Finally

So, it took me a year and 2 months, but I finally killed someone. Oops. And the old line is true: sometimes, the greater sin is that of omission rather than commision.

I should note, I'm fine. Really. I'm not crying myself to sleep. You know, you can't be perfect. You can't save everyone. You can't develop clinical acumen without seeing bad things happen sometimes. And am I going to jail or to court? No. Thanks for the concern, but I'm not the dead one. To quote House of God, the patient is the one with the disease. IF 9/7/05

"I wish I could do it over again"

Sometimes, I catch myself saying that I wish I was back in college, a little wiser, and could relive some of my youth, correct some indiscretions, prevent some tragedies, and shatter a couple kneecaps on folks very much deserving. It would be so nice to have that time over again with some of what I know now.

This is entirely wishful thinking. My God, I can't imagine how much it would suck to relive all that drama and torture, muchless trying to pass organic again. And P-chem, what a nightmare. And the angst and dilemmas and all that trash, it'd be Hell and a half to put myself through all that again. I don't really want to relive college. Sure, I wouldn't mind the free time and freedom from responsibility, but that's not really what I want.

I want to feel like I felt in college. I don't want youth back, but I want the feeling, the novelty. I want to feel things for the first time again. I want to hate like I hated back then, and love like I loved back then. I want to experience the things I should've experienced back then.

And I know, I can't go back. It's gone, and I'll never have it back except in memory, but that's what I'd like, to feel that again.

Why I wanted to be a doctor

When I wrote my essay for applying to medical school, I was convinced that I wanted to be a doctor in order to help people. And I'm sure that every other medical school personal statement read pretty much the same. I want to help people. And that was all fine and good before I went to medical school, but during med school, when I realized that I didn't go into medicine to help people, that was pretty disappointing.

The truth of the matter is that when I started the process to becoming a doctor, I didn't really see what it meant to be a doctor. I had a very romantic notion that being a doctor meant helping people. Never did I conceive of a day when I would wake up and say, "Damn, can't these people get sick on my off day?" And truth be told, I probably had a better idea of what it meant to be a doctor than 75% of applicants.

I thought medicine because it was intellectually stimulating, because it meant meeting new and different people and becoming involved in their lives, because it would be spiritually rewarding. And all these things have some truth to them, but really, it's not enough. I could say the same about a dozen different professions: teacher, doctor, priest, detective, researcher, psychologist, social worker, lawyer, even financial adviser.

And in med school, like so many other medical students, I discovered that my juvenile conceptions of why I wanted to be a doctor didn't hold water. They were romantic ideals and not motivating factors. They were concepts, but not desires. It sounded good on paper, but when the alarm went off in the morning, it wasn't enough to get me out of bed.

So I had to sit down and think about what I really wanted out of medicine, since I had $130,000 worth of motivation to finish med school, and the thought of going into radiology was repulsive to my vision of health care. And I realized that I wanted to be a doctor not for patients but for me.

One of the most selfish decisions you make in life is how you want to spend it, because ultimately the only person who enjoys that decision is you. And so I went into medicine for me. I wanted to be the person who says, "I think it's cancer." I wanted to be the person who patients go to in order to understand themselves. I wanted to be someone intimately involved in other people's lives because I enjoy it.

And part of that is helping people, and part of that is feeling good at the end of the day, and part of that is the intellectual stimulation. But diagnosis and treatment is really no different from doing tech support on computers, which I've done to death. You assess the machine, find the problem, attempt to remedy it. And I'm sure some people view medicine in the same vein that I view computer work. But it's the people I enjoy. If there were no people in it, I'd want nothing to do with medicine.

Because I love taking care of people, because it's what makes me feel good. Helping someone who's sick and helping them understand themselves, that's where the fun is. It's knowing that Mr. S is a scratch golfer, and whatever I do to him, he's got to golf. It's knowing that seeing me every 3 months is more valuable to Mrs. K than any of the meds I prescribe because she's lonely. No machine can give you that. And you can teach anything in the world, but teaching someone about himself, that's priceless.

Because there's no textbook on the cardiovascular system of Steve. That source of knowledge is me. And that's why I went into medicine.

