Category Archives: Doctorhood Quest

Springtime in Richmond

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The ospreys are back on the Richmond James River marking the arrival of spring in this city that sits at the hub of Virginia’s highways. Match Day, a different mark of spring, took place earlier this month. It always falls in March, an odd kind of Ides of March. This year, with that phase of the Doctorhood Quest behind me, I was unaffected by it. My Match Day will forever dwell on St. Patrick’s Day of 2023. That’s the day I found out I was moving to Richmond.

It was about this time last year when I saw Richmond for the first time. We visited the city only a week or so after Match Day to look at apartments. We wanted to move to our new home as soon as we could. I liked Richmond instantly. I’ve visited enough places and lived in enough more to know, as a gut feeling, if a place I visit is a place I could live happily. I had that sense about Richmond.

Spring is always a transition season but since I started the Doctorhood Quest it has come to mark additional important transitions that didn’t exist in my pre-doctor world. As I write this, I’m three-quarters of the way through my first year of residency (or one seventh through the whole thing). Residency years start on July 1, meaning that as spring slides into summer it marks the closing of one year and the opening of another year in residency. Residency years are hard years. As happy as I was last March when I transitioned from medical school for residency, I am enthusiastic to leave my first year of residency behind for the second year.

The seasons of my first year of residency almost followed the seasons as I knew them when I lived in Vermont. Summer was a glowing time when everything seemed possible because the leaves were new and vibrant; the sun stuck around longest. Fall was my favorite season because by that time the year was familiar; the weather was perfect. Winter was dark and gloomy; it was hard to understand why the world didn’t pause the whole season to drink mate and eat chocolate. Spring came with new hope and new beginnings.

With the ospreys back on the river and a recent vacation behind me, I’m excited to embrace spring. I love the ospreys and was so disheartened to learn last fall that they left for the winter. In Richmond there are numerous walking bridges across the James River from which you can see osprey nests and watch them hover-dive-catch fish. This spring marks a year living in Richmond and a year since graduating medical school.

Comparing this spring to last spring, I know the parks of Virginia way better now and so plotting my days off has become more exciting. And, more down to business, I’ve learned so much about medicine and how to be a doctor. The Doctorhood Quest continues just as the seasons march along unwaveringly. Year two of residency will be a time to develop independence and hone my knowledge. Internal medicine residency is three long years. So, I have two springs left before I get to confidently say I’m ready to work independently as a physician. Two more springs of celebrating the ospreys’ return as a resident. Then we’ll see where the Doctorhood Quest sends me. Perhaps I’ll also celebrate the James River ospreys as an independent physician too; only time will tell where I am three springs from now.  

How Strange to Be Unable to Name a Daffodil

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“We saw daffodils!” I said. My voice sang with an enthusiasm that only such a definitive sign of spring could coax from me on such a rainy, gray afternoon in February. My co-resident looked at me blankly. The importance of a daffodil passing through their genius brain just as the medical terminology doctors like to use pass through patients’ ears – jargon without meaning, hardly in and definitely right out. “You know, it’s one of the first flowers of spring. I saw it in the park.  They’re yellow…” I gave up and the conversation moved on to other topics.

Doctors are more diverse than we once were, but our makeup doesn’t come close to mirroring the population we serve. My visible profile is common in the medical world – white (always very common) and female (slightly more females are entering medicine than males these days). Yet my unseen profile, my story before medicine and path to medical school, is unusual for a doctor.

Sometimes I’m reminded of my different background when it’s easier for me to relate to patients than my colleagues who come from medical families and have never known what it is like to not know what “coronary artery disease” and “hypercoagulability” mean. Other times I’m reminded of my different background when it’s easier for me to understand the social determinants of health such as why someone might not have transportation to appointments and why medications might not be worth the monthly bill to a specific individual. Where I grew up if you didn’t have a car you went nowhere; further, I solely used public transportation for most of my 20s. I’ve also run a tight budget most of my life which has given me a lot of practice deciding where my money will and won’t go.

