Just Let It Go

Tonight marks the final night before our residency selection lists become final. Tonight is the last night of agonizing over which program I want most, which city would I be happiest in, or which path would afford me the greatest opportunity in my chosen field.

I spent the night surrounded by friends at my medical school's Christian association at their first event in the new year. Faith is something that I have struggled with my entire life. Whether it be faith in myself, faith in others, or faith in the divine, I have tremendous difficulty in sustaining faith of any kind. As we went around and shared our experiences with residency applications, I was envious of my colleagues' sense of peace and the complete acceptance of the unknown.

My interview period was marked by anything but acceptance. Traveling from city to city nearly every other day, I felt increasingly lost in the vortex of choices, decisions, and opportunities. With each passing interview came a new challenge, further clouding my ability to know what I truly wanted. Instead of letting my horse run free, I gripped the reins even tighter. I must work harder, I thought, then I will know what I want. I spent hours calling people, making spreadsheets, and reading program descriptions.

Tonight, I felt the familiar call of exhaustion, and I had looked forward to an evening of exercise and relaxation. But that's not how plans work. By a series of seemingly random events, I got out of class late and ended up at this event instead. As I listened to the wise words of those around me, I had an epiphany. Be it the word of God himself, coincidence, or some strange combination, I felt a sense of peace rush over me for the first time in months. Like slipping your head underwater in the most perfect bath, all sounds muffled and all worries subdued. It's time to let go.

I have no idea what my future holds, and part of me still wants to bury my head in the dirt like a frightened ostrich. All I know is that no matter what happens, the outcome I get will be the right one. Now it is time to sit back, let the algorithm and all upstream forces work their magic, and finally relinquish control. 

What Burnout Looks Like

"Take care of yourself, you don't want to burn out." A phrase I've heard many times again. That could never happen to me I thought. The cynicism, the apathy, the loss of compassion. I always believed I had an endless supply of compassion, that it was one of my strengths. But no matter how resilient you are, everyone is at risk. Everyone has a breaking point.

It can start out so subtle, sneaking up like gas prices until one day you just can't. It starts out as just feeling "more tired" than usual, despite sleeping at least seven hours. Then, you slowly stop doing things. You justify it as "I'll treat myself to take out" when in reality you've exhausted the mental reserve required to make dinner.  Scotch tape atop the cracks, trying to keep them from spreading. You stop studying, telling yourself you've done enough work for the day and deserve a break. Next, you find yourself overly annoyed waiting in line at the grocery, I mean how long does it take someone to get out their debit card really. You justify it as "oh what annoying people, how are they everywhere", while behind that your subconscious is screaming the mantra of "I can't do this anymore, I can't take anymore".  You stop going to the gym and spending time with friends, justifying it as "I  need me time" which although true, you don't want to even give people a chance to figure out that something is wrong. You don't even want to acknowledge the downward spiral you are on.

Sleep begins to intrude into wakefulness and wakefulness intrudes into sleep. You spend the entire day trying to stay awake, coffee after coffee, and lie in bed awake at night trying to silence your forever active brain. Stifle its cries for help. You find your eyes filling up with tears randomly throughout the day - quiet rides in the elevator, making your coffee in the cafeteria. You tell yourself it's from that difficult patient interaction you had the other day, but you know it's not.

Burnout looks like smiling faces, and kindness, all the while on the inside you are rolling your eyes as the 6th patient that enters your office cannot answer basic questions like "what brought you here today?", "what medications are you taking?",  and "when did the trouble start?". You begin to wonder what you could possibly do for the 3rd patient in a row who denies having diabetes and refuses to take their medication, all the while begging you to fix their diabetic neuropathy. You begin to see your patients as inconveniences, frustrations, numbers, morons. Morons? I knew something had snapped inside me the moment that crossed my mind. Never in 4 years have I ever thought of my patients as anything less than remarkable. This is not what first year me would have wanted. But frantic residency applications on top of 10-12 hour shifts, and studying...you lose yourself. Day in day out there is always someone reminding you that you may not match.

