Category Archives: Bioethics

A Labor of Love

07 Wednesday May 2014

Posted by in Bioethics, Medicine, Philosophy, Writnig

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I stood in the room, gowned and gloved, waiting for the woman to push. There was a thin trickle of sweat running down my back where the bright lights of the delivery room were trained. The baby was just short of the pubic bone, nearly ready to be born.

The mother-to-be had been pushing for hours and was exhausted. We watched the strips that recorded her and her baby’s heartbeats—each time that she pushed, her heart rate spiked to more than 170 beats/min and she closed her eyes and blew the air out of her lungs as we urged her on. “Push. Push. Push.” “Breathe. Breathe. Breathe.” We continued, our implacable rhythm timed to the clockwork contractions of her uterus.

Her exhaustion had caught up with her; I could read the defeat in her eyes as she whispered to her husband, “I can’t do it.” He smiled into her eyes and whispered back quietly, “Yes, you can.” My eyes were transfixed by this private moment between husband and wife, for all intents and purposes alone in a crowded delivery room, oblivious to the five other people standing around.

My hands moved on autopilot, assessing the baby’s position, a job my eyes should have done, as well. I stood there, doing what I was supposed to by habit—this was the fourth delivery that I’d done, after all, and I was a 5-week OB veteran. I stood there watching this moment, this beautiful, private moment, and some of life’s mysteries became clearer.

It was suddenly apparent to me how much I’d given up to be the one bringing this couple’s baby into the world. The fact that I could be welcomed into this intensely intimate moment and thanked after I’d done my job attested to the value of the profession I was joining. But in this moment, I wondered, at what cost?

This couple was a few years older than I. They had been married since they were my age and were having their first child now. They were madly in love, had jobs that fulfilled them, and were bringing their first child into the world.

At that moment, I had one purpose, one raison d’être, one thing I was searching for—that obsession, that passion, was medicine. In pursuit of it, I’d given up my hours, my sleep, my financial future, my social life, and my relationships.

My family was thousands of miles away, rarely seen and always missed. My friends were languishing, with unreturned phone calls and text messages on my phone, forgotten among 14-hour shifts and minutiae that needed to be memorized for each rotation. My love life was challenged by my constant lack of time and impossibly high standards—not to mention my jealous, unforgiving mistress named medicine.

She pushed again, and I snapped back to the here and now. Her son was crowning, and my hands moved automatically. I checked for a cord around his neck, pulling him out of his mother’s womb, one arm at a time. He was born from a warm and safe womb into the cold and lonely world he would now inhabit.

I swaddled him in blankets and placed him on his mother’s chest as his parents stared at him with love, drinking in the sight of his fingers, his toes, his perfect little features. I finished my work quietly. They thanked me warmly as I left the room and ripped off my gown and gloves as I went, their eyes never having left their beautiful baby boy.

I smiled as I left their delivery room, lost in my bittersweet thoughts. I kept walking because my shift had been done 20 minutes ago. I walked to a house filled with books about medicine and the tools necessary for its practice—stethoscope and white coat among them. I walked to an empty house and an empty bed. I was on again in 9 hours.

Ann Intern Med. 2014;160(9):653. doi:10.7326/M13-2673

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Third Year: A Survival Guide: In memes

15 Tuesday Apr 2014

Posted by in Bioethics, Medicine, Philosophy

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Third year of medical school is a different beast from anything you’ve had before. You’re going from studying the basic sciences in a laboratory to functioning as a part of a healthcare team. You’re expected to truly learn to begin to be a doctor- and by the end of it you’ll be expected to manage patients to some degree autonomously. It’s a lot of work, a lot of fun, a lot of misery and just a lot- all at once. So with that in mind here is what to expect- #whatshouldwecallmedschool style.

Third Year

(http://whatshouldwecallmedschool.tumblr.com/post/80871300029/medical-school-in-a-nutshell)

This is going to be you much of third year- sprinting around the place, going nuts and basically losing your mind. Live with it and own it.

That said, the biggest thing that worked for me in third year was confidence and trying to get comfortable. Some people and some places have this idea that medical students just sort of stand around like part of the furniture. And there are those who do that!

