As I finish up the last days of rotation of medical school, I can’t quite believe how fast this will all be over. Everyone will be going off in their own directions- and leaving this little nest where we first got our baby doctor wings. I’m excited to be done and have some time off since ! holy moly ! I do have to move and pack up all the stuff I’ve accumulated after the years I’ve been in this current apartment. I’m sad at the same time too though, I will miss being with my friends and familiar faces. And did I mention my awesome graduation gift? My mom and I are going to the Galapagos :D

So there are many “last of” since I’ll be graduation pretty soon! The other day I participated in the anatomy memorial. I’ve been performing in it since my first year on my flute – sometimes alone, sometimes with other students. I think it’s really important to be thankful and grateful for the wonderful gift that we are given as medical students – I still very vividly remember my cadaver, little idiosyncrasies about her – and what I imagined her life to be from those, and then just incomparable, practically indescribable nature of what the whole experience was and the true miracle of human body. I’ll never forget walking in and thinking how real all the bodies looked, not able to do the first cut, or much of anything the first lab because it was just too real. I remember holding my cadavers hand as we dissected out the muscles of the forearm and how real it felt despite how cold and lifeless her hands were. I remember some of the more unpleasant aspects of the dissection and trying to balance our education with what was going on – sometimes at home in the private moments crying about it. I remember our team always working to make sure she was carefully taken care of when we were finished with the day – that she was properly wrapped back up and everything was squared away.

Never before in one of these ceremonies had I felt so different from my fellow classmates. At this point, I’m the farthest apart in years – they are ending their first year and I am ending my last in medical school. You could say it was the typical difference of being bright eyed and bushy tailed – not quite knowing what lies ahead, and just the sheer amount of change that happens in your twenties. I didn’t feel a sense that I had lost my idealism or innocence – I think that having to deal with real people and the real problems they face and come to you as a physician with makes you see things differently. It’s not a difference that is bad or worse, it just is simply different. I wondered how they would feel if they were in my shoes and if they could identify more specifically the profound difference I felt. As always though, they have wonderful enthusiasm for what they are doing and the journey they have started and it is an honor to be a tiny part of that. :)

The list is split up between the medical students, and as soon as that’s done it’s time to go see patients. I get impatient when there’s silly conversation before we split up, and if it lasts too long I break from the group. I have things to do, and being that I don’t know what has happened with my patients overnight – I want to make sure I have enough time. I am intensely goal oriented. Don’t get in my way. My fellow med students have made fun of me for this, but !! I have things to do!! Don’t dare take that chart from me!

My new patient for the day is an late 70 something year old woman. She’s been through a lot – her acute medical problem was attempted to be resolved by medical management but that failed so she ended up having to go to the OR. She has a colostomy now (a colostomy is when they take a piece of your intestine and connect it to the outside and you have to wear a bag to collect what comes out of the intestine, done for various reasons and can sometimes be reversed – depending on the various reasons why it was done). I can immediately tell she’s just fed up with all of this. Not so fed up she’s about to jump out of the bed to leave AMA (against medical advice) but pretty darn frustrated.

Really, as far as my end goes – infection standpoint she’s doing excellent. This I hope, will be something I can use to life her spirits. I also don’t need to ask too many probing questions since she’s doing well, so more time I spend with her can be hopefully helping her feel a little bit better.

When I’ve worked with younger medical students in the outpatient setting, I sometimes talk to them about finding something that the patients eyes light up about and they smile about. Especially for outpatient medicine where patients can do whatever they want with what you tell them – forming that relationship is important. I don’t know if there’s even been evidence based medicine but it makes intuitive sense that you’ll take advice more seriously from someone you feel a bond with. Although this is in the hospital, I know if I can do that with this patient – maybe she’ll feel a little bit better from this endless stream of people coming in her room, poking her, interrupting her sleep, and never quite giving her that warm smile that she needs.

I emphasize as I talk to her that I know she’s been through a lot, but am careful to be too much on the side of “Wow! You’re amazing!!!” because my guess is that it will turn her off. I notice when I discuss her eating she’s particularly unhappy about her diet at this point. I note that when she’s back on a full diet this will be something, hopefully, she will be able to feel encouraged about.

