Category Archives: Doctorhood Quest

Thankful

Posted on by

This post comes after a several-month blogging hiatus. The break wasn’t intentional, but life has a way of carrying us forward in unexpected ways. The past few months I continued to write, but in a different genre. I drafted several novels. I have two fantasy series that occupy my imagination currently. I’m not done with them. Novel writing is a long-term project, like most things in my life. Yet, despite stories unfinished, the flow of my days has brought me back to this blog. Afterall, the doctorhood quest isn’t over. It begs the question of whether the doctorhood quest will ever be over as there is always more to learn, but that introspection can be left to the future.

The past few months oscillated between easy schedules with plenty of time to contemplate life and my least favorite part of residency, night shift. I’m gleeful to report that I finished my last scheduled night shift of residency last week. Of course, I’m in residency. Another week or so of nights will sneak into my schedule before I graduate. Such is the way of residency, unwelcome and unfriendly work schedules. I skipped Thanksgiving because I was on night shift. I celebrated Christmas on November 30 because December is a doomsday schedule in my residency program. I wrote this blog at 3 o’clock in the morning because my sleep-wake cycle was still upset from night shift despite a week of day shifts under my belt. Schedule challenges aside, December is a month of reflection and giving thanks. I find myself in an interesting place – seeing how far I’ve come while also noticing a long road ahead.

I have 7 months left of residency. I have a job for post-graduation (more on that in a future post). I completed the administrative hoops to get official physician’s licenses. I scheduled my last exam – the board exam. Once I pass the board exam, it signals that the past 9 years of training taught me what I need to know about doctoring…at least on paper. Completing those tasks is enough to be grateful for without needing to look below the surface or consider the complexity that made them possible. But giving thanks is more than checking off one’s to-do list. So, let me dive deeper into some of the things I’m most grateful for currently.

On the top of my “thankful for” list are the countless people who helped me get to where I am. Many of these people are unnamed and their time in my life was brief. Together they made me the doctor I am. I must first give a nod of thanks to my patients. They have taught me more than they know. To be a patient is to be vulnerable, and they navigated that vulnerability with bravery. Next, I give a nod to my professors and peers in medicine. Medicine is a team sport, anyone who tells you otherwise is lying. Every day I learn something from my colleagues in medicine. Collaboration for the better good is one thing I love about the medical field. And last, but not least, I’m thankful for the friends and family who have supported me on this journey. They are the force that keeps me on the path forward. I will not imagine what this journey would have been without them. 

After the people in my life, I’m thankful for my circumstances. I’m thankful to live in the sunny city of Richmond where native passionfruit and pawpaws hide in the park. Where the river flows under and around osprey in the summer and ducks, geese, and cormorants year-round. Where snow falls occasionally in winter and daffodils bloom in February. Where cultures born of many pasts and futures come together, not always smoothly but always with hope. I’m thankful for my apartment where I can track the exact location of the sunset throughout the year – knowing the season by the building behind which the sun dives first. I’m thankful for the plants that dominate my living room. They ensure that there is no day without a flower blooming in my home. I’ve always said that I’ll know I’m rich when I can always have a fresh bouquet of flowers without concern for budget. When I thought of that definition of wealth, I didn’t realize that tending plants would make me rich faster than working. In retrospect, I should have realized that “wealth” is a nebulous term.

And finally, I’m thankful for my experience. My experiences on the doctorhood quest and in other aspects of life. I have never had a job that is as consistently rewarding and infuriating as being a physician. Most days the reward outweighs the frustration, which is why I continue to return. I had over 20 jobs before entering medical school, some were fun and others inspiring, yet I would not return to any of them. Apart from work, this year’s vacations, day trips, and glorious hours lounging I cherish. As December unfolds, I’m thinking about the experiences I’ve had and those ahead. There is never a dull moment when one accepts that the only constant is change. With the days of 2025 numbered, I’m thankful for what this year was and the hope next year holds.

