Song of Ascents

"Are you ready to leave clinical medicine?"

His indifferent tone belied the importance of the question, not just to me but to the eight other people currently sitting around the table, waiting for my response with varying degrees of patience and interest. Outside, an unseasonably warm January day coaxed buds from the trees dotting the hospital campus.

I looked over at the chief medical officer of the hospital and blew out a wry breath. A half truth slipped out before I could stop it. "Is anyone really ready to leave clinical medicine?"

Perspective

My boss leaned back and put her hands on her hips.  "Well, you know what?  I think we kicked ass today.  Well done."

I didn't lift my eyes from the transfer paperwork I was filling out at top speed.  "Do you think so?  I just feel like I got my ass handed to me all day."

She was unfazed.  I saw her shrug out of the corner of my eye.  "No, I think we did a good job.  It was tough today but we took care of patients."

I grunted.  "I guess."

--------

Her words came back to me several hours later, when I was driving home berating myself.  It's something I do often.  Over the years my commute has naturally become an opportunity for me to take stock of the day.  I like to take stock of things, sum them up.  This is especially true of work, where I don't have the time or space to emotionally process during the shift.  I do a kind of final evaluation, sorting my experiences and trying to put them away before I get home. 

The trouble is, I'm never satisfied with my own performance.

Is it a win that I stabilized a transplant patient enough to make it to her critically important transplant meeting tomorrow?  Or is it a sign that I can't manage patients efficiently, since it meant she was with me for nine hours?  Does it mean something that she and her husband thanked me when I checked in with them one last time before I left, two hours after the end of my shift?  Or should I focus on the mother of the child with an earache who had to wait two hours to be seen while her son cried in pain?  She told me off pretty soundly when I finally got in the room.  I couldn't tell her that I had been prepping and transferring a patient with intracranial bleeding and coordinating care for my first ever case of acute angle closure glaucoma, and I didn't mention that we were short a doctor that day.  My instinct isn't to defend myself in those situations.  I just apologized.

I saw so many sick patients today.  Bowel obstructions, cancer complications, my transplant patient.  Two patients with heart rates sprinting away, their owners pale and panting for breath.  I reassured a post-stroke patient that their recovery was just beginning.  I kept someone out of a nursing home by helping to arrange for assistive devices at home.  I made two little kids laugh during their exams!  My boss is right.  She did a good job today and so did I, damn it.  So why don't I feel like I did?

Maybe it's because we were so busy.  My charts aren't finished.  Wait times were long.  That kid with the earache?  He wasn't the only one who had to wait a long time, and people were annoyed about it.  When my night colleague came on, there were patients who had been waiting for hours already queued up for her.  She was nice about it, but I know that's a lousy situation to walk into.

Or maybe there's no external reason.  I know one of my strongest traits is perfectionism; it's a double-edged blade that medicine has sharpened and hardened over time.  I don't know what today would have had to look like for me to feel like I did well.  I just know that I always feel like I'm not disciplined enough, not knowledgeable enough, not efficient enough, not fast enough.  Not kind enough.  Not consistent enough.  Not enough.

I still don't feel like I'm enough.

Sometimes they die

Honestly?  I hate traumas.

I can't stop thinking about one I got a while back.  Auto vs. motorcycle.  A nice young man had been driving at dusk - not texting or anything as far as we know - and turned left in front of a motorcyclist who wasn't wearing any gear.  He never even saw the motorcycle coming.  The driver in the car was fine.  The guy riding the motorcycle - another young guy, I never quite learned his age - became our patient.  I was the backup doctor in the room but it still felt like he belonged to me.

Traumas don't go the way you would envision from watching a show.

Complex Redemption

There are some patients I saw during my time in residency that truly changed me as a person.  I've written about a few, but there are many more.  Here is what I have to say about one of them.  Names and other personal details are of course altered for privacy.

I took a deep breath, forced the best smile I could, and turned the doorknob.  Inside, Rosa sat in her wheelchair like usual; a few months ago we had celebrated her regaining her ability to walk with a cane after her stroke, but she quickly went back to the wheelchair as it was easier for her.  Today was our monthly meeting to discuss her chronic conditions.  In medicine we call this secondary prevention.  Primary prevention is focused on keeping someone from having a serious event like a heart attack or stroke, while secondary prevention tries to minimize the person's risk of another event occurring.  We are trying to keep history from repeating itself.  Rosa and I had been working together for nearly a year at this point, although perhaps "working together" is a misnomer; our appointments generally consisted of her giving one word answers to my questions, me setting some homework that she would promise to work on over the next 2-4 weeks, and then a short period of silence where I tried to discern something about her true mindset or intentions.  No matter my approach, I had never gotten any closer to her.  And she had never done a single thing she told me she would do.  She never checked her blood sugars.  She never drank less soda.  She never took her medications.  She wouldn't take walks or eat vegetables.  And she would never tell me why.  She just showed up, timely and polite and unknowable, for every visit.

As I entered, Rosa's aunt and caretaker glared at me silently from the corner - both aunt and glare cornerstones of our appointments.

"Hi!  How are you today?"  I asked Rosa.

She promptly burst into tears.  Her caretaker made no move from her seat across the room.

The deluge lasted at least five minutes.  I sat in silence with my arm around her, flabbergasted.  Where has this come from?  She had never given any sign of sadness before.  I handed her a stream of tissues, mute in shock and witness.

When it was over, she sniffled one final time, sat up straight, and said, "I'm fine."

I almost laughed.  "Rosa, what do you mean you're fine?  You basically cried on my shoulder for the past few minutes."

"I'm fine."

