Category Archives: Medical Musings

First Code: Part 2

My resident says to call her after I finish my work. It’s early evening, and I’ve just returned from a teaching session, which was relatively uneventful except for a code blue announcement that made us pause our discussion on antibiotics. Two sets of closed doors had muted the words so I didn’t catch the exact location, but it hadn’t been in a place close enough for us to respond to.  We had finished talking about penicillins and moved on to fluoroquinolones.

I click the mouse to sign my note, adding it to the plethora of documentation in the electronic medical record.  As a medical student, my information bytes don’t count towards anything, but I go through the motions to help me prepare for when they will. I pick up my phone and I punch in the five-digit extension to my resident.

“Before you leave, stop by the computer room at the emergency department. I need to talk with you,” she says.

A brief flash of anxiety. Does that mean I messed up on something?

Take two flights of stairs down, make a quick turn, press my badge to the reader and wait for the beige emergency department doors to ponderously swing open.  Two turns down two more halls, right and right again. I slip into the computer room where we often type up our notes and slide onto a stool next to my resident, slightly breathless.

She swivels her chair to face me. “I have some bad news,” she says gently, her eyes meeting mine. “You know the code blue called this afternoon—”

Somehow, I know what she’s going to say, and everything instantly goes still inside me.

“It was for Ms. ——. She died.”

Silence inside me, the eye of a hurricane.

You died?

You were not supposed to die.

You were supposed to get better in the ICU and come back to our team and I was going to take care of you and you were going to get physical therapy and get stronger and go home and you

were

not

supposed

to

die

This wasn’t part of my plan.

You were alive yesterday.

“She might still be at her room… you could go see her if it would help you find closure,” my resident says.

I know I need that closure—I need to see you one more time. You were my patient for nine days. You were my responsibility. You still are my patient.

I’m biting my lip the whole way down the hall.

I’m not going to cry in the middle of the hospital.

I show up at the wrong ICU on the wrong floor and have to stop to look up your room number on the computer.  Backtracking down a floor, I try again.  This time I get it right.

As I approach your room, counting off the numbers on the walls, I see the curtain is drawn. The room looks deserted; no legs or shoes are visible beneath the fabric hem.

The early evening sunlight spills though the window and the curtain is a glowing sheet of sea-foam green. I peek around it before entering to see if you are still there. Your familiar gray hair spills onto the pillow as I catch sight of you.

I still clean my hands with the slippery foam sanitizer as I step into the quiet ICU room.  Habit, I suppose.

It is so still.

No beeping monitors, no waveform peaking and falling with the rhythm of your heart and the pace of your breaths. For the briefest moment, I entertain the thought that maybe you still are alive. Maybe they made a mistake, and you are just sleeping.

I’ve wakened you so many times over the past week, stirred you from sleep to check your heart and lungs and to see if you’re still having nausea. Maybe I can wake you again. You look so quiet, your eyes closed tight, lashes interlaced. You could be asleep.

But as I pause, I realize there is no breath in you.

That’s when I break down, standing alone beside your bed in the same white coat I’ve worn since I met you. I touch your forehead—your skin is smooth over your skull and not quite cold—and brush away your strands of hair.

I am still crying beside you when the nurses arrive to begin preparing your body, removing the stiff plastic tube protruding from between your lips, pulling off the array of cords and bandages we connected to you in our attempt to stave off the inevitability of death.

One of the nurses gives me a hug and hands me a couple of paper towels.

“She was my patient,” I say by way of explanation. “I’ve only been on wards for six weeks,” I add, trying to excuse myself.

I’m a novice still. I have not seen death like this before.

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Perhaps with time, I will stop crying so much when this happens, when time runs out and red bleeds to blue.  Perhaps I will grow to accept that the air we inhale at birth is only on loan and must one day be returned to the sky.

But you were my first.

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First Code

You were fine this morning.

No crackles in your lungs, no new murmurs in your heart, no grimace as I press into your abdomen, no redness around the catheter line protruding from beneath your clavicle. Nothing new to remark on as I pound away at the computer keys five minutes before I join my team for rounds. Alert and oriented times three, sleepy but able to be aroused.

I am in another room one floor down from yours, awkwardly swaddled in a contact precaution gown, when my resident’s phone beeps. She listens for a moment and then is tearing off her gown and heading for the door; she has to see you immediately. I rush after her, untangling myself from blue plastic sleeves and sweaty gloves.

I only realize I’m on the wrong floor when I see signs for the pediatric unit–not the one I’m looking for.  Turning, I scramble up the stairs.

