When the Hands of Time Come Down with Carpal Tunnel Syndrome: Surviving the Residency Rut

Isn't it strange how quickly time flies?

If I earned a dollar for every time I heard that as an intern, I would likely end this year by walking up to the Gods of Residency and Improbable Living On A Little More Than Minimum Wage, coolly handing in my sickly, pen-and-crumb-stained coat and announcing, "Later, suckers - The Good Life just called, and it wants me back."

Or would I? Well, maybe it's my annoyingly evanescent, cheery, comeback-kid naivete speaking here, but...the answer for me is no. Apologies, grouchy, disillusioned doctor brethren .

(And somewhere, a prototypical wizened, gray-haired, overworked, be-spectacled physician-father still owing $10K in loans watches in despair as his bright-eyed five-year-old dresses up as a doctor for show-and-tell, and heaves a sigh: "Sonny, let me tell you: stay far away from medicine, okay? Go buy some lottery tickets. Or maybe try out for that famous show - what do they call it - American Idolism or somesuch?")

You see, after years of desensitization to such things as, say, watching thoracentesis procedure videos while chomping on a lunchtime salad, or thumbing through "Nummular Eczema and Guttate Psoriasis: A Diagnostician's Dilemma" powerpoints while sipping a nonfat extra-hot extra-foam cappuccino at Starbucks, medicine has gleefully invaded my soul. As a result, it's hard to imagine doing anything else, even if someone offered me an Out.(Unless, I suppose, such an Out involved being a Mystery Shopper at Anthropologie...or the person who gets paid to write those airplane magazine travel articles where they critique various 5 star hotels and fancy restaurants. Seriously! I'm good at that kind of thing: "The creme brulee at Chez Panisse, a delectable, buttery vanilla-infused flan capped with a crispy wafer of perfectly caramelized sugar coating, is the exclamation point on a sophisticated, blissful gastronomical sentence." Yes? Do any travel magazine writer scouts read this blog?)

That being said, no intern is immune to the Residency Rut.

The Residency Rut comes on slowly, insiduously, just as that once-pleasant salmon pink shade of daily progress notes begins to resemble partially digested Pepto Bismol. It's the point where days seem to congeal together in endless repeat...where the passage of time is measured in cycles of laundry (and renewed resolutions to purchase yet more underwear, until my entire closet is brimming with an endless supply of socks, underwear and scrubs - no more laundry!!), numbers of acne cream tubes (futilely, sigh) purchased, bottles of multivitamins consumed (Trader Joe's Gummi Bear Vitamins are my secret weapon in the battle against hospital food).

The Residency Rut, of course, in true medical form, carries its own pathognomonic signs and symptoms. A sampling:

- IOWS (I Only Wear Scrubs) Syndrome: the repudiation of the social norm of wearing tailored clothing in favor of sporting reversible, drawstring-based apparel to locales other than the hospital. Associated signs include more than 2 sets of scrubs in afflicted person's dressers, relegation of all non-sneaker shoes to the back of the closet due to disuse, and wearing of scrubs to public places such as grocery stores and gyms. As a result, the sensation of wearing jeans, slacks and dresses becomes strangely foreign (not to mention, rudely tight (yikes). Unfortunately, scrubs are false friends; that drawstring reassures you that you're svelte when in fact you've grown by half-a-person.

- Pen-Resistant White Coats: White coats are unable to succesfully contain a black ballpoint pen for longer than 2 minutes. This may, in turn, provoke the telltale reflex manifested by the seasoned resident - See Stray Pen on Table/Hand of Unsuspecting Fellow Resident; Mindlessly Grab and Place in Own Pocket.

- Weather Dissociation: Sunshine and blue skies become phenomena to be witnessed in snatches, i.e. through hospital windows in front of the seventh floor elevator as one makes their way down to the emergency room to admit a patient. Moreover, such glimpses underscore the truth of the anti-intern weather truism: the sun is guaranteed to be shining, the temperature beach-perfect and the air glorious precisely on the day you are on call.

- Food Pyramid Remodeling: The definition of "edible food" grows more inclusive, embracing such items as 2-day-old leftover pizza abandoned in a tepid resident lounge, or an 8-oz can of prune juice that beckons nonchalantly in the communal resident fridge. (I will name no names, but I have sighted a fellow resident sipping from a can of Ensure - vanilla flavor, to wit - one particularly brutal post-call morning.) As a result, the "food pyramid" transforms into a "food square" founded upon the four C's (Croissants, Coffee, Chocolate and diet Coke.)


- Mint Aversion: Okay, this one requires some background explanation. So let's face it, medicine is full of Smells. One's nose quickly learns that, in order to survive in the hospital, it must recalibrate, raising its threshold for defining a Truly Intolerable Olfactory Insult. But when a scent tests the limits of even this recalibrated nose - manifesting a "Code Brown" of sorts - hospital personnel know it's time to break out the CPR/defibrillator of olfactory codes: oil of wintergreen. Oil of wintergreen is the aromatic equivalent of a fire extinguisher: every unit has an emergency supply, stashed next to the unit assistant's secret (or not so secret anymore, heh heh) oatmeal raisin cookie supply. At the onset of the code, simply uncork the diminutive-appearing bottle and let the battle of the vapors begin. Unfortunately, the result is often a disconcerting olfactory tug-of-war wherein your nose and mind are conflicted (Brain: think wintergreen thoughts! think wintergreen thoughts! Isn't that wintergreen just so pleasantly non-malodorous? Nose: I don't care how much you try to brainwash me with dubious mint; there is some stank going on in here). In any case, the result of this odor antidote is that over time, an intern quickly develops a Pavlovian aversion to the scent of mint. It's like one veteran nurse confessed to me as we braved through one particularly challenging aromatic emergency: "I can never eat another York Peppermint Pattie again."

When the Residency Rut hits, there's only one antidote. That is: the rite of passage \of being an intern, otherwise known as Complaining.

By mid-year, interns are apt to crab about anything that is crabbable: cafeteria food, the weather, parking/driving/traffic, 4-hour rounds (too long), 1-hour rounds (not enough learning), sit-down rounds (too passive), walk rounds (too much exercise), overnight call, call until 7, call until 3, the very task of being in the hospital, too much autonomy, not enough autonomy, last-minute admissions, early-morning admissions, lack of space/computers/TV's/pager battery life/bathrooms/coffee cups/coat-pocket room, computer-based medical records (where did my note go? why did it delete my note? the computer ate my note! I HATE COMPUTERS), paper-based medical records (My hand hurts. Why is this paper pink? Writing notes is so 1998), messy handwriting, too many lectures, too few lectures, conference food (a favorite complaint), too many forms, paperwork, the smell on the sixth floor ward (okay, the smell on the sixth floor ward is a legitimate complaint - hands down wins the Most Minty Ward of 2009 award. What is going on up there??).

Talking to fellow interns across the nation, it seems that Complaining is a universal attribute of residency. It doesn't matter if you live in a place with four seasons (too much variation and high heating bills, can't wear open-toed shoes in the winter) or one (too boring, can't really justify coat/boots purchases); if you live in a bustling city (too crowded; expensive; parking nightmares; why are there so many people on the road at this hour??) or quaint town (nothing to do; dust storms; why are all my patients truck drivers?). Case in point: one might be mere minutes away from a glorious beach, living in a city with 300 days of sun. And yet, even this scenario carries complainability (where the complainants invariably seem to be So-calite females trying to find parking on a foggy Friday night in North Beach...)

