Otherwise, Yes (freeflow)

The exhaution does set in eventually. It's not that bad. But it's enough. It's the hours on end of concentration. Organizing your thoughts, your time, your day. Keeping updated on everything, flowing in towards you, random bombardments of packets of information. Thinking about the science, the evidence, dealing with your uncertanties, knowing that you don't know, constantly asking, sometimes groping to make a decision. Meanwhile walk into the room with a smile, or a solemn face, or something inbetween depending on which patient it may be, it's not insincere, it's just hard. Everyone is different. Every patient deals with varying degrees of illness in different ways. Family dynamics. Or complete and utter lonliness. Both are to be dealt with, across the hall from each other. Some are aloof, or cute, or just are, and talk endlessly, making your day difficult, making you feel bad that you wished they would just be quiet. Some are wonderfully positive, refreshing for you to interact with, they give something to you everyday when you visit them as you marvel and rejoice in basking in this person's positivity - yet feel a pain inside that perhaps they even don't feel because you know that they suffer. Some are lost in grief, and to those you put in energy, but the day's constraints hold you back, and after some effort you realize you can't solve the problem in 3, 5 or 15 minutes. But sometimes it really, really is - the "small" thing that makes a difference as cliche as it is. The compassion, the soft, sticky, organic side of us wrestles and plays and merges and breaks with the test tubes and the white coats and the machines. Day in and day out. Everyday, I get to know many people more intimately than most know them. I go inside them, inside their lives, their minds, I tell them about their kidneys, their heart, their veins, their lungs, and I sit next to them when they cry, hold their hands, make them laugh, tell them bad things and good things. Two intimate friends, but not close. And I make many of these friends every day. Yesterday I had 8 patients under my care, I knew them intimately, I spend time thinking about them, their problems, how to solve them, I fielded their different personalities - and today most of them are gone. I was immersed into their world for a day and then I tore myself out, with the words, "Ms. Franks is discharged."

If you did all that everyday. Wouldn't you be exhausted?

No Internet for 2 Months = Withdrawal Symptoms

I just got internet in my apartment. I've been busy with intern year but I've got plenty to share and I'll start putting stuff up here again from time to time.

See "you" soon!

Standing Down Here, Looking Up There

"Doctor, patient ______ cardiac enzymes came back high, what do you want to do?

"Doctor, Mr. ______ is complaining of suprapubic pain and he can't urinate."

"Doctor, Ms. _____ in room 530? Her migraine still didn't break, what else can we do for her?"

"Excuse me Doctor, Mr.______ is having difficulty breathing, and he's on his second blood tranfusion - I think you should come take a look at him."

When I was in school (which was until 1 week ago) I was primarily repsonisble for doing well in my studies (if that can be called a responsibility). On occasion I was in charge of a group kids either when I was teaching or taking care of a bunch of my younger cousins. I was an RA in college, there I was responsible for keeping the peace on my hall and creating bonds between hall members. When I worked in the library at my medical school, I was responsible for making sure nobody walked off with a book or a laptop. I've been responsible (and irresponsible) with money, and I've been responsible for washing the dishes from time to time.

But I've never been responsible like this.

I've gone from being a kid who's been in school all his life to a young man (who still feels like a kid) who is being called "doctor" by whole lot of people. Like my fellow intern said himself, "When someone calls me 'doctor', I still don't take it seriously." I heartily agree. It's not that "doctor" has some big meaning in society (although it apparently does). It's not that people look up to doctors like gods (that stage in American history has passed -at least on the outward - thank God) - it's that I am starting to really see what being a doctor entails. And since at the same time I know who and what I am in reality, I can't help but not take myself seriously. But others do. The questions at the beginning of this entry (all real questions that were asked of me) are a testament to the fact that others do. I think this is the case right now, but what about in a year? In 2, 5, 9, 21 years? By then I will feel more comfortable with what I know, with my skills and experience as a physician. Will I start taking myself seriously then? My hope is that I don't. In a good way. In a good way, I hope that instead of starting to take myself seriously, I just realize that if you believe in God, that He gives you all the good that you have, then you can't take yourself seriously. You just stay humble. You just stay you. In place of taking myself seriously, I just have to focus on the patient. I just have to focus on learning as much as I can so that I can give the best which is what every person I treat deserves by the nature of this field. I have to focus on being a better person, so I have something of my person to give in my interactions.

