Surgeons

I sat waiting for the surgeon I’d work with to arrive at the hospital. Being a medical student involves a lot of waiting. On the wall across from where I sat and next to my surgeon preceptor’s office was a wall of fame, of sorts, of surgeons gone by. The black-and-white photos caught my attention because every single surgeon depicted there was a white male. The irony was that most of the surgeons I would come to respect in the weeks to follow would fit neither or only one of the “white male” descriptors. The surgeon I was waiting for, for example, was neither white nor male. She would single-handedly show me what it meant to be an excellent surgeon.

The operating room is cold. The lights are stark. If you are helping with an operation you “scrub in” (which involves washing your hands in a special way and putting on sterile gloves and a sterile gown). Once scrubbed in, you maintain sterility the entire procedure which includes only touching sterile things and keeping your hands in front of you and between the level of your bellybutton and chest. Bathroom breaks and snack breaks aren’t an option for medical students in the operating room, so I tried my best to do those things before entering the room.

Once the patient is settled on the operating table, they’re put to sleep by anesthesia.  As soon as it’s confirmed that the patient is asleep, their eyelids are closed with tape to protect their eye structures and a tube is placed down their throat to help them breathe.

While the patient is asleep surgery unfolds. All surgeries are done with a team of people, the surgeon is only one member of that team, and the surgery is not successful without every team member. The patient is covered with drapes except for the area where the operation will occur. This is interesting because the humanness of the patient is lost. Their body becomes a workspace once the drapes are placed. It may sound disrespectful, but it isn’t. Rather, the drapes are meant to protect the sterile workspace and maintain patient modesty.

Surgeons are the artists of medicine. Much like carpenters and painters and jewelers and other craftspeople they make their living by using their hands. The difference, however, between surgeons’ hands and carpenters’ hands, for example, is stark. The surgeons’ hands are soft and their fingers nibble while the carpenters’ hands are rough and their fingers strong.

Surgery is all about feel and dexterity. Surgeons tie knots with thin thread to keep arteries from bleeding. They sew with curved needles using plyer-like instruments. During surgery, it’s the surgeon’s hands that impress. Their fingertips can feel the difference between disease and health in tissue. Their hands can somehow hold more tools than you thought possible.

Ask a surgeon about surgery and about the operating room and their eyes become bright. They smile. They draw pictures and use their hands to describe structures. They talk about the neat surgeries and bodies they’ve seen. They talk about how many operations they’ve done. Surgeons are like artists. They love their craft and exude a love for their studio (the operating room).

I would eventually join a surgery led by the surgeon I had waited for by the surgeon wall of fame. A resident and I were helping her. The resident was soon to finish and become an independent practitioner. The surgeon was busy operating; I was holding a camera (used to see inside the abdomen); and the resident was doing something else to help the surgeon. “People will not take you seriously because you are a small female,” the surgeon said to the resident. “Don’t be disheartened. Respect is earned.” The surgeon would go on to discuss the importance of appropriate financial compensation for your work and doing excellent work. I would hear this message about differences and respect several times during my surgery rotation. I would feel why multiple women ahead of me thought they needed to tell me and my colleagues this information. Yet, it wasn’t new information because I, like most others, didn’t make it through my 20s without learning how my different identities help and hinder me.

There are many things that you could die from if it wasn’t for surgeons. But, as lifesaving as surgery is, it is also fraught with risk. Your surgeon can kill you. Having life and death literally in one’s hands is not a light matter, and you see its weight on the shoulders of surgeons when you work with them. The riskiness of surgery is also why the road to becoming a surgeon is a long, hard one. It involves many years filled with unfortunately long workdays. Apart from a grueling training marathon, surgeons have high personal standards for their work. High standards coupled with hard training leave many surgeons with a robust ego.

Egos aren’t all bad. You want a confident, proud surgeon. This is because you want someone who is very good at what they do and who takes pride in their work to operate on you. However, egos can be detrimental too. Too much ego can lead to poor listening skills, lack of self-reflection, and a complete disrespect for others. High-quality surgeons are confident because they are good at their work and love it, proud because they save lives, and humble because they know they are human and will make mistakes. The best surgeons are not only confident, proud, and humble but also curious. Curiosity makes the best surgeons because they not only love operating but, also, dig to the bottom of their patients’ stories, investigate thoroughly any mistake or less-than-perfect outcome, and keep up on the latest research and recommendations in their field.

On our last day working together, the surgeon that made me understand surgery had time to sit with me in her office by the surgeon wall of fame. She gave me some advice and her philosophy on medicine. “It’s nice when patients appreciate your work. You saved their life. But, they don’t have to and that’s not why I do it. I like to help people,” she said. The conversation continued for a bit. “People talk about quality of life. I don’t think it’s fair to say that you don’t want to do surgery because of the quality of life. Quality of life is something you make. For example, right now I pick up lots of call [24-hour shifts]. I do it because I am well compensated but, also, because it is good experience. I like to help people… I like having the cases [surgeries]… But, I won’t pick up call forever. Right now, it makes sense… It’s all about tradeoffs. You can work less and then you make less money… You can set the terms of your work,” she said.