Lest the gentle reader begins to perceive America's future doctors as a crop of whiny, ungrateful minions, let me hasten to elaborate a bit further on the role Complaining really carries. Much like oil of wintergreen's questionable efficacy in masking unseemly odors, Complaining - more accurately, commiserating - is a coping mechanism of sorts...if we didn't have some way to vent, we'd probably explode. (And you can imagine what that would do to patient care.) Every intern is going to experience the "I Got Slammed" days, which evolve somewhat like a bizarro, macabre "12 Days of Christmas": 12 hours of working; 11 hours since a real meal; 10 new admissions; 9 notes to write; 8 labs that didn't get drawn (and have to be re-ordered and re-followed up); 7 family members waiting for updates from you; 6 studies to chase down (and a hibernating radiologist that can't be found); 5 discharge paperwork sets to complete STAT; 4 consultants to call; 3 rectal exams to adminster; 2 patients that are crashing/hypotensive/septic, and - all together now - a pager on steroids.

In such cases, the bond of commiseration is part of what draws interns close together. Chances are, during those two-month marathon sessions without weekends off, there's someone else who can empathize with the plight of eating Cheerios and chocolate for dinner for a week straight. Or someone else who understands the incongruity of waking a soundly sleeping patient at 6:05 am to chirp contritely, "Hi Mrs. Adams! How's that diarrhea? And how are you feeling today? Uh - that is, before I, uh, rudely and inconsiderately woke you up from the rare snatches of actual decent sleep you managed to steal - sleep made all the more valuable in the context of your noisy neighbor who keeps yelling for the pirates to leave him alone?"

And then comes the turning point: where the trivialities, trials and tribulations of internship begin to transform from mint-green-scrub-filled monotony to a bizarre, Scrubs-esque, zany and quirky world to which You, gentle intern, have now gained access. It's like celebrity gossip - you're amused, enthralled and secretly drawn despite having a million catty things to say (oh come on. Don't pretend you didn't at least look at the picture of Seal with a mullet.

So here's to surviving the Residency Rut in one piece. Did I mention how much I miss having weekends off like normal people? Or how my brain has completely forgotten what it feels like to get 8 uninterrupted hours of sleep? Or how Trader Joe's just stopped making my favorite chocolate-chip date-nut bar? Or why we no longer have papaya at our morning conference breakfasts?

Grrr.

Match Day Musings: A Blast From The Past

So for those of you in the know, last week marked a rather momentous occasion in the world of future doctors: Match Day.

This event, however, is more than a "Day". It's the culmination of four years of willingly adopting an alternate lifestyle: Friday nights in the anatomy lab trying to make sense of a cadaver's arteries and nerves; Friday nights on call struggling to subdue a hyperactive pager; Friday nights cramming the brachial plexus pathways and Krebs cycle enzymes to coax out a few extra points on Step 1 (somehow these tasks take on a special poignancy on Friday nights).

This is the Day of Reckoning, where the universe is supposed to right itself according to the karmic equations of justness, where finally (finally!) money (money!) is to be earned Doing Something I Truly Love (or for a certain subset of folks, Something That Truly Makes Bank). In some cases, the outcome appears not quite so karmically just, leading to the day's semi-bittersweet tinge. But, when the dust settles, there is still solace in the pretty awesome fact that yes, you're going to be a doctor.

So one year later, here I was, walking down the street to the hospital to take another night of call. The bars and lounges lining the street seemed to be pulsating with a particuarly heightened sense of happiness, brimming with rather, shall we say, "happy" looking individuals toasting their future careers. That's when it hit me: today was match day! I stopped for a second, surveyed the scene and smiled benignly, like a mom who sees her young child eagerly begging to take out the trash every day and clean up Fido's "mess" since he's now become a "big boy". Ah, the happy, happy innocence of youth.

In the spirit of nostalgia that such occasions always seem to bring, I managed to dig up my own innocently happy musings during Match Day 2008. Here it is, in honor of match day and all the stellar folks who are now going to - heh heh - be interns next year!


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Written on Match Day 2008

Congratulations! You win a million dollars!

Congratulations! You've won a lifetime supply of Loeffler Randall boots!


Congratulations! You have been hired as Zingerman's International Chocolate Cherry Bread and Magic Brownie Consultant, involving daily taste-testing responsibilities!


Okay, so maybe not literally any of the above. But on March 20, as my shaking fingers ripped open that little white envelope to read my destiny in internal medicine, it pretty much felt like the same thing. (Well, the Loeffler Randall boot thing might be slightly, just slightly, more amazing. But I digress.) All the dreary days spent in Step 1 and Step 2 studying limbo, running on the treadmill to the pleasant entertainment of anatomy and pharmacology flashcards, languishing in the scrub-wearing rut and clothing erosion of third year, nursing shoulder injuries from Overstuffed White Coat syndrome and Prolonged-Retracting-in-the-OR-itis, falling asleep in the middle of dinner post-call....After years of relative modesty ("Oh no, Ms. Jones, I'm not a doctor yet - still got a few years to go!" *insert pleasant hearty chuckle*) and acting as lowest rung on the totem pole ("Can I get you a refill on that motor oil acid backwash - uh, coffee?"), here, FINALLY, was our day to shine.

Yes, for those eternal cynics and naysayers out there, I'm fully aware that in just a few short months we will essentially go back to being both modest and the lowest rung on the totem pole once more. But let's just try to stay in the sentimental, mushy feel-good mood for the moment, hmm?

On match day, as M4s on the brink of being *real* doctors, we stood wiser and older (as - sigh - my cavernous undereye circles will attest...future business for some generous dermatologists in my class?); having whittled down our white coats to the essential tools and cheat sheets we needed (hint: incoming M1s, resist urge to buy $400 ophthalmoscope), finessed our history taking and physical skills to the point where we no longer spent 2 hours obtaining a careful review of systems from a new patient ("So what were you saying about that tingling in the middle of your left pinky toe that comes once a year? And can you tell me more about that problem you have with your teeth itching?"). After a nerve-wracking month of waiting, largely spent rehearsing the task of saying, artfully and convincingly, "Hi, I'm Dr. K and I'll be taking care of you today" without breaking into a cold sweat, here it manifested: our futures in medicine.

Of course, the moment of suspense was only intensified by the super long process, planned by the powers that be in your typical, drawn-out, let's-make-them-agonize-as-much-as-possible-to-give-them-their-money's-worth-since-they-did-pay-us-a-month's-rent-in-fees NRMP fashion.

So you all know about the month of waiting after ranking our choices in February. The next step happened three days ago (March 17), at 12 noon EST, where we all received a "Did I match?" email from the NRMP. Hopefully, this would inform all of us that "Congratulations! You have matched!" (If not, though, then one would get ready to Scramble.) I was all set to check my email exactly on time. However, at 12 noon EST, my moment of reckoning was slightly shattered by the fact I got pulled over for driving with an older license plate. Unfortunately, reasoning with the police officer that today was You Find Out If You Match Day, or that I was just coming out of Waiting to Find Out If and Where You Match Month didn't quite work. So, after driving home, carefully rescuing a screwdriver from the depths of my supply closet, cleaning up all the old shoeboxes, toilet paper rolls and batteries that came toppling down after removing said screwdriver, wrestling off my old plate in the freezing Ann Arbor wind and replacing it with the a snazzier BNX 9007 - and then lovingly placing my Obama '08 sticker I had just received in the mail on the dusty depths of my rear bumper - I finally turned on my computer and affirmed that, indeed, I had matched. Whew.