I pressed her but got little in response.  She wouldn't tell me why she felt so sad.  I asked if she wanted to try counselling and she said no.  I asked if she was feeling depressed and she did say yes, so we agreed to start an antidepressant that day.  A month later she came back for her check-in.  She hadn't taken the antidepressant.  When I asked her why, she shrugged and said she felt better, and wouldn't elaborate.  And so we fell back into our routine.

One day after maybe two years of this pattern, I walked into the room not with my previous forced enthusiasm but with the sort of calm, professional blankness that comes with knowing you are about to have another pleasant but fruitless encounter.  In hindsight I can see that the lack of progress had been wearing me down gradually, but at the time it felt like an abrupt change.  After our usual exchange of Hi-Rosa-how-are-you-I'm-fine, I simply said:

"What do we need to talk about today?"

"I don't know."

"Well, would you like to talk about your diabetes today?"

"Not really."

I paused.  "Okay, then.  What would you like to discuss?"

"I don't know."

Always previously, I had pushed past her recalcitrance, prodding her to some sort of lopsided discussion about her medical conditions, behaviours, habits, and so on.  After all, why else would she come and see me?  I had been determined to help her in some small way.  But that day, hearing her respond so casually - not really, I don't know - I was suddenly furious.  So much effort.  So much time spent with her.  So many clinics where I let myself run late to attempt to talk to her.  And for what?  So that after years of this, she could flush our agenda down the toilet as though none of it mattered.  Just like that I was done.  If she wanted to waste this time, I was going to let her.

"Okay... well do you need refills of any of your medicines?"

"I don't think so."

"Anything you need from me today?"

"No, not really."

"...Well, okay then."

The visit was over about a minute later.  I never saw her again.

I still struggle with the choice I made that day, born as it was from the cliff's edge of patience.  Perhaps I did the right thing externally, but internally I gave up on her, and that alone makes my judgment questionable.  Should I have kept pushing, had more compassion and perseverance?  Was I serving some vague therapeutic purpose?  Did I set us both free from a pointless rut we had been stuck in?  Or did I just cut off a source of easy emotional investment that she wanted but didn't want to work for?

The truth is probably buried somewhere in the middle of all of those possibilities.  I don't claim to see it clearly.  After she stopped coming to see me, I prayed for her and prayed for her, and then I got angry at her again and shouted at God about how ridiculous the whole situation was.  And ultimately I trusted Him to redeem it all for good.  And this is the nature of medicine and ministry, right?  Many times it goes nowhere that we can see.  Often in this field there is what psychologists call a complex separation from our patients, one without closure or denouement, and thus also without any kind of satisfaction on the part of the provider.  It is stressful but unavoidable.  Most of my career I will attempt to take care of someone the best way I know how, and I will never know in this lifetime how it really turned out.  And in the midst of that uncertainty, in those stories that seem to stop at failure, I can choose to let my viewpoint be similarly limited or I can look further out and further ahead.  I can shout at God and be done with it, or I can choose to trust that He is the author of redemption.  He makes all things new and good in His perfect timing.

I'm still coming to terms with that.

Another step back, or, This is what it looks like to recover from severe burnout

I am in that featureless, dimly lit middle stage on the journey out of burnout.  They say with attention to the issue, it gets better and that with time I can be fully invested in my work.  Right now it varies day to day.  Some days I drag myself out of bed late, reluctant to meet people and be happy.  Some days I rise from bed fresh and invigorated; I cherish these days as harbingers of change.


I laugh with coworkers.  I bring coffee, help decorate our new clinic.  I like the patients I see.  I am lavish with my emotional coin since urgent care requires so little of it overall.  No one asks me to be their everything here, so there is no emotional abyss of investment to guard against, so I can be generous with myself.  I encourage, educate, rebuke, reassure.  I remind myself not to get too possessive or protective of these people; these are not my patients.  They are just patients.  I get to do immensely satisfying things like sew lacerations and fish things out of ears and burr metal flakes out of a man's eye.  I puzzle over rashes.  I argue about antibiotics.  I work twelve to fourteen hours a day, then drive home and smile easily at my husband.

At work, I get a card someone left at the front desk.  A card?  For me?  Yes, says my receptionist.  I don't tell her the truth: I don't want a card. 

It has my name on the front.  I open it and read it aloud to my nurse.  It is from a patient I saw a week ago who was in emotional crisis.  I remember that we talked for a while and after I determined that she was not in imminent danger, I started her on some medications.  I told her she needed a therapist.  I remember that I tried to show her kindness but not too much.  

The language of the card is effusive.  My compassion and flexibility floored her, she writes.  My prayers gave her strength.  She tells me I saved her.  She asks if she can see me again at the urgent care clinic.

I read the letter feeling as though someone has started to press down on my neck.  My nurse cries and says she has goosebumps, which is a helpful signal to me to pause for a moment.  I just want to run, but a reaction is required here.  I mumble something about how touched I am, but really I'm uncomfortably reminded of how much of my shows of compassion are a farce, external signposts that freely promise warm, green destinations but lead instead to cool grey expanses of indifference.  I push away the dread and remind myself that navigating a continued doctor-patient relationship with this woman is not my job anymore.

How nice of her, I say.  But no, she can't come and see me again.  I put down the card and pick up the next chart in the rack.

The Other Side of Disillusionment

It took a couple of weeks after I graduated residency this summer to finally bring it up.

"You know what?"

My husband looked over at me. "What?"

I looked at him for a moment, and then finally said the thing that had been brewing all day, slowly forming in my mind as a firm conclusion.

"I hated residency."

He half-smiled. "Yeah, we knew that."

"No. I really hated residency.  Really, really, really hated it."

His smile dropped away.  "I know."

