From Such Great Heights

I recently learned that the temporal lobe, the region of the brain that processes sounds, is also responsible for registering visual information and certain types of memory.  Given the profound effect one song can have over your senses, this anatomical proximity is not the least bit surprising.  As a real-life example, we’ve all had the experience of a song transporting us to another time and place.

Today, I was sitting in a coffee shop in Provincetown, attempting to study neural pathways, when Postal Service’s Such Great Heights started playing on the radio.  The rhythmic bass and techno-bleeps ricochet across my cranium, overwhelming my senses.  I was brought back to the summer after senior year of high school, a summer spent in Cape Cod before starting my freshman year at Dartmouth.

To the tune of Ben Gibbard’s sweet choir-boy vocals, I vividly remember driving around the piers of Wellfleet with my best friend Alanna in her red mustang convertible.  I can breathe in the marshy smell of the bay, feel the sea breeze rustling my hair.

I am thinking it’s a sign, that the freckles in our eyes are mirror images and when we kissed they’re perfectly aligned.

I felt a visceral ache at this line, remembering the feeling of being in love for the first time- the vulnerability, the newness of everything. The imminent possibility of getting your heart broken.

And then the chorus: They won’t see us waving from such great heights. This line felt like it was written specifically for Alanna and me that summer. The ember of her cigarette glowing firefly-like as we sped over marshland.  We were at great heights, about to embark on our inevitably successful adulthood lives at our respective reputable institutions.  We felt invincible, sprinting down the dunes with flares of white sand erupting behind us.

Come down now, but we’ll stay.  But we were still kids after all, and we needed our years of recklessness, hazy neon-streaming nights, mornings of regret. There was this whole mysterious world waiting for us, if we could get there fast enough.

 Alanna and I lost touch soon after that summer.  It wasn’t any one’s fault really, Alanna’s mother picked up and moved to Florida to escape an ugly divorce, and Alanna was forced to tag along.  She had spun out of control at college and it took her some time to get back on her feet.  She called me several years ago to apologize for too many drunken nights, some angry words exchanged in high school, things I had long forgotten about.  We reminisced briefly about the “Stanger,” as we affectionately deemed her Mustang, about our nights driving around Wellfleet piers.  Then we hung up.  It wasn’t until much later that I realized the purpose of the call.  She had just completed Alcoholics Anonymous and that phone call had been her making amends.  But everything looks perfect from far away, come down now.

I hear Such Great Heights and I feel the frothy Cape Cod water lapping at my toes, this vast turbulent blackness in front of us.  And then MGMT’s Kids is my senior year of college, thick hookah smoke, patterned tapestries draped over Jake-the-Philosophy-major’s bed, the two of us slowly regaining a timid grasp over reality as the shrooms begin to wear off.  Death Cab for Cutie’s We Looked Like Giants is sophomore year of college, the loneliness of driving along starlit Vermont roads in the wintertime, Pinback’s Good to Sea is carelessly riding bikes through the Botanical Gardens in the summertime.

With each of these songs, a pulse of neurotransmitters is propelled along my temporal lobe and throughout the limbic system, evoking a distinct memory and flood of emotion.  Evolutionary biologists would suggest that Mother Nature had designed us this way intentionally.  These neural pathways allow us to make a split-second association between a predatory call and danger; or to distinguish the cry of another baby from our own.  (You may have witnessed this phenomena along with a mother at Whole Foods; while a stranger kids’ crying might annoy her, her own offspring will kick her maternal instinct into full gear at ninja speed.)  Like much of our anatomical designs, the interconnectedness between our sound processing and our emotional-memory brain regions is a survival mechanism.   But I doubt Mother Nature would have intended for a tenor voice and some techno rhythmics to make your heart jump into your throat, or that a few twangy strings of a guitar could make your hips start mysteriously gyrating on their own.

On long family road trips, my Dad insists on listening to same half dozen artists- Bob Dylan, the Doors, the Beatles, Crosby, Stills and Nash, and the Grateful Dead.  And despite our persistent groans from the backseat (“Can’t we just listen to Jack Johnson again, pulease?”), he doesn’t hear us at all, in fact, we don’t even exist to him.  Because to him, it’s 1969 and instead of a Prius he’s riding a motorcycle.  He’s wearing his favorite distressed leather jacket, and perhaps driving too fast and careening too sharply around turns because he’s young and he’s reckless like we had been too.

