On This the Last Day of My Medical Education…

2 04 2014

Image

…I wanted to share a letter that I wrote to myself just less than two years ago, on the day before my third year of medical school began.  The day before I officially started working in the hospitals for the first time.

I was terrified.

Honestly, I did not think I was capable.  The two years in front of me felt daunting and impossible.  I did not think I have the strength of character to go down such a difficult road.  I seriously questioned whether this path was right for me.  I seriously questioned whether I was right for this path.

I am a person who invests in multiple interests in order to protect myself.  It seemed to me, however, that medicine demands that you invest in it wholeheartedly as a career, or you will not make it through the process.  I wasn’t sure I could do that.  I wasn’t sure I would make it.

I was telling all of this to a pretty incredible friend, and she inspired me to capture all of my fears and self-doubt in a letter to address to myself, to read two years later, on my 27th birthday.

Today, April 2nd, 2014 was my last day working in the hospitals as a medical student.  In a few months, I will be a first-year resident.

I have so many feelings and words I want to say that I don’t know where to begin right now.  But today, as it was my last day, all I could think about was this letter that I wrote to myself two years ago.  I really hadn’t read it since I wrote it.  But today, for some reason, I really wanted to read it.

So I read it, and now I share it with you here today, for anyone who may question whether medicine is for you, or for anyone who was/is ever terrified that a career might demand your undivided focus for a lengthy period of time.  I just hope you know that you are not alone in your fears, doubts, and hesitations.  And even though I ended up sticking with medicine, it doesn’t mean I would have been unhappy had I ended up figuring out that medicine was not for me.  For me, the important thing was to give myself a break, and let myself truly try medicine before I made a decision one way or another.

It really isn’t the destination.  It really is the journey.

And so today, as I’m nearing the end of this leg of my journey, I find myself reflecting back on my last few years here, and that is where my super cheesy letter to myself finds its start…

———————————————————–

Dear June,

Happy birthday!  Hope you are enjoying the Sunshine or rain or whatever weather it is today.  Remember to travel slow enough through life to appreciate what is around you.

When you read this, you may have decided that medicine is not for you.  And if that is the case, I hope you realize that this is more than ohkay.  I write this not as a prediction, but as emancipation.  I know that you are scared of giving 100% because you are scared to fall short.  You’ve always tried to do a million different things at the same time, and all of those eggs in all of those baskets gave you security to know that even if you fail, you have all of those other baskets to hold you.  It was the courage to not care about failure that allowed you to be successful in different domains.  It was spending 40 hours a week for 4 months working on a project because it made you happy, and not because it would look good on your CV.

Somewhere along the way you forgot how to enjoy whatever it is that you’re doing.  You became so afraid of what the next moment holds that you forgot to love the present one you inhabit.  You are about to enter core clerkship tomorrow, and looking back in 2014, I hope you look back realizing that you squeezed every moment for what it was worth.  You can worry about being wrong, looking stupid, acting a certain way to please patients or staff, but what did it do for you in 2011 and the first half of 2012?  Nothing, except create a mask of fear that you used to protect yourself, which only ended up consuming you.

When you look back from 2014, I hope you realized every day that each rotation is 4 weeks long.  That means that each rotation is 20 to 24 days long.  Each day you spend in the ward, in the clinic, or in the OR is one less day there.  You are going to end up choosing just one specialty, or maybe you will decide to drop out of medicine altogether.  Either way, it means that each day you spend in internal medicine, in trauma surgery, even in obstetrics and gynecology, is 5% of your entire time in that field.  You may never scrub into another surgery.  You may never deliver another baby.  You may never see or treat that illness again.  And for sure, there will be many patients who you will never see again.  And they deserve your full attention.  They deserve the you who laughs and loves with all your heart and all your soul.  They deserve a person who cares just as much about their comfort as their treatment.  They deserve a person who sees them.  And that requires you not burdening yourself with fears and worries and concerns about the future that you have absolutely no control over.  It requires you to be authentically you and present in the face of fear.

