Friday, December 11, 2009

Fighting the Cynic Inside

I have always envisioned myself as becoming a doctor who would empathize with her patients. Regardless of they were, where they came from, or what they presented with, I always wanted to approach my patients with patience and compassion. Now, three weeks into my Night Float rotation, I am finding this vision much more challenging than I anticipated.

One of the wonderful aspects of my residency program is that our hospital runs its own Emergency Department for women of all ages, pregnant or non-pregnant, with any sort of acute OB or GYN issue. It is a high paced environment in which patients are rolling in with anything from labor, miscarriages, cancer complications, surgical complications, sepsis (aka widespread infection)… the list goes on and on. It makes for fantastic resident training.

On nights, when I am not in the delivery room or the OR, I am often found tending to these high acuity patients. After all, one would think that a person would have to be really sick to come into the ED at 1:00am, right? Ha. This is where the issue of my dwindling patience comes in. Let me introduce you to the 24yo non-pregnant female who came to see us last night. Her chief complaint? Vaginal SPOTTING between periods. In the setting of a history of irregular menses. I’m serious, this was a regular problem for her and she decided that one day of spotting was an emergency. She had gone through HALF of ONE pantyliner. Clearly not hemorrhaging. There are also the dozens of women each week who come into the Emergency Room after getting a positive home pregnancy test. I mean, really? You need to come in to the ED at 2:30am for a positive HPT?!? Oh, and the woman who “lost a tampon” in her vagina?

The icing on the cake was a patient I had the other night. She was a 20yo female who was pregnant with her THIRD child in the last THREE years. She had had ONE prenatal care visit during this pregnancy and not for lack of insurance or health care provider. She didn’t know her last period and as a result, we had no idea how far along she really was. Her chief complaint? She had come to the ED because she decided that she wanted a C-section that night. SHE decided. I was shocked.

I’ve seen many a bitter physician throughout my training - the sort that blame their patients for everything. I don’t ever want to become that person. Fighting cynicism, however, is an ongoing battle. Especially when you feel like there are so many patients who take advantage of our services.

Now I am educated enough to understand that our shabby health care system, with its limited access to primary care, is largely to blame. Our G-rated version of sex education has also left women so unfamiliar with their bodies that they run to a physician for the most minor issues. I also understand that WE were the ones who failed S.M. when we let her have two babies at our hospital and never set her up with reliable birth control. But remembering this is a struggle. I am resolved to doing it, to be the kind of doctor that I would want to go to. But it takes a conscious decision I make each and every day.

Tuesday, December 8, 2009

She Growns Up

I don’t know how it happened. But it finally has. I am starting to feel like a bona fide doctor.

As you can read in my previous posts, the first couple of months of intern year were racked with insecurity. For instance:

The first week of my intern year, my 2nd year resident and I got called to a postpartum hemorrhage on the floor. One of our recently-delivered patients was found to have active vaginal bleeding a couple hours after the birth of her child. We rushed to the bedside. There was blood all over the bed, her hospital gown, and her legs. She was crying. Before I knew it, my 2nd year bolted into action. She was calling for vital signs, IV access, Pitocin, Misoprostol. She shouted out an order for Morphine to make the patient comfortable. She gowned up into sterile gear and started a vaginal exam at the bedside. Before I knew it, she was using her hand to clear out the uterus. Out came handfuls and handfuls of clot. In less than 5 minutes, the uterus had been evacuated and the bleeding had stopped. I will always remember that moment in my intern year. It was one of awe – awe regarding my resident’s ability to keep her cool and bring order to a frantic clinical scenario. It was also one of terror – terror regarding the idea that in 1 year, I would be expected to handle that situation with the same level of calm and skill. It seemed a daunting task.

Fast forward to my first shift on OB nights. It was 2am. The high pitched squeal of my pager shot me out of my near slumber. “Postpartum hemorrhage, pt J.K. in room 5015.” I jumped from my seat and headed towards the elevator. On the ride up, I recalled the steps in the management of post-partum hemorrhage in my head. Before I knew it, I was running it. I was calling for vitals, calling for IV access, for Pitocin, Misoprostol. I was clearing out her uterus. I was calling for a stat hemoglobin. Before I knew it, the patient was stable and her bleeding had stopped.

It didn’t hit me until later, when I was recalling the experience in my head, that I had missed something. That feeling that had haunted me for months – the panic, the insecurity, the tachycardia – was not there. In its place was an excitement, a sense of pride, and a rush that shouted “yes! I did it!” Yes, folks, I am growing my doctor wings.

Monday, November 16, 2009

Becoming More Than a Resident.

Oh, medical students. Feels like just yesterday I was one of those chipper, eager-to-learn little students dressed up in my short white coat with a Maxwell’s in my pocket and stethoscope around my neck. The best rotations were with residents who:
a. Were enthusiastic about their job
b. Made your experience hands-on
c. Made an effort to teach
The worst rotations were with the residents who saw medical students as nuisances and spoke to them only to assign us non-educational busywork to do, a term known as “scut work”. For me, the most dehumanizing part was that these were usually the same residents who couldn’t be bothered to acknowledge our existence or learn our names. As I looked towards graduation, I swore I’d be the former type of resident.