On the Ethics of Work-hour restrictions

In Samuel Shem’s fictionalized memorial The House of God, he paints a forbidding picture of residency training (Shem 1978). Understaffed and overworked, teaching hospitals abound with sleep-deprived residents enduring lengthy work hours subject to brutal, often dehumanizing conditions. When the book was released in 1978, many residents found that Shem’s more harrowing depictions of residency training resonated with their own experiences on the ward floors. Yet long hours, constant fatigue, and emotional sacrifice had all traditionally been a part of medical training. For many future physicians, the grueling hours were seen as a painful, but necessary, rite of passage.

This all changed in 2011 with the landmark passing of the Libby Zion Law. Libby Zion was an 18-year old patient admitted to New York Hospital complaining of seizures and flulike symptoms. Attended to by first and second year residents, Zion was prescribed an anti-seizure drug that fatally interacted with another medication she was currently taking, resulting in her death to cardiac arrest. In response to the tragedy, Zion’s parents launched a campaign to raise awareness regarding inadequate staffing and overworked residents at teaching hospitals (Lerner 2006). Shortly thereafter, the Libby Zion Law was formally passed, restricting resident work hours to 80 hours or less in order to prevent dangerous levels of fatigue that could result in potentially fatal medical errors on the job. In July 2003 the Accreditation Council for Graduate Medical Education (ACGME) adopted similar regulations for all accredited medical training institutions in the United States (Philibert, Friedmann 2002). The latest mandate, put into effect in 2011, restricts intern hours to no longer than 16 hours in a day.

Yet, instead of being greeted with a collective sigh of relief from overworked physicians, the work hour restriction laws were controversial. While healthcare researchers expected reduced work hours would result in a boost in resident morale and reduction in patient mortalities and other on-the-job errors, studies proved otherwise. According to a paper published in the JAMA Internal Medicine in 2013, sleep hours among residents did not go up significantly and the risk of depression symptoms stayed the same after the work hour rules took effect in 2011. Perhaps even more alarmingly, a greater percentage of residents reported that they committed medical errors on the job than prior to the reform (Choma 2013).

Residencies have traditionally required so many hours of training because, as with any difficult task, proficiency necessitates practice. Medicine in this respect can be appreciated as both a science- requiring a strong conceptual foundation, and an art- where the intricacies of a delicate last stitch, or the detection of a hidden marker for a rare disease- are essential. While the science element can be taught in a classroom, the art requires feedback, experience, and lengthy amounts of time to fully appreciate. The concern for many physicians is by restricting their work hours they may also be diminishing the quality of their art. And the concern does not only lie with the doctors, but the patients as well. Would a patient feel safe knowing that the surgeon about to operate on their failed heart has been restricted to a certain number of hours of training a week?

There is also the issue of staffing. Amidst work hour restrictions for physicians-in-training, the number of patients requiring medical care continues to rise dramatically. In Dr. Pauline Chens New York Times opinion piece “The Impossible Workload for Doctors in Training” she contends that work hour mandates create an impossible “Rubik’s cube conundrum” whereby residents are forced to “do the same amount of work in fewer hours” (Chen 2013). Restricting resident work hours, she claims, is the equivalent of “[telling] airline pilots that they could only work a certain number of hours, but they had to fly 50 percent more flights.” Confronted with this paradox, physicians are left wondering: if interns work fewer hours, who will be caring for their patients?

The attempt to achieve a work-life balance is an enigma because the two components- work, and life- are both necessary in order for us to achieve our full potential as humanistic care providers. While work is clearly important to becoming a successful physician, one must not devalue the other part of the equation: life outside of medicine. The necessity of having some time off during training is made all the more apparent by evidence of the devastating effects of burn-out when physicians don’t have enough time off. Studies indicate that physician burn-out has reached an all-time high in recent years. Nearly half of aspiring doctors end up becoming emotionally, spiritually, and physically overwhelmed over the course of their training, resulting in a loss of empathy and a compromised work ethic (Chen 2008). Furthermore, late shift workers such as first year interns are subject to higher risks of gastrointestinal disorders, cardiovascular disease, breast cancer, miscarriage, preterm birth, and low birth weight of their newborns (Bøggild 1999). nNumerous studies have also found that the sleep deprivation that results from 24-hour work shifts leads to cognitive impairment equivalent to that associated with a blood alcohol level above .05 percent (the legal limit in most states.) Would a patient want an intoxicated doctor making diagnoses or conducting surgeries?

Supporters of residency work-hour restrictions further contend that many of these policy studies do not represent accurate reports of resident hours. Surveyed residents may not be strictly abiding to time regulations and consequently underreporting their hours to avoid a loss of accreditation of their programs. While largely speculative, one could imagine how a few added hours of rest could not only reduce medical errors, but additionally boost overall resident moral and happiness ratings. A better overall lifestyle may attract more premedical students into the medical field who would be otherwise deterred by horror stories of endless shifts and little room for life outside medicine.

