Dec 28, 2011

The Twelve Doors of Christmas

I worked every day this Christmas holiday, 7am-7pm, sometimes longer. It was the first time I'd been away from my family during Christmas, and my first Christmas as a doctor. Here are twelve of the doors I walked into this Christmas Day.


Starting the holiday in the OR, ready to c-section twins in my Christmas scrub hat!




Door 1: The Intern Call Room (A Sad Resident)


I open the door to my call room to change and find my fellow intern sitting on the bed, crying. I asked her what was wrong? She said she had cried all the way into work, because her two small children didn't understand why she had to leave Christmas eve, why she wouldn't be there to watch for Santa and see them open stockings in the morning. I was so sad for her. It's hard to want to be with other people's babies, she explained, when you just want to be with your own.

Door 2: The Gift Shop (Good Sam)

I open the door to the gift shop. Christmas Eve, the hospital gift shop is advertising all holiday merchandise 50% off! I buy myself an ornament, to mark this first Christmas working as a doctor,. The first of many, I'm sure. I named him Sam, after Good Samaritan hospital.

Sam the Snowman

Door 3: Triage (The Reluctant Partygoer)

I open the curtain to the triage room. There is a woman I just can't get rid of. You're not in labor, I explain. You're rarely contracting, your cervix hasn't changed. She refuses to leave, insisting that she's in labor and will just come right back if I discharge her. I wonder why anyone would want to sit in triage on Christmas Day if they didn't absolutely have to. I ask her if she wants to go home, since she doesn't have to stay here? She replies that she has a large family party at her house to go to, and just really doesn't want to go...so she has presented for preterm labor. I ask her when the party ends, and discharge her home afterwards.

Door 4: The Resident Room (My Family)

We all walk into the resident room. It's a small lull in the day, so all five residents crowd into the shared resident room and turn on a tiny TV and make popcorn. National Lampoon's Christmas Vacation is on, and we share an hour and a half of watching it together, laughing, occassionally interrupting to return pages, and just enjoy being together. We are all away from our families this Christmas Day, and are grateful to enjoy our residency family.

Door 5: The Resident Room, later (Her Family)

One of the resident's kids come to visit. They have on their new Christmas PJs (see next photo), and have come for Mom to give them a hug before they get tucked into bed to wait for Santa.

Door 6: Triage, later (Santa Surgeons)

We all put on Santa hats and open the door to triage to take a picture in the emergency birth room. John, one of the second years, later tried to keep wearing it and pass off the hat as a scrub hat. Turns out Santa is not allowed in the operating room. HO HO NO.




Christmas Call Team!

Door 7: The Intern Call Room, later (My Other Family)

I open the door to my call room and open my iPad. My family has woken up in California, and are opening gifts. I have them wait until I am between deliveries, and then get on iChat with them and watch them open presents. My husband even opens a gift for me, with me "holding" it up via the screen. It was fun to feel like I was a part of it even though I was here.


Ryan and me "holding up" my new sweater!

Door 8: An Antepartum Room (Christmas Dinner)

I'm taking care of a girl that has been admitted for weeks for preterm labor. She'll likely be here until delivery, and would not be home this Christmas. I open the door to her room to round on her, and find about twenty-five people in that room, along with a Christmas tree, gifts, and even a crock pot plugged in with something delicious-smelling inside! This girl's entire family has come and brought their Christmas party to her room. I almost fall over with happiness when they invite me to sit down and eat with them.

Door 9: A Delivery Room (The Manger)

I walk through the door after being paged for delivery. I am delivering a nice Hispanic woman, Maria. She names her baby boy Jesus. I love it. How many people get to deliver Jesus on Christmas Day?
The hospital's special holiday newborn outfits, on the delivery table

Door 10: Another Antepartum Room (My Kiss)

I go into another long-term patient's room. She's been admitted with preeclampsia, and staying until she is delivered, which might be a couple more weeks. She has a few family and friends over, and they have a table full of yummy-looking sweets, and a glass jar full of Hershey's kisses. I talk to her for awhile about her baby, the plan of delivery, and ask if she has questions. She says no. I say, "well, I have a question." I point to the jar and smile. "Can I have a Kiss?" One of the guys in the back calls "So THIS is the kind of doctors we have working here. Come back here, sweetheart. I'll give you a kiss!"
I want to die. And definitely not round on her for the next few weeks!

Door 11: Another Delivery Room (Sixteen)

I walk through the door of another delivery room as a baby's heart rate drops. We put the mother her on her side, give her oxygen, and the baby's heart rate comes back up. I'm not ready to leave though. I sit in the rocking chair in her room, watching the heart rate tracing, rocking as she falls asleep. She is sixteen, and here in labor with her first baby. I rock, and think about the Christmas that I was sixteen, eleven years ago. I fell asleep excited Christmas Eve, in anticipation of my stocking. I wanted, and received, things most teenage girls would like- a new pair of cool shoes, some clothes, bubble bath, fuzzy slippers. This girl's stocking would maybe have things for her baby, or maybe no stocking at all, as she labored here Christmas Eve. I rocked and rocked, and watched her and her baby for a long time, until my pager finally pulled me away.

Door 12: Home (At Noor's)

We push the door open to the apartment. I'm staying with my dear friend and fellow intern Noor, who is working the same long Christmas days as me. She lives much closer to the hospital than I do, and offered to let me stay at her house. I am so tired. We share a piece of leftover chocolate cake, and stretch out on the couch with HGTV and a bottle of wine. I fall asleep that night, happy that I've survived my first working Christmas, and happy that it's over.

Me and Noor

Dec 23, 2011

Missing Grandma

Recently my grandmother was sick. I got news of a stomach bug, and didn't think much of it. Then, she was sicker. She went to the OR for a bowel resection after an obstruction was diagnosed, and had subsequent kidney failure. I anxiously pressed my parents for what the surgeon said, for a consent to send me the operative report, for information on previous kidney function, and prognosis. I asked, and asked, and they just couldn't tell me much. I desperately wanted to see her, wanted to talk to her physicians doc-to-doc, to really understand what was going on and evaluate her with my own eyes and hands, to tell her I love her. Because after all my time working in the ER, the ICU, with patients that are very sick, I know that there are no guarantees at eighty-five, that sometimes there are things we just can't fix.

And I was here. Working. Taking care of other people's families, while I just wanted to take care of my own. I would get little bits of information, and tell my parents what I knew about her illnessess, that this was a normal course for bowel obstruction, that often times kidneys can recover if it is an acute failure. I talked to my sister before she went to visit, warning her that Grandma would look sick, and have a tube coming from her stomach to her nose draining vile looking green liquid, and that this was normal and she shouldn't be alarmed by it. I was angry about being here, knowing the only time I would get off for this illness was if she died from it, and by then, what would my being there matter?

I thought about Grandma as I touched my patients, caring for them, praying that somewhere, some other doctor was taking good care of her. That some other doctor was away from his own family because he was taking care of mine.

And she got better. Not all the way yet, but better. The kidneys recovered, as I thought they would, and she was able to eat again. But this experience stuck with me, because someday, someone I love will be sick, and I won't be able to be there. I won't be there to care for my loved one, to explain to my family what is really going on, what these medical words mean, and I'll be making guesses over the phone, just like I did this time, waiting for an operative report to be faxed and feeling helpless. This is an unspoken sacrifice of becoming a physician, and one that I underestimated. Somewhere in the greater universe, it makes sense to me that this is the sacrifice of all physicians, and that we take good care of our patients because these patients could be our own loved ones, and sometimes they are.

But I still wanted to be there.

ToMAYto, ToMAHto

I work with with thirty-three different attendings. Who want patients managed, needles held, stitches thrown, lacerations repaired, knots tied thirty-three different ways. It was part of the learning curve, at first, learning which attending liked what, remembering who to call about different problems and learning to not be upset when I didn't remember who preferred what. And now, I'm starting to develop what I like. Many attendings have offered me pearls, on patient management and surgical skills, and I'm starting to develop a framework of what I want to do, what I think works well. And this is even more frustrating, because then I end up with someone new, who doesn't like the way I am doing something, and makes me do it a way that doesn't feel natural, or right. And really, no one is very wrong, but it means I am never right. It's like how some people say "toMAYto" and some say "toMAHto." No one is actually right, and everyone insists that they are.

Here are some examples:

Yesterday in the OR, an attending showed me a way to reload my needle without touching it with my fingers. Use the pickups, inch it out, and regrasp it in a way that it was ready to throw the next stitch. Better technique, he explained, it would allow me to avoid needlesticks and was a more sophisticated surgical technique. I practice, and look forward to my next c-section, where I can practice it again on a real patient. I start, expecting the attending to be impressed or at least not say anything, but she yanks the needle out of my hand and shows me how to do it....exactly like I used to. I pick up the needle, reload it using my fingers, and silently curse this frustration.

