I Think I Can...

Less than a day to go...

So ready to be done with this:

Photo credit: my roommate Lamya

Pre-boards mani-pedis with friends today:

And vacation to look forward to next week.  Taking deep breaths....

Make it Sweet

Messenger

My work is loving the world.
Here the sunflowers, there the hummingbird —
equal seekers of sweetness.
Here the quickening yeast; there the blue plums.
Here the clam deep in the speckled sand.

Are my boots old? Is my coat torn?
Am I no longer young, and still not half-perfect? Let me
keep my mind on what matters,
which is my work,

which is mostly standing still and learning to be
astonished.
The phoebe, the delphinium.
The sheep in the pasture, and the pasture.
Which is mostly rejoicing, since all ingredients are here,

which is gratitude, to be given a mind and a heart
and these body-clothes,
a mouth with which to give shouts of joy
to the moth and the wren, to the sleepy dug-up clam,
telling them all, over and over, how it is
that we live forever.

~ Mary Oliver ~

Some friends and I decided to buy tickets to go to a yoga class at the top of a very swanky midtown hotel this past weekend, which included a live DJ, great views of the city, and a couple of ridiculously delicious ginger margaritas after the class.

Mary Oliver has been coming up a lot in our house recently, for various reasons.  So it was delightfully apropos when on Saturday, at the end of a phenomenal yoga class, the instructor read this poem during savasana (for the non-yogis: that is the part at the very end of the class where you get to lie still on your back with your eyes closed and gather all the benefits and effects of your practice to take with you before you leave.  Or just rest and relax after the workout, depending on how you prefer to think about it.  I almost always fall asleep into the world's shortest, most delicious naps.  Regardless, savasana is the definitely one of the best things about doing yoga.)

There were probably about 150 women in the room.  And about four men - I counted.

I have written before about how wonderful, how healing, how spiritual, how restorative yoga can sometimes be for me.  This class was one of those - and it could not have come at a better time.  I have been studying for Step 2 of our medical boards for the past few weeks... and although I have found that medical school induces a rather constant need for this kind of replenishment, there are times when the need is especially severe.  Like now.  I even considered for a split second not going - I had forgotten about the class until my friend reminded me of our plans the night before, and it felt like I couldn't sacrifice the couple of hours it would take out of my study schedule.  (I mean, med school is just totally crazy like that - I cannot believe I have become the kind of person who would ever think something like that.  But evidently I have.)  Fortunately, fortunately, though, I fought off the crazy and went.  And of course it turned out to be exactly what I was needing, both for my body and for my life.  I think that when you need to hear it, it is suddenly apparent that you are not just working on physical poses in yoga.

Our instructor for the morning led the class based around the theme of the sanscrit word Rasa- which, in one of its translations, means delight in existence.

And she was so good at bringing that to life in her class, reminding us to move because it feels good.  To delight in the movement and in what our bodies can do.  To delight in the day, and the good fortune it was to be able to be there, doing yoga, and sharing the experience with our 150 new closest friends.  She was energetic and encouraging and funny.

Hey, we could be telemarketing right now!  But we're here, doing yoga!  Delight in this!

Rasa.  It also means Nectar of the Gods, sweet nectar, bliss.

It was a long class.  It was a really fun class.  It was the kind of class that is so fun that you forget how hard you are working.  She reminded us that this is how it should be - in life, as in yoga.  Make it fun.  Do it because you like it.  Stop worrying so much about it.  Delight in it. 

Perfectionism is your biggest obstacle to happiness. You gotta let go of that shit. 

She said that she can always tell who the advanced practitioners are, because they are the ones that are smiling. 

You are alive; make it sweet.

Taken by my friend Kathy H.

Studying for the boards is making me slightly - how shall we say - cray cray.  I take a quick study break to check a favorite blog and then suddenly a certain picture of this person's babies makes my chest feel like it is constricting.  I get a NYTimes headline alert pop up on my phone that Roger Ebert has died, and I suddenly need to run for a bathroom break, now.  Because I'm all teary-eyed.  I get to the library around 8 am and leave around 5 or 6 pm and I am mostly being studious and diligent all day, and by the time I stand up to leave, I have this wild, intense sensation swimming around through every vessel in my body - it 's hard to explain, but it's like a mixture of wanting to cry and laugh hysterically and tear my hair out and go to sleep forever and run 12 miles and punch someone in the face, all at the same time.  Like every Christmas morning before you got to go see what Santa left in your stocking and every piece of bad news you've ever been given in your life, all rolled into one emotion, chased with a shot of espresso, and then run over by a Mack truck.  It feels like I want something, more than I have ever wanted anything in my entire existence - I want it so badly I feel like I might literally burst - and I don't even know what that thing IS that I want.  