And now as I'm beginning to reflect that drawn-out NRMP style of information conveying, I guess I should come to the point and return to that memorable Match Day at the Sheraton three days later. Amidst swanky chandeliers, hors d'oeuvres and a throng of family and friends, us nascent matchees placed our names in a giant fishbowl and waited to be randomly selected to come up on stage, where (if our hands were functioning) we were to open our envelopes and share our fate with the entire class. Suspense was obviously the theme of the day -and not just to find out where you'd matched. Did I mention the huge bowl of $$ on stage, filled by contributions from generous faculty and not-so-generous M4s, to be gifted to the last person who was called?

With each name called, I found myself even more on edge, hoping that everyone had matched into a place they loved, waiting to see where friends and classmates had matched, awed by the stellar places that were read. And while there are always the initial disappointments and bittersweet moments, I think we did, overall, really well.

So, at this point, inquiring minds likely demand to know, what about me? Well, right smack in the middle of the pack, I finally got called up to stage. It's funny how almost every moment is just framed in minute detail: pushing back chair, standing up (smoothing down skirt to make sure none of those unflattering bumps or wrinkles would detract from zee moment - I mean, Match Day is picture haven!), taking deep breath, clutching onto wrinkled unspecified amount of money to deposit into fishbowl, maneuvering gingerly to stage, entering in the wrong direction at first and being gently guided to the other side, then walking across the stage, receiving the envelope of destiny from the Dean with my name printed in official Times New Roman, wondering tangentially why anyone would pick Times New Roman - such a blase, anti-climactic font, really - to convey such important news; wouldn't a more celebratory Castellon or embossed Cursiva be more appropriate?, tugging hard at the envelope with fumbling fingers to open it, wishing I hadn't clipped my nails quite so short because now I was having diffulty getting the damned thing open, finally extricating the little plain piece of paper and unfolding it, scanning down the page to read:

Congratulations! You have matched! (At least *this* was in bold.)

And then I discovered that, despite all the doubts and hand-wringing and second-guessing and more agonizing of the past month, I was looking at the program name of my Number One Choice. The program that I'd fell in love with when I interviewed, the one that spoke to my goals and interests in medicine, that appealed to me in its uniqueness and friendliness, and, yes, location. And this means: I'm moving to California! I will officially live in a box and pay a good 180% markup in rent - but I will be minutes from the beach! the mountains! the view! the fog! Peet's Coffee and Tea! Farmer's markets! my own gourmet salad fixings garden! and SF shopping!! I will ride up cute little crooked streets on my bike and stroll by Fisherman's Wharf and eat Ghirardelli chocolate and sourdough bread - on days off. So come visit me!

The rest of the day was pretty much a haze. One of the more memorable points was receiving a voice mail from my best friend in Texas, in which she stated, "At this point, there's only one thing that needs to be said-" and then proceeded to sing/rap our old song-to-blast-with-windows-down-anthem-of-college-days, 2Pac's "California Love". (I'd post it on here, but sadly, she's threatened to disown me if I ever make this fabulous message public.) I remember eating a lot of chocolate, hugging a lot of people, taking pictures and then celebrating a few hours later. Let's just suffice it to say that it was, overall, a pretty good day.

A good day, of course, but also definitely bittersweet...for those that didn't end up where they wanted, for those experiencing the disappointments that are invariably part of this day. Bittersweet for everyone leaving, I'd say, regardless of where they matched. Probably more than one of us felt that underlying sadness that comes from leaving the cocoon that you've called home for 4 years (or even longer) - the place, after all, that helped us to get where we're going next.

Ann Arbor, after all, is where I learned how college football can consume a city (and how fun it is to back a team that's actually good!), what exactly one means by "freezing fog advisory", proper usage of the nifty terms "catacorner" and "yooper", how to use one's hand to depict state geography, the intricacies of Thinsulate vs down vs fleece. This is where I bought my first Nalgene bottle (trust me, peer pressure forces you to have one in Ann Arbor), found that I could literally treat a grocery store as a second home (yea Whole Foods!! It has food, samples, free internet, chocolate, coffee, and bathrooms. What more do you need?), and that two little heavens on earth exist; one in a little place called Zingerman's Deli and the other Nichols Arboretum in full bloom. This is where I learned how gloriously beautiful spring is when it follows a nasty winter, the art of planting cherry tomatoes and cilantro on your patio, and how running from Dexter to Ann Arbor with brave souls from your class makes for a not-so-bad half-marathon. Oh yeah, and this is also where I learned all the medicine I know, too. (So, for the record, at least I have someone to blame. Heh. Heh.)

So - swallowing little old lump in throat - this is officially the transition to goodbye. Time to join the ranks of all the M4s unloading books, furniture, electronics, real estate, socks (yes, socks), and sundries to all those eager thrifty spenders in classes below me. And as I pack, I'm wondering: how on earth did I accumulate so many shoes in 4 years?? And, grrr, time to start going through and archiving the 4000-odd emails I have in my university webmail account, which apparently is - gasp! - being sent to cyberspace wasteland after we graduate. (And I thought they really loved me.) But apart from that, I'm clinging on to the good month or so I have of being a relaxed, cheery M4, awaiting graduation in May.

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From Hollywood to the Hospital: Redefining Glamour

For the naive, happy, carefree outsider, the world of medicine often carries an oddly "glamorous" mystique. For proof, we look at Popular Media, where the glory of doctordom is handily presented in broad strokes: 5-second miracle brain transplants, routine chest-cracking/bare-hand heart massage and placenta-less, assembly-line pregnancies. In this world, general anesthesia is essentially a formality, replaced by the swoon-inducing, sheer hotness wattage of budding Patrick Dempseys and Katherine Heigls.

The media mystique is pervasive:
- You've got doctor soap operas featuring chiseled, Botoxed doctors barking "Nurse, scalpel, STAT!" as they powerfully steer gleaming gurneys through endless hallways, while scandals fester in deceptively innocent supply closets.

- You've got cheesy doctor documentaries with the token James-Earl-Jones-esque baritone gravely narrating things like, "The young boy's heart had stopped beating and all hope seemed lost - when finally, Dr. Smith decided to take a chance on a miracle", accompanied by some kind of backwards-ticking digital clock and a beeping red heart rhythm pulsing ominously on the screen.

- You've got doctor beach-lit featuring a tortured young doctor-protagonist questing after a tainted stethoscope which has been implanted with a timed-release, deadly diarrhea-inducing virus and is now spreading the runs among patients with each auscultation. (This, sadly, could actually be real life. Reader, meet C difficile.

- You've got beanie babies inspired by loveable, charismatic interns such as yours truly. (Come on! The Obama girls are too glamorous to be anything but doctors when they grow up.)


In 2008, 31,000 people applied to jump on the medicine glamour bandwagon in 2008 - and that's 31,000 people who are clearly not reading this blog. (Perhaps, by listing this statistic, I could be part of the search results for "number of applicants to medical school", which Google reports has been searched for 5,833,000 times. Talk about instant increase in blog readership!) At least some of them (or their parents) must have been motivated by the seeming panacea of glamour offered by the M-bomb. After all, what better way to quickly sum up the biodata of "steady-income-earning potential with requisite intelligence, strong likelihood of compassion, PLUS a lifetime of free medical consultation bypassing hours of flipping idly through backdated issues of Golf Digest in a cramped doctor's office" than simply attaching the "M.D." after your name?


Ah, glamour. In former, naive, pre-internship times, I thought the term referred to things like strappy patent leather high heels, Paris, Fred Leighton drop earrings, spelling glamour with a "u". Back then, I also used an eyelash curler, sometimes read Dostoevsky and Sedaris by a crackling fire, served as an upstanding member of the DSW Frequent Shopper Rewards club, lovingly tended to a clothing collection which conspicuously lacked drawstrings, reversibility, and the color group "sickly pale green".


