Why Medical Matins was private, even after residency was over

As you may have read, this blog was private from December 2017 to February 2020. While I was thus censored by my institution, I continued smilingly recruiting for it, and then serving as a chief resident. It made the last year and a half of residency (already difficult because of the responsibilities of the role of an upper-level resident, the added weight of administrative chief duties, and the process of applying for fellowships) a white martyrdom.

Inside the Student Jail, Heidelberg, Germany.
CC License. Wikimedia Commons.

Gradually I opened up to more people about this event. But during it, I could tell few people how painful this was: two friends in the residency, one attending who happened to also be a personal friend, my family, and a few friends outside the program. I want to share a short post which was originally written on March 23, 2018. Writing this post two years ago, during outward silence, felt like scrawling on the walls of a strange prison. The topic of the post was what I should do with the now-private Medical Matins.

What should I do with the blog itself? I am tempted to post a lot of very unedited content while the blog is private, then launch it again as public when I am no longer employed by this institution (and no longer bound by amiable agreement not to publish it). I am tempted to leave the blog derelict, floating in the massive amount of online content, for others to find. I want this so that I don't have to do any more work, and yet so that others can think well of me if they find the good things available on the blog. 

I know derelict internet things die, and I don't want Medical Matins to die. It's a helpful outlet for me. The blog gives me an occasion to pray the litany of humility (which I set as the default text of each post before I replace it with the actual content of the post), and then organize my thoughts and prioritize my emotions using the blog.

And I think Medical Matins is good for others. At least half a dozen (I've never counted and I'm trying not to over-estimate) medical students and others have contacted me through this site to ask about pro-life and pro-NFP residency. And it's been found by others who have disagreed, and resulted in dialogue.

So why, you might ask, didn't the blog pop back up in July 2019 after I graduated from residency? Well, at the close of residency, I didn't ever want to fight anyone, ever, again. I didn't want to be called into offices, I didn't want to give explanations, I didn't want to be chastised. I didn't want to diplomatically meet with others about whether my chastisement was just. I didn't want to write letters and discuss issues. To show you why I felt so deeply cowed, here is some more writing from March 2018, three months after I took down Medical Matins. I wrote this post into a draft which remained unpublished for the past two years. (It's also important that you know that I wrote it after a long week of nights, and after some additional personal disappointments, and I know my emotional milieu was messy.)

Should I continue blogging? It has caused me so much pain. This is a blog about my experiences, and I always return to that mission when I feel like a post has strayed. And the experience of my blog being censored is one of the most painful experiences of my residency. Why would I not write about it? Why would I not continue to write after this censorship is over?

I'll tell you why. I am an introvert, I am vain, and I am proud. This is a terrible combination in someone made to fulfill a public vocation, to train long into adulthood and be corrected by others, and to witness publicly to unpopular truths in an unfriendly culture. My introversion and faults are punishingly heavy because of my recent mistakes and failures, with a background of my censorship and another large-scale issue that I might open up about soon. My soul's problems can be a prison, without anyone's censorship! A prison that I am sadly used to, and one that I am striving to grow out of. The introvert grows quickly exhausted with people, and the vain person grows depressed and angry with failure. Perfectionist, the vain and proud cannot cope with failure. So I walk into a prison of my own making whenever I am corrected, disliked, or discovered as less-than. This is one reason why I don't think I can restart MM--I can't spring back when I have so many prison doors between me and the future.

Dore's depiction of Lucifer, as described by Dante in the Inferno.
CC License. Wikimedia Commons 

Faith shows the reality in all this turmoil. Humility makes me acknowledge that yes, I am correctable, not always likeable, and lesser in many ways. But Christ welcomes me in my humility and does not wait for me to become loveable to embrace me. In a way, I say "Thank God!" because to be loved before becoming worthy of love is a warm relief in the coldness of others' disapproval. But in a way, my pride interferes with God's unconditional love and says "But I want to perfect in se, I want to be admirable before I approach God." 

I stand where Satan stood, able to lock myself into a self-made prison. Let me avoid it. I must let go of the desire for any merit in myself and only look to love God and find comfort in doing His Will. If I do this, I will find strength to fight again. I will find the ability to restart MM if that is what God wants.

Inside the Templar's Prison.
CC License. Wikimedia Commons

Let's pull up that litany of humility one more time:

O Jesus! meek and humble of heart, Hear me.
From the desire of being esteemed, deliver me, Jesus.
From the desire of being loved...
From the desire of being extolled ...
From the desire of being honored ...
From the desire of being praised ...
From the desire of being preferred to others...
From the desire of being consulted ...
From the desire of being approved ...
From the fear of being humiliated ...
From the fear of being despised...
From the fear of suffering rebukes ...
From the fear of being calumniated ...
From the fear of being forgotten ...
From the fear of being ridiculed ...
From the fear of being wronged ...
From the fear of being suspected ...
That others may be loved more than I, Jesus, grant me the grace to desire it.
That others may be esteemed more than I ...
That, in the opinion of the world, others may increase and I may decrease ...
That others may be chosen and I set aside ...
That others may be praised and I unnoticed ...
That others may be preferred to me in everything...
That others may become holier than I, provided that I may become as holy as I should…

Please pray for me as I continue occupying this small part of the internet with my own opinions, for my own good and perhaps the good of others.

Why didn't MM's author fight censorship?

CC Andrela Bohner

As I've described before, Medical Matins was a private blog from December 20, 2017 to February 29, 2020, to fulfill a requirement from my graduate medical education department after my blog was discovered and I went through an administrative process which examined the blog content.

My first reaction was deep shame. I have been conditioned over several decades to please others, and to be disciplined was very difficult. This was also my first reaction when I was called into the office in medical school for bringing a fetal model to a lecture containing material on elective abortion.

My second was confusion. What was going on? Was I really in the wrong, or was this about the truth of my opinions on issues like marriage, transitioning, and contraception? When it was over, I felt outrage. I was censored because of the nature of the blog and what I wrote about. (It is my firm impression that had I held the opposite opinions, I would not have been censored.)

Good came from this, and even during the process I could appreciate it. First, I learned to care a little less about pleasing people. If I have something true to say, I should not be ashamed when people are upset. Second, in a safe space with few or no long-term consequences, I went through my career's first little trial for the truth. Third, I encountered persons who I realized need a great deal of prayer and sacrifice, and I believe it is my duty to pray and sacrifice for these people in particular.

However, I felt that the end result (censorship) was not acceptable in a university environment. I know secondary education's lost its soul, but if the university is not the setting for professional, intellectual exchange, what is? I began to go through channels so that the institution would have some intellectual honesty about the importance of different opinions on issues.

Then, I abruptly stopped, and today I want to write about why. 

Shortly after the blog issue was concluded, a patient was admitted for excision of a cesarean scar ectopic. I was on night float, and at first I heard with trepidation that there was CSP admitted because I feared that there would be an ethical mis-step. However, the surgical plan sounded like it would meet the ERDs' definition of an "indirect abortion" and satisfy the principle of double effect. Relieved that I would not have to get involved, I waited for the scheduled procedure a few days later. Then, a few evenings later, the day team announced that the surgical plan had changed. The new plan involved fetal dismemberment. Aware of the culture that anyone can "stop the line," (link if that one is broken) I nevertheless had to think what I could do to help while I was working at night and going home in the morning. I emailed the director of the Ethics Committee, just to notify him of the change in the surgical plan. 

I came back that evening to anger. The other residents perceived that I had been judgmental, holier-than-thou, obstructive, shifty, and simply wrong. I was corrected by one of the residents in front of everyone at evening hand-off. 

Ultrasound appearance of a uterus after a C-section,
with scar between the yellow arrows.
CC License. Wikimedia Commons.

As in other situations, my first reaction was shame. I was basically silent, although (since no one on my night team knew I'd done this) I did have to offer a half-sentence in explanation to them, which I had not planned to do and certainly not in that setting. Later, I formally apologized to a few attendings and the residents involved. There followed a very uncomfortable month when I felt highly disliked. Stray comments praising BTLs and LARCs and disparaging the ERDs (ordinary fare otherwise) felt sharper.

