close quarters in surgery especially in the operating room.
19. A string: I got this from an old magic trick kit I found at home and used it to practice tying knots. During any downtime between surgeries, my hands could be found tying knots.
20. Forceps: These one-time use instruments were for packing wounds, unpacking wounds and for pulling out tight line seals.
21. Scissors: For cutting things. Also for one use only.
22. Sterile Q-tips: Also good for packing wounds.
23. Alcohol prep swabs: For swabbing things.
24. Steri-Strips: To close small, mostly-healed or already-sutured wounds.
25. Elastic bandage wrap: For tight dressings.
26. THE LIST: i.e., The list of patients on the service. Updated every morning, printed, annotated, updated, “run” (reviewed in full) several times a day, updated, re-annotated and always kept within reach. Because I didn’t have space in my pockets for a notebook to jot down teaching points, the back of the list also served a notebook-like purpose.
27. Suture removal tray: Appropriately named.
28. “Teggies”: Tegaderm, a (mostly) waterproof bandage ideal for sealing gauze, line insertions and more.
29. Xeroforms: Lubricated dressings to prevent sticking.
30. A corner of Surgical Recall: A great book with details about common surgical procedures for quick review before a case. Only a corner because this 824-page book just happened to be on my table at home and definitely did not reside in my coat pocket.

Strictly speaking, not all of this was in my white coat pockets. Some was obviously attached, such as my ID badge; others were draped around my neck, like my stethoscope; and still more resided in my scrub pockets, such as my cell phone. But, believe it or not, nearly all of this did, with some practice, fit into my white coat. And almost everything pictured got daily use.

Not pictured:

Trauma shears: Only on me while I was on the trauma surgery service.

Snack bar: I relied mostly (by which I literally mean for the majority of my calories) on ProBar Peanut Butter Chocolate Chip meal bars. My daily bar is not pictured likely because I had already eaten it.

iPhone: My phone was essential during third year and was most useful in the hospital for coordinating with my team, looking things up on UpToDate and quick studying.

Card holder: I bought a pouch that stuck to the back of my phone’s case and held all my cards. It was one of the MVPs of third year, allowing me to leave my wallet at home while still keeping my credit card, driver’s license and school ID with me at all times.

Pager: Probably still clipped to my scrubs when I took this picture.

The post In My White Coat Pockets: Surgery Clerkship appeared first on in-Training.

As a third-year medical student, I am confronted daily with my own ignorance. Often, while talking with patients, the diagnostic decision tree can spiral away from me becoming an abysmal labyrinth leaving me feeling at best, inspired to learn and, at worst, inadequate. Missed connections constantly remind me that in becoming the best physician I can be, there is still so much more to learn. But what if instead of backing away from the unknown, I stayed there with my patients? What if I could use these moments as opportunities to practice something much deeper and more timeless than simply discovering areas I need to study?

It started during my first week of clinical rotations while talking to a 40-year-old man who had already suffered multiple heart attacks from illicit drug use. His symptoms piled up, and the decision tree became more complex with each exchange. A moment came when he told me that he had been drug-free for six months. Suddenly, the labyrinth disappeared leaving me disarmed from my detective role. I was overtaken with a sense of presence when judgments and even thoughts themselves dropped from my consciousness. From this state, I set aside medical knowledge and expressed genuine admiration for his important accomplishment. It seemed as though a heavy weight of shame lifted off his shoulders as he visibly relaxed for the first time. Soon after, my attending physician joined us, piling on more questions, rebuilding the labyrinth, exposing what I had missed and highlighting the areas that I needed to study.

Later that night, in study and reflection, I found myself filling in these gaps of knowledge, attempting to untangle the intricacies of my patients and trying to make sense of their signs and symptoms. However, my mind kept returning to the patient I had encountered earlier that day. I experienced this subtle feeling that something important had happened. I became curious about the man and his story, but above all, I wondered what the most important part of that appointment had been.

Then, about a week later, it happened again. This time, it was the fatigue of a seventy-nine year old man, which carried with it an inherently long differential diagnosis. As the interview progressed, I felt it coming again: the dead ends, the unknowns and the labyrinth returning. In perhaps my naiveté, I made a bold suggestion that his fatigue, which was triggered by chopping wood, could simply be a sign of his body slowing down from aging. These authentic moments have a way of slicing through encounters and exposing the heavy truth that we so often dance around quietly.

It was his reaction that again disarmed me. He began speaking with great pride about his pastime of splitting wood, his unwavering work-ethic and his determination to continue living life on his terms. His fatigue was not disabling, and, deep down, I think we both knew he was pushing himself too hard. Our conversation pushed the medical questionnaire right into therapeutic territory. As I sat with him in mere presence, I allowed him to speak openly about his story and symptoms. And that’s when it clicked: Hidden behind every unknown and bundled within every patient interaction is an opportunity to practice deep presence and empathy.

I’m not suggesting clinical knowledge is unimportant. As a third-year medical student, I am repeatedly thrown into new environments where I am tasked with integrating two years of didactic knowledge into my patients’ lives. It’s a tremendous undertaking, but too often, the focus stops there. This is a shame because research has shown that both empathy and presence are skills to be refined rather than just innate qualities. These are skills capable of growth, and they undoubtedly lead to better patient outcomes. During our third-year of medical school as we begin rotations in the clinical setting, we are in the ideal environment to begin the noble pursuit of these practices.

As our careers progress, the practice of medicine will continue to be shaped by new and unforeseen forces. Impending technologies like artificial intelligence (AI) with its exponential growth are almost certain to radically disrupt healthcare in the next generation. As more data interpretation and science begin to be outsourced to AI, what skills will be absolute premiums for the physician of the future in the art of medicine?

For two years, I was not aware of this question as medical school conditioned all of us to see patients as constellations of signs, symptoms and lab values. This pattern recognition, now applied to real patients, is a skill I hope to master. But our work requires more than this. Third year has introduced me to the idea that power exists in the white coat, in making a genuine connection with patients and just being present with them.

So every day I practice meditation, which is an activity known to enhance presence and empathy. I carry this practice into patients’ rooms along with my questions and stethoscope constantly striving to perfect these tools. As third year marches on, my increasing medical knowledge results in hesitancy becoming less and less frequent; however, medicine is not yet a perfect science. There will never be a point in my career when I know everything, and the labyrinth does not come spiraling back during some unique patient presentation. In those moments, my patients will require something more than medical knowledge itself. It is then I hope to remember this truth: amidst the unknown, our patients represent opportunities to practice the timeless skills of empathy and simply being present with them.

The post Timeless Opportunities in the Unknown appeared first on in-Training.

In our preclinical psychiatry courses, we learn about the ideas of transference and countertransference, which is when patients project their own thoughts and feelings onto their therapists and vice versa, respectively. We’re told that patients who had close relationships with their parents start to develop similar relationships with their psychiatrists. Additionally, we are informed that sometimes the psychoanalysts who harbor feelings of hostility and resentment toward their spouses will start to hold those sentiments for their patients.

What we don’t learn about, and for which I was most unprepared, is what happens when we see our reflection in the people that we help to take care of on a daily basis. We can intellectually comprehend defense mechanisms, the DSM-5 criteria for major depressive disorder or the pharmacology of psychotropics; however, we’re never taught about what to do when, sitting across from  patients, we end up sitting across from ourselves.

I completed my six-week psychiatry clerkship at an inpatient facility in Greater Boston; I helped to care for adults, pediatrics and the elderly. I gained substantially from my experience, learned tremendously from my patients, preceptors and even discovered quite a bit about myself.

I’ve always been an anxious person; I can’t remember a time in my life when I didn’t over-analyze or worry about something inconsequential. As a kid, I burst into tears at the thought of having to make a phone call, and as an adult, my heart beats out of my chest when spending time with people who I don’t know very well. I have always been slow feel comfortable around new acquaintances and have made only a few close friends in my twenty-five years. Other than my parents, my support system has proven at best tenuous among my peers.

This past summer, my long-term girlfriend and I went our separate ways, which deepened my anxiety and allowed depression to seep in as third year began. I felt my isolation intensify as my classmates and I scattered across New England, leaving me to face my loneliness and all that came with it alone.

It seems appropriate that at this unique time in my life, I started my psychiatry clerkship. I began to understand the emotions I was experiencing through the lenses of the patients I met and interviewed; it was both enlightening and deeply uncomfortable. Months later and I am still grappling with what I felt.

One day on the adult inpatient psychiatric service, I was asked to speak with a man in his mid-thirties who was admitted the previous weekend for symptoms of major depressive disorder including suicidal ideation. My attending stated that he would be good for me to talk to and get to know.

Many of the details of his life were foreign to me: trauma, substance abuse and bouncing between jobs without a sense of direction. I listened to him discuss his struggles, offered advice and counsel where I could and thanked him for being willing to discuss his life with me. In a Boston accent that Matt Damon and Ben Affleck could be proud of, he always reassured me that I was welcome to talk with him anytime.

