Having trouble even knowing where to begin writing about my experiences with inpatient medicine. Despite knowing how sick you have to be to get admitted to an American hospital in 2008, I was not prepared for the pain I have witnessed. Every patient seems to have so many problems: an acute exacerbation of their emphysema or heart failure on top of their underlying diabetes and vascular disease and drug abuse compounded by a history of heart attack, stroke, and cancer. Either that, or they only have one, but it’s the one that is enough. And I don’t know how to process the experiences I have had even in the span of a week, especially now that I have been able to take somewhat more responsibility for admitting “my own” patients.

One patient, a known drug abuser, writhed in pain in his bed. He was begging for pain medication, but little could be done: so much drug use had dulled his responsiveness to opioids. And he had broken his “pain contract” with the outpatient pain clinic by seeking pain medications from more than one doctor, so he was no longer welcome there.

Down the hall, a man on the cusp between middle and old age sat reading a mystery novel while an IV delivered fluids into his arm to treat his dehydration. “I was in the hospital when my ‘friend’ died,” he said, slightly accenting the word, “and I guess I just stopped taking care of myself after that. We were together for almost forty years.”

One of my patients was a diagnostic challenge from the minute she came in from her nursing home for nausea and vomiting. She was sweetly demented, so she couldn’t say much about what had been going on, and she would tell different members of my team that it hurt at different times in different places. We kept getting excited every time we thought she had a new disease to add to her extensive medical history, hoping she was sick: if those really were enlarged ventricles on the CT scan of her brain and she had normal-pressure hydrocephalus, it meant we could do something for her. Otherwise, she was condemned to her dementia. She sat on a board of trustees only eight months ago, her brother said, and my eyes burned. We still don’t know how to treat her urinary tract infection.

The same patient left me kicking myself when the neurology team gave her the diagnosis of not normal-pressure hydrocephalus, but Parkinson’s disease, a long-standing interest of mine. How could I have missed the tremor in her hands, the rigidity of her limbs, and the classic expressionless face? Easily: I was fitting her symptoms to the diagnosis (NPH), not the other way around, and I never stopped to ask myself the question “what else could this be?” We started her on Sinemet to replace the dopamine her brain has run out of, and I know it’s probably all in my head, but I could swear that overnight she became more animated. Her eyes met mine when I said goodnight to her today, and I realized it was the first time she had smiled at me.

The hardest patient was a middle-aged man with end-stage liver failure and untreated AIDS. His body looked alien, humanoid but not like any other human body I had ever seen. His belly was enormous, perfectly round and stretched with ascites, the fluid seeping into his abdomen because it could not pass through his cirrhotic liver. His arms by contrast were stick-thin, all the muscle melted away. His legs were puffy with fluid, soft swelling over sticks. And his head was so shrunken and wasted I could hardly believe it could contain his skull. He looked out at us through wet brown eyes in an emotionless face, tense and quiet like a scared animal. His breathing became unstable this afternoon and he was moved to the ICU, sedated, and put on a ventilator. I guiltily felt a little better once he was sedated because he didn’t seem quite as much like a conscious soul trapped in a distorted body.

My last patient today was a middle-aged man with metastatic cancer. His cancer was originally diagnosed in another country a year ago. They gave him symptomatic treatment, and he felt better, so he thought he was better. This week he started having pain again, and his CT scan showed the mass had spread to three other organs. It was Stage 4 of 4, inoperable. Not years but months. His son grasped desperately at other explanations – it was an infection, it couldn’t be cancer because his father didn’t look sick enough. He asked me in his own words to help him understand the biology of cancer, seeking answers in mutated DNA bases and cells that lose the ability to stop spreading, eating through walls into other organs. On the first day we thought the patient spoke only Portuguese, so we relied on his adult children and the interpreter. On the second day I found out he speaks some Spanish, and from then on our communication has flowed through a wide-open channel, mixing our “fazers” and our “hacers” and cracking jokes and crying. It wasn’t the first time this year I have been so grateful for my Spanish. Exhausted from having no days off for two weeks, being on-call last night till midnight, finishing my work at home, and then coming in at 6:15 this morning and staying until 8, I still went in to say goodnight to him after I dropped off my note in his chart. And time slowed down for a while as I sat on the edge of his bed and we talked softly. He still feels shocked, and shakes his head at what he understands about what he is facing, but his voice was full of peace. In half-Spanish, half-Portuguese he spoke with deep gratitude of the love and compassion and professionalism he has experienced during his hospitalization. I wound up leaving at the end of this whirlwind day feeling that he had blessed me and my work, and I was uplifted, even though he was so far the patient I have seen who has gone most dramatically from health to illness. Obrigado, senhor.