An attending that puts me on the stool in front of the mother. She does this under the assumption that this is a good position for me to deliver the baby, but I have figured out the real reason. She puts me on the stool, then waits for the crucial moment when the baby is about the deliver, then rolls me out of the way and delivers the baby herself.

Antibiotics. Some give antibiotics for GBS+ mothers at the beginning of inductions, and some only when they are actively laboring. The downside to the first option is a mother can receive fifteen doses of a medication that burns their veins and is unnecessary for that long. Alternatively, a mother can labor quickly and not get enough of a dose in and end up with a baby in observation in the NICU for 48 hours. So, I started to ask each attending, when would you like the pencillin started? They couldn't believe I was asking this, like I didn't know. Then, I would ask with one option offered, would you like this when they are in active labor? Some people then thought I was correct, and some thought I was an idiot. So, no matter what I think or what I would do, I look stupid at least half of the time, just trying to please everyone.

I am fairly ambidextrous, and can operate either right or left-handed. Some think this makes me versatile, and encourage maintaining both. Others yell at me to pick a side and stick with it. Now I don't know which side to stand on. Likewise, I can clamp and cut cords after delivery lefthanded. Usually I hold the baby in my right arm, tucking baby's feet under the crook of my elbow, and clamp and cut lefthanded. I don't know why I do this. It just feels right, to hold the baby securely in my more dominant arm, and use my left hand for the instruments. But, attendings sometimes ask me if I'm right or left handed, and when I tell them right-handed but better with fine motor skills with my left (due to violin training, I think), they frustratedly instruct me that I should only be managing scissors around a newborn with my dominant hand. Again, I'm not sure which that is.

There are probably infinite variations on how to do one surgery, one delivery, and that's what I'm learning. Even though I've never had a bad surgical outcome, somehow I am always wrong with how I do it. I'm trying to take the best of everyone's suggestions (ie yelled orders), and compile it into my own technique, but starting to realize that it will be awhile before I can really employ what I think is best. And I can't say I wouldn't be the same later, after a career's worth of doing what I decided is best...I'd probably want to hand my hard-earned knowledge along too. But it's frustrating now.

I think I'll go sit down on the roll-ey stool and practice reloading my needle.

Nov 20, 2011

Lessons In Cultural Competency

I'm white.

I mean, really white. Scandinavian mostly, a little Irish and Scottish, and part Sicilian. Not Sicilian enough to give me the gorgeous olive skin of my relatives, rather, just enough to turn my eyes brown and leave me with the fair and freckled skin of generations of peoples who have never seen the sun. When it comes to those "race" boxes on standardized forms, I only get to check "White" or "Caucasian." There's really nothing else there.

But, I can switch fairly fluently between English and Spanish in the exam room. I've begrudgingly completed the "cultural competency" courses of medical school and as required by my employer. I tell myself that I'm open to other cultures, I enjoy experiencing things different than what I'm used to. I really did consider myself culturally competent, at least for a white chick.

But this month, I've had a few situations that were new to me, and showed me far more culture and much less competency than I had ever seen with any of the informational videos provided by the HR department. It turns out that understanding, and respecting, another culture that is much different than your own is very difficult, especially when a pregnancy and child is involved. And sometimes that a new culture is a lot of fun, and it's a privilege to join it, at least for a little while.

Lesson #1: Las Mujeres
I come into the room to say hello to a new patient. She is ready to push, but I can't see her. There is not a word of English, and at least twenty people in the room, all female.
"Excuse me, excuse me." I jostle through the crowd. I say hello, and introduce myself, and ask, in Spanish, if she wants everyone in the room for delivery? I'm expecting most to leave, but instead, they all circle the bed, and are ready to help her push.
Who are all these people? I start to get a little irritated as they touch my delivery instruments "No, please, those are sterile", and bump me as they crowd around the bed (hello, please give the doctor some space!). But I come to find out that in this patient's culture, all of the females she loves are here for delivery. The dad is nowhere to be found, but this patient's mother, grandmother, great-grandmother, multiple tias (aunts), sisters, nieces, and even her own young daughter are here, ready for her delivery. In this culture, birthing is women's work, and all the women are here to work.
The mother cries "No, no puedo" when told to push. The tias respond with a chorus of "Si! Se puedes!" And so it goes on, until this baby- a girl- delivers, and all the women crowd over to the warmer to see the new nina, the new addition to their family.
I smile, for the small reason that they are now in the pediatrician's way instead of mine, but for the bigger reason that this is an enviable culture. I'm not even sure if I have close relationships with half as many women as this girl had at her bedside supporting her for delivery. They all were there, and knew what to do, how to support her and love her during this significant event in all of their lives. Se puedes, indeed.

Lesson #2: A Native American Preemie
There was a patient who came to our clinic from the Indian Reservation, with the complaint of bleeding. She bled off and on, and eventually went into labor, and delivered a twenty week-old nonviable baby. These are very sad situations, and we have people and programs at the hospital set up to help families cope with this. However, this family wasn't interested in the bonding time offered, or even seeing their baby. That baby needed to be out of the room as soon as possible, as it is bad luck to be around anyone who is dying, and particularly the spirit of a dying child that could affect future fertility. I came around the nurses station a few minutes later and looked suspiciously at a mound of blankets in a metal bassinette. Was that...? One of the nurses picked up the blankets, and gave them to me to hold. It was the baby, the smallest one I had ever held, with an irregular, slow heartbeart visibly fluttering under tiny ribs, with small hands and wispy eyelashes. I touched his forehead gently and pulled my hand back, startled, as I felt how cold it was. The longer that baby was cold, the more slowed-down his metabolic processes would be, and the longer he would hover somewhere in between a heartbeat and inevitable death. I wrapped him up in a swaddle and tucked him under my sweater, holding him close to my chest, sitting at the nurses station for about forty five minutes, until I couldn't see a heartbeat any longer.
And here is the cultural difference that I struggled with: His parents weren't wrong. To me it seemed wrong, to let their baby die cold and alone, but that's only because of my own learned customs of love, grief, and healing. It seemed like the right thing to do to me to bridge the gap for this baby between this earth and wherever these little ones go to, but just because I felt that was right doesn't mean his parents were wrong.

Lesson #3: An African-American Queen

It's three in the morning. At this point, I'm wondering why I went into obstetrics. There are floors above me filled with sleeping patients, sleeping residents, and yet I am running around the third floor, awake with another laboring patient. This girl is sweet, a 16 year old here with her mother, who is earnestly coaching her daughter's labor. She's ready to push and have a baby girl, so I put my gown and gloves on, and get ready to help her to push.
She doesn't need it. She pushes well, and her mom shouts "That's it! Push hard, baby! Soon we'll hear that queen holler!" And I smile. Not the absent, tired smile I feel like I usually have, but a genuine smile. For a minute, my shoulders relax away from my ears, and I remember why I loved obstetrics. I'm excited for this family. I'm ready to meet this queen, too.
Aftwerards, I congratulate mom, and grandma. As I'm leaving, I can hear grandma on the phone talking to someone, saying "Listen to that baby holler! Speaking of, you should have seen this young woman that delivered her. Not but a baby herself."

Lesson #4: A Somali Refugee
There is a fairly significant Somalian population in Phoenix, a community of refugees. Most tend to be difficult patients- mistrustful of the hospital system and Western medicine, along with a significant language barrier and cultural gap. The roles between men and women are so much different than I could have imagined based on my own experiences. In our house, my mother had a career. My husband changed careers and moved to support mine. I go to work, and he does the dishes. In their house, the husband is the decision-maker. The patients will not answer me, not acknowledge my presence or information, until their husbands are there to communicate directly with me. The mechanics of birth are challenging because of scar tissue left behind from genital mutilation. It's hard to do an exam under the many layers of robes that the patients insist on wearing. They tend to refuse medications, and epidurals, and any procedure outside of the normal vaginal delivery.
Because of all these things, when my Somali patient's baby's heart rate went down, and then came back up, I thought it was a good idea to talk to her about a c-section. She didn't need one now, I explained, it was only that I wanted to talk to her and answer her questions while everything was calm and her baby's heart rate was fine, while I had time to use the translator phone and could explain everything about the consents.
Three hours later, I'm bleary-eyed. I've tried to be sympathetic, and explain things differently. I've tried to sit back and enjoy the melodic rhythm of a language that I don't understand. But I can't. I've spent my night sitting here, instead of in bed, and I have no consent. What it came down to was the patient understood why I was talking to her about it, but said she didn't want surgery. She wanted to be healthy, and babies die every day, so if something happened, she wanted to remain healthy and not intervene for the baby.
No!! I want to scream. This is America! I can almost certainly make BOTH you and your baby healthy, even if you needed an emergency section. But, she didn't believe me. She wouldn't sign the consent, and ultimately, I can't make her. She is deemed mentally competent, and able to make decisions for herself and her unborn child.
In the end, after my shift had ended and my friend had taken over for the day, the baby's heart rate went down, and she watched them stay down- for ten minutes- as she and an attending tried to cut through genital scar tissue to deliver the baby as fast as possible vaginally, since the patient was still refusing the operating room. My hours of trying to consent her were wasted, she had more of a wound that she would have with a simple cesarean, and her baby was in the NICU.
Did it make sense to me? No. Was I angry, and worried for her and her baby? Yes. But I had to leave this situation with these frustrating conclusions, and realize that maybe that was what she wanted, because she was a culture so different than mine.


