The End of the Beginning

After a long pause in my blog posts over the last few months, the day has arrived. The day that I have anticipated for so many days. The day that I knew would eventually come but somehow imagined might never come. The day that I have longed for, and feared, for decades. The day that this blog has led up to all along: residency graduation. At moments like this, my words begin to sound cliché despite my best efforts: a spectrum of emotions is cast as clouds across my sky, and I find it difficult to sift through and focus on the most poignant of them. And so today I will borrow Margaret Atwood’s eloquent words  from “The Moment.”

The moment when, after many years
of hard work and a long voyage
you stand in the centre of your room,
house, half-acre, square mile, island, country,
knowing at last how you got there,
and say, I own this,

is the same moment when the trees unloose
their soft arms from around you,
the birds take back their language,
the cliffs fissure and collapse,
the air moves back from you like a wave
and you can’t breathe.

No, they whisper. You own nothing.
You were a visitor, time after time
climbing the hill, planting the flag, proclaiming.
We never belonged to you.
You never found us.
It was always the other way round.

Today, it becomes easy to say, “I own this.” I achieved this. It is mine. Residency, the hospital, the world. I conquered it. But in reality it is residency itself, that metaphorical beast I struggled with for so long, that is releasing me from her firm grasp. Letting me go out into the world, setting me free.

I do not own this. It is, rather, a shared experience. Thousands of doctors have come before me, have traveled their paths to becoming a healer. Thousands of doctors will come after me. The constant observers are time and nature; they watch us, over hundreds of years, coming and going and proclaiming along the way. Our stories all weave together into a tapestry of memories. And so it goes.

And if there is anyone who owns this, it is not I. It is the thousands of patients I have cared for over the years. They have taught me how to be a doctor, a listener, a healer, and a confidant. They have put their trust in me without really knowing who I am. They have demonstrated endless patience with me, as I struggled through the obstacles of being a resident. They tolerated me when I was at my worst – overworked, exhausted, and still learning. Some of them spoke so eloquently about their illnesses that they provided me with a new perspective on disease, on hospitals, on medicine, and on my profession. These thousands of patients, over the last eight years of my training, helped me to become the doctor – and the person – I am today. At last, I have reached a place where I will be able to give back to my patients in my way.

There is an overwhelming sense of peace that sweeps over me today. As the wind fingers through the trees, as the summer sun beats down, I am free. Today, for the first day, I am free. After four 4-year commitments to science, study, and sweat – high school, college, medical school, and residency – I have completed the beginning of my journey. My life has been divided into segments of four for the past 16 years – over half of my life. It is almost bizarre to think that it will no longer be divided into segments of four. That I will no longer be the unaware freshman, or intern, just starting out and learning everything anew; that I will no longer be the sophomore, or second year, too wise for her own good; that I will no longer be the junior or senior, rising to the heights of my greatest potential. No, from here on out, life will be divided as I wish, or not at all. My growth will not be measured in quarters – it will come sporadically, in starts and stops, as it does naturally.IMG_1524
As I reflect on these years, it is almost surreal to have finally accomplished my goal. It was a goal I set such a long time ago as a young child, a goal that required years of dedication, sleepless nights, and hard work. A goal that I did not even understand until I found myself partway through the journey. And today my mind is teetering, uncertain. Where do I go from here? My life was wrapped around this goal for most of my years. It has become a fixture in my life – a constant challenge, day in, day out. It has been with me, it seems, forever. Without it, I feel lost. But I also feel thrilled to be lost. For this is what life is all about. Our stories are not carved from rigid pathways or concrete bounds, but rather they wander from time to time, curve up hills, stretch across valleys, turn sharply and unexpectedly, and find nooks and crannies. I am ready for this change, excited for this change. In the words of Winston Churchill, “Now this is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.”

And so I find myself here, at the end of the beginning. Finally letting go of a goal that has captured so much of my attention and focus for many years. Grateful to be here, indebted to all the loved ones, professors, nurses, doctors, and patients who made this journey possible. Although I may not own this place, I love this place. I am in awe of its organic beauty. The trees unloose their arms from around me, the birds take back their language, the cliffs fissure and collapse, and the air moves back from me like a wave, but for the very first time I feel that I can breathe. No longer is there a seemingly insurmountable goal looming over me, pressing weight into my shoulders, taunting me, burdening me. I am here, today. For once, without expectations or concerns. Ready to stretch my mind, ready to reconsider, ready to ask a million questions, ready to dance, ready to break free from the bounds of a pre-determined road and to embark on a new path, something entirely my own.

And so,
here goes……

Coming to a close…

As the first half of residency nears an end, I recall this year – with all of its trials and tribulations. There were days when I walked through the ominous double doors of the hospital’s front entrance and wondered if I would ever emerge from them again – and if I did, how changed I might be. There were days when I was so frustrated to look down at my pale blue uniform and realize that the blueness had penetrated me, coursed through my veins, made me sad. There were days when I was angry to be in the hospital and not home. And there were days I was grateful to be here, honored to care for my patients with compassion and concern. This place has grown on me, and it has challenged my perspectives on healing, illness, and hope.

