Med School Musings

Drawing the Curtains

As we all enter residency, we are thinking of how we are going to be the best doctor we can be in our respective specialty. Regardless of the field we are going into, I believe we all have common goals: to be compassionate, patient-centered, culturally sensitive, and evidence-based. These are the qualities we will all be constantly working on throughout the rest of our careers. Despite these noble goals, I believe there is one topic incredibly important to medicine we neglect. That topic is death and dying. Thus while I will strive to achieve the common goals of being compassionate, etc., I hope to reach a point in my career as a physician where I truly understand and am sensitive to the matters of death and bereavement.

From the outsiders’ point of views, patients see physicians as people who are regularly in contact with death. Doctors give the prognosis of death, they announce the time of death, and they heartbreakingly relay the news to family and friends. Thus shouldn’t doctors be most comfortable with death? Shouldn’t physicians know how to deal with those who are grieving and those who are dying? Wrong. In fact, most doctors are extremely uncomfortable with death and are at lost on what to do to help patients through their dying processes or to console family members and friends.

“I had insinuated my hand into that mysterious nexus of stars and fate and destiny, and I had reduced that great passing of life into an arbitrarily calculated moment in time.” –Dr. Chen on the practice of announcing time of death.

Why do we suck at this? After dealing and being in the presence of death multiple times over years, physicians should have developed some sort of method to handle this heavy part of being in medicine. Unfortunately for most physicians, the method has been to become unfeeling, detached, or awkward.

Who can blame them? Dealing with death is hard. Hard does not even begin to describe it. Regardless of the Kubler-Ross stages we are taught, every person deals with death differently – every family does. The ways people approach death and grief depend on family dynamics, culture, personality, and past history. The process is not the same for any two people.

Many years ago in my death and dying class in undergrad, we had to pick a death/bereavement topic and write a paper on it. During that time, I had some recent developments in my life, and I saw my family go through a personal, heartbreaking loss and then something else I’ve never seen them go through before. I’ll spare the details, but the memories I have of those moments of black, white, kneeling, despair, and anger-anger-anger-anger drove me to look into how the Khmer Rouge affected modern-day Khmers’ grieving processes.

For context, my parents and their brothers and sisters fled Cambodia in the 70’s to America because of the Khmer Rouge. Cambodians went through a horrific, terrible time between the years of 1975-1979. The civil war/genocide was a nightmarish time of bodies left stranded on the roads, humans violently killed, and mass graves left to rot. By the end of the war, around one to two million people died; about 20% of Cambodia’s population. There was no way to bury a family member, and many surviving Cambodians were left not knowing where the bodies of their deceased family members were, and not knowing how to properly bury and grieve for them.

Grief was interrupted for many of them and left unresolved. Many never had any closure and many felt guilty over not being able to give their family members a proper burial. Then years later, the mannerisms of Cambodians changed; they became more secretive and closed off. Articles stated that as they became more closed off, Khmer families began to approach death with anger and resentment. It was a way of coping with grief adopted from the war where many blamed deaths on Pol Pot (the leader of the genocide).

What’s my point of bringing this up? Just to show that death and bereavement is complicated with each person.  Each human has a history that a doctor most likely won’t be aware of, and thus there is already a lack of understanding from the start. It’s a puzzle, a never ending dark maze that physicians get dropped into – they don’t know the beginning or the end.

So how do we, as future doctors, act in these situations? How do we make our patients the most comfortable when they are in a painful area no human should be at?

There is no right answer.

But there are some good answers.

The quote I used above is from one of my favorite books called Final Exam: A Surgeon’s Reflections on Mortality by Pauline W. Chen. As a brilliant, compassionate transplant surgeon, Dr. Chen reflects on her experiences and from them, I take away many messages but one story stands out particularly to me.

While still a resident, Dr. Chen said that she usually found herself pulling away during the last minutes of a patient’s life, making herself busy while waiting for her patient to die all the while watching family members move in and out of the rooms with teary faces and bunched up tissues. One night, however, as she left the room again of another dying patient, she watched as her attending resident drew the curtains around himself and the wife and the dying husband. Curious, she peeked into the room to see the attending leading the wife to the bedside and then slowly whispering something to her as she cried. Those words, as she found out later, were words explaining how life leaves the body, giving the patient a peaceful death. Days later, she received a letter from the wife thanking the team for ensuring her husband’s peaceful death. Dr. Chen described it as an experience that showed her a new world of medicine; it showed her that she could do more as a physician than just cure or diagnose. Ever since then, she states that she’s never left the dying and the family alone. She drew the curtains around all of them, spoke to the family slowly, and touched and hugged family members.

