Stress

I started third year on triple block. On psych consult I worked 8am-6pm and on inpatient psych I worked 8:30am-3pm. On primary care I worked 10am-4pm three days per week, I went to lecture once a week with similar hours, and had three-day weekends. Neurology was the most time-consuming of the three, starting at 7:30am and ending around 4pm. I had plenty of time after I got home to study, hang out, and watch movies. Third year seemed manageable. But after triple block I started ob/gyn.

Most days this past month I have woken up at 5am and have gotten home around 7pm. Occasionally I would leave before 6pm and consider it a good day. On one lucky day I got to leave at 5pm. I relished the days we had 8 hours of straight lecture (including a lunch lecture) because it meant that I could go home at 5pm and study. Unfortunately, the lecture days weren’t quite the godsend I’ve made them out to be: even though the lectures started at 9am, I had to round on my post-op patients at 5:30am, write notes on them by 6:15am, and attend M&M conference at 7am followed by grand rounds at 8am. I also had to work a Sunday shift, meaning I only had Saturday to relax and recharge (i.e., study) followed by six more grueling days of work.

When I got home at 7pm, I would eat dinner and read up on the next day’s cases (the patient’s history, the disease process, the surgical procedure, and the relevant anatomy). I tried to get 6 hours of sleep each night, but it was never enough. As the clerkship went on, I found myself too tired to keep up with my studying. I would literally fall asleep at my desk with my head bent over my book. Before ob/gyn I thought people were just exaggerating when they said stuff like that.

For me, the most stressful part of medical school is how constant and unrelenting the workload is. I no longer have time to be the good boyfriend, the good listener, or the good son. I no longer have time to make my own breakfast or lunch. I no longer have time to exercise (no, speed-walking and retracting don’t count). I no longer have the time to enjoy my life in the carefree manner I used to. Every decision I make to take a break by watching TV or meeting up for dinner directly impacts the time I have to study and how well I do in the rotation. But that is precisely what I need to do to ensure my mental and spiritual wellbeing. I simply have to accept the fact that I cannot be the best medical student I can be while simultaneously being the best person I can be.

It’s not the amount of information we need to learn that is so overwhelming, although that certainly contributes. It’s not the fact that we’re being thrown from team to team every 2 weeks as soon as we start to feel comfortable with and confident in our fund of knowledge, interviewing efficiency, and clinical reasoning. It’s not the uncertainty we feel from learning every new attending’s special way of doing things. It’s not the isolation we experience from never seeing our friends unless they’re on the same rotation. It’s the fact that we have to do all of this while working 60+ hours each week, with fewer and fewer days to catch our breath and re-evaluate and reassess our situation. It’s the fact that we’re on an unyielding, terrifyingly fast treadmill without the safety cord to stop it if we falter or fall off. At some point, we all need to take our feet off the machine and rest for a little while. And we need to take control of the treadmill instead of letting it control us.

Dying

During my psychiatry rotation, I was consulted to see a woman for depression. Four months prior to admission she received a liver transplant for accidental acetaminophen overdose. She began feeling depressed after the surgery because of poor body image related to the surgical scar. She believed she had gotten to the point where she needed to be taken to an inpatient psychiatry ward to take a break from her life and reorient herself to her situation. One week prior to admission, she came into the ED complaining of depression, requesting to be admitted. The attending informed her that the inpatient ward was for very sick people and it did not seem appropriate based on the information she was telling us. The attending further informed her that there was insufficient reason to commit her because she did not pose a risk of harm to herself or others. She left with the impression that she needed to be actively suicidal to be admitted. One day prior to admission, she ingested a bottle of acetaminophen while sitting in her car in a garage, with her husband and two kids in the house. The husband saw her and asked if she wanted to be taken to the hospital, but she said no. The next morning her father came and took her to the hospital.

In the hospital she denied suicidal ideation, saying that she never wanted to hurt herself and currently doesn’t want to either, but felt that she needed to get admitted to psychiatry at any cost. Because of her actions and despite her denial of suicidal ideation, she was admitted. She clearly had a number of psychiatric problems, including a personality disorder that impaired her insight and judgment. I thought that she would realize that inpatient psych wasn’t really the place for the therapy she needed and that she would eventually find appropriate help. I was wrong.

