Doctoring


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As many of you know, last week I graduated from medical school AND officially released my book, Tales of an Ugly Docling. The book is a collection of stories and essays about my experiences working as a medical student in clinical settings, much like the posts I make on my blog. All of the proceeds from sales of physical copies of the book will be donated to medical charities worldwide.

The Kindle version of the book is currently FREE on Amazon (from 5/20 to 5/24)! I am doing this as a “graduation gift” from me to all of you! Please take advantage of this promotion: download the book, rate it, review it, and spread the word!

Also to promote my book, I have a new WordPress site and blog at http://www.uglydocling.com. In the future, I will be posting my medical stories in the new Ugly Docling blog, and I will repurpose Nervous Impulses for things I do outside of medicine, such as traveling, cooking, photography, and music. I encourage you to follow my new blog to continue reading about my adventures in residency and beyond.

I want to thank everyone who has followed me through my journey in medical school over the past four years. The thoughtful feedback and support have really pushed me to continue writing, and the whole experience has made medicine so much more meaningful for me! Let’s have many more adventures together in the coming years!

Ugly Docling cover copy

 

Tales of an Ugly Docling, my book of essays about medical school, will be officially released on May 16th (2 weeks from today)! The Artist in Residence program, which funded the materials for the project, will be hosting an artist reception/book signing that day 4-6pm at Sierra Arts in Reno, Nevada.

Not in the Reno area? Most of my readers aren’t, but you guys have really been a huge support in making this happen. So for you, I will be releasing my book on Kindle FREE for the first week! Just as a way of saying thanks for being awesome.

(Note that 100% of the proceeds of the book will be donated to medical charities worldwide, so more people will benefit if you also order a physical copy through my website,www.uglydocling.com)

Ugly Docling cover copy

An update on my upcoming book… Here is my first draft of the cover! I made it with a combination of pencil drawing, scanning, Paint, XnView, and Photoshop (on a Mac and a PC). I’m not too much of an artist, and I’m kind of indecisive about the kerning aspect, so feel free to give me any feedback on how to make this better!

I wondered for a whole year what I was going to title my book, and suddenly, “The Ugly Docling” came to mind. I think it’s fitting on many levels.

For one, the Ugly Duckling is the story of a nerd kid who grows up to be a doctor (or engineer, or astronaut, or member of any profession that draws from the smart kid pool.)

I’ve been a misfit since elementary school. First it was because I was an immigrant, had an odd name, wore different clothes, and didn’t speak the language. But even after I grew accustomed to American culture, I still struggled with being a nerd. I tried so often to dumb myself down so I could be accepted by other kids. I wanted people to know that I was a musician, a poet, and a tennis player, but I would be mortified if anyone found out that I was in MathCounts or Academic Olympics. And though I spent way too much time trying, I never had nice hair. For me, this one was tough; high school is all about the hair.

Fast forward to medical school: Everybody is a smartypants. Everybody is charismatic. Everybody has nice hair. Well, almost. When we tell people that we are going to be doctors, they react with kind words of admiration, appreciation, and respect. (And then they show us skin lesions for diagnosis.) Yet, when I found my old MathCounts roster and pointed out that a couple of my classmates were on it, they were mortified. It really is bittersweet to look back on those years. But hey, let’s face it: doctors don’t just pop out of thin air; they were Mathletes when they were little! Nobody makes fun of a doctor. So why are American kids taught to make fun of nerds? I consider this book to be a big hug for my young self—and for nerd kids everywhere. Nerd kids: It gets better!

But my personal Ugly Duckling story continued even after I met up with the other swans in medical school.

Perhaps because of our common unspoken background as nerds, the culture in medical school is reversed. We admire and compliment each other for knowing the right answer at the right time. We fear being laughed at when we act ignorant or incompetent. Some may brag about how they never study, but they are either lying or willfully endangering lives and mocking the practice of medicine, and the rest of us know in our hearts that we would never refer our own patients to those individuals.

