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.

Suffering

It's 6am and I've been up for three hours, the consequence of coming off a long weekend of night shifts.  I read for a while, but as often happens to me, eventually I was driven to write.  And so here I am.

My hands are healing, I think, and my feet.  In retrospect I've been through this cycle a dozen times before and just didn't recognise it.  It matches what my neurologist told me about my disease.  It's a cyclic dance, led by demyelination, followed by damage to the axon, the long delicate wire of the nerve cell, as it loses its insulating myelin sheath.  I lose some function.  Then comes whatever healing the body can muster and some degree of functional improvement - all set against the relentless drumbeat of the disease state itself.  So I get worse, and then I get better, sort of.  What matters to me now is that I've crossed back over the invisible line that lets me use my right hand.  I can write again, so I can do my own paperwork at work.  I can hold a glass in my dominant hand without thinking about it.  I can put my car in gear without reaching across my body.  I can type a bit.  I'm definitely not back to normal.  I still wear a wrist brace (like this one) on the right about half the time since it's very fatiguing for me to control my wrist and fingers simultaneously.  I prefer to use a big silly-looking pen that's easier for me to grip.  I've switched my mouse to my left hand and don't plan to switch back.  And at this point I still can't really do repetitive tasks that require fine motor skills - scissors, suturing, chopping vegetables.  But it's so much better than it was.

Obviously it's going to get worse again eventually.

I've been thinking lately about suffering, and about God's purposes in allowing His children to suffer.  I have found myself crying out to Him this summer in confusion and pain.  Why, God?  Why this?  Why now?  Why my right hand, the hand I rely on?  Why should I suffer like this?  It's a hard question, and a nuanced one.  It's different from painfully pouring oneself out to serve others,  different from the direct and expected consequences of sin, different again from persecution for my faith.  This just... sucks.  It sucks every day.  And nothing I or anyone else did caused this.  I think the temptation is to see suffering as meaningless, just a random consequence of living in a broken, messed-up world, but Christians don't have that philosophical out.  We trust and believe that we have a personal God, one who cares for us and is invested in us.  So why the suffering?

Yesterday I sobbed through a talk given by Joni Eareckson Tada, a lady who is a staunch believer in Jesus, an author, speaker, and artist, and a quadriplegic since the age of 17.  I highly recommend that you listen to the talk, although if you're not dealing with personal hardship/ disability it may not resonate with you.  She confronts the endless gauntlet of her daily life (you'd better believe that being a sharp mind trapped in a useless body involves suffering) with a matter-of-fact courage that frightens me.  She does not spare anyone the harshness of truth.  I'll give you an example.  For anyone, but especially a quadriplegic, to say, There are better things than walking.  There are better things than the use of your hands, is deeply shocking, right?  But with reflection I've realised that of course that is true, especially for a Christian.  Jesus is better than anything.

The goodness of God is the truth that sustains a person through even the deepest darkness.  I thank her for reminding me of that.  Joni Eareckson Tada exemplifies for me the concept of suffering well, something she touches on in that talk.  It's hard for me to get my arms all the way around the idea, but I think it's a mixture of day-to-day grit and unswerving, joyful faith in a good God.  I don't know how to do it yet like she does (I'll grant that she's had fifty years to learn how to suffer well and I've had, like, two months).  But I think most people never learn how.  It's just not guaranteed.  And I think it's a lofty goal but a worthy one, this idea of suffering well as a Christian.  I have this disease.  There is no getting rid of it.  But to suffer well... if that is my race to run in this life, God grant that I might achieve that.

Spoons

A few weeks ago, my hand cramped solid around a woman's leg while I was trying to put a splint on her, and then went limp for the rest of the shift.  Let's talk about spoons.

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.

Tired.

