Once upon a time

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In a stark room full of fluorescent light and a single rubber couch a butterfly sat and worried her wings. They were very big and very beautiful and she told me about all the things and people that had hurt her while her iridescent wing lost strips ripped off in her worrying fingers. When she sobbed great big tears formed and made her heavy and she said, “I never do this, I swear – I don’t usually cry.” She wanted to fly south for the rest of forever but she loved her family so she built them something grand to help them forget her by. What she had built for her family was beautiful and delicate, constructed so carefully by a soft person for the people she loved, and what I built for her wasn’t like that at all. It was haphazard and rough, because I had spent the time we were talking just barricading that room full of fluorescent light, trying quickly to make a place for her to stay for a while where she could be safe, even if it meant she couldn’t fly there.


In a stark room full of fluorescent light a teenage bear raged and raged at a universe that had sent him careening thirty feet off a cliff and left him with three broken limbs and great big paws that were swollen and fractured. He still wasn’t sure how he had slipped off that cliff or whether he had ever stood there at all and sometimes he could forget, but when he couldn't he knew that that fall was maybe the worst thing he had ever done to himself in a long list of bad things. At those times he reeled from the shame of it and it filled him up until it overflowed into great big screams and paws pounding at pecs and sharp claws slicing. That's when I would stand up and lift my arms above my head and stretch myself as big as possible in that stark room so I could push against the edges, so I could crash my body against the walls to make the space big enough for him and his raging, and everyone outside of the room peered in but let me push the walls bigger, until the rage passed and the bear’s paws throbbed with new pain and his old wounds had opened and we sat together and stitched them back up, memories of his claws scraping desperately against a rocky bluff fading again into the background.


In a stark room full to the brim of fluorescent light there was an insect. He sat calmly on the gurney until I entered the room and he trained his hundred eyes on me. They glimmered and glistened with something unfamiliar to me as his mother sat beside him begging him to turn away. The insect didn’t listen though and his hundred eyes bulged with that glistening glimmering sickness that started over time to coat everyone that was near him in slime. His mother, soaking the seat of a chair with it in another room, begged me to take her son somewhere else for a while, where maybe that sickness could drip away onto something besides her family.

When I went back into that room the insect turned his dripping hundred eyes on me again. I sat down on the seat across from him to tell him he’d be going to the hospital. I knew he’d be upset but wanted to tell him eye to eyes. I chose my words carefully and handed them over gently, but suddenly wings six feet wide that I didn’t see before unfurled behind him and he launched into the air above me, landing fast to grasp my hands harder than I could stand, harder than I could comprehend for a moment until I wrenched myself free and tried not to pinch the glowing of his wing in the door as I closed it on that stark room full of fluorescent light, sopping wet with his sickness. My heart beat hard outside the room.


In a stark room there was a lioness sitting on a rubber couch under the fluorescent light. She growled angrily every time we walked past, and stood back on her hind legs when she saw us and said, “Oh hey look, it’s the shrink squad.” She was sick, though, and wouldn’t let us take her vitals, and one time I sat down in front of her and looked deep into her deep brown feline eyes and asked her please to let us take her temperature because I was worried about her health. “No!” she said. “You don’t care about my health, you just care about covering your ass. If you really cared about my health, you’d hold my hand, you’d look in my eyes.” I sat down in front of her then and I took her big paw in mine where the claws sat conspicuously in their sheaths and I held it and I looked in her eyes and I said, “Please let us take your temperature. I’m truly truly worried about your health.” Her eyes were surprised and she let me nudge the cold thin rod of a thermometer under her tongue alongside her big teeth. The next day she said if we truly cared we’d bring her flowers, we’d bring her cake. We didn’t do those things but she did stop calling us the shrink squad.

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HIPAA Disclaimer: All of my stories are fictionalized and I never share PHI. Details are always changed, added, obscured or omitted. Most stories aren't about a single patient but rather are mished and mashed and sorted for narrative sense.

Photos are taken by myself from the Yayoi Kusama Infinity Mirrors exhibit at SAM.

Hope Lost And Found

I am long overdue for some sort of reflection on intern year after having officially worked my last day as an intern a few months ago. Here's a small piece of what it was like for me:


At the beginning of this year I bought a ukulele. I started intern year at a sprint, like anyone does, arms full of hope which was quickly extinguished, lost in an atmosphere so devoid of hope that all of it flew out of my arms to settle into places so far in between it might as well have been floating in the vacuum of space.