These are the real stories of cultural competence. I watched the required videos from human resources, but I didn't learn what these situations taught me- that cultures are so different. Sometimes it's fun, and sometimes its horrifying, but the "competence" isn't learning to manipulate situations to fit your own culture. It is learning to recognize other cultures and try to accept them, to try to bridge a gap for yourself in between your beliefs and these new ones, where you understand a little bit more than you did before the interaction.

As I sit here with my afternoon coffee, reflecting on these interactions, I reach for a butter spritz cookie- my grandmother's recipe- to have with my coffee. No reason other than it's 3 pm, and that's what Swedes do.

As I head for the cookie jar, I smile. At least I am competent in one culture.

Oct 13, 2011

A Month on Labor and Delivery

Day 1: I feel great. Excited for labor and delivery, have my lunch packed and my latte in hand. Hair is brushed, lipstick-ed mouth is smiling. Bring on the month.

Day 4: Kinda tired. Thirty-two people are now in the world that were not only a few days ago, and since it was my hands that guided them out, I am now responsible for seeing their mothers every day starting at 4:30 am.

Day 5: Hair brushing now seems like superfluous vanity. Give up in favor of extra thirty seconds of sleep.

Day 5, later: Am primary surgeon on a cesearean section for the first time. Realize that nurses do a "count" of all surgical instruments/sponges before I close the patient, to make sure nothing is left inside. Nurse reports to me "Counts are correct, Doctor." I smile. Thank you.

Day 6: How did my fridge get empty? I seriously don't remember eating all that.

Days 7&8: Don't have time to go to the grocery store.

Day 9: I am now grocery shopping in the hospital cafeteria. What do we need? Milk? Cereal? Fruit? Dinner? A recent trip to the cafeteria yielded 6 milk pints, 5 pieces of loose fruit, a box full of salad, three tins of cheerios, and a takeout box filled with cooked chicken breasts and potatoes. The cafeteria worker laughed at me, then realized I was serious and rang it all up. Swipe...and done.

Day 10: Baby count continues to climb, as does the length of my postpartum rounding list.

Day 11: Find time to go to Fresh and Easy. Please bear in mind that F&E is about 500 feet from my house. Someone with a good arm could throw a ball into their window from my front yard. Nevertheless, I feel a great sense of accomplishment and provision for my home as I drive over. Get there and realize that the coupon I have been carrying around in my scrub pocket for five days has expired yesterday. Frick. My smugness evaporates, and deflated, I buy the groceries anyways.

Day 11, later that evening: Realize I have forgotten to buy dog food. Rather than make the journey across the street again, opt to serve the dog a chicken breast mashed with potatoes, left over from aforementioned cafeteria shopping. He loves it.

Day 13: Thinking of the raw pork loin waiting for me in the fridge (it seemed like a good idea sitting there all pretty and healthy in the grocery store case), I opt to bring home dinner from the cafeteria. Chicken enchiladas- a favorite of my husband's- were being served, and I bought a plate and took it home. I slid it onto my own china, reheated it, and served it. About halfway through, he squints at me, and asked if asked if I had made these? I just laughed and asked...what do you think? He laughed too.

Day 15: I didn't have time to do my laundry, and ran out of underwear. Opted to buy a new pack from Target instead of devote time to mountain of dirty clothes. Must remember to maintain efficiency and get all other shopping done as well while I am there. Cat sand? Check. New mop? Check. Dog food! Yes! What else? I just cant remember.

Morning of Day 16: What is that smell? I turn my head. It's stronger now. I surreptitiously sniff my armpit. Oh God. That's what I forgot at Target. Deodorant.

Day 18: Deodorant still not purchased. Just when I'm about to give up and start changing my scrub tops thrice daily, I pick up a prescription for the hospital pharmacy and notice they carry deodorant. Hallelujah.

Days 20 and 21: Working both weekend days. Miss husband. He comes to hospital for lunch. I feel bad that he's driven 45 minutes each way to see me, but he insists that the Banner Bistro makes the best chicken sandwich in town, and he was hungry for a good chicken sandwich, so it's really not my fault. He also brings me and my fellow intern our favorite frozen yogurt treats, which I know is an additional 20 minutes out of his way.

Day 23: So, so tired. Realize that between the drive home and needing to come back at 4, I will spend only eight hours at home. Decide to sleep at the hospital, which allows me to sleep in until 5:30, and roll out of bed and into my patients room. Don't care that my hair isn't brushed, but realize the deodorant I've worked so hard to procure is at home. Dammit.

Day 23, later that morning: Purchase another deodorant from pharmacy. Pharmacist grins at me. "Didn't you just buy one of these?" I glare at him, and add a toothpaste to my purchase. He laughs at me.

Day 24: Baby count: 97. How is it possible that there is anyone still pregnant left in Phoenix? I must have delivered everyone by now.

Day 25: My first needlestick, while suturing a difficult vaginal laceration. Must figure out how to get to occupational health.

Day 26: Buy second pack of underwear and larger laundry basket.

Day 28: Mother, upon hearing laundry plight, mails me five pairs of Victoria's Secret panties. I'm sure the postage cost more than what I spent on Fruit of the Loom pack from Target. Gratitude for supportive family eases my tiredness and makes me smile.

Day 30: Had a slow day today. Only delivered one baby. Is it true? Did I really deliver everyone? I was kinda joking before. Hmmm...

Day 31: Never mind. Pregnancies, if not in Phoenix, have now appeared from surrounding areas, including, but not limited to: Camp Verde, Strawberry, Show Low, the Grand Canyon, Colorado City, Buckeye, Salt Lake City, and California. None of these places are within two hours drive of the hospital. Appreciate, really for the first time, that this is a true tertiary care center. Humbled by the fact that I am part of a program/medical center that people travel hundreds of miles to get to, because of what we can provide in terms of high-level care. I don't work with these patients right now- they go to the more experienced residents- but wonder how it happened, and will happen, that in a few months I will be helping to provide care that people drive hours to receive.

Final Count: Babies: 106. Husbands: 1. Supportive family members: more than I deserve. Lost hours of sleep: countless. Pairs of scrubs: 44. Hospital Meals: 61. New pairs of underwear: 17. Exhausted and humbled residents: 1.

Counts are correct, Doctor.

Oct 9, 2011

Pretty (Tired)

I used to be pretty.

Theoretically, I still could be. I have some decent raw material. Taller than average. Slender, athletic frame, if a little pear-shaped. Hair that is straight without intervention, light brown with natural strawberry highlights. Brown eyes, dark eyelashes, full lips. Clear skin with a few freckles. Maybe not beautiful, but okay. More than some people have to start out with, and I feel like I should make the most of it.

I'm working in the clinic right now. I adore office work. Things that most people take for granted- sleeping at night, wearing your own clothes to work, eating lunch- are joys that I get to experience in clinic that I don't usually get while working on the wards. I can put on pants that fit, a purple shirt that looks good with my skin tone, and put on thirty seconds worth of makeup. Undereye concealer, powder, a little blush, a lipstick that has been in my white coat for months. Four people stop me this morning to tell me how great I look. "Wow, are you wearing makeup?" "You look great!" "I like you in your clothes" (side note: does this sound inappropriate to you? Would you also like me out of my clothes?) "You are really pretty." They always sound a little surprised when they say that.

I smile and laugh a little. I tell them thank you, that this is how I used to look in my other life. This is how I looked before I went to medical school, became a doctor, and worked harder/got less sleep than a mother of perpetually newborn twins.

When I'm at the hospital, I wear the required men's scrubs. They are too short, hug my hips too tight, and gap in the chest. My hair is always up and never combed. Sometimes I wear my surgical hat even when I'm not going to the OR, just because I feel like it's cuter than my head. My skin is dull, I have pimples from my surgical mask, and I look bruised on the thin skin under my eyes. My joints ache with tiredness. I look weary. I feel old.

I always sort of wondered when I would start looking older. I look young for my age, and always have. Indeed, the "little doc" came out of people's surprise that I was old enough and accomplished enough to be wearing a white coat. When would I stop looking like the "little doc" and just a doctor? Now I know.