The code blue is repeated overhead just as I round the corner, breaking into a half-run. People are already swarming around your room, spilling out of your open doorway and into the hall.  I squeeze past them, feeling like a minnow in the ocean.

You lie with your eyes closed, salt and pepper hair spilling over the pearlescent earrings you haven’t removed since you came here over a week ago. A doctor’s voice projects over the noise as he calls out his role as code leader. An anesthesiologist is already at the head of your bed, fitting you with a mask to feed you air.  The crash cart is already at bedside.

The names of medications are called out over the noise, approved, administered.

I squeeze your toes, pinching hard enough to feel your joints beneath my fingers, but you do not pull away like you should. Your skin is cool to my touch, and that chills me.

Move your legs. Move your legs, show me you can move. Squeeze my fingers. Can you hear me? Can you hear me?

Your heart rate is too slow.  We are pacing it, the muscles in your chest and abdomen jerking in rhythm as invisible tendrils of electricity seek out your heart, trying to capture its beat.

Open your eyes. Can you hear me?

Someone is asking for your pulse again, and I press my fingers into the crease where your leg joins your hip, seeking out the beat in your femoral artery.  No time to waste hunting for the smaller arteries I routinely check on pre-rounds.

Your heart is still pumping, tracing out peaks in fluorescent green on the monitor.  I can feel it and confirm it.

Another IV line. The needle slides beneath the skin over your wrist, the same wrist I took your pulse in this morning.  That all seems so long ago, that quiet time when I woke you up to ask you how you were feeling and to press my stethoscope to your skin.

I am in free-fall with no time to contemplate if I can fly.

The ICU will take over from here.  Everyone is unplugging monitors and switching cords and unlocking the bed’s brakes so they can roll you out of the doorway, oxygen tank and IV line in tow.  You are surrounded by a halo of monitors as the beeping bustling fades down the hall away from me.

My team and I regroup for rounds; we still have several patients to see.  The next one is mine, and I need to discuss the mass in his gastrointestinal tract.

I am fine, I tell myself.

I am fine.

 

I am not fine.

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Intention: Humanity

I’ve heard that at the beginning of a yoga session, people may set an intention to guide that period of time and help it translate into life as a whole.  While I haven’t formally done yoga before, I really like the idea of setting intentions.

In past years, I’ve picked a word or phrase to help guide the year in lieu of writing out a list of January resolutions (which I never seem to look at again anyways).  This year, I set an intention to be curious about life and each new experience it brings.  I was in the tentative first few weeks of a new relationship as 2016 rolled in, and my goal of embracing curiosity helped me to keep my heart open to the day-by-day unfolding of what has now become a beautiful part of my life.

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I’m finding that sometimes life can knock the wind out of you, and other times it can give you wings to fly.  The relationship that started with curiosity has been an incredibly wonderful instance of the latter.

Time has been moving quickly, and now I’m exactly 30 days away from starting my first clinical rotation.  The idea of setting an intention is coming up again, this time because I’ve spent a portion of the past two days thinking about what it means to be a compassionate medical caregiver.  I’ve also been spending a good deal of time pondering how on earth I’m going to manage being a clinical student.  I’m 26 now, and I can see that I’ve grown a lot (especially in the past year), but I’m still trying to figure out who I am.  So perhaps part of this is a cry from my soul to reaffirm who I am, to reconnect with the reasons I am in medicine.

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I’ve decided I want to set an official intention for my clinical years.  I already have one (hopefully) realistic goal for clinics: walk into my rotation on Day 1 with my head up, get along well with my team, learn from the mistakes I make, connect with the patients I’m assigned to follow, and walk out the door at the end of the day with my head still up.

As the lyrics go, chin up buttercup.

I also want to have a broader intention for my full 16 months of clerkships.  I think I’m starting to sort that out as I try to chart the courses of the rivers draining into the cognitive and emotional depths of who I am.  What are the reasons at the core of why I want to be a physician?  Why am I doing this?  What is going to get me out of bed every day for the next several decades?

It reminds me of when I was in the throes of applying to medical school several years ago, asking the same question–why medicine?–as I agonized over my AMCAS application form and the ensuing secondary essay questions. I actually went back to some of those essays today, blowing dust from the computer files.  It was like opening a time capsule and reliving the tense anticipation of applying to medical school: waiting for a secondary application invitation…waiting for an interview…waiting on pins-and-needles for an acceptance.

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Are my reasons still the same as they were when I was a 22-year old student fresh out of undergrad?  I believe they are, at their core, although they’ve evolved and grown with the passage of time.