Two months later I overheard her being discussed during my neurology rotation. She was in the hospital for altered mental status. Imaging of her brain showed diffuse cortical changes consistent with carbon monoxide poisoning. My initial reaction was that she attempted to kill herself again, but she was found at a residence without a garage. The story of what exactly happened has not been fully explained, but it is not hard to imagine what will happen next. We have heard of three potential suicide attempts (two acetaminophen overdoses and one carbon monoxide overdose). One of these days she will succeed.

I’m writing about depression because most of us do not consider it a terminal illness, although 35,000 Americans die from it yearly. Eleven times that amount attempt suicide. Because of risk assessment, looking at various demographic data and emotional/support factors, we can convince ourselves that we are doing our best to prevent their deaths. But suicide is wholly unpredictable. Imagine a cancer that vacillates between indolent growth and aggressive symptomatic expansion. How will you ever know if you’ve treated it? I believe this woman will likely kill herself. She is on the verge of doing it already and has exhibited repeated worrisome behaviors. She is dying from her disease and traditional therapies have not been successful. She is a dying patient and there is nothing medicine can do. She is my dying patient and there is nothing I can do.

Medical Hierarchy

As everyone knows, medicine is hierarchical. On the bottom is the third year medical student who sees the patient first (and sees the glare in the eyes of the grumpy entitled ones who don’t want anything to do with anybody but the attending) and makes all the mistakes of forgetting to ask about pertinent re­view of systems or failing to perform all the relevant special exam skills. Next up is the intern or PGY-2 resident, who guides the student along and gives them advice. They ask you the questions you forgot to ask the patient, and only after your one hundredth time responding with, “I don’t know,” do you finally remember to ask the one hundred and first patient that question. But the residents are often strung out from overnight call or getting dumped five new patients in an hour and don’t always have the time to teach you in a forgiving manner. They can be blunt. They can ignore you. Both suck. Above them are the senior residents, above them are the fellows, and above them are the attendings. They have even less time for you.

That’s how it works for the hospital anyway. In the outpatient setting, it’s completely different. It’s just you and the physician and he has himself overbooked in order to see 20 patients per day. You go in, do a focused exam, report your findings, explain what you think it is, and define a treatment plan. All in 10 minutes; after that, the physician makes sure everything you said is correct, writes the prescriptions, and sends them off on their merry way just in time for you to see the next patient. If they’re running late, you end up shadowing the physician until he catches up, which may take the rest of the day. Then he has to write his notes for the day, but he doesn’t want to keep you around doing nothing, so he kicks you out quickly. It’s almost impossible to find the time to get constructive criticism and feedback.

From the patient’s point of view, I’m sure it can be exasperating. They wait in the room for fifteen mi­nutes (outpatient) or half a day (inpatient), and the person they see peek their head behind that door is very different from the person they expected to see—and usually much younger. The medical student isn’t as skilled at determining what parts of the history and physical are important. They ask questions out of order, they fumble with how to frame the question correctly, and they make the patient stand up and sit down and stand up again because they haven’t yet gotten fluid with the exam. Then the student leaves, the patient doesn’t know what the diagnosis or management plans are, and is left waiting another ten minutes (outpatient) or three hours (inpatient). The attending finally comes in, the patient corrects any mistakes in their story (embarrassing the poor med student in the meantime), and wonders why the physician is doing all these weird things to his body that the student never did. That’s how it goes for a mediocre student (I would know). For an excellent student, the patient may just experience déjà vu: the physician asks the same exact questions the student did and performs the same exact exam maneuvers.

But I wouldn’t have it any other way. Going in there and making mistakes is the best way to learn. It’s in correcting your mistakes that you learn best, and it gives you that innate, unshakeable knowledge of disease, of diagnosis, and of patient care. That’s what you need to be a doctor.