In all honesty, to be that type of resident has been a challenge. As an intern, I am constantly working to get one of a thousand things crossed off my to-do list. The most basic of actions – stopping to say hello, introducing myself – requires effort. As the year goes by, and I get more comfortable and efficient with my work, I am becoming more able to be that resident I aspire to be. I try to teach. Engage in benign pimping. Review suturing, knot tying. But this is constantly a work-in-progress.

One thing I've noticed is that my ability to be the "good resident" is equally proportional to having a "good medical student". The proactive, eager medical students are by far the easiest to teach. L.W. was a perky, well-learned sub-intern on my Oncology rotation. She anticipated what needed to be done throughout the day and did it. She made my life easier. She had done her reading. As a result, I loved teaching her. The passive, uninterested medical student brings the "bad resident" out of me. Fast forward to our next Oncology sub-intern who clearly had not studied basic oncology, who hangs out in the background and waits to be told what to do, who showed up late. I am finding it much harder to be enthusiastic about taking time to teach her. Instead, she gets a lot of scut work in return...

Saturday, October 3, 2009

Escaping the Inevitable

Any OB/GYN will tell you it’s inevitable. Sometime, no, multiple times during your career, you will perforate the uterus. They all have a story in which an instrument they so gently insert into the uterine cavity goes a little too far… and into the abdomen. But it could never happen to me, right?

It was the last case of the week and I scrubbed in to do a D&C Hysteroscopy with an attending I had never worked with. I sit down to do the procedure while Dr. M supervises. I examine the patient and note the position of her uterus. I place the speculum and visualize the cervix. I place the tenaculum, a grasping instrument which allows the surgeon to manipulate cervix. I sound, or measure, the length of the uterus and then dilate the cervix. I look inside the uterine cavity with the hysteroscope (an intrauterine camera). Everything is going super smoothly and I am proud of my independence in the case. Then it came time for the curettage. I introduce the curett, a long instrument with a sharp metal loop at the end used to shave off the endometrial lining. It is entirely done by feel. Once I feel as though I am done, we re-introduce the hysteroscope to make sure the uterine cavity looks clean and intact.

This time, I am having a difficult time getting oriented in the uterus. I move the camera past what I believe is the cervix, but the uterine cavity just looks more lumpy than usual. I rotate the camera to try and get my bearings when I see something that makes my heart drop. My camera focuses in on two round bulging structures that look frighteningly familiar. “Dr. M, do you want to take a look and tell me what this is?” She takes control of the hysteroscope and is quiet as she examines these structures. Finally, I say it. “Is it BOWEL???” Everyone in the OR, the circulating nurse, the scrub tech, the anesthesiologist, rush over to the camera screen. To get bowel, aka intestine, into the uterus would not only require a perforation of the uterus, it would require a huge tear. How clumsy could I have been to do that without feeling it?

Then again, it really does look like bowel. Dr. M and the surgical staff don’t know what to say. They have never seen anything like this. We remove the hysteroscope and two other GYN surgeons are called in for a second opinion. The wait for them to appear was painful - you could taste the tension in the room. Meanwhile, thoughts race back and forth in my head. Will we have to cut her abdomen open? What if I perforated her bowel too? Will we have to do a bowel resection? How are we going to explain this to her and her family? I thought about my own fate as well. What will the program say? What if I get sued? No attending is ever going to want to work with me again. Maybe I picked the wrong field after all. I am just going to quit before I hurt anyone else. I even start seeking help from a higher power. Please God, please don’t let me have perfed the uterus. Please…

Finally the other surgeons show up. They replace the hysteroscope. Although it’s a bit bloody and messy inside the uterus, we can’t seem to find those structures again. The consult surgeons suggest using a resectoscope, which is bigger and can dilate the uterus much more to increase our visibility. What we find is shocking. We see a perfectly normal and intact uterus. Dr. M and I can’t believe it. We examine every wall of the uterus 5 times. One ostia, another ostia, anterior wall, posterior wall. All smooth. All intact. No perforation, no bowel. Nothing but normal uterus.

The consult surgeons laugh. “See! We told you everything would be fine! There’s nothing!” The rest of the OR and Dr. M. breathe a huge sigh of relief. As for me, it takes me a good ten minutes before I trust that everything is going to be okay. What. A. Scare.

We never did find out what it was that we originally laid our eyes on. On theory was that we saw clots. My theory is that it was a miracle. God really must not have wanted me to quit my residency program.

Friday, October 2, 2009


It has been awhile since I have written.

In one's life, there often comes a time when they are let down by the person they rely on most. For me, I have been more than let down. I have been crushed and devastated. My plans for a future with my presumed best friend and soulmate - getting married, becoming a wife, a mother - have ended. And I don't know if they can ever be mended with him.

This last month has been felt like I have been cut off from the air I breathe. I can only now begin to type these words.

I won't say much more. I will simply continue my professional journey into the world of medicine. Because right now, it feels like it is all I've got.

Thursday, September 10, 2009

Drug Seekers

When I found J.M., he was wincing in pain on the ER stretcher. Attempting to get moderately comfortable, he shifted his position from side to side to no avail. I introduced myself. He was my age, clean cut and pleasant, resembling someone I might have been friends with under different circumstances. He explained his story. One year ago, he had fallen off a room and injured his lower back. With the help of his Orthopedic Surgeon, he was back to himself after a couple of months. Unfortunately, he recently re-injured his back and the pain was intolerable. I could see the discomfort on his face and tears welled up in his eyes as he told his story. “I can’t walk. I have to call the neighbor to help me to the bathroom. Do you know how embarrassing that is?” My heart broke for him. He was on an impressive regimen of Percocet and Oxycodone at home and it just wasn’t managing his pain. As I set out to examine him, no doubt a painful endeavor, I recalled something an ER Attending had said to me. “ER docs are notoriously bad at managing patient’s pain. So make sure you don’t forget to make a patient comfortable.” So, before I went any further, I said to J.M. “I’ll be right back with some pain medication for you and then we’ll finish the exam.” He looked at me with gratitude. “Thanks.” he said.

