Christmas in Connecticut

Taking a quick break from the anti-technology holiday I am having here in Connecticut (where they invented Christmas I am told!). I am currently at the Glastonbury Library with about 10 mins on the computer to check email and such. Despite a rough start to this holiday vacation, things are turning out to be very relaxing. Barb's family, Charlie and Jolly, have a wonderful home just outside Glastonbury that just oozes "New England". We had a fabulous Christmas dinner together with friends and neighbors. My days are filled with naps, books, walks in the countryside and a bit of sherry every now and then! Tonight we are taking a walking tour of "Mystic Seaport" where they put on an entire nautical show of some sort. Tomorrow, the family is spending the day in New York city and I may go hang out at the Metropolitan Museum of Art or perhaps just stay home on the couch and nap some more! A luxury during medical training that is more precious than gold to me!

It feels like such a wonderful home in so many ways here. Sort of a "Norman Rockwell" kind of Christmas to me in many ways. We even roasted chestnuts on an open fire! For real! I will get some photos uploaded as soon as I return... I can't say enough about having friends like Barb, Mark and everyone else in my life. This Christmas and past year have seen a lot of changes and challenges with medical school and personally. Having such a warm home and time away during this Christmas has been amazingly rejuvinating. I have also met some wonderful new people and continue to work on maintaining the relationships I already have in my life. I am really looking forward this coming year to seeing the fruits of all the growing this past year. Gotta run now!

A Break From Introspection

This is one of my favorite little places to get a quick bite to eat in Seattle. It is in the parking lot of a Winchell's donut shop of all places in Wallingford, perhaps one of the least Hispanic areas of our fair city! It is called Rancho Bravo Tacos and this truck used to be in Kirkland but they said business never really took off there. I highly recommend the rice and bean bowl with carnitas and the green sauce. Inexpensive, filling and very tasty. Oh yeah, their large horchata is VERY large!

So, my first weekend off in a while! I have two weeks in which to do whatever I want. today I am packing up the condo I rented while I was at "County Medical Center". It made things really nice to be a block from the hospital. If I can manage to get most of it done this afternoon I will return to Barb & Mark's house, my close friends, that have given me a room to use as a home base during this crazy time in my life. They are still storing my motorcycle (which is for sale in the spring if you know anyone wanting a sweet BMW!) and what few possessions I still own! (mostly backpacking gear and a small desk I refinished myself that I love!)

I am also getting ready to head out to Connecticut for Christmas with Barb, Mark and Barb's family! (The photo to right is a trip we took together to spend Thanksgiving weekend in The Yurt!) I may also get to see an old friend from Seattle, Yvonne, who was spirited away to Boston years ago and has been converted I think. She loves it out there from what I hear. I leave at 10pm on Christmas Eve (that link will track that flight on the day you click it, so on the 24th you will know where my plane is!) and just like Santa I will travel this entire country in just a few hours, to arrive Christmas Day morning in Boston. Then I catch a bus from the airport to Glastonbury, CT where Barb grew up! Looking forward to a white Christmas with close friends for sure. It has been one hell of a year and a little down time is in order. I return to Seattle on December 30th and have been invited to a "murder-mystery" New Year's Eve party in Yakima, WA! Sounds a little sketch... but maybe!

In addition to all this, I spent about an hour today trying to remember how to play MY CELLO! Yes, I have not played in about a year due to some problems I had with a hand tremor. The tremor is still there, but is better and I miss the sound of my cello. I just decided to add photos of my cello to my photo page because I want everyone to see how beautiful it is and publicly proclaim my guilt at neglecting this sweet instrument.

12 Weeks of Internal Medicine and All I Got Was This Lousy T-Shirt!

I did it. Today marks the end of my 12-week Internal Medicine rotation. Did I get a t-shirt out of it? Not really... but I did get a sweet pair of scrubs and a white coat with all sorts of county hospital nastiness on it! Oh yeah, I also left with what I like to call "The County Medical Center Hack". Some sort of lung badness that I don't know how to diagnose!