Let’s return for a moment to this hypothetical scenario of Alex and Jacob. Our first instinct may be to side with Jacob. Honorably taking over the unfinished duties of his colleague Alex, he is clearly portrayed as the victim in this scenario. Under closer scrutiny, however, is Alex truly at fault? A competent and well-liked physician, Alex is doing his job to the best of his abilities given the time constraints. “I didn’t set these work hours,” Alex asserts, “but I have to stick to them.” Perhaps the real culprit is the flawed system in which he operates.

So how can we begin to “fix” a broken system? On the one hand, sleep-deprived and overworked residents are more prone to medical errors as well as physical and emotional distress. On the other, enforcing strict work hour shifts can result in discontinuity in patient care, reduced education engagement and a greater strain on an already under-staffed workforce. It is clear from the Libby Zion case that the previous model of 100+ hour workweeks and no limits to overnight call must be changed. However, rather than accreditation bodies strictly enforcing work hour restrictions, I believe that reasonable work hours should be established on a case-by-case basis. There needs to be greater communication between residents, attending physicians, and other hospitalist staff to ensure that they are working efficiently together as a team without one member (the Jacob of the group) bearing the brunt of the labor and feeling overwhelmed. While performance evaluations can be one method of feedback, face-to-face communication is even more valuable. Specifically speaking, many of the problems encountered in this scenario could be resolved through a cooperative effort between Alex and Jacob whereby they diplomatically assign responsibilities before their shifts. This dynamic teamwork should not be limited to physicians either- a growing midlevel practitioner and nursing workforce should be fully utilized to meet the needs of an expanding patient population. As with any major policy change, the first few years of reform are bound to be tumultuous. Only with time will we begin to see how a stronger work-life balance can improve medical training holistically.

The OSCE Exam

 

 

When I enter the examining room, Mr. Stone is visibly distressed.  His chest heaves erratically as he struggles to catch his breath.  His chief complaint: heart palpitations.

After a brief introduction, I fire off a barrage of well-rehearsed questions: when did the heart palpitations first begin?  Do they radiate outwards or stay localized in one spot? Is there anything that makes the pain worse, or anything that makes the pain better?  At one point, Mr. Stone grows teary-eyed as he talks about his father’s death due to a sudden heart attack. “I’m really scared, doc.  Do you think what happened to my Dad could happen to me too?” Placing my hand delicately on his knee, I explain that his heart palpitations may be a result of anxiety from his stressful work environment.  I assure him that I will return with an attending physician and we will discuss future steps.  For the first time during our brief encounter, Mr. Stone looks relieved.

            Despite my warm promises, I don’t return to the examining room, nor do I present his case to an attending physician.  I’m not a doctor, and Mr. Stone is a perfectly healthy lab technician who happens to moonlight as a standardized patient.  The scene you have just encountered is the first year OSCE exam, or Objective Structured Clinical Examination, a famed milestone along our journey to become physicians.  The OSCE assesses students’ abilities to clinically examine patients, physically diagnose medical disorders, and demonstrate strong communication skills. It’s a bizarre, yet clinically sacred ritual, a socially acceptable form of “faking doctor” that has become a mandatory component of most American medical curricula. 

            In addition to the more nitty-gritty aspects of a physical exam- maneuvers like asking the right questions or correctly manipulating the chest and lung exam, students also receive points for how well they “praised patient for taking steps to improve health,” “used encouraging and supportive gestures,” and “showed empathy.” In other words, we are graded on how good we are at being humans.  And given the widespread concern regarding over a loss of empathy in medicine (http://www.ama-assn.org/ama/pub/education-careers/graduate-medical-education/question-of-month/medicine-lost-compassion.page?) it’s no wonder that so much emphasis has been placed on our convincing capability for “humanism.”  In recent years, soaring rates of physician burn-out, healthcare reform restrictions favoring shorter, less personal visits, and an admissions process that traditionally favors excellent scores over interpersonal skills have largely yielded the societal conception of the physician as an uncaring, unsympathetic, or sterile individual. 

            Reflecting on my last OSCE, I debate whether compassion is something that can be taught in a class or is an innate kind of ya-got-it-or-you-don’t binary.  Is the OSCE a truly effective when it comes to evaluating the less clinical aspects of medicine?

Hospice

For a hospice center- a place where people go to die- it felt disarmingly comfortable.  Yellow, wistfully patterned carpet, matching wall paper, and pastel-themed chairs salvaged from the seventies; there was no hint of death here.  Even the pervasive old-people smell you usually encounter at these places had been somehow-miraculously- masked with fresh citrus spray.  We were sitting there, a dozen or so first year students, nibbling on diabetic cookies and fidgeting in plastic-covered chairs that groaned with exhaustion.