Patience with Patients

Posted on by

The patient had stage 4 lung cancer which meant it was advanced. They’d already been admitted to the critical care unit (ICU) several times because they couldn’t breathe. There was one test to determine if the patient’s cancer had spread beyond their lungs pending. Given their rapid decline, I suspected that it had. The patient’s cancer doctors recommended chemotherapy. Yet, the patient wasn’t sure they wanted chemotherapy. When I saw the patient, they were taking a medicinal herb and a medication they bought online to treat parasites. They explained, not entirely incorrectly, that cancer is a parasite of sorts.

Autonomy is a guiding ethical principle in medicine which states that patients have the right to decide what happens to their bodies. I believe that autonomy is one of the most important ethical principles in medicine. I also think that it differentiates modern medicine from historical medicine. This patient’s story provides an example of autonomy in action.

On the one hand, my heart dropped upon hearing the patient’s plan. There is no research to suggest that the herb or anti-parasite medication they’d opted to take would slow or cure their cancer. There is robust evidence behind radiation, chemotherapy, and surgical treatments cancer doctors recommend to treat cancer. There was the hard truth that if this patient’s disease progressed as expected, they’d be dead within the year without science-supported treatment. There was a risk that if the patient waited too long before starting chemotherapy that they’d be too weak to survive chemotherapy treatment, making it no longer an option. On the other hand, chemotherapy is extremely hard on the body regardless of how strong a person is when they start it. And there was a chance that chemotherapy would make the patient feel terrible and fail to save their life or even prolong it.

When I saw the patient, they felt okay. They needed oxygen at night but, overall, were able to function almost normally. They’d taken steps to improve their health by decreasing the amount of alcohol they drank and the number of cigarettes they smoked. There was no research saying that the herb and anti-parasite medication they’d decided to take were harmful.

I collected my thoughts. My job as a doctor is to provide advice. My goal is to provide enough information so that patients can make their own informed decisions about their health. When I spoke, I acknowledged the dearth of research to support the over-the-counter treatments the patient had chosen for their cancer. I reinforced the truth that they had control over their body. I discussed the reasons their cancer doctor recommended certain treatments. I cautioned that there might come a time when they would be too sick to endure the treatments their cancer doctor recommended. I also reminded them that a middle ground was possible where they took the herbs and medications they chose on their own while also taking the treatments their cancer doctor recommended.

The patient decided that they would think about their options while continuing only their current home remedies. It’s seldom that there is only one right path in medicine. I felt that the patient understood enough to make their own decision. I worried about the patient, but I also knew that they were balancing all aspects of their life while I was mostly focusing on their medical conditions. I, undoubtedly, didn’t know some parts of their story. Only they could decide the best course of action for their body.

The doctors I’ve grown to respect throughout my training are the ones who have patience with patients. I strive to be that kind of doctor – one who isn’t scared to have hard conversations but is respectful of the path patients chose for themselves. In the end, the patient with lung cancer’s life was only theirs to live. I would be there to offer advice as we gathered more information and time went on. I would be there to offer an encouraging word and support. But I was not the one living in their body each day as the end of their life unfolded. Their cancer was theirs, alone, to fight. And though I was an expert advisor, their cancer battle strategy was theirs to decide.

The Process of Learning Medicine Works

Posted on by

I started my last year of residency on July 1, 2025. In the doctorhood quest, the days pass slowly while the years pass quickly. As time marches onward, I sometimes forget how far I’ve journeyed on my own doctorhood quest until an experience reminds me of where I’ve been.

This July I was reminded of where I’ve been when I had the opportunity to work with new third-year medical students. The third year of medical school is when future doctors start their clinical training – in other words, they leave the library and the classroom to enter the clinic and hospital. The third year of medical is a dramatic transition from learning theory to applying it.

