Engaged

This year I got engaged. It wasn’t a surprise as it came about after countless dialogues while driving between mountains and feasting spots, while plodding along trails below tree line, while standing next to rivers, and while gazing out at the horizon from mountain tops. Like most aspects of my fiancé and my relationship, the timing of engagement was mutually agreed upon and, once decided, a joint undertaking of finding rings, figuring out the legality of things, and planning a wedding unfolded.

It’s funny to me that I’m planning my wedding as I also undertake my third year of medical school. I am a person of action, but usually my time is spent on professional endeavors. I’ve only chosen careers that are consuming, where even when the day is done the puzzles of work linger, tossing and turning in my mind as I go about the rest of my life. I’ve never considered relationships beyond friendship as required or even goals. I’ve always seen marriage as something I’d consider only if someone fell into my life who made me think of it. “Fell” being the key word. I’ve known for many years that happiness and loneliness come from within. The loneliest years of my life I was in a long-term relationship. My happiest times correlate only with my internal state. I fought hard on many occasions when I was single to be allowed to go about my business as I saw fit. And as I think about marriage, the annoyance of having to explain that I am whole without a partner remains somewhere in my skin. But, yet, as I undertake one of the hardest years of becoming a doctor, I am also signing away singleness.

My fiancé and I have discussed marriage and dreamed about growing old together since months after we started dating. There are people who bring out your happiness, who make you laugh more than most, and who force you to think about the world differently. My fiancé is that person for me. And in our short time together, we’ve weathered many storms. There was the first years of medical school – torturous as the hours of study dragged to the future. There was COVID. There were those times when we could have died in the mountains. Where we literally talked each down the cliffs, teetering on an all-to-real edge. There is this current stretch of doing the “long distance relationship thing.” There were the times we shared with family and friends, where it was so easy to feel connected. How seamlessly he fit in with my people (including when my sister and her partner lived with us for a month starting days after he and I moved in together) and how his people made me feel like family from the beginning (starting with the Thanksgiving dinner where I met his parents and everyone in the extended family all at once).

I knew it was time for us to finally start planning our wedding for two reasons. First, since our first marriage conversation we’ve wanted to get married before he follows me to residency and the clock is ticking until that time comes. Second, the realization popped into my head that I couldn’t imagine being happier with another person.

Engagement is neat in the sense that it brings people together. Our families and friends have offered advice and help as my fiancé and I embark on wedding planning. It’s such a fun thing to have a joyous project to work on. Engagement is as odd as it is neat. There are many norms about engagement and marriage which have stood out to me because I rejected them. I didn’t want an engagement ring. My wedding dress will be red. I prefer small, intimate gatherings. My ceremony must be outside. There will be no registry. There will be no escorting down an aisle.

And as I often do for my career, I’ve spent some time reflecting on marriage. I like to ponder why things are important and worth doing. My younger self often thought marriage was giving up something of yourself for someone else. I’m glad to report that that isn’t the case. Marriage is about two very different people taking on a shared adventure, where there are lots of side adventures together and apart. Marriage is just a formal way of saying “I trust you and want you to be my life-long co-hiker no matter how boggy the trail or how craggy the mountainside.”

And as he said when I read him this post, “’Fiancé’ is a weird word, let’s get married already.”

Update from Labor and Delivery: Non-Surgical Edition

We worked to the rhythm of the fetal heartbeat, ticking along at 140 beats per minute.  We hadn’t met the baby yet, but the baby was getting ready to come out and greet our world.

The soon-to-be-mom wasn’t in as much pain as she had been last time I saw her. The epidural took the edge off her contractions. She could talk to us again and was even happy (albeit also tired).

The team got ready to start pushing. The contractions were the right distance apart and strong. The cervix was dilated to 10 centimeters. We explained the process of pushing the baby out – for each contraction she’d push 3 times, each for 10 seconds. While pushing she’d pull her knees out and back toward her ears because that opens up the pelvis and helps the baby fit through. The first contraction we practiced. Not many laboring humans get the pushing thing perfect on their first try. But, it didn’t take this soon-to-be-mom long to learn what to do.

