Do the work

In some fields of medicine, it's all about skillz. Surgeons are all about skill. Radiologists are atuned to visual skill. Anesthesiologists have skills. Other fields of medicine, like internal medicine, don't have much in the way of procedural skill.

Medicine attracts detail-oriented perfectionists. It's all lists and tables and planning and proper medication selection. For lack of a better way to describe it, medicine attracts nerds. And it's because internal medicine is ultimately a specialty that demands planning.

And part of that is what attracts me to outpatient medicine. People think of planning when they think of placement, but the planning that intrigues me is stuff like what a patient needs over the next 3 years. This lady will need a pap and pelvic in 1 yr. This guy needs a colonoscopy in 10 years. This kid needs his cholesterol checked. This lady needs a glycohemoglobin every 3 months.

And it's funny to me that I still get a lot of pats on the back for doing nothing more than my job. It says so quite clearly in my contract what my job requirements are, and I've done them, and people think me a competent resident for it.

I have a very hard time taking a compliment from anyone, and part of it is because I don't feel that I've done anything worthy of praise. Y'know, all the time people are praised for doing their jobs. I don't get that. It's your job. It's what you're paid to do. Why should I take praise for doing my work? The way I grew up, I've always thought that praise is for exceptional work. When I do exceptional work, then I know enough to reward myself.

Diagnostic and Statistical Manual

When I did my psychiatry rotation in med school, the most valuable piece of advice I got from one of my attendings was while we were sitting in the conference room, talking about a tragic case of a little boy abused since the age of 5, neglected and physically assaulted, but thankfully no sexual abuse. He still carried horrible emotional scars despite being in a nurturing, safe environment at time of evaluation.

Me and the other medical student sat there flipping through the DSM, trying to pigeon hole this kid into a diagnosis. He lacked 1 criteria for post-traumatic stress disorder. He certainly lacked criteria for major depression. We presented the case to our attending over coffee. He watched us for about 5 minutes before becoming fed up.

"That book can't tell you anything about what your patient has. You're trying to diagnose with DSM, but it can't tell you that someone's depressed. It can't tell you someone is sick. It just tells you what to look for. Is that book going to offer any reassurance? 'You don't have PTSD because you don't have the necessary number of criteria met.' Ridiculous."

He took our DSM's away and asked us what this kid had. And that was when I realized the difference between cookbook medicine and clinical skill. After a certain amount of time, a doc's got to be able to look at someone and say, "You are sick." DSM is the psychiatric diagnostic equivalent of a Brother P Touch. Nice for labeling, but I wouldn't use it for much else.

A letter to an ex:

More in the series of painful letters never meant to be read by the intended recipient.

Ever since this all began, I've been in anguish. It's been torture for me to sit by while you sorted through your feelings, not saying no, but never really saying yes. But watching you tonight, watching you two pawing each other made me realize a lot of things.

I've been doing a lot of remembering, and really, I can't think of a time that you ever really opened up to me. I get all these cards and letters, but you never talk to me. You say things, but there's nothing behind it. I don't want your letters if you're not willing to share yourself with me. I've bared my soul to you. That's just not fair. I don't want your letters if you can't share with me who you are.

You say we're good friends, but I never see you, never talk to you. You're willing to hug everyone but I'm left standing around. I've never felt like a friend to you. I've always felt like an outsider, and it was stupid of me to think that I could have a relationship with you when you've never shown me a token of affection.

Half of my enjoyment of our relationship was finally feeling accepted by you, and that I was worthy of your affections, but that didn't last, did it. It was a battle just to see you, to hold your hand, to touch you. And now, it's like you're not in my life at all.

If you don't want to be friends, that's fine, but I don't like being treated like a second class friend, and that's how I've felt for a long time. You don't talk to me, you don't sit near me, you don't make eye contact, and I hate thinking that I have to compete for your friendship. That's not what being friends is about.

If this is how it's going to be, I'd rather never see you again. What's the point of this 'friendship' when we both know it's a joke. Let's call this what it is. You want to make this out to be all nice and pretty. Well, if this is friendship to you, I want no part of it.

And as far as our mutual friends go, you need not worry about me ruining your fun anymore. You can have them all. I've burnt longer bridges in my life.

A letter to a girl I knew:

More in the continuing series of painful letters never meant to be read.

Hey, I think it's great that we're friends and all, and I have a great time hanging out with you. But is that it? Call me crazy, but haven't we connected? Maybe just me... We could be like peas in a pod, but you're just not where I am. And I doubt you ever will be. And I've given up hoping. I think to myself that it'd be great or nice or special, but I'm thinking in that hazy dreamy way, the kind of thinking you do when it's raining outside, and you think of how you'd love to go outside and play, but if the rain stopped, you know you'd still be inside. It's not reality. It's not even a world of 'might have been's. It's all fantasy and conjecture. There's no truth to it.