I hoped to at least lend a listening ear to this patient. I wasn’t expecting to see bits and pieces of myself and my life in him and to have his story so deeply resonate with me.

This patient struggled deeply; not with self-confidence, not with a lack of belief in his own talents and abilities, but with a firmly held belief that he had nothing to contribute. He stated that he felt like he was worthless. His anxieties seemed to eat at him as he told my attending and me how depressed he felt about his life. He told us about toxic relationships, about how the smallest bit of criticism sent him spiraling and how so often, he felt like a burden.

Through tears, he stated that he always let people take advantage of him. He felt as though people always wanted something from him, that he allowed it and didn’t know how to stop it from happening. Never before had I seen myself in another person like I did that day. I thought of my own struggles and feeling like my world was collapsing around me. My mind turned to my own feelings of worthlessness such as having nothing to offer anyone, the intense, all-consuming fear that no would ever need me and that no one would ever love me. Right in front of my eyes were memories of days when I felt so horribly about myself that I would spend hours wandering around with nowhere to go or to be and hiding my tears behind sunglasses. I thought of my own relationships including ones in which I felt both taken advantage of and also that I was burdening the other person all while feeling as though, somehow, I deserved it.

My patient stated that he became depressed about everything and questioned whether or not he would recover. It frightened me to hear those words. I felt as if my patient’s mental state was my own writ large. I was worried that I could very well end up in the same situation and feeling as if life was no longer worth living to the point of being confined to a locked unit for my own safety. I felt the same feelings that my patient was feeling; I no longer enjoyed what I previously had, no longer looked forward to anything and no longer felt that things would turn around despite my desperate efforts to convince myself otherwise.

In many of our talks, my patient would fall quiet for seconds or minutes at a time letting silence fill the room, and our thoughts would permeate the space between us. In these moments, I was most at a loss for words; I wanted to say something comforting or reassuring, but I knew that I wouldn’t believe those words myself. I faced an impasse on how I should respond. I questioned whether I should perform my role as a student doctor and offer what I believed to be false hope or if I should speak as a friend and inform him that I had though those same thoughts, had those same feelings and knew intimately how he felt. Frankly, neither felt very appropriate.

Thankfully, my attending stepped in during our conversations. She told our patient that he was a good person and reminded him that she saw him as a kind, sensitive person incapable of hurting anyone.

He stated that he didn’t know, and he didn’t want to hurt anyone.

Neither do I, I thought. So why do I always feel like I am?

My attending continued by saying that the keys were to build up mental armor and find ways to not let little things bother him.

Never truer words spoken, I thought. Why can’t I do that?

She told him that we build up the armor so that we can keep living. If we don’t have the armor, we would never live. Every negative thing that anyone ever said about us would destroy us. We build up the armor to only let the things that matter affect us.

Our patient seemed to understand this. Seemingly defeated, he stated that he didn’t know how to do this and that he just let it all get to him and then he felt  awful again.

I let the words sink in for myself. I let every negative thought or feeling weigh on me and lay me low. Neither I nor my patient seemed to have the armor that my attending spoke of, nor did either of us seem to know how to build it up to its original height. I didn’t know how to stop it all from flooding my brain or how to stop from feeling as though I was merely a hindrance to others. Like my patient, who often felt like he offered only that which could be extricated from him, I felt I could offer nothing but medical advice that felt increasingly meaningless and unfulfilling. Like my patient, I felt that there was no way out and no way to cope with how bad things had gotten.

My attending concluded that our goal was to help our patient get better, as we wrapped up our interview. She told him that we would talk more tomorrow.

As we got ready to leave and continue our day, I again offered thanks to my patient  for being willing to talk to me even when he didn’t have to do this.

One final time, he reassured me that it was no problem.

I rotated off the unit not long after this patient was discharged; I crossed paths with him one final time as he was headed to an outpatient appointment at our hospital. He seemed brighter and more relaxed; maybe I was only seeing what I wanted to see. In the months since my psychiatry rotation ended, I’ve had the proverbial good days and bad days. In general, I say that things have gotten better, but like when I saw my patient for the final time, I wonder if I’m only seeing what I want to see.

I carried with me from psychiatry a far greater experience and understanding than I ever anticipated. I learned what it truly means when we say that we are not alone. Through my patient’s same wants and needs, I saw my own thoughts, feelings, hopes, dreams, fears and my own desire to be liked, to be wanted, to be needed. I felt, for the first time in a very long time, a genuine human connection. I learned not transference or countertransference but, rather, empathy.

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“Dr. C. is a white cloud, so you won’t see much with him on call this weekend,” my attending mumbled. I immediately asked what he meant by a white cloud. He gave me a withering look like he always did when I asked too many questions. He went on to explain that a white cloud is a doctor who never has anything crazy happen while on call. He stopped walking, turned around, looked me in the eye and said, “We are black clouds.”

I had just started my third year, and I had already witnessed six patients die. I had never been called a black cloud before this, but it immediately stuck and seemed fitting. Wherever I went on rotation, troubled patients seemed to follow. It was a double-edged sword though. From the outside, being a black cloud seemed exciting, but as much as it was exciting, it caused me emotional toll. I saw the worst of the worst: I saw patients mangled, maimed and dying.

My classmates and I didn’t talk much during third year about the patients who we saw die. It was an unspoken truth that some of us had probably seen more than a fair share of morbidity. Sometimes, it seemed like other medical students wanted to be black clouds because they wanted to be involved in the excitement. Of course, it didn’t stop any of us from continuing, but those volatile patients sometimes weighed heavily on my mind.

The initial patient encounter etched permanently into my memory was my first code. During my internal medicine rotation, I received the title of “black cloud” in the second week of my first month of my third year. We ran into the intensive care unit (ICU) after receiving the page, and I saw blood everywhere. The nurse quickly informed us of the details. The patient had undergone esophageal surgery the day before and subsequently vomited bright red blood twice, which caused diminished peripheral pulses. Unfortunately, his family, who had stayed with the patient for a few days in the ICU, had left thirty minutes prior to his episodes of hematemesis. What struck me the most is that he died without the comfort of his family’s presence. Rather, he was  surrounded by doctors, residents and medical students who did not know him. We were just there for the code blue.

There are parts of that code that I try to forget. A code is always a hodgepodge of people milling about and working hard to keep a patient alive. During this particular code, the various medical and trauma teams discussed what should happen since the patient was going to be pronounced dead. After some discussion, it was decided that the surgery team would call the family. The surgery team members who had been called to the bedside were not the team members who had operated on the patient. Therefore, no one was familiar with the patient or his case other than the health records they had glanced over during the code.  

I passed the intern a sheet of paper bearing the family’s phone number. Obviously exhausted from tedious shifts, he dialed the number. I don’t blame him for forgetting the patient’s name, and I am sure it wasn’t intentional. He had never met the patient before, and this phone call to the family was his only part in the patient’s care. Crestfallen, he crumpled into himself when he realized that he had identified the patient incorrectly during this significant phone call.

I will always remember my attending physician’s words and actions in that situation. As soon as he responded to the code blue, he pulled me out into the hall and whispered, “Close the other patients’ doors.” I didn’t ask why: I just made my way around the horseshoe-shaped ICU and slid the doors closed. It was a simple thing that I thought purposeless, but I also knew I was no help as a third-year medical student with limited experience. Later, I asked him why he had me do this. He explained that it was to protect the other patients from hearing the code and possibly reliving what they had experienced with their own family members.

At the end of the call shift, the attending asked if I had any questions. Ashamedly, I asked, “How can you watch someone die and move on with your day?”  

To my surprise, he brushed it off he said, “Just try not to take it personally or get yourself emotionally involved. It will ruin you if you invest part of your heart in every patient.”

I was floored. This was an attending who brought patients their favorite snacks or games, and he was always smiling and laughing wherever he went. I trudged out of the hospital that day feeling defeated. At that point, I hoped that I would never lose that tightness in my chest, that swelling of emotion and that lump that arose in my throat when I realized the patient was going to die alone. However, I felt a wave of embarrassment when I remembered how excited I was to respond to that code.

I try to remind myself of this when I hear the code pager ring, the call for a trauma room or the ringing of my phone in the middle of the night. I will admit that I am still excited to be involved in these emergency situations. I’ve seen what I can only describe as miracles and people brought back from the edge of death. However, I have also witnessed people die when I felt like they would survive. Most of the time, there is a fifty percent chance of devastation and a fifty percent chance of a miraculous recovery. Now, my excitement in responding to a code is that I may be able to positively affect the outcome instead of merely being ready for a rush of epinephrine.

I carried these moments with me: the good, the bad and the in-between. In the darkest moments though, even when there seemed like no light could be found, eventually something would pierce the darkness.

Similar to a code blue, my third year of medical school was also a hodgepodge, but it included beautiful, funny and poignant moments. I can say now that I was not prepared for it, but I don’t think any of us could have been. Maybe being a “black cloud” isn’t a bad thing: Maybe some of us are just magnets for long, volatile call nights and days. My mentor claims to be a “black cloud” and jokes that someone must publish her call schedule because she believes that more patients show up to the emergency department while she is there. She never really complained about her crazy nights other than saying that she was getting too old for the excitement and inherent stress. After thirty years in practice, she has seen countless patients die, but she hasn’t lost her hope or her spark.  

