True Joy

Some inspirational words I would like to share with future physicians and others, now that I have turned in my rank list for Child Neurology residency and therefore really, truly, contractually dedicated my life to caring for sick children. May we each find our own way to live out these words, as have the dozens of dedicated and inspiring pediatricians and pediatric neurologists I have met on the interview trail.

This is the true joy of life, the being used up for a purpose recognized by yourself as a mighty one; being a force of nature [...].  I am of the opinion that my life belongs to the community, and as long as I live, it is my privilege to do for it whatever I can. I want to be thoroughly used up when I die, for the harder I work, the more I live. Life is no “brief candle” to me. It is a sort of splendid torch which I have got hold of for a moment, and I want to make it burn as brightly as possible before handing it on to future generations.

–George Bernard Shaw

 

Medical Writing

I am excited and grateful to have been selected as a 2009-2010 Medical Humanities Scholar by the American Medical Student Association (AMSA).  I expect this series of seminars on “Becoming a Physician-Writer,” led by established physician-writers, to be a practical and inspirational stepping-stone towards my goal of incorporating writing into my future career in multiple meaningful ways.

As I wrote in my application to the program,

I chose a career in medicine because of my twin loves of science and communication, and my belief that medicine represents the ultimate combination of these passions. Medical practice is the communication of scientific knowledge into the understanding of disease, and its translation into the ability to treat illness and therefore alleviate human suffering.  I also believe that information about medical science can be both inherently fascinating and empowering, as a tool for non-physicians to understand their own health and make informed choices.  Finally, communication about healthcare and patient experiences can encourage medical providers to reflect on their own beliefs and actions, resulting in better care that is more inspired, thoughtful, and compassionate.

I had the great pleasure while interviewing at a residency program yesterday of having many of my interviewers ask detailed, thoughtful questions about my interest in writing and the writing experiences that I had described in my residency application and personal statement.  One asked about my favorite pieces that I have written and my favorite work by established physician-writers; another gave me some new reading suggestions; and another strongly encouraged me to continue my writing throughout residency and to dovetail it with my goal of making contributions to clinical education.  What a joy to have my (hopefully) future mentors and senior colleagues share my belief in the value of medical writing in all its forms.  I certainly believe, as do the creators of the AMSA Medical Humanities Scholars Program, in the importance of writing in community and I look forward to further developing my community of fellow writers and readers.

Here’s a great overview of many of the dimensions of medical writing, with some recommended resources, by Dr. Audrey Young–she was the first of our physician-writer discussion leaders.

 

Looking Back

On a bit of a whim today, I decided to go back to the blog that I kept before I started this one, and wound up importing and then reading through almost all of my old entries (fifty of them! a bigger task than I bargained for).  I have kept their original posting dates; anything from 2006 or 2007 is from the old blog.

I started that blog when I began medical school, and although it was the right decision for a number of reasons (logistical and otherwise) for me to switch to this blog, going back and incorporating most of those entries today was very powerful.  I feel I am reclaiming my experiences across the gulf that separates me from the first two years of medical school, which were much more didactic and abstract, but also times of great idealism and excitement about my profession.  Rereading them, I don’t feel that I have lost too much of that idealism or enthusiasm now that I have more clinical experience, despite the inevitable bumps and bruises of third year.   And that was part of the whole point of blogging during medical school in the first place.

Reposting those entries also encourages me to acknowledge the role that spirituality and spiritual exploration played for me earlier in medical school.  Although I no longer identify with any particular religion or participate in any formal spiritual practice, I think the lessons I learned from attending a Unitarian Universalist congregation and learning about Buddhist meditation have not been forgotten, just sublimated into the underlying whole of who I am, how I live my life, and how I will practice medicine.  The previous blog was explicitly about both spirituality and medicine.  In this one, I didn’t set out to discuss anything other than medicine, but especially for a pattern-finder like me, medicine has come to relate to every other aspect of my life and so this blog has wound up being no less inclusive.