Sitting down with my journal, I parsed out four reasons why I am in medicine:

  1. When I’m able to bring a moment of compassionate connection into a hospital room or patient interaction, I feel like my soul has been nourished (and hope the feeling is mutual with the person I’ve connected with).
  2. I enjoy being able to share information; it’s gratifying and gives me the sense that I’m contributing something to other’s lives.
  3. Medicine is full of stories if I stop to pay attention and listen to them.  I want to learn people’s stories and give them the space to share them, if they want to.  This ties in to reason #1.
  4. Learning engages my mind and makes me feel incredibly happy and alive.  The medical field is one of lifelong learning.  This leads to reason #2.

Ultimately, I found that everything can be reduced to the following: (1) I find compassionate connection with other humans to be deeply satisfying and meaningful and (2) I enjoy the personal growth and sense of contribution to society that comes from learning new information, thinking critically, and teaching others.

So these are the bare-bones reasons of why I am in medicine.  Medicine is an environment where compassion and information-sharing can be practiced on a daily basis, and it positions me at a time point in peoples’ lives where this is especially needed.  I personally found, when undergoing a minor (but painful) medical procedure recently, the only two things I cared about were whether I trusted my provider (i.e. whether I felt he cared about and respected me as a person) and whether he was competent (i.e. could do everything efficiency and effectively).  I know everyone has unique priorities when interacting with the medical team, but I feel that trust and competency would likely show up as common themes.  And those are words I’d like to be able to be applied to me.

I actually feel a bit vulnerable sharing all this on my blog, because it gets down to why I’m doing what I’m doing.  And of course, there’s always the question, is it enough?  Are my reasons good enough?  And am I?  I have to believe that I am, and that I can do this.  I may not become the absolute best at what I do, but I will try my absolute best.

So my intention for the next year and a half?  To be compassionate, to pay attention to people’s stories, to accept that I’ll make mistakes, and to do what I can to learn from them.

In a word?

Humanity.

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Just One Step

Attempting a new endeavor sometimes leaves me feeling like I’m standing in my hiking boots at the base of a slope, debating whether there are enough handholds to scramble up without falling and breaking my leg.  Or my neck.  Whether it’s writing papers, doing research, or starting a new phase of medical school, it’s often daunting to summon the internal energy needed to begin.

I’m beginning to realize, however, that my ability to gauge the energy required to take a particular action is not always so accurate.  I enjoy meeting goals, and I have some long-term ones in place as guiding stars for my life journey.  It’s like picking a distant mountain peak and saying, I am going to trek from here to there.  Doing so may keep me from getting completely off-course, but if I think that I need to have enough energy to make the 100-mile hike in a single shot, I’m not likely to ever get out the door.

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In reality, I would only need to have enough energy to make it to my first campsite.  I wouldn’t presume to have enough stamina to make it to the end without pausing, and if I felt beaten at the thought of doing so I wouldn’t blame myself.  But I certainly do that with less tangible journeys.  If need to start something and feel overwhelmed at the thought of carrying it to completion, I can respond to myself in any number of ways and they usually aren’t positive.  It’s something I’m trying to become more aware of, and perhaps this post is, in its own way, a part of sorting this out.

Being more realistic certainly would help.  If I realize that I only need enough internal power to get started–to create the ignition spark–it will help keep me keep the big picture in mind without feeling daunted by its implications.  One strategy I’ve used is committing to a first step that is so small, it would be ridiculous not to do it.  Need to write an email I’ve been putting off because it feels like too much to do?  Just log into my computer and open my inbox, and that is all.  No expectations beyond than that–if I get into my inbox, I’ve accomplished my goal.

By beginning with something small like that, I’m able to overcome the inertia of starting because I narrow my focus to what I need for the step right in front of me.  I’m no longer trying to bully myself into walking for miles; I’m just lifting one foot off the ground. I’m surprised each time I do this by how well it works–usually I end up getting far more accomplished than I had planned.

So far, I’ve applied this strategy mostly for writing-related things like papers or emails.  We all face more in life than emails, however.  I have a few landmark peaks in the distance, and the highest one would be realizing my dream to become a physician-writer.  That’s what I’m aiming for: to be someone who cares for the body without forgetting that it contains the human spirit.  It will be a lifelong journey, one that will hopefully include matching into residency, graduating from medical school, finishing my post-graduate training and finding my place in the world as an attending physician.  Right now, I’m just trying to figure out how I’m going to make it through clinics.  It feels overwhelming to think about right now, but I’m going to try taking the one–step approach to starting my rotations this April.