-----

Yeah, I finished residency.  I think I'm expected to say something like, "Man, there were a lot of ups and downs!  It's an intense period of your life and it's really hard.  But it's over now, and I'm soooooo excited to do medicine my way!"  But you know what?  I hated residency so much it's hard to just get over it.  It feels trite to say that, because in medicine it's kind of like saying that water is wet or MIs are deadly.  But I learned from watching my fellow residents that "hating residency" can mean many things; some of us just loathe the suck, while others are truly damaged by the process.  No one comes out the same as they went in - we all finish somewhat better as physicians but somewhat worse as human beings - but some of us come out in pieces.  I hated residency so much that I couldn't even admit it to myself properly during the process because to admit how deep my disillusionment went would be to rob myself of the stoicism necessary to endure through until the end.  No wonder empathy takes a record dive among residents.  If that was my introduction to real medicine then I wish I could afford to have no part in it.

But why hate residency? you say.  It's hard training and hard work, but it's necessary for you to become a doctor.  You learned a lot.  And it was a job and you got paid.   And I don't mean to ignore the good parts of the past few years.  I made some good friends who I think will be with me for life.  I met a few people who I consider role models.  I had some funny mishaps.  I found out just how well and how long I survive on minimal sleep (the answer is: a long time, but not that well).  But plumbing the depths of exhaustion while learning what this profession is and is not made me question the very premises that led me to medicine in the first place. 

1. Medicine is not what I wanted it to be because it is a business, you guys.  It's one thing to know that from the outside in a vague sort of way.  It's another thing when you have to send a nice old man with dementia to the homeless shelter because no one wants to pay for his hospital stay and his family won't take him back.  Or when you realise there's a gaping hole in the safety net for those with mental illness that can only be filled by paying cash to a dubiously trained caretaker.  Or when pediatricians or obstetricians or family docs or specialists won't take Medicaid patients because it "doesn't pay enough".  Or when you see patients who are begging you for solutions and you have nothing for them despite living in a first-world country because they don't have any money.  There were so many times that I cried at the lack of options for someone, all because of money.  More money means better medical care in so many ways, in ways that you have probably never thought of.  In ways that make me feel ashamed.

2. A doctor's job is not what I wanted it to be, because it's mostly paperwork, or at least it feels that way.  This is especially true in primary care.  About once a week during residency, my medical assistant would thunk down a thick folder next to my computer.  It was full of forms for me to review and fill out or sign.  FMLA, disability queries, home health updates, refill requests, Rx prior authorisations...  Half the time I had no idea how to even complete the paperwork so I would just do my best and hope it was good enough.  You want to know why your doctor's office has started charging for forms to get filled out?  Because I would spend literally hours every week on charting and forms and calling around to places for various things.  Forms do not get magically filled out by form fairies.  Forms get filled out by doctors staying an hour or two late every few days to clear the backlog.  I didn't even have what would be considered a full panel of patients for a primary care physician since I was only in clinic about 1/3 of the time.  I cannot even imagine how much paperwork a full time family doc has to do.

3. My patients are not who I wanted them to be.  I think I am a fixer.  I need problems that I can actually solve.  But in medicine you meet so many people with things you can't fix, or problems that are not yours to solve.  I keep a list in my head - not intentionally - of all the people I met who I just could not help.  It's longer than you might expect.  I remember a guy who was an alcoholic; he would binge drink and then come in with a horrible flare of pancreatitis, vomiting uncontrollably and in severe pain.  And yet he would leave after being treated and then come back a short while later, drunk and sick again.  We offered him so many resources for quitting, and he would lie to us, and refuse... it was like we weren't even there.  I saw many people like that - people locked in a struggle with their demons, grappling with them as their medical team essentially stood by and watched.  There were many others who were just too sick for any medical treatment to offer much.  I don't know what I'm meant to do with those people, either in person or as the haunting memories in my head. 

4. My colleagues are not who I wanted them to be.  Residency doesn't bring out the best in anyone, and we are all flawed to begin with.  There were a lot of times when if we hadn't needed each other I think we all might have been at each others' throats, while at the same time there was a lot of irritating pretense that we were all doing okay.  There were some minor and major betrayals from attendings, one of which almost cost me a timely graduation.

5. I am not who I wanted to be.  Remember when I said residency doesn't bring out the best in you?  I don't deal with authority very well, nor do I work particularly well as part of a team unless I am the leader.  I am easily demotivated when under stress.  I am absolutely certain that I was a grumpy, harsh, lousy person to deal with about half the time (and any time administration wanted me to do something).  I am prone to emotionally overinvesting and then I have no way to fill that empty well back up.  And I am full of selfish pride.  I spent a lot of time in residency not thinking about how best to serve others but instead focused on how best to survive intact.  The irony of that is that I didn't survive intact, not really.  I finished residency feeling depleted, angry, and afraid of the future.  Would I have fared better or even worse if I hadn't been so focused on myself?  Who can say?  It's hard to imagine how it could have been worse, though.  I spent months at a time just getting by.

Residencies are required to do exit counselling as part of staying accredited by the ACGME, the organisation responsible for policing postgraduate training for physicians.  My "exit interview" consisted of a 90 minute group SWOT session for my graduating class, a stupid and contrived format that they had clearly settled on as a way to keep people from talking a lot and thus complaining.  It meant I didn't get to say any of what I wanted to say.  What I wanted to say was, I gave you the last gasp of my idealism and true youth and you gave me back the ashes of dreams and a smaller version of myself.  What I wanted to say was, no one told me it would be like this.  If they had told me, maybe I would have chosen work that doesn't take so much more than it gives.  What I wanted to say was, I have finally learned to hate medicine.  You've convinced me to run away.