It’s not just my economic background that makes me different from many of my co-residents (though I’ve come to realize more with each passing year that economic background is a mountain that dominates world view). The nuances of my difference from many of my colleagues present themselves at unexpected times such as on slow days when making small talk with co-residents and supervising physicians.

I grew up in a world where medicine was minimally understood, mysterious, and (perhaps) feared. The distance of medicine was partially possible because my family was healthy and required minimal medical care; it was also who we were. Our lack of medical knowledge did not mean, however, a lack of knowledge. For my colleagues who have known the medicine way of life since childhood as they watched their parents (many doctors and some nurses) come and go from work, the hospital system is familiar and almost second nature. I didn’t grow up knowing the hospital. Yet, I know other things that are part of who I was, am, and will be.

For example, I know the birds, trees, and plants of my childhood and I’m learning the ones of my new home in Virginia. I know how to grow plants indoors or in a garden because I grew up in a culture where we all knew how to tend plants. In a similar way, I don’t believe cows are cute because I’ve been almost late to school chasing them after they got out of the fence. I know how to stack 6 cords of wood in a day, use power tools and wood tools, and change my car tires because these are skills that were necessary in the world where I grew up. I notice architectural details, complementary colors, and other design elements because these were some of the themes of my childhood.

Being an older resident with a different background and careers prior to medicine is isolating at times. A small portion of my co-residents can relate or are interested in where I’ve been before medical school. I’ve become accustomed to this. My life extends beyond the hospital. I have family and friends who understand the nonmedical aspects of my life just as my co-residents understand the Doctorhood Quest in a way non-physicians can’t.

I have so much to learn about medicine from my co-residents and supervising physicians regardless of whether they understand any aspect of my life outside of residency. But, on days such as when I find a resident who can’t name a daffodil, I’m torn between amusement and sadness. In my world it’s ridiculous to be unable to name one of the most common spring flowers in the US. The realization that there may be many doctors who can’t name a daffodil reminds me just how different we all are. It also reassures me that there is much I can teach my co-residents too. And, perhaps more importantly, it reminds me how much physicians can learn from our patients and non-doctor colleagues if we find time to listen.

The Doctor Pronounced Them Dead, The Doctor Was Me

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It was raining when I left the hospital. Perhaps the rain marked new beginnings for a soul recently gone or perhaps it was simply droplets falling because the clouds were too full to hold them. Death wasn’t new to me. My years in emergency medicine prior to starting medical school ensured that. I’d felt and smelled death before. I’d contemplated its inevitability and its conflicting identities of tragedy and blessing. Some of the deaths I’ve seen were sad beyond measure and some peaceful.

This patient’s death, the one I’d witnessed just before stepping into the rain, was my first as a doctor. For the first time it was my job to do the exam that declared the patient legally dead. It was my first time stating the time of death and filling out the paperwork declaring death. It was my first time calling a patient’s family to deliver the news that their loved one had died. I’d wondered how long after starting residency it would be before I would complete these somber duties for the first time. Now I know, 8 months.

It was one of the easier deaths I’ve witnessed. It came at the end of a long life. It was expected given the patient’s condition. In fact, just that morning, I’d started the patient on medications to keep them comfortable as they entered the home stretch of their life. I’d spoken to the family as they visited that day. As I walked in the rain, I couldn’t help but wonder if the patient had waited to hear their family members’ voices one last time before giving in to rest. After all, the patient died only hours after their family left the hospital. Their family wouldn’t see them again.

When a patient dies, we complete a discharge order, note summarizing what happened during the patient’s hospitalization, and progress note describing the circumstances of their death. This paperwork makes the process of death much like any other administrative task a doctor has. Yet, though technically similar, these notes feel different. Unlike other daily progress notes and summaries of hospital stays that fill patient’s charts, these death notes are not just a chapter but a conclusion and, because of this, they seem more important.