I surprised myself this July as I answered third-year medical student question after question. No question was too hard – I could either answer by reaching into my mind or by easily referencing the resources I’ve come to consider my external brain. Not only did the answers come easily but so did the process. It was once hard for me to sort through patient data and make sense of it. It isn’t anymore. Work that felt overwhelming years ago – reviewing data, seeing patients, writing notes, and pitching medical ideas – is now second nature. Of course, I don’t know everything there is to know about medicine. I never will, which is one reason I love medicine. But, these days, it’s easy to identify gaps in my knowledge and easier to know where to find the answer. I know when to ask a colleague vs. ask a specialist vs. look the answer up myself.

I was a third-year medical student about 4 years ago. Now I supervise medical students of all levels. When I coach my students on how to improve the way they present patient information in verbal and written form, I’m reminded of how these things once were hard for me. As I help students review a new consult or a new admission, their questions and hesitancies remind me that I too once had the same uncertainties. These days when I work with medical students, it’s obvious to me that the process of learning medicine (student, then resident, then independent doctor) works. My own experience is a testament to that. I can’t wait to see what medical knowledge and healthcare wherewithal I’ll have after another 4 years of being a doctor. Stay tuned.

The Bitterness of Slow Declines

Posted on by

They were miserable. It was obvious from the silence they kept as their spouse explained everything that had happened since our previous appointment. It was obvious from the frown on their face and the apathy in their voice. It was obvious because no matter how many things I mentioned that I knew they liked, they didn’t smile or brighten once.

They weren’t excited about their new hearing aids which enabled them to hear birds again. In fact, they often didn’t bother turning the hearing aids on, per their spouse’s report. They were afraid to go outside for fear of falling. They couldn’t change a lightbulb because they felt weak and dizzy.

They had once been the person everyone in the family relied on to fix things. They had once been the advice giver. They had once been able to keep up with even the most social of butterflies. They had once been independent – free to run errands and tend their lawn without supervision. And now, they were none of those things.

The patient had tried therapy. We were always optimizing their medical conditions to keep them as healthy and functional as possible. The thought of starting another medication to help with depression was suffocating for both the patient and I because they were already on many medications. What was left?

Everyone who lives a long time eventually slows down. Some slow down and then die before developing medical problems that cause them to visit doctors and hospitals often. Others find that their social calendars fill with doctors’ appointments. Either way, or somewhere in-between, the transition from independent and fast to reliant and slow is hard. It’s an identity shift and a lifestyle change. The bitterness of slow declines is that they don’t ask permission. The body marches along, making changes that upend everything that came before, without giving time for the person undergoing the changes to accept or adjust to them.

I knew the patient was suffering and, yet, I didn’t have much to offer. I wanted to see the patient through this phase. Was it the last phase of their life? Probably. How long would this phase last? It could last days, or it could last years. It was impossible to tell. Almost the only thing I could do was acknowledge their misery. Call it what it was. I referred them to doctors who specialize in caring for the elderly. Perhaps those doctors had a secret for helping this patient. I hoped they did. Perhaps it was a secret I, too, would uncover.

At the very least, I stood witness. I knew who the patient was and who they had been. I acknowledged their struggle. At that appointment and the previous and the next, I listened to my patient for no other reason than to ensure that they felt heard. Listening wouldn’t change their situation, but sometimes the only thing I can offer as a doctor is a listening ear. And sometimes, that’s enough to help my patients make it through until our next appointment. Occasionally, it’s enough to make my patients feel better. Such situations remind me that medicine isn’t always about medicine, sometimes it’s about being human.

The Tired Mind

Posted on by

The foundation of medicine is curiosity. Desire to understand how the human body works – how those workings can break and malfunction and then, how they can be fixed again. Interest in the human experience. Wonder about how the mind can influence the physical. Joy in the triumphs of human capabilities. Humility in the shadow of human limitations. Thrill in the story of each human life. Medicine is built on questions and the pursuit of their answers.