Maybe it's just for this test to be over. 

I am lucky to have lots of people in this life that appreciate its sweetness, and work at finding it.  And so the studying has thankfully had lots of sweet interludes.  I have been grabbing lunch breaks with good friends and enjoying amazing ice cream with my roommates and showing up for outdoor workouts in the evenings, and it feels so good to just turn my brain off for an hour and get covered in dirt and grass and push my body as hard as I can make it go.  And I have also been buying the occasional pair of shoes that makes me happy. 

Gonna make it sweet, DAMN IT.

When our teacher read Mary Oliver's words at the end of the yoga class, this is the phrase that jumped out and seared itself into my attention:

my work

which is mostly standing still and learning to be

astonished.

Why those words? I'm not really sure. I think I love them so much because they remind me of how much sweetness and beauty and awe-someness there is in the world. We have only to learn to see it. These long, long hours in the library, with this one, seemingly all-consuming and colossally anxiety-inducing goal looming, make this difficult for me to remember, much less do. When it's not this, it's something else. Life is hard; there is always something. I need this constant reminder.

You are alive; make it sweet.

I was reminded recently of this title of an Alice Walker book of poetry:

...which I am taking seriously as my new life motto.  I just love it.  I just want it tattooed on my forehead.  Along with so many other things I need to constantly remind myself these days.  Like: 

Everything is going to be ok.

and

Life will go on.

and

My worth as a human is not going to be determined by what happens six days from now.  Or the week after that or the month after that.

and 

Delight in existence.

Maybe especially that last one.  

The new shoes.  I love them.

And, last random thing for tonight - this cover, which my sister Ellen first introduced me to and which will always and forever make me think of her.  It is awesome and funny and it just makes me smile every single time I hear it and I love singing along at the very tops of my lungs in my car or in the shower.  For some reason it has been stuck in my head tonight.

I take my boards this coming Wednesday.  If it's your thing, I would sure appreciate your prayers for the exam and for the days leading up to it.  

Sweet.

What I Wish I Had Done

I wish I had held his hand more.

One week from finishing my third year of medical school, I just had my first patient die.  

Mr. Wallace* had stage IV adenocarcinoma of the lung.  He was living independently, grocery shopping in his electric-powered wheelchair.  He had been on chemotherapy and radiation and he was all set for another round of palliative treatment when he came in to the hospital.

The last time I saw him, he kept talking about how his friend was about to visit, and he was futzing with his cell phone and saying that when she came, he was going to have her put her number in his phone under "family" instead of "friends" in his contacts list.  

I'm not quite sure why.  He didn't seem to have any family, at least not any that we had heard of during his nearly-three-week stay with us.  She was a good friend of his.  I am not quite sure why it was so important to him that she be listed as family in his cell phone, but it was something that he perseverated on often during that last week.  

"When she comes," he would say, chin tilted up so he could peer through the glasses perched at the tip of his nose at the small flip phone in his hand, "When she gets here, I'm going to have her put her number under family here in my phone, instead of under friends.  When she gets here, I want to have her change her number and put it under family instead of under friends."

He repeated himself over and over.  I would say okay, that sounds great, the first couple of times, and then try to ask one of the questions I needed to ask him - "Mr. Wallace, how is your pain?"  He would ignore me and keep mumbling and muttering, rarely looking up or acknowledging my question, although I knew he had heard me.  I would smile and nod for a few seconds and then try again, "Mr. Wallace, how is your stomach feeling this morning?  Have you had a bowel movement?"

Eventually he would look at me and answer my questions.  I would lean on the side rails of his bed, trying to get a little closer to him so that neither of us felt like I was shouting at him.  I tried not to push very much or very hard on his belly - I knew it was painful for him.  I knew it was riddled with metastatic cancer that was no longer being treated.  

I was off today when he died.

My intern updated me later on in the evening - we were both surprised.  "Didn't think he was that close," she said.  I was taken aback and immediately sad.  So strange, I thought.  Mr. Wallace, gone.  He was just here.  In fact, he had been in the hospital for my entire rotation there.  He was admitted on my first day on service, and he was the first patient I was assigned that day.  