However, I’m just spinning my wheels. I’m not reaching her. Sometimes I’m just not the right person – or maybe I’m just not “getting it.” The moment arrives though when I take her hand and she looks me right in the eyes and I do my best to show and say that I hear her and although I’m not in her shoes, I can imagine what it might be like. I smile at her, and try to make sure that our encounter ends on a positive note. She needs that. And when we come back in with the fellow – I smile at her – and a small smile is on her face when she sees me. :)

So now, many hours from being at the hospital and seeing her, I wonder how she’s doing. I know that last week, one of my patients had a really down weekend and I really wish I could have dropped by to his room to have a silly conversation – we had bonded over a couple of trips he had taken. He refered to me as his friend even though I’m really Heather the medical student. I worry that this weekend this patient will continue to feel frustrated, and I know that her feeling encouraged and positive is more medicine that the antibiotics my team had carefully selected for her. I wonder if this comes at the expense of the people in my life. And that working to help patients takes away from me being the nice smiley person at home because I’m too tired to do that anymore. But, I worked hard to become a doctor (31 days till graduation) and being compassionate is far too important to me. So I don’t know that balance, but luckily Wolfie brings me the soccer ball (well actually tonight it’s a duck! maybe because we chased some ducks today!) to play regardless – he knows that if he wants my attention, he has to ask for it.

The patient on the service has AIDS. A new diagnosis of AIDS. No HIV, no careful months of monitoring viral loads and CD4 counts – and when the CD4 counts reach the level where opportunistic infections become more likely antiviral medications are started… and more careful monitoring… just AIDS. And an infection that is an AIDS defining illness – one that means your immune system is compromised and cannot fight something off that a normal immune system would fight off easily.

The patient looks like they have had a hard life. They act like they have had a hard life. When they don’t like what you say, they meet you with stony silence. They don’t have the boundaries of proper society, they get angry and become overally abrasive. They blame the medical establishment for not listening to them. They have a history of leaving the hospital against medical advice.

But the thing that breaks your heart is the questions they ask in those honest moments where they are vulnerable and desperate. Can’t you just order dialysis and cure them? They heard that worked. Or how about just removing all of my blood? And it’s clear that they never had the chance that you did in life and you’re standing there in your nice clothes, brain full of education, and a support system there behind you… and you just feel like all the chances you had in life they never had weren’t really fair but isn’t that just how life is?

You know you’ll go home, and cry like you do over these conversation you hear. It’s not the first time, and certainly not the last. Wolfie will come running over, concerned, and lick your entire face over, with special attention to that spot at the corner of your eye where the hot tears come from – and you’ll never feel those tears turn cold because a poodle licks them up to fast. And it doesn’t matter to Wolfie when you begin to sob about the injustice of it all – his tear roundup service is always ready.

Then a few days later when the patient’s family member begins to ask about using herbal treatments, special diets and you watch the attending patiently explain that they won’t cure HIV or AIDS. You watch the group of attending, resident, students walk away – and see the family member wipe tears away. You feel unsettled, because you know this situation repeats over and over again.

Everyone wants to know outcomes – what will happen to this patient? It depends – but the biggest barrier for these types of patients will be themselves and the rough tough exterior they have used to get them where they are. Hope for the best.

I came across this via my favorite newspaper the nytimes, Doctor’s Diaries. For those of you are really interested in what it’s like, I think this is really great to watch. I normally keep interesting links and the such over in the tumblr blog (listed in the sidebar) but so many of the moments captured are the things I that remember the strongest as far as the medical school training end goes.

My favorite parts –
-The description of the hierarchy in medicine, from the attending as the deity and down to the 3rd year medical student, a trembling monk.
-Watching the fumbling during the physical exam trying to learn the equipment and practicing on each other. Many fond memories of that :)
-Kind patients who tell you that you’ll make a great doctor as you fumble your way through things – and even though you feel like an incompetent idiot they still tell you they want you to be their doctor when you finish.
-The discussion of at fourth year how far they’ve come and how they wouldn’t have expected that even during 3rd year.