I think this process will age me. Like the presidents. Those guys always start out looking okay, and gradually their wrinkles form and deepen, the skin looks sallow, their hair goes gray. By the end of the term, they have aged much more than four years. And I think this four years of residency will do the same to me.
However, hopefully then I will have a stable practice that I love, a little more sleep at night, and more working hours during the daytime. I can wear comfortable scrubs that are made for women. I'll feel better, even though I'll be older.

And hopefully I'll make enough money to buy more expensive cosmetics, and afford a few units of Botox. I think I'll probably need them. :)

Sep 16, 2011

Like A Surgeon...Cutting For the Very First Time

Ok. I know that is a Weird Al song, parodying Madonna's "Like A Virgin." Nevertheless, this melody is what plays through my head as I learn to be a surgeon.

At first, it was little things. A "gateway" surgeon, if you will. I could sew up fascia, and close skin. Then, I got to come around to the surgeon's side of the table, and do a little more. A skin incision here, a fascial incision there. I'd retreat back to the assistant's side for the important things, like opening the uterus, delivering the baby, sewing the uterus closed

Today I stayed the whole time on the surgeon's side. And suddenly, all these little pieces of things that I had learned to do on their own added up to me being the primary surgeon, me being able to do an entire cesarean section on my own. I could ask for the knife, and retractors, and scissors, and all the things I needed and actually be able to use them. I could smile as my chief resident handed me the suture to close the uterus, instructing me to "sew like the wind" as blood poured out of the gaping incision. I could reach my hand into a person's abdomen, and feel their aorta pulsating under my touch, hold their uterus and feel the baby kick my hands, feel their pointy vertabrae from the inside instead of the outside.

It's kind of like working in the cadaver lab, but this person is alive! It always startles me how warm everything is to my touch, how their is so much movement in vessels, muscles, enclosed babies...how much life I can feel resting in my hands. And I think this is part of the draw of surgery...to be able to do this to another person, to have your hands deep inside them and not only have them live through it, but have a desired outcome from it.

Even routine surgeries are scary for me at this point. I am more focused then I ever have been, with time slipping away from me as if it was only seconds. I leave warm and sweaty, more tired than if I had run a race. It's scary, but exhilirating.

Like a surgeon...cutting for the very first time...

A Few Stories

Once in awhile, the residents get together and just laugh. We have to, with some of these patients. Here are a few stories from this past month's work:

A kind resident goes to evaluate a woman that has presented for multiple times for drug seeking behavior, on the premise of chronic pain. She probably does have pain, at least from being so addicted to narcotics, but we don't want to prescribe anything because it's not good for her, and not good for the baby. As I'm leaving triage, I hear her shouting at my (male) colleague: "Bitch, you don't know my pain!"

I enter the delivery room and greet a woman who is fully dilated and ready to push. I begin to give her my earnest speech about how to push with an epidural, how to pull your legs back and take a deep breath and curl up around the baby. This speech is complete with a demonstration that I think (hope) is helpful and I'm sure makes me look like a giant fool. As I talk, the woman sneezes and delivers her baby.

In clinic, my friend was performing a well-woman exam, and asking about any changes to the patient's breasts. The patient says, "Well, they've gotten bigger..." and asks the doctor to measure her breasts to fit her for a different sized bra! My friend, being a kindhearted woman who used to work in a department store and thus is qualified to do this task, considers it but ultimately decides this is a doctor's office and refers the woman (in all seriousness) to Victoria's Secret. Do you document that referral on the chart?

Meanwhile, on the antepartum ward, another resident is called urgently to evaluate a patient. She has had a cerclage, meaning her cervix has been tied shut in order to help her avoid premature delivery. It is much akin to the string tied at the base of a balloon. It appears that the cerclage has come out, as the nurse reports finding a long black string with a knot in it. The resident comes right away, and the nurse presents him with a paper towel spread between her hands. On the paper towel is a lone long black pubic hair, with a knot tied in it. He explains to the patient, Ma'am, the cerclage is fine. And no, I don't know how that hair had a knot in it.

Over on labor and delivery, I am working with the most anxious patient in the world to push. I'm trying to distract her, to calm her, so we are talking about her horses at home, and shooting animals in the wild, and her latest hunting trip. (Let me say here that I do not have much to add to this conversation, as I am a liberal almost-vegetarian.) Nevertheless, I act interested as she says she'll just die if this baby is a city boy instead of a country boy. She pushes a little more, and I tell her I can see the top of the baby's head, and he has some hair! She asks me if by looking at the top of the baby's head, if I can tell if he is a Republican?

The next delivery I have is normal, and uneventful, and to very nice parents. I hold the baby up and announce the arrival of their baby boy! Both parents start crying; the dad in joy, the mother in horror. What? I glance at their pink carseat, the baby's name written on the board. Oh. Yeah...this wasn't the Liliana they were expecting. The dad is ecastatic, and has already named the baby Jr. whatever his own name was. The mom asks me if I'm sure I got the right baby? I am sympathetic, even though this question is obviously answered as the baby is still attached to her via the umbilical cord. It's not often in this day and age that parents don't know what they are having, and even fewer times that it is not what they expected. On the postpartum visit the next day, she asked me if she could go home. Was she feeling okay? "Yes, and I need to get to BabiesRUs. I have a lot of exchanging to do."



Sep 15, 2011

A Different Life?

I've recently had a little more time for reflections on my life, my chosen path. I'm working nights, and when it's not too busy, I'm able to lay down in between patients. I don't sleep because I am always waiting for my pager to jolt me out of bed, but I can enjoy the quiet. It's getting cool again, and I'm able to run outside, putting one foot in front of the other as my mind untwists whatever is subconsciously present, much like a dream. In these moments of quiet, I wonder about what my life would have been like, had I not gone to medical school. I don't doubt that becoming a doctor was a good choice for me, but was it the only one that was right for me, like I had thought at the time?

Let me be clear. I don't regret becoming a doctor. But, I think about what my life might have been like, as someone else. Or at least as myself, having made different choices. I could be a yoga instructor. I would have been good at that. I could be a professor, with a doctorate in clinical nutrition- my other professional love- or maybe a dietitian, like some of my friends from college had become. I could join my friends on their travel, because I would have time and money too, without worries of massive school debt or a constrictive schedule where I celebrate two days off in a row. I could be a wife and mother, a homemaker, like so many of the women at my gym and who come to see my at the hospital.

I know I am already a wife. But I'm talking about being a different kind of wife. The kind of wife that takes care of chores, the kind of wife ever available for listening, and sex, and companionship. The kind of wife different from what my own husband has. He has the kind that spends every other night away from home and is away even more hours on top of that, who can be distracted, with a limited attention span and patience, who wants to use the bed only for sleeping and expects an equal contribution, if not more, to household chores. The kind that a "dinner out" consists of driving 45 minutes to the hospital and enjoying a cafeteria meal together in between pages.

I think in a different situation, I could have really enjoyed being a mother now. I feel separated from my peers as they have children, as their facebook pages are filled with darling photos and cute anecdotes. I look at my facebook page, and decline putting up another status, because I don't have much to say outside of my life at the hospital. I deliver babies every day, and hand them away to anxious mothers, eager fathers, most younger than I. I am a little jealous, not only for these couples starting their families but for the sole fact that the mother is in bed at 4 am while I am up making rounds.

My dad says that anyone can get pregnant, but it takes a special person to have a baby- meaning me, the obstetrician. He says that I'm special, because these choices that are difficult, and sometimes isolating, that set me apart from other twenty-somethings...they mean that I have worked hard enough to get to have this privilege of being different, of getting to do a really important and special job.

One of the very best things about my new job is the other residents. Aside from childhood friends and a few treasured college/med school friends, I haven't connected well with others as a young adult, I think because my life took such a sharp turn away from the typical twenty-something experience. I'd go to church, to small groups, gym classes, and parties, and find that I really didn't have much to offer to a conversation once the conversation turned away from medicine. Relationships shifted into a more familiar territory- ie doctor/patient- as acquaintances began asking me advice on their pregnancies, but it didn't do much for me feeling like one of the gang. Some didn't understand why I was gone so much, why I wasn't available to volunteer more or be more reliable. And now, I have seven other people that deeply understand my situation. We can never get together all at once, because at least two of us are always working at any given time. We can share these stresses and fears about being subpar spouses, worries about becoming good doctors, laughing at jokes that others wouldn't understand or find funny. They understand that a date is spending time together, regardless of whether it is at a cafe or cafeteria.

