The Light Comes Back

I was lucky enough to request yesterday off months ago so that with Lumberjack, my best friend, and her partner, I could drive down to the middle of nowhere in eastern Oregon right near the center of totality zone on our momentous eclipse day here in the States.

Because we're the four of us busy people, we maybe didn't do quite enough to prepare (i.e., find a place to stay the night in totality zone before they were all booked). I'll tell you the four things that I think were vital to our success this adventure:

  1. We bought certified eclipse glasses
  2. I read Annie Dillard's essay on her experience of the eclipse in 1979 (available to read here at the Atlantic only for a short while longer)
  3. We made a playlist
  4. We set out very early

 

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Totality was spectacular. First the light turned greyer. The shadows began to fall wrong across the landscape and our bodies. I watched my husband smile nervously in a new shade of blue, the shadow of his face falling short and sharp across his shoulders — beautiful and otherworldly. I felt nervous myself, a base anticipation pervasive. We toasted then to our resilience in darkness. It descended heavily and suddenly but light could be found at all the edges, sunrise on every horizon. In totality the dance between sun and moon was spectacular and clarifying. We laughed and exclaimed. People ran in circles. Crickets chirped. Suddenly my heart ached knowing this tango between two epic celestial bodies would soon end. And then with a brilliant glitter emblazoned at once across both of them, triumphant, the sun came back. We toasted to the return of light.

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As we packed everything up, peed in the trees, and got back in the car, the sun was clawing again for purchase in the sky. I cried, then. I've been thinking all year about hope and how to hold onto it when you're plunged into a world of darkness. It turns out the light always comes back.


Then we drove eight hours home and we all sang loudly to Total Eclipse of the Heart, which is an excellent song. (I won't wax on the cheap and obvious metaphor for any longer, I promise.)

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.

Heart to Heart

Today my med student was looking really dysphoric on rounds so I asked him what was wrong. He told me he was feeling really hopeless about how hard it is to help the people under our care on the inpatient unit.

I decided to sit him down to talk about it. He brought up time constraints, space constraints, financial constraints, energy constraints. He brought up a lot of the very real constraints, challenges, and cruelties of inpatient psychiatric care and his own feelings of hopelessness and helplessness related to those. He spoke, as an example, about his patient that he just feels would really benefit from hours of daily psychotherapy from a really skilled practitioner.

And my first instinct was to come up with ways in which this patient didn’t need that, and to combat it with the small list of support items we do offer. Because those are the answers that have been given to me for years when I ask the same questions. Because those are the answers that help us sleep better at night and come into work easier in the morning. Because those are the answers that alleviate our feelings of horror and guilt.

But I stopped myself. Because I don’t think those answers are true or acceptable; I’ve been rejecting them for years. There’s never been a time in my life other than right now when I’ve longed to internalize them more. And that’s a big part of the reason this first month of internship and especially these last few days have been so tough. And it was really surprising to me how in that moment – talking to a student, someone I’m meant to be mentoring – it suddenly would have been much easier to say that stuff, and for a split second I almost did. But I can’t.

Because let's face it  medicine has got a lot of issues. Psychiatry has a lot of issues. We've got a lot of work to do before we should feel, as a society, proud of the work we do trying to take care of the sick and vulnerable.

So I said, “I know, right?” and “It really sucks.” and “I’ve struggled with these feelings too, for a long time.” I told him how it’s especially hard now as a resident when I’m in a position of slightly more power and responsibility but with even more red tape to wade through. I told him how hard it is to find a balance between perpetual outrage/frustration and self-care, but he had to try.

And then I told him that even though it sucks, that doesn’t mean it’s hopeless. Every day we can be better for our patients: I talked about two examples of improvements in my own practice with specific patients that I’ve worked on already in this first month. And every day we can keep our eyes on the long-term goal: we can work together, slowly, for real progress in the way we treat patients.

After this conversation I realized in medicine we don't have this conversation nearly often enough, if ever – I certainly missed out as a med student. So even though it’s monumentally frustrating to call this my biggest success of the day when I wish it was something bigger and directly related to patient care, I’m gonna take what I can get. And besides: helping take care of our med students and ourselves really should be considered a big win.

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