Asian parents

I visited my dad this weekend, and I haven't seen him in a while, but hanging out with my dad reminds me that sometimes, having Asian parents can be trying. It's often said that you can never really get along with your parents until they treat you as an equal, and your relationship changes from person who runs your life into one of friendship. Once you're friends with your parents, that's the first time since childhood that you can really love your parents again.

With my mom, this is easy. She understands that I have my own life now, and every now and then, she'll say something like, "Oh, you're going to make more money if you specialize. You should do endocrine! I love my endocrinologist. He's really smart like you! And when are you going to give me grandchildren?" She doesn't tell me what to do anymore. She doesn't harp about paying my bills or any of that. She lets me live my life, and I love her for that.

My dad, he has a hard time with that. This weekend, he told me that I should pursue further academics, and I should get more advanced degrees. This is a little difficult, since the only more advanced degree than MD would be if I picked up a PhD. That won't happen. That I can deal with. Then he started telling me how to be a doctor. That's pretty much intolerable.

After going to school for 4 years of undergrad, another 4 years of med school, and now into my 2nd year of residency, I am familiar with how to be a doctor. And any advice of how to be a better doctor I'm not going to take from someone who isn't a doctor himself. He told me how to talk to patients. I've had classes, lectures, standardized patients, and real life experience on how to be a doctor. It's too much to bear sometimes, trying to have someone tell me what to do when I'm far more expert in the matter. He might as well have been telling me how to manage diabetes it was so far out of his realm of expertise.

Truth be told, my mom does something like this every now and then, but it's not motherly wisdom, but a nurse's perspective. "Be nice to the nurses, because we like nice doctors." It's her professional advice. And it's not an order or edict, but something a mom says, along the lines of eat healthy and don't get too stressed out.

I imagine that the hardest part of being a parent is the knowledge that at some point in time, your kids grow up, and they don't see you as their mentor anymore. They've found others who they now emulate and seek advice from. That must be tough, but it happens, and after that, you can't go back. It's a lesson in life that I've come to accept, but I'm sure that if I have kids, I'll probably do the same thing.

Observations

People make very astute observations about me, and sometimes, these things are nice to know, just for my own benefit. For example, one friend pointed out my tendency to correct myself with the phrase, "Wait, that's a lie." Another friend pointed out that I seem to have a rule for everything, and I do. Last weekend, someone pointed out that all my similes and metaphors are food-related.

The food thing, that's a little disturbing really, but the rules, that's something I've known about. I do have rules for everything, because it's how I deal with the world. To be fair, (1) they're not my rules but rules of etiquette or morality or behavior, etc that I adhere to, and (2) I don't enforce these rules on anyone but myself.

I can't help the rules. It's how I've learned to deal with a world that makes no sense. I make sense of it. I exert my personal guidelines upon myself, and let that serve as an example. And there's a lot of silly stuff that I do that I know no one will follow, but it's me.

I'm a virgin, and I don't believe in pre-marital sex, not for me at least. I don't think sex is something people take seriously. People should. I've yet to convince anyone to engage in abstinence, but it's not like I'm handing out pamphlets.

I say please and thank you for everything. It's such a common courtesy, but I am not a dictator. It is not my place to order people around without some respect. Along those lines, anytime anyone helps me with something, I personally thank them. I thank most every nurse taking care of my patients in the hospital. I thank the operator for connecting me. I thank my attendings for their help. I believe that when you ask for someone's help, you should acknowledge their effort.

I never raise my voice in anger. It's not for me to put my emotions onto other people. I try to keep a calm and steady voice. Anger is often misdirected, and thus, I have come to try to contain my anger till I can vent it in a controlled and benign manner.

I always address people properly, or as they would want to be addressed. Self-identification is a crucial element to how we perceive ourselves. I am a different person when I am Doctor IF as opposed to Mister IF.

Part and parcel to that, I try to learn everyone's name. Calling someone by name is a powerful thing. It shows that you value him as a person. It has to be one of the most influential actions you can do on a daily basis.

I've got tons more of stuff like this, everything from how to eat correctly to how to hold an umbrella. And I'm sure you think I'm nuts, and maybe I am. I'm guessing that 99% of this stuff goes entirely unnoticed, but I'm happy if 1% is managing to get through. And if you don't believe that such minor actions can have any meaningful effect, then I have a proposal:

Next week, every person you interact with, find out their name, call them by name every time you see them, and personally (that's face to face) thank them for helping you with whatever needed to be done.