From my few weeks spent with her, witnessing death was never monotonous. It never lost its sting. While I know that we, as future health care providers, must be empathetic and compassionate, we cannot personally invest all of our emotions in each patient, or we would live in constant disappointment. Losing a patient is difficult, and throughout the year, it never got easier. I found solace in my mentor. As “black clouds,” both she and I experienced what we would subjectively deem the worst cases, together. She never grew numb to the tragedy of death. As I continue on this journey to become a physician, I hope to never grow ambivalent towards trauma or death because while I may be labeled as a “black cloud”, I never desire to be a walking cloud of pessimism. As the story goes, every black cloud should have a silver lining.  

Image credit: “Storm over Frankfurt” (CC BY 2.0) by CoreForce

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Day One

“So, how long have you been on surgery?”

“I mean … I had OB/GYN before this,” I answered in an attempt to set the expectations low without prompting the surgical residents to think I was incompetent.

“Oh,” one of the residents sighed.

I could tell by the way the other two residents turned back to their computers that my two weeks on transplant surgery would be my “first” surgical rotation.

“Follow me,” Dr. PGY-III said as I chased him down the hall into the supply closet. “You need a medical student kit.”

With that, he began filling my pockets with an assortment of items as he listed them aloud: Tegaderms, Kerlex, gauze pads of varying sizes, a binder, staple removers, suture removers, caps, a paper tape, cloth tape, culture tubes and flushes. He also threw four syringes in my pockets, thought for a moment and then threw another four in there. The words sounded like English, but I wasn’t really sure what any of the stuff was.

Later, as I rushed back from the cafeteria, a fourth-year medical student caught sight of my stretched pockets and smirked.

“Surgery?”

Day Two

Drs. PGY-III, PGY-II and PGY-I collectively decided that I was taking too much time to open the flushes and staged an intervention. Typically, I unwrapped them gently like one would open a Lindt chocolate bar: quietly and with intention.

“Just do this,” Dr. PGY-II said before he slammed the plunger of the syringe into his thigh so the tip burst from the plastic packaging with a loud pop.

As a medical student who had been operating under the ‘be seen, not heard’ protocol, this was startling.

I also learned a second thing on rounds that day. Apparently, there is a balance between having too much stuff in your pockets and not enough. In both situations, you can’t find anything you need.

Day Six

Dr. PGY-I decided to teach me how to use the copier with the automatic stapler.

“So,” he said as he pointed at the screen, “which corner are you going tell the copier to staple?”

“Uh…,”I hesitated.

Over the past two years, the baseline issues I have with distinguishing my right from my left have been exacerbated by the fact that all radiographs are mirror images. As a result, I no longer trust myself.

“Top left?” I responded as I glanced at my hands.

“No. Top right.”

I briefly wondered why this topic was not covered in surgical textbooks before I hit the ‘top right’ button on the copier. Magically, when the copies of the patient list printed, each packet was neatly stapled in the top left corner. I did not think too hard about this; there is so much that doesn’t make sense.

Day Seven

We transplanted a kidney. I was surprised to discover that the donated organ showed up in a little plastic container actually labeled ‘Tupperware.’ Dr. Attending #1 transferred it to a plastic, blue bucket containing ice and then handed the bucket to me.

“Hold this,” he said as he turned back to the recipient’s abdomen.

For the next thirty minutes, I could only stare down at the kidney and dig my nails into the bucket. By the time Dr. Attending #1 asked for the kidney, I was completely cross-eyed from the exhausting task of making sure it did not fall on the floor.

Afterward, the resident on pediatric surgery asked me how the transplant went.

“Oh my gosh! That was so cool!”

“That is literally the first time I have seen you smile,” she said, sounding surprised.

I was surprised too. I didn’t notice that I had stopped smiling.

__________________________________________________________________

I know that being a third-year medical student is like being a transplanted kidney. One starts the day in one body. School is composed of lecture halls and written exams. However, the world has shifted by the end of the day, and shockingly, one’s old body is not present. “Teaching” is reduced to five sentences whispered between patient rooms. “Exams” consist of single questions which present themselves just as sporadically. This new body is unfamiliar, and the medical student, the transplanted kidney, is expected to thrive in this bizarre, artificially constructed cavity.

In this scenario, much like a newly transplanted organ, one’s survival depends on the precise administration of a cocktail of immunotoxic medications. While these are not tacrolimus, cyclosporine or steroids as for organ transplants: They are residents who smile, nurses who make you look good, attending physicians who point to you and then the extra seat at the table, classmates who work with you instead of beside you and the free cup of coffee that occasionally crosses your path.

Unfortunately, not all transplants are a good fit for the body in which they are newly-housed. Even with all the medications, sometimes the organ doesn’t take. Sometimes, the vein becomes thrombosed. Sometimes, the immune system rejects the organ. Sometimes, there are other things going on — other anatomical or social factors — that make it difficult to care for the transplant. The result is that one ends up right back where you started: on dialysis and with an uncertain future.

Though I am now halfway through my third year of medical school, time has done little to relieve the indecision with which I started. And so, maybe, like a transplanted organ, I feel lost. Similar to how one transplant is not always a great match for an individual, I am not a good fit for every service. The truth is that incompatibility is built into the biology of transplant. So, when things don’t go according to plan, maybe it’s no one’s fault: Maybe, that is completely normal.

Despite the fact that transplantation is not a perfect solution, I can’t help but recognize something magical in the procedure. Where there is sickness and death, transplants can provide significant improvements in quality of life. The transplanted organs adapt to startling surroundings. Despite it all, they survive, and in doing so, they can dramatically change the trajectory of a patient’s story.

As medical students, I think we all dream of playing this role. We want to change a patient’s experience for the better. We want to make the observation, sift out an overlooked detail in a medical history or provide an encouraging conversation that makes a difference. We are eager to be needed and wanted. Sometimes the ambiguity of our roles makes it unclear how to do this. But when those moments come, no matter how small or infrequent, they leave lasting impressions. Deep in the chaos of third year as we find ourselves flying awkwardly from one rotation to the next, we find moments when we belong.

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When I received my surgery clinical site assignment for third year, my eyes widened with fear and hesitation. For part of the rotation, I would have to experience trauma surgery: the one surgical specialty that was not on my to-do list. I began to question my competency as well as resilience to handle call days. I was already thinking of the worst.

On the first day, I met the lead student on the trauma team. Shifts began at 4 a.m., and since the hospital was an hour away, that meant I actually had to wake up at 2:30 a.m. She gave a tour of the trauma area, showed us the student room and explained everything the students were in charge of: patient lists, wound care, round notes, responding to trauma overhead announcements and call days. Apprehensively, I chose my first call day date and hoped for the best.

Later that week, I reached the hospital again carrying my overnight bag. As I walked to the staff entrance, it was eerily quiet. Only the dark sky and puddles of water accompanied me. Once in the student room, I grabbed the on-call phone and accompanying pager, sat down and began working on the patient list. The team met at 6 a.m. for the morning sign-outs. Afterwards, the previous on-call student was relieved, leaving me as the sole student until the following morning. It was alarming to think that if someone on the team needed help with a task, I would be the student to call.

The team then embarked on morning rounds. Going from patient room to patient room, I assisted in any wound care needed or ran to get the necessary supplies. Later, I returned to the student room and continued to update the patient list until the evening. Time passed and no trauma calls were heard. The door opened and the overnight physician assistant (PA) walked in the room. “We have an incision and drainage (I & D) surgery in a half hour if you want to attend,” he stated.

“Okay, I’ll be there.” A half hour passed by before I heard the first trauma announcement overhead. The pager buzzed at the same time and somewhat startled me. I grabbed the on-call phone, pager and shears and quickly walked to the emergency department (ED). Gowning a lead vest, I entered the trauma bay to find the PA already there. He gave a nod of recognition, and I felt an ounce of relief. Relief that I arrived on time and before the patient.

The other members of the trauma team followed, and we waited until the patient arrived. Emergency medical technicians (EMTs) appeared through the door and brought the patient in on a stretcher. He was involved in a motorcycle crash. Just like clockwork, the team assessed vital signs, airway, breathing, circulation (ABCs) and evidence of bodily injuries and gained peripheral intravenous access all within a few minutes.

“Sir, can you tell me your name? “Do you know what happened to you?” I asked. He became belligerent and demanded to be unrestrained. A decision was made to sedate him in order to better assess the degree of injuries. Little did I know, I would be suturing his eyebrow later that night in the ICU.

After the patient was appropriately cared for, I followed the trauma surgeon to the operating room (OR) for the I & D. Shortly into the surgery, his phone rang. Another trauma patient was arriving. This one sustained two gunshot wounds, and he would need an emergent exploratory laparotomy. The surgeon rapidly finished the I & D surgery, ripped his sterile gown off and ran to the trauma OR.

