According to one of my attending pediatric physicians, there are four rules to remember about wards:

1. Everyone is “projectile” vomiting.
2. No one is “constipated.”
3. A “fever” is probably not a fever. (am I remembering this one correctly? hmm…)
4. Never answer one of the general house (hospital) phones if ringing.

🙂

While kids are adorable and helping them get well (and helping their parents find peace) is very gratifying, I don’t think pediatrics is for me. I find the process of working with “two” patients– kids and their parent(s)– to be disconcerting; it leaves me feeling scattered. I also feel strangely when not able to build a good rapport with a child due to lack of time. I want to have deeper relationships with kids that I feel the hospital doesn’t afford me. Perhaps outpatient pediatrics will be different.

A reflection from week 1 of the IM rotation

Mr. H had an acute kidney injury. No one trusted Mr. H when he said he didn’t smoke meth recreationally and that he accidentally smoked meth the night before on a cigarette he bummed from a friend. No one trusted him when he said he had relentless chest and neck pain on hospital day 1, day 2, or even day 3. (“It’s just because you’ve been vomiting and have sore muscles now,” he was told.) When discussing his case, many of the physicians working on his case scoffed and jeered at his story, his complaints. Sly smiles, dripping with derision, smeared on the young doctors’ faces. “They’re all liars,” a resident expressed, shaking his head in disapproval. “Why do you say that?” I asked. “Because drug addicts are liars. They don’t want to admit that they use drugs, and they won’t tell the full story. I learn more about these people by reading their charts when they arrive in the ED than I do from talking to them.”

By hospital day 3, none of the physicians wanted to spend more than a few minutes checking up on him in the morning; the intern stayed long enough to ask if Mr. H experienced any more nausea, vomiting, and anuria overnight. When Mr. H began to talk about his chest and neck pain, the intern left the room. “I have other people to see this morning, so I’m going to go,” he told me quietly before he slipped out from the room as Mr. H was talking. I stayed behind to ask Mr. H to elaborate on his pain, its character and location exactly. I wasn’t convinced that he simply had sore muscles, despite the fact that when I pressed on his chest, he winced in pain as if his chest was very sore– something that made sore muscles seem likely. Upon asking, he described his pain as sharp, internal, and accompanied by “crackling” or “bubbles” in his neck. I felt his neck. Under my fingertips, his skin danced as if it was resting on a water bed made of crumpled tissue paper. It audibly crackled. I may be a spring chicken, but I know that that finding on physical exam was anything but normal. I presented his case during rounds, to the mild disinterest of the doctors on my team (only interested in the part about whether or not he could be discharged that day), and noted that I’d like the attending to check on his neck because I found it to be strangely crackly. “Was it crepitus?” the attending asked suddenly looking more alarmed. I thought to myself, “Crepitus… What is crepitus…?” as I looked at her blankly. “Um, I’m not sure I know what that is.” She said she’d check it out.

He ended up having a pneumomediastinum likely due to an esophageal perforation that caused air to become trapped in his chest and neck– a finding that is termed “crepitus.”

I was lauded by my attending for my finding. I started hearing from other senior doctors in the hospital that they were also impressed with the finding. One of my later attendings told me that I should feel proud for performing a thorough physical exam, paying attention to the patient’s concerns, and finding the sign of his pneumomediastinum (a pathological situation that could’ve been much more consequential for him if his perforation had not closed up spontaneously!). “This isn’t something many of the residents would do; they’re too busy to stop and perform a thorough exam.” He continued, “Let this be a lesson to all of us.”

Perhaps this experience is not simply about taking time for patients, taking time to be thorough or to follow-up on complaints or odd findings, to not anchor ourselves to the easiest explanations. Perhaps this is also a lesson in trust, non-judgement, humility, generosity, and compassion. What greater gift can we give to someone than our time, attention, and thoughtfulness?

On that note. To all the addicts, people experiencing homeless, and those who are otherwise considered deplorable in the eyes of others: you matter. I hope I never stop trusting you when you say you’re in pain. I vow to maintain a sense of generosity of spirit and attention with every patient no matter who they are.

