Tag: medical student

of letting go

~ karuna ~ Leave a comment

It’s amazing to me how far I’ve come. I rode the wave of medical school; I was crushed under its weight and dragged across the bumpy sea floor. I rose from the sand after the water receded and was not only still whole but was stripped of old vestiges and ideas and misconceptions. I was stronger, and I was no longer afraid.

Much of the tumult of this journey was feeling like a laughable outsider. The language and rules and norms of this new culture were foreign to me; I was a stranger in a strange land. I was a foreigner in what could be a quite brutal milieu. I was self-conscious and vulnerable, scared that my ignorance and my sensitivities and disenchantment and disappointment meant that something was indeed wrong with me– as if this ailing system of inequities and capitalistic fantasies confirmed my greatest fear of not belonging, of being some kind of mistake, of needing to leave the healing profession altogether. What a relief it was to realize that my sense of self– both my professional identity and personal identity– could be completely separate from my “belonging” or acceptance inside a disdainful medical culture and a healthcare system (i.e., insurance companies, pharmaceutical companies, and other for-profit institutions) run by dusty dodos and fossilized pterodactyls. It doesn’t matter what anyone thinks of me within a rotten environment. I am free to be myself, and that’s all that matters. I am not perfect, and that is perfect. I am worthy of love simply because I exist– not because any one of my supervisors or employers or whoever else thinks I’m valuable.

I let go of my need to impress anyone or be validated. I am free to make mistakes and to learn and grow without my shortcomings– or my perceived belief that I have shortcomings– threatening me or my identity. My self-worth is not dependent on how much I know or what I am “good” at or what anyone else says I am.

Peace is available to me, but it is not something anyone else can construct for me or give to me. It is from inside of me. I’m grateful that I learned all of this in medical school. It was a profound piece of hidden curriculum.

Home Visit

~ karuna ~ Leave a comment

[This writing was from late February/early March 2020. This was my last home visit before the pandemic hit my city.]

I rushed from a busy ward floor of the hospital to my car to drive to go meet Ms. Bee for a home visit. Her rose colored wooden house with peeling paint surrounded by overgrowing vines and grasses appeared to rise up from the earth organically. It felt out of place on the side of a very busy four-lane thoroughfare of our city and surrounded by newly built, imposing condo buildings that lack the character and charm of her small dwelling. Her house was like a lush desert island in a sea of concrete. “My mail box has been knocked over so many times by drunk drivers. I can’t even count them anymore! One time it got dragged all the way to the corner store,” she recalled with genuine amusement.  

We met in her living room of her home. She sat in her burgundy recliner that seemed to envelop her tiny, bony body, just like her large knit sweater seemed poised to swallow her up at any moment. The moss green carpet beneath our feet felt like an earthy mat. Her medications lined up on the table next to her large recliner gave the impression that Ms. Bee doesn’t move much from her perch. She and her house felt like steady old relics in a city of non-stop movement, expansive growth. Time seemed to slow down a bit inside her little house. There was nowhere to be and nothing left to do other than sit and connect.  

Talking with Ms. Bee was like stepping back in time. When asked if she had any life advice or lessons she’d like to share with young people today, she spoke of her work as an orthodontist’s assistant. You can learn a lot from people’s mouths and learning when to keep yours shut. She also spoke of her childhood picking cotton on her family’s farm and on farms out west where her and her siblings worked with her parents to earn money in the late 1920s and early 1930s. Picking 350 pounds of cotton a day is an unbeatable teacher. She recalled her family’s covered wagon, her father finding a shade tree every summer under which he’d sell the family’s watermelon crop, and the corn they grew for her family of 15 to eat.

Was this modern-day home visit with Ms. Bee a little glimpse into the practice of medicine of yesteryear? Connections were made at home, and a physician was able to assess a patient as a located, contextual, relational human—not as a member of a revolving cast of characters participating in the drama of the contemporary clinic. Similar to how doctors used to visit her family farm when one of her 12 siblings became ill, I met her in her environment, and for that reason, I feel like I learned a great deal about who Ms. Bee is. Seeing where she lives and how she lives painted a three-dimensional picture in full relief of what it meant for Ms. Bee to take care of herself. Her home environment provided me with a glimpse into what made Ms. Bee more than any other elderly woman with a handful of common chronic health conditions; I saw her as a full person rooted deep into the land on which she lives, the same sprawling piece of land on which she was born 99 years ago.