An elderly woman with an oxygen tank rolls by slowly.  We become silent- suddenly- so all you could hear was the squeaking sound of the tank’s rusted wheels grinding along.    We were still young in our training.  Upon these brief encounters with death, we were obediently quiet.  Death, to us, was synonymous with failure, something insidious but too far away, not yet dissected or mastered.

What must it be like to know that you are going to die?

We all know that we are going to die at some point, but don’t acknowledge it on a moment-to-moment basis.  We can’t feel the whirling chaos of blood ricochet off our stenotic arteries with each heartbeat.  We don’t wheeze as the paper-thin alveoli of our lungs collapse into themselves, or feel our mind slip away in quiet pieces.  We don’t see our neighbors’ lifeless, enshrouded form wheeled out, leaving neat little indented ribbons on the yellow carpet. 

At the anatomy memorial last week, a widow pulled me close to her face—eyes magnified to extraordinary proportion behind thick-rimmed glasses—and told me that only moments after her husband died, he no longer looked like himself.  She told me quite matter-of-factly how he began to decay right away. 

We are led on a tour, oohing and aahing at the game room, the lounge, the “fitness center and spa.” One of our group members asked the tour guide if she thought that most of the patients and their family had come to terms with the fact that they were here to die.   Our tour guide shook her head, somberly.  Most of them were angry, fearful, in denial, she said.  She proceeded to explain that an important part of her role at hospice center was to foster acceptance of death, to allow the patients to most fully enjoy their final days of life.

We pass the recreation center where an impressive number of patients are watching Monty Python and the Holy Grail on a tiny black-and-white television.  On the screen, a female actress is gyrating her body on a pole and sensual jazz music plays in the background.  In the audience, one man sleeps deeply, head lulling.  A woman’s hands shake uncontrollably as she fumbles with her knitting needles. 

I wonder how they can function at all, how they are not immobilized by the incessant urgency of when it will happen.  The exact moment- where will they be.  Are they fearful of the unknown, of the absence of being, of the pain, of all of these things?  Do the anarchists among them, in the final strides of life, become avid-church goers, scrambling to reconcile things with a vengeful God?  Do they look back at life with a sort of resigned sense of fulfillment, or are they riddled with regret?  At the last moment, do they willfully let the body go, or do they simply get too weak to fight off the grip of death and succumb? 

            We’ve reached the final leg of the tour- this is the “private quarters” of the hospice the woman says, with a note of esteem in her voice. We notice that many of the rooms have two beds in them.  The tour guide explains that the spouses of the admitted patients often move in to live with them.   Next to one of the rooms, there is a black-and-white photograph of a woman in a one-piece bathing suit.  She is beautiful.  She smiles with an impish grin on her face and one hand rests against the sinusoidal curve of her hip.  The picture looks like it was taken in the 1950’s.  A card beneath the photograph reads: “My beautiful wife Edith.”

Maybe the scariest part of dying is a fear of being alone.  Loving someone so fully, so completely that you don’t want to be without them, and you can’t stand the thought of them alone.   Or perhaps, it’s the latter, that we are just driven by a primal fear, an animalistic instinct to avoid falling.  

 

Soul of a Doctor

As I embark upon the long, challenging journey of becoming a physician, I am faced with a future of uncertainty. Will I be able to master the sheer volume of material in medical school?  Will I be capable of adjusting to the strenuous lifestyle of a physician?  Will I be able to treat my patients effectively?  Will I listen and care, empathetically? And on a larger scale, with the full implementation  of the Affordable Care Act this year, how will the American healthcare system be impacted?  Will I be able to pay off my tuition bills years down the road?  Given all of the doubts, the hard and long struggled ahead, why do it at all?

 In Soul of A Doctor, third year medical students wrestle with many of the same uncertainties I’ve encountered as I approach my first year of medical school.  In many of these stories, students address their glorified preconception of the medical profession, and then an incident where that image is shattered.  In some incidences, a solution is simply beyond their control; an ostensibly healthy patient that goes into cardiac arrest, or an aggressive cancer with no cure.  In other incidences, students bear the full burden of their shortcomings- one student describes his sadness that unlike Oprah, he simply could not get through to a patient, while another is frustrated by the constraints of pressured patient-doctor encounters that leave little room for compassionate listening.  In “Inshallah,” which means “God willing” one student wonders whether religious or ethnic differences will impact her ability to earn the trust of their patients.  Before they even graduate from medical school, students are already confronted with some of the challenges in being not just a physician- but a good one.

