Halfway through M3

I'm on break right now and can't stop thinking about whether I killed anyone or not.  It's not possible yet because I'm 'only' a medical student.  I think perhaps the thing that's gotten me thinking about this is me reading a book by the title of "House of God".  If I had to sum up the book in one phrase, it would be that it is the 'the cynical side of medicine we don't want to hear about, yet the cynical side of medicine that we need'.  Yes, the phrase is reminiscent of the ending of "The Dark Knight".

In any case, being half way though the third year of medical school, I'm beginning to panic.  Very very soon, I'm going to be very responsible for the lives and well-being of live human beings.  Thus far, it's been easy mode.  No matter what stupid mistake I made or tried to make, there were interns, residents, chiefs, fellows, and attendings to make sure that the level of my idiocy never shined through to the level of healthcare delivery.  Soon, that will change.  Gradually, I will be more and more responsible and liable for the patient.  What's worse is that the fear comes in two: A fear of hurting someone and the fear of personal failure.  But are those two the same things where my classmates and I are headed?  Yes, and no.  Depends on what matters more to each one of us.  I really hope I care more about the patient.

As I start to dig in again thinking about what is to come ahead in January, I'm excited and wary.

Done surgeRising at 4am everyday

Okay. Just finished my surgery rotation.  Man that sucked.  I'm sure it's much better as an attending than it is as a resident or a student.  Students have to get to the hospital to round on the patients before the senior, who has to get to the hospital before the attending to round on the patients to present to the attending.  Overall, the experience is one that I will never forget and one that I will never regret.  I saw some of the craziest things; liver transplants, for example.

About half-way into the rotation, I felt myself getting bitter about waking up at 4 or 5am in the morning even on the weekends and having to come into the hospital.  Then I remembered something again.  Something that I realized earlier this year.  I COULD complain about going into the hospital.  But...BUT...before I complain, I need to remember that there are other people who want to be in the hospital even less than me, earlier than me, and longer than me.  Sometimes, that's the resident.  Rarely, it's the attending.  Every single time, it's the patients.

No matter what field of medicine I go into, I need to remember something.  People come first.  Medicine is not a job.  It's a commitment.  Getting paid is not the number 1 goal.  Helping people get better is the primary goal.  Everything else is just frosting and sprinkles.

Still torn between surgery and emergency medicine.  Why can't I do both?

Capacity

So as part of being on the psychiatry team on the consult service, I get called a lot to go assess if a patient has the capacity to make a medical decision.  That decision can be anything, e.g. leaving the hospital, agreeing to the procedure, going to the bathroom instead of having to have a catheter, etc.  Sometimes, it's very clear that the patient doesn't have capacity.  For example, there was a patient with brain tumor who was being evaluated for decision to seek subacute rehabilitation following discharge from the hospital, and when I went to go see him with my senior resident, he looked at us and told us that he believed he had no brain tumor, and that we had promised him earlier in the day that he could go home when in fact we had never met him.  Other times however, it's not so clear.  Another patient today had gross hematuria (bleeding from the urethra) and needed a cystoscopy (tiny camera through the urethra to look at the bladder) to evaluate the bleeding.  Her bleeding was so bad that her hemoglobin level was dropping to dangerous levels and she needed to be transfused multiple units of blood during her hospital stay.  Despite this, she wanted to go home because she felt no pain.  After evaluating her with my attending physician, he came to the conclusion that she had the capacity to agree to having the cystoscopy, but didn't have capacity to refuse it.  She understood that having the procedure was beneficial to her, but didn't understand that not having the procedure and going home was detrimental.  In a way, it sounds like we're forcing her to have the procedure, but apparently, it's not, and many doctors operate on this paradigm.

Assessing whether someone has the decision-making capacity for choices that impact the quality of their lives is a huge responsibility, and one that is not always easy.

"We need to end black on black violence"

...is what one of the patients said today.  She was convinced that her ex-husband was the anti-Christ and that her cousin was shot, her husband is cute, she doesn't need anti-psychotic medications, her 401k wasn't being adequately maintained, there is going to be a war in California, etc.  She mentioned the above things in that order when most of those things were not associated with one another at all.  She at least stuck by her guns though.  When I spoke to her a few hours later, she was very sure and could not be convinced otherwise about her beliefs mentioned previously.

Psychosis isn't what media outlet has led people to believe.  It's not usually the desire to kill people and wear their skins or something gruesome like that, but it is simply being unable to function correctly due to the lack of control over our own minds.

