Home, again.

As I write this, I’m in the passenger seat of my car that has thus far travelled approximately 2400 miles- across seven state lines, through the plains of Iowa and Nebraska, the evergreens of the Rockies, the incredible natural beauty of Utah, and the desert of Nevada. Ten minutes ago, we crossed the California state line and my dad now navigates the winding roads of the Sierra Nevada while tall pines surround us and seems to extend endlessly, all the while an upbeat Bollywood tune provides the perfect soundtrack to a homecoming that has been a surprisingly bittersweet one.

When I started medical school, I was wrought with anxiety about leaving a place that I had known as my home for as long as I could remember. However, earlier this week, during the first hour of our cross-country road trip, as the now-familiar roads and highways of southeastern Michigan became more and more distant, I was filled with a deep heartache that could only be attributed to leaving behind a home. Again.

In the last few months, I’ve had the ability to revel in what made medical school not only bearable, but also enjoyable- the people. We’ve somehow been celebrating for weeks on end, and at the risk of sounding like a trite Vitamin C lyric, my classmates and now fellow doctors (!) created something miraculous: we created a family of our own. I had the privilege of learning and growing with some of the most amazing people I’m sure I’ll ever meet.

A few weeks prior to Match Day, when it seemed that our entire lives depended entirely on what was inside a sealed, white envelope, a close friend shared with me a passage from Sylvia Plath’s “A Bell Jar” that I had almost completely forgotten-

“I saw my life branching out before me like the green fig tree in the story. From the tip of every branch, like a fat, purple fig, a wonderful future beckoned and winked. One fig was a husband and a happy home and children, and another fig was a famous poet and another fig was a brilliant professor…and beyond these figs were many more figs I couldn’t quite make out. I saw myself sitting in the crotch of this fig tree, starving to death, just because I couldn’t make up my mind which of the figs I would choose. I wanted each and every one of them, but choosing one meant losing all the rest, and as I sat there, unable to decide, the figs began to wrinkle and go black, and, one by one, they plopped to the ground at my feet.”

While it seemed incredibly depressing at first, I realized that the situation Plath describes could actually be optimistic. Each fig that Plath saw was a wonderful option and while she could’t make the decision today, that didn’t mean she would never be able to make the decision. And maybe, the decision would be made by forces that were beyond her complete control. And if so, would that really be so bad? Perhaps it has been my incredible luck, but despite never imagining myself living in Michigan for a substantial amount of time, I can not imagine going through medical school any where else, and with any other group of people. While I won’t deny the agency I had in this decision and know that this experience didn’t simply fall into my lap like a fig, I also know that a large portion of the decisions that led me to this point and those that will follow were beyond any planning or prediction. And for that, I’m grateful.

The end of this blog post also marks the end of this blog. I had begun this as a way to catalog one of the most important chapters of my life. But it grew into something so much more; it became a time capsule of experiences, places, and people that I will always look back on with so much more than fondness- it will be accompanied by a feeling of being home. Again.

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Pictured Rocks National Lakeshore, Upper Peninsula//Michigan, 2016

 

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A sublime sadness

So often, when I begin writing about something sad or uncomfortable, I subconsciously steer the discussion towards a positive turn of phrase. Perhaps it’s a quirk of my writing, or perhaps it is my own way of dealing with the sheer discomfort of sadness. An internal battle of wills that forcefully shapes my words and sentences and conveys a message of hope. The reality, however, is much different- not everything can be blanketed in quiet contentment. Sometimes, even the fiercest of optimists must acknowledge that the sadness, in and of itself, is as powerful as the cheer that they cling to and champion.

Just over three months away from finishing the long journey of medical school, I’ve recently been anticipating all of the celebrations to come: discovering where I’ll complete my pediatric residency training over the next three years, that last day of my last clinical rotation, finally receiving the doctorate on stage in front of family and friends and enveloping myself in the likely weeks-long giddiness that will come with the relief of being done with something so life-altering, only to look forward with that same giddiness of all that is yet to unfold.

