When I grow up...

A big focus in life at the moment is answering the question: What kind of doctor do I want to be? Unfortunately for me, I am currently undecided. Here's where I am:

Internal Medicine (likely fellowship in cardiology or critical care)

Pro: Some patient continuity, variety, acute care, flexible lifestyle

Con: Not heavily procedural unless I go into the cath lab

Total time: 3 years residency + 3 years fellowship

General Surgery (likely critical care fellowship)

Pro: Very procedural, the OR is fun, prestige, variety, some patient continuity

Con: Not sure I love GI problems, tough lifestyle, required lab year

Total time: 7 years residency, with fellowship as one of my research years

Pediatrics (likely fellowship in cardiology or critical care)

Pro: love the patient population, patient continuity, flexible lifestyle

Con: not procedural (again, unless cath lab), limited places to practice

Total time: 3 years residency + 3 years fellowship

I've ruled out anesthesiology for lack of patient continuity. Plus, if I'm going to be in the OR, it's going to be my OR. I would likely match in any of these, though surgery would be toughest. Current plan: subi in each, await my surgery grade and see where we stand.

ps note the M4 schedule has been posted on the sidebar, for those who are curious.

Professionalism

We has a small group lecture on Friday to discuss professionalism. Our facilitator was supposed to have us discuss what professionalism means to us and how we think we learn it, but instead the conversation became a reflection on the tenor of the interactions we have witnessed over the last year in the hospital. We all agreed that by-and-large the demeanor displayed towards patients was very professional. Not always warm and fuzzy, but at a minimum, respectful. The few occasions we witnessed something less were generally in the context of extreme burn out.

What was more interesting is that we witness a lot of unprofessional interaction between medical professionals. The doctor-nurse relationship has been beaten to death in many forums, but it also exists between consulting and primary teams, between different specialties and between levels in the hierarchy. In particular, medical students can be the target of unprofessional, disrespectful behavior; most commonly from non-physicians on the care team. There is something about wearing a short white coat instead of a long one that signals to nurses and scrub techs that it's ok to abuse you or ignore you at will. Maybe it's because in a few months when we graduate we will be their bosses. Maybe it's because we have zero power to retaliate. Maybe it's because we're new and young. Whatever it is, we have all experienced it.

In the end, having a collective bitch session was very therapeutic. We are at a stage in training in which we have no autonomy, no choices, long hours and constant evaluation. Being able to complain to others who understand and don't recoil with a look of disgust at our temporary lack of compassion and empathy was very freeing. And the truth is, everyone else in the world complains about their job, their coworkers and their customers at times. Is it so surprising that we, as (future) physicians, would need to as well?

Being a positive deviant

I just finished writing a couple of essays for school. One of the assigned topics was on Atul Gawande's book Better. In the book, he lists his five suggestions for being a positive deviant; basically how to be Better.

1. Ask an unscripted question

2. Don't complain

3. Count something

4. Write

5. Change

I find it an intriguing list because it bears some similarity to the ideas I try to use to not just be better at what I do, but be a better person.

1. Ask more questions than you answer. I, like many extroverts, like to talk. It doesn't have to be about me, I like explaining things, I like reading out loud, I like debating - it's a hunger to participate. The risk, of course, is that with all the talking I find I've spent two hours with someone and I don't know their name, what they do or whether they've ever been West of the Mississippi. People have interesting stories and I can't hear them if I'm the one talking.

2. Don't whine. This is essentially the same as don't complain, but he's right.

Whining is not attractive and let's face it, everyone could come up with something to whine about. Interesting people find things to be happy about. Really interesting people can radiate their optimism to others.

3. Move the goal posts. Having a purpose is important. It creates focus, creativity and energy. They key is to be flexible about goals and to have them in multiple spheres of life. For example, one of my goals is to graduate medical school, but another (more fun) goal is to get stamps from every continent on one passport. Goals are personal - it's about what you are passionate about and should reflect who you are and who you want to be.