Four milligrams of Morphine later, I returned to his room. He was still writhing in pain. “Doctor, the medicine didn’t touch me. When I was in the hospital last time for this, they gave me Toradol and Dilaudid.” I gave him both. After examining him, I called the Orthopedic resident to come down to see him. Clearly this patient’s pain control issues and lack of mobility warranted his admission to the hospital. The Orthopedic resident did not agree. Our conversation went like this:
Ortho: “I know this guy. He’s had back problems forever. He just wants a prescription for pain killers and he will go home”.
Me: “You don’t understand. His pain medications are NOT working. He CANNOT WALK by himself.”
Ortho: “How did he get to the ER then?”
Me: “He told me his Dad carried him in!”
Ortho: “Allright fine. Get some X-Rays and I’ll come and see him”.

Long story short: Ortho came down. Saw that his X-Rays had not changed at all - meaning his back issues had not gotten, that we could see, any worse. Ortho found out he ran out of his Oxycodone last night. Offered to write him a prescription for new pain medications and send him home. The patient agreed. Ortho got him to demonstrate his ability to walk. Ortho also found out that he had been to 4 ERs in the span of 2 weeks asking for pain control. Needless to say, his story got fishier and fishier. And I got more and more embarrassed.

How could I have not seen this? Was it because he looked like someone I could relate to? Was it because he didn’t have a history of drug abuse, like so many of our other patients? As a physician, how do you balance being compassionate and being taken advantage of? How do you avoid enabling prescription drug abuse? Let me know if you have any ideas...


Sunday, August 30, 2009

The Learning Curve

I’m finally finished with my first OB rotation! The moment is bittersweet. I love obstetrics. It is exciting, emotional, and empowering. It is also one of the most difficult rotations of intern year. I struggle to stay under the 80 hours of work each week. Each day, I am pulled between the operating room, the labor floor, Triage, and the postpartum floors. Our Triage is unique in that we see all pregnant women regardless of gestational age as well as non-pregnant patients with GYN issues. We essentially function as a women’s emergency room. It is great for my training and experience, but it also means there is never any downtime. When I am not in a delivery or on the floor, I am in Triage seeing several patients at a time. Aside from the hours, the technical skill set we are expected to acquire is huge. In addition to fundamental knowledge about pregnancy and women’s health, we have to master the technical aspects of the trade. Learning how to read a fetal monitor. Learning how to work the ultrasound machine. Learning how to check a woman’s cervix as she progresses towards labor. Learning to deliver a baby. Learning to break her water or insert a device to measure her contractions. Learning to do a C-Section – how to get into the pelvic cavity, pulling the baby out, clearing out the uterus, suturing, knot tying… the list goes on and on.

As a medical student, I got a taste for some of these skills and learning them was always fun and stress-free because there was always someone who walked me through it. Now as an intern, I’m much more on my own. Clinical decisions are made based on my exams or assessments. Avoiding a tear or birth complications are based on me delivering her baby as smoothly as possible. Avoiding post-operative pain and bleeding after a C-section depends on me controlling the bleeding by suturing and tying knots well. There is so much more pressure riding on my skill set than ever before. It’s a scary place to be because I truly want the best for my patients. But I also can’t second-guess everything I do simply because I am new at this. Part of my learning to be a good physician is taking ownership of my clinical judgment.

So, now, I leave Obstetrics a little more skilled and a little wiser. Above all, I leave with determination to do things even better, and with more confidence, the next time around.

Wednesday, August 26, 2009

The Honor

It is the stage in which new life enters the world. Where women overcome the seemingly insurmountable challenge of giving birth. As a new intern, the delivery room is a thrilling place. However, I often wondered – will this ever get old? Routine? You hear time and time again about the OB/GYN who no longer does OB because of the “lifestyle”. Will that ever be me?

It was 4:00am and I was nearing the end of my 24 hour call. I had delivered 6 babies throughout the day and night and the shift was finally winding down. I was at the computer reviewing patient labs and vitals, trying to stay awake for an early morning of postpartum rounding. My pager goes off. It reads: “DELIVERY IN LDR 19”. I jump out of my sleepy stupor and rush upstairs. I gown up for the delivery elated at the opportunity to catch one more baby before the end of my shift. After all, I could use the extra practice with hand skills and suturing technique. I approach the patient and explain what will happen next. She is visibly tired from pushing. Her mother and husband whisper words of encouragement and take turns stroking her hair. This is her first baby. She is both scared and exhausted. We push for about 10 minutes and make little progress. The baby is crowning but at this point, we can only see the top of her head. This continues for another 10 minutes. Our patient starts to lose patience. She starts wailing in pain and threatening to give up. She doesn’t want to do this anymore. “Please, I just want to stop,” she wails “I can’t do this anymore!” Her husband encourages her to keep pushing and opens himself up to her wrath. “Shut up! Just shut up! Don’t touch me!” she screams. The tension in the air is palpable.

