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.

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.

Here's What Happened To Me This Year

In February something very bad happened in the world, which is that my father died.
It broke my rib, the sudden force of my sadness shattering and then settling into that sharp pain which lasted for weeks. I was numb to everything else in that period. I barely breathed, the pain stretching long fingers to my throat and chest wall and tethering them still. Even my anxiety went away, washed out by that heat at my side. My carefully cultivated optimism cracked with that rib and in seeped the idea that there was no being okay after all, that there were things that you don’t recover from in the end. My father was a great, great man, one of true magnitude. You don’t get over that.

Eventually my rib started to heal itself. By April I could move again without wincing. Instead I became bathed in fear like an electric current. By the time anxiety returned it had sensitized all my nerve endings so that anytime anyone I loved got in a car I felt the sting of panic.

When the world around you feels as if it’s made up of knives, the stuff of the atmosphere itself sharp and cutting like razors, then a person tends to contract. That’s what happened to me. Sadness was a big, growing, sopping mess at my center and it was heavier every day.

When I started my intern year in July I knew I would have to find some way to survive. Sadness was that mess at my center and fear was an electric rash that was opening up new raw places every minute. It’s so hard to walk around like that. I put my head down and braced myself for the year ahead with the wounds I had. I worried I was getting smaller.

New people I met saw me as permeated by rage, I think they characterized me by it – frothed up into flaming rants at the least provocation. But even then I felt broken, like a skipping record, like a wrung-out rag trying not to mildew. Rage was a reflex that spewed forth from something more difficult to characterize but that surely saw its origins in that deep well of mourning in me. October turned over. I sunk deep below the surface of hard times.

Bitterness is a hardening and a contraction. The dense, buzzing cloud comprising my father’s death, medicine, the pressures of being a new doctor, my own hard unforgiving nature, all the darkness I have to face, my isolation – I realized this month that it’s getting to me. I am not cloudstuff tossing out my limbs for human contact but the bitter pit of a bruised peach with its flesh torn away – hard, the only touch that can mark it a scratch.

Halfway through December, on the plane back to Seattle from a visit home to Chicago I think that bitter pit broke open and I found myself left drenched in the evidence of my own desperation. It took me a while to get to sleep with sob-swollen eyelids. I resolved to face the world with better optimism, but the next morning I was met with the greatest hits of medicine's litany of horrors as we rushed an otherwise well patient to emergency surgery, and optimism flitted away.

Here’s what happened to me this year: Bitterness was all around me, gushing, and so I painted my sore skin with it. Layers and layers of that tar. I’m trying now to peel it back to walk around abraded. I’ll have to find some other balm. But sometimes you show the universe your cracked-open self and someone fails to catch the debris and you have another opportunity to get worse again. Tacking that rising tide of bitterness on raw skin is a reflex that’s hard to suppress.


Starting intern year in the same year someone important to you dies is hard. You are faced with the world's most awe-inspiring tragedies while you're grappling with the idea that the universe sometimes takes vital things away and then goes on barreling forward anyway. And I’m a stubborn, heartbroken dreamer that assigns greater cosmic significance to myself and everything – which I see as a prerequisite to my vocation and one of my greatest strengths, but which is also hurting me. I’m a narcissistic mystic who can’t cope with a universe that goes on okay in my father’s absence and so this one must not be.

I need to let go of my broken thought processes, but I don’t want to – it’s too compromising, it’s odious to me. Truly moving forward feels like a latch blowing open on sadness, allowing it to disperse all through me. Isn’t it poison? But I see that I have to try now. My stubbornness is turning me into a worse person, a worse doctor. I can’t shield myself with bitterness anymore, and so I’ll have to find some other balm. (The balm is joy. Joy and hope.)

But the world hasn’t seemed such a hopeful place anymore. I’ve wanted to find a way back. And then I haven’t, because sometimes mourning feels like having the truth scraped across your eyes. It’s hard to remember that that is an act of obfuscation, not revelation. The biggest strength is in finding hope despite hardship.

At a NYE party I regretted committing to I found joy and laughter in an imperfect place with imperfect people in a formulation of the universe I would never design. I thought hard on the fact that you have to take people as they are and try to inspire the best in each other. Nothing is gonna be what you would have chosen. But you have to be able to feel the joy with the sadness. See that they exist because of each other. Grief comes from love and there is no love without the glinting threat of grief on the horizon.

I invited people to bring their baggage, their grief, their dashed hopes and wild losses of 2016 to the party. We got the fireplace running and each of us threw the lot of it in to burn as the night went on, so it all could meet some form of cosmic reconstitution.

So in our little gas fire I burned bitterness. I wrote it down on an index card with a hand made furious by desperation and champagne, and I tossed it in the fire. And then again. And again, with fear. And I burned them all again the next day, and the next, and the next, and today. And I think I’ll have to continue, every day for the rest of my life. Burning them away.

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.

Grief: Dark Shadows

Every day, at least once, it comes back to this: I’m tired of this being the worst year of my life.

It’s just that all in this world seems so marred by the dark to me lately. Everything so heavy, dark and brooding, thick and bitterly saccharine like molasses. All seems to be pressed on on all sides by something very monstrous and diffuse. I can’t seem to think about anything except my patients, whose lives have trailed themselves through such tragedy. The spectre of my father’s death hangs always. I can’t escape sirens, always right outside my window, ambulances in front of me any time I step out the door representing either the weight of expectation on me as a doctor or the burden on this world of new tragedy or both. I always seem to be walking up a hill in this city and even when I’m walking down it’s not buoyant or good – characterized by nothing more than being not-uphill. And negative in its own way, a tumbling. Even when I try to look for the good in this world it feels weak and without power – brought down by the mud its feet are stuck in. And I am unsurprised by each new piece of horror brought to my attention, though still dejected. It seems there are shadows in every corner.

I miss my lake. I miss my husband. I miss soaring on runs and feeling at home. I am so, so tired.

After my first call shift, which was terrible and similarly filled with horrors and harbingers, I slept for the most restful four hours in weeks. When I woke I felt fugued, feeling briefly like I had pulled myself up through the dark clouds by a great force of will and obstinance, a gasp of fresh sunshine on my face, a muscle-up through the muck. I looked around at the bright and beautiful restaurant I had chosen for brunch by myself, where I had been a few weeks earlier with Lumberjack. It was soaked through with sunshine.

But soon the coffee and mimosa started to dig their sharp edges into my belly.

I am mincemeat. I am the raw bloody face of someone punched then pushed across the gravel. I am shaken to broken pieces in my fragile glass innards then set back down with my vessel intact.

I ordered something spiced and biting but wished for that warm melting I had had with my husband sitting across from me, weeks ago. At the restaurant’s store I browsed the cards section with tears coming to my eyes at the casual relevance of sympathy cards. I wonder if there will ever be a time that those don’t feel like they apply to me. I meticulously sniffed $12 soaps and picked the thing softer and warmer. I carefully chose five stems for a bouquet, pouring myself into the bright and tangy ones, hoping to bring forth again the joy I used to feel from being made of passion and fury. A dahlia, a dark daisy. Two peppered support stems and a single pure white tapering one to make me feel like I could bear holding onto this vision of myself – intensity – which lately feels dark and frightening and unstable.

I feel rattled like I’ve been other times I’ve been on inpatient psych but I don’t remember how I put myself back together before. Then I had Lumberjack by my side, listening with an open face as I got home every day, holding me on our couch. Then I had runs on the lake. Then I had a father.

Everything feels so different now.

I don’t know that I see the way out now. But I will try to paint myself with sunshine. I think the way out now will be a different way.