As I left the hospital after my last day working with her, I thought about the surgeon I’d worked with. She was a calm and patient teacher – something that is rare. She had saved many lives. She had seen the inside of the body many times. Her hands could tell the difference between a fat glob and a cancer by feel alone. I’d seen her talking to patients with a patience you don’t find in all surgeons. I’d seen her interacting with all levels of hospital personal with a respect and kindness that was genuine. I’d heard her talk through her clinical reasoning; it was thorough. I’d seen her do surgery; she excelled. She was exactly what I’d call an excellent surgeon. I would have no hesitation sending my patients or family to her because I knew she’d treat them well and operate with precision. She was the first surgeon to go on my mental surgeon wall of fame. After that first day waiting outside her office, I’d decided to construct my own wall of fame (for surgeons and other types of physicians) because the one I’d seen in the hospital was outdated.

Rainy Days

The rain fell. It fell hard. It was a mate drinking kind of day. It was a flood-warning day. And the rain reflected my mood. I’d seen a rainbow just before the rain started. With the rain comes rainbows, but on this rainy day I was feeling the grayness more than the light reflected off the raindrops.

And I thought about a text I’d gotten from a friend not many days before the storm hit my town. She’s a good friend and checks in when the world is in shambles and I’m ignoring the news – which is to say, she checks in whenever something happens in the world I should know about because I almost always ignore the news these days. Despite my efforts at ignorant bliss, I’d heard about some of what she said already. And I felt the same as she: what we were doing seemed pointless when so many people were suffering. And yet, it seemed school would give us skills to better help the world. However, the future is hard to predict.

On this rainy day, I thought about allies and who we can trust. I’d recently seen a patient riddled with cancer. It doesn’t require one moment of school to recognize a dying person. This patient was the picture of death. Their eyes were dull, their movements slow, and their skin ashen. The patient couldn’t eat, yet begged for food, and now their cancer had spread so much that it was making connections between their organs. Their pain was barely controlled. They didn’t desire surgery or treatment; they wanted the pain to stop. They wanted to eat. On one hand, the patient and their healthcare team knew exactly when the pain would stop – the word wasn’t mentioned. The family of the patient, on the other hand, pushed for treatment. Treatment in this case meant prolonging life but not ending the pain and not preventing the eventual end we already knew.

Medicine can’t change fate, nothing can. The family had convinced the patient to continue with treatment, and yet the patient wavered. The patient didn’t want to disappoint their family, but they were so tired. I reflected on their family’s choice to push the patient to continue fighting. I realized that I hope that the folks I call allies are there when I need them, when the going gets tough. And I hope that in the tough moments of my battles they think about what’s best for me, even if it’s not their preference.

I wondered if the betrayal of a family wasn’t so different from the betrayal of a country. In this case, though, the patient wasn’t allowed to pursue their end in peace. The news of Afghanistan was quite the opposite. We’d left so many allies to die perhaps avoidable deaths. And I thought back to the day the Twin Towers fell. I was in 6th grade and now I was in medical school. Seeing images of babies handed to strangers on planes in a hope they’d have a better life didn’t seem like much progress from the smoke and rubble that filled New York City when the towers fell. Politics are complicated, but I wondered about the definition of “progress”; was it simply a fiction invented to instill hope? I wondered about trust; which allies are ones we can trust? I wondered what could have been done differently.

On this rainy day, I thought about the good of the individual and the good of the whole. I’d seen a young patient recently walk away from treatment. It would have been a simple procedure with an 80% chance of completely curing their disease without them even needing to stay in the hospital. Declining treatment is a right. But by saying “no” this patient had most likely condemned themselves to metastatic cancer in under a decade. They’d decided to die of cancer well before they turned 50 because their cancer wasn’t curable once it spread. When they declined treatment, the cancer hadn’t spread yet and we most likely could have cured it.

I weighed my feelings about this patient’s decision against my feelings about people declining COVID vaccines. They were both examples of people making health decisions. It is our right to decide what happens to our bodies. But, choosing to die of cancer compared to choosing to put others at risk of infection feels starkly different. You see, the thing about cancer is you can’t pass it to others. The thing about viruses is that they spread. While you might be just fine after catching COVID; others may die when they’re infected. And it could be you who infects them.

The rain fell and I thought about the nature of the world. I had an exam looming and I wanted to ignore everything else. Like rain drops on a rainy day you don’t have to look that far for sad things in life. It’s also true that with rain comes rainbows. And while I’m certain I like rainbows, I’m not certain they make up for whole rainy days.  And it seems that some of us get more moments with rainbows than others. There’s something about the angle between the sun and the water drops. Not everyone has the same angle.

Engaged

This year I got engaged. It wasn’t a surprise as it came about after countless dialogues while driving between mountains and feasting spots, while plodding along trails below tree line, while standing next to rivers, and while gazing out at the horizon from mountain tops. Like most aspects of my fiancé and my relationship, the timing of engagement was mutually agreed upon and, once decided, a joint undertaking of finding rings, figuring out the legality of things, and planning a wedding unfolded.