This is my last month of medical school as far as rotations go – not quite at the one month mark for graduation but awfully close. It’s really crazy how fast the time has gone by – even compared to 3rd year. I’m looking forward to it being over in some ways, but not necessarily looking forward to the upgrade in responsibility and far longer hours!

It’s kind of cool though, one of my very good friends in school that I was on the same track as for 3rd year, I’m back with for the last rotation. I remember being on our early rotations, not sure what to do, working on doing history and physicals together, reminding each other to do certain parts… so its a special thing that we get to come back together to finish things out. The only bad thing is the hours are really long, especially for a last rotation when senoritis is in full swing. There’s so much to know as well, other specialties there is more overlap, but sometimes when they discuss things I feel as though someone is speaking another language to me.

As I’m wrapping up med school, I’m trying to think of something profound to say about my journey. I’ve never been particularly good at writing – I know what good writing in general looks like but being able to do it myself is always hard. (so bear with me!)

I think back to starting medical school and already that felt like a huge journey. Getting into medical school was a trying task, I never was someone who was top of their class but always did do relatively well in classes. Standardized test wise I was never strong, but at the same time I wasn’t awful either. I went to graduate school with the purpose of strengthening my application to medical school and that had meant an additional two years of work and being heartsick of wanting to get into medical school. It was nothing I regret but it has just made everything longer. The main thing I remember is that overwhelming desire to want to become a doctor, and just these anxious nights of wondering if I could ever do it, if I would ever be good enough, how long would this take…

Then came medical school. Finally here. I felt a lot better about myself because I was finally doing what I really, really wanted to do. Medicine wasn’t something I feel as though I was “born” to do, but it’s something that I feel so passionate about on many different levels. My beliefs about life and death are pretty different than most, and I don’t work towards a goal of heaven – I just feel and have always felt that no matter what I did it had to serve humanity and work towards the greater good of humanity. It wouldn’t mean I had a greater reward, it wouldn’t change what things happened to me in life (although do I wish it would have given me a pass on my father!), but it meant that I used the gift and talents I had for something that did more than just put food on the table. So knowing I had secured that for my future gave me great peace inside.

Overall though, medical school was hard. I feel as though I’m reiterating things that I’ve said already, but it took a huge emotional toll on me. I know how the general public feels about doctors, and working to see why that is and what in the training leads to the general mistrust and dislike was hard. Maybe my observations on that are good for another post. :) I think people seriously under estimate what medical school is like. I don’t fault people for not understanding although it does frustrate me at times! I think it’s like anything else that the training is really intense – I have no idea what going to law school is like or what training in the military is like, but I have a vague idea that it’s “hard”. So the same would apply for someone outside of medicine. Luckily, my life is no longer consumed by it so it has become less important to me that people really understand just how terrible it is. Hopefully I’ll just be over proving to everyone how hard things are for residency :)

I would say though there are two things that are my favorite parts of medical school – the free clinic, and my friends I’ve met here and the ones I’ve continued my friendships with. The free clinic is something that relates back to my own personal goals and beliefs about service and the community, as well as being a huge opportunity to push myself and manage people, deal with personalities, and something I’ve dedicated myself to wholeheartedly. My friendships have really seen me through some incredibly hard times – times I was just so miserable and unhappy, I’ve been lifted up – or told to knock it off! They’re friendships I’ve made from the blog here, people I’ve met in college or grad school that I’ve continued to stay close with. Definitely mean a lot to me and things I will always treasure.

Maybe if I remembered better how I dealt with things or how I saw the world I could point out discrete, identifiable differences. I know that I’m different, I know I handle and deal with life better than I did before. It was never one patient, it was never one attending – but instead this wonderful mix of being pushed, being told I wasn’t good and next time to be better and in the cheesiest sense – getting a baby pair of wet wings that still need to be dried in the sunlight, don’t flap well together – but beautiful wings with little drops of moisture that capture the sunlight – and give hope that my generation of physicians will do better than the ones that came before us. :)

I think it’s especially important as a physician to reserve judgment. People do all sorts of remarkably stupid things, but they come to you for help – not for advice on what the stupid thing they did was. I don’t think it’s bad to tell a patient that what they did is bad for them or wrong, but in a way that empowers the patient (in the ideal situation too of course ;) ). Hopefully all of us were raised with a parent, two parents, or people who acted like parents and got all the scolding one should need in life.