But if I know you like I know me, then by the time you read this letter, you will have made it through intact and complete.  You will have opened yourself to learning without self-judgment.  You will have made it through knowing yourself fiercely and having the determination to be yourself unapologetically.  You will have set yourself free from not only others’ expectations, but your own, which are infinitely harsher.  You will have treated each day in the rotations like it was your last one there, because it very well could have been.  You will always remember that what makes you you isn’t your technical prowess or limitless knowledge, but how you use all of that to listen to patients, colleagues, friends, family, people; and leave every person that you interact with a happier, healthier individual than before you met, whether you decide to do that using medicine, or not.

Congratulations, June =).  Happy 27th!

With love (and I write this because I think you often forget to love yourself),

June
July 29th, 2012 (the day before clerkship begins)





The Confidence to Drive on the Other Side of the Road

28 05 2013

Time has flown by, and I am now at the end of my third year of medicine.  I am currently doing my rural family medicine rotation in a small town in Australia, and I have been loving my time here.

Because it is a small town, the only way to get around is to drive, and, of course, in Australia, they drive on the left side of the road, which is the opposite of what it is like in Canada.

Now if you had asked me whether I could drive on the other side of the road a year ago, I would have told you NO WAY, especially not in a big, crazy busy city like Sydney (which I did just last weekend), because I hadn’t driven at all for three years, much less on the other side of the road.

Now I’m sure there are readers who will be thinking that I am silly for thinking that driving on the other side of the road is a big deal, but you should know that I am so anxious and hesitant, getting myself so lost in the potential consequences of my actions that I can too often become paralyzed and fail to end up taking a step at all.

So then how was I able to be bold and brave (as a couple of my colleagues put it) and drive on the other side of the road in a new country in a busy, chaotic city with massive traffic and poorly designed roads (Sydney) when I haven’t driven in three years?

Well, it’s all thanks to trauma surgery.

The short answer is that when you learn how to deal with patients coming in with gunshot wounds, stabbings, massively broken bones, and injuries from being hit as a pedestrian by a car; you become less stressed about the littler things.

The long answer is that I absolutely loved my trauma surgery rotation, and found it an incredible privilege to be there.

Watching the surgery residents deal with incoming trauma, I noticed how calm they were.  The patient could be unconscious with massive wounds and completely fractured bones, but it was as if the more serious the situation, the calmer the residents were.  Patients would sometimes have massive hemorrhages, be deteriorating quickly, and require immediate intubation/chest tubes/etc; but unless you were experienced, you wouldn’t be able to tell how serious the situation is from watching the staff calmly at work.

Wanting to be effective, efficient, and optimally care for my patients; there were a couple of times when my voice started speeding up and increasing in pitch, my walking pace became more rapid, and my shoulders tensed themselves up reaching towards my ears.  I felt like I needed to quicken my pace to take care of the patient this second, but twice I remember two different residents telling me to chill out.  I remember then recognizing how stressed/anxious/frustrated/impatient I was at the time, and I deliberately took deeper breathes, relaxed my shoulders, and smiled gently.  It was as if I was doing a heavily simplified form of mindfulness therapy on myself.

But hey, it worked.

The biggest lesson I took away from trauma surgery was why I needed to be calm.  I will be always grateful to the residents who made me realize that when my shoulders tensed up, my brain also tensed up.  I would lose my ability to think coherently, I would become extremely absentminded, and I would lose (most importantly) my sense of humour.  Essentially, in times of stress I lose who I am, and that, beyond turning me into a mindless automaton, has the side effect of rendering me useless as a clinician, to the detriment of my patients.

Sometimes it feels like if I am too relaxed at work, I am not doing my job right.  I worry that if I am too calm, I am forgetting something important.  But actually the opposite is true.

I worry that making jokes and allowing too much of your personality to show through is arrogant or unprofessional or a hindrance to my performance as a future doctor.

