Nearly Match Week!

This is probably going to be my last post on this blog. I haven't posted since last July!! I think the issue is that although  I love blogging, I don't find weekly updates about my own life really compelling. So I may start another blog, but it will likely have different/more branched out content. Anyhow, here's what's been going on! I did 2 weeks in the adult ICU, as I posted. Then a month of NICU, a month of child neurology (when I fell in love with the field and decided I would apply in Child Neurology, a 5-year double board residency), a month of genetics, pediatric rheumatology, and a month of adult Medicine Sub-I (where you are supposed to function like an intern). The latter was at our county hospital, which was overwhelming. One dude came in with a CD4 count (a measure of how bad your AIDS is)  of 4. Normal is in the high hundreds. So from July - November, I was on service continuously.

Then, I spent two months interviewing with child neurology programs. I did take a week off for Christmas, but it was such a whirlwind it didn't feel like a real break. This usually included a two-day interview with both pediatrics and child neurology. I went to 20 programs all over the country!!! By the end of it, I was incredibly tired and had been sick twice :)

Next week is Match Week. On Monday, I find out whether I matched in the original algorithm, and on Friday, I find out where I'm going. I've been super nervous, but Match Week is finally almost here. And then, I'm going South to do an away rotation where B is currently working. So he can't come to Match Day, but my mom and dad will both be there. It's a highly emotional day and some people are really unhappy with what they get, so I'm glad my school's Match Day is so chill (breakfast and then everyone opens their envelopes at the same time when the clock strikes 9). Last year, two of my friends were very unhappy with their matches -- one in Emergency, one is Psychiatry. Both matched to good programs, but not their top choices.

Also, Dusky the still-beautiful cat is ill with a nasal cancer and has been placed on oral chemo and kittycat hospice. She is doing okay (eating, drinking, meowing, sleeping), but has about 2-3 months by the vet's estimate, less by my own. She's much more timid than she used to be and has lost 5 pounds, but I think she believes she just has a left-sided cold. The diagnosis is nasal lymphosarcoma. I've had her since I was a teenager and literally can't imagine life without her. Sigh. Poor wee cat.

From the ICU to the ICN: The Beginning of 4th Year!

I started fourth year in the ICU -- the adult ICU. I was rounding with the pulmonary service, and it was quite a shock to the system after a year in the research setting. Our team consisted of an attending, an R1 about to become an R2, an R1, and me (RX= Resident in year x). I learned an incredible amount in a very short time. I learned about ventilators, I learned about lung-disease, I learned about a different way of assessing acid-base status (instead of Henderson-Hasselbach, my attending was a fan of the Strong Ion approach). The chief resident asked me to identify Howell-Jolly bodies on someone's peripheral blood smear -- which I kind of did! I was able to look at cells under a microscope, at least, because of my research year :) So I had a lot of fun. But it's also tough -- long hours, a lot of feeling undereducated, and just complex issues that everyone else is comfortable with. However: they fed me lunch FOR FREE every day! Every. Day.

 Last night, the night before I started my sub-internship, I dreamed I was being asked a series of questions I couldn't answer. LOL. The subconscious mind is so ridiculous. Today was the first day of my sub-internship in the intensive care nursery. Very ill children and a very different way of doing things. I already have two patients, and I'm going to try to figure out how to present them tomorrow. I don't even know what to read tonight because there is so much. However, I really like the content -- the babies are adorable (of course) and the problems are really interesting. A lot of diseases of prematurity, and a lot of congenital malformation. And a free lunch (okay, so I am a little food-centric. Food keeps me from being hangry). My resident is really smart and really nice -- I hope this will be a good working relationship. I have to not bug her -- I tend to bug people when I'm excited. I ran into one of my students from the master's program on my rotation! She's in the year below me now, I think. Or maybe in my year? I'm all mixed up at this point. After a certain point in life, what you are doing matters more than how old you are.

I have a lot of work to do, but it's the good kind. The kind where if you work really hard, you might be able to reach your goal. I have an entire month of this, so I really hope to be somewhat competent by the end of it. I am so excited to be working in a field I think I want to do for the rest of my life. And on that note: the residency application program opened on Sunday! I registered and started entering my information. There is something so fresh and summative about putting everything career-related into one online application -- it's like looking at an updated CV. It sort of gives you the perspective to handle one challenging day.

In the meantime, I am determined to find time to write up the rheumatoid arthritis paper from the research year. My mentor has already asked me how the writing is going. It is not going. It is paused. Oops. I should probably un-pause it by the end of the week. In fact, I should write them both a detailed update with a timeline.

Rica: How are you doing with your intern year? Are you excited? Stressed? Overwhelmed? Send us a message from beyond the bar!
Che: When does your program start? Oh, wait, I can stalk your blog and find out!
Mom: Come back from NC and tell Dad to stop playing the video games we downloaded for him on his birthday. My brother and B are irrepressible. You gotta love em, though.

Hugs,
Nia

How Am I Going to Learn Enough?!

I am so frustrated right now. I've spent the past few days reading about ventilator management, lung volumes, and acute respiratory distress syndrome. We've covered congestive heart failure and why the traditional way of thinking about acid-base disorders is incomplete. However, for some reason I just can't get questions right when people ask me point blank. For instance, even though I read an article my preceptor suggested a few days ago, I just couldn't summarize it when he asked me to this morning. What has happened to my recall? In high school, that wouldn't have been a problem. In fact, I think memorizing medicine in general would have been easier in high school.

I'm quite sure the British system does have something over us -- they take kids right out of high school and teach them, so they still have the ability to stay up all night and study, or memorize things as soon as they read them. I don't know if my brain is aging or rusty, but it's just maddening to know that you can't recall something that you thought you knew. Today, at the end of the day, a neurologist was quizzing me about locations of strokes in the brain. I *knew* this stuff at the end of last year -- and now it's gone -- poof -- like the wind. F*%K. A great way to end the day, looking like an idiot in front of your senior resident. Terrific. I'm being quizzed about everything except the lung on this pulmonary rotation.

And here's the twenty-four million dollar question: If I don't have this stuff memorized now, when on earth am I going to have a chance to learn it? How am I ever going to become the type of doctor I want to be -- the kind that understands physiology, biochemistry, and disease? How many times a day can I feel like a complete idiot? When will I know how to manage patients on my own? What the hell is wrong with me? Seriously, just shoot me now.

The child upstairs is singing 'Colors of the Wind.' The most relevant line from that song:

You'll learn things you never knew you never knew.

It's clearly a song about med school.

Anyway, there has been another milestone in the process of becoming a doctor: I have my basic lifesaving skills card, and I actually performed my first real CPR during a Code Blue in the ICU on Friday. It's physically more demanding than I realized. He was in shock, of a type that has a very high mortality, so the prognosis was unfortunately grim from the start. Then I had to call the family to let them know that the patient had passed away. I was grateful that my resident trusted me to make the phone call myself.

You know, what they don't tell you about medicine is that it's not the long hours, the terrible things that happen, or the yuck factor that makes it difficult. For me, the long hours are fine as long as I have enough food; the patients are the brightest part of my day, even if things are taking a turn for the worse, because you can't just abandon people if things go to pot; and the yuck factor is negligent because I was fortunately given a strong stomach. It's the doctors. The residents sometimes, and the senior doctors often. Some of them have a gift for teaching students, but most do not. They personally resent the extra work teaching requires, no matter that they chose to remain in academics. A few seem to particularly enjoy humiliating medical students, especially if there's an audience or a competitive aspect involved (like grades).  I guess it does make them look smarter, but how are they going to feel when one of those junior doctors is the one taking care of them when they grow old? The Hippocratic oath involves promising to teach the next generation of doctors as though they are your own lineage, not as though you are shooting fish in a barrel, and I hope I remember that if/when I get to that stage in my career. Hazing went out with the baby boomers.