Birth is trepidatious, exciting, and boring all at the same time. First there is a lot of wondering about how the whole process will go. Then there’s a lot of wondering what the baby will be like. Parents are excited to meet their child for the first time. From the health care perspective, there’s a lot of standing around. A lot of blood and mucus and other types of goop. The work comes in waves, as the contractions come and go. Between contractions the laboring human rests and the rest of us wait. It’s really all about the laboring human. The rest of us are just accessories and moral support. On this occasion, the soon-to-be-dad was a great team member. He was encouraging without being overbearing. He was engaged without hovering. The support people the laboring human brings with them aren’t always that good, but you’d be stressed too if your partner was doing all the work and all you could do was stand by waiting.   

This soon-to-be-mom tapped her tummy and sang to her baby in between contractions. She had made up a song for the baby that involved the baby’s name. She told us she had spoken to the baby throughout her pregnancy. She explained that she had told the baby when they were eating. She told us that the baby knew that they ate yogurt every day at 2:30 pm.

The soon-to-be-mom worked hard when the contractions came. The baby moved down the birth canal. As the baby came closer to meeting us, the soon-to-be-mom became more uncomfortable. If you’ve had a baby via vaginal birth you might know what the pressure of a baby’s head is like as it makes its way out – the rest of us can just imagine. The soon-to-be-mom had a good epidural, but it didn’t’ take away the pressure of the baby’s head. It didn’t take away the pain that came with tissues stretching.

We saw the baby’s hair for many minutes before we saw the baby’s head. Head then shoulders and then the rest. I helped deliver the placenta – best described as a warm squishy sac.

The baby cried upon entering our world, a sign of lungs waking up. The baby started covered in white wax and slightly gray, but soon turned pink. The baby snuggled up on the mom’s chest. The baby was perfect, as all babies are. All babies are both perfect and look like aliens if you ask me. Regardless of babies’ alienness, you still tell the parents congratulations on having their baby (this is very important).

Mom rested. She then sang the baby’s song. Once the placenta came out, we made sure the bleeding stopped. We made sure any tears (they’re common apparently) were sewed up. The obstetricians tell me vaginal tissue heals quickly. Life is a curious thing, especially the beginning and the end.

Mom and dad were lost in staring at their baby as we cleaned up mom. The nurses made little ink baby footprints on a certificate for the parents and on hospital paperwork. They took baby’s vital signs – baby was doing well with its itsy-bitsy everything.

We left their room. Time to return to our station. Many little hearts running between 110 and 160 beats per minute bopped along on our monitors counting down the hours until their parents got to meet the baby they’d made. We joke that labor and delivery is the only floor in the hospital were pain is a good thing, only because it means that it might be time to have a baby.

Birth is trepidatious, exciting, and boring all at the same time. I’ve seen the toughest cry at the sight of their child. I’ve seen smiles and laughter and looks of amazement and terror at being a new parent. And I’ve only been on labor and delivery for a few weeks. Imagine what it’s like to make a career of helping people bring their babies into the world.

The COVID-19 Vaccine: Celebration and Differences

Repost of a post I wrote for the Global Health Diaries, the blog of the Global Health Program at the University of Vermont Robert Larner M.D. College of Medicine and the Western Connecticut Health Network. Find the original (split into 2 posts) here and here.

My partner and I both work in healthcare and had the opportunity to get our COVID-19 vaccines months ago. Never in the past would I have expected to await a vaccine with such anticipation and feel such gratitude upon receiving it. Among the many other social and scientific features COVID has brought to the forefront of our attention—one, at least for me, is a renewed appreciation for all the vaccines we have previously developed. To think that we can stop smallpox and polio is a relief. But, also, COVID is a reminder of all the diseases that have escaped vaccines to prevent them. HIV comes to mind.

My friends and family in the US are in various stages of COVID vaccine completion. The variance is largely because of their age, profession, and which state they live in. What is reassuring to me is that for my US community the debate is not whether to get the vaccine but, rather, when.

