Saturday, December 25, 2010

Hypochondriasis

I’ve lost 5 pounds since Thanksgiving.  Some people might liken this to a sort of Christmas miracle.  Others might brush it off as a general lack of nourishment and exercise while studying for exams.  But I’m a medical student.  So I think I have cancer.  This is the funny thing about stuffing your head full of facts on disease.  You are exposed to so many ways your body can malfunction that you become incredulous to the idea that anyone can actually be healthy.
I think this is why rheumatologists don’t run or play basketball.  They’re afraid of getting osteoarthritis and needing that bilateral knee replacement.  And I have yet to meet an ophthalmologist who wears contacts.  Because there’s this pseudomonas infection that eats through your cornea in 12 hours and leaves you blind.  Heck, I’m surprised Ob-gyns don’t just adopt.  It may seem a little crazy, but med school has a way of infusing some anxiety into every little ache or pain.
I remember accidentally puncturing the outside of my right ankle while cycling about 6 months ago.  It was a nice deep puncture, full of dirt and bike grease that oozed blood onto my sock.  I vividly recall worrying about all the tendons with funny Latin names in that part of my ankle.  Crap, did I slice my flexor digitorum longus?  But even as images of ankle anatomy flashed through my mind, my more sensible inclinations took over, and I forced myself to rinse out the wound, put on my shoe, and continue cycling.
Three days later, my foot swelled up with infection.  Now, I was sure I had necrotizing fasciitis.  I remember turning to my girlfriend, Tiffany, and telling her that I would need my foot amputated, at which point she promised to still love me.  But of course, the infection went away with antibiotics.  It turns out there was no necrotizing bacteria, and I still have my right foot.
I think they warned me before starting school that I would become a hypochondriac.  I’m pretty sure our dean even addressed this at our white coat ceremony.  But at the time I laughed it off, certain this only happened to the crazy kids.  I didn’t have to worry because I was level-headed and still fairly invincible.  But that’s the thing with studying tumors and tendons—you lose a bit of that invincibility.  So I guess I am susceptible to bouts of hypochondria after all.  But really what I’m worried about is this new bump on the back of my head.  Like I said, I think it may be cancer.

Saturday, December 4, 2010

A Holiday Toast to Not Being Miserable

When interviewing for medical school, a student interview is often part of the hoop-jumping process.  In these interviews, they always ask you if you have any questions.  I think you’re supposed ask about stuff like research, curriculum, and the latest scholarly article on treatment of disseminated intravascular coagulation.  It shows that you’re genuinely interested in medicine.  During my interviews, I always asked students if they were happy.  Along with medicine, being happy is one of my genuine interests.
Asking students about their happiness earned me a good number of calculated smirks.  Most students would slip on this knowing grin before assuring me they were not miserable, which was comforting, of course.  There was, however, one student tour guide who glared at me and flatly asserted, “We’re in medical school.”  I remember some of the applicants around me chuckling and even nodding.  But he was being serious and I don’t like to laugh at other people’s misery.
What transpires over the course of years, or perhaps decades, that turns wide-eyed applicants into weary-eyed professionals?  None of us enter medicine with aspirations of becoming jaded or cynical.  I wonder if some of us just end up sacrificing too many of our meaningful daily experiences under the piercing focus of our long-term ambitions.  True, we all sacrifice for the things we love.  Medicine is no different in this regard.  But then again, as students we tend to lay especially grand offerings of time and energy at medicine’s alter—trusting that our intellect, emotion, and efforts are being poured into a worthy pursuit (and trusting that this pursuit is nothing like a subprime mortgage).  What is sacrificed now will be reimbursed with interest later.  At least, that is our hope.  Yet in our fury to get things done, joy often becomes ancillary and delayed gratitude becomes a habit.  Maybe even a way of life.  If foregoing happiness becomes our nature, how soon until it is forgotten altogether?
I knew before entering medicine that there would likely be holidays spent at the bedside of unhappy patients.  There will be attendings and residents who will chew me up and spit me out for the least of my screw-ups.  And on occasion, my textbooks might not leave as much room on my bookshelf for poetry or comedy as I’d like.  Yet, in spite of all this, people before me have survived to smile and tell jokes and some to even still laugh at them.  It makes me think that perhaps joy isn’t so much the result of choosing the right school, or even the right specialty.  Maybe it’s more of a skill, like inserting an IV or stitching together a nasty wound.  Sometimes you watch a skilled physician perform a procedure with such ease that you forget the practice and effort behind it.  Maybe the same thing can be said about joy.
I have this theory that babies are born with this unbridled capacity for joy and excitement, but perhaps as we get older, cynicism starts to creep in as our ability to express joy with child-like abandon simply atrophies with disuse.  Really, I’d rather not find out for sure whether the latter part of this theory holds any truth.  So I force myself to keenly cherish that last sip of coffee before I run out the door, late for class in the morning.  And I savor that bit of giddy energy that dances in my stomach when a grumpy patient warms up to me after a few minutes of conversation.  I drink in the little moments of elation and hold them on my tongue until they turn into euphoria.  In the back of my mind, I know I must for fear of ever becoming that student when asked if I’m happy, can only respond “I’m in medical school.”