For this reason, I am dreading my presentation tomorrow. What should be an opportunity to present and learn something will instead become a who-can-take-turns-outshining-the-dumb-med-student session. Am I the only one surprised that many doctors are, to put it mildly, not very nice people?

Okay, done venting. Mom and Dad, it's still worth it. Make change from the inside, and all that.

I'm So Terrified.

Medicine is terrifying. On Monday, I officially begin the first rotation of my fourth year. I will be expected to know more than I did last year, to care for patients more fully, to have memorized a larger percentage of relevant facts. That is scary enough; but at least the damage I can do to my patients will be limited by the supervision of those above me. One thing that really scares me, though, is being expected to teach third years. I do not know enough to teach third years! I've been off the wards for an entire year. I have no idea what I'm going to do or how I'm going to learn the material I need to learn. This afternoon I am having a little attack of nerves that makes it hard to breathe, let alone study. I'm going to go home to my nice B and spread my books out on the dining room table and try to get some work done. It's just difficult to read and process information as though you have all the time in the world when you have a Clock O' Doom ticking in the back of your mind.

Change is Good. Change is Good. Change is Good.

"The old order changeth, yielding place to new

And God fulfills himself in many ways 

Lest one good custom should corrupt the world."

-- Lord Alfred Tennyson, The Passing of Arthur

Here I am, just before another corner. Friday was my last day in lab. On Thursday, my lab took me out to lunch at Pacific Catch at the corner of Lincoln and 9th, which was amazing. They gave me parting gifts -- a pediatric rheumatology textbook from my boss, a cute cardigan from our senior technician, and yummy hand lotion and tea infuser from my junior mentor. I brought them thank-you gifts, but was touched to receive things from them. I think the art of gift-giving is dying. It's sad. But that's another blog post. Anyway, with the lab folks, I really felt as though we had managed the true spirit of giving something you think the other person will like because you appreciate them and were thinking about them. One way to achieve this is to limit spending. Small consumables are more likely to make it into the "how thoughtful, I'll definitely use this," category.

Lab bench, all cleaned up before I leave for good.

The last few months of the research year are over. It's been fun. One highlight was a student conference at the Mayo Clinic -- technically it was free, but I have yet to be reimbursed :(. I roomed with a Pharmacy student, and we even went running by the river in Rochester.  We saw goslings! Rochester is a really cute little town. They are trying to encourage diversity, which means our waitress didn't know how to pronounce the eight very non-Christian names at our table, but actually cared about how to say them. The conference was interesting, but the food was unfortunately better than the content. You know there's something wrong when a poster you stumble across on your way to lunch is better than any of the day's speakers, keynote included. That said, there was some *amazing* student work presented. Out of three keynotes, the last was actually mind-blowing (pun intended) -- a neurosurgeon who has been part of a team that is inventing an implantable chip to measure neurotransmitter levels (like dopamine) in the brain, and then transmit the information to a computer. Amazing!! There will be so many applications for the technology.

Another random, cool event was my old high school best friend, Div, coming in from Dubai! She was visiting her brother on the peninsula and they all came up to the city for dinner, so B & I joined them. We ate at Udupi Palace, a South Indian restaurant. Delicious but precarious -- the dinner plates were literally too big for the tables, so the edges were hanging off the sides over our laps! Div is doing well, and unofficially planning a wedding! She's in banking, not a bio teacher as she originally planned, and I'm going to be a pediatrician, not a lawyer like I was thinking about in high school.

High school friends, 10 years later!

I'm trying to write a personal statement for residency. Meaning that I'm thinking about trying to write a personal statement about residency. It's much, much harder than I anticipated because I'm switching fields. All my research and volunteer work has been in aging/rheumatology up until now, and now I'm shifting gears entirely and working with kids and embryology. Somehow, I have to articulate my trajectory, the 'ah-ha' moments, and why I want to work with kids. I feel like there is an entire category of things -- exams, personal statements, impressing my supervisors -- that I'm no longer rocking. Nia needs her groove back. Ah, well. If you can't beat 'em, just keep plodding forward.

B is home from DC. People keep asking how married life is. It's awesome, because I'm rooming with my life partner. It's so worth it. It's something I'm grateful for every day. We celebrated our one year anniversary by running Bay to Breakers, which is a 12K (7.5 mile) race that starts down by the San Francisco Embarcadero and winds its way through the city and Golden Gate Park to end at Ocean Beach. It was on my bucket list, and B kindly agreed to run it with me. I was the 6202nd runner to cross the finish out of 23, 072, and the 1853/11,793 woman, at a pace of 10:22 minutes/mile (1 hour 17 minutes overall). Not too shabby. B was my coach and ran with me, instead of jetting on ahead. Nice B! Che and Rica did B2B as well, walking in costume (thousands of people dress up), and we all met up at the end for tacos!! Yum. Che was a naked lady and Rica was a superhero. My favorite costume was the guy who dressed up like he was riding an ostrich, with feet dangling on either side of the bird, so it looked like the ostrich was running the race. My least favorite costume was The Silver Surfer -- running behind his reflective outfit was like having a glaring mirror in my face for three sunny miles. I also enjoyed seeing the Salmon, who always run the race as a 'school,' backward from Ocean Beach to the Embarcadero (going upriver to spawn). I almost got a salmon high-five. The most popular costume was a pair, running as the Lorax and The Tree -- the tree was nearly 8 feet high!

I am going on vacation.

The next two weeks will be packed: Open House party this weekend with our friends & my parents' friends, etc, and then a week of very intense review/getting things done before my pulmonary rotation. The Open House will be a nice break from reality. We are sending the cat on vacation to my parents' for the party, because my mom wants to attend and she's allergic to the cat. My dad saw our place last week, took one look around at the mess, and said, "Well, since our friends (meaning real adults) are coming, you can host the party at our house if you want." Thanks, Dad. Thanks a lot. But then, he has many strengths beyond tact. I hope the weather is nice so we can go outside. I don't remember much clinical medicine, so I need to study like crazy. I bought and borrowed the books for my rotations, and they all weigh a ton. I really hope 4th year works. I am excited to study more focused areas of medicine than I did with my longitudinal clerkship. Also, wouldn't it be nice to have an MD?

Here's the To-Do:

Open House!
Study pulmonary medicine
Study neonatology
Study child neurology
Write personal statement for residency
Research rheumatoid arthritis paper
Write rheumatoid arthritis paper
Meet with pediatrics department chair/advisor
Come up with list of residencies to apply to
Get photo taken for residency
Ask research mentor for a recommendation letter

Busy = Happy.

Love,
Nia

Change is in the Air Again!

Okay, although I am totally overwhelmed, I need to write. So much has happened this month. Much of it has been very, very good and exciting. A lot of it is scary. And no, I'm not pregnant.