Review how to take a medical history.  One step.

Find one video to practice the eye movements in the neurological exam.  One step.

Watch the video.  One step.

Sign up to volunteer again at one of Stanford’s free clinics.  One step.

They’re little steps, and they don’t seem like much, but they’ll keep me from postponing everything until I feel ready.  Because, honestly, I’ll never feel completely ready.

And one day near the end of April, I’ll take a deep breath and remember to keep my head up.  And I’ll take one step that will carry my over the threshold into my clinical years.

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Swim

I survived boards!

To sum it up as concisely as possible, preparing for my Step 1 exam was like diving into the ocean, and I ended up going for a longer swim than I anticipated.  Long story short, I took boards in September instead of during the summer, which is partly why I’ve been away from blogging for so long.

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I also wasn’t sure where to start writing again.  Which is why this post if being written in December, long past the reasonable timeframe for using my I’M-STUDYING-FOR-BOARDS-AND-CAN’T-WRITE excusplanation (my latest neologism: a cross between an excuse and an explanation.  I coined it specifically for this post). 🙂

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Since I’ve taken time off for research before starting my clinical rotations, I had the flexibility to extend my study period, and that’s what I ultimately did.  For some reason, saying I took additional time almost feels like a confession.  I suppose part of me feels a little guilty for having the opportunity to study longer (other med students may not have schedules that are so accommodating), and part of me wonders if I should’ve felt ready sooner.  However, a friend passed on some advice from his sister (a medical resident) that helped to ease my decision: take the time you need, and take the exam when you feel ready.  It’s okay not to rush it.

I think it’s unlikely that any student ever feels completely ready for boards, but at least it’s possible to feel that we’ve done everything we can with the time and resources each of us have.  For me, this was the right choice even if it did mean doing a lot of swimming and diving (figuratively speaking, of course, since my real-life water skills fall into the category of barely-good-enough-to-not-drown).

I finally came up for air after my full day at the Prometric testing center, only to realize that life was waiting for me above water like a clamoring flock of seagulls.  To be honest, part of me wanted to just go back into the water and turn into a mermaid.  Over the last several years, the life of studying (for college, the MCAT, med school, and finally Step 1) has become a familiar ebb and flow around me, and it’s comfortable in its own odd way.

Well, I guess it’s time to get pushed out of that comfort zone.  I’m done with my preclinical years, and there will be no more quarters to define the pace of my life, or daily lectures and midterms, or labs where curiously-shaped cells make faces at me through the microscope lens.

Now I’m gearing up for my clinical years.  I still have a few months to prepare myself, but it’s daunting for me to think about functioning as part of the medical team.  I’ve had opportunities to participate with patients throughout the first two years of medical school, but it was always briefly, as if our interaction were a haiku of three lines instead of an essay of three hundred.  I’ll still have supervision and guidance, but my responsibilities and expectations will be greater, including the expectations I place upon myself.

One thing I’ve been thinking about is how to connect with people on a personal level, because that is important to me.  Sometimes medicine can feel very mechanized, and with the pressures of being a clinical student, I can see myself losing sight of the more ephemeral aspects–the very things that make this pursuit worthwhile.  I’m worried that in trying to navigate wards and find my way around, I’ll lose some of myself.

And maybe I will for a little while, as I try to orient to the life of a clinical student with its early hours (on some rotations) or intense schedules (on others).  But I also have faith that I’ll be able to find myself again if I do.  Beneath my white coat (which still feels like a costume when I wear it), I’m an artist and a writer.  That, I think, will help me find my way home to what I care about: the story, the healing art of listening, the release of telling, the feeling of having been seen and understood.  That’s my hope, at least.

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I was surprised by a rain shower today as I left a meeting at the hospital.  I found some leaves with pearlescent water droplets reflecting the diffuse light, and the constellation of spheres made me think of a universe in miniature.  Maybe this is what souls look like, with droplets of memory and experience coalescing to reflect the light and shadow of who we are inside?

My imagination is getting the best of me.

But I like to think that if each droplet were a little world of its own, and if I were as small as an ant, I’d be able to see and appreciate each one.  And when we meet people, that’s really what we do, isn’t it?

Each of us has our oceans, and each of us is a universe of our own.