In all honesty though I did learn a lot during my 12 weeks of internal medicine. Luckily, some of what I learned was actually medicine (I feel that I passed my final today anyway) but mostly what I learned during this rotation was about how to balance a professional life and medical training and to accept less than your normal 140% when it comes to "duty". It was a very challenging rotation that saw a number of personal insights, mistakes and revelations...

Earlier this last year I learned some very painful but important lessons as you may have read in previous posts. It has been a number of months and it took time to understand the tools I had been given by that experience. I now feel like I was just given a huge suitcase of shiny new power tools with sharp blades and I thought I would be able to walk out the door and build my own house. Just like medicine, reading the book and memorizing a few facts does not mean you really have any idea how to treat patients without some skilled instruction and practice! Like many weekend home-improvement warriors, I plugged in my shiny new power tools and set off to remodel my life. Instead, I ended up in the ED with lacerations and bruises but also with a new found respect for my power tools!

In the process of this "home improvement" I learned a lot about balancing my personal life with the struggles and needs of medicine. It was truly "Internal" medicine. During this rotation I chose to put medicine second on my list of priorities which was a new thing and something I felt terribly guilty about. In the past I learned the hard lessons of using medicine as a scapegoat to avoid hard personal challenges and this time I was determined to make better choices. This time I put my life first and used my new toolkit to try a little "life improvement" project so to speak. Despite the fact that what I tried to build came out a little lopsided and the roof leaked and the windows didn't close properly and.... well, you get the drift, I think it was a success.

I thought neither medicine nor relationships would settle for second place in my life as they are jealous and bitter rivals. I had heard many stories about rotating through Internal Medicine at a major county hospital. Just like surgery, it was part of the "old school" of medicine and that personal lives, personal needs and even bathroom breaks would not be tolerated. I was wrong. Everyone during my rotation (the attendings, the residents, the chief resident, my clerkship director) absolutely everyone was understanding, supportive and all had a personal story themselves. They had all tried to manage this heavy responsibility of medicine in one hand and the people they cared about in the other at some point. They all struggled with how to be human outside the hospital while at the same time trying to be at 120% inside the hospital. To me, I felt like I was living on credit trying to be 100% outside and at the same time trying to shine inside. Every day I became more and more overdrawn and I knew that at some point, unless I did something, the bank was going to foreclose.

Earlier this last year I foreclosed on my relationship and used medical school as an excuse. I felt I was failing at both. I could not take it and I decided on medicine over love. In truth, love was pushing me to grow so hard and in so many ways I just could not handle it at the same time medicine was asking the same. Instead of "stepping up to the plate" I bailed out on someone that cared about me. It was the worst mistake and the best gift of my adult life. I then studied for my boards, passed them, and eventually sorted through the wreckage I had caused. It sounds like a failure but it was the best thing that could have happened to me because I felt like I finally had grown up. This time, instead of choosing one over the other, I juggled both because I knew I had to. I could not give up on either because they were both necessary for me. My insecurities told me I was failing at both, but in retrospect I see I was doing fine. I got excellent feedback from my clerkship and I also now realize that I gave more time, energy and dedication to the person I was with than I thought possible. I actually gave a little too much, perhaps overcompensating. In the end, I did both well, not perfectly, but well. Sadly, the relationship collapsed but I don't see it as a failure. It was not about luck or timing or anything, it was about choosing. About taking responsibility for what I wanted in my life and accepting the consequences of my decision.

During this internal medicine rotation I tried to make better decisions with regards to someone I cared about. In this I feel that I succeeded although perhaps I overshot the mark some. For the first time in my life I feel like I have all the puzzle pieces in front of me and now I simply can focus on putting them together. I have my professional life figured out and I understand what that means to me. I understand also where my priorities are with regards to my friends, family and eventual life partner. I have decided I want them all and that to make them all happen I will have to make some hard decisions and sit in some uncomfortable places, but I choose those places over an incomplete life.

