Author Archives: Jett

Listening to the Birds

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As our appointment was ending, I congratulated the patient on getting fitted for new hearing aids earlier that day.

“Yes, we are looking forward to the new hearing aids,” the patient’s spouse said. The hearing aids would be shipped to them soon. “They love hearing the birds. They know all the birds’ names.” The spouse paused. “I miss them telling me which birds we hear. Now I’ll say, ‘Hear that bird?’ and they’ll say, ‘What bird?’ because they can’t hear it singing.”

As my patients like to tell me, “Getting old is not for the faint of heart.” Being not as old as them, I don’t know what it feels like to be their age. But, having worked with hundreds of people as they age, I’ve had the opportunity to observe what getting old is like. Perhaps the most interesting thing is that no two people experience aging the same way. Despite the variation, there are some truths I think are universal about aging: 1) one cannot do everything at 80 that one could do at 20, 2) life experience cannot be erased, and 3) attitude matters.

The happiest old people I’ve met are those who embrace aging as life’s reality. They are flexible and willing to adapt their goals and expectations to meet their ever-changing body and mind. For some people this means that they give up the independence they once cherished. They turn in their car keys forever, accepting that their slow reflexes and poor vision have made them dangerous drivers. For others, they let their children or other trusted people help them navigate new technology that they don’t understand because navigating that technology is essential for life admin (like bills) and connectivity (communicating with others). Others relinquish their identity as the one who cares for everyone else and accept help from people they previously cared for. Going from the person everyone depended on to the one that depends on everyone else is one of the hardest transitions I’ve witnessed my patients make. Whatever transitions people go through as they age, they are huge and require self-reflection and grit.

And while aging is a lot about the mind, it is also about accepting that our bodies change with time. The most resilient old people I’ve met are the ones who are flexible not just with how they approach life, but also with what they expect of their body. Many elderly people remain healthy and independent until they die. But even in healthy old people, their bodies are not what they were at 20. They simply move slower and, perhaps, are less physically strong. The happiest old people I’ve met know that their slowed body is not a sign of weakness, but a sign of wisdom. The happiest old people I know, continue to challenge themselves in new ways that they could not have imagined in their youth. They do not have the same expectations of themselves that they did at 30 because they already mastered being 30.

As people age, it is common for them to interact with the health system more than they did in their youth. Regardless of how many diseases and ailments an elderly person develops, I’ve noticed that the ones who endure the hospital and their doctors’ appointments best are those who accept that caring for an aging body takes lots of time. They dislike spending days in the hospital, but they also know that sometimes that is an adventure they must undertake. They weather their healthcare interactions with inspiring patience and endurance.

My clinic day ended hours after the patient who couldn’t hear birds anymore left. As I walked to my car, I thought about how much I loved listening to birds sing. I thought about how hard it must have been for that patient to realize, perhaps all at once or perhaps over time, that they couldn’t hear the birds anymore. I hoped that their hearing aids would help them. What a strange goal to have, the goal to hear birds again. The goal of regaining something previously taken for granted. I wondered what my goals would be when I was that patient’s age. I hoped I had as much perseverance as they had.

The Strength of a Mother

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Her son was dying. Yes, we were keeping him alive in that moment, but he was dying anyway. We could not fix what was killing him; it was simply too progressed. There was no way out except death. We knew this and, perhaps, he knew it too as the soul peeking through his eyes became more distant and the fear that had been there was replaced by blankness. He was too sick to make his own decisions. The decision about what to do fell upon his wife. Having to make decisions about the end of her husband’s life tormented the patient’s wife. He was a fighter and he had always told his wife he wanted to live. The patient’s wife could not imagine life without her husband. She felt alone. She feared past demons reemerging when he left her. Yet, the fact remained that this wife’s husband, this mother’s son, was dying. As the plan stood, he was dying slowly.

It was under these circumstances that the mother and wife sat down to talk with us, the patient’s care team, to discuss how the plan could change to reduce suffering. We described the options. There was the option to continue forward as we were; using every medication and intervention we could to keep the patient alive. We explained that this would be futile and would still result in death, but the decision was theirs. The second option was to stop the medications and interventions keeping the patient alive and replace them with medications and interventions to keep him comfortable. We could not predict the future. We guessed he would die within days if we turned off the medications currently keeping him alive. He would die more quickly without medications to raise his blood pressure and transfusions to replace his red blood cells and platelets, but he would not suffer because we would treat every symptom he had from pain to breathlessness and anxiety to insomnia.

