2011 to 2012

Ok, I promise this will be the last reflective post for a while. But as the year 2011 comes to a close, I need to take a quick look back on my New Year's Resolutions, and see if I accomplished any of my goals. I also have to establish my resolutions for 2012, since my personality is often obsessive about goal-setting and life-planning.

Last year I tried to keep my resolutions pretty simple. I wanted to amalgamate all the information I had learned during our first two years into some legit knowledge, culminating in the first Step of our Board Examinations. Somewhere between working EMS, making music videos, health policy yada-yada, and making poor life choices (PLCs) at med skew prom, we learned a few things. To this day, I still do not know how I passed our Renal exam first year (finishing up Five Star Nerve was full-time employment), but somehow I got my "P" in Physiology and made it through. Using Step 1 as a means to put together all these classes and subjects was crucial to getting started on third year, and I am very glad I put in the time in effort (although it was a bear of a final semester). I can say that it honestly helped prepare me for the questioning and "pimping" that physicians like to do, especially during Surgery. That preparation let me get a running start after July 1.

I also wanted to take more responsibility for my patients, specifically developing a cohort of patients here in Asheville, NC (Resolutions no. 2 and 3). I was lucky even to have the opportunity to work out here, and I couldn't have found a program that fit my personality better. My ring of 3x5 notecards with all my patients and their medical issues on it makes me feel like I'm an integral part of the health care team (and I am, Kelly!). I speak to my patients on the phone, see them in other clinics, and I feel personally responsible to study their illnesses and problems so I am ready to answer as many questions as I can. Both of these goals were also accomplished, although optimizing patient care is not a resolution just for 2011.

"Three" sounds like a pretty manageable number, so I think I'll have to set three more New Year's Resolutions in 2012. One is obvious: I need to learn how to cook something. My days of cafeteria gorging are over, and I am tired of feeling like an idiot when people talk about cooking. No, I don't know what a "pin-roller" is and what one would use it for, and besides salt, pepper, and cumin, are there any other spices? I'm lucky to know what "cumin" is anyways (thank you, Morocco). So I asked my gourmet-chef-friend Blake for advice, and I have purchased a book called The Best 30-Minute Recipe Book. I need easy to make, short recipes that I can eat over a couple days' time. If anyone else has any suggestions, please help.

Two is also simple. Just as I wanted to spend 2011 in Asheville, I would love to be at either Harvard or Princeton for a Masters in Public Policy later next year. It has been a dream of mine to study health policy since before medical school, and now is the optimal time to engage in this learning. If I am not accepted, I can always try to garner this degree during a year off in residency, but I would prefer to go back to school now. I want to be prepared for fellowship and public service opportunities earlier in my career (or at least have these options). Plus, I will have so much more perspective as a physician, understanding the global issues my patients face every day.

Three, I want to make sure I go one place crazy in 2012. The travel bug bit me years ago, and there are more white russians to be drunk. Southeast Asia anyone?

The year 2011 C.E. was wonderful. I traveled through Morocco, Egypt, and Turkey, I finally started work in the hospital, and I decided what kind of doctor I want to be. Even if I take a year off, I am more than halfway to MD. Tempus fugit. I don't know what 2012 will bring, but I am optimistic that it can be even better that the year prior. See you then.

Three Years Later

This picture look familiar? Yep, that's me. Three years ago this Christmas, unwrapping my first (and still my only) stethoscope from underneath the Swendiman Family Christmas tree. That next morning I drove back to Chapel Hill, and unwrapped one of the best Christmas gifts I had ever received: my first acceptance into medical school. Three years later, here I am.

Every year around Christmas, I reread my first blog post (A Littmann, A Letter, and Some Courvoisier). It brings back one of the most uplifting moments I've ever experienced. I can retrace each one of my steps that night before opening my letter to medical school: unpacking the car, doing the dishes, cutting open the envelope, and calling my parents. Every time I read it, I can't help but smile by the last paragraph (Yes, I do believe in Santa). Med school was (and still is) a dream come true. The reality has set in by now, but I can still feel the elation that warmed my heart that night in my kitchen in Chapel Hill. I can still feel the weight being lifted off my shoulders. I am so glad I recounted that experience, so I can relive it every year.

