So Here's To Hope

I'm pretty sure I cried straight through the first half of 2020.

In my defense, I was having an objectively tragic year. I left not just my job but my career under the unrelenting pressure of my worsening disability. My husband and I moved, again, this time for a job I knew I needed but wasn't sure I wanted. Two close family members developed devastating chronic illnesses. And I realized that I'm gradually losing my ability to walk and use my hands. All this against the backdrop of, y'know, the raging collective trash fire that has been 2020.

All I was was sad, all the time. I couldn't even talk to anyone about it, really. I just cried every day.

Midway through the year, a close friend sent me a link to a book and informed me we were going to read it together.

I clicked on the link and was greeted by a bright yellow cover with - of all things - an enormous smiley face on it. The Happiness Advantage, the cover screamed. How a Positive Brain Fuels Success in Work and Life. I snorted and texted her back some version of absolutely not. I wasn't about to buy a yellow smiley book on being happy. I don't like yellow. Or being told how to feel. I'm not even sure I like happiness. I find it suspicious a lot of the time, schmaltzy and commoditized, and often exhausting. A forced smile in a toothpaste ad. No. 

When it arrived a mere two days after I ordered it, the book and I stared at each other for a bit. I can't believe I'm reading this stupid book, I texted my friend. Don't ever doubt my love for you. She responded in the cheerfully assumptive manner of someone who never has: we should discuss once a week. Do you want to do one chapter at a time or two?

I truly didn't expect this book to change me so much.

The breakthrough came when we got to the chapter about gratitude. Gratitude: another word I have learned to eye suspiciously, given its cachet with trendy influencers and people who like motivational posters. It conjures up carefully posed social media posts full of product placements - cynicism lacquered in toxic positivity. This was different, though. The author gave a simple hypothesis: maybe the brain can be trained to be more optimistic by marking the good things that are already present in one's life. Invoking the power of accountability, he suggested telling a close friend or loved one three things you are grateful for each day, things that didn't have to be profound but did need to be specific. This appealed to me. It seemed practical and attainable. Maybe we could try it?

So we began. Every day, we would tell each other about a great cup of coffee or a glimpse of beauty, a moment of laughter, a kindness we received. For the most part we kept it small. Almost immediately, we realised that just hearing about the other's happy moments brightened our own day. We didn't anticipate this recursive loop of happiness, but we embraced it, and it became its own self-reinforcing system. We would reach out to each other greedily in the evenings, sometimes simultaneously: tell me about your day! What are you grateful for?

Some days it was a real stretch. It's 2020; a lot of crummy things happened. And nothing about this exercise changed the essential facts of my life. But with practice, we learned that even on the worst days, there was something to feel legitimately grateful for.

This may sound basic, but consider its effects. In the manner of a river slowly changing its bed, my focus has gradually eroded away from the major obstacles I face, instead eddying around bits of happiness. I'm learning to better appreciate small pleasures. And I'm finding that I'm emotionally stronger for it. Far from this change being a distraction or a waste of time, when I turn back to the big challenges they are somehow less overwhelming, because I recognize now that my life will always have a wealth of good things in it. I just have to take the time to notice them.

It's my prayer that in 2021, we would all be able to apply this lesson. There is joy trickling through all the little cracks in our lives, and this next year I hope to settle into that understanding further. It's a small goal, but I'm satisfied with that. A change, no matter how incremental, can gather a curious momentum of its own with time, gradually pressing through the mud to find hope.

So here's to hope.

Happy New Year.

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?"

Like air

I fought for her as she held
her diamond breath in her
hands, close
close to her chest
finite and precious
saving it carefully, losing it
every other word

When I returned
heavy-laden from long hours
she smiled
took my hand and prayed
and I felt
the breath I had given her
being returned

Healing

"Your kidneys have shut down.
There's nothing I can do.
I'm so sorry."
Her husband held her as she cried.
Later, I came back.
We talked of the power
of The Great Physician.
I prayed for her.
She clutched my hands in thanks
And I realized
That in my helplessness

I had offered true medicine.

