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.