Tuesday, December 27, 2011

Turning to breathe

I don’t sleep well anymore.  The moment I crawl into bed, the dread of next morning’s alarm is already sweeping over me.  It is an awful feeling, but the alternative is to experience a slow defeat under the weight of my own eyelids—two foes that swiftly subdue and then mock me by planting my nose into the spine of every textbook.  So I choose the former dread over the latter mockery.  But then I don’t dream well anymore.  My dreams are less dreams and more frightful fits of anxiety.  In my dreams I confront the shadowy thoughts I’ve suppressed during the 75-hour work week—the dirt stirred up by the crashing waves of my subconscious.  Here lies the sadness of ailing patients.  Here lies the disapproving looks from attending physicians.  Here lies my frustration with derisive team members.  My anger at sub-standard medical care.  My fear of becoming jaded.  I wake intermittently throughout the night, always turning instinctively to glance at those four glowing digits to make sure I have not overslept.  Then in the brief conscious moments before I sink back to slumber, I swim in the softness of my pillow and allow myself to be embraced by the warmth beneath my comforter.  In that sacred space between bed sheet and blanket—between anxious meditation and malignant awakenings, I maintain a grasp of what I know is still good.  So as my nights grow darker, my grip gradually tightens around these moments of peace.  Waiting for the next alarm to sound.  Really, waiting for anything to signal the dawn.