Then, I entered the world of medicine.


Some people think the hardest part of medicine is getting used to the "blood and guts". Tales abound of the 6'2, broad-shouldered football player who faints at the sight of an IV line or the neophyte intern who trembles with nausea after smelling the yeast growing under her patient's pannus. Sure, there's weeping ulcers, bile-stained dressings, toenail fungus, prolapsed hemorrhoids, inflamed follicles, oozing pustules, frothy sputum, ecchymoses, furuncles, liver spots, blood-streaked stool, tarry stool, fatty stool (sorry, there's a lot of stool). But forget all that. The hardest part of medicine in a nutshell? Quite simply: the sacrifice of the wardrobe.


At first, my natural instincts protested against the scrubification of my soul. You see, in those pre-medicine days, I was an ardent follower of the venerable art of wardrobe sciences, the reigning neighborhood shopping marathon endurance champion. I was the kind of shopper who obsesses over the subtleties of onyx vs jet black, who tries on two (seemingly!) identical pairs of the SAME SIZE trouser jean to evaluate subtle, sub-size/style variations in fit or wash, who navigates to fitting rooms using only smell, memory and touch due to the tower of clothes in her arms obscuring her vision. I curated my closet with the same fervency and dedication of a Smithsonian expert, organizing clothes by color, texture, season, temperament/mood, number of compliments (or odd stares) received.


And then, one fine day while journeying along the path to medicine, I suddenly found myself facing the prospect of obtaining my outfit from a vending machine.


I stared into the bowels of the behemoth, Darth-Vader-like automaton ScrubVendor TM, where rows of puke-green 70% polyester cylindrical bundles appeared to mock me, daring me to select them. The prospect of donning a pair of drawstring pants in my early 20s - not just any drawstring pants, but a pair of bunchy, tapered, thigh-enhancing, leg-shortening, crotch-disfiguring pants - flooded over me; feeling suddenly faint, I grabbed onto a chair for support. I briefly contemplated quitting medical school, then decided to furtively drive 30 miles to a specialty store to pick up a tailored pair of boot-cut, low-rise scrubs.


For a while, I continued to stubbornly resist enculturation into the world of medical fashion, determined not to be taken in by the temptations of tackiness marauding as socially acceptable norms. I boycotted clogs, refused to pair scrub tops with jeans/ khakis/mismatched scrub bottoms, never wore a scrub top without at least one "safety shirt" underneath, and of course, never, EVER did things like wear scrubs to the grocery store or the gym. Even as the anemic green rags snickered with a tempting, mindless, just-choose-me-I'm-so-convenient appeal at the fashion-challenged hours of 4am, I resolutely marched to my closet, determined to exercise my brain cells in choosing a real outfit that reflected my mood (needless to say, there were several outfits consisting of black, metal chains and spiked cuffs). While every other (sane) individual soft-shoed around the tiled hospital floors in ergonomic harmony, I was the one clack-clacking away in 3-inch heels, inciting intrigued/annoyed glances from nurses and unit assistants shopping for Louboutins on eBay/trying to reconcile medications.


But of course, like so much else, things change. Maybe it was the time I was sitting on a swivel chair, clad in a flowy A-line skirt and cognac pointy-toed heels, grasping a pair of heavy-duty pliers with one hand and the callused, toenail-fungus-ridden diabetic foot of a schizophrenic patient in the other, trying to complete the assigned task of removing said toenails with said pliers. Or perhaps it was the time the intoxicated college student in whose arm I was trying to place an IV decided to wake up and retch all over my camel-wool trousers and tie-neck blouse (at least the boots were spared!) Or maybe, it was waking up at an ungodly hour one morning and realizing that by wearing scrubs I could snag an extra fifteen minutes of beautiful sleep!!. That was it. The shapeless, tapered duds went on. A thunderclap was heard, and somewhere the evil denizens of de-fashionization cackled and rubbed their hands in glee.


Clearly, the glamour of medicine does not emanate from its wardrobe. It's also not likely to stem from the routine tasks of internship (see: Bowels, Idiosyncracies of; Missing Studies/Tests/Labs, follow-up of and endless waiting for; Google/Wikipedia, worship of; Agitated Patient, calming of; Mysterious Dizziness in 32-kg, 125-year old gentleman, lengthy workup of; Chicken With Head Cut Off, constantly running around like.) To be honest, it's probably more glamorous to be a resident of Albert, Texas - just think: if you had twins, you could almost double the population!


But even if it's not glamour in, say, the we-are-all-devastatingly-attractive-and-scandalous Grey's Anatomy sense, there is still something extraordinary about being part of the fold - about being one of the scrub-clad army of neophyte physicians. It's funny, the way it works. When the thin catheter you're inserting in a patient's chest suddenly slides in perfectly and the cloudy fluid drowning his lungs finally starts to drain; when you suddenly connect textbook facts in the context of your patient to arrive at a diagnosis; when you update a patient's family member and realize that they actually seem to trust and respect your opinion - that heady rush of "specialness" sort of hits, as close as I've gotten to sensing the M.D. glamour. But invariably, it's at these very moments that my undereye circles are their most cavernous, my stomach is likely staging a vocal, Graham-Crackers-Are-Not-Enough-themed protest, my scrubs seem especially ill-fitting, or my stethoscope is once again yoking me unceremoniously and un-glamorously to the doorjamb. Go figure.

So pshaw, TLC. You don't want no scrub? Pass 'em to me. They may get no love from you, but I know how to work it.

Happy Holidays: Who Needs Barbados When You've Got the ICU?

I woke up the other morning and realized with a start: Oh-my-gosh-it's-already-December-how-did-that-happen? (This was after I did the whole mentally cursing at the 5 alarm clocks buzzing in succession at 4 am - see my earlier posts for more information/whining on that). This realization may not have occurred but for the fact that, for the past few weeks, my clock radio has been stubbornly, cheerfully featuring such saccharine ditties as the hot-chocolate-craving-inducing "Winter Wonderland", the never-fails-to-be-slightly-creepy "Santa Baby", or the theatrically diva-esque, classic Christmas earworm "All I Want For Christmas".

Even then, I'm a bit slow in the mornings. Luckily, I'm a dedicated Walgreens customer, and anyone who knows anything about Walgreens knows that this store is like America's weathervane. To wit:

• Pondering if a recession is looming? One glance at the teetering display of unsold nose-hair trimmers and As-Seen-On-TV Ab Rollers, and you have your answer.

• Trying to keep up with current city trends? Check out the ever-changing display in front of the checkout counter - here, a revolving display of San Francisco staples: canvas grocery/tote bags (the more in-your-face logos about recycling and environmental consciousness, the better), stainless steel water bottles (plastic and polycarbonate = decidedly c. 2005), petroleum-and-paraben free chapstick, mini-compost bins, umbrellas.

• Curious about the ethnic makeup of the neighborhood? Again, that friendly front counter, home to such clues as Yin-Yan sticks, dried seaweed snacks (endorsed by an evilly-grinning porcine cartoon man promising "Most crunchy Snack! Top quality!"), Thai Ginger Chews, Hot Tandoori Mix (which, in an embrace of the gaudiness-gets-dollars marketing philosophy, flashes a shiny lilac and tangerine wrapper showcasing a picture of tired-looking green peas, glistening oil-soaked peanuts and dangerously neon-yellow noodles).

• Wondering what contemporary songs the discerning music aficionado will soon blacklist from her MP3 player? Linger and listen in the aisles while listening to soulful crooners negotiate ten octaves in pleas for lost loves and one-more-chances - then give into your urge to buy earplugs STAT.

