Change is in the Air

Today was the last day of classes in the conventional sense; the end of the course-based portion of my degree. Or as some people may see it, the ending of an era. In the new year there will be classes here and there but everything is changing. Gone are the days of being spoon-fed information from lectures and studying specific details for the sole purpose of passing exams. In the new year we study to heal. We study for the day that a nervous patient in the ER looks us in the eye and asks "What's wrong with me? Am I going to be okay?"

In January we start our transition into the hospitals. We will be asked to read and read and read some more to further enhance our knowledge base. We can no longer ask our instructors "Is this important to know? What's on the exam?" because that responsibility is now on us. We as individuals must decide what is important for us to know. There is no right or wrong answer. There is no set list of things to know. Small group cases are about to be replaced by real life people whose symptoms and experiences can't be summed up by any textbook or study guide.

The year of 2017 brings on the transition into real life. A world where things are not perfect; where the system is understaffed and people are overworked. And I know I am not alone in meeting these changes with mixed feelings, mostly a nervous excitement for the unknown. There is something comforting about routine. Over the last year and a half we all developed our own specific formulas for success. A little bit of A,  a dash of B, a lot of C, and boom we pass our exams; rinse and repeat. But now we are starting anew, having to adjust to new learning styles, social dynamics, and exam questions. Change is terrifying because it is so destabilizing. Having started over in so many ways throughout my life, I've come to know that the unknown can beautiful if you give it a chance. In the face of these new challenges I know that I will stumble, fumble, and likely fall. Yet, eventually I will adjust and regain my footing more stable than ever before.

Owls and Odds and Ends

Today I took a short nature walk to escape the tangles of axons and nuclei and cranial nerves that I am supposed have memorized. As chance would have it, I noticed a group of people with cameras staring up into a tree. Curiously, I wandered over only to see a large grey owl, perched on a great arched branched. As the crowd grew bored and eventually disbanded, the owl rotated its head 180 degrees, opened its eyes and stared right at me. We made unbreaking eye contact for a short while until it blinked slowly, resumed grooming, and then spun its head back around the other way and began to doze.  I stared in amazement for well over 20 minutes just admiring its beauty and unexpected comfort with my presence. Never have I seen a bird so close and so unfazed by the hordes of people stopping to photograph it. Despite being somewhat out in the open in broad daylight, it went on with grooming and sleeping as if none of us existed.

As I headed back, I realized that I am slowly becoming more like this owl: learning to complete my daily tasks and remain calm in the face of vulnerability, incessant observation and evaluation. Last week I dissected a human brain. It still boggles my mind that I held the closest thing to a soul in my own two hands. That brain once actively expressed thoughts, feelings, hopes, fears, memories. THAT brain was once a person - something I still haven't fully wrapped my head around. And I finally had the courage to stare death in the face and look into the eyes of the donors who so graciously donated their bodies so I could learn. This was something I was far from ready to do last year, and yet here I am. Ever nearer is the transition into working with real people and having to translate all that knowledge in my head into competent care. The mere thought of it sets my heart aflutter from both excitement and mild terror.

But like how I became comfortable in the anatomy lab, I have no doubt it will eventually happen in every stage as I advance in my studies. I just need to remember to be like that owl. Calm, poised, confident - words I would rarely use to describe myself but need to learn. Hopefully, one day I too will be at peace with my own vulnerability and the perpetual uncertainty that is medicine.

Reflections on Year 1

I can officially say I survived my first year of medical school, miraculously without failing any exams as I had expected. I can't help but look back on the person that I was before starting medical school and who I am now. I have to say I feel like I have both grown a lot and barely changed. I walk away from my first year with an immense and exponentially growing body of knowledge, and yet I still feel like I know nothing. In spite of a greater acceptance of my own inevitable demise after having held the hand of many a dead, I still feel unprepared for watching life leave this world. Deep in my heart I know I have found my career path and where my passions lie, yet I still feel lost and unsure that I am up for the challenge.