Finally, about the patients.  I started this new blog in part because I wanted to stop blogging anonymously, feeling that it does a disservice to myself, my colleagues, and especially to my patients and their stories if I write under the false comfort of anonymity.  As they say, there is no anonymity on the internet.  But more importantly, I never want to use this blog or anything else I write as an outlet to say things I would not say otherwise, publicly.  This is my voice, speaking about my experiences, and for that voice to be genuine I feel I have to claim it with my name.  That also means I fully embrace the responsibility of telling patients’ stories in ways that contribute to a larger understanding of health and medicine, without revealing their identities and without exploiting their shortcomings.  I have struggled a lot this year about how best to approach this last point, recognizing that humans are imperfect and that their (our) imperfections often are what contribute to poor health, bad outcomes, negative relationships, or unsuccessful interactions and interventions.  I think these stories can be retold and learned from in a professional manner, without any judgment or criticism of specific patients or medical providers, and looking back I see that the stories I have told since the beginning of medical school have in fact been overwhelmingly positive.  Rereading individual stories also made me realize how vivid these people and interactions still are for me as much as three years later.  I reflected on this in a writing exercise a while back in which I wrote again about Ms. A., and realized that though writing about her had preserved many of the details of the experience for me, there were other details I remembered that I had not blogged about at the time.  The whole experience was more vivid because I had written it down, not as a rote recording of facts for the future, but as a way to relive it and to universalize its messages so that they can be applied to future patient interactions. These people I have met during my medical education are the soul of this blog, and, of course, the soul of this profession. I think they would have stayed with me regardless of whether I wrote about them or not, but I firmly believe that reflective writing has revealed the messages of each experience to me in a deeply meaningful and important way. Through writing, I have seen past the surface of these interactions, opened up avenues of patterns and connections between larger themes, and become more fully present to my own experiences: emotions, reactions, missteps, and the fire that keeps burning, keeps me going, as I start to approach the end of this phase of my medical education.

 

Self-Directed Learners

Here’s a nice brief piece from the New York Times on the cognitive abilities of babies and young children. A number of the research studies and findings mentioned are classics of child psychology, and I don’t know that saying that “in some ways, [children] are smarter than adults” really means much. But I like the direction Gopnik takes it next:

Sadly, some parents are likely to take the wrong lessons from these experiments and conclude that they need programs and products that will make their babies even smarter. Many think that babies, like adults, should learn in a focused, planned way. So parents put their young children in academic-enrichment classes or use flashcards to get them to recognize the alphabet. Government programs like No Child Left Behind urge preschools to be more like schools, with instruction in specific skills.

That's a lot of brain for a little baby.

One of the basic experimental paradigms in research with young children as subjects relies upon their innate tendency to look, and look longer, at whatever is new or unexpected for them.  This is the ultimate in self-directed learning, in which babies design their own curriculum by devoting more attention to the stimuli that will teach them the most.  What I take away from this article is an affirmation that young children are pre-programmed to learn, and that with appropriately supportive environments–most of all, the attention of loving caregivers–learning is what they will do.

To quote the great neuroscientist Louis Armstrong,

I hear babies cry
I watch them grow
they’ll learn much more
than I’ll ever know
and I think to myself
what a wonderful world

On a related note, I would encourage anyone interested in education to head over to the website for the master’s thesis project of my fourth grade teacher, Kent Daniels. His unusual classroom was filled with computers, couches, camaraderie, and the most self-directed learning I did until probably college. He treated us nine-year-olds like adults, but he also clearly kept alive many of the same innate drives to learn that we had had since early childhood. Scroll down through this page, or use the search bar throughout the website, for some discussion of our student-created “learning contracts” and the experiential basis for our education that year. Again, this formative experience for me and for decades of Kent’s students is a far cry from the educational approaches and priorities of No Child Left Behind and other regimented instruction. It takes incredibly dedicated and creative teachers like Kent to make classrooms challenging and enriching for all students, but I do hope that continued inquiry into child brain development and educational psychology will inform future educational policy and maybe swing the pendulum back towards something that retains that joyful hunger for learning that children have in their earliest years.

 

What is Child Neurology?

The short answer is… my future career!

I know I have mentioned in my time capsule posts that Child Neurology has been my intended specialty for a while, but as of this week it is official, because I just submitted my application and distribution list to the San Francisco Match.  I will definitely spend more time later talking about why Child Neurology, but I wanted to put together an introduction to what Child Neurology is.  It’s a field that not a lot of medical students are aware of, and I get lots of questions about it whenever I tell someone that it is my future specialty, so hopefully people happening across this post will find it helpful.

What is a Child Neurologist?