In this milieu, I felt that just finishing residency without being hated would be great, so I stopped seeking further attention regarding the blog censorship. As of this writing (which occurred originally in March 2018), I just hope to quietly finish residency with no more moral discussion.

Good things came from this CSP episode, too. I had a fruitful conversation with the Ethics Committee meeting that month (which I could only attend because I was on nights and I was off-duty at that hour), and recommended an article on CSPs that I think makes a stab at the truth. And the Ethics Committee saw that there were some communication, personality, and practice concerns surrounding the issue, and my "stop the line" email was not the most concerning aspect of the case. It is a relief that at the end of these two episodes, at least some dialogue occurred. 

Burnout: There is No Fix

I like the contrast between how resigned Simon
is to this situation, and how resigned Christ is.

I couldn't go to the recent CMA conference, but several friends told me it was great. It focused heavily on burnout, as have the past five or so years. One of my parishioners, a family med resident who attended, reported that the talks were very holy and quoted lots of saints, but finally she didn't feel like there was a real "fix" to burnout.

My experience of the last two CMA conferences I've attended have been similar. Lots of discussion of personal holiness and the sacraments. Lots of discussion of holistic medicine and the importance of relationships and integrity in practice. Lots of discussion of hope, courage, and mercy for times of desolation. Not a lot of easy fixes. And I think that reflects the truth.

There is no easy fix for burnout. There's rest, hobbies, leisure, exercise, healthy eating, meditation, good marriages and friendships, and patience through desolation. None of those are easy. You have to force yourself to make time to rest (and then actually use that time to rest), you have to force yourself to exercise, you have to force yourself to develop relationships, you have to force yourself to pray. There is a lot of violence in pursuing the virtuous life. And, if you believe Augustine (and I do), we never get to the easy part of habitual virtue by ourselves. God's grace makes a way for us to become saints.

There's a small amount of relief whenever you acknowledge an unpleasant truth, be it some personal imperfection or some fact you can't control about the outside world. There is no "fix" for burnout, just the continued pursuit of a virtuous life and patience through desolation.

Most emotional delivery of my life

I was recently in a delivery with an attending and the baby was extremely stressed out and had failed an operative delivery. We went back for a C-section. We ended up doing a "red" (emergent) C-section even though heart tones weren't down in the OR, because the mother started to have a seizure. Between her tonic-clonic activity and the baby's profound asynclitism, molding, and caput, it was the hardest C-section I've ever done. I couldn't get the baby's head out, so my attending tried. She couldn't, so I tried. I couldn't, so she tried again. Everyone was screaming. And meanwhile, because it was a red section, the room was in chaos. My chief was pushing from below and another attending was called. The original attending couldn't get it out, and I tried one more desperate time (all the while screaming for a Murless) and got it out.

It looked dead, but it had a good one-minute Apgar. It's doing fine now, and so is mom. I spent the rest of the C-section crying, though, because I thought the baby was dead. Five minutes feels like so much longer when your brain is screaming, "the kid's heart rate is slow, the kid is dying!" And that baby was more limp than any other baby I've seen.

Except, perhaps, for the vaginal breech I did the other month. That was awesome.

All's well that ends well, but that C-section was the worst delivery I've ever been in. Please pray for me. The 19-day streak that I mentioned at the end of the last post turned into a 26-day streak followed by one weekend and another 24-day streak. I am so tired!

Seven Quick Takes

It's been quite some time since I did seven quick takes, a blogging/sharing technique created by Jen Fulwiler in the peak of her blogging days. (It's a cheap way to write a quick post when you're studying for CREOGs.)

#1

I have begun to realize that unity among pro-lifers is harder than I thought. I went to a huge benefit dinner for a (very successful) evangelical pro-life group, and I had to will myself to keep smiling. There was so much talk about how God would save America and how America was going to become great. There was so much talk about proselytism. As a Catholic, I know that God promised His Church would survive, not that my decadent country would survive. And I'm around to evangelize by example, not by discussing acceptance of the Lord with women in crisis. 

But I don't have to love everyone's tactics. Pro-life needs unity.

#2

Speaking of unity, Christian unity would be great for the culture, too. I've mentioned before that a lecturer I had in med school defended the LGBTQ community (awkwardly, and not to the enjoyment of the LGBTQ in the audience) by pointing to Christian disunity. He was attempting to explain how LGBTQ Christians should be comfortable with Leviticus, and expansively pointed to the number of denominations there are. The bible means whatever you want! 

At this point I'd settle for SSPX or the Orthodox Church coming into whatever communion with the Roman Catholics as is possible.

Here's something to help Christian unity: pray for an increase in your desire for Christian unity. Pray that the disunity will start to be painful to you, rather than just a bummer fact. Schedule this prayer for every time you pass a church of another denomination. Simply pray as you drive: "Lord, unite us."

#3

Are there any college students or PhD candidates reading? I would like a Catholic PhD so that I can fund bench research in mitochondrial replacement, methotrexate mechanism of action investigation, naprotechnology basics, and ectopic rescue. This is a big call--tell friends and relatives I'm looking.

#4

I have several friends who are rapidly becoming more and more accusatory of the Pope. We don't owe him affection, guys! We owe him filial obedience in matters of faith and morals. In the middle ages and renaissance the papacy was super messed up, but Catholics like St. Hildegard, St. Catherine and St. Joan continued to respect it supremely. They respected it because they worshipped Christ and trusted in His decision to establish the office. Let's do the same.

#5

Speaking of Pope Francis, there was a break-out session at the CMA conference about his theology. According to the presenter, his work is a type of Christian personalism, a theology of encounter. Authentic encounter leads to renewal of life and joy, in the pope's view, and a God-given mission follows on this renewal. The Christian mission is always one of mercy, the pope has said, and everyone is called to this mission of mercy. 

Moreover, the pope emphasizes frequently that the privileged starting place for our evangelical mission is with the poor. This is because the mission is modeled on Jesus, the "man for others," and thus will entail suffering as we accompany others into the Father's arms. This break-out session was largely drawn from Evangelii Gaudium, but much of Pope Francis' other work echoes these themes.

#6

I started cantoring at my parish a few months ago. I haven't cantored since middle school, and have been saddened by the weakness and loss of range in my voice since residency. My parish desperately needed cantors, so I volunteered.

I was shocked at how much stage fright I've developed! I can do a crash C-section fearlessly but I'm shaking while singing the Ave Maria that I sung at age ten in front of a packed church? It shows me a well of timidity (a form of pride) that I didn't know I had. I've been trying to care less and less about "human testimony" (Jn 5:34), and this is another chance to do that. Plus, it definitely confirms that I am an alto. I tried so hard to be a soprano as a kid, and now there's no doubt left.

#7

I had a wonderful, consoling, productive vacation. This makes me want to be a better doctor, but it also makes me want a calmer schedule. In particular, it makes me dread my upcoming 19-day run without a golden weekend. Say a prayer!

Control and Being a little Legislator

I have realized that I can't control anything, and I'm trying to live with that.

This is as much a psychological milestone as it is a spiritual one. Human beings can't influence most of what happens to them: we can't change the weather, we can't change history, and we can't change the people around us or their choices. Christians embrace this like they embrace the inevitability of suffering: they see that God has made it a way to go to Him.

It's refreshing to admit I can't control a lot. As a doctor, I can't control who will page or call me and whether it means I get out of bed on call. I can't control who will walk into my clinic or how long they'll need to talk about it. I can't control who will come into triage or the ED and whether they'll need a complicated workup or a surgery that day. At the most extreme: I can't control how placentas and cancers grow and I can't stop babies and women from dying. There's a vulnerability that can be exhausting (another patient? I already need to see twelve. Another ultrasound? Another phone call?). It's hard to maintain generosity and avoid being lazy. Also increasingly since residency is the inability to control my body: I can't just stay up as long as I want--my body turns off after 36 hours on and I miss meetings that I schedule after that.