I call her name loudly to get her attention. I remind her that she can do this, she will do this. We remind her to breathe… and focus… After several minutes, she calms down and breathes deeply. I feel around the baby’s head and note that there is plenty of room. The nurse pours on some Astroglide to help the baby slide out easier. I hold pressure with my fingers at the base of her vagina. “Push where you feel my fingers,” I tell her, “Push my fingers out.” She closes her eyes to focus on the task at hand. She pushes with all her might. The crown of the infant’s head slowly advances out. Then her forehead. Then her face. With two more pushes the infant is out. For a split second, the room is silent.

I hand the child to her mother and she whispers in the softest of voices, “Oh, my baby.” The patient’s mother and husband burst into audible tears of joy and the three of them embrace around the newborn child. I feel a lump in my throat upon seeing this display of love. My eyes well up. I look to my resident and my attending standing next to me and their eyes are teary as well. We look at each other and without speaking a word, I know we are all thinking the same thing. This is what we signed up for.

I realized then that this experience could never get old or routine. The delivery wasn’t about practice or refining my skills. It was about the immense honor when a woman trusts you with her body during the most intimate of all experiences. It was about the privilege of being the first person in the world to lay hands on a newborn child. This is something I could never, ever take for granted.

Monday, August 10, 2009

Slippery Babies

Babies, and their entrance into the world, are always unpredictable. At this point in my short residency career, I have delivered about 12. By the middle of my weekend on call, I felt pretty darn comfortable with the process. The head is delivered with a little downward pressure, followed by one shoulder, then the next. The rest of the body is delivered quickly after. Then, with a swift move of the hands, you flip the squirrely little neonate into a secure football hold while you suction out his nose and mouth and clamp the umbilical cord. Seems pretty straightforward right?

Ha. Today’s call day reminded me that I am a mere intern with a lot to learn.

Working in triage today, I hear the team call out, “She’s complete (read: fully dilated)! We’re taking her straight to L&D!” Being the team member assigned to vaginal deliveries, I hop out of my seat and follow the patient up to the labor floor. We rush into the room and everyone takes their places. Patient is moved to the bed, nurses pace around frantically setting up for the delivery, and my attending physician, Dr. T, and I gown up in what one patient called our “storm trooper outfits”. It’s true. Baby deliveries are messy! You have virtually every body fluid being thrown your way at any given time. You’ve got to protect yourself! So, we don our face shields, surgical boots, surgical gowns, and sterile gloves. Now the process of pushing to delivery can vary anywhere from a couple of minutes to a couple of hours. As the baby catcher, you generally have a bit of time to get mentally prepared for the upcoming events. Alas, that was not the case today.

One push and the baby’s head slides out easily. Too easily. My hands on either side of the head alternate between applying upward and downward pressure to ease out the baby’s shoulders. All of a sudden, the rest of the baby catapults out. I try clumsily to secure the baby in my football hold but can’t get a grip on her legs – she just comes out way too fast. Before I know it, in painful slow motion, I am fumbling to keep this baby in my grasp. And everyone is watching. After a split second in real time (but eons in my brain) I regain my grip. Like a magician pulling a rabbit out of a hat, a jump up with the baby in my arms. Ta da!!! “Here is your beautiful baby girl!” I quickly clamp and cut the umbilical cord and place the baby in her mother’s waiting arms. A decent recovery but my face still burns with embarrassment. Shaken and struggling to remember what to do next, I undo the clamp on the placental sided umbilical cord to collect a routine cord blood sample. I replace the clamp and hand the specimen off to the nurse. When I look back there is umbilical cord blood spraying all over the place. It’s hosed the floor, the nurses, my boots. Apparently, in my self-conscious stupor, I replaced the clamp but did not secure it shut. Don’t worry, everything that came out was from the placenta, not the patient, so no one was hurt by my debacle. Just my increasingly fragile intern ego. And my happy place with those labor floor nurses.

Saturday, August 1, 2009

Bad News

M.K. was 5’4” weighing it at only 100lbs, but she was feisty. You could tell she was a knockout before the cancer came. She had big blue eyes and blond pixie haircut reminiscent of Meg Ryan in her Sleepless in Seattle days. She had come to our care after noticing blood in her urine. Didn’t think much of it – she had been battling cervical cancer for five years and figured this was just another bump in the road in her fight against cancer. Thus far, she had been through surgery, radiation, and several rounds of chemotherapy. And despite the orange-sized mass protruding out of her left backside, she anticipated being out the door almost as soon as she came in. Unfortunately, the bleeding persisted. And then, her platelets dropped. A week later, the bowel obstruction came. Her tumor had grown into her intestine and she was no longer able to pass stool through a portion of her large intestine. The nausea and vomiting became so bad, she couldn’t eat or drink. A CT scan revealed that the tumor was now 4mm away from invading her spinal cord. A week and a half after she came into the hospital, the oncology team knew she would never leave alive. But M.K. didn’t.

Being human presents a big obstacle in providing good medical care. It is simply not in our nature to be the bearer of bad news. We want to impart hope, to heal, to cure. Unfortunately, there are many times in medicine when the only thing a patient needs is the truth. The cold hard truth.