In addressing all of these concerns, the medical students’ stories in Soul of a Doctor were refreshingly honest, even when they didn’t paint a picturesque image of the healthcare profession.  Many of these accounts dispelled the negative stereotypes that I had held towards medical students- as unsympathetic, sterile, or unfeeling.  On the contrary, these accounts manifested a deep desire to learn and heal, an ease with language, and an inherent compassion.  There were certain accounts that resonated particularly strongly with me.  For example- in “Imagine How You’d Feel” student Andrea Dalve-Andres describes her own internal turmoil when a woman’s baby is born still and she requests having her photo taken with the lifeless child.  “Her child had just died, and I found myself asking: How easy would it be to just walk away?” she writes.  But who is she to tell her patient how to properly mourn?   As many of the essays demonstrate, a medical students’ largest challenge is not necessarily mastering clinical or scientific principles, but in many cases, learning how to become empathetic physician.

Last year, when I was in the midst of applying to medical school, a friend and M1 told me that being a medical student is an incredible privilege.  At first, I didn’t understand what she meant.  From my understanding, medical students work an insane number of hours, study all the time, and pay huge tuition bills.   We are supposed to consider ourselves…privileged? After reading Soul of A Doctor and reflecting on some of my own experiences with patients, however, I think I have a better grasp of what she meant.  A physician has the most intimate encounters with the human experience, hears their personal narratives, details about their lives that they may have never told anyone.  Medical students have the opportunity to explore every part of the human anatomy- inside and out. They take on the pain of their patients, and may even determine the outcome of a life.

This is perhaps my greatest uncertainty entering into the field of medicine. Will I be capable of taking on the magnitude of another’s suffering?  And will I truly possess the “Soul of a Doctor?”

Patient Encounter

A slow day at the clinic.  My mind begins to wander, running through a grocery list from earlier, an argument with my mom.  Against the quiet buzzing of medical machines and a nurse yelling somewhere blindly, to no one, for an insurance claim.

            “Team 6, your patient’s here,” the same nurse, insurance claim in hand, interrupts my thought process.

            We look down at this form.  Name: DA.  White male 40.  New patient, Height 5’10, Weight 140, Blood Pressure: 130/95.  Unremarkable lab values.  The M4, our team leader, reads through the patient’s history, chewing on his pen tip anxiously.  “Unremarkable..unremarkable..” he mumbles, , pausing momentarily to read to a text from his phone that makes him smile. “Hannah, do you want to do an H and P on this guy?”

            I feel my palms grow clammy.  I hadn’t done a history alone before at promise clinic.  On normal nights at the clinic, I stand there uselessly with my notepad while a small army of medical students attend to the patient- one firing away questions-, the other frantically auscultating and palpating and percussing, a third consulting Wikimed for the latest diabetes drugs.  On some nights, they let me take the patient’s blood pressure.  Or, more accurately, they let me click a button on a machine that will automatically record the patient’s BP, heart rate, pulse, etc.  Tonight, however, half our team is missing for exams and other various commitments.  I have suddenly, miraculously, been promoted up one notch on the med student totem pole. 

“Are you sure?” I ask.

            “Yeah- just do a basic work-up on this guy.  Figure out what’s going on.”

            I glance at his chart again before heading into the room.  No recorded family history.  Previous alcohol addiction, narcotic addiction, several incidents of manic episodes, 20-year history of bipolar disorder and schizophrenia.

When I enter the room, I am immediately overcome with the odor.  Whiskey, stale smoke, another vile scent I can’t quite identify.  If I had to guess the patient’s age, I would have suggested 50 or 60.  I almost couldn’t believe the charts.  40 years old? Skin weathered and browned, wrinkles drawn tightly around the hammocks of flesh under his eyes. He’s complaining of a pain in his left side.  He describes it as sharp, stabbing.  His eyes flicker around the room as he speaks like wild flames.  The pain began about four days ago after he had been visiting his brother for Thanksgiving.  First he was vomiting and sick with flu-like symptoms, then this strange pain on his side.   His brother is his only family member he has maintained contact with.  When I attempt, unsteadily, to examine him he winces at the pain.   

I report to my fourth year on the patient’s symptoms and he runs a quick differential diagnosis- rules out an myocardial infarction (normal heart sounds) or cholestasis (pain on the wrong side), ultimately deciding the pain is musculoskeletal in origin.  As he’s jotting down notes for the case, the patient emerges limping and breathless from the bathroom.  His eyes are wild.

I just went to piss– he says, and my piss was red.  It was bright red, like blood.

Ok. Ok. The fourth year and the attending nodding in unison.