In the wake of everything in the news today, the fear surrounding the uncertainty of our collective future is at the forefront of my thoughts. From shootings to radical political decisions, globally I am scared.  I am scared for the world and I am scared for myself as a budding young professional; what kind of life can I expect to live? But of all the fears I have, the thought of being thrust into the medical world, already riddled with uncertainty, feels the least frightening of them all. Many of the "bad habits" picked up by society are even more pronounced in medicine; the need to be perfect and free of mistakes, to work long hours and show an almost altruistic level of devotion to your career, forgoing personal care. I had always made a deal with myself that if I couldn't take care of myself both in medical school and as a future physician, that I would quit, and that deal is still in place.

During our end of year wrap-up, my class unanimously agreed that finding a reasonable work life balance was the most challenging thing about medical school, and we were warned that it only gets harder as time goes on. Personally, I feel that this challenge stems from a fear failure; that if we need to take time off because we are going through a rough time or fail an exam because of a break up that we have somehow failed as people. In medicine, there is a culture that failure is not acceptable.  We are often held to unreasonable standards of perfection, and expected to maintain our grades and commitments to the medical community when we are hurting. There is less stigma about taking time off to grieve a loss in other careers, why is there so much stigma around this in medicine? What a beautiful irony we live in where we are expected to care for others by failing to care for ourselves.

We need to change our medical culture to be more tolerant of failure because, contrary to popular belief, we are not superheroes. We fail exams, we fail at relationships, and unfortunately we do make mistakes that can potentially have devastating consequences for other people. But collectively shaming individuals for being human, even by omission of support for people struggling, is not the right way to prevent mistakes. We need a system that is supportive of self-care, promotes growth from failure by helping us to learn from our mistakes, and has many safeguards in place to prevent tragedy in the face of human error.

With all of this in mind, I pledge to start off my second year by promoting vulnerability, and open and honest communication with classmates, using myself as a guinea pig. I promise to openly ask for help when I need it, support when I feel down, time off when I find it hard to function, and encourage others to do the same to hopefully start creating the culture of medicine that I want to work in. 

Invisible Disease

Yesterday I stood in the shoes of my patients. Although for a short period of time, it was a firm reminder of what some people struggle with everyday. Invisible disease is pervasive in our society, it is everywhere, and yet because it is invisible, it is nowhere. We as humans are flawed in that sometimes when we can't see something, we don't believe it is there. But for the person experiencing it, it is all too real.

I suffer from chronic knee issues from an overuse biking injury, worsened by having congenital flat feet. Most days, I keep it well controlled (thank you orthotics), but some days the pain makes it harder to walk. In and out of physio for years, I've never been able to be completely pain free. I never walk 100% pain free but I can usually get up to 95%. However, I can rarely stand for long periods of time without pain (I have trouble in the anatomy lab and yes this is something that worries me for clerkship). Yesterday, I needed to hop a bus go to the other end of the city and I knew that ride would take about 45 minutes. I tried to arrive at the bus stop 15 minutes early to guarantee a seat but the line was already stretching around the corner. When I boarded the bus, all the seats were full. After a few minutes of standing the pain began to escalate. I knew I wouldn't last the whole ride so I just kicked aside some of the dirt, sat down on the bus floor,  and just rubbed my knees to help alleviate the pain.To my surprise, the people around me just stared at me with this look of repulsion. No one seemed to be asking themselves "Is she okay?", but more like "Eww how can she sit on the floor, that is disgusting, what a weirdo". They averted my eyes when I tried to make eye contact, and of course no one offered me a seat (and after those looks, I didn't dare ask for one). Thankfully after 25 minutes a seat opened up, but this experience had me reflecting on how different this situation would have been if I had had a bandage around my knees or crutches.

While I sat on the floor I honestly felt a little humiliated, like I was less than human. All because of how people looked at me. Sadly, this is the kind of thing that people with invisible illness encounter everyday, sometimes many times a day. The moral of the story is something that Disney movies and cliches have been trying to teach us for years: you cannot judge a book by its cover. You cannot tell if a person is sick or suffering just by looking at them. Many people have become experts at hiding their invisible illnesses to further avoid unpleasant experiences like the one above. This may be especially true for people suffering from mental illness, which is even more stigmatized in our society than physical illnesses (this will probably get its own blog post at some point).

So the next time you see a young person taking an elevator up one floor, or someone who looks able-bodied using handicap parking, or someone who is asking for more time off work for mental health reasons when they look "fine" don't judge them. Yes there is always the possibility that they are lazy or "scamming the system", but those people make  up a small percentage of society. Step back for a minute and give them the benefit of the doubt, because there may be more going on than you realize.