Basically, next month is the culmination of the research year. Some of you have already heard that my molecular biology project was going really slowly. However, the fellowship I'm on expects us to have a finished, completed project that we did ourselves at the end of the year. So around December/January, I panicked a little bit and tried to think of something I could do that piqued my interests, aligned with my abilities, and was feasible in a condensed time frame if I worked hard. The project I came up with looked at predictors of refractory disease in rheumatoid arthritis patients, which I was totally psyched about because it was clinical, had statistics, and dealt with both medicine and health disparities/epidemiology.

I've basically been working every day for a long time on this project, and I finally have results! I love my data. But they are alarming, showing differences in outcomes based on level of education when adjusted for medication use and other factors. I am beyond excited that it looks like we have some interesting data. I just sent the dataset to my mentor, so I'm just crossing my fingers that she doesn't run my numbers and get something totally different. That would be a minor tragedy. My big boss I think was a little skeptical at first, but she seemed pleased at my lab meeting today and had some great ideas for what to do next.

So next week I have to somehow do the following: Finish and practice my talk, actually do the 10-minute talk for a symposium, present my poster, finish my resume and personal summary form for the Dean's office to kickstart the residency application process, go to a 2-hour evening journal club (which curtails my ability to speak with my husband on the East Coast, sadness), finish additional data analysis for my presentation, work on a different poster for a different project I've been doing on the side, and pack for a 3-day conference the week after that. Oh, and remember to give my little boss a birthday present. Actually, when I write it all down it doesn't feel so bad anymore. Thank you, therapeutic blogging. I was sad to miss meeting up with my Auntie from India, who was only in town tonight, due to a confluence of work-related and traffic-related factors. But she got to hang out with my dad (she's dad's brother's wife).

In the next month, I have to finish all my research because then I'm back on the wards! Here's my 4th year clinical schedule:

2 weeks of adult pulmonary medicine
4 weeks of neonatal intensive care nursery
4 weeks of child neurology
4 weeks of pediatric genetics
4 weeks of child rheumatology
4 weeks of adult internal medicine
4 weeks for residency interviews + some vacation time (or time to mourn lack of interviews!)
4 weeks of To Be Determined + some vacation time
4 weeks pediatric infectious disease
4 weeks of end of year required curriculum

I am so excited about this. If I do apply in child neurology, I'd like to fit in some adult neurology somewhere. So little time, so much to learn. Many of my old classmates are graduating soon. I'm a little sad when I think of it, but I'm very, very glad that I took a research year. Although I've been in medical school so long (6 years next year!) that when I graduate, it will be quite a shock to my system. If I had gone straight through, which is a big if, I could have been a 2nd-year resident by now. Then again, hopefully the added maturity will be a good thing when I have an MD behind my hybrid name. I should blog about changing my name. Anyhow, I am also nervous/excited because I finally was able to arrange a meeting with the child neurology department chair, whom everyone literally raves about (Pediatric department chair: "I'd trust her with my life...in fact, I have").

In fun news, I'm also doing Bay to Breakers! So are three people from my lab, one of my old friends who is coming in from out of town, and B. I'm so pleased B agreed to be my running buddy. He usually tries to do shorter distances because he needs to be able to sprint for Ultimate, but he was really nice about the 12K. I'm told the entire first half of the race is uphill. Ick. But then, I was also told that it's so crowded that you are forced to walk at points.

For those who asked, B is doing well. He and the other employees got to take a big group photo with The Boss of the House that Shall Not Be Named. Pretty snazzy.

And, just in case you were wondering about my political views, you heard it here first:
Keep your MITTens off my kittens. No more drama. Vote Obama.

April Showers, a 12K, & The Match!

It has been raining a lot. My research facility is located on a hill, which means that you get pretty wet from rivulets and waterfalls as you climb up to work. I think we're getting all the downpour we missed out on this winter. I am lucky enough to own two beautiful umbrellas and good shoes, so I can actually enjoy the torrents. Usually with a hot cup of tea. I'm drinking way more tea than will be sustainable on the wards. Yes, it's almost that time -- the moment I go back to the clinical life! Yikes (Which end of the patient is up, again?). It seemed so far away all year, but now I'm only two months away.

Warming up before the race

On the Sunday after St. Patrick's Day, we ran a 12K (~7.5 miles) to benefit the Edgewood Children's Foundation called Emerald 12K Across the Bay. It was a beautiful run, staring at Fort Baker and climbing up the (steep!) hill to the Golden Gate Bridge, crossing the bridge, and then winding down past Chrissy Field and ending near Ghirardelli square. My dad walked the whole 7.5 miles!

Beautiful views of the bay the whole 7.5 miles

Post-race party with live band at Ghirardelli square

Free chocolate milk from the Nesquik rabbit

The weather was breezy, sunshiny, and cold in the morning but perfect for running. As I crossed the bridge, I saw huge, graceful pelicans fishing at the mouth of the bay. I could see Alcatraz like a jewel in the water. It was amazing. I've never run that far before. My time was 1:20:38, for a pace of 10:49/mile. Just for perspective, the winning female runner did it at 5:32/mile. She's a year older than I am!

Speaking of clinical life, the Match happened two weeks ago. The Match is a huge, nationwide event that occurs the third week of March. Medical school seniors crowd into a room, open tiny white envelopes, and find out which residency program they'll be working at for the next three (or four, or ten) years. My friends all matched! Most of them seemed very happy. E is doing internal medicine. CL is doing pediatrics, and had some great advice for me. Dee is doing internal medicine. T is going to LA to do psychiatry, which is great because his wife, K, was offered a teaching position down there (congrats you guys)! Maybe they'll go all Hollywood on me and start doctoring/teaching the stars? Mimi won her coveted dermatology spot, for those of you who were biting their fingernails. Many, many people are staying in or around the SF Bay Area, which means I might see them once every six months during their training...

The evening of Match Day, there was a class party at a cafe near the beach. I went even though I am no longer in their class, just to say congratulations. Unluckily, it was pouring rain (again). Luckily, it was indoors and we had seats by the fire. Butters brewed an awesome, hoppy beer and brought it! Dee baked a pie (her first! With homemade crust! It was delicious). There was wine and excitement and congratulations. I couldn't believe how grown-up everyone looked. I am so very proud of them and all the hard work they've invested. The matched folks graduate this May with MDs. Dear Lord, they are going to be doctors. Our 2013 graduation will be so lonely without them. Can you believe how time flies? And the handful of us that added a year are left to plunge into the breach.

A beautiful gel for Western blot, loaded and ready

Research is going...strangely. After working on a basic science project all year, I'm not sure if it's going to manifest itself or fall through. However, I've also just started a clinical project that might save my behind when the NIH people come after me for Results with a capital R. Crossed fingers. It's interesting work, looking at what types of people don't respond to treatment for rheumatoid arthritis and how their bones erode. It's actually great stuff. We'll see how it goes; the deadline is a conference coming up in May (and prior to that, an abstract due next week).  I can't believe how much molecular biology and statistics I've learned this year. I hope all the clinical info regarding patients is still in my head somewhere. Unfortunately, I've had no time at all to work on my master's thesis, and I'd love to edit it and submit it. My brain is going to explode one day, wait and see. It'll be interesting. Anyhow, this week I get to teach a high schooler volunteering at the lab. She's a bubbly senior, five foot nothing, long dark hair, wants to major in chemistry. Rock on, my little friend.