It was in this culture that I realized I may still be a misfit. Yes, of course I have studied my tail off, and of course I want other students to think of me as being a stellar student. But to the degree that I still have gaps in my knowledge, I question my doctoring skills. When I get an answer wrong, I question if all my classmates are smarter than me, if I can be a good doctor, if other doctors will want to refer their patients to me. For the first couple of years, I focused so much on test scores as measures of my doctoring skills. But then, when the exams were over and I was thrown into the real world of hospitals and clinics, I was humbled to learn so many things that were never taught in the medical classroom. These are the things that I felt moved to write about.

I’m ready to let the word out that I am publishing a book this year, thanks to the Artist in Residence program*. The book will be a collection of essays that document the adventures and insights of a medical student, much like the posts I make on G+ and my blog. As part of the graduation festivities, there will be an art show at the Sierra Arts Gallery in Reno on May 16th, where I will have my reading and book signing event. The proceeds of this event will be donated to medical charities locally and world-wide.

Right now I am in need of suggestions for medical charities to benefit. I have been a long-time fan of Doctors Without Borders, and recently heard about Child’s Play (which provides toys to children’s hospitals around the country). I also want to recognize my readers by letting them suggest any medically-related charitable organizations or causes that are close to their hearts. Please post any suggestions in the comments, and include an explanation of why the charity is important to you.

Please feel free to spread the word! I’m very excited about this project, and hope that my messages (and the funds they generate) will reach many people in need.

*The Artist in Residence program is a collaboration of the University of Nevada School of Medicine, Sierra Arts Gallery, and the Healing Arts Foundation at Renown Hospital. Every year, they give awards to graduating medical students for pursuing artistic endeavors related to medicine. It is funded by generous donors in the Reno community.

Have you ever had a doctor break down and cry with you as you received bad news? Sometimes I have to work really hard not to be that doctor.

Each day in Oncology clinic, I see all the stages of grief. Everyone battles cancer completely differently, and I get to experience it all as one giant roller coaster.

One minute an old woman comes in after her last round of chemo left her hospitalized. She absolutely insists on taking another round. Her doctors hesitate to give her more chemo and radiation than she could tolerate, yet she refuses to go to the grave without having pulled out all the guns. The defiance in her eyes is contagious. I want to shout, “Yeah!! Go get ’em!”

Next thing we see a young man whose cancer had no business interrupting the course of a well-plotted life. He’s already nauseated just worrying over how the treatments will affect his family. He and his wife raise a slew of questions, exploring every crevice of every possibility. Our uncertainty makes them visibly uneasy: Curing cancer is a numbers game, from our perspective. But for each individual patient, we either achieve a cure or we do not—and the side effects are definitely not worth it for a not-cure. I wonder if he might talk himself out of getting any treatment at all.

Then we get a happily oblivious patient, a guy with brain tumors so far gone that he no longer has the capacity to understand his own plight. We try to explain that he needs to take his chemo pills diligently. He smiles pleasantly and agrees, indicating that he clearly won’t do anything of the sort. While this is truly terrifying to me, part of me also thinks that perhaps, for a cancer patient, he is in the best of all worlds.

The tearful patient really gets to me. Someone had given her false hopes about her prognosis, so then it became our job to set the record straight. The doctor apologizes profusely. The patient retreats into heaves and sobs as she begins to mourn her own death all over again. In her mind, we have just killed her. I hand her a box of tissues—inadequate for the gravity of the situation. Yet she smiles briefly as she takes the box from me. We continue the conversation as she empties the box. Pagers ring, and we silence them without answering. Occasionally I stare at the ceiling so the tears won’t crash down.

Where in my medical training was I supposed to learn how to let a patient die? How do I tell the dark news, and then, how do I react? Do I grieve the disease, or do I fight it? What does the patient need to hear? Is it inappropriate to laugh with them? To cry? Is it unprofessional to admit that the cancer, in beating the patient, is also beating the doctors?

What is a good doctor?

This year, I spent Christmas Eve in the ER… as a patient.

1:00 pm. After signing all the paperwork and explaining my situation, my husband and I were asked to find a seat and wait for my name to be called. The waiting room was pretty empty. Before we’d even agreed on where to sit, my name was called.

They took my vitals, and saw that I was not going to die. When asked again, I stuck to my story.

“Fast service!” My husband commented.

“That was just triage,” I told him. “The real waiting begins now.”

“But at least they got you through triage fast!”

“Umm, I’ve already triaged myself. That’s why I’m here in the first place.”