But there is something about this time for me that fills me with a sadness so keen and sublime that it must be acknowledged. I know I am not alone in this, the sadness has taken on different forms in those around me, sometimes in the shape of terrible anxiety and even anger. What is most striking about the sadness that fills me is that it seems to be layered with a remarkable sense of loss, a feeling of something that is slipping away so quickly and quietly that there is little that can be done about it. More so than the realization that this part of the journey is coming to an end, I’m understanding that the sadness that seems to be surfacing now has much more to do with the loss of a role I have come to simultaneously disdain and cherish. Yes, I can’t wait to be done with schooling and get to the heart of what I’ve been hoping to do for so long, but I also grieve for the truly “in-between” role of the student. Especially over the past two years, I’ve been in the strange position of identifying more with my patients than with the doctors who I so often trailed during morning rounds. Sometimes, in those initial moments when a diagnosis is made and relayed to the patient, I find myself staring at my patient’s glazed eyes as I realize that something is being lost in translation.  What is more remarkable, as I turn to look at the truly competent physician is that he doesn’t realize the confusion quite yet. Usually by the end of the discussion, both doctor and patient are on the same page, or at least within the same chapter. But this is the restless feeling that nags at me for several long moments after the conversation is over, that feeling that I am crossing over to a role that can, and sometimes inherently will, separate me from truly understanding my patient.

The other layer of my own sadness is rather an amalgamation of all the sadness I have seen over the past few years in others. Perhaps it is fitting that now, when I’m able to take a deep breath before the upcoming challenges of residency, I’m reflecting on all of the suffering that I’ve seen and compartmentalized. The sadness is fleeting in real-time, only taking on a full form when one experience is put in conjunction with another. The sadness arises in force when I remember that patient on my first clinical rotation who looked at me from his hospital bed, struggling not to gag on his nasogastric tube, and told me to “try to stay as young as I could forever. Being old is a tragedy.” It comes in a wave when I remember the quiet muttering during labor and delivery rounds when we discussed the patient down the end of a long, dark hallway who was currently in labor with a child who would come out unbreathing, on the cusp of life but never being able to make it quite over. The sadness lingers when I think of that first code I participated in, pushing my hands down firmly on an oddly flexile chest of a woman, still hooked up to her dialysis machine, who looked up at me with unseeing eyes, her face a color I can’t describe or forget. This sadness couples with grief when I remember meeting a young teenage girl who stared up at the ceiling of her hospital room, attempting to come to terms with the fact that she would never be able to walk again due to a traumatic spinal cord injury. The sadness strikes me down when I replay the scene in the neonatal ICU when I saw a mother meet her child for the first and, what would likely be, the last time.

The incredible thing about this sadness is that it is not finite. There’s seemingly an endless reservoir of this emotion that draws you in, threatening to pull you under with the weight of it. It does recede, but it does so while leaving a residue- understanding that this sadness will come again and again; each time it will feel foreign before becoming undeniably familiar.

 

The golden hour

Here’s the thing about the residency interview trail- you actually end up spending a lot of time by yourself in parts of the country you never thought you’d find yourself in. Usually you’re in transit, making your way from one interview to the next, and if you’re lucky, you see some incredible things (and meet some incredible people!) along the way. This past week, I found myself driving  during one of my favorite times of day: the golden hour. The “golden hour,” or “magic hour,” is used to describe the light right before sunrise or sunset when everything takes on a different hue because of where the sun lies in the sky. The colors are less sharp, and slightly less defined; they are somehow softer, more ephemeral, but also more peaceful. As I was driving through the middle of America during the golden hour, marveling at the surprising pinks and oranges found in the plains all around me, I remembered where else I had heard this term. The “golden hour” was a phrase coined by a well-known trauma surgeon to describe the time that the patient had the greatest chance of survival following a major insult. It’s been a controversial term, but most doctors would agree that prompt medical attention is both common sense and a generalizable rule.