By the time I got to the other OR, the patient was already on the table. He was extremely nauseous and bleeding internally. Again, there was a packed room. Someone whispered to me that I should scrub in, and I knew I shouldn’t question that order.

One entry wound was found in the patient’s left arm, and the second was observed on the left chest. However, once the abdomen was opened, we found that the second bullet pierced the diaphragm and stomach, traveled through the small bowel in multiple places and stopped in the pelvis. The patient required immense work including multiple bowel resections. The warmth of the OR overtook me at one point, and I had to step out to drink some water. Even in the trauma bay, the rooms are kept warm for these types of unstable patients. The saying of blood, sweat and tears was coming to fruition in front of my eyes. Yet, it was remarkable to be a part of saving this patient’s life even if it was helping to retract and suction excess blood or fumes from the cauterizer.

Needless to say, my first on-call day was nothing I would have expected it to be. Certainly, it was a day of experiencing many firsts. That morning I arrived not having set any expectations for myself, but I left feeling fulfilled and encouraged. After two years of primarily being in a classroom, I had been brought into the real world of medicine, and it was enormously enlightening. I was slowly becoming familiar with some aspects of my role as a future physician such as becoming comfortable in the unexpected and at times, being placed into situations when immediate action was needed. This was a sign of many call days to come, and it was not so frightening as I had originally thought it would be.

Image credit: “155/365 – Pager of doom” (CC BY-NC-ND 2.0) by hddod

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Morning rounds passed without a hitch. I felt the usual: limited understanding and poor clinical synthesis. The residents assured me that this was normal. After morning rounds, my team, composed of the attending internist, a second-year internal medicine (IM) resident, a first-year radiology resident, and three third-year medical students, ascended to the computer lounge. We chatted about life as third-year medical students, patient conditions and the questions we wanted to ask our patients. We exchanged courtesy greetings with the team’s pharmacist, case worker and social worker.

We began our rounds. The mood was relaxed with a twinge of nervous anticipation as the students knew that oh-too-soon they would present their patients to the attending and then receive responding critique. We headed around the corner and arrived at our first patient. We prepared outside his room and reviewed his laundry list of co-morbidities and non-specific symptoms. Frequently, he had been in and out of the hospital over the past few months, and now, his wife was present to discuss his options. The patient was under methicillin-resistant staphylococcus aureus (MRSA) precautions; thus, only the attending and residents, donning gowns, gloves and masks, entered the room. I and the other medical students eavesdropped from outside the door.

Soon, we were jolted to attention by an overhead announcement, “Attention, code blue. Six south. Attention. Code blue. Six south.” No one batted an eye: my team and I were on seven north. “I wonder if we have a patient on six south,” wondered a fellow third year medical student. She glanced down at her pre-round notes and was mildly surprised. “Huh, I guess we do: I have a patient there.” Suddenly, her head cocked to the side, and she squinted. “Well, he could have become septic,” she postulated. Then, the second-year IM resident walked out of the MRSA patient’s room.

She looked distressed as she quickly de-gowned, de-masked and de-gloved. Immediately, she was on the phone speaking in a concerned yet quick manner. The radiology resident and the attending quickly closed the conversation with the patient and congregated with us. The IM resident briefed the team as the radiology resident took the mobile workstation to the elevator. The rest of the team headed down the stairs, around the corner and into a crowd of nurses. The IM resident took command and in a booming voice, announced, “We are the medical team in charge of this patient’s care. What’s going on?”

The nurses began to explain in choppy sentences. Apparently, about five minutes prior to our arrival, the patient’s nurse walked in to administer an injection and saw the patient sprawled across the short side of the bed: He was unresponsive. A code blue was called. Quickly, the triage team attached the electrocardiogram (ECG) leads, and a dangerous, yet shockable rhythm flashed upon the ECG screen. Just as the triage team was ready to shock, the patient’s code status was discovered to be ‘do not resuscitate’ (DNR). The team turned off the automated external defibrillator (AED), and the patient expired. When the blood cultures had been returned, they resulted in four out of four cultures positive for gram-negative rods.

Our team was in disbelief. The patient was seemingly fine last night and even this morning during my fellow third-year’s pre-round visit. He was a bit hypotensive but without change from baseline. He was a bit delirious but still oriented to time and place. He had been walking around and talking freely with the nurses the previous night. What could have happened within the last hour and a half for him to completely decompensate? The IM resident then confirmed the expected sepsis caused by bacteremia and exited the room. I looked at the patient and could only see his feet upright and hidden under the blanket. It was my first and last image of that patient.
Our medical team collected in the hall while the other team’s resident rushed to print the ECG strip. Understanding the situation, our attending responded appropriately “Alright, anyone want to take a shot at what we could have done?” We were silent. I wasn’t sure if this was because no one knew the answer or if no one wanted to acknowledge it. The attending went on to explain the proper management of bacteremic sepsis. He was also quick to note that specifically, in this case, he believed that no dose of antibiotics following admission would have saved this patient. We agreed in silence.

And with that, we moved on. The IM resident detached herself from the team to call the patient’s family members and inform them of the patient’s status. Despite its limited utility, she also offered the family the option of an autopsy. I checked my watch and saw that I had to be back on campus in ten minutes. I said pleasantries to our team and left. As I walked to class, I felt a sense of gloom. It wasn’t sadness, and how could it be? I didn’t know the patient: I had never met, talked to or even seen him prior to that day. It was more of a realization of the role vigilance will play in my medical career. However, vigilance would not be the only requirement. In order to be a competent physician, I needed to know how to cope with patients’ deaths.

Image credit: “MS” (CC BY-NC 2.0) by Popfossa.

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I used to daydream that my first patient as a medical student would be a happy, reasonably healthy elderly woman. The patient would tell me I reminded her of her grandson. I would let her show me pictures of her family, kept in her purse. When I eventually discharged her, she would take my hands in hers and smile. “What an excellent doctor you’ll make one day,” she would say.

Idealism blooms in the warmth of imagination; reality is usually less hospitable.

My real first patient was a cachectic and homeless woman with HIV who had been off of her antiviral medications for the past three years. She was in an altered mental status after using crack-cocaine. Her multiple, severe infections probably explained why she’d been, in her own words, “defecating for the past three days.” She didn’t use the word “defecating,” though.

The resident and I arrived outside her door, donning gloves, gowns and masks. I put the mask on incorrectly, so my glasses fogged up with each breath. I felt like an astronaut preparing for a spacewalk only without any training. We entered the room, walked to her bedside and observed her. I was no healer. And she was no patient of whom I’d ever dreamed.

She was E.T. with her dark, wrinkled skin stretched tautly around her over-sized head, her eyes barely open and her body aching for home. And we were the scientists staring down at her in our ridiculous hazmat suits full of wonder and awe. Only I did not feel wonder, nor awe. I felt dumb, uselessly staring at her through my foggy glasses. I felt ashamed for comparing my first patient to a fictional and notoriously unattractive alien.

And yet…

I imagined reaching my hand out to hers as Elliott and E.T do in the movie. Our hands would touch finger pad to finger pad, affirming to her that she was here with me, really, and to myself that I was here with her, too. I imagined our fingers glowing with warmth as they met, infections evaporating from her body and fear from mine.

I imagined her getting up and leaving the hospital. I would watch from the hospital window as she got onto the bike I’d left for her in the parking lot, rode into the clear, starry sky and then further away into the cosmos.

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Members of the medical community all know that patients shouldn’t smoke, but are there exceptions?

During my internal medicine rotation, a wiry young man with a long, scraggly beard had decided to discharge himself against medical advice. My attending had told us that this patient was there for “drinking too much.” As I was attempting to interview him, he was taking off the clothes the hospital had placed him in and changing into a Guy Harvey shirt, cargo shorts and flip flops from his drawstring backpack. He took out a lighter and flicked it to see if it still worked. As his hands were trembling, he took out a pack of cigarettes. As his voice began to rise, he told me he was getting out of there because he needed a cigarette “right now.”

I tried to distract him by saying we could see about that. In the meantime, I tried to talk to him. He had been diagnosed with schizophrenia although he didn’t believe the diagnosis. He had a tumultuous relationship with his mother, and he drank everything … everything: even cooking sherry as the salt didn’t bother him anymore. Through the changing of clothes, he made the transformation from patient to civilian, albeit for the IV hanging from his hand, and began to shake more violently. “If I don’t get a cigarette right now, I’m going to punch someone,” he said.

“Okay, I understand. One second.”

At that point, I got my attending. I was panicked by this uncertainty of what to do as this was the more human element of medicine that I wasn’t as explicitly taught in my pre-clinical years.

“Let him have a cigarette … Just watch him,” my attending said.

The head nurse watched him and me warily as we walked the stairs out of the hospital. “You make sure you come back with that thing in your hand!” she said skeptically. He assured her he would.

