Picture Books

Being a medical student is a lot like being a toddler. A small child is exposed to so many new things each day, her world grows exponentially in a short amount of time. Likewise, each day I see new things and am exposed to new situations, forming a frame of reference for the rest of my career. We show babies picture books in the hopes that once they see an picture, they will be able to apply that knowledge next time they encounter that image. What else is medical school? I see something once or twice, learning the character of that disease, in the hope that next time I see it, I'll correctly diagnose that patient. Of course, I had a lot of books during my didactic years in school. But the picture books are formed during the clinical years.

Some pictures in my book:

The joy on a father's face when I hold up his baby for the first time

My first written prescription

A tiny 15 week old fetus with perfect fingers and toes, laying in my hands

The subtle differences between polyps, ulcers, cancers, and rashes

The waxy covering on a baby I just delivered

A young patient dying from incorrect treatment of neutropenia

Riding along for a home visit of a bedridden patient

A chest wall covered not with skin but with the surface of an extensive breast tumor, beginning to be gangrenous, and my hand holding her hand

A tiny heart beating on ultrasound

I suppose the nature of these snapshots is that they are something new; something different, shocking, heartbreaking or joyful. You remember them clearly to try to create a healthy experience, to fix something earlier than when you saw it before. There's a weight of these images; a responsibility to know them and learn from them. After all, these picture books form the foundation of a physician.

The Family Doctor

Every physician is a family doctor. I don't mean to say that they all specialize in family practice. On the contrast, the majority of physicians now enter subspecialties. My point is that every physician, no matter their specialty, ends up being "the doctor" in their family. Sometimes this is okay. There's not a holiday that goes by the someone doesn't want a mole looked at, a consult on pain or bleeding or GI trouble...whatever ails them. Usually I don't mind taking a look and giving an opinion, although sometimes it is tiresome. What I'm struggling with is where and how to draw the line between family and patient. I think the real issue is that there is no line to draw within myself. I am not a doctor from 9-5 (or 7-11, more realistically), and a daughter, a granddaughter, a niece, a wife on all the other hours. I've said it before, you are never "off call" as a doctor. It is a casualty of the training. You think and observe medically, every moment, without thinking about it.

This duality is something I haven't learned to balance yet. It can be hard both ways: for a doctor-daughter to be a family member while entrusting her parents' care to other people, and for a daughter-doctor experiencing human grief whilst being expected to care for and relay medical information to the rest of the family.

My dear friend lost her young fiance last weekend, after he collapsed during a half marathon. She said he had a massive brain hemorrhage. My friend heart breaks for her, while my doctor-friend mind wonders if he had an arteriovenous malformation, if the increased heart rate and blood pressure probably triggered the rupture of the aneurysm. There is no separation between these two thought processes for me.

So, I am learning to manage this new addition to myself. It is easier to go to the hospital and just flip through the chart, rather than pestering a relative for information that they don't have. On the other hand, if I find something abnormal, I feel compelled to do something about it, and maybe miss out on the richness of caring for someone simply as their granddaughter, their friend. It's hard as a doctor to trust the care of someone you love to another doctor. But you have to, otherwise you'll be exhausted of patients before you even step foot in your own office.

iRx: An Oncologist's Prescription for Treatment

Oncology allows room for the humanistic side of medicine. A lady presented today for a follow up on her metastatic uterine carcinosarcoma. She had been feeling very weak from her chemotherapy, and needed another treatment and a CT scan. She wanted to go to Monterey for two weeks over the as holiday to visit her son, but it interfered with her treatment schedule and she would have to come home early. The oncologist told her not to worry, and to come in when she got back for her treatment.

This recommendation was not on the treatment schedule published by the American Cancer Society, but it was on Mary's* treatment schedule. Why? She is 85 years old, with metastic cancer. A visit with her son may be the best medicine for her. Will her cancer progress faster given the treatment delay? Maybe. Will this be her last Christmas, either way? Probably. The oncologist knew this and governed her treatment accordingly.

This is what I love about oncology. You see a patient for a prolonged period of time, in a manner that no other practitioner experiences. You get to know what matters to them and their family. It is one of the few practices that you can stray from published guidelines and still remain in practice. You can make treatment decisions based on the person, not the disease.

Amid a practice of dying patients, success lies not in the prolongation of years, but in the improvement to your patients' health. And even though you know how it ends, there is great satisfaction in contributing to the well-being, both physical and mental, of these patients in their time of sickness.