I think that the only way to avoid becoming resentful of medicine is to not amputate your life to placate your own insecurities or expectations of yourself. I think many of us in medicine feel a need to be perfect all the time. I think there are many reasons for this but a big one is that many of us feel anything less than perfect is a failure. It is egocentric and selfish in many ways. We are not perfect and we struggle to be good friends, good partners and good physicians and it is good to realize that you can't always do them all well and at the same time. The key is balance - accepting your limitations and adjusting as necessary when needed. It is a lesson I learned during this last rotation. Despite my lack of proficiency with all these new tools I know that at least I now have all I need to build the life I want. It is just a matter of practice, learning and moving forward with the understanding that I will get better at using the tools as I go along.

Perhaps I should start with a doghouse or maybe the garage before I try and tackle the tile work in the kitchen or the fine cabinet work of my life...

Delivering Death, Delivering Life

I recently have had the chance to work closely with a Palliative Care physician while in my Internal Medicine rotation. Although we did not spend much time discussing the field of Palliative Care, we did spend time together delivering the news to one of my patients that although 2 weeks ago he was healthy, he now only had anywhere from 6 to 18 months to live. He has small cell lung cancer which is very aggressive and inoperable. The woman I worked with is a doc that spends 50% of her time working in Emergency Medicine and 50% in Palliative Care. I found this role very intriguing and am thinking of exploring it further.

Although I had a reasonable amount of exposure as an EMT to dying patients and their families, I have not yet had much experience as an MD with this. I have always felt a certain longing in my heart for those encounters though and miss my time as an EMT for just this reason. It may sound odd, morbid even, but I find those encounters the most satisfying, energizing and indescribably beautiful. So many people in our health care system don't NEED medical care - what they need is self care. They need the desire to be healthy & happy but instead of doing the work to maintain their own bodies they lead destructive lifestyles and only then do they turn to medicine for a pill to alleviate the consequences. These patients drain me.

It is the dying patients, the terminally ill, the trauma victims in the emergency room that make me feel alive, feel needed and ultimately humbled when asked to serve in their time of crisis. It is in those moments between life and death that you can touch their sorrow, their joy and their fear and you truly see something normally hidden. The families of those dying people radiate something brilliant that you can almost touch. You can see the tangible tendrils of love between those that will live and those departing. It breaks your heart and at the same time it fills you with love and a sense of what life is truly about, what truly matters. Everything is in balance and when you see the pain you also see the joy, they are one in the same and can't be parted. It is these patients that reveal the true nature of loss and grief and that similarly reveal the nature of love and joy.

As a healthcare provider I found the relationship to these emergent patients the most satisfying, beautiful and ultimately transcendent. It is where I found the love of medicine, not just the enjoyment, fascination or challenge. This is perhaps why I gravitated to Emergency Medicine in some respects. I have also glimpsed it in Surgery and perhaps understand what draws some students to travel that hard path. What I recently learned with my cancer patient though is that someone does not need to have their life draining onto the floor of a trauma resuscitation room to evoke that same space and need to serve in me. It is when I first entered someone's home as an EMT with screaming family members surrounding a blue and dying body that I first felt this focused sense of wonder. It was the immediate threat of death that seemed to reveal it all, but I just recently discovered that it does not take the immediate threat to reveal these truths. It simply takes the undeniable truth that death is about to arrive.

That is what happened this weekend when I told this young, 57 year old man that he was not going to grow old with his wife, he was not going to see his grand kids graduate. That instead he was going to see one more winter, two at best. He is a stoic, matter of fact sort of man and he took it with a clear and thoughtful face, but you could see it. The small things fell away and the person he was became clear. His sense of sorrow, joy and purpose became clear. He saw his own mortality and it was humbling to be the one to offer it to him. As I have seen in the days since, it is also an honor to be a part of this realization for him and having a role in making his remaining days alive good days seems very valuable and meaningful to me. It is not about "saving him" in the physical sense. It is about serving him. It is not about curing him, not about fixing his problems. There are no solutions. It is about giving him the chance to live every day without the distraction of pain. Without the physical suffering of his cancer and allowing him to fully experience whatever and whomever it is that he loves.

I want to see him return to his life without pain. I want him to have the time to love those close to him. Without our treatments he would likely be dead within a month or two. With the treatments he will be largely asymptomatic (without pain) for anywhere between 6 to 18 months. That time is a huge gift and I am lucky to be able to help offer it. This was a good way to spend my last few days.