When I was a pre-med and even as a first-year medical student, I never thought I would spend part of my rotation making sure a patient didn’t run off with an IV in his hand to get lost in the hospital to end up with a nasty infection. He smoked his cigarette and came back so calm I almost wouldn’t have recognized him. He was ready to continue being treated after being shown a little kindness, some trust and a little lee-way for smoking a cigarette, which is often viewed as a hard stop in medicine.

If my attending hadn’t let him smoke that cigarette, the patient could have followed through on his promise and assaulted someone or at least brought chaos on the ward with his state of agitation. He could have walked out regardless of what we told him with the IV still in place and never returned or returned in much worse condition.

Sometimes, as a medical student, I wish medicine would simply allow me to follow the guidelines, removing the messy situations like turning a blind eye to patients sneaking cigarettes. It would be so much easier. I sometimes forget that medicine doesn’t exist in a vacuum and neither do my perceptions of patients or theirs of us.

Undoubtedly, tobacco and nicotine use is detrimental to one’s health and not recommended by anyone in the medical community. However, even though smoking a cigarette was not in the patient’s best interest, it was the best decision my attending physician could make for the safety of everyone on the unit. In this instance, flexibility in the ever-changing face of human suffering seemed to be the best panacea. Like the smoke from the cigarette, the permission given for this patient to use nicotine, which is a black and white issue in medicine, showed me just a little bit of grey.

The post I Need a Cigarette appeared first on in-Training.

Ten o’clock…

Eleven o’clock…

One o’clock…

My mind was racing with anticipation the night before I began my internal medicine rotation.

This is what being a doctor is all about, I thought as the hours ticked by. Diagnoses, evidence, groundbreaking trials and managing complex conditions.

I was nervous. Although internal medicine wasn’t my first rotation of third year, I still wanted to impress my attending and residents. I planned to arrive early to pre-round and collect a thorough history and physical so that I would have ample time to come up with differential diagnoses and a plan before rounds began.

Two o’clock … Sleep.

Five o’clock … Alarm bells ring.

Even without a full night’s sleep, I was ready and excited to hit the floors. I looked at the list of newly admitted patients with my residents.

Heart stuff, heart stuff, kidney stuff … Ooohh! Eye pain with possible blindness, I thought to myself. I’ll take the eye pain!

It was different and intriguing. Hopefully, I could follow through with my plan to impress today. The residents looked at each other knowingly, smiled at me and wished me good luck when I called out which patient I wanted to follow. At that moment, I wasn’t sure if they were actually wishing me luck because it was my first day or if there was some other reason that I would soon discover.

Step 1: Dry off sweaty palms.

Step 2: Use hand sanitizer — don’t forget hand hygiene!

Step 3: Knock on the door loudly enough to wake the patient.

Step 4: Enter the room and say, “Good morning Ms…”

“LEAVE ME ALONE! Everyone has been waking me up all night. I’m so tired. My eye hurts so badly. It needs to be closed. Get out of here and don’t come back!”

Step 5: Apologize and quickly back out of the room.

I slinked back to the nurses’ station where the residents were looking at patient charts. They asked me how that encounter had gone, and I could feel my cheeks turn bright red. I was embarrassed that I was not able to connect with my patient. What was worse was that I was kicked out of the room before I even finished saying her name. How was I ever going to give an impressive presentation on rounds?

I looked through the chart and did the best presentation I could, but it was far from remarkable. I felt like a failure, but more than that, I felt disappointed: disappointed that I couldn’t care for my patient, disappointed that I couldn’t give a good presentation and disappointed in myself.

After lunch, I squashed my disappointment and tried again.

Step 1: Dry off sweaty palms.

Step 2: Use hand sanitizer — don’t forget hand hygiene!

Step 3: Knock on the door loudly enough to wake the patient.

Step 4: Enter the room and say, “Good afternoon Ms…”

“Oh, it’s you again,” she chimed.

“Yes, it’s me again,” I replied. I tried to sound confident but felt my nerves creep up into my throat. “I can see that you’re in a lot of pain, and I was wondering if we could talk more about it so that we might be able to do something to help.”

She paused for what felt like an hour. “Alright, if we can talk quietly.”

That was it; I had my in. We sat and talked for a little while before I went back and reported to the residents. All of them seemed genuinely shocked that I was able to have a conversation with this patient. They repeated how they weren’t able to “get much out of her” and how she was a “difficult patient.”

What does the term “difficult patient” mean? Is it a patient who doesn’t do exactly what doctors want? Is it a patient who takes too long to answer questions or whose answers are too wordy? Is it a patient whose family member asks too many questions?

Why are we throwing around this label — which has no specific definition — to describe patients who take up too much time or are not always pleasant? It doesn’t seem fair that it only takes one provider using this label to bias the rest of the healthcare team.

Over the next several days, my patient began feeling a little better. As her pain decreased each morning, our conversations became more comfortable, livelier and deeper. The vision in her affected eye was still not good, but it improved slightly with each passing day. It became a running joke that she could distinguish a little bit better what colors I was wearing and if I had a necklace around my neck.

On my last morning with her before she went to the operating room, she asked me if she would get an eye patch if she went blind. I told her that I was not sure and then inquired why she asked. She wanted to know if her eye patch could have glitter and bedazzling on it so that she wouldn’t have to look like a regular pirate; she stressed that she wanted to be a pretty, sexy pirate.

We laughed for a good while about this. The moment was brief, but it lifted a weight out of the room. As the laughter subsided, both of us let out a sigh of relief. For several days, her room was filled with pain that was more than just physical. She had fears and frustrations due to uncertainty about her future, but with time, she found acceptance. One moment of acknowledgement that everything would be okay, even if she went blind, allowed her to attain comfort, hope and even laughter.

As I left her room, I couldn’t help but think that this “difficult patient” was actually very funny. She managed to find positivity in a negative situation: the potential loss of vision in one of her eyes. For many people, this situation would be one filled with grief and self-pity. For her, it was different, as she viewed it with humor and a silver living. I admired her greatly for this. I think about this patient often, especially when I hear of other “difficult patients.”

Lesson learned: Always be considerate.

Are your patients scared? Are they in pain? Are they frustrated? It is common knowledge that feeling unwell can completely change a person’s demeanor. In the hospital setting, there are many sick patients and many more patients who are waiting at the door, desperate for help. It can be frustrating when patients who come seeking help seem to be the ones adding barriers to their care by not readily providing a history, being willing to participate in the physical exam or other tests or complying with the treatment methods suggested. It is important to remember that the main goals of care are to help patients feel better and improve quality of life. Ultimately, taking a little extra time to assess for other factors that are making the patient seem “difficult” may help achieve these goals, strengthen the physician-patient relationship and may even save time overall.

After taking the time to empathize with patients, we should always follow up with one of the most important questions in health care: “How can I help?”

The post The “Difficult Patient” appeared first on in-Training.

My former pediatrician always had the brightest smile. She was an effervescent “people-person.” Between her and episodes of Grey’s Anatomy, I always thought that all physicians were outgoing butterflies flapping back and forth between patients and their vibrant social lives. Physicians are usually depicted as extroverts, and medicine a profession of the people.

And then, there is me. If I am ever at a party, one will find me with my back pressed against the wall hoping to skip the small talk and waiting to find one person who might be willing to do the same. Similarly, I hang back in large group conversations and prefer to listen rather than share. A few years ago, I read Susan Cain’s book entitled Quiet and realized I was not only different from my party-loving friends, but I was also the textbook definition of an introvert: someone who gains energy from alone time, prefers being thought-oriented rather than action-oriented and enjoys creating deeper relationships.

Although I have been learning to embrace introversion in my personal life, I still question how well introversion fits into the field of medicine. I question whether I should pretend to be an extrovert in front of patients and my teachers. Is it possible for introverts to succeed (and thrive) in medicine?

Recent studies have demonstrated that extroverts perform better than introverts during years three and four of medical school, which consist of clinical rotations. Medical school and residency interviewers may even favor extroverts, thus making these interviewees more likely to be accepted.

In group cases and rounds, extroverts have the edge as they tend to be more comfortable answering questions with limited information and processing time. For all of these reasons, evaluators may rate extroverts more favorably on evaluations than introverts.

While extroverts may perform better during clinical rotations, the skills in question may be narrow in scope. The traditional structure of monthly rotations can make it more difficult for introverts to have time to become familiar with staff, patients and the facility’s atmosphere. The introverted tendency for reticence may be mistaken for lack of engagement or interest. In small groups, introverts, even though they may be thinking deeply about a conversation, may be less likely to be “engaged” in the talkative sense.

Extroverted physicians are viewed as more personable, warm and assertive while introverted physicians are sometimes thought to be like real life versions of Dr. House: people lacking the ability to follow basic social norms and only having super-intelligence as a redeeming quality.

Cain, the author of Quiet, argues that society has an “extroversion bias” and also asserts that introversion is both undervalued and misunderstood. She elaborates by stating that introversion is not the same as social anxiety, lack of social skills or even a need to be around other people. Cain encourages all individuals to embrace their natural personalities and argues that introversion confers its own unique benefits.