Tuesday, October 26, 2010

Examining Robby

I interviewed a 27-year-old patient the other day who was in pretty bad shape.  I’ll call him Robby.  Robby was a morbidly obese Hispanic male who due to some health complications was suffering from congestive heart failure in his mid-twenties.  Congestive heart failure is a condition where your heart doesn’t pump blood as effectively as it should, and as a result, your body retains fluid causing generalized swelling.  You don’t often see it in twenty-something-year-olds.  But here was Robby with his normally heavy frame made even plumper by CHF.  To put it bluntly, he was a sad sight.
The first thing I noticed when I walked into Robby’s room was the smell of stale urine.  The next thing I noticed was that the room was occupied by one of the largest human beings I have ever seen.  Now, everything in medicine has taught me to find compassion, set aside preconceptions, and ignore unpleasant odors.  Yet if I were truly honest with myself, I would acknowledge that a small perhaps veiled part of my consciousness could not completely block out the unkind prejudices that one might associate with a foul-smelling, 300-plus-pound man.
Without a doubt, the nobler part of my medical student being felt sorry for Robby.  This part of my soul wanted to cry out against the indignity of letting anyone to sit in his own filth.  I thought if I were a nurse, perhaps I would be the one kind enough to bathe Rob—not so much to restore his hygiene, but to restore his dignity.  After all, I entered medicine because I believed in the goodness of restoration and healing.  But as always, our virtue is rarely left unperturbed by our demons.
The darker part of my psyche balked at the physical examination.  Because taking a blood pressure might mean getting my instruments dirty.  And touching this patient might even mean soiling my shirt sleeves.  And while I am the first to pay lip service to compassion for the broken and ailing, heaven forbid that I transfer anyone’s stale odor onto my own hands.  I hate this part of myself.  Often, I am tempted to pretend such feelings don’t lurk in the shadows of my consciousness.  But then I’ve always believed that darkness is galvanized when we ignore the bit that resides in our own hearts.
I think there are people in this world who would look at Robby and see nothing but a beautiful soul in poor health—saints among us who know only compassion in its purest form.  I have always admired these people, especially when they happen to be physicians.  And I never fail to wonder whether their undiluted humanity was acquired somewhere in their education and experience.  Or are some people just born with a deeper well of compassion?
I sat across from Robby, holding his thick arm in my substantially smaller one, and I took his blood pressure.  I ran my fingers along his swollen ankles in search of a pulse buried in his puffy feet.  And I examined him as thoroughly as I possibly could, realizing that I was not only learning to care for a patient, but I was hoping to wash away a tiny bit of the sickness that swims in my own pulse.  Because in my more hopeful (or naïve?) moments, I think that I may one day be able to finally exorcise that stubborn stench.  Yes, maybe one day.