Thus far in my short career in medicine, I have seen too many times what happens when doctors are afraid to tell patients and their families the truth. At best, a patient lives the last months of her life with the false belief that she will eventually get better. And she is subjected to the pain and discomfort of tests, procedures, and medical interventions that do nothing to prolong her life and everything to prolong false hope. At worst, it means a patient dies in a cold hospital room surrounded by white coated strangers, with tubes coming in and out of every orifice and ribs cracking under the force of CPR.

I have also seen the alternative. A great oncologist at my hospital always tells his patients the same thing when they first meet. “You are well now, and we will do everything we can to keep you well. But there will come a time when I will have nothing left to offer you. And when that time comes, I will say to you, we are done.” We had that talk this week with another patient, K.A. Because she had had time to think about it before, she was able to say, “Okay, I am done fighting. I just want to be comfortable. I want to live my last months at home with my horses and dogs and die surrounded by my family.”

The same went for M.K. and her family. Before we had The Conversation, her family wanted everything done. It didn’t matter if how futile or physically painful it was, they felt this obligation to do everything to prolong the life of their daughter. And the dutiful daughter M.K. was, she felt obliged to go along with it. Each time we walked into the room, the anxiety was palpable.

Then The Conversation came. M.K. and her family learned that with the way things were going, she would never make it to treatment. She didn’t have much time left and now we were asking M.K. how she wanted to spend the remainder of her life. The room swelled with sadness and tears that afternoon. But curiously enough, it also swelled with relief. The patient and her family had finally been given permission to let go. It was if they had needed to hear that it was okay to stop fighting.

The useless medical treatment was replaced by comfort care. The IV was taken away. The daily injections were stopped. The anxiety in the room disappeared. Shortly after, M.K. started to lose consciousness. It won’t be long before she’s gone, but when she is, her life will end in the most peaceful of ways. Without pain, surrounded by friends and family in a room filled with love.

Sunday, July 19, 2009

Patience with Patients

From the beginning of medical school, we have been taught to extend the same attention, compassion, and skill to each patient we see. A noble expectation, no doubt. So what do you do when you have a patient that is so dreadful, so condescending, and so entitled, that every interaction feels like verbal assault? Let me tell you about S.M., a 61 year old female with newly diagnosed Endometrial Cancer. Her cancer was caught so early, that we were able to cure her with the most benign of GYN Oncology surgeries – a transvaginal hysterectomy. Now this is a surgery that is so minimally invasive, women usually head home the very next day. Wonderful news, right?

Not for this particular patient. S.M., a heavyset Caucasian woman with a wild coif of graying hair, was convinced she was on the verge of death from the moment she arrived onto our hospital floor. How dare we ask her to roll on her side so we could listen to her lungs! She was suffering! And it didn’t matter that she had doctors to guide her medical decision-making – she was going to tell you what kind of medications she wanted. “I only want Demerol”, she ordered, “And Tylenol too! But not the generic, it has to be brand name!” And when she needed her IV replaced, we were ordered to bring up the Anesthesiologist from the OR to do it. No mere nurse could come near her. It had to be a licensed physician who placed her IV. Within her first 24 hours in the Oncology unit, after having to wait about 5 minutes for a nurse to fulfill one of her many demands, she picked up the phone and called the hospital C.E.O. to complain. Everything was wrong with her care. The food was bad. It made her nauseous. She didn’t get the right pain medication. The care was sub-par. How could we treat a little old lady so egregiously?

S.M. complained about anything and everything under the sun. So much so that after a while, I found it hard not to tune her out. Especially when I had a floor full of truly sick or dying cancer patients. Whereas normally I will pop into my patients’ rooms to chit chat throughout the day, I found myself avoiding hers like the plague.

By the afternoon of her second hospital day, she complained of worsening belly pain. And just like each exam before, she moaned and groaned when I touched her belly. The nurses and I rolled our eyes. Dutifully, I reviewed her vitals. Wait a minute. Her heart rate was up. I looked back at her labs over the last two days. Her hemoglobin had dropped 5 points since before her operation. A tell tale sign that she was losing blood somewhere. A CT scan later that night confirmed this. There was a large hematoma (blood collection) in her pelvic cavity where her uterus used to be. And it was making her sick.

The evening was spent stabilizing the patient. We transfused her. We did serial checks of her blood counts. We gave her pain medication. We did all the things we would have done for any other patient in the same condition. And in the end, S.M. was fine.

That night, I couldn’t stop thinking about this patient. She had been 36 hours out from her surgery before I noticed her drop in hemoglobin. Why? Was it just carelessness? Would I have missed that in one of my more beloved patients? Had I let her attitude affect the medical care I was providing? I knew the answer to these questions. I had let myself miss something in my patient, simply because I didn’t like her. And I was ashamed.

S.M. was discharged home on Friday. And thankfully I can say I strived to be a different kind of doctor after this incident. I know that I am limited by being human and I would be lying if I said I ever grew fond of this patient. But I learned a valuable lesson about keeping the practice of medicine separate from the emotions of human nature.

Sunday, July 12, 2009


Being a resident makes you cranky. There are the 14 hour days that begin before sunrise. There is the constant reminder that you are on the bottom of the hospital totem pole. There are the attending physicians that only acknowledge your existence when you screw up – but never make the effort to ask your name. There is the incessant feeling that no matter what, you just don’t know enough… that self-deprecation that comes along with having to say “I don’t know” another time. There is the anxiety that comes with trying to manage a floor full of patients and the incredibly long to-do list that comes with it. And inevitably forgetting something important off the list. Intern year is just a humbling and ego-swallowing experience.