The reason I write these somewhat wistful and non-cogent thoughts down is that upon talking with other residents, I've found this to be a fairly common thought process, and not one that I think might be intuitive to someone outside of residency. A chief resident mentioned to me that she loved her job, but felt like she could be completely fulfilled with a different life as well- one as a homemaker and mother. A third-year resident who I adore has a craft closet and could stay home happily baking bread. My heart broke for another resident who came back sobbing back from maternity leave. My best friend from medical school wrote me that she was literally sitting in clinic the other day, looking at the patients piled up, wondering what she had gotten herself into, wondering if maybe she should have considered other options, like cooking school. One of my loved co-interns told me once that she thought what she did was important, and she wanted to be good at it, but at the end of the day, this was a job, and her life and family came first. The census overall is that we love what we do, but we'd love a normal life for once too, and fantasize a little about what our life would look like if we hadn't invested all this money and time, if we had made more typical choices.

Kinda makes me feel better about my half-fantasy of becoming a stay-at-home yoga instructor.

Aug 4, 2011

The Parking Garage

One of the perks of my new job is that I get to park in the physicians' garage. This may sound minor, but is a substantial benefit during the Phoenix summer. While initially exciting, it has proven to be an interesting insight into the sociology of doctors.

It is labeled "Physicians' Garage" and "Parking: Doctors Only." At first I thought, I'm a doctor. Sweet! I have finally reaped some reward from the eons of school and debt I have undergone. However, on further examination, the first three floors are "Parking: Doctors Only" with blue tape around the pillars. If you continue up to the 4th and 5th floors, there is red tape. I notice that my parking sticker is red.

What does this mean, you ask?

The first three floors are reserved for ATTENDING physicians only. They get a blue sticker. The resident physicians have a red sticker, and have to park on the 4th and 5th floors (the 5th is uncovered). So, the reward for completing medical school is a car that is equally roasting as the CNA's in the parking lot down the road, except I have to walk up five flights of stairs to get to mine. I pull in at 5 am, and wind up the garage past floors of empty spaces, and park in the crowded upper floor. The cars on the first floor are shiny, new, and mostly expensive. Undoubtably, they do not have a gas tank that is perptually one-third full. They have dark tinted windows, rendered irrelevant by the fact that their "covered parking" is actually fully covered. Later in the morning, the bottom floors become more full, and then empty again by the time I leave.

I have drawn a few conclusions from the sociologic observation of the physicians' garage:
1. I am not a doctor
2. I will become a doctor after residency
3. At this time I will
a) have more money
b) sleep more
c) be able to touch the steering wheel with my entire hand instead of two fingertips
d) said steering wheel will be attached to a choice car that will not be running on fumes
e) and generally have a better quality of life overall

I look forward to parking on the bottom floor of the doctors garage.

Just for Laughs

They say to smile instead of frown, since smiling takes 15 facial muscles and frowning requires 35. It's a simple matter of efficiency.

Some women take this advice a step further, and laugh instead of push. Every now and then I'll have a woman that is ready to deliver, and instead of pushing, something will make her laugh and she'll just pop that baby out. Instead of screwing up the face and pushing as hard as she can, the woman will give a laugh (creating some abdominal pressure) and the head will come out.

What a fun way to deliver. I love it.

Aug 3, 2011

Spinning

I grew up in Southern California. At least once a week during the summer, my dad could be persuaded to drive me down to the beach, where I would spend the day catching waves on my garage sale board. I loved it. Sometimes, I could catch them just right, and ride them all the way in. Other times, I would think that I had caught it, only to end up on the top of it. I could ride it for a split second before looking down and seeing only air between my board and the water, and then feel the weight of the wave crash on top of me. I would be spun underwater three or four times with the force of the wave, and then swim hard, only to run into the bottom of the ocean. I was disoriented from the spinning, and didn't know which way was up.

I really wanted to work out today. It was a long day on labor and delivery, and I had missed my last few days' workouts due to circumstances outside my control. All day, I planned to go to a favorite class at the gym. Another delivery? It's ok. I'll be out by 5. I didn't do that paperwork right? No problem, I can redo that. Did you see that postpartum patient? No, I'm sorry, I didn't realize I needed to. I will do that now, and it will be okay because in three hours, I will be pumping weights with friends. Dr. Kennard, did you see this patient's fetal heart tracing? Dr. Kennard, we need you for delivery. Dr. Kennard, you have a call on 2054. Dr. Kennard...Dr. Kennard...the med student is interrupting my charting again, to ask some inane question and interrupt my train of thought. Dr. Kennard, you have a new patient. My head was spinning. I just needed to leave, and go to the gym, and everything would be okay.

I ended up leaving late, and the drive that should have taken 35 minutes took over an hour for traffic and construction. I finally pulled into the gym, proud that I kept my resolve to go and not succumbed to the takeout and recliner that were now paging me. I was too late for the class I wanted to go to, but there was a Spinning class available, so I walked in for that. I set down my water bottle and scrub top that was going to double for a towel, and adjusted my bike. The pedals didn't work. I moved to another bike, not in the ideal position since the class was getting full, but it would have to do. Those pedals didn't work either. I was frustrated, as now I was missing the warmup and there was only one bike left. I went over there, and began to pedal. All of a sudden, the seat fell backwards, causing my feet to slip and the pedal to hit me in the shin. I burst into tears.

That was the low moment for me. Sitting in the bike with my knees above my ass, crying, wiping my face with the scrub top where my tears were probably mixing with amnion and blood from the day, disappointed and frustrated that this one thing, this one class I had wanted to do, was now full of people and broken bikes. And in that moment, this Spinning class reminded me of how I used to feel when I thought I had caught a wave, only to crash spinning into the ocean.

As I extracted myself from the bike, I wondered where these tears had suddenly come from. Rather than sadness, emotions that seem to bring tears to me include disappointment, anxiety, frustration, and fear. And the start of my residency has been laden with all of these emotions, among better ones. Disappointment in myself, that my skills aren't better. Disappointment of unrealistic expectations being unmet. Anxiety, elevated to a level that my baseline anxious self couldn't have predicted. Frustration, with myself and others, with the learning curve of learning a new job and a new lifestyle. Fear, that I'm messing something up. Fear that at best I will annoy someone or create more work for them, or at worst that I will hurt somebody. The first six weeks of my residency has left me spinning, not knowing which was is up. Just when I think I've caught the wave, that I'm on top of it, I find myself underwater, not sure how I got there or how to swim upwards, how to do it better next time.

I'm hoping I'll get better at catching the waves. I think I will, only because I watch the residents above me, confident in their skills and knowledge, able to manage multiple tasks and do excellent work. I have to hope that they were like me one day, desperate just to stay afloat. Somewhere between now and then, I'll get better, become more confident, and have the reserve to deal with a faulty Spin bike. Until then, I think I'll stick with the treadmill.


Jul 22, 2011

Medical Students

"HI!"
A loud voice jolts me out of my post-call, sleepwalking state.
"I'M SARAH! I'M A THIRD YEAR MEDICAL STUDENT! AND YOU ARE......."
(she peeks at my badge)
"DR KENNARD! IT'S NICE TO MEET YOU!" She reaches for a handshake.

I peer at her blearily, wondering why this woman is crushing my hand.

It wasn't that long ago that I was a medical student. I remember starting a rotation, wanting to make a great impression, and feeling like I needed to be super friendly and introduce myself to everyone. I was always a little hurt when a resident would blankly stare at me, looking like they wished I would just go away.

Now that I am a resident, I know why they looked like that. They were more tired than I ever knew was possible, and wished that I would just go away.

It's difficult to be a resident. It's hard to have a student breathing your same air, looking at you for scraps of knowledge and slivers of experience. You are jealous of them, because they have slept all night while you've been paged for insignificant notices (emergent Colace, anyone?) You are too tired to even reach for your coffee, never mind engaging in conversation with the bright-eyed, bushy-tailed mini doc sharing your space. Regarding teaching, the difficulty is twofold: I'm a first year resident, so I still feel like I know very little, and am unsure of teaching. My own learning curve is so steep, I don't have extra time or capacity to full engage someone else in learning. The other challenge is the kind of teaching that I do end up doing.

Student: "I went and saw the patient. She asked me if it was okay to play with her pet's poop. I wasn't sure, so I told her I would ask you."

Me: "I think what you're thinking of is the risk of toxoplasmosis to pregnant women, which can be transmitted through cat poop, so she shouldn't clean the litter box."

Student: "Oh okay. I thought that was it, but I wasn't sure what animal did that."

Me: "That being said, it is not okay with her to play with ANY kind of poop."

Student: "Well, I thought so, but I didn't want to say anything without talking to you first."

*Student leaves to readdress patient.*

Student comes back. Resumes earlier discussion.

Me (wondering): Are we still talking about this? Are you kidding me? It should go without saying that people should not PLAY with POO. You should know this, and you are fully authorized to give those instructions, without my explicit permission. We have now spent seven and a half minutes clarifying something that a three year-old knows.