Saturday, October 29, 2011

Pediatric Impressions

“Mi hijo, tu amigo esta aquí.”
His first day in the hospital was my first day on pediatrics.  I sat in a meeting room full of doctors and soon-to-be doctors—all on duty for the pediatrics inpatient service.  Every morning the team on call ran through the new admits.  “This is an 8 year-old male presenting with knee pain.”  We discussed the boy’s symptoms, came up with a list of diagnoses, and looked at radiographs.   An hour ticked by as discussions were held and decisions made.  People scratched their heads mining for answers.  Some rubbed their chins sifting through thought.  It was my first day and I mined the corners of my head and sifted through the hairs on my chin for anything.  It was his first day and he was the topic of our discussion and decision-making.
He was a kid with knee pain, abdominal discomfort, and subjective fever.  X-rays showed there was something disrupting the bone in his knee.  Maybe infection.  Possibly cancer.  We needed a bone biopsy and orthopedic surgery had already been consulted.  It was my first hour on pediatrics—I had yet to meet him—but his was the first story I knew.  He was a lytic bone lesion awaiting biopsy to rule out malignancy.
We walked in for the first time.  He sat up and shot us a tense glance.  It was our first meeting and I supposed that six white coats marching single-file into my room might make me tense, too.  But there we were—a combined one hundred and sixty-three years of experience all draped in the sterility of white.  He was eight, draped in a hospital bed sheet.  He was a large kid, carried a barrel-shaped torso and was a solid foot taller than most second-graders.  His dark eyes stared out over the baby fat on his face in a look of wide-eyed innocence.  It was day one.  He was our interesting new case, and he was in the corner room.
I walked into his room two weeks later by myself.  Two weeks on the pediatrics floor had taught me to leave my white coat at home.  Kids don’t like it.  He smiled at me.  “Your doctor friend is here,” mom announced and he smiled some more.  I felt proud because shy kids do not smile for everyone.  I sat down with a book in hand and greeted mom.  No, still no word on the biopsy results but they should be back soon.  I had been reading aloud in my spare time.  He wasn’t very good at sounding out the big words yet and I wasn’t too busy.  In our second week, we were working to remedy our situations together.
Week three.  The final pathology results came back positive for cancer.  He was in a lot of pain and playing a lot of video games.   We still read together and he still smiled when I poked my head in.  But he was having nightmares and throwing tantrums.  Requesting pain meds by name.  We needed to run more tests—more blood draws, more scans.  The pediatric oncologist was now calling the shots.  Time to start chemotherapy.  Time to cut down the IV fluids.  The parents remained always at bedside.  Sometimes mom and dad would take shifts but mostly, they were there together.  I learned about metastatic acute lymphoblastic leukemia.  He learned about the cancer in his knees, his hip, his pancreas, his jaw.  I thought about how pancreas was too big a word for an eight-year-old.
“Hey buddy, how you doing?”  His face was blank.  I wondered if four weeks in the hospital had begun to hollow him of the things that make children jump and play.  He looked at me, and through me.  No answer.  I talked about his favorite TV shows and brought his favorite book.  I looked at the corner of his lips.  No response.  He shook his head when I asked to read to him.  He shook his head when I asked to play with him.  So I sat with him and I talked into the air.  Mom smiled at me.  “Your doctor friend is here.”  I looked at the corner of his lips.  No movement.  He wanted to go to sleep, wanted to go home.  Mom looked at me and I kept talking into the air.  Mom smiled at both of us and I paused to stare at the book in my hand.  She kindly inquired about the treatments—if they were helping, why was there so much pain?  She wanted to know how much longer.  We’d been there for four weeks, and I had no answers.  Four weeks, and I just had big words.  Shy kids do not smile for everyone.
Dysthymic, listless, blunted, anergic, depressed.  These were our words.  “What’s wrong?” we prodded every morning.  We smiled and offered and reassured every morning.  We felt our efforts graze his hollow stare, leaving untouched the painful frown beneath.  His vocabulary for describing thirty days in a hospital was painted in his eyes and in his face.  It floated upon his screams, picked up by nurses down the hallway.  He screamed through most of the night and slept through most of the day—except when he screamed during the day as well.  I sat down with a book.  He closed his eyes.  “Hey champ, you want to read this with me?”  He blinked and rolled over.  Mom leaned over him.  “Mi hijo, your doctor friend is here.”  He screamed that he wanted to sleep.  I leaned over him.  Let’s work together.  No.  You are being a baby.  No.  I will bring you a bottle and we will have to feed you like the little babies.  No, no, no.  I made him angry and anger made him sit up in bed and look at me.  The chemotherapy is working and you will be going home soon, I told him.  No.  If you do not walk, we can bring you a stroller to sit in.  No!  His screaming and crying fueled his walking.  He walked to the window and looked outside the hospital.  At the freeway.  At the houses across the freeway.  He wanted to go home.  Yes.  Yes, in five days I said.  Yes, you will go home.  His eyes met mine.  “Five days?”  I explained that if everything went well, he might go home in five days.  His frown softened.
Four days passed.  I didn’t know if he was counting, but I knew I wanted to keep my word.  On the fifth day he had a seizure.  It was the beginning of my last week on pediatrics.  I walked into a room full of doctors and nurses bustling in organized chaos.  White coats were discussing and deciding.  Lights were being shined into both pupils.  He wasn’t frowning.  He wasn’t moving.  Doctors were talking.  “Can you hear me?  Squeeze my hand if you can hear me.”  I sat down next to mom and she was trembling.  I went to look for some tissues and returned with a box.  She squeezed my hand and we stared at him and all the concerned faces huddled around him.  We listened to the beeps of the monitor.  We gathered his belongings as he was rushed back to the PICU.  A tube was placed down his throat and more monitors were hooked up.  I sat with mom.  The doctors were not ready for her to visit in the PICU yet. 
“He was mad at you, you know.”  He had been counting.  I nodded.  I knew.  She smiled through her tears.  “I told him that he had to be good and everything had to go right, but he was mad.”  I understood.  “He said you had told him that he was going home.  And he said you lied and you weren’t his friend anymore.”  I blinked.  “But I know you were just trying to give him hope.  I was trying to get him to be good and trying to support you.”  I told her I was sorry.  I told her when he woke up, I would apologize to him as well.  We sat together.
Posterior reversible encephalopathy syndrome.  The doctors mentioned that it was not uncommon in our kids with cancer.  Most recover completely, but not all.  We would wait and see.  I visited him on my last day with pediatrics.  I put on the sterile yellow disposable gown.  The blue gloves.  He slowly opened his eyes and met my gaze as I slid in past the glass doors.  The tube was still down his throat.  Mom smiled at me.  I touched his arm and spoke to him directly.  He made a weak attempt to gesture with his left hand, shot a weak glance down at the tube coming out of his mouth and then steadily closed his eyes and turned away.  I told him that if he could hear me, I wanted to apologize.  
I talked, hoping that he could understand me.  Hoping that I wasn’t simply talking into air.  I said I understood he could not speak with the tube, and I understood he was mad at me.  I apologized for lying to him.  I told him he had a seizure, a setback.  Then I explained that I would not be seeing him every day anymore—that a new team would be taking care of him.  I said I would try and visit often.  But I wanted him to know that everyone was working together to help him get better.  I wanted him to know it wasn't going to be easy, and that I didn’t know how many more days.  But that he would not be in the hospital forever.  He would get better and leave the PICU.  That he would get better.  Go home.  Mom asked me why they were changing doctors, and who would be on the next team, and where I was going.  I told her that students rotated to a different service every six weeks.  “That is too bad,” she said.  She gave me a hug.  We allowed gown and gloves to wrap snuggly in a single embrace as I smiled and blinked.  I fought to hold her gaze as she thanked me.  I turned, felt my breath waver, and stepped quietly out of the room.  I washed my hands, wiped my face and exhaled steadily to clear the tightness in my throat.  Then I turned back around to wave goodbye through the glass doors of his PICU room.  
I visited again a week later after the tube came out and he could whisper short phrases.  I visited again a couple weeks after that when he left the PICU and was back into his old room—the one in the corner, the one where he started.  I visited again this week.  Mom recognized me, smiled and turned to him.  "Mi hijo, your doctor friend is back."  It was his eleventh week in the hospital.  His hair was thinning and his cheeks ballooned with all the weight he had gained.  The ugly effects of chemo.  On his bedside table was a small laptop playing old home videos.  Mom told me that family members had compiled a DVD of memories to help him remember.  Help him feel at home.  He sat and stared silently at a younger version of himself blowing out candles for his fourth birthday.  Chasing his cousins around a park near his home.  Then dancing with a girl in kindergarten.
“Dude, you are a really good dancer, huh?”
He nodded.  Then after a pause, “She...she was my girlfriend."
“Your girlfriend?  She is pretty.  Well, I bet when you are a good dancer, all the girls want to dance with you, huh?”
Another pause.  “Yeah,” a bashful smile spreading across his face.
“Hey, I brought a book for us to read.  Is that okay with you?”
He nodded again.  He looked at the book as I turned open the cover.
“Alright.  But you are going to have to help me with the big words, okay?”