After we described the above options, the wife began crying. She accused the healthcare system of missing something. Of not doing everything. If emotions were tangible, then this wife was the physical manifestation of agony. That’s when the mother spoke.

“This is not their fault. I believe them… I believe that they have done everything they can.” The mother paused. “I have cared for my son his whole life. I have loved him and fed him. He is my son. I will not see my son suffer. I do not want my son to suffer like this.” The mother paused again. “My son is already gone. I see it in his eyes. He is not there. It is time to let him go.”

The conversation unfolded between the mother and wife. The care team was there as witness but it was not our conversation. It was not our right to decide what happened next.

“I am all alone. I am afraid,” the wife said.

“You are not alone. You have me,” the mother said. “And if you have me then you have my people because they do what I say. I will stand by you.”

The patient was one of this mother’s children. The mother was old enough to have grandchildren and great-grandchildren. In the days leading to this conversation, it became clear how large her family was from how many visitors the patient had. The mother sat tall and confident. She spoke with sadness and wisdom. She spoke as someone who had seen others die before.

“I will not see my son suffer. Let’s do this together. We will do this together. Let him go,” the mother said. “I know my son. He is gone. You can decide, but I will not visit again because he is already gone.” The mother paused and held the wife’s hand. “We will do this together. We will mourn together.”

The patient died less than a day after he was transitioned to medications to treat only his symptoms. Most of his family had seen him prior to his death. I will never know how the story of the wife and the mother unfolded after the patient’s passing. Yet, I believed the mother when she said she would be there for the wife. From the conversation I witnessed it was evident that the patient’s mother knew more about life and death than most people; she had a knowledge gained over her lifetime. She also knew her son as only a mother could. The guidance and support the mother offered the patient’s wife as the patient died were some of the bravest acts I’ve witnessed.

The Difference of One Day

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The Doctorhood quest is a journey with finite phases.  To reach the next phase you must pass through the hurdles of the previous phase. Like all quests, each phase must end. Now having passed 2 phases, I’ve noticed that the transition between the phases is jarring.

I recently finished my first year of residency, called “intern year.” In the Doctorhood quest, many consider intern year the hardest phase because it’s the time when you begin to practice as a physician and know the least. You are a student one day and then the next day walk into the hospital with your new title of “doctor.” You find yourself with a mountain of responsibilities that you aren’t sure how to manage. It’s a bit of a joke because one day does not make a physician. So, even though you have the “doctor” title starting the first day of intern year, the difference between an intern and a student only begins to emerge as the months drag on. By the end of intern year, you find yourself teaching medical students and realize that you are, in fact, more knowledgeable than you were 12 months prior.

A similar transition exists between intern year and the second year of residency. In my residency program, we even get a new badge declaring us “resident physician” rather than “intern physician.” One day you’re an intern, working under 2-3 layers of senior physicians and the next day you’re a resident with only a very senior physician overseeing your work. As an intern you always have a resident to ask for help. When you’re a resident you’re the one that the interns turn to with questions. Of course, there are people who teach and help you as a resident, but they are more distant and more senior than before. As a resident, you are expected to find answers to many of your questions and you are expected to make many decisions on your own.

On the second day of my second year of residency, a physician who has been teaching residents for years entered the room to lead one of the educational sessions we (residents) have weekly. Before he started his lesson, he acted out strutting down the hall as James Bond does, “Now that you’re all residents you even walk differently. You have that swagger,” he said. We all laughed. A day does not make a physician. A physician is made over years. Today I feel like how I felt during the last days of intern year because the time between today (early on during my second year of residency) and the end of intern year is short. I’ve been questing long enough to trust the process. I know I’ll feel confident as a resident by the end of this year. And, who knows, maybe I do walk the hall a little differently now than I did a year ago. I did, after all, forge intern year and live to tell the tale.

