Saturday, December 13, 2008

A gut feeling

On my surgery rotation, my energy and hard work was appreciated but I didn't quite feel like I fit in. When I asked my colleagues on general surgery what they thought I would be "when I grow up," I had several people tell me that I would undoubtedly love Obsterics and gynecology (OBGYN). I have always appreciated forming strong doctor-patient interactions in clinic, something that I really missed during rushed general surgery clinics where patients became a nuisance and their questions just slowed us down. I didn't just want more patient interaction, I wanted more meaningful interaction with my patients. That said, my love for surgery taught me that dedicating my life to clinic like a family practitioner wouldn't be enough for me. My colleagues noticed in me that I wanted to pursue a career in which I had the best chance at being a real practicing surgeon- a physician who is able to perform a surgery and really take care of them afterwards. They saw in me a future OBGYN. I wasn't sure about the idea because I hadn't done my OBGYN rotation at the time, but I was very excited to start.

It didn't take long for me to realize that my colleagues were right. In fact, on my first day of OBGYN I had the revelation: this is what I want to do with the rest of my life. Almost instantaneously, everything fit. I loved working with women. I loved the challenges of pelvic anatomy. I loved that all of the procedures performed in the operating room had significant meaning that I would have to follow up with important discussions with the patient. For example, I had a hard time getting excited about reducing a hernia on general surgery. What was the point in spending time with the patient afterwards? Instead, in OBGYN my patients were having emergency C-sections to rescue their babies or exploratory laparotomies to remove a suspected cancer followed by hysterectomies. I loved the importance and meaning of everything I did in the OR. I loved that afterwards, I got to really talk with my patients and help them understand what happened in the OR and why.

I have really enjoyed all of my clinical rotations. I have a passion, however, for OBGYN. This field makes me feel more alive. I am excited to go to work everyday with this field. This field makes me feel like it's all worth it. This field makes work seem easy again. Oh my goodness- I think I'm going to be an OBGYN!!!!!!!!!! :)

Thursday, October 30, 2008

On death and dying

My experience in general surgery and trauma calls at night immersed me in a world with really sick people, some of which ended up dying. My first experience with death was overnight on trauma call. A man came in as a "cat 2 MVC + EtOH" meaning he was like most of our trauma patients at an inner city hospital- drunk, driving, and badly hurt. After securing his ABCs (airway, breathing, circulation), we saw his only obvious injury was a broken arm. He started becoming more agitated and it took almost 6 of us to hold him down so that we could finish our exam for injuries. A few moments later, we realized that he had no pulse and that his heart was no longer beating. I started chest compressions on him for what seemed like forever (in actuality about 3 minutes). As I was beating on his chest I couldn't help thinking that I was keeping him alive at that moment. I didn't expect the chest compressions to work- I had heard of the statistics that less than 10% of patients who receive CPR make it out of the hospital alive- but somehow miraculously he re-gained a pulse. He was brought back to life. We re-evaluated his injuries and discovered that he had an acute abdominal bleed. His blood pressures started dropping and we realized that he would need to go to surgery immediately to try and stop the bleeding. I helped transport him into the operating room. He lost his pulse again. We started chest compressions again but realized that stopping the bleeding, and not keeping his heart pumping was his best chance at life. Without much time for the usual sterile techniques and precautions, we essentially sliced into his abdomen and 3 L of blood gushed out of his abdomen, soaking us all. We quickly surveyed his injuries and realized that they were too severe to correct, he still had no pulse, and there was nothing we could do for him. He was pronounced dead a little after 20 minutes when I first met him. I helped sew up his abdominal incision and couldn't help myself from thinking that just 20 minutes ago, I was talking to this man, hating him for being so agitated so drunk so careless. Now, he was becoming cold and stiff as I finished up his sutures. Now, I realized that I had seen life leave a person's body for the first time.
After watching so many episodes of ER and other medical TV shows that dramatize what I did for the past 4 weeks, I can now appreciate why so few physicians watch them. The truth is, after crying after watching a patient die on TV, I had no emotional response to seeing my first patient die. I felt numb. I wanted to feel something. Instead, I went on to work up the next trauma that night and went on to the regular OR cases later that morning. I always thought that death and dying would really affect me and my ability to practice certain types of medicine. Instead, almost instinctively, I became numb to it all. Almost instinctively, I adapted the same coping mechanisms for dealing with death (dark humor, sarcasm, indifference) that I had promised I would never have. And despite the fact that I wish I could feel differently about my first patient's death, I realize that if I had let it get to me, I would have had a difficult time continuing to work and finishing this rotation. I'm not really proud of who I became over these past few weeks but I felt that I had to in order to get through all experiences that were thrown at me.
In the end, I witnessed 4 patients die on trauma call and I was responsible for withdrawing life support for one of them. It never become easier to witness death but I did stop searching for an emotional response. I hope that a few days from now, once I've caught up on my sleep, I can reflect on these patients and their deaths... and maybe even have a good cry to prove that I'm not numb after all.