The conversation about the vaccine is very different for my Paraguayan friends. I have not experienced vaccine fear among the Paraguayans I’ve known—which is to say their access to the COVID vaccine is not limited by personal belief but rather distribution.

I connected with all my friends in Paraguay on Easter, an important holiday in a predominately catholic country. I was excited to hear about their celebrations. In Paraguay, the week leading up to Easter is called Semana Santa (Saints Week) and is especially important. It is a time of sharing chipa (a traditional food that’s like a hard cheese biscuit) and enjoying the company of family and friends. Visiting has been limited this year because of continued concern for COVID, but my friends still report making chipa and enjoying the company of family.

When the topic of COVID came up, one of my friends said, “Estamos acá en la lucha, en Paraguay no hay vacuna, a nosotros es imposible recibir la vacuna…primero tiene que ser por las personas saludes, por los militares… y después recién por nosotros, dicen que van a inmunizarnos, pero no sé…por nosotros acá nuestra lucha es esperar la vacuna y quedar en casa. (We are struggling here, in Paraguay there is no vaccine, it is impossible for us to get the vaccine…first it must be for healthcare workers, for military personal…and then, after, for us. They say they’re going to vaccinate us, but I don’t know. Here our struggle is to wait for the vaccine and stay home.)”

This friend has been studying online since the pandemic began. She hopes to someday work in healthcare, but she is not able to go to the hospital to continue her clinical training for fear of catching COVID. One of her uncles was hospitalized for 15 days for COVID (he is doing well and made in home for Easter). Many of her family members caught COVID this March, but only the one uncle ended up in the hospital.

One of the things that continues to strike me about my Paraguayan friends is an unwavering optimistic outlook even though COVID-19 vaccination in just beginning in their country. My friend’s comment, “Here our struggle is to wait for the vaccine and stay home” struck me. She said it in a matter-of-fact tone that did NOT hint at frustration but, rather, exuded unwavering patience.  In thinking about my friends in Paraguay, I began to wonder if the closeness of families (not just emotionally but geographically) is a protective factor against feelings of isolation I’ve heard from many of my US friends. My friends in Paraguay either live with their parents and extended family or on the same block as them; compare this to my friends in the US whose families are spread out across distant states. This comparison reminded me that even though this pandemic has touched lives across the globe our shared experience is also a highly personal experience shaped not only by our uniqueness as individuals but also by the culture of the society in which each of us live. 

COVID-19: Oddity of a Shared Experience While Living Continents Apart from My Paraguayan Friends

Reposting a post I wrote for the Global Health Diaries, the blog of the Global Health Program at the University of Vermont Robert Larner M.D. College of Medicine and the Western Connecticut Health Network. Find the original post here.

In early March, I had a Zoom call with the other community health Peace Corps volunteers I served with in Paraguay from 2014-2016. One of my colleagues still lives in Paraguay and he shared his impression of the Paraguayan response to COVID-19 compared to that of the US this spring: “Here [Paraguay] everything is locked down. Police will stop you if you’re on the street to ask why you’re out. People are getting restless because, as you know, here many people don’t eat if they don’t work. But Paraguay is taking this seriously. It’s mind-blowing to hear what’s happening in the United States. It’s hard to believe the news of people protesting masks and attending large gatherings during these times.”

At the time of that comment, the US was still widely debating the validity of masks and COVID-19 cases and deaths were still increasing. Vermont, where I live, was among the US states that chose a more aggressive public health approach with the hope of containing viral spread. For much of the spring and summer most business in Vermont were closed, including gyms and many restaurants. There was no curfew, however school was cancelled or switched to completely online and wearing masks in public places was mandated. The almost complete shutdown only lasted a few months. In late summer, many businesses in Vermont started to open again. Now, schools are back in session (many school districts have a hybrid of online and in-person classes). As a second-year medical student, I have in-person classes twice a week and online classes three days a week. I am required to get a weekly COVID-19 test and report any new symptoms and contacts daily.