At its best medicine is cutting-edge. Exciting. Grounded in the clearest understanding of the world the best science has thus far provided us. Yet, medicine isn’t always at its best. Medicine, after all, is a profession performed by humans. And humans are fallible. Medicine doesn’t stand above or beyond bias and money. And physicians, like all human beings, get tired.

The tired mind is a weak medicine mind. The tired mind processes slowly. The facts stand right in front of a tired mind, yet the mind is too weary to see them. The tired mind makes mistakes. Rushes when it shouldn’t. Forgets. Gets distracted by unimportant details. The tired mind is more likely to cut corners. Tired minds place patients in boxes of diseases rather than notice the nuances that make each patient unique. The tired mind is about clocking in and clocking out. The tired mind doesn’t ask questions. Because questions must be answered. And answering questions takes time. The tired mind has used up its time.

I think about the mind often at the wee hours of the morning on nightshifts or when my dayshifts drag on in a string of events. Not necessarily unfortunate events but overlapping and clashing events that make up a typical day in medicine. As shifts pile on top of each other, the events of each shift blend creating fog within the mind.

I know when my mind is tired because medicine isn’t interesting during those times. When my mind is tired the wonder of medicine evaporates. The wonder is replaced with drudgery as many tasks become repetitive and the clock ticks. When fatigue prevails, work hours are reduced to time that feels stolen. Stolen in the sense that work hours become hours I can’t sleep, can’t see the sun, can’t visit people I love, and can’t do hobbies I enjoy. When my mind is tired work hours are exposed as time spent looking at numbers that almost tell the story of human existence. I know that life is more than the sum of the numbers that describe it but, when I’m tired, I can almost believe life is no more than numbers.

When my schedule eases and balance between work and free time is restored, the wonder of medicine returns. The thrill of seeking the answers to mysterious questions – the function of medications, the disease behind a constellation of symptoms, and the life experience that led a patient to the hospital or my clinic – takes center stage again. When there is balance and my mind isn’t tired, medicine is thrilling. Thrilling because few other professions let one spend their day unraveling mysteries. Hearing the stories of real humans and decoding what those stories mean from a wellness and health perspective.

As my days as a resident dwindle, I find myself thinking about what it will take to minimize the tired mind and maximize curiosity during the next phase of my career. It was my love of stories and my delight in solving riddles that carried me through the 8 years of medical training I’ve already completed on the doctorhood quest. One more year and I’ll be an independently practicing physician. Even if I’m called to do more training, no future training will be like medical school or residency. Nothing can be. Medical school and then residency are times of growth, but they involve too many hours spent with a tired mind.

I plan to make the next step not the way of medical school and residency. How do I find or create a job that serves me as well as my patients? How do I ensure my work fosters curiosity and promotes wonder? How do I make work more than task completion and income earned? How do I make sure that the formulation of questions and the pursuit of their answers remain at the center of my work? To answer these questions I must explore the nuances of the profession; a wholly different pursuit than gaining the medical knowledge required to become a physician.

Count Down

Posted on by

The sun sparkled through the bright green leaves of late spring. The osprey floated overhead, having returned to Richmond at the first signs of spring months earlier. The James River still roared because summer’s dryness hadn’t set in yet. My morning soundtrack was birds singing, then replaced by the bustle of slow Richmond when the city finally awoke. The late morning sky was speckled with swallows. The crows cawed. The birds that flew past had nest material in their beaks. I drank mate as the day lazily passed.

When the sun returns and the days are warm and humid, I think of Paraguay. The land of the Guarani; a place that hasn’t been my home for years yet, somehow, is where I’m grounded. When I have slow moments, my mind slips back to the breeze in the mango trees and the sun dancing on the red dirt. I think of my Paraguayans neighbors and friends who smiled so easily and were quick to laugh. In Paraguay the music always blasts too loudly and at the wrong hour. The motos zoomed up the road, their riders helmetless. In Paraguay, the days were slow even when they were fast. I thought the pace was because of the heat when I lived there. But, perhaps, there is more to the calm that sits it the lowlands around the Paraguayan River than just the temperature.