Well, now, I think that it still is a very delicate line, but I know now that if I become so stressed that I lose my sense of humor or I worry so much about doing the right thing perfectly that I become paralyzed, not only do my patients suffer, but it is not sustainable for my career.  If I lose my ability to enjoy the work that I do, why am I going into work at all?

So thanks to the month with my incredible trauma surgery team, I learned how to be calm in the craziest of situations.  I try to remember that joking and laughing at the right moments is not unprofessional or arrogant, but necessary and important for patient care.  Whenever I feel my shoulders tense up and my voice quicken, I take a deep breath and I remind myself that if I can handle patients with gunshot wounds, perforated appendices, and ischemic bowel in a calm, logical manner; what’s a little bit of driving on the other side of the road on the other side of the world?





Patient-Centred Care: If You Could Only Change One Symptom…

26 07 2011

Prelude: As seems to have become a habit of late, I am again cramming all of my month’s blog posts into a matter of days.  Although in theory I suppose I should rejoice in what appears to be my dedication to spending more time living life than writing about it, the truth is this blog is important to me and my personal reflective process, so in practice, I think I simply need to concentrate on posting more consistent, but shorter posts.

Let us see how long this can last…

A little while ago I was at the hospital with the privilege of shadowing the Esophageal Clinic, consisting of four doctors who jointly saw patients one after the other, providing a superb level of patient-centred care that I had yet to witness firsthand in Montreal.

The team consisted of a gastroenterologist, a general surgeon specializing in the thoracoabdominal region, a thoracic surgeon, and a surgical resident specializing in minimally-invasive surgery.

Four extremely talented and competent doctors in one room meeting one patient at a time, spending, in one case, an hour explaining all the options to deal with a particular patient’s achalasia (i.e., difficulty getting food to pass from the esophagus into the stomach).

It was incredible.

I believe the patients are referred to this clinic only if their case is particularly difficult, and I think the idea is that the team of doctors comes to an understanding of each patient together, and offers the best options based on the situation.  For some, maybe all that can be done at the moment is a nitric oxide prescription to try to increase gastric motility.  For another individual, perhaps there are a range of options (from Heller myotomy to balloon dilatation of the lower esophageal sphincter).

I appreciated that the team discussed each individual before seeing them, so that they can provide a professional, united front for the patient.  Each doctor took turns taking the lead at different moments, and they supported each other while joking with each other as well.

In particular, I appreciated that they always asked this: “If you could only choose one symptom that you want to improve after today, what would that be?

I thought it was a beautiful question for so many reasons.

For one, it made care tangible.  Because many of these patients were referred because their diseases were particularly challenging to treat, many of them had multiple illnesses and symptoms that were bothersome.  To focus on the chief reason why the patient came to the clinic today meant that they could focus on trying to improve that one symptom, and perhaps continue forward in a stepwise fashion when the patient comes back in three months.  I think this piecemeal plan is rightly cautious and likely prevents the risks of overmedicating while allowing for better understanding of the nature of the individual disease based on how each treatment helps or fails to.

Perhaps more importantly, though, I think that understanding the principle symptom helped the team much better understand that patient’s perspective.  There can often be a great difference between what is physiologically wrong with someone’s body and how that problem manifests in and bothers the individual patient.  So for example, physiologically, there may be a sizeable diverticulum in one’s esophagus, but if the top concerns of the patient have nothing to do with the diverticulum, is it worth the risk of surgery to remove it?

It was eye-opening to hear firsthand how the same mechanical problems in the esophagus can create such a range of symptoms depending on the patient’s life circumstance.

In short, in our first year of med school, we were assigned to describe what the difference is between the “disease” of a patient and the “illness” in the individual.

For one of the first times since starting medical school, I genuinely believe that I see that difference influencing the action of practicing physicians.

And it gives me tremendous hope.