The attending physician on my team and I had a good farewell chat today. He asked me for my critiques of our workflow and structure as an internal medicine team. I was pleasantly surprised to be able to open up to him about what I find remarkably troubling about the hospital (the windowless rooms, the lack of green spaces for workers and patients/families, the silo-ing of departments, the lack of time afforded to residents/interns/students to spend with patients after rounds end, the inefficiency of inter-team communications, the constant deluge of new information and feeling like it’s impossible to learn it all so quickly.) It was a good conversation. He offered me a few take-home points for my time moving forward on the IM service. Here are some notes I took:

+ Absolve yourself of self-judgement regarding how much you “must know” about the minute details regarding diseases/medications/physiology (in regard particularly to board exams). Instead, deepen your care for your patients ; then, you’ll be able to go find any nuanced, detailed information about their disease process/medications you “don’t know” when you need it. Don’t get lost in the scientific details and then forget to take time to also know your patients.

+ Healthcare systems, including our hospital, do not exist outside capitalist ideology. Doctors, nurses, social workers, and pharmacists are all workers in a very traditional, capitalist sense. I found this a refreshing reminder. Analyzing my time at the hospital with more of an anti-capitalist lens regarding the structures and functions of the workplace and how that intersects with the production of capital is helpful for me.

+ Start each day with an objective in mind. What can I learn, observe, witness, investigate each day? Take advantage of time in the hospital as something I may never have again (since it’s looking like a hospital is not my ideal future work environment…).

+ Keep dreaming big. What could hospitals look like if they centered their work around people rather than profits? Make this part of your work. There is no need to accept normative models as necessary in the future of healthcare.

+ We see people in the hospital at a breaking point in their disease process. There is value in following their disease up-stream, to the time before they emerged in the hospital, to find out the roots of illness. What can I do about up-stream causes of disease? This is a rich place of inquiry for me.

internal medicine clerkship week 4: a few notes

“I am thankful for small mercies.  I compared notes with one of my friends who expects everything of the universe, and is disappointed when anything is less than the best, and I found that I begin at the other extreme, expecting nothing, and am always full of thanks for moderate goods.”

~ Ralph Waldo Emerson

There are many things I could write about, but right now I’m hung up on something. The work of hospital medicine has left me feeling the opposite of inspired. And that reminds me that if I feel uninspired (and then frustrated and indignant that I’m not inspired), then perhaps I was operating under the expectation that this clerkship would be inspiring, meaningful, profound, etc. or worse: operating under the expectation that I deserve to be inspired. An unfortunate …albeit liberating… realization, this is.

“When we run away from boredom, we are running away from ourselves.”

~ Josh Korda, published on Lion’s Roar

I thought that I would– on some level– feel passionately about internal medicine. Instead, I feel whatever the opposite of passion is. Dispassionate. No, that’s not the right word, because I definitely don’t feel any sense of impartial feelings that would be suggested by the word “dispassionate.” I feel something more akin to being restless… uninterested… anxious… averse… bored.

I’m doing exactly what I want to be doing: serving people on their road to recovery, and yet I feel this simmering pot of feelings (not-inspired, disinterest, restless aversion, boredom) inside of me. Where are these feelings coming from? What story am I telling myself?

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a boulder, a hill, a man

“Kierkegaard and Camus saw Sisyphus — the Greek figure who was destined to push a boulder up a hill forever — as a potential hero. There was great liberation there, they said, because rather than constantly chasing the new, the stimulating, the novel, Sisyphus was given the opportunity to let go of wanting life to be different than it is, wanting to escape old age, sickness, death, frustration, sadness, loneliness: all the stuff that is life. His unique position allowed him to confront the baseline of his existence.”

Josh Korda, published on Lion’s Roar

Maybe my internal medicine (hospital) clerkship experience is like the boulder Sisyphus pushed up his hill every day, non-stop. If so, then I, like Sisphyus, am being presented with “the opportunity to let go of wanting life to be different than it is, wanting to escape” from all the things I find abhorrent about my day-to-day existence right now. This resonates with me.

