Echoes from the Third of Medical School

The click-click and rickety wheeze of plastic jarred me back to the present from my thoughts about what I wanted to say about finishing my third year of medical school. Even though it’d been 3 years since I operated an ambulance stretcher, I knew that sound like I knew my own voice. The stretcher sound was among the many I’d learned in the past years.

The third year of medical school was a robot period. A term coined by my sister back in our college years. A robot period is a time when you just do as if you were a robot because sometimes you just must get to where you’re going.

I’d ended my third year of medical school learning that the squeak of premature infants is distinct from the wails of infants born on time. I also learned that the cry if a one-year-old is different from the tears that well silently and then exposed loudly before a 5-year-old boy gets a shot.

Before the crying nuggets served by pediatrics were the perfect one-two, one-two sounds of the hearts I heard in family medicine. Or the easy wooshes of lungs moving air happily. In outpatient internal medicine, I discovered the crackling stiffness of arthritic knees.

Before that there was the more forceful woosh of the ventilator in the intensive care unit. Pushing air into the lungs of someone who was silent. That same person had once been a DJ. How odd it was to see them existing quietly when they’d been mixing beats and filling dancefloors for most of their life. Neurology is a dark specialty.

And there was the sizzle sound and burning flesh smell of the electric scalpel in the operating room. The sound of metal tools on metal trays. The snap of putting on rubber gloves and the crinkling of paper gowns as everyone took their assigned places for the operation.

On internal medicine, there were the patients yelling for help. Some of them knew they were yelling. Some were just trying to reconnect with their minds which were lost in the fog of being sick. The beep of heart monitors. The dull sound of lungs full of junk. Oxygen monitors and bed alarms dinging, dinging, dinging.

Before all that, were the screams of women in labor. Of babies announcing their successful arrival with a gurgle-cry. The patter of footsteps as nurses and doctors ran because a baby was coming faster than everyone thought it would.

And that brings us all the way back to the beginning of the year. To psychiatry, where adult tears fell to the sound of congested voices. Or flat voices trudging along telling the stories of visions that no one else could see.

All those sounds are behind me. Today, I find myself listening to bachata and reggaeton. The traffic hums outside of my window. I’m studying for another huge exam. Exams are old news, but this is my penultimate of medical school. It’s the final countdown at long last. It’s been such a noisy year.

Just before I finished the year, I pulled out my violin. I hadn’t played it for almost as long as I hadn’t operated an ambulance stretcher. The songs that were like oxygen in my teens came back slowly. My fingers were awkward on the strings and bow but the jig I’d always loved most bounced around the room just the same. If you do something enough, you don’t forget. If you practice, you get better. Third year of medical school is about practicing. And the best part of practice is not practice, but what you’ve learned after doing it. That’s where I am now. Really glad to have done the year while also certain I’d prefer to never do it again. I’m grateful for the things I learned and the people I met. But, mostly, I’m excited to move on to the next phase of the doctorhood quest.

Grateful

I found myself lying on the floor. The sun had set but it was still early – a tragedy of New England once the summer fades. I was not tired or sad. My to-do list was as robust as ever and my goals circled high above my head, seemingly in the clouds. Yet, I was lying on the floor not even stretching. No music, podcast, book, or movie playing. To be fair, I spent a fair amount of time sitting on the floor (my preferred studying location is at my floor desk) so lying on the floor wasn’t that much of a change. It was the stillness and purposelessness of the activity that was unusual for me.

There was a period of my existence when I could not be still and had to always be actively engaged in something. However, the need for constant stimulation dissipated when I was in Paraguay and, I’ve often thought, “good riddance.” I recall my early 20s. I worked fulltime, studied in college fulltime, trained for marathons, went to parties, and built my first career. It was exhausting. It was the way of life I knew. The way of becoming successful. Of fulfilling the American dream. Then I moved to Paraguay where everything seemed so slow. Hours sitting and drinking terere in the shade. Hours spent sitting and sometimes chatting, often staring into space silently, sometimes cooking or napping. I came to enjoy rainy days where it is common for rural Paraguay to shut down. Rainy days were filled with lounging and drinking mate. I precisely remember the moment I realized that when the Paraguayans told me they were doing “nothing,” they meant it. What an odd thing nothing is.

I’ve reached that point in medical school where I’d rather it was over. That point when the hours of studying, sitting in the hospital, trying to learn everything I can, and testing to see if I know enough to care for my patients are quite tedious. I do NOT say this out of despair; I still know medicine is exactly what I want to do professionally. I still love patients and the puzzles they present, but I’m ready to be good at something again. I recall a similar feeling junior year of high school, junior year of college, 6 months into my first professional job after college, and 6 months into my life in Paraguay. There’s a time in all learning curves where it’s truly a terrible slog. That time when you’ve learned an unfathomable amount, still feel mediocre at managing what you know, realize you still have a ton left to understand, and know that it will still be a while before you’re “good at it.” Whatever the mysterious “it” is.