The short shutdown and recent opening of Vermont is in stark contrast with the experiences of my Paraguayan friends during these past 6 months. I’ve remained in contact with friends in the Paraguayan community where I worked when I lived there during my Peace Corps service.

This fall, just as in the spring, my friends in Paraguay are mostly restricted to their homes. When my friends and I spoke in early summer, they said that only a few members of their extended family were still allowed to go to work. One friend shared her perspective on Paraguay’s infrastructure, “Our hospitals can’t take care of people if they get sick,” she said. “We are worried.”

In early September, I got a voice message from one of the Paraguayan women who is like a mother to me. She was on the verge of tears. She is the primary caretake of her 90-year-old mother. In my friend’s message she told me that she is scared that her mother will die of COVID-19. My friend does not have a car. The nearest hospital is 2 hours by bus. I don’t know if the buses are running right now.

I’ve returned to Paraguay twice since leaving, once for a friend’s wedding and once to meet a friend’s son before he turned one. I was planning to visit again this year because two of the children I taught when I worked there will turn 15. In Paraguay, 15 is considered an important birthday and some families have a large, wedding-like birthday party to celebrate. The two children turning 15 are like younger siblings to me and I wanted to see them during their special year.

In late September, realizing that I probably won’t travel anywhere outside of the US soon, I made a traditional Paraguayan drink called cocido. It is a warm beverage made from steeped yerba mate (similar to tea) and burnt sugar. It’s a perfect study beverage for fall and it reminds me of my Paraguayan friends and our times together. I shared a video of making cocido with my Paraguay friends. One of them mentioned that I should make chipa, a traditional Paraguayan biscuit that is often eaten with cocido. “I miss chipa!” I said over text. “I haven’t made it because it’s better in Paraguay. I’ve been waiting to visit again so I can have it there.”

My Paraguayan friend responded, “You should make chipa. Don’t wait to come to Paraguay. You’re not going to be able to come for a long time. Things are not well. Lots of people are getting sick here now. We don’t know what is going to happen with this virus.”

My friend’s comment was in stark contrast to any previous conversation we’d had about me visiting Paraguay. My Paraguayan friends remind me often that I am always welcome in their homes. Before COVID-19, every time we talked they asked when I was returning to Paraguay. Now my friends seem too far away to visit. Yet, despite the feeling that travel to Paraguay is morally forbidden during these times, there is something novel about sharing the same public health crisis in my home country as friends abroad. It is not often that the primary public health concern in the United States is the same as that in Paraguay. It is the first time since I’ve left Paraguay that I feel my life is still intertwined with the lives of my friends in Paraguay. It’s not reassuring, but it is interesting to consider how interconnected our global community is despite the borders, oceans, and mountains that separate us.

Resilience

Not so long ago, a couple of brilliant new medical students asked me how many notecards I do a day. “Doing a notecard” means quizzing yourself on its contents and making progress in remembering the information it contains so you can answer test questions on the topic. Talking about the number of notecards we do daily is typical shop talk in medical school—everyone is trying to figure out exactly how to learn the mountain of information that makes up medicine. Almost everyone decides early on in their medical school career that the only way to learn what we must learn is with notecards. But, what is the perfect number to do in a day?

I avoided answering those new medical students’ question about how many cards I do a day. I wanted to help but, it’s an unanswerable question. I am not a robot. If I were a robot, I’d do something like 500-1000 notecards a day. But that’s not how life works. Some nights I don’t sleep well. Some days I have meaningless meetings that take up the best study hours. I gotta eat. I gotta move my body. Some days, it’s just too sunny to stay glued to my desk. Sometimes I’m tired and I retain nothing. Sometimes I get bad news and I’m sad. Sometimes I’m sick. Sometimes I’m on fire and I cruise through notecards like a genius.

We talk a lot about resilience in medical school. Here are the typical discussion questions:

  • What is resilience?
  • Why is resilience important?
  • Can resilience be taught?
  • How does one become resilient?

Thinking about notecards led to me some answers. Here they are:

What is resilience? Why is resilience important?