I was alone in a new city and alone in a new role I didn’t know how to wear for a lot of reasons. The cloak of physicianship burdens upon you suddenly not just the obvious – the responsibility for human lives – but also darker, sinister things that are similarly heavy – a power over people nobody shows you how to soften, the shame of a tradition of institutional oppression that’s now officially dirtied your own hands by vocation, the towering knowledge that much of the time medicine is hurting people. Adjusting to the new responsibility of being a doctor felt really impossible.

There’s something special about going to work in a hospital – where there is no luxury of the mundane to fill in the gaps between flashes of drama. Most people working in a hospital recalibrate in some way, but my own response to intensity has always been intensity. And this first year of doctoring was one winning an intensity contest. My father had just died, my husband was living 2000 miles away in the city that felt like home, and going to work every day was a new jack-in-the-box of horrors, each one a stab at the raw place in me that bleeds for people but progressively softened my cringe reflex into something that was like having the chills almost all of the time, hair on perpetual end.

So for a while, I got home every day and played the ukulele. I sucked at it and had learned my first song, poorly, drinking bourbon in the rented house prior to my best friend’s wedding so I could play them a love song, just a few weeks before. I knew that song* – Can’t Help Falling In Love With You – and maybe four more.

But playing those songs would pull out the tears from my eyes that I had suppressed all day and massage that raw place a little and put a little dressing on my wounds. Playing the ukulele every night meant the hard places in me from medicine didn’t become as hard. It was a balm that helped replace bitterness, which is so tempting to tack on to yourself when you’re in medicine. Bitterness is all around, because of tragedy, because of overworked healthcare providers, because of disparity, because it’s hard to help sometimes – it’s a sticky plethoric tar that protects you if you paint yourself with it but hardens in layers until before you know it the only touch that can mark you is a scratch.

Intern year loped along and by the end of it I was thin and ragged, gasping for air and just hoping I’d make it to the finish line. Hope felt long gone. I was well aware it was a perspective problem – the patients that did well left the hospital, and so I didn’t get to hear from them, and the ones that did poorly bloomed in my awareness, taking over my thoughts and ideas about how medicine works and what’s likely to happen to people. Pessimism was joined by sacrifice – in my last month I’d become uncomfortably accustomed to losing the things I wanted to be as a doctor:

 me, tired, part of the way through a 30 hour shift

me, tired, part of the way through a 30 hour shift

  • Spending an extra minute with a patient that has more questions
  • Standing up for a patient in pain that’s been labeled as drug-seeking
  • Swallowing snarky comments in favor of well-crafted criticisms
  • Trying to teach med students to think better

For the sake of:

  • Getting to the next admit they give me on the rotation with no cap
  • Eating my first meal of the day
  • Working my 85th hour in a week
  • Writing more billable notes at the insistence of hospital administrators

It sucks when these are the sacrifices. It sucks when you’re used to that sting. It sucks when getting a win – maybe by doing something on the first list – is the only thing that’s gonna inject some hope into the situation, but you can’t. It sucks when hope is so thin on the ground.

I didn’t enter medicine because I thought it was easy but I did go into it thinking I could do it proudly. At the end of intern year, I was very seriously doubting that. I was very seriously wondering two things: 1) Would I ever be able to find a way to do this so that I’m proud of myself, and think I’m doing more good than harm? 2) Is there a way to tolerate all the tragedy without becoming a monster?

I still don’t know the answers to those questions. (They’re really hard ones to answer in the field I’ve chosen. Spoiler: not being an intern anymore helps.) Sometimes I would get home from work and I’d get my ukulele out and I’d claw for hope by playing sad songs fast and fiercely, feeling something besides sorrow, reminding myself of all the people in the world that have made it through hard times and the practices and traditions that help to share the burden of hardship and the balm of joy (music). I’d do this at 1am when my alarm was set for five the next morning. I’d do this after really hard days when patient courses were long and arduous. I’d do this when I was thinking of my dad. It was a balm when hope was thin.

And then – on my very last day of intern year, and I still can’t believe it went down like this, I taught one of my patients how to play the ukulele.