I’ve found that the people you work with and work for- attendings, residents, interns, nurses and above all the patients appreciate you trying to do things. So when you’re asked a question, answer it with confidence (not a question). Surgeons especially hate that. If you’re not sure, start talking about what you think is going on- typically someone will cut you off if you’re rambling. But if you see someone starting to fall over asleep you should probably stop.

Don’t be afraid to get your hands dirty and do things. In my third year, I’ve delivered babies, opened incisions, stapled heads, done ABGs and placed more Foleys than I would ever want to. The reason I got to do those while some of my colleagues didn’t is that I asked if I could!

Even when you’re on a rotation you’d NEVER ever want to go into- try to learn something.

On a psych interview

What I tried to do (most rotations) was pick one thing or one skill set I’d like to learn that I found interesting, was cool, or could help in me in my future field of choice. And then go out and try to get good at it.

So on OB, I learnt to deliver babies, and do cervical exams. The only way I got to do those is by letting my residents know that I wanted to learn and do those things, and them being nice enough to let me. But still- try!

 

Also, some residents may in general be not the most interested in teaching- that’s the luck of the draw. And that’s okay.

 

 

 

The other thing is prepare to do a good impression of a piece of furniture in some situations.

“This is my medical student”

My favorite is when you’re rounding on a team of 10 people, you all squeeze into a patient’s room and then you’re introduced in an offhand fashion as you have to half sit on the patient’s grandmothers lap.

Though seriously, people don’t really hate medical students. They know we’re learning, that in a year or two, or three we’ll have an MD or a DO after our names and need to take care of them. And most are okay with us learning on them.

It helps if you are comfortable, a little charming, and not totally creepy- a high bar I know.

It’s okay being the wall, but if you’re comfortable introducing yourself do so.

And with that we’re back to confidence. If you want third year to go well, be confident. If you’re not, fake it- till you feel confident and comfortable. The hospital is an alien environment for everyone initially, but if you want to be seen as a better medical student (and one of the most important things for anyone evaluating you is how you interact with those around you)- for two med students with the same thoughts, grades and physical appearances- confidence can make one seem a far better physician to be than the other.

 

As I round off the remainder of my surgery rotation and consequently the last rotation of third year, expect some more gems like the ones above. And if you’re interested in medicine/ in med school/reminiscing about the torture that is med school dive into #whatshouldwecallmedschool. I’ll leave you with a link to one of my favorites.

http://whatshouldwecallmedschool.tumblr.com/post/81984496130/welcome-to-third-year

 

 

 

 

The Goldilocks Conundrum

05 Friday Jul 2013

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This was initially meant as a submission to the Gold Foundation. I submitted it to their essay contest on what it means to be a good doctor, on time, but with a blank entry sheet so it was never considered. Clearly, I’m a genius. The title is inspired partially at least by my obsession with the Big Bang Theory. Enjoy!

The Goldilocks Conundrum

When I told people I was going to med school, the first thing I’d hear was “oh, you’ll be a good doctor”. As an idealistic and energetic first year I was flattered every time a standardized patient said that I came across as a good doctor-to-be. Of course, I wasn’t a good doctor- primarily because I wasn’t a doctor. My exposure was to esoteric subjects like biochemistry and physiology- I wasn’t much good to any person in distress. Like my classmates I believed I was going to be a great doctor- all that was missing was clinical knowledge, clinical acumen, and experience.

Now, as a second year med student with almost all of my classroom experiences behind me, I’ve developed a degree of clinical acumen and clinical knowledge. I’m still lacking in detail, and I often mistake horses for zebras- like the time I made a diagnosis of possible Ebola virus in a patient with bloody diarrhea. It turned out to be Salmonella from bad chicken. But, I figure, once I’ve studied up my First Aid and learnt the theory of medicine, I’ll be a good physician. The question remains, who or what is a good physician?

As a naïve newcomer to medicine, I believed a good doctor was someone who not only knew the medicine and the art of diagnosis, but also deeply cared for and was invested in each patient’s prognosis and care. A good physician would put his or her all into a patient, and if the patient didn’t make it, would feel sadness at their loss, yet that physician would get up and do it all over again, a dozen times a day. And at the end of the day, they’d go home and see their loving, caring family and be well adjusted parents and spouses.