I am slightly alarmed at their nonchalance.  Blood in the urine?  Couldn’t that signify kidney failure, or hepatitis C?  I can’t get up to go examine his urine, and the attending signals me back down. .

 

In the patient information form, he lists his address as “Landing Avenue bridge.”  The attending is puzzled.  She had been planning on giving the patient some aspirin and a heating pad.  But where can he plug in the heating pad? she muses.  The guy lives under a bridge.

I suggest that we send him to Robert Wood University Hospital so they can do an EKG and run further tests.  

The attending doesn’t look up from her prescription pad.  Under the harsh, sterile glow of the clinic lights, shadows loom under her tired eyes. He’s been here four times this month, she says.  There’s not enough beds.  He doesn’t even have charity care.

 

When he leaves, he is overly grateful.  Thank you, thank you. He says again and again.    I watch him limp off, while his girlfriend crutches his weight, eyeing us suspiciously, and I wonder how he will get home from here.  Walk the four miles to landing lane?  Hitchhike?  Crash on a friend’s couch?  I picture the two of them huddled for warmth in a ratty sleeping bag, transiently comforted by the dulled roar of traffic above them.  I wonder whether they can see the stars through the slits in concrete.

When I was eight years old, I was sure that I was schizophrenic.  Sometimes, when I was sitting in school taking a test, or staring up at the ceiling in my parent’s bed, tracing the cracks in decaying wall paint, I would hear voices.  They would start as quiet whispers and grow louder and harsher, until they were yelling angry profanities in a foreign tongue, many different voices entangled in incomprehensible cacophony.   I read in a book I found in my uncle’s house in Newton Massachusetts that schizophrenia first strikes in your twenties.  Sometimes out of nowhere, unannounced, colors and sounds start to merge, or non-existing hummingbirds beat their wings in your periphery.  Faces, without warning, invert in on themselves.  So it would only be a matter of time before my reality would begin to peel like wallpaper, revealing fault lines that rip across a paper-machete wall.   

I return to my house and throw my white coat into the laundry room, hoping that a few cycles in the wash will eradicate the smell.   I pick up our kitten, breathe in his fur smell and let his hummer-motor purr drill against my neck. It’s already 10:30.  I’m physically exhausted, but my mind continues to race.

When I told my mom about the episodes of voices when I was younger, she taught me how to quiet my mind.  This technique- this exercise in mediation- worked beautifully.   The voices would slow down and the words disentangle themselves until they were a quiet hum, a sort of spiritual mantra, and then nothing at all.   When I reach that state of quiet, everything else seems to just fall away.

My last thought before I reach the quiet is of him.  Several fault lines away, patient AA is tossing restlessly, his body fighting against some pathogen consuming his viscera, while a vicious battle rages in his mind.

Med School: Rollercoaster or Free Fall?

During our first day of medical school orientation, a dean stood in front of a class of bright-eyed, smiling students and told us the next year would be a rollercoaster.   She pointed to a diagram of a timeline projected on the screen.  “This is what a typical M1 year will look like.  As you can see, you’re at the highest point. It’s all downhill from here.”

 “You’ll begin medical school feeling pretty great, you’ve worked hard to be here, you’re excited to wear your new white coats.  Then you’ll get to your first biochemistry final, and you’ll begin the emotional decline, somewhere around September.” We laughed, anxiously.  The decline was a dramatic fall, a vertical line descent with no apparent end in sight.

“Then you’ll reach December, and finally have some time off for the holidays.  You’ll see friends and family, you’ll start to recover slightly.”  She indicated a weak incline on the graph.  “And then you come back from break and boom- cardiopulmonology.  The killer class.” 

Again, the path began its descent and flat-lined somewhere in mid-March.  “This is what we call the pit of despair.  You’ll be tired, burnt out, you’ll question your decision to go into this field, you’ll want to quit.”

 The line continued at this plateau until around mid-April.  “Now, spring’s here, and end of first year’s in sight.  You’ll be getting excited for the summer and anticipating a well-deserved break.” The line began to rise again, slightly, but had not risen even close to our starting point.   It trailed off, an uncertain, trembling trajectory, into 2^nd year.  I realized that what this means is that we end the first year of medical school in a significantly worse state than where we had been when we started.  Medical school wasn’t a rollercoaster, I thought.  Rollercoasters have ups and downs, loops and turns.  They are fast-paced and exciting and adrenaline-wrenching.  People pay money to go on rollercoasters, they live for that thrill.  Med school, on the other hand, was a free fall.  A descent into the proverbial “pit of despair.”