And it's any wonder why nurses love me.

Stethoscopes

Digital things are nice sometimes, but there are times when it's overkill. One such place is physical diagnostics. Nowadays everything is digital. It's next to impossible to find a manual BP cuff, to the point where I'm thinking of carrying one in my coat. And the new rage is the digital stethoscope.

This stuff is ludicrous. And I say so as someone who owns 3 digital cameras and buys DVDs and CDs with some sort of unholy compulsion. Obviously, technology offers benefits, otherwise I'd be wasting my money. But it's not without its follies.

With cameras, everyone loves digital for the convenience, but truth be told, I'd rather shoot film. Film is an art. It takes skill and care and a thorough understanding of the medium. It captures a range of colors and shades that is unmatched by digital. Even the crappiest film picture rivals the best digital can offer.

Don't get me wrong, I've gone through 2 rolls of film in the last year, and I own 3 digital cameras. I've obviously been sold on digital, but it's no substitute for film. It'd be like trying to replace a Steinway grand piano with a Casio.

But when it comes to medical diagnostics, there is no replacement for analog. We've sold into this digital world, with automated BP cuffs and pulse monitors, but if you've ever worked with me, you should know that I trust these things like I trust a rabid coyote in a butcher shop.

You simply cannot replace the art of BP measurement with a machine. And similarly, I wouldn't trust a digital stethoscope, because it is simply taking sound, making it digital just to make it analog again.

Part of the wonder of medicine is interacting with people, and it makes me a little sad to think that we're coming up with more and more ways to distance ourselves.

Please understand me

The Kiersey Temperament sorter is one of those things that I do every year or two to see where I'm at. When I was in high school, I was a very strong ISTJ, which is very detail-oriented, probably the nerdiest of the personality types. Somewhere in college, I became an ISFJ, which was much more consistent with a career in medicine. The type is called the Protector and is common among general medicine practice.

Once I got into medical school, I had a subtle shift from ISFJ to INFJ, and right now, that sounds about right. I was trying to figure out my career choices in medicine and when I looked at the INFJ careers, it was my residency dilemma in grid form.

But reading through some of the stuff on INFJ's, I realize that other stuff hits home too more than just choice of career. I don't really believe that something as banal as a questionnaire has the power to explain my life, but it's a useful tool for introspection.

Some things really made sense, like my utter inability to take praise, or my ability to work well with people despite being horribly introverted. Or how I hate taking leadership positions, but when I do, I run a tight ship. But much like that crappy TV show "Crossing Over" it's easy to say these things and get people to identify.

The relationship stuff was pretty much right on. I have no interest in relationships that won't go anywhere, and I really do prize intimacy. What's the point of dating if it never goes anywhere? I'll admit that I've had opportunities, but it's a waste of time going out with someone if she's not someone you'd want to spend time with. There's sex I guess, but I'm a good little Catholic boy.

And besides, I'm not interested in sex as much as I am intimacy. I'd like to be close to someone. I feel like there's no one in my life who has ever known me intimately, and that's sad. And on bad days, I wonder if it'll ever happen. But like I've said, my outlook on life isn't as gloomy as it used to be, but it's hard not to feel alone sometimes, and that's not something you can overcome by yourself, y'know?

You can't go back

I met a 1st year medical student and it was very strange meeting someone who's so far back in the process I started what seems like a lifetime ago. I can barely remember being a 1st year, but what I do remember is with some fondness. I miss it.

Well, to be fair, I don't miss the stuff that happened as much as I miss the stuff that I thought would happen, if that makes any sense. I thought that med school would fix all the problems in my life, much like I thought high school and college would.

I thought that my life would enter a new phase and that things would be different, and I even tried to be different. I acted all extroverted and put myself out there, and expected some reward for my troubles. I got rewarded all right. My friends I'm sure recall with some chagrin that emotionally I did pretty badly in my 4 years of med school. And part of that was setting myself up for failure. My expectations were too high.

If you asked me the day before first year where I thought I'd be right now in my life, I honestly thought I'd be married by now. Really. Part of me still has a hard time believing that I'm so very far away from anything resembling marriage. I thought that I would find meaning and fulfillment, but that too seems rather intangible.