Now, I’ve come to believe that image of a good doctor in my mind is flawed. If I’m too invested in my patients, chances are, I’ll become an impaired physician. If that happens, I’ll probably be an alcoholic, or start abusing drugs misbegotten from my own prescription pad in order to forget the people I couldn’t save, the mistakes I made. If I spiral down that path, I’ll likely cause damage the whole way down- to family, friends, and perhaps even patients.

The other path, the one which many doctors take, is detachment. I can choose to look at my patients like bags of organs, with a dysfunction that I can repair or replace. If something fails, if they don’t make it, I can insulate myself enough to not be truly hurt. In this case, I’ll protect myself from self-destructing and perhaps even accrue wealth, prestige and power. The downside is, I won’t be practicing medicine for the reason I went into it. Instead, I’d be functioning as an automaton and a machine- which should be anathema to a physician.

If I were to truly be a good doctor, I’d have to be like Goldilocks. Just right. I can’t be a callous, uncaring person who sees patients as bags of enzymes and organs. Nor can I be completely invested in and care about every patient who sits in my exam room, or haunted by my failures. I need to be able to care about my work, and care for the people who need me, but also be able to let go. I need to be able to separate home from work, and to keep my family safe from my professional demons. I need to be able to go home at night, and let go of the day’s travails and sleep without being haunted. Yet my failures need to inform me, to teach me as a physician, and as a human being.

That’s a nearly impossible standard, especially since we don’t talk about it as a profession. We don’t discuss how to let go- we don’t discuss how in Rudyard Kipling’s words to allow “all men count with you, but none too much”. We are taught everything about medicine, except to express and deal with our feelings. We keep them bottled up inside, unexamined somewhere deep in our psyche. Expressing our doubts, our feelings, our weaknesses is frowned upon, or seen as touchy-feely and weak. So, we repress our feelings and our demons, exorcising them if we must with alcohol and drugs.

A good physician? I’ve seen some of those. I’ve seen physicians who can stand in front of a crowd of medical students and talk about what gives them strength, what keeps them going, their challenges and the pain they’ve felt, and how they got over them. One, a doctor who works in the trenches in the Emergency Room spoke about how every day, he sees people who are terrified, afraid and often having the worst day of their lives. And that his job is to make their worst day a little bit better, a little bit more bearable. He spoke about the cost, about the difficulty of separating work from home, about the losses and failures that haunted him but how every day when he walked into his house and saw his daughter’s eyes, his demons were banished.

The practice of medicine is a truly human profession- flawed, challenging, inspiring and infused with the sadness of mortality and the fear of futility. To practice that art well, may be one of the toughest things in the world. But, if my mentor’s words are true that challenge may also end up being the most fulfilling thing in my life. I’m not a good physician yet, and not just because I’ve not received my MD. I’m still learning, still finding my humanity. That’s a process, a long road I may walk every day of my professional career. So I start my search for the perfect temperature porridge, warm enough to be compassionate, cool enough to remain objective.

Bon appétit.

It Gets Better

04 Thursday Jul 2013

Posted by in Bioethics, Medicine, Philosophy

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I was sitting in the coffee shop today, and I must have looked a little miserable as I kept running my hands through my hair surrounded by papers trying desperately to get work done. I guess I did, because two guys sitting a few spots away called out to me and asked if I was a third year medical student. Surprised, I looked back at them and they smiled and said, “it gets better.” They had seen the OB-GYN textbook I had lying buried under a pile of papers I was reading and working on, and figured that was the source of my apparent angst.

Funnily enough, it wasn’t. I was knee deep in a long paper on end of life ethics that was challenging to write, and hadn’t yet cracked the textbook that day.  I did, later, and it wasn’t quite as much joy as a tub of ice cream or a nice long run, but it wasn’t agony. Their conversation did give me pause though.

The first two years of medical school aren’t pleasant, no matter what school you go to. The process takes the top 5% or so of students based off their scores and grades, all typically Type A personalities and pushes them into a room together where they’re then tested and graded.