I had entered this patient’s room in order to clarify a few things and give a few updates before I sat down for the afternoon to pound out my notes so I could – I hoped – leave a little early on my last day (I had a plane to catch). But instead I saw that little plastic four-stringed piece of magic labeled “OCCUPATIONAL THERAPY, 7TH FLOOR” (we were on the 5th; this is how it always goes in hospitals – nothing and no one is where they belong). I saw my patient struggling to finger a G chord (I had struggled too, at first). I saw a person clawing hard at hope in a hard situation. I saw my humanity rushing back at me during all those late nights playing sad songs fast and fiercely, thinking of patients that did poorly and situations that were fucked up and all the ways bodies and minds and medicine failed us. So I sat down on that hospital bed and spent several hours teaching chords and sharing my favorite tab sites and practicing sing alongs. One of the songs we played goes like this:

Don’t let us get sick
Don’t let us get old
Don’t let us get stupid, alright
Just make us be brave
And make us play nice
And let us be together tonight

It’s the song** I’d been playing and singing to myself all year, the one I chanted like a prayer hoping to ward off black clouds and bad omens, hoping to make the hospital feel more like a team room than a battleground. I sang this, finally, with this patient, who was sick but getting better, who was brave.

Ultimately, this tool I had been cultivating for my own sanity over the course of the year was one I got to share with a patient as I crossed the threshold from intern to resident. We almost missed our flight but didn’t.


 

So here’s my intern year survival tip: go to the place where hope seems thinnest.

I don’t know why. It’s something I felt compelled to do.

Go to the place where the darkness is thickest, go with all your hope gathered in your arms and into the vacuum it will disperse until you’re gasping, breathless, from the thinness of it, from the scarcity of hope in the sparse and lonely atmosphere, reaching in the darkness with hands wet with its thickness, its beefy angry sopping heaviness, drowning in the horror, hope lacking.

There, find it again. Reach and reach. Dig and dig. Fight harder for hope than you ever thought was possible, than you ever imagined, than you ever thought you would. Pile it back into your arms and get ready to plunge again.

Matilda

*This is, of course, Can't Help Falling In Love With You by Elvis Presley: link here.
**The song is Don't Let Us Get Sick by Warren Zevon: link here.
***Please note my posts are always HIPAA compliant -- I always change details and I never include PHI.

How Testing Can Kill

Doctors are sometimes terrible at statistics, and our biases -- including the hugely prevalent interventionalist bias in American medicine -- inform the way we look at numbers and probabilities in really dramatic ways. Here's an article ("Bias in the ER" from Nautilus) I read recently that talks about where doctors fall short, and how they can improve, in interpreting the numbers.

One really egregious example of this is in the way we often look at screening tests. I've had a lot of med students in my time as a tutor in medical school and my time as an educator in residency ask questions that shed light on how rudimentary are understanding often is when it comes to the risks of running a test. And we need our patients to understand this too! I wrote an illustrative example -- let's pretend there exists a disease called blarg cancer.

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Let’s do a math exercise with made-up diseases and numbers. Let’s say we had an organ called the blarg and sometimes people get blarg cancer. Blarg cancer is bad and results in significant morbidity and mortality so we want to screen for it. We find a molecule that shows up in the blood of almost every single person with blarg cancer – what a great screen! We are so pumped. But we soon start to realize that sometimes it shows up in the blood of people that DON’T have blarg cancer. So some people we’re screening are showing up as positives even though they don’t have blarg cancer. But no biggie, right? It’s worth it because we’re catching people with blarg cancer we wouldn’t otherwise catch.

Let’s pause the story to take a terminology break: sensitivity is a quality measure of a test that tells us how often the test turns POSITIVE when someone has the disease you’re looking for. If a test is highly sensitive, this means that if you have the disease, the test is going to turn positive almost every single time. This means you’re catching basically everyone with the disease. So the screen for blarg cancer I described above is highly sensitive, because I said the molecule “shows up in the blood of almost every single person blarg cancer.” Another way of thinking about it is that a test with very high sensitivity has a very low false negative rate. People who get a negative test result can rest assured they almost certainly do not have the disease.