The doctor-patient coin has two sides. I can't control how my doctor interprets the evidence on re-scoping versus empiric titration. I can't control what she'll find on that colonoscopy, either. I can't control what the meds will do, I can't control whether I develop extraintestinal manifestations, and I can't control whether or when I'll lose my colon or get cancer. (I also can't control the past, which includes a lot of knowledge about UC that I sort of wish I didn't have.)

And there are a scattered other few things. I can't control whether my siblings will stay Catholic, whether my married friends will stay married, whether my archdiocese will close my parish, whether the state will stop payment from CMS to my hospital....

There are some things that I can control a little more, but always weasel out of my grasp. I can't always seem to control the cleanliness of my apartment. Sometimes it looks like six frat boys live there and I can hear my German-standard cleanliness mother (who had us wipe the microwave and oven doors as part of the list of things to do with the dishes) tsking in my mind. Mom, I think I've wiped the oven once and vacuumed three times since moving here.

Then there are the things I wish were in my control and might be in my control, but I don't think my will is disciplined enough. These are all the parts of the life of virtue that I think I could do better on, even though my life now in residency tempts me to excuse all kinds of stuff. I have to learn to live like a saint even while working my current schedule. What if I died in residency? What will be my excuse that I didn't possess my own heart in each moment, form my conscience, and use every opportunity to love God and calmly grow in virtue?

But my old approach to virtue doesn't work now. (Lots of people said this about med school, that they're undergrad method of studying didn't work in med school. I didn't have to make that transition from TAC, but perhaps it'd have been better if I did, because I'd have recognized this need for something new sooner.) I can't legislate little changes any more. 

In med school, I wanted to be able to floss every day, so I made a little law for myself, invented a method for predisposing myself, created positive self pressure (a dental appointment), and unconsciously created negative pressure (shame). And it worked. The same thing worked for a lot of pious practices and projects. Now I can't get myself to floss, even though I applied all the same interventions. The same problem exists for a lot of my pious practices and projects. I don't know why this is, but I have a strong hunch: the core battle of my life, chronic exhaustion, makes it hard to pressure myself to do things. There's not enough energy for sustained enforcement upon myself. 

But the other day I had a realization. Considering the relationship between myself and God, I am never the legislator. God makes the laws and He stands under the reality in which I exert my free will with His help. This helped me realize what doctors of the Church and saints have long known: all that is needed for holiness is to follow one's conscience in each moment. When each opportunity to floss presents itself, I accept His grace and take care of my body. And because God's will is less totalitarian than man's, I might even decide (shocker) that flossing is not indicated in certain situations. (Do you floss after 30 hours at work? I fall into bed.)

Cognitive Disorders

Medical training and life in general is overflowing with cognitive mistakes. I've been meaning to blog about them since fourth year of medical school. Here are ten common cognitive mistakes; look how close to the truth each one is. (This is reprinted from some handout I got some time in med school. If I'm plagiarizing, let me know and I'll take it down.)

1. All-or-nothing thinking: you see things in black-and white categories. If your performance falls short of perfect, you see yourself as a total failure.
2. Overgeneralization: you see a single negative event as a never-ending pattern of defeat.
3. Mental filter: you pick out a single negative detail and dwell on it exclusively so that your vision of all reality becomes darkened, like the drop of ink that discolors the entire beaker of water.
4. Disqualifying the positive: you reject positive experiences by insisting that they "don't count" for some reason. In this way you can maintain a negative belief that is contradicted by your everyday experiences.
5. Jumping to conclusions: you make a negative interpretation even though there are no definite facts that convincingly support your conclusion.
1. Mind reading: you arbitrarily conclude that someone is reacting negatively to you, and you don't bother to check this out.
2. The fortuneteller error: you can anticipate that things will turn out badly, and you feel convinced that your prediction is an already-established fact.
6. Magnification (catastrophizing) or minimization (also called "the binocular trick"): you exaggerate the importance of things (such as your goof-up or someone else's achievement), or you inappropriately shrink things until they appear tiny (your own desirable qualities or another person's imperfections).
7. Emotional reasoning: you assume that your negative emotions necessarily reflect the way things really are.
8. Should statements: you try to motivate yourself with "should" and "shouldn't," as if you had to be whipped and punished before you could be expected to do anything. "Musts" and "oughts" are also offenders. the emotional consequences are guilt. When you direct "should" statements toward others, you feel anger, frustration, and resentment.
9. Labeling and mislabeling: this is an extreme form of overgeneralization. Instead of describing your error, you attach a negative label to yourself. "I'm a loser." When someone else's behavior rubs you the wrong way, you attach a negative label to him. "He's a louse." Mislabeling involves describing an event with language that is highly colored and emotional labeled.
10. Personalization: you see yourself as the cause of some negative external event, for which in fact you were not primarily responsible.

Objections (and New Sidebar Gadget)

"You live at a breakneck pace. It stresses me out."

"How can you be a good consecrated virgin with all this work?"

"How can you be a good doctor when you're doing these side projects?"

The first objection comes most often from my body. Ulcerative colitis and residency don't play together well. A UC colon loves a predictable schedule, well-cooked and wholesome food eaten slowly. Those things are basically impossible in OB/GYN residency, where I'm eating quickly between triage patients and deliveries and trying not to have an episode of diarrhea during a C-section.

The second and third objections come from my conscience. I work a lot, and not by choice. I worked 2430 hours in the 244 days between July 1 and February 29. That's 11.6 hours for six days a week, with a seventh day off (and includes the days I was not at work while on vacation). I'd like for things to calm down so that I can focus more time on my relationship with Christ. I could work to the bone my entire life and never get to know the man who saved me and stooped to make me his little consecrated virgin. That would be a horrible tragedy.

I am also pursuing several projects on the side, including a video (done with shooting by the time this comes out!), a set of brochures (should be done with this one completely by the time this post hits), home improvement, blogging for two sites (including this one), keeping up the scholastic life (which includes writing and submitting essays to various journals), research (don't remind me about the phone calls I have to make for my research right now...), and attempting to network with others fighting for the culture of life (which involves archdiocesan events, meeting people for dinner and coffee, and emails). How can I take care of patients when I am so tired and have to finish all these notes so quickly? How can I study and be a good learner when I'm trying to get four doctors with crazy schedules to Chicago to shoot a video?

I just thought this picture was funny.

My response to these? Part of me argues that I'm in a rare time in my life when I can spring back from fatigue after working these hours, and I can spend this much energy on things. But the other part of me completely concedes that the objections are true and I'm doing it all wrong. 

It's unrealistic to respond by promising I'll never go to another pro-life or pro-family event, or that I'll never write another paper. I need to establish a new balance of work, leisure, and prayer.

Part of being less overwhelmed is beginning to assume that the duties of adult life (taxes, car maintenance, housecleaning) are not a project and are just like brushing teeth: no big deal, just gotta do it.

The other part is limiting my projects. I used to limit myself to five active projects in medical school. This may sound like a lot, but I remember when I said "no" to eleven awesome-sounding opportunities in one week. It was a good lesson: not everything that sounds awesome is really important to a career (much less to a life). I'd like to introduce you to a new side-bar gadget: the Project Kitchen. I'm not allowed more than two active projects, with up to four on the back burners.

Intern Happenings (and four months in review)

In the past four months, I reupholstered some Craiglisted chairs (previously tiger-print), made some curtains, wrecked a car, bought another car, and survived (almost) to the end of the "dark time." This post starts silly, but concludes with big thoughts on how things are changing through my intern year.

BEFORE

When I visited the house where these tiger-print chairs were, it worked in her scheme. Some people can pull things off that I could never make work. So I reupholstered them with an on-sale green curtain fabric from JoAnn. When I bought the chairs, I knew I was taking on a Project. I thought to myself, "it's okay, I'll bang it out in a weekend and be done with it." This was a big mistake. Now that my time is more precious than it has ever been (I pulled another 90-hour week last week), I think I might have other people do my little projects so that I can focus on bigger things.  I learned that upholstery is like surgery: it's easy to do "well-enough" but much harder to do beautifully. This picture doesn't quite hide the fact that my corners look like badly made bedsheet corners. The original owner had done the tiger-print upholstery herself and it looked perfect.