B continues to work at the pale house in a certain capital city that shall not be named on a public blog. He's coming home weekend after next, though. Yay! Maybe it'll stop raining enough for us to go hiking. It has occurred to me that it's very late and I should go to bed (this is laughable: by hospital standards it's not even the end of the day). But I am so very happy to get a chance to sleep that I should carpe noctem. Bonne nuit.

What a Non-Catholic Can Learn from Observing Lent

A week ago was Ash Wednesday. I saw many people at work going about with a black ash cross on their forehead. Although I am not a Catholic by any stretch of the imagination, I have always respected Lent. I think it has a beautiful symbolism, in so far as my understanding goes. If you want to learn more generally about Lent, here's a good overview. The forty days of Lent (Sundays do not 'count' because Sundays are a celebration of salvation) mark a time of prayer, penance, and fasting (meaning a different diet, not total starvation) in preparation for the resurrection of Christ at Easter. Many people see the temporary sacrifices of Lent (chocolate, TV, internet) as another way to do penance, develop self-discipline, and remember the sacrifice of Christ -- for instance, this 25-item list put together by and for teenagers. Pretty impressive for high school students, right? One could argue it is artificial hardship, but I was thinking how valuable it could be for anyone, not just the Lent-observing Christian, to 'do without' for 44 days.

It seems this practice would bring us closer to those people who have less than we do, while reminding us that we have much more than we think. Especially during this Great Recession, I've been remembering the old saying, "Use it up, wear it out, make it do, or do without." Not that I live a deprived life -- we live in comparative luxury on our modest income (ie my research stipend and his intern stipend). But of course it's good to be careful and frugal with money, and to be thankful for what you have -- no matter how much it is.

The 44 days of Lent are also valuable to the non-Catholic as a dedicated time to learn a new habit. It takes people anywhere from 18 to 91 days (depending on the individual, the behavior being learned, and which study you read) to really establish a habit, but 44 days is a pretty solid amount of time to devote to a new practice. Check out this Slate article on one (Indian-American) woman's experiment with becoming a morning person. You could apply this to anything, from nagging your children/spouse/employees all the way to kicking a dependence on caffeine, alcohol, or cigarettes. Speaking of which, isn't it neat that our medical school's first-year syllabus requires that we attend an AA meeting if we've never been to one, so that we understand what it is we are recommending to patients?

So my Catholic neighbors and colleagues have inspired me to re-examine my own life. What do I indulge in? What could I do without? What would make me a better person?  I think as I get older (I'm now 27 years and 4 months old), I need to decide what my priorities are going to be. As a high school student, especially, I had this strange idea that I could do everything. I could act in plays, sing in a choir, choreograph dances, ride horses competitively, study hard, do research, volunteer, etc etc. And I could do it all, but I was perpetually exhausted, never saw my family or friends, and I think I averaged about 4-5 hours of sleep a night my junior and senior years. Obviously (in hindsight), that was not sustainable. However, we'll see if I've still got it (residency is coming)!

Our little older Siamese (she's 13) had a health scare this weekend: she chewed a bump off her shoulder which turned out to be benign (a self-operating cat! Dr. Cat, M.D!). But the reminder that she, like all of us, is mortal made me want more focus in my life. I am currently deciding on a specialty (almost there; really close to deciding), starting a marriage, and trying to find enough time for family and close friends. Given that I am in the medical field, I don't know how much room there will be for anything else. Maybe kids, someday? Running? Riding? Pets? I don't think I'll be choreographing another can-can anytime soon.

At this point, I want to devote more time to my career and calling -- to becoming a really good doctor. It takes way more time than I had anticipated. But not more time than it deserves. Because it's worse to be a lousy doctor than to not be one at all. I'm in a research lab at the moment, but the MD is the goal. I need to start thinking about my future patients: which skills do I need to acquire in order to be the doctor they would want? So until Easter, I am going to read one article or chapter every day that will make my sub-internships easier during fourth year and beyond. I am also going to spend ten minutes each morning in a lovely meditation taught to me by a friend who was also a minister a few years ago. It went something like this:

The Friend Map:
Picture a map of the United States or the globe in your mind. Picture everyone whom you carry in your heart -- friends, loved ones, colleagues, frienemies, or any other group -- as pinpoints on that map. Now scroll across the continent, sending a prayer/good wish for each person. This cultivates gratitude for their presence and a loving demeanor, both of which will strengthen your ability to weather storms. And who knows? They may sense that someone is thinking of them/praying for them.

Choosing a Specialty

Lately, the most pressing questions in my professional life have been a) which medical field to go into and b) how to get myself published. Part (b) is a topic for another post, but the choice of specialty question has been plaguing me for a couple of weeks now.

So far, I've narrowed it down to a few fields I think I'd be most happy in. Here's the list, in no particular order, with the training required for each:

1. Neurology (adult): 1 year preliminary medicine + 3 years' neurology
2. Child neurology: 2 years preliminary pediatrics + 3 years' child neurology OR 3 years pediatrics + 3 yrs child neuro
3. Pediatric rehabilitation: Same as child neuro, but put "rehab" in place of "neuro"
4. Adult rehabilitation: Same as adult neuro, but put "rehab" in place of "neuro"
5. General pediatrics: 3 years of pediatrics

So I think I'd be happy in any of these fields. The problems I have with deciding are related mainly to i) competitiveness and ii) scheduling 4th year rotations so that I have a good chance of doing well and getting a recommendation in my chosen field. Basically, I have two available slots, and I was hoping for a 'warm-up' rotation so that I could really do well in my 2nd one. I want to step it up my fourth year!

In terms of competitiveness, neurology and adult rehabilitation are not that competitive, but the 1st year -- preliminary medicine -- is. This is because everyone matching into the more competitive fields of Radiology, Ophthalmology, Anesthesia, and Dermatology (the ROAD to the good life, we call it) has to first do a prelimininary medicine year. These are the students with honors across the board, Alpha Omega Alpha (medical honor society), and great board scores as well as research in their field.

Child neurology and pediatric rehabilitation are not supposed to be competitive, but they have very few spots available each year, and so it tends to be that either you get interviewed/ranked at many programs or nobody ranks you (this refers to a complicated process known as "The Match", in which programs interview selected students applying in their field, and both rank each other so that a computer algorithm can decide who goes where).

What all of this means for me is that I have to take a cold, hard look at my scores, grades, research, and qualifications so that I don't under- or oversell myself when trying to find a position for residency. My record is that I come from a very good school, but my Step I is unfortunately quite awful, my Step 2 is quite decent, my grades are solid but nothing special, my research experience is strong but not PhD level, and I won't be a member of AOA. I do have gumption and passion and lots to give in terms of intangibles, though!

The other issue, of course, is whether I'd like to work with children or adults more. This is a huge decision and is, I think, the biggest 'branch point' in the above decision-making. I have written out lists of pros and cons, I have flipped coins, I've asked friends/families/advisors. I get different answers depending on my mood, the person I'm speaking to, etc. My mother even wrote out a flow chart analysis thing (it's so nice to have an MBA Mom with a great deal of patience for my ridiculous anxiety). Right now, I'm favoring the kiddos. And their parents. I really like parents. Parents are adorable. But we'll see!

I Am Done with Step 2 CK!!

Simulated Exam Screen with Heart Mitral Valve (score95.com)

I haven't written in a very long while, because I was overwhelmed by that anxious, itchy feeling of not knowing how you've done on a very important exam. As you know already, I was wondering what would happen if I did very poorly or didn't pass. But last Wednesday I got my Step 2 CK (Clinical Knowledge) results back, and not only did I pass, I passed comfortably. No 'squeaking by' like with Step 1. What a wonderful Christmas present! And maybe I'll stop making careless mistakes in lab now. A huge weight has been lifted. I'm hungry again. I care about life again. And I'll start posting more frequently now that I have a little more time to devote to writing.