And that’s where the gratefulness comes in. I’m grateful these days because I’ve played this game before. I’m grateful because I know myself better than I did last time I played the game of learning something completely new. I’m grateful because I know already that I’m attracted to activities that seem impossible yet, at some point (after many days of struggle), I do wind up being excellent at them.

So, I found myself lying on the floor. It was junior year of medical school. It was the breaking point. It was about to be a landslide into graduation. In a couple of blinks, I’d start residency. I was closer to becoming a physician than I’d ever been. I lay on the floor contemplating the joy and misery of learning. I thought about some patients who had changed my worldview ever-so-slightly. I thought about the amazing teachings and mentors who I’d encountered while wandering about the hospital wards. I thought about the first day I showed up to work on an ambulance (my first clinical experience), years ago now. “I won’t let you kill anyone,” my chief had said then. I contemplated this. Soon, it would be I who had to prevent patients from dying if it could be done. That was kind of a big deal. I felt humbled. I had much to learn despite having learned so much. I was grateful for this moment of pause while lying on the floor. Life is quite a whirlwind when you seek out challenge. The secret, therefore, is to be grateful for the moments of calm when they come. Even the worst storms have eyes; I remind myself of to look for them.

Surgeons

I sat waiting for the surgeon I’d work with to arrive at the hospital. Being a medical student involves a lot of waiting. On the wall across from where I sat and next to my surgeon preceptor’s office was a wall of fame, of sorts, of surgeons gone by. The black-and-white photos caught my attention because every single surgeon depicted there was a white male. The irony was that most of the surgeons I would come to respect in the weeks to follow would fit neither or only one of the “white male” descriptors. The surgeon I was waiting for, for example, was neither white nor male. She would single-handedly show me what it meant to be an excellent surgeon.

The operating room is cold. The lights are stark. If you are helping with an operation you “scrub in” (which involves washing your hands in a special way and putting on sterile gloves and a sterile gown). Once scrubbed in, you maintain sterility the entire procedure which includes only touching sterile things and keeping your hands in front of you and between the level of your bellybutton and chest. Bathroom breaks and snack breaks aren’t an option for medical students in the operating room, so I tried my best to do those things before entering the room.

Once the patient is settled on the operating table, they’re put to sleep by anesthesia.  As soon as it’s confirmed that the patient is asleep, their eyelids are closed with tape to protect their eye structures and a tube is placed down their throat to help them breathe.

While the patient is asleep surgery unfolds. All surgeries are done with a team of people, the surgeon is only one member of that team, and the surgery is not successful without every team member. The patient is covered with drapes except for the area where the operation will occur. This is interesting because the humanness of the patient is lost. Their body becomes a workspace once the drapes are placed. It may sound disrespectful, but it isn’t. Rather, the drapes are meant to protect the sterile workspace and maintain patient modesty.

Surgeons are the artists of medicine. Much like carpenters and painters and jewelers and other craftspeople they make their living by using their hands. The difference, however, between surgeons’ hands and carpenters’ hands, for example, is stark. The surgeons’ hands are soft and their fingers nibble while the carpenters’ hands are rough and their fingers strong.

Surgery is all about feel and dexterity. Surgeons tie knots with thin thread to keep arteries from bleeding. They sew with curved needles using plyer-like instruments. During surgery, it’s the surgeon’s hands that impress. Their fingertips can feel the difference between disease and health in tissue. Their hands can somehow hold more tools than you thought possible.

Ask a surgeon about surgery and about the operating room and their eyes become bright. They smile. They draw pictures and use their hands to describe structures. They talk about the neat surgeries and bodies they’ve seen. They talk about how many operations they’ve done. Surgeons are like artists. They love their craft and exude a love for their studio (the operating room).

I would eventually join a surgery led by the surgeon I had waited for by the surgeon wall of fame. A resident and I were helping her. The resident was soon to finish and become an independent practitioner. The surgeon was busy operating; I was holding a camera (used to see inside the abdomen); and the resident was doing something else to help the surgeon. “People will not take you seriously because you are a small female,” the surgeon said to the resident. “Don’t be disheartened. Respect is earned.” The surgeon would go on to discuss the importance of appropriate financial compensation for your work and doing excellent work. I would hear this message about differences and respect several times during my surgery rotation. I would feel why multiple women ahead of me thought they needed to tell me and my colleagues this information. Yet, it wasn’t new information because I, like most others, didn’t make it through my 20s without learning how my different identities help and hinder me.