-----
Of course I don't have the luxury of running away.  My husband and I are in the kind of debt that you would not believe thanks to my training; let's just say our monthly student loan payments are six times our mortgage payments.  I obviously have to work.  For now, I've chosen the next best thing to nothing: urgent care.  It feels like I'm letting people down by doing this instead of choosing Work That Will Help People.  But at this moment in my life, fresh out of training and counting the cost, I'm not sure what that work is.  So I'll treat colds for a while, and we'll see.  Maybe residency has just been an extended low point and I'll recharge.  Maybe my questions about the practice of medicine have no answer.  Maybe I'll learn to be okay with that.  Maybe I won't. 

R1 Winter, or, The Wall

When people are miserable, they get cagey about their emotions.  It's a protection thing.  I understand that.  But it means I can't verify with certainty what I suspect: that I am not the only one who is struggling right now.  I know all the cheery, hopeful, "Hey, we're doctors!" posts have disappeared entirely from my Facebook feed (at least from my class; the crop below me just matched so of course they're thrilled), so I am fairly certain I'm not the only one having a hard time.

On that note, let's talk about hitting the intern wall.

I'm an intern, which is generally equivalent nowadays to being a first-year resident.  (Intern status used to be a year below being a resident, but for a bunch of boring reasons they've mostly merged the two at this point.  In short, it makes residency shorter and more secure.)  First year is the foundation for your clinical training, so it's the time when you have the least control over your life and when you work the hardest.  The learning curve is necessarily steep, although since you were already ascending a steep learning curve in medical school, you think you're probably prepared for what residency holds.  You're wrong about that.  Residency is a new beast entirely.  The mix of being at the bottom of the totem pole again, having new and weighty responsibilities, working significantly longer hours, and suddenly being bad at everything you do is exhausting.  It's all-the-way exhausting, actually, as in it wears you out until you're wrung dry.  That point is what doctors call hitting the wall; when you have nothing left and yet you have to keep pulling the same hours and seeing the same awfulness and making the same hard calls.  It's burnout, plain and simple; for an excellent article on this, read this JAMA publication; the Wikipedia article is also pretty good.

I hit the wall right at the end of December, during my first pediatrics rotation.  One day I was chugging along, doing more or less okay; the next day I started to feel kinda hopeless for no reason.  My patient load started to seem overwhelming and defeating.  January I was on labor and delivery, something I neither love nor hate, but for various reasons our team was effectively a rudderless ship which was horrible for all concerned.  Feeling abandoned by the residents who you depend on to help double-check your work is pretty scary, and all those negative emotions take an enormous amount of energy to maintain.  By the time I started internal medicine in February my tank was close to empty, and that was before I had a truly, truly stressful month, including a high patient load and a sick family member requiring me to take a week off work.  You can't be a person, do life stuff, and do residency stuff at the same time.  You just can't.  You will suffer and one of those other things will suffer, because the truth is that residency takes up everything you have to give.  The evening before I left on my emergency trip, I was so tired and so worried and so overwhelmed that I couldn't even pack a suitcase; my husband had to do it for me as I sat on the bed and sobbed helplessly because it was too hard to figure out what I needed.  Things have not gotten much better from there.

It's been a bad season, you guys.

Both my Maslach Burnout Inventory and my PHQ-9 scores are pretty terrible. The PHQ-9 is a quick screen for depression; the MBI is specifically for burnout. Basically I hit the intern wall so hard, and my ears are still ringing from it.  I've got precious little fight left in me.  I'm not really capable of providing the level of personal care I was giving six months ago because I'm not capable of caring that deeply right now.  I want to, I just... can't.  It's hard enough to convince myself to go back into work every day.  It's hard enough to not snap at people all the time.  It's hard enough to make sure I only cry about it in the dark, quietly, where I won't upset anyone else.   And on a side note, I'm kind of angry that this is essentially expected.  Why is something this terrible expected?  And why don't we know how to fix it?  And why haven't we overhauled the system so there's less attrition and fewer patient care issues from burnout?  Why do we as a profession just let this happen to everyone?!

Anyway.

I'm very grateful to have a good, steady job that lets me reliably have a roof over my head and food to eat.  I'm grateful that I have reliable employment.  But that's all.  It's not a calling right now.  It's just work, and it's a lot of work.

Today at church, though, we sang this, and despite my hopelessness and exhaustion, this resonated deeply:

I will remain confident of this:
I will see the goodness of the Lord.

It's paraphrased from Psalm 27.  And it reminds me that when you belong to the Lord, there is always cause for hope.  I really needed to hear that.

Residency training, day #1

Things I learned from my first day of residency training:

1. Lower your expectations.
2. Be on time.
3. Pay attention. 
[3a. If you're falling asleep, hold your breath until your brain thinks you're dying, freaks out, and floods your system with adrenaline.  Problem solved!  You are now awake, if twitchy and a little pale.]
4. Don't make excuses for your stupidity.
5. Don't harbor regrets for your stupidity.
6. I am probably as ill-prepared as I think I am, if not more.
7. Things will probably be okay anyway.

I'm doing a bit better spiritually/ emotionally, by the way.  It's incredible how the Lord comforts us in our struggles.  My attitude toward residency isn't settled yet, but it'll get there.

Wherever there is jealousy and selfish ambition, there you will find disorder and evil of every kind.

I wrote this a week or two ago, but followed the advice of a wise friend who suggested I wait and make sure I could handle this much transparency.  I'd be lying if I said this issue is closed, but I've already sat on this post in one form or another for months and I'm starting to feel like I'm hiding it.  That's not okay.  I don't want to give the false impression that this walk with Christ has no stumbles or sharp turns in it, and I don't like keeping secrets.  So here it is.