As I glance out the windows at a stone garden where a little girl in a hospital gown throws a ball to her father, I wonder if residency is a process that will encourage me to close the doors of the hospital, inch by inch, never to return again, or if it is a process that will allow me to re-open the doors, ever so slowly, as I recover from the hours that I have spent here healing patients.

The sun shines bright, and rain pours down outside. Clouds linger in the distance. The rain is gray but sparkles. The greatest paradox. A beaming smile curled with doubt at the edges. Eyes wide and bright through tears. Hope high in the midst of devastation. Expect the worse, hope for the best. Residency is not unlike a downpour in sunshine – and I, drenched but warm, through it all, have reached the peak of this mountain and am now ready to trek down the other side. Unchartered territory, slippery at times, but less daunting – and less exhausting – than the ascent. This I can do.

We are entering into a transition time in the hospital. As July approaches, the new interns – with fear and enthusiasm that now amaze me, although I was one of them only 24 months ago – are entering the realm of the hospital for the first time as doctors. A momentous occasion. But as I gaze at them, I realize that an insurmountable barrier has formed between us. How can I tell them what to expect? How can I explain to them how they will change in these coming years, how they will be challenged, and how hard they will be pushed – emotionally, physically, and intellectually? No words or experiences will do this journey justice. It is very much an individual journey – shaped by our unique encounters with patients, physicians, and one another.

Earlier this year, I used to approach my drive to the hospital with dread. But now I approach my drive to the hospital with a sense of wonder. I understand, sadly, that I will not be able to save everyone who rolls through the doors. But I am confident that I will be able to make a difference in the lives of my patients. I am confident that I will work to help people heal – and even to alter the course of their lives.

The sun shines on a downpour. Tears, regrets, the past trickle down into the drains. The grayness of the world is lessened by these rays, which boldly penetrate a place where they are unexpected, but where their warmth – and persistence – are always welcome.

Reflections on residency thus far…

To assume that residency can be explained fully to one who has not experienced it in its entirety is naïve. It is almost a living thing – changeable, ravishing. It is a path forged through jungles which holds mystery even after the turns, trials, and tribulations have been fully exposed. As residents, we take photographs along the way to capture moments of progress, anger, fear, frustration – but only in retrospect, and perhaps not even then, it is possible to understand which moments will become significant. Why are there patients whose brief encounters are vivid to me still, while others have simply faded from my memory? How is it that I can paint with certainty the eyelids, the fingers, and the nose structure of my first cadaver from six years ago, but that I can now say so little about the eyelids, fingers, and noses of my patients? I can remember the face, tanned, broad, with graying eyebrows, of the woman whom I first declared dead. But I cannot remember the faces of any of the others who followed. They blur together – a swarm of people whom I have watched depart from this world. Strangers, patients, bodies in stretchers – but not faces.

Steve McCurry, National Geographic

Surviving residency means learning to look away. Or, more precisely, learning to see through the very elements of life – and death – which used to stop us in our tracks. Writing has revealed to me how muddled – and how out of our control – this process is. I have learned to listen clinically – I have learned to listen to the words that will save me time later, that will clinch the diagnosis, so that I might have a minute to steal five minutes of sleep or a slice of sustenance. And, sadly, I have learned to discard all the other pieces of a patient’s story. The details of their personal lives have become meaningless to me – even troublesome for my primary tasks, efficiency and depersonalization.

Medicine practiced in this manner draws me farther away from my writing faculties – and my sensitivities – than I have realized. The process of depersonalization is far more amenable to cartoon drawing or improv comedy than it is to writing – something light, humorous, distant. My art and writing have become vapid. I can observe, but with strict limitations and great distance. I have skillfully walled off the emotions of my patients. In the last two years, in spite of all the tragedy I have faced, I have not shed a single tear for a patient. I wonder why.

There is an unspoken culture in medicine that it is cowardly to break down on the job. It is cowardly, in fact, to personalize the emotions of our patients enough so that it affects our performance. We are expected to rise “above this,” if you will – to be objective, discerning physicians. And I have done exactly this, with raving reviews from my superiors. But it makes me concerned that there is something missing. Perhaps taking care of such sick patients should not be so easy.

This is why illness close to residents – among ourselves, our friends, and our families – hits us so hard. It is not merely the illness itself, but all the implications that come along with it. In spite of our adept skills, it is far more difficult to depersonalize the illness of a loved one than of a stranger. These situations create a dichotomy in our minds – in order to perform our day-to-day tasks, we almost need to believe we are invincible. But when those around us fall, we must accept – even if briefly – the reality that we are not.

I am not sure what the solution is. With the demanding hours of this training, and the way residency – a living, breathing being – devours our lives, takes from us any ounces of energy which we may have remaining, brings us into the void of the hospital in all its intensity – I am not sure how we can open ourselves up to this, emotionally, and survive it. And so, at least for now, we do not.

I watch my fellow residents. We walk around this hospital like zombies, more absent then present. I can only wonder how we will emerge from this – as alienated as we are now, or will we regain some sense of warped humanity after all of this is over… Only time will tell.