My pandemic reading list

~ karuna ~ Leave a comment

I’ve spent the past 12 weeks riding the highs and lows of being isolated at home, unable to go into the hospital or clinic. I’ve volunteered my time delivering food to families and elders in the housing projects; I’ve also organized self-care and mental health activities for fellow students. I do my school work– sometimes with great difficulty, depending on the week and the day; the unfolding, no-longer ignore-able injustice in my community and our nation is so traumatic and thus hard to bear some days. Feeling hopelessness or grief easily derails my “productivity.” I have no reading list, no summary in bullet points, no cleanly organized cross-section of information through which this time can be understood.

evaluations

~ karuna ~ Leave a comment

As I read evaluations given to me at the end of a clerkship, I wonder about what the utility of an evaluation is. It’s a chance for physicians and residents to comment on my personality, work ethic, interactions with patients, and clinical knowledge. Yet how much do these observers really see? What kind of snapshot does my limited time with them provide? How much weight should I put into assimilating what they write into an understanding of who I am as a future doctor?

I receive lots of positive comments and then the one or two token constructive comments: have more initiative, read more before coming into clinic each day, know the basics, keep working on your assessment and plan. What does this give me?

I am writing evaluations to three individuals I worked with who I think could do a much better job at being compassionate. Is it my place to critique their interactions with patients? Is it my place to critique their interaction with me as non-constructive, unhelpful? I suppose so. I feel strange evaluating their skills which rest on the foundation of their personalities and qualities/characteristics. Perhaps that is the crux of this situation: being a physician (and developing oneself into a “great” physician) is about how you are as much as what you know.

a struggle in 55 words

~ karuna ~ Leave a comment

Charcot foot and weeping ulcerative wounds dragging on the bare ground.

He wanted more time, more options, more consultations with vascular specialists.

A below-the-knee amputation, deferred.

He needed a wheelchair so he could leave the hospital. No one could find him funding for one… for days. Days! Social workers, nurses, doctors, students scrambling to help.

To DNR or not to DNR…

~ karuna ~ Leave a comment

I wrote the following reflection at the end of my palliative care rotation in December. It was in response to a clerkship essay assignment in which I wrote about the value of having a Do Not Resuscitate (DNR) order in place for terminally ill cancer patients.

On second thought, I can see the value of a full code status order when living with terminal illness: peace of mind, a glimmer of hope, and preserving the “will” to live for the patient. Being full code means someone else— likely the MPOA but also maybe the entire family— will have to decide when it’s time for their family member to die; in some way, the patient is abdicating their individual choice regarding how and when they die and deferring it to others.

Bizarre but somehow comforting, I’d assume. Full code might mean valuing not giving up in the fight, collective decision making, and having a strong warrior spirit throughout illness. It might signal to the family that their loved one is unwilling to leave them or give up on them.

But could a DNR be something that seems scary and “wrong” simply due to lack of education? What if their ideas of DNR are simply incomplete and/or skewed by misperception? What if they knew a DNR could be a family decision *before* crisis strikes? What if the grief of dying could be dealt with early and not left to the symbolic gesture of love that full code status affords?

A false dichotomy

~ karuna ~ Leave a comment

I find it personally fascinating to see how the very simplest of human tendencies comes out in the crucible that is the emergency department (and perhaps more broadly in the crucible that is the hospital). As humans we sort ourselves into “us” and the “them” in many ways, but perhaps the most insidious manifestation of this is in situations in the emergency department. Troubling is our capacity– yes, our collective capacities– to reinforce that we, the members of care teams at the hospital, are different from those who present to the hospital in fragile, vulnerable, troubling, decrepit, annoying, boring, and/or disgusting states. Patients can easily become the “them” to our “us.” Why do we do this? Maybe in some basic instinctual attempt to assert control and organization over what can be a chaotic and unpredictable environment. Or maybe in some attempt to make the working conditions in the ED (i.e., the pressure, stress, or fatigue) feel more bearable by focusing on something other than the reality of hard work. Or maybe to make one’s self feel better about their own perceived deficits or displeasure. Or maybe because we see something in a patient we don’t like about ourselves or someone we know. Or maybe out of sheer boredom. Either way, those that belong to group Them can easily become a point of fascination, revulsion, or apathy for those in group Us. Not only are “they” bare in body, mind, and (one could argue) spirit in front of “us” in the ED– without much ability to hide, without much privacy in tact– but “they” also become something of a spectacle for “us” to laugh about or analyze or judge or doubt. “They” are different than “us,” and in so far as they are not us, they become less than us. In a quick slip of the mind, they become less than fully human.