I’m on the lung team and we don’t get many pregnant patients. We recently had one though, in the 2nd trimester who came in for cold symptoms. Urine drug screen was positive for cocaine and marijuana, patient also smokes cigarettes. Here’s where I think the reserving the judgment is incredibly difficult. Obviously, this mother is not making wise decisions and it’s worth mentioning that what she’s doing is a not good idea. Likely, she will become very defensive because everyone knows that pregnant women shouldn’t be partaking in that kind of stuff. It’s hard to not let your own biases come in to play as you speak with the patient, it’s hard to imagine why this person is making these choices. Luckily, the crack baby epidemic of mentally handicapped children never came to fruition and hopefully this child will live a healthy life. It is doubtful due to more of the social situation the child will grow up in as opposed to the fetal exposures, but I try to hope.

So my rank list is due tomorrow. I honestly don’t even want to tell anyone what my final list is because its just such a hard decision – and hearing people’s opinions has made me more upset than help. I changed it last monday, and I feel as though this is what I should stick with. It’s a really hard decision, and I think if you know anyone making this choice, the best thing to do is listen and nod and not say anything really. There is enough on the plate to consider about training, future career goals, without having emotional connections thrown in too.

A year ago my life was so different, my parents would retire when I graduated and they would be able to do their own thing. But now, life is where it is – so just have to trust that decisions will work out, and if they don’t you’ll do what you need to do to right the situation again.

So the big dates are:
March 16: Find out if you matched. If not… you scramble.
March 17-18: The scramble
March 19: Find ouf where you matched.

If you missed it: Part 1 Part 2

Then it’s time to meet my attending. Normally I have a lot more time than this, so I write my notes super slow and make my handwriting pretty. This morning though – no time to do that so my handwriting can still be read, but it’s a little on the wild side.

We start in the ICU. This ICU is cramped and uncomfortable. The patients here are not of real interest, and I don’t know their cases well. The other ICU has an interesting case though. Normally, I have more time so I would have looked up this patient and gotten their story, but not this morning. The attending I’m with needs to make a personal call, so I scope out the scene first.

I look over at the patient… hrm. I don’t have a good feeling. Attending comes in, looks at the patient and mirrors my feeling. Nursing comes over and mirrors the same sentiment. Patient has end stage liver failure and was found unresponsive. Patient is waiting for a transplant. Labs looks awful. Patient’s liver failure is due to Hepatitis C, most likely from IV drug abuse. One could say patient’s liver failure is their fault, but in the end to me that’s not what matters. Patient has a family, a family that now has their loved on in the ICU looking awful, and that makes me feel upset. As we work this patient up, I see another patient, an older person on a ventilator occasionally moving their head. Patient has gloves over their hands, maybe to prevent them from pulling things out? I wonder about the sense of all of this, people who are old enough to have had “a good life” but are now in the ICU ventilated, likely to get some kind of other infection, bed sores, etc. Is it wrong to allow patients to die without coming to this?? Something to think about later.

Back to the original patient with the liver failure. Patient needs to be at a different hospital. Go to visit the patient. Look for fluid in the abdomen. Discuss some of the physical exam signs of fluid in the abdomen (ascites). Some of these… well I have seen before, as my father’s oncologist showed me. Hrm. Kind of painful. But everyday is kind of painful because my Dad is always somewhat on my mind. Just right under the surface, and there’s always something – and really it’s just because my Dad is always on my mind more than anything.

We finish up, and go see the various patients I had seen on my own. As we go visit them, I update the doctor about what I had found and any changes – and what the plan is from here on out. It’s fairly routine, there’s nothing unusual about this part. “Mr. Smith is the 45y/o male who came in with nausea and vomitting, since admission he’s been doing well, no further emesis (vomitting) and tolerating a soft diet….”

So that’s the basic gist – it changes by service but that’s close to the general scheme of how it goes. You see patients, write notes, see patients with attending and report on them.