I spent the weekend in my pajamas cleaning out all my old clothes, things I didn't use anymore, trying to desperately use my physical environment as a way of grounding my mental head space. I took the time to gently trim the leaves and water my many spider plants. They aren't mad I forgot to water them, they love me just as I am.

Burnout looks different for everyone. The only commonality is you often don't know it until it's too late. Do not ignore the red flags, the warnings, the changes you see in yourself. Catch it early, because it is a nasty hole to fall into, and even more difficult to climb out. 

Residency Matching and Panic Attacking

12:00 PM The platform is now open, you may begin your application.

The email caught me dead in my tracks, so much so that I nearly missed the elevator I was waiting for. Can it really be? Have three years really flown by in the blink of an eye and soon I will be a resident?

The last few years were replete with memories from touching patient encounters, exasperation from the many obstacles and shortcomings rampant in our healthcare system, and a better understanding of who I am as a person. My white coat no longer feels like a Halloween costume; it is now a tattered garb of pen stains, food stains from many meals in the middle of the night, and pockets stretched and misshapen from stuffing them full of medical equipment. The latest batch of clerks have been dispatched to the wards, looking as overwhelmed and perplexed as I did a little over a year ago.

In a few months I will no longer be a medical student, I will be a resident. I will be able to prescribe. This future reality is both terrifying and exhilarating; I often alternate back and forth between these two emotions whenever my mind wanders to the topic. Now faced with the immediate stress of hunting down reference letters, gathering documents, selecting schools and programs, it feels as though there is no time to process this new impending chapter in my life. Once the applications are complete, my focus will then shift towards visiting schools and interviewing for positions, and then subsequently studying for my licensing exam.

My mind can only begin to process how far I've come and how much further I have yet to go. But for now I take it one day at time. On patient at a time. One document at a time. One breath at a time. 

My First Week in Rural Medicine

I was given the choice of doing a rural family medicine rotation anywhere in the world. In the end, I decided to go to a Cree community in Northern Quebec. "What do you see ?" My friends and family ask. Let me tell you.

(View from the plane)

I see a community. A community of loving caring people with a beautiful set of traditions that I can only aspire to. I see an obesity epidemic caused not by laziness, nor by lack of self control but by poverty and an environment that does not make the right lifestyle choices an easy option.

I see nature; the great river, the towering tall trees in the distance that seem unwavered by the change in season. I hear the musical songs and chirps of birds, some of which are very familiar and others that I am hearing for the very first time. I see dogs that look like people's pets that have no home and roam these gravel streets alone.

I see broken glass and bottle caps and candy bar wrappers - the litter of self-medication against trauma and injustice. I see the concerned look from a mother to her child, who lies there feverishly half asleep and coughing. I see a another pregnant woman for her 28 week visit. It is her 5th child, she's only 20. I see the elderly man, whose lips are blackened with the charcoal that saved his life from bottles of pills ingested in yet another suicide attempt to block the pain and loss.

I see smiles, I see laughter. I see families whizzing by on 4x4s and pick up trucks, honking loudly in celebration of weddings and hockey games. I see children playing in the streets, riding their bikes in groups. They own the place. Some young girls run up to me, curious to know where I'm from and what I am doing here. They proudly show me their blisters from a long day of playing and they ask for band-aids. I come back a few minutes later with band-aids and the group of children has doubled. They wear their band-aids like badges and excitedly show me the slime that they bought at the corner store.

For the first time in my life, I'm a minority. Everyone around me looks different from me, speaks a different language. I can feel myself being watched everywhere I go. And yet I feel safe, except at night. I'm not supposed to go out walking alone at night, a driver is to bring me home.

No matter how much I've been taught in textbooks and in lectures, being here brings everything to life. I have so much to learn in a few short weeks and so little time to soak it in. 

Super-ego steroids: debunking some myths about psychiatric illness

Psychiatry has always been one of those rotations that I had dreaded because of the heavy subject matter. At the same time, I have looked forward to going through this because I was hoping to finally be able to reduce some of my own prejudice and stigma around mental illness (we all have some of it, let's be honest). I had come into this rotation with certain ideas based on my own anecdotal encounters with family members who suffered from mental illness, as well as my own experience with caring for my mental health in this rigorous program. I would like to share with you some of the thoughts, feelings, and lessons that I have experienced over the last three weeks.