*name has been changed

Grandma's Rules

My grandmother, who has spent 84 years on the planet, is wise. This is an excerpt from a letter that she wrote to me after my first patient died:

Rule #1: Sometimes patients die

Rule #2: Doctors can't change rule #1

Seems obvious, but to a young doctor who is committing her life to preserving health (delaying death?) this was a profound thought. An allowance of myself to do the best I can, but not to be expected to fix everything.

Thanks, Grandma.

The Custom Baby

I saw a woman today for her annual well-woman exam. She had her husband with her, an older guy, and a ring that was at least 4 carats on her hand, with a matching necklace. She was wearing a shirt with my high school's logo on it, so we chatted about that and about her son who goes there now. Near the end of the exam, she asks about what her options are for getting pregnant. Since she is 40 and her husband is 67, it doesn't seem like a great idea, but we talk about in vitro fertilization, artificial insemination, etc. Since the dad will probably be dead by the time the kid is in college, it doesn't seem very fair to the kid, but whatever. But then it gets weirder. They look at us and say "How can we guarantee that we have a boy? We only want a boy. It would be a shame to go through the trouble and expense of in vitro and just have to abort it because its a girl."

I was just floored. I had always thought that most parents in America maybe wanted one sex or the other, but adjusted to love the baby they got. But they were serious.

As the doctor explained the process by which the sperm could be separated out by chromosomes, and how only the Y chromosomes could be used for the fertilization process, I was thinking. They want a boy, but they assume what they get will be a healthy child. In any pregnancy, disability is a possibility, but especially when the baby develops from older eggs. I couldn't imagine that they would tolerate a disabled child if they weren't willing to have a normal girl.

Furthermore, is it okay that we can make that happen? Would you like a boy or a girl? Blue eyes or brown? A cup of smart, a tablespoon of athleticism, and a pinch of musical talent? Because we can custom make a baby, just for you.

That line is blurring; what we can make versus what God (or whatever higher authority you prefer) gives us. I know that I don't feel comfortable as the physician being in the position to choose one viable embryo over another. I don't have it all figured out. I don't think there is a clear answer. For most educated and difficult dilemmas, things are not black and white but shades of gray.

Speaking of, would you like gray eyes?

A Heart Restart

A funny story from my time in family practice...there was a patient that I saw for about two weeks while he was in the hospital recovering from a cardiac arrest and technical death. I got to know him and his wife, who was a nice lady but an eccentric, rather intense individual. When I asked him about the sequence of events related to his heart attack, he said that he had been feeling chest pain and shortness of breath, and the "blacked out." His wife then took over the story, saying "And I was so mad at him! I hit him squarely on the chest and yelled "You're not going to die on me, you son of a bitch!") The punch to his chest, called "precordial thump" in medicine, restarted his heart to a normal sinus rhythm and he lived. She wasn't trying to save him, just really mad. And he lived.

Five Again

Twenty years ago, I was in kindergarten. Like many classes, we had 3 "cards" on display for each student- yellow, red, and green. When the green card was showing, you were on good behavior and doing well. Yellow signaled you needed to slow down and shape up. I don't even know what happened when you had the red card showing. Probably a sentence worse than death (ie benching, principal's office, etc).

I was a conscientious student, even at age five. My card stayed green the whole year, except for one day. I was screwing around a little, off task with a friend, when my teacher turned my card over to yellow. In an instant, my world screeched to a halt, my stomach dropped out of my shoes, and my throat closed as I tried not to cry. Eventually my card turned back to green, and life went on as usual. But I never forgot that feeling.

At age twenty-five, I was on my first medical rotation, in my first operating room. I carefully scrubbed in and was watching the surgery from a ringside seat. The surgery went on for an hour, and stretched on to two, and I absentmindedly scratched my nose. (When you scrub in, you can't touch your sterile gloves to your mask or hat, which are considered "clean" but not "sterile.") One nurse caught me, and I was thrown out of that OR faster than I knew what had happened.

And suddenly, I was five again. Horrified from head to toe at the consequences of my thoughtless action. Throat closed, I waited for the surgeon from outside the sterile doors. He came out, and was actually very kind about the incident, saying that it happens to everyone, and provided more specifics on sterile procedure. But I just remember that feeling being exactly the same, twenty years later.