The inside of my car was fogged when I got in. Somehow the rain had cooled the outside while the warmth of the inside of my car lingered. I turned on the windshield wipers and blasted the air. I couldn’t really see but I decided I could see well enough to start slowly rolling forward. The rain drops bounced off my car. As I drove in the rain, I became sure that it marked new beginnings for a recently passed soul. Nothing else could possibly make the sky weep so beautifully. I wonder if the person whose soul had passed believed in some kind of afterlife. I imagined them observing my little car driving through the rain from wherever they were. I hoped they were happy. At least I knew their troubles in my world were done. May they rest in peace.  

The Winter Doldrums

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Winter in Virginia is quite nice from a weather perspective. Most winter days this year have been in the 50-70s and sunny. Yet, despite the loveliness of winter in Virginia, spending so much time in the hospital (as us residents do) means I only catch glimpses of it. Like a plant kept too far from the window, I feel like I’m missing the sun’s warmth. I’m in the middle of a several-month stretch of hospital rotations where either I have one day off a week or am working nights – which is the perfect environment for the winter doldrums to flourish. So, it comes as no surprise that I’ve found the doldrums creeping in around the edges of my life like a vignette Instagram filter darkens just the outer edges of photos.

My doldrums is a weariness that hovers below the surface and presents itself in small ways. Forgotten facts like place names and life tidbits that were once second-nature. Moments at work feeling longer than eternity and moments at home passing faster than light moves. Waking up tired after sleeping enough. Sitting on the couch sipping mate and watching my plants grow more often than I usually do. Contemplating where I’ve been and missing Paraguay as I trudge home from long shifts. Like most moods, I’ve taken some time to observe my doldrums. It seems stable and temporary, especially knowing better times will be here soon.

Learning medicine is a long journey where knowledge builds with each passing situation, decision, and interaction on the job. Now that I’m over 6 months into residency, residency (itself) is familiar. My focus has shifted from learning my new role and how to complete tasks to growing as a doctor and deepening my knowledge.

The doctorhood quest is a process with a high level of granularity. I make daily tradeoffs between learning more and undertaking life (chores, fitness, rest, etc.) – sometimes the pendulum falls on the side of learning and sometimes it falls on the side of life. Everything can’t be done at once, or ever really, but progress is made step by step.

The upside of the doldrums is that it’s a contemplative state which is suited for winter when the days are too short to maximize outdoor time. I’ve been thinking about what kind of doctor I hope to be by the end of residency. I’ll be done with residency sooner than it seems on these long winter nights. Just as winter will soon be replaced by spring. With the start of spring, winter and its moods will fade. The doldrums will melt away leaving a summer state of mind. Moods and periods of life are nothing more than a type of season. What a lucky thing that summers are long in Virginia and the winter doldrums finite.

My Hero List Grew by One That Night

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It was early during residency. I was still adjusting to primary care clinic which included learning how the computer system worked. I still didn’t have home access to the electronic medical records so I couldn’t review my patients ahead of their appointments. I also couldn’t write my patient notes at home. All my patients were new to me. Between the challenge of learning new patients and the computer system, I fell behind in clinic one day.

My patient appointments stacked up like logs against a dam before it bursts. And, with my appointments running behind and my slowness with the computer system, the notes I had to write for each patient appointment were pushed to the end of the day.  My last appointment ended an hour late because it started an hour late.

There I was, already after closing time and just starting to fight the computer system to write my notes as fast as I could. Everyone else in the clinic had left an hour or so earlier. I was hungry because I hadn’t thought I’d need to bring dinner.  I’d already eaten breakfast and lunch at the clinic. I was startled when I heard someone in the hall. The janitor walked by my office, “Late night?” he asked pausing outside my open office door.

“Yeah. I’m new here and I’m still slow with the computer,” I said.

“And they just left you?” he asked.

“It’s okay. Hopefully my notes will be done soon,” I said.

“Well, thanks for your work,” he said.

Hours passed. One note at a time, like small footsteps, my pile of remaining work dwindled. The janitor stopped by my door again. “I got you these. It’s not much but it’s all I could find,” he said. He handed me a bag of BBQ potato chips and a mini-Fanta orange soda.