Halewright

One Test to rule them all, One Test to define them; One Test to bring them all and into knowledge bind them

Like Bilbo and Frodo did in their times, I am about to embark on an adventure beyond the borders of all I have known.  (Did I actually just compare medical school to the Shire?)  This morning (since this post has taken me past midnight to write), I’ll begin my two-month journey of studying for the USMLE Step 1–an eight-hour long exam which will test all the medical knowledge I’ve learned in the past two years of medical school.  To speak with a bit of poetic license, it is the exam which will determine my destiny.  It is the One Test to rule all tests, the score to end all scores, for the grade I receive on it will influence how desirable of an applicant I am when applying for residency in a few years.

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Thankfully, my future is (in reality) influenced by more than just the score I receive on this test.  Nevertheless, the Step 1 is a very important exam, and I’ll be devoting about 10 solid hours a day to studying for it.  Factor in time for meals, exercise, and the ebb and flow of natural life, and I’ll be starting my days around 6 AM and ending around 9 PM.  As intense as this will be, I’m excited about this block of time to study and really see how everything fits together.  I hope that I will be like a hawk soaring high above the landscape, taking in a panoramic view of everything that is going on so I can hone in on details and dive for deeper understanding.

I like to think of funny things like that.  It makes life more interesting to me. 🙂

Levity aside, it’s going to be an intense two months.  For me, a bright spot is that I’ll be studying with a very close friend, and we’ll be sharing the journey together.  As the old proverb says, “a sorrow shared is a sorrow halved; a joy shared is a joy doubled.”  I’m looking forward to teaming up with my friend to make deeper connections with the material as we grow into the doctors we dream of becoming.

That dream, however, is something I’ve been thinking about recently.

Very recently, for a few bleak weeks, I lost sight of who I wanted to be in medicine.  After nearly two years of studying and training, I felt that my path had led me into a seeping bank of fog.  I couldn’t see my way forward into the life-giving occupation I had imagined when I applied to medical school, and I began to feel increasingly lost.

For several agonizing days, I felt that I had lost my purpose.  After pushing myself in my studies for months while simultaneously struggling with the fact that life goes on even when you don’t feel like you have the reserves to deal with it, I was beginning to burn out.  It’s something that happens, and it’s a real thing.  I don’t think I burned out all the way, but reflecting on the past months, I see that I was beginning to.  I’m okay with admitting that because I know it happens to others too, and I hope that we can begin to dialogue about it more since doing so will help us, our colleagues and our future patients.  It will validate our own human experience.

It’s okay to be worn out sometimes.

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What helped me re-engage with my purpose was a recent encounter where I didn’t feel listened to.  It was a situation when I wanted the comfort of being heard, and I instead felt more like an avatar for my electronic medical record.  The interaction was relatively brief, but served as the wind to blow away the fog I had been muddling through.  I realized at a visceral level that, as a medical professional, I want to help my patients feel heard.  Even if they don’t always want to open up to me, I want each person to know they have had the opportunity to talk and be heard.

Yesterday, I watched a fantastic TED Talk by Dave Isay called “Everyone around you has a story the world needs to hear.”  Dave Isay is the founder of StoryCorps, which started as a recording booth at the Grand Central Terminal in New York to allow anyone to record an interview with another person.  In his talk, he discussed how empowering and validating it can be for people to tell their stories.

Of recording interviews as a radio broadcaster, he said “Over the next 15 years, I made many more radio documentaries, working to shine a light on people who are rarely heard from in the media. Over and over again, I’d see how this simple act of being interviewed could mean so much to people, particularly those who had been told that their stories didn’t matter. I could literally see people’s back straighten as they started to speak into the microphone.” (TED)

This was the other light that helped me begin reconnecting with my meaning in medicine.  I want something more than the technical skills and knowledge can give me; I want to be a healer through stories.  I want to be an artist who creates a space for people to speak themselves into existence.  Going back to the creation account in Genesis, words are what brought substance out of the void.  I think this is what can happen in our lives today when we pay attention to what people have to say–when we pay attention to their experience and their feelings and thoughts and what it means for them to be a human and a patient.

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I’m finding my way again, one step at a time.  So as I study the names of medications like ticlopidine and ticagrelor or diseases like loa loa and acute sclerosing glomerulonephritis, I’m also paving the way for stories to be told.

Since I love words and neologisms, here’s a word I’ve crafted to describe what I want to be:

Halewright (noun)

From Old English hǣlu-whyrta, corresponding to hale (health) + wright (builder, creator)

Someone who aids in bringing healing and wholeness to other humans through the act of listening to their stories.

And so the journey continues…

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Patient-Physician

Yesterday, I performed my first rectal exam.

