We’re PRISONERS. Handcuffed. Placed in a 6 x 8 cell. Told what to do and when by wardens who have no idea how to handle a ward. When you are fighting the uphill both ways, barefoot in the snow battle to become a physician no one mentions THAT in the brochures for medical school. But then, perhaps there would be an excess of baristas and an even greater shortage of physicians.

Then, when you’ve actually made it – when the battle is over and you stand triumphant over the enemy that were drugs you were unable to pronounce, diseases you knew you and half of your closest acquaintances had acquired, origins and insertions of muscles you previously did not know existed, and every crease and crevice of every bone in the body. You are victorious. You will go out. You will use those drugs to treat those diseases and heal the muscles and bones of the bodies of people who place trust in you and your education. Except it’s not like that at all. Because you are prisoner 8675309. Yeah. They’ve got your number. THEY. Who is the infamous they? Who is holding bright, motivated new doctors hostage? The insurance companies. The patients. Their parents or their children. Google doctors.

TRAPPED!! New physicians rush into the fray of practice believing their desire to cure disease, heal the masses, change the world will be enough to overcome the red tape. New physicians are armed with the drug of choice, the gold standard test, and algorithms designed to identify, evaluate, and treat disease. But then again, “anyone can find disease, to find health, should be the object of the physician”.¹ So the physician seeks out health and prevention of disease, and is met with a grown man with his fingers in his ears saying “nah-nah-nah, I can’t hear you”….seriously.   The insurance company denies the drug of choice because it’s not the preferred drug on the plan. The gold standard test has to be pre-authorized – by someone who graduated from high school. The parent denies the vaccinations that have eradicated disease because Google said Andrew Wakefield said mercury in vaccines causes autism.

FREE public service announcement: Vaccines do not cause autism. Vaccines prevent disease.

However, like most new providers despite the challenges, “I find I’m so excited, I can barely sit still or hold a thought in my head. I think it’s the excitement only a free man can feel, a free man at the start of a long journey whose conclusion is uncertain.”² At the end of the day, a patient realizing out loud YOU are their doctor, THE person they can confide in, the person that will treat the disease, cut the red tape, and jump through the flaming hoop, if necessary. Because, YOU ARE A DOCTOR. “Some birds aren’t meant to be caged. Their feathers are just too bright.”²

1 AT Still

2 Red, The Shawshank Redemption

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“I love crocodiles. They’re like little tiny babies,” number three reports from her seat in the back. The next question: “Mom, do you love little tiny babies”, hits me from left field, but I swing with an, “Absolutely. I love you, baby. Yes ma’am.” However, lately, I’ve been up to my armpits in alligators. And, I am not loving that. Nope. No way. No how. This is not the adventure I wanted to take. Never-the-less, here I am.

Premedicine students see the beauty of medicine for all of the things it can be. The chance to develop a cure. The opportunity to offer a cure developed. Patients graciously accepting a developed cure and well, being cured. Or perhaps they see the chance to intervene in a patient’s life prior to the development of disease. Offering preventative medicine to interrupt the disease process prior to its onset. Maybe educating parents on the developmental milestones for their little tiny babies. Even still, the premedicine student may see the possibility of offering comfort to patients when there is no cure. Premedicine students see medicine in its purest form. The reason we all set off on the adventure.

As medical students, the medicine becomes the adventure. Learning the science of medicine itself is the challenge. Miles of books to be read, seas of drugs to be learned, mountains of tests to be taken. Once the finish line of medical school is passed, the adventure continues through residency. Residency is where you BEGIN the adventure that is learning the ART of medicine. A friend once told me you can train anyone the science, but it takes a person with the inner gift to master the art of medicine. Our gifts are revealed in times of turmoil and distress. I remember something about coal and diamonds…but I digress. Frederick Douglas said, “Without struggle, there can be no progress.” The last year fighting alligators in the swamp has helped me to progress – as a mother, as a physician, as a friend, and as a wife.  Take no prisoners, leave no witnesses.  I have learned a very powerful lesson. “Don’t taunt the alligator, until you’ve crossed the creek.”