We can shelter ourselves inside a bubble of self-importance, of clinical distance from “them,” but ultimately, “they” are as much us as we are. They are us. We are as much addicts as they are, scared as they are, mortal as they are, naive as they are, foreign as they are, weak of mind or body as they are, helpless as they are. If we were suddenly forced to live indefinitely on the streets like our community’s homeless do, how quickly we might realize how similar we are to them in shape and smell. If our drugs of choice were suddenly criminalized (choose one: sugar or alcohol or coffee), how quickly we might realize with a broken heart our unity with those caught in addictions to criminalized substances, and how quickly we might realize the “liars” that we all are.

The emergency medicine clerkship has been nothing but learning. Some of the biggest lessons for me have been in skills such as suturing or interpreting radiographs or crafting a thoughtful differential diagnosis, yet some of the lessons that made the biggest impact were ones regarding the practice of patient education and communication. Working in emergency medicine felt like being at the pulse of healthcare. I saw people receiving life-changing diagnoses or reassurance that there was nothing amiss with them. I saw life-saving interventions and simple interventions. I saw patients who had never in their lives been to a doctor for a check-up and those who maybe didn’t fully understand how the healthcare system in the United States works; some came in for complaints that were probably better suited to a primary care clinic and then other people came in with true medical emergencies. Through each encounter I had with a patient– regardless of their health literacy or level of acuity– was an opportunity to glimpse the privileges and pitfalls of medical practice in the emergency department. Ultimately, I think I’ve grown as a person because of this clerkship. In some way, I feel more aware of my own humanity, including the dark shadowy parts full of cobwebs– the ones that my patients showed me.

dislocated joints

~ karuna ~ Leave a comment

It’s difficult for me to judge if my dislike of certain rotations through medical specialties/sub-specialties comes from a genuine dislike of the type of work required for the specialty or if it’s simply a reflection of my dislike for 1) the faculty I work with in the specialty, 2) the specialties’ working conditions, or 3) more broadly the ecology of the healing environment.

faculty as… role models?

The interpersonal dynamic in the emergency department at one particular hospital where I work is an example worth highlighting. Physicians I work with there have been less than welcoming and sometimes even outright condescending toward me. The one that was actually kind to me and helped me try to learn something new during one of my shifts also spent half of the time on shift talking with the other physicians about finances and how big their retirement funds are and/or gossiping about one of their colleagues who I happen to have as a professor (and who I happen to find is a very kind and generous teacher). That dampened my respect for the whole group of them, unfortunately. I enjoy the work of emergency medicine (figuring out what the diagnosis is for any individual who walks into the ED), but the work environment and the personalities it seems to attract are less than appealing.

On a different note, my pediatric outpatient faculty were some of the kindest, most generous, and most flexible physicians I’ve met thus far. They openly valued families (including their own!) as much as they valued their profession, and their priority was always establishing comfort, honesty, and education in their relationship with patients and their patients’ parents/guardians. They were active members of patient advocacy organizations and legal-medical partnerships. They seemed happy in a way that seemed qualitatively different from other physicians I’d met. I admired them.

working conditions

Let’s take part of my pediatrics clerkship as another example. Specifically, let’s examine my week-long rotation in the newborn nursery. I worked in a closet. Literally. When not examining a baby in a patient room or in the incubators of the nursery, I spent hours reading, typing notes, and studying in a closet. The workroom for trainees and students is a 12 ft x 12 ft former equipment storage closet that’s been converted into a workroom. We worked at computers and desks stuffed into a very small windowless space. No better way to go a little crazy when working a 12 hour shift when your home-base is a closet. Unfortunately, the physicians’ workroom is only slightly more pleasant, as it is also an oversized closet with no windows that happens to have soft lamp lighting rather than harsh fluorescent overhead lighting. I think this example is so valuable because it illuminates a small piece of medicine that I find rarely talked about: physicians and trainees as capital. The political economy of medicine is not divorced from capitalism and its exploitative necessities. This is a recurrent theme of my clerkships that likely deserves its own separate post.

ecology of medicine

Ah, and the best example for last: my primary care clerkship site. Now, my primary care preceptor truly deserves a post of his own; I can already see the title of that piece of writing, in fact. It would look something like, “Where the #MeToo Movement Meets Medicine,” and as you can probably guess, it would be an essay about the intersection of mysogyny, toxic masculinity, and the practice of primary care medicine. I won’t launch into a full analysis of my experience right now, but allow me to dive into a few observational sketches regarding my experience. My preceptor is a middle-aged man who operates with many unchallenged assumptions, theories, and “truths” about the world. For example, he believes male ObGyns are better than female ObGyns and will only refer his female patients to male ObGyns. He believes part-time physicians are phonies and care more about going to “yoga class” than “doing something that has merit in the world”; he criticizes people (women) who choose to be part-time physicians in order to also raise a family. He also believes that wearing gloves while examining men’s genitals is a reflection of prejudice on the part of the physician (or in my case, a trainee), yet he purports to always wear gloves when examining women’s genitalia. He also gives unsolicited advice to me about my appearance or about what I should do with my life. And don’t even get me started about me being “pimped” (med training lingo for “quizzed”, “grilled”, “roasted”) in front of patients in their exam rooms that he likes to do…