Being a resident also makes you thankful. In the past three weeks, I have met a 35 year old female with cervical cancer so widespread, she had to have her uterus, ovaries, vagina, bladder, and rectum removed. I’ve cared for a 55 year old woman with ovarian cancer who went to the operating room only to have the surgeons discover that her disease was so extensive, they could do nothing but close her back up. I’ve cared for a 19 year old who was told in her home country that her ovarian mass was benign – only to present to us with a 20cm malignant germ cell tumor that was eating away her abdominal wall. I wiped the tears off the face of a 56 year old woman with end stage liver disease, chronic lung disease, and degenerative joint disease – who stayed with us for 15 days without a single visitor, get well card, or flower.

All of these women had problems much bigger than my own. Yet, each of these women, in their own ways, had hope. I watched them take joy in simple victories. Being able to eat and hold down solid food. Visits from loved ones. Freshly washed hair. Being able to get out of bed and walk to the hall. What I didn’t see, not once, was bitterness. Sure, there were sad moments, anxious moments. But there was never that “why me?” attitude I expected to find on the Oncology service. Instead I found women who face their realities with such grace, it leaves me humbled. It fills me with a resolve to quit my complaining and be thankful for the many, many blessings I have in my life.

Monday, July 6, 2009

My First LEEP

The GYN Oncology rotation is one of the most dreaded rotations of intern year. You are relegated to spending 12-14 hour days on the floor managing moderately to very sick cancer patients. As the go-to person on the floor, all the abnormal vitals, labs, imaging, nursing concerns and patient issues come your way. Add the litany of paperwork each patient requires and this makes for incredibly chaotic days. What makes this rotation so hard is that, unlike other surgery rotations, we don’t get to break up our day with the fun of going to the operating room. We are 99.9% handcuffed to the Oncology unit.

So imagine my joy when my senior resident asked me on Friday to head down to the OR to do a LEEP procedure*. It was the end of a long week of scut work** up to my eyeballs. I could think of nothing better in that moment than the reprieve of going to the operating room and working with my hands to do something definitively to help a patient.

It had been more than 6 months since I had seen the inside of an operating room but I wasn’t too nervous. I mean, the attending doctor knew I was an intern. He would show me what to do, right? I head to the OR and meet the attending doctor and the fellow. We scrub, get into our sterile gowns, don our sterile gloves. After the patient is getting prepped and draped, the attending hands me the loop. “Here you go.” Then he sits back and waits. Hmmm. Here I am, standing between the patient’s legs, with the loop in my hand, not quite sure what to do next. How deep do I go? Where does my excision start? Where does it end? I mean, I am all about being proactive, but this is a woman’s cervix I’m working on. Not only do I not want to be the one to mess up her girly bits, but it’s now or never that I learn how to do this right. “Um, Dr. T? Think we can do some practice runs? So I can get the motion down right?” Fast forward to 7 practice runs later, yes seven, and I am ready for the real thing. My hand is no longer shaking from nervousness. I hold the loop in my hand, push down on the edge of the cervix, push the “cut” button on the bovie, guide the instrument up until the perfectly round surface of the cervix is excised. “Look at that. That is great cut!” says the attending and I beam. It’s silly what a sucker medical trainees are for positive reinforcement.

By the time we get the patient cleaned up and out of the OR, it has been a mere half hour that I have been gone. But I was re-invigorated. Re-inspired. My quick surgical jaunt reminded me of all the operating that awaits me over the next four years…

* A procedure in which the surgeon shaves off precancerous lesions from the cervix using an electrically-powered loop

**Scut work: the glorified secretarial, errand-running, busy work that makes up the day to day life of an Onc intern (as described above)

Sunday, June 28, 2009

Day One

What a week. Who knew the jump from being a medical student to a resident could be so big? My first day was Wednesday. I donned my long white coat and headed out the door at 4:30am to begin my rotation on GYN Oncology. I started pre-rounding on my patients, collecting vitals, lab results, fluid ins and outs – nothing I hadn’t done before as a medical student. After rounds, when the attending physician, fellow, and resident headed down to the OR, is when the terror began. All of a sudden my pager goes into overdrive with calls from the nurses. “Patient A is complaining of pain – what do you want to write for her? Patient B is tachycardic, what do you want to do? Patient C has drainage from her incision site, can you come take a look at it?” And as I stand at the patient’s bedside, a nurse and two nurse assistants eagerly await my response. I look down at the patient. And yes, I see a stapled incision down her abdomen. Draining pinkish fluid. Crap. Now what?!? As their eyes burn holes into the back of my head, I think to myself, “Man, I wish my last surgery rotation wasn’t 10 months ago…” Trying to use my brain was like trying to pedal the wheels on a very rusty bicycle. It just didn’t…want…to…work…
“Would you like me to place a pressure dressing doctor?” The clouds parted and the light of heaven shone down on me that moment. “Why yes, nurse! Yes, I would!”

As a brand spanking new intern, that’s the moment you realize that:
1. You are no longer a med student.
2. You are calling the shots.
3. You have no idea what you are doing.

Can you say PANIC?!?