“Thank you so much! You’re so kind,” I said. I was too tired to be giddy but in better circumstances I would have been gleeful for the snacks.

“Have a good night. Hope you can leave soon,” he said and walked away, back to his own work.  

I don’t think he’ll ever know how much he saved me that night. When I was finally done with my work and as I walked through the empty clinic and then the empty parking lot to my car, I thought about how much I appreciated the janitor. I’ve often thought it odd that society focuses so much on big names and money. In my experience, heroes are always humble strangers acting out of kindness and with no motive or expectation of recognition.  

That night I was reminded that all it takes is pausing to offer a little help to transform a person’s night. The janitor clearly had already ingrained that knowledge into his existence. And like the heroes who came before him, I added the janitor to my life’s hall of fame as I walked to my car to drive home. My hall of fame isn’t a hall of fame like those for baseball players but, to me, it’s a lot more important. And, in case you’re wondering, I’ve never had a more delicious bag of chips and can of soda.

Today We Start Insulin

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“Today we are going to start you on insulin. Given your high A1C level (a lab that shows your average blood sugar over 3 months), it is recommended so that we can better lower your blood sugar. Lowering your blood sugar is important because when your blood sugar is this high it can affect many aspects of your health including severely increasing your risk of heart disease and stroke,” I said. It was the second time I’d seen this patient in my clinic. They were quick to laugh and had a full life.

The patient hung their head. This was the first time I had started someone on insulin as a primary care doctor (we use insulin exclusively to manage diabetes in the hospital, but in the outpatient setting it’s reserved for specific indications). Starting insulin isn’t supposed to be punitive but some patients feel as though it is because of the stigma associated with diabetes.

There are numerous medical diseases and conditions that are stigmatized. Among the most common I see are diabetes, obesity, psychiatric diseases, and sexually transmitted diseases. People with diabetes are often blamed for having the disease. If or when they require insulin, the patient may feel like their need for insulin is a failure because their blood sugar was not controlled with other treatment measures. People with diabetes can be labeled as “weak” and “lacking self-control.” This labeling is out-of-place and unproductive. While lifestyle (such as diet and exercise) does contribute to the development and progression of diabetes, lifestyle is only part of the story.

In addition to individual choices, other parts of life like genetics, environment, and the social determinants of health have an important impact on health outcomes including the development of chronic diseases like diabetes. Further, it is critical to be able to have open and respectful conversations about patients’ individual situations and how their lives might be optimized to manage their diabetes and to reduce their likelihood of developing complications from diabetes. Stigma gets in the way of having these open, respectful conversations. When people have diabetes, the disease can severely increase their risk of death by heart disease and complications such as vision loss, nerve damage, kidney damage, and infection. This makes management of diabetes with a multimodal approach – including lifestyle optimization and medications – essential. Judgement has no place in developing a therapeutic plan.

When I recommended insulin to my patient, it was not as punishment. It was without judgement. It was out of concern for their health. The strategies we had tried to lower their blood sugar to that point weren’t working. The patient was doing so well otherwise. They didn’t have kidney problems. Their feet still had feeling. They hadn’t had a heart attack. I wanted them to live without these complications for as long as possible.

As the patient left the appointment, I was hopeful that our new strategy would help them lower their blood sugar. I also hoped that this patient felt respected even if they were unhappy about starting insulin. I’d see how they did with the insulin at our next visit. Time would tell if insulin at the dose we started would work for them or if we would need to make further adjustments. Chronic conditions require long-term (often life-long) treatment plans. Flexibility to adjust the plan as life develops is critical for success. This patient with diabetes was no exception. I looked forward to working together to lower their blood sugar in the months and years ahead. 

More Than Half the Days

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It was a regular primary care visit and my patient felt well. I clarified several of their questions about how to take their medications properly and why some of the medical treatments we’d prescribed them were important for their overall health and life expectancy. The conversation flowed. They were engaging and exuded positivity.