Welcome to the Hotel

There are nights when being a physician in the emergency department is like working as a hotel manager on an event weekend. Tonight was one of those nights. Rather than saying, “My name is Dr. ___, and I will be taking care of you. What brings you into the emergency department today?” A much more fitting opening for most of last night’s shenanigans would have been, “Welcome to Motel 9. We have a beautiful ground-floor view of a drunk man stripping his clothes off just beyond that half-opened curtain. On the other side of the building, we have a free live music performance – a patient clucking continuously for all to appreciate. In the corner we have a young woman and an elderly man arguing over who will get to have their c-collar taken off first – that is, which one of them will be sober first. Pick your poison. This is a full-service operation, 24-7. The customer is always right!”

We aim to please.
“Doctor, I need a sandwich.”
“Doctor, I’m cold right now. I need more blankets.”
“Doctor, I really need to go to the bathroom. Now.”
“Doctor, you can’t let me go home. I’m not sure if I can get into my house.”
Yes, right after I take care of one or two dying people, I’ll get right on it. Full-service motel. We wouldn’t want any of you to go without a sandwich for more than two hours in the emergency department. That would be pure sacrilege.

And so I am drained. Ready for a reprieve from constant service, constant sacrifice, constant work. In time.

Between a Rock and a Hard Place: ACGME Passes New Duty Hour Regulations

Yesterday, the ACGME officially approved new duty hour regulations to be effective July 2011. The initial proposals have been a hot topic of discussion since they were first introduced in June. Read a prior post, Resident Duty Hours: Loopholes in the New Regulations, for a more detailed analysis of the fine print. The current interns and second year residents are now officially “the residents who got the short end of the stick.” No one seems to care. We labored through intern year and we survived. Yes, it was difficult, but we made it. So did all of our predecessors. And now we are limiting hours to “protect” interns – we are switching the pyramid such that senior residents, rather than interns, are spending more time in the hospital. The senior residents, PGY-2 and above, will now be required to stay for 24 hours – the interns must leave after 16 hours.

Great idea in theory, but far more difficult in practice. Hospitals across the country are going to struggle to comply with these new regulations. Options include switching to a night float system, bringing in more hospitalists and PAs, or – and this seems like the least reasonable, but the most likely – just let the senior residents sweat it out. They can deal. Right…

I am curious how many people who sit on the ACGME board were interns when the new computer order systems began to replace handwritten charts. With the advent of computer ordering, residents are more closely monitored and are required to place electronic orders in a timely fashion – or else. I cannot count the number of times that I have been running a code, intubating a patient, placing an urgent central line – and have been interrupted because I need to find a computer to type in a laundry list of orders. Regulations and systems can be helpful – but they become a problem when they are so cumbersome that they compromise patient care.

And this is where the intern comes into play. Although the job of an intern is tiring because of the hours, it is not overwhelmingly difficult from an intellectual standpoint. An intern can always ask for help. As senior residents, however, we rely on interns to help us with some of the more mundane tasks – order writing, note writing, etc. Although these tasks may seem mundane, (1) they are important and (2) in retrospect, I realize that I learned a lot from them – by directing a patient’s care on the micro level, even if I am only writing orders that someone else has instructed me to write, I gained substantial amounts of medical knowledge during my intern year by doing, rather than by reading or thinking.

Another problem is that second year is not easy. Do the board members remember what it was like to be a second year resident, and do they have a sense of what it is like now? I worked as an intern in the medical intensive care unit in my last month of intern year, and one month later I worked as the senior resident in the coronary care unit. Which was harder, and which did I need to be less fatigued for? Most definitely the latter. In those first months of second year, fresh out of intern year, residents run the intensive care units, the emergency department, the medical floors. And it is important that we have time to think. If we are bombarded with our job as a senior resident and the tasks of the intern – order writing, note writing, etc. – we cannot do either well. In a 24-hour time period, it is the senior resident – more than the intern – who needs a short nap. After all, the seniors – not the interns – should be the ones making critical decisions about patient care in the middle of the night.

The 24-hour rule has also been changed with these new regulations, from 24 hours of patient care plus 6 hours of transfer of care to 24 hours of patient care plus only 4 hours of transfer of care. I find it almost comical that we are going to try to cut hours in the intensive care units, where rounding on new patients can take until noon or beyond – which far exceeds the proposed limit. The loophole I mentioned before – that residents can stay later to take care of one patient – is going to be used to excess, and not necessarily for the right reasons. There is no possible way to finish medical rounds earlier than we do on post-call days. Programs are already struggling to meet the current work-hour regulations.

Good ideas in theory are not always good ideas in practice. Although the ACGME has good intentions in mind (I agree with the principles behind them), the hospitals are left to fend for themselves. With limited money and limited residents, these new regulations put hospitals between a rock and a hard place. And ultimately, that will put senior residents in a difficult situation. I hope that implementation of these new policies will be a matter of concern – it is easy to publish guidelines, but much more difficult to execute them appropriately.