Child Neurology – also known as Pediatric Neurology – is a subspecialty combining pediatrics and neurology (see below for training).  It has been board-certified since 1969.  A Child Neurologist diagnoses and treats the disorders of the brain and the rest of the nervous system in children and adolescents.  The common, “bread and butter” conditions of Child Neurology include epilepsy (seizure disorder),  headache, and behavioral and developmental disorders like autism and ADHD.  The scope of a Child Neurology practice ranges from these to more rare genetic, neuromuscular, metabolic, and degenerative diseases affecting the nervous system.  Here is a helpful information sheet from the American Academy of Pediatrics, geared towards parents.  Like most specialties, the scope of ways to practice Child Neurology is broad, and can include private or academic practice, inpatient or outpatient.  The age range seen by Child Neurologists includes young adulthood all the way down to the immediate newborn period.

According to the American Medical Association’s Physician Professional Data, there were 1,352 Child Neurologists in the US in 2008.  This is 0.44 per 100,000 people.  (By comparison, there were 59,441 pediatricians which is 19.3 per 100,000, although I am not sure if that is just general pediatricians or includes subspecialists.)  This included 805 mainly office-based Child Neurologists, 229 hospital-based residents, and 176 hospital-based staff physicians.  According to the Association of American Medical Colleges, the median income for a Child Neurologist in academic practice in 2008 was $146,000 for “early career” (assistant professors) and $191,000 for “mid to late career” (associate and full professors).  By comparison, the figures for a pediatrician in academic practice were $136,000/$167,000, and for an adult neurologist in academic practice $139,000/$191,000.  (All of this information is from the AAMC Careers in Medicine subspecialty pages, which is a great resource for medical students that requires a password from your office of student affairs.)

A Child Neurology Society workforce study in 2003 estimated 817 full-time equivalent Child Neurologists, which is 1.14 per 100,000 children in the US.  They reported an average income of $149,787, with academic faculty earning less than their colleagues in other practice settings.  Child Neurologists earned about $18,000 less than other pediatric subspecialists, and about $22,000 less than adult neurologists.  Although Child Neurology is not a heavily procedure-oriented subspecialty, 70% of survery respondents reported performing or interpreting electroencephalograms for reimbursement, 16% perform electromyelograms and nerve conduction studies, and 60% perform lumbar punctures.

Several sources report that Child Neurologists have the highest levels of career satisfaction of all subspecialists.

What is Child Neurology training like?

The standard training for a Child Neurologist is:

• four years of medical school (the M.D.)
• two years of a Pediatrics residency (they are usually three years long, though some people “fast-track” into other pediatric subspecialties and do only two)
• three years of a Child Neurology “advanced residency”, one year of which is adult neurology

After the five years of residency, a Child Neurologist is eligible to become “double-boarded”, with board certification in both Pediatrics and Neurology with a Special Qualification in Child Neurology.  Some people go on to do additional fellowship training in epileptology, neuromuscular, stroke, and so on.  Also, there are some variations from the training path I outlined above, including doing more than two years of pediatrics residency, doing one year of neuroscience research and one year of pediatrics, or doing one year of internal medicine and one year of pediatrics before entering the Child Neurology residency.  Finally, a few programs have combined five-year residencies that include both the pediatrics and the child neurology components.

There is also a separate residency program in Neurodevelopmental Disabilities (NDD), a newer subspecialty you can read about here.  This requires two years of pediatrics residency followed by four years of NDD residency.  Many training programs offer both Child Neurology and NDD positions.

How do you apply to become a Child Neurologist?

An important thing for medical students to be aware of is that you can apply to Child Neurology residency directly from medical school, unlike most other pediatric subspecialties where you apply after the start of your pediatrics residency.  Here’s how it works:

1. Through the San Francisco Match or “Early Match”, you apply for the Child Neurology residency position that you will start in your third year after you graduate medical school (post-graduate year three, or “PGY-3″).  I graduate in 2010, so I will start my Child Neurology residency in the summer of 2012.  The application deadline and other dates for this match process are earlier than the regular match; it varies from program to program, but the target date given by the SFMatch is August 26 for this year.  The online application opens in June.  You interview in September through December (mostly October and November, I have heard) and then you submit your rank list and find out where you matched in January.
2. You apply to the Pediatrics residency position the same way you normally would, through ERAS (the regular match).

“Word on the street” has it that this may all change in coming years and that everything will be through ERAS, so this information may not be accurate in the future, but to the best of my knowledge it is now.