Maybe I'm too idealistic in this whole matter of my life. I have a lot of rules, as my friends enjoy to point out. Maybe too many rules. And I have to wonder if maybe not having so many rules would move things forward instead of stagnating.

Names

I think that I can manage to get more done in the hospital than most, and I'd like to say that it's my razor sharp clinical acumen, but in reality, it has next to nothing to do with my clinical skill. Because honestly, I'm not that good. My medical students were shocked to discover that their all-knowing senior resident only scored a 200 on his Step 1. One even asked me, "Two hundred and..." "No, exactly two hundred. Two zero zero."

I am, as one might say, not that smart. It goes without saying that I'm in the top 10% in this country, seeing as I've graduated college, obtained an advanced graduate degree, and am now training in a profession, and my IQ's prolly in the 130-140 range. But does this mean that I'm a smart doctor? Not really. I haven't made too many mistakes, and I have yet to kill anyone that wasn't already on the way out the door. But I'd have to say, there are better doctors out there.

But still I've managed to outperform a lot of these geniuses in the hospital setting and the simple reason is because I've bothered to learn people's names. I wish I was kidding. That's it. All it takes to be an outstanding doctor. That's my great secret.

It sounds so silly, but people actually feel a lot better when you address them in person, as an equal. When I was an intern, I'd track down the nurses for my patients, make sure they were squared away, find out what needed to be done from their end. I'd befriend the clerks and techs and respiratory therapists and it became easier and easier for me to do more and more difficult things, because I knew who to talk to in order to get stuff done.

And that's my great secret to being a good intern. Oh yes, and not killing people. That's important too.

So you wanna be a doctor

When I was an intern, I had a patient who, after extensive workup, had a simple fecal impaction. He was in need of manual disimpaction, which has to rank up there as one of the most humiliating jobs imaginable.

The matter of actually disimpacting someone isn't so bad. It's relatively simple. It's figuring out who's going to do it. And to be fair, I could've told the nurse to do it. Surgery was on board: I could've had the surgery residents do it. But I had some time in the afternoon, so I did it. I didn't get much, but a little rectal stimulation and some judicious enema use, and voila, one working colon.

And everyone around me asked me the same question: why did I do it, when I could've just dumped the work on someone else? It would've been quite easy for me to call surgery and say, "This is your domain. Do your worst." Or I could've told the nurse to do it. Wouldn't have made any friends, but wouldn't have had to do something that I'd rather forget. And honestly, I couldn't believe the attitude.

Y'know, I'm a doctor, and I'm taking care of patients, and they're my patients. They're my responsibility, and at some point in time, someone has to say that the line stops here, period. It's like heparin dosing. I track the PTT's, because while it's someone else's job to monitor that stuff, it's my name on the chart. It's my care.

Whenever I meet pre-meds, I try my best to discourage them, not because I am cynical or spiteful. It's because people go into medicine and don't have a clue what that means. They think it means sipping scotch neat at the country club and talking about how to improve your short game, or picking out which BMW to buy. Even worse, people go into medicine thinking that it's all about saving people or comforting the dying.

If you want to save people or comfort the dying, be a priest. Seriously. It's a better use of your time. Medicine is about dealing with shit. It's pulling stool from a grown man's rectum, or losing sleep at night trying to remember if you ordered a CT scan, or arguing with an HMO about getting a patient's MRI covered. It's messy work, and no amount of BMW's or scotch or people in the community kissing my ass is ever going to make it worthwhile.

The reason to go into medicine is because you love it. It's because seeing sick people and helping them deal with their illness is something that you enjoy doing. You can sit in a radiology suite, sip coffee all day in scrubs, earn $250k a year, and still hate your life. MD after your name won't fix that.

I knew I was in the right line of work when I had a patient of mine in the hospital, and I can't stand this patient in the clinic. One of my chronic pain med patients. But the patient needed surgery, so I stopped by, and we chatted for a while, and I realized that as much as I don't like taking care of this patient, it's my responsibility. If not me, then who?

When you are faced with the most unappealing jobs in life, like trying to manually disimpact someone, and can still go home and add up the day and come up in the black, you know you're there, because any number of people I know in medicine would've endlessly complained about such humiliating work, and I would not let one of those people take care of me.