Dealing with this will never be easy, but I pray, as a future doctor, that I will have moments like this that unveils to me a different way to approach death. A different way to provide something to patients when I have nothing good left to give. Let us always remember to not run from death, but to take it on, and to morph it into something compassionate and dignified. This will be one of my main pursuits in becoming a physician.

“By evading death, we miss one of the best opportunities for us to learn how “to doctor”, because dealing with the dying allows us to nurture our best humanistic tendencies.” – Dr. Chen

And that says it all.

-M

Education, Med School Musings, Uncategorized

Dear Third Year Student

Dear upcoming third year student who must be so incredibly thrilled to be done with the Kreb Cycle,

Welcome to the year of being ‘The Wallflower’! Now bear with me before turning the page and shaking your head in disbelief. Dictionaries define ‘wallflower’ as someone who is shy and thus blends into the sidelines. I think the word, if you take out shy, defines third year in a nutshell. You’re about to embark on a year of switching rotations. A journey of constantly feeling uneasy and then comfortable only to have to fall back into that uneasy emotion in a matter of days or weeks. You’re going to pass through every emotion in the book. The bad ones (nervousness, awkwardness, discomfort, confusion, pity, anger, fatigue, sadness, apathy, helplessness, jadedness), but I promise, also the good ones (pride, awe, wonder, curious, comfortable, confident, decisive, empathy, sympathy, appreciative, contemplative, joy, happiness)!

Now you must be thinking, ‘What a depressing letter to read’, but I urge you to forge ahead.  Third year means you’re the least experienced of the medical team. You’re going to have plenty of moments where you don’t feel like you’re helping or that you’re actually more of a burden. Residents and attendings will discuss plans at rapid fire, and you’ll feel lost to the terminology, trying desperately to figure out when is the right time to ask a question or rapidly browsing through UpToDate to figure out what exactly is happening with a patient. As the patient workload increases, you’ll start to feel like someone just merging with the sidelines. A wallflower.

I write this letter to remind you all that when you’re starting to feel like that, please remember that this is not a bad thing. Your duty as the third year medical student is to not come up with drug dosages or perfect solutions to a patient’s decompensating heart failure or treatment of ovarian cancer. You are there to learn. To be constantly curious. To observe. As the wallflower, you get a special advantage over residents and attendings. You have more time with patients and more time with your thoughts. So use that time wisely, open your eyes and ears, reflect, and truly take in your surroundings.

On emergency medicine, understand how swiftly death and disability can fall upon humans and build compassion for those patients lost in the frenzied haze of white walls and numerous diagnostic tests. On neurology, appreciate how intricate the human brain is but also understand that complex neuro terms fall on deaf ears of patients. On surgery, acknowledge every kind of fear people have going under the knife and be in awe of how intricate the human body is. On medicine, think beyond the heart failure and cirrhosis to what living and social situations your patients will encounter post-hospital. On pediatrics, embrace your inner child, revel in the innocence of babies, and step into the shoes of a worried mother or father. On family medicine, truly wonder why a patient is not progressing in care – transportation, culture, unsafe neighborhoods. On OB/GYN, be awed by the miracle of childbirth and learn to be gentle with sensitive matters of unwanted pregnancies, miscarriages, and vaginal bleeding. On psychiatry, draw up your empathy and do not let their illnesses define who they are.

Appreciate the residents and the attendings. Be in awe of how they juggle their patients and their home lives. Thank those who take time out of their busy hands to teach you. Be grateful to the nurses, PAs, NPs, techs, and support staff who guide you in the right direction. Welcome the caffeine and infrequent extra sleep hours. Hold the patients’ hands that want to be held. Offer a tissue to those who are crying and return the hugs rarely given by patients. Smile. Make eye contact. Communicate. Listen.

This year will be the game changer in your medical career. You’re going to learn what specialty is right for you, and you’re going to learn so much about medicine and human nature in general. Just remember to take with you the lessons you’ve gathered and observed and let it guide your future practice.

‘The best way to find yourself is to lose yourself in the service of others’ – Mahatma Gandhi

Enjoy third year!!!

Best,

M

(I write this as I come to the end of my fourth year of medical school as a piece for the upcoming third year students at my med school as well as a reflection on what MS3 was like)

Med School Musings, Travel - Asia, Travel - Indonesia

The Other Side of Substance Use

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In our last week of neurology/psychiatry module, we covered substance use disorders. The lectures went from 8am to 12pm and they focused on the symptoms of intoxication, symptoms of withdrawal, and treatments. It was rather dry, and while the professors tried to do their best to have us understand that substance use is a disease, the message fell short.