But that's not so easy.

The amount of knowledge needed to properly care for the type of patients we see is immense. The amount of time we have to see the patients is little (given that we are being paged for the needs of many patients in one night). The energy that is required to keep on pushing yourself through the night, continuously learning on the run, is high. All these words that I write now, all the thoughts that make me human, are replaced by a sea of data, demands and the exhaution that comes with a 12 hour shift of concentration and focus. Throw in the dynamics of being in an academic setting with expectations that you are concerned about meeting; of interacting and working in a hierarchical setting of various levels of physicians, nurses and administrators; of finding moments to keep oneself spiritually grounded; of combating the fears and doubts about one's own abilities - and it makes for a challenge the likes of which I have never encountered.

There's so much else I could and want to say, but I'll keep it for another time. For now, let's just hope I'll be able to rise to the challenge.

Tired.

The day I was going to start my residency was when I published the last post... five nights later I am finally able to make it to the computer to write something... but I'm tired - so I'm going to sleep.

For now, suffice it to say that I was so damn nervous on my first night that I told an attending that we were going to order a "stressmill test" (i.e. a treadmill stress test) for a patient.

The rest of the nights were better, but these past few nights have been the beginning of something I have never experienced before in my life.

More later when I can.

OH MY GOD I'M STARTING RESIDENCY TONIGHT.

"Hi, My Name is Frank, and I'm Terrified."

The room was filled with twenty and thirty-somethings, buzzing about, coffee cups in hand, smiling, greeting, laughing, conversing. Today was the first day they were meeting, starting off a relationship that would last at least three years, if not for the rest of their lives.

"Hi, my name's David, and you are...?"

"So, where are you staying?"

"Are you from around here?"

"Which medical school did you go to," were random components of the various conversations taking place across the room. Everyone was talking about everything except the one thing that was on their minds: "I'm starting residency, and I'm terrified."

It was the beginning of Orientation for the Internal Medicine residency at my hospital, and I was one of the calm-on-the-outside but petrified-on-the-inside people who mixed and mingled with now and future colleagues.

We got our schedules. We got our ID badges. We got our full-length white lab coats symbollic of all that is doctor with our names and medical degree neatly embroidered on them - a patch on the side with the name of our institution, its logo, and the words, "Housestaff Physician" on it. And, last but not least, we received our pagers - the little black box that would become a part of our bodies, reminding us at every moment with its panicked cry that our life was not our own any longer - that instead our life now belonged to the people we served. This is what we signed up for. This is what I wanted to be all my life. Now I stood with my white coat in one hand and my pager in the other, my bag slung across my shoulder, excited and scared at the prospect of slipping the coat on and clipping the pager to my side.

But I was also scared. Scared of what? Didn't I just go through four years of medical school; two years of studying day and night and two years of wandering the hospital floors learning about the practicalities of medicine and interacting with patients, physicians and nurses? Yet throughout that that time I was never the real decision maker.

The two years I spent in various hospitals were all about learning how to work in the medical setting, how to ask patients the right questions and about reviewing and increasing my knowledge. Then I was simply a medical student, and no one really expected anything of me except that I show up to work on time, give basic answers to basic medical questions, and be able to interact with a patient at some minimum level.

All that was changing now. Now, I will get paged and be asked by a nurse what to do for Mr. Johnson's elevated blood pressure. I know the answer. That's basic physiology and pharmacology, something I've seen a dozen times before in the hospital. But this time, what I say, she will do. And what she does, will affect the patient. All of a sudden I doubt myself. Do I really know which medication to give for this particular patient and his unique disease-state? How much should I give? Is there something better than the choice that I am thinking of? What if I say the wrong thing? In the past, the resident would have said, "No, you should do X instead for Y reason." Now, it's just me, the nurse and the patient. I'm the one who's supposed to direct the care of this human being. Of course I will always have senior residents around to help, supervise and teach, even now. Still, the knowledge that I will now be directly responsible for patient care, that nurses will be calling me to ask what should be done in a particular situation, is very burdensome, and quite unnerving.