Tuesday, August 23, 2011

Scrubbing


Third year can be exhausting. When I was on my obstetrics and gynecology rotation, my car rolled into the hospital’s dim parking structure anywhere from 4:45 to 5:30 in the morning and I rolled out sometime between 5:00 and 8:00 at night. The time stretched between those two poles was like a slingshot propelling me from room to room, task to task—a frenetic scramble to stay on top of what my team was doing. But perpetual motion is good. Because pause gives sleep an idle target upon which to pounce. I remember one day in particular, when my knees buckled halfway through a 4-hour laparoscopic cystectomy. I could barely believe it myself, but after staring at a screen in the dark for 2 hours, sleep was upon me before I could sidestep its claws. I ended up catching myself with a startled yelp before I did something really embarrassing like wake up on the OR floor. My resident asked if I was alright, probably assuming I had tripped, because honestly that’s what it looked like. I quickly chimed “yeah, I’m okay.” The surgery went on. I was wide awake for the remainder.

Being in the operating room, or OR, can be tricky. Of course, staying awake during surgery is an obvious tip every student should keep high on their list of priorities. But there are a number of more delicate rules, most of which become habit over time. And this is precisely the problem. For surgeons who have scrubbed into thousands of surgeries, OR etiquette simply becomes nature. This means that trying to explain to fresh 3rd year students how to scrub into a surgery is like trying to explain to an alien how to order drinks and have fun at a bar. Even if you could verbalize all the proper steps, your alien is bound to forget something. And the results are always awkward and frustrating. So I decided to piece together some advice for anyone having to scrub into surgery for the first time. I present to you my very own medical triad:
  1. First—and most important—is come to peace with the fact that you will look like a complete buffoon the first half dozen times you scrub in. In every operating room, there is a field of items, including the patient, which are draped in blue. This is the “sterile field” in which the surgeons and scrub techs work. You will violate this sterile field multiple times in your first few surgeries, and people will scream things like “NO! Don’t do that!” but it will be too late. You will have touched the untouchable. Sterile will rendezvous with non-sterile. And the result will be great shame and condemnation. But 99.99% of the time, the patient will not die. So unless you are in the unlucky 0.01%, the best advice I can give is to be fully resigned to the fact that for your first few times scrubbing into the OR, you enter as an alien buffoon. So be okay with laughing at yourself. It’s a healthy defense mechanism.
  2. The only other real key advice is to make sure to wear your facemask ANYTIME you enter the OR.  Even if you are not scrubbed in—even if you are just peaking in for a millisecond to say “bye” to your gorgeous resident—put a facemask over your mouth. Your kisser is synonymous with a filthy oracle of doom that spews forth death and plague. If you remember this, you might avoid the lament of nurses and scrub techs everywhere. But you won’t remember this. And even if you do, the only difference is that you will be an alien buffoon wearing a facemask. 
  3. Tie your mask tight but evenly. But not too tight. Okay, there is really no way around the fact that your mask will slip into an awkward, uncomfortable position early into your first surgery, and you will stand for over an hour trying to adjust your mask using only the muscles in your nose and lips. Important Note: you CANNOT touch your mask with your hands after you have scrubbed in. Such actions will call forth hellfire and gnashing of teeth. I spent my second surgery, a vaginal hysterectomy, with my mask slicing upward into my eyeballs for what seemed like 2 hours. After the first hour, I began to embrace the possibility that I might go blind, but at least I was preserving the sterile field.
So really, what it boils down to is if you can successfully play the role of surgical buffoon for your first few scrub-ins without getting too down on yourself, you will get over the hump and the OR might even be fun. You will screw up, get yelled at, have to scrub and re-scrub until your hands are raw, and sometimes want to stick your tail between your legs. But if you are lucky, you will not gouge out your eyeballs via facemask. Then perhaps you’ll retain just enough of your vision to witness future buffoons walk in through the OR doors.