Beyond these discrete examples of his unchecked beliefs and his own biases, he operates his primary care practice in a cultural milieu that is worth pointing out. His patients are almost exclusively older people aged 40+, and his clinic looks to be straight out of the nineties or the early aughts. I don’t believe this is a coincidence, because he operates under an old-school type of doctor-patient relationship that is ultimately paternalistic and not necessarily keeping pace with interpersonal/political/social advances in medicine. A few examples: He prescribes unsolicited marriage counseling, personal psychological assessments, and life advice to men (and maybe women too, but I’ve never seen that). He tells his patients what to do without establishing the patients’ goals for their health/life, and he operates with full deference and thus without any challenge from his patients. In short, he does not practice shared decision making and he is often not forthcoming with his patients in regard to why he is prescribing certain medications or why he is ordering certain blood tests or radiologic studies. This is a kind of model of “doctoring” that puts physicians in a place of extreme privilege and endows them a font of authoritarian power from which to unceasingly draw. And ultimately it robs patients of their autonomy.
While I have absolute confidence that this particular doctor is operating with his patients’ best interests in mind, I hope to never be like him when I am a licensed physician. I guess that means I’m having a good learning experience at this clerkship site?

Overall, my clerkship experiences thus far have been galvanizing. I don’t particularly like any specialty I’ve seen so far, but not necessarily because I don’t enjoy the work that the specialty entails. I believe it’s due to the toxicity of the environment, culture, and interpersonal dynamics I see in each specialty. I want to desperately do something radically different than all that I’ve seen thus far. Which leads me to a challenge: how will I be such that I will not re-create these problematic patterns in my own practice?

healing with both hands

~ karuna ~ Leave a comment

She had gone to a voodoo priest for help in interpreting this dream. Each of the lumps had significance, said the priest. They represented ‘the three mysteries,’ and to be cured she would have to travel to a clinic where doctors ‘worked with both hands’ (this term suggesting that they would have to understand both natural and supernatural illness).

– Paul Farmer, “An Anthropology of Structural Violence” in Partner to the Poor: A Paul Farmer Reader

I feel so conflicted some days about my medical training because I have yet to reconcile a personal tension that is floating on the surface of my mind.

  • How can I be both an indigenous woman and a western medicine doctor?
  • How can I hold my spiritual beliefs regarding illness/disease and my belief in evidence-based medicine at the same time?
  • How do I practice traditional forms of diagnosis and healing through prayer, singing, ceremony, communion in a medical culture that doesn’t acknowledge indigenous epistemology, spirituality, or traditional forms of healing in its training, science, or practices?

I feel that my cultural values and spiritual beliefs are not “allowed” in this culture of medicine in which I am being trained, and that makes it hard to envision how I can be what I’m being taught a “doctor” is. This task feels daunting, as it requires that I map my own way mostly unassisted. Surely someone has come before me on this path… but where are they? Who are my mentors?

I’m reminded of a young Hmong woman, Mrs. W, who I met while on my internal medicine clerkship. Mrs. W is a woman who came into the hospital in a state of crisis: hemorrhage. Surgery saved her from internally bleeding to the point of hemorrhagic shock, and for that she is grateful. But now science, by way of the various teams of physicians caring for her, cannot explain why she is experiencing a whole host of issues including hemolytic anemia almost a week after her surgery. Despite throwing every analytical test at the problem– everything just short of a bone marrow biopsy, I should say– and finding no compelling explanations, there are no answers for Mrs. W and her husband. After weeks in the hospital and little relief from her situation, she told our team of trainees and students supervised by the attending physician that she wanted to go home to consult with the shaman with whom her family calls upon in times of sickness. She said that her husband believed that the recent passing of his parents might be the reason she was getting more sick; it might be because the parents were trying to communicate something to her or her husband. The shaman, she explained, would be able to pass along messages and instruct her and her husband in what offerings to give.

This moved me. Here was a patient to whom I could relate! I deeply wanted to swap notes: What it feels like to be held by your rituals and ceremony. What dreams show of the spirit world. What songs or chants you sing in praise or in prayer. What an adequate offering looks like. What healing the spirit, mind, and body feels like, looks like, sounds like, and smells like.

Maybe my work as a physician is meant to be among other people who hold spiritual beliefs about healing. Perhaps this is what Mrs. W taught me. I‘d like to heal with both hands.

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