There are many things that you could die from if it wasn’t for surgeons. But, as lifesaving as surgery is, it is also fraught with risk. Your surgeon can kill you. Having life and death literally in one’s hands is not a light matter, and you see its weight on the shoulders of surgeons when you work with them. The riskiness of surgery is also why the road to becoming a surgeon is a long, hard one. It involves many years filled with unfortunately long workdays. Apart from a grueling training marathon, surgeons have high personal standards for their work. High standards coupled with hard training leave many surgeons with a robust ego.

Egos aren’t all bad. You want a confident, proud surgeon. This is because you want someone who is very good at what they do and who takes pride in their work to operate on you. However, egos can be detrimental too. Too much ego can lead to poor listening skills, lack of self-reflection, and a complete disrespect for others. High-quality surgeons are confident because they are good at their work and love it, proud because they save lives, and humble because they know they are human and will make mistakes. The best surgeons are not only confident, proud, and humble but also curious. Curiosity makes the best surgeons because they not only love operating but, also, dig to the bottom of their patients’ stories, investigate thoroughly any mistake or less-than-perfect outcome, and keep up on the latest research and recommendations in their field.

On our last day working together, the surgeon that made me understand surgery had time to sit with me in her office by the surgeon wall of fame. She gave me some advice and her philosophy on medicine. “It’s nice when patients appreciate your work. You saved their life. But, they don’t have to and that’s not why I do it. I like to help people,” she said. The conversation continued for a bit. “People talk about quality of life. I don’t think it’s fair to say that you don’t want to do surgery because of the quality of life. Quality of life is something you make. For example, right now I pick up lots of call [24-hour shifts]. I do it because I am well compensated but, also, because it is good experience. I like to help people… I like having the cases [surgeries]… But, I won’t pick up call forever. Right now, it makes sense… It’s all about tradeoffs. You can work less and then you make less money… You can set the terms of your work,” she said.

As I left the hospital after my last day working with her, I thought about the surgeon I’d worked with. She was a calm and patient teacher – something that is rare. She had saved many lives. She had seen the inside of the body many times. Her hands could tell the difference between a fat glob and a cancer by feel alone. I’d seen her talking to patients with a patience you don’t find in all surgeons. I’d seen her interacting with all levels of hospital personal with a respect and kindness that was genuine. I’d heard her talk through her clinical reasoning; it was thorough. I’d seen her do surgery; she excelled. She was exactly what I’d call an excellent surgeon. I would have no hesitation sending my patients or family to her because I knew she’d treat them well and operate with precision. She was the first surgeon to go on my mental surgeon wall of fame. After that first day waiting outside her office, I’d decided to construct my own wall of fame (for surgeons and other types of physicians) because the one I’d seen in the hospital was outdated.

Pull Up Your Compression Socks

Some of my friends and family have asked how I study so much. Others just give me a funny look, shake their head, and say becoming a doctor is too much school. And, to be honest, I mostly agree.

And that’s were compression socks come in.

When I was studying for my first board exam (aka STEP 1 which is a 7-hour exam that lightly touches most topics in medicine from skin rashes to embryological development) I started wearing compression socks. Every day before sitting at my desk with mate and breakfast and before firing up my computer, I’d spend a few moments pulling on the rainbow or patterned compression socks I’d chosen for the day. I’d never worn compression socks before I started studying for STEP 1 – not while hiking multiple 10-mile plus hikes a week, not while working 10-hour shifts on my feet, and not while training for marathons on city streets.

But studying from well before dawn to well past dark did me in. The truth is that studying all day is terribly grueling in the most passive way imaginable. The body rebels against stillness, and my bodying not only rebelled but went to war. My calves became so tight I could hardly walk. They’d throb at night. They’d throb in the morning. My shoulders and back were full of knots. My hamstrings constricted to a fraction of their normal length. I have a standing desk. It only made my hips tight. And. Yet. The studying had to be done. To help get through the hours, I’d stretched when I could. My workout routine become very consistent because without it I couldn’t concentrate.

The compression socks fixed my calves. I discovered them by accident. My partner wears them at work to avoid varicose veins, and one day I tried on some of his socks. It was a game changer; I could study all day and my legs would be okay. Just okay, but okay was way better than terrible.

It seems a bit dramatic to say it feels like your body is going to turn to stone simply because you sit still too much. “How do you study so much?” family would ask me in the final weeks leading up to my exam. I never exactly knew how to answer. And now I realize why – because studying  in medical school is less about the “how” and more about the “why.”