But what if we looked at the golden hour in a more abstract sense? Maybe we’re in the golden hour right now. There’s been so much tragedy in the last few weeks, months, and even decades, that it’s easy to think that we’re all heading down hill so fast that nothing can be done to change course. But I think we need to challenge that assumption. What if right now, when everything seems so dismal and violent, we’re in that sliver of time where our decisions have consequences not only for our generation and the next, but also for the course of human history? It may seem grandiose, but maybe we have the opportunity, at this very moment and perhaps not for much longer, to make a concerted effort and a decision to choose peace and tolerance. What if we are, right now, living in a golden hour that decades from now will be seen as a major turning point?

I’d like to think that sixty years from now, I can look back and say that we, as a group of people learning to live together, made full use of this pivotal golden hour- recognizing the importance of prompt attention and having valuable discussion right now, while remembering that the golden hour is also called a “magic hour” for a reason and that optimism is not foolish, but rather a deliberate choice.

In the golden hour

Yearning

It’s springtime here in the mitten. Though I’ve written about spring before, something seems different about this particular spring. No longer am I marveling at the fact that all that snow does in fact melt into nothingness, seemingly overnight, and no longer am I surprised by the birds who have returned to where they belong. This time, I almost expected it- waited patiently through the onslaught of negative temperatures, wind chills, and snow storms, for our earned reward of warm sunshine and blue skies.

What I didn’t expect was a new emotion that accompanied the change of seasons- a feeling that didn’t quite have a name until discussing it with a friend, who had somehow miraculously understood exactly what I was thinking and had felt the same thing: “Oh, it’s a yearning,” she said.

A yearning. Understandably, this word isn’t often used in everyday language, but it is a wonderful word nonetheless. Defined as “a deep longing, especially when accompanied by tenderness or sadness,” it encompasses a spectrum of emotions that are often felt all at once. Interestingly though, it doesn’t describe the object being yearned. Just the emotion, which makes it even more perfect. You don’t need to yearn for something. Sometimes you can just yearn. However, what exactly is it about beautiful blue skies, gorgeous bike rides by the lakeside, and unbelievable sunsets that give us (or at least, me) a sense of wonder and discovery as well as a sense of yearning? A feeling of having something and also a feeling of not having it or wanting more?

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Perhaps it is because we are so often working towards something- for example, getting through the winter to get to spring or biking through mile after mile just to get to the lakeshore – that when we have achieved it, we experience a momentary sense of loss. Yearning is in that minuscule millisecond between “oh, here we are” and “ok, what’s next?”. Even more specifically, maybe yearning is the feeling of “oh, that was it? Should there have been more? Less? What do I do with this in front of me?”

So, maybe, the yearning that has accompanied the turn of seasons this time around for me, and I suspect for many others in a similar position, has to do with the fact that we are 365 days away from being done with what has, up until now, been the most intense experience I have encountered. A year left until medical school is over, yes, but also a year until everything changes. All over again. It is understandable then, that the yearning that accompanies this spring above the ones previously and, maybe even those to come, is an extended living in the moments of “oh, here we are” and “ok, this is what’s next.” A constant source of ensuring that we are making the most of where we are while necessarily looking at the future and dealing with uncertainty in every aspect of our lives- where we’ll be and who we’ll be when this is done.

So often, when I can’t find the words to end something, I rely on others to do it for me. From “Two in the Campagna” by Robert Browning:

“Just when I seemed about to learn!
Where is the thread now? Off again!
The Old trick! Only I discern-
Infinite passion, and the pain
Of finite hearts that yearn.”

Tethered

Over the past few weeks, I’ve had the opportunity to witness something, over and over again, that is usually witnessed only a few times in any individual lifetime. Each occasion momentous and special, each occasion life-changing.

Of course I’ll never forget that first time a baby slipped into my hands, eyes still squished together, hands and arms clutched against his chest, still uncrying and unbreathing, almost unknowing that he had exited the womb- the only place he had ever known. I’ll never forget putting this baby on top of his mother’s abdomen as she and his father reached down to marvel at him. The stark realization crossing my mind that he had, just moments before, been there. Underneath the towels, skin, layers of tissue, in the womb that was now vacant. And now he wasn’t. He was outside. His cord was the only thing tethering him to the place he had left behind. The stark realization crossing my mind that we begin our lives by leaving.