***Addendum: If you are California-bound, UCSF now has a requirement that Step 2 CK and Step 2 CS be completed and that a passing score be reported before they will rank you for their residency programs, including Child Neurology. This means you will need to make sure to take these exams early, possibly before your school’s required deadline. I don’t want to be the last word on this, so please check with them even if you are applying this cycle and think you won’t be able to take the exams in time.***

There are currently about 76 programs offering Child Neurology training, and about 9 offering NDD training.  There are Child Neurology programs in all areas of the country, both in and outside of major urban centers.  Most programs have one or two positions per year; the largest have four and five.

Do we need more Child Neurologists?

Yes.  A 1998 AAN taskforce estimated that there was approximately a 20% staffing shortage relative to the demand for Child Neurology services.  A follow-up study in 2003 confirmed that waiting times to obtain an appointment with a Child Neurologist were on average 49 days, which most respondents considered excessive.  They also found that referrals to Child Neurologists were increasing, and that in most cases this demand could not adequately be met by general pediatricians or adult neurologists.  Not all slots in Child Neurology training programs are being filled, so the shortage of Child Neurologists is expected to continue at least until 2020.  This brings me back to the beginning of my post: I hope to help spread the word to medical students about the field of Child Neurology, so that more people will consider this satisfying and in-demand subspecialty.

Useful links:

Child Neurology Society (CNS) – A professional society for child neurologists with a great acronym. Check out their free education membership with access to their child neurology case studies.
Child Neurology Foundation – The outreach and philanthropic arm of the CNS. They offered summer research scholarships to medical students interested in child neurology until the recent economic downturn, and hopefully they will resume this program in the future.
American Academy of Neurology (AAN)
American Academy of Pediatrics (AAP)
San Francisco Match: Child Neurology – Includes everything you need to know about the application process for Child Neurology and NDD residencies. The program directory is only available to current applicants.
AAMC Careers in Medicine – Password-protected site with information about specialty and subspecialty training, practice characteristics, compensation, demographics, and even personality types.

Have questions?

I am no expert on this, but I am very happy to talk to other students who are considering Child Neurology or others with questions about the field.  You can contact me by leaving a comment on this post or by clicking the Contact link in the upper right hand corner of the page.  Thanks for reading.

 

On My Way

I feel at the moment that I am perched on the top of a hill.  The long, slow climb of third year is behind me, and I can see ahead of me in the direction I am already starting to move: forward through fourth year electives and a subinternship or two, two residency application processes (more on that soon), two Step 2 exams, and on to graduation in the not so distant future.  Doing all this while planning my wedding just makes me feel all the more future-focused–I even have a countdown timer widget on my iGoogle homepage that ticks down the days, hours, minutes, and seconds (approximately) until I get married, within days of graduation.  I just added one for the day I get my MD:

With all of the procedural things that need to happen between now and when I get my degree and my license, it’s easy to forget the actual process that is occurring underneath, the real reason I am here: I am training to be a doctor.  I can look back from the top of this hill and see how far I have come since the beginning of medical school, and especially in the last year.  I like talking to current third-years, not just because I like to be in a position of giving advice and guidance (which I hope is useful for them, since I certainly appreciated all the help I got from upperclassmen and want to pay it forward) but also because they remind me that I have learned a great deal in the last year and I am on my way to becoming a doctor.  I need the reminder sometimes.

Last month all the fourth-years underwent a rite of passage with the somewhat unnervingly simple title of the “HMS Comprehensive Exam.”  Everything you have learned in medical school, in five hours.  It was our second OSCE (objective structured clinical examination), following the one at the end of second year for Patient-Doctor II.  We were told this exam was “designed to evaluate your ability to integrate the knowledge, skills, and attitudes you have acquired over your three years of medical education” and I thought it was fairly well designed to do so, with a series of nine stations each testing us on those three domains of knowledge, skills, and attitudes (communication, more or less) during an encounter with a standardized patient.  Those lucky third-years I mentioned will have their own chance to take this test next year, so I will not go into specifics about the stations.

On the day of the exam, it took me a little while to get into the flow of the encounters, which were very tightly scheduled and scripted (e.g. “eight minutes for clarification of history, then five minutes for a focused physical exam” and so on for twenty minutes total).  Some of the stations felt relatively straightforward, like the rapid-fire radiology practical; none of them felt easy.  I thought I totally flubbed the one on back pain, doing a cursory neurological examination that didn’t evaluate some of the most important reflexes for the patient scenario.  I’ve been a dedicated student of neurology for seven years now and had great training in the neurological examination (and the importance of a thorough one) during my clerkships; where did that go in the moment?  During the feedback immediately after, the preceptor asked if I wanted her to demonstrate the neurology exam skills she was telling me about.  I hung my head and said no, that wasn’t necessary.