About Those Weight Loss Drugs

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Several friends asked my opinion on a group of weight loss medications called “GLP-1 receptor agonists” like semaglutide (Wegovy). Specifically, they asked me: 1) Are these drugs cheating? and 2) Will these drugs worsen stigma and mistreatment of people who live in large bodies?

These questions are hard to answer concisely. I am going to try. I will first clarify several concepts then answer each question individually.

4 Foundational Concepts

1) GLP-1 receptor agonists aren’t a silver bullet. They can have serious side effects including severe nausea and vomiting, kidney injury, gallbladder disease, and pancreatitis. Some people who try these medications can’t continue them given the side effects they experience. Another challenge is that GLP-1 receptor agonists can be too expensive for patients to afford because insurance companies don’t always cover them and there is no cheap generic version available in the US.

2) BMI (body mass index) compares a person’s weight and height as a tool to understand if their weight has a negative impact on their health. It is flawed. BMI was developed using mostly data from white men. Half of my patients aren’t white. Another half of my patients aren’t men. So, the BMI brackets of “underweight,” “healthy,” “overweight,” and “obese” don’t perfectly describe most of my patients because they aren’t white men. BMI is also flawed because it does not describe body composition (fat vs muscle vs other) which is relevant to how weight affects health. As such, BMI is complex to interpret when someone does not fall at one extreme of the scale. Despite its flaws, BMI is helpful when used with other information (like waist circumference, labs, vitals, history, etc.) to understand how a person’s weight affects their health.

3) Obesity has a specific definition based on BMI and several other factors. The most basic definition of obesity is a BMI ≥30 kg/m2.

4) Obesity is a disease with a multifactorial cause. Obesity is NOT caused by weakness or lack of self-control. There’s growing information about the genetic and environmental contributors to obesity. Additionally, there are certain medications that some people need to live given their other health problems that contribute to weigh gain. Like many other diseases, personal choices can contribute to the development of obesity. Personal choices, however, do not define or explain obesity completely.

Are these drugs cheating?

No. GLP-1 receptor agonists are useful because we know that weight loss is more effective with them than with diet changes alone. GLP-1 receptor agonists are ONLY approved for weight loss in people who have obesity or people who have a BMI ≥27 kg/m2 with a condition that is likely a complication of their weight like diabetes, high cholesterol, or high blood pressure. Weight loss in these populations is important because it will improve their overall health and, importantly, lower their risk of heart disease. Heart disease is the leading cause of death in the US so it’s serious.

Note that GLP-1 receptor agonists were first approved to treat diabetes (regardless of a person’s weight) and continue to be used for that purpose. These medications are also recommended as part of the treatment of chronic coronary artery disease in specific situations.  In other words, not everyone on a GLP-1 receptor agonist is taking it specifically for weight loss.

Will these drugs worsen stigma and mistreatment of people who live in large bodies?

They shouldn’t since they are proven treatments for specifically defined diseases (just like most other medications we use). Subjective judgements of body size that classify people as having a large body aren’t good predictors of people’s health status. It’s important to realize that what societies and individuals consider a “large body” is often based on cultural and individual beliefs and is variable. When looking at weight from the medical perspective, we use specific objective data like BMI and other medical information (like body composition, labs, and vitals) to estimate how likely a person’s weight is to negatively affect their health.

While not all people with large bodies (from the perspective of society) have obesity or negative complications from their weight, some do. If my patient’s weight negatively impacts their health, it’s my job as their primary care physician to include weight loss as part of their medical plan to help them live a long and healthy life. Weight loss medications are one tool in the toolbox.

My goal is to treat people with compassion and respect. I believe that if I continue to strive to practice medicine that is fair and kind regardless of my patient’s body size, I can help reduce the stigma placed on people with large bodies. GLP-1 receptor agonists can help people with obesity lose enough weight to lower their risk of developing heart disease and other complications associated with obesity. The opportunity to help people achieve their best health is one reason why I went into medicine. I’m excited that we have the GLP-1 receptor agonists and will continue to recommend them when medically indicated.  