Uncomfortable Moments and Peer Pressure

Last week, for the first time since I started medical school I felt profoundly disappointed in myself. I wasn't true to myself and I didn't take care of myself because I felt peer pressure. Peer pressure that I was warned about and that I always thought I would able to resist. Peer pressure that I created out of my own insecurity and ended up giving into.

I was shadowing the delivery room with one of my fellow colleagues. The experience was only expected to last 2-3 hours and then I was free to go. But like everything else in medicine, things rarely go as planned. Very shortly after arriving in my over-sized scrubs, I was thrust into a heated discussion about pregnancy, delivery, and abortion; one that I wasn't quite ready to have so early in the evening. While lost in the whirlwind of emotions and thoughts,  my attending asked me a rhetorical medical question about my personal health. Not realizing the rhetorical nature of the question, I replied earnestly which I realized immediately by their reaction was not the right thing to do. An awkward silence fell between us and from that moment on I felt that I had to make up for it and prove myself to them. That became an uphill battle as the evening progressed since it seemed like my colleague and attending had some kind of connection. I felt that they had more in common, that the attending always found my answers to questions lacking in comparison to my colleague's.

After several hours of waiting, my watchful eyes turned to the patient board; no one was fully dilated and ready to deliver. I decided that I was ready to go home... until I found out my colleague was planning to stay all night to see a delivery. With the approving nod from my attending, I felt trapped. I immediately became self-conscious and worried that it would look bad if I left early. I struggled with myself, already the victim of a week of sleep deprivation. I desperately wanted to go to bed but my fear of not looking "good enough" took hold of me and I decided to stay. At around half past midnight, with no deliveries in sight, I finally had to courage to leave.

My colleague was doing nothing wrong wanting to stay, they were simply showing a love and passion for seeing all aspects of medicine; something I would most likely have done at their age. But my priorities and my health have changed, and self-care will always be my number one priority. This experience taught me that I will need to show that I can take initiative, be a team player, and go above and beyond DURING my shifts so that when I need to take care of myself after a long day, I will have the confidence to be assertive and leave.

Medicine is a career path riddled with self-sacrifice and self-care has been tossed out the window like the smoking remains of dead cigarette. How can we care for others when we cannot care for ourselves? The system needs to change and we need to be the ones to change it. We need more doctors, nurse practitioners, and healthcare professionals working in teams so that everyone can work reasonable hours and no one person is left crumbling under the weight of managing too many patients at time. As a lone individual I am like low grade inflammation; not too worrisome, not exciting, and almost undetectable. But look back in 30 years and the terrain that I have traversed will be almost unrecognizable. 

I Miss You

Sometimes you get lost in medicine. Lost in slides and sections, in cells and pathways, in diseases and pieces of parts of people until you almost forget what real life is. What your own life is. Patients you sort of expect to die. Knowing that it is coming doesn't always make it easier but you accept it as part of the job. When you lose people in your personal life however, it often hits you like a freight train, whether you expect it or not. As I sat down for group work this morning, I noticed an email in my inbox with an obituary update. When I opened it, I became cognizant of the date; today's date. I felt a sinking feeling in the pit of my stomach and I realized that I'd forgotten the two year anniversary of the death of one of the most important and influential people in my life--my cousin. One of the only family members I was close with aside from my parents -- a precious commodity for an only child. He took his own life after a long battle with depression and an obstacle course of struggles that had been placed before him. Life just wasn't fair to him.

In medicine, sometimes you spend so much time compartmentalizing things and being stoic for your patients and peers that you forget to be vulnerable within yourself. You forget how to be vulnerable period. Ironically, my cousin played a huge role in helping me learn to be vulnerable and helped me get to where I am today. He taught me how to ask for help, and more importantly, how to open the Pandora's box within yourself that you are afraid to see, and how only with that kind of introspection can you learn and grow.

No matter how busy you are with papers and patients, always remember to take the time to tell the people closest to you that you love them and appreciate everything that they do for you. Spend time with them because you never know when they will be taken away. And no matter how much you try to hide from loss by burying yourself in your work, like puddles to a hole in your boot, the pain will always find you.