Wednesday, October 6, 2010

A Brief Guide to Test Week

One of the crowning achievements of all medical school admissions offices is their ability to assemble such a brilliant collage of neurotic behaviors.  Our test on the kidney is this Friday, which means it’s exam week.  Which also means my classmates and I are finding creative ways to bolster our individual expressions of neurosis.
Many med students—perhaps myself included—will generally stop sleeping during this electric week.  Within this group exists a rarer breed that begins purchasing double-caffeinated espresso by the handle starting Monday morning (I think the Starbucks on our campus is having a special this week).  Still others give up shaving, or bathing, or changing their clothes for a string of five or six days, spurning hygiene in favor of multiple-choice glory.  A rather common variation of the anti-hygiene syndrome is the collapsible food pyramid.  This is when a med student foregoes the standard five food groups, essentially packing away the beloved pyramid, with the aim of living out of boxes labeled “Nabisco” for a few days.  This is like camping.  I think.
However, while the surface expression of exam-induced neurosis can be quite variable, the pathognomonic lesion is the Facebook update which cleverly indicates yes, I do indeed have an upcoming test (especially a new status containing notions of how much/little I am studying).  For the sake of fulfilling this duty, I have written a haiku:
The Kidney
Concentrates my pee
As my concentration vies
To produce the most
Sometimes I joke that I applied to medical school not because I wanted to become a doctor, but because I love tests and I heard medical school had some good ones.  Of course, this is just me being facetious.  But it is also probably 9.22% true.  There, I confessed my neurosis.  Now I need to get back to studying.

Saturday, October 2, 2010

To Do

Over the summer, I picked up an age-old practice that is popular among my peers.  I started a “to-do” list.  It was one of those moments in early adulthood where I worry that I am becoming an adult too early.  But since medical school is brimming with forms to fill out and meetings to attend, I grudgingly yielded some ground to age in order to prevent schedules and errands from derailing my mind.  Plus, it gives me an excuse to own an iPod.  It’s curious how tapping a back-lit rectangular touch-screen is somehow infinitely more satisfying than keeping a pen and pad.  But I’ve realized something else in 2 months of electronic list-keeping.  Having a to-do list doesn’t guarantee anything will actually get done.  In fact, my list seems decidedly more effective at highlighting (or back-lighting) all the things I don’t have time for.  Kind of like a chubby middle finger—with all the things I can never get around to tattooed from nail to knuckle.
Some of the regulars on my list include a pair of jeans that need tailoring, a tooth cleaning that requires finding a new dentist, and an oil change for my car that is roughly 2000 miles overdue.  I think of these tasks as the loners who checked into my sad motel of errands and never checked out.  And the problem with housing such tenants is that you never know which ones are going to turn out to be closet psychopaths—introverts who never call any attention to themselves until one day they set the entire establishment ablaze.  Maybe I’ll get tartar buildup, all my teeth will rot, and I won’t get into a good residency because straight teeth and a good smile are the first things a residency director notices during an interview.  Maybe my car’s engine will explode while I’m cruising down the freeway and they’ll have to shut down the 405 so rescuers can pry me out of my self-inflicted burning wreck.  Or maybe, I’ll get too fat for the jeans I bought 3 months ago.
Aside from the undone errands, I have also managed to partially embark on a handful of recreational endeavors.  Like the acrylic painting I started last Christmas.  I felt inspired to create after my girlfriend, Tiffany, and I went on a holiday hike and took some beautiful pictures.  Nine months later, I am the proud owner of a half-inspired canvas which adorns the floor of my storage closet.  There’s also the novel I started reading this past summer, One Flew Over the Cuckoo’s Nest.  I got 90 pages into it before school started 8 weeks ago, and it’s been collecting dust on my nightstand ever since.  I am quickly entering that nebulous territory where if I don’t pick the book up soon, I might as well start again from the beginning.
But among all the great un-achievements I’ve amassed, the most disheartening are a handful of aspirations I have long held but never appropriately addressed.  Sure, it’s nice to have healthy teeth, clean engine oil, and fitted jeans, but when I’m old and broken, I can’t imagine thinking to myself “if only I completed more errands.”  No, the items most worthy of regret are always the ones that don’t fit nicely on a to-do list.  Things like travelling and improving my Spanish, learning to rock out on the drums, and spending more time exhaling as I swan dive into forward bend.  Aspirations that have nothing to do with due dates and everything to do with the character I hope to embody.  Sometimes, I wish they had taught me in first grade to accomplish all my life goals before I turned thirteen.   Because now I’m stuck behind the eight ball wondering, will I be any closer when I am a working physician?  When I have kids of my own?  When I’m senile, have erectile dysfunction, and have forgotten to save up for retirement?  Exactly how swollen is this middle finger going to get, doc?
But even as I stumble, I try not to lose heart.  Because if medical school has taught me anything, it’s that hope plays a key role in the therapy of all chronic conditions.  It’s what ailing patients say when you visit them—just one day at a time.  It’s a faith that in the midst of disease and deadlines, we’ll find space for the things that are important, for the things we love.  For me, this includes writing.  Writing to tell a story, writing to find myself, and writing for no other reason than to finally check off an item that has been on my to-do list for over 4 months.  So at least for this moment, the swelling has gone down just a bit, and this is a hopeful sign.