So was it worth it? I'd say so. This year brings a unique perspective to my annual reflection, because for the first time I am actually doing what I set out to do. The reason I was so excited to become a doctor was not because of the long hours in the Health Sciences Library or the weekly multiple choice tests. I wanted to be a physician to work with patients, to care for sick people. For the past six months, that's what I've been doing. Yes, I don't have an MD behind my name yet; and no, I don't have my own patients (although I would argue that in the Asheville program we do have our own people we follow), but finally I'm in the hospital and out of the classroom. So yes, it has absolutely been worth it. Those first two years in college-on-steroids were well worth the time to get where we are today. And yes, I'd do it all again if I had to.

I haven't flunked out (and neither Ronnie nor I have been kicked out), so I would have to say that the past 2.5 years have been a success. For the first time in my life I am excited about what I am doing academically and professionally. Sometimes I think back on my undergraduate career, and I wish I had worked as hard then as I do now. Oh, the possibilities! I could have picked up another major or actually learned Spanish (you have no idea how much Portuguese was a waste 5 years later). I could have broadened my horizons, taking classes in anthropology and American history. But I guess that's over now, and I shouldn't regret the hours and hours I put in on the X-Box, training my fingers for a future career in Surgery.

Well I guess it's appropriate to take this opportunity, three years after learning I would become a doctor, to come out and say what kind of doctor I actually want to be (I considered doing a parody on The Decision - LeBron James, but I don't know yet what city I will be taking my "talents" to). Plus, I think that cat is out of the bag already. Earlier this month I verbally committed (on the phone to my Mom, of course), to pursuing a career in Surgery, but I knew well before that. After my first 6 weeks here in Asheville in the OR, I was hooked. Two months before that, Surgery wasn't even on my top 3, but after getting the opportunity to work with some amazing mentors, and gaining a better understanding of the massive amount of medical knowledge it takes to be a great surgeon, I knew there was nothing else I wanted to be. As the year has progressed, that commitment has only been strengthened. Don't get me wrong, I have thoroughly enjoyed almost all of my time in other specialties, but Surgery remains the clear winner.

When I did recruiting as a captain for the UNC Swim team, people often asked me why I chose Carolina. Was it the combination of great athletics and academics? Was it the people? Or, did I just like wearing Carolina blue? I always told people that I had visited many other places; I had a great time at colleges with great academics, great swimming programs, wonderful people, and a positive atmosphere. But at Carolina, I knew I was "home." There were so many things about UNC that were good, but at the end of the day, it was just a feeling. In Chapel Hill, I was home. Why Surgery? It is where I feel the most comfortable with patients and providers. It is the specialty I feel to be the best balance between medicine and procedures. Frankly, I just feel at home.

My favorite game to play with my third year colleagues is "tell me your choices for future specialty, broken down by percentages." For example, when I was entering this year, I was somewhere around 60% Emergency Medicine, 30% Pulmonary/Critical Care doc, and 10% Pediatrician (see, Surgery wasn't even on the list). Now I'm 99% Surgeon, and 1% Pediatric Hospitalist. (So obviously I should combine the two? Peds Surgery anyone??). I guess that's enough to make it official; beyond a reasonable doubt. One of the benefits of the Asheville program is that by now I've seen a little bit of many specialties, so I don't have to wait until June until I've seen all the core clerkships. Another weight off my shoulders.

Three years ago I found out I would be a doctor. Three years later I know what kind of doctor I want to be. I wonder where will I be in another three years...

Limping to the Finish

I'm very tired. In fact, I can honestly say that today, Friday December 16th, I am the most academically burnt out I have ever been in my life. I can only compare how I feel to junior year of college, right at the end of the collegiate swimming season. I was mentally and physically exhausted, and I needed a break (in fact, I tried to quit the sport - but no quitting here!). As I limp to the finish line, aka Christmas break, I am ill. My mental exhaustion has turned into a terrific cold, and I had to miss my first clinic ever yesterday (NB: Moms don't want you coughing all over their kids, and I don't want their kids coughing over me). It is time to relax, do nothing, and forget about medicine for a whole two weeks.