The last station for me was in our simulator center, with a lifelike robot patient hooked up to computers with an ICU-style display of his vital signs and his labored breath sounds filling the room.  As I took his history and did my exam, pressing my stethoscope against the speakers under his plastic skin, he continued to struggle for breath.  I asked for a few diagnostics and tried a few “interventions” but nothing changed.  I finally thought of two different things I could try, but I wasn’t sure which one was right to do.  I can’t find the right words to describe the deer-in-the-headlights feeling I was having, but I was terrified.  How was I supposed to know what to do, when I hadn’t seen this situation before?  What if I made the wrong decision?  I was in an urgent situation, completely alone, a medical trainee’s worst nightmare–in fact, I have already had nightmares about this, and I have never even experienced it.  I just froze up, and the preceptor stopped the encounter early and started the feedback session.  It turned out I had missed a large part of the “point” of the station entirely, because my management of the situation never even got us to that part of the story.  He was kind and tried to guide me through a reflection on what had happened, but I was so flustered I broke down, and talked through tears.  I felt like a failure.  I felt sure I had flunked the exam.  I felt that I couldn’t be a doctor.

Today, I got an email with my final scores from the exam, with an elaborate spreadsheet comparing my performance to their standards.  I passed.  In fact, I did a little bit better than the mean.  My lowest station score was on the last station, but it wasn’t miles away from the mean.  And on the skills score for Management, what I struggled with the most in that station and in so many of the difficult times during third year, I was just about on par.

I am not allowing myself to get complacent after seeing these results; I got the message very powerfully from my experiences during the exam that there is still so much more to do.  But at least by this one metric, this test administered by very experienced faculty to many classes of HMS students who have gone on to become good doctors, I am right about where I should be at this time.  I am on my way to being a doctor–to knowing enough, and to having the skills and the attitudes, to give my patients good medical care.  By this time next year, I will have my MD and I will be responsible for patients as an intern.  I know that that is far from the end of the story, as I will learn and grow so much in my ongoing training (and in the months between now and then).  I guess these exam results just reassured me that somehow I am on track to have what I need to do that job, and I have the basics to build upon.  I can look back from this hilltop, and truly see how far I have come.  And I look forward with excitement to the journey ahead.

 

A Chef in Med School

My lovely and poly-talented (yes, that’s more talents than just multi-) friend and classmate Michelle Hauser has just started a blog, A Chef in Med School.  Head on over for some advice on healthy eating that is based on real science, and check out her videos on YouTube.  I will happily volunteer to taste-test whatever you cook up with her!

 

Healthcare Blogger Code of Ethics

Welcome to anyone who is finding this blog for the first time through the Healthcare Blogger Code of Ethics. I am proud to have been accepted into the HBCE community. I am using this recognition to renew my commitment to protecting patient confidentiality and the ethical use of health information, and I welcome dialogue on this subject or whatever other feedback you have for me. Thanks for reading.

 

Empathy

Reflections on Psychiatry, my last patient-oriented month of third year

Psychiatry was a very difficult rotation for me.  Despite their relative physical health, many of the patients on the inpatient psychiatry service – a locked unit in a part of the hospital many doctors didn’t know how to find – seemed even sicker to me than patients on other services because the level of impairment experienced by some of the patients on the unit was so devastating, even worse than many patients on inpatient medicine units.  Mental illness is powerful enough to reach into every part of a person’s life, and many of the patients had lost their jobs, their homes, their relationships, and their physical health—not to mention their self-esteem, pride, or even identity.  For many patients on other services, whatever illness brought them into the hospital was threatening one or more of these aspects, but rarely all of them.  In particular, it was tragic to see how, unlike medicine, in which a loved one’s illness often brought spouses or families closer together, many of the psychiatric illnesses struck directly at these relationships.  Watching a patient with probable borderline personality disorder interact with her mother, I saw how warped their interactions were and how tested their relationship had been because of the daughter’s mental health issues.  Similarly in schizophrenia, it was heartbreaking to listen to a patient refer to the family that had struggled for years to keep him safe and care for him at home as “just faces I see every day”; as much as the family members understood the patient’s condition, this “autism of schizophrenia” must have felt like a constant slap in the face.  I can’t imagine the pain of watching someone you love be turned into “someone else” by mental illness in a way no physical illness could.