With some of the patients being around my parents' age, I got to thinking, "this isn't just interesting, it's extremely sad, especially to the people who are in that person's life".  And so I was reminded yet again that patients are much like myself, human.  I wonder how many times I'll forget and remember again before I have the association down completely.

Study day

I've been studying for the past 2 days.  Actually, I went to the bar for a second last night with some people to talk logistics about school events that we have to plan.  Anyway, I'm studying at the moment, aside from writing this entry.  I have my neurology shelf tomorrow and I'm feeling okay about it.  I took a practice test that is sold and administered by the same company that makes the test that I'll be taking tomorrow and I did fairly well on it.  Well enough to pass anyway.

In any case, I feel like I've come some ways with dealing with exams.  During the first year of medical school, I freaked out whenever there was an exam.  In second year, I was just tired and feeling ragged inside from having exams every 2 weeks or sometimes weekly (because failure is not an option).  But this year, things are different.  I'm calm about my exam preparation.  I still cram, because I still believe it helps to a certain extent, but I'm better at preparing earlier on for the exam too now.  In fact, I kind of enjoy the day before the exam because it means that I have control of what I can do with my day.  Being at the hospital is different in that your time is not your own.  It's your resident's, it's your attendings, it's pretty much anyone's time except yours.

But I digress and complain.  In the 3rd and 4th year of medical school, students are expected to fulfill their duties at the hospital each day and go home and study more for the next day and also for upcoming exams.  And so we're somewhat forced to study every day.  Except that's a horrible way to think about it.  We shouldn't be forced to learn each day.  We should set out on our own to study and to become experts in what we've committed our lives to.  I think this applies to all people.  Even those that feel hopeless and directionless - to learn something new each day that interests us, or may be of use to us some day is a valuable and productive thing to do.  For our sanity's sake.  For our future generation's sake.  For yourself.

"I'm jaded, Bro."

I'm working with a resident this week who's on his second year of residency, and has 2.8ish more years to go to finish residency in his specialty.  From what I've noticed, his demeanor towards patients isn't terrible, but it's not all that great either.  One of the patients said to him at the end of the interview "Your student's been smiling the entire time, but I haven't gotten a single smile out of you yet".  At that point, the resident gave the patient a meek smile and moved on.  Later on, I got to talking to him a little bit and he said to me "Bro, I'm jaded about all of this.  You should probably hang out with someone who's more motivated.  Working hard can be rough on a person."  His gave reasons for being jaded.  His friends whom he had graduated college with had all gone in different paths and those who had entered the financial world were already buying 6 figure houses in affluent neighborhoods and his dentist friends were making "real money" and enjoying their lives outside of the great hours they worked at their offices.  I wanted to tell him, "yeah, but none of them are doctors like you. none of them went through the med school and residency experience that you went/going through," but I don't think that it would have made a difference.  This was a man who had already made up his mind to be unhappy about where he was.

And this is my first experience with a doctor who is unhappy with their lives.  I think I may have been fortunate up to this point to only meet doctors who loved what they did.  And today made me question if I would be happy in the specialty that I'm thinking about.  It is THE most important question that a med student, or any human being has to ask him/herself before entering into something that could potentially direct him or her down a certain path for the rest of their lives.  But you know, the answer is that I don't know for sure but I probably will be happy.  Happiness/the state of being content is such a subjective thing.  Most of the time in our lives, we have direct control over it.  Even through times of adversity, we can decide to celebrate it and work with the situations that we're dealt, or we can also choose not to.

Even within the most hopeless situations in our lives, we almost always have a choice.  The challenge is remembering that we have that choice.

I don't like what you have to say. Good bye.

I saw a patient today who got into a verbal altercation with her partner while in an automobile.  Several things led up to that point, but long story short, she had had enough of the conversation and decided to jump out of the car.  Considering that the vehicle was moving, she fared well.  No major injuries and could not recall the event, the events leading up to the event, and the few days in the hospital she spent after the incident.  The extreme lengths to which people are willing to go in order to do things their way amazes me.

Another patient came in because she fainted a few days ago and had no recollection of it happening.  Apparently this happens on a very regular schedule, but years removed from each event.  Peculiar, interesting, and most likely more to the story than the patient shared.

I'm not sure that patients ever share their full stories.  There may be rare occasions, but none of us are perfect story tellers, whether it be due to conscious decision to withhold information, or just because we don't want to divulge too much.  Regardless, it's a physician's job to work with a puzzle that may be missing pieces, but to put it together to construct something cohesive and sensible.  As a student who formerly trained in engineering school, this inexact science is a daunting and unattractive task.  As a medical student and future doctor, this is the rest of my life, and I'm looking forward to each day and patient that's left in it.