It was so hard to get my sorry self to work yesterday. I had the flu a couple of weeks ago - I don't recommend it - and the cough and fatigue have lingered. I entered this stretch of shifts feeling sluggish and still a little short of breath. My coworkers cracked good-natured jokes the whole weekend about how I needed to check in as a patient. Considering I've spent most of the last two weeks first feverish and vomiting, then alternately passed out and hacking up a lung, it felt more accurate than amusing. I'm pretty tired.

Residents: you are enough.

I remember the day I decided to quit residency.

It was January in my intern year and I was on one of my internal medicine rotations, which always were my least favourite.  I felt like my life consisted only of long hours and a surfeit of other people's suffering.  That morning, after four hours of rounding alone on my patients, I was about fifteen minutes late for morning group rounds, and mid-month evaluations were being held.  During my evaluation, I was told by my chief resident that I did not do a good enough job of being on time.  She was clear that my job was not to be right, it was to be punctual.  She was there to help with the rest, she said.  Then at rounds I got some questions wrong and was told by an attending I needed to review some topics and make sure I knew my patients better.  We also concluded two of my patients were terminal.

Cut to twelve or thirteen hours later when I was finishing up my evening call.  I was in the middle of checking out the patient list to the nighttime senior - a fast-paced, highly regimented process in my program since our patient lists tended to be long and medically complex - when the other chief resident breezed into the room.  He had seen some of my notes on my patients, he told me.  They were lacking in depth.  I needed to take more time and make sure I was being appropriately thorough.  He breezed back out of the room and, after a pause, I completed my checkout.

A short time later, sitting in my car in the parking garage, I went to turn my car on and couldn't even initiate the movement.  Instead I sat there in the cold as the sum of the day became clear.  A profound heaviness took up residence in my chest.  Had I accomplished anything that day?  I got criticized for taking too long and not taking long enough.  Likewise, I didn't know enough but wasn't meant to know more.  And I couldn't help many of my patients anyway, since many of them were dying.

What the hell was I doing this to myself for?  I had no answer.  Yeah, I'm done, I thought, and turned the key in the ignition.

-----

Obviously I'm writing this as a licensed, board-certified physician who works full time in clinical medicine, so we know how the story ended.  But I will never forget that moment, sitting there in the chill darkness, quietly listening to my last big dream break apart.  I cannot describe the pain of that to you, especially because I know that I am a creature that was made for hard work.  Why did this happen?  Because I couldn't hack it?  Not tough enough, or in the modern burnout parlance, not resilient enough?  I pondered that for a while and almost accepted it as true.  But now that I've had a little time to gain perspective, I reject that.

I'm a low maintenance, mentally tough woman with deep emotional resources and the personal grit necessary to grind out hard work over months and years.  My childhood dreams always involved work and adventure, not the more domestic goals many of my friends had.  I'm a career woman at heart and I'm comfortable knowing God made me that way.  But residency broke me (twice, actually, but that's a different story).

There are a lot of articles out there discussing how horribly residents get treated, whether it be through overwork (you try staying awake and doing hard mental and sometimes physical work for 24-48 hours continuously), emotional fatigue without time to process, or genuine personal abuse.  There's also a lot out there about burnout in medicine, although not as much on treating burnout in residents.  I obsessively read what little there was my second year of residency, looking and looking for solutions, but they're few and far between for those still in training.  The truth about treating burnout is one that is directly addressed in discussions of burnout in attendings: it doesn't usually get better unless/ until your circumstances change.  The articles discussing burnout in residents try to dance around this fact, which is disingenuous of them.  There are mitigating measures you can take, of course, but those are a wound dressing on the infection, not an antibiotic.

In the end, I didn't quit.  I started some crappy counselling where she mostly told me I needed to sleep more, sometimes with tears in her eyes.  I started gardening a bit and I took up knitting, so that no matter how many people I saw who I couldn't help, I would have something tangibly positive to pursue.  I cried every evening about going into work the next day.  I started Zoloft.  I was on that for six months.  I knitted more.  I made all my loved ones ugly scarves.  My herbs died, but at least I got outside in the sun a bit.  Mostly, I moved on to second year, which in my program isn't quite so horrible, and I was able to upgrade from misery to numbness and a simmering anger that lasted until graduation.  Since getting out of training I've been tentatively exploring happiness again, and it is fresh, beautiful territory.  I'm grateful but I'm not used to it yet.