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The Noble Profession

In general, I find primary care to be a rather noble specialty to go into. While the hours are fairly lax, the pay isn’t particularly good and the procedures aren’t particularly sexy (probably because they consist of the physical exam and blood draws). The physicians who enter primary care aren’t always the noblest of people either: some people are forced into it because of less competitive scores or because of financial incentives (debt forgiveness for setting up practice in a rural area). But my heart is warmed whenever I see a physician practicing primary care because he believes in long-lasting relationships with patients, preventive medicine, and public health measures. Sometimes it is their faith and dedication to what they believe is the heart of medicine that makes their behavior so inspiring.

Dr. Vaccaro and I recently saw a patient named Jessica Rose. She was a young woman who presented with paresthesias along her hands and feet. She had been worked up by her prior primary care doctor and had been brushed off as crazy, meaning there was no physiologic reason he could find to explain her symptoms. She decided to find a new primary care doctor; she searched on Yelp and found Dr. Vaccaro. Before her appointment, she went to see a neurologist at Northwestern and had a few more blood tests that showed low vitamin B12. While B12 deficiency can cause a neuropathy, the neurologist wasn’t sure that it explained her symptoms. Regardless, he started her on B12 supplementation.

When Dr. Vaccaro and I saw her, she came off as genuinely concerned with her symptoms. But at the same time she did seem to exhibit some hypochondriasis (she was extremely precise in describing what was going on and had searched on WebMD for possible diagnoses). It was unclear how to interpret the patient’s actions and behavior. After performing some physical exam techniques, Dr. Vaccaro was also not convinced that the low B12 was causing her symptoms. He ran some blood to check on her B12 and her copper and iron as well. Since it would take a day or two to get the results back, he had to go back in and talk to Jessica about what he thought she should do in the meantime.

He decided to tell her that there was a high probability that the symptoms she was experiencing were not physiological. He believed there was a 50% chance she would blow up and scream about not being taken seriously, threaten to find another doctor, and storm off to write a negative review on Yelp. He was willing to take that chance because he believed she really needed to know what his medical opinion was on the situation. So he went in and said exactly that. Jessica was actually relieved. She told us that she just wanted to make sure there was nothing that could hurt or kill her that she was missing. She said she was okay with her symptoms being a result of anxiety, because that would be easier to manage than some unknown and undiagnosed disease. (As it turns out, her blood work came back with some concerning copper and iron levels, but that’s a story for another time.)

While it turned out to be a (relatively) happy ending, Dr. Vaccaro took a risk that could have damaged his reputation and relationship with patients. He did it for the same noble reason he entered primary care: he believed it was the right thing to do for the patient.

Amethyst Sunday Morning

Amethyst Sunday Morning sounded like an odd name for an Alcoholics Anonymous meeting when I first headed over there as part of my psych rotation, but it turned out to be nearly the exact opposite from what I expected. I remember a character in this one movie I saw who compared AA to being forced to go to church when you don’t believe in God. I presumed it to be slow and painfully tedious, filled with sad, depressing people talking about their sad, depressing lives. But instead it’s an open, warm, and welcoming place of friends. It’s full of fun people who tell their stories and share in the triumphs and failures. As I sat there listening, I realized how universal the themes were. Nobody is perfect, and we all make mistakes and fall short of our ideals. Some people turn to alcohol, some people turn to work, and some people turn to religion, but it seems like we all have to find strength somewhere to help us with the challenges we face in life.

AA starts with one person telling their story for 30 minutes. This is called a “lead,” a way to get the conversation going, but it sounds much more like a testimonial at a baptism. A coffee break ensues, followed by 45 minutes of comments. The comments are supposed to relate to the lead (what they found interesting, congratulating them on their sobriety, or giving them advice for some difficult times ahead), but most of the time they were only tangentially related, if at all. I think most people just want to tell their own mini-stories, and AA provides a safe forum in which to do that. (And yes, people do introduce themselves as “I’m John and I’m an alcoholic,” to which everyone replies, “Hi, John!”) The meeting closes with everybody holding hands and reciting The Lord’s Prayer.