This year has been a long year, and I don't really think I ever got a real break. Beginning in January, the race to learn all the things that I should've learned over the first 18 months began, and I worked my way through spring break. The six weeks that we had off between second and third year were filled with Boards studying and a not-so-relaxing vacation across North Africa. Between losing our bags, night time train rides, and driving back to Chapel Hill from Charlotte at 4am (after 18 hours of flying) for Orientation the next morning, I didn't get much sleep. Then after a week of acclimating to the new time zone, I jumped into Surgery full-throttle, followed by Obstetrics and Gynecology, which was full of night floating and vagina. Finding a place to live in Asheville was a mess (damn you, Craigslist). The transition into continuity clinics was hectic as always, and I threw in the GRE just for shits and giggles. Then there were applications to Masters in Public Policy programs due December 1st, and Inpatient Medicine weeks through the weekend. General surgery research here, Athletes in Medicine speech there. So this will be the first real break I've had this year. And I need it so badly.

I look forward to a New Year that is a little less stressful. Having applications in is a big weight off my shoulders, and I plan to do much more continuity and less scheduled added clinics on the side. That should free up more time, and allow me to feel like I'm really spending time with patients inside of rushing from place to place. Fellowship applications (i.e. dollar dollar bill money for grad school) are due at the beginning of the January, so hopefully I will finish those over Christmas break (yes, I will probably have to do something productive over the next two weeks). I just can't wait to cut out some of the additional things I do, as I am a habitual over-committer. In the beginning of the New Year I will focus on school and relaxation, or maybe getting into better shape and learning new dishes (but I'll save those resolutions for my New Year's post!).

Ultimately, I just want to be home. I've only been back to DC once in the past year, and yes, that makes me a bad son, since my sister lives only a few blocks away from Mom and Dad. Palm Sunday was the only weekend I made back to Kensington, and I think my parents are starting to miss me (but believe me, by the end of Christmas they'll want me out again). Seriously though, it's time to sit on the couch, eat Continental pizza, watch Carolina games on my rents' new big screen, and pig out.

I'm pooped. In fact, I'm too pooped to poop. So I'm definitely too tired to write. This break will do wonders; I know it will. So look for a peppier, more thoughtful writer next week!

The Death Rate in America: A Follow Up

A couple weeks ago I wrote a post a about a patient who really touched my heart. He was a patient recently diagnosed with ALS, and the type of person that makes one ask, "Why do bad things happen to good people?" An incredible individual who had been dealing with health problems for a very long time, but kept his head held high. He was the first continuity patient of mine to hear such a grave prognosis.

I often hear physicians say it is very important to separate your work life and your home life. Not that you can't do work at home, or talk about medicine with your spouse or family, but you can't be up all night thinking about your patients. One, you will never sleep, and two that is a quick recipe for burn out. At some point you have to have mental space. With this particular patient though, I found that I couldn't keep him out of my head. I would brush my teeth and get into bed at night, and his case would creep into my consciousness. I think it was the helplessness I felt that I couldn't let go. I wanted to be able to do something. I guess this was the first time I've really dealt with the reality that doctors don't always cure. I know this has been a common theme of my posts this year, but saying it out loud helps me reinforce the idea that there isn't a magic elixir. There is no pill for age; everyone dies.

After dealing with this on my own for a while and writing about it, I reached out to one of my preceptors for guidance (something I probably should have done earlier, but hindsight is always 20/20). She helped me change the way I was looking at this whole situation. I really shouldn't feel "helpless;" that really isn't the right word, because as a physician I can help. I can try to give each person the best quality of life possible, and ultimately, isn't this what we are trying to do for every patient? She noted that patients with incurable diseases are often some of the bravest and strongest people she has ever met, and it is an honor and a privilege to spend precious moments with these individuals. There are fewer things in life more rewarding. It is often with these patients that one can make the most difference in a medical practice.

Another wise woman is my mother, who (God bless her) has been watching and reading about my early journey through medicine with a different perspective: a non-medical one. Yes, she still is the only doctor in the family (Dr. Mom?), but in a few years that title will fall to me. She told me that there is a "first" in everything that we do, and as this journey continues, there will be many more "firsts." There will be a first saved life, and a first mistake. A first surgery, and a first crazy diagnosis. Every new disease is a first. This first just hit me a little harder than I expected.

I don't want to become desensitized to either diseases or people. I understand that some desensitization is necessary: meditating on the fact that one is delving into the human body during every surgery is probably going to get in the way in the operating room. But I don't want to forget the person. I want to find that happy medium: understanding the gravity of a diagnosis or a procedure, but also turning energy on its head to help in a positive way. Appreciating the human condition, but not dwelling on it. This is a balance I've discussed with my ethics professor and a number of my preceptors. It will be a significant part of my journey.