Despite the popular culture portrayals of gregarious and outgoing physicians, there are actually more self-described introverted physicians than extroverted ones. A Medscape report surveying over 15,000 physicians found that thirty-five percent self-identified as introverts, and only twenty-eight percent identified as extroverts with the remaining respondents reporting to be somewhere in between.

Additionally, there is increasing pressure to evaluate prospective medical students based not only on standardized examination scores and GPA, but also on personality test results. While these changing admission standards are well-intentioned, medical school acceptance committees should not conflate introversion with a lack of interpersonal skills.

Despite these potential disadvantages of being an introvert, I am uncomfortable portraying a false extroverted persona. At the same time, I recognize my introverted tendencies leave room for growth.

As I try to reflect on and constructively review my behavior and responses, I have become committed to maintaining this self-awareness. Constantly, I remind myself to introduce myself to other hospital staff members even though it has never felt natural to go out of my way to speak with passersby. I now contribute more to small group cases by thinking aloud and answering more questions. I am working on filtering and synthesizing information to give confident oral presentations in stimuli-saturated environments.

Even though extroverts may feel more comfortable in group-settings, I find my introverted leanings to be most useful in front of one person: the patient. While there is always a little small-talk, we usually dive right into the important topics. After all, these conversations often involve matters of life and death.

Sometimes, I feel as though I should be more like my witty, charming pediatrician who I grew to admire. However, I also feel as if my introverted instincts such as careful processing and leaving space in conversations for my patients to speak have been critical for building rapport with patients. While extroverts may make their patients comfortable through humor and warmth, introverts may instill the same level of comfort to their patients through active listening, reflective thinking and compassion.

Whether introverted or extroverted, everyone finds some actions and behaviors more natural than others. I am still finding my individual path and appreciate that medicine provides moments of both unfamiliarity and comfort. For better or worse, introversion is and will always be a part of me and my practice as a future physician.

The post Embracing Introversion in Medicine appeared first on in-Training.

I just finished my two month surgery rotation, and as a third-year medical student new to the wards, I had a steep learning curve. One of the things I learned the hard way, causing me to nearly cry during rounds, was how to properly present a patient’s history and physical examination findings.

The Preparation

Extracting relevant clinical history information from a patient for the first time was not an easy task for me. Heightening the difficulty was my uncertainty about whether the questions I was preparing to ask were capable of pinpointing the correct diagnosis. However, when I was called upon for duty, I played my part. I asked the questions and received relevant answers that allowed me to narrow down the differential diagnoses on my list … at least, in my opinion.

The Excitement

I thought that I had completed all that was required for a comprehensive history and physical examination: facts about present illness, review of systems, inspection, palpation, percussion and auscultation. If I arranged my negative and positive findings neatly, I thought that I would be able to confidently determine the correct diagnosis of the newly-admitted patient and impress my seniors and the attending physician, who was a consulting surgeon, during rounds the following morning.

After all this and a thoughtful review, I finally fell asleep rather late that night. I had been busy assimilating the patient’s information and thinking of answers for the potential questions or critiques that may be hurled towards me by the attending physician in the morning. Even though my exhaustion allowed me to fall asleep, when I woke up the next morning, I realized that I had never conquered the fear I felt leading up to my first bedside presentation. However, I said to myself, “Let the sun rise.”

The Pause

I presented a case of a newly-admitted 70-year-old female patient with a chief complaint of intermittent severe pain and swelling in the right upper quadrant for the past three months. My presentation of the patient’s history was flawless as I read it aloud to the team during rounds. Anticipating the storm of questions that may be awaiting, I presented one fact after another, pausing in between each new piece of information during the subjective portion. No questions so far … phew!

Unfortunately for me, the consulting surgeon knew the patient very well as they had met prior in the surgical outpatient clinic, and he already knew her diagnosis. Fortunately for the surgeon, he did not have to solely rely on the information I was sharing with him. He began to ask questions as I presented the physical exam.

The Questioning

The first question posed to me by the consulting surgeon was, “Student Doctor Mlay, could you show the locations of the dorsalis pedis and posterior tibial arteries you just mentioned on your physical exam findings?”

“Anatomy. Oh great, I have to get in my mental time machine and travel back to the first year of medical school,” I complained in my head.  Pausing for a bit, I directly and correctly identified the locations of the two arteries … with mild self-assurance.

“Okay, good,” said the consulting surgeon. “Now, how can we tell if the swelling is intra-abdominal or simply fluid that is third-spacing in the abdominal wall?”

“Oh! That’s a tough one,” I thought.

Luckily, this question was directed to the group at large; he didn’t specifically ask me, and it was my first presentation, so I kept quiet. No one on the rounding panel knew either, so we all stood there in silent solitude hoping that we would not be called upon individually for the answer.

While scanning the faces of everyone in the group, the surgeon stood there and finally focused his gaze on me while grumbling in disbelief, “Kids these days don’t study.” With a sigh, he then went on to explain how to examine abdominal swelling and how to determine if it is indeed of intra-abdominal origin.

I finished the objective portion and continued until I had reached to the assessment part of the SOAP presentation. I stated what I thought was the most likely diagnosis, which was carcinoma of the gallbladder.

Then, the consulting surgeon interrupted me with a question: “Student Doctor Mlay, do you think your clinical history and examination lead us to the diagnoses you just mentioned?”

I nodded and reaffirmed what I believed to be the most likely diagnosis: gallbladder carcinoma.  

He agreed and explained the high likelihood of of gallbladder carcinoma in this patient. He put in some orders, and then the panel moved on to another patient.

As the surgeon caught up with me by the patient’s door, he said, “Allen, you really tried your hardest presenting today, but nothing you said painted a compelling picture of the patient’s most likely diagnosis. In the future, try to emphasize the points that you believe make your suspected diagnosis the most clear.”

“Yes sir,” I replied. Even though I wanted to explode with explanations about how I hadn’t slept very much the night before because I was preparing for rounds, I guess that I could not blame the amount of sleep I had for my less-than-ideal presentation. Therefore, I still needed to perfect my clinical history-taking, examination and presentation skills.

The Struggle 

In the days following that first presentation, I performed a heavy literature review of any clinical skills tips I could find on the internet. I read chapters upon chapters about performing and presenting the clinical examination, and I practiced incorporating even the tiniest suggestions. My attending was right; I had presented unorganized information then forced it to fit a possible diagnosis. It took me a great deal of study time to understand that, and it was worth it.

I am still learning about what skills make a great doctor. My first presentation was a struggle because I had to prove to myself that I could get through it and that I will be a master of clinical examinations one day… even though I don’t yet know the exact date.  For now, it is time to listen, watch and learn one new clinical skill at a time while understanding that as a student, I am not expected to be perfect, but I am expected to continue learning, observing and perfecting my skills.

The post My First Lesson from the Wards appeared first on in-Training.

Editor’s note: In accordance with HIPAA, all names and identifying details have been changed to protect patient privacy.

I was starting my surgery rotation, the second rotation of my third year, on the colorectal service. It was my first 24-hour on-call shift, which meant that my team would be responsible for multiple surgical services overnight. I anticipated this shift with mixed emotions having just watched a fellow medical student leave her overnight shift. By that, I mean she stumbled out of her overnight shift. While I feared the inevitable caffeine crash and my reflection in the mirror the next morning, I nevertheless looked forward to experiencing the balancing act of managing numerous services, which included the gastrointestinal surgical oncology service.

In the middle of the night, the resident received a page from a nurse requesting that the team counsel Bob, a patient with pancreatic cancer, about his future appointments because he had many questions. The resident was busy juggling several different patient concerns, so he directed me to Bob’s room to be the first line of defense.

When I entered the room, Bob was preparing to get out of bed to use the restroom. He was so frail and thin in his hospital gown. The mere sight of him reminded me of a small child wearing his father’s T-shirt and swimming in cloth. As the nurse prepared syringes for his intravenous therapy on the other side of the room, I held out my hand to help Bob. He adamantly refused, asserting that he could do it himself. On taking his first step, his legs buckled, gravity pulling on his upper body until he toppled into my arms.

As he struggled to rebalance himself, he tearfully moaned, “What’s the point? I’ll be dead in a month anyway.”

With his body quivering in my arms, I froze. Moments passed before I thought to reposition him in the bed until a nurse could aid me in supporting him as he walked across the room. I remained mute and paralyzed from the sudden epiphany that there was nothing I could say or do to erase the inevitable truth that Bob was dying. As more nurses and the resident entered the room, I quietly excused myself, rushed to the staff restroom and burst into tears as soon as the door shut behind me.

Like a towering wave upon a beach, the weight of all of my emotions crashed over me, and questions rushed through my head.

What’s the point of what? Of medicine?

What even is my role if not to cure disease?

What kept me from saying “I understand” or “I’m sorry, sir” as I stood there motionless?

For days, these questions plagued me making me feel powerless and profoundly disappointed in myself for not having been present for Bob when he needed someone most. When I thought of Bob, images of my own family flashed into my mind. When I imagined Bob trembling on the edge of his bed, I remembered my dad who was paralyzed from cancerous lesions in his spinal cord attempting to swing his legs over the intensive care unit bed to walk during the hours before he passed away.