1. Psychosis is anxiety on steroids
Psychosis is effectively a loss of one's connection to external reality; it can manifest with features such as paranoia, hallucinations, etc. Contrary to what I had previously believed, psychosis is a response in some people to overwhelming anxiety. When emotions become too overwhelming for a person to handle sometimes their brain will create these psychoses as a way of alleviating that anxiety. We have all experienced anxiety and seeing psychosis as an extension of that for me has helped me better relate to these patients.

2. Psychosis is on a spectrum
Again from anecdotal experience with people I know, as well as input from the media, I had always thought that psychosis was like an "all or nothing principle" and that one day people "snap". One of the greatest revelations I have had in this rotation is that psychosis is on a spectrum and many people who are psychotic have good insight into their condition. I have had numerous patients tell me that despite taking their medication they are still hearing voices in their head that tell them to hurt themselves and others. They know these voices aren't real and are in their head. They try very hard to ignore them but sometimes it can be very difficult. They have calmly and eloquently explained this to me, stating that they think they need a higher dose of their medication which is supposed to stop these voices.

3. Personality is fluid
Prior to psychiatry, I had always confused temperment with personality. Temperment is more of an animalistic state of being, i.e. are you a calm person vs someone who is more volatile at baseline. Personality is a combination of a person's temperment, opinions, personal characteristics and emotional responses. Growing up as a somewhat anxious person I had always felt that there was no hope in changing something that was so ingrained in me. However, through various psychotherapies we can change our emotional responses and various facets of our personality. These changes are a slow and require a lot of work. But the way a small simple stream of water can erode a boulder, we all have the ability to change ourselves. Even looking back on the last three years I have noticed changes in my personality - I have become more positive, more patient, and more spontaneous based on the experiences I've had and my own personal commitment to self growth.

4. I have much admiration and respect for the patients I have met in the ER
I know that seems like an odd thing to say - that I admire patients coming to the ER for psychiatric care but I promise it will make sense so please hear me out. These people have often been through so many traumas and overcome so much in life, I can't even begin to imagine what they must have gone through. Many of them have such strength in the face of adversity. They come to the ER because they have insight into how they are feeling and have recognized that they have exceeded their capacity to cope on their own. I think we can all remember a time where we were overwhelmed and were maybe too afraid to ask for help. It takes tremendous strength to reach out to others for help, and even more to open up about pain and suffering to a stranger.

5. People with psychiatric issues are good people who need help
The majority of people I have met were contributing members of society, highly intelligent and caring people that grew up in environments where they were never able to learn proper coping mechanisms to deal with the difficult situations that they were living. I will never forget one man whom I met in the emergency room. He had presented for suicidal thoughts after many months of loss; first his job, then his family under tragic circumstances. When I came to see him, he was sitting and listening to another patient who was crying in a corner. At the start of our interview, I had asked what they were talking about and he said the following: " We are all kind of in the same boat here in the ER, but that doesn't mean we can't be there for each other. I had nothing else to do and if I could sit and listen to someone and have them truly feel heard why shouldn't I? Is that not what being human is all about?" My inner clinical instincts recognize that this is partially a coping mechanism on his part. That aside, throughout the interview this patient strongly valued being kind to your fellow man - something we can use more of in world of violence and unsightly comb-overs.

Over the past three weeks, I have seen more random acts of kindness in the psychiatry emergency than I have for months walking around the streets. I hope that reading this blog has helped you to have a greater appreciation for the people behind the labels of psychiatric illness.

Medical Miracles

As much as some people believe that doctors are god, we are not. We are fallible like any other human. We are not all knowing, not all seeing, nor all powerful beings. We rely on our extensive knowledge base (with the ability to look up what we don't know), our physical exam findings, lab and imaging results, and how well the patient responds to different treatments. We often objectively manage patients in situations of uncertainty by covering our bases. This translates into throwing multiple medications at our patients and hoping that one of them was the right one to treat the underlying disease. It's not an ideal way to practice medicine but sometimes it's the best we can do. However, I now know what it feels like to be in the position of my patients' families having personally been faced with this difficult situation.