1:20. We made our way back to the waiting room. A lady was sobbing loudly. A man was pacing frantically and occasionally moaning in agony. A volunteer was apologetically offering blankets. I opened a textbook and got to work.

3:30. I’d reviewed the textbook chapters pertaining to my condition, decided on the course of action I would take as the ER physician, and also made several attempts to set a new record for Fruit Ninja. About a dozen other people had since arrived and been called in. I went up to the triage desk again.

A couple was yelling at the triage nurse and threatening never to come back again. When the nurse finished dealing with them, she turned to me with a very exasperated look and asked, “Can I help you?”

I tried a different approach. With a smile and a casual tone, I said, “I just wanted to get a rough idea of where I am on the list.”

She scanned for my name. “You are at the top! I have you on the fast track, but there aren’t very many beds turning around.“

“Wow, really? I’ve been here for two hours.”

“You will probably be the next person called,” she reassured. Then, on second thought, she added, “But we also get heart attacks and strokes.” Of course, I knew all too well.

4:30. After several more people fast-tracked past me, I was brought into a room in the pediatrics ER, which I knew served as overflow for when the main ER was full. It was freezing, and I had to change from my winter clothes into a thin gown. I was given one small blanket, which quickly lost its heat. I huddled into the blanket and asked my husband to pile on several extra sheets from the cabinet. After pressing all the levers, I gave up trying to raise the back of the bed, so I stayed lying flat, bundled, craning my neck to watch the TV in the corner of the room.

5:30. The doctor came in to make his initial evaluation. He laughed when he saw me, but was kind enough to bring several more hot blankets. He asked me again what happened. As a courtesy, he listened to my heart and lungs. He told me the list of tests he wanted to run, instructed me not to eat or drink anything in case I had to go for surgery, and then disappeared for another hour.

6:40. The nurse finally came back to put in an IV and draw my blood. A really sick baby had arrived just after me, and the doctor had been too busy to write orders for any of my tests.

7:00. My husband wondered out loud how much longer we might be there. It had been six hours, and we were just gathering the first, most basic of the studies. The nurse said, best case scenario, another three hours. I knew that I wouldn’t be staying overnight or going for surgery, but that it would be late evening before all the tests were collected. I asked him to call home and tell the family not to wait on us for Christmas Eve dinner.

So this is probably a typical ER day for any given patient: boring, exhausting, uncomfortable, and inefficient. And I might add that those IVs are ridiculously itchy! I can only imagine that patients without medical degrees must find it excruciatingly frustrating to wait, wonder, and suffer. Most of the patients probably don’t know what’s going on, what’s being suspected or tested for, how serious it is, or even whether or not they are going to die.

I’ve worked these shifts, and I’ve treated patients like me. It’s notinefficient from the other side of the door. I know those ER docs are running around frantically on a day like this, constantly seeing new patients, doing procedures, running codes, writing notes and entering orders, calling consultants, following up on results, reassessing, reassuring. In fact, I have never seen an ER doc take a lunch or dinner break no matter which shift they were working.

How frustrating that there should be such a difference between what the patient experiences and what the doctor experiences! I feel slightly embarrassed by it, almost like I need to apologize. I’m sure it’s hard to see your doctors as real human beings when they’re running in and out and making you wait for hours in between. It’s really hard to convey just how much work there is to be done, how much there is to think of, between those hectic runs into the patient room. I don’t know how we can close this gap. But at the very least, I want to say this, in case no one else ever does: Your doctors care a lot about your well-being and work really hard for you, even when it doesn’t seem like it.

I wish I could show you a picture of this young couple huddled over the side of a crib. Their faces were clouded with deep concern. Their baby had spent the greater part of 4 or 5 years in various hospitals, for treatment of a multitude of problems. His endocrine problem, which brought us into the treatment team, was the least of these. Even though we were only monitoring one lab value, we came by to check on this little patient every day. Every single time, we walked into this same scene with his devoted parents huddled over his crib.

I wish I could show you a picture of this child. Like so many Pediatric Endocrine patients, he was tiny for his age. He lay floppy in his bed, barely able to move his claw-like limbs. And he had these fascinating buggy eyes that seemed to stare in opposite directions.