In a very strange way, after having repeated the above scenario over and over again, sometimes in a room surrounded by family members anxiously awaiting the arrival, sometimes in an operating room in which doctors anxiously rushed to ensure the safety of both the child and its mother, all of the images seemed to blend together. The only thing punctuating these images was the cutting of the cord. Each cut punctuating time, indicating the beginning of a life as we know it, but also marking the end of something else. The end of an existence that we all, undoubtedly and unequivocally, have an understanding of but no concrete awareness of. An existence that is celebrated for about 40 weeks before we even get here. 40 weeks before we’re even able to take our first true breath.

Perhaps, it was almost inevitable, then, that being around so much beginning, I began to think about ending. In the past several weeks, two reflections on life and death have so eloquently and authentically put into human terms the unbelievable enormity of both those phrases. Interestingly, but not surprisingly, both pieces are written by doctors. Being so close to both life and death on a regular basis inevitably forces you to address and attempt to understand the words and phrases that we so often use without a second thought. There isn’t an easy way to talk about either without being overwhelmed by the mere uncertainty of it all.

And yet, it’s a shared experience. We’ve all seen life and death before, everywhere and all the time. We’ll see it again, when we least expect it and sometimes when we do expect it. And one day, we’ll have experienced both sides of the coin. What’s interesting, however, in both of these experiences, we’re tethered to the world we know for longer than we realize. We’re tethered for 40 weeks longer than we realize at the beginning, not just physically, but also through the hopes and dreams, and sometimes fears and uncertainties, of those that come before us. When we leave, we’re tethered through the memories, stories, and shared experiences of those that come after us. And this, I believe, is the remarkable and hopeful bit in all of this- that life and death aren’t necessarily as disparate or abrupt as we like to think. That, while the cord is cut to mark the beginning of something and the ending of something else- in the words of one of my favorite poets, Wendell Berry, “be careful not to say/Anything too final. Whatever/ Is unsure is possible, and life is bigger/Than flesh.”
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The Chief Complaint

In medicine, certain phrases rule above others. Alongside the medical jargon that is littered among the hastily scribbled notes on the edges of a patient list, the one phrase that will undoubtedly be present is “chief complaint.” At its most basic level, the “chief complaint” is the reason the patient has happened to find their way to your clinic, emergency room, or operating room. And it also becomes the patient’s identity. Countless conversations among healthcare teams begin with “Oh you know, that patient in room #28? You know, the ‘GI bleeder’!” or end with “So, we’re discharging that seven year-old in the morning, that ‘status asthmaticus’ patient.” All of this is to say the “chief complaint” is, well, chief.

However, it’s important to also remember that the chief complaint doesn’t give us the whole story. There’s more. LOTS more. Just ask any medical student on their internal medicine rotation who’s happened to spend several hours discussing just a few patients, and then has gone back to spend several more hours writing patient notes (that whole electronic medical record thing is…let’s just say, not the most straight forward). Context is important and the chief complaint is just the hook- the thing that reels the doctor in and says “this is important, but there is more here, figure it out.” There is always a story there, a remarkable narrative. I’m not the first one to say that storytelling is an innate part of medicine. William Osler is often cited, but I think it’s important to linger on some of his words: “Listen to your patient, he is telling you the diagnosis.” The art of listening to a story, reframing it, and retelling it is at the core of the healthcare professions, however, I would also argue that storytelling is at the core of the human condition. We seem to be genetically wired to tell our stories and listen to others.

Recent events have only further contributed to the idea that context and storytelling is important. Plenty has been written, shared, and discussed by very intelligent people regarding the state of race relations in the United States over the past few weeks, and I expect more will be said about the truly horrific and deeply unsettling Senate Report on the Use of Torture. My fear is, however, that these discussions will be eventually become limited to “chief complaints,” simplified for the sake of convenience or to avoid redundancy and we’ll lose the nuances in there somewhere until these stories are slowly whittled down to one-liners. Until these large, complex narratives will become lost in the fabric of what happened that one time, that one year, with that one community. Recently, I read a quote that made me pause and think about how each of these stories, whether or not we chose to engage with them, impact us:

“There is a sense in which we are all each other’s consequences”- Wallace Stegner

This is, of course, true in medicine. A change in treatment guidelines can have its origins from a simple case study which details a novel treatment. The patient we see tomorrow is affected by the way we take care of the patient we see today.