I often get the sense that real struggles with sin are not okay to talk about in a lot of church circles, but I don't currently have any thoughts on eschatology or the latest Joyce Meyer book, so this will have to do for discussion.  Let me start by saying that I'm still really ashamed of the content of this post, which is proof that this internal journey is nowhere near finished yet.  But it would be dishonest of me to pretend this isn't going on, and it's something that many, many doctors (Christian and not) have a hard time with, so it should be brought out into the light and examined with the eyes of truth. 

The real story of my winter and spring is not auditions, or rotations, or matching, or medicine.  Those things just form the backdrop for the action.  The real story of my past six months is how, for the first time since coming to know Christ several years ago, I fell unresisting into sin - the sin which some have said lies at the root of most other sins, pride.  I have almost no idea how to even talk about it.  It's so hard.  It came about so gradually at first, over years, that I didn't even notice it, and it started with something very simple and not wrong at all: I liked emergency medicine more than family medicine as a potential career.

You all know that for me, the FM/EM fight has been raging for years, and I always put it like this: I feel like FM has big strengths and undeniably lends itself to missions, but I just honestly like the ER so much.  And that sounds good.  But I didn't realise that other things were building up around that, things like: ER doctors get to tell cooler stories.  All family physicians get to do is drudgery, and they don't get any respect.  I would really like the flexibility that comes with shift work.  I don't have fun managing diabetes and such.  My feet hurt when I walk the floors on internal medicine.  I would hate to have to run a business so I'll never be a clinic doctor.

I have listened to so many incredible doctors warn about how obstacles to serving Christ creep in and take the form of our desires for comfort, stability, respect, and choice.  And you know what?  I still have let all of those things creep into my heart.  And I was so sure that everything was fine that I let it get worse.  By fourth year, my thoughts went more like this: yeah, I'm going to be an emergency doctor.  I'll do all the interesting stuff.  I will be the Christian who survives in a demanding secular environment.  I will be the spiritually sound one who still has the trendy job. 

Pastor Mark Driscoll did an interesting sermon series this year about identity, and he mentioned something that resonated like a bell for me: when you commit identity idolatry, that is, when you define yourself by something other than your relationship with Christ and put great worth in that identity, you eventually get extremely nervous.  This is because you can sense that whatever or whoever you have pinned your identity on is not reliable enough to keep you stable.  I recognise this in myself during audition season.  I had let my career become everything to me, the deepest part of my desires for my future and the center of my self-image; and the strain was starting to show.  My anxiety about matching into family medicine vs. emergency medicine was profound.  I probably cried about it 2-3 times a week for months.  It became very important to me that I match into an EM residency, although I still didn't realise why.  I just knew that I had to match into emergency medicine.  I had to.  That was all there was.

Except I didn't, did I?  I matched as a family medicine resident with a Christian residency program.  (How I was brought there when I was essentially running full tilt in the other direction is a whole other post.)

I wish I could tell you that I'm thrilled to start at this program.  I should be.  It is an incredible place, filled with deeply admirable people, and they deserve better than I am giving them.  And it is really sick that I can look at their graduating class and think, I really want to be like each of those people both as doctors and as Christians, and yet I feel shame when I tell people that I am going into family medicine. During my spring rotations I had to constantly interact with ER attendings and residents and a hot little knife of embarrassment jabbed me every time.

I haven't been able to pray with a whole heart since October or November.  I feel like I'm fleeing from the Word even as I seek it.  I have no peace about my immediate future even though it's settled now.  I am terrified that I am denying myself joy in the beginning of my residency.  I've admitted to myself that I crave recognition and am full of self-righteousness, that it's possible I never wanted EM for the right reasons, and that part of me wants to simply switch those terrible reasons over to my new field without working on my heart so that I can keep my pride.  There have been many layers to this repentance and each is more painful than the last, and I'm still not finished; at this point part of me doesn't even want to continue, which is why I persist in this spiritual listlessness.  I feel like a fraud and I feel an inch tall.  I wonder how the Lord could possibly use me for His purposes when I am such a sinner.  I wonder why on earth He would inflict me on such a good Christian ministry when I am anything but an asset to them right now.  And part of me can't help but repeat that maybe if I'd loved Him more, if I'd been a better Christian, I would be headed to work in an ER right now - which is totally theologically unsound.  The Lord doesn't work that way.  I know there is victory and freedom in Christ, and I have reveled in that in the past, but I am so far from that now.  And I worry that I don't know how to truly seek the ways of the Lord instead of the world.

So there you go.  I am lost and I feel like time is running out. I trust God's promise that He is with me always, even to the end of the age, but I also remember Jesus' clear warning that following him requires taking up your own cross - a metaphor for death to self and a call to sacrificial living.  My faith is small right now.  I'm glad all He asks is a mustard seed's worth. 

Wrong Place, Wrong Time, or, January: Internal Medicine

I think my month in Internal Medicine will be forever coloured by this last week - incidentally the last gasps of the rotation - starting with Saturday.

It had been a hard week with a high patient load, so I launched into my last weekend working the general floors with perhaps an overabundance of enthusiasm.  It was going to be a good day, I was going to see all my patients quickly and well, and things were going to present no problems.  It was 7am on a beautiful morning.

Cut to lunch, where I was trying to sip at a cup of soup that was too hot while talking to my husband, except the call kept getting dropped somewhere in the Atlantic or in space.  The morning, despite my resolve, had gone anything but smoothly.  It involved: patients being jerks, patients taking out their frustrations on me, patients telling me they hoped Jesus forgave me for what I was doing to them, etc.  Every visit had taken twice as much time as it should have.  There's something about people you are helping being mean to you, one after the other, for hours, that wears out a very particular part of you, and I was worn out.  But it was not my turn to stay late that day, and all I wanted to do was eat some calories and GO HOME.

