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……


On winter solstice, or becoming real

December 2011. X marks the spot. In exactly 18 months, this journey will be complete. But now is the time that I begin to get nervous. Residency is easy, relatively speaking. Easy, you may ask? After these blog posts about grieving, hardship, long hours, and sacrifice? But how?

Ah, my friends, I have painted the picture too grimly. It is only with time that my lens has cleared and reveals…life in the real world. Residency offers us much protection. We have strict hours restrictions. We still go to school, and get paid to do it. We always have an attending to call on for help. We always have the excuse that we are “still in training” when there is something we do not know. We are protected from much of the litigation that floods the world of medicine today.

It is the life of an attending that is difficult. As emergency physicians, we bear the weight of people’s lives on our shoulders – and we do it alone. And, in some sense, we harbor responsibility for each bad outcome that happens on our watch, in our department. And – if we are good – we ask ourselves, again and again, “Was this something I could have prevented, if I had acted quicker, smarter, better?” And we ask, “Was there something I missed?” And we ask, “What if?”

There is a quote from a children’s story that I will cite here…

“What is real?” asked the Rabbit one day.

“Real isn’t how you are made,” said the Skin Horse. “It’s a thing that happens to you.”

“Does it hurt?” asked the Rabbit.

“Sometimes,” said the Skin Horse, for he was always truthful. “When you are Real you don’t mind being hurt.”

“Does it happen all at once, like being wound up,” he asked, “or bit by bit?”

“It doesn’t happen all at once,” said the Skin Horse. “You become. It takes a long time. That’s why it doesn’t happen often to people who break easily, or have sharp edges, or who have to be carefully kept. Generally, by the time you are Real, most of your hair has been loved off, and your eyes drop out and you get loose in your joints and very shabby. But these things don’t matter at all, because once you are Real you can’t be ugly, except to people who don’t understand.”

– Velveteen Rabbit, Margery Williams

Residency is all about the process of becoming real, of walking farther along the path to “doctor-hood” – the path to adulthood. The path to making one’s own decisions and standing by them, come hell or high water. But you realize that this journey to “real” has happened only after it is complete, all finished, in the blink of an eye. Real creeps up on you that way, nice and quietly, and then it is there forever.

But, as I look back, the Skin Horse was right – Real is a process, bit by bit, day by day. Over the years, residency has taken its toll, the wrinkles are there, my hair has been loved off, and the memories of all of my patients – through life, death, and everything in between – are present in me, subconsciously affecting my decisions at each critical turn. And real hurts, too – more than you would imagine. No one ever said it would be easy. It is scary sometimes. Sad sometimes, too.

But it is real, after all.

I still remember when one of the bravest attendings I know told me that she had hoped, in those first few years after residency while driving to her single-coverage overnight shifts at the hospital, that she might get into a minor car accident just so that she could have a reason to call out that night, not go. She is one of the bravest people I know. And even she had a hard time becoming real, in the beginning.

People ask me what I want to be when I grow up, now that I will be graduating in 18 months and interviewing for jobs in less than a year, and I look at them, perplexed. I know what I do not want to be when I grow up – a medical resident. That is for sure. But what do I want to be? Maybe a real doctor, maybe not. Maybe a writer, but that will never pay off my monstrous loans. Maybe a teacher, I have always loved to teach. Or maybe I just want to be me for a while, and be free for a while, not a slave to my occupation.

I always used to have an answer to this question. In high school, I wanted to go to college to be pre-med. In college, I wanted to be pre-med to go to medical school. In medical school, I wanted to go to residency. And somehow, after all these years of a nice, clean and cut path to success, I find my feet faltering at this next step. Part of me is hesitating, does not want to venture on anymore.

The more time passes, the farther I travel, the less I know. But maybe this is all part of the process…I am not real yet, after all.

Where Trauma Meets Tragedy

“Full Trauma Now.” The words blare across the emergency department. There is a rush towards the trauma bay – stretchers, x-ray technicians, nurses, medical students, residents, attending physicians. We dress in our protective gear – plastic blue gowns, gray gloves, face masks, blue marshmallow hats. And we wait. “Have you heard the story?” One nurse whispers to another.

“It sounds bad…car vs. tree, I think, or maybe bike vs. tree, I’m not exactly sure…” She tilts her head up, as if trying to grasp the story from thin air.

One of the technicians pipes up, “GCS 4 in the field. Not intubated.”

A nearby resident raises an eyebrow, “Really? They haven’t intubated yet?” He gets his equipment ready – suction, tube, blade. Everything is in order.

And we wait.

Minutes go by.

A nervous, hushed wave of conversation ripples across the room. The hum of stretcher wheels fast approaches, or perhaps we are only imagining it. The air is thick with anticipation.

This is the trauma bay. The small, rectangular room where life meets death. But I have rarely seen a death here. Because we have become so skilled at keeping people alive, we are often able to stabilize patients for just enough time to whisk them away to the operating room or the intensive care unit. Even so, this is the room where a sudden life change is first realized, observed, and recorded. This is where it all begins. A bay – it is not a fitting term, really. Bright red airway bags, big computer screens, beeping monitors, life-saving carts, stretchers, fluorescent lighting. And there is no peace here. It is not a bay – more of an ocean, with unseen waves, trade winds, thunder, lightning strikes.

