November 17, 2014

I'm all about that beta

(To the tune of "All about that bass")

You know I'm all about that beta,
'bout that beta, no preggo
I'm all about that beta,
'bout that beta, no preggo
I'm all about that beta,
'bout that beta no preggo
I'm all about that beta
'bout that beta (beta beta beta)

Yeah, it's pretty clear, I see line number two
So now I'm worried, worried -
What am I gonna do?
'Cause I got that CMT that makes my heart race
And all the gross pus in all the right places

I see my future now - my life is gonna stop
When I hit nine months - ready to just pop
I'll have a baby, baby - gotta raise him up
And every inch of me is nervous
From the bottom to the top!

Now my mama she told me don't sleep around with those guys
She said they'll say they're all clean but you know that that's all a lie
You know I tried to be safe, used a condom most of the time...
Should have listened and gotten an IUD from my Gyn!

But now I'm all about that beta
'bout that beta, no preggo
I'm all about that beta,
'bout that beta, no preggo
I'm all about that beta,
'bout that beta, no preggo
I'm all about that beta
'bout that beta - Hey!

Let's hit the OR stat!
Before my tracing goes all scary flat!
No I'm just playing with variability
I'm here to tell ya
Gotta check me - all this pressure -
Time to push 'cause I'm complete!

Now my mama she told me don't sleep around with those guys
She said they'll say they're all clean but you know that that's all a lie
You know I tried to be safe, used a condom most of the time...
Should have listened and gotten an IUD from my Gyn!

You know I'm all about that beta
'bout that beta, no preggo
I'm all about that beta,
'bout that beta, no preggo
I'm all about that beta,
'bout that beta, no preggo
I'm all about that beta
'bout that beta

You know I'm all about that beta
'bout that beta, no preggo
I'm all about that beta,
'bout that beta, no preggo
I'm all about that beta,
'bout that beta, no preggo
I'm all about that beta
'bout that beta

August 16, 2014

Kindness is the best medicine

I was caring for a woman in the emergency department the other day, and when I was discharging her she thanked me for being kind. I was surprised, because I generally think that part of being a doctor is being kind to all your patients. I tried to wave off her thanks, and she explained: "Most people don't treat Muslims very well, so I thank you for being so nice today." I was at a loss for words. What I wanted to say -what I tried to say - wasn't true: that I couldn't imagine why someone would act that way.

I immediately felt guilty. The woman's complaint had been superficial - a headache - and despite an expensive work up she seem to recover just fine with some time and attention and a Tylenol. She hadn't filled her role as the "sick patient" the way that I wanted her to, and in my mind I had been dismissive. But here she was, thanking me for the kindness that I had shown her.

It is easy in the emergency department to grow jaded quickly, to always think the patients are trying to get something from you that they don't deserve: narcotics, a place to sleep, a turkey sandwich, or just some attention. As the end of my shift grows near, I find my tone of voice loses its softness, and the compassion that I used liberally on my earlier patients now seems to be missing, replaced by efficiency.  Sometimes, the patients ARE faking; a lot of the time, they need something from us - whether it's medical or not. Sometimes what they really need is someone to listen and offer a kind word. I'm grateful that this is free and easy to offer. I'm ashamed that sometimes I forget.

August 5, 2014

Thirty days a doctor

What is it like to be an intern?

The class above us tried to warn us: "You can't prepare for it, even if you try." "It's harder than anything you'll ever do." "It sucks.  It really sucks.  But it gets better, eventually." The problem with making the transition from medical student - eager learner, always wishing you could be more helpful, not really responsible for anything - to brand-new physician is that the change in attitude and expectations is earth-shattering. You sign your orders and they get carried out.  You put in a lab draw for a patient, and the nurse draws the blood and sends it off.  You write for a medication to be administered, and it is.  In one swift moment, when you sign into the EMR and start writing notes and orders, you go from bystander to decision-maker.

It takes about a millisecond for the terror to set in.