            When the dean had finished her speech, we filed out of the auditorium with a very different demeanor than the one with which we had entered.  What would compel this woman to give us a speech like this?  To encourage us to turn back now and demand a tuition refund before its too late?  To prepare us for what’s ahead?  Or to terrify us?  But any fears that had been evoked from the speech quickly dissipated as we left the cool, dank building and traversed into the sunshine-laden fields outside to sit in the grass and talk excitedly.  Our conversations would be laughable to any upper level student, debating whether we’d prefer “Plastics or derm or orthopedics,” or hinting about our MCAT scores.  We were still abuzz with the newness of everything, our freshly minted white coats, the endless potential of a future not yet clearly defined for us.

            And so summer turned fall, fall turned into winter, and all the while I waited for that predicted descent into the pit of despair.  But it did not come.  I would listen to my classmates complain about the endless amounts of work, and just shrug.  I would sit calmly and offer half-hearted words of advice to a friend having her third panic attack this week, while I just couldn’t understand her anxiety.  Every day in medical school was an exciting adventure.  We were learning about the fundamental secrets of our human body, and I was surrounded by intelligent, interesting, and highly charismatic people.  I was blown away by just how sociable the medical students here were- a complete rejection of the typical “premed stereotype,” well rounded, fun-loving, spirited, athletic, diverse.  Even on those long marathon-days of studying, I’d be studying with friends, us challenging one another intellectually, deriving pleasure from the reward of really understanding.  Winter break came and I gushed to my parents and college friends just how much I loved medical school, how all of those terrible things they had heard about medical school being impossibly difficult and overwhelming were all myths.  I was happy.  I felt like I was in the right place, amongst like-minded people.  After having changed careers multiple times (a self-diagnosed “Life ADD victim”) I finally had found my calling.

            And then came February.  It was a record-breaking winter.  There were apocalyptic-predicted snowstorms occurring nearly every week and polar vortices with temperatures plummeting into the subfreezing ranges.  Having completed biochemistry, cardiopulmonology, and renal, we were halfway through our Gastroenterology course.  And what I learned week one, is this course basically translates to, well, shit.  It’s a course largely centered around poop- how we make it, where we make it, what can go wrong in the process of making it.  The lectures were a stark contrast to the physiology of renal and cardiopulm.  Whereas these physiology classes were largely conceptual, big-picture, highly clinical- and we found ourselves memorizing endless biochemical pathways.  Our lectures had dwindled to about 20 or 30 students.  And suddenly, without warning, I found myself on that predicted free-fall.

            …

            A low was this past Saturday night.  I forced myself to stay in and study as I was already falling behind in the course work.  And instead of studying, I was on blogs- countless blogs- reading stories of students that had dropped out of medical school to pursue other careers.  Accounts by current doctors about leaving their practice after they had become burned out, undercompensated, and fed up with all of the governmental hurdles.  Voices resonant of our dean’s that first day, warning me to not sacrifice my life for medicine.  I was worried about mountains of debt, worried about never achieving a work-life balance, worried about falling into a deep and inescapable depression.   Despite my best judgment, I began that interminable loop of self-doubt, of questioning whether this was the right career for me, the resurfacing of childhood dreams of being a writer (Jo from Little Women as my inspiration).w  I envisioned a life free of studying, or work, or debt.  A careless life spent in a notebook, perhaps in some rustic cottage overlooking a beach in Cape Cod.  I envisioned my smiling, wrinkle-free, no-bags-under-my-eyes, headshot on the back of a novel, amidst a sea of raving reviews.  “The courageous first novel of a girl who dropped out of medical school, and lived to tell her story.”  It was a low point and in tears, I texted my parents. “I am seriously considering dropping out of medical school to become a writer.” 

            My Dad, always the voice of reason, texted back “Finish med sch and practice for 2 years.  Then Decide.”

            My mom sent me a picture of my dog, looking dejected on the couch.  “Rough day, sweetie?”

             It wasn’t until the following day, when I hadn’t responded that she called me.  “Were you serious with that text yesterday?”

            Choked up, I told her I was in a rough spot.  Feeling less than excited by school and spending far too much time reading these unproductive online blogs.   She said, “Hannah- think about it.  Do you know what it would be like to be a writer?  No schedule, the lack of structure would drive you crazy. Writing is important to you, it will always be a part of your career.  There are plenty of physician writers who are very successful.  Think about all of the fodder you’re building for your writing.  All of the experiences that you can reflect on later”        

And so I listened.  I decided to take it one day at each time.  Focus on just getting through this lecture.  Then focus on getting through this course.  Then focus on getting through the year.   Don’t listen to the naysayers, because they are often the loudest.  The physicians who love what they do have no reason to go on Student Doctor Network and vilify the field, dissuade potential applicants.  Writing will always be a part of who I am, and while it doesn’t need to be the primary source of my income, it can certainly be a very effective creative outlet.  The process of writing- of refining my craft, of reflecting each day- is essential to achieving a left-brain-right-brain balance.  It may even make me a better medical student, and most certainly will make me a better doctor.  So I’m not yet ready to give up on my writing.  Maybe it will make it beyond my own personal journals, and maybe it will be confined to my own personal records.  Either way, it’s an important part of me and something I refuse to give up in medical school.  