Anyhow, in line with my bustling social life as an intern in San Francisco, I end up taking several weekly jaunts to Walgreens - where I catch up on my "reading" by reviewing the packages of various OTC medications (one day, I will smoothly tackle those "Doctor, what dosage of Metamucil did you want to give now?" questions from pharmacy)...followed by a few more hours scrutinizing face creams in hope of finding the magic cure to hospital-inflicted Problem Skin....followed by a jaunt down the snack aisle to peruse the various metabolic-syndrome-inducing ethnic goodies...and invariably culminating with me buying some form of chocolate.

It was finally at Walgreens, after a few concerned mothers began steering their kids discreetly from my path, that I realized I was sashaying down the Foot Care aisle to the beat of Beyonce's R&B-ified "Rudolph the Red Nosed Reindeer". (If anyone can R&B-ify Rudolph, it's Beyonce.) This, coupled with the appearance of Limited Edition white-chocolate-and-peppermint Ghirardelli Squares - and the stuffed reindeer that started screeching "Meeeerrrry Christmas, Baby!" when I accidentally knocked it from its shelf - jolted my being into realizing that Christmas was around the corner.

Spending the holidays in the hospital, a seemingly depressing prospect, is actually....indeed quite depressing. For every intern across the nation, it is a time of reflection; a time to ponder exactly what mind-altering substance s/he had ingested when making the decision to enter medical school; a time to ponder the feasibility of partnering with a gleamingly-white-toothed infomercial "M.D." and launching a career sponsoring Botox parties. After all, the holidays are when normal people are supposed to sup, laugh and relax with families - or, as the case may be, engage in passive-aggressive standoffs with in-laws, gossip about blatantly tacky re-gifted presents and office-party hookups, argue with the airport security guard about to confiscate the $300 bottle of Napa wine in your carry-on.

But there is a wisp of silver lining - or, at the very least, a Claire's-Accessories-esque, contact-dermatitis-inducing yellow-dyed nickel lining - to this sad cloud of intern drudgery. Which is: working over the holidays allows the intern-victim to lay legitimate claim to the title of Generally Good Person/Humble Hardworking Servant/Martyr.

It's the sort of thing that gets you admiring, sympathetic glances from, say, grandmothers, friends vacationing in Barbados ("You're working full-time on Christmas, Thanksgiving, Boxing Day, New Years' Eve, Kwanzaa AND New Years' Day? What kind of messed-up job is that? Oh sorry - got to go, our mai tais just arrived") and cashiers at Walgreens. It might theoretically work as a facilitator of chemistry/booster of perceived attractiveness in the Potential Significant Other/Hot Date marketplace, except said intern would actually have to be physically present at said marketplace, which is of course impossible to do when you're on call and in the hospital that day. (Thus, single readers out there, if an intern you meet in September 2008 happens to let slip the sexy fact that they are working in the ICU on, say, Thanksgiving Day 2009 - yes, they are indeed interested.)

Even if an intern's spending 99% of it in the hospital, and thus is determined to wear the sullen mask of Intern Slave throughout, December is one of those months that burrows its pesky snowflakes-and-sleighbells, cinnamon-and-nutmeg-scented way into your soul. And, slowly but surely, it began to finagle its way into my grumpy mind. Maybe it was the green and red tinsel festooning the "The 7 South Team Works To Help You!" bulletin board collage, featuring action-shot cutouts of sprightly nurses bounding to gather medications, beaming unit assistants holding up remarkably expediently-processed order sheets, and startled-looking doctors trying to untangle their stethoscopes out of door hinges (why does that always happen to me??), all captured in the candid glare of flash photography. Maybe it was Gus, the perenially cheerful janitor, whistling a soulful version of "Christmastime" as he cleaned up the remains of a low-salt, pureed-diet tray a psychotic patient had decided belonged on the floor rather than in his stomach (who could blame him?). Or maybe it was the sudden, unexplained appearance of an yellow- slicker-sporting stuffed bear in the resident lounge, which dutifully belts out "Singin' in the Rain" at oddly random, unprovoked intervals. (I'm not sure what the last one has to do with Christmas - but the notion of anyone singing anything in the resident lounge has to be associated with a special season.)

In any case, it wasn't long before I was idly humming the theme from Charlie Brown's Christmas as I recorded patient vitals ("The patient's bed alarm is going off, but I can't figure out why - we'll need to call maintenance," one flummoxed nurse told another as I passed by), or found myself moved to shed a tear or three as a black-and-white Tony Bennett crooned "My Favorite Things" on a Christmas CD collection commercial in a patient's room (only $12.99 + S&H! If anyone wants to buy me a Christmas gift...). My bah-humbug, I'm-a-grumpy-intern exterior had officially waved the white flag of surrender to the subliminal effects of seasonal marketing. And so in my first move of acceptance, I logged onto sephora.com to take advantage of my newfound elite shopping status, partaking of the joy of holiday sales. (Damn subliminal marketing.)

But the other "great" part about working over the holidays is that you instantly have a bond with all the other lucky souls who are sharing the hospital space with you: fellow interns, cafeteria cashiers, pharmacists, nurses, social workers, CT techs (okay, maybe not so much the CT techs. Since they are never working when you need to order a STAT CT on a sick patient over the holidays.) It's why you can walk by a total stranger vacuuming the corridor on Christmas morning and exchange a high-five and warm hello like you were old college buddies, or why you finally get to mooch some extra coffee from the notoriously eagle-eyed cafeteria ladies.

And people, need I mention the most obvious highlight of working the holidays? Quite simply: Chocolate. Don't even get me started on the chocolate. It's everywhere - ensconced in workrooms, randomly making appearances at conference tables and floor kitchens, burgeoning from boxes in the resident lounge - and it seems everyone is always offering you some. One nurse actually accosted me in the hallway, grabbed my hand and marched me to a potpourri-scented break room where she poured me cups of hot apple cider and warm baked chocolate-banana bread. (That bread was so good, I think it makes up for every hour of working over the holidays.) And one particularly devious resident, whom I will not name, has taken it upon himself to plant mammoth boxes of chocolate covered macadamia nuts in vulnerable interns' paths (Hawaii's annual economic boost in December, I'm convinced, must be attributable to this resident's mass purchase of macadamia nuts for us common folk). Anyway, I firmly subscribe to the philosophy that no obstacle is too insurmountable, no barrier too impenetrable, no task too monumental, no patient too complicated as long as you have a decent bar of chocolate at hand. And with all the chocolate that marks Holidays in the Hospital, I think I'm pretty set (unlike my scrub size, which I think may be on its way upward after this month).

So on Christmas Day, while rested folk celebrate good tidings and cheer (or at least try to prevent die-hard Republican Uncle Leo from provoking die-hard Democrat Aunt Betty at the dinner table and causing another one of those notorious family cold wars that had the children crying for hours last year, poor things!), look up at that stale bottle of Pepcid you're about to grab to treat that nagging heartburn (Aunt Betty never really grasped the term "cooking light", did she?) and think of me. For my scrubs-clad self will be marching resolutely to work at 0600 on Christmas Day, past shuttered store windows and rows of sparkling Christmas lights, bearing the tell-tale battle scars of cavernous undereye circles and alcohol-gel-dehydrated hands. But to be honest, it's not going to be that bad. Fun people + Official Stamp of Good Person from the Universe + TV in resident lounge + Enough Chocolate to Happify an Army = content, overworked intern.


And with that, time to get back to work - I think Tony Bennett's playing in room 56. Long live the holidays!

Arugula and Intern Year Are Not Mutually Exclusive: Or, Yay, Barack!