B and I went to LA this past weekend so he could visit old law school friends and I could take Step 2 CS (Clinical Skills). It's an in-person exam set in a simulated clinic. The exam was so odd. We were in a long hallway with over twenty doors, and standardized patients behind every door, and proctors in the hall, and buzzers and announcements going overhead. I felt under time pressure and could not do a lot of physical exam, sadly, so I hope that is okay in terms of whatever grading rubric they use. And it's a pass/fail exam, so I just hope I pass. I don't need a good score :) I am not allowed to say anything about the actual content of the exam, but it was just a weird experience. They are all actors. For one patient, I wasn't sure if he was "supposed" to be malingering -- that is, pretending to have symptoms for some other benefit. But he was an actor, which meant I was pretending to be concerned about his pretend symptoms while trying not to act as though I thought he was pretending to pretend. And they say it isn't an acting exam.

So, in a word: Phew!!

Gingerbread and Counting One's Blessings

Thanksgiving is almost here, and we have more than enough to be thankful for. B passed the California Bar Exam! He was enormously relieved, especially given that two of his twenty colleagues did not pass this time around. B will also be on the East Coast for a few months this spring for an internship, and then will be looking for work. Where he ends up will determine where I seek a residency next year.

Assuming I pass my own exam. Results haven’t arrived yet, so I feel a bit stuck in limbo right now. I keep playing the ‘what-if’ game – what if I failed? What on earth do I do then? What if I never graduate from medical school? Finally, I got so tired of this that I called my own bluff and started to compile a list of alternate careers I could do if medicine did not work out:

Clinical research director. High school teacher. Biostatistician. Medical transcriptionist. Policy analyst. Medical writer. Bench scientist/technician. Guidance counselor (ironic). Riding for the disabled instructor. Any other thoughts?

The clinical skills exam is coming up in mid-December, and I plan to start studying immediately after Thanksgiving break. We are going to his parents for Thanksgiving and mine for Christmas. Things at work are a bit hectic, as well – I feel guilty going anywhere for Thanksgiving because it puts a forced pause in an experiment where no pause should be, and my boss offered to feed my cells over the Thanksgiving weekend. Yuck. There’s nothing like knowing you are putting your boss out to take the fun out of a holiday. I am also hugely inexperienced and am dealing with quite a steep learning curve. I’m sure that I supply the more seasoned scientists with plenty of laughter over my naive mistakes. 

As you can probably tell, I am feeling all out of balance... plans I thought I had made so carefully to schedule things out this year have gone awry, and I just hope that somehow it will all work out. I am learning important things about myself, though – I do not think I want a wildly unpredictable career where I play five different roles and juggle far too many responsibilities. Although I doubt any medical career could ever be low-stress, I would like medium as opposed to very high stress on a daily basis. A little bit of time for family would be nice, as well. I think that this culture really does emphasize doing as much as you possibly can, and de-emphasizes things like family time, sleeping, and food. No wonder obesity has become a problem – poor, stressed-out working people have too little time to cook, so they simply eat processed foods or eat out all the time. And they are so busy working that they are never able to go for a walk. It's a double whammy.

Anyhow, one of the sovereign remedies for the blues is to think happy thoughts. Funny things qualify: the other day, the children who live above us were dancing around while it was raining out. Somehow, the rain amplified their footsteps until it sounded like an army was marching over our heads. Of course, they will now forever be known as the Storm Troopers.

Secondly, one of B's colleagues called Swarthmore College, our alma mater, a "potted Ivy." I thought this was both highly flattering and quite appropriate (but then, I'm biased. I loved Swarthmore).

Another form of happy thinking (appropriate for the upcoming season) is to list the stuff you are grateful for. So here goes... 

Things I am Grateful For: (Here are the ones I can think of right now, in no particular order)

Being happily and newly married.
All the wonderful people who came to our wedding/sent us love.
Living in the same town as my brother!
Having adorable parents fifteen minutes away.
Warm gingerbread with cold milk.
My thirteen-year-old cat, who is still pretty feisty.
The friends I've made in medical school, and the friends from college who stuck around.
Having a job with good colleagues.
A car, a roof over our heads, food, comfortable clothes, and some extra goodies.
Good in-laws. Seriously.

To facilitate putting the attitude of gratitude into practice, I just got one of my favorite things in the world: a new blank journal. It's been a year since I kept one. For $3.99, isn't it worth it to feel as though your life is, once again, a clean, fresh sheet of paper just waiting to be written on? The only feeling that tops it is when you've filled it.

To NIH and Back Again

The NIH Clinical Hospital: Every patient is on a research protocol

I recently made a brief journey to the National Institutes of Health for what I believe qualifies as my first-ever business trip! That is, if you consider a 'business trip' to be one that is both mandated and paid for by your employer. It was an incredible trip. I met nearly 100 other medical students also taking a year "off" from school to do research. They represented an incredible range of schools and interests. I took a chance by going to a neurology networking lunch one afternoon, and was invited to do an elective at NIH next year by one of the physicians there! Wow. We also attended presentations about residency selection, balancing a clinical practice with a research career, finding funding, and dealing with student loans.

The keynote speakers were very famous people -- Francis Collins (NIH director, working on aging), Anthony Fauci (he and his PI essentially discovered the treatment for Wegner's granulomatosis and his lab went on to develop AZT, the first antiretroviral, discovered much of the natural history of HIV/AIDS, and convinced three presidents to fund AIDS interventions in Africa), and Marston Linehan, whose lab is responsible for discovering the basic pathways of kidney cancer AND creating new techniques to vastly extend life in patients with kidney cancer. I was in awe that such brilliant people were also such good speakers and seemed very personable. They encouraged us to take over from them in the next generation. What shoes to fill!

Building 50: My Old Lab!

We were housed at the Hyatt in Bethesda -- my roommate was a wonderful person who studies colon cancer risk decisions and wants to be a rural family medicine doctor. I was very glad to have met her. I also reunited with medical students I had met on the interview trail years ago, but had gone somewhere else. There was not too much time to socialize except for the meals --  which were delicious and plentiful. I was very grateful that NIH had organized the weekend for those of us funded through NIH student grants (of which there are many). Bethesda was beautiful in October -- crisp air, deep blue skies, fluffy clouds, and trees just beginning to change. I very much enjoyed being back there after four years away. It was over so soon.

Trees Changing Color at NIH

I flew home and found, to my surprise, that I was sitting next to two medical students from Yale, a year my junior, going to a surgical conference in the Bay Area! We spoke at great length about the Bay Area and medicine versus surgery. We called our little area of the plane 'Medical Student Row,' and were continually being visited by other students on board who were also attending the same conference.

Cat in a Bag

NIH or no NIH, however, there is no place like home. My sweet cat had been moping around, according to B, but she was perky when I arrived, and we found her contently chewing on a receipt in a brown paper bag that evening.

Cactus and Aloe in Window Silhouette

Exam Rose!

Our plants were looking wonderful, the rose B had given me to cheer me up was still in bloom -- and this reminds me that now, and for the next month or so, you will please forgive me if you hear very little from me. I must somehow gear up for all the examinating that lies ahead. There are now only 18 days between myself and Step 2 CK.