My dad often quotes Paul Simon, saying "After changes upon changes, we are more or less the same."

I am.

Happy Turkey Day!

Just a short thought...

Closing a c-section really reminds me of stuffing a turkey. Seriously. It has exactly the same motion. You have the opening, you grab the uterus, and stuff it back into the abdomen, pushing all the stuff (intestines, etc) back with it til you've got it far enough in. Then you close the abdomen.

Happy Thanksgiving.

Twins!

Today I had the privilege of helping with the birth of twins. A lady that I've been seeing for about a month came in for her weekly check (35 weeks gestation), complaining of some mild back pain. I decided to check her cervix, and she was 5 cm with membranes bulging through the opening! I called in the attending and he scheduled her for a c-section over our lunch break.

Note: normally lunch is a sacred time for me, as my blood sugar drops into subhuman levels in the late morning. It was a sign of how exciting this was that I was thrilled to not eat lunch.

We brought her in to the OR. The doctor let me be his first assist again. He carefully cut through all the layers: skin, fat, fascia, muscle, and finally the the uterus. There was one twin, head poised and ready to be born. He eased that baby out of the uterus, and I peered into the uterus, expecting to see the other babe. Instead, all I saw was a milky colored balloon with what appeared to be a lizard inside.

Honestly, I had never seen an intact amniotic sac...by the time I get to the mommies they are either already ruptured or the water bag has been cut during the c-section incision. I really wondered if everything was all right. The doctor knew what to do though, and he incised the water bag, grabbed the kid by the feet (he was breech), and lifted him into this world.

The babies both cried right away, and were a great size for 35 weeks (7 lbs and 6.5 lbs, I later found out). Such a blessing.

However, mom's belly looked like a war zone. One open uterus, two placentas, two bloody gushes following the placentas, two ruptured membranes...carnage. The surgeon was moving fast, removing the placentas and suturing, and I was helping him dab and suction and suture...until mom's uterus once again resembled a uterus. We tied her tubes (can't blame the lady after having twins), and we put it all back in the abdomen and begin to close her incision. Slowly my heart rate began to fall to normal.

I am so thrilled I got to see a twin birth, right before my ob/gyn rotation ended. SO worth not having lunch!

An (Unintentional) Funny Story

Last month, when I was in my second month of Family Practice training, I saw a young man with a cold. I had been with my attending long enough that she trusted me to manage uncomplicated patients on my own, including taking the history, doing the physical exam, and writing the prescription under her license. This guy seemed like a perfect case for me; midtwenties with a cold. Upon taking the history, I learned that the man had a bilateral lung transplant a few years ago, and with the physical exam, it seemed to me that this was a case of bronchiolitis obliterans, not a simple cold. Awesome. I called the attending in to come see this guy, as he was so not an appropriate patient for management by a medical student.

Leaving the attending to treat the patient who was autodestructing his lung(s), I went into exam room #2, a sinus infection. Easy enough. Confirm the diagnosis by physical exam, write out a Z-Pak or some Bactrim, and we both would be on our way. Upon questioning as to why he was missing his nasal septum, he admitted to me that he regularly snorted cocaine. Again, awesome. I waited for the attending to finish admitting the first patient to the hospital, and explained the situation. She came in, and unleashed a lecture which would not be allowed in a managed care facility.

"You stupid asshole. You think you can just get away with this habit? You will lose your job, your wife, your kids, and end up in jail. If you are lucky. If not, you will end up in my ER and die, because there is not one thing I can give to to treat a cocaine overdose. Or worse, you will end up a vegetable that can't wipe his own ass."

I guess that's an advantage of being in private practice. You can say whatever you want to the patient.

"Also," I added, "your sinus infection will never clear up if you keep snorting."

The attending and the patient both stared at me, and then laughed and laughed. The guy said he understood what we both said, and left with a prescription and resources on treating cocaine addiction.

I was not trying to be funny. I know in the scheme of all the (true) life-threatening adverse outcomes the attending told him, the minor matter of sinus trouble was laughable. But it seemed to me that the reason this man had taken time out of his day to see the doctor was because he was bothered by his sinuses. So, if that was what mattered to him most, then that's how I would point out how his cocaine use affected his life. Plus, it was true. They wouldn't clear up if he was using, no matter how many antibiotics I gave him.

Nevertheless, it was a funny story out of a very un-funny situation. And a very good reminder that patients are often much more complex than how they present.