AFTER

Don't let this quick succession of pictures fool you. It took at least four months from start to finish. I kept dragging my feet at the last part, which was to screw the reupholstered seats back onto the chair frames. It was so hard and I developed an almost subconscious block to doing it. I'd do everything else on my to do list, and then (oops!) I wouldn't have time to fix the chairs. The item "Screws" hung out on my iphone Tasks list for ages.

Aaaaaaand I wrecked another car. I was changing from nights to days and forgot to set an alarm. I woke up to a text from my second year asking where I was. It was a nightmare come true. In two minutes I was out the door and in the car and rushing to work. I rushed a little too much! The accident wasn't wholly my fault, but if I hadn't been stressed, I bet I could've avoided it. I ran into a tree (swerved to miss the other car, who went off). The tree won.

The story of me buying the other car is funny, because it highlights how my crazy busy schedule only permits the extreme way of doing ordinary adult things like car-buying. My dad (630 miles away) discovered that you can buy cars from rental car companies. This is nice because the car company has a vested interest in the car working and being easy to maintain, so you know you're not getting a total lemon. It's also nice because you can drive the car for a brief period before you buy it.

So they tried to find me a car from a rental car company. We failed several times because the cars they found kept being driven to unplanned locations (like Vegas) by the people who were currently renting them. It was like requesting a hold on a library book, but then you find out that the book was returned to a library in another state.

We finally had a car that showed up where it was supposed to (in the same city as I was!). The only time I could pick it up was between work (6pm leave-time) and flying out for Christmas (10pm flight). So after work I took an Uber to the rental lot, signed my life away in the typical ritual of car-buying, drove off with a new car, then left the car in my apartment lot while I took a taxi to the airport for Christmas. It was a bizarre experience.

The answer to everything.

I have now driven 42 hours in that car and am pleased with it. It's a lot of car for a person trying to live poverty (it's got a back-up camera and a fancy screen that tells you stuff), but I just hope I don't wreck it by the time I get to tell you about the next few months.

A quickie update on some things in my last blast: neither of the illustrators were interested in my children's books, but that's okay. Again, I'm constantly learning to triage my projects. One of the patent proposals didn't work, but the other is in provisional status.

I'm also flying a lot this year: a friend's wedding, home for Christmas, to Chicago to film a video for NFP-only applicants to residency, to a conference in Toronto, and to another friend's shower (and again for her wedding). Attempting to plan a bridal shower (sorry, Mom) while also planning a video and submitting a poster to two things was a lot.

In addition, I got the "dark schedule," the intern schedule with four consecutive months of L&D, then nights, then MFM, then L&D. It's aptly named, as these four hard months coincide with January and February, the peak months for burnout. I'm now on vacation and feeling a little more human. I know the second year and the third year who got this schedule, and they changed. Fatigue changes you; you get snarkier, and sometimes speak badly about patients. You complain more. You talk about other people behind their backs. You search for any comfort--in food, in entertainment....

I don't want to change, but I see myself doing it. Is my wrecked car a symbol of something destroyed in me? Is my lovely dining room a symbol of something superficially nice in me? More on this to come. For now, I'll stick with frivolous updates on chairs and cars. Yay upholstery!

Two months in review (7-8/2015)

In the past two months, I've been on night float and on the ultrasound service. I've worked an average of 68 hours per week and used 1-2 servings of caffeine per 24 hour period. I've delivered 35 babies, done 5 C-sections (as primary surgeon), and done about 160 ultrasounds of various types.

I'm learning how to admit patients to triage, evaluate them, "dispo" them (send them home or keep them), answer dozens of types of nurse and patient phone calls, and "update the board" (keep abreast of what every patient is doing in labor and delivery). I'm also working on ways to wash laundry only every other week, recycle in my small borough, cook only once a week, make a bed while getting out of it, and shower in the time it takes to sing a Credo. I've replaced a car battery, hung blackout curtains, and bought several loads of furniture. And most importantly, I'm trying to make space in all this work for the liturgy of the hours, meditation, the rosary, confession, and Mass. I've made a lot of mistakes, but I'm being patient with myself as I try to do better. It's been a challenge.

I enjoy the work, especially when the deliveries are beautiful or I get things right. I'm at a good hospital with excellent and friendly nurses and my upper levels and chiefs are paying it forward, being kind to me so that I can be kind to the students and the next generation of residents in the future.

Things to learn in the future are how to not miss morning meditation, how to write discharge summaries in ten minutes, how to round on a dozen people in an hour and a half, and how to do dishes only once a week without starting an impromptu microbiology lab. I am also working on having local NFP resources printed for handing to patients in clinic (which is happening in the next two months) and having my elevator speeches together for when I am doing nothing but seeing postpartum and clinic patients. Any prayers would be appreciated!

More on Guessing and Pride

As a follow-up to the last post, I made a flowchart of all the little worries and calculations that can go on in a med student's head whenever someone asks a question. The more pride, the more anxiety, timidity, pompousness, envy, and regret. Right-click>open in new tab/window for full size.

Guessing and Pride

Vocabulary: Pimp (v.): to ask questions, often in front of other trainees or professionals, to assess a student's or resident's preparedness, medical knowledge, or professionalism

Third year medical students get used to getting pimped. We're advised (by survival guide books, by older students and residents, by faculty) to guess if we don't know an answer. This advice is logical. A third year knew even the smallest biochemical details of the pharmacology he's being asked about a mere six months ago, but after STEP 1 and two or three other rotations, he's refocused so many times that he can't exactly recall the correct answer. A third year sort of knows what to study for clerkships, and definitely never knows what to study for particular attendings. In general, a third year has just enough knowledge to know what's being asked, what the answer choices mean, and what he's missing to know the correct answer. (It's a very frustrating experience.)

We're advised to guess because we have enough knowledge to say something vaguely correct. I followed this advice, and had good and bad results.

I should have played the lottery during my pediatrics rotation. That's how lucky my guesses were. One outpatient physician with particularly pronounced ADHD forgot that he told me the most common cause of URI was "viral." When he asked me the question and I informed him that it was "viral," he was very pleased. I answered a few more softballs correctly, then he hit me with a hard one. "Why no fluoroquinolones for this patient?" he asked.

Fluoroquinolones! My M1 box of memories contained something about teeth...or was it cartilage? Tendons? Shoot! I had to pick between them. Because I remembered "cartilage" and "tendons," I eliminated "teeth," and then flipped a mental coin. "Cartilage malformations," I said. The whole internal answer-picking had taken only a fraction of a second.

"Correct!" the attending said. I got a fabulous evaluation.

Inpatient looked like it was going to be a different story. Our attending was demanding and taught in a more classical fashion: we presented patients in front of everyone on rounds, wrote detailed notes, and did long mock case workups. While I was in front of the room at the board (pen in hand) pretending to work up a child with renal failure, he told me a stool culture came back positive for Shigella.

"So," he said. "You wanna give him antibiotics?"

His CBC was terrible, he was febrile, he already had an IV in, and I very much wanted to give antibiotics. I remembered that Salmonella and Shigella had funny reactions to antibiotics...something about the child would feel better but there would still be bacteria in the stool...for even longer? But that was only for one of the two species (darn the person who named these two things so similarly!!)... Do I hazard a guess, or do I just give the antibiotic? I gambled.

"We could," I said, "but doesn't it prolong clearance in the stool...?" I trailed off gingerly, just in case I was wrong.

The attending raised his eyebrows.

"It does," he said, surprised. Apparently I'd skirted the trap he usually set for students. He then told a few case histories of patient's he'd treated. "So," he concluded, "if it's just going to be fluids, what do you want to use?"

"D5 half-normal," I replied. That wasn't a guess; that's what everyone in the unit was on. He gave me a mischievous look and pressed further.

"There is one case in which you would consider using quarter. Do you know who?"