4. Choose. It's easy to follow orders and do what's expected. It's far more fun to go out on a limb and find your own path. It's harder, to be sure, but you learn much more. That's not to say you can't go with convention, just make sure you choose it, rather than letting life or others choose it for you.

5. Try everything once. Okay, within reason. But experience is a great way to learn things and fear is a poor excuse for ending up 75 with a bucketload of regrets. Trust your ingenuity, your resourcefulness and your survival instinct - you'll live through it and you might even like it.

Why is it that I feel slightly foolish publishing my philosophy and Gawande confidently makes a fortune off of his? Oh yes, because I'm not yet an accomplished surgeon at a world-renowned hospital. Still, I don't think it's a bad list. Plus, I'm wearing two pagers and he's only wearing one...

I graduated high school a DECADE ago?!

This is a photo of me getting dressed for new years this year. It was a low-key affair with low expectations so it turned out to be an okay night. I wasn't quite back to myself -I'm still not- having just been traveling internationally. I always get a bit brooding when I return home. I don't like giving up the freedom of traveling - life is a bit too tied down and restricting for my taste. I wonder if I should have taken more time off - a whole year of traveling instead of just a few months? I also miss the person I am when I'm not here - I'm more confident, easygoing, in-the-present when I'm away.

I'm not usually very big on new year's resolutions, but this year I have a few. They are more reflections on self-improvement that stem from travel, but new years is as good an excuse as any.

1. I choose confidence. I choose to be okay with who I am. I will own it.

2. I will read more non-medical non-fiction.

3. I will stop using medical school as an excuse.

I'm going to head back to California for a couple of weeks in early April and then hopefully off to Turkey the first week of May. Hopefully that will sate the nomad in me until next December.

Why I never call anymore

Recently, characters on tv have taken to enrolling in medical school. For example, the revamped Scrubs show will be set in medical school (the original started in residency). I'm actually quite curious to see what Scrubs does with this as the first few seasons were a fairly realistic portrayal of life as a resident.

On Brothers & Sisters, the youngest son and war vet, Justin, started medical school this season. His classes don't really seem anything like mine, but that could simply be a curricular difference. Medical schools all teach the same facts the first two years, but the approach to disseminating the information is quite varied. What was interesting though, it that they wrote him as a stressed out character that became removed from everyone else in his life. He lost track of much of the family gossip and was not there to support his girlfriend during his midterms; even telling her "there are going to be times when I'm not there for you."

I actually really appreciated this portrayal because honestly, that's how it happens. Like it or not, everything else comes second to medical school. Right before a final exam, your laundry, the dishes, phone calls to parents, gchat - everything is put on hold. If you're dating a medical student and you have bad news - hold on to it until the exams are done. Think of it as a preview for life to come: if you marry a doctor you will always come second to whatever patient is on the other end of that beeper. My 10 year anniversary? My daughter's first ballet recital? Your father's funeral? If I'm on call and that pager goes off... I have to go.

We joke about it sometimes, but I'm a little scared. In not too long I will be responsible for people's lives. I am leaning towards pediatric subspecialties; that could be your child. And if it was your child - consider - aren't you glad that I put everything else second to my education?

Breaking bad news

A recent assignment for school caused me to recollect a patient from my previous hospital. An excerpt (the original essay is several paragraphs longer) from my assignment summarizes the story...

The patient, an 8-year-old boy, was the elder of two sons of a recently immigrated family. He had been admitted for status epilepticus, which proved to be refractory. He was ultimately placed in a medically induced coma (which he continued to seize through for a month) and the parents were asked whom else they would like present for a discussion of his prognosis.

The family requested that a doctor from their home country be involved and so a teleconference was established. Various members of the care staff reported their opinions and summarized the boy’s course to date. There was almost as much silence as there was talking and each person was careful to solicit and answer questions. The questions themselves guided the discussion. The parents really needed to believe that every option had been exhausted. They believed that because we had been able to find an etiology, we should be able to find a cure.