I'm doing fine now, but it's the end of another long, dark winter, and I'm sure there are residents suffering and questioning themselves and their commitment.  If you're one of those residents, I feel deeply for you.  I can't tell you whether to stay in or leave the field.  But I can tell you that it's probably not your fault that you're having a hard time.  Medicine is difficult at the best of times; it's the nature of the beast.  And the current setup for training is draining, demoralizing, and at times outright abusive.  It's normal to struggle with a burden like the one you are handed during residency.  You're not imagining it.  Other people don't have to go through this.  You're not being overly sensitive.

So get some of your own crappy counselling if you can.  Maybe you need some Zoloft.  I highly recommend something positive and physical and low-maintenance like growing some plants or knitting.  Read The Resilient Practitioner, which hopefully will help you as much as it helped me.  Email me if you can't afford it and I will buy it for you.  And please believe me when I say that it can get better.

A Break In The Darkness

I have a little eclipse story to tell.

My husband and I were lucky enough to live within driving distance of the path of totality, where the moon would completely blot out the sun.  As soon as I found that out, I decided we were going to have to make a day of it and drive north to see THE REAL THING.  I perused blogs and astronomy websites; I purchased multiple sets of eclipse glasses (after the first set turned out to be fake - thanks Amazon); I had happy daydreams about laying out in the sun in a green field, slowly watching the moon eat the sun, and then perfectly witnessing all of the crazy things happen during a total eclipse.  I was especially excited to see the eclipse itself.  I badgered my husband into taking the day off.  We may never get to see this again!  It will be amazing and it's only a few hours away!  Pleeeeeeeeease.  Pleaseplease.  

The night before, I checked the forecast one last time and found to my dismay that essentially everyone in the path of totality was going to have a spotty view of the eclipse except people living just east of the Rockies, which we do not.  Weather in our town was meant to be perfect, but of course without the chance to view all of the amazing phenomena that come with a complete eclipse.  My husband and I talked it over and decided to take the chance.  Better to potentially see THE REAL THING than to definitely not see it.

Cut to the morning of.  We left late, first of all, which - although I'm not a very nervous person - sent my nerves through the roof.  It's not like the moon is going to hold off on beginning the meeting because there are still some stragglers coming in.  Then the clouds started gathering as we drove.  At first it was just some cheerful light clumps, but after a couple of hours it was clear we were heading into a storm system.  My husband got one glimpse of the very beginning of the eclipse while we were on the road.  Then, nothing.  Clouds.

My pastor recently had been teaching us about improbable prayers.  He pointed out that in Acts when Peter was headed for execution, the church prayed for his release and he was indeed broken out of prison by an angel.  When he showed up at the house where they'd been praying, they were amazed!  His point was this: pray for things so incredible that if they happen, you will be shocked.  Pray for improbable things.  Give God that chance.

Well, why not, I thought.  Driving that morning, every time I looked up at the dense cloud cover, I prayed.  I know this isn't particularly important, Lord, but please.  Please clear the weather so we can view this spectacle.  In fact, clear it so everyone can view it.  Please make a way in this.

And you know what happened?  It started raining.  Yeah.  Raining.  On and off for the last hour or so of the drive, it sprinkled and poured by turns.  We didn't see another glimpse of the sun that entire time.  I kept praying but my mood gradually soured.  Come on, God, please?  Let everyone see the eclipse during totality, including us!  Matt kept an eye on the radar, but there was no chance that we could outrun the huge bank of clouds in the region, no chance that we could cut east or west and find a clear spot within our little slice of totality.  We were stuck.  So we kept to the original plan, although there was no happiness in it for me anymore.