Many times, my non-medical friends ask me if life in the hospital is really like what they have seen on T.V. Their idea of practicing medicine is composed of the life-saving heroism on ER, the incestuous romance of Grey’s Anatomy, and the intellectual masturbation of House. I am here to say that it is all baloney. If you really want to know what residency is like, the show to watch is Scrubs. And my present life resembles Season 1. The intern that doesn’t know what she’s doing. The nurses who go through this every June and graciously fill me in on the many things I don’t know. (“Doctor, I think you want to write for Morphine 2mg every 4 hours for her breakthrough pain, right?”) The senior physicians who expect you to know it all already (or at least pretend to).

Somehow, I think all of us medical students have the idea that when we start residency, our brains will somehow already be filled with the basic information necessary to take care of patients. Ha! If only it was that easy, my friends.

Sunday, June 21, 2009

Signing My Life Away

This week marks the start of intern year, the first of my four year residency program. I’ve waited for this day my entire life and I am both excited and thrilled to begin a life of taking care of patients in the most intimate of ways. I also start this process, however, laden with fear and trepidation. Sure, my dream of being a physician is being realized. But so is four years of 80 hour work weeks, sleep deprivation, and little to no time for anything but medicine. As a medical student, I’ve experienced this life. On my surgery and OB/GYN rotations, I walked through life like a zombie. My schedule was simple: work-sleep-work-sleep-work-sleep. My fatigue and lack of exercise made me moody and irritable. My lack of food made me skinny. My lack of time with family and friends made me lonely. My lack of “me” time made me depressed. What brought me comfort during these times was the fact that in a few short weeks, my rotation would end and life would return to normal. Fast forward to today: I am about to start a four year long rotation. Shit.

We spend our adolescent and young adult lives trying to figure ourselves out. What makes us happy? Fulfilled? Balanced? Content with who we are? And when I hit 30, I felt like I finally did it. I had my best friends and a supportive family. I had my love of yoga and running. I had a burgeoning interest in cooking and wine tasting. I had my love and memories of international travel.

It seems like a cruel joke that now that I’ve figured out how to live my life to the fullest, I have to give it all up. It is difficult to think of my very full and complex life being reduced to one dimension.

I guess the new challenge, now, is to figure it out all over again: Happiness, the condensed version. Appropriate for an 80 hour work week.

* Check out the very appropriate article in New York Times this week by Dr. Pauline Chen:

Sunday, June 7, 2009

The First Day of the Rest of My Life

The day has finally come… I am officially a doctor! A physician! An M.D.! And I have my beautifully crafted diploma sitting beside me to prove it! I will no longer be a mere medical student at the bottom rung of the hospital hierarchy. Today is the day when I am bestowed the honor and privilege to hold a person’s life in my hands. Wow… I better not mess it up.

I didn’t think I would feel different after my medical school graduation. After all, it’s just another day, right? But walking on that stage, being hooded in front of my family, friends, and mentors, was something else. It finally hit me. I have had this dream of becoming a doctor for the last 20 years (seriously, check out my fifth grade notes on becoming a “docter” when I grew up). I’ve studied. I’ve taken tests. I’ve worked all hours. And now that day is here. It’s a remarkable and powerful feeling to finally reach a goal that has been out of your grasp for so many years. While a thousand different thoughts and emotions are running through my head, one thing I know for sure. I am going to be the best physician that I can be. I have worked too hard to become anything less than that.

While I can’t deny I am on a graduation high right now, today is also bittersweet. It’s the day that I leave everyone who means anything to me for a life unknown on the Other Coast. I take with me only my fiancé and rainbow of emotions. Will I like my residency program? Will I like my co-workers? Will they like me? Will my suturing and knot-tying be up to par in the operating room? Will I remember how to deliver a baby? Will my patients have confidence in me? Do I have confidence in me?

Stay tuned to find out.

Wednesday, April 29, 2009

The Doctor as the Patient

I hate being the patient. I know that sounds ironic given my choice of careers, but I do.

Last month, I was kept up until the wee hours of the morning with a dreadful bellyache. Placing the doctor’s thinking cap on my head, I made a mental checklist of all the possible sources of my discomfort. I ran through the usual home remedies and over-the-counter treatments without success. Ugh. Looks like it was time for me to make a trip to the doctor’s office.

Now, being at the tail end of medical school, and about to embark on my own career as a physician, going to the doctor is a completely different experience. I no longer go to the doctor as a patient. I go with the knowledge that doctors are human. They are not all knowing - they only know as much as they have read or experienced. They have other lives – meaning they’d like to get your visit over with soon so that they can go home to their families too. On the other hand, having spent the last two years seeing patients as a medical student, I also know what it’s like to have patients who are skeptical of your ability and desire to help them.

All this knowledge makes it a dreadful experience when it’s my turn to be the patient. Take last week, for example. I dutifully brought the Prilosec I had been taking as well as the dosage schedule. I brought the Mylanta. I articulated clearly the onset and character of my belly pain. I tried my hardest to respect the time and expertise of my physician. However, there was the voice in the back of my head, the medical student, that kept second guessing her. “I told her my pain is not epigastric and not related to meals, so why is she still talking about reflux? And why should I continue the same medication if it’s not working? Isn’t she going to check for H. Pylori? What if I have an ulcer?!?” So, in the politest way possible, I ask her these questions. And then I ask her some more. And some more. Until she finally throws her hands up and tells me “Let’s just treat it like reflux and see what happens.”