Saturday, September 13, 2008

Learning you can't help someone who doesn't want help

My first week of inpatient medicine was exciting and amazing. Patients came in very sick and one to two days later they were able to come home again. From my eyes, it looked as though patients were on the verge of death and were given another chance at life everyday in inpatient medicine. I found it so exciting that we were able to diagnosis a problem and fix it- what could be more gratifying than that?!

Unfortunately, at a metropolitan hospital, not every patient wants to get helped. In fact, we had several patients who left "AMA" against medical advice for one reason or another. One patient in particular really disturbed me when he left AMA. A patient came in for a life-threatening condition where his airways were closing up and he was unable to breath. Since he was so sick, he had to get a tube placed into his throat to breath for him. For several days, he was kept alive through the help of machines. On the 4th day, he woke up and extubated himself (a crazy painful ridiculous thing to do) and demanded to be discharged. He was brought to our floor to stabilize his other medical problems, try and figure out what caused his airways to close up in the first place, and to make sure that he was stable enough to go home. Within 5 minutes of arriving, he demanded to leave. I spoke with him to try and find out why he wanted to leave. I thought that if I tried hard enough, I could convince him to stay, I could be his advocate. Instead, after everyone on our team tried to reason with him he walked out. I felt really uncomfortable watching a man who I knew would not live much longer without medical help walk out, convinced he was doing the right thing for himself. He was so proud that he showed the doctors who was "boss." He loved making a scene. It was really painful for me to see that his need for another drink was leading him to a very soon early grave. He could not be reasoned with and everyone on the team shrugged him off. In the end, we cannot make a patient do anything. A patient has the right to make their own decisions, even if they are the wrong decision. Even so, it was really discomforting to know that the next time I saw this patient medicine would not be able to do much to help him. To me, it was my first experience watching a patient die.

Sunday, September 07, 2008

Outpatient --> Inpatient

I completed my 2 month rotation in family medicine and outpatient clinics (TB, urology, cardiology, ENT, ID, ortho peds, rheumatology). Although my first week was overwhelming (wait I have to remember all the right questions to ask the patient, do the right physical exam techniques, remember my findings, write a note, present my findings to my attending, and carry a conversation with a patient I just met?!), I used the low-pressure outpatient clinics to stay positive and focus on doing better with each clinic. Each day I feel like I was able to improve on something or learn something new or really reach out to one patient... but each day I did that I was confronted with 1000s of things I still hadn't learned, the reality of how much better I could have done something, or thing I shouldn't have said. With each day I felt like it was one step forward and a 28479 steps backwards.

I met so many amazing patients in such a short time- one afternoon I had a patient who was an inmate, a middle-aged woman who never learned how to read, and a male to female transgendered patient. I felt privileged and even excited to be able to work with so many interesting patients, even though it was through considerable hardship in their life that they became "interesting patients." My outpatient experience was exciting everyday because everything was so new- I'm sure that migraines aren't thrilling for most practicing physicians but for me, it was such a thrill to have a patient who I wanted to help, read about how to help her, and recommend the appropriate treatment for her.