But we don’t necessarily need to look to medicine to understand the validity of Stegner’s words. We all affect one another’s narrative, whether or not we actively seek it out. The way we interpret, discuss, and act in response to recent events will shape the future for not only our generation, but many generations to come. In my opinion, the best thing we can do is to carry as much of this narrative forward as we can, and not settle for discussions that rely solely on a “chief complaint.”

A Threat to the Sterile Field

July is a month that has long held significance for the healthcare field. For medical students, residents, and physicians all over the country, July is a month that marks an abrupt transition into a new group of individuals entering the clinical landscape. Oh, and it’s also considered to be one of the “most dangerous times to go to the hospital” for patients. Doesn’t exactly instill a lot of confidence in budding healthcare professionals, does it?

July 1st, 2014, marked an especially significant transition for newly-minted third-year medical students all over the country (including myself- M3 already?! How did that happen?) because we finally moved (read: were thrown head-first) from the all-too-familiar world of classroom learning into the wide, open world of hospitals, clinics, and operating rooms. Never have I felt more uncertain of anything than I did on the night of June 30, 2014. Having no idea of the expectations or the reality of the third year of medical school, I sat there wondering exactly what kind of role I’d play in patient care when the most I could do was deal with a paper cut. A more pressing concern that night, however, was how to use the pager that had been assigned to me (really- a pager?, haven’t we moved beyond the 20th century?).

To make matters more interesting (read: terrifying): I was starting off my clinical years with my surgery rotation. So, not only did I have a piece of 1980s technology attached to my hip that wouldn’t stop going off at inopportune times, I was also going to be spending the majority of the next 8 weeks figuring out exactly how to…well, just exist in the operating room. First, I learned that common sense quickly degenerates when you’re in the OR. You think washing your hands is easy? Think again- that’s actually a 3 minute long process that involves various plastic items and strong chemicals that I still don’t know how to pronounce. You think putting on gloves and a gown is no big deal? Actually- not when there are parts of the glove that are “sterile” and every time you touch the wrong part, you will get told to get a new pair of gloves and scrub again (so far my record is 4 pairs of gloves that I somehow managed to unsterilize in the span of 2 minutes with every single person of the surgical team looking at me like I’d left my brain in the sink where I had just spent an inordinate amount of time scrubbing my elbows clean). Here’s the best part- do you think standing and walking around is easy? It should be, right? I’ve only been doing it for approximately the last 25 years. NOPE- the sterile field is a sacred space that everyone protects fiercely, and one misplaced hand motion or wrong step will make you feel like that piece of dead bowel currently being resected from the patient’s abdomen.

I realized, within the whirlwind of my first week of the rotation- when I didn’t quite remember to put my mask up at the right time, when I forgot my surgical cap in my white coat hanging awkwardly outside the OR, and when I would wander the hallways and staircases looking for my resident or attending physician like a lost child, that was the threat. The threat to the sterile field, and most likely, a threat to myself.

Somehow, within the last four weeks, however, I learned how to not screw up. Not badly, anyway. Don’t get me wrong, I still have no clue what I’m doing most of the time- the last time my pager beeped at me, I didn’t realize it was mine and let it go off for a whole minute while being annoyed and wondering “why people just can’t turn off their pagers”. Oops. But, as I scrubbed into a surgery (while getting the gloves right the first time around) last Thursday, drove the laparoscope around our patient’s abdomen- navigating innards and blood vessels, and suturing a 1-cm cut in the skin, I felt like I’d reached some kind of warped M3-pinnacle-of-success. That’s the second thing I’ve learned so far- the third year of medical school is all about small (read: very small) victories.

And, so as July, 2014 wraps up to the relief of many a physician and patient, I feel like I can take a deep breath too. I’m still very uncertain about pretty much everything in my life right now, and I don’t know exactly what tomorrow will look like, much less next week or next July, but I also remember another end of July when I had no clue what I was getting into.

Happy 2 years, WordPress!