Soon I realize I have morphed into the patients we physicians all dread to encounter: The know-it-all, internet searching patient who knows a thousand times better than you what is wrong with her. She knows what tests to run and knows what medicines to take. In fact, the only reason she comes to you at all is because she needs you to write the orders. If she could do it herself, she would. I have also become the hypochondriac patient. The one that has made a list of all the things she could possibly have. It doesn’t matter that she doesn’t fit the patient profile. She is convinced she has all of them. And right now, I have it in my head that I have an ulcer. I have also become the non-compliant patient…because I am convinced I do not have reflux. I will not change the types of food I eat or times of the day I eat or my sleeping position.

Fast forward to today. The belly pain went away a couple days later with the tincture of time. And while I still don’t know what the cause was, I did learn a valuable lesson. Being a patient is no fun. Having the answers about your body in someone else’s hands is a scary and frustrating experience. Could the doctor have been a better listener? Sure. Could she have taken my questions more seriously? Of course. Could she have empathized better with my discomfort? Yes. Most importantly, will I always aim to do these things with my patients? Absolutely. And hopefully my patients will agree.

Saturday, March 21, 2009

Match Day!

Now that the whirlwind of celebration has started to die down, I can sit down to write about this pivotal day... and the events that brought me to this place.

Since I was about 15 years old, I knew I was going to be an OB/GYN. Growing up in a traditional household of an immigrant family, nobody talked about the body below the belt, let alone all the trouble it could get you into. By the time I reached the hormonal sea of adolescence, I had many more questions than I had answers. Suffice it to say, my teenage friends and I learned about our bodies and our sexuality the hard way, through trial and error. While, by the grace of god, we never got ourselves into too much trouble, I loathed this feeling of unfamiliarity with the most intimate aspects of my body. It was like I had been carrying around this mysterious set of equipment for which I had no instruction manual (unless you count Seventeen magazine) . By the time I reached a place where my vagina and I were friends, I knew two things: I wanted to work with young women my age and I wanted to make sure they were educated about their bodies in a way I never was.

Fast forward to the present: I am in the tail end of medical school (3.5 months until graduation!). I've got a masters in public health under my belt. I've spent countless hours working with homeless and at-risk youth. I'm proud of my work thus far. But until now, all of it has been just another step in getting me closer to my goal of being the grassroots, pro-active physician and reproductive health advocate I've always dreamed of. And I'm not quite there. Yet.

Fast forward to Match Week: So, Match Week is the most important day in every medical student's career and for me this was no exception. This is the day in which the student learns (a) if s/he was accepted into a training program in the field of his/her choice and (b) where she will be pursuing this training. Now any program in the United States will give you the same set of skills to be good doctor. But some programs go above and beyond to train their physicians to both provide good patient care and become real leaders in the health care field. Within OB/GYN residency programs, this can be manifested by a program's emphasis on research, availability of mentors, opportunities to practice abroad, or inclusion of family planning training. As I am sure is glaringly obvious from what you've read so far, this was important to me.

Of course, nothing in life is easy, and getting the residency program of your choice is no exception. For me, this process complicated by the fact I am going through the match as part of a couple. The "Couple's Match", as it is commonly referred to, is when two people link their applications together in the hopes of matching into a program in the same place. To make this even more difficult, my handsome fiancé decided to pursue one of the most competitive specialties in medicine: Orthopaedic Surgery. Every year, about 900 medical students apply for about 700 spots. That leaves 200 medical students unmatched each year, without any residency to go to after graduation. So to make the couple's match work for us, he had to secure one of those coveted spots in the same place that I did. No pressure, right?

Finally Match Day had come. And man, were we nervous. As I usually do when I'm nervous, I put on my best dress, did my hair, and slapped on some make-up. I reason that if I look good, I will feel good, and all this goodness will somehow translate into good news when I open that envelope. (Makes no sense, but desperate times call for desperate measures!) The boy and I drive up to campus. When we enter the ballroom, the room is permeated with nervous energy. Classmates are chatting incessantly, as if the more they socialize, the longer this moment will be postponed. The dean calls everyone to their seats. He speaks for about 10 minutes but I don't hear a single word. I breathe deeply in and out to calm my rapidly beating heart. Finally, he releases us outside to the wall of envelopes. My fiancé and I make our way to the beginning of the alphabet and take down the envelopes bearing our name. Our futures lie inside these little packages. Not knowing if the news they contain will be good or bad, we find a tiny little corner away from all the commotion. The cheers of relief, joy, and congratulations have already started behind us. I begin to tear at my envelope and realize I can't do it. I don't know if I can bear seeing our 10th or 12th choice on the page. "You go first." I say to him. He rips open the envelope. As he unfolds the paper inside, I meticulously monitor his face for any sign of emotion. He reads the letter.

"We did it! We got our number one!" He screams. The next thing I know, he is jumping up and down hugging me in happiness. I open my own envelope to confirm that my letter says the same. It does. Now I am jumping up and down as well, half laughing, half crying, part screaming. We run to join the rest of our class in celebration. He's right. We really did it.

I'm a happy girl right now. I am going to train at a place that will allow me to be the kind of physician I've always dreamed of. And I am taking the love of my life with me. Of course, as any Type A personality will tell you, now that we know where we are going, I'm already thinking about the next step. Cross-country moving plans, possible home-buying, wedding planning, pre-residency vacation planning...

I say bring it on.