From a physician’s perspective, after a month of seizing and coma there was likely to be little brain function left. A multitude of testing revealed a genetic defect in a sodium channel, which was blamed for the seizure activity. The boy was not a surgical candidate because the seizures were multi-focal and originated from both hemispheres. Everything had been tried and nothing would break the seizures, which were still occurring roughly every three minutes. There was nothing more that could be done.

Most of the conversation centered on the futility of our treatments. That we, as doctors, could not even promise he would wake up if we took away the sedatives. Eventually the parents chose to withdraw support. I think they knew their decision from the moment they sat down; they just couldn’t say it out loud. I didn’t get the sense we had persuaded them; more that we gave them a safe and justified way of letting go and not feeling as if they were bad parents, that they were simply giving up because it was hard.

It was then, when they stated their decision, that I was so thankful for the private room (not a patient room) the whole conversation took place in. The family had somewhere they could be where they wouldn’t be disturbed or overheard. Not by a nurse who needed to take vitals, not by a doctor checking on another patient. They couldn’t hear the business of medicine still working around them, healing some of the other children who would eventually be able to go home to their parents. But the room also allowed us, as the medical staff, to separate the conversation we just had from the rest of our work. When you walk out the door and back onto the ward, you leave the heaviness in that room and focus on health and healing on the floor. The spatial separation aids the mental and emotional one.

That separation is not learned with one conversation. Or maybe it’s always imperfect. But I do know that I was unusually quiet the rest of the day. When a friend needed sympathy later that night, I just couldn’t muster any. His problems seemed so petty. The boy was only eight and he was dead. Dead because of a sodium channel, which seems like such a insufficient and small reason. He had a little brother who clearly didn’t understand what had happened. He had a mom and dad that somehow had to keep going. And while I wasn’t consciously dwelling on it, something in me didn’t let it go immediately. Within the week though, the petty problems regained their gravity and the pressing concerns of work and medical school applications took over.

- * - * - * - * - * -

I have to admit that delivering bad news became easier. Maybe not in the moment, but my recovery got much faster.

With regard to the family in the story, the little brother had ongoing issues coping with his brother's death. I personally think some of this had to do with the fact that the parents never allowed the younger son to visit the older one (they didn't want him to see his brother sick or in pain). Then again, I am neither a parent nor a psychologist, so I am not at all qualified on the subject.

spilled milk

I've alluded to the idea that the last month hasn't been the happiest in my personal life, which is true. And while I'm now managing to be honestly happy most of the time, I still have hours/days when I just feel achingly sad. I have found though, that when I get into one of those moods that stepping back a bit helps. Yes, it is appropriate and natural that I am sad, but the man I met who lost his arm, his son and his wife in the same week has much more to bear. The parents who had to withdraw care on their 3.5 year old son have lost so much more than me. It doesn't invalidate my own grief, but it certainly puts it in perspective for me.

Positive Framing

My dad likes to send me links to interesting articles he finds online. Recently I received one about Japan's health care problems (which I didn't read) in a journal that also had an article on characteristics of successful women (which I did read). Apparently these women exhibited something called "positive framing."

"Positive framing and positive thinking... are two different notions. The latter tries to replace adversity with positive beliefs. The former accepts the facts of adversity and counters them with action."

This, I think, sums up my last few weeks very well. They have been extremely turbulent and somehow, three days ago, my mind pulled the plug on the purely emotional reactions and kicked me into action-mode. It's not that everything is suddenly okay, but that I have accepted what is and decided on actions that will eventually result in a restoration of my usual level of happiness.

And I have to say, when I dried my eyes and took stock of the life I have, I was really grateful. I have wonderful, supportive friends who were there for me, the respect of my peers and professors and lots of interesting opportunities ahead of me.

I'm certain I didn't choose the easiest road, but I (still) think it's the best one for me. Besides, you can't "live to the point of tears (Albert Camus)" without actually crying once and a while.

Frustration

Medicine is an interesting career in that it has very specific points at which you are forced to make a choice about what you want. The quintessential one is match day; there is a specific date on which everyone finds out what residency (and where) they will complete. For the current M4s, match day is this week. Medicine is also unique in that you are told where you will go - you don't get to weigh offers and choose one. You interview, you state your preference, and you hope to god you get what you want.