Thursday, May 6, 2010

Medicine, Year 1

I talked with my dad on the phone for 30 minutes last night. 30 minutes. Probably not a big deal to most, but to me, this was something of an anomaly. My dad isn’t much of a talker. Growing up, the vast majority of our conversations began and ended with school, grades, and standardized tests. This has been a trusty recipe for 30-second conversations, especially since I’ve always managed to keep my academics more or less in order. As I’ve gotten older, however, I’ve learned to pick up on my dad’s preferred mode of communication—his actions and his hard work. His “I love you” is an 80-hour work week and his “good job” is a split-second smile and a nod—you might miss it if you haven’t learned to pay close attention.
When my dad learned that I wanted to attend Duke for my undergraduate education, he told me that the price tag for tuition could only be justified if I were to aim for medical school. Otherwise, it simply “wasn’t worth it.” I knew that I really wanted to go to Duke but I also knew very little about becoming a doctor. In the end, I agreed to give the pre-med route a shot and that was my first decision to pursue medicine. I know, not much of a decision.
Despite a general lack of interest in most of what I was learning, I ended up doing pretty well in all my pre-med classes. This didn’t give my dad much to talk about and it was a good thing, sort of. However, I’ve learned that passion-less work will eventually catch up with you in some shape or form. For me, it was burnout. By the time I had finished my junior year at Duke and was gearing up to take my MCAT, I was wiped. I was sick of the soul-draining cycle of stuffing information that I didn’t care about into my head so that I could brain-puke it onto a test, so that I could get the grade I wanted, so that I could go to my grad school of choice, so that 20 years from now, I could perhaps be in a position I wanted to be in. It was all too results-oriented. I realized that I couldn’t embrace the journey because my initial decision to pursue medicine was rather uninspired. I was good at the classes, I liked the idea of helping people, but it felt like I was travelling smoothly, aimlessly down this default path, waiting for lightning to strike.
And then I chose to pursue my medical education at USC’s Keck School of Medicine, at which point my dad basically told me to fuck off. This was after I spent a year working in an ER, and deciding that I really did want to do medicine after all. I think it really forced me to own up to this decision, the fact that my dad hated it—not my decision to go into medicine, but my decision to attend Keck. I was lucky to have garnered a few acceptance letters, and my dad felt that at best, Keck should’ve been my third-choice option. Simply put, he had looked at the U.S. News rankings, and to him it was rather clear. He didn't talk to me for a month. In his eyes, it was love unreciprocated. He had done his duty, working tirelessly so that I would have every opportunity. And now, he felt I was abandoning my end of the bargain, foregoing his love. I have since gained a better appreciation of the cultural overtones that led to my dad's actions and from this I have found forgiveness. But at the time, I couldn't see much beyond the pain and bitterness. There were nights I went to bed with murderous thoughts.
It’s a funny thing when you choose an unpopular stance on anything. You feel added pressure to perform, to succeed, to avoid ever having to hear “I told you so.” And this is how I embarked on my education at Keck. For the first many months, I wavered between an inextinguishable fear that I had made a mistake and an unrivaled determination to make the most of my experience. As the year went on, however, these raw emotions began to dissolve into peace as I found myself enjoying my experience at Keck. And not surprisingly, with this enjoyment came relief. It’s been a transition, a challenge, a fulfillment. But more than anything, it’s been the first time in a long time that I’ve enjoyed the process—the journey independent of the destination.
So I talked to my dad last night and per usual, we talked about school. He had heard from my mom that I was enjoying medical school, and he expressed his pleasure. “You know,” he chuckled, “it’s sort of a relief because I feel like I’m essentially the one who forced you into medicine.”
“Ai-ya, Dad.” I shook my head. “You know if I really didn’t want to, you couldn’t have forced me.”
He hummed to himself in muffled agreement. Then after another brief chuckle, he brought up my White Coat Ceremony, which he had attended at the beginning of the school year. “You remember that—oh, what’s it called—that oath-thing you took?” He was referring to the Hippocratic Oath. “I remember being moved.” He took a breath and his tone deepened. “So, it looks like you are learning quite a bit, huh? I couldn’t be more proud of you.”
I paused to let this translate. In all the years I’ve known him, my dad has only said “I’m proud of you” one other time. Like I said, my dad isn’t a man of many words and tough love is the only kind he knows. But I’ve learned to read between the lines. Here he was, a year after intensely fighting my decision to attend Keck, stating explicitly that he was not only okay with it, he was proud.
I thought back to the Hippocratic Oath my dad mentioned. I remember standing in front of the school my dad never wanted me to attend and pledging a certain loyalty to “the profession of Medicine and… its members” and accepting a certain responsibility “for the good of the sick.” Now looking back, I think the Hippocratic Oath sums up pretty well the fact that our decisions are steeped in the influence of others—friends, teachers, patients, and parents. Our free will is inextricably knotted to both those that come before us and to those that come after. But even as we acknowledge the ways in which our characters and choices have been molded by those around us, we somehow take ownership of our individual paths. The day I stood up at my White Coat Ceremony and recited that oath was perhaps the baptism marking when my journey in medicine—one that began with a little coercion from my dad—fully became my own. And with a simple, rare “I’m proud of you,” I felt my dad acknowledge this fact as well.