A glimpse into the future

I almost watched a life leave this world last week. And it hit hard because this time next year the life of others will gradually become my responsibility. It was my first day of a desperately needed break, I was headed out to a night on the town. As I stepped off one bus and waited for another, I watched the commotion across the street as numerous firemen and paramedics struggled to save a life. One of the paramedics was vigorously performing CPR while another was attaching the defibrillator. They all stepped back as the machine did its thing and CPR was resumed. This repeated itself until a viable rhythm was restored and they began to load the patient into the ambulance. People around me also waiting for the bus watched with worried eyes and fidgety fingers. As we got on the bus, people turned to their phones and back to their own worlds but I could not.

Bit by bit, I can feel myself starting to assume that doctor role and all of the challenges that come with it. I have always been someone who has always appreciated the 9-5 routine; being able to turn off your brain as soon as you leave the door and go back to your personal life. That doesn't exist in medicine. Life and death wait for no one. Medicine isn't just a career, it is like a spouse. You gradually learn more about each other, grow together, fight together, cry together. You have duties to uphold 24/7. In the same way you make yourself available to your partner, you accept being on call and all that comes with it because the return is entirely worth what you put in, but that doesn't make it much easier. I can't even begin to imagine how I will feel in a year from now, but I feel like I'll be ready. 

The Miracle of Life

Earlier this week I had the privilege of being present for a C-section. It was probably one of the most existential moments I have ever had because I was a C-section baby and I was finally going to understand how I came into this world. As I stood in my scrubs and gown pretending to look important, I felt as if there was a blending of time and that there was no past present or future. Only heartbeats. When I shook the husband's hand I saw for a brief moment my father in his eyes. In his shifting stance and unsettled gaze, I pictured my own parents 26 years ago; what they must have been thinking and feeling.

The first and only time I had ever witnessed a birth prior to this experience was about 13 years ago, when I was at sleep away camp. As the free-spirited nature enthusiast I was, I ran away into the woods to escape the company of my fellow human counterparts. As I sat down by a tree, I noticed a deer approaching. The animal hopped around, haphazardly, with seemingly little coordination or purpose. I noticed a brown bulge emerging just under the animals tail and thought to myself jeez constipation in the wild is rough. As the bulge grew, my expression changed from amusement to awe as this once thought to be bowel movement took the shape of deer. This deer, a mere 15 feet away acknowledged my presence and continued delivering her baby. It almost felt like she wanted me to be there. I sat motionless, watching as mother nature unfolded her secrets to me. After a few minutes of straining, the fawn fell into the grass, the amniotic sac broke, and the small little creature uncertainly began moving, trying to stand. The mother licked the fawn gently until the little one finally made it to its feet and they both walked off into the forest like nothing had even happened. It was incredible. We as humans make such a fuss about having children, and this was just so natural and humble. The whole thing took about 15 minutes. I never thought I could find the same sense of peace in our man made world but much to my surprise, I had a similar experience standing in the OR that day.

"Alright we're starting," said the doctor to the team as the first incision was made. The room was calm, but not silent. Everyone was tending to their specified tasks, talking merrily as they went. I knew we were getting close when I was finally able to see tufts of black hair and with one good pull the head was completely exposed and shortly thereafter the baby was out. The climax of the event was when they removed the surfactant and the baby (and mother) began to cry. The baby was rushed off to be assessed, cord blood was taken, the placenta was weighed, and an inventory of all medical supplies was taken to make sure nothing was forgotten inside the patient. Surprisingly, it all felt so natural. I know we have been indoctrinated from such an early age that birth is a medicalized act (and almost all elements of society really). But amidst all the gowns and gloves and forceps and harsh lighting, the beauty of nature still came through. The miracle of life was no less incredible.

Surprisingly, the longest part of the procedure was suturing the mom back up, which again felt unusually natural and serene. Obviously this experience was a best case scenario and not all births go this smoothly. But as I stared into this tiny little face that had only been in the world a few minutes, I just found it so mind-boggling that life even exists in the first place. That we are here. That I am here. In the wild, I would never have made it for at least 20 different reasons, and yet here I am. And that one day, I will be reunited with the miracle of life when I have a child of my own.