Being Able to Help

12 06 2011

I was walking home after getting take-out from my favourite restaurant close to the corner of St. Catherine and St. Mathieu when I saw a public transit bus stop right in the middle of the intersection with no signs of moving.  I thought maybe the bus had somehow ran out of gas right in the middle of the intersection, but that seemed unlikely.  I then saw all the people gathered around to watch, and I feared maybe the bus had hit someone.  I dislike it when people stick around to watch accidents, but I thought maybe I could help, and I also wanted to ensure my personal safety, and let’s face it I was also curious, so I tried to survey the scene quickly to see what was going on.

I finally saw a young lady of Asian descent lying in fetal position on the side of the road with someone supporting and holding her head in place.  It turns out the bus driver stopped the bus in the middle of the intersection to ensure that the lady had some room to breathe without fear of being run over.  I watched from across the road and I literally froze.  I felt so ashamed as I stood there, motionless, wanting to go across the road and help, but I had no idea what to do.  I had no idea what I could do.  I racked my brain before I fell in shock at the realization that up to this point, we haven’t learned very many practical skills.  I didn’t know what I could do for the patient lying on the side of the road, when it really mattered.

I watched, as time seemed to stand still, at the woman on the other side of the road, to make sure that she was well taken care of. Someone was holding her head and someone else had just put on purple latex gloves and looked prepared to get involved and help the young woman.  I figured that the patient either had a seizure or a car accident, and when I saw that she was able to move her right hand and her right leg (she was lying on her left side), I felt a bit of relief.  When I heard the ambulance siren traveling towards us, I finally felt that the situation was in control, and I left the scene.

I literally froze across the road because I wanted to help.  I didn’t walk across the street because I didn’t know how to help.  In a way, it perfectly captured where I am in my medical career: filled with the sense of duty, obligation, and desire to help, but not knowing enough to do so.  To be fair, I later asked one of my medical mentors, and she told me that there really wasn’t much I could do for the patient in that particular situation without any tools, but still, I felt a bit in limbo and it was not a good feeling.

My first year of medical school is about to end in two weeks, and I really can’t believe it.  It has been one of the best years of my life, and I have my med school colleagues, theatre friends, and significant others to thank for that.  I’ve been fortunate enough to have had a lot of time to enjoy Montreal and all that it has to offer extracurricularly, but the accident that I saw reminded me that I am here, ultimately, first and foremost, to become a doctor.  We’ve had one year of lectures, and we have another 4 months to go in the fall, but after that, we will be in the hospital every day, and it will be time to step up.

The accident that I saw reminded me that I never want to feel so helpless ever again.

The only way to do that is to make sure that when January comes, I will put all of me and my focus into learning those skills that will make me a great medical doctor for my patients.

I simply can’t wait.





Takes One To Know One

12 06 2011

——————————

Warning: Certain details in this post concern a disease and may be a little bit graphic in description.  Reader discretion is advised.

We had an interesting discussion in class once, about whether as medical students we should try a watered-down version of the liquid concoction that patients drink to clear out their bowels before a colonoscopy. There were opinions on both sides, and mine generally sided with those who believe that as doctors we can’t possibly experience every procedure to understand what it might feel like for the patient, and even if we did, the experience may actually make us less empathetic.  One of the doctors admitted that he tried the solution and found no ill effects, so he really couldn’t relate to why his patients kept complaining about it!

That class, though, made me consider the importance of experiential learning – when is it appropriate?  And useful?

While it may not always be true that you have to experience something to understand something, sometimes it may help.

In med school, we are often told that our job is:

To cure sometimes,
to relieve often,
to comfort always

Truth be told I had some sense of what those words are getting at, but I think I didn’t quite understand the whole picture.

That is, until a recent bout of sickness.

I think it was a combination of stress from shows and school, the viruses and other microbes that had been stewing in me all winter, and my immune system constantly being weakened by the unfamiliar cold of Montreal that had finally given me the worst flu I had ever experienced in my life.