Google defines resilience as “the capacity to recover quickly from difficulties; toughness.” With that definition, it’s obvious that when you’re doing very challenging things like learning medicine it helps to be resilient. Becoming a doctor is a long process and you’re guaranteed to make a lot of mistakes. The only way you’ll make it to the “end” is by becoming an expert in self pep-talks and getting up when you fall.  

Can resilience be taught?

I don’t think so. Not once, ever, has any class, piece of advice, or discussion made me better able to endure a hardship. Every hardship I’ve endured was because I decided to bear it. I had family and friends who supported me along the way, but the healing and “how to do better next time” was mine alone to formulate. But, while I don’t believe we can teach others resilience, I do believe that resilience is learned.

How does one become resilient?

We become resilient by being challenged. The folks who are most resilient are the ones who have endured the most hardship. That’s not to say all people who have faced many obstacles are resilient; it’s just to say that you can’t be resilient if you never face a challenge. If you’ve never failed or been hurt than you can’t know what it’s like to dust off the dirt from a fall and try again. Without challenge, you can’t learn how to adapt your plan as life unfolds new surprises.

This principle is the basis of the answer to the notecard question I was asked. How many notecards do I do a day? I have NEVER, not once, done as many notecards as I hoped to do in a day. Yet, I have passed all my classes comfortably. In fact, not only have I never completed as many notecards as I wanted to…when I started medical school, I didn’t use notecards. Not using notecards was a grave mistake. When I started using them my grades improved by about 5% and, for the first time in my medical career, I had time to exercise, sleep, and socialize a sustainable amount. I switched to notecards ¾ of the way through my first semester of medical school. I was terrible at making notecards. But, I gave them a fair trial because I knew how I was studying before notecards wasn’t working. I had two choice at that point: sink or swim. Swimming involves adaptability. I decided I would rather be an otter than a rock in the deluge that is medical knowledge.

Deciding to use notecards may seem trivial until you consider that I’ve bet around $100,000 (so far) on becoming a doctor. It seems trivial except when you consider that it took me 6 years (of work) from the time I decided I wanted to become a physician to the day I got to decide how to study my medical school material. It seems trivial until you realize that I still have at least 5 years, probably 8, and many licensing exams between me and practicing medicine. The stakes are high. I could have failed upon switching to using notecards. But, I thought it was worth a try and I knew I would fail if I kept up what I was doing.

This past exam (fast-forward to my second year of medical school) was the first time I finally studied all the notecards I’d made for an exam. It’s been a little less than a year since I starting using notecards to study. I’m way better at using notecards than when I started. But, my journey isn’t over. This spring I take the biggest exam of my life (my first board exam – a national exam everyone who becomes a doctor must pass). How well I do on that exam heavily influences what residencies I can apply to and, ultimately, what type of doctor I’m allowed to become. It’s scary. My daily notecard count is only one part of how I will prepare for that exam. The number of notecards I did daily last year, over the summer, and now is different. How many notecards I do today will be different from how many I do each day when I’m in the middle of studying for that looming board exam.

What challenges and failure come to show us is that things can be done in many ways. They also show us that we can only control ourselves. For example, I can’t change how much information I’m expected to know for an exam. I can decide how to learn the information. Resilience is not complaining about something that never could have been. It’s about deciding to make your dream reality. It’s about jumping into the flood, scared out of your mind, with a willingness to evolve until you get to where you’re meant to be.

On Love

When from out of the blanket burrito you’ve created, like extra salsa, your blue eyes emerge, blinking and dazed as if they’ve never seen light. You seem stunned as if you didn’t expect the sun to rise as it has every other day. I’m glad you’re here.

When we each sit, heads bent over our studies, the sun dancing across your hair and alighting on our plants—we created quite a jungle house when we moved in together—I smile before diving back into the world of medicine.