However, there may be a diamond in this rough yet. I start on a new adventure tomorrow. I am excited. I am hopeful. I am certain I will be reminded of the initial beauty of medicine. What I am not – is looking back.

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I love my job. The reason I know I love it, is because I come into your room in the dark of the night to take care of you. I take care of you and yours when my own need taken care. I set aside the recitals, the school programs, and the PTA events to be with strangers at their time of need. I stand beside the gurney in the ER and discuss the risks and benefits of continuing your care. I discuss how aggressive you want me to be in your hour of need. Then, I follow you to the floor. I check in on your nurse to make sure that I’ve not forgotten the small details of care – like whether or not you have a diet ordered so you can have breakfast in a few hours. You may be feeling better or you may be worsening. I evaluate my treatment plan and worry and pine over you. Your job is to get well. My job is to worry. I do my job very well. The nurse pages me and your condition has deteriorated further. I stand with you as your soul leaves your body. I comfort your family after you have gone. We tell each other that you are in a better place. And my pager erupts. Someone else needs me. I think, as I take the stairwell, running over your last few hours. Is there a sign I missed? Did I do everything I could have or should have done? The next page is a new life entering the world.

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She grasps her chest dramatically and falls to the floor. Her eyes flutter as she tries to hold them closed. Her one arm across her chest the other flailed in theatrical fashion to her side. She’s dead. Her heart is broken. The other jumps from the bed, and after landing, reports her leg is broken. She hops about the room, unable to use the leg and there are no crutches or small wheel chair for her to use.

“Sweetie, are you okay?” “Mom, mom! Mom!!” “I’m not dead. I’m okay.” This last sentence in addition to the frantic “moms” break the trance that the chart-grind has induced. “What?!” I start. “I’m not talking to you. I’m talking to her.” She replies. This is number three discussing number two.   I realize the pretend play now. The doctor kit is scattered over the floor. Stethoscopes are draped from both necks. The pager hangs from one pajama dress. They rotate quickly back and forth who is the doctor who is the patient. So I join in, to number three, “are you taking care of her?” “Yes.” I smile, brushing the curls from her sweet forehead, “You’re such a great doctor.” “I’m not the doctor. I’m the mom.”

I watch in amazement as the two littles easily rotate roles. Why is this a difficult task for me? As I near the end of the second month of my practice, I realize over the last month, I have plunged beneath the seas of work and have not surfaced for life. The balance is off. I have the sensation immediately of being hit by another wave before I have gotten my breath. I can’t help but be distracted by the freedom with which they “practice” their craft. Magic Band-Aids are applied over broken hearts. The otoscope is used to evaluate the broken bone. The blood pressure cuff is applied to the ankle as a cast of sorts once the diagnosis has been confirmed.

Turning back to the computer, I stare at the work-list with charts, results, documents, and tasks taunting me. “You cannot complete me.” It’s like building a sandcastle at the edge of the sea. You may get the first towers built. You may insulate the castle with a moat. However, the tide is coming. And the work you complete will shortly be washed away. This is one of the most difficult lessons to learn as a new doctor. However, I am bound and determined to build. I will build a practice, but I will also build a life. It will be another long night. There are only a few times that there is this type of carefree play. The charts will wait. The broken hearts and legs I have seen through the day can have their notes finished after bedtime. Right now, I have two little girls that need a story and a cuddle, and I need a lesson in multitasking.

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Let’s talk about expectations. And I’m talking the Dickens’ kind. When you watch television, the food flaunts itself before you. Tempting you with golden buns and perfectly placed pickles. The models eating those perfectly styled burgers are the same – airbrushed to perfection. Most often, limbs are stretched to unrealistic proportions and curves are molded and erased to fit someone’s view of beauty.