When we got to the park I'd chosen, it was dark, cold, and wet.  The rain had settled into a steady light shower.  There was no way to tell if the appearance of things was from the storm or the developing eclipse, but you can guess what my suspicions were.  We found a low hill with good visibility only because Matt insisted.  I was ready to sit in a low parking lot and read a bloody book just to spite the stupid eclipse and the rain and the day and everything.  I pulled out my knitting, for goodness' sake, because why not?  There was nothing to see.  I can see clouds and rain whenever I want.  There was certainly no way to appreciate anything else.

I let myself talk to God about the whole endeavor one last time.  I asked you for such a little thing, God.  I've been looking forward to this for weeks and You know that.  You couldn't have given me this?  Thanks a lot.

Matt opened the car door.  "Get out.  You can see the sky, Zoe, get out of the car."  Well, duh, I thought.  Of course you can see the sky; you can always see the sky.  I want to see the sun.  But I abruptly got sick of my own bad mood and decided to play at being a good sport.  I got out of the car and peered up into the rain.  Sure enough, there was an odd-looking dark grey patch briefly visible through the clouds.  Matt nudged me.  "I think that is blue sky."  The more I looked, the more I thought he must be right.  

It got darker all of a sudden.  Darker.  Then, still darker.  A cold wind blew across the hill.  People started to murmur, wow, so cool, how about this.  Suddenly the horizon looked like it was on fire - all the most amazing sunset colors at once, spread out in all directions.  Diffused as it was through cloud cover and distant rainfall, the effect was especially mysterious.  Crickets started chirping and all the birds landed.  I grudgingly thought, okay God, this is pretty cool.  Thanks for this at least.  

Then people started screaming. 

I mean really screaming, in a way that was frightening and seemed out of their control.  We heard more screaming from across the park and even, faintly, the nearby town.  I realised everyone was pointing up.  And there, right overhead, the dense clouds had cleared perfectly in the right spot for us to have a great view of the total solar eclipse.  We got to see about thirty seconds of perfect corona leading into the diamond ring signaling the end of totality.  It was uniquely beautiful and unsettling in a way that eludes description.  We all felt a brief, hot wash of sunlight as totality truly ended.  Then the clouds closed up again.

I cried, of course.  Not at the eclipse itself, although it is something I will remember for the rest of my life.  I cried because God reminded me that a faith that endures is one that endures to the end of hope, through the disappointment and rain, trusting that there will be a break in the darkness.  He could have whisked all of the clouds away and left us with a "perfect" cloudless sky and the chance to see the entire eclipse process without interruption.  He chose not to.  But did He not answer my prayer (and surely the hopeful prayers of many others) in spectacular fashion and in a way that imprinted the event into our minds forever?  Cold, darkness, and rain!  A sense that time was running out!  Then - the clouds opening!  A perfect glimpse of THE REAL THING!  The return of the warmth of the sun!  End scene.  

Amazing.  Never doubt God created the concept of dramatic tension.

I am really sorry that I gave up on God answering my prayer too early.  And how kind of Him to package my subtle rebuke as a rare, beautiful gift and reminder of His faithfulness and majesty. 

The lesson is this: if He cares enough and is powerful enough to even just move the clouds so we can see something cool, how much more able and willing is He to help with the things that truly matter?  At the same time, when I pray that He would get rid of all the clouds and give me a nice sunny sky, I have to remember that often that is not His way, because when He does that I learn nothing and do not grow.  I thought that day that THE REAL THING was having good weather and seeing the full eclipse.  But in this, as in all things, that was just a cipher for what the Lord was truly doing for me that day - teaching me to trust Him more and being willing to risk disappointment and loss based on that trust.

OH HEY LET'S TALK ABOUT MONEY

In honor of everyone graduating and moving on to the next step, let's talk about money!  And by money I mean debt, because new doctors don't have any money!  All we have is bills to pay!

