On My Birthday

A Letter to Baby Me, from 30 Year-Old Me

Dear Catharine Jane,

A good friend said to me very recently, "if I only knew then what I know now..."  We usually do not have the benefit of hindsight to help us live in the present, but I think that we can still learn a lot by paying attention to our own story, by telling it, by writing it.

Dang, you were a cute kid.  I look at the picture above and I find myself moved with compassion for you.  It is amazing how much easier it is to think of myself with kindness and gentleness when I look at you like that.  I want to protect you, I want you to be happy, I want people to show you love, I want you to have true joy in your life. 

Look at your mom's hand, holding onto yours.  Probably both because she loves holding her baby's hand and also to get you to hold still.  You are pulling yours away, probably both because you want to move around and explore, and also because you just hate being told what to do.  See the ring on her hand?  That ring was her grandmother's, passed down to her mother, who then gave it to her.  She will give it to you, too, on your twenty-fifth birthday, and it will be your most treasured possession. 

You come from a big tribe that values family above all else.  You are named for both of your aunts - your dad's only sister and your mom's only sister.

You will be the oldest of your parents' five children.  You will be the big sister and live up to just about every stereotype in the book.  You will be bossy.  You will make your brothers play dress-up in your mom's skirts and heels and lipstick with you.  You will share your room with one brother and you will play dolls together when you are supposed to be napping.  You will fight with your siblings.  You will scream at each other.  You will punch, slap, pinch, kick, and pull each others' hair.  You will tell on each other.  Your fighting will make Mom cry.  You will build Lego pirate ships with your brothers and help them catch tiny baby lizards in your backyard.  You will be your first sister's most enthusiastic babysitter, and you will perfect your diaper-changing skills on her.  You will suggest to your parents what country they should adopt your second sister from, and when she is matched with your family, you will show her picture to everyone in your junior high school.  You will want to kill all of them at some point or another.  But you will also be ready to kill other people on their behalf, if you ever think that anyone has harmed them in any way - the girl who will once stand your brother up on a movie date before he is even old enough to drive, for example.  Mom will actually be worried that you might track her down and beat the crap out of her, you will be so mad.  You will graduate from high school swearing that you don't ever want children of your own, but as soon as you do, your relationship with your siblings will begin that magical transformation that happens as people grow up - you become friends.  And just like that, they will become the most important people in your life (which is something you always knew, even if you couldn't admit it.)

You will go to college and hate it.  You will experience some of the hardest times of your life there.  You will stick it out, though, because you are tough, and you will discover that this is true as a result of having lived through those experiences.  You will suffer depression and you will recover.

You will love wildly and you will have your heart broken into a million glittering pieces.  You will discover how happy dancing makes you.  You will travel the world by yourself and with other people, and you will learn a thousand important things in the process.

You will eventually discover - to your simultaneous relief, joy and horror - that your calling is to be a doctor.  You will forget this a few times.  You will consider trying to talk yourself out of this.  You will regularly feel frustrated that you couldn't be called to do something fulfilling that required a little less in the way of hard work and sacrifice.  But you won't, for the life of you, be able to imagine what in the world that could possibly be.  

You will do hard things.  You will live through them and survive them.  You will be stronger because of them (even though that is such a cliche - and you hate cliches - it is true.)  You are brave.  Mom says that you are ballsy, and that you have nerves of steel.  She will tell you that you should be a surgeon, long before you will ever even consider going to medical school.  You are creative.  Abby tells you that you should be a writer.  By the time you are my age, one of your regrets will be that you never published anything in time for her to read it before she developed advanced Alzheimer's disease.  But take comfort in knowing that if and when you do someday write that book, you can still dedicate it to her, and I think that she will still know.  You love people fiercely.  Your soul is fed by your loved ones, and cultivating relationships with others is your joy.

I do not have this all figured out.  Far, far from it, actually.  But that's ok, and you know how I know?  Because I have never had it figured out.  Occasionally, I have felt that maybe I was close, but I usually wasn't.  And it has always been ok.  There is still so much in life that is uncertain and hard.  But you are a lucky one, kid.  You won the life-lottery when it comes to your family.  You've got more than enough brains and talent to get you where you are going.  You have more than your fair share of passion, curiosity and enthusiasm.  And even better, even more important, even more humbling - you are wildly loved and adored by your Heavenly Father.

Here is my life advice for you: give people big hugs.  Cook dinner with friends often.  See your family as much as you can.  Go dancing, even when you don't feel like it (maybe even especially when you don't feel like it.)  Take deep breaths.  Pray as often as you remember to.  Trust that there is a plan for you, and that it is a good one.  Take my word for it - you will end up doing things you never thought possible.  