References:

StatPearls, “Glucagon-Like Peptide-1 Receptor Agonists”: https://www.ncbi.nlm.nih.gov/books/NBK551568/

Cureus, “The History and Faults of the Body Mass Index and Where to Look Next: A Literature Review”: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10693914/

Clin Med, “Causes of obesity: a review”: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10541056/

New England Journal of Medicine, “Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes”: https://pubmed.ncbi.nlm.nih.gov/37952131/

CDC, “Heart Disease Deaths”: https://www.cdc.gov/nchs/hus/topics/heart-disease-deaths.htm#:~:text=Heart%20disease%20has%20been%20the,excessive%20alcohol%20use%20(2)

How does one deliver healthcare justly in an unjust system?

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I recently cared for a patient with a life-threatening bleed. They bled because their blood thinner level was too high. They were on a blood thinner to prevent stroke in the setting of a chronic abnormal heart rhythm (called “atrial fibrillation” or “Afib” for short). Afib requires life-long anticoagulation to prevent strokes. Afib puts you at risk of stroke because it increases the risk that clots will form in your heart and then travel to your brain causing stroke.

The patient’s blood thinner was called “warfarin.” Warfarin is an old, cheap blood thinner. The problem with warfarin is that its blood levels are affected by many things such as diet and other medications. Because of its fluctuating levels warfarin requires frequent monitoring (with blood testing at a clinic). Warfarin is notoriously difficult to manage. This patient’s warfarin levels were high likely because of a different medication they were prescribed for a short time.

For Afib, we have several other equally effective blood thinners that are a lot easier to manage than warfarin. The patient wasn’t on one of these alternative blood thinners because they couldn’t afford them. The most common alternatives to warfarin for use in Afib are Xarelto and Eliquis.

The manufactures of Xarelto and Eliquis each offer a one-month free coupon once in your lifetime. So, if you use each coupon (the two medications are similar enough you can use them interchangeably in this situation), you can get 2 months of free blood thinner. After that, there are programs that might help you either get a reduced price or free access to the Xarelto/Eliquis for 1 year. So, maybe you can get 14 months of cheap Xarelto/Eliquis. Let’s say you’re 50 when you are diagnosed with Afib. You’ll be 51 or 52 when you must figure out how to pay for your blood thinner for the rest of your life (likely 20-40 years).

You might ask, “Can you use GoodRx (or a similar application that compares drug prices and offers recurring discounts) and figure out the cheapest place to get Xarelto or Eliquis?”

Answer: You can. When I wrote this you could get 30 tablets (one month’s supply) of Xarelto at Wegmans for $555. This was the cheapest option on GoodRx. Eliquis was similar in price.

With the above information on Xarelto’s cost you might then ask, “How does the price of warfarin compare?”

Answer: When I wrote this you could get 30 tablets (one month’s supply) of warfarin for $4 at Walmart.

The decision (in this case) between Xarelto and warfarin isn’t really a decision because your finances determine what you can afford regardless of the medically recommended option or the comparative risks/benefits of the medications.

The average American salary was $59,500 in 2024. Xarelto at the above price would be $6,600 a year or about 11% of that average annual salary. The price of Xarelto/Eliquis doesn’t change regardless of how much money you make. Your other expenses including other medications, food, transportation, and housing don’t change regardless of how much your blood thinner costs.

I use this case as an example, however the list of medications that are too expensive for people to afford when they don’t have insurance or when the medication is not covered by insurance is lengthy. If you’re curious, check out GoodRx. You can look up any medication there, see what discounts they offer, and look at the retail prices of that medication. You’ll notice that the retail prices and the discounts are different at every pharmacy (Walgreens, Walmart, etc.). That’s how corporate healthcare works. Each corporation negotiates drug prices with drug companies. Some countries regulate the prices of medications sold in their country to help ensure more equitable access to medications – the US doesn’t.

How does one deliver healthcare justly in an unjust system?

You don’t.

You try.

You fail.

You try again.

References:

Forbes Average annual salary: https://www.forbes.com/advisor/business/average-salary-by-state/

GoodRx: https://www.goodrx.com/

She Must Be Just a Number to You

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“You see so many patients, she must be just a number to you,” the patient’s son said as he watched me perform the official exam declaring his mother dead.

“We care about all our patients and take the best care of them we can. Of course, I haven’t known your mother for as long as you have. You’ve known her your whole life,” I said. I finished my exam. I stated the time of death, gave my condolences, and left the room.