At this point, the resident part of me is downing ibuprofen and reaching for a large, caffeinated beverage. However, the residual student in me sympathizes for this girl. Yes, it was a stupid question. But how much of others' time did I waste as a student? Granted, I'm sure my questions weren't as ridiculous/obvious as this, but I am certain that many good doctors spent a portion of their billable hours invested in my learning and being kind and patient with me.

It's hard to be a student. Even if you know an answer, you hesitate to say it to the patient, because what if your resident/doctor wants something else? Then you have to come back, and ask about the poop, and look absolutely worthless. You want to say, "No! I really did know the answer! I just can't do a normal patient visit because I don't want to step on your toes or screw anything up for you!" You look bad either way. You worry that silence makes you seem disinterested, so you ask questions to fill the dead space, which seems reasonable when you are just sitting there but distracts the doctor from their paperwork. Sometimes I would ask questions I already knew the answer to, just to seem smart and engaged. Looking back (see above reflections on being a resident), I'm sure this made me incredibly annoying.

So, it's hard to be a resident. It's hard to be a student. Each come with their own challenges. However, I think I prefer being the resident. Despite the less sleep and more responsibility, I belong somewhere. I have a job to do in which I am allowed to make decisions and exercise clinical judgement and practice good communication skills. I get to come to work at the same place every day and get better at what I do, and will graduate a competent doctor and masterful surgeon. I know the nurses. I know that I can always get a plain chicken breast at the cafeteria grill, and to stay away from the calzone. All of these small pearls add up to something that I craved as a medical student, and could never get, as I was essentially starting a new job every four weeks. Familiarity. Belonging. Security. Confidence.

Medical students, take heart. Know that your life will improve. And in the meantime, work on a firm, not enthusiastically crushing, handshake. And don't ask about poop.

Jul 2, 2011

The Top Ten Things I've Learned In my First Week as an Intern

A List of the Top Ten Things I've Learned In My First Week as an Intern

10. An entirely new vocabulary of words, acronyms, abbreviations for all things ob and gyn

9. I no longer need a gym membership. I walked eight miles yesterday around the hospital. On that thought, it would be genius for someone to invent a pager/pedometer. It would let doctors know how far they've walked AND save space around the waist.

8. In reference to #9, I never fully appreciated just how many things could be clipped to the waistband of your pants. Cell phone, multiple pagers, wallet, pencil holder, etc. Better tie the drawstring of those scrub pants nice and tight.

7. I can now think in military time.

6. Keep extra underwear and socks in the call room at all times. I'm sure all ob residents have learned this the hard way. That amniotic fluid can really spray.

5. 3:30 to 4:30 am is the "witching hour", as my upper level resident says. Not night, not morning yet, it is the hardest time to be awake. It is physically so difficult, bringing intense nausea, faintness if I stand too long in the OR or a delivery, and achy joints. The older residents tell me this is normal, and why working overnight is so hard. They say you never get used to it, but learn things that make it easier on you.

4. My name is now Kennard. Not Anne. Not Dr. Kennard. Just Kennard. The nurse will say, "Did you page Kennard?" I call back. "This is Kennard, I was paged." I'm glad I like my last name.

3. My life is now indoors and fully climate-controlled. The only way I know the weather outside is by touching the inside of the windows in the call room. It was 118 degrees yesterday. Who would know?

2. The sound of my pager induces an acute stress response. I can't sleep when I'm working overnight even if I have a little down time, because I am just waiting for that thing to go off. And for God's sake (or at least my husband's), leave it in the car when I get home. Otherwise it will beep all night.

1. How big ten centimeters is. I know it seems obvious...ten centimeters is ten centimeters! But I am learning how to do accurate exams to know when someone is ready to have a baby. To facilitate this, I've taped a 10 cm measuring tape onto my mealcard. The cafeteria workers think this is hilarious and now recognize me and laugh every time I come in.

More to come...

Love,
Kennard

Jun 30, 2011

Thoughts from a Little Doc's [Dad]

Dear Annie,

When you were about 4 or 5 I took you to a weekend math conference I was speaking at in south Orange County. We stayed at the Westin Hotel and had a great time – swimming in the pool, watching TV, ordering room service. You didn’t even seem to mind sitting through my talk. After we got home, it was back to work as usual, and I don’t think we talked abut the trip again except for saying that it had been fun. About six months later we happened to be driving near the Westin and you said, “Look, dad. There’s the hotel we stayed at.” I said, “You’re right, sweetie,” surprised that you would remember the specific hotel. Then you looked right at me and said, “Room 405.”

It was then that I knew this was no ordinary child.

For you, information was always taken in, analyzed, catalogued, and stored in such a natural way that you were not even aware of the process. Details were useful, not threatening. Data about the world – both quantitative and qualitative – was always welcomed.

I think it has taken you most of your life to come to terms with the fact that you have a remarkable mind. Children can sometimes be unkind to a peer who seems a little different, especially if the genesis of that difference is intellectual. I know being a kid was rough on you sometimes. I tried to help – not always effectively – when you felt that the others did not understand you. The fact is, they probably didn’t. But I always knew that if you could reach the other side of childhood that you would have a remarkable adulthood.

And so you have.

At an age when many of those same peers are still trying to find their way in a complex grown-up world, you are leading the way. You are a doctor, Dr. Anne Kennard, perhaps the only palindromic OB/GYN in America. You are in a residency program at one of the top hospitals in the country, one of eight chosen out of more than eight hundred applicants.

They saw in you what I knew long ago: this is no ordinary doctor. Although just a first-month resident, your accurate diagnosis today of a breach presentation resulted in a good delivery in a situation that otherwise could have had a bad result. Once again, data was taken in, analyzed, and, now, applied. Mother and child are doing well.

I wonder if the mom, who is resting this evening after a busy day, is in room 405.

Love,

Dad

Jun 29, 2011

Changed For Good

I went to medical school at A.T. Still University, School of Osteopathic Medicine in Arizona. It was a brand new program, a school devoted to an innovative curriculum that gave students early clinical exposure, taught in a new inductive reasoning pattern, and valued underserved and primary care medicine.

Quite frankly, I didn't care much about any of these details. What I cared about was that this was the only school that I got an interview, and so I really wanted to be accepted there. Sure, I was fine with all the things that this school valued and taught. I think my natural bias was towards primary care to begin with, and I liked the idea of working with medically underserved people. But whatever. I would have gone to any school that wanted me, given that they were accredited and within the United States.

So, I was accepted. I started my first year with a trip with all my classmates to one of the Community Health Centers we would be rotating in during years 2-4 of school. And I was happy just to be there. The next year, our class of 100 was divided into ten groups of ten students, and we moved to our clinical sites at the community health centers. There were students in Hawaii, working primarily with homeless Hawaiians, students in suburban Seattle and Portland, urban Brooklyn, rural Ohio, South Carolina, and Alabama, Indian reservations in Arizona. My site was Central California, working with mostly Hispanic people who picked the great majority of the fruit for the nation.

I rotated through the different specialties, seeing these patients. I traveled to Hawaii's community health center, where I rotated through pyschiatry. I was exposed to different races, ages, citizenship statuses (or lack thereof), addictions, and problems, all united by poverty and limited access to health care. And I thought I understood, finally, why my school developed this new curriculum. They wanted to have us work in these settings to make us familiar with working in underserved medicine, in the hope that we might choose primary care and come back to be a doctor to people that desperately need one.

Then I graduated and started my residency, in a nice hospital that serves everyone from the very rich to people that just made it over the border. I thought more about my school, and the background it had given me with underserved medicine. And I think I understand that their vision, their goal in the grand scheme of medicine, was not to have doctors return to community health centers in primary care. Of course, this would be a wonderful bonus to their commitment to underserved medicine. However, I think they knew that by training young physicians within the lens of the underserved, we would be forever changed as doctors. Even if we chose the most sub-sub specialty in Newport Beach, California, we would always have the memory of working with those who had very little. And this, I think, is the heart of the program. Training doctors in the initial setting of underserved medicine forms a framework that affects the rest of a physician's career. I know for myself, my view of medical legislation, practice decisions and treatments are changed forever, no matter where or with whom I practice.

As I write this and think about these patients, I hum a song from my favorite musical, Wicked. As the song says, I have been changed for good.

I've heard it said
That people come into our lives
For a reason
Bringing something we must learn
And we are led to those who help us most to grow
If we let them
And we help them in return

Well, I don't know if I believe that's true
But I know I'm who I am today
Because I knew you

Who can say if I've been changed for the better?
(I do believe I have been changed for the better)
And because I knew you
I have been changed for good

Jun 28, 2011

Putting On My Gloves

Well, I've started work as a doctor. Two day shifts, one night...it hasn't been too different than being a medical student, except that I sign my own orders. But tonight was different.