How To Have a Conversation with a Medical Student

I realized how much more difficult it is becoming to talk to my friends about my daily activities the further I burrow into medical training. As new words and acronyms start to take over the nooks and crannies in my sentences I find people are asking more often to explain what I meant... Therefore, I thought I would try and start a little dictionary for the uninitatied. I will try and add to this post as time goes by if I get new terms that I think need a little explaining...

• "Rounds or Rounding" - this term is used for a wide variety of activities but usually means anything where doctors are all getting together to see patients or teach one another. Strictly used, it means we all get together as a group, our medical team, and walk around the hospital seeing all our patients, discussing their case, making plans for the day. Sometimes we sit in a room and do this as a group, sometimes we are going over a teaching case. In any case, we are "rounding" and this is sacred time! :)
  
• "On Call" - This is a difficult one and comes up often. I think it varies somewhat from place to place because there are many variations. There is "hospital call" and "home call". At "County Medical Center" we also have "long call" and "short call". In general, when I am "on call" it means I am staying the night in the hospital working. Often you start on day 1 in the morning and you leave the hospital on day 2 (see "post call" below) in the afternoon. About 32 hours awake and working. There is usually a "call room" in the hospital where you can sleep if things slow down, but rarely do you get more than an hour or two. During this time you have a pager on and you are admitting new patients that are sick and need to be hospitalized.
• "Post Call" - This is the second day of your "call" as mentioned above. This day you usually are sleep deprived and functioning on about half your cylinders. People have many different routines, I like to take a short nap then get some exercise and have a nice mellow evening out and a good night's sleep.
• "Post-post call" - Yes, this is getting insane, I know... this is a specific phenomenon though. This is the 3rd day after your call day. Techincally, you have had a full night's sleep but many people call the "post post call" day one of the hardest. Not sure, you are rested to some extent but your brain still does not quite add 2+2 correctly. Usually it smooths out in the afternoon and things get back to normal soon...
• "Q" - (As in "Q4" or "Q5") You will hear this in reference to the timing of things. Comes from the shorthand of writing prescriptions. Q is meant to denote how often something must occur. So, if I am on call Q5, that means I start a call day every 5th day. Currently, I am on call Q5 for "long call" meaning an regular overnight call period. I am also Q5 "short call" at "County Medical Center", which means it is a normal 10 hour day, but we admit patients in addition to our daily duties.
• "The Golden Weekend" - Since call is almost never Q7, it means you call days phase in and out of the normal work week. If you are Q5 and on call Wednesday, that means you next call day is Monday. Eventually you get a Thursday call, which means you leave the hospital at 3pm or so on Friday! This gives you a nice Friday evening and all weekend off. This is "golden" for us even though it is a normal weekend for the rest of the world!
• "The Black Weekend" - This is the sad state when your call falls on a Saturday. You work all week and then Saturday morning you are back in the hospital. You get out Sunday afternoon, but you start working again Monday so you effectively get to work 2 weeks straight!
• "PRN" - another prescription writing shorthand. Means "as needed" as in "take this prescription for pain as needed". I write on my blog PRN to keep my sanity!
• "The Intern" - this is your title during your first year is residency. Residency is your post-graduate training after medical school in your specialty. Here you are an MD, but still overseen by other docs. Your intern year is famous for being hard and getting worked to death as you rotate through all other specialties that are relevant to your specialty. Sort of like 3rd and 4th year medical school but now your signature counts for something and you get twice the workload!
• "The Senior" - This is the senior resident on your medical team. They are the boss for the daily duties and work in the hospital. Every team is overseen by an attending physician though (below).
• "The Attending" - Someone that has gone through all this crap already and is now a board certified physician in the specialty. They are where the buck stops and they are also responsible for your actions as a student and resident. They are there to guide and teach mainly and they review all procedures and documentation during any patient care.
  

A Few Minutes to Myself

It is about 6am and I just woke from a record 3 hours of sleep. I have a few minutes for a cup of tea and a moment to write before returning to the sick. My morning cup of tea is a highly valued period of time in my life. Even if it means waking 30 minutes early from an abnormally short sleep just so I can sit, drink and prepare. It gives me time to clear some space in my mind for the coming day.