I know that the proper course of action is bridge burning. It's the tried and true solution. And it wouldn't be because I hated you or resented you. It's be because every time I see you, I think, 'Maybe...' and every time I get a card or e-mail or phone call from you, I think, 'Maybe...' when there is no maybe, there is no possibility. There is no might. And the mind knows this, but the heart, it wants what it wants. And the only way to change its mind is to hate you, to resent you, to wish that I'd never met you. It's the only way to stop the wondering and the fantasies and the endless string of maybes. It's the easy way out, the model solution, but I can't bring myself to do it. And maybe I know that it'd be pointless. The maybes would still be there at night or in my dreams.

They wouldn't go anywhere. These feelings aren't the ones you can just chase off, because they're not lust or infatuation. It's not love either. I don't believe in love. You can't grasp it. You feel it like you smell cinnamon in an apple pie, and it blows away in the cold and wind. No, love is nothing to connection. Two people connecting, that's real. That's firm. You can't throw that away any more than you can throw away your parents.

So I guess it'll just be status quo, with me wondering if I'd ever had a chance, or if I was always out of focus. But I'm just festering, rotting away, waiting for something to happen when it never will. And I wonder what will happen when you finally find someone. Maybe that part of me will die, like I hope it will.

A letter to a once best friend:

Like I said previously, I thought I'd throw up some letters I've written here, letters that will never be sent to the desired recipient, but are interesting to read, in a jaded and painful way.

I can't believe you. Maybe you don't realize that you are the only friendship I have let survive in spite of betrayal. You say things like, "Does our friendship mean so little..." well maybe it would do you well to realize how close you were to not being a friend at all.

And you start off about her emotional state and whatever. What the hell am I supposed to do, huh? She was the one that rejected me. Somehow by listening to you, that's supposed to make everything better? I've tried to be the bigger person. I've tried to pretend that I was ready to move on, but guess what, I'm not. And if you think that I'm gonna feel sorry for her for rejecting me, and that 'my emotional state' isn't helping? Well, I don't give a damn.

I can't deal with other people's problems right now. I'm trying to piece together what's left of my life and trying to get back to even keel, and in case you haven't noticed, this isn't helping.

You can rush me all you want, and that's fine, but guess what, if I took what I've got on hand right now, I can come to pretty simple conclusions: you're a jerk and she's a bitch, and going behind my back was about the shittiest thing anyone's ever done to me. So there's your emotional resolution. So stop bothering me, leave me alone, and let me deal. I don't have time for your shit.

Going back to the well

For some reason that I don't get, being back around my old med school is making me itch to blog. Or maybe it's just using a real keyboard again instead of what my laptop claims is a keyboard. But I am brimming with the desire to blog. Creepy, no?

And I realized as I was driving today that I write a lot of letters to people that will never read them. I mean a LOT. You know, sometimes, it's nice to get your feelings about a person down on paper, so that you can vent all your frustrations without actualy hurting someone's feelings. So, they mostly sit in a pile in my room and maybe one day if I ever get drunk enough, I'll mail them all out, but probably not.

But I thought, since almost everyone that I write these letters to will never read this blog (I'd guess that most don't know it exists), I thought it'd be neat to put a few of them up. It's not like I haven't done so before. They're usually full of bitterness and shame and anger, and that's stuff I don't really ever show in life. It's the dark side of me that you never see.

Of course, I'm nowhere near those letters right now, so it'll have to wait for another day. For now, I plan on packing up, going home and drinking myself silly. What a nice day. Oh, and someone e-mailed me from one of my personal ads. How bizarre. A strange day today indeed.

Twin XL

Next time you go to Bed, Bath and Beyond, find the best sheets they have, the ones with the ridiculous 500 thread count and realize that it comes in twin, full, queen, and king, but no twin XL. That is because everyone knows that Twin XL is for pitiful college students and has no place in the real world. Except in my bedroom.

I still have a Twin XL. It's a pillowtop, so it's very comfortable, and it's a breeze to move. I even bought new sheets for it. I like it. But I know, it's for the kids. It's for college boys and girls, forced to accept the whimsy of some university dorm's conformist mattress.

I thought about replacing my twin XL now that I'm out of college. I'm a big boy now. A-D-U-L-T. Adults sleep in queens or fulls. Not this twin XL stuff. As a friend of mine so aptly put it, the twin XL is nice when you're the only one in your bed most of the time, but when there's a chance someone else might be in the bed, it's nice to have the room.

The thing is, I've been slumming on other people's beds lately, crashing on the charity of friends, and I don't know what to do with the bed. I had the same problem in hotels during interviews. I hover on the edge of the right side (the side where your right side is towards the edge of the bed) and I'm not entirely sure what to do with the rest of the space.