It was about 10:30 pm, and I had just finished helping to deliver a baby. I sat down to write my delivery report, and heard a nurse call "911 to triage!" I watched a couple nurses run after her and then decided that since I am a doctor now, perhaps it wasn't a bad idea for me to go too. I wasn't stressed because I knew the 911 pager had been activated, which meant that a group of residents with actual experience and an attending would show up soon. But I decided I would go and just be there in the meantime.

It turned out to be a patient that had shown up to triage when completely dilated and was starting to push her baby out. I introduced myself, and asked her a few questions, in Spanish, keeping an eye on the door for someone that would know what I should do. No one came, and the nurse handed me a set of sterile gloves, and said "put your gloves on."

And I did. I pulled on the sterile delivery gown and pulled on my gloves, and delivered the baby just as the more advanced resident and attending arrived. I stood there holding that baby, knowing that this mother was my patient, and that me being there had mattered. I had put on my gloves, and was a doctor.

It was a great feeling and an I think an important transition, as I start my residency, and gives me a lot of excitement for what is ahead.

Jun 7, 2011

Thoughts From a Little Doc's [Mom]

Dearest Annie,

You indeed became a physician yesterday. As we have enjoyed the festivities of this weekend, I have reflected on the journey of the past four years. You have grown and changed quite a bit over these years. But you are not the only one who has grown and changed. I have also grown and changed as I have watched your journey. With that in mind, I will reflect on a few of the moments that were touch points for me.

Did you say “thank you”?

Although many years and experiences went into the making, the real journey began when we flew to Arizona for the interview at ATSU. You called excited with the news that you had been granted an interview, but that the interview was to occur within a few days. ATSU had invited you to bring a family member along. They were keenly aware that the rigors of medical school would require a support group that was “on board” with your goals. So, after a whirlwind trip to Nordstrom with your dear sister to pick out an interview suit, we were off to Arizona.

I knew that I had one job on this trip: to deliver you to the interview on time. Having never been to Phoenix before and not yet in possession of a GPS unit, I must have reviewed the route from the hotel to ATSU twenty times. I breathed a huge sigh of relief when we entered the parking lot. Because of my fear of screwing this up, we arrived forty-five minutes early. Not a moment too soon, in my book.

It was a grueling day for both of us. I was allowed to be with you for all but the hours of direct interview. You were poised, confident, and charming. I tried to strike a balance between sharing things about you that I thought the interviewers should know and coming off as a stage mom/helicopter mom/hopelessly doting and tiresome parent. You nodded enthusiastically as the presenter reviewed the curriculum and testing schedule that would be yours if you got in. I wondered if anyone could possibly live through it. After a grueling ten-hour day, we walked through the exit. Before I gave it a moment’s thought, I said, ‘Did you say “thank you”?’ The look on your face reminded me that this was not our usual exit together after a birthday party. You had just made it through a very grown up day. It was time for me to grow up, too.

“Back to School” Shopping

A favorite tradition in our family over the years was the annual “back to school” shopping trip to Staples for school supplies. The aroma of freshly sharpened pencils evoked excitement for a brand new school year. The list included the usual items such as binders, folders, college-ruled paper, a pencil pouch, and a supply box for the top of the desk. There was a yearly discussion between you and Jennifer on the merits of colored pencils versus felt tip markers. Crayons were a “must have” at any age. A box of sixty-four with the built-in sharpener could be counted on to increase your popularity when it came to choosing partners for group projects.

The night before, we looked at each other and wondered what one should bring to the first day of medical school. ATSU had issued you a computer “tablet,” which was the latest technology for new medical students. Were you supposed to bring the computer in a backpack? What else should go in that backpack? We settled on the usual assortment of items, including the crayons. Maybe you would need to color and label pictures of anatomy. Who knows?

*a note from the little doc: the other students laughed at me about the crayons in my bag. And then wanted to borrow them.

Over time, we knew that all of these items were necessary and useful. What we didn’t know is that Dad and I should have bought stock in the company that makes 3 x 5 note cards. You must have gone through thousands in the last four years. The other important purchase was “Phyllis.” Phyllis is a full size skeleton that shows important landmarks such as the origin and insertion of the major muscles. Phyllis has oddly been a source of encouragement, having been named for Dr. Phyllis Agran (a pediatric gastroenterologist) who guided you through a rough patch in your own health during your middle school years. Like the box of sixty-four crayons, Phyllis ensured your popularity in your early days of learning anatomy with your peers. She also provided comic relief when dressed up in a myriad of outfits.

Mom, I’m calling to tell you that I am on my way to the E.R.

In fairness to me, this was not the first time that I had heard these words from you over the telephone. You have had a series of mishaps over the years, including numerous painful ear infections, a broken toe, a concussion, a pierced eardrum, pneumonia…. Need I go on??? The fact that they were uttered at 10:00 at night did nothing to ease the immediate panic. You found my panic to be hilarious and said, “I’m working in the E.R., not going to the E.R!” Frankly, this possibility did not even occur to me.

For the well being of our patients, please leave your children at home.

I saw this notice when signing in for an appointment with Dr. Thanos, the gynecologist/obstetrician who delivered Jennifer. As every parent knows, memories of your children when they are young are very vivid and can feel as if they happened yesterday. Sometimes you are startled to see your child standing before you today and you wonder how she got there. As I absentmindedly read this sign, my sense was that you were home being cared for by Grandma while I was at the doctor’s office. I was glad that I had not offended anyone by bringing you with me. Then it occurred to me that you were actually in the office, because you were doing a rotation with Dr. Thanos. As a student doctor, you said that the sign was more appropriate than anyone knew.

*note from the little doc: Don't go to the gynecologist with your mother. Not as a child, and ESPECIALLY not as the doctor. Even if you are curious about her DEXA scan results.

Stay away from that, it has germs on it!

A mother should have a nickel for every time she has said these words to a child. With this kind of money, she could book a week in paradise, complete with margaritas. I spent years steering you away from anyone who was coughing, sneezing, or had a runny nose. I quarantined you or anyone else in the house that had a fever, and zapped every surface you touched with Lysol. I kept your little yellow immunization card in a lock box with birth certificates, passports, and the deed to the house.

Bird flu, swine flu, tuberculosis, flesh-eating bacteria. All of these were the subjects of sensational news stories during your clinical training, complete with dire predictions of uncontrolled global outbreaks. My usual admonitions to stay away from germs no longer applied. Those who suffered needed you. I could only pray for your protection.

Yes sir, that’s my baby. No sir, I don’t mean maybe.

By now, you have delivered numerous babies and provided care to many who are sick. You have shared joyful news with some families and devastating news with others. I know that you are ever mindful of the awesome responsibility and profound privilege of being present during a family’s moment of greatest joy or deepest sorrow.

In looking back over your life, your innate character and experiences have led you directly to this moment. I do not remember a time when you did not want to be a doctor. This drawing is from a school assignment that asked "What do you want to be when you grow up? What does that person do?" You drew it when you were about seven years old. Twenty years later, it is time to say, “Congratulations, DR. ANNE KRISTEN (BONSANGUE) KENNARD!” You finally made it. I love you very much.

Love,

Mom

Jun 3, 2011

Today, I Am A Doctor

I've watched friends go through bar mitzvah celebrations. This Jewish coming of age ritual occurs when the thirteen year-old child becomes responsible for his actions, is considered "adult" in the community, and is privileged to uphold Jewish law, tradition, and ethics. He undertakes years of preparation and study, and finally stands in front of his congregation, proclaiming "Today, I am a man."

Today, I am a doctor.

I spent four years preparing to get into medical school. I spent another four learning about the human body and how to help and heal. I took the Osteopathic Oath, promising to honor the medical profession and my patients, practice ethical medicine within my scope of practice, and to uphold the tenants of osteopathy, joining generations of healers who have gone before me. I stood before my family, friends, and teachers, and felt the weight of the doctoral hood placed on me, it's long length and green stripes proclaiming to all that today, I am a doctor.

The thing is, a bar mitvah-ed "adult" is still a thirteen year-old kid. I'm still a little doc, just in a long white coat. And even though I am considered a doctor, I still start over, for another four years, as a resident, the doctor who is the least experienced and needs to learn the most about her chosen specialty. I'm hoping that somewhere, in this transition to fully-trained physician, I'll feel like my new coat fits.

The transition is joyful. I can't help but grin as my white coat brushes my knee instead of my hip. I love writing my new name (which is a natural palindrome): Dr. Anne Kennard. I am humbled and honored to be considered an "adult" in the medical profession, at the same level as my teachers and role models. I think about an office full of people waiting, a patient on an operating room table, a tray of sterile instruments set out. How could these things all be for me? I've wanted to be a doctor since I was eight years old. This is truly a lifetime dream come true.

The transition is also scary. I think about what the added twelve inches on my coat hemline adds to my life. I am responsible for patients, and since I am in obstetrics, I care for two or more patients instead of only one. I need to be an excellent diagnostician, a gentle and effective healer; not because my malpractice premium depends on it, but because it is my responsibility as Doctor. My decisions, my words, my touch will tremendously impact others. Consequences for mistakes rest with me alone; I have lost the safety net of being a "student doctor." I could really hurt somebody. But, I can also really help someone.