We go from being the valedictorians or the smartest people around, to being that dreadful word- average. Our psyches and our selves can hardly adjust to the change from achieving a routine 93 and being vaguely pleased to the pressing fear that this test may be the one that pushes you below 70. If it doesn’t, you then start looking for a yardstick convinced the exam must have been easy then. You go from being the person people look at and think, wow they’re smart, to feeling like an impostor who got into medical school as an elaborate cosmic joke. Sometime in the first two years, you’ll think about quitting. Maybe even every day. You’ll look at the books and the piles of lectures, and think “how can I ever learn this stuff?” You’ll go and learn to see patients and consider it totally a waste of time when you could be studying for the important stuff like enzymes that catalyze reactions. You’ll likely live your first two years in fear, dread and a caffeinated high that when you crash will lead to weekends ‘wasted’ in sleep.

It’s not a pretty picture, and to put it bluntly, the first two years of medical school are horribly rough- for some people. There are some in my class who excelled in the first two years, loved the minute details and the never ending reams of paper to read. They did very well in the first two years and likely loved it. I wasn’t one of them. I didn’t like the never ending memorization with what seemed like minimal to no usage of what we learned. In college, I’d thought I was book smart, believed it with all my being. In med school, I learnt how very wrong I was. The first two years of medical school weren’t fun for me, but they weren’t pure agony either. Like anything else, they were marked with periods of good and bad- but I will say that they make you feel like a fool often, grasping for details you missed. There were days I considered quitting, but it died pretty quickly once I remembered the debt I was in!

That said, I’m one and a third rotations into third year, and I’m rediscovering my passion for medicine and what brought me in here. I’ve been seeing people, actual human beings, not just anatomical drawings of them and the hard oak of a library desk with a blank wall beyond. I’ve even been helping them sometimes. I’ve been doing things like listening to hearts, taking histories, making diagnoses. On this rotation I may even get to deliver a baby. Some of the nurses took to calling me “Doc”, a word I’m not at all used to. When they’d ask me what to do with a patient, I’d actually feel as though my toils and my labors weren’t in vain. So, I still spend a fair amount of time with my nose in my books, I don’t have as much of a social life as I’d like, and most of my meals are spent in the company of my favorite TV show. But, it’s much better because my reading, my work, my toils are all towards a readily apparent goal. What I learn today in my readings may well help my patients tomorrow, the next week or the week after that.

So, for those of you still in the depths of the tunnel with only a faint light trickling in at the end of the tunnel, know that it does end, and you will survive. Your misery, your minimal social life, and your never ending time with the books will have purpose and meaning. Till then, I’ll leave you with this story from one of my favorite books (Blue Collar, Blue Scrubs, which I highly recommend  by the way).

There was a person (who’d later become a Mayo Clinic trained Orthopedic Surgeon) working throwing rocks. That means that someone would go through and use a jackhammer to break down huge segments of concrete and this future surgeon would go behind him lifting 100s of pounds of concrete- ass outstretched in correct lifting posture, and bending his elbows he’d throw them into a truck. His boss, when he would begin each day would call out, “I don’t want to see anything in the next twelve hours but asses and elbows!” So, for the first two years focus on keeping those asses and elbows moving. It does get better after.

Waterboarding. AKA Thinking about Step 1

31 Thursday Jan 2013

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Studying for Step 1 -http://whatshouldwecallmedschool.tumblr.com/post/24640000623/studying-for-step-1

 

If you know any second year medical students, right about now they’re at least freaking out about Step 1. Good words for this state are worried, scared, terrified, crapping their pants, praying, anxious, depressed, terrified and crapping their pants again.

 

For those of you lucky enough not to know what Step 1 is, it’s an exam. That doesn’t sound too bad you say. It’s an 8 hour exam. Okay, that could be hard. It’s an 8 hour exam based off two years worth of medical school material. That’s hard. It’s actually an 8 hour exam based off two years worth of medical school material which tests esoteric facts sometimes, and asks you questions which may seem simple but in reality are nowhere near.