Everybody feels the same. I know it. The chief residents themselves told us stories of how nervous and scared they were when they first started. My friends who have now finished the residency remember clearly the pure fear that drove them in those first few months. Fear of messing up, fear of not meeting academic expectations, fear of doing or saying something stupid - but mostly fear of messing up.

Of course for me, things are a little harder starting out. You see, the normal routine of residency is what's called working on "the floors" (the medical ward). You arrive at 7am, find out from the night shift people what happened with the list of patients you are taking care of, and then round on them. You check up on them, review and order lab tests as needed, and spend the rest of the day managing your patients, whom you know quite well. At 5pm you finish and go on to the next day (unless you haven't finished your work or you're on call, then you stay longer). The "floors" have 4 teams consisting of one resident and two interns each (an intern is a first year resident) and they altogether take care of 40 patients (10 patients per team). I, however, will be starting on something called "night float". This means that while everyone else starts on Monday at 7am, I will be starting on Sunday at 7pm. For the next two weeks, I will be working from 7pm to 7am the next day, and my job will be to admit patients who need to be admitted to the hospital and, mortifyingly, to take care of any random problems that come up with any of the 40 patients that my colleagues take care of during the day. This means that my pager will be going off all night - my first night - with problems of patients that I really don't know that well at all. That doesn't really help combat my urge to run into the first closet I can find and hide.

Regardless of the fear and the difficulty, I am excited. This is one of the most challenging moments of my life and I know that I do much better as a person in the face of a challenge than otherwise. Despite my misgivings, I feel full of positive energy, ready to tackle whatever lies ahead. This will be great, God willing. I just have to keep on reminding myself that every doctor, big-name or otherwise, started out as a scared little intern.

All physicians start out the same, like me and one of my colleagues, who candidly introduced himself to the class with the words, "Hi, my name is Frank, and I'm terrified."


* * *

And now for your viewing pleasure...

The REAL Ghostbusters

And by "Real Ghostbusters" I mean, "Orientation". The real orientation. Which starts tomorrow.

The last two days were spent sitting in front of a computer screen learning the Electronic Medical Records (EMR) system that my hospital uses. It's comprehensive. There are no physical patient charts - all the information is neatly (but somewhat complicatedly) stored in the EMR system. I won't be "writing" orders, notes or history and physicals (H&P's) - I'll be typing them all up. There are of course positives and negatives to this.

The positive is that everything is very easily accessible, quick (once you're proficient at it), supremely organized for the purposes of having accurate records which of course impacts patient care positively, helps conduct research, and is a cutting edge instrument in holding health care professionals accountable for EVERYTHING. For example (and this is true), if you pick your nose while signed into the system, it records that you picked your nose at such and such time, at such and such place, while signed into such and such patient's chart - and in fact tells you the velocity with which whatever finger you used approached your nostril - all of which could possibly be construed as inattentiveness to the case of the patient.

Imagine the court scene.

"Your honor, I submit before the jury the fact that Dr. Brown - as the Electronic Medical Record clearly shows - was picking his nose at an incredible rate of 14 picks/minute. Let me ask you this, ladies and gentlemen of the jury... is it possible - even in the slightest - that a man, nay, any human, nay even goat, could concentrate on even the most mundane tasks while picking his or her or its nose at such an unthinkable speed, let alone on the complex medical case of Mrs. Rinkadink and her multiple paper cuts???"

And of course the disadvantage of having everything on Electronic Medical Records is the same disadvantage we all face in having everything in our lives computerized. One day, when our computers become smarter than us and consequently take over the world, they/it (?) will have access to all of our health records and financial information - traditionally two of the most private components of an individual's life. Also we shouldn't forget that our modern lives as we know it are completely dependent on the computer systems we have set up to manage it - business and all its aspects, banking, transport, electricity, water and other utilities, etc would all collapse or implode or turn pink or whatever if our computers took over. Or quite simply if a "computer system" broke down, or the internet caught a cold or something along those lines.

Well, thank God that probably won't happen in the near future - until then we just have the government and insurance companies to worry about.