Another quality measure of a test is the specificity, which measures how many people WITHOUT the disease will have a NEGATIVE test. We call it specificity because the question we’re asking is: is this test specific to the disease we’re looking at? Will it turn negative every time someone doesn’t have the disease, or are there some cases in which it turns positive for a reason other than the disease in question? A highly specific test means if you get a positive test, you can be pretty sure that this person has the disease. In other words, a test with very high specificity has a very low false positive rate. The screen for blarg cancer I described above doesn’t have great specificity, because I said, “sometimes it shows up in the blood of people that DON’T have blarg cancer.”

Sensitivity and specificity are measures that we calculate for EVERY TEST we do in medicine! We often think of our tests as arbiters of truth-in-diagnosis, but that is a really dangerous myth. Unfortunately we just don’t have magic diagnosis-revealer wands we can wave over patients to determine if they have diseases we’re looking for, and we need to be really careful not to think of the diagnostic tests we do as diagnosis-revealer wands, because it can cause a lot of problems, some of which I’m going to outline now.

Alright, back to our blarg cancer screening test. Let’s say that our test has a sensitivity of 95%. Wow! A+! Such a good sensitivity. That means that if 100 people have blarg cancer, 95 of them will test positive. You’re catching almost everyone.

Let’s say the test has a specificity of 80%. That’s not so bad, right? Still a B? But definitely not as good as the sensitivity. It means that of 100 people that don’t have blarg cancer, 80 of them will have a negative test. In other words, 20 people out of 100 without blarg cancer will test positive.

Let’s figure out what all these numbers mean. Blarg cancer has a prevalence of around 1%. This means that if you picked 100 people from a crowd, 1 of them would have blarg cancer. If your hospital has a patient population of 100,000 then 1000 have blarg cancer. The sensitivity of your test means that if you start screening you will catch 1000*0.95 = 950 of the people with blarg cancer. The specificity of your test means that of the 99,000 people that don’t have blarg cancer, 99,000*0.8 = 79,200 of them will have a negative test. But – uh oh – that means 99,000-79,200 = 19,800 will have a positive test even though they don’t have blarg cancer.

Now most people see that number and say to themselves, “Well, it’s not that big of a deal. There’s a psychological discomfort but at least we’re catching the people that do have cancer!” But it’s not so simple. What do you do after you have a positive screen for blarg cancer? You have to do something about it! So you remove their blargs. All the positive screens, or 19,800 + 950 = 20,750 people have surgery to get their blargs removed.

Surgery complication rates for blargectomy are about 20%. That’s any complication, including anything from a minor infection of the site to something more serious. Perioperative mortality rates are much lower, 2%. That’s not too many people (good job, surgeons!), so it makes you not worry too much. It includes people that died in surgery, died shortly after surgery, or died for a reason directly related to their surgery (e.g. sepsis from surgical infection). So let’s do the math. If 19,800 people got surgery that didn’t really need it (false positives), then 0.02*19,800 = 396 people are going to die from complications of a surgery that they didn’t need.

Well, you think, that really sucks. But we did surgery on 950 people that really needed it! But wait a second – surgery isn’t always effective. Cancer really sucks, and even when we do surgery for blarg cancer, it’s only effective in the long run 30% of the time. Surgery saves the lives of 30% of people with blarg cancer, so you saved 950*0.3 = 285 people.

So think about that. You saved 285 people, but you killed 396. Still want to do that test?

And that’s not taking into account a whole host of other factors, like lead-time bias, complications of surgery that aren’t fatal but are life-altering, and the mental health implications.

“But Monica,” you’re probably thinking, “Blarg cancer and all those numbers are made up and this is a totally hypothetical scenario.” Yes, I made this example up, but it’s a teaching example that reflects REAL LIFE EXAMPLES. We have learned this lesson time and time again. Read up on PSA screeningCA-125 screening, and dementia screening. This lesson is the reason we only screen smokers for lung cancer. This lesson is the reason mammography for breast cancer screening is undergoing so many changes in recommendations.

“Okay, Monica, I’m convinced. So should we stop screening then?” NO!! That’s not what I’m saying at all! There are plenty of screening tests that have held up under scrutiny and proven themselves to be effective and worth potential adverse effects. The medical community currently holds up the pap smear as an example of a good screening test (when it's administered appropriately and at appropriate intervals), with high sensitivity and high specificity, with a high enough prevalence of disease to make it worth it, with the potential to save lives if caught earlier, and with a lower rate of adverse effects.