It’s funny to me that I’m planning my wedding as I also undertake my third year of medical school. I am a person of action, but usually my time is spent on professional endeavors. I’ve only chosen careers that are consuming, where even when the day is done the puzzles of work linger, tossing and turning in my mind as I go about the rest of my life. I’ve never considered relationships beyond friendship as required or even goals. I’ve always seen marriage as something I’d consider only if someone fell into my life who made me think of it. “Fell” being the key word. I’ve known for many years that happiness and loneliness come from within. The loneliest years of my life I was in a long-term relationship. My happiest times correlate only with my internal state. I fought hard on many occasions when I was single to be allowed to go about my business as I saw fit. And as I think about marriage, the annoyance of having to explain that I am whole without a partner remains somewhere in my skin. But, yet, as I undertake one of the hardest years of becoming a doctor, I am also signing away singleness.

My fiancé and I have discussed marriage and dreamed about growing old together since months after we started dating. There are people who bring out your happiness, who make you laugh more than most, and who force you to think about the world differently. My fiancé is that person for me. And in our short time together, we’ve weathered many storms. There was the first years of medical school – torturous as the hours of study dragged to the future. There was COVID. There were those times when we could have died in the mountains. Where we literally talked each down the cliffs, teetering on an all-to-real edge. There is this current stretch of doing the “long distance relationship thing.” There were the times we shared with family and friends, where it was so easy to feel connected. How seamlessly he fit in with my people (including when my sister and her partner lived with us for a month starting days after he and I moved in together) and how his people made me feel like family from the beginning (starting with the Thanksgiving dinner where I met his parents and everyone in the extended family all at once).

I knew it was time for us to finally start planning our wedding for two reasons. First, since our first marriage conversation we’ve wanted to get married before he follows me to residency and the clock is ticking until that time comes. Second, the realization popped into my head that I couldn’t imagine being happier with another person.

Engagement is neat in the sense that it brings people together. Our families and friends have offered advice and help as my fiancé and I embark on wedding planning. It’s such a fun thing to have a joyous project to work on. Engagement is as odd as it is neat. There are many norms about engagement and marriage which have stood out to me because I rejected them. I didn’t want an engagement ring. My wedding dress will be red. I prefer small, intimate gatherings. My ceremony must be outside. There will be no registry. There will be no escorting down an aisle.

And as I often do for my career, I’ve spent some time reflecting on marriage. I like to ponder why things are important and worth doing. My younger self often thought marriage was giving up something of yourself for someone else. I’m glad to report that that isn’t the case. Marriage is about two very different people taking on a shared adventure, where there are lots of side adventures together and apart. Marriage is just a formal way of saying “I trust you and want you to be my life-long co-hiker no matter how boggy the trail or how craggy the mountainside.”

And as he said when I read him this post, “’Fiancé’ is a weird word, let’s get married already.”

Autonomy In Medicine

Set Up

I’ve been thinking of patient autonomy and the humanness of physicians a lot recently. In my short time training to be a doctor, I’ve had many experiences that have brought these topics to light. Here are a few examples:

  • An attending physician told me he usually first recommends pills to women seeking birth control because he believes that women find it reassuring to have their period every month. Odd perspective as my experience as a woman is that some women find periods reassuring and many find them annoying. Odd perspective as my short time in his clinic showed implant and injectable birth control methods as the most common forms of birth control requested and used by patients. Odd perspective as research has shown LARC (which include implants and IUDs and NOT birth control pills) have greatly decreased unwanted pregnancies because they’ve removed the mishaps of having to remember to take a pill every day. Medicine is complex. It requires both keeping up with research and checking your personal beliefs at the door. The approach I’ve seen most physician take when discussing birth control is to outline the different available birth control options so patients can decide themselves which is best for them.  
  • I overheard an attending physician talking to a resident physician about a D&C they did recently. A D&C is a procedure that can either be used to end a pregnancy early on or clear a miscarriage that occurred early in pregnancy. The patient these physicians were discussing had the procedure to end pregnancy. The resident physician stated that she thought the patient was looking for validation from the attending physician for choosing to have the procedure. The attending physician shrugged. I (medical student) asked what the attending physician had told the patient. The attending physician said, “She doesn’t need to give me a reason for the D&C. I told her she doesn’t need to give me a reason to terminate the pregnancy.” I found this statement to be a powerful example of approaching medicine without imposing personal beliefs on a patient.
  • An attending physician walked out of a patient room and told me the patient’s problem was that she was naïve. This was his reaction to the patient (a pregnant woman) planning to visit friends/family in another city while in the third trimester of her pregnancy. The patient had gained too much weight during pregnancy. She also had high blood pressure at this appointment. When asked the patient described improving her diet. The physician laughed at her when she described eating salad. In self-defense, the patient then described eating very healthy-sounding salads. The patient’s trip would delay the follow up blood pressure reading the physician wanted by two days. The physician did not explain why he was concerned about hypertension specifically in the last weeks of pregnancy. I wondered why he didn’t recommend that the patient monitor her blood pressures with a home blood pressure cuff and bring in a log of her blood pressures when she was able to schedule her next appointment. It seemed the risk of delaying a blood pressure reading in the clinic by two days might be outweighed by the benefit of social support during the final weeks of pregnancy. I questioned the choice of “naïve” as his diagnosis. Why should she know about preeclampsia if he didn’t tell her? Naïve is a loaded term and isn’t one I’d be quick to use to describe a pregnant and uninsured woman with friends/family in multiple cities. Medicine is a team sport. Patients are the captains and physicians are the coaches. It’s important to remember that the patient is part of the team and that while they don’t bring medical knowledge, they do bring life knowledge.
  • The patient told the attending physician that they stopped their antipsychotic medications. The physician recommended that the patient continue taking their medications. The patient refused. The attending and the patient came up with a plan to watch for warning signs that the patient’s psychosis was returning. The patient continued to attend group therapy even though they stopped their medications. This allowed the group therapist to send a community crew out to the patient’s home to check on the patient when that patient showed psychotic behavior at the online group therapy session. The patient did not self-identify that their psychosis was returning. However, because they continued to attend group sessions they were still connected to care and were brought to the emergency room before their psychosis led to self-harm. I found this case an excellent example of a physician respecting autonomy while also trying to prevent serious health outcomes for her patient.

