Tag Archives: Change

Remarkable People

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Movement at the periphery of my vision caught my attention as I sat at a stop light on my way to work. The movement was a person standing on the sidewalk. Perhaps they were dancing in their mind. Their movements were rhythmic but not in the way most people move to a beat. Something was wrong. Then I realized they were foaming at the mouth and a string of drool hung from their chin. Their eyes were open, but I wasn’t sure they saw the world around them. The explanation didn’t take a medical degree to deduce: Drugs. Likely cocaine or another stimulant. Opiates make people sleepy, not interested in dancing on a street corner.

That day in clinic I had a new patient scheduled who hadn’t been seen by a doctor in several years. The patient was young. They had a history of substance use disorder. The last notes in our system, from several years prior, said they’d stopped using drugs. Previously, they’d used almost every class of drug: alcohol, tobacco, cocaine, benzos, and opiates. As I waited for their appointment to start, I wondered how they were doing, now years later.

The patient entered my clinic calm, clean, and collected. They were articulate and respectful. They had cool hobbies including gardening and beekeeping. “Last time you saw us, you hadn’t used drugs for a few years. Is that still the case?” I asked.

“Yeah, I don’t use drugs anymore. Haven’t for years. I still smoke cigarettes though,” the patient said.

The conversation about their health unfolded. I looked at my computer to go through the never-ending reminders the healthcare system required me to complete with my patients. The reminders for the current appointment included cancer screening and offering nasal naloxone (maybe better known by its brand name “NARCAN.” It’s a nasal spray that reverses the effects of opiates and, if given soon enough after an overdose, saves lives).

“I know you said you don’t use drugs, but I have a reminder here for naloxone. Would you like free naloxone just in case?” I asked.

“No. I’m good. I used to have it. It saved my life twice…and I saved the lives of two other people. I had a friend that said over his time, he saved 60 people with NARCAN,” the patient said.

“I’m glad you were able to do that. I’m glad you’re still with us,” I said.

I finished going through the reminders. We finished our appointment. The patient was healthy and didn’t even need any blood tests.

I thought about the patient as I walked to my car. Beekeeping is awesome. I hoped I’d get back to gardening someday too. As I put my car in reverse, I remembered the person I saw foaming at the mouth on my drive to work. The contrast between the person I saw on the street corner and my patient that day was stark. The contrast reminded me how life is nonlinear. I thought about how the patient had saved their own life and the lives of two others. The patient I’d seen was a remarkable person. The phrase popular for healthcare workers during the COVID pandemic came to mind, “Not all heroes wear capes.” I decided the phrase was accurate but needed modification. Perhaps a better phrase for remarkable people in the world is, “Not all heroes wear capes, but they have baggage and have learned to carry it with grace.”

I hoped the person I saw dancing to drugs and foaming at the mouth would turn down a different road in life. Maybe that person on the street corner would someday tend their own flowers and suck honey from honeycombs too. Maybe the person I saw on the street corner had saved a life right before I saw them. Maybe their life had been saved by an unknown remarkable person. Afterall, the only thing that makes people remarkable is what they’ve done. Every day each of us can decide to do something new. Every day we can evolve and refresh. That’s the most exciting thing about life: The only constant is change.

The Process of Learning Medicine Works

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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

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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.

Knowledge

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“People believe shit and don’t believe sense,” my supervising doctor said. The comment was in reference to patients who believe remedies without any evidence to support their efficacy will treat disease better than medicines which have robust research behind them proving they work. It wasn’t a comment saying patients shouldn’t believe or do whatever they want, it was a comment that each of us should challenge ourselves to investigate the facts behind claims. It was a nod to science – the scientific method designed to prove that observations are (or are not) significant.

Perhaps the statement wouldn’t have caught my attention in a different era, but with the state of current affairs it did. These days there are attacks on science. There are TV stations and online blogs calling themselves “news outlets” yet report nothing but opinion, and poorly informed opinion at that. There are threats against the true investigative journalist; stories based in research.

Current affairs. The thought that one can simply say whole groups of people don’t exist and think they’ll disappear…or assume they don’t have a right to be who they are. The assertation by certain politicians that experts know less about their industry than folks who never studied it or never worked in it. The propaganda that people who move from one country to another didn’t do so in good faith, didn’t have a dream for a better life, and weren’t needed in the country where they arrived. The dangerous opinion that one’s beliefs are the only beliefs; forgetting that we’ve proven time and time again that all humans are fallible and that diversity of thought and world view make our species stronger.

The ability to think critically and analyze the validity of people’s claims is a form of power. It’s powerful to set one’s emotions aside and examine the truth behind one’s feelings. With a critical approach we can gain knowledge, not just vibes. With knowledge we can grow and change. We can learn to better understand those different from us rather than expect everyone to be like us. We can embrace diversity. We can embrace transitions from one identity to another. We can include everyone. Knowledge helps us understand that prohibiting words like “diversity,” “transition,” and “inclusion” won’t make people who live those realities disappear and is a form of coercion and censorship. 