Well, This is Just About the Cutest Thing Ever

So far this week, I have had patients who have been 87, 88, and 95 (all women).  The two older ones are just as sharp as tacks, and the two younger ones are just as sweet as they can be.  :)  Interviewing them can be tough and time-consuming, because they can be pretty hard to understand (none of them have many teeth left), but ohmygoodness is it worth it.  Hysterically funny and totally adorable.  It has been especially cute and hilarious how many of our senior lady patients have had not-so-secret crushes on the two young male doctors on our team this month.  

I randomly came across this ridiculously sweet video today (which is in no way related to my most recent post and only because I have had so many precious octogenarian patients recently) and thought I'd share.  It's short - enjoy!  :)

Marrying At 100
from Zack Conkle on Vimeo.

On Turning 30

It sucks and I'm freaking out about it.

There, I said it.

I really wish that I didn't feel that way, but I do.

I really wish that I could be all, Yeah! 30 is the new, like, awesome something-or-other, and I feel great about life, and I am so excited for this new decade that's gonna be the best yet, and I'm so comfortable in my own skin, and I am so much more me now, and I am sure that I have nothing but great happiness and wild success just around the corner, now that I'm 30, and blah, blah, blah blah blah.

But, I don't feel like that.  At all.

I actually think stuff that sounds like that is really effing annoying.  I also think people who say stuff that sounds like that are usually full of sh*t.

On the other hand, I find people who constantly complain about being so (fill in the blank here - old, poor, single, tired, stupid, fat, unlucky, whatever) to be just about equally as undesirable to be around for any time at all.  And, as much as I realllly dont want to be one of those people I despise so much for their obnoxious and whiny woe-is-me attitudes, I am ashamed to admit that I have been one of them, more and more often lately.  I have probably thrown a personal pity-party for every single one of the above reasons in the last week alone.  It is totally gross.  And absolutely, horrifyingly embarrassing to admit.

But, because one of my little personal challenges - and, actually, one of my new year's resolutions this year* - is to be less sarcastic and more sincere (which I think encompasses honesty and transparency and authenticity, including in what I share here), I am just going to come right out and own it.

I am not super excited about turning 30.

Which, honestly, feels really sad for me.  But it's the truth, so there you have it.  And it has so much less to do with 30 as an age or a stupid number or some sort of milestone, and it has so much more to do with just where I am in my life.

I am definitely not speaking for all people about to turn 30, or all women about to turn 30, or all women in medical school, or all single women, or med students, or people who own dogs, or people who have a thing about loading the dishwasher a certain way, or whatever.  I am only speaking for me.  It's not really about 30, and I do realize that it sounds stupid and silly and dramatic.  This is just what I am thinking and how I am feeling, right at this point in time.  

Life in medical school is equally awesome and sucky on most days.  I can literally go from "This is the greatest thing ever!" to "I hate my life, what was I thinking" in the span of an hour.  I can often think the same subject matter is either fascinating or coma-inducing, depending on my mood and how much caffeine I have recently had.  

I have probably eaten cereal for about two-thirds of my meals this week (I eat real lunches at work because it would be too embarrassing to bring cereal.  Otherwise 100% of my meals would probably have been cereal.)  I have also eaten ice cream for more than two dinners in less than two weeks, and tonight I had cereal and cookie dough.  Old, leftover, frozen cookie dough from back in December when I was making Christmas cookies.

I am so lonely it sometimes physically hurts.  It is all utterly exhausting.  

I often wish that I didn't want kids, or couldn't care less about having a family, or thought that marriage was a crock.  It would make this all so much easier.  But I LOVE my family.  They are the most important thing in the world to me, and I count them as my biggest blessing.  I miss them all the time.  Being single is really tough at this juncture in life - I want to fall in love and have a life partner and have babies and raise a family of my own.  I want my own home and my own little kiddos running around and I want to come home to someone I love and someone who loves me.  

I have hoped and wished and prayed for these things to come into my life.  When they haven't, I have hoped and wished and prayed to stop wanting these things.  I have bargained, pleaded, cried.  Almost without exception, it nearly always feels like anything must be better than living in this limbo, this simultaneous state of deep longing and total uncertainty.  