Reflection

Medical school, residency, and being a physician teach us to solve complex problems. They teach us the complexities of the human body and how to cure diseases and treat symptoms. They teach us to think critically and sift through data efficiently. They provide us with guidelines and treatment recommendations. But, medical school, residency, and practicing medicine don’t and can’t teach us the complexity of each patient. They can’t give us the ability to foresee the future or understand patients’ life goals better than patients do themselves. And, despite our great knowledge as physicians, we can’t (and will never) have all the answers. Despite extensive training, medical research, and detailed guidelines medicine is still decided by humans (yes, physicians are just humans) and is (therefore) based partly on intuition, experience, and practiced guessing.

In medicine we are fixated on being right. Our goal is to reduce suffering, cure disease, and help patients navigate illness. And while as doctors we strive to cure, as humans we know that life can be more complex than curing. As humans we know life is paired with death. As humans we know not all questions have an answer and not all problems have a solution (at least yet). And as humans we know that health, sickness, healing, recovery, pain, and death are individual experiences that share commonalities across individuals but (ultimately) are unique experiences that each person endures differently.

In my short time in the hospital, I’ve already observed patients losing their autonomy. I’ve seen patients’ wishes ignored and explanations of why skipped or glossed over. I’ve seen us (medical experts) angered when patients don’t follow all our recommendations, insulted when we’re asked why, and forceful that our way is the only right way. And I’ve seen patients suffer. I’ve seen patients suffer taking our recommendations and I’ve seen them suffer when they refused our recommendations. And while suffering seems to be a part of some points in all lives, it also seems that sometimes in addition to our patients suffering we (physicians) push our patients to accept a treatment plan that is discordant with their values and life goals. It seems sometimes that we add to suffering by piling on shame or judgement.

In medical school, in residency, and as physicians we are taught to find the truth and to be right and to be directive. We are taught to recommend the best medicine has to offer. Yet, the best options based on evidence are not always the best option for an individual patient. And even if they seem right, the best options are not foolproof. The best options are based on probabilities, percentages of effectiveness and likelihood of reducing disease or preventing further harm. Probabilities are helpful, but they are not certainties.   

I’ve been thinking of medical recommendations and patient autonomy and the humanness of doctors because medicine can be hierarchical. It can be rigid with the attending physician setting the law; a mix of other players like nurses, medical students, and resident physicians in the middle; and the patient disempowered.

There are more cases than I presented above that I’ve experience which illustrated the complexities of patient autonomy and the humanness of doctors. Medical school is a whirlwind of learning. What I’ve come to discover, however, is that all the learning isn’t strictly medical. I’m also learning how I’d like to conduct myself when I’m an independently practicing physician, the ethics of medicine, and the challenges of working in a field where the outcome is dependent on the efforts of all team members.

As I reflect on the hierarchy and the complexity of medicine, if I could hold one piece of advice for myself as my training continues it would be to ensure my understanding of medicine is excellent while also remembering that patients are autonomous individuals. This advice reminds me that my job is ultimately to help people navigate the complexities of health and illness. This advice acknowledges that patients can say “no” and that the “why” is just as important as the “right answer.” This advice helps me to remember that my patients and I are a team. And just as I can decline or refer a patient to another physician if I am not comfortable with a patient’s request, my patient can also decline my recommendations or seek the medical expertise of another.

Update from Labor and Delivery: Non-Surgical Edition

We worked to the rhythm of the fetal heartbeat, ticking along at 140 beats per minute.  We hadn’t met the baby yet, but the baby was getting ready to come out and greet our world.

The soon-to-be-mom wasn’t in as much pain as she had been last time I saw her. The epidural took the edge off her contractions. She could talk to us again and was even happy (albeit also tired).

The team got ready to start pushing. The contractions were the right distance apart and strong. The cervix was dilated to 10 centimeters. We explained the process of pushing the baby out – for each contraction she’d push 3 times, each for 10 seconds. While pushing she’d pull her knees out and back toward her ears because that opens up the pelvis and helps the baby fit through. The first contraction we practiced. Not many laboring humans get the pushing thing perfect on their first try. But, it didn’t take this soon-to-be-mom long to learn what to do.