I am currently on call at the "County Medical Center" where I am doing my internal medicine rotation. On average I get an hour of sleep on call nights so tonight was very much a luxury. I could have had 4 hours of sleep but when I tried to close my eyes last night my mind began to race. Thoughts of all the things I did not have time to think about during the preceding day seemed to swirl in front of my closes eyes. It is as if there is conservation of thoughts in the universe and all my unexamined reflections need inspection before they would allow my brain to retire. I could just not get comfortable and tossed and turned for over an hour before I awoke tired and a bit stunned.

I don't really understand why my brain seems to be so prodigious at producing thoughts in general. Most of them result in nothing of use in my life and as a matter of fact, a large majority seem to make my life more difficult. Still, they must be thought it seems. This is perhaps why I always found activities like rock climbing and riding the motorcycle relaxing. Things many people view as stressful.

In New Mexico, when I worked as an astronomer at Apache Point Observatory, I would rock climb 3-4 times a week on the nearby dry limestone canyon walls. It was here, with my climbing partner John Hymer, that I learned the peacefulness that could be found amongst the rocks, ropes and chalked fingers. People would ask me, "How in the world do you find clinging onto the side of a cliff relaxing in any way!". Simple. When climbing there is only one thought. "Pat attention to the rock, hold on". It was like a holiday for my brain to remain focused on one item alone. The rock. My body. Meditation...

The hospital is the opposite of meditation. You have thousands of thoughts running around your mind and to make it worse, they are not your thoughts. They are details about the mechanisms of action of this drug or that. How you tell the difference between and exudative or transudative fluid. Do you order an LDH? What about protein and cell counts? Didn't you hear something odd about cholesterol in pleural fluid once? Your brain swirls with all that you need to know or at least be familiar with and your life, the outside world is put on hold. In fact, it does not exist any longer while you remain in the linoleum lined halls. (which reminds me of an excellent book I am trying to read that I must point out here) Your thoughts seem to get re-routed into a holding area. There they stay, getting more and more agitated by the minute because they want their time. When I lay down to sleep, they come.

This is not my normal routine. I always seem to think a lot, but in the last few months since rotations have started I notice how static-filled my brain has become. It is as if clinical rotations are like fertilizer & sun lamps and things are growing faster than I can maintain them. I crave time away, time for my mind to wander, to be empty, to experience the world through my senses and not through my analysis. Training is fascinating at times, but the space it occupies in my life sometimes seems cumbersome. I am finding how hard it is to balance. More exercise, more journal time, more sensory experiences and indulgences. I am trying to add weight to the parts of my life that feel neglected but I also worry about the total capacity of this balanced beam. You can't keep piling items on in order to achieve balance, but during training you can't easily lighten the load on the other end either.

The Labor of Love

I feel compelled to discuss something I heard in a friend's email recently because it is an issue close to my heart right now for several reasons. The statement she made was that she wanted a permanent relationship but that she wanted it to be with the right person. The key word that caught my attention was “right” in regards to the person. (this email was not from someone I was recently close to, just FYI)

This has been a slippery slope for me in the past and the present. I have left wonderful people because they were not “right” and wonderful people have left me for the same reason. Over this last year I have started to drift away from the idea of someone being “right”. I see now more than ever in my life that love is not a feeling or an experience that we wait to have, we wait to find or that finds us. It is a decision that we make and by making it we enjoy the rewards, costs, pleasures, pains, the benefits and the drawbacks. It is all a package and we bear the responsibility for the decision to choose love. To decide upon it.

This may sound less than romantic but I think the romantic angle has not served me well in the past. Yes, I do want romance and to feel swept away or to find a soul mate, but I also think I have used that line of thinking for a long time to distance myself from commitment and responsibility. I now believe that there are many right people out there, we simply have to make the decision to commit to one. We simply have to choose to love.

I am not saying this can happen with just anyone but the list of check boxes required in the choosing needs to be short and succinct - like poetry. The best words in the best order. What is truly important? What really drives a sense of respect and gratitude for someone else in your life? I know for myself that intelligence & courage are key along with a lack of fascination for the superficial. I also believe compassion for others is important, a desire to give back to others and your community in some way, any way. Then comes the long list of details. Some more important than others and these may add up more or less to the mechanics of how your decision will function.