In that cold classroom with my addiction notes in front of me, I was transported back to the coolness of Bandung and the tables outside the treatment center where I would hang out and share coffee with the “druggies”.

I will admit that the area of substance use and addiction was a topic I was very unfamiliar with before I signed onto the Indonesia Initiative project. For those of you just reading this, I worked with Rumah Cemara (RC) this previous summer. RC is a community-based organization that focuses on fighting stigma against HIV/AIDS and substance use. I spent my summer interviewing and learning the stories of the clients at the treatment center. In lack of better terms, my time there changed the way I view this population.

It’s so easy for society, whether it’s Indonesia or America, to take a look at these drug-users and immediately judge them and cast them aside. These kind of reactions are some of the reasons why many drug users relapse again and again. Society does not accept them, and they are labeled as outcasts. They are seen as people who did this to themselves. They walk around experiencing discrimination everywhere – family, community, and the workplace.

Regardless of the motives behind their initial drug using, these “druggies” are still humans. Addiction is a disease characterized by constant relapse and horrific withdrawal symptoms that can really push the human body to the limit. Many of them struggle with mental illness and mood disorders. A majority of them lack a home, a support system, money, and love. So tell me, if you were in those circumstances, wouldn’t it be so easy to pick up drugs again?

I write this specific blog just to bring some more emotion and shed some humanity onto the dry substance use lectures we receive in medical school. These “druggies” made me laugh and smile and so welcomed. They had amazing stories of trials and hope. They all had a fighting spirit that was so admirable.

Now many would argue with me that not all drug users are like that – motivated and hopeful – and I agree, but it does not give us the right to stand from afar and judge and pretend like we know their background stories. Cast them off as hopeless and not worth the time.

My time and work with RC has not only opened my eyes to the world of substance use, but it has given me a newfound respect for this population. I hope to be able to carry this demeanor into the clinical setting when I rotate through psychiatry and beyond the grounds of medical school.

And I challenge my friends to do the same. Don’t just walk out of a room with a substance use patient shaking your head. Take the time to truly ask how they are. Shed a little compassion.

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Once again, I thank Rumah Cemara and my amazing Indonesia team (Teresa, Anum, Omer) for inspiring this blog.
-M

Med School Musings

To Be Enthralled

Clouds litter the sky illuminating a bright white light that sears the humans’ corneas. It creates a bumpy path as the plane soars forward through the daytime skies. With every bit of turbulence, there is always some sort of clearing ahead. Honestly, it’s a great metaphor for medical school. As I write this entry, I’m currently sitting on a plane heading towards Toyko, Japan. It’s the first time in a very long time when I realized that I have absolutely no school work to do. No studying, no memorizing, no reading handouts, no listening to lectures. It’s weird.

I cannot believe that a year has gone by and now I’m an MS2. And what an incredible year it has been.

I’ve had the privilege to explore the human body anatomy via cadaver dissection. We’ve held the human brain that is the treasure to all of our thoughts, actions, and emotions. Cleaned out muscles and ligaments that we use every day without thought. And held the heart and traced its veins and arteries.

I’ve learned about the critters that crawl under the dirt, in the water, in feces, and enters our body. How different cancer cells can proliferate and manifest. How our lungs expand, our hearts beat, and our kidneys filter the body. We’ve seen the skinniness of pulmonary diseases, a kid with “half a heart” with the greatest spirit, a comedian who loves his life despite the many hours of dialysis.

I’ve explored the hard issues we will face in medicine. The death of a patient and the grieving family. The stages of childhood and the importance of nurturing youth. The distribution of supplies and services, and who has the medical decision making power. Care of the old and the young.

I’ve had the pleasure of meeting patients from Nepal and the Congo, learning the different parts of the physical examination, including the infamous rectal examination, and have taking history become second nature.

I’ve found the greatest group of friends and have amazing, supportive classmates. I’ve kept in touch with those far from me and fostered relationships.

I’ve experienced rock bottom and how things can go up. I’ve studied for 12-13 hours a day and slept a great amount to very little. I’ve understood more how to work in medical teams. How to be very patient in things and fight for what you want. I’ve learned that Friday is not study time, but my time to relax. I’m amazed with how much information the human brain can store and how much more I can stretch it.