Just as the condition of the patients on inpatient psychiatry was more serious than many patients on other floors, it was also much harder for me to maintain an emotional distance in order to protect myself.  In other rotations it has been easy for me, as a young woman with no physical illnesses more serious than allergies and mild migraines, to enforce a separation between myself and my patients: I don’t have diabetes, I don’t have liver failure, and so on, and so I was able to view their conditions objectively while still empathizing with the patient as a person.  In psychiatry, the border between my mental experience and that of the patients is much more blurry.  We all have coping mechanisms (adaptive or not), stressors, thoughts, and moods; we all have a psyche.  Many of us “normal” people (i.e. the caretakers) have even had our own mental health problems.  It felt like the difference between “us” and “them” was only one of degree, or luck.  There but for the grace of God go we…  While this made empathizing with the patients easier in a way, it also made any degree of empathy threatening to my own equilibrium as part of the treatment team, by opening myself up to the pain of their illness and being unable to dismiss it as something that happens only to other people.  As a daily defense mechanism on the unit, I observed and certainly sometimes participated in humor that derived amusement from patients’ behaviors.  At other times, I just went home and watched television for hours, to try to hide from the emotions stirred up by the day.

It was in this context of the push and pull of extreme emotional empathy and extreme emotional distancing that I finally felt the cord tying myself to a patient as fellow human beings snap – not permanently, but at the time completely, or so it felt.  My day on the psychiatry ward had ended, and I was attending an early evening session of a bedside teaching elective that had spanned the year.  An email had informed us of a special opportunity for some students during this session to accompany “Dr. P”, one of the senior psychiatrists, and discuss interviewing “difficult patients” rather than our usual pulmonary physiology or cardiac exam findings.  Since I was on the psychiatry rotation and therefore had the chance for regular teaching sessions with Dr. P already, I asked to be in one of the regular groups.  Through an administrative misunderstanding, I was put in his group anyway.

My classmate “H” eagerly volunteered her patient “Mr. C” as our interview subject.  As the small pack of us entered his room, she brightly called out, “Hello, Mr. C!  It’s me, H!”  He muttered something unintelligible.  Dr. P introduced himself politely and explained that he was teaching this group of third-year medical students about interviewing, and they began their conversation.  What followed is hard for me to remember in detail, because it was a dizzying blur of contradictions, non-sequiturs, and barely-speech.  Dr. P modeled perfect interviewing behavior by starting with open-ended questions: “Tell me about yourself.”  When that produced a tangle of thoughts that trailed off, he tried again with more specific questions: “Where did you grow up?  Any siblings?  Were you ever in the military?”  The answer to that last one was no; a few minutes later came a fragmented story about his time in the Air Force.  It was like trying to use one of those notoriously poor internet-based language translators: each response that came back was nonsensical, yet delivered with complete confidence in its sense.  Dr. P tried gamely for several more minutes, but it was clear that this interview was exhausting even his normally extensive patience and persistence.  We thanked Mr. C for his time and left the room.

In the small conference room at the end of the hall, with late afternoon sunlight streaming through the windows and a top-floor view of the surrounding leafy neighborhoods, including my own, Dr. P pieced together a discussion about difficult interviews.  My mind was still in the room with Mr. C.  I witnessed the way he lay almost motionless in his hospital bed; the lines and monitors tangled around him; the sores on his legs; his broken-down appearance that looked like more than old age (he was in his early sixties.)  He did not seem to be suffering, or in pain.  His history was hazy—something about alcohol, maybe also an accident.  Sitting in the conference room, I looked down at him through my own eyes and felt… nothing.  No stir to empathy for the depth of his deficits.  No urge to help.  No reproach for perhaps drinking himself into oblivion.  Not even pity, of the kind that builds walls.  Just an emptiness.  In my mind I responded to his unstated but unavoidable question  of, “Well?” with, “I’m sorry.  I have nothing to give you.”