I have a lot of friends outside medicine right now trying to change jobs or get into graduate school and many of them have mentioned they envy the structure medicine provides. The next few years of my life are basically planned for me, but I find that terrifying. What if I can't make myself attractive to a residency program I want? What if I get stuck in a city I hate? What if I choose the wrong residency type (ie peds vs. surgery)?

I feel as if I have given up so much to do this, to be a doctor, and it doesn't end. I gave up a financially better career (banking) in a phenomenal city (NYC) to spend two years in night school just to apply to medical school. Now I'm living in a place I don't really like that's far from family and friends because it will give me the best chance at one of my top residency choices. I don't have the time (or energy) to play tennis or read books anymore and I can't keep a relationship together. I can't even make it to a friend's wedding or my 5-year college reunion. What do I have to give up next?

I know that what I'm doing is the best investment for my future and that I truly want to be a physician and yes, I am aware that eventually, when this is all done, I will have job security and a decent income (well... that depends a little on Obama...). I guess I just wish I was a little happier now. It's all well and good to plan for your future, but I seem to forget that I have to live in the present.

Pre-dissection reflection

I've finally put my finger on why dissection is making me feel a little hesitant and slightly uncomfortable. It's not cutting into a body per se; I was fine while watching surgeries. It's the fact that dissection is intentionally destructive. Surgery is about health and healing, about the best interest of the patient and their future functionality and quality of life. Dissection is about complete and total deconstruction with no consideration for the future. It feels like a violation because this is invasion with no intent to heal; it's taking apart a human lego set piece by piece knowing that not only can you not put it back together, you're not even going to try.

On the one hand I want to be respectful, this was a person and even in death they deserve to be treated well. On the other hand, I want complete detachment and dehumanization because otherwise, how do I (inexpertly) flay someone's father/brother and just go home and make dinner?

In some cases, the body donor willingly gave themselves, but the family did not. How do I look those family members in the eye, knowing that what I'm doing is against their wishes? I don't really want to meet the family (now); that will only make it harder to keep cutting. Do they really want to meet me? Do they really want to see who is doing this to their father/brother? Will I look undeserving to them? Not what they imagined a future doctor will look like?

What the doctor said

a poem by Raymond Carver, for our consideration as we think about the relationships we build with patients.

He said it doesn't look good
he said it looks bad in fact real bad
he said I counted thirty-two of them on one lung before
I quit counting them
I said I'm glad I wouldn't want to know
about any more being there than that
he said are you a religious man do you kneel down
in forest groves and let yourself ask for help
when you come to a waterfall
mist blowing against your face and arms
do you stop and ask for understanding at those moments
I said not yet but I intend to start today
he said I'm real sorry he said
I wish I had some other kind of news to give you
I said Amen and he said something else
I didn't catch and not knowing what else to do
and not wanting him to have to repeat it
and me to have to fully digest it
I just looked at him
for a minute and he looked back it was then
I jumped up and shook hands with this man who'd just given me
something no one else on earth had ever given me
I may have even thanked him habit being so strong

Introducing Pre-Mortem

I keep a book of things I would like to do before I die. Some are little: own a pet (not yet). Some are adventurous: skydive (done it). The book reminds me of the cool things I've done and the amazing adventures I have to look forward to.

I began this long before that horrible movie "Bucket List" (which no, I did not and never will see). Over the summer I began making the list electronic in case anyone wanted to follow along. Each post is a different goal; I will update them with photos and stories as I accomplish them.

http://design42pm.blogspot.com

Reading medical memoirs

It is probably not surprising that throughout my post-bacc career I have been reading a series of medical memoirs, novels, and essays. There was House of God, which everyone reads at some point (and I have been told to re-read in residency), Better and Complications, both by Atul Gwande (he's kinda famous among the medical set), The End of Medicine (by a finance guy) and the Man who Mistook his Wife for a Hat (pop culture famous book on neurology by Oliver Sacks).