Virginia summer is like Paraguay. Maybe that’s why I like it here. Or I could like it because Virginia is a warm version of Vermont. Vermont, my original home with its harsh winters, perfect summers, and rugged greenness. It’s also possible that I like Virginia just because I do. Richmond, the city no one’s been to. A hidden gem of sorts – not too big and not too small. It’s home to a diverse assortment of people. Richmond feels very southern but not lost in the south. Odd, given its history. I feel at home here despite having a New England constitution and a Vermonter’s tenacity for liberty. Liberty of spirit, body, and mind…something I’ve noticed our country has been undermining recently.

The late spring unfolding to summer is a transition time. It’s a change of season. And for me, along with every other medical resident, it’s also a transition from one residency year to the next. In a few short months, I’ll start my last year of residency. As such, it’s time to start planning my next steps. I’ve been thinking about the job I hope to have after residency and how I might find it. Medicine is for planners, everything in medicine takes a long time and requires strategy. I’m a planner so I fit right in. But I’m also a dreamer. Not all doctors are dreamers, yet I am. I’ve been dreaming of birds singing all day, never to be replaced by noisy cars and music I didn’t pick. Dreaming of grass between my toes and the quietness of trees. I’ve been dreaming of trails yet to be explored and reflecting on the trails I’ve already walked.

I’m always counting down to things that will come. Some counting is more meaningful than other counting. My residency countdown is meaningful. It was for the “after residency” phase of being a physician that I went into medicine. I’m finally almost there. Just 14 months left of the doctorhood quest. A year-ish is a short time when I remember that I’ve been chipping away at the doctorhood quest for 8 years already. What an invigorating thing to look for a job again rather than think about school. I’m excited to have a job that allows more time than I have currently to sip mate and contemplate if the sun is prettier here or in Paraguay. There isn’t enough time allocated to such contemplation during residency.

Giving the Body Time to Heal or to Live

Posted on by

When reading a book on ventilators* (mechanical breathing machines) to expand my knowledge of how to use them, I was struck by the author’s comment that ventilators are not curative but simply tools to buy the body time to cure itself. This factoid is known (at least subconsciously) by many physicians though not often so simply stated or at the forefront of our minds. The author’s bluntness made me wonder whether most of medicine is like that – interventions designed to keep death at bay until the body can mend itself, if such mending is possible. Or, if not mending, interventions that slow down damage to the body thereby allowing people to live longer than they would without the intervention.

The thought of medicine acting as a time warp – bending time to give the body space to mend– renewed my awe and appreciation of the body and its functioning. Without intervention the body is extremely resilient. With medicine available to help it along the way, it is incredible.

In primary care clinic, my patients and I frequently discuss the need for putting in time before results are realized. Medications and actions inherent to primary care are usually designed to prevent damage that would need mending. In that way, preventative medicine, as primary care is, is designed to give the body more time to live. Primary care time is composed of daily endeavors to live healthfully. It includes time spent doing physical therapy to optimize muscle function. Time spent sleeping, exercising, and eating well. Time – built from seconds – with each small action and decision along the way adding together, hopefully generating an outcome that may not have otherwise been possible.

In contrast to primary care, hospital time is more finite and about letting the body heal itself. In the hospital I also discuss time with my patients often. Common conversations include time left before patients can leave the hospital, time left to live, and time needed to recover. We discuss the shortcomings of the crystal ball I don’t have. We review the annoying truth that medicine isn’t magic and that sometimes it takes days to reduce leg swelling with pills that make one pee, to heal tissues that are infected, or to get medications to reach their therapeutic level in the body.

Bending time to let the body heal or to delay deadly damage is a simple concept but complex when applied to real life. The question remains: If time is bent will it change the outcome? And the more medicine I do the more muddied my answer to that question becomes. The answer is between sometimes and often. Medicine is based in research that investigates if behaviors, medications, and procedures help improve outcomes – survival, functionality, etc. Yet even the medical recommendations we are confident about are still probabilities and not certainties.