Why is the Doctor's Kid Always Sick?

Today I was the first assist on a c-section...very exciting for me. Usually a surgical nurse does that job, but today the obstetrician let me be the one to help him with the instruments, and help suture and staple the patient closed, layer by layer. The baby was big (over 9 lbs) so I had to push hard on mama's belly to get enough force to help baby come out of the incision. When she came out, I suctioned her mouth and nose, and she began to scream.

And scream. And scream. All through the closing procedure, through her measurements, and through our dictation of the surgery. All through daddy holding her (saying "it's okay, daddy's here"...melted my heart...), and mama trying to breastfeed. She screamed through the nurses taking turns holding her and reassuring mommy and daddy that yes, this was normal, and yes, everything was all right.

I came over to check on mom, as I always do after a surgery, and she grabbed my arm and asked. "WHAT is wrong with her??!!). "Nothing" I said. "She's got a great, healthy set of lungs." Dad laughed, and mom just looked at me. I heard the nurse sarcastically comment "Boy, that's a doctor comment if I ever heard one. This one's learning early."

The thing about being a doctor is, you know what can truly go wrong. You worry when the baby is silent. When they cry for a long time, you have peace knowing that the lungs are well-developed and they have created enough intrathoracic pressure to close the fetal circulation, allowing baby a healthy heart to start their life outside the womb.

My mother, who works as a speech-pathologist in a school, says that doctor's kids are always the sick ones. Maybe it's because the parent brings home patient germs, maybe its because they are too busy to deal with keeping them out of school. But I'm inclined to think that its because they know nothing is really wrong. They see so many health crises per day that one simple cold doesn't even fall on their register of illness, and they send the kid off to school.

I think most doctors are not cold people with indifferent comments. I just think they have seen a lot, and tend to tell it like it is. This is not to say that most are not compassionate; on the contrary, most doctors that I've seen care a lot about their patients. They may not be the most user-friendly professionals, but they do care. I sure care about my patients. And I'm oddly kind of pleased with the nurse's comment, because I feel like I'm learning to be an effective doctor.

Will the Real Doctor Please Stand Up?

Yesterday a woman had a stroke in Costco. Her family and a cashier yelled for medical help, and I walked (ran?) over, thinking that I would help until a doctor showed up. While waiting, I introduced myself and took her pulse, and asked the manager to bring the AED just in case it was irregular. I asked her who she was and where she was, what day was it, and did a mini neurological exam. She seemed confused, and had muscular weakness on the left. I just stayed with her and made sure she was breathing and her pulse was regular, and soon, the paramedics arrived. The manager of the Costco thanked me profusely. I was happy to help. Of course, I would have been grateful to get a free hot dog too, but whatever. Happy to help.

A similar episode happened at church last week. I was walking around the cafe, hoping to score a free muffin (are you seeing a trend here?), when one of the pastors grabbed me. "You're a doctor, aren't you?" "Well, not quite...I'm still in medical school...what happened?" It was a kid that had bounced out of one of the bounce houses right onto his tailbone. He was laying in the grass in severe pain. I talked to him and looked at his backside and assessed him neurologically, and he seemed okay. Since he was very overweight, I advised his parents to take him in for an xray to rule out a vertebral stress fracture, and told him to put some ice on it and give him some ibuprofen.

In both of these situations it became apparent to me that another doctor wasn't going to come...and that I was the most highly trained medical professional in this situation. What? When did this happen??? Will the real doctor please stand up?

It doesn't seem like it should be me...but in these situations it was. I am not a licensed physician, but in these cases I was the closest thing to it. It struck me as a great responsibility, and an honor. You are never "off duty" as a physician. There is always the possibility, wherever you are, for sickness and injury. And you try to help the best you can...even as a little doctor.

A Day Off

I know that a torn ACL should not be a cause for celebration. But when it is my attending's wife having surgery and I get an unexpected day off because of it, its hard not to root for the injured knee. Today was busy- I got to do all the things that usually have to happen during business hours that I am normally not home for.