Eep! How time flies in the world of a delinquent blogger. In the span of multiple weeks since I last posted, a run-down of what's been happening in the world of the medicine intern and beyond:

• 
  Someone absolutely awesome was elected president

• I finished 2 straight months of wards without passing out, quitting, hyperventilating, or regressing to a fugue state in which I am reduced to waddling aimlessly in the hospital clutching an abandoned hospital gown as a security blanket

The first event, arguably slightly more momentous than the second, has already garnered a fair share of coverage by such fringe publications and offbeat blogs as Newsweek, Slate, Time Magazine, etc. etc. In the spirit of the day when HIAD becomes a household name (laughter? is that laughter I hear? As Joe the Plumber ekes by on his $250,000 annual pittance, "K" the blogger battles callused, carpal-tunnel ridden fingers, an overheating laptop and frown wrinkles gratis....all for you, my Loyal Readership (Population: 4?). At least you can play along.), here's my personal, intelligent contribution to the fray:

WOW.

Okay. It doesn't take a rocket scientist (or a doctor?) to understand the impact of this watershed election, that it's a symbolic and cathartic achievement dedicated to the sacrifices of past activists, a moment to be treasured by citizens valuing equality, civil rights and justice, etc. But: how about understanding the unfolding of the campaign through the eyes of an overworked, underpaid, grouchy, TV-deficient resident carrying several risk factors for don't-care-about-elections-because-it's-not-like-they're-going-to-discharge-my-patients-or-give-me-weekends-off-or-a-pay-raise syndrome?

The average layperson, after all, knows the life of a resident is fairly "busy", with that pesky pager potentially interfering with such things as Eating, Sleeping, Going to the Bathroom, let alone those civic duties known as Voting and Being Politically Informed. And yet, across America, zombie-like interns buried in their tired HIPPA-compliant progress notes and fecal-occult-blood-testing cards unhooked the stethoscope-noose around their neck, looked up at the rousing voice of change - and Cared.

I know I speak for more than one intern when I say that even 12-hour days filled with scutty minutiae did not keep me from being an informed and politically (over)involved citizen. I promptly joined the ranks of approximately 99.99% of my fellow San Franciscans by buying my OBAMA-BIDEN 2008 sticker (and sporting my "Read My Lipstick: I'm Voting Democrat" bonus button), cheerfully canvassed voters by phone in swing states after work (luckily, as election results now show, I didn't hurt Barack's campaign too much), scrimped on lattes and shoes to direct my small-dollar, working-class, earned-by-the-sweat-of-my-brow, fished-out-from-the-change-return-slot-of-vending-machines contributions to his campaign, treasured and categorized every one of the 15,009 email correspondences and text messages sent by Barack and friends (Say what you will, but I know the campaign personalized mine. I just know. I mean, we're on a first-name basis! And they liked me so much that they're still emailing me. How many of you can say that???)

Don't get me wrong - it's not as though my life as an intern was on complete hold during this peskily nail-biting, convulsion-inducing, rapture-producing election season. The two arenas simply coalesced and congealed, much like those uneaten pancakes Barack ordered at a diner in Pennsylvania, or like Joe Lieberman's efficacy in the Senate. My key memories of the campaign unfolded in the sterile environs of the hospital. It was while palpating a patient's abdomen early one September morning, for example, that I saw on the TV the headline from CNN: "Breaking News: McCain Picks Gov. Sarah Palin as VP". (Seconds later, two nurses were in the room responding to the call button said patient had pushed, prying my hands off the patient's abdomen - upon which I had absent-mindedly begun compressing with unrestrained panic as I imagined the implications of a VP Palin.) And it was during one long night as cross-cover intern that I ran down 9 flights of stairs, bounded across corridors, leapt over such obstacles as runaway crash carts, lost medical students, beeping pagers and piles of inkless gel pens, breathlessly punched the code to the resident lounge just in the nick of time to tune into PBS and Gwen Ifill moderating the presidential debate. (To think. If I'd been running to a code, I probably could've saved a life or two.)


Like most of my fellow residents, I stayed glued to CNN, quoted stirring passages from debates to anyone who would listen, poured out my vision for the country and helpful suggestions for his campaign in eloquent messages sent to barackobama.com. Okay, so maybe I was the only one quoting passages and sending messages, since my wet-blanket fellow residents apparently felt it was more important to do "doctor" things like write orders, check patient vitals or reconcile medications. (Talk about misplaced priorities.)

And the result, as we all know, was sweet. That extra little tremor in the earth you felt at around 11 pm EST on Nov 4, 2008? No, wise-alecks, not me in high heels stepping down from the bus....no, not the stampede of patients fleeing from my Strep Throat RapidScreen Test swab...no, not the thud of my shopping bags after a very productive 5-hour shopping spree at H&M. (You all, I must say, are very poor guessers.) That jolt was the rumble of about 760,000-odd San Franciscans cheering and toasting the official Democratic victory in unison. After all, this is the city that placed on its official ballot Proposition R, calling for the renaming of the city's Oceanside Water Treatment Plant to the George W. Bush Sewage Plant. (Rumor has it the workers at the sewage plant revolted against this, not wanting to work for a company with "George W. Bush" in its name.)

On the political squawk-box, you heard a lot of talk about the crucial role of various key voting blocs: blue-collar America, white-collar america, green-collar america, hockey moms, diaper-changing dads, parsnip-sauteeing, arugula-wilting singles, bald white gun-toting racoon hunters, manicured black Prada-wearing metrosexuals, Porta-potty-frequenting ultramarathoners, etc. The truth? I humbly submit before you: It was us, the Supposed-to-be-White-but-More-like-A-Gray-Brown White Coats of America, the Interns, that brought it home for Barack.

And on that note, I think I hear some parsnips calling my name. Change.gov, here I come.

Killing my circadian rhythms softly: Night Float Adventures.

Remember that principle of "see one, do one, teach one" I was talking about in my last entry? Well, nothing quite exemplifies my residency program's unshakable confidence in its neophyte interns quite like a rotation schedule that has said intern taking care of 80 medical inpatients - that's all the medicine interns' patients - by yourself. Overnight. In the second month of intern year. (Maybe the "see one" part was the one month of rotations and patient interactions during the day??)

Welcome to my life as night float intern, a bizarro universe where my day begins at 7 pm and ends as the sun rises. Judging from my past whining about not being a morning person, a logical reader might posit that this owl-like lifestyle would be a welcome schedule pour moi. However, in a cruel twist of illogical fate, it just so happened that after a month of 4:19 a.m. wake-up calls, I actually had been falling into a pseudo-rhythm of sorts...rolling the rock one inch further up the hill in my Sisyphean quest to become the sprightly morning person who "just can't sleep" past 6 am. Suffice it to say that that rock has now rolled back down the hill with renewed vigor, squelching me triumphantly in the process. My circadian rhythms have not only gone incognito; they're in desperate need of a GPS system (or one of those nifty iPhones that can find out where you are with the touch of a button. Sorry, I'm in San Francisco...got to have the iPhone plug.)


Contrary to what you might think, night float is not in fact the brainchild of cackling, sadistic anti-resident conspirator ghouls haunting the hospital basement. (What, you don't believe in ghosts? Just wait until you've stayed up 7 nights in a row. ) The system was actually designed with an altruistic, noble goal: Let's Help Our Interns Get Some Sleep.


Let's expound on this. See, in the world of yore, hapless Intern X arrived at the hospital at 0600 am, flitting around the hospital floors all day like one of those hyper, in-denial, confused flies that keep hitting the windowpane thinking they're escaping to the sky beyond. She would continue to stagger in a semi-awake fugue state for that night and half of following day and, if all went well, departed at 12:00 noon - capping off a grand total of 30 bed-less and home-deprived hours spent breathing hospital air.