On a more serious note - as if residency itself wouldn't be enough of a mesmerizing spiral of to-do lists - sitting in front of a computer screen, everything relating to patient care being taken care of by an endless series of clicks and clacks, only adds to the distance from our own humanity that paradoxically tends to occur during this time of a physician's training. Surrounded by suffering, we first put up barriers to allow ourselves to function properly (or else if we ran out of saline we could just cry some bags up on a daily basis), and then the nature of residency itself, embedded in the time demands of the current health care system, serve to take us further and further from the world of the heart that should underly every interaction with a patient.

Watch that idealism leak out of my ears faster than we can bomb another brown-person country.

For me, on a more personal note, keeping the big picture in mind is hard enough. Maybe my super-fast mouse clicking during residency will make it harder than if I had to slow down a bit and actually take out a pen. Or maybe not. Probably not.

Maybe this whole entry was just another soul's muffled cry against the coldness of modernity.

Orientation I

Tomorrow I start orientation at my new hospital. The first couple days will basically be learning the computer system, after that the real stuff begins... and the countdown to the first day of residency has started...

Me Intern, You Patient

So yesterday I decided, for some unknown reason, to visit the Department of Medicine at the hospital where I'll be a resident for the next few years. Since I'll be doing my Internal Medicine residency the Dept. of Medicine will be my home away from home. All my superiors (my program director, the chief of medicine, the chief residents) spend their days there, teaching, administering and evaluating us, the residents. I wasn't sure if it was customary to "drop in to say hello" before the actual orientation but one of my friends in my class said she had done the same and it was really nice.

"I met my attendings [fully trained docs], my program director, the chiefs - it was cool!" She said. "I can't wait to start there!" She said.

So off I went, thinking that I would walk in and introduce myself to the department secretary under the pretext that I will inform her of my new address in Chicago (we just got our new apartment, moving in soon), and just take it from there. I imagined the whole scene - I would walk in, confident as usual in my khakis and blue and black striped shirt with a smile on my face, introduce myself and be ready to receive a, "Oh! You're one of the new interns? Nice to meet you! Your address? Sure - oh, did you meet the Chief Resident? I think she's around here somewhere - let me introduce you to her!" And things would just progress nicely from there.

Of course, that is not how it went at all.

My wife dropped me by the hospital and I waltzed inside. My hospital. The place where I would get the training to earn the title of "doctor". I stopped at the concierge.

"Excuse me, could you please direct me to the Department of Medicine?"

"The deparment of medicine?"

"Uh, yes."

"Hold on." The woman at the concierge desk started flipping through a binder in front of her. "The deparment of medicine..." she repeated slowly, her brow ruffled in confusion. "What are you a resident or something?"

Oooh that sounded nice.

"Yes," I said happily, "I'm starting in a couple weeks."

She turned to the woman beside her, "Beatrice? Where is the 'Department of Medicine'?" Her tone of voice implicating that I had no idea what I was talking about.

"Oh, I think that's in the other location - you know, on Highland.", said Beatrice.

Both these women were obviously thoroughly confused. I started thinking of another possible name for it but couldn't come up with anything. In the meanwhile, the lady in front of me turned back to me and repeated with full confidence the same exact answer that Beatrice had, as if she had secretly referred to a hidden source that was completely unbenownst to me or anyone else.

"No, no I know it's here - I was here for my interview a few months back and I went to the - oh! Maybe it's the department of Graduate Medical Education?" An epiphany. That must be it.

"GRADuate MEDical eduCAtion!!? I ain't never heard of that before."

Sigh. I looked over to another place, a different desk across the lobby hall. Maybe they could help me. The woman called over someone else and asked her about the same imaginary department of medicine that I had asked her about - probably placing it in her mind in the same category as unicorns and carebears. Luckily this new lady knew a little bit about the hospital and said, "Of course there's a department of medicine - every hospital has one." I was vindicated. And I was on my way.

Half way there, I realized that the whole pretext for this visit - that I would inform the department secretary of my new address and take things from there - was a sham. I had no idea what the zipcode of my new place was yet. Six, zero, something, zero, one. Crap. In a flash, the butterflies in my stomach turned into octopuses. What was I going to say? Was I the only fool to drop in and say hello to the folks at their residency program before orientation? But my friend did it, why couldn't I? It seemed like a nice thing to do. But what if it wasn't really customary, what would they think of me? Turning back seemed like a very good option at this point.

