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.

Drawing (1).jpeg

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!

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