It will present a case about a patient, who’s got certain symptoms. Somehow you recognize the disease. Excited you read on, to find that they’re asking not for the treatment, which you remember, nor for the side effects which you remember as well, but for the treatment of that side effect… (Course that’s only some of the tougher questions, but you get why medical students devolve into a quivering ball of anxiety with just the thought of this exam.)

So, we live in fear, going through new material, required sessions at the hospital and lectures that at the moment seem irrelevant to us completely. We chafe at any distraction from our prime study time, and are constantly anxious and jittery. Coffee consumption skyrockets, breaks consist of eating hurriedly in the face of work.

But, funnily enough we still don’t study per se. At least I don’t. Not enough.

At the moment the fear and the anxiety are there, but for some reason the motivation to really work is still missing.

Hoping it comes soon, with <90 days to the Boards.

 

Indoctrination

24 Monday Dec 2012

Posted by in Bioethics, Medicine, Travel

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Funny thing about life, things you thought you’d never be able to do become a habit. And once that habit forms it’s dreadfully hard to break or even step away from.

The first months of med school I was always worried I’d never be able to put in the work. I was worried that the sheer quantity of what I needed to know was so much I’d be discouraged and apathetic and stop before I start. That was before I realized the potent power of indoctrination.

This winter break marks one and a half years since I began medical school. I’m three days into break, and all three days I’d catch myself thinking of things I had to do. Thinking, wait I didn’t hear lecture. No, wait there was no lecture…. I think of tasks, lectures, studying, emails, work all that needs to be done. And I’ve consciously had to stop myself from thinking of the work.

Instead I’ve thrown myself into all the things I’ve neglected these past six months in medical school. This involves exciting things like endless hours of TV. Getting up to go to the gym’s surprisingly become a chore since I have to break away from the fascination of Newsroom or Royal Pains. I think I’m succesfully resisting the indoctrination at this point- getting 10 hours of sleep a day, eating relaxed meals and not doing anything. The bliss of stillness (relatively speaking of course) is unparalleled.

I still however have work to do, and I intend to do it smack in the middle of my vacation. Since my bioethics program is so relaxed I have papers still due, however I intend to do them in the next few days- sitting at a little cafe in London.

So that’s how I intend to get away from this before I start the torture of preparing for my Boards. For those of you who remain blissfully unaware- the boards are the licensing exams we have to take over our medical education. The first one, Step 1, is to be taken at the end of second year. It covers all the material we’ve learnt in the first two years of medical school and is a 8 hour behemoth. So, I intend to profess ignorance at my eventual fate and enjoy the next few days in London.

Happy Holidays!

How to Survive Medical School (or What I do instead of studying Cardio)

16 Tuesday Oct 2012

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Take a look around a medical school around this time of year and you’ll see two very different groups of people.

The first group seems delighted to be there- happy, motivated, driven, “gunning it”, ready to go out there and save the world. For the most part, they enjoy the rigors of medical school. They’re the people with perky looks, dressed nicely, smiling and being pleasant.

Then, there’s a second group. The second group has bags under their eyes. They’re tired, cranky, a little depressed, constantly cursing at being in medical school. They walk with their heads down, their eyes seem sunken and their clothes are most often sweatpants and T-shirts. There may be coffee stains on their clothes, and as they pass out in a mound of books- drool coming out of a corner of their mouths.

The first batch, as any medical student could tell you, are first years. The second batch are second years.

First year of medical school as you walk in the door, you’re excited, driven, motivated. You’re in med school! You “gun” everything- studying for hours upon hours till exhaustion, and then once the test is done partying and drinking to oblivion. You’re excited about almost everything, you’re brand new and you want to learn- and by golly you show it!

Second years, by contrast have been through the cycle. Having been forcefed vast tracts of information every 6 weeks (on average, 120 hours of lecture total) full of arcane facts that aren’t clinically relevant and despite the school (and the block’s) stated policies of testing “big picture” stuff will still be tested. So you prepare to be able to recite Bernoulli’s equation, the resistance of a vessel, the histology of polyarteritis nodosa, or some other information that in all likelihood is never tested. That’s okay you say, we all jump through hoops. Now do it again, and again, and again. Take a weekend- sometimes between the end of one and the start of the other. At the same time, realize that you’re actually supposed to be taking care of patients in a year- so try to learn to do that as well. Then, add in the required doctoring material- some exceptionally good, some mindblowingly boring. Plus minor things, like eating, cooking, working out, laundry, showers…