Thursday, August 4, 2011

Introduction to Clinical Mediocrity

“Oh well.” The nurse midwife shrugged her shoulders and went on to see the next patient. I had to get out of there. I wasn’t proud of wanting to leave, because maybe I could have helped things if I had stayed longer. But with frustration stewing just beneath my smiling exterior, I felt like it was time to go. And it was time to go. I was only scheduled to be at the clinic until noon, and it was now a quarter past one.
“Can you please fill out my evaluation before I leave?” The midwife nodded, took a look at my form, and then made me read off each category, noting which grades I should check off for my performance. The print was too small, she said. I did it with a smile. “Grab some of my super-juice on the way out” she hollered from a patient’s room after we were done. I filled my cup with the green concoction that she had purchased from a health food store, took a few sips, and tossed the rest in a trash bin on my way out of the hospital.
“Oh well” is something you say when your milk expires. It is appropriate for lost pens and broken vending machines. “Oh well” is not something you say to a nurse after she goes sprinting out of clinic and hospital in hopes of delivering to a patient the prescription you forgot to write. There is nothing dismissive about providing substandard care. I wanted to trash "oh well" like I had trashed the super-juice.
For the most part, third year is exhilarating. You come home exhausted because you’ve emptied yourself into new experiences. You deliver your first baby, you perform your first Pap smear, and you see 19 cm tumors being dissected out of people’s bellies. The most frustrating thing about third year, therefore, isn’t the sleep debt you quickly accumulate, or taking call on weekends, or even the time you spend studying for exams on top of it all. I think the most depressing part is that long hours spent in the hospital will eventually bring you right up against the darker underbelly of medicine. The inevitable truth is that we will all see patients—people who lean on us—being mistreated, mismanaged, or sometimes even blatantly misled. I wasn’t exhausted when I came home from the clinic that day. I was furious.
I had spent the morning at an obstetrics clinic working with a certified nurse midwife and her team of two nurses doing routine check-ups on pregnant women. “You will be helping me with the computer today,” she told me after I introduced myself. I gave her an eager nod, “alright, sounds good.” It was only my second day on the new LAC computer charting system, and the electronic procedures were all foreign to me. But you learn that as a third-year student, the right answer is always “of course I’ll do that” or “yeah, that sounds good.” So I watched as the midwife saw her first patient while indicating to me which icons to click, what things to type, how to create and file new notes—stuff like that. Then she entrusted me with the charting.
Even as I settled into my role, I quickly realized some things were being overlooked. After interviewing one of our first patients, the midwife insisted that I include in my note, “no vaginal bleeding, leakage of fluid, or uterine contractions. Positive fetal movements.” This is a pretty standard review for all pregnant women—except in this particular interview she asked none of those questions. In my most pleasant tone, I piped, “Oh, did we ask the patient these questions?” The midwife looked at me incredulously, and replied “don’t you think she would have told us if she had any of those?” I nodded and kept my lips tight. Maybe the midwife’s assessment was fair. Maybe not. You learn early on in medicine never to assume, and I didn’t feel comfortable making even these seemingly small assumptions. I know enough to know that this is how you get in trouble. So my frustrations began to mount.
After we saw a few more patients, she began asking me to include in every chart that “patient was counseled on preterm labor precautions.” It would have been appropriate except that no such counseling occurred. I started growing uncomfortable with some of this. As a medical student, you are often so busy trying to learn the culture and practice of each rotation, you sometimes lack the time and insight to raise valid questions. And even if your wits catch up with you, your position at the bottom of the totem pole sometimes precludes you from wielding a voice. So you learn to choose your battles wisely—especially if they involve engaging a superior who is expected to evaluate you. In retrospect, I regret not asking the midwife to clarify what she meant by preterm labor precautions. Somehow, in the heat of learning a new computer system and working in a new environment, my wits just never caught up with me. Or maybe they were being drowned out by my own frustration.
Things got worse when a Chinese couple came into our clinic toward the end of the morning. They spoke Mandarin and I was excited to be able to communicate fluently with them. The midwife dove into the exam while asking the husband a few questions, because his English was marginally better than his pregnant wife’s.  I started translating and taking my own history on the side, taking joy in answering a few of their simpler questions in Chinese. As I flipped through the patient’s electronic chart, I saw stated in previous records that there was a prior complaint of green vaginal discharge. I turned to the midwife and asked if a pelvic exam would be appropriate to which she simply replied “well, she was given antibiotics last time so she should be okay.” No exam. No repeat culture. Not even a few questions regarding whether the patient was still having symptoms. Instead, the couple was ushered out of the room, and I was left to finish the charting. After a few moments the midwife poked her head back into our room. “Are you ready for the next patient?” I was ready to leave.
The next patient turned out to be the lady for whom the midwife forgot to prescribe antibiotics. The positive urinalysis results were lying on the desk beside the patients chart, and we somehow missed it. The nurse ran to the bus-stop and returned with the prescription still in hand. “Oh well.” I can’t remember exactly how I felt as I left the clinic that day, because my head was spinning a bit. I do know that my thoughts never mirrored the midwife’s flippant “oh well.”
It’s clear me that providing adequate care for our patients comes with a multitude of challenges. New computer systems. Large patient loads. Limited time. I knew this when I signed up for medicine. I also understand that at some point, I will surely do worse than forget to write a prescription. We train ourselves to avoid mistakes, but hopefully, we also train to own up to the ones we do make. I entered medicine because I felt it was a humane endeavor. But it’s also a human endeavor. It is not empty of error or devoid of tragedy. Even as such, my feeling is that we can always do better than “oh well.”

Monday, July 25, 2011

Green

I don’t like new highlighters. I rely on good highlighters to carry me through medical school’s wordy and often cryptic prose. In a literal and beautiful way, highlighters add color. Add balance. But new can be frustrating. Yes, new embodies the anticipation of unraveling long-awaited treasures on the eve of change. New is progress, growth, flourish and potential, all waiting to be uncapped. But new is also awkward.
It’s a green excitement that bleeds through your pages with good intentions—where subtleties are underscored with thick lumbering strokes yearning for a more seasoned grace. But that grace is not today. No, today my newness remains emerald in approach yet spinach in execution. Bold in enthusiasm, but slim in experience. With patience, with work, I have faith that green can one day soften into sage. But today, green is still green. It bleeds, it stains, it awaits tomorrow. This is the experience of learning—learning to provide, to perform, to care, and to comfort. Learning to highlight. Green is the journey of medicine as a third-year student.