Time for another guess. Babies are all water balloons at birth, so my brain spat out:

"The neonate?"

The attending clapped and grinned. "That's hot!" he said (which must have meant something different when he was a teenager). "Strong work." And I got another fabulous evaluation based on guessing.

But this has terrible effects, especially when we're asked to guess in front of other people. Those of us with the vice of pride (which is many doctors and student-doctors, and (so I'm told) a few other humans) do terribly in this environment. We have one of several reactions. It's a little complicated, so I made a flowchart.

I was typing this post while my attending was at a meeting; he came back and we had a mini lecture/pimping session on hydrocephalus. And I guessed some more. It will never end.

For Reference: People Never to Become

The Workaholic

Src

On internal medicine I worked with a resident who terrified me. I don't mean that she was malignant. She terrified me because when I looked at her I saw a possible future self, a self that I could all too easily become. She had just gone through a family death and had obviously thrown herself into her work. She worked almost constantly: at five in the morning she was checking her interns' patients' charts from home, and at nine or ten she finally left the night team alone in the resident lounge.

How could I possibly be attracted to that, you ask? She was incredible! She was constantly energized, she seemed to know everything, and she managed complex patients with ease. She was chic, funny, friendly, and beautiful. 

The first time I encountered her was actually on my OB/GYN rotation. Gyn was consulted on an ICU patient of hers. The patient had widely metastatic cancer, was comatose, and was intubated. The patient looked agonized and the family members looked weary. This resident strode into the room, looked at the people in front of her, and (with grace, directness, and ease) began a conversation about withdrawing from the ventilator. Two minutes later the patient was extubated. Wow, I thought. That's a doctor who gets things done. That's someone who cares about people. 

I was incredulous to find out that this was my upper-level resident on wards. I was so excited. But I soon slipped from hero-worship into terror. Ever since that wards month, I've been careful not to become the Workaholic. It's hard! I have been getting up in the four- and five-o'clocks for all three of my audition rotations. My odd jobs keep me busy, and mealtime and prayer time are constantly threatened. But I've seen the danger at the end of the workaholic road, and it's awful. So I'll fight to make time for deep relationships, character development, and personal enrichment.

The Malignant Attending
Someone please remind me when I'm an attending to build people up. There are two forms of mechanical air exchange and there are two forms of medical education: high pressure and gentle encouragement.

The first model, which we'll call the "Sergeant" method, is horrible. In this model, every mistake is loudly called out and the student is made to feel small. "What are you doing? Use your brain!" my attending on my second away rotation has told me. "That's stupid," and "How many times do I have to tell you?" are commonly heard in his OR. He swats hands instead of using words to say "[give me the] suction," or "off [with the retractor you're holding]." This behavior extends to the OR staff, residents, other physicians, and basically anyone other than the attending. I've seen several very childish displays. My current attending openly champions this form of teaching, stating that it's the sergeant who saves his men's lives by laying instincts into them. But habits don't have to be formed by negative conditioning.

I have always thought that the most effective way to teach is the Socratic method. Applied to clinical education, this would look like a gentle person asking, "Tell me what you read last night," and letting the student talk. This would say, after a student conducted a history or physical or did some procedure: "Tell me what you did right and what you'll do differently next time."

In the OR, the residents and I exchange many looks when we work with this attending. "Never throw your subordinates under the bus," one whispered to me one day when the attending was out of earshot. Mentally, I vowed never to do so. It's horrible. Not only does it make your students feel like dirt and resent you, it leads to passive-aggressive behavior in staff, it makes residents believe you're a senile joke, it makes everyone eager for your retirement, and it makes you habituated to treating people like slaves and objects.

Med School Cultural Immersion

First of all, the ultimate reference for med school memes is whatshouldwecall medschool, a tumblr. Sorry that some of the references are crude. Some also take the Lord's name in vain. Some of my personal favorite references are to gunners and the strange way third-year med students learn.

When the gunner on your team promises not to take on a lot of patients so that no one has to work hard and you know it's gonna end like...

A gunner is a med student with too much ambition. There are stories about gunners tearing pages out of textbooks to lower the maximum score of the rest of the class. My classmates joke about people gunning, but I don't know that anyone's really so enthralled and exclusive at my school. Gangnam style and #Selfie parodies exist. The wink at 6:38 in this parody is a gunner move.

For third year, two Let It Go parodies (this one and this one) are brilliant. The second one is part of a whole series. Most of What Should We Call Med School is about third year and it's all true. All of it. I remember when I was really upset by the combination of continuous evaluation, helpless incompetence, and ridiculous expectations created by third year. I went to WSWCM and read memes for two hours. And I felt amazing, because I realized I wasn't alone.

The Third Year Manifesto, last part: An Analysis

There are days that I want to ask the hospital at large: “When do I get my personhood back? When am I treated like I have the dignity that everyone else does?”

I want to be comfortable where I work. I want to be safe to be myself and express my limitations. Instead, I cork up dozens of questions a week. I’ve violated the sterile field a half dozen times and don’t bring it up. I hate being told that I can’t do something because being so uninvolved, it's not what I’m paying for, and I have more to offer. I hate being told that I can do something because I will be watched, I will fear derision and misunderstanding, I will fumble out of fear, I will put on my game face and fumble out of incompetence, or I will get lucky and be deluded so that the next fumble hurts more.

I want is to be satisfied with the way my life is going. I want the basic esteem of others. “Oh,” is all I wish that people would think when they saw me, “she’s a medical student. You know, those people can’t do much. But they sure try.”

#

Once, I caught myself apologizing to someone in these exact words:

“I’m so sorry for taking up so much space!”

After uttering this ridiculous sentence, I went out the nearest door in a polite rush. Only after the door shut behind me did I shake my head and think, “what a stupid thing to say. I’m taking my own personhood away; apparently, I don’t need anyone else’s help.”

So, now that it is the fourth year of medical school, I am deciding: no one is taking my dignity away, least of all me. If they demean me in the OR, they are doing something inappropriate. I will graciously excuse them, like one ignores a person passing gas.

I am determined never again to agree with the lie that I am a worthless idiot. That lie leads to an psychological hell.

Part of the reason I became such a doormat/basket-case of self-critical emotions and permitted everyone else’s criticisms (petty or cruel) to sink me, was that I had a lousy idea about humility. I had this glorified picture of religious life in somewhere between 1600 and 1900 in which saints were made by kissing floors. Didn’t St. Bernadette, St. Jeanne Jugan, St. Therese, and many others have to be grossly misunderstood and abused to become saints? Don’t you have to believe all the derogatory things people say about you if you want true humility? Yeah! So, I was excited because I’d heard (correctly) that the third year was a lot like a floor-kissing novitiate.

But there is a basic misunderstanding there. Cultures that file away at personal dignity crowd out holiness! A person tossed around in such a culture becomes so distraught over himself and convinced of his incapacity that he can’t have the magnanimity a saint needs to become like the all-loving God. Believing himself to be a microscopic locket—always too small, always wanting, always disappointing—this miserable man can’t imagine becoming a vault, a temple.

It is a lie of Satan that I am worthless. I want to do great things for God. I want God, I want to be like Him, and I expect He will make us that way. So if I ever stoop to another floor for a kiss, it will be because Jesus is there, waiting to kiss me back and make me His gorgeous, eternal, perfect bride.

Third Year Manifesto, Part 2: Stories

In which I vent all the stories that I've kept bottled up so as not to be a whiner. The last part of this trio of posts is coming tomorrow.

#

I obediently submitted to being taught how to insert a Foley every time I inserted one. Today (the first day of fourth year) was the first time no one approached me and said, “oh, let me show you how….” It was disorienting. Wasn’t someone going to smother me with their preferences?

I breathed. I felt free! But the freedom was not to last. As I proceeded, I heard a very distinct “hmpf!” behind me, in the same tone people use when they raise an eyebrow and say “well, that’s interesting!” and really mean something much less benign.