Everything you thought you knew is now suspect.  Now that your decisions carry weight, you find yourself in a sea of ignorance.  How much is an appropriate dose of Tylenol?  How do you know that patient can have Motrin? The most common-sense and basic care decisions are suddenly a source of anxiety, because now you can't just say "let's give Tylenol," you have to be specific: "Let's give 650mg of Tylenol, every 6 hours as needed."

The minutiae of patient care - the things that always just seem to happen on their own before - turn out to be details that you have to anticipate and write an order to accomplish.  You want your diabetic patient to have a fingerstick before meals? Make sure there's an order for that, or it won't happen.

The amount of medicine that you realize you don't know is staggering.  To top it off, the medicine you thought you used to know has seeped out of your brain in the months between your senior year sub-internship and orientation for residency, so now you suddenly can barely use a stethoscope or a speculum.

The hardest part about being an intern has nothing to do with doctoring, though.  It has everything to do with adjusting to a new workplace, with all the foibles that accompany such a task.  Once again, you've landed at the bottom of the hierarchy, and there are interpersonal dynamics to learn and follow, relationships to parse, and expectations about what you should accomplish and the speed at which you should be able to perform.  You will never be fast enough, just accept that fact now.  The seniors will chastise you for being slow, and they'll ask if you've done half a dozen things, then before they've finished summarizing all the things you've forgotten to do, they'll ask if you've done the first thing on the list yet - all while still talking to you! (I kid you not.  That literally happened to me multiple times.)

Some of your co-residents will be better at shepherding you through this transition than others.  Some will have completely forgotten what it's like to be an intern: lost, afraid of making the slightest mistake, worried about how stupid you feel and/or look, afraid that making a mistake will harm your patients, embarrassed by how long it takes to do everything, exhausted by the sheer force of will required to manage a new EMR as well as trying to meet the expectations and idiosyncracies of everyone around you.  Others will be a shining spot in your day, the ones you hope you'll rotate with because they never make you feel stupid, they encourage you to ask questions, and they give you feedback in the nicest of ways.  Some will make you feel like your insides are shriveling.

I've been in the Emergency Department for the past week (3 more weeks to go) and at first, I almost felt ashamed by what a relief it was to escape L&D.  But I realized that a large part of that relief is predicated on the fact that I don't feel like I have any particular expectations to live up to in the ED - I don't have any major expectations of myself and, as far as I can tell, neither do my attendings - whereas in the OB/Gyn department, I am always holding myself up to what I think I should be doing, and always feel as though I'm coming in below the standard.  I simply do as much as I can and don't worry about where I'm falling short, unless it's an obvious area of importance, because emergency care is not my specialty.  Back in the OB/Gyn department, I always want to feel like I'm doing a good job, and it's hard to feel like I'm not meting my own expectations.

In short, being an intern is like this: waiting for four years to get on a rollercoaster that you've always assumed would be the best ride of your life...then finding out that the first part of the ride is a series of hills and valleys and loops that make your stomach drop like a stone and wreak havoc with your emotions.  Almost every day, I come home feeling like I've had both the best and worst possible day, all in the span of a few hours.

The only way to make it tolerable is to pick a specialty you love.  Even in the ED, while I'm trying to avoid the obvious OB or Gyn cases as much as possible, when I end up with the occasional patient with birth control questions or a positive pregnancy test or concerns about her bleeding, I get to remember why I went into OB/Gyn. Women's reproductive health just is fascinating to me, and I love getting to talk about it with my patients. (There's nothing like some real talk about how great IUDs are to brighten my day!)  Those moments make it worth it; the rest of it is just the toll on the road.

June 30, 2014

Paging Dr. L

I can hardly believe it, but the day has come. Tomorrow is my first day as a doctor. They've given us long coats, taught us to use the computers, and explained medical malpractice insurance. We've seen the passing of the old guard, with the graduation of this year's senior residents; we've met with the new senior residents to get to know them better.

All weekend, I was nervous thinking about how to tomorrow would go. Today disappeared into doing nothing and I feel like I wasted my last day of freedom. But as I packed my tote bag for tomorrow, I began to feel more settled. Putting my stethoscope, scrub cap, glasses cord, and various reference books into my bag made me feel like I was more prepared. These few accoutrements are like security blankets, my lucky rabbit's feet against the unknown.