Why do I study so much?

It comes down to the end. The goal. The reason I bothered to enter medicine at all. It is only knowing where I wish to go that makes studying so much that I must wear compression socks worth it. I didn’t come to medicine because I wanted to study all day. I entered medicine because curing diseases and helping people through sickness is the professional contribution I wish to make to our world. I had plenty of time before starting school to explore many different professions. But, the one that captivated me was medicine. Medicine combines puzzles, science, and true stories. I study so much because every piece of information about symptoms and labs and geography and humans is a tool that might help me understand what is ailing a patient. I don’t study because I like it, I study because I want all the knowledge tools I can fit into my toolbox brain so that when I meet someone’s grandmother, someone’s father, someone’s friend, someone’s brother in a moment when their health is faulting…I know how to help them heal. 

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.

Holding a Brain in Your Hands

My first semester of medical school I went to the anatomy lab 2, 3, 4, sometimes more times a week. Sometimes twice a day. In our anatomy lab we were split into groups and each assigned a cadaver for dissection. Cadavers are people who donated their bodies upon death to science, we call them “donors” in our lab. The 20 donors in our lab were once 20 people who had the vision to let us, 120 aspiring doctors, disassemble the human body so that we could intimately understand how it fits together.

The idea of cutting apart a human, even if they are dead, is disgusting to most people—including all of us who showed up to anatomy lab the first day. It never got easier to dissect my donor. I spent a little bit of each hour in lab wondering who my donor had been in life and if she had any idea what happens in an anatomy lab when she decided to donate her body. Yet, now that I’m done with anatomy lab and have had months to stew on my experiences there, I can’t imagine not dissecting a cadaver as part of my training to become a physician. Let me share one, relatively low on the gruesome scale, experience to illustrate how profoundly moving and informative it was to be able to explore a human body piece-by-piece.

Toward the end our months in the anatomy lab it was time to open the skull and see the brain of our donor. Weeks before that we had dissected the spine, opening up the vertebral column so we could see what the spinal cord looked like. Each week of lab leading up to the day we opened the skull was spent tracing nerves from the spinal cord and brain to each section of the body we had examined. Nerves look like strings, specifically they look like white, cotton strings soaked in oil. We spent many hours memorizing the names of those strings (the nerves) and their paths through the body.

So, on the day we finally got to open the skull we understood how the brain was connected to every muscle and structure in the body. We knew intellectually how they were connected but, also, physically how they were connected. Our hands had followed the course of many nerves until their routes were as familiar as the path of a zipper on a favorite jacket. We could imagine the journey of the nerves through the body without seeing them. Hence, we felt ready, excited, and nervous to meet the globe that controlled it all. We were ready to see the brain.

You can hold a brain in both your hands. It fits there comfortably. It weights about 3 pounds. In other words, it’s about the size and weight of an average cantaloupe. Such an unassuming structure for the burden it carries. It is our brain, in the end, that makes each of us who we are. It shapes our personality, our feelings, and our behavior. Without our brain we simply take up space. We can’t even breathe.

When I held our donor’s brain in my hands, I knew it would be the first and last time I held a human brain. I didn’t hold it for long, but I felt its weight. Its actual weight as gravity pulled down on it, but also the weight of the life it had traveled. Whoever my donor had been in life, it was the brain in my hands that had guided her. Every person has a brain something like the one I was holding. We each have our own globe of cheese, an organ science still doesn’t know much about, that pretty much decides everything in our lives. To think, I was holding the center of human nature in my hands. The feeling isn’t something I’ll forget.

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.

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.

Today I’m Grateful

The past few months have a been a tornado. I’m 3 weeks out from finishing my first semester of medical school. What has “med school” meant for me so far? 4 hours or more of studying a day no matter how many hours I spend in class. Showering the formaldehyde smell out of my hair because I’ve spent hours in the cadaver lab dissecting or practicing structure identification. Discussing the ethics of assisted suicide, abortion, and patient consent. Considering how to evaluate research. Practicing physical exams and asking patients about their health.

But, even on days before an exam, when I’m exhausted and uncertain I know half of what I should, I’m excited to be doing what I do. I know how to feel a heartbeat through someone’s skin. I know how to watch a heart contracting using an ultrasound machine. I’ve held human hearts. I’ve explored their chambers and vessels. I know the path blood takes to and from the heart. I know what makes the heart beat. As the days pass, I know more and more about what makes human bodies function, how the body can break, and what we can do to fix it. For this intimate knowledge of life, I’m grateful.