#

The first vaginal delivery I attended on L&D, I did what the clerkship director told me to do: I protected the perineum and stayed close, in case I could actually be allowed to deliver the baby. This is called, good-naturedly, “being aggressive,” and it’s a good quality in medical trainees.

In that first delivery, a senior resident and an intern were also there. I guess if I were more shrewd, I would have known that it was bound to be the intern’s delivery. But who was I to know that what the clerkship director told me wasn’t right?

The senior resident decided to put an end to my aggressiveness. She put her hand on my hands and pushed them away from the field. Pushed. No exaggeration; the equivalent force could have shoved a gallon of milk several feet. The embarassment (and the sheer force) moved me to the back table for the rest of the delivery. When she asked me later, “did you see how the baby did xyz during abc stage?” I felt like saying, “No, of course not. If you want me to see things, don’t push me away.”

#

When a gentler resident was graciously allowing me to suture subcutaneous tissue in the OR, I put my needle driver down on the field, with the needle still in it. It was the first time I had ever done this, because it was the first time I had to cut off my needle to tie. (It was the first time I wasn’t using 4-0 and subcuticulars in the skin). The scrub tech slapped my hand, chiding me verbally. I blushed with angry embarassment underneath my mask, but tractably apologized, etc. Then, she said these words exactly (I remember them and you’ll see why):

“There are some people,” she said self-righteously, “who’ll slap your hand for that. I won’t, but there are some.”

I tried not to stare at her blankly. I guess it never dawned on her that she, SHE had ACTUALLY (not metaphorically) slapped my hand. I guess people who use that phrase end up acting on it without realizing it?? She has been the only one to do that.

#

One day in surgery I learned that the scrub tech, the scrub-nurse-in-training, and I were all within a few years of each other. I was the oldest. I was paying, snipping, uncomfortable, and chastised during the surgery. The other two, who were allowed to take a lunch break (during this six-hour surgery), were paid and thanked.

The fact that I’m paying to be there seems to some surgeons to mean that I’m not to be thanked and that I’m automatically incompetent. It seems to say, “she can’t do anything.”

“No, no,” one surgeon said when I reached for a towel to drape a patient. The scrub tech, who had offered me the towel, knew me better than that surgeon. He was being a pal, and he knew I have seen patients draped dozens of times and I could do it. But no! “She’s a medical student, she doesn’t do that,” the surgeon said.

“Excuse me, Doctor Bossy-Pants,” I burned to say. “I am a medical student and I can do that. Watch!” But it’s her sterile field, it’s her OR time, I’m her responsibility and (the real reason) she’s grading me. So I didn’t do that. I backed down. I abased myself.

The Third Year Manifesto, Part 1: Cutting Suture

I will now discuss the stuff of third year that is not happy and glamorous. Having a blog places slight pressure on a person not to whine. But not to disclose the negative parts of medical school would be dishonest. So it’s time to air a few grievances, and (because I can’t seem to not do this) discuss morality and holiness at the same time.

At some point during my third year, I got very demoralized. It’s hard for a person who wants to do great things well (and is used to doing great things well) to find herself unable to hope even for mediocrity.

One response to this predicament: Ah, what a chance to grow in humility!

THIS IS AWESOME.

"Ah," goes this response, "I have had many peers, past and present, who have struggled to get the things I’ve gotten, like A’s and letters of recommendation and leadership positions and success…. Now, God is making me more like them, to help me see that they are my brothers in everything. I have nothing of my own and am happy to have God, because I truly lack nothing."

Another and much more human response to this predicament:

THIS IS TERRIBLE.

In its severest form, this disappointment becomes sadness, loneliness, isolation, depression, and despair.

It was a war between these two responses for the second half of third year. However, it is old news that 1) I am a little soul and 2) there's a war going on in me between holiness and not-holiness. God is exerting Himself to the maximum and employing all kinds of things (sacraments, virtues, habits, circumstances, living people, dead people, people I’ve never laid eyes on, angels, and even me) to make me like Himself. On the other side are all kinds of things (occasions, vices, habits, circumstances, living people, dead people, people I’ve never laid eyes on, angels, and especially me) persuading me to stay in my nice little hidey-self-in-hell-hole.

But morality aside for a teensy moment: seriously! This year was so demoralizing at times!

Do you have any idea what it is like to stand in a surgery, not allowed to do anything except trim suture? Somebody ties a knot around [whatever], and I come in with scissors and snip it. That is 90% of my intraoperative action. This is especially painful because I’ve been given great responsibility and responded rather well to in the past. I wish I could speak my mind in those ORs.

“You know, I am a person.”

Snip.

“With an intellect.”

Snip.

“A rather good intellect.”

Snip.

“And I have pretty good hands, too. Did you know I paint? And I’m handy around the house.”

Snip.

“And if you let me stick-tie the ovarian vessels/close the fascia/dissect adhesions/use a bovie/debride dead tissue/MANY OTHER EXAMPLES, I bet I could do it.”

Snip.

The worst part is, I am not even permitted to stupidly cut as I like. I am chided because I am not doing it properly. Since the clinical years of medical school are a dizzying merry-go-round through services and surgeons, I can never acquire expertise in one thing. Many have pretened to, but no one ever has, given me a comprehensive lesson in how to properly cut all types of suture in all places according to the preferences of all surgeons. (I expect even the Eternal Father would have difficulty with this one. Just kidding, Abba.)

“Whoa!” says one surgeon. “Too short.”

Or again, the surgeon is uncomfortably silent after I cut. I timidly ask, “too long?”

At least I have never cut someone’s knot. There was once when I took the blame for a broken knot. A few minutes after I snipped, one of the resident’s knots came undone. To save the resident face, I said, “Oh, I cut your knot, didn’t I. I’m sorry.”

I became the queen of taking flak this year. There was an “Oh, thank you,” after every correction; there was a sincere-sounding “I’m sorry,” after every action someone objected to.

Today, while snipping, I grew less and less successful. I began to wonder whether there was a problem with the scissors. Surgeons and residents are quick to ask for a different instrument if the one they’re holding does something silly or inefficient. Not being a surgeon or a resident, I waited out my silly, inefficient instrument for a good five more snips. While I waited, a new scrub tech clocked in. This meant I lost the rapport I’d built up with the first one (my pulling a gown and gloves, helping in setup, etc) I didn’t think anything of this at the time, but now I wonder whether er shift change made a difference in the answer I received when I eventually asked, “Do you have another pair of scissors?”

There are at least four pairs of scissors in almost every set. I know because I know their names: curved Mayos, Mets, tenotomies. There are also Potts and Dietrichs, but even I wouldn’t use those for suture (now I’m just showing off how many types of scissors I can name without looking things up). The suture scissors are called “heavy sciz” by some, but their real name is straight Mayos. Technically, you’re supposed to use the straight Mayos for stuff, like foam, suture, and mesh. Cutting these undelicate things with the better scissors would dull the blades and damage tissue. But I’ve seen surgeons get frustrated with a pair of straight Mayos. They drop them to purposefully exclude them from use, then start to use the curved Mayo’s or the Mets. I’ve even seen someone use the tenotomies. So certainly it would not have been absurd for me to use a different pair of scissors. But what did the scrub tech say?

“Is it the scissors, or is it you?”

I felt like exploding.

“Please,” I wanted to say, “even if it is me, could you think of a different way to say it? Maybe ‘show me how you’re cutting’? Or maybe, just maybe you could humor me? I humor people to ridiculous extent. Could you just hand me the curved Mayos? Maybe then I’ll learn that it is, in fact, not the scissors. And you know what else? Even if it’s not the scissors, I don’t like that you said ‘me,’ as if I/me/my person is a problem. My technique might be lousy, but why the ad hominem? Why do I become a problem because I don’t cut suture properly? And anyway, who has taught me how to cut? No one! I have had to cobble things together myself!”

See the med student, doing nothing?
Oh wait, I forgot to get them in the camera view.