55 words

I fell down a little narrative medicine hole today, and in so doing, I found a writing mechanism called the 55-word story.  There is an excellent discussion of this mechanism in this JAMA article from 2017.  Writing is a tool for processing, reflection, entertainment, teaching, and so much more.  But sometimes you just don't have any bloody time.  Enter this tiny sliver of writing!  It's almost a game - 55 words exactly, no more, no less, but in any format you'd like - and completing one is terribly satisfying.

I am going to start doing this, and I hope it will be a regular event.  Here is today's story.

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.

The Importance Of The Physical

My charge nurse stepped out of a room and waved to get my attention.  "We need a doctor in here, please," she said in a level voice.  In non-ED-charge-nurse speak, this roughly translates to, "GET IN HERE RIGHT FREAKING NOW THIS PERSON IS DYING."  I dropped everything and headed in.

Boundaries, or, Sometimes I'm An Idiot

"Hey, so..." I exhaled.  "This second job is getting on my nerves.  Wait, I don't think I told you.  I got a second job a few weeks ago."

There was a pause on the line, then my best friend said, "What?!  Why?!"

Let me tell you why.

Listen. Listen. Listen. Listen.

I am not doing this anymore.

It was Tuesday, I was in the occupational therapy clinic for just the third time, and I hated it already.  The first visit consisted of testing my weak, uncoordinated hands; picture me failing to pick up tiny metal pins and put them in tiny holes, and then bursting into tears.  The second visit was full of painful exercises that left my hands limp.  Today I was doing silly putty exercises under supervision and it was making my arm cramp.

I threw the putty down on the table.

Disability: Having A Sound Bite

Gasps greeted me as I walked into the exam room.  "Oh my- what happened to you?!"

Caught entirely off guard, I struggled for a response, but blanked.  There was an awkward pause in the room.  The problem was...

(Sporadic) Money Update: 2018, or, Imagine Me Rolling My Eyes

I am so sick of paying down debt.  So let's talk about it!

My husband and I are in the middle of this debt-paying thing.  At this point we have completed several of the most important steps:

- figured out how much debt we actually have, which is horrifying but necessary
- refinanced all of our loans for a lower interest rate (which will save us approximately $40,000 over the life of the loan)
- sucked it up and started paying ridiculous amounts of money on our loans

That means that we are in the "paying ridiculous amounts of money" stage.

Uncertainty, or, 2019: Midnight Tracks

I love planners; I'm a bit obsessed with them, really.  I've always had one.  I think by nature I'm a plan-maker, someone who takes the long view.  Years of practice and training have taken my penchant for journalling and turned me into a list-maker as well.  At this point, if I don't have a formal planner, I eventually clutter up my life with piles of to-do lists and thought fragments.  This year, when it became fatiguing to write, I tried to abandon my paper planner for digital alternatives that I can talk into, but it's not the same.  So a 2019 paper one it is.  Usually I get something with monthly and weekly pages, and room for notes - pretty standard.  My planner choice* is different this time, though.  For the first time, I want a goal-setting planner, I think for several reasons.

Reflections on Primary Care

Just because I haven't written about burnout in a while doesn't mean I don't still care about it.

Over the past year or so, I've become an avid, sympathetic reader of a blog called Reflections of a Millennial Doctor.  The author, M, vividly details her struggle with burnout and giving up on primary care.  She fought so hard this past year, wrestling with whether or not to stay in her current practice or throw in the towel and try her hand at something else.  She recently admitted that she will be leaving her practice soon for a job as a hospitalist.  I can relate - not to the hospitalist part! I hate hospital medicine.  But her tale of getting bled dry by her clinic job resonated with me deeply.  Honestly, I don't know how her primary care dreams survived her training.  Mine didn't.

I remember being a medical student and writing an essay about the importance of trajectory change for my family medicine residency application.

Sometimes they live

A patient walked out on me the other day.

It doesn't happen every day, but it happens often enough.  I usually never find out why.  Sometimes it's to go pick up children or meet another time-sensitive obligation.  Sometimes it's to go smoke a cigarette or get a dose of drugs.  I think sometimes they get scared and feel as though running from the department can help them escape their diagnosis.  Whatever the reason, I learned early on that I have to be able to let those people go.  The other side of the patient autonomy coin is this: they're responsible for getting the care they need and it's not my job to force or coerce them.