Response to Susan Patton’s Article in the Wallstreet journal

Response to article that appeared on February 13th’s Wall Street Journal online magazine
http://online.wsj.com/news/articles/SB10001424052702303496804579369420198599600

Dear Susan Patton,

On behalf of educated women, men, and humanists, I would like to address your most recent “straight talk” article in the Wall Street Journal.  This is not the first time you clutched your 1950’s nostalgia pearls and waved a reprimanding finger at the promiscuous, ambitious and single twenty-something women of today.   In the Princetonian last March, you encouraged us to exploit our ivy league education as an opportunity for husband-hunting.  This Valentine’s Day, you took your antifeminist proselytism a step further, now urging us to put the brakes on our careers entirely in order to find our one trust fund, err, true love.  In response to your compelling offer, we, the career-driven young women of today, respond with a resounding “Nah, we’re good.”

Abraham

 

In a practiced gesture, I remove the towel from each part of our body. First the legs, then the chest, finally, and without hesitation, the face. At this point, I pause and really examine him. Yellow-jaundiced skin. Pearly, half-open eyes staring vacantly up at the ceiling. Mouth ajar to reveal gold fillings in his back molars. Weeks ago, we had decided to call him Abraham. A sturdy, stoic name. A name fitting for an elderly body with barely any adipose tissue and long, tapering bones.
We don’t really talk much about Abraham.

After this past whirlwind month of Anatomy Class, we all have been more concerned with differentiating between the nerves in the hand than contemplating how Abraham died, or more importantly, how he lived. None of us question what would compel someone to donate their body to our unsteady, fumbling hands, or what the final days of his life were like. We haven’t considered what his profession was, whether he had a family, a wife, whether anyone is thinking of him right now. Thinking of him not as we do- but rather, as a living, breathing, un-dissected person.

By week four, we’ve taken apart the superficial back, dissected through the brachial plexus in the chest, torn through the shoulder and hand.

By week five, we’ve cut up the superficial muscles of the face.

By week six, we’ve bisected his head in half. As I hack away at the fascia surrounding his eyes, I realize, he doesn’t even look like a human anymore.

The only identifying mark on Abraham is a tag that hangs off his big toe with the number “24” written hastily in marker.

When we leave at the end of lab, futilely scrubbing our bodies to relinquish the smell of phenol and decay, he lies covered next to cadaver #25- a slightly overweight woman- cause of death liver failure, and cadaver #23- a 50-year old man- cause of death lung cancer. We know that Abraham died of “general debility.” We know that he was ninety-two.

But beyond this, we know nothing of Abraham. We don’t even know when he died. Perhaps- at this very moment- his wife is lying in the bed they shared for sixty years, restless with loneliness in a bed made for two. Perhaps his granddaughter just gave birth to his great grandson, fists balled tightly like sea snails. Perhaps his son is suffering a deep depression, remembering his father and regretting that he never really had the chance to tell him sorry from that last fight. Maybe Abraham did great things, ran a company, inspired lives. Or maybe he struggled with alcoholism and homelessness his whole life, cheated, lied and stole. Maybe no one misses him at all. Because really, what difference does it make now how he led his life? Because now he is bones and cartilage and nerves and vasculature, no different from Cadaver #23 and Cadaver #25. He is another cadaver amongst a sea of lifeless flesh.

One day, I tell myself, I’ll say a prayer for Abraham. I’ll celebrate the life he lived, and give thanks sacrifice he made for us. Maybe I’ll write a note to his family, and tell them that he has helped medical students that will one day save lives just like his.

One day, I say, I’ll do this.

But not today, of course.

Because today I need to learn the difference between the flexor carpi ulnaris and the flexor carpi radialis. I have an anatomy exam in one week, a clinic visit tonight, I’m behind 6 lectures, and the test-induced anxiety is beginning to set in like storm clouds. Last night I had a dream that I was cutting up human bodies. Carefully, meticulously, hacking away and sealing their limbs in plastic bags. Serial killer or medical student, have I forgotten the difference?
Before I leave, I recite the nerves of the body, the muscles of the hand. Almost like a prayer for Abraham, as I cover his face, tuck in his arms, seal up his body tightly.