Even though a thirteen year-old is still a kid, the bar mitzvah is significant, celebrated, and honored. To that community, he is an adult. I'm still the little doc. But today, I was welcomed as a physician into a community that includes Hippocrates (Greek "Father of Medicine"), Paracelsus (Renaissance physician who pioneered use of chemicals in medicine), Andrew Taylor Still (founder of Osteopathic medicine), the Mayo brothers (founded the Mayo Clinic), Jonas Salk (first effective polio vaccine), Donald Pinkel (my mentor, discovered ALL cure and founder of St. Jude Children's Hospital), and generations of surgeon generals, centuries of healers.

Today, I am a doctor.


May 8, 2011

Mother's Day

I am not a mother. Well, maybe except to the dog, but I wasn't expecting anything from him. So I was a little confused when a mother's day greeting found me today. It was from my parents, and I adored the message.

"Happy Mother's Day, Little Doc! Anyone can have a couple of babies, but you will have thousands. You are celebrated today along with the women you care for...Happy Mother's Day to a doctor of mothers."


May 2, 2011

The Gift of Health

I had two patients in the ICU today, next door to each other. One was a 92 year old woman who was sick, tired, and ready to die. Her body "had just wore out", she told me. Her family was grasping at every tiny diagnosis, not acknowledging the larger picture, that her body was just shutting down. They encouraged her to keep going, to sign a full code status. She wanted a Do Not Resuscitate order.

In the next room, a 92 year-old man was intubated, with shock, hypotension, kidney failure, and a bowel resection for an obstruction following the repair of a hip fracture. His wife knew he had wanted a DNR order, but was feeling guilty about honoring his wishes. She didn't want her husband of 52 years to die, but acknowledged that he had been a vibrant, outgoing person, and wouldn't want to live on a ventilator. She told me that he had never met a stranger, loved to talk and would leave someone new having learned their life story, and she was sure he wouldn't want to live without the ability to speak and give love to those around him. But she still couldn't bring herself to let him die.

As we left those rooms, my attending doctor shrugged and told me "All living things, big or small, eventually die. Why do people not know this?" He was frustrated, having seen many people die and even more live, because of the ability that we have to keep someone alive, which in many cases is more punishing than death.

I've been thinking about health lately. People think that health is a given, it is something they are owed throughout their lifetime. Doctors know better. With the intricacies of the human body, it is incredible that anybody is healthy. And while sad, it is not surprising when people aren't. Nobody is owed health; but it is something many people enjoy and take for granted. Young people, especially, do not know how precarious health is, unless something unusual has happened to them. My parents are beginning to learn, as their friends become sick with cancer or other things that can kill them. My grandmothers know this lesson well, as they survive more and more of their childhood friends.

My mother called me recently, telling me about her own frustrating diagnosis of osteoporosis and many grandmother's debilitating back pain that will preclude her from traveling to watch me graduate from medical school. I was sad, of course. I didn't want either one of them to suffer, and I would miss my grandmother on my graduation day. But, I gently reminded my mom, these things are okay. They are not comfortable, and will need care, but they won't kill you.

I am a regular person, overlayed with the knowledge of a doctor. I look at my family's medical problems through the lens of knowing what can really go wrong. But I also ache for the wife of my patient, because I understand her too. Her husband sounded a lot like my loving, outgoing, talkative husband, and I could see how, after enjoying fifty more years with him, it would be hard to not make a decision out of grief.

It had been a gift to me, as a young person, to deeply and intimately understand the frailty of the human condition. I ride my bike over to the diner with my husband, finishing my lunch in the time it would have taken for my elderly patient to finally get himself into the car. I look at how fast my fingers type, seeing the arthritic nodules of an elderly woman's fingers as she slowly signs her name. It's kind of a sad gift, a wisdom that carries weight along with knowledge. But, I am glad to have received it in my youth, and appreciate it throughout my lifetime.

Apr 25, 2011

Tales from the ER

I ended my one and only rotation in the emergency department today. I learned two valuable things:
1. It is correct when doctors tell you that the emergency room is 90% boredom, 8% interesting, and 2% terror.
2. I cope well with true emergencies, making fast and accurate decisions...but I don't like them.

Here are some stories from the ER:

Boredom
  • A woman comes in for hand pain. Further elucidation reveals that she "slept on it wrong."
  • Countless drug seekers, with some nonspecific abdominal pain complaint, who have had so many CT scans that you expect their belly to light up from the inside. They will moan and writhe so much that you finally cave and write the script just to get them to shut the hell up and get out of there.
  • A kid with a rash x 3 weeks, which has been evaluated by numerous primary care providers. What makes you think that at 10 pm with a busy ER, I will be able to accurately diagnose and treat your rash any better than the other doctors you have seen?
  • Colds and viruses. Please, go see your primary care doctor.
  • Anxiety. Anxiety. Anxiety. You would not believe how often this diagnosis came up and how many insidious ways it can present. And how even thought you are 99% sure it is anxiety, they need a full, expensive, cardiac workup for you to be able to discharge them since they came in complaining of chest pain and/or shortness of breath. These typically present between 10 pm and 7 am.
  • A parent wondering if permanent marker was toxic if absorbed through the skin (kid had done some "face-painting"). Definitely a firstborn child. Subsequent kids would walk around for months with marker on their faces.

Interesting/Funny
  • A woman came in with numbness and tingling down her right thigh. She was dressed very nicely, and told me that she had just come from a wedding. The (male) attending wanted an MRI. I asked if she was wearing anything new. Turns out she had worn Spanx for the first time under her nice dress, and it had compressed her lateral femoral cutaneous nerve. She took off the Spanx, and the numbness and tingling went away.
  • A poor ninety year-old woman came in after tripping and falling on her carpet. The carpet ripped away her paper-thin skin, leaving her patella and a good part of her lower leg tissue exposed. I spent an hour and a half putting in fifty stitches, and had a wonderful conversation with her while doing so, learning all about her long life. She loves to needlepoint, and asked how I did the stitches, and if sewing people was similar to sewing upholstery.
  • A man came in under arrest after attempting burglary. He had fallen on glass while robbing someone's home and was brought in by the police to get his knee sewn up prior to going to jail. As per usual, I asked him what happened to his knee. He told me he fell on a rock while playing basketball. I commented that the rock must have been pretty sharp, given the perfectly clean laceration he had (a confidence afforded by the fact that he was handcuffed to the bed).
  • A kid who had eaten a scorpion. Is it toxic if the venom is ingested?
  • An old Hispanic man, yellow as a canary, coming in with abdominal pain and a big stone in his bile duct.
  • A four year-old girl with a cut deep into her foot from a rotary blade. I made a game of wrapping her up in a sheet like a burrito, which she liked, and then cringed as I began to inject lidocaine and start suturing while she screamed and tried to flail the arms and legs that I had wrapped up so tightly.
  • People on/withdrawing from drugs. Always interesting to watch.
  • A heroin user with a kidney stone who begged for pain medication. Nothing worked. He was furious when I told him that since he had developed so much tolerance to narcotics, they weren't effective for him anymore.
  • A heroin user who unscrewed his IV and left AMA ("against medical advice"), then used the line to inject mass amounts of heroin and ended up right back in his old exam room, now unconscious and apprehended by the police.
  • A heroin user who had multiple abscesses from skin popping, each filled with several CCs of pus. They needed to be drained (fun to do). She had a lot of anxiety over the needle with the numbing medicine. I tried to refrain from pointing out that she put needles in her skin several times a day anyways, so what was the big deal?
  • A woman complaining of vaginal bleeding during pregnancy. Normally this would fall under the "boredom" heading, but what made this unique was that this individual was transgender, and I was greeted by a penis and testes when I lifted up the gown for the pelvic exam. He/she was so desperate to identify as female that she had sought medical attention for a "female" problem. Definitely a psychosomatic diagnosis.
Terror
  • Multiple trauma victims of a multi-vehicle crash, all coming in at once.
  • A child bleeding to death internally after sustaining blunt abdominal trauma from a trampoline fall.
  • A man with an eyeball hanging out of his socket after an injury.
  • A drunk driver laying in the trauma bay next to the man he killed, separated only by a curtain.
  • A ten year-old who successfully hung himself.
I'm glad I'm going into Ob/Gyn. There is some inherent terror in that specialty as well, and the emergencies affect two people, not one...but thankfully, they are few and far between. In the meantime, I can enjoy an overall healthy population and followup with the same patients for a long time. I missed that in the ER...I wonder about some of these patients and don't like that I will never find out how their story ends. It was a good rotation for me to do. And good that it's over.