Monday, July 11, 2011

Statistically Speaking

I reclaimed my life a few weeks ago. After three months in academic quarantine, I finally took my medical board exam. The boards are a Faustian rite of passage crafted by some black angel of medicine—an 8-hour standardized test designed to crush your soul in preparation for clinical rotations. Or in the words of the masseuse I visited afterwards, “Holy cow. Why do they do that to you guys?” But I forded the river, kept my oxen alive, and lived to see Oregon without too many of my kids dying from dysentery (see below). So for this, I am grateful.
To be sure, there are plenty of things I’d rather do than reminisce about 3 months in preparation for multiple-choice hell. But in the same way a masseuse might untwist the knots you’ve accumulated in your back, I thought reflecting on some of the highlights and lowlights (they are the same thing) of studying could purge myself of some pent-up demons. So I present to you my stats:
Money spent on coffee in 3 months: $95.58
Plants that died because I forgot to water them: 2 small plants, 1 tree
Plants I am going to buy in the near future: 0 (lesson learned)
Hours spent listening to Jay Z’s “Dream” on repeat: 18.65
Practice questions/cases seen: 4073
Practice patients that I killed: 861 (disproportionate numbers died from misdiagnosed infections or drug-related mismanagement. It was devastating losing the little ones.)
Most consecutive hours spent in the library: 16 (This was an accident. And a tragedy. Tiffany dropped me off on this fateful morning, got held up late at work, and as a result, I was stranded without a ride home. A resident who was studying for Step 3 shared a desk with me for 12 of those hours. As he left he wished me luck, eyes glowing with pity.)
Books I read outside of board-review texts: 0
Time it took me to finish my first book after taking the boards: 2 days
The feeling of picking up that first book in 3 months without having a highlighter in the other hand: priceless
Highlighters that gave all their juice to my cause: 4
My favorite color highlighter: trusty neon yellow (this guy is a warrior)
My favorite pen: blue ballpoint at first, red later on (the color of rage)
Recently, I’ve been fighting to reclaim those parts of my life that I’ve forfeited for many months. Because by mid-June before my test, I had gracefully spiraled into a deep, dark place where the light of perspective no longer shined. I found this the best place to study. At one point, I even confided jokingly to a friend that I would sacrifice my firstborn for a respectable 3-digit score. We laughed even though we both knew I was mental. I’m trying not to be mental. I tried frantically after my test to pack in enough time in the sun, the waves, and the company of friends and family before the start of my third year. Naturally, third year started without regard to time spent doing happy things. So for now, it’s back to the coffee, the highlighters, and yes, the library. Back to chasing heftier stats and higher scores. It seems like all I can do is clutch whatever brief moments of sanity I am afforded and grasp on tight to perspective even as I slip from one relapse to another. I guess I'm okay with that. In fact, I'm grateful for it. Maybe I'm mental.

Tuesday, May 24, 2011

Noisy Junk

I cleared out my desk today. Yes, I’m done with second year. At our school, like many medical schools, only first and second year students get assigned desk space. As third- and fourth-years, you move around with your clinical rotations, engaged in a more nomadic academic life. So today, I officially gave up my home. Actually, I was supposed to clear out my desk and turn in my key last Friday after I finished my final, but it somehow slipped my mind in the excitement of being half-done with medical school.
There was really nothing much to clear out. My friends know I rarely study at school, and most of what was left was junk. I threw everything away, except for a dozen drumsticks which I found housed in a bottom drawer. This made me smile because it seemed funny that someone would stow a pile of drumsticks in their desk.
The sticks were from a skit my friends and I put on for Keck’s talent show earlier this year. We called ourselves “Noisy Junk,” which is a great name for a ragtag group of amateur street percussionists. Imagine a band of medical students eager to beat out their angst on trash bins and paint buckets, and you pretty much get the point. I actually got blisters on my hands from rehearsing, and lost one of my drumsticks mid-act when I got carried away in the frenzy that was our finale.
So hauling these sticks back to my car seemed to nicely sum up the year. You work hard, endure, and hope that when you lose yourself in the whirlwind, it’s for something worthwhile. And when it’s over with, when the details are long-forgotten, hopefully you can look back and smile. I dropped one of my sticks while walking to my car and the thing clattered down a flight of stairs before rolling to a stop. You know, I’m still learning that when sticks go a-flying mid-act, sometimes you just have to take comfort in the fact that life never came with a script—just hope no one takes a stick to the face and slide back in rhythm with the next measure. The show certainly does go on, and damn, does it go fast.

Sunday, May 8, 2011

A Mother's Day Memory

My seventh birthday was coming up. I told my mom that I wanted to have it at Putt Putt Golf, the local mini golf center in Tallahassee where I grew up. It was going to be my first birthday party outside our home, and I had been absolutely set on Putt Putt ever since attending a friend’s party there just a few months prior. I was an entirely unoriginal kid. But my mom—she went to work planning and preparing my special day because it was what I wanted.
Looking back, it must’ve been a small leap for my parents, too. My family was only a year or two removed from living off my dad’s grad student stipend of 800 dollars per month. So spending money to host a kid’s birthday bash was a fairly new concept for them. Unfortunately for my mom, she was unknowingly engaged in a losing battle. I think in retrospect, I really wasn’t looking forward to celebrating my own birthday as much as I was hoping to re-enact the birthday party I had previously attended. Like a lot of kids, I simply wanted to do all the cool things everyone else had done.
Well, my mom invited all my closest friends, and we all gathered on the 18-hole course. My parents paid for everyone’s putters, and immediately, I knew something was wrong. You see, my friend’s party featured this young, excited mini golf employee who led everyone through introductory birthday activities, cheered us on at each hole, and handed out prizes. I remember looking around, and feeling indignant about receiving only a club and a ball. So I hounded my mom about how she had messed up the planning and how critical it was to have this silly worker leading all the fun. My parents ended up asking the management, who informed them that the goofy teenager with the official golf visor was only included in the more expensive birthday package.  I was crestfallen. It’s embarrassing how clearly I can recall the overwhelming disappointment I felt from a birthday nearly two decades ago. But then, I doubt many of us are especially proud of what emotional maturity we displayed as seven-year-olds.
I’m not sure why certain memories seem to randomly stick with us more than others. But I’ve grown to appreciate this one, because it illustrates a lot of what my mom embodies. She has always worked quietly, moved tirelessly to provide the best for my brother and I, regardless of how consistently unappreciative we have been in return. And I know she has always worried herself with notions that she was somehow failing to provide us with key opportunities afforded to other kids—either because of financial limitations, or because her lack of familiarity with aspects of American culture. I’m sure it probably broke her heart a little when her seven-year-old son made clear that his birthday wasn’t of the same caliber as his peers’.
For this, mom, I apologize. If ever I could sit down with my seven year old self, I would tell him that the only time he should ever feel disappointment is if he lets you down. In fact, I would tell him that his only job in the entire world is to make you proud—to do right by you. And if he could just do that, he will grow up to be more than okay. He might even one day realize he’s no longer that thankless punk, but a man who owes you the world. You’ve given me everything, mom, I love you, and I hope you have a happy Mother’s Day.