Memories of my mom and brother listening to him and comforting him reawakened the sense of sadness and helplessness that I felt in that moment which was the same as I had just felt with Bob. I thought of how lucky my mom, brother and I were to have been with my dad. I thought of how lucky my dad was to have had us. Bob had no one. I was ashamed that, in leaving Bob’s room, I had put my emotions first as if they were more important than his, and that I had left him alone when he had no family of his own.  

That whole week, I tossed and turned as I lay in bed wondering whether I should go back to him. To apologize? To show that I cared without pitying him? To assure him that no prognosis is definitive? Ultimately, I never returned to see Bob; my rationale was that he wasn’t on my service after my on-call day and that nothing I could do would help him.

Now that time has passed, I am able to reflect back on my encounter with this vulnerable patient. I recognize that the point of medicine really is not to become the arbiter of life and death; it’s about being present for patients in their times of need. If we lived in a world with time travel, I would have sat on the bed next to Bob while the resident and nurses entered the room. I would have remained silent for as long as he needed to mourn and grieve.

I realized that the uncomfortable conversations will likely never become more comfortable for me and that I may never convey how much I care with a simple “I’m sorry.” The act of listening has more power than any words can communicate. In times of distress, there is always a reason to revisit the patient, and there is always a way to help.

When necessary, relinquishing control over patients’ health to be a better provider seems incredibly difficult for all of us to do, either because of our own past experiences, our fear of failure or our preferred ignorance. As student doctors, our role is not to simply cure disease; it is to alleviate suffering in whatever seemingly small ways our patients may need. It is with this mindset that I will be approaching not only the rest of my third year, but also the rest of my career.

Image Credit: “P1090144” (CC BY-SA 2.0) by rkimpeljr

The post An Encounter Cut Short: A Lifelong Lesson appeared first on in-Training.

In the third year of medical school, book smart but clinically naive learners are thrust into the daily routines of the hospital and outpatient clinics and are suddenly expected to assist with the care of real patients while learning on the job. It’s a difficult year in every sense, and entering this crucible of learning naturally incites a mix of confusion, excitement, apprehension, anxiety and horror. I’ve been asked by medical students in the classes below me about my third year experiences. Every student’s experience is unique, but listed below are the things I’ve discovered along the way that have helped me survive and even enjoy my third year. Hopefully, they will prove helpful to you.

1. You will cry. It is inevitable that the highs and lows of third year will evoke the full spectrum of emotional responses. I’ve fought back tears watching parents welcome their babies into the world and watching children grieve over their dying parents. I’ve cried in the bathroom hiding from my team until I composed myself after being yelled at by an angry patient who didn’t want me participating as a part of the care team. I’ve cried in the car driving home from the hospital due to sleep deprivation, hunger and the prospect of a 45 minute commute. When your emotions well up, remember that you’re not the first or last medical student to feel that way, then find whatever helps you process and move on after those moments. Debrief the difficult family meeting with your resident or attending. Write down the moments you’re thankful for and re-read them when you have a discouraging day. Find a soundtrack for your commute that lifts your spirits. Reset your mind with a work-out at the gym, dinner with a friend or an episode of your favorite show.
2. You will find your people.  It may take you a few rotations, but you will find others who share your passions, your perspective on medicine and your sense of humor. You may find closest friends among fellow medical students, residents, attending physicians, social workers, nurses or administrators, and you may find them among more than one specialty. When you find them, they will mentor you, gossip with you, laugh with you and watch out for you. If you haven’t found them yet, keep looking! The sense of belonging you will eventually feel is worth the wait.
3. Residents and attending physicians are people too. Since they’re only human, give them grace. They’re typically more sleep deprived than you and have far more responsibility. Ask what you can do to help them out. Thank them for the time that they take teaching you. Bring an extra sachet of your favorite kind of tea or a sweet treat to perk up their afternoon in the physician lounge. The occasional plate of cookies to share with the team is not expected but definitely appreciated.

As time and clinical demands allow, I would encourage you to ask your attending physicians and residents non-clinical questions because these conversations will help shape your professional identity. I’ve had some really interesting conversations with these supervisors and teachers about questions such as:

“How do you see your personal spirituality or faith intersect with your medical practice?”

“What led you to choose your specialty?”

“What advice do you have for someone who is undecided on a career trajectory?”

“How do you approach a difficult patient or family member?”

“How do you think medical trainees can combat burnout?”

Be on the lookout for opportunities to learn from the life experiences of your teachers.

4. You are ineffective if your mental health is in shambles. You only have so many free hours in the week, but some of those should be set aside for self-care actions such as going to the gym, adding on an extra hour of sleep instead of another UWorld problem set, making healthy food or meeting up with friends whenever possible. For me, it meant attending church on Sundays and a weekly Bible study, meal prepping healthy-ish foods on the weekend, keeping a gratitude journal and following a consistent sleep schedule that allowed me seven hours of sleep most nights. I found that I learn better when I’m valuing my mental health.
5. Remind yourself frequently that you belong. “I belong here” became my silent mantra during my rotations, and I believe that reminder to myself helped me address my own feelings of impostor syndrome. You are not an outsider; you are a contributing member of the care team. You are not inadequate for the task. You were made for this. You have trained and prepared for these moments. This mindset is rooted in sports psychology. Athletes who see an event as a challenge to overcome perform better than those who see an event as a dangerous threat to their abilities. Likewise, you will perform better if you have the mindset that you are up to the challenge. Stay humble, but approach third year knowing that your first two years prepared you for the challenges ahead.
6. Be teachable. Walk into the hospital each day with the conscious mindset that you are there to learn. Armed with this attitude, when the attending doctor criticizes your knot-tying technique or your inability to name ten causes of post-operative fever, you will accept the critique more gracefully because you primed yourself with the mindset that you are there to learn and improve. Study hard to know that answer for next time, but don’t expect yourself to know everything yet. Ask for feedback with a genuine desire to discover how you can improve for next time. Ask questions for the sake of learning and taking better care of your patients, even if it’s not a “high yield” topic for your upcoming shelf exam. Medicine in the real world isn’t a multiple choice exam, and your patients will rarely present like the textbook. Cultivate genuine, intellectual curiosity, and you will end up learning more and being better prepared for the next patient you see.
7. Have fun. Joke with your team. Follow interesting cases. Familiarize yourself with your patients’ journeys, not just their past medical histories. Think back to all of the work you have put in to get to where you are now. While it is your job to work hard and do well, it is your responsibility to soak in every moment and enjoy the experience. Never again after your core rotations will you see such a wide spectrum of medicine: from pediatric check-ups to in-patient psychiatry to colorectal surgery. Try to appreciate the novelty of whatever each new week brings, and enjoy the ride.

Your third year is, perhaps, the year of the greatest personal and professional growth that you will encounter in all of your many years of education and training. No amount of advice will make it an easy year, but hopefully following these tips will ease the transition and help your third year to be your best one yet. You are laying the foundation of who you will become as a physician, and for that reason alone, it is a task worth doing with the best of all that is in you.

The post How to Make Third Year of Med School the Best One Yet (or at Least Survivable) appeared first on in-Training.

Medical school is scary.

Intimidating.

Daunting.

Sometimes I wonder how I am standing here,

Already in third year,

Still thinking they made a mistake by letting me in.

I was born and raised in Mexico and only spoke Spanish until I was about fifteen years old. I moved to the US in high school, struggled because of the language barrier and lost my confidence. I got into medical school in my late 20’s through a bridge program because my MCAT score, especially the reading part, was not good enough.

Somehow, I managed to make it through my basic science classes and eventually finished second year. Then the USMLE Step 1 happened. I do not believe I have ever felt so inadequate as during this time. I studied passionately for twelve to sixteen hours every day for five to six weeks only to find that I ran out of time during each block in my exam because my English reading proficiency will never be like a native speaker. My comprehension will always take me a little longer. Even before getting my score back, I felt like a failure, since I knew I could not perform to my potential and that took a toll on my confidence.

Soon after, I started rotations. The nervousness combined with excitement kept me going for the first couple of days of my rotation, but that feeling of failure followed me. I had to relearn another language of OB/GYN acronyms and was daunted by all the things I did not know and the responsibilities I felt like I could not accomplish. Then, an attending forced me to present a patient who I was not familiar with and proceeded to demolish me in the middle of rounds with other students, residents and nurses to witness. A lot of what he said is a blur, but somewhere I remember he said he could not understand what I was saying because of my Spanish accent. That is when I realized I should not be here. Immigrants are not supposed to go to medical school, they are supposed to find a stable job, have a family and give their children an opportunity to grow up in this nation and live the “American dream,” right?

What am I doing here?

Should I even be here?