We began our Project Prepare sessions this week, which is a training program to teach us how to perform the male and female genitourinary exams in a sensitive and skilled manner. This was a big milestone for me, as I’ve been anticipating this day with some apprehension for about a year now. I remember one of my Practice of Medicine TA’s telling me about Project Prepare when he was a student in it last fall, and although I knew I would have my own turn in the program this year, time flew by faster than I expected.

So here I was on a Wednesday afternoon, about to learn how to perform the male breast, GU and rectal exam.

I had been told that the educators in the program are fantastic teachers, but I hadn’t realized just how amazing they would be until I met my trainer. The Project Prepare educators are people who have dedicated themselves to teaching these exams on their own bodies, and they are truly incredible. Because of them, what could have been a very discomforting experience ended up being one of the most amazing educational moments I’ve had yet. (Here is a San Francisco Chronicle article from 2003 on Project Prepare.)

I entered the simulated exam room with my three classmates, feeling as on-edge as if I was the one about to get a GU exam instead of the one learning to give it. Our instructor quickly set me at ease with his warm and genuine manner, though, as he explained that he would be modeling for us the same sort of communication we would be using with our future patients.

It really was a whole-hearted experience for me.  Here, I was the vulnerable one, uncertain about what was about to happen, while he was the calm one with years of experience. The dynamics were immediately appreciable; his approach to the encounter made all the difference.

That afternoon, I felt that I was the patient seeing a doctor, rather than a medical student seeing a patient. Now that I’ve been in medical school for a year, I’ve begun seeing more distinction between the identities within me—I am both patient and physician-student. At times, I feel a tension between these pieces of myself.   I believe this tension is not a bad thing, for it reveals an effort to maintain multiple perspectives, but it makes me think. In some sense, we all have this tension within us, although it may be defined by different parameters for different people. It is the same tension within the mother who is also an employee, the son who is also a husband, and the sister who is also a student.

This multifaceted dynamic within me is something that I have to accept as part of living within two worlds—or rather, within multiple hemispheres of the sphere of humanity. Even as I write this, I am a bit hesitant to admit this. This isn’t a struggle that I wanted to have, but it is one that I expected. Our Project Prepare session threw it into new light for me, and it has made me think of it again.

As I sat across from the one who was both my patient and teacher, I keenly felt the importance of bringing compassion and warmth into an encounter. If I can be as help my patients relax as well as my teacher helped me to, I will be very satisfied.

Over the course of the following three hours, we learned how to examine the breast tissue and the surrounding lymph nodes (although breast cancer is rare in males, it can still occur and is essential to screen for). Step by step, we practiced the genital examination and learned how to properly word our dialogue to minimize unease or apprehension. We checked for inguinal hernias and learned how to properly set up for the rectal exam.

As we neared the end of the session, it was my turn to do the digital rectal exam. I had already filed the nail on my dominant index finger to a down hairline crescent of white (we were provided with nail clippers and emery boards earlier in the session to get our nails as short and smooth as possible), and so I coated my gloved finger with lubricant up to the main knuckle.

The rectal exam was actually the most amazing part of the experience for me. Using the pad of my fingertip, I defined the contours of the prostate gland as I swept my finger across it, feeling for any abnormal textures or lumps. I had a sense of awe at examining that which I could not see, like trying to read Braille written within our bodies.

Like trying to find shapes in the spaces between the clouds when looking at the sky.

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Afternoon sunlight and fall foliage at LKSC

I found it a bit funny how the day ended for me—I was participating in a poetry reading at the Cantor Center’s new Anderson Collection that evening, so I went almost straight from practicing the genitourinary exam to reading poetry at the event. It was a wonderful time; members of the Pegasus Physician Writers at Stanford shared original pieces of poetry inspired by the art collection, and the St. Lawrence String Quartet gave a stirring performance of Benjamin Britten’s Second String Quartet in Three Movements.

In a way, this odd juxtaposition of prostates and poetry seemed almost fitting to me. In Project Prepare, I looked again at my identity as a medical student within the greater world, which I relate to in part through writing. Creative writing is what helps me process the struggles of life, and I like to think that it will help me to better relate to my patients since it reminds me that everyone’s life is a story. We all have backstories, and we are all read as sentences and paragraphs, sometimes even as chapters.

Oftentimes, there are multiple storylines that run through our lives.

I am a patient.

I am a student-doctor.

I am human.

Halloween 2014

I biked to class today in a green and gold gown, trying to keep its flowing sleeves tucked into my backpack straps so they wouldn’t fly out like streamers on either side. I hadn’t dressed up for Halloween since I was a young child, and although I felt a thrill of excitement at doing so once again, I didn’t want to draw much more attention to myself than I already did pedaling down the rain-washed paths in medieval costume.