It's exciting to realize I'm starting the first day of my real career. I've waited so long to do this, and it's finally here. Watch out OB/GYNs are on the loose!

May 5, 2014

Poured Wine

I want it to be Spring.

I bought skirts and dresses and light scarves, and I wanted to put them on and sit in the late afternoon sun drinking rosé wine.  I did this, and I thought of my fragile French professor, who was une vraie française provençale, who drank her bone-dry rosé with a single ice cube in the golden warmth of a Nice cafe.

I want to read books in the sun and feel the air gently against my cheek, but this wind is too brisk to be frais.  The long winter has dragged its feet into Spring's domain and I want it gone, I want to shake it off like a dog that ran through a puddle.  Instead, it clings close, holding on for one last month.

Every spring, I forget, the way my voice forgets to separate you and all when I talk to my family on the phone.  The barest hint of warmth and sun sends me sprinting to a garden shop for seeds and soil, even if that single warm day is in February.  But this is May, and it is still too cold for rosé on the patio or for sandals or shirts with no sleeves.

I poured the wine anyway.

March 31, 2014

A Perfect Match

The morning of the Match, I woke up from a dream where my envelope was drawn first and I matched to a program in Philadelphia.  Five hours later and I knew that at least half of that dream - where I matched - was real!

The deans from Academic Affairs had placed the envelopes with our Match results in a giant brass cage that spun with a handle.  One by one, they drew an envelope, read out someone's name, and collected a dollar in return for the results (the last person called then got to collect the money as a reward for having to wait that long!).  They didn't draw my name first, or second, or even at the beginning - I was somewhere in the middle. All of us were seated around tables in the Alumni Center, waiting anxiously for our chance to find out where we were headed.  One by one, my friends at my table opened their envelopes.  We crowded around them each in turn, peering over shoulders to exclaim with excitement when the location was revealed.

When my name was called, I took my envelope back to my seat.  My hands were shaking and my heart was beating so hard, I almost couldn't tear it open.  When I pulled the paper out, I smoothed it flat against the table and scanned it, unseeing, looking for the line that said where I was headed for residency.  I think I even had to ask my friends what it said, and then I saw it: OB/Gyn residency at Albert Einstein Medical Center! PHILADELPHIA, HERE I COME!

Now, I have to confess something.  Einstein wasn't my first choice, it was my third choice.  But after I submitted my rank list, even though I really liked my first and second choices a lot, I kept thinking about what living in Philly would be like.  I actually had two different dreams where I matched there, and I when I thought about my interview days, I definitely had the most fun at my Einstein interview.  And Einstein was the program that I felt had really wanted me the most - when I sent them an email to let them know I had them as one of my top 3 choices, I got an email back from the department Chair and the program director. So when I read that I was going to be one of their 5 new interns, I was actually thrilled. My eyes teared up (but I didn't quite completely cry) and I was really, really happy with where the Match had sent me.

What they don't tell you about medical school could fill volumes, and even when you've been trucking along, you always sort of think that Match Day is going to be the best, happiest day of your life.  Sure, I was happy with where I was going - but not everyone was.  Later that evening (taking a break from our pub crawl before heading out again to go dancing), several of my friends and I were chatting about what the summer would bring.  The emotional reality of Match Day is not a pure and simple happiness, even if you get your top choice.  I had this realization that my friends would all be moving far away - some of my very good friends would be on the complete opposite side of the country, in Arizona.  While I was lucky that a lot of my friends from other schools were coalescing in Philadelphia (and one of my best friends would even be living in the same neighborhood/region as me!), some of my friends were leaving for parts unknown with only one or two classmates to join them.

As I've started looking for apartments and calculating moving costs, it's been difficult to wrap my mind around leaving Milwaukee.  This past weekend in particular, I've been in a nostalgic and sad funk, with a lot of fears picking away at my excitement.  I'm moving not only to a new city, but a whole different part of the country. There's a whole bunch of new cultural nuances I'll have to relearn, the way I had to readjust when I moved to Wisconsin. There's the scary thought of being completely alone in another new, larger city that I'll have to figure out on my own.  And running through it all has been a bit of melancholy for my romantic life.  Just when I've opened myself up to possibilities here, the time has come to move on and move forward.