“People believe shit and don’t believe sense,” my supervising doctor said. I laughed at the comment because in the context it was funny. But it wasn’t funny when I thought about how many people have, do, and will suffer because powerful people are unwilling to believe sense. Unable to hear reason. Disinterested in knowledge. We can’t change other people, but we are responsible for ourselves. I challenge you to look for sense, not shit, when making your decisions in every facet of your life. If each of us challenged ourselves to do that, the world would be different from what it is today.

Giving the Body Time to Heal or to Live

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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 Floors Don’t Shine Like They Used To

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I walked into the Veterans Affairs (VA) hospital where I have primary care clinic. I hadn’t been there for a few weeks between vacation and working in the ICU (critical care unit) at a different hospital. Yet, I’d heard about the budget cuts and other residents had shared murmurs of uncertainty related to what was to come for our patients. Entering the VA hospital for the first time since the budget cuts started to take effect, I was immediately struck by how gross the floors looked. And, as I was processing the dullness of the floors and their peeling finish, I heard a woman next to me comment on the floors too.

I used to joke to my spouse about how frequently they refinished the floors at the VA hospital. Over the past 2 years it seemed that every time I worked nights or left late, they were refinishing the floors. These efforts resulted in a floor as shiny as the shoes of the sentinels at the Tomb of the Unknown Soldier in Arlington Cemetery. And, until the floors looked dull, I’d never thought about their symbolism.

Every patient seen at the VA hospital is a veteran. Some of them wouldn’t have access to healthcare if it weren’t for the VA. Most of them wouldn’t have access to some of the most critical medical resources that our veterans need for good health without the VA. Mental health care is one example of such a resource.

I settled into my day at the clinic. A patient I hadn’t seen before was among my first patients. “I’d like to be screened for PTSD,” he said.

“Okay, why?” I asked. PTSD stands for “post-traumatic stress disorder.” It’s a condition that can occur when people experience things that are mentally traumatic. It can include flashbacks to the event(s) that disrupt life, nightmares that prevent sleep, and mood challenges that make it difficult to function in daily life.

“My daughter thinks I have it,” he said.

“Do you have nightmares?” I asked.

“No. But I think about things that happened. I just push the thoughts out of my head though. You know, I saw people die in Vietnam,” he said.

“How often do you have those thoughts?” I asked.

“Multiple times a day,” he said.

“How long has that been going on?” I asked.

“Years. I also get angry really easily,” he said.

“Do you get angry over things that other people don’t?” I asked.

“Yeah, all the time. I just get angry fast,” he said.

“Any thoughts of hurting yourself?” I asked.

“Hasn’t come to that,” he said.

“What about thoughts of hurting others?” I asked.

“All the time, but I don’t act on it,” he said.

The conversation unfolded. From my assessment he easily met criteria for PTSD. “Well, I think your daughter’s right that you have PTSD. Do you want treatment for it?” I said.

“Yes,” he said.

We discussed our options for treatment. I was grateful that we had options. How awful it was to think he’d potentially lived for 50 years with thoughts of the people he saw die in Vietnam haunting him multiple times daily.

Mental health is a huge part of health for all people and an especially common challenge for veterans. It has taken years of population education and eradication of misinformation to create an environment where veterans feel comfortable asking medical providers for help with their mental health. In my experience younger veterans are more comfortable discussing things like depression and PTSD than older veterans. But it’s an important issue for all veterans. To put it in perspective, about 18 veterans across the US die by suicide daily.

The VA offers more mental health services than any other healthcare system I have encountered. People using civilian healthcare often wait months to be seen by a therapist and longer to see a psychiatrist. When working at the VA, I can ensure my patients’ mental health is supported as soon as I learn it is a challenge for them thanks to the VA’s dedication to the mental health of our veterans. The VA’s effort to help manage mental health challenges among veterans matters. For example, suicides among veterans diagnosed with PTSD decreased by 32% been 2001 and 2022.

What makes medicine different from most other industries is that we don’t deal in money, property, or things. We deal in lives saved, lives lost, and human suffering. What does the shine of the VA hospital floor say about the future of our veterans’ healthcare? Time will tell. Yet, looking at the landscape of US federal budget cuts and executive mandates, people’s access to healthcare in this country is declining. I suspect that it’s only a matter of time before the health effects are felt broadly. Of course, these federal healthcare budget cuts and restrictions are concurrent with cuts in federal funding for research. As a result, we probably won’t be able to quantify the impact politics today had in terms of lives lost and population health deterioration. Perhaps the symbolism of a floor, which one walks all over for their personal benefit, is fitting symbolism for the value current political figures place on the health of others.

References:

  1. VA releases 2024 National Veteran Suicide Prevention Annual Report: https://news.va.gov/137221/va-2024-suicide-prevention-annual-report/

Heat Wave and Other Environmental Concerns

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A co-resident of mine recently gave a presentation on how global climate change is impacting health at one of our residency educational sessions. As someone who grew up in a Vermont family who thinks a lot about the environment, it was a basic talk. Basic as it was, the presentation was effective in starting a conversation about the health impacts of climate at my residency program.