This, more than any other factor, makes me feel most miserable.  I have never before in my life seriously questioned whether any of those things would eventually happen.  But, you know what?  It is not guaranteed.  Not even close.  And just because I want those things with every cell in my body does not mean that I will get them.  I know plenty of people who have wanted those things and not gotten them.  Really nice people, too.  Just because you're a nice person does not mean that good things will happen to you.  Life can be shitty that way.  

God, this must sound so pitiful.  But honestly?  This is where my head is.  This is where I have been, with a few various interludes and reprieves, for months and months now.  

Some days, the best solution I can come up with is to purposefully ignore these feelings rather than address them.  Some days are really good, and I don't have to do that - I just feel happy and content and not anxious.  Some days I feel despair.  Some days I will myself to feel hopeful and optimistic.  Some days I actually do feel that way, no self-coercion involved.  

I am ok, I really am.  Things are not awful, they're just not awesome.  

Anyway, I guess the point in my writing about all of this is just simply to be honest.  One of the things that I have learned over these 30 years, that I feel pretty confident that I can trust to be true, is that if I feel a certain way, I am probably not going to be the only one.  I have often been encouraged by others' stories.  I have been surprised by their vulnerability, surprised by how open and honest they have been in what they've shared.  I have identified with their stories and felt relief that someone else said it out loud.  And that made things feel a little more ok, made me feel a little less alone.  So maybe there is someone out there in the world who is reading this and thinking, Hey!  I'm turning 30 and I think it sucks but I don't want to say it because I don't want people to think I'm a loser if I admit that, and I really don't want to be that woman-turning-30-and-freaking-out-about-it cliche, but damnit, I kind of am! ... well, if it helps at all to know, there are at least two of us.  :)

*My other resolution this year was to shampoo my hair less.  Having great success with that one so far!

Inauguration

The past couple of weekends, while rounding on patients, I got to periodically keep up with the various playoff games as they were happening because so many patients had the games on in their rooms.

Today, everyone had the inauguration ceremony on.  Our team just happened to stop into two consecutive patient rooms with serendipitous timing, the first just at the right moment to see the swearing-in and then the second just in time to catch Beyonce's national anthem.

Our patient, when Beyonce started singing - quietly, musically, sweetly - said out loud, "Why she singin' like that?  Why she bein' all quiet like that??  I don't like this voice."  Her mother chimed in, "That's not Beyonce!"  And then, a couple of seconds later, when the singer opened up her famous pipes and started belting it out, they both together said, "There she is!!"

So there was our whole team, six of us, standing in a semi-circle around our patient's bed, with our patient and her mother sitting on it, and all of us in the room watching the TV screen for the whole two minutes and twenty-five seconds it took for our national anthem to be sung, not moving.

And I have to admit - I got ever so slightly choked up.

Looking around the room, I was suddenly filled with pride, even patriotism.  The people in that room represented at least five different ethnicities.  We had originated from at least three different countries.  We hailed from several different states and had very different backgrounds.  Most of us spoke different languages from each other.  We all stood, spellbound together, and watched our democratically-elected African-American president be inaugurated for the second time, peacefully and with great celebration, in front of an enormous crowd at least as diverse as the group we made up.  It was sort of beautiful.

I was also thinking about where I was four years ago, when President Obama was sworn in for the first time.  I was in Charlottesville, VA, in the middle of my post-bac year, probably studying for an organic chemistry exam and praying with all my might that my efforts in that program would get me into a medical school.  And that made me think something else, too - it continually amazes me how crazy-fast time flies, but not only that, it made me realize just how glad I am to be here, in this place, doing this work, with these people, today.  I may not always feel it, but I am lucky.

The "D" Word

I have a vividly clear memory of a conversation with my sister-in-law that happened years ago.  At the time, I don't think she was even my sister-in-law yet; I think she and my brother were dating or maybe engaged.  They must have been in their senior year of college or just graduated, and she was somewhere in the midst of the very long academic-requirement-and-standardized-test-filled process of getting into medical school.  Someone asked her where she thought she might want to go, and she told them she was hoping to get into UAB, in her home state of Alabama.  She was a resident there, she explained, and going to a public school with in-state tuition would be far less costly than other options.  As a happy bonus, it also happens to be quite a good school, but, as she told her inquisitor, keeping her student debt load as low as possible was a priority, because she did not want to feel its pressure someday exert influence on her choice of medical specialty.