Who knows what the summer will bring? I know I'll have almost a whole month to explore my new city before residency starts.  I know I'll have to pack up everything I own and haul it across the country.  And I know that it's going to be scary and exciting and new and terrifying and probably a little lonely at times.  

But I also know that it's going to be worth it.

March 19, 2014

It's Real, Now

Monday, March 17th was the day. Not Match Day - not the day we find out where we're headed for the next three or four or five years of our lives - but the (unofficially-titled) SOAP day. As 11am ticked closer on clock, the five of us in Health Policy sat around the conference table after class and counted the minutes until we would get The Email.

At noon Eastern time, the NRMP released emails and the results on their website: a simple title ("Did I Match?") and a first line in the email that said, for most of us, "Congratulations! You have matched!"  Those who didn't match were notified that they were eligible to begin the SOAP process, an alternate way of finding a position for unmatched senior medical students.

Needless to say, we were all on tenterhooks.  Silence would fall around the conference table and then we would burst out again with the same comments: "AHHH!" and "THIS IS THE LONGEST MINUTE OF MY LIFE!" and other frantically hyperbolic statements. At the stroke of 11, we all logged in (or attempted to!) to find out our results.  I actually got locked out by the website experiencing thousands of medical students trying to discover their fate at once, but luckily my email arrived right on time with those three sweet words: You. Have. Matched.

The immediate flurry of text messages and Facebook posts then began and after confirming that all five of us in the room had matched, we giggled sporadically and set about telling everyone that it's official: we're going to be doctors of the kind that we chose!  For the rest of the day, I kept having moments where I thought, "It's real! It's really happening! I'm going to be an OB/Gyn!"

I knew exactly how I wanted to celebrate.  Last fall, I applied for an award called the Warrior Healer award through Med Students for Choice.  They pick two graduating medical students who are choosing to dedicate their lives to OB/Gyn and, in particular, to providing abortions as part of their eventual practice.  I was selected as a semi-finalist, but the award went to two other (absolutely deserving) women I would be honored to call my future colleagues.

However, applying for the award - and thinking about what its title meant - got me to thinking.  There couldn't be a better way to sum up how I feel about my future career: I aspire to be a great Healer, and I refuse to back away from the fight it's going to take for my patients to have access to birth control, abortion, and basic human dignity and autonomy.  I have already pledged myself to fight for them, and my residency will be just the first step along that path.

After I passed my first Licensing exam, I got a tattoo as a sort of pledge to myself: medicine will always be a part of who I am and what I do.  I picked a symbol that would always be relevant, because as much as I think art tattoos are awesome, I can't see myself committing to a piece of artwork for my lifetime.  I can commit to a symbol, however.

I did a lot of searching for a symbol that would encompass everything I stand for and what I am pledging to spend my life doing.  The symbol for the goddess Ishtar (and her other incarnations, Astarte or Inanna) stood out as simple and beautiful: an eight-pointed star inside a circle.  Ishtar was the Assyrian and Babylonian goddess of love, sex, fertility...and war.  

The design: an eight-pointed star, symbol of
the goddess Ishtar (aka Inanna or Astarte).  Ishtar is
the goddess of love, sex, fertility, and war.
I knew this would be the design for me.  I decided to put it on my back: it could be easily hidden and easily shown.  I wanted it centered in my upper back, like the badge of honor I felt it would be.  My friend Grace went with me for moral support and helped me get the design sized and situated in just the right spot.

We got the initial placement right with the help of a little tape.
Greg, the artist who did my first tattoo, drew up the design, then had it printed on transfer paper (like a temporary tattoo).  This let him place the tattoo design exactly where I wanted it to go.

Next step: using cool transfer paper to put the design
on my back!  I double-checked in their mirror to make sure
the size and height was how I liked it.
Once I had it at the right height (right between my shoulder blades), Greg had me sit in one of the chairs and lean forward so he could work.