I saw him every day.  But I didn't usually linger too long at his bedside.

He talked slowly.  He mumbled and he rambled and he repeated himself and he ignored questions and he would just keep talking and talking and talking and most days I would finally end up raising my voice just above his and say "Ok, Mr. Wallace!  We'll see you a little later, then, ok?  Bye, Mr. Wallace!" as I backed out of his room.  

I wish I had been more patient with him when he kept talking and talking and talking, repeating the same sentences and phrases and questions over and over and over again.  I had other patients to see.  Other patients that had a lot of the same issues.  Elderly, hard of hearing, terminal illnesses, chronic pain, intractable nausea, hard-to-manage constipation.  

We had a very busy service.  It was a terrible call schedule.  Our team was an extra-special black cloud.  I was carrying five patients - the most, by far, that I had on any other service, all year.  We had morning rounds and noon lectures and student rounds and team rounds and notes to write and people to call and presentations to give and we had all the usual medicine clerkship lectures and exams plus a ton of extra end-of-third-year exams and random things that the school of medicine so conveniently decided to clump all together right in the last two weeks of the year, coinciding perfectly with a multitude of other deadlines.  

I was exhausted, burnt out, feeling physically terrible and emotionally brittle.  Little sleep, long hours, rare days off, constant demands.  Stretched way too thin.

But if I am very honest with myself, if I really, really think about why I didn't take more time with Mr. Wallace, or with a lot of my patients like him, it was because I felt helpless.  I felt totally impotent to help him, completely powerless faced with his problems.  He had originally been admitted for a pneumonia, but then it was one thing, after another, after another.  We had a terrible time fixing his constipation, then his diarrhea, then his constipation again.  We could not seem to get his pain under good control.  His nausea was refractory to everything we could think of.  His pneumonia cleared right up and he did not look better.  He did not get stronger again.  He did not get out of bed again.  His breathing improved only marginally.  We were only providing what amounted to palliative care, and we weren't being all that successful at it.  

I had such a hard time being with him because I knew that we were not making him better.  

A couple of hours after I learned that Mr. Wallace had died, in the middle of my ineffectual review for my exam tomorrow, I suddenly thought of him again and was overwhelmed.  As if the news had not actually sunk in when I heard it, but had just then fully absorbed and hit my bloodstream.  And I started to cry.  

I thought about the last time I went in to see him.  I thought about the first time I met him, and all the times in between.  I remembered how he had been asking for a shave.  I remembered his bald head, his hollowed-out cheeks, his jaundiced skin, the way he only sometimes wore his dentures, how obsessed he was with his cell phone.  And then I thought about how he won't be there tomorrow when I go in, and I cried.  I am still crying.

Maybe this is everyone's experience the first time their patient dies, I don't know.  But I also just thought about all the times I could have stayed with him longer, but didn't.  I thought about how I had stopped doing much of a physical exam on him when I went in to see him every morning.  I didn't want to exacerbate his pain any more than necessary.  But I wish I had.  I wish that I had touched him more.  I wish that I had held his hand more, just held it and stayed for a little bit longer.  Just listened to him for just a little bit longer.  He had to have been so lonely; I never saw any visitors in his room.  He had no family.  I am sure he probably talked so much from the moment our team would hit his door to the moment we left because he had no one else to talk to.  

I want to believe that we provided good care to him in the final days of his life.  I want to believe that I did a good job with him, that I was at least a little bit kind and comforting.  But all I feel right now is sadness, and regret that I did not do more.  Maybe it always feels this way.  Like I said, this is my first go-around.  I guess there is no way I could have known.  But I wish I had not left his room quite as soon as I did yesterday.

*Name changed to respect patient privacy and HIPAA law.

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?

Trauma

I don't care what surgery service you're on, even if it's not trauma - it's ALL trauma.

Seriously?  Surgery is trauma for everyone involved.  Even an uncomplicated, routine case involves fairly significant trauma for the patient.  Don't be fooled into thinking otherwise - it is very carefully controlled trauma, but trauma nonetheless.  Minimally invasive?  I mean, sure, you end up with three or four tiny little neatly-closed incisions around the belly, but have you ever seen the whole process?  The way those trocars get maneuvered around in their ports, the shoving things around, tearing things down, cauterizing whole swaths of tissue... man.  I love watching surgeries.  I think it's the coolest thing, and it is super easy to become desensitized to the violence of it.  But yikes.  Surgery is no joke. 