When you scamper away, a mountain goat of a human, taking off when you see a steep incline with rocks on the trail ahead, I chuckle. I’ll find you at the top of the pitch, eyes glistening, waiting. Maybe a kiss before we forge onward. And when we get to the summit we see the world unfold before us. Each of us thinking our own thoughts, but knowing somehow our thoughts fit together like the parts of an ice cream sundae—dazzling all on their own but grander together.

When I’m sitting on the couch, studying or writing, and you ask “Are you hungry darling?” As I light the candle for the dinner table I’m already full.

It’s those times when love seems like such an obvious thing. And, as happy as I am alone, I’m glad you decided to journey with me.

Loneliness Lab

It seems fitting to talk about loneliness now. Some things are opening but the COVID19 pandemic continues to close many social spaces and requires people to not only stay home but to physically distance themselves from those who live outside their home. It’s been interesting to watch the Facebook and Instagram evolution of my online network. The pandemic started with cutesy mask photos, ebbed into anger, and now includes random questions to spark online conversation and exercise videos.

There are those who have been gravely affected by the financial toll of losing work or of illness during COVID times. But setting more extreme circumstances aside, I’ve noticed that those who seem most impacted by social distancing are those who are very extroverted, those who live alone, and those who were lonely before the world shut down. I think for many, the slowed pace of life during a pandemic has unleashed an uncomfortable amount self-reflection. I imagine many are grappling with questions like: How do I occupy myself? And, how do I feel connected to those I care about if I can’t see them?

I think the silver lining of widespread feelings of loneliness during mandated social isolation is understanding. You or I may feel isolated today, but it took the extreme circumstances of a pandemic to get us there. Many are unluckier. They feel isolated daily, on normal days, or for long stretches of their lives. Many of those people are our family and friends. I think the pandemic has shown us that people feel loneliness at different thresholds and endure the feeling in varying ways.

We can observe the evolution of our own feelings during COVID, especially if they are new feelings, in the hope that they will provide greater insight into the feelings others in our lives may have at different times.

Thinking about my career as a physician and my role as a member of a community and family, I will always know and meet people who are lonely. I think it is easy to forget how common loneliness is. It is not something that is always worn outwardly and loudly like a football jersey. Often it is subtle. And while we might not be able to drive the loneliness someone else is feeling away, each of us can be an encouraging force for others. We can be present to listen when someone else needs to share. We can be a connection in their lives.

The nice thing about pandemics is they usually end. For many, the end of this COVID shutdown will be a return to normal. It will be easier to travel and socialize again. The feelings of isolation and stress and sadness many feel now will magically lift when social distancing is no longer required for public health. But, for those who feel isolated for other reasons, the struggle will go on. You and I should remember that. Not to be negative and pessimistic but, rather, to remain in touch with people beyond ourselves. Loneliness is a powerful force. If we are feeling it now for the first time, we should take note. We should take note so that we might be more empathetic later when we are not feeling isolated and someone in our network is.

Memory

When it doesn’t occur in an explosion, change often happens in such small increments that we don’t notice it happening. Medical school changed me in both ways. The start of school launched me into a new world of academia. I was pushed to study more efficiently and more than I ever had. I adapted to a new lifestyle. These changes were dramatic but expected. Starting a new job, which is how I view school, is usually that way. However, looking back at my first year of medical school (so far), I changed in unexpected ways that were not obvious in the moment.

Not so long ago I was learning brain anatomy. The topic was interesting and boring at the same time. The individual pieces of information were simple, however, woven together into pathways and functional groups these bits of the brain were quite complex and somewhat indeterminate. As I was considering several parts of the brain involved in forming memories, I found my mind wandering beyond the curriculum. Memory is an interesting thing.

My sister has always had a good memory. She can read a document 3 times and recite in perfectly; this worked well during her acting career. She always remembers things I’ve long forgotten from when we were kids. My memory has never been like hers. As a high school student, I thought that memory was an innate quality. I thought memory wasn’t something that could be trained and changed. I took that belief to college where I worked hard. I’ve always known that most things can be achieved if I work hard enough. Since college and until now, I haven’t thought too much about memory.