When someone first takes the baby steps to venture into medicine, they expect to find the cure for cancer. They expect to heal the sick and raise the dead. However, all is not as it seems.

The hamburger, and I’m not just attacking hamburgers – but that’s what’s on the menu tonight, is perfectly stacked and delicious appearing. However, when photographed from the back reveals the T-pins, sponges, and wax to make it so. So much more is revealed when the actual food itself is discovered to not be food at all but some substance that takes a better photo. Those ads sell because they appeal to the your (and my) mind’s eye.

Medicine, when photographed from the back-if you could do that, reveals the red tape of unrealistic processes and procedures, coding complications, and the reality of the EMR. The delusional that enter medicine only see the styled front. We see patients. We see disease processes that can be treated. We see magic.

Who among us has not given “the talk” – I’m sorry your loved one is dying – only to see them make a full recovery. Later, they return so you can bang your head against another wall convincing them controlling their diabetes and hypertension could help ward off another heart attack. Who has not seen a patient survive a fatal congenital anomaly to later tempt fate with smoking, drug use, or some other equally destructive behavior?

But the dang ads are so tempting…everyone looks so happy. Not in the cigarette or drug commercials (I already told you those were fake…pay attention) – but the ads that are our experience. Ads that convince us this path is ours. Physicians, innocently, but deceptively coax students into deciding their specialty is the right one. Often, one preceptor can change the entire direction of a student. Recruit them to the dark side – because we have cookies or ice cream – or give them such a strong aversion to the field they determine then and there they will never practice in that specialty.

It is so difficult to then leave that daydream with perfectly proportioned everything and enter reality. Although they have seen some tarnishing of some their ideals, most residents graduate with a fire to still heal the sick and raise the dead. In the first years (let’s be honest weeks) of practice, it’s hard to see the magic. It’s hard to remember that even though the burger is not as pretty as the ad, it is still pretty damn tasty.

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Birthdays are special days. The day you became you. The culmination of your parents’ genes into what is uniquely you. “Today you are you! That is truer than true! There is no one alive who is you-er than you!”¹ I have had a truly remarkable year. This time last year I was beginning the final year of residency.   I was at the top of the food chain. The senior walking through the halls. The short-timer.

The hubs and I spent a wonderful weekend away. We went to our old haunts to eat, drink, and celebrate. Celebrate the survival of another year. But oh, we have done more than survived this year.

But what about those that haven’t? The day prior to our whirlwind celebration Katroo-style, I had a full clinic afternoon. I was on the verge of celebrating a year that has past and a year about to come when I was smacked with a patient in the afternoon whose years have now turned to months. She reminded me of how just mere months ago, she was diagnosed in her own whirlwind. In the blink of an eye, she went from an 80-hour a weeker for the local university to a patient with cancer. Every day is about the next appointment. The next time to take medication. The next symptom. On leaving, she told me she was just glad to have survived this long and wanted a hug, in case. She was weeks past her original deadline. There will likely not be another birthday for her.

The next day brought the stark contrast. Giggles. Singing. Dancing. The happiest of birthdays.  I am so incredibly blessed.

Then, from the top of the mountain we were thrust to the valley. Knocked from our swirling glitter to the cold black and white of a multi-trauma MVA on the side of the highway. Thank God for a complete training that helped us help those in need as we were witnesses and first responders. I should’ve paid more attention during the wilderness medicine afternoons, though. The side of the road is neither an office nor a hospital.

After, when we were both coated in the blood of the fallen, it’s difficult to find that light. Where did the sun go? How did the clouds and darkness move in so quickly? How do you celebrate life when you find yourself surrounded in death? It was a long ride in silence followed by a longer hot shower. Then, true to medical form, you discuss. You dwell. You share with people who both understand, and who wish they understood, (but secretly are glad that they don’t).

PSA: Wear your freaking seatbelts people. And hug your loved ones.

We found the light, it eventually always comes back, and enjoyed the opportunity to celebrate another year, another milestone, one another.