Birth is trepidatious, exciting, and boring all at the same time. First there is a lot of wondering about how the whole process will go. Then there’s a lot of wondering what the baby will be like. Parents are excited to meet their child for the first time. From the health care perspective, there’s a lot of standing around. A lot of blood and mucus and other types of goop. The work comes in waves, as the contractions come and go. Between contractions the laboring human rests and the rest of us wait. It’s really all about the laboring human. The rest of us are just accessories and moral support. On this occasion, the soon-to-be-dad was a great team member. He was encouraging without being overbearing. He was engaged without hovering. The support people the laboring human brings with them aren’t always that good, but you’d be stressed too if your partner was doing all the work and all you could do was stand by waiting.   

This soon-to-be-mom tapped her tummy and sang to her baby in between contractions. She had made up a song for the baby that involved the baby’s name. She told us she had spoken to the baby throughout her pregnancy. She explained that she had told the baby when they were eating. She told us that the baby knew that they ate yogurt every day at 2:30 pm.

The soon-to-be-mom worked hard when the contractions came. The baby moved down the birth canal. As the baby came closer to meeting us, the soon-to-be-mom became more uncomfortable. If you’ve had a baby via vaginal birth you might know what the pressure of a baby’s head is like as it makes its way out – the rest of us can just imagine. The soon-to-be-mom had a good epidural, but it didn’t’ take away the pressure of the baby’s head. It didn’t take away the pain that came with tissues stretching.

We saw the baby’s hair for many minutes before we saw the baby’s head. Head then shoulders and then the rest. I helped deliver the placenta – best described as a warm squishy sac.

The baby cried upon entering our world, a sign of lungs waking up. The baby started covered in white wax and slightly gray, but soon turned pink. The baby snuggled up on the mom’s chest. The baby was perfect, as all babies are. All babies are both perfect and look like aliens if you ask me. Regardless of babies’ alienness, you still tell the parents congratulations on having their baby (this is very important).

Mom rested. She then sang the baby’s song. Once the placenta came out, we made sure the bleeding stopped. We made sure any tears (they’re common apparently) were sewed up. The obstetricians tell me vaginal tissue heals quickly. Life is a curious thing, especially the beginning and the end.

Mom and dad were lost in staring at their baby as we cleaned up mom. The nurses made little ink baby footprints on a certificate for the parents and on hospital paperwork. They took baby’s vital signs – baby was doing well with its itsy-bitsy everything.

We left their room. Time to return to our station. Many little hearts running between 110 and 160 beats per minute bopped along on our monitors counting down the hours until their parents got to meet the baby they’d made. We joke that labor and delivery is the only floor in the hospital were pain is a good thing, only because it means that it might be time to have a baby.

Birth is trepidatious, exciting, and boring all at the same time. I’ve seen the toughest cry at the sight of their child. I’ve seen smiles and laughter and looks of amazement and terror at being a new parent. And I’ve only been on labor and delivery for a few weeks. Imagine what it’s like to make a career of helping people bring their babies into the world.

The Psychiatric Rotation

Disclosure: The patient story here was written with a patient I saw in mind, but the details have been changed to protect anonymity. The story is reflective of many patients I saw during my psych rotation and while working in the ED. You will note that I chose nonbinary pronouns. This is because brain illnesses (just like many illnesses of other organs) set in regardless of gender. Brain diseases, like many other diseases, are related to genetics, life experiences, and other social and environmental factors. A tricky aspect about brain diseases is that we aren’t exactly sure how most of them develop and we are quite far from having a cure.

I looked down at them lying on the stretcher in an ED bed. They were snoring quietly, and their face was neatly framed by their hair. Their eyes were closed, and they looked peaceful. I didn’t have much time to ponder the full circle that this scene represented and the eerie foreshadowing of the end of my psych rotation. They had received the magic 5-2, 5mg Haldol and 2 mg Ativan. Haldol is an antipsychotic that is sedating and Ativan a benzo that’s also sedating. In other words, the patient was chemically restrained. Put again, they were put to sleep for a short time to end their psychosis. And a scary psychosis it must have been as it was filled with delusions of people hurting them and murdering children. We shall call this patient The Singer.

I’d seen The Singer awake and stable during the first few days of my psychiatry rotation, weeks before I saw them sedated. When I first met them, they were being discharged from the psychiatric inpatient unit of the hospital. They’d been in the hospital for weeks. They’d been restrained many times. They’d spent a good chunk of their stay believing the hospital staff were hurting them. When I met them, they didn’t have those delusions. They were looking forward to finishing a song they’d started writing before entering the hospital. They were looking forward to going back to their job and were inspired to possibly start biking again. They were discharged from inpatient to home with quetiapine and an intensive outpatient treatment plan (dialectic behavioral therapy group sessions). Quetiapine is an antipsychotic. Did you know most drugs in its class are effective about 20%-50% of the time? That’s not a passing test grade. But, then again, 20% of patients helped is better than zero. And, of course, medications only have a chance of working if you take them.