I found a few things about the experience fascinating. First, almost everybody had a coffee drink in their hand or on the table in front of them. It might have been because it was an early Sunday morning, but I think it’s because these people feel stronger and more resilient every time they drink something that is not alcohol. Second, there was a common thread of people turning to alcohol because of feeling left out and/or not fitting in, especially in military families who move around every few years. Third, and most interesting to me, is that they describe alcohol as a friend, someone who understands them and makes them happy. They described it as a love affair with Jim Bean. One person went so far as to compare it to domestic violence, where alcohol would keep knocking you down and you would keep coming back like a battered woman to the abusive relationship. Fourth, alcoholism does not discriminate. There are people of every age, of every gender, and of every ethnicity who have all fallen victim to the siren call of alcohol but have found their bearing again. Fifth, alcoholism is a lifelong disease, similar to diabetes. These people don’t say that they used to be an alcoholic; they still are alcoholics, even though they’ve been sober for 20-30 years. They’re still dealing with their disease, in much the same way a diabetic will always be fighting off diabetes. They’ve just been lucky not to have a relapse in a long time. Sixth, these people treat the program as their religion and apply the principles of the program to every aspect of their life, not just alcohol. They speak of AA’s co-founder Bill’s story similar to gospel (and some even know exactly how many pages certain passages are). The period where Bill faced a multitude of difficulties trying to quit before finally re-emerging a new man sounded strikingly similar to the temptations that Jesus faced before being crucified and coming back to life.

I can imagine AA—like church—to be terrible if it’s forced upon you, but one of the requirements to beginning the program is that you have to be willing to stop drinking. I think that’s essential. You absolutely cannot prescribe AA to someone if they don’t want to quit, because it will be wholly and utterly ineffective.

And I did find out why it was called Amethyst Sunday Morning. Amethyst literally means “not drunken” (think of a- as not and methy- as alcohol) and comes from Greek legend where Bacchus, the god of wine and revelry, got so drunk he was about to harm someone he loved. She was protected by an amethyst gem and Bacchus saw the errors of his drunken ways. It may be an odd name for an AA meeting, but it’s certainly appropriate. I was recommended to hear the stories being shared at another meeting called The Mustard Seed. I can’t wait to find out how it got that name.

First month on rotation

Two weeks ago I switched from psychiatry consult/liaison to inpatient psychiatry.  It felt like starting all over again from scratch, but not in a good way. Instead of being excited and thrilled to try something new, I felt like I was just watching people get work done around me—that is, when I wasn’t in their way.  I feel like switching teams is a little bit like moving apartments.  The basics are all the same (your couch, your desk, your bed, your silverware), but they’re organized differently.  And it takes a certain amount of time before you stop looking like a doofus walking out of the elevator not knowing which direction to turn.

My consult/liaison team consisted of three med students, five residents, two fellows, and one attending.  As each new patient came, he was assigned one resident and one med student, whoever was next up in the queue.  The residents came in with us and watched us as we conducted the interview.  Once we said all we could think of, we glanced at the residents so they could ask all the questions we knew we needed to ask but just forgot to.  We quickly discussed the assessment and plan together, then went off to see the newest consult patient.  We discussed all of our patients as a team over lunch (sometimes after a student-led presentation) then visited them together.  At the end of the day we would write our notes, call collaterals, and set up patient appointments. It was all very safe, encouraging, and structured.

My inpatient psychiatry team consisted of two med students (myself and someone who had already been there for two weeks), one resident, one attending, three nurses, and one social worker.  On my first day, I arrived 30 minutes too early due to a paging fiasco and took the elevator to the eighth floor.  I stepped out and stopped dead in my tracks, looking left and right and left and right, seeing only unlabeled doors and empty offices.  Luckily, a few minutes later another student came and led me down the seemingly convoluted path into the workroom.  I waited about 30 minutes until the resident came in, then waited quite a bit longer because he had nothing for me to do.  He finally found a task that even an unfamiliar, foreign med student could do—get consent from a patient to discuss his care with his sister.  I started in on it, but the patient did not want to sign the release.  And I failed at the one task I had all day long to do.  I felt meager and out of place; the resident must have sensed my defeat because he let me go home at 3pm.  I felt more tired than all the times I stayed in the hospital on consult/liaison until 7pm.

But I got used to it pretty quickly.  But this past Monday I moved again.  I hope it won’t take me very long to figure out the right way to turn after exiting the elevator.