So of course I was asked to stop eating and go and help one of the students from the other IM team do a history and physical down in the ER.  I stared at the asker blankly.  First of all, we have two internal medicine teams at my hospital, and they don't share work.  Ever.  I would go so far as to say that is the point.  Second of all, no one needs help on an H&P - it's a one-person job.  There's no way to speed it up or spread out the work. 

There was a moment of silent communication.  You know, the kind that isn't really socially appropriate.  My eyes said, you're really doing this to me?  And her eyes said, absolutely, and don't think you can finish eating, either, because I mean right now.  And my eyes said, you know I've had a bad day, right?  And her eyes said, I work in internal medicine so every day is a bad day and right now I need to spread the wealth; you'll do.*

Of course I said yes, dumped my soup, and went down to the ER.  She'd only given me the patient's first name (I'd forgotten to ask for more) so I couldn't find the patient.  Five minutes later my classmate walked up with the completed H&P and a text from his boss saying, Oh hey The Zoe doesn't have to help you anymore.

I went home posthaste.  Horrible hospital.  Horrible patients.  I dragged myself into work the next morning with zero units of motivation and zero units of hope.  Because I just knew it was going to be another bad day.

And I was totally right.  Well, I was wrong, but I was right; the patients were somewhat better, but that afternoon I came down with a rip-roaring GI virus.  I had vomiting and diarrhea every 10-15 minutes for eight hours, at which point I couldn't really walk very well and my friend rightly got scared and took me to the ER for IV fluids.  (That friend took care of me for two days straight.  I am so grateful.)

I think the virus is gone now.  But I had no idea that your body is weak and miscalibrated for days after something like that.  I don't remember Monday because I was sleeping the deep, wonderful sleep of phenergan.  Tuesday I miserably worked half a day, got sneered at by more terrible patients, gave up, and went home early to have a coma.  Today, the same (minus the terrible patients - I started a new rotation).

So whatever else I did or learned this month, all I can think of is the last five days.  And the last five days sucked. 

Lessons:
1. Living by yourself sucks!  Especially when you get sick.
2. Despite IM getting to see all the really cool diseases, I can't deal with seeing the same mean people every day and being forced to care about their bowel movements.  Thus, I am not an internal medicine doctor.
3. My prayer has changed over completely from, "Lord, help me love my patients" to "Lord, love my patients through me."  Because my love runs out too quickly, and despite my best intentions, it comes with strings.  Be nice to me.  Accept my help graciously.  Use deodorant sometimes because you live in a first world country and you are not that sick, you are just being lazy.  People need far more than I can give.  But the Lord's love is endless and perfect and patient.  How much better for everyone around me than the imperfect crumbs that I have.

Next up: pulmonology.  Whatever that is.



*This person is very nice, so probably it didn't go like this on her side.  And since she is an IM doctor she probably likes IM.  Probably she would tell you her eyes went, Please just help out for the common good.  And my eyes went, No, you're not on my team and I don't like helping people and also I hate you.  And her eyes went, I really don't want to have to force this on you but I have 3000 things to do so just do your job so I can do mine.  And my eyes went, I'm on the phone and don't want to do any more work and DON'T YOU SEE I HAVE SOUP.  And her eyes went, just do it and stop being a snotty medical student.  And my eyes went, fine but I'm not cleaning my room and you can't make me.

Again With The Future

Okay so this year has been pretty hard.  I submit evidence for your perusal:

• my husband was deployed to fight in Afghanistan
• I got pretty classic adjustment disorder after he left and almost quit school
• Step 1 board certification exam - enough said
• my husband got some injuries overseas, but not bad enough to send him home - I had to hear about these at work via Phone Calls that started with, "Hey, we need to talk now" instead of, "Do you have a second?"
• holidays by myself for the first time ever

I haven't said much (anything?) about my husband's deployment on here for several reasons.  The first is that deployment is difficult to talk about in a way that will reach others.  Unless you have experience with being in limited contact with your loved one for months at a time while he is (as far as you know) in mortal danger, you can't really know.  I didn't know.  The second is for what the military calls OPSEC - operational security.  You never know who's reading, and so the less information that is floating about, the better.  The third is quite simply that medicine is easy to talk about.  A year of solitary nights (broken by bouts of workaholism when the silence gets too overwhelming) is not.  He has been gone from my days this last year, yet he is inescapably present - an excruciating paradox.  I hate this limbo.  Anyway.  This year is finished and I don't mind.

Next year promises to teach me about uncertainty, which makes me itch.  I've never dealt much with uncertainty.  My whole life, I knew I wanted to be a doctor.  It was a vague plan that, as I got older, developed all the necessary steps. But I've completed all of those now.  Cue nausea.  I HAVE RUN OUT OF PLAN OH NOZ. 

Just like there's the quintessential first year conversation ("I'm so stressed I will never pass this test I hate my life") and a standard second year conversation ("I'm so stressed what are you doing for boards I hate my life"), there is one conversation that all third years have, constantly, until it's settled.  It revolves around what field to go into.  And for the first time I don't mind participating in the talk because we're finally talking about something constructive.  Sort of.

My dilemma is this: I want to do missions, possibly long-term.  But what field prepares me best for that?  The easiest answer is probably family practice - primary care, teaches you to deal with all types, good for developing relationships with people.  But.  The second tier of my problem is that modern suburban family practice makes me want to go back to retail while I frequently leave the ER singing.  So do I just do what I want?  Is that a good enough reason?  Here's why that last question is even worth asking: sometimes the Lord gives us honest desires as clues to what to do next; sometimes those desires are actually temptations (not from Him) and He asks us to walk away from them.  We have to wait for His guidance to be able to reliably tell the difference.