The medical student impostor syndrome had never been stronger or more discouraging. I was so afraid about faculty finding out about me and dropping me from the program. The impostor syndrome I experienced was extremely debilitating and, at some point, it handicapped my performance in my rotation. I even doubted the way I walked; I constantly looked at my badge to make sure it said Ana Meza-Rochin and not someone else’s name. I even told some doctors that I would rather shadow and observe instead of seeing a patient on my own because I felt so afraid and incapable of doing so whereas, a few months back, I would have fought to be given the responsibility and opportunity to show them what I could do. I was not that brave girl who fought until she reached her dreams anymore. I was a different person.

Thankfully, I had great preceptors who taught me with patience and made me feel comfortable doing basic tasks such as finding a baby’s heartbeat with Doppler ultrasound, measuring fundal height or asking simple OB questions. Later, I was sent to see a new OB patient by myself. She had a Hispanic last name, and her mother accompanied her. When I walked into the room the patient spoke to me in English, and I followed along. I did the typical questions and physical exam, and then the midwife came to see the patient.

As the midwife asked the patient about information in the chart, the patient’s mother, who had been carefully observing me and looking at my badge, whispered to me, “Do you speak Spanish?”
I moved closer to her and away from the other conversation and whispered back, “Yes.”

Smiling, she asked, “Are you from Puerto Peñasco?” She was referring to a small town in Mexico.

Confused, I said, “Yes.”

Before I could ask her anything else, she asked, “Is your mother Dr. Rochin?”

I stood quietly for a couple of seconds in denial echoing that faintly familiar name in my head, kind of like trying to recall a dream. “Yes,” I answered.

“Your mother was my doctor in Mexico, and she delivered my children including her,” as she pointed to the patient. “It is amazing to see the daughter of my doctor taking care of my daughter and her child.” She said that with the biggest smile and with tears in her eyes.

Speechless, I walked out of that room and sobbed. Something happened to me at that moment. First, by reminding me who my mother was, I was reminded of who I was, which I felt like I had forgotten. Second, I was reminded of the “why.” It was like something fell from my eyes that allowed me to see further than my own frustration, fear and feelings of worthlessness. I understood where I was coming from, what it meant for me to be standing there regardless if I felt competent or not and where I was going. The what am I doing here? question due to feelings of inadequacy became more like a WHAT AM I DOING HERE? out of excitement for doing the impossible.

My mother’s school badge

Immigrants often do not get the chance to stand on the top of mountains of opportunities, of distinguished careers, of success, of believing they can do anything they can dream of not only for their children but also for themselves. I realized I had been focusing on all the things I did not know–on all the ways I felt awkward, not ready, not worthy, helpless–instead of focusing on how far I have made it, the great privilege I have to be training to be a doctor, all the lessons hidden in each day’s struggles and the new adventures awaiting me tomorrow. That just blew my mind.

Third year is a fun, hands-on year, but also a very challenging one. Challenge comes in different forms and directions for each student, and sometimes it feels that we are the only ones going through adversity. I believe it is important to focus on the “why” and on the good. Always look forward, but also look back. Looking back is an essential reminder of the great obstacles that we have overcome, all the growth we have endured and all the things we now know. It is hard to realize those things when we are only surrounded by great physicians who constantly challenge us to think more critically and ask more of us each time to make us better doctors. Looking back reminded me of why I am devoted to where I am going and thankful for the challenges that have brought me to where I am.

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As a third-year student early in my medical training, I exist in the space between patient and physician, identifying with neither fully. This unique position allows me to learn the practice of medicine while also introspectively remembering the patient’s perspective. The space between has become most apparent to me in my experiences with antenatal counseling.

The goals of antenatal counseling are to prepare patients and their families, inform them of possible medical complications, share associated risks and benefits of treatment options, and provide an understanding of survival outcomes. In some cases, this counseling primarily prepares the physician-patient relationship for future decision-making in the antenatal and postnatal periods. In its best form, the shared decision-making model involves the exchange of the physician’s knowledge and patient’s values so that they can make informed medical choices together.

I was recently observing a counseling session and listening as the neonatologist recited a litany of possible consequences: prematurity, trajectories and associated interventions for each gestational age. I listened to the possibilities of intubation, extracorporeal membrane oxygenation, the risks of intraventricular hemorrhage, bronchopulmonary dysplasia, necrotizing enterocolitis, total parenteral nutrition or gastric tube feeds. Amidst the downpour of information, I looked into the eyes of the mother across from me, and I began to think of the other mothers with whom I had spoken over the past year. I began to consider the medical decisions that they had made for their unborn children.

Attempting to meet her gaze, I realized that her wide eyes were fixed, set looking simultaneously everywhere and nowhere. Her eyes betrayed the reality that she was drowning in information and swept up in the deluge of emotion. As the counseling concluded, I heard the hollowness of the physician’s words echo without the patient’s presence: the time when counseling ceased to benefit the patient.

This experience elucidates the reality that the training to become a physician is not only about acquiring knowledge, but also learning to impart that knowledge upon others–most importantly, our patients. But, in this process of knowledge transfer, is it possible that the information we deliver becomes akin merely to the terms and conditions of a software agreement, the obligatory pop-up hastily scrolled through and accepted by the user–in this case, the patient?

As future physicians, we must share these terms and conditions, which include poor outcomes, complications and side effects among other information, as part of our moral and legal obligations of care. But when do these obligations force us away from our commitment to care simply as humans bearing witness to another’s experience?

Over the last year, I have had the privilege of speaking to parents about their experiences with complex pregnancies. In these interviews, I realized how families struggle to approach and integrate information provided by physicians. This difficulty is compounded by time constraints, stratified by education and socioeconomic status and intensified by patients’ previous experiences with health care. Furthermore, the conversations alone threaten the framework of expectations and the hopes that patients had for healthy pregnancies and babies. For many families, weeks of reassuring ultrasounds and predictions of routine care were instantly dismantled by new imaging findings.

Some families further created a dichotomy between information provided by the medical team and hope itself. But for most, the spectrum of outcomes predicted by the physician did not affect a parent’s hope for an outcome outside of what was medically anticipated. Parents’ hope could not be contained by prognostication. One mother said to me, “Doctors need to give us facts and hope: our hope makes us human.” Implicit in this mother’s statement was her innate need to preserve hope.

Physician counseling not only challenges hope, but also does not appear to offer any true meaning to patients. One parent explained, “I didn’t listen; I didn’t think those bad things my doctor shared would actually happen to me.” To her, all of this doctor speak was just amorphous. In other words, medical prognostication is inherently impersonal. I recall one mother was particularly frustrated because she felt doctors could not answer her seemingly simple question: what would her baby be like? Another asked, “What will be my child’s experience and what will my experience be raising my child?”

Each mother struggled to conceptualize her child’s cognitive and physical abilities despite physicians sharing a great deal of technical knowledge and data. Therefore, many parents sought out the stories of other parents like themselves on social media and medical blogs, searching to understand the lived experience of a particular potential disease process. For some, this provided comfort; for others, this created new fears, medical misunderstandings or false expectations.

As I watched parents look for answers outside of their physicians, I was reminded of a question in philosophy: the “redness of red,” examined in Frank Jackson’s (1986) thought experiment concerning epiphenomenal qualia as a refutation of physicalism. If someone who has never seen red were provided with complete knowledge of red, would a person still learn something new when experiencing the color red? In the parent experience then, is the lack of parent understanding during antenatal counseling because the very redness of red – the lived experience of one’s child – is so personally and experientially grounded?

Foremost, descriptions of various diseases–ones compounded by a multitude of unknown factors–make the physician’s attempts to explain red incomplete. Ultimately, parents are not interested in objective information about red; instead, they seek the experience of redness in all its colorful glory. They do not want data about their child; they want their child.

In our desire to provide concrete information and explanation, we as physicians often create  meaning akin only to terms and conditions. Our attempt to educate is often received as a blur of data so daunting and foreign that patients inevitably skim through it, click accept, and remain lost.

The families’ ability to comprehend antenatal counseling is, understandably, compromised and stymied. One father captured the complexity of multiple care trajectories and uncertain outcomes in simple terms: “When you plan for everything and anything, you truly plan for nothing.” It seems that the families dealing with complex pregnancies still do not know what to expect when they are expecting.

I wonder if we are able or even equipped to give parents what they need and desire when it comes to antenatal counseling. Perhaps it is our lack of experience that prevents us from imparting true understanding. Do the cases that defy the predictions of even the most seasoned physicians make us wary of certainty? Maybe we impart appropriate uncertainty given the inherent limitations of our technology to accurately predict fetal outcomes to the degree parents’ questions require. Might we actually shy away from the unsavory and colorful details to preserve hope for families? I suspect the answer is yes, yes to all.

I have been thinking about how these experiences will shape my own practice. What will be my role? How am I to provide counseling, the kind that imparts understanding and maintains the need for hope? I don’t pretend to have an answer today. But I hope that someday when I must impart a poor prognosis, I will notice the patient before me and honor the complexity of our relationship.

I hope to avoid my knowledge and news becoming akin to terms and conditions, where all of the ‘anythings’ and ‘everythings’ amount only to ‘nothings.’ My goal is to foster personal meaning and understanding so that together we can navigate the complexity of prognostication to make informed medical decisions.

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