I have now finished my three-month surgery clerkship, and I start medicine tomorrow, meaning I am a quarter of the way through my third year of medical school. I’m not sure I like that idea. I don’t feel a quarter of the way towards being as smart, wise, skilled, or experienced as I hope I am by the end of my third year. Not that there is necessarily a way to gauge the intangible elements, although there is a log students keep of the more tangible elements (see below). It’s hard to tell how much progress I’m making since so many things still feel so new, though it has been fascinating realizing from conversations with my fiancé (also a third-year med student, though he started in July rather than May so I had a two month head start) how much I changed in those first two months at least in terms of language, and perhaps understanding or at least wards-savvy. We’ll see how I feel when I’m on the medicine floors and am hopefully more “in my element”, surgery being a very foreign though welcome experience for me. I hope to have time to reflect on those three months more here on this blog. Anyway, I’m going into my medicine clerkship with an overall feeling of having a lot to learn, both about diseases and about how to be a someday-doctor.

A few mid-year New Year’s resolutions for this transition point:

1) Stay organized and on top of my schedule, no matter what. In my last week on surgery I missed a required class because I both lost track of time and failed to remember that the class was meeting that day rather than its normal time slot. Not a big problem this time around, but in order for me to meet the professionalism standards of medicine, it can never happen again. This is a post for another day, but for better and for worse perfection is the expectation in medicine, at least as far as definable errors go. As fuzzy as my brain can be particularly if I’m low on sleep or busy and disoriented on the wards, I can’t miss appointments with patients, faculty, or my classmates who are now truly colleagues. Fortunately, hope has arrived in the form of my new PDA-and-favorite-toy, an iPod Touch. I wanted something that could handle email, calendar, and contacts with the ease of a traditional PDA, run at least the essential medical software (Epocrates), and also replace my worn-out iPod as a source of entertainment for the walk to the hospital or while at the gym (see below). So far I’m very, very satisfied with my somewhat unconventional choice of a PDA (with thanks to my fiancé, who made the same decision and also helped me realize that it’s exactly what I was looking for). Mine has been dubbed Penny, both short for James Bond’s tireless assistant Moneypenny and named for the behind-the-scenes hero Penny of the Inspector Gadget cartoons. She uses a special computer-book to get instant information and make Gadget’s otherwise hapless schemes possible. So that’s goal number one: obtain and use the information I need to stay on top of things.

2) Get healthy. Seriously. While I try to stay healthy in terms of eating right (but note: chocolate is always right), getting a decent amount of sleep, and keeping stress in check, I have never ever been good about physical activity, and it’s becoming ever more hypocritical of me to be in medicine and not participate in one of the most well-established ways of promoting health and preventing disease. So I joined a gym, and I’m posting about it here so the world is a witness to my goal of working out regularly. I’m excited about the gym’s many group classes, especially yoga, and Penny will help keep me entertained on the elliptical. I don’t expect to ever run a marathon or bench press more than… (you don’t want to know what I can do now) but at least I hope I can be one of those doctors who can empathize with the difficulty patients have in getting enough exercise, but also show them that it’s possible to make positive changes.

3) Reflect every day. I’d like to think that I’m pretty good at reflection in terms of it coming easily to me when I take the time, especially when I sit down to write here or in other forums and the words flow for hours. But I think it would help me grow more as a doctor in both knowledge and empathy if I took a little time more often. While I was on surgery, I felt like all I had the mental capacity for at the end of the day was to come home and flop down on the couch and watch Chicago Hope reruns. (Note: Chicago Hope is a TV show about surgeons. There has to be some interesting psychological observation in there somewhere that I unwound from a day of surgery by watching a surgery show.) But I think I was letting myself off too easy, and I think it would have been better for me if I had taken a couple of minutes to just go back over the cases of the day and what I learned from them, in terms of both hard facts and professional development. We were given two pocket-size booklets at the beginning of our third year to keep track of patients we see, tasks and procedures we do (I finally did a successful intubation! Heck yeah!), and topics we cover. And I have been terrible at keeping up in them. I hope my course directors aren’t reading this – but if they are, I am hereby promising to be better in the future. I think it will be a useful exercise for me to sit down with those books at the end of every day and update them, not just as a record the way the books were assigned, but as a jumping off point to fix in my mind the patients I saw and the topics I learned about.

I know this post wasn’t in my usual reflective vein, and there is so, so much more I could and should say about my experiences so far, and my three goals are neither original nor particularly interesting to anyone but me. But at least they were rooted in reflection and recognition of a few of the many things I have to work on, and if you can’t come clean to your own blog (and its handful of readers), then who can you come clean to? So I’m crossing my fingers as I enter another clerkship, and especially medicine, that I will have come a long way by the end of these next three months.