For example, there is no promise that if we control patients’ diabetes, they won’t die of a heart attack. They might. Research suggests that if we treat diabetes the chance of dying from a heart attack is lower for the person with diabetes. Similarly, we know that if we don’t place someone who can’t breathe for themselves on a ventilator, they will die. But we can’t promise that they won’t die after we place them on the ventilator. They might. In both examples, we are just giving the body a chance to pursue an alternative outcome from what is most likely at the time we act. It’s a chance, not a promise.

Even in the case of more definitive medical cures – like surgical removal of a tumor or chemotherapy – cure is not a guarantee. The body first must recover from surgery and avoid complications like infection to benefit from the surgery. The body first must survive chemotherapy before benefiting from the cure, and there is a risk of cancer returning.  Considering the limitations of even curative interventions, the argument that their primary role is to give the body an opportunity to heal itself remains. Fate is like magic, beyond medicine. Yet, the body is capable of astounding things. As such, even if medicine does nothing more than bend time for the body it is still a worthwhile pursuit. Because with medicine we might extend life and reduce suffering during whatever days remain in a person’s life. That opportunity, even if not guaranteed, is why people like me go into medicine.

*The Ventilator Book by William Owens

The Language of Medicine

Posted on by

“63 yo M with a hx of DDKT (2019), ESDR 2/2 membranous nephropathy, DMT2, ischemic cardiomyopathy, HFrEF (EF 30% in 2023), Afib (on apixaban), CAD s/p stent and CAGB who presented with SOB with exertion and orthopnea. Admitted for CHF exacerbation 2/2 rhinovirus and missing medications. Course c/b Afib with RVR and AHRF requiring BiPAP.”

The above is an example of a typical “one-liner” in medicine using a fictional patient. A one-liner is a summary of a patient meant to communicate to other physicians the most important features of a patient’s medical situation. The spelled-out version of the above one-liner may be slightly more comprehensible for non-medical people, but likely not by much:

“63-year-old male with a history of deceased donor kidney transplant (2019), end stage renal disease secondary to membranous nephropathy, type 2 diabetes mellitus, ischemic cardiomyopathy, heart failure with reduced ejection fraction (ejection fraction 30% in 2023), atrial fibrillation (on apixaban), coronary artery disease status post stent and coronary artery bypass grafting who presented with shortness of breath with exertion and orthopnea. Admitted for congestive heart failure exacerbation secondary to rhinovirus and missing medications. Course complicated by atrial fibrillation with rapid ventricular response and acute hypoxic respiratory failure requiring bilevel positive airway pressure.”

I present these patient summaries to illustrate that medicine has its own language. Much like one might learn Spanish if planning to work in Mexico, part of becoming a doctor is learning the language of medicine. What makes medicine even more challenging is that each specialty has its own dialect which comes with unique acronyms and fancy terms. In part, the reason it takes so long to become a physician is the time needed to master medical language.  

Yet, despite so much effort spent understanding medical language, the best physicians don’t just communicate with each other. Physicians also communicate with patients. It’s a unique language mastery to be able to translate complex medical terms and concepts into language that nonmedical people can understand well enough to make informed decisions about their healthcare. Part of the physician’s job is to be a translator between medicine and everyday language. At times, this can be more challenging than one might imagine.

Becoming a physician takes at least 7 (usually more) years of training. And since being a physician is a job, physicians spend their entire work week thinking about medicine. Spending so much time lost in the language of medicine makes it easy to forget which phrases are medical jargon and which aren’t. The seasoned physicians I most admire are those who, despite so much time spent thinking in medical language, can easily code switch (going between different languages and cultures) to everyday language when working with patients. I strive to be like these physicians. Often, it takes a lot longer to explain medical information in nonmedical terms because medical language provides a means of synthesizing information. The extra time is worth the effort to ensure patients understand their medical situation. 