Although most days were exciting for me, I had a few days when I felt a tug of the negativity of medicine that so many of my classmates have warned me about. I worked with a patient who had many serious health problems and yet was always ready to blame someone else or something else for the poor care she took of herself. I was really discouraged to meet someone who didn't seem to be invested or even interested in their health. This woman's health problems were a reason for her to be concerned and to make life changes; instead, she did nothing and came to see a physician sparsely. As I talked to her about ways that she could improve her health I started feeling resentful for talking to this woman who clearly didn't seem to care about her health. I disliked this woman for her excuses, for her poor health habits, for her disdain of her own body. This woman was going to die very soon as a young woman with poor habits, and she totally did not seem to care when she was told this. I left clinic that day feeling deflated. I was disappointed in myself. I felt guilty for having a visceral emotional response to this woman. I felt guilty that I found being negative about patient interactions. After speaking with other students and physicians I learned that everyone gets a patient like this. The trait that I realized would be helpful in my future would be to learn that coping with situations and being able to move on from them. In my last week of clinic, I was able to see this patient again. She had started to make some positive changes that I was very eager to hear about but I still had a negative thought in the back of my mind questioning whether she would be able to maintain these positive changes.

I hope to keep all the valuable lessons I learned in my first 2 months in mind with my next rotations. Tomorrow is my first day of inpatient medicine- my first taste of the grueling hospital hours of medicine, my first experience with overnight calls, my first opportunity to work with very sick patients. I'm not sure what to expect with this new rotation. One thing that I know will be true throughout the next two months- I will always have much more learning to do.

Saturday, August 02, 2008

Medicine hits home

My parents came in on Friday and we had an amazing time out at dinner. It was one of the best time's we have all had together here in Cleveland. This morning they were planning on leaving to drive to Canada. I made them breakfast and we were just milling about the house. I was running about the house and in passing quickly asked my dad how he was doing and didn't really pay attention to the answer. A few minutes later, I realized that my dad was unable to speak or move his L arm. In medicine, we learn to immediately assess patient mental status by asking three questions: who are you, where are you, and what year is it. Dad could not communicate with me and I could see the terror in his eyes as he struggled to realize that he could not talk. I instantly knew what was going on and all that I had learned about rushed past me- what tests he needed, chances of survival, etc. I brushed it all aside and pretended that nothing big was going on and that we were just going to the emergency room "just in case." On the drive over, I was freaking out in my head... I knew that my dad was having a stroke and that he needed to get to the hospital very soon in order to reverse the damage to his brain. As his daughter, I joked about Cleveland traffic and pretended that it was just another Saturday. In my head, I kept thinking of how terrifying it was to see aphasia (the inability to speak to others) in my father's eyes. In my head, I kept thinking how serious this may be.

Luckily, we live very close to the emergency room (<1.0 mile) and I know key words that will get you immediate attention at even the busiest hospitals (i.e. I'm a medical student here...he stopped being able to talk 5 minutes ago...). In the ER, I saw a team of physicians mill about him, doing the exams I was thinking of doing. I understood what was going on but I was torn as to what I should tell my mom. Should I tell her everything that I'm worried about with the risk of scaring her? Should I hide the worst scenario because it's not really likely and risk hiding a possible truth from her?

It's scary for me to realize that my parents are not as young as I always thought they were. It's even more frightening for me to think of my parents as patients.

Luckily, my father began improving within 10 minutes of his episode. He was able to move his hand again and slowly regained the ability to speak. This is a very good sign in medicine... if his symptoms resolve in under half an hour, it means that he didn't really have what is known as a "stroke" but a milder version of a similar situation. He is still at the hospital in the neurology observation until so that they can make sure that he continues to do well. He is doing very well- he has no residual physical effects from what happened. He is, however, having a lot of trouble dealing with what happened. He still is struggling to come to terms with why it happened to him and what it means about his age and his health. (FYI if you read this and are in contact with my dad please pretend you know nothing about this. He will tell people when he has come to terms with what happened and is ready to tell others about it.)

