Beneath the Surface

I’d like to thank you ahead of time for indulging me, because I’m about to spend an entire post airing out a few of the worries and fears that have been building up. You know, when people ask me how med school is going, my answer is usually, “Great! I love it!” I dislike talking about myself to a fault, to the point where I think I subconsciously cut conversations short with a boring answer so I don’t have to continue saying things about my life. (I’d rather think that, than face the fact that I might actually be boring!) Anyway, I do love my experience as a medical student so far, and I will continue to talk about that in other posts, but it doesn’t mean that I don’t often feel unsettling fear or doubt. Here, I try to put these feelings into words so that they don’t overcome my ability to participate in the moment and continue learning as actively as I can.

First, I’d like to address the exhaustion that I’ve been giving in to more often lately. When I first started undergrad, I said “yes” to everything I was invited to. I’m not kidding! I told myself that to say “no” meant that I would miss out on making friends early. As an example, I forced myself to sit with new people at lunch in the freshman cafeteria every day until one day, I sat down with a group of people and they proceeded to ignore me because they already knew each other too well. I ended up attempting (failing) to keep up with their conversation, and then realized I was probably being annoying. At that point, I realized that we had passed the Time when sitting with random people was Socially Acceptable. (Though some people had the ability to continue throwing themselves into groups of new people throughout the year and integrating just fine. I had limits even as a bright-eyed freshman.) Please don’t feel sorry for me, I’m just giving an example of how hard I tried during freshman year to meet new people. Now, I feel tired after 6 hours of class, and can’t bring myself to go to events that I was originally interested in. I often spend lunchtime trying to recharge so I can face people again later. It’s not that I dislike talking to others – in the moment I really enjoy talking to friends and just being in everyone’s presence. I just no longer have that mentality of “forcing” myself to do anything. I’ve come to terms with the extent of what I call my social stamina, but I just wonder if this will affect my capacity to function after a long day of talking to patients.

Second, I think I have a hard time committing to things I was originally very excited to start. I have about ten Word documents with unfinished posts and ideas for this blog. The ratio of my half-finished knitting projects to finished ones is ridiculously high. I started a collection of recipes I like, and it currently has two recipes in it. This is a trait of mine that I’ve wanted to work on improving for a long time, and each time I get interested in something new, I promise myself that I’ll stick to it. We recently finished our midterms, and I’ve found myself with some extra time. I decided to pull up the Note on my phone where I’ve been keeping a list of books I want to read. It was a fun walk down memory lane – apparently I wanted to re-read “Eragon” at some point – and I decided to check “The Wheel of Life” by Elisabeth Kubler-Ross out of our school library. This morning, I read about three chapters before I impulsively decided I should write this blog post instead. I’m afraid that I will live my life with a whole lot of 30% hobbies instead of completely focusing on a few passions. And how will that affect my ability to decide on a specialty? As an aside, I found another note in my phone of Things to Do Before Chicago, which I felt unusually sentimental about – it’s already been more than a year since we started med school! Time really flies. The note included things like “dry clean,” “transfer stuff to hard drive,” and “clean [my dog].” Ominously, “tell my brother about itinerary” isn’t checked off as done, so I hope that living uninformed of whatever this itinerary was hasn’t affected him.

Finally, perhaps most seriously, sometimes I have this fear that my capacity to care for others is only based on what I think of myself. For example, I’m really fond of a certain memory from back in preschool. My friends and I were at recess, and we were rooting around in the dirt for worms to collect in our buckets as usual, which I hope is a normal activity for children to participate in. One boy with bright white skin and light sandy hair came to join us, even though my other friends didn’t really like playing with him. He was blind and could never find any worms. Anyway, long story short, everyone ignored him while showing off the worms that they found. I remember that partway through recess I started giving him half of my worms so that he could have some to show off, too. It’s not that I remember that recess fondly because he was especially happy that I gave him some worms. I don’t even know if he was that excited about it. Instead, I mostly feel proud that my three- or four-year-old self was nice enough to know not to exclude somebody who had joined us. Does that translate to who I am now and what my motivations are? Am I only empathetic because I couldn’t think of myself as a good person otherwise? What if I were only nice to people because that made me feel better about myself? Is that okay?

I like to end every post with something optimistic, so here it is. Keeping a constant log of my flaws and fears in my brain is a very draining process. I think that by putting these negative thoughts into words, I will be able to parse out what I’m okay with and what I want to change. I can’t say that I can change that much, because these are worries that I’ve had for years, but I can at least continuously make an effort. Right?

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Beneath the Surface

Crazy Thoughts

For a reading workshop during our MS1 symposium, we read “The Use of Force” by Dr. William Carlos Williams, who was a physician that was more well-known as a poet. The short story was first published in 1938 and describes an encounter between a pediatrician and a little girl with diphtheria. The child is not cooperative during the interaction, and he ends up prying her mouth open forcefully to get a look at her throat. During our discussion of the story, which included a group of first-year med students led by a psychiatrist, I believe that we all agreed that we didn’t like the way the physician treated his patient, and that we were glad the encounter was a fictional story. We then had a conversation about different motivations when working with patients and whether there were more appropriate ways to deal with ingratitude. However, something about the character’s narration of his inner emotions resonated with me, which made me pretty uncomfortable. It’s not that I’d ever been gripped by fury and violence when interacting with a patient before, but there was a specific incident in my memory that had emerged when I read the story.