It is also trauma for the residents and the med students.  At least for me it is... the whole time you're standing there during the surgery, the attending can pimp you at will - basically, he or she can just ask you anything they want to ask, related to the surgery or not - and I never feel totally confident about my answers.  It can happen at any time and without warning... you're never free to just relax, you always have to be on guard for random flying tricky questions smacking you in the face and making you look like a total idiot.  It can be trauma for the nursing staff and the scrub techs - some attendings have notorious temper control issues, and all attendings have very different, nuanced personal preferences about how they like things set up, what they like to use, etc, and they are not shy about letting someone know when they don't get it right.

Surgery is trauma physically and emotionally, too.  Being on your feet all day is less than ideal for your back.  The crazy hours lend themselves to terrible self-care.  I have literally not worked out in three weeks now and am starting to feel totally nuts mentally and super crappy physically.  Nutrition has mostly gone to pot - remember the cookie party on Sunday night?  Yeah, it has basically sustained me all week.  Only I have long-since finished the actual cookies and have now started in on the huge batch of gingerbread cookiedough that never made it to the baking stage on Sunday.  That was my dinner tonight.  Not kidding.  Trauma regarding my personal life - today, my attending asked me if I had kids.  When the answer was no, the question was, well, are you married?  No?  Ok, well, what about someone special, then?  I said no, absolutely nothing, nothing at all going on my life.  And his response was wellllll.... at least... at least you can do what you want whenever you want...?

It's even trauma for the floor nurses. Ok, so this incident didn't actually have anything to do with surgery, and I don't even know if it was one of our patients that was involved, but when I got to work a couple of mornings ago, some of the nurses were shaking their heads and muttering in disgust.  When I asked, one nurse told me that everyone was all in a tizzy because one of the patient's parents had been, shall we say, getting amorous in the patient's hospital room.  Not only that, but it was happening while the patient, a young baby, was crying the entire time.  And not only that, but the nurses knew this because they could hear it from out in the hall!  Ugh, really?  Gross.

~ ~ ~

And then there is the actual trauma.  The awful, horrible, heart-pounding, life-flight bloody trauma, that, when you are in a pediatric hospital, can just be too much to bear.  

Last night there was one of those.  

It came in just as I was about to leave at a decent time in the afternoon, and it was absolutely horrific.  There are really no words for when something like that happens to a small child.  But one of the worst,  sickest aspects of the whole experience?  The truth is that a part of me was thrilled to be there for this case.  It feels horrible to admit that.  It was such a hideous tragedy.  I think I was mostly just so happy to finally be helping, to finally be useful, to finally be able to use skills that I actually do have and to feel like I actually did know what to do and how to do it and then actually be able to do it.  I love being in the operating room when I am getting to participate. 

We operated for probably close to seven hours, sewing and sewing, trying to put this little girl back together.  

When we finished around midnight, I went home and slept for roughly about three hours before I got up to go back in this morning.  We rounded, went to grand rounds, had lecture, went to clinic, went back to the school for a lab on advanced vascular access.  

It was sort of a shitty, blah daze of a day.  A reminder that I have not even started to do a fraction of the studying I need to do for the exam that is fast approaching.  No breakfast food left, no coffee made, not even any crappy energy bars left to grab on my way out the door.  A text from my landlord letting me know that hey, fyi, your rent check bounced, again.  Oh yeah, my financial situation is still so far down the shitter that it is actually in the water-treatment facility an hour down the highway.  Half a dozen more automated phone calls from my credit card company telling me that my payment is late, again.  Which was then followed by a voicemail informing me that my precious doggie has finally figured out that she can clear the fence and so now, even though we have finally bullet-proofed the gate that she had continuously, ingeniously found a way to foil until very recently, she is still escaping.  And when she was put back in the yard and tethered to a line set up on her leash, she chewed straight through her leash and severed it completely.  Her dog walker has apparently not been showing up and she has also somehow destroyed the latch on her crate door, so now I have zero good options for her while I am gone for 14-hour days.  