I approached the elevators that went up to the department, and stopped. Then, I turned around, and started walking back where I came from. Forget it. I'm not doing it. There's no need. I'll just see them on orientation day. I walked half way back to the main lobby and then decided I was being stupid and that there was nothing to be afraid of. I spent two years of medical school approaching doctors and residents that were my superiors and asking them for help for this or that; I interacted with program directors and chiefs of medicine with the greatest of ease and confidence during my interviews for residency; I've given speeches before large crowds without any difficulty - damn it I can go and visit my own program administrators and just say "hello"!

I marched straight back, walked to the elevators, pushed the button and went up. Following the signs for the department of medicine I found my way to the hallway full of offices and conference rooms. My heart started pounding. My hands, dry just moments ago, were now covered in cold sweat. What the hell was going on? Just as I started getting cold feet again I saw one of the Chief Residents walking into her offce - I recognized her from my interview day.

"Hi, Laura?" I asked. I had been in touch with her over email for scheduling issues.

"Yes?" She responded in quite a friendly manner. Then, the heavens closed up, and any light that may have been shining on my being at that point ceased to exist, and the rest of the converation went something like this.

"I'm intern. I found apartment. It next to train station."

She was very gracious with me. "Oh! Hi, nice to meet you! That's great. So how far is it from the hospital?"

"Ten."

"Uh, great, that's awesome! So, you just came by..."

"Hello. To say hello. I live next to the train."

"Right, yeah, you already said that - well that's great, it's very nice to meet you, here why don't I introduce you to the other chief."

"I have address too."

"Oh, okay, did you tell Mary about it? Did you meet Mary? Why don't you come with me."

::grunt::

Laura led the way to Mary's office, the department secretary. I followed her, meandering on all fours, stopping to munch on some plants that were in the hallway.

"Mary? This is Dr. Saleem Niazi, he's starting here with us this summer."

Mary stood up and smiled, "Welcome! It's so nice to meet you, so just dropped in to say hello?"

::grunt::

The chief filled in for me, "He just found a place close the hospital, do you have the address", she asked me?

"Yes, but no zipcode, hahahaha, no zipcode. Is it problem?"

"No, no, we'll collect all the updated information when you all come in for the orientation", Mary said genially.

Finally, after a series of grunts and broken sentences, I was able to release a single complete sentence to facilitate my exit from the area.

"Well, it was nice to meet you both and finally put a faces to the names." I mustered a smile, acknowledged their mercifully pleasant responses, and left.

* * * *

The sweat that had burst out all over my body had cooled in the early evening breeze. I waited for my wife to come and pick me up from in front of the hospital. I don't think I had ever been so nervous in my life. Why? Perhaps it was that residency and all its new and terrifying responsibilities were embodied in that place and in those people. Perhaps it was the idea that the people I met would be my superiors, evaluating my behavior and progress throughout my training. I've never been one to be so nervous about such things though. When I related the story to my wife she comforted me by reminding me that I am always a harsh critic of myself and things probably went just fine and that it was natural to feel the way I did given the new, "first-time", situation.

I hope she's right. Otherwise on my first day of residency, I may very well walk into the first patient's room and say, "Me Intern, you patient."

Not Yet Chicago

After 17 years of living in New York, I moved to Chicago. My residency in Internal Medicine starts on July 1st and so we had to stuff our sedan with all our essentials and head out to a foreign land, where we know very few, and where very few know us. The land is different. I don't know any of the roads. I need a map by my side to navigate the massive grid that is unique to the entire "Chicagoland area" (which I believe refers to the city of Chicago itself -apparently referred to as "downtown" - and surrounding suburbs).

Will Chicago ever feel like home? My residency lasts for three years, but will I end up staying longer to do a fellowship? I didn't realize how much New York was home until I was getting ready to leave for here. This whole process, of packing, moving to a new place for the first time, wandering strange, unfamiliar streets in search of a place we can call home, has been reminding me of the nature of life itself. Are we not after all constant travelers in this world? Isn't this life simply a journey from one state of being to another, regardless of our status in society, our wealth, our family... where we live? Shouldn't the feeling of displacement that I am experiencing now be, at some level, a reality in my heart at all times - since we are all ultimately displaced from our one true origin?

"From Him we come and to Him we return."

Will Chicago ever feel like home? So far, not yet.