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. 

Sights Set on 2024

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Stopping by Woods on a Snowy Evening

By Robert Frost

Whose woods these are I think I know.  

His house is in the village though;  

He will not see me stopping here  

To watch his woods fill up with snow.  

My little horse must think it queer  

To stop without a farmhouse near  

Between the woods and frozen lake  

The darkest evening of the year.  

He gives his harness bells a shake  

To ask if there is some mistake.  

The only other sound’s the sweep  

Of easy wind and downy flake.  

The woods are lovely, dark and deep,  

But I have promises to keep,  

And miles to go before I sleep,  

And miles to go before I sleep.

2023 was a year of change. My themes of focus were quietness, absorption, and forward movement. I wrapped up medical school, moved halfway down the East Coast, and started residency. Despite all the professional development, I enjoyed a 7-week adventure in Puerto Rico, visited Paraguay, hiked the 33 highest peaks in the Catskill Mountains of New York, and undertook other small hiking/traveling/outdoor excursions as the opportunity arose.

Residency leaves me tired and overworked, but my progress toward becoming the doctor I wish to be is rapid. On one hand, Frost’s line “miles to go before I sleep” is a literal interpretation of what I expect 2024 to bring professionally. I have many professional goals which will march along as the days pass. On the other hand, the “stopping by woods on a snowy evening” part of Frost’s poem (pausing in an unusual place), resonates with me as I think about my personal goals and themes for 2024. As I set my sights on 2024, three themes are on my mind: quietness, pause, and connectivity. It’ll be a year where I focus on personal health.

Quietness

This was also my first theme in 2023. I’m carrying it forward both because I think it is of utmost importance and because I still have growth to achieve in this area. Being a doctor and learning to become a better doctor involves constant stimulation and 1000s of decisions daily. Adult life is full of challenges including finances (bills and earnings), home management, and unexpected disruptions like illness. With so much happening, I find that it’s easy to get lost in the hullabaloo and lose track of my inner calmness. As the unexpected challenges of 2024 unfold, I will continue to cultivate my inner quietness because I believe it is at the core of resilience and central to success.

Pause

Related to quietness, my second theme is pause. As the hustle of life unfolds, I easily forget to stop to appreciate small and large successes and delights. In 2024, I will take time to pause so I can absorb the joys of life. Focusing on joy will train my mind to see the positive and diminish the negative.  

Connectivity

The aspect of connectivity I plan to focus on in 2024 is the mind-body connection. My medical training has been extremely demanding in multiple ways. I have watched my health decline as the doctorhood quest unfolds because of my schedule, external pressures of doctorhood and the healthcare system, and the stress of my work. While my medical training will remain vigorous throughout 2024 and beyond, in 2024, I plan to focus my free time and energy on re-cultivating my physical wellbeing. This focus on physical health combined with my focus on quietness and pause will strengthen my mind-body connection. I think cultivating my own mind-body connection will ground me as I seek to connect with my patients, colleagues, family, and friends.

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.

The Social Determinants of Health

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I was walking home from a series of hard shifts. My mind slid back to the first code I ever worked. “Code” is medical slang for when you do CPR and try to get someone’s heart to start again after it stops. My first code was a trauma-code. The story was that the patient lost a literal game of Russian roulette. The injury they had from the close-range bullet was not compatible with life. But the patient was young and when their heart stopped, the doctor overseeing the case didn’t pronounce them dead right away. Their heart didn’t respond to CPR; they died.  

That code was years ago. I hadn’t thought about it too much since it happened. Medicine is full of sad stories. I was surprised that the memory of the code entered my thoughts as I walked home. I wondered why I was thinking of it. I realized quickly: I was angry.

I don’t often get angry when working in medicine. The more common emotions I have on the job are excited, interested, happy, annoyed, exhausted, and sad – sometimes within the same interaction. I’ve only been angry a few times in my ever-lengthening medical career. I wasn’t angry at my first code, so why had I thought of it when I was angry?

On that day when I remembered my first code, I had cared for a patient who was dying of advanced heart failure even though they had the unblemished skin of youth. At first it would seem my current patient and the patient who died during my first code had nothing in common except an early death. But as I thought about it, I realized that they had more in common than it seemed at first.

Both patients would die harsh deaths. The code was fast, and the heart failure would be slow. And while both patients had easily observable health conditions, I found myself wondering if they were dying of those conditions or if they were dying because they were victims of something much greater. Could their deaths have been avoided if society hadn’t pushed them down so many times in their short lives? Were they dying of disease or of the social determinants of health?