Not gonna lie, it does hurt a little.  Most of the time it's a sort of
stinging feeling, a little bit electric/zappy.  But over some parts of my
back it was a lot more sensitive...I focused on just breathing.
For some reason, the upper right quadrant of the tattoo seemed to be more painful...but then he would switch and do more work on the left side, and the fresh skin was pretty tender there, too! Overall, though, it was more painful than my first tattoo but not that bad - pretty tolerable except for a few minutes here or there.

The pain was good, though...I kept thinking: this is for Texas, this is for Missouri, this is for Ohio, this is for South Carolina, this is for Kansas; this is for Dr. Tiller, this is for my mentors, this is for Dr. Phelps, this is for Dr. Carhart, this is for Dr. Torres, this is for all the doctors I have met or know of who do this openly or quietly and hope to retire one day; this is for every broken condom, for every missed pill, for every teenager who didn't know any better, for every mother who can't have another child, for every rape survivor who finds herself pregnant, for every woman who wanted a baby and whose wanted child will never survive outside the womb...I will take this pain for a few minutes to show that I will always be there for them.

That is the power of a tattoo for me: it is transformative; it is identity manifest as art; it is pain transmuted into power.

Most of the way done! (Thanks, Grace!)
After about half an hour to forty minutes of actual tattooing time, he was done!  He had me look in the mirror to see what I thought - and it was perfect!  We had initially talked about maybe adding some shading to the star points to make them a little more three-dimensional, but I love the way the lines are clean cut and simple.

There it is! All done.  It's hard to see the details in this picture, though.
Now I just have to get through the next week or so with some careful showering maneuvers (I'm supposed to avoid having the water stream directly onto the tattoo) and I should be good to go!  My skin feels a little bit tight, the way a 2-3 day old sunburn might feel, but otherwise I don't feel a thing.

This is the best view I could get...lots of mirrors
and positioning my phone juuuuust right.
Now there's just a day and a half between finding out where I'm headed for the next four years - to find out where I will learn to be the Warrior Healer I am pledging to be.  I'm so excited! and I can't believe it's really happening! But somehow, it is...all the work of the past four - no, eight - years has been for this.

February 26, 2014


For all that it's the shortest month of the year, February has felt like the longest.  Maybe it's the long stretches of free time I have almost every day, since I've been on an outpatient clinic rotation that consists of mostly half-days and essentially no other work.  Maybe it's the bitter, bitter cold we've been having, which was split up by two glorious days of 40-degree weather.  Most likely, though, is the fact that February has been this empty space in the Match process.  Interviews for everyone are either over or winding down by mid-January, and once the rank list system opens on January 15th, the hard thinking begins.  

Making a rank list is difficult.  There are a lot of factors that I looked at with each program, trying to weigh good training against location against interpersonal connections against overall vibe.  For me, there were a few criteria that buoyed up good programs and caused other programs to be nearer the bottom of the list.

Positives: The top programs on my list had all or most of these characteristics:
- solid training, good reputation
- academic institution
- mid-sized (3 of my top 5 have 8-9 residents/year)
- ready access to abortion training without stigma or obstruction
- fun residents, people I could see myself wanting to hang out with
- good location: either at home or in the Midwest, or in a Midwest-vibe kind of place
- diverse patients and considerable access to underserved populations
- politically liberal location.  One can only struggle for so long against a sea of red...

Negatives: Programs at the bottom of my list tended to have the following characteristics:
- questionable reputation
- possible flaws in training - not enough Gyn cases, difficulty accessing subspecialties, unusual rotation schedules, problems in matching residents to fellowships or low boards pass rates
- smaller programs (4-5 residents/year)
- abortion training that was opt-in or that was difficult to access; or training that required extensive travel; or many rotations at Catholic hospitals where abortions, tubal ligations, birth control were not performed/administered
- weird residents, or people I didn't click with as well
- interviewers asked strange or offensive questions.  This happened only a couple of times but it left a bit of a bad aftertaste that was hard to shake off, even if the rest of the interview went well
- community programs
- non-diverse patient populations (particularly if fairly affluent and privileged). I'm interested in public health, treated a bunch of suburbanites would be a dream practice but not necessarily that fulfilling
- location: either too suburban, or in a town that's too small; or in a place that I wasn't sure I would fit into