Cancer sucks. It takes so many lives from us and results in so much suffering and tragedy. Please don’t think that I’m not taking cancer seriously, or trivializing it. But we can do harm too. And we do. We HAVE to be careful in what we do as a medical community. We have to take that seriously.

So what’s the message then? The message is that as physicians it's our job to understand that everything we do incurs risk and that we need to work with patients to use the information we have to determine when that risk is worth it and when it isn’t.

Basically, use your brain. Do the math. Be a critical thinker. IT’S OUR JOB. Our patients need us!

Dear New Intern: Remember That You're Brave

It took me until the end of my intern year to fully understand and internalize this message, so I’m going to say it loud and clear here:

BEING A DOCTOR IS BRAVE!

I spent most of the first part of my first year as a physician climbing the giant mountain of fear and anxiety and paperwork that is intern year, and it’s hard to scrape together perspective when you’re doing that. Especially when you have very little time for reflection. And especially when everything is terrifying all the time, so you feel like a scared mouse.

Being a doctor is terrifying, and so what you’re doing is brave.

Not many people go to work and prescribe treatments that could help or hurt people.

Not many people talk to a million different strangers all the time.

Not many people sign up to answer the plan of care questions from nurses that have been working in the hospital longer than you’ve been alive.

Not many people take on the risk of using your own damn judgment when it comes to what to do for a patient.

Not many people have ever run to a code blue. Not many people have to try to think of what to do when a person is really sick.

Not many people wake up in the morning to take over responsibility for people’s lives.

Most people aren’t brave enough to be a doctor.  You are.

Give yourself some credit for that.

You're a doctor! Yep, you! (Intern Survival Tips)

A year ago I couldn’t believe people were talking to me when they said doctor. Now I can’t believe I only have 3 days left until I’ve officially made it through my intern year. (Thank goodness.)

This year has been a really big challenge – and I’ve learned so much. I know I have a long ways to go, but looking back on the person I was a year ago makes me really proud of how much I’ve grown. But there are a multitude of things I wish someone had told me (and I'm sure I would have had to learn the hard way anyway).

 Here's me on my first day of orientation. I think I wore this white coat less than a dozen times this year.

Here's me on my first day of orientation. I think I wore this white coat less than a dozen times this year.

This post is about one specific thing – how to keep your head when you get a page or a call you don’t know what to do with. It was the first thing I freaked out about on my first day, because getting a page is the first freaky thing that happens, since that's the life of an intern -- answering pages.

I’m a pretty anxious person. These tips might not be relevant to you if you’re not like me, so feel free to ignore them. At the beginning of this year I couldn’t believe that I was the one expected to answer pages, that when something happened a nurse had to tell a doctor about, I was the first person that would find out. It was unbelievably nerve-wracking until I hammered home the lessons below and realized I was up for it.

Here are three things to remember when you get a page you don’t know what to do with.

  1. You have time. You always have time to think, I promise, so take a deep breath. The only instance in which you don’t have time is if the patient is coding, and if that’s the case nurses know exactly how to start a code without you and your senior will be running it. in every other case, you have a second to take a deep breath and gather your thoughts. If you take this step, everyone will be better off because you’ll have your wits about you.
  2. You went to medical school. You learned some things, and they’re still in your brain. After you take a deep breath, take a second to come up with one relevant or semi-relevant piece of medical information you know. Remind yourself you know things. And that’ll get the ball rolling and soon you’ll be listing out your differential.
  3. You’re not alone. One thing about feeling like the dumbest person in the hospital is that it means you can’t throw a Foley kit without hitting three people you can ask for help. ASK! Know your senior’s phone number. Call consults liberally. Ask the nurse paging you, “What have other doctors done in this scenario?”

No offense, but you’re an intern. Everyone in the hospital knows you’re inexperienced – that’s kind of the point. This is your very first year as a training doctor and you’re here to learn. The most important thing isn’t that you remember everything and know exactly what to do in every possible scenario, it’s that you keep your head and enlist the people you need to learn from and get the job done. That’s how safe patient care works, how learning works, and how you succeed as an intern!