The social determinants of health are non-medical factors that influence health; they’re the social and structural realities that shape how people interact and live. The social determinants of health include access to education, food, and secure housing. They include neighborhood exposures (the positive like puppies and playgrounds and the negative like violence and drug misuse). They include skin color, first language, sex, and gender. The list goes on.

I was angry because there was nothing more I could do for the patient with heart failure, just as there had been nothing more I could do for the young patient whose heart stopped all those years ago. Society had failed them. Collectively the two patients had experienced racism, the jail system, drug use disorder, mental health struggles, unfair treatment by employers, barriers to education, and likely countless other obstacles that I did not uncover during my short interactions with them. The patient dying of heart failure was difficult. They didn’t trust the healthcare system and they were profoundly unpleasant to work with. As I learned more about their story, I came to understand that while it is never okay to be mean it is also sometimes easy to see why a person could become mean. This patient had been knocked down so many times throughout their short life that it seemed all they knew how to do was fight. And, unfortunately, they were fighting for their life. And while they had not yet acknowledged it, they were losing. Would it be months before they died? Maybe a year or two because they were young? Maybe they’d be a miracle case and live much longer. I, however, don’t count on miracles.

I was angry because I thought the healthcare system was the last part of society to fail my patient with heart failure. I (and my team) tried to build a case to make them eligible for advanced heart failure treatments, all of which have strict criteria. The criteria are strict because all advanced therapies for heart failure are complex and require incredible collaboration between the patient and their care team, otherwise they fail to work. Among the options for some patients (not all) is heart transplant which has even stricter criteria because organs are scarce. In the end, the patient I was caring for was deemed not a candidate for any advanced therapies. They were not a candidate because they showed a consistent record of disregarding medical advice and missing their follow up medical appointments and prescribed medications.

After days of long conversations with the young patient with heart failure I understood that it wasn’t just personality that drove them to fight against medical advice. It was a fear of death, a desire for independence, and a long history of mistrust built on a life of the system failing them. There were many negative social determinants of health which had worked against them their whole life. I was angry because what is done can’t be undone. Just as death cannot be stopped when it comes calling. It’s unfair when and how death calls; it’s a metaphorical game of Russian roulette.

Being angry about the social determinants of health doesn’t solve them, but sometimes being angry is a place to start. And so, on that walk home and for a little while after, I let myself be angry. Part of writing this post was sorting out why I was angry. The next step is figuring out what can be done to address the social determinants of health. They are numerous and complex so there isn’t one solution and they’re slow to change. The young patient with heart failure reminded me that while I’m focusing on learning the science of medicine right now, I can’t forget the public health and community work I did before I jumped into residency. I can’t forget because when I’m an independently working physician, my patients won’t come to me with just disease. They will come to me with life stories that influence every aspect of their medical care.

10 Years Blogging

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September 2023 marks 10 years of my blog Connecting the Dots. I started the blog in 2013 to document my experience in the Peace Corps in Paraguay. When I finished my Peace Corps service in April 2016, I had already formed the habit of writing and decided to keep going to share my experience of becoming a physician. Some months and years I’ve written more than others as my life unfolded this past decade. My blog has documented my time in post-bacc and as an EMT as I strived to build a resume strong enough to get into medical school. The blog was a constant as I trudged my way through 4 years of medical school. And now, after 10 years blogging, I’m 2 months into residency.

I’ve periodically wondered if I should stop blogging. Life reflection/journal blogs like mine aren’t designed to become highly successful or business ventures like other types of more broadly relevant blogs. But I keep blogging both out of a love for the writing process and because my journey has been a unique one. I suppose a key lesson that the Peace Corps and then medicine have taught me is that every human has a one-of-a-kind story that if given the opportunity to be documented as a movie or book could be the next blockbuster/best seller. Most folks, however, will lead their amazing lives and die without much of a trace. My posts about people I’ve met and lessons I’ve learned are my way of remembering all the lives I’ve intersected with as I trundle along my life journey.

The warm welcome I received in Paraguay as a Peace Corps volunteer gave me an opportunity to learn about a culture different from my own and to make life-long friends with individuals who I could not have imagined if I never did the Peace Corps. Similarly, the experience of being a doctor gives me a window into countless lives that are nothing like my own. Medicine, above all, has taught me that there is nothing as fantastic, comical, tragic, beautiful, and surprising as real people’s stories. I’m often reminded that as outlandish as any fiction story might be, reality is more extra and harder to believe.