At the end of the day, though, I found a few things interesting: my top 3 were pretty set from my impressions during the interview trail, as were my bottom 3.  The problem lay in the 7 remaining programs in the middle - each of which had some good things going for it and each of which had at least one serious flaw.  I agonized for a long time about where to put the middle programs, when someone passed on a piece of advice they'd been given.  It sounds simple, but when you put it to use it's quite profound:

"Don't get your first choice and be disappointed that you're not at your second choice.  Don't get your fifth choice and be disappointed that you're not at your sixth." 

Basically, after you make your list, picture yourself getting into each program (starting at the top) and see if there are any programs you wish you had put ahead of it instead. If there is, that program should move up in your ranking above whatever program you're on.  This should be done down the whole list, too - because you want each spot to be the very best option out of the remaining choices.  Keeping this advice in mind, I was able to sit down one Sunday morning and try to visualize my life at each place.  I must have been in the right mood, because my middle ranks just fell into place.  I put the list online and certified it ("what if you get hit by a bus! at least you'll still match" was the phrase that was most often used).  This was in early February, and then for a while I put the list out of my mind.  Occasionally I would peek at my list, which I kept on my phone, to check and see if it still felt right.

Yesterday, I logged into the Match website one more time.  I double-checked the list, to make sure everything was in order.  I double-checked that it was certified, which means it's ready to participate in the Match.  And then I took a screenshot of the list with the green "certified" text at the top, just as insurance.

The rank lists close at 9pm ET tonight.  Then the real waiting game begins.

January 28, 2014

May Die Tonight

Her room is at the beginning of the hallway into the hospital ward.  You might think this is a noisy place to be, but it is actually the opposite.  A long expanse of administrative offices provide a sound break between the elevators and the rest of the rooms beyond hers.  Further into the ward is the nurses' station, which is full of bustle and paperwork and ringing phones and vacuum-tubed medications at all hours of the night.  But the beginning of the hallway is calm and quiet.  It is the best place for her to be.  The small, square magnet on her door frame has a blue background and a white tree, a subtle sign to anyone who enters that the patient inside is dying.

I helped admit her when she first came in, with septic shock from an infection, but especially ill because she had metastatic cancer that had immobilized her gut, altered her urinary tract, and prevented her from eating.  She was in pain and clearly uncomfortable.  Her mother was a dominant force in the room, giving us the history and settling her in.  It soon became clear that the patient and her family were devoutly religious, and hoped she would be healed in a miracle.  She was only on our floor for a few hours before we transferred her to the ICU.

We followed her course from afar, knowing that if she survived long enough to leave the ICU she would return to our service.  We read about how she broke a bone just by repositioning herself on an x-ray table, because the cancer had riddled every part of her body.  We read the notes of the music-thanatologist (someone who studies death), a harpist who played bedside music in vigils that provided comfort for the patient and her family.

When she came back to us, she was in worse shape but the focus had shifted from treatment to providing comfort and pain control.  After a week or so with us on the floor, she began to weaken, as we had predicted would happen.  The cancer was too voracious; every day became a waiting game.

Each night, when our team would "sign out" our patients to the overnight doctors (give them a brief overview of each patient, with instructions in case of any overnight issues), we wrote at the bottom of her note: May Die Tonight.  We added it when her breathing had become labored, with pauses; however, we had underestimated her strength.  Each day, the footnote remained the same.  It was intended as a warning, a small heads-up for the covering team that they might want to be certain of how to pronounce someone dead, of which forms to fill out, of what kind of documentation would be required.

As the days went by, however, it became clear that "May Die Tonight" was more of an aspiration than a warning.  I found myself dreading and yet needing to visit her room each day, wanting to be available for her mother and family but uncomfortable at the way her death reflected my own mortality back at me.  I dreaded the daily toll of being frank in the face of her mother's continued (but diminishing) optimism -- or was it purely denial by now? -- that a miracle would occur.  I dreaded the strong memories of my grandmother's death a few years ago, a tableau of home hospice that prepared me for the stages of death as this patient progressed toward the end of her life.