I recently started one by a female neurosurgeon, Katrina Firlik, and I am struck by how familiar it all is. I work in neurology, not neurosurgery, but I have seen many of the conditions she talks about. She didn't have to explain holoprosencephaly or hydrancephaly; I've seen them. I certainly don't have the knowledge base of peds neuro resident or even probably a well-educated, interested medical student, but I am conversant with the best of them on a limited subset of conditions.

The other theme that strikes me is that I have already begun the personal transformation that comes with being a physician. Dr. Firlik spends time explaining the sense of humor in the OR, the detachment of the physicians, the cold practicality that contributes to efficient care in times of crisis, but these paragraphs already ring hollow. They are exactly how I would explain it to someone on the outside, but there is really no way to make it ring true unless you've been there. Patients will never quite understand how you can tell them the worst news of their life and then spend an enjoyable afternoon hiking.

There are lot of things you don't realise when you start down this road to become a doctor, but this one might be the biggest, the most subtle, and the most significant. There is no undoing the change in how you view people and sickness; in this one way you will forever be apart from your non-medical peers.

Choosing a School

I am sitting in the law library (view from my chair, right) working on my biochemistry term paper on dentatorubral-pallidoluysian atrophy (DRPLA), but my mind keeps wandering. I have now heard from all my medical schools and must begin choosing where I want to spend the next four years. I have narrowed it down to three at which I have been accepted: Michigan, Mt. Sinai or UPitt or two at which I have been waitlisted: WashU or UPenn.

I am content to live in any of the above cities and they will all cost me about the same amount of money, so how do I choose? I am so paralysed by the decision that I have actually asked several of the attendings I know at the hospital to rank them for me (which they did: Upenn got 3 votes and WashU got 1 for the top spot).

I think what makes it so difficult is that I would be happy at any of these schools. All of them set me up well for the future; there is no wrong choice. I am extremely fortunate to be in this position and I recognize that. But I still have to choose. And I am still stuck.

In the meantime, this paper still needs to be written. Back to biochem.

Where are you from?

I have always found this to be a particularly difficult question. And I always thought this made me weird. Nationality, or a defining point of origin, is central to our way of identifying ourselves and each other. But how do I answer it? I have two passports, where I was born is not where I lived the longest, my first language is not my best language and I am an immigrant to my father's country.

While browsing Wikipedia while studying for my organic chemistry final I came across something startling: I am not the only one. Ok, so that's not the surprise of the millenium, but I certainly did not think that people who had grown up in multiple cultures would be a unique sociological group. But we have a name: Third Culture Kids.

Summer

This summer is simply bursting with potential. Besides the very important observation that my MCATs will be over and I will again taste alcohol and drink sunshine, it's also brimming with highly anticipated releases. A new Harry Potter movie, a new Harry Potter book (already pre-ordered!), Pirates of the Caribbean, and Spiderman. Short of a fourth Lord of the Rings, I don't think there's a better possible cluster of likely-to-be-worth-the-ten-bucks sequels.

The summer is a blissful in-between. I will have some follow-up essays to write for my applications, but I won't hear acceptances/rejections/interview invites until fall or winter. I will have Organic Chemistry Lab, but the grade will be largely irrelevant. I will be occupied, but without the pressure and weight of the rest of the year. It is as close to a summer vacation as adults ever really get. And who knows, maybe I'll even manage to flee the country for 10 days in August (Belize? Italy? Namibia?).

If I can just make it to June.

And yes, I know Tolkein didn't write a 4th Lord of the Rings.

What do I really want?

Economists have a different way of quantifying cost that most of us. It's easily illustrated with an example: buying a candy bar at a vending machine. Let's say you have exactly the eighty-five cents in your pocket that each item in the machine costs. Most of us would say that the price of the item is, rather obviously, eighty-five cents. But an economist would say that it's not just the money you actually pay for the item, but also the utility cost of what you otherwise could have done with that eighty-five cents. In other words, buying a Snickers is eight-five cents plus the cost of not buying a Twix. The cost of options not chosen is called the opportunity cost.