Monday, April 25, 2011

Hardcore

At the end of two years of medical school, there exists a rite of passage. It’s called the United States Medical Licensing Exam, Step 1. Or “the boards” for short. Like all standardized tests, you get a numerical score that in part determines what you get to do next. Because of this, people like to use some combination of the words “awful” and “stressful” to describe the process of preparing for this exam. So far, I’ve managed to stay fairly glued together. The first few weeks, I was pretty pumped to review for this test, but now the newness has mostly worn off. Kind of like a fast-flaming relationship, huh? But I’m similar to many medical students in that I have this strange and sick part of me that actually enjoys the intensity of it all. And I guess I have to, because after 18 years of schooling, I still keep coming back for more. So I’ve learned to get hyped about pulling all-nighters and working long hours—if only to delude myself into thinking there’s nowhere I’d rather be than right here in the library.  In anyone else, we might diagnose this as masochism, but in ourselves, we diagnose it as being “hardcore.” Maybe it’s no wonder it can sometimes be a fast-burning candle?
I think this strange hardcore-ness is what allows med students to take a sort of collective pride in our workload. It’s why we overhear classmates boasting to friends about breaking the 100-hour barrier in their studies last week, or eating only 3 actual meals over the course of 6 days. It’s fascinatingly ridiculous. Yet I can’t deny the small pinch of admiration I feel, even as my eyes begin to roll straight to the back of my head—which lends me to what I actually wanted to write about. I saw the most hardcore thing of my life the other day.
It happened while I was taking a bathroom break at school. Sometimes, I hold my pee while I’m studying just so I can reward myself after reading number of pages. Yes, it’s extremely stupid, but I already told you that being hardcore is a psychological illness of sorts. Anyway, whatever self-deluded pride I had ballooning in my chest upon entering the men’s room quickly disappeared as I prepared to wash my hands and return to my books. As I turned toward the sink, a guy walked past me holding a stack of notes. Okay, I thought, I’ve seen this before. It’s not unusual for students to bring some notes with them while they take care of business in the stall, whether they admit to it later or not. But no—not this time. I watched first in curiosity and soon in awe as this student headed not for the stall, but for the urinal! I feebly tried to look away, but of course ended up ogling the kid as he held his notes in front of him while he unzipped and peed standing up.
Now, I absolutely understand that writing about bodily functions is never reputable. Especially if your stories involve staring at others as they relieve themselves.  But I felt this encounter called for the grandest of exceptions. I came out of the bathroom that day a bit giddy because I felt like I had witnessed some type of barrier being broken. It was an academic feat I had never even considered, much less attempted. Sure, I’ve been known to bring my books to the dinner table or listen to lectures in the car when I want to take advantage of those precious 15 or 20 minutes. Yet here was someone legitimately studying while micturating because he refused to afford even 30 seconds to idleness. This had to be the hardest of all cores. I considered snapping a picture with my phone but thought this would go against all sorts of student conduct policies and/or federal laws. I still can’t help but think it would have turned into a phenomenal motivational poster.
I recount my public bathroom run-in not only to highlight the lunacy that is my mind, but also to remember a moment of pure hilarity. Yes, the laser-like focus I’ve directed toward my board exam has at times left me whining in despair and punching things in frustration. But sometimes, it also leaves me to laugh at how absurd the whole situation is. Who in their right mind actually appreciates the sight of a grown man cramming at a public urinal? So I figured in my efforts to embody all that is hardcore, I had to pay homage to this inspired stranger who I now consider like a brother to me even though I only really remember the back of his head. Truly, he has given us all something to aim for.