So, to break down the above one-liner into everyday language as an example:

“This 63-year-old man has a complex medical history. He has a condition called ‘heart failure.’ Heart failure is when one’s heart does not pump as well as a healthy heart. He has heart failure because the blood flow to his heart was blocked before he had his heart surgery. When the heart doesn’t pump as well as a healthy heart, fluid can build up in the body. One place that fluid builds up is in the lungs; this causes trouble breathing.  This man came to the hospital with trouble breathing, likely because of a heart failure exacerbation. A heart failure exacerbation is worsening of heart function usually because of a stressor. In his case, he likely had worsening heart function because he got a common cold (caused by a virus called “rhinovirus”). He was at particular risk of severe cold symptoms because his immune system is weaker than normal because of the medications he takes for his kidney transplant. His heart failure also likely got worse because he missed medications for his heart. While he was in the hospital his heart rate was very fast because of an abnormal heart rhythm. He was at risk of developing a fast heart rate because of his history of an abnormal heart rhythm called “atrial fibrillation” (“Afib” for short). Also, while he was in the hospital, his breathing got worse. When his breathing worsened, we placed him on a machine called “BiPAP” which helped him breathe and gave him oxygen.”

I used to code switch often when I was in the Peace Corps. I transitioned between Spanish, Guarani, and English depending on who I was talking to and the topic of conversation. I never expected how much practicing code switching then would help me now. But, every day at work I shift between medical and everyday language. When I forget to switch to everyday language, I’m quickly reminded by the confused look on my patients’ faces. I enjoy being able to explore different worlds. Transitioning between medical language and everyday language is one example of exploring different worlds. The better I get at translating the more I feel like a bridge connecting the medical world to the rest of humanity. It’s rewarding to be an expert in medicine and a guide who helps nonmedical people understand the strange world I’ve spent years mastering.  

Quandaries of Liver Transplant

Posted on by

In the US about 10% of those on the liver transplant list die prior to transplant and over 20% are removed from the liver transplant list after being listed1. The hospital where I’m completing residency is a major liver transplant center. While living donor liver transplant is an option for some people, the patients I take care of are awaiting a liver donation from someone who died and donated their organs to others.

The patient was the color of a yellow highlighter. Perhaps you think I’m exaggerating that a person can be so yellow – I’m not. People turn bright yellow when their liver fails. The color comes from a pigment called “bilirubin” that the body can’t eliminate easily when the liver is sick. The patient’s eyes gazed off into the distance, into the future, or perhaps they gazed into nothing. They told me their name and answered questions, reassuring, but the slowness of their speech hinted at how sick they were. They were under my team’s care as we did the workup to determine if they were a liver transplant candidate. To be a transplant candidate patients must go through a thorough social and medical review to ensure they have the social support needed for post-transplant recovery and that they have no other medical conditions (like cancer) that would disqualify them from being a liver transplant candidate. If deemed a candidate for transplant, then a patient will be placed on the liver transplant waiting list (“transplant list” for short) which means they can receive an offer for a liver when one becomes available.

The workup of the patient the color of a yellow highlighter was ongoing. People whose livers have already failed are in a precarious state. They are at risk of confusion from toxins building up in their blood because their liver doesn’t filter the blood anymore. They are at risk of infection which can quickly kill them because without the liver working properly their immune system is weakened. They are at risk of both bleeding and forming clots. (Yes, these are opposite problems, and a failing liver puts one at risk for both through several complex mechanisms.) When the liver fails it disrupts the fluid dynamics of the body. Blood and other body fluids pool where they shouldn’t which can lead to swelling in the abdomen (and other places like the legs) and possible damage to the kidneys, heart, and/or lungs. In short, when the liver fails it causes just about everything else in the body to fail too.