Parenting is complicated, of course. There are many tremendous tasks associated with caring for a child, and despite excellent efforts, children don’t always turn out as one hopes or predicts.  But, seriously, no one could have been prepared for this! And yet, I have never seen any parents who loved their kid more than these brave people loved this poor child.

Pediatrics can be a tragic, heartbreaking field to work in, especially at a tertiary care center like UCSF (where I’m currently visiting). Every patient has several big problems. Too many will die shortly. Families have to split time between the hospital and the life they want. Parents put off their education, their careers, their relationships, their other children. They drag on in these horribly straining circumstances for months, years, indefinitely—until their trials end abruptly in the death of the little one. So many times a day I wonder how all these families make it through such times.

The beauty of Pediatrics is getting to be a part of these stories, to see example after example of courage and resilience, and to help bear these huge burdens in some small way. It’s the little head poking around the IV pole, shouting, “Excuse me, Doctor, I can’t see the TV!” It’s the five-year-old grinning when asked about his new diabetes, then running over to bite his brother’s head. It’s the sigh and nod of a tired mother writing down the dosages of yet another new medication regimen. It’s the gorgeous young couple huddling over the crib of their severely-deformed son.

The beauty of Medicine in general is seeing people in the most unimaginably horrific circumstances, and realizing, they are just people. They are not a list of diagnoses. They are not limited in their ability to be happy.

A husband and wife were about to bring their baby into the world. She lay across the surgery table. He sat with scrubs, cap and mask, anxiously waiting by her side. She grinned, even as her eyes glistened with tears. He spoke reassuringly as he squeezed her arm.

They had imagined this day over and over. Within minutes, with this birth, their lives would change forever.

A curtain of sterile draping fell between her head and abdomen, separating the excited parents from the hectic operation about to take place on the other side.

It was my first day in the OR since Anatomy dissections. She looked strikingly like a cadaver, except that she actually bled—multiple suction tubes flooded with blood. The OB with a flock of residents were frantically cutting, digging, and cauterizing.

“This is the uterus,” they held up something huge and nodded at me. When they pierced it, amniotic fluid gushed out as if a hose had exploded.

From the chaos they pulled out a small bundle. The nurses rushed to it with a bulb syringe and sucked the fluid from its mouth. Then it began to cry.

The dad stood up when he heard the sound. First his head emerged above the curtain, and then a video camera pointed in our direction.

I gasped. Everyone froze. Without missing a beat, the doctor held up the baby, smiling at the camera. Nurses quickly wiped off the blood. Then they swept the baby off to a table along the side of the room, and the video camera followed.

Work on the mother resumed. Placenta out, uterus closed, skin stapled.

The whole thing only took about 20 minutes. Nothing went wrong. It was a great case for a first-time medical student. And I found it to be horrific.

Only a thin veil separated the family’s experience from ours. For them, a beautiful beginning of a new life together. For us, cutting and sewing and blood and guts. I almost felt it was out of place to say congratulations.

This is how I was born into the world of Medicine. I was thrown in headfirst, unprepared and alone. I would learn, over the years, that some of life’s most precious experiences—birth, healing, death—are gruesome. I would witness many more than my share of such moments, again and again, as part of the routine of my career. I would struggle to find the beauty in the madness of this reality. Yet I would find it.

As a patient, that is often the extent of my contact with my radiologists. I’m told that no radiologist has ever been recognized at the grocery store by someone shouting, “Hey, that’s my doctor!” Some people even think that a radiologist is someone with a two-week certification from the local community college. One might wonder, “Where is the doctorly glory in this desk job?”

And yet, in a little dark cubicle off in the corner of the hospital basement, ALL THE MAGIC OF MEDICINE UNFOLDS!!

Well, at least, that’s how the Physics geek in me feels about Radiology. If you are interested in this geekery, read on!

In the earliest stages of medical school, we were taught about clinical problem solving using simulated patients (i.e., fake patients on the computer). We would click through the questions we wanted to ask, the physical exam maneuvers, and any tests and imaging we wanted to order. Then we were expected to make the diagnosis and plan the treatment. That was a bit overwhelming at first, and the actual reasoning came slowly, but this exercise taught me one reliable shortcut: The radiologist has all the answers! No matter how confused I felt by the clinical picture, the diagnosis could usually be made by ordering an imaging study and reading the interpretation given by the radiologist.