That was then. Now, in today's modern world, we not only have microwaves and TiVo: with night float, we have Intern X going home at a reasonable hour on the - wait for it - same day she came in, thus enabling her to return to her own little converted-closet-aka-you-really-pay-$1500-a-month-for-that-room? and crashing in her own "bed" (using the term figuratively, of course, since said room isn't large enough to accomodate furniture and a human being.) Now, as haggard interns wrap up a 15 hour day, no sight is more gladly welcomed than that of the rested and showered night float as she strides in, valiantly squelching all circadian protestations against starting a workday as the sun is setting. For it is this unlikely superhero who will release the interns from their workday, taking over their patients.



Of course, as the economic principle TINSTAFL (There Is No Such Thing As A Free Lunch) suggests, such a tremendous boon doesn't exactly come without cost. "Cost" in this case refers to that scrappy soldier, that multi-pager-balancing, order-juggling, scrub-clad acrobat, that sensitive soul who, like Atlas balancing the world on his shoulders, takes on the Patients and Their Care when the clock strikes "shift change". This pantheon of intern freedom and sleep enablement is, of course, the Night Float. While the interns snooze soundly at home, she takes on the role of Confused, Bruised Fly for the night, tending to patients while the city sleeps and informercials for arthritis cream play endlessly on TV.

"Night float" is a deceptively ethereal, serene-sounding phrase, conjuring up meditative images of shimmery physician-wizards dispelling illness with a wave of a magic wand while riding on the odd airborne unicorn. (You thought of that image too, didn't you?). Reality goes probably more like this: Night float, balancing a phone on one shoulder, flipping through various stacks of "sign-out sheets" describing all the happy snoozing interns' 80 patients, trying to listen to the nurse on the other end of the line, fumbling in a dingy white coat to find the two pagers buried under the graham cracker packets that have simultaneously decided to begin insistently beeping (the pagers, not the graham crackers - although strange things happen at night), while nodding to another nurse that has just tapped you on the shoulder to talk. I think being a night float intern is kind of like how it feels to be a Walmart, if a Walmart could feel: stuffed with an assortment of random items, trying to be organized but somehow always chaotic, always struggling to produce exactly what a demanding customer wants when they need it. Not to mention, both of us could probably benefit from some disinfectant and a nice hot bath around 3 am.

But wait, say you, the astute reader. Being a doctor takes years of medical school and residency...and during the day you have three levels of care - intern, resident, and attending - triple checking work on a team of patients....and now, one lone intern is in charge of handling the workload of about 40 people. At night. How is this legal again?

Well. Lest all of you decide to start boycotting hospitals altogether, let me reassure you that the night float does have "backup" in the form of 1) a senior resident on call and 2) the night attending on call. These are the people to page if Things Are Getting Weird or Scary: i.e. a patient starts going into ventricular tachycardia every time they try to have a bowel movement, or is hurling their oxygen monitor at the window, or threatening to sue the hospital if they can't have a cigarette (true stories.) For all other items, however, the night float relies on such help as 1) Google 2) a dog-eared handbook termed the "Intern Survival Guide", 3) coffee and graham crackers. Trust me, somehow it's a system.

Importantly, this system hinges upon the vital piece(s) of paper known as the "sign-out". At first blush, the sign-out looks like any other normal piece of computer paper: 8 1/2 by 11 inches, white, 4 straight edges, that sort of thing. But don't let that fool you: the 0.5-size Arial font that it bears might as well be gilded gold ink. For the sign-out is the night float's passport, Frommer's guide, boarding pass and pocket translator all in one (if only the destination were, say, Brazil as opposed to ward 7 south. But still). Its humble pages contain such key highlights of each intern's patient as "Name", "Room number" and "Meds", along with assorted important pearls - "What to do if patient's heart starts beating at 240 bpm", "Patient's wife is very high maintenance - soy milk at bedside at all times", "Call senior if patient's blood pressure drops to 70/40 and he looks sick".

The sign-out is how an intern, paged at 0300 by a nurse on 6 Center that Patient X can't sleep and needs something now, knows that Patient X needs Ambien in lieu of Restoril (since the latter makes him sleepwalk to the kitchen and sleep-eat through all the coffee creamer packets.) Or how she knows, when paged by a nurse that Patient Y's blood pressure is 85/40, that this always happens during the night when the patient is sleeping and there's no reason to call a code.

To ensure that the night float does not spend the entire night watching the Olympics on the doctor's lounge flat screen TV (who, me?), there is also a "To Do" section, which usually entails such things as: "Make sure patient has a bowel movement tonight - very important" or, "Patient needs to finish all her colonoscopy prep solution!! Check at 8 pm and make sure she drank the entire 3 liters!!", "Follow up on chest xray and make sure patient is breathing okay and not sick", or "Check blood counts at 8 pm and transfuse blood if Hct less than 27."

As the night float learns, the hospital is a different place in the wee hours. Maybe it's the antibacterial hand gel fumes and incessantly beeping machines, or maybe it's the bad hospital food. Somehow, the conversant and lucid individuals of the day become pain-racked, fearful, sleep-deprived, blood-pressure-dropping or -raising, constipated or diarrhea-ridden, urine-retaining patients. Somehow, as the sun sets, the sweet 70-year old knitting-a-scarf-for-her-godchild-libarian-slash-grandma starts to pull out her IV and insist that the Russians are coming to kidnap her. Somehow, around 3 am, the pleasant 26-year old college student awaiting surgery for an infected gallbladder starts to break out in hives and have difficulty breathing.

And thus, night float life is filled with intimate knowledge of sleep medicines, pain pills, laxatives and stool softeners, blood transfusions, patients' nocturnal hallucinations, hearts beating too fast or too slow or funny rhythms...along with the odd adrenaline-searing experience of rushing to a code or running up the stairs to help a crashing patient.

I'll write more later - but right now, it's time to answer yet another page. Day time folks: just be glad you don't have to convince your night-time selves to drink an entire container of colonoscopy prep. It ain't pretty.

Green Tea and Beyond: The Wisdom of Medicine.

How do you really learn medicine?

As I complete lap #2 in the 12 month intern year cycle, this question often rears its niggling, bemused head (okay, maybe that's my bemused head. But the question is still niggling. And I still got to use both those words!). And it especially niggles every time I meet a patient who grips my hand gratefully when my white coat enters, in their eyes an implicit trust that I will not only Tell Them What's Wrong, but I will Help Them Feel Better. For those patients, I'm a magical computer that can instill diagnostic meaning and context to myterious symptoms and physical findings, such as "My pinky toe, Doc, it's been twitching southward at exactly 5:03 pm for the past month. What's that mean?" or "Why does the corner of my right eyelash itch when I'm trying to sleep?"

In essence, for many patients I'm regarded as an auror, or a tea-leaf reader, or maybe a slightly better-dressed $1.99/min telephone psychic, taking in the facts and symptoms calmly with just the right gravitas inflecting my "Mm-hmm", "Uh-huh" and "I see", cooking them in the white-coat-aura machine and emerging triumphantly with a Diagnosis and Treatment Plan. It's kind of like in high school, when you learned about the concept of a function in algebra, there was that annoying picture in your textbook showing a picture of a computer taking in x and spitting out f(x) . (That one's for all my fellow high school Mathletes and Math Club alumni! Long live the differential!) I don't think I ever really understood that function computer thing until now - when, presumably, after 4 years and a $150,000 education, I'm supposed to be that computer, able to spit out f(symptom) at a patient's whim. Where symptom could be anything: that vague scratch in their throat, that faint pink rash on their upper arm, the strange rumbling in their stomach after eating that street-corner hot dog (come on, patient - I think we both know what caused that one.)