But I said, smiling doormat that I have become, “Oh, probably me.” And she said what I should have been doing. My success was unchanged: some good cuts, some lousy ones. In retrospect I think the scissors were fine and I was fine. The problem was that the incision was getting deep (down to the retroperitoneum) and therefore the sutures were getting further and further away from me. When you have to stand on tiptoe and crane your neck and reach to cut something, nothing works quite as well. I can’t wait to be the surgeon or the resident and have a legitimate place to stand so that I can see the operative field all the time.

Plot twist!

I have not posted in a long time because at the beginning of this calendar year I became sick and was eventually diagnosed with ulcerative colitis (UC). This post is long, but it contains no gross images! Yay!

On the first day I had symptoms, I formed a little differential. By day three at the latest, this thought had occured to me: "huh; IBD would give me this. UC, to be specific. Could I have UC?" But for several reasons, I thought that was unlikely. The most prominent reason: I was not special enough. Patients were special people! They deserve special treatment, they have these big gifts from God, they're special cooperators with him in redemption.... I was not one of those people. I was just plain me, just one of the patients' helpers.

We had to memorize a chart like this as M2s.

I remember when my mom was diagnosed with a lifelong autoimmune condition, I thought: "Wow. God gave her something big. It's permanent. He's not taking it back, (barring a miracle). He must really want her help with someone's case." But I wasn't that special.

So for a week, I ignored the symptoms thinking that my subclinical IBS (which 60%+ of med students have due to stress and environmental factors) was just getting worse with the crazy schedule and heightened stress of IM. Or maybe it was because I didn't have enough yogurt. But then, things persisted; then, things got worse.

I knew I had to say something to my upper-level to explain why I was ducking into the bathroom and sitting down on the job so much. I didn't want to say anything. I wanted to tough it out and be invincible. But my conscience was pricking me: you're not invincible and it's pride to think and act like you are. Admit your weaknesses. It's humility; it's human; it's the truth; and it will explain why you're randomly in the restroom. But I could never find a good time! I was seldom alone with the upper-level; the other med student was always there.

At last, I had a chance. She and I were in the ER physician's work-room. The room had frequent in-and-out traffic and the walls are glass, but we were alone. In this relative and extremely transient privacy, I wrestled with my conscience.

"But I don't want to tell her!" I whined to myself. "It's just because of that new medication I started a few weeks ago."

"That wouldn't last this long," my better judgment pointed out. "You know that's not a side effect of that med. You're sick, it's the truth. You need to tell her. And this is an opportunity for humility. And somebody is going to pop in here any minute, so you need to act NOW."

I spoke up: "Say, Laura," I said timidly, "I need to tell you something: I'm sick. I just wanted to let you know that I'm not uninterested in what's going on when I leave...I just have to be in and out of the bathroom. A lot."

Well, then she did the inevitable reflex thing that I figured she would do and took a mini-history. ("What's going on? How long? Did you see someone? Do you want some Imodium?") And then she told me, to my great relief, that she knew I wouldn't slack off and that I was free to do whatever I needed to do to get better. "Take some days off," she urged.

"Take 'em while you can," chimed in an attending, because someone (of course) had come into the work-room. At least they hadn't heard exactly what my chief complaint was.

"I think I'll be okay," I said at the time (ha!). "I just wanted to let you know."

Fast forward a few days, and I'm collapsing on a chair as I pass by it while rounding with the other med student and his intern. I wasn't dizzy/lightheaded, but I was just so malaised that I couldn't stand up any more. That got people's attention. Interns have an even stronger reflex to take a history, so I had to tell her even more. It was embarassing; I know everyone is medically curious, but I would have liked to keep things closer to the vest among people I was working with.

And it was frustrating! As much as I wanted to be flat in my bed, I also wanted to be a good med student. And that day (the day I collapsed) we were going to observe a tracheostomy and some other cool stuff. Darn colon! </rant against my own organs>

I became alarmed when the intern said I should go to the residents' clinic and probably to the ER after that. "What?" I thought to myself. "Go to the hospital? For this? Whoa. I guess I could imagine my story in the top paragraph of one of those admitting H&Ps."

I ended up not going to the ER. Instead, I got a work-in appointment with my GP across the street. (We still went to the resident clinic, where two of the seniors took my blood pressure and took another HPI. And then a partner of my GP, with whom I later worked, asked a few questions that seemed sheerly to satisfy his own curiosity. Yeesh people. Shoo!) All this time I was very tearful, because I was very embarrassed.

At the appointment, becoming an inpatient came up again, as did the ER. I asked my GP to keep me as an outpatient, but my story still apparently bought me a CT. My GP wasn't in clinic that afternoon, but she told me to stay on the hospital campus until she phoned me with the results (in case she had to admit me?? The unsaid words were louder than the ones she said). My first CT went well. It really is a fast test, except for the hour you spend drinking the two doses of po contrast. They couldn't find a vein for IV contrast, so I just did po, and that stuff was tasty. (No, honestly. I gulped it, it was so nice. </digression about grape-flavored radiation>)

She called first about the bloodwork. "Labs are all normal," she happily told me. I was less happy.

See, it seems like every time I go to a doctor, they tell me that everything is normal. That's another big reason that I didn't tell anyone about my symptoms. Every time I come in: "Well, it doesn't matter." "Well, you just need more sleep." "Well, your bloodwork was all normal." Remind me that when I'm a doctor I'm not giving up until the patient feels better!!

So, once I heard that the labs were normal, I figured it was inevitable that I would get the "well, looks like nothing" treatment. But I really wanted it to be something! I was terrified that the CT would come back negative. While I waited for her call about the CT read, I attempted to nap in a dark, empty exam room. All the while, I was thinking to myself. "IBS. It's IBS. I'm making all this fuss over something without pathological findings. Labs normal, imaging normal. Don't even think about biopsy. I'm wasting all this money and time and people are all in a fuss; how embarassing. And since it's IBS, it's all my fault. I do have bad eating habits...."

Finally the call came. And as soon as I put the phone to my ear and didn't hear an immediate "everything looks good," I was happy. I immediately recognized the Pause that comes before "bad" news.

This is not me. Source.

[Pause.] "So, mmatins, your CT showed [Pause] a pattern of [Pause] proctocolitis."

I was so overjoyed that it wasn't normal that I didn't hear the last word. "Of what?" I asked. I was so relieved, I could have sung (except that I was exhausted x10^23).

"Proctocolitis," she repeated.

Silently, I said to myself, "Sounds like UC. I bet I have UC."

"So," continued by GP on the phone, "even though the most likely cause is infection in your age group, I still think you should see GI if this pattern... [Pause] recurs."

My brain was saying, quite calmly, "I have UC. How about that." Before that day was out, I said (even aloud) "I want a colonoscopy." But I tractably accepted her plan of a 10-day course of antibiotics and a GI appointment later that month. The antibiotics which made me more nauseous and more malaised than I hope I ever feel again. (Remind me never to prescribe levaquin and flagyl so flippantly again!) And I didn't get better. And so my brain kept saying, "I have UC."

I missed about a week of work. When I came back (not physiologically better but psychologically better for not bottling it up and for being rather far along in the Kubler-Ross due to my constant self-diagnosis), I still hadn't seen GI. And people still wanted mini-HPIs! My upper-level finally ran into me in the hallway and, finding that I was no better and agreeing with my provisional self-diagnosis, texted a GI doc. (I protested; I didn't want to be treated differently from any other person.)

My GP called the next day and, finding I was no better, asked "Can't I just put you in [the hospital]?"

And I said, "At this point, I really wouldn't object."

"We could put you on teaching [the service the residents work]."

"Ah," I said. I'd always thought I'd want to be a patient of residents if I were ever in the hospital (to pay back my debt, you know?), but I didn't think that it would happen during my IM rotation with the residents I just worked with. "Actually, I think I'd prefer if we didn't."

"Okay," my GP said. "Now, I have a med student working with me right now, but you don't know her, right?"

"Actually, we're pretty good friends."

"Oh, all right. I'll just round without her. But this way, you can get in to GI faster."