As my psychiatry rotation marched along, I changed from inpatient psychiatry to outpatient psychiatry. I’d see The Singer in the outpatient setting too. I observed their dialectic behavioral therapy session (group therapy focused on developing social skills and strategies to manage emotions). I interviewed them at their medication follow-up meeting. At that meeting, they told us they’d stopped their quetiapine. They didn’t want to take it. They didn’t like it. We could not and were not going to force The Singer to take their medication. They complained about not being themselves when taking the medication. I couldn’t blame them because quetiapine is sedating and does sometimes make people feel flat, emotionless. The psychiatrist counseled The Singer on looking for signs that they might be slipping into psychosis again. The Singer identified not sleeping as one of the triggering factors. I worried for them. I worried their delusions would return if they weren’t on quetiapine.

After outpatient psychiatry, I transitioned to the consult service which determines if patients in the ED need psychiatric hospital admission and provides psychiatric evaluation of patients anywhere in the hospital. I was with the consult service when I saw the sedated version of The Singer in the ED. The Singer had been sedated because they were not safe. Their delusions of rape had returned. They were agitated and not taking care of themselves. They were making risky decisions. We hoped to help them by admitting them to the hospital.

I knew The Singer was a musician because the ED was the third setting in which I’d seen them; the first time I met them, they told me they were a singer.  I knew their living situation and their hobbies because I’d talked to them about them. I knew why they had stopped taking their medications and I knew that part of the reason their psychosis had returned was because they’d stopped taking quetiapine. After leaving their ED room, I drafted the psychiatry consult note that would be a record used as justification for involuntarily admission to the hospital for stabilization. We’d come full circle, The Singer and I. I started my time on psychiatry with them being discharged from inpatient treatment and I was ending my rotation with them being admitted again to inpatient treatment. Same cause. Similar presentation as last time. Had we made progress? How many times would The Singer repeat this cycle? I reflected on the fact that chronic illnesses are just that, a chronic struggle to be well. A chronic ebb and flow of good and bad days.

The ED consult note I wrote about The Singer was the first psychiatry note where I left the mental status blank and simply said they were chemically restrained at the time of consult. The mental status is the bulk of a psychiatry note. It’s where you summarize a patient’s emotions, thoughts, words, and behavior. A psychiatry note without a mental status exam is quite limited. Psychiatry is about talking to patients to understand their feelings, thoughts, and emotions. It is almost impossible to evaluate for feelings, thoughts, and emotions if you can’t or don’t speak to a patient. Sure, when patients aren’t sedated, you can observe them or try to use writing or sign if you can’t speak to them formally. But, talking is the core of psychiatry. Psychiatry is the one field of medicine that does not forget to ask the patient’s opinion. I reflected on that bit. It reminded me of the key lesson I hoped to remember on future rotations when time was crunched and my patience strained – you have to talk to patients in order to know their thoughts and story. It may sound simple. Perhaps it is. Perhaps the pile of labs and medications and interventions that occur in the hospital make it difficult to always remember that patients are people who got sick. The sickness doesn’t remove the fact that they might be a singer or a biker, it just adds another layer to them as a person. Seems straightforward. We’ll if it remains straightforward at the end of a 13-plus hour shift on surgery.

The COVID-19 Vaccine: Celebration and Differences

Repost of a post I wrote for the Global Health Diaries, the blog of the Global Health Program at the University of Vermont Robert Larner M.D. College of Medicine and the Western Connecticut Health Network. Find the original (split into 2 posts) here and here.

My partner and I both work in healthcare and had the opportunity to get our COVID-19 vaccines months ago. Never in the past would I have expected to await a vaccine with such anticipation and feel such gratitude upon receiving it. Among the many other social and scientific features COVID has brought to the forefront of our attention—one, at least for me, is a renewed appreciation for all the vaccines we have previously developed. To think that we can stop smallpox and polio is a relief. But, also, COVID is a reminder of all the diseases that have escaped vaccines to prevent them. HIV comes to mind.

My friends and family in the US are in various stages of COVID vaccine completion. The variance is largely because of their age, profession, and which state they live in. What is reassuring to me is that for my US community the debate is not whether to get the vaccine but, rather, when.

The conversation about the vaccine is very different for my Paraguayan friends. I have not experienced vaccine fear among the Paraguayans I’ve known—which is to say their access to the COVID vaccine is not limited by personal belief but rather distribution.

I connected with all my friends in Paraguay on Easter, an important holiday in a predominately catholic country. I was excited to hear about their celebrations. In Paraguay, the week leading up to Easter is called Semana Santa (Saints Week) and is especially important. It is a time of sharing chipa (a traditional food that’s like a hard cheese biscuit) and enjoying the company of family and friends. Visiting has been limited this year because of continued concern for COVID, but my friends still report making chipa and enjoying the company of family.

When the topic of COVID came up, one of my friends said, “Estamos acá en la lucha, en Paraguay no hay vacuna, a nosotros es imposible recibir la vacuna…primero tiene que ser por las personas saludes, por los militares… y después recién por nosotros, dicen que van a inmunizarnos, pero no sé…por nosotros acá nuestra lucha es esperar la vacuna y quedar en casa. (We are struggling here, in Paraguay there is no vaccine, it is impossible for us to get the vaccine…first it must be for healthcare workers, for military personal…and then, after, for us. They say they’re going to vaccinate us, but I don’t know. Here our struggle is to wait for the vaccine and stay home.)”