Boundaries and Bosses

I have two bosses. They are both incredibly bright, lovely women who happen to have advanced degrees and a lot of clout. Big Boss is the head of our lab. She is one of those people who looks between 10 and 15 years younger than they are. She is very driven, down-to-earth, straightforward, and to the point. She is always juggling several things at once but somehow manages to get all the important things done. She keeps her promises. She doesn't have a lot of patience with personnel drama. However, her husband works in her lab, so I have a window into her world through their interactions.

The second boss I call my Little Boss. She is a young attending physician-scientist who works in the lab, and I'm helping her with her first big research study. She has a three-year grant and has nearly completed the work mid-way through her second year. She has been that kind of worker throughout medical school and her PhD program. However, she and her husband have just adopted a two-year-old boy and she is feeling a powerful maternal urge, I think. She is now planning to leave academia this year for half-time private practice so she will have more time with her son. I do not know that this goal will materialize for her, given the climate of private practice these days. I hope it will, since she feels compelled to leave so soon to pursue it. I have my doubts.

My Little Boss

I have come to realize that in my lab, the blurring of boundaries between work and home is so great that most of the folks who work here could write each others' biographies. Each day, we all sit down to lunch for an hour from noon to twelve, the unwritten rule being: No Work Talk. Every time I have mentioned work at lunch, I have been gently hushed until I, greenhorn that I am, got the message. It is the socializing, networking, debating, and gossiping hour, but never work. It seems so civilized and old-fashioned. It is a far cry from the inpatient hospital world, where sitting down is a crime and chewing (meaning eating) a sin. In addition, Little Boss and Big Boss tell me so much about their lives. I know about their kids', pets, spouses, their home lives, etc. Perhaps the culture is that way because everyone is a parent -- Big Boss has two teens, four others have grown-up kids, and Little Boss as well as two other scientists all have kids under two.

Little Boss says that part of the reason she wants to leave is that she thinks that private practice will have more well-defined hours. For instance, in our lab, she can go home in the middle of the day if she wants to have lunch with her son. But she hates feeling that research is this amorphous entity that could take up 20 hours a day if she allowed it to. She'd rather have the stricter hours of a clinic, knowing that when she packed up for the day, she was not bringing her work home with her. I think the people she works with are far more important than the job description on paper -- if they value family time, that will affect the culture of the workplace. I personally think our lab environment is much more family friendly than the clinics I've seen -- of course, I've only really seen clinics that are affiliated with big hospitals. Perhaps community clinics are more flexible.

I am very grateful for this year. It is giving me a chance to study, think, earn a little money, work hard but sleep enough, and reflect about my future. I really, really needed it after an emotionally overwhelming and academically underwhelming third year. The other day, Little Boss introduced me as her "senior medical student," and I could not help but think that I am really too far behind in my studies to be referred to as such. Then again, that is what my precious year is for.

Today, both bosses were helping me prepare for my lab meeting on Friday afternoon. Big Boss wanted me to include more basic science, more details about the mechanisms, signaling molecules, hypotheses and how we were going to test them. Little Boss was of the opinion that this would put my audience to sleep, and that I needed to clarify the basic principles, questions, and background. The lab meeting is a practice session for the Works in Progress talk I am giving to the other year-long research fellows on Wednesday. That one is a bit more nerve-wracking because there will be another student speaking as well, before me, and one whom I know to be very hard-working. Anyhow, my task now will be to take the advice of Little Boss while somehow also pleasing Big Boss. I am so thankful for all this feedback and attention -- it's far more than I got last year. It is challenging, though, to navigate two opposing opinions -- clearly, Big Boss trumps Little Boss, but I work much, much more closely with Little Boss and want to keep her happy.

My only fear is that I will be pressured to divulge all the personal details of my life while at work. I guess I just have to guard against it. I have already been put in an awkward position a few times because my higher-ups ask me to keep secrets from one another; I don't want them to know enough about me to get under my skin. Ironically, it's safer perhaps to discuss things here, on this online blog, than at work. It's getting late now, so I think I will turn in for the evening. Good-night!

Mountains Ahead

Dolores Park on a warm fall day (Ingrid Taylar)

The Bay Area's hallmark late summer seems to have come at last, three days before the official beginning of autumn. After fog and wind all summer, it's been 80 degrees with warm nights and bright sunshine. It is a cruel trick for visitors to this region that our summer starts as soon as tourist season ends, indulges us for a month, and then gives way to a chilly fall. This morning, I took a minute to look out over the channel where the bay meets the ocean on my way home from work. Stunning. It does make up for missing the brilliant red and gold leaves of the East Coast. I sense that our sunshiny autumn will bring exciting change and mountains to climb!

Clean, white paint instead of baby blue/taupe/coffee.

At home, B has been hard at work to brighten up our ground floor apartment -- he loaded up the storage shelves that we built, which freed up some much-needed room, and then he painted two rooms by himself! We had chosen the colors many weeks ago, but he finally decided that he would paint before he starts work again. The bedroom was a pinkish-beige color; we opted instead for a more neutral golden-cream. It looks beautiful! The bathroom was a tiny, multicolored space with a bright yellow bathtub, so for that we chose a clean, white gloss. It looks like an entirely new place. Apparently, latex paint can take up to a month to cure, so we are camping in our living room for the time being. It's fun to have a makeshift studio.

I have managed to put our little Siamese on a successful diet (she was gaining weight due to her asthma medication), and she looks pleased with our place thus far. She likes to sit in the window seat in the sunshine, or else to guard our front door. I have also found a few minutes here and there to finally hang our pictures and put away odds and ends. Our living room is wood-paneled (including the ceiling), so after the exams I'm going to look a way to bring more light in.

B's delicious home-made whole-wheat flatbread zucchini pizza!

On the work front, B has been approved for his internship! I'm so glad he painted the house already. We were both surprised that he would start on a weekday, but apparently there was a motion to be filed this Friday, so they needed all hands on deck. My own lab project has been challenging, but I finally managed to sub-clone the gene I am working on, so my boss left for her conference on Friday a slightly happier woman. And of course, the boards are coming ever closer. I manage not to be nervous while actively studying, but when I'm speaking with coworkers or attending research meetings, there is a tiny undercurrent of dread always ready to claim my soul :) We (especially B) have been cooking and freezing up a storm in anticipation of my boards studying in the evenings and his working from 6 am -7 pm every day. The feline friend will have to find something to occupy her time with both of us at work all day! Right now, her strategy is to yell loudly anytime anyone approaches the front door.

I guard: No-one in + no-one out = happy cat.

Step 2 National Licensing Exam on the Horizon

As some of you who have been reading this for a while know, I feel like I shortchanged myself for Step 1 (the first national medical licensing exam). My studying was not that effective during the short time I had, given my master's thesis work. I think I achieved maybe two weeks of good solid studying, and barely squeaked by at the last minute. I later found that most people start studying months, if not years, in advance! It was too little time given how much exam material was not covered in the curriculum of our first two years, and given how little emphasis was placed on the exam by our program. I was probably naive and should have done my own research about the importance of this 8 hour exam, but when someone you trust tells you that you are worrying over nothing, you believe them. Oops.