• I had a plumber come fix the leaky toilet
• I took the pets to the vet for shots, checkups, medicine, and wing clipping
• I paid the water bill in person and got a stamped receipt (rather than my usual routine of poking it through the crack in the door)
• I did enough grocery shopping to sustain us through a lengthy famine, which is probably how long it will be before I can go shopping again
• I mopped
• I made chicken, black bean and rice enchiladas in happy preparation for my sister's visit this weekend
• I actually washed my clothes instead of just buying a new pack of underwear
• I studied (like every day)

I thought being a medical student would preclude any fun and extra time I might have. And to some extent that is true. I don't notice it really until I am around a friend who has a job, has friends, has places to go and money to spend. And then its a little lonely when I need to stay in and study. However, this is actually better than I had expected. I can still cook nice dinners for my husband, pack him a lunch, and visit with my sister. I can work out and work on my house and still be a good student. It gives me hope someday that my practice as a doctor will not consume my life; that I will have time for my husband and children. I want to be able to be a good mother and a good doctor. I think it also depends on the professional choices you make. What specialty you choose. Yes, I've chosen to make medicine my life, and nothing else would be right for me. But I also want other things in my life, and hope that it only gets more balanced from here.

Surprise!

I delivered a baby...always a thrill, but this one had an unexpected twist. I didn't know what sex the baby was supposed to be, so after I delivered the baby I held it up for mommy and said "Congratulations! It's a boy!!!" Well, mom and dad both stared at me and said "they told us it was a girl- 99% certain. We picked out a name- Layla. We have a pink nursery." I said "well, of course you can name him anything you want....but I think he might be teased if he's named Layla." They just stared at me. Finally dad said "are you sure??" "yes, i'm sure...come here." so i pointed out the male parts...a couple times before dad believed me!

I came back the next day to do the postpartum exam, and the baby boy was dressed in a little pink sleeper...mom's parents were coming over with some boy clothes later, but hadn't gotten there yet. Hee hee hee. I love that in this age of modern medicine, these funny things can still happen.

A Sad Story

I love ob/gyn. I love the mommies, I love the daddies, I love talking to them throughout the pregnancy. I love deliveries and c-sections. I love the older women, talking to them about menopause, osteoporosis, and healthy aging. I even like gyne surgery and pap smears, things I never thought I would enjoy. Most of all, I love feeling like I can make an uncertain or uncomfortable time a little more understandable and comfortable for a woman. Ob/gyn is great. The highs are high...a healthy delivery, a healthy mommy. The lows are low.

Today I saw two babies die. One was a second trimester miscarriage, one was an IUGR with not enough lung maturity to survive. In both cases, it startled me because it was supposed to be a normal pregnancy. Only when I saw the mother's water break in her 15th week and only when I opened the uterus did something seem wrong. The 15 week old baby was perfect, 6 inches long, with facial features and tiny fingernails. I don't know why it was born too early. What I do know is that it was my responsibility to help the mom deliver safely and to support her, and communicate to her that this was not her fault. It struck me as a tremendous burden on the physician, to both medically and emotionally care for the patient while experiencing their own shock and grief over the situation.

One way to survive is to distance yourself from the patient and the situation. This to an extent is the calling of the doctor, so he can provide the best care possible. I feel like I am good at this. But I also feel like it is not in my nature to become a doctor who is aloof and distant from patients' needs and pain. One of the main reasons that compelled me to go to medical school was that I care about people.

So my question is this: how does a doctor deal with his or her own sadness over a patient's situation? I suppose in the end it is a mark of a doctor who cares deeply about his patients, and that is the kind of doctor a patient needs.

A Funny Story

It takes awhile for those close to you to get used to thinking of you as a physician. A funny case-in-point:

I had gotten a bad head cold after receiving the intranasal live swine flu vaccine. My mom asked how I was feeling, and I responded "Well, I'm not quite ready to go to the OR yet." Mom said "What?? I thought it was just a head cold!" "As the surgeon, mom, not the patient...."

It takes awhile.

New Blog

Well, I have never blogged before. It seems like the 21st century's solution to "dear diary", and it seemed presumptuous to assume that anyone would have time/interest to read the ins and outs of my life as a medical student. However, it seemed to me that I am experiencing so much that is new on a daily basis, that this might provide a record to me of this unique time in my life- the funny stuff, the first experiences, the hard stuff. Also, much like a diary, perhaps it provides an outlet for me to "work out" problems I have, observing patient pain, doubts about becoming a doctor, difficulties with training. Doctors by definition have a difficult job, as physical suffering is our job to treat, and sometimes it is hard to see patients in pain. I don't know if I feel this more acutely as a student, and this will fade as I become old in the profession, but for now I think this blog will be a good record of my thoughts and progression to becoming a physician.