Big Dreamers

Last week I switched to a medicine wards month. Sometime in my first few days I dreamt I woke up in a hospital bed on a ward that was outside, a cool blue feeling permeating the corridor like a heavy morning dew. My team was rounding. It was my team in both senses – I was a patient on their team, and also I was one of the team’s interns. They rounded on me in the manner of the latter. I gathered I had been out of it for a while – I didn’t know the day or what was going on – but soon pieced together that I had ovarian cancer, and my status had been grave at first. They told me my hemoglobin was 2.0 on admission.

The team talked shop for a while about how I was doing and what the next steps were. The attending concluded by saying to the crowd, “I knew we should have imaged you when I felt that mass on exam a few months ago! I told the oncologist but he wasn’t impressed. And look at that – fucking ovarian cancer! I told him!” He hadn’t told me he’d felt a mass at my last visit.

Like many of my dreams, this one will be a fun one to talk about in psychoanalysis when I finally have time for 3 hours of training-focused therapy a week. I think even with the most simple modalities of reflection this dream says a lot about some of the worst places of turmoil we go as residents.

How does someone be a doctor and a person at the same time? How do you navigate your role as intern on a team without losing the perspective of the patient? What if you’re sick too?

I spend a lot of time on teams feeling like the one closest to patients, feeling like it’s my job to play arbiter in the ways I can, to try to pick through the politics of maintaining safe and congenial team dynamics without feeling like I’ve thrown patient respect out the window. It’s hard to remind doctors to take a minute to remember the person without tromping all over the ways they’ve developed to cope, and without layering on too much acerbic vibes between you and your co-workers. It’s especially hard when you’re having trouble remembering yourself.

And, of course, there’s the Resident as Patient theme. I was a patient and my own doctor in this scene. I think it indicates I see myself as sick in some ways. This isn’t new to me. Residency makes you sick. You work more hours than you ever have with more responsibility on your shoulders you could have imagined – you get worse before you get better. You become less human before you become more human. But how do you treat yourself? It’s the obvious question, especially given that as doctors I think many of us are reflexively trying to come up with the treatment plan.

The finale is the gaslit resident who goes to work every day absorbing the message that all of the hardship we witness and work through in hospitals is somehow okay. In this dream my attending sends me the message, “You were sick, very sick, for three months. I didn’t tell you. Now I’m talking about it as if it’s not a big deal.” Gaslighting in residency – the underlying message sent when we avoid talking about the subject that what we witness isn’t a big deal – is something I’ve been running up against a lot the last few months.

Doctors cope with the nature of medicine in a lot of different ways, and it’s hard to be too judgmental about how we make it through. I understand that talking about how messed up everything is all the time isn’t sustainable, and that some form of repression/suppression is necessary to make it to tomorrow. But medicine is hard. I know that’s never gonna change. I’m not asking for it to – then it wouldn’t be medicine, and it wouldn’t be the career for me. But I think the way to achieve wellness in residents necessarily involves having better ways to talk about the hard things, to share the ways we get through them, and to have mentors that help us see how to become doctors that are better at appreciating humanity and more human themselves. I know that nobody’s really figured that out. But we need to be brainstorming more. My examples shouldn’t just be ones of repression and jaded hardening. They should be ones of stoic triumph in the face of huge challenges. We should at least be talking about how to get there.

Burnout and "The Good Ones"

I’ve been thinking a lot lately about the kind of burnout that happens in people that come into medicine with eyes wide open, thoughtful and informed and generally pretty intolerant of the kinds of cognitive dissonance that help most people get through.

I’ve heard too many stories of “the good ones” quitting – the ones renowned for empathy, advocacy, patience – the people that still get mad about the ugly way things are, and try to be better. There’s even a Scrubs episode about it (or several).

We’re all starting our intern year in just a few months. Residency (along with the third year of medical school) is notorious for making jaded cynics out of the most doe-eyed baby docs. It’s daunting.

There’s a classmate I’ve been getting to know much better the last couple weeks (dissection makes fast friends) and I feel we have a lot in common – he goes on some of the same rants that I do, for example. During one of his particularly snarky rants something really struck me. I realized I’m so worried about this friend losing his hope. I’m so worried about him feeling overwhelmed by the isolation of being the one that cares all the time. I’m so worried about him quitting.

What struck me, I guess, was that with all of his rants I’ve been seeing myself in him. I’ve really related, really connected, to his anger. So, this really begs the question: am I worried about myself?