Despite all the medicine that helped me realize he needed to be seen in the ER and despite all the great care he received there, I can't help shake the feeling of a "hidden blessing." Dad wasn't supposed to come with my Mom to Cleveland. What if this had happened to him while he was alone at home with no one to tell him he needed to go to the hospital? What if this had happened on the drive from Chicago? What if he hadn't been able to come upstairs to try to talk to us for a second time? What if we didn't live as close to the hospital? I really hope that something like this never ever happens again. That said, I feel really lucky that I was here able to help my dad get the care he needed and I was there to make sure both of them understood what was happening with the physicians. I can't help thinking that despite my scientific training coaching me otherwise, everything really does happen for a reason. I just hope that that we can all use the reason behind this experience to help us all.

Sunday, July 27, 2008

Week 2: starting to get real

This week was amazing. I'm becoming more comfortable everyday in the clinic but I'm also realizing how much more I need to learn everyday, so it ends up feeling like one big step forward, a tiny steps back. I'm trying not to feel overwhelmed and focusing on improving everyday.

One of my most memorable experiences this week (besides doing a female and male exam all by myself!) was in my family practice clinic when I got to speak with a patient on naloxone therapy. Naloxone therapy is a therapy for preventing deadly withdrawal to heroin addiction. As a medical student the greatest gift I have compared to any other point in my training is TIME. I had the time to really get to know this patient. I got to ask her more than the usual questions about fevers, chills, nausea, vomiting, diarrhea, constipation- I got to find out about this woman's life and how she became an addict. She shared her story with me and cried as she re-lived many of the decisions she wishes she could take back. As I told her I was proud of her for working so hard to get her life back on track, I realized that I was one of the first people to ever say something like that to her. It was with this patient that I remembered why medicine was so exciting to me in the first place- the real opportunity to impact and change a person's life.

My goal for the next few weeks is to remember to be excited and enthusiastic around the patients. I want the patients I work with to remember me as being excited to be able to work with them. Sometimes I'm focusing so much on asking all the right questions and doing the physical exam and remember it all to present to my attending that I forget that my main priority as a medical student is to know my patients better than anyone else around. This week I'm going to change that.

I also want to work on continuing to build confidence- even though I feel like I'm a long way away from being a real doctor, I need to start acting like one around my patients. I want to be more confident and self-assured around my patients this week.

Sunday, July 20, 2008

1st week as "Student Dr.Grob"

One week done! It went by so fast! I am doing the next 4 months of rotations at an inner city hospital. It's really inner city... someone got shot in our hospital's parking lot during orientation; someone else got shot outside my family medicine clinic so we aren't allowed to go outside during lunch. I am doing a 4 week rotation through family medicine (Obsterics included!) in a Spanish-speaking clinic, rheumatology, pediatric orthopedics, and urology. So far, I LOVE IT!!!!

I especially like my family medicine clinic where I feel I have the most time to get to know my patients and decide on how to treat them. I have had a hard time learning how to balance listening to patients, writing notes in the computer, doing a physical exam, and figuring out what is the cause of their chief complaint and then how to treat it. It's a big jump from practicing talking to patients and doing a physical exam! I recognize that I have a lot of work to do but everyday I feel like I'm learning something and everyday I feel more comfortable tackling my daily responsibilities than the day before. That said, I know that some days will be harder than others. It's going to be hard not to take hard days personally.

This week I want to challenge myself to act like a real doctor and figure out the treatment for my patients (including drug doses!) before talking to my attendings. I also want to start studying more after coming home from the clinics. Overall, I hope to continue to have my daily focus on being positive and excited about this awesome experience.

In the meantime, it's really awesome to walk around with a pager... even though I haven't gotten any pages. :)

My major gripe so far: how heavy my white coat is stuffed with medical instruments, books, pocket books, cell phone, and PDA.

Sunday, July 13, 2008

Learning how to be a doctor... starting tomorrow.

I start my clinical rotations tomorrow! For the next 4 months I will be doing rotations in outpatient clinics, family medicine, internal medicine, and surgery at a city hospital. I'm really excited to get started! I'm also a little nervous! Ok maybe more than a little nervous! I'm excited to get back to medicine and start applying my learning. I just hope that I can keep up with it all.

Before I get overwhelmed with working in the hospital (i.e. tomorrow), I want to set some goals for myself for the next few months.