Medical school has made me reconsider memory. As I thought about the corticospinal pathway carrying motor signals from the brain and brainstem to the body and the anterolateral pathway carrying temperature and pain signals in a chain of neurons up to the brain, I realized that these things were complicated. But, they didn’t seem as complicated as they would have back in August when I started medical school.

These days, I find myself reading words I can’t pronounce and remembering them. I find myself reading dense documents about the presentation of a disease or the features of a drug and remembering more than I did when I read comparable materials in October.

As I was studying what parts of the brain are responsible for different aspects of memory—working, long-term, emotional—I realized that I have trained my memory since starting medical school. And, while my brain’s approach to remembering is still different from that of my sister’s, memory formation is dynamic. The brain is plastic just like the rest of life. Considering this, I’m curious to see how much my brain will change by the time I reach the end of medical school. Residency. And beyond. 

But, first, time to finish the last 4 weeks of my first year of medical school – hours that will be spent learning many aspects of the central nervous system beyond memory and brain structure.

The Mountains

These days between the hours of studying, the doctorhood quest unfolding slowly and quickly at the same time, I find myself hiking whenever time allows. It’s difficult to describe what I find in the forest as I climb to a mountain’s peak. Some days I go quickly, not observing the trees and moss as I forge up the trail. Other days I step slowly, methodically looking at the ferns and the rocks and the sun rays that scatter across the forest floor.

Sometimes my mind buzzes with thoughts—of friends, family, and school. Of puzzles I still have left to solve or chores that await me when I get home. But, more often as time goes, I find my mind mostly empty. An uncommon feeling in my daily life in town. As I get lost in thoughtless contemplation, the chipmunks make me smile as they scuttle around me and the grouse make me jump as they burst into flight before I see them. The sound of their wings is in stark contrast to the silent trees around me.

I stop for a sip of water partway up a steep stretch of trail. My forehead is crusted with salt from sweating. I feel my heart pounding. The wind picks up and the trees creek and groan. I look up and see their branches waving. Even a brief pause allows my breath to slow before I hoist my backpack to my shoulders again. Onward.

I’ve done enough trails to know which rocks are most likely to make me lose my footing. I avoid them. Mud jumps from the trail to my pants. The trail gets steeper and I shed a jacket layer. Once taking off the layer, I climb higher and the wind gets stronger. I put the jacket back on. It’s a dance of layers—just enough to stay warm, not so many that I roast. I sweat regardless.

As I climb the final pitch to the mountain top I have on my warmest layer—in summer just a windbreaker and in winter a hefty coat. I hike so much, there are many days when I get to the highest rock and there is no view. Clouds never did bother me, so the clearness of the day doesn’t impact my decision to take to the hills. When it is sunny and clear at the summit, the landscape around my mountain stretches away from me. I think about what all the distant hills and valleys have seen, countless stories they can’t tell me.

Some days the wind threatens to push me over as I pause at the summit. On days when I can see the mountains beyond my mountain, I ignore the wind and take time to watch the sunshine. The rolling hills and fields below are a patchwork of cloud shadows and sun patches. Beyond them are the mountains of some other state. When I hike in Vermont, the mountains beyond are always pointer than the one I climbed. The green mountains were scraped by glaciers and, therefore, have softer features than their neighbors in New York and New Hampshire.

I don’t doddle as I descend to my car. My heart is filled by the fresh air of the summit. I’m ready to return to the hustle of regular life by the time I get back to the parking lot. At the same time, as I turn my car toward home, I’m already daydreaming of my next hike. The mountains don’t let me forget them, no matter what adventures I have waiting for me in the lowlands. 

Burnout

Alarm. Study. Class. Study. Eat. Study. Bed. Alarm. Study. Class. Workout. Study. Study. Bed. Alarm…Repeat. Repeat. Repeat. Sometime in the future substitute work for class and study.

My sister and I have a term for the life leading up to burnout. We call it living like a robot. It’s a life where work and/or school consumes you and sometimes you fit in sleep and things that make you happy. Most of the time in the robot life you simply work and wish you were sleeping.