Scholarship Exam, 1940

Thinking back, I'm not sure why I believed them. My entire life, people have been telling me that I took my academics too seriously. I have often heard that an exam or a grade was unimportant, only to study hard and then realize that it did make a difference later on. Working for a grade only when it 'counted' seemed wrong to me somehow. Shouldn't we be working hard for the sake of doing our best? What frustrated me about this Step 1 episode is that I did work hard the first two years of school, but I felt my energies were often directed toward irrelevant material, such as alternate therapies, politics, and social concerns. Those things are important, but not at the expense of learning the basics of allopathic medicine! I did not make sure that what I was learning correlated to what I needed to learn; I trusted the school to do that and they didn't. I suppose I wish our program had been, for lack of a better word, a stricter one. I also wish I was a little more realistic about the preparation needed.

This brings to mind another myth you hear when applying to medical schools: that all medical schools are pretty much equivalent during the first two years, because it's the clinical years that matter. In my opinion, this is blatantly false. The first two years are your foundation. The quality of teaching and the strength of the syllabus sets you up not only for your board exam studying, but also for the wards. If I were giving someone else advice about choosing a medical school, I would tell them to examine the syllabus for all four years carefully, and look at who is teaching the basic preclinical courses. Are they PhDs without any clinical background? Are they MDs without any teaching background? Are they junior or senior medical student teaching assistants (who are often great)? Do the same professors teach the course year after year? Lectures? Case-based (not necessarily as effective as it is popular)? Both? How well do preclinical grades predict performance on the Step? What sort of board preparation (if any) do they offer? What is their board exam pass rate (can they give you the actual numbers)? In our case, had I looked into this further, I would have seen some serious red flags in terms of the right fit.

Please don't get me wrong -- I am very grateful for all that I have gained and learned during my time in medical school. I understand that no medical school is perfect, and that often, we only get out what we ourselves put in. There are amazing things about my program, which I won't go into here. However, I do not know if I would recommend my program to other pre-medical students. I have no resentment or bitterness about what we didn't learn, but I do feel the need to be truthful about it to others embarking on this journey. For myself, my goal is to move onward with my life and career using everything I did learn.

Anyhow, my experience with Step 1 was a very high-stress way of taking any exam, especially one that turned out to be so much more important than I realized. I do feel that certain doors are now closed to me in terms of both specialty choice and competitiveness of residency programs, which is sad because I know I could have done much better. Looking on the bright side, though -- there is another licensing exam. While a decent Step 2 score may not entirely make up for a low Step 1 score in terms of residency applications, it would theoretically help. Thank goodness there is another exam! Now the pressure is on to prove myself. From every challenging experience or mistake comes a chance to do better, right?

I still have some time before Step 2, so my plan is to go through all the material once through briefly to get a feel for the scope of the material, maybe review some Goljan pathology or internal medicine, and then do as many practice questions as possible from USMLE world. It seems as though everyone uses some variation of review book + online question bank to study for this exam. However, everyone also says that you only need two weeks to study for Step 2, that it's easier than Step 1, etc. That may be true if you felt well prepared for the first Step. Needless to say, I shall not believe it:)

Many of my classmates have taken Step 2, and many are taking it around the same time I am. I hope we all have a better time of it. I will try to continue blogging as I study. Good luck to those taking the exam, and good luck to all those applying for the spring Match! I hope people end up in places and specialties they love. My plan is to smile and keep on keepin' on.

The Year Ahead

The dust from the wedding has mostly settled. We've moved into our new place, our photographers are slowly getting back to us, and we're still writing thank-you notes to all of the wonderful people who contributed to the start of our married life. We moved into a new place, B is taking the Bar as we speak (goodluckgoodluckgoodluck), and I started my research fellowship. On Friday, we are leaving for a 10-day belated honeymoon in Hawaii! I think all the red tape at work has been taken care of.

Today I started thinking about what happens when I return from the honeymoon. What are the most important things to focus on this year? I want to give a lot of thought to my future career and my professional identity. As a doctor, one can travel many paths: clinical care, education, research, administration. It's hard to do everything, and it's impossible to do everything well. My mentor and I had a conversation about this. Her take was that at some point, you just have to accept that with all the things you do, you will do none of them at your absolute full capacity. While that is true, I don't think it follows that you should overextend yourself to the point where you feel you are doing a mediocre job of everything. So this year is about career discernment. How do I want to make an impact in the world? How can I be of most use? What path will give me the most fulfillment?

The other concern is practice. Often, something just isn't going to be fun or interesting until you have devoted enough time to becoming good at it. I'm 26 now, and one important question comes to mind: how long am I going to spend being a beginner at many things, as opposed to advancing in a few chosen areas? So this year is also for taking stock of the skills and talents I have and capitalizing on them, rather than trying everything on for size. I'm getting impatient with not knowing anything about anything. Also, if you are a beginner you end up taking a lot of help and not giving very much back.

One of the lessons I think America can learn from the UK is that of encouraging vocations in young adults. I think many 16 or 17 year olds do know what kind of work suits them. The trouble in the States is that our indecision is encouraged, even applauded. We do four years of college. Then I did four years of masters/MD, with one research year and one additional clinical year still to go. But the choices that once felt so freeing are beginning to drag me down. I want to define myself further, not open even more doors and then stand before them all saying, "Look at all the things I might do!" Which is why this year is important.

All of this said, I have compiled a checklist of things I want to focus on this year. Hopefully, I will look back at this next May and have a tangible record of whether I met my goal.

2011-2012 Checklist:

1. Work on my work ethic.
2. Submit my thesis work to a journal for publication.
3. Finish a cohesive research project at the lab this year.
4. Decide my top two specialty choices and arrange electives accordingly.
5. Find a non-academic activity to channel my creative energies.
6. Develop good study habits and practice with my licensing exams!
7. Make time for friends and home life.

Even when plans don't work out, isn't it fun to plan? I almost feel like anticipation is half the fun! Hmmm. I don't know if that applies to a honeymoon. Anyhow, until next time!

Dr. K, Teacher and Friend

I've been away celebrating the life of a wonderful friend who happened to be one of our professors. He died when a medical center shuttle ran a red light and was hit side-on by a big-rig hauling cars. He was only 52, and he left a 5-year-old son and a 7-year-old daughter. Our entire community was left in shock at the loss. When I heard the news, I basically couldn't believe that he was gone forever. It was a heartbreaking loss, but (and this is a testimony to his amazing and bright personality), I also felt gratitude for having been one of his students. He was my advisor, and he was one of the key founders of the small case-based curriculum I went through my first three years. He was well loved by many. I didn't always agree with his perspectives, but he and I got along really well (everyone was tickled by his personality, I doubt there was anyone he didn't get along with). He was clearly a devoted teacher and loving father. He wore his heart on his sleeve in the best possible way.

Just to give you a sense of him, this was an excerpt from his last email to me:

"Ni, your letter MADE MY DAY.

thank you so much for taking the time to let me know how you are.
With all that you have to do, it's a bit of a gift from you to me.

know that I am here to help as we go forward in whatever way I can.

warmly, -k"

He was not just loving, but hypomanic (by self-admission): he did inpatient medicine, teaching, worked in Africa to further medical education there, was the curriculum and technology developer for our tiny program, and was the college advisor for over fifty medical students. He touched so many lives, but was never reserved or distant. Not long before his death, I bumped into him in the library, where he told me about mourning for his mom. They had been very close. I was amazed at how open he was with all of us, and how much of his life (especially about his family and kids) he shared. His sense of humor was outrageous but always kind and considerate (which is not an easy feat).