¹Theodore Seuss Geisel

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One month behind me, I have a feeling of euphoria – and it’s not because I was kissed square on the mouth by a complete stranger. No lie. Well, I don’t suppose he was a complete stranger. I had taken care of him for two days. In the bargaining process for discharge, had I known that was what his hand held, I would’ve made my play from the other side of the room.

Apart from that, it was an interesting last week of my first month. This month, I was voluntold* to be a hospitalist. This was in addition to my expected duties of family medicine previously planned – outpatient, inpatient, obstetrics.

For you that don’t know the difference between a hospitalist and a doctor that visits the hospital, let me paint you a picture. The doctor that continues to do hospital work sees their patients in the hospital. Simply put, you’re sick; your doctor takes care of you. (A dying breed as mentioned previously.) The doctor has medical records, has rapport with the patient, and has the important history-medical and social.

This is drastically different than the hospitalist doctor. The hospitalist meets the patient for the first time at his or her worst. The patient is frustrated that they do not have “their doctor”. The hospitalist is frustrated with the limited amount of information available (or is not frustrated-and that’s even worse). I’m not sure how that is the hospitalist’s fault-however they take the brunt of the punishment.

And it is punishment.

I have grown so over the last week. TS Eliot said, “Only those who will risk going too far can possibly find out how far one can go.” I have had quite a few moments possibly going too far. The line between what was residency and what is becoming practice is quickly blurring-along with so many other lines.

Starting a practice has not been everything I had dreamed, but it also has not been the nightmare I feared. I have had a lot of help. I did miss the first day of first grade. I did drown a bit on rounds. But, I’m euphoric simply because I did survive. 264 months left.

*Deputy Adam

voluntold (v.): past-tense of voluntell; volunteered for something you didn’t want to do and have had no choice in.

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Hospital medicine and outpatient medicine are two very different practices. At SMA, we try to blur those lines and bridge the gap. Who doesn’t want to see their family doctor when they’re the most sick? It is a dying art, and we know it. This week, I’ve been an obstetrician, a rural family practice doctor, a hospital doctor, an attending, and a hospitalist. It was a busy week, and all of my personalities are tired.

I delivered my first post-resident baby. By section. At 10. At night. The mix of fear, loathing, and excitement left me with a serious case of heartburn. She was beautiful, though. And mom and baby did well, despite the complications along the way. You know the feeling you get right before you bungee-jump? I want to go. I don’t want to go. AHHHH! Yeah. It was like that.

It’s the same, isn’t it?! I was just practicing medicine and delivering babies in June. Why all of a sudden is it so different?

In the office, we are busy. We have a full schedule. What. In. The. World?! Most docs fresh out get a break. They get an easing into their schedule. It’s the natural order. People have to find you. They have to fill out paper work. They get put into your schedule. And slowly. Surely. You build a practice. Why didn’t my schedule get the memo? Must’ve been the ad in the sports section!? Maybe it’s the referrals, (keep ‘em coming). I’m not complaining, really. I’m just trying not to drown. I think I needed a few more lessons before deciding to do an open ocean swim.

The hospital service for SLFP was completely reasonable for a new attending. I had an awesome group of slaves, I mean, residents who are perfectly capable. One of the many selling points of SLFP residency is that it does train residents to be doctors not residents. I feel the need to regurgitate the lessons and lectures I have just learned, myself, so few months ago, to the new doctors in training. I find myself, when asked a question, looking around like “Are you talkin’ to me?!”

But in all seriousness, instead on the hospitalist service, you almost wish you had a gun that was holstered. You might need it! Some patients arrive armed. It may only be an index finger, thumb, and a paper bag. Or it may be the arm of a chair that has been disassembled and is now a bat for a minor-leaguer. So, duck if they have a bat. Because, after seeing 21 or more patients in 12-13hrs in a 72 and fluorescent environment, maybe it’s better your holster was empty. As 30 seconds to learn a lifetime of past medical that brought the poor soul in front of you is not long enough to know whether you should fight back or just get their coffee. Maybe I won’t be a barista after all.