Each night before bed, I would check the computer one last time to see if she was still living.  Part of me wanted to know so that I wouldn't be surprised in the morning; part of me was hoping each night that tonight would be the night, that soon my patient's pain and suffering would end and she would slip away to be with the Lord, just as she and her family believed.

It is a strange feeling to hope that your patient will die.

January 22, 2014

Chess and Butterflies

Everyone at my school is required to take two sub-internships (or "acting internships," as they're known elsewhere): one in a surgical field, one in a medical field.  For surgery, students pick all sorts of specialties or subspecialties; for medicine, we can pick from pediatrics, internal medicine, or family medicine.  All year, I had been dreading this month on the medicine ward team.  To me (and to anyone going into a surgical specialty), the endless rounds and notes and complicated admissions and calculations of fluid requirements, renal and liver function, and acid-base calculations are great ways to torture students and residents into submission.  Add to this the fact that there would be four months of vacation, boards studying, and an anatomy elective since the last time I had put hands on a (living) patient and I was pretty sure that January was going to be a hellish month.  

Much to my surprise, it has been great so far.  Part of this is due to my team: my senior resident is full of boundless energy and good humor (she reminds me of one of my best friends, so much so that sometimes I forget that she's evaluating me), the interns on the team are super nice and easy to work with, and both of the attending physicians have been fair to work for and great teachers to boot.  I've been learning a lot about how to handle patients independently, and the workload hasn't even been as much as I expected.

What I've really come to appreciate, however, is the actual intricacies of the work of internal medicine.  Much of the cerebral exercise of medicine--exactly what makes it so frustrating to someone like me, who prefers action and pragmatic, instant solutions to the long-term waiting of medicine and diagnostics--the cerebral exercise of medicine is exactly what draws internists to their field.  I found myself thinking about how I learned to play chess.  I read through a set of rules in the chess box, played a few games against my father and uncles, and taught my brother how to play.  I quickly tired of the game, though.  The only way to be a true chess master is to have the ability to think thoroughly about consequences: one must be capable of anticipating how the move now will impact the board six turns later.  In the same way, internal medicine is the chess of the medical field.  By adding up the signs and symptoms and lab values that a patient has, the internist comes to a conclusion about what disease process is going on.  She then makes a plan that not only addresses immediate concerns but anticipates problems down the road.

For example: a patient comes in from home with a pneumonia.  The patient is ill enough to be hospitalized but not ill enough to require a ventilator or significant interventions.  The internist makes sure to put the patient on appropriate antibiotic coverage, ensures that physical therapy is seeing the patient once it's clear that the patient is getting better, and when discharging the patient makes sure that he leaves with prescriptions for the right antibiotic as well as follow-up appointments with his regular doctor.  She might also send him with a prescription for a probiotic supplement (to ward off C. difficile diarrhea, a condition for which one is more at risk after having taken antibiotics) or with instructions to have a lab drawn to check on his kidney function if the antibiotics given during the hospital stay are harmful to the kidneys.  In all ways, the goal is not just to fix the immediate problem, but to look ahead and anticipate the next problem before it starts.

To put it another way, internal medicine seems to be the art of looking at butterflies and trying to see which ones will cause hurricanes and which ones will simply fly off to the next flower.

I suppose I've never been good at chess, though.  I always wanted to be the kind of smart that can look six steps ahead and know what the best moves are as well as the most likely moves of my opponent; however, even when I was playing chess or Risk or other strategy games, I grew tired and frustrated with them quickly.  I prefer the Zen approach of the surgeon: living in the present, dealing with what is in front of them, and approaching a problem with a concrete solution rather than a hypothetical or invisible one.  I do not think this is a superior approach; it is simply a different one.  

Some in medicine live in the present; they are the surgeons.  Some live in the future; they are the internists, pediatricians, and family physicians.  And some live in the past; they are perhaps the pathologists.  They delve into what has already happened, students of the body's history in order to explain the body's present.