And yes, if someone came over, I could share the space, and I guess that's what a big bed is for really, but that's not something that I'll be doing anytime soon, for a variety of reasons. I'm still Mr. Good Catholic, for one thing.

The ridiculous part? I get better sleep on my sofa. Instead of moving towards more space, I'm going to less.

AFK

AFK - IRC/chatroom/IM slang for Away From Keyboard

So, I'm visiting a friend who's an avid blogger and a student of medicine, as I once myself was. And it's just so tempting to blog from the computer of another blogger. It's got this dirty feeling, like a keyboard used for so many other thoughts and emotions and angst is now being compelled to account for my own pathos.

But really, it got me thinking about medical students. It's a funny life, medical school, and it's entirely detached from reality in the sense that you make no money, you loan ridiculous amounts of money, you drink like a fish and somehow, at the end, you graduate into one of the most prestigious professions on this planet.

There are a lot of things I wish I did in medical school and now, it's not nearly as easy or convenient and I thought it'd be nice to have such regrets in list form.

(1) I wish that I'd studied harder. Not only because I could've gone into dermatology, which seems more and more ideal the more I think about it. I wish that I had more answers. I wish that I didn't have to go around looking stuff up all the time, and that I'd actually bothered to learn it.

(2) I wish I'd figured out what I wanted to do with my life before residency. I mean I knew that I wanted internal medicine, but I was still pretty torn on the primary care thing. Knowing what I know now, it seems like I wasted a lot of time and could've chosen the best residency for what I wanted to do.

(3) I wish I'd slept around. Seriously. The amount of social interaction I have with people that I don't have to work with on a daily basis is minimal. I don't meet people, and I certainly don't meet women. I know, I know. The people who know me in person aren't buying this one for a second. Me, sleep around? Unlikely. But at least I wish I'd dated more. Well, dated at all during med school. I guess I tried, and that was what was important, but it was a pretty miserable time.

(4) I wish that I'd been more adventurous. I don't have time to do a lot of fun things these days. I don't have the chance to try new things and to experiment. I pretty much have time to eat and sleep and play on my Gameboy. Time was much more abundant in medical school, and that was time that I should've been using to expand and to grow. I should've grown more, as a person. I know that the prevailing theory is that medical school makes you grow as a person, but what I mean is that I wish I did more to be a well-rounded person.

(5) I wish I'd taken up golf earlier. Seriously, golf is fun.

(6) I wish I'd toured the country. I don't have real vacation time anymore. Or more aptly, I have real vacation time now, and not the luxurious amount of free time that medical school gave me. I should've gone to San Diego and Portland and Burlington and Raliegh, and all those places that I'm never going to get the chance to visit because my 3 weeks of vacation are now spent on sleeping and visiting my family.

(7) I wish... holy shit, this other blogger has the exact same desk as me. This is freaky. I'd better stop.

Being a senior

Part of the funny thing about the end of the year is that in a few weeks, I'll be a senior resident. That's strange. It doesn't seem like I'm all that much more in charge of things. But I've been spending the last few months thinking about what I like about the seniors I've worked with, and what kind of a senior I want to be.

And it's funny to be at this stage in my training, because I've worked with residents I'd trust with my life, and I've worked with seniors that I wouldn't consent to treat me if they were the only person who knew CPR in the middle of the Australian outback.

And my biggest problem with seniors, and the thing that I hope I don't do, is that some of the seniors I've worked with are more concerned about inconveniencing themselves than they are of helping me out. I've had seniors who've left for the weekend or left the hospital after rounds, and a list of other things that are pretty much a laundry list of shitty things to do to your juniors. And some have even dared to say, "Oh, it's because I trust you." That doesn't fly.

My biggest complaint, and a big piece of advice to anyone in any supervisory position, is that when you're in charge of others, you have to take care of your people first. If you take care of yourself first, then you don't really deserve to be in charge, eh? Part of being a leader is leading.

The only useful thing I learned from the one business course I took (other than the fact that Powerpoint is meant only to accompany your report, not replace) is that there is a difference between leading and managing. And one can only hope that if your superior cannot lead, he can at least manage.

Sleep is good

It seems like this month on ICU, I can't have a quiet night of call. It's full of DKA and hyponatremia and other excruciating things. I wish I could just have one quiet night of call. That's not too much to ask, right?

And it's funny, being on call, because never have things been so diametrically opposed. I can either take care of patients or sleep. That's not fair, because one is good for someone else, and the other is a basic human need to remain sane.

So, really, I am being driven to insanity, because I can't sleep, and that's not fair, not in the least, because I suffer and the patient suffers.

You honestly cannot comprehend how relieving it is to have someone die because it means there's one less patient that they can call you about.