So as first years moving onto second years, we must continue to revel and delight in the knowledge. To always be fascinated and enthralled by the wonders of medicine. To take part of patients’ stories and absorb their pains and happiness. This is the way to find joy in medicine.

Med School Musings

Perspective

It’s been a while since I’ve put a pen to paper (metaphorically). But in the middle of looking through my valvular disease notes, I decided to just put everything away and start writing. Letters

I’m going to go ahead and be honest and say these past few weeks post spring break have been rough. Things that I assumed were going to make my year, and the small things too, nose-dived, and the decline was extremely rapid. Do you ever have those moments where you can see the future brightly and clearly and all the sudden the vision just explodes into a bunch of fragments? Excuse my dramatics, but that’s what I’ve felt like in the past few weeks.

There were moments where time seemed to stand still, and I would just be sitting in my living room, staring at the ceiling. A feeling of nonsensical anger and sadness and confusion would just sit in my stomach, and I didn’t know whether I should cry or shout. Right when it seems like things were looking up, somehow, they ended up plummeting again.

I’m usually a very optimistic person. I’m the girl with the smile in the morning and an energizer bunny throughout the day no matter how many hours of sleep I have the night before. But lately, I’ve kind of viewed the world through some negative lens. I’ve come to realize how awful and poisonous negativity can be. It seeps into your nerves and muscles and saturates your thoughts. It’s venomous – distorting how you choose to live each day and view other people.

So in the car after hearing another piece of bad news, my roommate and I looked at each other and realized how focused we have been on the wrongs, and how it’s affecting our day to day living and expressions.

The day was slightly breezy with lazy sunshine. A coolness had seeped into the weather’s arms, banishing the heat that had been saturating the air in the past week. The air was crisp and the leaves were beginning to blossom with green. My roommate and I took a sigh and changed our perspective. Yes things seemed to suck now, but look at what we have. A loving family, the greatest best friends, the most amazing group of supportive friends scattered across the states, a wonderful med school family, and an education.

Perspective. The word has come to take on quite a significant meaning for many of us quite recently.

So I choose to focus on the Little Things. The list of things gathered from my sporadic lists as a child and online lists and my own sweet memories. Here are some I can apply to my life recently:

-Letting your hair down after it’s been tied up all day
-Changing into sweatpants
-The moment you realize your hiccups are gone
-Achieving the perfect milk to cereal ratio
-When close friends visit you
-Skype/facetime between friends
-Finally trying a restaurant from Yelp you’ve been wanting to try

Because while I don’t exactly see the light at the end of the tunnel yet, I just have to believe there is one. And these little things will keep me going.

-M

Med School Musings

One-Eighth

Bear with me. This will be a long post.

First semester of med school done. 1/8 of a doctor! One-eighth of the path done. Several versions of this exploded across my Facebook that Friday as my classmates and friends from my med school and other med schools finished their last exams.

It was a gloomy and cold day. The clouds were pregnant with rain and the grayness loomed over the hospital buildings. Despite the weather though, there were face-splitting grins and bone-breaking hugs being exchanged. Talks and whispers of winter plans and how we’re going to celebrate tonight were the only things you could hear in the hallways and outside the lecture halls. It was going to be the first night in a very long time when we would not have one reading, one lecture, one flashcard on our minds.

For the past two weeks, all we’ve done is sat in front of our computers, our cadavers, our notes, and our flashcards and memorized, memorized, memorized. My roommate and I would break into hysterical giggles by the end of the night when we’ve realized that all we’ve done was wake up, crawl out of bed, into our chairs, open our laptops, and then continue assaulting our brain with info. I’m sure we looked fantastic that week!

Lippincott Flashcards
Lippincott Flashcards

Memorizing was such a habit to us by now. The night we were done, my friends and I found ourselves trying to memorize each other’s phone numbers in the car as we drove to the restaurant. After one of my friends pointed it out, we all stopped and then burst out into laughter.

It’s amazing to think about how much we’ve crammed into our brains. Incredible to realize how much information our minds could store. But besides anatomy, Kreb Cycle, medical ethics, T cells, B cells, bacteria, viruses, and parasites, what else have I learned?

1] I’ve learned to deeply respect those who donate their bodies to science.
Almost three years ago, I visited a Plastinarium in Guben, Germany and had the opportunity to walk through and see so many different sculptures. Bodies and models depicting blood vessels, muscles, bones, ligaments, and multiple cross-sections. All, of course, from bodies donated. But even after seeing that, my appreciation to those donors never bloomed until I was elbows deep into the bodies dissecting around and revealing the different structures. It really has been such an honor to be able to experience and partake in human dissection.