I have watched many patients meet their fate here. And yesterday, for one, the tears welled up. I know exactly how to hold them back – have become an expert, in fact, at letting them come just far enough to the brim of my lashes, so that if I smile it almost looks as though they are a twinkle and not a tear. Have I begun to feel again, after these years of blocking everything out? Perhaps. I was pleased to discover them – quite unexpected, I might add. Incredible that after all this time the tear ducts still function in the old, familiar way. A miracle, really.

As I watch this woman’s tragedy unfold in front of my eyes, I realize that she will not make it. I look at her, I look at the CT scan, and I know – with certainty. I no longer have the naïve hope of a medical student. I no longer need to look to my attending for confirmation. I almost wish I did. I glimpse the family at her bedside. Children, grandchildren, sister. I watch them weep. Their eyes are wide – too much hope, I think. I want to brace them for what lies ahead. But I know that would be impossible. A shock is not absorbed, or even felt, at first. It just is. It glares you in the face.

This is my last day as a second year resident. How the time has gone by. How much has changed. Children, grandchildren, sister. I watch them weep. And for a moment, I let myself remember what it feels like to be one of them. I, in my white coat, with too much knowledge for my own good. I, the doctor. No more or less powerful than they are, when it comes down to it. I put myself in their shoes. Slip them on my feet, feel the worn leather, tap them on the white floors, now splattered with blood. I watch them weep. And I feel something – not as much for her, but for them. For all the trials they will face in the coming hours, for all the tears they will shed, for their loss.

They loved her so much, didn’t they?

Writing to Save Oneself

An article published recently in the Los Angeles Times, Test-taking anxiety, indicates that when students write about their anxiety, they tend to perform better. At the University of Chicago, a group of 20 college students were given a math test. In the 10 minutes prior to the exam, one group of students was asked to write down their feelings about the test. The other group sat quietly. As compared to their baseline scores on the test, the group that had written down their feelings improved by 5 percent, while the group that had sat quietly worsened their scores by 12 percent.

The idea that writing is therapeutic, and can even improve performance, is not a new one. It has been utilized effectively in poetry therapy for centuries. The first known poetry therapist was Soranus, a Roman physician who lived in the 1st century A.D. And the same concept is now being implemented in medical schools, as discussed in a recent article in The Wall Street Journal, Poetry, Painting to Earn an M.D..

The process of writing has much to offer all kinds of people – physicians, patients, bloggers, novelists, musicians, engineers. To pick up a pen and express how we feel is a momentous step in the process of self-discovery and personal growth. Perhaps incorporating writing more into the daily life of physicians and patients could be an effective way to improve communication, reduce stress and anxiety, and develop closer relationships in the hospital setting. From a practical standpoint, this becomes difficult when there is simply not enough time to take a step back from things and write. But if a brief amount of time were allotted each day – even 15 minutes – to writing, that might provide a source of relief for weary minds and downtrodden souls.

The concept of narrative medicine has taken hold at some university hospitals, with Columbia University at the forefront of this movement. The idea behind narrative medicine, at least in part, is to hurt and to heal through writing. The process of taking a blank page and beginning to express all of the grief, life, death, pain, hope, and fear that lives and breathes in the walls of the hospital is a formidable one. It is almost overwhelming. There are so many stories to tell, so many plights to share. But this could bring into the world of academic medicine a fresh breath of air – and a new source of healing.

Frozen, Briefly

The train halts. Beside the platform, a young mother holds her daughter’s hand. The girl is dressed in a red petticoat, the hood flapping carelessly across her back. One leg swings aimlessly – white cotton tights, gripped by a polka-dotted rain boot, greet onlookers with a clumsy hello. People scurry across the platform with brown paper bags, yellow plastic grocery bags, purses clutched against their sides, briefcases swinging purposefully, large duffel bags weighing down a lopsided shoulder.

The little girl hops on to the train. The mother follows absent-mindedly, responding only to the tug of a bright red mitten but not to her daughter’s voice. She grasps a yellow plastic grocery bag, filled to the brim and stretching thin with the weight of its contents. Her face and boots are worn, older than she is, with creases in all the familiar places. Her chapeau is young – slanted blue wool with a dash of feather on the side. Her hands seem to be the most comfortable part of her – calloused, ringless, tightly clutching the bag. A pale blue watch across her wrist – she glances at it but does not react, as if time will not make the difference.

The little girl – bright red bow in a bouncing cascade of blond pony tail. She hums to herself, tilts her head in different directions, almost upside down. A man in one of the nearby seats glances at her with half-interest, eyes almost but not quite lit, considers smiling – but refrains. The lines of his mouth barely curve upwards. The little girl continues on, twisting her head all the way around towards her back, her chin nudging against the edge of her hood.

The mother looks straight ahead, a steady, tired gaze, as pipes and darkness flash by the windows. What is this world made of, after all? She wonders. The measured hesitation of a stranger. One polka-dot rain boot hovering on a platform edge.

More than ever, the bags we heave as the muscles of our arms reach pure exhaustion. As the world flies by, we clutch them tighter.