Thursday, April 14, 2011

Skipping a Beat, Year 2

As medical students, we take great pride in our intellect. Our chests and egos inflate a bit, knowing that we emerged from the pre-med slaughterhouse to don a white coat and be pronounced the “cream of the crop.”  We can memorize biochemical pathways and recite long lists of tongue-twisting drugs with the best of them.  And this is, in part, what we were selected for. Because on the second week of school, a thick packet of notes awaited each of us in our mailboxes—a week’s worth of learning condensed into about a hundred some odd pages of medical minutiae. Our task was straightforward: to read, retain, and regurgitate. And thus, the heavy lifting began. From our second week up to the very end of our second year, we danced this ritualistic choreography of picking up a weekly packet and stepping in time with its contents until we’d learned every move and flurry—the whole time hoping we weren’t skipping a beat somewhere along the way.
But while learning the basics of medical science is both challenging and rewarding, it can at times feel quite narrow. In all the memorization and analysis, whatever inclinations we have for the creative and the expressive are sometimes left to atrophy. As with many processes of degeneration, it happens slowly. I didn’t even notice at first. I just knew that the small handful of writing assignments I was given during my first year took me an inordinate amount of time to write, but that I enjoyed these exercises in a manner disproportionate to their academic worth. And then I bumped into my friend, Sylvie, at the beginning of our second year of medical school. As I recounted my summer of research and lab work, she shared her own adventure of travelling through China, making a video documentary of Chinese medicine and the art of healing. She told me how as a dancer, she was thrilled to be able to create something again.
I still remember Sylvie’s exact words in regards to the demands of medical school and what little room it leaves for creative pursuits. “You know, Jay— sometimes this place just has a way of taking it away from us.”
I think I just nodded in agreement and probably muttered something clumsy, which I have a tendency to do when something strikes me as poignant or poetic. But Sylvie was right. I’ve never considered myself much of an artist. I was never a dancer, or a painter, or a photographer. And I sure wasn’t someone who would think to spend a summer in China filming a documentary. Yet I longed for a creative outlet. So I chose to write. I recount all of this because in order to understand what I gained from making writing a part of my education, I must start with why I initiated this project in the first place.
With regards to the process of writing, I wish I could say that my thoughts always flowed beautifully from mind to keyboard and that my efforts to create were always fluid, natural, and effortless. Sometimes they were. But more often than not, I labored to find the words I wanted and I struggled to express the mess that fills my mind. I once read some commentary from Ray Bradbury about his experience writing Fahrenheit 451. In it, I think he talks about how after he created the characters, the story almost wrote itself. God, I wish my writing wrote itself. But then again, Ray Bradbury is Ray Bradbury. I’m a second year med student with a blog. And for me the writing process was not only slow at times, but somewhat maddening. There were pieces that I drafted, edited, edited some more, and then trashed in favor of starting over from scratch.  Some of these pieces went unpublished after I gave up.
There was one composition that I remember was particularly difficult—“A Holiday Toast to Not Being Miserable.” I remember the frustration of trying to capture what it meant to be happy in the midst of a packed schedule full of exams and commitments. Naturally, every time I returned to my draft, my thoughts and feelings on such a layered topic would change depending on my day’s mood. I ended up reworking the entire piece multiple times before I was happy with the final product. Embarrassingly, it took me a combined 10 hours to write five paragraphs. But remember what I said about being disproportionately happy over seemingly negligible accomplishments? That was me. I think it was the personal journey I saw reflected in five paragraphs that mattered most to me. I could have cared less if it took me 50 hours to write.
In writing, I find freedom—freedom to be open and honest about my shortcomings, and freedom to be honest about myself. It’s strange, but in the space I’ve created since beginning this project, I’ve also found a greater patience for others. I remember one incident in particular. It was after a fairly tough exam, and as with every exam, we returned to the computer lab to review our scores and whatever questions we may have missed. As I sat down to review my mistakes, a fellow student whom I have much respect for walked in looking flustered and sat down next to me. As this student proceeded to review his exam, he grew more and more agitated and started to complain aloud about the test. Heatedly, he commented about how terribly he’d done and how unfair the test was. At first, my heart went out to him as I knew how frustrating it could be when you work so hard yet fall short of your personal standards. But then as he got up to leave, he bent down as if in pain, looked around and muttered loud enough for those around him to hear, “I can’t believe I got a 96.” I was speechless. In fact, I was angry. Because it just felt so petty that a student could act this downtrodden and then flaunt a near-perfect score in the face of his classmates.
I thought about this experience for quite some time after it occurred. I allowed it to bother me until I finally concluded that the stress surrounding test week does strange things to even the best of us. While complaining about a 96 might seem cheap, I have always been quick to acknowledge how little the first two years of medical school have to offer in terms of things to hold and call our own. Perhaps for some students, test scores begin to feel like the sole fruit from two years of academic labor. And from this perspective, I feel like I can begin to understand how 4 points lost might somehow feel like a catastrophe. After all, there are certainly times when I feel as if I’ve lost a piece of myself somewhere in the binders of notes that lie piled up on my desk. Like Sylvie said, sometimes it just has a way of taking it away from you. I guess this is really what I was trying to avoid by providing myself with a creative outlet. I just wanted a space to work, and build, and grow outside of school. A space to point to and call my own.
Finally, I wanted to address all the support I’ve received throughout this past year. Although writing and maintaining my blog was very much a personal journey, it would have been much emptier were it not for the responses I received from those around me. By nature, my project was one in which most of the work was done independently. From its inception, skippingabeat.com was really designed as a personal space where I could sift through my thoughts freely and artfully. What I didn’t anticipate was how much inspiration would come from the conversations I had with friends, classmates, and family regarding my blog. It was fun hearing from old classmates I hadn’t talked to since college or even high school. Yet perhaps the greatest honor came from a couple close friends who spent the past year applying for medical school. They told me that my writing helped them laugh when it was hard to laugh, and provided an honest perspective in the midst of a tiresome application process. I know these friends, and I know they like to use hyperbole, but nonetheless this made me smile.
So regardless of whatever quiet expectations I had at the beginning, I’ve been fortunate to find friends and mentors along the way who’ve helped shape this project and who continue to make it meaningful. For those of you who aren’t aware, I was mentored by Dr. Jo Marie Reilly over the past year, and I cannot express to her my gratitude for her role as both an editor and a role model. You would be hard pressed to meet a doctor with a bigger heart and a warmer presence.
So after a year of toiling with HTML and java, and projecting my thoughts out into cyberspace, I’ve clearly enjoyed the experience. I garnered some recognition, built some new relationships, and rediscovered a creative voice. But what have I really gotten out of it? I think to summarize, I have to go back to what Sylvie said about creating space in medical school to explore those non-academic areas where joy, hope and growth reside. I hate to use the word “balance” as it has a tendency to become cliché in medicine. But the reality is that somewhere between undergrad and medical school, I’ve realized that I can no longer take balance for granted. As we dive deeper in our super-specialized professional pursuits, it can be tough making room for all those non-specialized but nonetheless special areas that make us happy and make us human. But it’s worth fighting for. Because we all have a tendency at times to stare at our feet as we forge on ahead to whatever destination lies in the distance. Yet if we refuse to lift our eyes to distraction or detour, we’ll wind up at the finish line with little more than asphalt and pavement as our experience. And what’s the fun in that? So for me, as I move forward, I’m glad to have established skippingabeat.com my scenic detour—a diversion I hope to revisit regularly as I continue along this road to becoming a doctor.