*Teresa, local CM comedienne.

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The oldest is reading now. I gave her Homer’s Odyssey for some light summer reading. She looked at me confused. Instead, I gave her Don Quixote de La Mancha. After all, she did start Spanish last year in primer. I’m not sure why she can’t leap into reading these texts. They’re the basics, right? The middle duck is now writing letters. On good days, she can copy her name. However, she refuses to scribe for me to help with the new overabundance of charts. Slacker. Finally, the Biz is starting to color within the lines. We are overjoyed. I have put in her application to Julliard, but they have not yet responded.

Surely at this point you’re thinking to yourself how ridiculous this sounds. It sounds ridiculous, because it is just that, ridiculous. I don’t expect the divas to learn something one day and be experts in the field the next. Why do we expect residents to become attendings overnight?

I stand in the dawn of my practice ready to face the day with some trepidation, some excitement, and a whole lot of fear of the unknown. The funny thing is, I know these people. I know this place. I know the computer system. And I know where to find the bathroom. Everyone knows the most important thing in starting a new job is to find the bathroom. However, as I open the doors on the next chapter of this great adventure, I feel myself wanting to hide in the bathroom.

Tomorrow will be just like the last day of residency. The only difference is that there will be no one to sign off the charts. No one to sign out to after the work is done. The office will be the same. The medical record will be the same. And there is a great likelihood that the patients will also be the same.

The difference is, it’s now my license. The difference is, my nurse and I will have our patients. We will not have patients that we inherit (if we haven’t already). I will not have restrictions on duty hours. There is no next rotation. This is our life. So like a deer in the road, I stand staring into the headlights that threaten to run me down. I do not plan to be road kill. And all those that wanted venison tonight for dinner, will just have to starve.

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It’s a golden weekend.  Two days.  No work.  All play.  Golden Weekend!  Those are like unicorns or leprechauns.  To those in residency, the golden weekend is mythical.  Because, in reality, who has two days that they don’t fill with work?  Normally, in residency your every day work-list builds up while you are in the confines of your 72 and fluorescent environment.  You may finish all of your charts, review all of the laboratory values, sign the documents, but there is still work to be done. 

Typically, at SL we have more than our share of golden weekends.  Some may say we have it easy.  (Don’t admit it to the GME, but we do!)  We usually average two golden weekends a month.  Sometimes more.  Say it ain’t so!  However, as third year comes to a close, I find myself spending golden weekends moonlighting, reviewing for boards, and preparing presentations.  There is a point that medicine actually became my life.  I’m not sure when that happened, because the things appeared at onset to be independent.  The swirling of ice creams that has now melted into…one…big…mess. 

In medical school, the kids, (you know, the single-party until 5am-sit through exam day-and still survive med-school), always wished they had my life.  The life of having a regular someone to come home and share in your struggles or successes, in addition to having a baby with her own struggles and successes.  It was a Venn-diagram with me being the only common link.  Slowly, as I have progressed through and am now at the precipice of beginning life as a REAL doctor, there are very few things that lie outside of center. 

This golden weekend, I’m coloring outside of the lines.  I have turned off my pager and left it in the car.  I logged out of Citrix, as the notes can wait until Monday.  The questions for board review will still be there after the weekend.  The presentation can be finished next week.  This weekend, I have a dear friend coming into town that I have not seen in forever.  At least it feels like forever.  The last time we had a visit was sometime in the blur of intern year.

This golden weekend, I will drink wine and monster energy drinks.  I will eat carrots and peanut butter.  I will laugh at our silly mnemonics that saved our butts on Neurology exams.  I will broaden the blue with memories, paint, music, and food.  I will share the divas with their favorite shoe-loving aunt.  It’s definitely a golden weekend.

If you have more than enough, you have too much.
Unless it’s love. Or shoes.  ~NW

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