Six months ago this was not really a problem because I didn't need to make decisions yet, but my time cushion is running out because soon I need to start arranging my fourth year.  Fourth year for osteopathic students is mostly for audition rotations - you travel to the residency programs you really want to get into and rack up some face time.  Hopefully you impress the program with how smart and personable you are and help assure yourself of a spot there the next year.  Not to belabor my point, but I cannot start setting up audition rotations if I don't even know what field to look into. 

This is by no means a unique problem - I can list five classmates off the top of my head trying to make the same decisions - but I do think I have an edge.  Just because I don't know the plan doesn't mean my God doesn't have one.  And I know He will let me know, and I know it will be in enough time for me to make the right decisions.  I just get impatient sometimes.

Okay fine, I get impatient every day.  AT LEAST I'M HONEST.

Late night moment of doubt

Spending a week around people who are more married to their jobs than their are to their spouses has left me feeling lonely and wary of my career.  Four more months of this - four years in the long term.  Working and working in order to - what?  Work?  Seriously?

It's funny.  Being out doing "real medicine" is meant to remind you of your reasoning for putting yourself through the awfulness of the first two years of medical school.  But right now it just seems like a rat race.  Remind me; why am I doing this again?

The last eight days, or: Med School When You're Really, Really Depressed For Some Reason

So you could say I've been dealing with a major depressive episode.  I'm not sure why, to be honest.  My best guess is that my learned hatred of medical school coupled with a bunch of other personal things combined at just the right time to throw me off course almost completely.  To show you what I mean, let's use me as an informal psych case study!  Here is what the last week has been like, with a new but ultimately textbook twist at the end:

Monday I cried between every class and a little bit in class.  Then I took a test.

Tuesday I fought with everyone.  And then apologised.  And cried myself to sleep, then slept oddly.

Wednesday I think I avoided everyone because of the snow.  I thought about cleaning or making food but just sat on the couch instead, possibly doing nothing at all.

Thursday I woke up determined to have a good day.  I got my hair braided and chatted.  Then I sat in bed and cried.  A lot.

Friday I made it through a whole day of class - barely - then sat hopelessly on the classroom floor for half an hour because I couldn't pack up my things to go home.  Then I went home and crawled into bed and cried.

Saturday Matt was home.  We went shopping, and then I was so tired I slept most of the day.  And, after surfacing for dinner, a full night.

Sunday I woke up, cried, and went to church.  Then I was so tired I slept most of the day.  Matt went back to training.  I scraped myself out of bed and went to study with a friend.  Then went home and cried.

Today I woke up and it was like someone shook me awake, handed me my life, and said, "I don't know where the hell you've been for the last six weeks, but you have a test today.  And one tomorrow.  And makeup work to do.  And next week you have three tests, as well as a mock patient to see and a patient interview to do.  Get up."  And so I have spent the day in a spasm of anxiety-driven energy.  I'm grateful because it let me do things, but this is also just a different kind of wrong, albeit one I have more experience with. 

Depression is insidious and poisonous.  Anxiety is like trying to tame a beast - it has energy, it fights you.  Which means you can fight it. Fighting depression, it has seemed these last weeks, is like fighting quicksand.  The phrase doesn't even make sense to me.  You push, it gives, you get sucked in deeper.  I don't know how to deal with that. 

But at least after today I understand why they say anxiety and depression are two sides of the same coin.  At least this will make me a better doctor...?

I need a break!

Still here.  Took a test Friday; probably failed it.  My grade can take the hit, but it is never fun to work so hard for such terrible results.  I will find out how I actually did on Monday.  Another (really hard) test is approaching on Tuesday that I already don't have enough time to prepare for (no, I'm not joking). 

>.<

I am SO OVER IT.  I was on the phone with my madre a couple of days ago and I told her I hate school.  She really tried to convince me that I actually love school and that this is just a phase, but I really am so sick of all the constant pressure.  Three days after spring break ended I was already thinking of summer.  I'm just dying to be finished with this school year.  I want to swim and go to the beach and read books.  I want to sleep in and shadow physicians and try to remember why I'm doing this to myself and everyone who has to listen to me.  And it's tough to look ahead to third year, when things will lighten up and get a lot more interesting, because I will likely be alone then and so I am actually trying not to think about it at all, which really just means I have nothing to look forward to in the long term.  I AM GETTING DEPRESSED which is NOT HELPING and I would call myself a total slacker and a wimp except every single person in my class feels this way right now.  No wonder few people make it through med school unmedicated.

I do not like this, Sam I Am.

Okay, okay.  Positives.  Uh... the weather is getting way nicer!  And God is always so good, even in the difficult patches.  His faithfulness astounds me all the time.  Aaannd... I get to go on my first medical mission this summer which should be totally sweet.  AND my best friend since the 9th grade (she has known me almost half my life!) is coming to visit on Tuesday; that's the best thing to happen all semester.  There are good things.

[sigh]

Sorry this is such a sad panda entry.  I'm sure things will pick up soon.  I have good days, I promise.

...I think it's time for a Scripture dump.  Subject: victory/ refuge.