I wore heels today.  My feet were killing me.  When I left the school, it was dark already.  I walked to the parking garage in the dark, drove home in the dark, got home to a completely dark house.  Not a single car in the driveway, not a single person at home.  And I just burst into tears and proceeded to have a small breakdown.  My first cry on surgery.  My first cry in a good long while, actually.  My roommates got home a little while later and walked in and said "hi" to me and I started crying again.  I took a long, hot shower and sobbed.  I am crying right now, sitting in bed and typing.  

I don't really know how to deal with this stuff.  When I started this post a couple of days ago, I meant for it to be sort of a funny "wow, this is super tiring and intense and ridiculous and how about those inappropriate parents?!" post, but then last night happened, and I was mostly really put-together about it until a couple of hours ago.  Now I just feel drained and exhausted beyond belief and I can't think about last night at all without crying.

If you are a pray-er, maybe say some extra-special ones for a little girl in an intensive care unit tonight.  She has a really hard road ahead. 

Surgery Dreams

... dreams that I have while on my surgery rotation, that is.  Let me know if you want to take a stab at deconstructing this one.

~ ~ ~ 

Last night, I dreamt that I was in some sort of indoor/outdoor castle for some sort of interview (unclear what the interview as for - it seemed to be some sort of admissions or job interview, or possibly both - you know how things can do that in dreams) and I was interviewing with a close friend, and the interviewer was a surgeon (again, not entirely clear why, maybe the school/job had to do with surgery, I don't know, but he was a very important and intimidating person.)  And I thought it was all going quite well, until at one point, for some reason, I had to stand up to deliver my responses for that part of the interview, and for some reason, there was what I thought was a hand-sanitizer dispenser on the wall next to me, and for some reason I knew that I had to clean my hands before I would be allowed to speak, and so I  stood up, reached out my hand, dispensed some into my open palm and then proceeded to rub my hands together, immediately realizing that I had made a mistake, and that it was actually regular soap instead of sanitizer, and so now I was in the middle of this very important interview, wearing a suit, with both hands entirely covered in liquid soap.  No sooner had I made this tragic error than the surgeon-interviewer lowered his chin, scowling at me from under furrowed brow, folded his hands on his lap and announced that my interview was over.  And my very good friend, who had been seated behind me while all of this happened, laughed at me and said something to the effect of "too bad for you" before continuing to converse with the interviewer, with whom she suddenly was best friends. 

It was awful.  

And then after that my flying skills came in handy when I joined some sort of outdoor field game involving something like keep-away with a small French horn.  Whatever.

On second thought, if you know anything about dream interpretation, I probably don't want to hear your read on this.

~ ~ ~

PS.  Last night, we hosted a Christmas-cookie-baking party at our house... sooooo you can guess what my dinner was when I arrived home twenty minutes ago.  Also, I am seriously contemplating sleeping in clean scrubs so that I can save the 38 seconds that it takes to put them on in the morning.  Don't judge.  I am also going to bed NOW... it's 8:30 pm and I have to get up in less than 8 hours already. Sweet sleepy Jesus.

Oy.

The costume changes alone are exhausting.

for tomorrow: clinic clothes, OR clothes, workout clothes

Notes to Self

This morning, I woke up and this man will still be president for a good while yet:

image from the NY Times

But more importantly, I woke up this morning and, other than being way too tired because I stayed up way too late for surgery time with friends to watch the election returns, I did the exact same thing I always do, every day.  Which is to say that I stumbled through my morning routine, downed some oatmeal with peanut butter, went to the hospital, and worked, along with all the other people.  And my joy at the president's reelection notwithstanding, the immediate thing about the day after the election that makes me the happiest is a tie between not having every single Facebook status update on my feed be something stupid and political, and not having to hear "... and I approve this message" for another couple of years, at least.  

I say more importantly because today really was just like any other day in our country.  The day after a huge election to decide our leader, the day after a bitter and ugly campaign race between two very different candidates, the day after our huge and diverse and struggling country all went to the polls - life went on as usual.  There were no riots, no violence, no coups.  I went and voted, as a woman, driving my own car, and then went to my job, where I am pursuing my dream, getting a top education, and training to enter the career field of my own choosing.  There were no hostile, tense or unkind words today among colleagues in the operating rooms, even though as a collective we made an impressively mixed gathering - we were men and women, young and old, black and white and everything in between, from all different backgrounds, histories and countries from around the world.  Those of us who were American citizens had undoubtedly cast our votes for both parties, and those who were not able to vote undoubtedly held similarly strong and varied opinions regarding the candidates.  And everything was normal.  