During the summer of 2014, I was a volunteer at a children’s development center in Taipei, Taiwan, working with children with cerebral palsy and other neurological disorders. Every day, I played with the kids, helped them when they had difficulty eating lunch, and guided them through various physical therapy activities. I was specifically assigned to a very sweet 4-year-old girl, Jackie. Our main goal at the center was to maintain or improve the kids’ mobility and cognitive abilities. As an example, every morning I would grip Jackie’s arms and walk her from the toilet to the sink, making sure that she put one foot in front of the other instead of seizing up or getting her legs tangled. The whole process took about 20 minutes – I quickly learned how incredibly patient every teacher there had to be during my few weeks there.

One day, I was getting ready to change Jackie’s diaper before their post-lunch nap. I usually had her lie down on the mat, but I had seen other teachers sit the kids down for short periods of time. One of the teachers suggested to me that I could cross her legs, so that she could practice balancing and sitting up for the amount of time it took me to cross the room and get her a fresh diaper.

After I was sure that Jackie was sitting up on her own, I went over to the area where all the kids’ backpacks were kept. There, I knelt to reach into the back of the cubby and grabbed one of her diapers. Timmy, a boy with Angelman Syndrome, had just walked in holding his nanny’s hand. He had dark, curly hair, and was wearing an orange bandana around his neck. He was always very fashionable and smiled at everyone. But he also had cuts and bruises all over his legs, and the teachers were always scolding him for recklessly careening across the play area. He turned to me with that joyful smile on his face, and I smiled back.

Then I turned, ready to head back to Jackie with diaper in hand. Suddenly, I realized that she had toppled to one side, still in the same spot that I had sat her down. Her legs were still crossed, but they were now in the air, and her head was resting on the ground. All around her, the teachers were busy changing the other kids’ diapers, and no one had noticed that she had fallen. She wasn’t crying or yelling. I have no idea what she was feeling inside – perhaps she was frustrated to be in such a predicament, or perhaps she was patiently waiting for me to come back.

Either way, I had a sudden, horrible, mad urge to laugh. And I have no way of explaining why. There was nothing about the situation that I found funny, and I immediately rushed across the room to pick her up. Luckily, she was unscathed and I changed her diaper with no further incident. But still, right before I flew into action, there was that singular moment where I almost – but did not – burst out laughing. Was I sleep-deprived? Was I desperate and frustrated, and somehow, the combination of emotions and exhaustion had produced this very inappropriate reaction in my brain? Retrospectively, I’m not so sure. I do know that I’m very glad it didn’t happen, and that to everyone else nothing appeared out of the ordinary.

Still, I want to address this completely irrational impulse I had in the moment. It’s the only time I’ve been so disturbed by a feeling that I can describe surely as wrong, and yet nothing really happened. It brings me back to the story that we had read. The physician in Dr. Williams’ short story did end up violently prying open the patient’s mouth, in a sense succumbing to the eagerness for aggression that had been cumulating during his visit. Meanwhile, in ordinary everyday life, I’m sure that physicians do sometimes experience emotions or feelings that are not optimal or even appropriate, whether it be tears welling up when talking to a patient, or feeling frustration toward a patient for their lack of understanding, or fear of failing a patient while reassuring them. Sometimes they might be confused or even repelled by what they are thinking to themselves. But they don’t show what’s happening internally, and perhaps compartmentalize those thoughts to be able to continue acting as a physician.

I guess my question is, when a feeling that seems inappropriate occurs and we “compartmentalize” it, where does it go? It’s very likely that we will never again address the fact that we had that feeling, and instead, act like it never happened. Is it okay for me to not ever acknowledge that I had almost laughed at Jackie, the girl who trusted me to take care of her, when she had fallen, and to speak about my time with her fondly?

We stress the need for empathy in doctors constantly, because it is of course a core characteristic that anyone going into med school needs to have. We are also taught that to make mistakes when treating a patient is inevitable – which is why we should learn to ask for help and learn from what we did wrong. We talked in our ethics class about how in surgery, moral mistakes (mistakes of judgement) are perhaps more grievous than technical errors. But I wish there were more discussion about what should be done in the case where a mistake never manifests itself physically and is rather a mental one – an error of the psychological kind. While our moral restraint ensures that these thoughts stay internal, I still believe that we should encourage discussion so that our moral compasses stay on the right track.

Crazy Thoughts

The First Step

I want to write about what I think is the first big mistake I’ve made in medical school – that is to say, the first mistake that made me stand back and think, should I be doing something different? I’m not talking about mistakes like thinking I can study all of histo the morning before an exam, or setting my alarm to 6:30 PM instead of 6:30 AM. While those are certainly mistakes that I’ve made more than one time and should probably stop making, they’re not the kind that made me question whether I could be wrong about my approach to life in a broader sense.