While I have known patients this year who were difficult, trying, mean, or just too far gone, patients who stretched our abilities even to hold our tempers much less to provide any kind of care, this was the first patient who inspired no feelings of any kind in me.  And that was terrifying.  All of the others at least felt like human interactions: relationships marked by dislike, disgust, enmity, and of course warmth, friendship, grief, compassion, and caring.  But never before a failure to respond on the most basic human level.  This, I realized, is burnout.  I cried as I walked home, leaving the hospital by the back entrance and blinking in the beauty of the sunshine and the Fens.  The tears dried up quickly.  I threw on shorts and sneakers and went for a run, pounding the sidewalk with angry feet.  I flopped on the couch and watched TV shows back to back to back while I ate leftovers.

When I began my third year, I vowed to myself not to lose the idealism that brought me to medicine, my compassion for people that moved me to understand them and to care for them.  When I began my third year, I didn’t see how anyone could lose that, how bright-eyed medical students became the jaded, uncaring doctors we have all heard about.  I think that this one patient encounter, this one empathic failure, was a sobering gift at the end of my third year.  People often ask me how I have changed during third year, and I think it’s this: even this early in my clinical experience, I have developed a far more nuanced understanding of how compassion inspires doctors to do what they do.  We don’t love every patient; far from it.  But we can come to medicine out of a desire to help people, out of a belief that all people deserve to be helped, and this gets reinforced and rekindled by the patients who do touch our hearts.  For the rest, as I discovered in a previous rotation, we do our job anyway and give them good medical care.  So when I call this patient encounter a gift, it’s because it was a humbling warning, a call to attention that will help me to continue forward with a more subtle and also more durable sense of purpose.  I learned that I might not always have empathy for all of my patients.  But never on that day or since did I question whether I should, or could, be a doctor.

 

Time Capsule II

Where I am at the beginning of my third year
Where I am at the beginning of my fourth year

age: 24
age: 25

residence: Boston, MA – medical school dorm
residence: Brookline, MA – apartment with a roommate

relationship status: four years seven months, and engaged
relationship status: five years seven months, and still engaged (twelve more months to go…)

exam status: USMLE Step 1… passed, I hope
exam status: USMLE Step 1 passed (plus Surgery, Medicine, Pediatrics, Ob-Gyn, Neurology, and Psychiatry shelf exams), Step 2 CK and CS on the horizon

expected date of graduation: May 2010
expected date of graduation: May 2010

future career: physician, academic medicine in a large urban area, mostly clinical and some education (student and resident levels)
future career: physician, academic medicine in a large urban area, mostly clinical and some education (student and resident levels)

front-runner for future specialty: Child Neurology
front-runner for future specialty: Child Neurology

other possible specialties: adult Neurology, other Pediatrics subspecialties, Ob-Gyn?
other possible specialties: other Pediatrics subspecialties, Ob-Gyn

outside activities: … (when I can: yoga, meditation, jewelry-making, cooking)
outside activities: TV, gym/running, jewelry-making and other craft projects, cooking, wedding planning, NYTimes Sunday crossword puzzles

vices: chocolate, online bead stores with free shipping, Target, shoes, Target shoes, jewelry, kitchen stuff, a very messy room, RSS feeds, cuteoverload.com
vices: chocolate, Second Time Around (that’s nothing new), kitchen stuff, a usually messy room, wedding-related RSS feeds, cuteoverload.com

listening to: Tammany Hall NYC, The Weepies, or anything else from the Scrubs/Garden State soundtracks; misc. alternative/indie rock, soul, Ella Fitzgerald
listening to: Bic Runga, Ingrid Michaelson, lots of mixes

with me at all times: keys, HMS ID, wallet, cell phone, migraine meds, makeup, my Nalgene
with me at all times: keys, hospital ID, pager, iPod Touch, wallet, cell phone, migraine meds, makeup, my stainless steel water-bottle, NYTimes crossword puzzle

last time I read a book: last night
last time I read a book: umm… uhh… does Martha Stewart Living count?  [edit: I technically just got back from Spring Break, during which I read about 1.3 books, but before that...]

last time I went out to a movie: I truly can’t remember…
last time I went out to a movie: I truly can’t remember…

average hours of sleep per night: seven
average hours of sleep per night: six and a half (very variable)

coffee consumption: one per day, usually drip made at home
coffee consumption: one per day, usually drip made at home, then a cup from the cafeteria at lunchtime, and sometimes Starbucks when I think I deserve it…

All in all, not a lot has changed… at least not a lot that is captured on this list.  Stay tuned for a post on how things have.