It came to the part of the visit when I went through my system-generated reminders based on the patient’s medical record (topics and screenings I was supposed to review at certain intervals with my patients as their primary care doctor). Among the reminders was a depression screening questionnaire which was due.

“How many times in the past two weeks have you felt like you would be better off dead? Options are ‘not at all,’ ‘several days,’ ‘more than half the days,’ and ‘every day,’” I said.

“More than half the days,” the patient said. The questionnaire was 9 questions long. By the end, it was clear that the patient had untreated depression. Interesting how the first part of our appointment didn’t suggest depression. To uncover the patient’s depression required additional, and specific, evaluation.

“Tell me more about what you mean by these feelings,” I said walking through their answers to each of the questions on the depression screening questionnaire.

The patient would go on to describe living alone with no friends or family nearby. No activities outside the home. A lifetime of being socially awkward – preferring to be alone because of the awkwardness. Feeling as though they had a hard time connecting with people. “I thought it was just normal for someone my age,” they said, referring to their feelings of sadness and thoughts of death.

How common is depression? Is it normal to be depressed? What exactly is the difference between the medical definition of depression and a transient dark mood?

A lot about being a primary care doctor is brainstorming solutions to life’s persistent problems. Sometimes there are medications that can help, but usually the non-medication interventions and lifestyle changes are just as (or more) important than the medications.

The patient and I discussed how to take their antidepressant correctly (they were already on a medication for depression, but they were not taking it daily as intended due to confusion on how it was designed to be taken).We discussed exercise classes to strengthen the mind and body and to create an avenue to be around other people sometimes. We discussed hobbies and activities that brought them joy. We discussed what might be normal for their age.

This patient was motivated. Perhaps they could find a path to better mental health. It would take time. The brain is the hardest organ to heal. To help ease the journey, my clinic had all kinds of mental health resources (including exercise classes) patients could use for free. When we finished our visit, I walked the patient over to the mental health team’s office attached to my clinic. The mental health team would share with the patient additional resources beyond those offered by primary care such as individual and group therapy sessions.  

The statement, “more than half the days” would resurface in my thoughts for weeks to come. Not because it was unusual, but because depression is so common. I’ve known how common depression is since I entered healthcare. But, for the first time, I have the chance to help some patients find a path to healing now that I’m a primary care physician. Of course, the clinic where I work is special and has more mental health resources than most primary care clinics in the US.

What would I have done for this patient and others like them if my clinic was not set up to help people with mental health challenges? What if there were no therapists, wellness classes, or psychiatrists on staff to help any patient who came through my door? What if this patient had to wait for months before they could be seen for their mental health concerns?

When the phrase “more than half the days,” crossed my mind I thought about the 1000s of people walking around feeling they’d be better off dead more than half the days of their lives. I thought of the probability of there being time during their regular primary care visit to be properly diagnosed with depression. I thought about the probability of their primary care clinic having the resources needed to help them if their depression was diagnosed. The math suggested that many people’s depression would go undiagnosed or, if diagnosed, untreated because many people couldn’t access the treatments they needed. To be profitable primary care appointments get shorter and shorter, with many clinics scheduling appointments that are 20 minutes or less. The length of the appointment doesn’t factor in the complexity of the patient even though as patients become more medically complex, a 20-minute appointment becomes more absurd. Between health insurance access issues, healthcare costs, and healthcare professional shortages many patients don’t have access to medications, therapy, and other mental health treatments that have been proven to work.

Healthcare in the US has so much opportunity for improvement it’s maddening. No setting reminds me of this more than primary care. No disease category reminds me of this more than mental health. The better I know the US healthcare system, the less hopeful I become that it will ever serve all people. But sometimes there are little micro settings where all the resources a patient needs are there if they choose to use them. This patient was in that situation and, so, I was hopeful that they’d find a future in which they felt better off alive than dead more than half the days. I was hopeful that they wouldn’t die by suicide.

Depression can be sticky and hard to overcome in the best circumstances. But depression, like all diseases, is more likely to be cured when the patient can access the best treatments. The more I learn about healthcare, the more I believe everyone should have access to the best treatment for the most common conditions. And, currently, that is not the reality in America.