Of course, good doctors rarely use that shortcut in real life, and the answers are not always readily available to radiologists. But a lot of what we know in medicine, we know from imaging. Even though the clinical picture is not usually as confusing as it was to me as a first-year medical student, and I can now make many diagnoses based on the patient’s story and my exam (shocking!), seeing the pathology is what really confirms what I think I’m dealing with. Seeing is believing.

And that’s why radiologists are so excited about the advancing technology that has revolutionized medicine again and again. As we build faster computers and higher resolution scanners to give us clearer and clearer images, we are closing the gap of uncertainty. This makes a crucial difference in many cases where the more we can know for sure, the better we can tailor the treatment. Knowledge is power.

I’ve always been interested in the nitty-gritty of how the universe works. Perhaps it’s not surprising, then, that the Radiology textbook I’m reading for my current rotation is the best book I’ve read during medical school. It explains how shadows are translated from densities, and densities from pathology. It explains how to extrapolate the reality of a disease from a 2-dimensional image. And the more I read, the more I come to appreciate the order and logic behind what most doctors and medical students dismiss as something for the experts—some call it “voodoo”.

The real magic lies in that order. The shadows are not random, they are purposeful. Within them, the truth is plainly shown to those who understand. I just love that!

 

Seriously. I have thought about this, and I’m pretty sure I meet clinical criteria for addiction when it comes to studying.

Consider these criteria for “substance dependence” (and kindly think of studying as a substance for the purposes of this discussion):

(1) Tolerance, as defined by either of the following:
– An increased amount of the substance is required to achieve the same effect.
-A decreased effect results when the same amount is used.

I first tried studying when I was in elementary school. I liked how it made me feel. I got a buzz from being smart, like I was on top of the world, and often I could see things that other people couldn’t. But as time went on, it took more and more studying to get that same feeling. Now I’m in medical school, studying 40, 60, 80 hours a week in order to feel smart. I can’t just feel smart after studying for half an hour, like I did when I was young.

(2) Withdrawal, as manifested by either of the following:
-The characteristic withdrawal syndrome occurs.
-The substance is used to relieve or avoid withdrawal symptoms.

When I don’t study, things can get out of hand. I start to feel resentment toward the people (usually family members) who are taking up my time and keeping me from studying. I get anxious about what’s left of my evening and when I will get to study again. I get headaches, sometimes I lose my temper. If it goes on for a long enough time, I can even get delirious and do things that are completely out of character—like shopping, baking, or scrapbooking.

(3) The substance is used in increasingly larger amounts, or over a longer period of time, than desired.

Sometimes on a Friday night, I think, “I’m just going to study a little bit, since it’s the weekend and I have plenty of time.” Monday morning hits and I am left wondering how I managed—yet again—to get nothing done besides studying all weekend.

(4) The patient attempts or desires to decrease use.

Believe me, I’ve tried many times to cut back on my studying habit. I’ve stayed clean for a couple weeks at a time, maybe even for a whole summer. But it’s only a matter of time before I go back to the same old environment, with classrooms and teachers and all my friends who are studying… and I always cave in again.

(5) A significant amount of time and resources are spent obtaining, using, or recovering from the substance.

I know that I have spent a lot of time, and even squandered my life’s savings, on studying. Textbooks are at least $50-100 a pop on the streets. Sometimes you can get them cheaper, but you don’t know what’s been put in them (scribble marks, highlighting). And I don’t have a job, so I can’t keep up with how fast I go through them. I’ve ended up in a lot of debt!

(6) Important social, occupational, or recreational activities are given up or reduced because of substance use.

I try hard to make time for family and other things. Sometimes it hurts their feelings when I don’t make it to their golf games, or to their graduation dinner, or to their wedding. I can’t seem to hold down a job for long either because I end up studying so much. And that’s too bad. I really do mean well at heart.

(7) The patient has knowledge that the substance use is detrimental to his health, but that knowledge does not deter continued use.

Sure, I know that my habit is going to kill me sooner or later. I don’t always sleep, or eat, or use the restroom when I know I should. I keep studying even when I am sick. I just… can’t help it.

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