How amazing is that?  

Even more than the outcome of the election, the thing that I was most glad about this morning is our incredible good fortune to live in a country and in a period of history where all of that is possible.

~ ~ ~ 

So, I went to work today, I scrubbed in to a few surgeries, I ate my lunch during our late afternoon lectures, and then, when they were over, I had enough time to make it to an evening yoga class for the first time in weeks.  Now, this is going to sound all crazy-hippie-yoga-crackpot (and especially now that you know how I lean politically) but tonight's yoga class was exactly what I needed, and not just to stretch out my sore back muscles.

I don't really know much about this sort of thing, and I think that going to church just because you really like the pastor's sermons is not the best or most valid reason to go to church, necessarily, but I do believe that going to church even for any random reason can put you in a space right when you need to be there to hear right what you need to hear right when you need to hear it.  And when it happens, you know, because that word speaks to your soul.  And I know it might sound strange, but I have also had that experience in yoga classes before.  In fact, when I was a senior in college, I used to go to this Wednesday night yoga class.  I went almost every week, almost the entire year.  I adored the teacher, and the class actually met in a multi-faith chapel on campus - we would stack up all the chairs and push them to the sides and corners of the room, and then fill every available space on the carpeted floor beneath the stained glass windows and the quilted tapestries with imagery of doves and we would do an hour-long yoga class as the sun set.  The lights in the chapel would be dimmed, and often we would end class in near darkness.  

That yoga class was one of the most powerful spiritual experiences I have ever had, even to this day.  I was just able to meet and connect with God there, for whatever reason.  It can be hard for me to do that in a church, at least consistently.  But that yoga class that year was like a sacred time for me.  I have continued to practice yoga as regularly as I can since then.  I have been to probably over a dozen different studios and practiced with more teacherrs than I can recall, but I haven't had another yoga class come close to the spiritually transformative experience that my practice was that last year in college, until tonight - the class I just took tonight was by far and away to nearest approximation to it.

Anyway, that was a lot of rambling just to say that I don't think that you need to be in a church to conect with God, and I don't think that you can only hear a message you need in a more "traditional" spiritual setting, whatever that means to you.  Nor do I think that if something speaks to you in a yoga class, that it means you are buying into Buddhism or Sanscrit or Hindu spirituality or whatever.  But I do know that tonight, something about the class just touched me in a way that I really desperately needed, spoke words to me that I was only dimly aware I needed to hear.  I actually cried a tiny bit at one point, it moved me so powerfully.

Weird, right?

I raced home to try to get it all down on paper before I forgot what it was that the teacher said during class that grabbed my heart and gave it such a good shake, but what I remembered is definitely not going to do justice to the way I heard it in class.  At any rate, some of the basic gists were something along the lines of this:  "Be here.  The future is only a concept- you have never been there.  You are here, now.  You are alive right now where you are.  Be here.  Only when you reach the limits of your own strength do you discover the strength that comes from outside yourself.  Only then do you discover who carries you.  You will get tired if you are doing this on your own.  Your worth is total and complete, and it depends on nothing - not what you do or what you accomplish."

Yoga is pretty cool like that - the asanas, or the physical practice, are so symbolic of the way we tend to approach our lives.  The teacher can be talking seemingly about one thing, but then when you pay attention, deeper layers of meaning reveal themselves.

Life has been tough lately.  School is tough.  Surgery is really tough.  Lots of other things are really tough.  And I am starting to feel the kind of worn-down that makes me feel numb and disconnected, and not at all like myself.  I just feel completely subsumed by the demands of what I am doing every day, and by the end of each day, I'm not really happy or sad or angry or proud or excited or loving or... anything.  I don't really feel.  I am just tired.  Drained.  And I find myself thinking a lot these days that the people I am working with have no idea who I am, because I am not myself.  Not a good version, anyway.  But I have also been realizing that they have no idea who I am because, paradoxically, being so exhausted makes me focus only on myself.  I feel like I am constantly in Survival Mode.  I am self-conscious and insecure and unsure of myself.  I become more difficult to engage, I am distracted and distant, I don't go out of my way to care for anyone else or show that I am interested.  Honestly?  I probably seem like a total bitch.  And later, I end up berating myself for how I must be coming across, and that only makes me feel worse.