Just like when I started my blog 10 years ago, I don’t know where I’ll be in 10 years. Reading some of my first posts, it is amazing to me how far I’ve come. I’m sure the next decade will be equally full of surprises. I can’t wait to reflect on the inevitable unforeseen events to come and then write about the highlights.

To those who have read my blog for a while, thank you for your unwavering support. To new readers, thanks for stopping by to sample and for considering future readership.  

Here are some of my favorite posts over the years (I’ve left many out for brevity):

Getting Ready for Departure – DC Chapter, 12/8/2013, on leaving DC, the city I went to undergrad and built my first career, for the Peace Corps

Getting Ready for Departure – DC Chapter

Ideal Boyfriend, Ideal Girlfriend, 11/10/2014, quotes from the 7th – 12th graders I taught in Paraguay describing their ideal life partners

Ideal Boyfriend, Ideal Girlfriend

White, 12/12/2014, on being the only white person in my Paraguayan community

White

Crosses in the Sand, 8/6/2015, on a uniquely Paraguayan form of ant control

Crosses in the Sand

Overheard In Paraguay: Friendship, 10/19/2015, on friendship that last forever

Overheard In Paraguay: Friendship

Guardian Angel, 1/23/2016, on feeling cared for

Guardian Angel

See You Soon Dearest Paraguay, 4/11/2016, on finishing my Peace Corps service in Paraguay

See You Soon Dearest Paraguay

Determination: 2 Girls, 1 Hill, 1 Tree, and 1 Ladder, 11/12/2017, on childhood and the nature of determination

Determination: 2 Girls, 1 Hill, 1 Tree, and 1 Ladder

Christof, 6/25/2018, on kindness and thinking of others

Christof

Below the Surface, 12/28/2018, on returning to Paraguay and learning an unexpected lesson

Below the Surface

Q-tips and Time, 5/16/2019, on how our perception of time changes as we age

Q-tips and Time

True Love, 7/27/2019, on true love as witnessed in the ED

True Love

Memory, 5/24/2020, on thinking about how memory works

Memory

Goodbye For Now Vermont, 3/21/2021, on moving out of Vermont (again) and reflecting on my time there

Goodbye For Now Vermont

A Cup of Coffee, 10/24/2021, on acts of kindness witnessed in the hospital

A Cup of Coffee

Together,  1/7/2022, on working as part of a diverse medical team

Together

Echoes from the Third of Medical School, 4/12/2022, on finishing my third year of medical school

Echoes from the Third of Medical School

Windows to the Soul, 9/6/2022, on caring for critically ill patients

Windows to the Soul

Nothing to Do but Be Happy, 2/14/2023, on waiting for medical school to end while spending a few months in Puerto Rico

Nothing to Do but Be Happy

Goodbye Danbury, 4/15/2023, on my time in Connecticut

Goodbye Danbury, CT

What do you want to be when you grow up?, 5/25/2023, on becoming a physician

What do you want to be when you grow up?

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.

In the Quiet Presence of Plants

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“Some people look for a beautiful place, others make a place beautiful.”

~Hazrat Inayat Khan

I’m a keeper of plants. Some might call me a gardener but, having grown up in the rural US, I reserve the term “garden” for plants that root in the ground. And so, I’m a keeper of plants because all my plants are rooted in pots.

I have over 75 plants in my smallish apartment. Some of them have followed me through 6 moves. Some joined just this month. The only common feature among them is that they prefer Virginia to any place we’ve lived before. I attribute this to the sparkly sun here which was a key feature that drew me to the state in the first place.

My plants are as diverse as Richmond. There’s the Norfolk pine I’m growing as my Christmas tree. There are begonias adding their clashing leaf patterns to the balcony-dwelling jade plant, banana plant, snake plant, umbrella tree, and palm. On my desk is a battalion of orchids, most of whom bloom in spring. There are calatheas, peperomias, and bromeliads mixed in with the succulents and cacti. The coffee plants, passion fruit vines, and lemon trees are some of the newest additions. A dear friend got me a money tree for luck, around the time I got a lucky bamboo – it was a period of much change, so luck was needed. These lucky plants keep on growing. My crown of thorns hasn’t stopped blooming since I got it 5+ years ago. The fig, rubber, and dragon trees all were recently decapitated to encourage side branches (so far these experiments have been fruitful).