My amazing tank after our last dissection!
My amazing tank after our last dissection!

2] I’ve learned how complex but beautiful our bodies are.
There were so many times in anatomy lab where my partners and I would get so tired of just standing there and cutting off fat layer after fat layer. Our eyes would stray to my partner’s watch and our backs and fingers would ache. But then we would reveal a beautiful artery or a fascial layer and suddenly the fire was reignited again and we were back it with renewed vigor (my favorites remain the splenic artery and arcuate line of the rectus sheath – don’t ask me why).

3] I’ve learned how important it is to hold onto your hobbies. Sometimes you need to choose life over work to hold onto who you are.
The work keeps coming. The lectures never stop and the handouts just keep getting longer. Thus, there were many times where my roommate and I just threw our hands up in the air and decided to call the day off (especially after anatomy labs). Merely to rest our brains and come back at it fresh the next day. It’s healthy. It’s good. Frankly, it’s necessary. And that is also why I continue to blog. Writing was a huge part of me before medical school, and I plan on it being a huge part of my med school/career.

4] I’ve learned how crucial a support system is.
I cannot even began to explain my gratitude to my parents, my brother, my cousins, and all of my friends. Every encouraging e-mail, call, and text have meant the world to me. And I really don’t know where I would be without my med school family. In a matter of months, we’ve all managed to become super close and keep each other sane throughout the process, and I really could not ask for a better group of friends.

My global health partner
My global health partner
FAAAMily
FAAAMily

5] I’ve learned that one day we WILL be putting this information to use on real-life patients.
The clinical cases we read are interesting. But that’s it when we read it on paper – just interesting. A foreign concept we need to put into our brains. But then we meet face to face patients that actually suffer those conditions, and suddenly interesting becomes real and a little terrifying. In our heads we go from a student pouring over books to a doctor standing in front of a patient – a person who is relying on you to get their diagnosis right and to know their treatment options. The patient interviews, the preceptorships, and volunteering at student clinics – these have all made medicine real for us this semester.

6] And above all, I’ve learned that even when you tell yourself you can’t, you can.
What more can I ramble on about that? Simple fact.

But what other fun things have I learned? Well, I’ve learned that formaldehyde is almost impossible to wash out of your scrubs completely, the concept of dressing up seems very foreign after spending a week in hibernation inside in sweats studying, the best part of the day is food, you have to celebrate every exam with drinks, choosing where to eat is quite a dilemma, associating food with body parts is completely normal and acceptable dinner conversation, little things like grocery shopping becomes annoying, when you place free food amongst ravenous med students – it becomes a battlefield, falling asleep anywhere is a scary concept because you don’t want your picture taken, coffee becomes the lifeline of some people, seeing interviewees every Monday makes your day because at least you’re not at that stage anymore, hunting down a library room is quite the task, the world outside the med school bubble appears alien, I have such amazing classmates with interesting backgrounds, the scent of coffee now that the semester is over makes me nauseous, and I officially cannot stand eating Subway.

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Now that it’s the end of the semester, I’ve allowed myself to flip through a small journal I’ve kept on me. It was a journal to record hilarious quotes and moments between friends and I and also a place where I could store pieces of inspiration I’ve learned from others. The pages turned my lips upwards. Despite all the stress we’ve been through, I can’t help but be thankful because wow, what a life we live. How fortunate are we to experience such an education and gain amazing friends and mentors from it too.

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So cheers to us for completing our first semester, and I hope everyone has a safe, wonderful break! Merry Christmas and Happy New Year!

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In The Moment, Med School Musings

Serenity

There are lights strung here and there. Blue cords of lights hugging the trees and casting glowing shadows upon the dewy grass. In the complete usual darkness, they create a source of vision for all those who pass by. They glow and they twinkle. They seem out of a place on campus usually bustling with activity and great minds working and studying. It is like a tiny relief in the midst of a chaotic world.

My hair whips around my face. The cadaver smell is gone. The air smells fresh, unpolluted and the wind is gentle and whispering. The breeze leaves goosebumps and promises of cooler weather. The night is still, only broken by the soft chirps of the nearby crickets.

My mind is empty and unthinking. I breathe and just close my eyes, and underneath my eyelids, I can still see the strings of lights twinkling. The wind continues to swish around me, and I stand still, muscles relaxed.

It’s a moment of rare serenity.

My med school decked out in lights
My med school decked out in lights