I felt so sick that I didn’t want to eat (which is as serious as a symptom can get for me, because that’s one of my primary methods of enjoying life), and then I felt chills and headaches so bad that I couldn’t even get up to walk 2 minutes to the pharmacy to get drugs that might have helped.  The worst of it, of course, is that I didn’t have people who could take care of me, and I had never really learned how to take care of myself during an illness like this.

I remember doing my research online to confirm that my symptoms were definitely caused by influenza viruses, and then I knew that the flu would be gone in five days, so my main plan was to just wait it out (with fluids, rest, Advil, etc), without going to the doctor, because he would tell me to do the same thing.

I took as few drugs as I could for the flu symptoms, both because I couldn’t make myself go buy them and because I didn’t want to spend the money.  I knew that I just had to wait five days.  It’s nothing, right?  Absolutely nothing.

Boy was I wrong.

Even if the time course of an illness is well delineated based on past evidence, such as in the case of the flu, while you experience the disease, it can be the most horrific experience of your life.  Even though I knew it would be over soon, I was so frustrated during those few days that felt like eternity, because my headache and hot/cold flashes prevented me from being able to sleep, and my illness completely annihilated my desire to eat.  Despite my belief that my mind could control the situation (i.e., mind over matter), I became very depressed and so frustrated because I knew I needed to eat and sleep to recover, but I could not do it, no matter how hard I tried.

And then, of course, it got worse.

I started getting bumps on my lips.  At first, it was just one little bump, and it was annoying, so I kept breaking the blister every time it would form.  Little did I know, but I think that blister was actually a cold sore, and by bursting it repeatedly, I let the herpes simplex viruses get out and about.  The result was that one little bump quickly turned into, and I’m not joking here, fifty bumps all over and around my lips.  I thought maybe I needed to go see a doctor at that point, but I felt so hideous and so lethargic because of the continuing course of the flu that I had even less desire to go outside.

I knew that the majority of the general population is carrying this herpes virus on their lips, but the reason why we don’t all have cold sores all the time is because our immune system is strong enough to suppress the symptoms of the virus.  Unfortunately for me, my immune system was under severe attack by the influenza viruses, and thus, it allowed for the opportunistic expression of the herpes virus on my lips.

I thought maybe I just needed to wait it out until my immune system fought off the influenza virus, then the cold sores would naturally resolve themselves.  Thus, my strategy remained the same: starve out the diseases.

Unfortunately for me, everything just got worse.  I continued to feel horrible from the flu, and the cold sores on my lips got so bad that my lips were just bleeding everywhere all the time, with pus and constant inflammation.  And worse yet, my gums and other oral mucosa were starting to get inflamed as well from the virus.  I didn’t know the virus could affect the inside of my mouth as well as the outside.

I felt awful and looked hideous, and I didn’t know what to do.  I felt so helpless, and thinking that it would all be over soon did not help me at all.  In fact, there were moments when I thought I would never get better.  I was no longer thinking logically.  I was no longer able to detach myself and think like a medical student.

I had completely become the patient, and it was only then that I finally admitted that I needed help.

I went to a walk-in clinic and waited for hours with bandages all over my mouth to try to cover up how awful I thought I looked.  I finally saw a doctor, and he prescribed valacyclovir for the cold sores.  He said that this medication is preventative so I should have seen someone earlier instead of waiting until this stage in the viral infection.  The funny thing is that I knew that fact already, and yet I still couldn’t motivate myself enough to go see a doctor before I felt like I absolutely had no choice.

Ultimately, and thankfully (knock on wood), I made a complete recovery, and I ended up, surprisingly, learning quite a few lessons about medicine.

My experience with the flu taught me that symptom management is extremely important.  Regaining functionality despite having the disease is what it’s all about (even if the disease is supposed to be short-lived).  When we can’t do things that we normally take for granted, like swallowing, life’s joys, including singing and eating for me, are greatly diminished, and that is extremely detrimental to a patient’s mental health, which further impedes recovery and healing, no matter how short the disease trajectory.