The plants sit along the windows and in layers such that those that need the least light live in the middle of my apartment and those that need the most are on the balcony for the summer or reside on the wide windowsill between my bedroom window and the blackout curtains necessary for daytime sleeping when I’m on nightshift. I know each plant’s light and watering preferences. I have a strategy for keeping each one alive when I leave for vacation.

Sometimes I wonder if it’s silly to have so many plants because I work such long hours outside of my home. However, when I come home to find a new flower bud or a fresh leaf unfurling, I’m reminded that it’s not silly but genius to have so many plants. The plants add a different beauty to the apartment than art (I have that too) and their quiet company is something I enjoy. With my plants even the most frustrating day can be softened when, upon sitting on my couch, I notice just how much the peace lily likes its new spot or how much the Chinese evergreen has flourished since we arrived in Richmond only months ago. And when I see the plants that I’ve potted up at least 3 times threatening to outgrow their current pots, I remember how we all change and grow with time. Sometimes our process of growth is too slow to see from day-to-day and only can be realized when we compare month-to-month or year-to-year. Yet, just as surely as my plants are renewing their roots and leaves, I’m also growing as the days of residency pass.

Hey Doctor!

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I got in the hospital elevator. One person was already in it – a maintenance guy by his uniform and the fact that he had a ladder in hand. Before I’d decided if I was going to say “hello,” he declared joyfully “Hey doctor!”

I glanced down at my badged (“doctor” was written on it in capitalized black letters on a yellow background larger than anything else on the badge). I looked around the elevator…yep just me and him…he was definitely talking to me. I said, “Hi!”

“Did you have to look at your badge?” he asked in a voice cracked in the way voices are when a laugh is bubbling up. We both burst into laughter.

I’ve been a practicing doctor for 5 weeks. While I feel ready and excited to be a doctor, the title is still new and I’m learning the role. Some patients and non-doctors take the title seriously and some don’t; however, when you ARE a medical doctor, the title comes with some weight as you know exactly what responsibility is behind it.

As part of my residency training, I work in a primary care clinic where I have a group of patients for whom I’m their sole primary care doctor for the duration of my residency. This means I’ll see them when they have a new issue and I’ll also manage their health maintenance. Primary care is about tackling health challenges before they become health issues and preventing people from experiencing life-threatening events and worsening health if possible. It’s arguably the most important part of the healthcare system even though it gets the least recognition, compensation, and emphasis in our corporate/profit-focused US healthcare system.

My first week as a primary care doctor I ordered a cholesterol panel (a blood test) for one of my patients. They had obesity and chronic pain. They hadn’t had their cholesterol checked before and at their age and BMI (body mass index) I wanted to see if we needed to start a cholesterol-lowering medication to reduce their risk of heart disease. During our appointment, the patient and I had a lovely conversation about their life and the changes they’d made to improve their health. I was inspired by them because it was clear that they were motivated and dedicated to their health – they had made diet changes and were finding ways to fit exercise into their routine despite having housing insecurity and struggling to make ends meet. 

The cholesterol panel came back several hours after the patient’s appointment had ended. I looked at the numbers and panicked. How do I interpret these numbers? I asked myself. This patient was relying on me to evaluate their lab results and provide recommendations on lifestyle and medication use. It was a big burden. I read some medical resources then, based on what I read, decided that their cholesterol was okay given their other heart risk factors. They didn’t need to start a new medication. I sent them a letter with the normal result.

Even after I sent the patient a letter about their cholesterol, panic lingered in my toes. Had I interpreted the results correctly? Would I need to call them back and tell them I was wrong, and we needed to do something different? Had a missed an opportunity to help them protect their heart?

Over the next week I researched more about cholesterol panels and then talked to my supervising doctor about the topic. In the end, I confirmed that I had made the right decision for this patient. I also learned there is a calculator I should use to determine patients’ risk of heart disease and the benefit of starting a cholesterol-lowering medication.

Soon interpreting cholesterol panels will be easy and fast. But the first time I did it for a real patient (a real person) was exciting and nerve-wracking. Just like being called “doctor” in the elevator this week required a little extra processing to realize that I was the doctor being referenced. I know I won’t have to check my badge for much longer to confirm my profession. I’m excited to grow into the person who can respond without pause to “hey doctor!”