At the time, I was still working random jobs to prolong my gallivanting the globe as long as possible.  I had no idea what I wanted to do with my life, but I had zero intentions of going into medicine.  I remember overhearing this conversation, and privately thinking to myself, "Well, now, that is just absurd."  After all, I thought, doctors are not poor.  They may not be investment bankers, but they do just fine.  Even the lowest-paid specialties in medicine earn significantly more than most other jobs.    And plenty of people go into plenty of debt for graduate school, but it works out - in a field like medicine, you will be able to repay your loans eventually.  How short-sighted to limit your options for something like money.  (I must confess that the other thing I thought during this conversation was, "Alabama??  Really???"  And not just because of some inherent prejudice I had against the south, although that was certainly part of it.  I totally adore my sister-in-law and my brother, and I was maybe just a teensy bit pissed off that she would not consider moving to Colorado, or some other, more desirable part of the country, closer to the rest of the family.)

I should stop here to note that I could probably tell dozens, if not hundreds, of personal stories and sprinkle them liberally with giant asterisks that would direct you to postscripts about the overwhelming force that irony seems to have in my life.  Seriously, if I have ever thought that something would definitely not happen to me, that thing will most definitely happen.  If I ever say that I will never do something, I might as well just start planning for the day that I will do it. *  

I am posting an article tonight about student debt that originally appeared about a month ago in the New York Times.  It is a subject that hits painfully close to home, and it's a rather interesting (in addition to distressing) factor for me to ponder as I near the point in medical school where I will need to get serious about one medical specialty and decide to devote my career to it.  Our schedule at Emory being set up as it is, I am approaching the end of the third-year curriculum, and have now rotated through many of the major specialties and spent a very small amount of time on just a few of the minor ones.

I, like my sister-in-law, came to medical school enthusiastically committed to the idea of primary care - its importance to health, the critical need in this country for more physicians in this specialty, my own career heading in this direction - and at this point, my theoretical commitment to it has not wavered.  On a personal level, however, I am not at all sure that this is the specialty I want to pursue.  Multiple factors obviously play into this: my experiences on my third-year rotations, my greater understanding of what different specialties entail, my clearer vision of myself, my talents, my interests and my future goals.  It would be naive of me, though, to assume that debt burden and future potential salary were not at least subconsciously casting their votes as I try to process this decision.  

*Of course, the multiple ironies in this story, starting with my going to medical school, include my moving away from family, to the south, where I am currently very much aware of the burden of student debt and its potential influences on choice of specialty.

Tackling the Problem of Medical Student Debt

By Pauline Chen, M.D.

December 13, 2012

Thursday's announcement from the University of California, Los Angeles, of a $100 million medical student scholarship fund should inspire all of us to question the fact that medical education in the United States is paid for largely by student debt.

The new merit-based scholarships, established by entertainment executive David Geffen, will cover all educational, living and even some travel expenses for a fifth of next year's entering medical school class, some 33 students. Mr. Geffen and school officials hope that eventually the school will be able to pay for all medical students and free them from the obligation to take out student loans.

"The cost of a world-class medical education should not deter our future innovators, doctors and scientists from the path they hope to pursue," Mr. Geffen said in a statement. "I hope in doing this that others will be inspired to do the same."

The cost Mr. Geffen refers to has skyrocketed over the last 25 years. The median annual tuition, or yearly cost for attending classes, is now more than $32,000 at public medical schools, and more than $50,000 at private institutions. And medical students must also pay for textbooks, equipment, room, board and travel expenses, adding $20,000 to $30,000 to each year's expenses and pushing the total four-year cost of attending medical school to more than $200,000 at public institutions and close to $300,000 at private schools.

Some medical students commit to military service or to practice in a medically underserved area to reduce costs. But the vast majority end up borrowing money from federal or private loan programs, or from family if they are fortunate enough. The median debt for medical students upon graduation is more than $160,000, with almost a third of students owing more than $200,000. And those figures do not include interest costs over payback periods of 25 to 30 years.

There are several reasons for the runaway costs. One is that the academic medical centers that house medical schools have become increasingly complex and expensive to run, and administrators have relied on tuition hikes to support research and clinical resources that may have only an indirect impact on medical student education.

An equally important contributor to the problem has been our society's placid acceptance of educational debt as the norm, a prerequisite to becoming a doctor. Obtaining a medical education is like purchasing a house, a car or any other big-ticket item, the thinking goes; going into debt and then paying over time with interest is just the way the world works. And, say many observers, newly minted doctors will earn big salaries, allowing them easily to reimburse their loans.

While it is true that most doctors can pay off their debt over time, those insouciant observers fail to consider how loan burdens can weigh heavily on a young person's idealism and career decisions.