Thursday, February 4, 2010

Pretty Hues of Vanilla

I interviewed a medical school applicant for the first time today. As a student-interviewer, I am supposed to ask open-ended questions in order to develop an accurate impression of an applicant. Basically, we are told to make sure there is a “real person” to go with the shiny résumé that sits in the admissions office. This being my first interview, I found myself struggling to formulate questions sharp enough to probe the “realness” of the lady sitting in front of me. What the hell kind of questions can you ask to penetrate the bullshit of interviews and reveal the true substance behind a person’s character in 50 minutes? And if by some odd play of fate I do elicit something meaningful and true, who the hell am I to judge that which is unveiled before me? It all seems quite silly and random to me—a microcosm of the entire medical school application process. This is why I ask silly questions like “what do you think about healthcare reform” and “tell me about your extracurricular activities.” It’s not that these questions aren’t important. It’s just that part of me feels like the ringleader’s accomplice, holding up another hoop for a tiger to jump through. This doesn’t tell you much about the tiger except that it is beautifully-trained to perform circus acts. Alternatively, if you want to know the true character of a tiger, you'd probably be better off throwing some raw meat on stage.
This is the problem with the medical school application process. It selects not so much for creative and brilliant minds as it does for individuals with an uncanny ability to jump through hoops. The Ringling Brother’s figured out that if you erected enough flaming rings, you could easily raise up a pride of felines both talented and tame enough to navigate a stunning barrage of obstacles. And in many ways, medical schools have taken on this model. A med student is essentially the Darwinian product of a countless number of unnatural forces, including standardized tests, GPAs, research projects, volunteer work, recommendation letters, two dozen short essays, soul-draining interviews, and expensive business attire. This supposedly “weeds out” the faint of heart and leaves you with a handful of elite specimens (minus the ones who figured out that law school is only a 3-year commitment). However, the fact is that this process too often leaves you with trained performers, a superb collection of conformists all of similar color and trait. Great for the circus. Perhaps not so great for the future of medicine.
It isn’t that medical students aren’t wonderful, intelligent, and compassionate. Because from my experience, they are—with little exception—all these things. But there is danger in creating a generation of physicians, all pretty hues of vanilla like the lab coats that they don. A homogenous group of leaders both in mind and motivation is always at risk of perpetuating tradition over pursuing new ideas. This is especially true when you consider that student physicians are masters at manipulating their schedules, efforts, and intellect to fit success’s long precedent. So while we may be great for shaking hands with the dean and rocking the medical board exams, what creativity and innovation will we bring to healthcare’s most daunting problems? Or will we stick to the script, put on a show, and leave the next generation asking the very same questions—what do you think about healthcare reform? Please, tell me about your extra-curricular activities.

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