I'd just come off wards, so my BS-reasons-for-being-in-the-hospital meter was still very accurate. "Do you think I could just get an outpatient appointment?" In the end, my GP also texted the GI doc. Apparently, when a specialist gets two texts in two days, you get a work-in appointment within the week.

As I sat in the GI doc's office, I heard her speaking with the patient in the next room. (This doc is delightfully loud, direct, fast, and very competent.) She was giving her colonoscopy prep instructions. "That's me in twenty minutes," I mused, resting my head against the wall behind me nonchalantly. I'd worked at a pharmacy in college and knew what Golytely was like. "I guess I'll find out how bad it really is," I thought.

Actually, she gave me a new-fangled prep that was super easy, so I have nothing to complain about. I was scoped and found to have abnormal but confusing findings (UC or Crohn's?), and had bloodwork done with showed probable UC. I'm now on meds to get me into remission...and we're (almost) almost there.

Was it hard to adjust to the fact that I have UC? Meh. Not really. I had the possibility on the back burner from the beginning, and I had lots of time to adjust. The view I have of chronic illnesses also helps. Now I get to be a prayer/suffering warrior and care for them!! (What a deal!) And life is not that different; as my GP remarked to me the other day, it's a good time in history to have colitis. (Mesalamine is amazing.) It's not a very inconvenient illness. Stress and other unknown factors might bring on flare-ups (and those might get pretty bad), there are some nasty complications and some extra-intestinal effects (all of those are yikes yikes yikes), and there's an increased risk of cancer (which brings lots and lots of colonoscopies into my future)...but I've got a very moderate case and there are a lot of ways to treat it. In the end, I gained a lot from the flare-up and I'll say more in a future post.

Internal Medicine

I am one week in to my second month of inpatient medicine, and I am run-down. I have seen a lot of sick people and learned a lot. It has been exciting, emotionally draining, and physically taxing. I wish I could tell you the story of the man with an enormous malignant pleural effusion, the story of the man with a hemoglobin of 1.8, the story of the man whose foot was amputated in the middle of the night, the story of the man with a failing heart, the story of the woman who presented with flu and was found to have leukemia, the stories of the several people found down, the story of the pregnant woman with flu, the story of the man with the three-foot aortic dissection, and the story of the man I thought was having a heart attack but who was really lying to me about his cocaine use....

Daily Mass and meditation have been hard to get to, and that sends me into a tailspin of scrupulosity and humiliation. However, I was able to go Mass almost every day in the past week and formation is still going on. When you read this, please pray for my bishops; they are making some important decisions and need your help!

My schedule now looks like this:

4:50 Rise, MP
5:30 Drive to work
6:00-8:00 See patients and write notes
8:00-12:00 Round with resident or intern
12:00-1:00 Noon Conference with residents (Midday prayer doesn't happen during the week)
1:00-5:00 Lecture, studies, or other learning with resident or interns
7:00 Mass, EP
8:00 Home, mediation
9:00 Bed (NP doesn't happen much right now)

Unless I am on call (working 6:00-9:30), then I exempt myself from Mass and meditation.I am on call every fifth day, and this means that there are some days I work on Sundays and Saturdays. The day after call ("post-call") is also a workday, so if call lands on a Friday, I work Saturday (that happened this past week.) If call lands on a Saturday, I work Saturday and Sunday. The residents call this a "black weekend," but because of the way the call schedule works, it is always followed by a "golden weekend" of both Saturday and Sunday off. Obviously, when call was on Sunday once, I went to an anticipatory Mass.

When I'm on call, my team picks up the new patients coming in to the hospital. This means that I am sent down to the Emergency Room, with nothing but my notebook, pen, and stethoscope, and asked to write an admission note (an H&P or history and physical exam) on the person. This means I need to find out all about them. Why did they come in? If for pain, where/when/how/how bad is it, and what makes it better/worse? Have you had this before? What other problems do you have? Surgeries? Family history? What medicines are you taking? And then, I ask them the "review of systems," basically asking about every other medical symptom I can think of, even if unrelated to their chief concern, so that I have a complete picture and can make an accurate diagnosis. Then, I examine the patient and attempt to make a diagnosis. I meet the intern outside the patient's door or in the physician's work room in the ER, and "present" the patient. "Mr. So-and-so is a 45-year-old white male with a past medical history significant for diabetes and CVA in 2001 who presents with a four-hour history of dizziness...." I consolidate my whole interview and exam with the patient into a one-minute presentation that ideally ends with my assessment and plan. This is all terrifying, but fun.

Two days before the call day, I am "on codes." A "code" or "code blue" is called when a patient goes into cardiac arrest. I carry a special pager on code days that goes off whenever a code blue is called, anywhere in the hospital. When that pager rings, it flashes where in the hospital the code is, and I immediately drop everything and walk/run there. I have been to three total, I think. There are usually plenty of people at a code, so I usually stand in the background. I gave chest compressions once. All three times, the person died. (The survival rate to hospital discharge from a code blue is extremely, extremely bad--don't let the medical dramas fool you.)

What does a medical student do in the hospital? I come early and see the patients assigned to me (usually three, yesterday four). I go into their rooms, (usually) wake them up, and ask them how they're doing. I follow up on their pain, nausea/vomiting, breathing, constipation/diarrhea, urine output, medicines, etc. Then I examine them. It's amazing how natural this is becoming! Then, I update them on any test results that I have seen and they haven't been informed about yet. I always leave big news for the resident or specialist, but if there is something simple I can tell them, I do. I ask them if they understand everything that's been told to them. Often, the answer is "no," and I know enough to help them understand. Then, I ask if I can do anything for them, and if not I leave and find a computer.

I pull up their chart in the EMR and write a progress note, including what I think should be done for the patient that day. Should we continue the IV fluids? Should we give a diuretic? How long have they been on that antibiotic and is that enough? Should he be taking a beta-blocker for that telemetry strip? Should we try an enema? Should he have an ABG? Can we adjust the FiO2? Do we need to consult someone? Can they go home today? If they have multiple problems (and almost everyone does), this takes longer than the actual patient encounter. Juggling lung disease, dizziness, heart failure, and acute kidney injury (for example, as I am with one of my patients right now) is a very tricky business. Managing pain is another huge undertaking. And making sure all the medicines are working for the patient is work as well, especially when they are often on so many! I like to really prune back the list, but sometimes it's impossible. Admission for a single heart attack (with no other medical problems) earns a person about eight drugs, right off the bat.

I submit my notes before 8:00, which is when the interns review my notes and see those same patients. They usually formulate their plan without taking mine into account (my notes are more for my education than the patient's care), but I have had some take some of my text and use it in their notes! Sometimes I round with them, but more often I join the "upper-level," a second-year resident. She has to see all the same patients again, too, because she checks the interns' work (and the attending physician checks hers). This is how doctors train! Daily practicing medicine with less and less supervision.

Rounding with the upper-level, we present the patients outside the door or while walking and then go in and see the patient together. We are supposed to know everything about the person--down to the last lab test result. So, I carry around a single sheet of computer paper per patient, crammed with an organized and traditional shorthand full of medications, symptoms, and results for up to fourteen days. For example, writing numbers in the four "fishbones" at right gives me 22 test results. Because each result has its traditional place (the white blood cell count always goes to the left of the CBC fishbone), I don't have to write down "white blood cell count is" or even "WBC."

Noon conference is mandatory free lunch with lecture. Every day, we learn about something in medicine. I'm sure the upper-levels have heard some repeats, but repetition is the mother of learning. After noon conference, the med students have additional lectures and we also do practice questions or join the interns for some teaching. "Teaching" from a young doctor is different, depending on the doctor. With one of my interns, I trooped up to an ICU and we found a patient on a breathing machine so that he could give me a one-on-one mini lecture (with questions and practice cases all throughout it) on ventilator management. With another intern, we did practice board exam questions. With a third, I was left alone to read and do practice questions on my own.

As you can imagine, I'm learning a lot. This ended up being a respectably-long and mildly interesting post...I dive into IM again tomorrow and have a black weekend the next week, so I probably won't be blogging again soon. Pray for me, and for my bishops!