When someone needs a transplant, it becomes a race to see if death or transplant will come first. The workup is prescribed. We hurry to send off the tests and complete the exams and procedures that the patient needs. Besides the workup, there are other barriers to liver transplant. For example, there is no road to transplant without health insurance. Just as there is no road to transplant if patients do not have friends or family to take care of them after their transplant. One also must have stable housing. Many people are not placed on the transplant list because they are disqualified or die along the way. Those who do make it on the transplant list frequently don’t survive until transplant. Livers are scarce. When a patient is on the transplant list, they are waiting for a person to die who has a liver that matches their body. Not any liver can be transplanted into any person. The liver and person receiving the liver must match so that the body of the person receiving the liver doesn’t reject it.

There are many people who need livers. When a liver becomes available who gets it? The answer is a combination of luck, being the sickest, and being the best match for the organ (like having a matching blood type and being the right size). Is it fair who gets a liver? Unlikely. There are race and gender disparities. Geography matters in terms of access to organs. Many patients never qualify for the transplant list because of the social determinants of health including problems related to poverty and lack of social support.

I thought of the patient the color of a yellow highlighter as I left the hospital for the day. No one could predict what their outcome would be. Even though experience and science told me the odds were against them, I hoped they’d get a new liver and recover well from the surgery. After all, I went into medicine not because I thought all outcomes would be happy but because I wanted to help people fight for the best outcome they could. Getting a liver transplant and having it work was the best outcome for this patient; it was the outcome the patient was fighting for. I came to work every day to help them survive until transplant. It was a big task, but few things are more motivating than the chance to help change another person’s life for the better. No matter what happened, I was grateful to be on the patient’s team. Grateful they trusted me to help support them through this challenging stretch of their life. Grateful we can transplant livers – giving hope for a new life in a situation where death used to be the only outcome.

  1. Annual Data Report of the US Organ Procurement and Transplantation Network (OPTN) and the Scientific Registry of Transplant Recipients (SRTR) from HRSA: https://srtr.transplant.hrsa.gov/ADR/Chapter?name=Liver&year=2022

The Branching Plan

Posted on by

I’ve arrived at the phase in residency where colleagues ask what my next step is. The 3 major options after internal medicine residency are:

1) work as a hospitalist (a generalist who only works in the hospital)

2) work as primary care physician (a generalist who only works in clinic)

3) do additional training in a medical sub-specialty (like infectious disease, pulmonology, etc.)

Yep, I know you’re amazed. It’s possible to do more training after residency…it’s called “fellowship”. Medicine is the kind of profession where one starts planning their next step year(s) in advance so now (over halfway through my 3-year residency) is exactly when I need to know my next step. Luckily, I have a plan.

My plan is branching which allows for wandering and discovery along the way. I’ll start as a hospitalist both to enjoy a pause from training and strengthen my financial foundation. Then, I’ll either start fellowship or tailor my generalist work to focus on the populations and medicine that interest me most.

As the residency tunnel starts to show its brilliant end, I’ve been thinking more about the bigger goal – why I decided to become a doctor in the first place. I started the Doctorhood Quest because I wanted to have a career that tangibly helped people. I wanted my daily work to involve direct interaction with the people I was helping. And the help I wanted to give was empowerment. Improving health and banishing illness is empowering because when we are sick, we simply can’t achieve our full potential. As a doctor I’m an ally with my patients on their quest to fulfilment. I love seeing my patients get better from acute illness. I’m honored to help patients die with dignity or to be part of the reason their suffering is minimized. I’m stoked to keep people out of the hospital by optimizing their chronic medical conditions and overall health.

I joined medicine because of the opportunity to work with patients. My branching plan is a strategy to ensure that no matter what happens with healthcare, I can adjust and adapt to achieve my bigger goal of fostering empowerment. People have inequitable access to healthcare and the healthcare industry is flawed but, despite healthcare’s many shortcomings, there is much opportunity to do good as a physician. In an ever-changing environment (like medicine) one must be flexible and adaptable. Having a multilayered and branching plan acknowledges that I’ll have to change throughout my career to achieve my bigger goals. What fun it’ll be to see where I end up 20 years from now!