Of course, not all patients adopt the pleasant world view that Doctor Knows Best. Some patients are a little more, shall we say, jaded. Or maybe skeptical is the right word. No, how about questioning? Challenging? Domineering? I-Googled-This-Yesterday-And-I'm-Not-Leaving-Until-I-Get-A-Biopsy? (Ooops, not an adjective).

The anti-climactic reality is that doctor-ing lies in between those two extremes. If you've followed my posts, you probably have already happened upon the rather non-concealed truth that I'm hardly an auror, or a tea-leaf reader, and hopefully I look at least a little more shapely than a computer spitting out parabolas (and those weird asymptote graphs - didn't you hate those?) when handed a patient's symptom questionnaire chart. But I would also, at this juncture, clear my throat rather pointedly and turn the reader to Exhibit A, which is Myself upon the eve of our medical school White Coat Ceremony, a day where my knowledge of medicine consisted of little more than how to wear a white coat. Compared to that happy-go-lucky rapscallion, my current self possesses some symptom-processing knowledge to match those impressive undereye circles, no? Even if, ironically, I seem to have lost the ability to wear a white coat without instantly attracting some sort of stain. (I need that irritating Cheer Detergent lady who always seems to be bleaching some unkempt bachelor's socks to accost me on the street and whiten my coat. That would be a miracle.)

As residents, we like to think we're more dynamic and critically appraising, more contemplative and (hopefully) more alive and alert than an isolated Google I'm Feeling Lucky search, But the uncomfortable part of the doctoring reality is that, even after all those tests and classes and presentations and memorizing, even though we Know Stuff and Treat Things, we residents are still doctors-in-training. The "in-training" part means that every patient encounter is still practice. And that a lot of times, we have to act a lot more confident and authoritative than we feel.

There's an infamous motto of medical training that runs like this: "See one, do one, teach one." This is not the learning style that medical schools stress in their glossy brochures, which feature the requisite multi-ethnic group of pleasantly dorky students gazing intently at a microscope or textbook (and yes, that does happen to be me looking at that slide of squamous tissue on page 2. The lone pair of 3-inch heels in the bunch!) These happy booklets are geared at convincing the pre-med student, whose often nearsighted obsession with getting into medical school can obscure thinking about what lies beyond, that Medical School X will give you the knowledge and tools to doctor away like a pro. What you find out, only after completing medical school, is that even if you memorize every fact and ace every test, there is still nothing that teaches you...like practicing on the real thing. Even if, for example, you were one of those annoying people who could recite the precursors to oxaloacetate and identify the exact defect of the hypoxanthine phosphoribosyltransferase pathway in Lesch-Nyhan syndrome...you still might not know that you never give Fleet Enemas to patients with renal disease. So there. Nyah.

As scary as the connecting between "practice" and "patients" sounds (and I'm not even thinking about the patient yet!), the system of medical education rests on this implicit nudging forward of residents beyond their comfort zones, of learning by apprenticeship. Of course, you always have backup - your senior resident, the attending, etc. But funadmentally, our education is based on the notion that the only way for residents to be comfortable inserting catheters and arterial lines, of performing lumbar punctures and placing chest tubes, of using a defibrillator to convert a dangerous cardiac arrythmia....is to practice. On, incidentally, real live people.

For mortals like me, who incidentally really, really warmed to that "doing no harm" theme mentioned in the Hippocratic Oath, the notion of Just You, Some Book Knowledge, and the Patient can be terrifying. Which might explain why my heart was racing as, standing in a patient's room at 2 am, with a nurse, heart monitor and crash cart to keep me company, I slowly injected a potent anti-arrythmic medication in the IV line of an 86-year old patient whose heart stubbornly beat away at 190 beats/min. Or why, despite my sustaining a chronic sleep debt rivaling the U.S.-China trade deficit, I suddenly felt every cell in my body poised on hyper-alert as I prepared to insert a 10-cm needle into the spinal column of a patient with possible meningitis.

You learn in biology about the "fight or flight" response - the biochemical changes of the body's "sympathetic response" that happen when you face the odd grizzly bear, hungry man-eating monster, someone rushing ahead of you to grab the last pair of 75%-off cognac Frye boots. Nothing, I submit, nothing captures "fight or flight" - well, the "flight" part, anyhow - quite like Intern Year. 2008 may be the Chinese Year of the Rat, but to interns it is the Year of Eternal Adrenalin.

The funny thing is that you start glimpsing a logic to the system, the veracity to the "see one, do one, teach one" principle. A procedure, done even once, takes on the aura of charted territory: despite - or perhaps because of - that initial terror gripping you before the first attempt, the imprint of the experience and its lessons are indelibly marked in your brain. And thus, another piece of the impenetrable, mysterious black box of medicine becomes visible. Terror and adrenaline is ultimately replaced by calmness, confidence, that serene feeling of This is familiar, and I know what needs to be done here.

It's this demeanor of calmness, I have found, that instantly identifies the knowledgeable, good doctor. (And I'm not talking about that strained "I'm calm! I'm really calm! I'm so calm! Where's my inhaler?" expression that we interns tend to wear on our face.) Case in point: A month ago, I remember being called on a patient complaining of chest pain; arriving at bedside I found a patient who looked pale, clutching her chest and wheezing for air. I was handed an EKG that showed an abnormal, very fast heart rhythm and tell-tale signs of cardiac ischemia. The nurse then informed me, "Her blood pressure's dropping - and she's going down on her oxygen." Despite having attended three cardiology luncheon talks that week, at that moment the only thought that ran through my head was Help! I need a doctor!

Much like a mirage, only except real, my senior resident appeared in my peripheral vision, walking to the nurse's station to file a chart. I pounced, breathless, shoving the EKG in his face: "Mrs.-Bates-chest-pain-she's-tachycardic-EKG-bad-she-looks-terrible-blood-pressure-dropping-think-she's-having-an-MI-help!" And he calmly surveyed the EKG, calmly reviewed the vitals, calmly entered the room,calmly examined the patient and patted her on the shoulder as he calmly, effectively reassured her, "Mrs. Bates, we're here - we're going to help you,", calmly instructed the nurse to bring the crash cart inside along with 2 1-Liter bags of normal saline, camly drew up a syringe of metoprolol, while calmly instructing me on the key clinical pearls of the differential diagnosis and treatment of tachyarrythmias. This was the James Bond of doctoring: so calm, cool and in control he made Buddha look tense.


In the end, the good news about learning to be a doctor is that If You Seek, It Shall Come. As you go through the experiences...watch your super-human senior residents achieve the impossible (ie. convince the patients to eat the low-salt renal diet tray? That's pretty much the litmus test of "impossible". I bow down.)...and, yes, practice...you begin to find out that more of the mysterious black box is becoming your readable tea leaf.

Which is maybe why, when I got called a couple of days ago on a patient with chest pain and a heart rate of 180, and another wheezing patient with oxygen saturations of 82%, I found myself actually striding directly to their rooms, my feet avoiding their usual detour to the resident-on-call. Instead of the usual stream-of-consciousness panicked chorus of "oh no oh no what do i do oh no oh no where's the resident help!", rational and logical thoughts of differential diagnoses and treatment plans were carefully building like Lego block towers in my head. (Okay, maybe more like a Lego hut, or a hill. But still. Progress.) "Let's get an EKG now - we'll draw a Chem 7, and please also have crash cart in the room," I found myself saying. In what, I suddenly realized, was an oddly calm voice.

Who knew?