First and foremost, I want to remember how to live a healthy balanced life. Physicians need to be able to set an example for health. I want to be proud of my health everyday. I hope to work out- even when I'm tired or grouchy after work- because I know that it will make me feel better. An adrenaline rush makes everything seem better. I need to use the time I have as a student to practice being a healthy physician. I hope to work out at least 4x/ week. Even on tough rotations.

The next few months will be challenging. I will be an inconvenience to all those around me (patients, nurses, attendings). My lack of clinical knowledge will get in the way of everyone. Everyone will know more than me. I don't want to take this personally. I want to use this time as an exciting opportunity to learn medicine. I'm not expected to know everything. I am expected, however, to be optimistic, enthusiastic, and energetic. When I inevitably make a mistake, I want to learn from it and immediately adapt. Dwelling on the mistake will hold me back.

I hope that I can remember that for many of my patients, I will be the main physician that they spend time with. I want to be alert, caring, and attentive to each and every patient I see every day.

Tuesday, June 03, 2008

Will I be able to do this?

Research block so far has been a nice break- working 8 to 4, having time to watch TV, call friends, work out, go on trips, no homework. Today I got a reality check- I received an email about scheduling my clerkships... and oh yeah they start next month. (!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!)

I decided to start reading about what to expect in the next 2.5 years of clerkships. I read about my responsibilities and how much my life was going to change. I read about long hours, realizing your flaws, and never knowing enough. I realized that I have no idea how to summarize a patient's life and current condition in 30 secs to 3 minutes, depending on my rotation. I'm terrified, to say the least.

What if it's too much? How will I learn this all? How will I find time for myself? Who will I be after surviving this?

Most of my friends are finishing up their first rotations on the wards. They survived. And now that I realize just how stressful their day to day lives have been the past four months, I feel they deserve a badge of honor- for replying to my silly emails sent from a slow day, for finding the time to call me when they haven't slept more than 4 hours/night for the past month, for finding how to balance their crazy new life with their old one, seemingly effortlessly. I'm impressed. I just hope I can do the same.

In the meantime, after these realizations, I now have some SERIOUS incentive to get back to normal study habits!

Thursday, May 01, 2008

So when do I become a real doctor, again?

Since taking my boards in March, I’ve been enjoying life on my four month research block. Although it’s been nice having a stress-free life and my biggest worry of the day is usually whether or not I should try a new recipe for dinner, it’s been tough adjusting to the fact that most of my friends are on clinicals. Everyone is learning so much and is actually DOING such cool things; I can’t help but feel jealous. I know I will get more than enough opportunities to do the same starting in July, but I still feel a little left behind. It certainly seems as though the last few weeks of my research block are going to have to be spent re-learning a lot of the medicine that I’ve forgotten already. This morning reminded me of just how much I have to review- and just how much longer it’s going to take for me to REALLY become a real physician.

I walk through the hospital to get to my research lab on mornings when it looks like it might rain. Today, as I zoned out and listened to the classical music in the skyway and smiled at the busy long white coats rushing past me, searching for a familiar face, a man stopped me and started screaming. As his screams echoed through the hallway, he grabbed onto me looking for help- all I could do was stand there. I froze, my mind went blank, and I just stood there asking him if he was ok. Luckily, long white coats from everywhere emerged and started calling for help. Now that the real help had arrived, I felt that I could walk away, but I knew that I hadn’t done my job. What should I have done? Who should I have called? How can you tell if his defibrillator really went off or if it was a psychiatric patient looking for some attention? Regardless of whether or not I could have really helped that patient in the skyway, my silence really concerned me. When am I going to be one of the people that responds to situations? When am I going to gain the courage to be the one helping people, not just another person asking if they are ok? When am I going to become a real doctor?

Thursday, April 03, 2008

I DID IT!

I got my scores back. I did better than I ever imagined that I could. Finally, I can write with confidence: it’s over…I’m finally done with Step 1.

Since scores are released at midnight, I stayed up late to find my score. At 12:01am I saw that my score was up. Forcing myself to click on my score report and then scrolling down to see what my score was took so much. All the stress, all the hard work, all the sacrifices… all boiled down to this one score. When I finally saw my score, I couldn’t believe it. My eyes filled with tears and I actually started trembling. I had done better than I ever imagined that I could have done; I rocked the boards.