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I had spent the evening before scrambling to hem my dress that it wouldn’t bunch up around my feet like an accordion; as I’m on the shorter side, I wasn’t surprised when my costume arrived with the skirt nine inches too long. After a last-minute trip to the fabric store to buy needles, and thread, I set to work, thankful that my mom had taught me how to hem by hand when I was younger (as my jeans and slacks never seemed to be the right length either, I had a decent amount of hemming practice growing up).

Our lecture on thyroid cancer was made memorable by a bunch of bananas sitting in front of me…

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…and I had fun seeing the various costumed characters scattered throughout the medical school. None of us dressed up as doctors, though; it’s as if there’s an unspoken agreement among medical students that wearing a white coat no longer counts as a Halloween costume.

Truth be told, the white coat still feels like a costume at times.

Some costumes you grow out of…others you grow into.

After snatching an hour of studying post-class, several of us went to the Lucile Packard Children’s Hospital (LPCH) to help give candy to the parade of children trick-or-treating in its halls. Every Halloween, the children’s hospital transforms into a kaleidoscope of candy-filled tables, brightly costumed children, and creatively dressed staff.

When I reached the children’s hospital, it was like stepping into the pages of a book. I glimpsed Glinda the Good Witch’s billowing pink skirts as we headed towards the stairs and caught sight of bone-printed socks peeking out from someone’s blue scrubs. Children swarmed the halls, dressed as ninjas and fairies, pirates and skeletons, superheroes, princesses, and animals. Not surprisingly, there were many girls in blue gowns with white braids, snowflakes and sparkles.

Some of my favorite moments were seeing the little babies—the ones only a few months old—cradled in their parents’ arms. These moments were both bitter and sweet, but the sweetness of seeing the little ones in their tiny costumes and sensing their parents’ love for them outweighed the pang. For this moment, at least, these kids could be kids.

As things began to wind down, my friends decided to make a last-minute stop at the Haunted House on the first floor. I tagged along and brought up the rear as we slipped through a door into a black-lined room swirling with eerie lights and little ghosts swooping around the ceiling. I have no idea what purpose this room actually serves in everyday life, but at this moment it was a dark cavern echoing with ghostly sounds. A ghoul slipped from the wrinkled walls behind me, and I squeezed closer to my classmates. LPCH had done well.

Looking back, I think what struck me most about today was seeing how much life filled the children’s hospital this afternoon. To me, it really was like stepping through a doorway into a magical realm. All the effort the staff and volunteers put into making this day as exciting and normal as possible for the children touched me.

It also reminded me how many people are living extraordinary lives. To the parents of the children here, to the children whose lives are anything but ordinary, I am in awe of you.

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Happy Halloween!

Healer’s Art

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I wanted to share a picture I drew this week.  It’s based off of a drawing I did as part of my first class in Healer’s Art, an elective founded by Dr. Rachel Naomi Remen at UCSF and now taught at medical schools across the country.

As some background, the purpose of this course is to help medical students clarify and cultivate their calling as physicians and recapture the heart of medicine.  It’s described in our course catalog as follows:

“For pre-clinical and clinical medical students.  Explores core dimensions of meaning, service and healing exemplified by the outstanding physician. Goals are to develop and preserve personal values such as service, harmlessness, compassion, altruism, self care, integrity, equality, justice, respect, and nurturing wholeness; to develop the compassionate listening skill that is foundational for clinical practice and for finding personal meaning and satisfaction; and to clarify a commitment to medicine as one’s life’s work.”

Healer’s Art is taught each fall at Stanford and this quarter came at a perfect time for me, as I am facing some questions of purpose and direction as I move forward into second year.  I know who I want to be, and I at least have an idea of where I want to go within medicine, but the questions are still there.  I suspect nearly everyone faces them and that they never truly disappear.  I’m okay with that, though, because the questions keep me on my toes and push me to explore more deeply why I do what I do.

In our first class, we were each given a little bag of crayons–tangy, waxy, new.  The assignment was simple yet complex: think of something which you value about yourself and don’t want to lose during your journey in medicine, and draw a picture or symbol to represent it.

And so, with my classmates, I drew.  Some of us knelt on the floor while others sat by tables, each of us working to pictorially capture flames too important to extinguish.  I felt like a kid again as I bent over my big sheet of paper with my handful of fresh crayons.  It had been years since I really used crayons.

After several quiet minutes of sketching, we broke into our small groups and scattered throughout the building to settle down and discuss the heart of our work.  Words like “trust” and “resilience” and “love” emerged, along with stories of past journeys, current experiences, and future hopes.