This friend has been studying online since the pandemic began. She hopes to someday work in healthcare, but she is not able to go to the hospital to continue her clinical training for fear of catching COVID. One of her uncles was hospitalized for 15 days for COVID (he is doing well and made in home for Easter). Many of her family members caught COVID this March, but only the one uncle ended up in the hospital.

One of the things that continues to strike me about my Paraguayan friends is an unwavering optimistic outlook even though COVID-19 vaccination in just beginning in their country. My friend’s comment, “Here our struggle is to wait for the vaccine and stay home” struck me. She said it in a matter-of-fact tone that did NOT hint at frustration but, rather, exuded unwavering patience.  In thinking about my friends in Paraguay, I began to wonder if the closeness of families (not just emotionally but geographically) is a protective factor against feelings of isolation I’ve heard from many of my US friends. My friends in Paraguay either live with their parents and extended family or on the same block as them; compare this to my friends in the US whose families are spread out across distant states. This comparison reminded me that even though this pandemic has touched lives across the globe our shared experience is also a highly personal experience shaped not only by our uniqueness as individuals but also by the culture of the society in which each of us live. 

Medicine of the Mind

“It’s a privilege to learn their stories…really get to know people,” he said when I asked for his nugget of advice for us students as we continue our medical school journey. “In what time you think you have, try to know them [patients]…exercise your privilege.” Before we get into the weeds, let me clarify what he meant as this quote is just a piece of a longer conversation. By “privilege” he meant the honor of getting to meet patients and having the opportunity to hear their stories. By “exercise” he meant take the time to be a good doctor which includes getting to know people’s stories.

This piece of advice came from a retired psychiatrist who, as rumor has it, retired several times and each time his patients convinced him to come back to practice. The way he carried himself reminded me of my late grandfather – tall but not imposing, with straight white hair that covered just enough of his forehead, and a quiet voice. But more than how he carried himself, his curiosity caught my attention. He was an old human, an old physician at that, who the week before he gave the above advice had comfortably engaged in conversation about pronouns and transgender care. He was a physician who listened to learn when I offered a rudimentary definition of “nonbinary.” I’ve met many a young person, with far fewer years to settle into old ways, who showed less interest in uncovering the nuances of the human experience.

“Really get to know people.” His words made me hopeful because they showed that even at the end of a long career there are physicians who still have a passion for the human story as much as I do at the beginning of the Doctorhood Quest. Being only 5 weeks into working in the hospital as a medical student, I have a long way to go before I can offer advice to students. But, for now, challenge accepted good sir. Let’s see how I do in the coming weeks and years at uncovering stories while also learning labs, diseases, medications, and all the other factoids that will help me reduce symptoms and cure disease in the patients I see.

Pull Up Your Compression Socks

Some of my friends and family have asked how I study so much. Others just give me a funny look, shake their head, and say becoming a doctor is too much school. And, to be honest, I mostly agree.

And that’s were compression socks come in.

When I was studying for my first board exam (aka STEP 1 which is a 7-hour exam that lightly touches most topics in medicine from skin rashes to embryological development) I started wearing compression socks. Every day before sitting at my desk with mate and breakfast and before firing up my computer, I’d spend a few moments pulling on the rainbow or patterned compression socks I’d chosen for the day. I’d never worn compression socks before I started studying for STEP 1 – not while hiking multiple 10-mile plus hikes a week, not while working 10-hour shifts on my feet, and not while training for marathons on city streets.

But studying from well before dawn to well past dark did me in. The truth is that studying all day is terribly grueling in the most passive way imaginable. The body rebels against stillness, and my bodying not only rebelled but went to war. My calves became so tight I could hardly walk. They’d throb at night. They’d throb in the morning. My shoulders and back were full of knots. My hamstrings constricted to a fraction of their normal length. I have a standing desk. It only made my hips tight. And. Yet. The studying had to be done. To help get through the hours, I’d stretched when I could. My workout routine become very consistent because without it I couldn’t concentrate.

The compression socks fixed my calves. I discovered them by accident. My partner wears them at work to avoid varicose veins, and one day I tried on some of his socks. It was a game changer; I could study all day and my legs would be okay. Just okay, but okay was way better than terrible.

It seems a bit dramatic to say it feels like your body is going to turn to stone simply because you sit still too much. “How do you study so much?” family would ask me in the final weeks leading up to my exam. I never exactly knew how to answer. And now I realize why – because studying  in medical school is less about the “how” and more about the “why.”

Why do I study so much?

It comes down to the end. The goal. The reason I bothered to enter medicine at all. It is only knowing where I wish to go that makes studying so much that I must wear compression socks worth it. I didn’t come to medicine because I wanted to study all day. I entered medicine because curing diseases and helping people through sickness is the professional contribution I wish to make to our world. I had plenty of time before starting school to explore many different professions. But, the one that captivated me was medicine. Medicine combines puzzles, science, and true stories. I study so much because every piece of information about symptoms and labs and geography and humans is a tool that might help me understand what is ailing a patient. I don’t study because I like it, I study because I want all the knowledge tools I can fit into my toolbox brain so that when I meet someone’s grandmother, someone’s father, someone’s friend, someone’s brother in a moment when their health is faulting…I know how to help them heal. 