I worked very hard for my hope early on, and that hard-won optimism is something I see as essential to my identity. Cynicism is so unattractive to me now. It dresses up truths in dissonance and distractions until what looks logical is excuses and rationalization. I see the familiar hipster misogynist nihilists that pride themselves on loving Fight Club as children more than I see them as edgy or smart – they haven’t yet developed into real humans with sophisticated understandings of the world and real-life experiences with humanity.

So, to me, there's some honor in quitting, if it comes before or in the face of cynicism. In fact, I always had given myself permission to quit. The decision to give myself that permission was conceived under the angst over whether I would go to medical school – I had met too many bad doctors that hurt patients. I didn’t want to become a cog in that machine. I knew that doctors that hated what they were doing were bad at it – they hurt patients – and so I gave myself permission to quit as soon as I hated it, and I’ve checked in with myself frequently in that regard. If I’m not doing my job better than another premed/med student/resident/physician would in my place – if I’ve become another cog in the machine – I might as well leave and let someone else do it. I’d rather quit than be adding more to the balance of harm.

But what that decision (to give myself permission to quit) looks like has evolved interestingly in these four years. What was once a judgement-free opportunity for reflection is now a scary window to a distinct, and unsavory, possibility. I know what quitting would look like for me now. I know what things might happen in my experience with medicine and what kind of person I would be, and I also know, deep down in my gut, that I don’t want that to happen. I want something out of medicine, and it’s not quitting.

It’s really hard when you feel like you’re the only one around to care about something. My third year of medical school, for this reason, was extremely, soul-crushingly isolating. And on top of that isolation, I felt this intense pressure to get really really mad about everything terrible I saw because nobody else was doing it. Somebody had to, at the very very least, notice. And when I looked around there was nobody but me to do it. Somebody had to care. So I felt the weight of thousands of witnessed traumas – I bore a lot of anger on my shoulders.

I remember coming home one day ready to go on yet another rant about something that had happened at the hospital, and Lumberjack saying to me, “Monica, you don’t have to get mad about everything. How can you do that to yourself? That’s unsustainable.”

And it was. But who else was there to notice? If I didn’t, it felt like letting a multitude of bad things slide. It felt like condoning them.

Isolation is so dangerous. I can’t muster the rage that’s called for in medicine by myself – I have a lot of feelings, but not that many. There’s strength in numbers.

And this, I guess, is what I need from my peers and colleagues. I need someone to co-rant with me. I need someone else’s gaze to meet when something terrible happens. I need to feel like at least one other person would back me up if I spoke up about something.

We really have to support each other. Resilience is relational.

Giving a shit is a 24/7 job. It requires constant vigilance to defray participation in a corrupt system that mediates daily oppression and institutionalized damage. The easiest way to get through medicine is the one where we fall into a state of cognitive dissonance that allows us to tell ourselves things aren’t so bad, it’s not our problem, hope is impractical. Avoiding that is really hard. And when you do avoid that, the unending effort required to maintain your humanity and your hope requires a lot of social support.

This is why I’m so grateful for my co-ranters within medicine.

I don’t like thinking about the possibility of quitting, but I also think it’s important, because it allows me to start building now a network that will allow me to spread some of this rage around. Supporting each other is a vital part of maintaining our humanity, of cultivating our hope, and of therefore effecting meaningful change. I’m really grateful to all the people that have helped me in those ways. Please stick around. Let’s have each others’ backs, as fellow humans facing a monolith together. Stay loud. Stay mad. Stay hopeful. Fight on.

Honoring the Hype

Someone asked me what to do if your career in medicine feels boring, you feel like you're only doing it because it's the right thing to do, and working part-time or choosing a specialty with good hours feels like hedonism. This is what I wrote in response.

If you think your career as a physician is boring, you need to take a long hard look at what you’re doing. The longer I reflect on what it means to be a physician, the more I understand it to be a calling. It’s truly a vocation, and I apply that word because I don’t think that it should be done by people who don’t feel compelled to don that yoke.

I’m not saying you need to be hyped for your career 24/7, or even every year of your life. But you’ve gotta have a little hype – that hype allows us to pick ourselves up on days it’s really tough, it makes us honor the privilege and responsibility of having lives in our hands, and it, hopefully, compels us to do better for our patients with a measure of humility.