The robot life is unavoidable sometimes if you have hard goals. I have always justified it by knowing when it will end. I’ve had several bouts of that life with years of rest between. Most of my undergrad I was a robot. My two years of post-bacc, pre-med studies plus all the work piled on top were some of the worst years I’ve known. Medical school is the first time I’ve not worked as I studied since middle school. It’s nice to have one job, just medical school. But, honestly, it’s still hard.

Medicine is cursed with a heavy dose of the robot life. This is partly because physicians have peoples’ lives in their hands, so expectations are high. It is partly because the type of people who become physicians are A types and have high personal goals. It is partly because health is ubiquitous and illness unavoidable. As humans, our ability to reach our full potential is partially determined by our health. If we are in pain or ill, we can’t do all the things we would if we felt well.

Medical school and then working as a doctor are challenging because the hours can be long. They’re also draining because the work is complicated and requires focus and lots of puzzling through piles of clues to find the best answer. The pressure is high because the puzzle directly impacts a human’s life. And depending on the gravity of the puzzle, the answer might impact a whole family.

Time and intellectual challenge aren’t all that makes medicine difficult. It’s a team sport, so office politics and business relationships come into play. But even teamwork isn’t the hardest part of medicine. Medicine is an emotional job. People who come to us as patients die. They lose function. They lose the ability to lead the lives they’ve always led. There are many happy outcomes, but not all patients’ stories end with joy. The sad outcomes add up as time goes on.

My time in healthcare as an EMT showed me that no individual patient impacted me unbearably. However, there are days when I feel the weight of all the patients I’ve helped. For example, I felt heavy after the last CODE I worked before I left the ED for medical school. A CODE is when you do CPR, shock, ventilate, and take other measures to try to revive a person whose heart has stopped.

That night I closed the curtain on a 30-something-year old with a wedding ring who hadn’t been identified yet. He was dead before he arrived, but we did CPR anyway. I was one of the last to leave his room. I never leave a dead patient before ensuring they’re presentable for family. CODEs are messy. If the family isn’t there to see us work, I see no need for them to experience the mess. I knew sometime in the night his partner would learn he was dead.

Tucking in that patient right before I ended my shift was hard. The death rested on top of the morning I walked into the ED to find teens on the phone crying. They, the teens, were calling their family to tell them their mother and uncle had died. Odd to have children deliver news most adults barely can. The sadness those teens felt added to the day I cleaned two CODEd patients back-to-back so they wouldn’t be bloody and dirty when their family arrived to say goodbye. After tucking in the second of these, I walked out of the room to find a visitor approaching. I interceded and joined her, but only upon entering the room did I realize she, the daughter, didn’t know her mother was already dead.

The sad endings add up. But, so do the good journeys and happy endings. The patients who turn our days around by sharing the most amazing stories or giving advice that is perfectly wise. Days in healthcare are brightened by visitors who show raw love toward someone stuck in a hospital bed. I’ve seen true love hiding in ED rooms on multiple occasions. It was working with old couples in the ED that showed me how I’d like to age.

It’s no surprise between the stress of the job and the rigor of the schedule that doctors and medical students burn out. However, knowing our challenges gives us the knowledge we need to persevere. Even within the field of medicine there are many decisions we can make to suit our goals. It begins with specialty and is followed by location and type of hospital. We have the information we need to know how a specialty, location, specific hospital, and extra projects we take on will impact our life or encroach on free time. We can decide, within the scope of meeting our obligations, when we wish to do extra and when we wish to do the minimum. Most importantly, we know that no state is permanent unless we let it be. 

I think at the root of avoiding burnout is being honest with ourselves and checking in with ourselves. There are stretches of school and work that must be survived. The robot life must be lived sometimes. But, amidst the madness we must decide when it will end. We can choose to rein things in when needed. We can choose to prioritize family or life outside work. Of course, to do this, we must know ourselves and what makes us happy. Once we know where we find happiness we can fight for it as fiercely as we fight for our patients. In the end, if we are not well, we can’t help anyone else at the level we can when we are in good health.