It happened while I was shadowing one day. The patient (I’ll call her Mrs. B) was there with her husband, and they were both in their mid-30s. She was sitting in a wheelchair, with thin tubes coming out of her nostrils, connecting her lungs to the oxygen tank next to her. What struck me was how engaged she was in what the doctor was saying, and how many questions she asked about what was next. Mrs. B had a manila folder full of papers on her lap (I hate how papers fall out of those folders so easily), and would ruffle through them to point to specific items she had questions about. Every time she had to reorganize the papers in her hand, she would end up breathing heavily, her body already desperate for oxygen after the physical movement.

I have to explain that I really admire when somebody is passionate about something, whether it be my classmates discussing the research they’ll be doing over the summer, or my friends talking about how much they love to run, or even overhearing somebody raving about a new recipe they want to try. I just love seeing people light up when they talk about something they’re truly interested in, and often I get so absorbed in what they’re saying that at the end I realize I’ve contributed very little to the conversation.

Looking back, I really hope that I wasn’t just staring at Mrs. B as she talked, because I was so taken in by how lively and forward she was as a person while talking about a disease that was in the process of killing her. It was an honor for me, as a first year medical student who could only tell you where the lung was and not much else, to be able to stand quietly in a corner of the room and learn from a patient many times braver than I was. I had my hands behind my back and was struggling not to move a single inch, so as not to disturb the intense level of energy and trust that had been established in that room. I thought that if I even rolled my shoulders to get rid of the ache that was creeping in, the patient, her husband, and the physician would all look at me in dismay because I had accidentally reminded them that I was there.

But then, suddenly, I was acknowledged. Mrs. B’s husband turned to me and asked, as if I had been involved the entire time, “So do you have any questions for us? We’re both teachers, as you might be able to tell, and we know that the best way you can learn is to ask us questions.”

What an amazing pair of people! I was so surprised, and I felt embarrassed for some reason. So I said, “Oh, no, I’m really just here to learn by observing. But thank you so much!” I mentally kicked myself immediately then, and I mentally kick myself now as I write this. I want to really think about why I felt like I had done such a wrong thing, why I felt so sure that I had let everyone in the room down.

A week before this experience, I had been shadowing in Interventional Radiology, and the resident led me along a hallway with thick, glass windows on either side. The windows looked in on the operating rooms, and the resident pointed a rack of lead vests out to me. “Please feel free to put one on and enter the room. You can see the operations more clearly then, since we do smaller procedures that might be hard to see from out here.” I nodded enthusiastically and thanked him, and he left to do the important things that residents have to do. But in my head, I thought, no, I’ll stay in this hallway so I can see as many different kinds of operations as possible. There will be other opportunities where I can enter the room and learn about the procedures more in depth. During that time, I felt that I had acted reasonably, and that this was the best way that I, as a med student of less than half a year, could learn about different aspects of specialties.

However, with Mrs. B, I was once again on the other side of glass window, peering in. This time, it was one that I had constructed myself by saying no, thank you, to learning more about the patient’s experience when she had offered. I thought that I had been actively engaged in learning while standing there in the room with the physician as she spoke to her patients, and yet I was politely removed, carefully keeping a distance under the excuse that I didn’t know enough yet and was only observing. What sort of image would that leave the patients with? That here was a medical student observing them as if she were still sitting in a classroom, watching a video of a doctor speaking to patients, rather than being there in the room, in real life, finally learning from experience after all the work she had put in to get to this point.

Flash forward a few months. The first-year med students at my school recently went through a team-building exercise where we were assigned into groups of 7-8 people, and we were recorded while we discussed items we would want to bring with us on a stranded lifeboat. There were so many things to consider – should we prioritize navigation and attempt to reach land? Or would it be better to try to survive as long as possible until somebody found us? Anyway, during the discussion I loved listening to my groupmates bring up movies they’d watched (namely, Life of Pi) or books they’d read and past experiences they’d had that justified their opinions as to what we should bring. We had an engaging and fast-paced conversation and eventually reached consensus. Afterward, when we watched the recording of our session, I was shocked to find that I actually hadn’t said anything, and instead had only laughed or agreed with what people said. But I had had such an amazing time! Did I really not contribute anything to our final product? I was again disappointed in myself, and felt similarly to when I had politely refused to ask Mrs. B any questions.

What I’ve slowly realized is that now that I’ve finally made it to med school and am realizing my dreams, it’s not enough to be involved as a listener, as an observer anymore. While it’s useful to absorb through listening and learning from talented peers, amazing physicians, and brave patients, that’s just not going to cut it if I want to engage with other people, if I want to truly participate in all the wonderful opportunities we have as medical students. This isn’t an inspirational piece because it’s all easier said than done, and I feel like it’s been a long, 6-month process of even realizing that I had a lot of self-discovery to go through. But I want to use this blog to document my thoughts along this journey, so that someday, maybe I’ll look back and think, “Wow, you finally made it.” But also so that maybe someone out there who’s feeling the same way will realize that they’re not alone. We all don’t know what we’re doing (I hope), but we’ll get there!

The First Step