These past weeks and months haven’t only been studying, despite how it feels at times. I’ve spent time with family. I’ve hiked many a mountain in both the sun, rain, light, and dark. I’ve eaten cake on mountain tops, carved jack-o-lanterns, and shared many a meal and snack with friends. I’ve walked up and down the hill from home to school while chatting with kindred spirits.

Friends new and old along with family aren’t all I’m grateful for this season. I also have a lovely home with a roommate with an eye for creating comfortable spaces where I can sip my mate peacefully. And, I have a partner who enjoys pie as much as I do. Helps keep life in order. Tells me my hair looks beautiful even when it’s greasy and fizzy (who knew hair could be both those things at the same time) and cooks me dinner so I can study.

I feel lucky this season. And, I’m grateful to have a few moments to soak in just how kind life can be. I hope your Thanksgiving is spent with people you care about or, at least, surrounded by tasty food. After all, the stomach feeds the heart. 

Marathon Goals

I remember the conversation I had with my best friend that sealed my desire to become a doctor. We were in our relatively new apartment, in the living room that was an extension of the kitchen. The city sun of Washington, DC filtered in the large windows and onto the bedraggled plants we had lined along the window sills. I’d been contemplating the idea of entering medicine for months. The thought came to me shortly after I started working in health communications. What I liked most about health communications was the medical research, knowledge of life, and opportunities to interact with people. I wanted to find a way to fill my days with those things rather than dabble in them. My friend worked in a primary care office, on the administrative side. She encouraged me as I talked about possibly switching careers. “You’d be a good doctor,” she said. Thus, began my marathon goal to become a doctor, a process I call “the doctorhood quest.”

That conversation was 5 years ago. Recently, what started as a thought became a real possibility. I’ve been accepted to medical school. There’s still the question of financing and survival, but with an acceptance to school, there is hope that the rest of the journey will fall into place. I will be a doctor.

Marathon goals. I’ve always been a planner and as a runner I prefer long distance. But, there is something uniquely challenging about making goals that will take over a decade to accomplish. There is no way to know the future, and absolutely no way to predict a future as distant as 10 years from now. But, somehow, the uncertainty and hidden challenges that the doctorhood quest presents have not deterred me. I reflected on the prospect of doctorhood during my years of Peace Corps service and, once back in the States, I started jumping through the hoops of medical school applications (I had no science background when I began). The long wait to medical school acceptance has only made me more excited to start my studies. The doctorhood quest isn’t even half over—medical school, residency, and board exams will be the longer leg of the journey. Yet, as I sit on an acceptance letter and wait to hear back from more schools, it’s thrilling that I’ve come this far.

People around me, to me or to others, often comment on how intelligent one must be to get into medical school. I usually remain silent, but smirk inwardly. I believe “smart” comes in many forms and not all are suited to medicine. I’m disinclined to suggest one person is smarter than another because life has shown me that humans have different gifts and society needs all of them to function. But, more specifically, my journey has shown me that medical school admittance has less to do with how smart someone is and more to do with how resilient they are. The doctorhood quest requires you to be gritty and determined. It demands that you jump up and try again each time you fall while tackling the perils of the road.

If resiliency and grit is the secret to pursuing marathon goals without losing hope, how does one get those? Experience and inward reflection are my guesses. We learn by doing and we expand our scope of understanding the more different experiences we have. Nothing proved this more to me than my years in Paraguay. I am not the same person I was when I first stepped off the plane in that hot, humid country. The people there showed me how they found happiness; they defined respect and God and love in ways completely different from any definition I’d ever encountered for those things; and, above all, they exposed me to foods, ways of life, and shared moments I could never have imagined.

Experience is the foundation for growth, but to truly grow one must reflect on those experiences. Paraguay, once again, taught me reflection. It is impossible to describe just how lonely and hard it can be to be the only one from your culture in a foreign place unless you’ve experienced it. Your world is turned upside-down and every definition and rule you ever thought was a given is no longer in play. Your default becomes mild confusion and curiosity about the new culture in which you have fallen. Most importantly, you are forced to examine how your culture does things and why. Once you start picking apart your host and native cultures, it’s an easy, logical jump to start evaluating and thinking about different aspects of your personal life—like your interactions, feelings, and activity choices. Once you build in time to reflect on experience you can start to shape your path more purposefully.

The secret to marathon goals is accepting you can’t know the future, but you can influence the present. The secret is celebrating small victories, making educated guesses about the best course of action today, and seeking out the people, places, and experiences that rejuvenate you when your hope falters. We do not achieve marathon goals alone (it takes many helpers) but it is only from within ourselves that we find the strength to withstand what’s hidden behind each bend in the road.