Goodbye For Now Vermont

It had been over 2 years since I’d set foot in the US and almost a decade since I’d lived in Vermont when I returned 5 years ago. In my time away, I’d forgotten that men might choose to grow beards, plaid shirts are stylish in some people’s eyes, and baggy pants on men (and women) are normal in some regions of the globe. I’d just come from a place where those things – beards, plaid, and baggy pants – were only seen on people experiencing homeness and overheating Peace Corps volunteers clearly out of place in the Paraguayan sun.

Yet, despite the plaid, the cold, and the lack of sun Vermont was better than I remembered it. It was nice being in a place where I was confident everyone I talked to knew how many legs a chicken has (I’ve met people in the urban US who don’t). When I arrived, I wasn’t too worried about liking Vermont. I thought that I’d just come back to start my journey to medical school and that was all. Vermont had more in mind.

I started my pre-med classes which can easily be summarized like this: I’d write a lab report then revise it until it was so boring it made me yawn. Only if I was absolutely bored reading a lab report could I be sure I’d get an A on it.

As part of the journey to medical school, I became an EMT. I remember being petrified showing up for me first EMT shift. My nerves eased when my crew chief (who’d started working on ambulances over a decade before I was born) told me in a matter-of-fact voice that the crew would not let me kill anyone. Our crew would have dinner together every shift (unless we got a call and had to jump in the ambulance). We’d talk about patient cases, science, sci-fi, trucks, and cake. We’d get 2 am calls. I learned to write patient reports in the middle of the night. I practiced finding things to talk about with anyone – an important skill when you have a stable patient and a 30 plus-minute ambulance ride to the hospital. I saw hoarder houses. I learned what it looks like when people fall and can’t get up. I saw what happens when a blood sugar gets too low. I reinforced the knowledge that drunk humans are poor historians.

After running all night (that’s what we called being on the ambulance responding to calls), I’d change into my business-very-casual work clothes and go to work. Then class. Then lab. The hours studying merged as they always do. But, as I prepared for the MCAT (an entrance exam for med school) I knew exactly who to ask to explain some of the physics concepts that weren’t sticking – the brilliant kid with the Vermont accent on my ambulance crew. He’d driven trucks almost as long as he’d been walking and hadn’t done much school. He was smart and if he’d wished to follow different stars he could have. 

“I don’t know the physics equations or anything,” he said when I asked if he could explain how hydraulic lifts work and the physics of pistons.

“That’s not an issue, you understand the concepts,” I said.

I could do pages of equations and get the answer, but it was the meaning behind the symbols and numbers I wanted. And as he drew out a dump truck to explain hydraulics, drawing to explain just as my father and step-father always do, I realized that I liked the people in Vermont more than I’d expected I would.

School, my first job after returning to Vermont, and my time on the ambulance ended around the same time. I transitioned to a new job as an EMT in the emergency department (ED). I learned how to place IVs and draw blood. I saw how the brain, heart, and bones can break. I sat with families as their loved ones died. I saw babies be born and people smile despite the unluckiest circumstances. I learned from fellow EMTs, nurses, and other key players in the ED. The ED attracts fiery spirits and I enjoyed being among them. The patients came and went – suicidal thoughts, dog bite, chest pain, weird rash, car crash, fall, stroke, homeless, ski accident, rape, stomach pain – and I learned about humanity. Healthcare gave me a new angle from which to view Vermont. I saw the stoic Vermonters I’d known growing up. I saw people who had just immigrated to this frigid, snowy state. I met people who have the lives that make up the opioid epidemic. I met folks like me and very different from me.

The people of Vermont gave me a window into medicine. I got into medical school and I decided to study at our state school.

While much of my time in Vermont has been centered on learning medicine, that is not all Vermont has been. I rediscovered the mountains and the forests. I spent countless hours walking along Lake Champlain. I heard the hermit thrush sing as I wandered in the forest. I was reminded how both loud and quiet the trees are. Between the mountaintops and the lake, I also found my life partner. We were hiking and feasting buddies at first, but life has a way of pushing the limits of friendship. I also found friends with whom I cackle and giggle, enjoy the sunset and a stroll, and who I know are standing by ready for anything when the going gets tough. And the going is tough sometimes because becoming a doctor is a long road.

Since returning to Vermont, I rediscovered why Vermonters are stubborn, fierce, loving, and independent – just spend a winter here and you’ll understand. And, while Vermont has been so much more than I imagined, I must say goodbye for now. Every time I leave a place, I can not promise I’ll return for good or stay away forever. I can only promise that the people and hidden hallows that shaped me while I was here will always be with me no matter where I am. As I look ahead to the last years of medical school, I plan to complete them in Connecticut (my Vermont medical school has a clinical partnership there).

With excitement that I’m moving once again to a neighborhood where we speak Spanish and with a heavy heart for the dearest friends I’ve left in my home state let me say, “Until we meet again dear Vermont, may the snow be deep in winter and the summer be sparkly and green.”