References:

Maybe Tomorrow

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“Maybe tomorrow you can be discharged,” the doctor leading my team said to the patient. I’d lost track of how many days in a row he had said that.

The patient had cancer and was undergoing treatment. Did you know that chemo is poison? We use it hoping to destroy cancer before we destroy the person who has the cancer. Chemo saves lives. Chemo causes all kinds of side effects. Chemo often works. Chemo doesn’t always work.

This patient was neutropenic which means that they had no white blood cells to fight infection. No white blood cells to fight infection means even the wimpiest infection could kill them. To avoid death by infection, they needed to stay in the hospital for IV antibiotics and monitoring every time they had a fever.

We couldn’t find the cause of their fever. No source of infection. 24 hours without a fever, “Maybe tomorrow you can discharge, you just need to be 48 hours without a fever to go home,” my supervising doctor said to the patient.

The patient’s red blood cell count dropped so they needed a blood transfusion. Were they bleeding? “Maybe tomorrow you can discharge, if you don’t need another transfusion.”

 They also had a rash. Was that from chemo, cancer, or something else? It was a really uncomfortable-looking rash. Blisters and red all over their torso. “Maybe tomorrow.”

The “maybe tomorrows” dragged on. All the patient wanted to do was go home. They wanted to have some control over their life. They wanted to feel the breeze on their cheeks. They wanted to live. They wanted to see their friends and family. But cancer is a tricky beast. It takes one’s freedom and lands one in the hospital more days than anyone would ever choose.

But, at last, tomorrow did come. We were all happy when the supervising doctor said the patient could leave the hospital. The patient was excited to go home. No one mentioned that it was only a matter of time before they’d be back to start another string of maybe tomorrows. Sometimes there’s no point in saying things that everyone already knows. No need to speak the unpleasant into existence. It will come when it comes.

The patients and families on the cancer wards are among the strongest people you’ll ever meet. Their strength is like the endurance of ultramarathoners, not sprinters. Their strength is one of days running into weeks running into months. Counting the years. Their strength is one of setbacks and small victories. Of bodies changed and freedom lost to be reinvented. Their strength is keeping hope for tomorrow while knowing that it may never come.

Tell Me One Fun Fact About You

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It can be anything. Your favorite vacation, a hobby…

“I’ve been to 157 US cities.”

“I love my grandchildren. I like to facetime them.”

“I have a mermaid tail. It’s pink and purple.”

“I have a wife and kids waiting for me at home.”

“I liked to play basketball as a child.”

“I care about people.”

“I used to ride in the rodeo.”

“My favorite place to vacation is the Caribbean.”

“My son recently got married. I don’t like my new daughter-in-law.”

I look at hundreds of labs values a day. I review vital signs, recorded bowel movements, and urine output in milliliters for all my patients daily. I place orders and write notes. I answer a nursing question about every 6 minutes during the busiest part of my day. I discuss every patient with my supervising attending. I discuss complicated parts of my patients’ treatment with my senior resident. I coordinate with nutrition, social work, physical therapy, occupational therapy, speech, and numerous others to ensure patients are taken care of while they’re in the hospital and safely discharged. I examine every patient every day and if their status changes (like their blood pressure drops) I re-examine them. I do more, but this paragraph is already too long.

The constellation of the medical workup I order, medications I prescribe, and information I gather about my patients’ symptoms are how I figure out what is ailing them and how to treat it. As you can imagine, when so much of my energy is focused on sorting through data, it’s easy to forget that under all the data I collect are people.

The best doctors I’ve worked with each have their own way of reminding themselves that they are caring for people not just treating vessels of illness represented by labs, imaging, and physical exam findings. And, within the past few months, I decided to develop my own method as I plan to be among the best doctors. It’s tricky because as a doctor there isn’t time to learn many of the details of our patients’ lives. There is time to learn something small, however, if I prioritize it.