Psalm 44:6-8
I do not trust in my bow, my sword does not bring me victory; but you give us victory over our enemies, you put our adversaries to shame. In God we make our boast all day long, and we will praise your name forever.
Matthew 11:28
"Come to me, all you who are weary and burdened, and I will give you rest."
John 16:33
"In this world you will have trouble. But take heart! I have overcome the world."
Romans 8:28
And we know that in all things God works for the good of those who love him who have been called according to his purpose.
Romans 8:35.37
Who shall separate us from the love of Christ? Shall trouble or hardship or persecution or famine or nakedness or danger or sword? ....No, in all these things we are more than conquerors through him who loved us.
2 Thessalonians 3:3
But the Lord is faithful, and he will strengthen and protect you from the evil one.
James 1:12-15
Blessed is the man who perseveres under trial, because when he has stood the test, he will receive the crown of life that God has promised to those who love him.
2 Timothy 4:18
The Lord will rescue me from every evil attack and will bring me safely to his heavenly kingdom. To him be the glory for ever and ever. Amen.

Explanation or excuse? Only God knows.

Today I am taking a mental health day.

Let me begin with yesterday.  After morning classes, I went home for lunch.  The plan was to have a quick lunch with Matt and then do some work before heading to my ( at times insanely useless) Clinical Skilz lab, where we would be "learning" about dermatology by staring at each other's arms.  On my way into my apartment, I tripped up a few stairs and totally wiped out.  Everything went flying.  I hurt my knee surprisingly badly considering I just tripped, and ruined a pair of jeans.  And that was it.  I limped upstairs, cleaned my knee, and went to bed instead of CS.  I just couldn't take it.  I did do some work later in the evening but the thought of going to class was somehow too much.

This morning I woke up on time for my classes; I then lay in bed for ten minutes alternately yelling at myself to get up and feeling totally overwhelmed by even the thought of putting bandages on my leg and figuring out what clothes to wear, let alone having to actually attend class.  All of my dreams had involved me either screaming or crying.  I made it into the bathroom where I stared at myself for a few minutes... and then I returned to bed, curled into a little ball, and retreated guiltily back into sleep.  When I woke up a couple of hours ago, I realised I'd missed all of my morning classes but still technically had neuroanatomy lab and Spanish this afternoon and evening, respectively.  Visualising actually being there literally sent me into fits of tears.  Clearly I am feeling a bit off balance, as hyperventilation and a strong desire to flee are usually the strongest reactions I have to gunners and/ or neuro lab.

And so your heroine finds herself at home, still in her pajamas, potentially without plans to do any work today at all.  There are two ways to think about this.

One (The Parent's Explanation): apparently I am exhausted in some measure, and that part of me decided it was time to take a break.  It is healthy and good that I am listening to it, and although I may have to play catch-up a bit, it will have been worth it for the recharge that I get.  And let's be honest, medical school consists solely of playing catch-up anyway, so it's not like my life will be drastically different in that regard.  I'll just be less likely to have a public breakdown.

Two (The Gunner's Explanation): part of med school is being exhausted in every way and learning to push through it.  It is irresponsible and quite frankly weak of me to have to take so much time off, especially after I didn't work that hard over the weekend.  Maybe I just don't want to work, and so I am taking any excuse available to shirk.  Maybe I just can't hack it.

Which is more valid?  [shrug]  I'm not sure, but the first one certainly is more comfortable, isn't it?  No one wants to think of oneself as a slacker, not in an arena like this.  And it hurts to think of oneself as inadequate.

But I was thinking further about this this morning, talking to my mum and Matt, and I realised: I have always known I was only above average.  Let me explain.  I am more intelligent than many people; this is just a gift that God gave me, like he gave others artistic or physical ability.  But I am definitely not a genius.  I fall in the 'gifted' category, which means among the entire population I am of above average intelligence, but among smart people I am basically average.

This is finally playing out in school; I have reached a level where only people roughly as intelligent as I am are around me, and I am now almost exactly in the middle of the pack.  Hard work counts for a lot when you are in the middle of the pack (vs. being absolutely brilliant, in which case hard work counts for much less - don't disagree with me, I have also seen this play out in my school.  Outliers are outliers for a reason), and I am only willing to sacrifice so much.

So.  I am smart but not smart enough to be the best.  I am willing to work but possibly not hard enough to be the best. Is this not inadequacy?

Thus the second argument is also true - in a sense.  If high levels of accomplishment and being tough were really what I am aiming for, then I would have dragged my sad self to school today because not doing so would be slacking.  But more and more I am realising the depth to which those aren't my goals.  Enjoying life as much as possible without totally sacrificing my career - you know, balance - that is my true goal.  My whole life I have surrounded myself with gunners because they push me, and my whole life I have refused (most of the time) to participate in the madness of being hardcore fully and felt guilty about it.  Now I am in a place that requires 100% daily and I am finally giving it... most of the time.  Maybe I should stop being ashamed of those exceptions.  Maybe.

Hx - I know this is weird, but

finals are finished and not being in school so suddenly kind of makes me want to die. I am assuming this is a really strange response to the sudden cessation of stress, which is in itself a kind of stress and really I just want to curl up in a hole.

Break is meant to be a Good Thing! I FEEL CHEATED.

Hx - Fine print

I miss poetry.  I miss the freedom to be serious, to care deeply and use bold phrases.  I miss long skirts and short hair.  I miss staying up too late.  I miss being able to easily resist the normalising pull of community, of society.  I miss feeling tied to the sun.  Sometimes I don't want to be accomplished, I don't want to be a runner with good grades, nice smile, so agreeable, well-liked, walking obituary.  I want fire.  I want to startle people.  I want courage - the courage to be outcast and honestly known.  I want to stand in the courtyard and be silent with the sky and my God and not tolerate interruptions.

I miss part of myself.  You never realise the cost of dedication until you are already handing it over.  Will I ever write again?  Will I ever be struck by the beauty of the night, or will I simply sigh and go back to dreamlessness?


I miss having a shaved head.  A lot.  I worry that my career will make me into a collage of myself, bits and pieces strung together, nothing at all when you look closely.  Fragments.  Exhaustion.