This concept is actually very useful when evaluating the decisions you make about your life. In my case, choosing to be a doctor weighs against choosing not to be a banker or a consultant. Given that I can extract my expected happiness (utility) from my future career in medicene, what I have done makes economic (if not fiscal) sense. The utility gained from not being a banker outweighs the utility gained from not being a doctor. Thus, given a willingness to return to school (be it business school or medical school) it makes more sense for me to be a doctor: lower opportunity cost.

However, if my extracted utility falls below a threshold then the equation no longer holds and I would be better served returning to my previous career. Everyone has this threshold, the question is: where? Some people will go to any school and apply as many times as necessary to get into medicene - their utility difference between medicene and everything else is very large. Mine is smaller. I will not simply attend any school to which I am accepted and I will not apply year after year. This is because some of my utility is derived from my level of excellence within a given field. If I come to perceive that I would be a better banker than doctor, that will drain some of the utility from the propect of being a doctor. For better or worse, which schools you are accepted into and how many times you have to apply is a proxy for your projected ability within a field. It may not be 100% accurate, but it's a readily available metric.

This description probably all sounds very cold and calculated, but it's not really. It's simply the logical functioning of how you weigh different amounts of happiness. It quite rightly integrates the happiness lost by letting go of an opportunity. Think about how many times you have done something because the alternative - always wondering - was worse? The opportunity cost was greater than the negative outcome - it was too high not to act.

A rock and a hard place

I am at the point in the get-into-medical-school process that requires the most commitment, the greatest resolve. I am taking the MCATs. Well, more precisely, I am studying for the MCATs so that I may take them on May 11th. I'm also in Organic Chemistry II, which I honestly wish would just fade into the background because I don't want to bother with it. It just seems so much less important to do well there than on the Big Exam except for the teeny tiny caveat that I've asked my organic professor for a recommendation.
I have realised that assuming I could do the above while continuing to work full time was a tad ambitous. And yet, I also have the nagging suspicion that if I were somehow to be more efficient, it woun't feel like such a burden. The thing is, I like eating with my books closed for a few minutes. I like taking a couple of hours on Sunday to eat pancakes and watch Meet the Press in my PJs. It keeps you sane - giving it up for one week, no problem, giving it up for a whole semester while you burn yourself out like a roman candle - yes problem.
Managing my time and shoveling knowledge into my head, while stressful, are not the biggest reason this requires resolve, however. No, the hardest thing to stare down is my opportunity cost - what did I give up to do this? I gave up New York City, no small thing as it's the only city I get homesick for and I've never had roots or a "home" in the classic sense. I gave up a really nice salary and all the comfort that buys. I gave up any semblence of a social life, although to be fair my job limited that too, though to a lesser extent.
I gave up the life I always thought I wanted, grew up aiming for, because I didn't want my boss' job. Or her boss' either. On some days, maybe after a hard organic quiz, I wonder if it was all a little drastic. If sacrificing the rest of your life for a little engagement at work is really such a great trade off? I'm living to work and I'm pretty sure that takes 10 years off my life-expectancy and doubles my risk of heart attack. I would love to say that stepping into the hospital makes me remember why and sometimes it does. I wanted to do something that allowed, if not forced, me to be a perpetual student and I've found it.
Maybe what I'm really feeling now is not the cost of what I've done, but more simply, reality settling in. No one job is going to make my life perfect and all the possibilities cost something. I have chosen to be happy at work even if that means sacrificing much of my outside life. Staying in finance would have meant a comfortable life but long hours at job I loathed.

I have this whole conversation with myself pretty often and I find it comforting that by the end I always conclude I did it right. Hating what I did turned me into a person I didn't want to be and even now, even with the MCATs looming I am generally happy and optimisitic. I don't have an overwhelming certainly that this is what I was meant to be or that I couldn't be happy with another profession, but that doubt makes this real. If there are no doubts, you didn't think hard enough. It's like the MCAT verbal questions: you rule two out and then go with your gut.