The D Word: A Brief Moment in Palliative Care

It's time to talk about death. The elephant in the room. The inevitable fate of everything alive on this earth. Someone once said life is a sexually transmitted terminal illness. In today's visit at a palliative care unit, I had the opportunity to explore the edge of the universe, the end of life that everyone feels so uncomfortable talking about. It was beautiful, heavy, and made me look inside myself in ways that I never expected.

From the moment I walked in, I immediately felt this odd sense of calm and peace, and I certainly hoped that the residents on that floor felt the same way. The walls were pastel colors, decorated with art. The staff were jovial and smiley as they bounded through the hallways. As I made my way to the conference room, I  could see into the patient rooms that had the doors wide open. I passed by dozens of patients, mostly lying motionless in bed. Some had family members around them, tears streaming down their face. I tried to avert my eyes out of respect, and walked quickly to my destination and sat down.

Our preceptor arrived and began to debrief us on what is palliative care. And to know about palliative care, you need to know what health is. According to the WHO, health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. But really, health is subjective; its definition varies from person to person. But from what I can tell, what health means in this context is giving people the opportunity to participate in as many activities that they find meaningful as possible. The goal of palliative care is to really give people the best possible quality of life during their last few moments by minimizing pain/symptoms, and giving people as much autonomy as possible. Non-pharmacological treatments are of utmost importance - you cannot use medication as a substitute for human care. It is really the little things, like having that cup of coffee every morning or spending time with a pet that play a critical role in helping patients die in peace. It is the one time where you really can't sweat the small stuff, because the small stuff is sometimes all you've got.

Fidgeting in my chair like an antsy child waiting for recess, I mustered up the courage to ask a few questions. What made you go into palliative care? I asked unblinkingly, my pen and pad in hand. Our preceptor said it was the honesty that captivated their interest, and the complete acceptance of death unlike in any other specialty in medicine. After my visit today, we learned that there are many positive things about death, namely that it is an opportunity to look back on your life and acknowledge everything you have accomplished. An excuse to resolve fights and salvage relationships with the people closest to you.

A lot of patients, unable to accept their own impending mortality put so much time and energy in trying to prolong life, that they miss out on really good quality time doing the things they love and making amends with the people they love. People who have accepted their fate may take the time they have left to fulfill things on their bucket list like skydiving. Towards the very end, they may have one last party with their loved ones and then die peacefully in the sleep, still with bits of confetti in their hair. Remnants of a life well-lived.

We were told that we were going to have the opportunity to talk with one of the patients dying of cancer. My heart sank. Of course it had to be a cancer patient. And of course the patient was dying of the exact cancer that I am at risk of getting, and have been worrying about the last few weeks.  It was time. My hands clenched and clammy, I entered the room and sat down in front of the hospital bed. The patient was propped up in bed, seemingly alert. Their voice was soft, their breathing labored, but full of life nonetheless. We were able to ask a few questions and get a sense of the shell of this person's life. Their sense of humor when answering questions was delightful and really helped calm me down and make me feel at ease. Laughter is the best medicine, even for ailments that one cannot cure. All in all, the patient seemed satisfied, accepting of their condition, and taking it day by day. We asked if there was one piece of advice for us aspiring young doctors, and we received the following: Live your life the way you want. Don't let anyone tell you what you can and can't do. The patient then asked us to turn off the lights and rearrange the room exactly as they wanted it. I couldn't help but smile; never too late to live life the way you want to.

When I got home, put my stuff down, calmly sat down, and burst into tears. Every fiber of my being was accepting that my death was inevitable. The tears of the realization of my mortality came splashing down onto my lap, rhythmically, like the labored breathing of the patient I spoke with earlier. As I sobbed, I felt consumed by loneliness and emptiness.  God I hope this isn't how I go, especially not in my early 40s or 50s. One can never really know when and how death is coming. Only that it is coming.

In medical school, not only do we have to come to terms with our own human weakness and the vulnerability of our individual self-discovery, but we must come to terms with our own death, and at a much earlier age than most. Before leaving the unit, I had asked our preceptor what helped them sleep at night and they said accepting that they too will die one day. Being fully accepting of their own mortality. I guess I have a little while to continue grappling with insomnia before I sleep easy. But when I do, boy will I ever sleep.