I had pronounced a patient dead almost daily that week. During this patient’s exam my emotions were not the emotions of a son who had just lost his mother without much warning. My emotions as the patient’s physician could not be the same as her son’s. I was sad, of course, but I also knew we had done everything we could for her. As a physician I must balance being emotional and being clear-headed so that I can make objective decisions about how to help patients with their medical challenges.

In medicine we push to the edge of current scientific knowledge, yet we are not capable of magic or miracles. We cannot predict the future and we cannot stop the inevitable. Death is part of life. Since medicine in the science of life it inherently involves death.

As a physician my mission is to prevent and cure disease and reduce suffering. A lot of suffering can happen when a person is gravely ill. Part of my job is to recognize when the fight for life is futile. Once the fight becomes futile, anything we do to prolong life also prolongs suffering. It is at the time of futility that I can offer a path that leads to greater comfort and death with dignity. This path requires a shift from a goal of prolonging life to one of promoting comfort. To stop fighting death is not a decision to take lightly. Further, the decision must be made by the patient or their appointed decision-maker (when the patient is too sick to decide). I can only offer guidance as part of the patient’s care team.

This patient, the mother of this son, had fought for her life. She had maxed out every treatment we could offer. She had failed other treatments. When she was worsening, we called the family to come into the hospital. When everyone who needed to be there was at her side, we turned off the medications and interventions that were keeping her alive. We did this because to keep those medications and interventions going would not save her. She would die regardless. She was suffering. Most importantly, she had made it clear when she was well that she would not have wanted to keep going in these circumstances.

When we turned off the medications and interventions keeping her alive, we gave the patient medications to treat her discomfort. She had pain, shortness of breath, and anxiety. She died shortly after we changed our approach from treatment to comfort. She died peacefully and surrounded by the people most important to her. None of this struggle made her a number. She was a person who had fought bravely and died with dignity. And, sometimes, that is all we can offer in medicine – a place that illuminates a person’s intrinsic bravery and permission to stop struggling.   

I have seen and will see many people die. My role in these circumstances is not a counting role. As a physician I ensure my patients get the best treatment available when there is a fight to have and the most comfort possible when there is no fight left. My role is to adhere to their wishes regarding their life and death as best as I can within the constraints of medicine. These are serious responsibilities that are both rewarding and harrowing. Rewarding because I know my patients receive the best care we can offer and a death as close as possible to what they would want if they had a choice. Harrowing because it is hard to lose someone I cared for and because I feel each patient’s loss, not as a friend or family member, but as a partner in the patient’s battle against death.

Being a physician has made me realize exactly how people aren’t numbers. It is my job to learn my patients’ stories and to partner with my patients to tackle their health goals. What happens to my patients is partially a reflection of how well I did my job and partially a reflection of the complexity of being human. The depth of the patient-physician relationship is part of the reason I chose medicine. My patients’ stories are sometimes tragedies and my relationship with my patients is sometimes difficult, but the opportunity to heal, cure, and reduce suffering is enough to make those challenges worth it. I am grateful for the opportunity to take part in my patients’ lives. Grateful even if we meet under extremely unfortunate circumstances. Grateful even if we meet at the end of their life.

Lost to Follow Up

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Two different cancer screening tests came back positive. The patient needed additional testing to see if they had these cancers, but the threat was real and could be life changing. As the months went on, the referrals I had put in for the follow up tests came back – “unable to reach patient,” “failed scheduling effort,” and finally “referral canceled as unable to reach patient, reorder if still clinically indicated.” The patient missed their follow up appointments with me. I saw, however, the ongoing social work notes in the chart. Half of these notes stated they couldn’t reach the patient and half suggested contact. Perhaps it made sense that this patient wasn’t attending to their cancer diagnosis/rule out follow up appointments. This patient had big fish to fry without cancer. They were struggling with drug addiction, didn’t have secure housing, and weren’t sure where they’d get their next meal. The electronic chart, filled with short notes attempting objectivity written in the same font used in 1980s faxes, told a story. The story was both an epic and a tragedy.