My way to learn something about my patients as people is to ask about something nonmedical. My phrasing is, “Tell me one fun fact about you. It can be anything, such as a hobby or a favorite place you vacationed.” I’ve learned about the most amazing people this way.

The above simple inquiry has made all the difference in my practice as a doctor and my ability to endure the hustle that is inherent to residency. It’s easier to arrive at the hospital 6 days a week by 6 am (and leave often more than 12 hours later) when I’m showing up to help someone with family and a mermaid tail to go home to compared to showing up for a pile of numbers representing blood counts, vital signs, and urine volume.

It’s the people who are the patients who make medicine different from any other profession where people aren’t the subject. And it’s the people who have shared their fun facts with me who continually remind me why I entered the medical profession and where I’m going with it. And for that, I am most grateful.

Night Float

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The hospital is 24-7 all year long so there are always staff who care for patients overnight. I was the doctor on a night medicine crew for a few weeks recently. That stretch, I worked in a veterans hospital which meant all my patients had two things in common: they were in the hospital and had served in the military.

Here are some snippets from my nights:

  • “Let us know if anything changes,” I said as I left the room having been called there because the patient’s heart rate had dipped for a few minutes. They were in the hospital because their heart was beating too slowly. Therefore, any time their heart went even slower it was concerning and I went to evaluate them. On this visit to their room, the patient’s symptoms were unchanged from earlier that night and the night before. They were stable, though lightheaded. How to best manage their heart was being explored by the day team. The patient had insomnia even when not in the hospital. I was holding the sleeping medication they’d used for months because it could make their heart slower. It was our second night together, the patient and I, and we were doing our best to get through it. They watched TV because they couldn’t sleep and I answered pages (yep, in healthcare we still use pagers and faxes), saw patients, and ordered medications as the need arose.
  • I stopped by a patient’s room early in the night because they were a “watcher” (someone who was on my “watch carefully list” because they were more likely than others to take a turn for the worse). They had recently turned 80 and were chatty. They glanced up at the news on the TV in the room, “Politics in this country is in a terrible state,” they said. I expressed my agreement. “We got shot at for this,” the patient said, shaking their head and nodding at the TV. Six million responses flashed through my mind; none expressed what I wanted to say. None made the gravity of their statement less.
  • I was called to a patient’s room multiple times over several nights. Every time they were writhing in abdominal pain. Every time they had their blanket over their head. What kind of trauma had this grown-up person survived to feel it necessary to hide under their blanket in the hospital? Our workup, so far, was negative. No explanation for their pain. We tried treating constipation and urinary retention. We tried nausea medicine. None of that helped. Tylenol wasn’t working. What else should I try? Should I give this patient another small dose of opioid medication like they got during the day? Were they seeking out opioid medication because they were addicted to opioids or were they just in pain? Did it matter if they were drug seeking because of addiction if their pain was real? Was their pain real? If their pain was real, was an opiate the best tool I had to help lessen it?
  • I walked briskly. A patient who was admitted for a small stroke had an evolving headache. Maybe it was just a headache, but I wasn’t going to just give Tylenol and not examine the patient. It would be terrible to miss a second stroke we might be able to do something about. Head and neck pain. Their neuro exam was normal – no weakness or sensation changes. I examined their neck. My heart jumped with joy. There under my fingertips was a good old regular muscle knot. We have great medications for muscle pain. Besides, hospital beds are uncomfortable. When this patient got home (especially if they stretched) their knot would surely go away. Finally, a fixable problem!

There’s something surreal about starting your shift when the sun is setting and driving home to sleep after the sun rises – driving in work traffic going the opposite direction as everyone else on the work-home axis. Some nights in the hospital seemed to move backward and other nights zoomed by. I don’t recommend the night shift and I never will – this wasn’t my first rodeo as we used to say in the ED where I first worked night shift. Yet, this was my first time on nights as a doctor. Night float afforded me more independence than I’d had previously. I grew as the nights trudged on. As I drove home on the morning of my last night shift, I felt a little bit more like a physician than I ever had before. And though tired and excited to transition back to days, the feeling of growth was rewarding.