In their wrap-up, the presenter mentioned that there isn’t much we can do as individuals about climate change because it is a systemic problem. As I left the presentation a different co-resident mentioned how they didn’t see the relevance between the presentation and our work in medicine. These comments reminded me of an interaction with yet another co-resident I’d had the year before – when that resident mentioned that they “don’t believe in recycling” when I was talking about recycling and compost programs in Richmond, VA.

This presentation on global climate change came right after a heat spell that broke summer temperature records across the US. In one week, my 3-person team admitted 2 patients for illnesses related to heat exposure. In the post-presentation discussion, my colleagues who work with adults and children mentioned how they can guess a child’s home zip code based on how bad their asthma is. Per those residents, since the bus depots moved to certain neighborhoods to “clean up” the center of the city the children in bus depot zip codes now have frequent asthma exacerbations.

Like most terrible things, the dangers of climate change are overwhelming. To slow the process and fix the problem does require global systemic change and political dedication. But, as Margaret Mead said, “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has.”

As a child my mom told me stories of how when she was a kid there was trash everywhere on the side of the road. And, while we still see trash on the side of the road, it’s improved a lot since her childhood. This shift occurred partly because individuals stopped throwing so much trash out their windows and dumping trash on the roadside and partly because we established systems to clean up trash. So, the less-roadside-trash-effort was a combination of individual effort and system change.

 “Green Up Day” in Vermont is a concrete example of combining individual and systemic effort to reduce roadside trash. Green Up Day is a yearly event in spring when Vermonters go out with trash bags and collect trash along the roads around their property. The trash bags are put in piles on the roadside and the towns pick up the bags. Because of Green Up Day, Vermont enters summer with minimal litter on the roadsides. Vermont is a state of natural beauty – their ability to keep their state beautiful fuels tourism and protects the land Vermonters love.

Slowing, stopping, and reversing global climate change is a lot more complicated than simple trash management. But the only way to address complex problems is to break them down into pieces. Below is a list of some things we can do on an individual level to help. The below list isn’t exhaustive, revolutionary, or original. BUT it’s a list of things I’ve been able to do despite being a medical resident with a terribly busy schedule, not having much physical or mental reserve, and abiding by a relatively tight budget. I share it with you because I disagree with my co-resident that we can’t do much on an individual level. Think about what could happen if the >144,000 medical residents in the US did these things. Think of what could change if even half of the >300 million people in the US did these things. And think what could happen if we each also demanded environmental responsibility from our networks, cooperations, and politicians.

  • Recycle. Even if you don’t have home recycling collection. Take the time to drop it off at a recycling center.
  • Compost. This can be organized compost or home compost. For example, Richmond has city-operated composed bins throughout the city – there’s even one at the public library. If you own property, you can set up a composed bin or pile of your own.
  • Limit your use of single-use cups and utensils. I bring my bamboo utensils, travel mug, and water bottle to work every day to minimize my use of single use items.
  • Use soaps, laundry detergent, dish soap, shampoos, and conditioners that come in paper containers. You can get bars or powdered soap. BlueLand sells soap tablets that dissolve to make foam hand soap if you don’t like bar soap for hand washing.
  • Get spices from bulk pins or in glass bottles to minimize all the small plastic bottles spices come in.
  • Use reusable bags when shopping, including vegetable bags. Remind your cashiers that you brought bags if they aren’t used to reusable bags yet.
  • Say “no” to plastic bags on your take-out food. Instead, use a reusable bag or no bag at all.
  • Buy things in paper, metal, or glass contains whenever possible. Avoid plastic containers as much as possible.
  • Re-use plastic bags. They’re easy to wash; I promise.
  • Make sure your sponges aren’t made of plastic. Even mainstream grocery stores sell compostable sponges.
  • Walk or bike to work as much as possible.
  • Don’t idle your car when stopped. If it’s hot, just get out of it and go stand in the shade. If it’s cold, stand and wiggle.
  • Think carefully before using single-use equipment at work and at home.
  • Turn off your lights when you leave the room, or you don’t need them.
  • Limit your AC use to what you need. Turn off your AC when you leave.
  • Change your lightbulbs to energy-efficient bulbs. LED bulbs are cheap these days.
  • Use reusable batteries and rechargeable gadgets rather the single use ones when you can.
  • Use paper party decorations rather than plastic ones. I think about sad turtles when I see balloons. I don’t expect you to have the same reaction, but paper streamers are just as cool as balloons and better for the environment.

Want more ideas about what you can do to help slow global climate change? Check out the United Nations’ page on “Actions for a Healthy Plant” at https://www.un.org/en/actnow/ten-actions. Another good page with ideas for individuals can be found at the Milken Institute School of Public Health at the George Washington University: https://onlinepublichealth.gwu.edu/how-to-reduce-climate-change.

Listening to the Birds

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

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

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

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

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

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

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

A Letter to My Intern Self

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Dear About-To-Be-Intern Self,

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

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

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

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

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

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

Yours truly,

Jett

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.

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