So I am the one who does the money things in our household.  It really happened by accident.  Matt was deployed shortly after we got married, before we had fully decided our financial plan as a couple, so all daily responsibilities were de facto handed off to me.  By the time he got back a year later, all the accounts and whatnot had my passwords on them and all the bills auto-debited out of my checking account so I could keep track of them (insofar as a medical student can keep track of anything besides the filtration system of a nephron).  Over the years of our marriage it has taken on a comfortable, natural sort of balance where we check in regularly with each other and the bills are somewhat more evenly distributed, but I still do the weekly bookkeeping and the nuts and bolts of our budget.  I like it.  It's like folding towels, which I also like - a nice, sequential task where the corners line up neatly with the bonus of a visibly completed task when I'm finished. 

That calm, simple task (money, not towels) kind of exploded once I graduated residency and everything changed.  Matt graduated law school and started working full time.  I switched from a modest salaried job to a higher-paid-but-extremely-variable hourly job.  We bought a house.  We sold a car and bought another one.  And oh, yeah - all of our student loans came due. 

I knew in a vague way during training that we had a lot of debt.  I would glance at it out of the corner of my eye from time to time, but everything was in forbearance or deferment, so nothing was due.  Out of sight, out of mind, amirite?  It felt insubstantial to me, like a theoretical concept.  And it's not like there was a way around it.  If we wanted to complete the training we had begun, then massive debt was part of the package.  Here I will also admit that I had a naïve, trusting sense that if my school didn't think we students would be able to pay the money back as physicians, surely they wouldn't be helping to get us all in such debt, right?  So I ignored it and kept working and surviving, and all the while the law of compounding interest ticked quietly away in the background.  I knew our debt was mumble-mumble-hundred-thousand-mumble-and-change, but I literally only checked it every few years when I was forced to.  And I had never even looked at Matt's student loans.  Law school was slightly less per year than medical school and it was a year shorter.  That was the full extent of my knowledge.

There is a reason that if you listen to Dave Ramsey and a caller states they have six figure student loan debt, he asks who the doctor or lawyer is.  It's because we accumulate student loan debt on a scale that most people never conceive of, and that's on top of "normal" things like credit cards and cars and family debt and having a mortgage.

When I took a deep breath and did the arithmetic, we were about $750,000 in debt.

Quite a number, isn't it.

Of course, I didn't add all of that up until about a year ago.  I promptly panicked.  It was only then that Matt and I finally sat down over lunch with a napkin and a pen and hashed out the basics of our repayment plan.  Could we have done it sooner?  Eh, maybe, but we didn't have all the numbers we needed to do the proper math, like my expected monthly income.  I certainly don't think we could have waited any longer than we did without ending up in some trouble, though.

Over the past year, I've learned a few things about money, which was necessary as I abruptly found out I knew nothing whatsoever about money other than basic budgeting.  Change was time consuming and mostly driven by need as we ran into financial thing after financial thing.  My colleague told me a horror story about blindly paying the minimums on her student loans for 10 years only to find out she still owed $150k, so we learned about refinancing and put all our loans on a seven year term with a better lender than the government.  We had cosigned a loan for a friend forever ago who was having trouble (please do not ever ever ever cosign anything for a friend EVER), so we learned about how to finally get some control of that loan to keep it from vomiting all over our credit.  I started listening to Dave Ramsey and reading The White Coat Investor.  We found out how behind we are on retirement stuff, yay.  And we finally got in the habit of throwing buckets and buckets and buckets of money at our debts.  We have paid a few small things off, which felt like a triumph.  The rest won't go away without years of consistent effort.