I called my parents first of course. I think that they were more excited than I was- I was still in shock about it all.

The next day was exhausting. Once I got my score back, this huge sense of relief swept over me. I was surprised by the physical reaction to finally being done. I came home after work and slept 3 hours on the couch. I think that after all these months of hard work, the stress and sense of impending doom were finally gone- it was a great feeling but an overwhelming one, too. I’m done. I’m finally done. :)

Wednesday, March 26, 2008

Step 1- done (kind of)

So I’ve survived- kind of. Five weeks of studying about 15 hours/day, without any days off plus all the studying for boards that I did when classes were still in session. It was really the last few weeks of studying that proved to me just how similar finishing my study plan and taking Step1 was to the race I ran back in September. In my race, the first few miles were a breeze. My last three miles were awful. I wanted to stop. In fact, I considered stopping the entire last three miles. Somehow, I was able to find the strength to get to that finish line. And somehow, after all that studying and after the countless times that I was convinced I would never be able to learn it all, somehow I woke up and it was test day and I knew that I had done the very best that I could have.

I haven’t received my score back yet even though many of my friends who took the exam earlier did (and did beyond amazing!). Since I don’t know how I did yet, I can’t really say if it was a “success” – however I end up defining what “success” really means on an exam like that. All I know is that I really gave it my all. I started early. I worked hard. I didn’t give up. I had more support and encouragement than I knew what to do with. What happened on test day is no longer in my hands. How I did compared to all the other medical students across the nation is something I can’t control. I just hope that regardless of how my score turns out, I can remember that I really did my best. It would be pretty awesome to get a great score though. :)

After the exam, I felt defeated. Many others (including David who rocked the exam) felt the same way. Very few people leave this test feeling great. I’ve just never left a test having absolutely no idea on how I did. It’s not a good feeling. I definitely didn’t feel like celebrating afterwards.

This silly test has been the culmination of 2 years of medical school. So much unneeded pressure has been put on this one exam. And you don’t really get a release from that pressure until you find out your score. There was a chance that I would find out my score today- I didn’t. A lot of friends that I ran into today, however, did. ALL of them did amazing. I’m so proud of them for doing so well but I’m so jealous of that feeling of release (and their awesome scores). I guess I have no choice right now, I just have to keep waiting until I find out my score, too.

Holding my breath in case it brings me good luck…

Sunday, January 06, 2008

Last post before the big push of 2008

Today is the last day of winter "vacation"- a break where I spent more than half of it doing work! Tomorrow is the first official day of the biggest challenge of 2008- mastering head and neck anatomy, learning neuroanatomy, neuroscience, the brain, psychiatry, and orthopedics all in three weeks all while continuing to prep for my boards exam. And after my last exam on February 1st, it's 5 weeks of buckling down until Step 1 of my medical licensing examinations. This definitely won't be pretty.

Before the craziness starts, I just want to take some time to be corny and inspirational- hopefully time well spent because I think I'm going to need all the motivation and inspiration that I can get these next two months. Below is a list of a few things I hope to keep in mind during this big challenge.
  • You can do this. You will do this. Look back at those workouts for training for the half marathon- they seem impossible even now after you finished the 13.1 mile race. You took it day by day then and made it to the finish line successfully- same is true for Step 1. If you have to, wear your medal from the race while you are studying. :)
  • Take good care of yourself. Working out everyday will be a good break from studying. Plus it will keep you healthy, energetic, and less depressed. The gym is a great place to learn your drug flashcards when you are running. Swimming will help you clear your mind and re-focus. Keep it up!
  • These exams are not about passing or memorizing details. These exams are about learning all the information that I can to provide a strong foundation for the kind of physician that I want to be. It is an honor to be studying to become a doctor- remember that you are learning to take better care of your future patients.
  • Play with Olive.
  • It's only two months. Work hard everyday and it will be over sooner than you think.
  • Only say positive things. Do not complain or dwell on negativity. This will only get you down and bring your performance down.