This patient was lost to follow up. Would we ever find out if they had cancer? Did it matter? Would they die before medicine could help them? Was medicine really what they needed? As I watched the story unfold, Maslow’s Hierarchy of Needs surfaced in my mind. This patient’s basic needs weren’t met – food, safety, and a place to stay. Cancer was so high up the pyramid of needs it seemed silly to discuss. Though, was it really that high up the pyramid? I know what cancer can do.

Health is multifactorial. Only one piece of health is access to quality healthcare. This patient was focusing on several nonhealthcare pieces of health – safety and security of the physical body. Perhaps they were also focusing on finding their next meal. Perhaps the recreational drugs they used were treating demons of a past filled with trauma. This patient was part of a healthcare system with robust social services to help with social problems like housing and food insecurity. Interestingly, the social services this patient could access are exceedingly rare in the US. Most health systems don’t provide these services and most insurances don’t cover them.

I hoped the patient’s basic needs would be met. I hoped that when those needs were met, they’d return to clinic so we could start the cancer investigation process. I hoped it wouldn’t be too late. Even as a physician I don’t get to write the story of other people’s lives. As the story in the chart unfolded, I was grateful that the patient was receiving social services. I was frustrated that in most other US healthcare systems a different patient in the same situation would receive no help of any kind.

“Lost to follow up” is the phrase we use for patients who disappear from healthcare. It’s a term that provides a label, but it doesn’t explain where these patients go and why they disappear. The label can have negative connotations because it’s easy to be frustrated when patients don’t want to take our (their doctors’) advice and follow our carefully designed plans. It’s easy to forget our patients (just like us) are products of the social determinants of health. It’s easy to forget (just like us) they have lives filled with complex situations regardless of their use of healthcare.  

I’ve found that it’s worth stepping back and trying to see why patients decide to become lost to follow up. When I do this, I often discover that they aren’t lost at all. Rather, they are fighting for the most important things in their lives at that time. And the important things they see are usually different than the important things I see. Since patients are the experts in their own lives, they are often right about what’s most important. Frequently nonmedical things have a greater influence on patients’ decisions than their health needs as dictated by their doctor.

As the alerts came to my inbox for missed tests, I thought about the patient the first (and only) time I met them. They had answered all my questions thoroughly and without hesitation. I wondered if I’d see them again. I hoped they returned to clinic before anything devastating related to their maybe cancers happened. I cleared the alerts. The patient would write their own story; I’d be here if they invited me to partake in another chapter of it. Even tragedies sometimes have plot twists and happy endings. I always (and unwaveringly) root for happy endings no matter how stormy the story becomes. 

References:

Wikipedia on Maslow’s Hierarchy of Needs: https://en.wikipedia.org/wiki/Maslow%27s_hierarchy_of_needs

Article on the importance of the different determinants of health: https://pubmed.ncbi.nlm.nih.gov/26526164/

HHS overview of the social determinants of health: https://health.gov/healthypeople/priority-areas/social-determinants-health

WHO overview on the determinants of health: https://www.who.int/news-room/questions-and-answers/item/determinants-of-health

The Doctor’s Dilemma

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Being a physician is a career that can become one’s life. There are many reasons for this including the 24/7 need for healthcare, the pressure from healthcare business for productivity, the need for advocacy to improve the system and increase health equity, and the desire to help others. There is also the added stress that medicine literally deals with people’s lives and wellbeing. Given these career features, being a physician historically was a way of life, not just a job.

Despite the historical trend that being a physician was a way of life and an identity that trumped all others, there has been a shift in recent years. This shift started some time ago and was, perhaps, expedited by the COVID-19 pandemic and the severe toll it took on all healthcare workers. The shift is that newer ages of physicians don’t just seek to be doctors – they seek to be partners, parents, athletes, cooks, travelers, readers, vacationers, relaxers, and gardeners to name a few identities they claim beyond the physician identity.

As a member of the newest generation of physicians I find myself caught between the old dogma that to be a physician is to prioritize it above all other aspects of life with the newer view that to be a physician is to be a person with a serious career. I think of these completing identities of “way of life” vs “profession” as the “doctor’s dilemma.”