Literally everything the teacher said in class tonight felt like it was personal, meant specifically for me.  A lot of it felt like a reminder of really obvious stuff that I shouldn't need reminding of, and other things were more challenging.

"Be here without effort.  It doesn't mean that the intensity will be any less, but let it be effortless.  Even when things are intense, that doesn't mean that you have to feel suffering.  Settle in here, embrace this, now.  Stop struggling against it every second of the way."  Back when I wrote about being out in the Hallway?  I still feel that way.  I still hate it.  It still feels really, really shitty.  And the more I try not to dwell on how much I hate it, the more impossible it is not to think about it all the time.  And it is totally exhausting.

I don't know how to ingrain the words I need so that they inform how I live day to day, when I am so tired and worn-down and it feels like it takes everything I have just to get by.  But I figured that writing them out was a good start to remembering them.  Especially, especially remembering the ones that made me cry tonight, the ones that speak directly to the absolute hardest part of life right now:  "You are not alone.  It is a lie, the isolation that you feel.  You are not alone, you are connected."

The Score So Far

One and a Half Weeks In: 

I have to preface this by saying that I was really, really nervous about the surgery rotation, for a few reasons.  The main reason is that I am not a morning person, I hate getting up at unreasonable hours (and for me, anything before 8 am is unreasonable), I am always late to everything, I am naturally a diehard night-owl, and I do not function well on little-to-no sleep.  Granted, I do it all the time, but I rarely feel like I am functioning well.  Anyway, needless to say, all those factors taken together made me very afraid that I was a) probably going to be the worst surgery student of all time and b) certainly going to be totally and completely miserable on the rotation.

The uniform.

I was also nervous because I hate feeling inept, and even though I feel that way every single day in medical school, I figured that feeling would be intensified on surgery (and this has actually turned out to be more or less true.)

New fall shoes! :)

Other reasons I was nervous include some of the questions mentioned in my previous post (and, full disclosure: the last question/concern was actually mine).  I was feeling really bummed that my heretofore somewhat-respectably-consistent exercise routine would be over forever, and that my much-healthier eating as of late would be out the window also.  

However, I am very happy to say that so far, none of my fears have been realized.  (Major caveat: I am starting out on my specialty surgery half of the rotation, and I am on the plastics service... they are notorious for having amazing hours - read: only somewhat longer than regular working hours, as opposed to inhuman hours - and they are also just a very laid-back and fun service to be on in general.  In other words, THIS COULD/WILL ALL CHANGE when I go to general surgery next.)  

In terms of getting exercise, I have actually made it FitWit most nights so far, and squeezed in a run one night when I couldn't go!

[winner: me]

Haters gonna hate.

How about eating healthy?  For the most part, I think I have done fairly well.  Eggs for breakfast!  Salads for lunch!  Apples for snacks!  Boo-ya!  Today was actually the first time in over two months that I have not packed my own lunch for work.  Pretty good streak, right??  But it might be over, sadly... I have no more groceries at home.  And today I had not one, but two Cliff Bars.  And a burrito.  And a beer.  And lots of Halloween candy.  Soooo... let's call it a wash.

Social life?  Haha... ok, this one has been sort of legitimately sucky.  Thank God I live with people I like talking to, because I have pretty much only seen them.  And I have only seen them a handful of brief times.

[winner: surgery]

But!  On plastics, you basically have weekends off (shhh, don't tell the other surgery students!), so this past weekend, I was able to drive up to Chattanooga to visit my great uncle John along with my mom, aunt Jane, and brother Martin.  Beautiful chilly fall weather, gorgeous leaves, lots of good food, plus seeing my great-grandparents' old home for the first time in probably 17 years...

[winner: me]

Great Uncle John, Aunt Jane, Mom, Martin, yours truly

And of course, there have been some holiday celebrations... that have consisted mainly of making Izzy wear this awesomely adorable costume (hey, it's my first Halloween with a dog!  I couldn't help myself.)  The roommates and I also carved jack-o-lanterns last night, which I haven't done in years.  It was a lot more work than I remembered!  But so fun.  And we also roasted the seeds... yummmm.  It also took a really long time, and so I didn't study at all and I went to bed really late, which made today sorta rough.

[winner: me, I think]

Izzy the WonderDog!

(She doesn't love wearing costumes.)

Also, on a somewhat surprising note, I have found that I am kind of loving surgery.  Like, a lot.  So all in all?  I'd say, so far... I'm still coming out ahead.  :)

Surgery Has Started....