I have spent way too much time in my life on the check boxes hoping that if I found someone that met all my criteria it would be easy, it would be safe and no one would get hurt and we would simply feel love. I think now see that I was being naïve and I see now that it is labor, like anything, hard and rewarding. The labor of love. It is something you build, something you sacrifice for and something you benefit from when your partner sacrifices for you. It is in sharing this mutual burden that you grow close to someone, you end up trusting them and you end up loving them beyond the initial butterflies and endorphins… The beginning of this labor is in yourself - in overcoming your fears and years of childish belief that love is destined, that it is perfect, easy or that you deserve it. You work for it and in that effort lies your appreciation of it. You always appreciate something more when you work for it, isn't that the old wisdom?

Suffering, Creativity & the Ego

I have been doing a lot of thinking lately about suffering, in the Buddhist sense. This is an entry I will expand upon soon but for now I will simply start it. Suffering is described in some circles not as something that is inflicted upon us but something we inflict upon ourselves due to our desire for the world to be different than it is. Of course, other people can do hurtful things to us, we can experience pain both physical and emotional, but where is the line between pain and suffering? Many painful things we seem to enjoy, like long distance running, mountain climbing, etc... Suffering is a whole different idea and I feel it encompasses not only pain but a sense of despondency or anger in addition.

When something hurtful occurs in our life it is most normally and naturally felt as pain, but soon our own decisions about how we choose to accept that reality into our life seems to govern the beginning and ending of suffering. I have just recently begun reading Buddhist texts on the nature of suffering, so my words are in no way meant to be educational, this is simply my reflection.

It seems suffering is best described as our intense and tortured desire for reality to be other than it is. Our anger, frustration and personal sense of betrayal that reality is something other than we wish it would be. Suffering is the difference between experiencing pain and the experience of being perplexed, angry and frustrated that our desire to not be hurt is in conflict with the reality that we are experiencing pain. Can pain be accepted and experienced without this desire to not be in pain? If so, does it relieve the sense of suffering we experience? The bottom line to this area of thinking is that if we simply learned to be more aware and accepting of what the world around us truly is, see reality for reality's sake, we would decrease suffering and increase the true experience of life (which is not always pleasant).

Of course, those of you that know me understand why I am thinking about this so much lately. I have had a series of challenges lately that have put a reality that conflicted with my wishes and desires into sharp perspective. My suffering seems to come from my inability to let go of my desire for reality to reflect my idea of what I wish it to be instead of seeing and appreciating reality for what it actually is. Appreciating is not necessarily a positive experience, it can mean appreciating the fact that something is painful or failing to be realized.

I have wondered lately if suffering in this sense is an experience most applicable to those with a truly creative mind, a strong will and perhaps a bit too much ego. For those with the ability to vividly imagine something in great detail - to truly create a vision of something in their mind and consciousness and that also have the will to develop the desire to see it realized may suffer to a greater extent. Why? Because we tend to create a vision of what we want around us and then we set our minds to the job with diligence and the expectation that we will succeed, that reality will reflect our wishes. Then, when reality fails to deliver what we intended from our efforts we struggle against that truth. We work harder and harder to reconcile reality with our expectation. We become upset, angry, frustrated or despondent that no matter how hard we try to control the situation, reality and our expectation are not the same. It is our attachment to our expectations, our refusal to alter or release them in face of reality that causes us to suffer.

The release of suffering is when we finally accept reality, release our expectations and then experience what is truly present. When I wonder about this I wonder if great artists, leaders, scientists or others that seem to posses these qualities of creativity, willpower and ego in excess therefor experience an increased amount of suffering in their lives? This is what I am pondering on today.... Without these qualities it is hard to create or shape the world around us but in excess they lead to suffering to the extent that our ideas and desires are beyond what reality can truly deliver from our efforts. Some things are just not within our control no matter how hard we try. What I love is how well this sentiment is reflected in the serenity prayer. There are few sentiments that are more true.