I will be joining the hospital Ethics Committee in January, which will add quite a bit of perspective. There will be many firsts there as well, and I look forward to sharing what I can of those with you.

Inpatient Medicine

As I've mentioned before, four weeks of this year are on the inpatient service: two on Pediatrics and two on Internal Medicine. I already completed my first week with the kids, so in my final three weeks of the semester I am spending seven full days on "Medicine." This week of Medicine is the closest we get to the hours that we'll work during residency. Morning report starts at 6:30am, and sign out occurs somewhere around 8:30pm (usually a 14 hour day). Wednesdays we have a slight break because we have lecture from 1pm to 5:30pm, and then have the rest of the night off. We work the weekends, with no break going into the next week of continuity clinics. Basically it's a long week, but I better get used to it. I'll be doing this for years and years to come. The 80-hour plus week is upon me.

The morning for the med student is usually fairly relaxed. At 6:30am we get the scoop from the night residents, hoping that nothing crazy happened the night before. Usually it's a lot of patients asking for more pain medication, and it seems that pain control often dominates the discussion during morning report (and rounds later). At 7am we get going on seeing patients. I generally see 3-4 patients, each of the Interns sees six patients, and the Chief Resident checks in on everyone. The Attending also sees all 18 peeps, and somehow keeps them all straight (I can barely keep track of the three patients I see daily - I hope this is a skill that improves over time). I've had the opportunity this week to read about all of my patients before rounds, which helps me know what I'm talking about when we're all together.

At 10am we "round." Rounds are where the whole team gets together and discusses the treatment strategy for each patient. On many services, Pharmacy, PT/OT, nursing, social work, and chaplaincy will also be present to discuss patients, but on Internal Medicine we have only had Pharmacists with us. All 18 patients are presented in a very systematic format (subjective, objective, assessment, and plan or "SOAP"), with specific attention to the overnight events. How long the presentation lasts depends on the Attending and the service. For example, my presentations in Surgery needed to be 15 seconds or less (surgeons are go, go, go); in Pediatrics they were between 1-2 minutes (peds is always a little more chill). Medicine is notorious for longer presentations, greater detail, and tedious rounds. While we rounded on six pediatric patients in 20 minutes, our Medicine rounds will last three hours - three times as long per patient. Needless to say, a second cup of coffee is mandatory. However, I actually have found that I enjoy rounding, although it is very Attending specific. The demeanor of the Attending physician makes or breaks those three hours, and I have been lucky to have very good teachers this week.

Everything is discussed in the rounding round, from medications to social issues. Pain control is the biggest topic covered though. There are an amazing number of patients who enter the hospital already addicted to prescription medications, and so many more patients who are in severe pain. Deciding whether to use NSAIDs (like aspirin), or the best pain-killers available such as narcotics (morphine, etc.), can be a tricky choice. The goal is to use the least amount of medication to keep the patient comfortable and the pain controlled, but balancing use vs. abuse is difficult. Sometimes it really comes down to a gestalt or gut feeling from the physician, and some docs are more willing to sign off on narcotics than others. How much a patient needs may also depend on how much time the physician actually spends with that person. Some people joke that in the future we'll all be out of jobs because machines will take over the world, but these are the types of decisions that a computer can't make. Dealing with pain is part of the Art of Medicine; a very difficult and subjective choice.

After rounds we start admitting patients. The Interns discharge any people ready to go, and then fill up the beds so we always have 18 on our service. Most of our admissions come from the Emergency Department, so I find myself constantly running down to the ED to take a history, do a physical, and then present to the Intern and the Attending. Here again, how you a present a patient totally depends on who you are talking to. Sometimes I just want to ask, "Do you want 5 seconds or 5 minutes? Just tell me and it'll make this all go smoother." But you're expected to get to know the individual docs and figure out what they want to hear. I do my best. If the physician starts looking bored, it's time to wrap it up. If they're snoring, just quit. Everyone gets interrupted, but ultimately if you move quickly and confidently, I've found the results are generally good. Some Attendings you will never please.

Admit, admit, admit, and then time to sign out, turning the patients over to the night residents! I have to be honest, being here over the weekend is depressing. Everyone else is enjoying the time off to catch up on work and sleep, and here I am back at the hospital (where the weekend meals are just terrible - Sunday is by far the worst...). But I better get used to it; welcome to residency. I'll just have to keep counting the days until Winter Break.