Sometimes self-imposed and sometimes externally-imposed the training physician (and all physicians really) are driven to do more. More reading and learning, more shifts, more leadership roles, and more research. It’s hard to balance the forces urging me to do more with the desire to also do nonmedical things like spend time with my husband, hike, and write. My medical training has taught me to hustle, be efficient, and work for long durations of time with high focus. As my training continues, I’m also learning how to say “no” and pump the break. Of course, these learnings are contradictory. The pendulum falls sometimes more on the hustle side and sometimes more on the relax side.

As I finish my 1st year of residency, I’ve been thinking about the doctor’s dilemma because in the remaining years of residency I’ll make decisions about my post-residency career path. While I contemplate my career’s trajectory, I also find myself thinking about other things in life. For example, living in a city apartment has made me miss walking barefoot on grass. I don’t suspect I’ll own a house anytime soon, but missing grass has made me think about homeownership more than ever before.

What do I put on hold and what do I pursue? What opportunities if not taken now will disappear? Where do I want to be in 5 years?

While wellness preaches “live in the moment” heavy careers, like doctorhood, require forward thought. Doctorhood requires the balance and blend of one’s professional dreams and identity with one’s personal dreams and identity. During my 2nd year of residency, I’ll become a team leader and gain more independence. With this greater responsibility doctorhood feels more serious than it did as a new resident when I had more people guiding me. As my training continues, it is my turn to step up with the answers. Patients will depend on me. Each choice, like whether to study or run, has a ripple effect on my future and (perhaps) on my patients’ futures. There simply isn’t enough time to “do it all” at the same time. Choices must be made along the way. The choice options are what pose the dilemma.

A Letter to My Intern Self

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Dear About-To-Be-Intern Self,

Intern year (as the first year of residency is called) is going to be tough. At times, in fact, it’s going to be downright awful. There will be stretches where you don’t see the sun and can’t remember the last time you felt anything but exhausted. The trend you noticed in medical school, in which current physicians and administrators don’t value your time (and waste it) and then wonder why your mental health is poor, will persist. You will be told by some to do more because “you’re a doctor now” and you’ll be belittled by others because you’re new and you don’t know what they think you should know.

You will be impressed by how your health deteriorates intern year. You are welcome to take some of the blame for your decline if you’d like, but the truth is that everything about intern year is the opposite of the wellness advice we give our patients. From your sleep schedule to your stress level, or from the food the residency program gives you to your work hours, there is very little healthy about intern year. It would be misleading to ignore these negative things that will unfold, one way or another, as they have for every intern. They manifest a bit differently for each person, but their occurrence is a guarantee.

Like all things in life, the negative of intern year is paired with the positive of these 12 months. First off, you’re paid – a huge victory after 4 years as a medical student. Your salary will be meager compared to your future salary (and it will be poop if you calculate the hourly rate) but remember that the intern salary is higher than the average annual income of Americans. Second, you are a doctor now. A real doctor. This title, alone, allows you to meet the most extraordinary people and hear their amazing stories. People will tell you things they never told anyone else. Your kind patients and your brave patients will be beacons helping you through intern year.  Focus on remembering the kind and brave patients more than the hard and mean patients; it’s the opposite of what your mind will want to do. I assure you that remembering the kind and the brave will help you more than you realize.

There will be difficult senior residents and supervising physicians; there will also be amazing ones. Take a moment to appreciate the inspiring senior residents and supervising physicians and reflect on why you respect them. You’ll be in their shoes before you know it and you can learn from them. Let the degrading and unkind supervising physicians and residents bounce off you; let them be a lesson of what you do not wish to become. The same goes for the nurses and other staff in the hospital. Nurses will be your biggest nightmare and your biggest savior throughout intern year. A knowledgeable and respectful nurse is gold. Thank the hard working and thoughtful nurses. Learn how to navigate the mean and not patient-focused nurses. You’re a doctor now and, once intern year is over, you’re going to be a team leader. Intern year is about getting ready to be a leader.