The volume of sensory information I am presented with each day is unreal: the smells (oh my goodness, the smells…), the groans and sighs and (yes, sometimes) screams, the deep shades of red that is blood, the texture of edematous skin, the tangle of lines and tubes and drains emerging from flesh and interfacing with a machine, the incessant clicks and beeps of telemetry and oximetry monitors, the awful sight of dismemberment and disfigurement due to accident or disease.

The volume of information I am presented with is similarly unreal: eponyms and Latin words and acronyms and phrases and medication names and dosage values and reference ranges and lab values and comorbidities and pre-test probabilities and more. Imagine these things tumbling from the mouths of my attending physicians and residents; I scoop them up off the floor or the table and collect what I can in lines of epic scrawl in my little pocket sized notebook, but inevitably the words overflow the pages and some things become lost in the fog that is my mind after a few hours of this cascade of information. The daily intellectual onslaught feels more pleasant to me, despite however overwhelming it can be. It contains tools. It all feels meaningful because I choose to believe that it is information that will somehow serve me later when I work independently with my own patients. I enjoy investigating on my own time the various tid-bits I scoop up. It’s a welcome distraction from the hospital itself, from the patients themselves.

A word or two about the built environment and the structure of hospital work: There are no windows in the physicians’ workrooms. Big hollow boxes filled with computers and the chatter of patient care coordination happening over the phone. There are no outside patio spaces or courtyards in which one can step outside and take a break. Some days, I feel the sun on my skin only when stepping far enough into a patient’s room to stand in the patch of sunlight coming through their window. Speaking of breaks: there is no structured break time. Lunch is expected to be eaten while listening to a physician lecture about a specific topic; I digest my food while I digest the nuance of emergent hyperkalemic medical management, acid-base disturbances, congestive heart failure, bacterial meningitis. I wait to leave the hospital until someone above me in rank tells me it’s a good time to leave, because that’s the expectation of me.

Sometimes, I get home and just feel like crying. And then there are days where I feel pretty good. There are the small blessings of the hospital: the extreme kindness of a nurse going out of their way to lend me a pair of scrubs. The elderly woman dying of heart failure who I check up on; the last few times I saw her, I would go into her room to see how she was doing, and she’d reach out for my hand. She’d hold it tight and nod back off to sleep. I also find gratification in sticking up for a patient of mine in the face of prejudice, ambivalence, disregard sent their way. Ruffling enough feathers to finally get traction on something a patient needs that is important to them but may seem trivial to others buoys me on some days. A few days ago, the doctor I was with told a patient point-blank that he had diabetes and would die from a stroke or heart attack or kidney disease unless he changed his life. He was in his late 20’s. I’m barely older than he is. I held his hand and we talked about what diabetes means and we cried together. That experience reminded me of why I decided to practice medicine.

Yes, on some level, I feel a sense of discomfort at the hospital because it feels impersonal, mechanical, procedural, sterile, inefficient, uncreative, soulless– all things I do not believe the built human environment must be or even should be. But I am more troubled by the way I find myself shying away from the awfulness of the hospital; I want to avoid the human horrors– suffering, disgusting sensory experiences, infectious diseases, pitiful states of being, unjust treatment of some patients, the way that people can be so mean and hurtful to one another when stressed or insecure– and ignore them. The reality of human suffering and diseases and dying and death is not a mutable phenomenon. And if at all mutable, it most definitely is not over the next four weeks of my internal medicine clerkship. I suppose it only makes sense then that I’d be increasingly uninspired, bored, restless, and averse as I face this unmutable reality of existence everyday for more hours each day than I’d like to admit. It’s also no wonder that I would feel such restlessness, aversion, and agitation in the face of feeling the desire to take away others’ suffering and being totally powerless to do so. On some level, I need to let go of my desire for things to be different. Over the four weeks I have left on this clerkship, I will be pushing a rock up a hill each day. And in that experience, I vow to commit myself fully. There is a lesson to be found tucked inside my lack of inspiration, my frustration, my boredom.