There isn’t a heavenly ledger that catalogues your gives and your takes from this world. We are all giving and taking – in fact each act of giving is an act of taking in some way, too, and vice versa. That’s what being a member of this human race is. You shared your bread with your sister and you gained generosity. You taught your brother and you gained a student. Your mother gave you life and you gave her motherhood.

To harp on a similar concept, there is no purely selfless motivation for pursuing medicine. Guilt will only take you so far before it corrodes.

I know that guilt makes up some of the fuel that powers my own motivation, but there are many other things too. Ambition, drive. And a deep, insatiable love and curiosity about humanity that means I care deeply about people, and also find a great joy in connecting with them. Do you see how that has some selfishness in it? I really want to help people, and also this way of helping people is one I find deeply satisfying and stimulating. It incites passion and drive in me. All of these things are roiled up together into the reason I’ve stayed on this medicine track.

(And you know what? I’ve checked in with myself every step of the way, to make sure I still wanted to be on that track. Before starting med school, I gave myself permission to quit if I started to hate it, if I didn’t think it was right for me. And so I took that seriously, and feel ever more confident on this path. I’ll continue checking in as my life moves forward.)

This is why I don’t think there’s a purely selfless reason to pursue medicine, and I am suspicious of people that claim they have one.

Now the reason I’m talking about this is because it matters for patients. I’ve been saying this for a long time now, but please believe that I really mean it: a doctor that doesn’t have some hype, that doesn’t feel connected to their career and therefore doesn’t connect to patients – in other words, a doctor that’s burnt-out – that doctor isn’t a good doctor. S/he might show up to work every day, might diagnose and prescribe as indicated by the clinical guidelines, might dot all the i’s and cross all the t’s. But the more and more studies we do, the more we realize how essential the relational component of medicine is. Having a doctor that’s well improves patient health. It’s just a fact.

So if working part-time is what it takes to maintain your hype, then please work part-time. If specializing instead of entering primary care is what it takes to maintain your hype, then please specialize. Etc! When you see a patient, ask yourself if you’re there in that room with that patient, fully mindfully present, human-to-human; if you’re not, figure out what you need to do to make it happen.

I’m not saying you need to quit if you’re not feeling the hype 24/7. But I am saying that you should take care of yourself, and not make a decision based on guilt, and really try to know yourself in this career. Nosce te ipsum; know thyself.

I sincerely hope that helps.

Best,
Monica

Books I hope you read: When Breath Becomes Air

When Breath Becomes Air, by Paul Kalanithi

Whether we like it or not, and whether we are aware of it or not, when we decide to become doctors we choose to ask the problem of death into our lives more bodily, more substantially, than most people. Paul Kalanithi took that to the extreme when he decided to become a neurosurgeon, and he wrestled with the problem of death – helping to guide patients across the landscape of health and disease which brings us so close to it – just as he wrestled with the problem of human meaning by choosing to become a physician after studying literature. His openness and vulnerability in discussing these problems in his book reflects not just a remarkable wisdom but also a rare and clear-eyed bravery, especially as the problem of death became personal for him.

Dr. Kalanithi talks in several places about the struggle at humanity’s very basis, and then he reinforces this foundational idea throughout the book when he talks about his own struggle. This constant striving really is essential to being human, and it reflects the conflict between life and death that we are all perpetually trapped within, and which he himself must face more readily than most of us ever will.

Living life means a constant balance between grasping and acceptance. We all must find our values – find the right way to spend our lives reaching while facing the knowledge that eventually, at some unknown time, everything we’ve reached will be taken away. Accepting death but knowing that the answer isn’t to stop the struggle – that’s life’s great challenge.

And Dr. Kalanithi faced it, and demonstrated it, beautifully. He takes the reader on our own, heartbreaking version of it. We get to know him, we grow to admire and appreciate him and his life, and this all the time knowing that his days are limited. I think knowing that Dr. Kalanithi died before he could see his book finished, but also having this version in my hands here in front of me, played out that never-ending challenge like Sesame Street teaches you how to tie your shoes.

This book was, ultimately and fundamentally, enough. I wish that Paul Kalanithi could have lived years and years longer to have written many more words for us, and I also accept that he didn’t. I am so grateful to him for baring himself open, for helping me figure out what it means to be a doctor, and for teaching me this really important lesson.