No one is good at being an intern when they start. Every intern gets better at medicine, navigating the healthcare system, and working with the interdisciplinary teams of healthcare. You won’t notice how much you’re learning at first. The days will pass slowly and the weeks quickly – before you know it, you’ll wake up and realize that you are a new version of you. You’ll blink and a new July 1st will be just around the corner. Then, intern year will be behind you…forever. I’m not delusional enough to say, “enjoy it while it lasts.” I am delusional enough to say fight for your health (because you’ll need to) during this year and soak up as much knowledge as you can. In the end, intern year exists to help you get closer to becoming the best doctor you can be. Intern year will force you to grow. It will challenge and push you to a new level. Always remember that intern year is finite and only one small phase of the Doctorhood Quest. It will pass.

You go this. I know you got it. At the end, you’ll know you got it too.

Yours truly,

Jett

Space

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I often think about space, specifically taking up/claiming space. My most conscious ponderings about space are while I’m running in the park near my house. I’ve observed that people are more likely to step aside for a male runner than me, a female runner. It’s so blatant that when my husband and I are running or walking together we strategically put him on the outside because people move over for him and not me. It’s an annoyance. I’ve started to run strong and serious. I’ve learned that a confident stride and a squared shoulder do help remind people that women also deserve to run without stride interruptions.

Guarding my lane while running is a newer claim of space for me. The first time I claimed space was changing how I sat. Changing my sitting stance was a project that took the better part of my twenties. For some reason women in my culture are taught to sit small and closed. I’ve found that sitting small is counterproductive. It has (perhaps) made it easier for males to harass me on public transportation and (definitely) made it easier for my colleagues in healthcare to ignore me. These days I try to sit large and open, just like my culture teaches their boys to sit. I don’t take the inside seat on the train/bus (that’s more for safety as I’ve learned the hard way) and I take up my whole seat even when it’s wider than I am broad. If there’s a seat at the table in a conference room, I take it. Which brings me to medicine, my most recent occupation (both meanings of occupation, wink, wink).

I have a very distinct memory from medical school related to being a female in medicine. I was mid-sentence presenting my section of a group presentation when a male member of my team cut me off, talked over me, and started his section of the presentation without letting me finish. It was so rude that several females in the class texted me in solidarity. The experience made me think about why seats at the table are not enough on their own. Seats must be claimed and, sometimes, defended.

Being a first-year resident brought with it a whole host of interesting space claiming challenges, many simply related to being a new doctor and some related to being a female physician. Filling the role of physician involved learning how to defend and explain my medical decisions, striving to take the high road and set boundaries when other members of my interdisciplinary team did not, and observing how physicians I admired conducted their doctoring and led their teams so I could model their techniques.

The challenge of being a new doctor exists for all new doctors. But filling the role of a female physician comes with its own occupational hazards. Here are some concrete examples from the past year of times I was reminded that I was female while at work:

  • I frequently must remind my patients that I am not their nurse — a challenge that my male counterparts don’t have.
  • My name is gender neutral, so nurses often think I’m male when communicating electronically with me before they meet me in person. (We have a secure chat in our electronic health record system that we use in the hospital). It is interesting to see how nurses’ tones change after they discover I’m female when they originally thought I was male. At times the tone change is dramatic and frustrating because I get more pushback as a female than as a male physician.
  • I have been lectured by a male supervising doctor about what clothes a doctor should wear. The lecture was somewhat confusing given that all the female residents wear exactly what all the male residents wear… scrubs of similar fits, styles, and colors. I doubt any male resident teams have been subject to such a lecture, but my all-female resident team was.
  • Several times I have found myself uncomfortable on rounds (that time of day when you talk about all your patients with the supervising doctor) because the male supervising doctor was very good at looking at my chest but never made eye contact.

The above situations illustrate that there are additional features of the medical terrain that female physicians must navigate that their male counterparts don’t experience.

As my second year of residency approaches (starts July 1), I’ll soon find myself no longer a first-year resident. In my second year of residency, I’ll start to be a team leader and I won’t be the new kid on the block anymore. I’m excited about this next step in my training. I feel ready to take on the challenge knowing I’ve learned a ton already and have a ton more to learn as a physician. I continue to have much opportunity for growth on my journey to lead with humility and excellence. As I wait for my second year to begin, I’m curious what the phase of “senior resident” (my title during my second and third (last) years in residency) will be like and the space challenges it will present. All adventures have space challenges however they present themselves in different ways.