My own picture sprang from a part of me that has faded somewhat over the course of my collage and now medical school years.  As a child, I loved to create stories and imagine fantastic odysseys, and one of my favorite pastimes was writing fiction. I loved to imagine things that could only live in the mind, like horses made of wind that, if touched, felt like streams of cool air blown from a fan.  In the past years, however, my mind hasn’t had as much time to wander such unknown paths.  Rather, it’s travelled the paths of biochemical mechanisms and lines of reasoning, and my writing has been reincarnated as reflective blogging and poetry.  And, while I love these paths, part of me misses the imaginative adventures of childhood.

As I reflected in the quiet moment prior to starting this drawing, a picture came to mind of me as a physician sitting beside a patient’s bed–a child’s bed–telling stories to help chase away the foreign loneliness of the hospital room.  To provide a portal to another world, a wall-less world of color and fantastic creatures.  To heal with imagination.

I shared some of this with my small group, and they shared in turn that the theme running through this picture seemed to be one of hope.  As I thought about it some more, I realized that in a way, it was.

Imagine hope.

For me, imagining hope means being able to see without my eyes–to look beyond time and space and see who the person before me really is.  The child that they were, the journeys that brought them here, the heartbeat beneath the gown.

Maybe I don’t have much time for imagining winged horses anymore, but just perhaps I can imagine the wings of the human soul.

The Color of Hope

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This evening, with the dusky sunlight suffusing the air with gold and pearl, I stopped to snap photos of some autumn leaves.

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I love autumn.  It’s my favorite set of months, and each time I remember that it’s fall now I’m filled with anticipation of Thanksgiving, family time and the coming holidays.  I adore pumpkin spices, warm cinnamon, fresh apples, steaming lattes and crisp evenings.  And I love the colors of the season.

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It’s splendid to watch the trees change color.  Green turns to red turns to brown and gray, like a sunset in slow motion fading to night.

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This summer, though, I watched with dismay as some of the pine trees on campus faded to brown.  I don’t know why this happened.  Perhaps it has something to do with the drought we’ve been experiencing, but that doesn’t explain why so many other trees survived.  I’m guessing it might have been an insect infestation or disease of some sort, but I really don’t know.

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I don’t like this kind of color change, this dulling to rust and brown.  Evergreens weren’t meant to be brown like this.

It’s not at all like fall.  The brilliant red leaves of the liquid amber can fade to auburn, and the flaming bracts of the trees outside my window can dull to a muddied gray, but that won’t stir the same vague sense of loss that these dying pines awaken in me.  There is something lonely about a lifeless pine.  Perhaps it is because I grew up where pines stretch to brush the azure sky, singing in the wind.  Or perhaps it is because I know it will be at least half a century before a tree this thick-trunked and tall stands in this place again.

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Fallen pine needles, like the strains of a song fading into silence.

It makes me wonder…why is it that the same series of color changes can stir anticipation and joy in one situation, and sadness in another?

As I thought about this, I realized it’s because with the autumn trees, I know the time of leafless branches will be followed again by spring.  It’s not permanent, while these dead pines are.  They won’t bud again next year.

But the other trees will.

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And so fall colors are colors of hope.

I paused to catch the simple yin and yang of a feather against a fallen leaf, the soft, gray down of a mourning dove’s plume against the crackling backdrop of earthbound foliage.  The similarity of their form is striking, perhaps further highlighting the sharp contrast of their textures.

It’s like life.  The dichotomy of what we experience–the good against the bad–ultimately helps us to more fully recognize and appreciate the good.

I suppose this is why we do what we do in medicine.  Our work is built upon hope–the hope of something good on the other side of suffering, whether that takes the form of a cure or the giving of comfort.  As I delve further into my life as a second-year, I’m beginning to realize everything is deeper, bigger, and more complicated than I had imagined.  I spent some days these past few weeks shadowing in the ICU, and sometimes I’m left wondering how I fit into this intricate network of human suffering and joy.  What can I give?

I can be a hope-bearer.  I can help people find hope.  Maybe it’s not the hope of everything turning out how we wanted or planned, but rather the hope that springs from knowing there are people who truly care and love.  I still have a lot to learn about this, but this is a beginning.

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Red.

This is the loss of green.  The loss of the fresh, living spring and the vibrant, bursting summer.  But it is still beautiful, so beautiful.  I can love the fall because I know the trees will bud again, and this hope frees me to fully embrace the spicy, glorious, flame-filled wonder of this season.

This is the color of hope.