For example, financial considerations have been shown to be a major deterrent for undergraduate students considering a career in medicine, particularly for students from diverse backgrounds. And even the most committed students who do make it to med school may eschew research or specialties like geriatrics, family medicine and pediatrics in favor of a more lucrative career in dermatology or ophthalmology.

These choices have enormous social repercussions. Despite the well-studied benefits of a diverse physician workforce, more than half of all medical students currently come from families with household incomes in the top quintile of the nation. Even more worrisome, student concerns about debt are exacerbating the nation's physician shortage. By the end of this decade, we will be short nearly 50,000 primary care physicians and an additional 50,000 doctors of any kind.

Educators and groups like the Association of American Medical Colleges have been trying to address the problem of medical student debt for more than a decade. Some have suggested simply freezing costs or prorating debt according to the earning potential of a student's chosen area of specialty.

But the most durable solutions thus far seem to be scholarships made possible by philanthropic donations like Mr. Geffen's. The University of Central Florida's new medical school, for example, was able to offer its charter class in 2009, consisting of 40 students, a four-year scholarship that covered tuition and living expenses thanks to several gifts. And the Cleveland Clinic Lerner College of Medicine, established with a $100 million gift from philanthropists Al and Norma Lerner, has been able to educate a small cadre of future physician-scientists while granting all of them scholarships to cover tuition costs.

Mr. Geffen's fund represents the first sustained scholarship to cover all expenses, not just tuition, for a sizable portion of students at a single medical school. Combined with his unrestricted gift of $200 million that led to naming the medical school in his honor a decade ago, Mr. Geffen's contributions represent the University of California system's largest donation ever from a single individual.

But the real importance of Mr. Geffen's donation for the rest of us lies in not its historic largesse, nor its hopeful vision. Rather, it is in the dramatic impact one individual can make when he makes medical education a priority, and the inevitable question such a gesture raises: Why has our society been so slow to do the same?

Fun With Words

Just playing around tonight with this cool website I just came across.  Here is the word cloud it came up with from this blog!  Kinda cool (revealing? embarrassing?) the words that it pulled... evidently I use ugh significantly more often than I use happy or sleeping.  

Coincidence?  ;) 

Day One

The patient was not a young man, but his disabilities and medical problems far outstripped his chronological age.  Chief among them was diabetes.  Disadvantaged circumstances, hard living, some drug use here and there, and good dose of the euphamistically-termed "health illiteracy" were among the many factors that got him to where he was that day.  Admitted to our service from the ED with a chief complaint of chest pain and syncope, he nonetheless had a laundry list of different issues we would need to address, including a seeping wound left behind from the recent amputation of all of his toes on one foot, the unfortunate and unfortunately predictable consequence of an advanced diabetic foot ulcer.  It was actually the least of his worries on this hospital visit.

The resident who had worked him up introduced him to the rest of the team and summarized his lengthy problem list, verifying details with him and clarifying others.  There was a serious discussion of the points that most concerned us regarding the state of his health.  The patient nodded along.  Very little of this was new information for him, but this most recent incident seemed like it had hit home in a rather new way.  He seemed eager to collaborate; he spoke of experiencing a wake-up call and told us that he fully intended to live a long life, as healthy as he could make it.

The attending wrapped up the summary of the plan going forward, checking to make sure all the patient's questions had been answered and that all of us on the team were on the same page.  The patient shook her hand and looked around at everyone else in the room, saying how much he appreciated the help.

There were the usual "okay"s and "very good"s and "we'll be back to check in on you, sir"s as we collectively straightened up and slowly turned to shuffle for the door.  His face still worked, betraying unfinished thoughts.

"Hey, Doc?  Can I tell you somethin' that's really just been on my mind?"  His voice dropped, softer, timid, something maybe a little bashful about it.  His fingers worried the thin sheets in his lap, rolling and twisting the fabric in small movements.  His chin dropped to his chest as his eyes momentarily closed; every muscle in his face moved together to paint weariness and suffering into deep crevices.

"Diabetes just... sucks, man."  Head lurched with voice for greatest possible emphasis.  "I just... caint even tell you how much it sucks.  It just makes everything bad, man..." he heaved a great sigh.  "I just caint even describe to you all the suffering it causes me.  It's just right up there next to marriage!"  And with that, hands slapped thighs, head lurched again, this time with crackly laughter.  His eyes twinkled at us, checking to make sure we got the joke, as he shook his head, shoulders bouncing.  A fine tension dissolved as we broke into smiles along with him, an unexpected bit of levity trailing behind us as we left his room and moved on down the hallway.

Welcome to the medicine rotation.