Today, in orientation...

Clerkship director, MD: "So let me just take a few moments to address some of your fears about this rotation."

[Student concern.]

"You are worried about getting enough sleep.... You'll be fine.  You'll be really tired, that's just the way it is.  But you will be fine."

[Student concern.]

"You don't think you will be able to study enough and learn all there is to know?  Ha.  Yeah, you won't.  Don't even try."

[Student concern.]

"Your knowledge of anatomy is rusty?  Um, yeah, none of you know anatomy.  Don't worry, we expect that."

[Student concern.]

"Getting enough exercise and eating healthy??  Oh, forget it!"  [Laughs hysterically.]  [Recovers a little.]  "Seriously, though, take the stairs."  [More laughter.]

Everything Possible?

During my nursery week on my pediatrics rotation, I saw a patient in the NICU who, even in the land of unbelievably tiny, critically ill infants, was doing exceptionally poorly.  She weighed around three pounds, required assistance to breathe, had severe hydrocephalus and a ventricular assist device to help shunt the excess fluid out of her skull.  She had already spent more than two months in the unit, and she was still two months away from her estimated due date had she made it to term.  She had been born via emergency C-section when her mother went into pre-term labor as a result of an infection at 22 weeks of pregnancy.  She had a twin sister that did not survive.

For reasons that aren’t entirely clear – perhaps unreliable dating of the pregnancy and therefore the infant’s gestational age, perhaps poor communication between the patient, the obstetricians, and the neonatologist – the neonatologist who was present at her birth believed that she was around 27 or 28 weeks’ gestational age.  She had to make a quick decision at the time of birth about whether or not to intubate the infant, and she says that even though her visual assessment of the girl was that she seemed terribly small, even for a 27-week preemie, she went ahead and intubated anyway.  She says now that she doesn't know if it was the right thing to do, that she had simply acted on the information she had at the time, and that she often regrets it when she passes by the isolette of this horribly fragile, tiny baby.

Babies born prematurely suffer more adverse health outcomes than term babies, and the more premature they are, the greater the number and severity of the complications they have, both in the short-term and the long-term.  Normally, the cutoff age for viability is 24 weeks’ gestation, and babies delivered at this age have a grim outlook – less than 50% even survive – but in this case, an infant even younger than that was kept alive when prevailing best medical practices would have dictated not to resuscitate such a premature baby.  The reasons behind these guidelines are numerous and range from the sheer probability that the child will live to the overwhelming health challenges they are guaranteed to have if they do.  Another, not at all insignificant factor, is the incredible amount of resources it takes to care for them after birth.  The daily average NICU stay exceeds $3,500 per infant, the average NICU stay costs $45,000, and it is not unusual for the total cost of an extended stay to exceed $1 million.  That is the kind of extended stay that Baby 22 Weeks is currently having here in an Atlanta hospital.  It is unclear at this point whether or not she will ever be well or strong enough to leave the NICU, and if she does, what quality of life she will be able to have.  Her mother won’t entertain any sort of conversation at all with her baby’s doctors about how to manage her case other than to “do everything possible”.  

~ ~ ~

No real deep thoughts here tonight.  It's test week, so I have neither the time nor the energy to do a whole lot of reflecting or writing.  I was just doing a quick little write-up for an upcoming ethics session we have during this last week of the peds rotation.  It is supposed to be about an ethical issue that we have witnessed during the rotation, and this is what I kept coming back to.  I am curious about people's thoughts.  I am not at all saying that this baby does not deserve to live, and I really hate the economic/financial expense argument when talking about the worth of a life.  I am in awe of what doctors are able to do, both before and after birth, to save the lives of infants with conditions that, until only very recently in history, would have had a 100% mortality rate.  I'm not even totally sure there is a real ethics issue here: the obstetricians tried to keep the mother's preterm labor at bay, the neonatologist acted to save the life of an infant she believed to be unquestionably viable, the mother wanted (and continues to want) everything possible to be done for a child that she loves.  Surely mistakes were made and surely this outcome was by no means unavoidable.  Maybe it's just the tragedy of the whole situation that gets to me.  Maybe it's just that, in a medical world with so much potential to do so much good, sometimes a lot of very smart people trying their best still get it wrong.  And maybe it's not the ethics of this case that gets to me.  Maybe it's that sometimes there are just no easy answers to be had.