Except when it is.

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.

News

I thought about being artistically coy in how I would introduce this post, but I can't bring myself to do it.  I got some bad news about a month ago and it has changed my life.

I was recently diagnosed with Charcot-Marie-Tooth disease.  In medical terms, it is a genetic neuromuscular disorder, caused (in my case) by a duplication of one tiny area of chromosome 17.  It leads to abnormal nerve structure and thus abnormal nerve signal transmission.  Over time, the nerves degrade and die off (this is called neuropathy), taking the muscles with them.  It starts in the feet and works its way up the legs, and at some point begins in the hands and works its way up the arms.  The rate and degree of progression is different for every affected person.

CMT is a progressive disease, and the form I have generally comes on slowly.  So it was with me, although I didn't know it.  I've been "clumsy" all my life, with weak ankles that are prone to rolling, and weak reflexes.  I've always gotten muscle cramps a lot.  My feet are always cold.  None of that held me back, per se, but there were a series of nuisances to be managed.  No stiletto heels.  Watch how you walk so you don't sprain an ankle again.  Do any workout besides running.  But otherwise, it was fine.  Then during residency, I started getting intermittent weakness in my feet and toes.  The cramps got worse.  I started having falls and trouble keeping my balance, especially when I'd been awake for long shifts or wasn't sleeping well.  People commented a few times on how my gait looked different, "like it's hard for you to walk."  They were right.  It felt very hard to walk.  I assumed I needed to sleep more and be more diligent about working out, chalked the falls up to residency fatigue, and kept pushing.

I know, I know.  I'm crazy.  No one in their mid twenties should be falling and having trouble walking.  I know.  But I... just didn't think about it.  I was trying to hold it together and finish training, and there was work to be done.  So I went to work.

Fast forward a few more years.  This spring I started tripping over my toes, and I realized I couldn't move them.  My right hand began cramping around my pen every time I picked it up.  I realized I couldn't feel the bottoms of my feet.  Then my knees started to constantly feel like they were giving out, and I finally got scared enough to pursue a possible diagnosis.  If you think a doctor can't have denial, think again; despite all of that I honestly thought they were going to tell me it was stress.  Instead, two neurologists and $3000 worth of tests later, I was given a diagnosis that explained every troublesome thing I've ever had with this body - and made it clear it is going to get worse.  And it has gotten worse; it's gotten a lot worse just in the past couple of months.  Apparently that happens sometimes.

I will be honest here and admit that I feel inexpressibly sad about it all.  I don't know what this will mean for my personal life or my career.  It's scary and taxing to try to navigate the sudden drop in my physical ability (a topic to discuss more in a later post).  I feel newly, terrifyingly dependent on Jesus, while at the same time I feel so confused that He would allow a time bomb like this to be seeded in my DNA.  I trust Him.  But I don't understand.

I expect the tone of this blog will change significantly from here on out but I don't yet know how.  I guess I'll just take it post by post and day by day.  But I knew that I couldn't blithely write about the happenings of my life and career while withholding this diagnosis.

On Terror

"EMS to ED."

My charge nurse hit the button on the transponder.

"This is ED, go ahead EMS."

"ED, this is EMS en route to your facility, emergency status - "

All the staff within hearing distance stopped what we were doing to listen further.

Change

So I'm changing things up for myself.

When I finished residency, you may remember that I was pretty much done with medicine but still needed to earn a living in order to pay off our debts.  I chose urgent care because I needed something that was simple in terms of the mechanics of the job and emotionally undemanding in terms of the patient care required.  I think urgent care is pretty much the pinnacle of that.  See patient, make 1-2 decisions regarding care, discharge patient, write short note.  Move on.  No call, no critically ill patients (most of the time), minimal paperwork, few moving parts.  The hiring process went very smoothly.  But for some reason that I barely understood given that I felt like I was aiming to get out of medicine altogether, I threw in an ask in my interview: I wanted to do a little work in my local ED if they were amenable to that.  It turned out they were.