Thursday, February 10, 2011

MISMA

What are you going to specialize in? It’s a question that plagues many med students. For me, it has become almost like a cerebral parasite—growing, replicating, taking over my thoughts. There are some kids who come to med school knowing exactly what they want to do. From day one, they stake their heart’s flag into surgery, or psychiatry, or delivering babies, and this effectively vaccinates them against these brain bugs. But I missed that memo. So I came to school hoping to figure it out as I go. The problem is the more I learn, the more my mind becomes riddled with the tiny eggs of new possibility.
All my friends know at some point or another, I’ve ruled out the likes of emergency medicine or surgery, only to rule them back in the next day after hearing a cool lecture, reading a good article, or even after enjoying an especially satisfying bowel movement. Maybe I’m just indecisive. But I’d like to think we all balk just a little when we see that significant fork in the road ahead. It’s not simply about choosing right, wrong, left, or middle. It’s that when I’m hiking and the trail splits, I catch a glimpse of the multiple winding paths stretched out before me, and I never want to choose just one.
I’ve always felt this to be one of the greater disappointments of growing up. As a kid, it seemed rather certain that I could be a doctor, and a fireman, and an astronaut, and a ninja turtle. For all I knew, I just had to get good grades and eat my vegetables. And as long as I remained a boy, my boyish professional aspirations were encouraged. Because a child’s job is not to pick his favorite cog in a wheel, but rather to imagine what infinite gears might fit together to power his constant daydreams.
Time travel, for example. Let’s set the dial back to fifth grade. I remember science being one of only five subjects in school—the other’s being math, English, physical education, and social studies. Social studies! Looking back, it’s almost comical how broad the real estate is under a title like “social studies.” But at the same time there is something exhilarating about education in its expansive unbridled infancy. In fifth grade, no one was asking you to specialize. Not yet, at least. But science soon became biology, biology became molecular biochemistry, and molecular biochemistry eventually turned into cardiovascular electrophysiology.  Sometimes I feel like I’m not so much choosing my favorite cog on the wheel as I’m choosing my favorite corner on that cog.
So here I am deciding on this question of specialty. And I’ve grown tired of not having a definitive answer. Therefore, I’ve decided to go ahead and announce that I will be pursuing a career in minimally-invasive super-heroic medical aeronautics. Or MISMA for short. I know some of my friends will laugh and tell me this is just a fancy acronym for pediatrics. At this point, your bet is probably as good as any.

Wednesday, January 12, 2011

I Have a Cold

I have a cold. As illnesses sometimes do, this one inspired me to write a self-centric view of evolutionary history. It is as follows:
Some 4-ish billion years ago, a string of RNA crawled out of earth’s primordial ooze, perhaps onto a catalytic piece of clay, and figured out how to spontaneously replicate. Life was conceived. This was not life as an infant or even a fetus, but life as an embryo. A naked strand of ribonucleic acid—unfeeling, insentient, immobile, and according to most scientists, actually still lifeless.
But then nucleic acids took on a coat of lipids, forming the primitive cell and life earned its name in the eyes of science. This primitive cell gave rise to early bacteria and bacteria to complex cells. Life began to move, communicate, and yes, sexually reproduce. These complex cells began forming colonies and soon, colonies yielded the first multi-cellular creatures—at first, nothing more than a slime-like blob, but a primitive creature nonetheless. Blobs eventually gave rise to sponges and jellyfish, which in turn yielded bugs and crustaceans. So not only did life begin feeding, it began feeling.
Over time, bugs and crustaceans crawled onto land, developed a backbone and started breathing dry air. Before amphibious land dwellers could monopolize terrestrial land, however, they were joined by their reptilian and mammalian cousins. So in a matter of a few billion years, life had not only developed the ability to scuttle across the continents, but also to see, smell, hear and taste. From these senses, complex thoughts and memories sprung forth. And as history proceeded from 4-legged rodent-like mammals to ape-like bipeds, life crossed miraculously into self-awareness.
Then at last, from the walking, talking, breathing, feeling, thinking, sensing, self-aware early primates came humans. Humans who would apply all the aforementioned gifts to study science, learn medicine, and pass standardized tests. It was life’s grandest act, according to humans themselves. But, of course, the lifeless, breathless, unfeeling naked RNA that started this whole journey spawned a much less tedious product. A cold virus. An infectious strand of ribonucleic acid that makes humans studying medicine wish they could for a moment be a bit more unfeeling, immobile, and insentient. Clearly, life evolved a sense of irony somewhere along the way.

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