The thing you learn somewhere halfway through first year is that medical school is a collection of 200ish of the smartest people you can imagine. We all went through college getting accolades, being told we were brilliant, seeing amazing grades and awesome results. Then, when you get to medical school you see the scariest thing of all. A passing score- or an average score. And then you realize that the thing you based your self worth on- your intelligence- no longer sets you apart from the herd. You’re somewhere smack in the middle. Truth be told, most people in med school are about as smart as one another. The difference is the hours people put in. Some, seeking to maintain that self worth, put in 15-18 hour days regularly- and cringe when they see a 94% on a test. Others, work hard but try to balance- and are happy with a mid 80’s grade. Still others realize the futility of the system and how irrelevant some of it is to clinical practice, and cherish having their lives- cheerfully taking the 70s-80s they get. None of those is “better” than the other- each seeks to maintain their self worth and sanity how they can.

But, if you’re in the second or third category- before too long, if you’re not careful you start completely losing your mind. So, how do you hold onto your sanity in this crazy pressure cooker of a system? Here’s my secret. I add in the things that make my life meaningful to me. (I never said it wasn’t an obvious secret…)

Most of us get addicted to something- I chose to get addicted to exercise rather than alcohol or other “helpers”. So, I work out. If I don’t, as I likely won’t be able to for much of this week, I feel the withdrawal. Medical school is such an isolating and lonely experience that I realized the value of the people in my life rather quickly. The value of a support system, people to talk to, go do things with, people to share the neurosis that medical school creates can’t be overstressed. It keeps most of my classmates holding onto the last shreds of their sanity. And for me, it lets me hold onto the last thread.

What else? I added on a masters program. Yes, I added more work to a medical school career. Clearly, I’ve gone around the bend and need to be committed. But, fact is- I was a philosophy major in college and I feel the need to think about the world we’re living in. I need to consider the why’s, the what for’s. If I don’t do that in a disciplined or a more direct way I end up asking myself the why and the what for about medical school- which is a terrible idea, trust me.

Also, I travel. I go where I can, when I can. More so, I do what I can. I have a fear of heights, so I jumped out of an airplane. This weekend, I’m going jet skiing on the Hudson River with a friend after our exam. I’m travelling to London with the same friend for New Years. I’m meeting up with my family in Hong Kong (maybe- or we may go somewhere else) after I’m done with Step 1. I’m going to take a flying lesson or two in the next few weeks. Not to mention, scuba diving, skiing, snowboarding. Med school makes my days rather boring, bland, and frankly depressing. So, I choose to inject what enjoyment I can into it- as easily as I can.

Also, one of the biggest things I’ve learnt to do as I became a second year medical student is to clean up your baggage. In my experience, every person has people in their life who demand but don’t give. People who are either too hard to hold on to, or that one just can’t help. I’ve learnt to let go easier- so that I can spend more time with the people who are really important to me. It took a close friend passing to learn that lesson.

And the last way I cope? This blog. I like to write, and I enjoy dispensing my words of narcissism, questionable wisdom, and nonsense with reckless abandon!

If you’re in med school- relax. You’ll get through it- just realize that the system’s nuts, chuckle, bitch about it to the people who you trust and who’ll listen. And then keep going. What’s that famous quote? “If you find yourself in hell, keep going?”

If you’re going to med school- the one person who you shouldn’t be asking about med school’s value is the med student who’s $100,000+ in debt, has spent a year and a half buried in a mound of textbooks away from what they came to medical school to do- practice medicine. The same med student’s “paranoid, antisocial, and weird” (Erich Segal) and that’s what medical school turns you into. At the same time, as you walk out of a class and discuss something you covered over a year ago, subconsciously the right answer will push its way out. Perhaps madness is it’s method for medical school.

And if you’re sending your loved one to medical school- don’t stress. It’s hard work, but it’s doable. Just tell them to find what they have to do to get through it and proceed to do it. Preferably nothing illegal. A medical degree is of limited use if one’s license is then suspended for criminal charges…