Here's roughly what our budget looks like now, in terms of percentage of our monthly income:

Tithe - 10%
Student loan payments ~ 40-50%
Retirement savings - 6%
Mortgage/ house stuff ~ 10%
Car payments ~ 6%
Other ~ 20-30%

I put things in the order we generally pay them.  It's not quite a painful way to live since we live in a cheap area of the country and we have never had a lot of money to spend anyway.  But I still worry sometimes, and clearly the two of us cannot afford to do less than work full time at the jobs we currently have for the next 5-7 years.  I especially always feel like that big retirement chunk hurts to lose, even though the reasons for it are sound.  We've settled into the plan and things are stable and workable.  I feel immensely thankful for that, considering how much worse it could be.  But I have to say... it's not really fun to have half your income going to student loan debt and to know that can't change for almost as long as it took to accumulate that debt.

I was talking to a premed student a while ago and she was telling me she got into multiple medical schools, but wasn't sure which one to choose.  One was the local state school.  The other was a private school in California.  We talked for a while about the similarities and differences, and then I offhandedly asked if there was much of a price difference between the two.  She turned sheepish.  Turns out the fancy California school was $30k more per year and she wanted to do family medicine.  I kinda lost it on her.  $30k per year becomes $120k on graduation becomes $150k after residency becomes a $2000 difference in monthly payments for 5-10 years.  Not very socially appropriate of me to lay it out like that, but she had never looked at it that way.  Last I heard she was headed to the state school.

So why bring all of this up?  Because no one ever talks to med students, residents, and doctors about money and it can really hurt us.  We shouldn't go to extremely expensive medical schools really ever, but especially not if we want to go into primary care.  We shouldn't take the max student loans out when it will cost us literally thousands extra a few years down the road.  We should learn about budgeting and investing and taxes and talk about it with each other so hopefully we can stop making dumb mistakes (example: I literally realized today that I have to be careful about how much money goes into my retirement account now because apparently there's a fee if I go over some arbitrary limit the IRS set.  This is called a contribution limit and it's really basic and I had no idea).  If it were just about money it wouldn't matter.  But as I explained to that premed student, money = freedom.  Freedom to have a long parental leave when you have kids.  Freedom to take low-paying work and get to missionary work sooner.  Freedom to support missionaries and sponsor lots of kids through Compassion International.  Freedom to leave medicine if you want.  Freedom to take a freaking vacation.  The list goes on.

So, med students, residents, fellow new docs, educate yourself as early as you can.  Treat debt like the enemy it is.  And talk to each other. 

Saying No

Teach more? Full-time academics? More emergency medicine work? Free clinic work? This week I said no to all of it.

When I was a teenager I perpetually went through boom and bust cycles of activity, where I would overextend myself for weeks or months at a time and then abruptly become an unreliable hermit for a while once my energy bottomed out. I always felt guilty about that. Other people seemed able to sustain one pace without suddenly giving out here and there. So once I got a bit older I became a committed believer in the power of 'no' to change your life. I started saying no to things all the time. I'm not going to do that. I won't be attending that thing. I will not be able to help you with that. No. No. No. And my life got a lot better.

Then residency happened. Residency is essentially one giant YES. You have one option to say no, and that is at the very beginning. If you say yes to residency, you have inherently said yes to everything in residency.* I'm not proud of how I handled that overall, but I am grateful that God brought me through it. I think.

I'm in an interesting stage right now where I have too many wonderful opportunities. Talk about job security - I could honestly work as much as I wanted and have as many jobs as I wanted, all of them good positions. This is new territory and it brings up old bad habits. For me, it's a real struggle to look at all of the ways that I could be helping people and growing and contributing and collaborating - and to have to say no to so many of them. I have to remind myself that I already have two jobs where I work more than full time and am climbing more than one challenging learning curve. It's enough. Often it's more than enough and I wish I could dial back even more than I already have. But there's so much more that can be done. There's so much more to do.

While I don't have a solution, it's a good problem to have. Can I say for certain that I'm glad that I didn't quit residency? No, I can't. But maybe one day.

*Don't get me wrong, there's always something optional enough that you can get away with saying no. I said no to everything I could. It just wasn't enough.

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.