I will never forget the moment in class on Dec 22 when I received a message from my family that within 24 hours a family member went from being in their usual state of health to being confused to being admitted to the ICU, unresponsive and intubated. Despite extensive blood work, cultures, imaging, and even a lumbar puncture doctors STILL had no idea what was going on and a discussion about DNR (do not resuscitate) had been initiated . What could have possibly happened? How is that no one could figure out the etiology of such a severe and rapid deterioration in an otherwise healthy person? Sometimes our tests fail us. Sometimes everything comes back normal and it can be difficult to reconcile these normal test results with the seemingly dying patient in front of you.

I was shortly thereafter excused for the holidays and it is my philosophy that one must keep on living. Subsequently, I tried to disconnect for some much needed rest and family time. On Christmas Eve, as a gesture of good will, I decided to accompany the in-laws to Christmas Mass. Having grown up in a secular Jewish household, I had never been to mass and was curious. As we sat in the pews, nestled between strangers, I receive a message that my loved one was no longer intubated, but still unresponsive. Dammit, what if this is permanent. Despite being present for the service, I found myself distracted by the children fidgeting and crying nearby, and even more distracted by the thoughts in my head. "We will now take a moment of silence for prayer to heal those who are ill" said the priest. The room fell silent, the only sound the occasional creaking of pews as everyone bowed their heads in prayer. Praying was never something I did regularly but when in Rome; what did I have to lose? I closed my eyes, and like a nervous teenager about to ask someone to prom, said: "Um so I'm not sure if anyone is listening but uh well there is someone I would like you to help...obviously you know who. But...yeah, I would really appreciate it and it would mean a lot to my family. Thanks for listening." It was far from eloquent but I felt comforted nonetheless that there was a chance that I had been heard.

The rest of my evening was uneventful. I awoke Christmas morning to open presents and enjoy the festivities. After breakfast I checked my phone and I had received another message that my loved one was sitting up eating breakfast, completely back to normal. No one knows what exactly was the cause, nor what was the cure. With that comes the unsettling worry of could this happen again, but for now all is well. Whether it was due to divine intervention or stellar medical management or some combination of both, I think we have had a true Christmas miracle.

My First Delivery

"PUSH!" I hear from outside the room.

I run over to the board only to see it's my patient and she's at 10cm.

I open the door to the room to find my patient already pushing, all the tools needed meticulously splayed out on the green blanketed table.

"We have a gown for you, here. It's your turn."

I gown up quickly, put on my white sterile gloves,  and gently make my way over to the patient.

She has her feet in the stirrups, legs fallen to the side and a bright light shining on the exposed area. No baby yet.

She begins to scrunch her face and I see the numbers on the nearby monitor rising. A contraction.

"PUUUUUUUUUSHH!" Yells the nurse. We all count "1, 2, 3, 4"... all the way to ten, repeat it another two times and as the contraction eases of the patient has a chance to relax. Her husband clutches her hand excitedly as the moment of getting to meet their first child draws ever closer.

Another contraction. As she pushes again I can see some tiny tufts of hair for a brief moment and then they are gone. With every contraction that goes by, I see a little more hair and a little more of the baby's head, until finally  the head no longer disappears back into the vaginal canal and stays permanently visible in between contractions. I hold one hand against my patient to help support her delicate tissues and the fingers on the other hand along the baby's head. For every contraction, with the guidance of my staff, I applied gentle pressure to help control the speed at which the baby was coming out. With one big push the whole head is out. I quickly feel around the neck for a loop of umbilical cord. Thankfully there is none. As she pushes again the baby rotates sideways as they always do and with one final push the baby comes rushing out into my hands. With the support of my staff we ease this new baby onto my  patient who is now a first time mom.

"Congratulations! It's a girl"

She begins to cry and her husband eagerly cuts the umbilical cord after we have clamped it. The baby finally begins to cry forcefully and goes from a shade of worrisome blue to rosy pink; a new little human starting it's first day in our great big world.