A really “mad case of the herp” – on my lips – taught me that part of what’s damaging is a disease’s attack on someone’s self-image.  My lips were like mountains of pus and swollen yellow on red, cracked canvas.  I couldn’t look myself in the mirror without cringing, and again, it did not help my recovery in the least.

Even though curing a disease is nice, and sometimes it’s possible, the most important lesson I learned as a patient is that the journey matters.  No matter how long or short the time a patient spends with a disease, how the patient is treated in the meanwhile – how they look and feel during the disease – makes all the difference.

Even if we think we know the endgame of a disease, the uncertainty is devastating, and the wait, as I found out, can be deadly.

And that’s why our goal as doctors is to relieve often and comfort always.

But the biggest lesson out of all of this?

I need to find me a GP in Montreal, ASAP.

————————-





The Three Wishes Fulfilled by Becoming a Doctor.

12 06 2011

———————————–

A family physician who returned to McGill for a 30-year reunion told us a few wishes that are fulfilled by becoming medical doctors.  Really, though, it’s more like three needs of ours that gets fulfilled:

1) The Puzzle-Solver.  Just like House, M.D., medical students are, by nature, curious creatures who like to understand and explore the human body, figure out illnesses, and navigate the uniqueness of human beings and our diseases.

2) The Fixer-Upper.  We like to help.  And feel needed. =).

3) The Soap Opera Star.  Have you seen Grey’s Anatomy?  It’s all about drama.  As doctors, we will have the privilege and responsibility of knowing intimate details about patients that very few, if any, others know, including close family members.  Medicine deals a lot with life and death considerations, serious repercussions, ethical dilemmas, and the complexities of interpersonal relationships, so it can be an intense career in those ways, and that’s sometimes just what we crave.

In short, medical students are individuals with needs, desires, and issues.  And we deal with our issues the only way we know how: by becoming doctors. =D.





My Ode to the GI Tract

11 06 2011

—————————–

Ladies and gentlemen.  You know what’s beautiful?  You know what the most elegant and delicate and precious organ system in your body is?

I didn’t think so.

Well, let me tell you: it’s your gut.

The GI tract has its own brain – one hundred million neurons!  Many more neurons than the spinal cord.  I’ve seen a segment of a GI tract excised from an animal, and it keeps contracting for hours!

The brain and the heart are pretty boss, but the brain only runs on glucose, and without the GI tract regularly taking up sugars, the brain has to start using ketone fuels that it does not like, so the GI tract can hold the brain hostage.  As for the heart, well, did you know that there is increasing evidence that keeping your teeth clean is the number one way to reduce heart disease?  Bad dental hygiene results in bacteria that gets into the blood via the gingiva in your mouth and travels directly to the heart where they just goes wild.  Didn’t know flossing mattered, eh?

Then there is the fact that the gut knows to not destroy all the bacteria that live in it, allowing for protective, commensal bacteria that prevent opportunistic infection and produce essential nutrients for us.  It is absolutely awe-inspiring how our regulatory T cells can identify this commensal bacteria via intracellular NOD receptors and suppress immune responses, thereby allowing for absorption of nutrients instead of constant, chronic inflammation as a side effect of relentlessly trying to destroy these good gut microbes!  Emaciation (i.e., abnormal thinness) can be a symptom in some HIV patients because they lose T cells in their gut that are regulatory, and thus the patients lose the ability to recognize what bacteria is safe and good for the body, so the body attacks these commensal bacteria and the result is an inability to absorb nutrients.

The gut is just beautiful: a selectively-permeable barrier that keeps us all alive.

This is without even mentioning how elegant the pancreas is.

Anyway, all this just because I wanted to say: Gastrointestinal Tract (I use full names when I’m being 100% serious), I love you.  I couldn’t live without you.

Cue music.