When I wanted to meet with him to discuss career decisions, he invited me over to his house for tea and discussed how he and his partner made his residency ranking list together so that his partner would have a say in where they lived after the Match. He encouraged me not to let board scores influence my decision about specialties. At the time, I didn't agree, but now I think I know what he meant. He had fought his whole life to do things that everyone said were impossible, and he wanted that sense of limitless possibility for me, too. He talked about his son and daughter constantly. He was just a bright, bubbly, happy person and I'm sure he wouldn't want us to be sad now. I have shed a few tears, but I am also filled with a light, beautiful sense of gratitude for his kindness and warmth that I am sure is directly inspired by him. Or Him?


Because, although I didn't know it, Dr. K was a devout Catholic. The priest said, "He was a good Catholic, and he was a true Christian. I know he is in Heaven now with his mother and father, with whom he was so close." Above is where his wake and service were held. The entire church was full. I went to the wake for family and friends because I didn't want to cry in front of people I didn't know. It was lovely to be around the staff, students, and my classmates who all knew him as well or better than I. Their warmth and support felt as though it came from K. His memorial service at the medical center was broadcast to three venues, which were all full. His students and colleagues spoke and it was clear to me that K had shared himself without hesitation with so many people.

The weekend before he died, he left me a voice mail on a Saturday night returning a call. I didn't call him back because I didn't want him to work on a weekend. I hope that the time not spent advising me was used to play with his kids or spend time with his partner. I know that their pain must dwarf ours now. It would have been nice to talk to him again before he died, but I know that Dr. K wouldn't have cared about something as trivial as that. He would simply have wanted there to be no regrets and only happy memories. That said, wasn't it amazing that he returned non-urgent student calls on Saturday night?

It really says something about a man when 300 people can say they all knew him well and loved him. It inspired me to live with joy and a sense of infinity, and to remember to follow my calling, no matter how unlikely it may seem. Thanks, K. You invested so much time in me and all those around you. You cared so much about our lives. You never said a harsh word. Now that you have moved on, we carry you with us always. We will always remember your way of living. We will always appreciate how you gave 110% of yourself. Your life was a huge success and inspiration to so many. You will be missed. And I am so utterly grateful that I knew you. I will try to be more like you going forward. Thank you for everything.

Rest in peace, dear Teacher.

My Last Clinic as a 3rd-year Student!

Wednesday (April 20th) was my last clinic as a 3rd year student. It happened to be psychiatry. One patient was a super brilliant, highly paid, very well-educated, slightly unstable man who came in because of multiple issues that cropped up once he started working full time. It was challenging for me to interview him because he engages in many dare-devilish practices that frankly scare me and that I've never really understood, and some that I've never heard of. But it was a great exercise in finding those little handles people have that allow you to empathize with anyone -- some small preference, a place they've lived, a hobby, a pet, a belief. In this case, the fact that we were both in the healthcare field was a common reference point, so that worked nicely and broke the ice.

The second one was just a check-in from a man who had previously had such serious problems with alcohol/drug abuse that he had to enter a live-in residential program and leave his family and home behind. Somehow, miraculously, he has not only stayed straight-edge but has reconciled to some degree with his wife and she brings their daughter to visit him regularly. He has been sober for two years now. He told us tearfully (although perhaps this is fortunate) that the child is too young to remember when dad lived at home. I have nothing but the utmost respect for my psychiatry attending. As I've watched him over the year, I've realized how often he sees people at the very lowest point in their lives and then guides them back to emotional, and often physical, safety.

Because I am in a longitudinal clerkship program, I have had precepting sessions with different attending physicians in the core disciplines (Internal Med, Family, OB/GYN, Pediatrics, Neurology, Surgery, Psychiatry, Emergency) all year long and at seemingly random times of day and week. We've had a couple of inpatient experiences (2 weeks on Medicine, 1 week on OB/GYN nights, 2 weeks on surgery, 4 days of cardiology), but for the most part it has been outpatient medicine.

We also carried a core patient panel of about 60 patients each in all of these disciplines, and followed them into the hospital whenever they were admitted or on labor & delivery (via really old-school clunky pagers that would go off when any of our patients checked in for any reason at any of our affiliated hospitals). It's been amazing. Frustrating, demanding, often sleepless, awe-inspiring, touching, poignant, tearful, and just absolutely incredible. Never again will I have such complete access to all the different services of a hospital. Never again will I just be able to walk into the room, explain that I'm a longitudinal student, and then participate in whatever happens that day. In my fourth year and from now on, I will carry a label. I will become not just a student, but a student going into X specialty. And then I will be an X specialty resident, then attending, and so forth. This year, I have had the honor of being taught by some of the best and brightest minds in medicine, many of whom took the trouble because I was still an 'undifferentiated student' who had not yet decided what to do.

I have had so many 'firsts' as a medical student this year. First solo delivery of a baby with my (gloved) hands. First digital rectal exam (also gloved). First solo pelvic exam (metal speculums are less uncomfortable). First time breaking the news that someone had terminal cancer. First time a parent told me, "Thank you so much for taking care of my child." First lumbar puncture. First code. First time comforting a grieving relative. First time staying up all night for two days straight.

First time cauterizing a liver in the OR. First person to see someone who had psychotic hallucinations. First time I've seen a terminally ill child. First time I've had to explain why a woman in her twenties had to have her uterus emergently removed and will never again have children -- the day after her would-have-been wedding day. First time someone said "no" when I asked if they were safe at home. First thank-you letter from a patient. First time someone explained to me that they had to choose a Christmas tree OR presents for their children this year, and so couldn't afford their seizure medication. First time I've seen a husband and wife in back-to-back appointments -- in the oncology clinic. First home visit (to a healthy and robust man in his late 70s).

The Girl in the Orange Hat (first child I delivered, held by proud mama & papa)

It's been a memorable year in such a visceral way, to experience these human beings and their stories. I remember their faces, the feel of a spine, the smell of blood, phrases they used, the sound of their coughs. I look at a patient's belly and see my own sutures holding their wound closed. I look at an infant and remember catching him or her, soaking wet and newly born. It is a huge, enormous, incredible privilege to be there when people are feeling their worst, or hear the most terrible news they ever will hear. Likewise when the wonderful things happen: miracle recoveries, successful treatments without side effects, a false alarm. The thing about our longitudinal clerkship, though, is that I've also been there for the in-betweens: the colds that drag on through the winter when a patient is immunocompromised, the thyroid medicine that's never quite right, the lady who everyone thinks is "difficult" due to a lanuage barrier. These are the daily lives of the people of this city, and it's amazing to be so involved.

The next two weeks will be calmer: we have an end-of-year course focusing on healthcare policy and planning our careers. I have more tests to look forward to, as well. I am taking Step 2 of the national licensing boards soon. Clinical Skills (CS) will be in about 2 weeks, and then I'll probably take Clinical Knowledge (CK) some time in July. CS is pass/fail, whereas CK is most certainly not. I'll be studying hard for that one! Also in the next two weeks comes apartment hunting, wedding planning, and recovering from sleep deprivation. I'm SO looking forward to the idea of a class breakfast tomorrow morning, when I'll see how everyone is doing as compared to last term.

After a year of ups and downs and struggling to glean a tiny bit of this terrible, beautiful beast that is clinical medicine, it is such a pleasure to sit here with a cup of tea and write to you, knowing that spring has finally arrived.