Don't become a doctor #8 - constant change

Today, we were talking about hypoglycemia, and if you talk to people who finished their training only a few years ago and you'll hear the words, "Hyperglycemia doesn't kill anyone. Better to be high than low." This has been dogma until recently, when several nice studies have shown that poorly controlled glucose in critical patients increase mortality up to 15%. Now, the thinking is the opposite. I've actually told patients that hypoglycemia is the price you pay for good glucose control.

Then, there's pulmonary artery catheters. 4 years ago, this was a bread and butter procedure for internal medicine residents. Now, I don't know any resident that's done more than one. Looking a little further back, there's beta blockers in heart failure, the use of thrombolytics, stenting versus CABG, anti-TTG Ab versus duodenal biopsy.

My point is that medicine is a field of constant change, and not little change. Big change. Talk to a doctor 15 years ago, and if you told him that you thought that his heart failure patient didn't need a Swann and should be on a beta blocker, he'd accuse you of malpractice (and 15 years ago, he'd have been right!).

Some people like fields that are understandable and consistent. Medicine is not such a field. If the thought of continually keeping up with the changing world of medicine scares you, then you'd best stay away.

Without a rudder

I just can't say what I want to say, I can't find the right words. I feel so mixed in my life. I can palpably feel the emptiness of my existence, and it hurts. I don't know if this is a fair complaint, but when there's no one else to buffer the bad times, it's hard to recover from the downs, and there's no one to share the ups.

It's hard to grasp the dilemmas of my life. I'm without a rudder.

chicken shit

So, I talk to a lot of the nurses on the floors. I know the names of at least half a dozen nurses in every unit, and probably more than that in the ICU's. I am often the resident that nurses come to, because they know that I listen.

And so, I'm never really surprised when nurses talk to me about their lives, because... well... I listen. And I don't make much of it, until recently. One of the nurses I know, I think she was flirting with me.

I say "think" because honestly, it's been that long since anyone has flirted with me. It's not like I'd know it if I saw it, and really, I don't want to read too much into it. But it certainly seemed like it.

Now, there was all that big talk about taking advantage of opportunities and growing personally and socially, but I completely let it hang. And I realize that it's because I'm chicken shit. And what can I say? I have no defense. It's who I am, and that's all I can say.


I've moved my laptop into the living room so I can watch TV and surf the net at the same time. This should tell you about how boring my life is. My whole life is working at the hospital. I wake up to go to the hospital. I come home and wait to go back to the hospital.

My attendings are mixed in their opinions on my complete and utter lack of a social life. Some think this is grand. I can dedicate all my attention to medicine. Some think this is horrible, that I run the real possibility of losing any semblance of normality.

I can feel it now, this complete emptiness in my life, and it's not so bad. It's not like I'm playing in traffic. It's just that there's nothing that inspires me. I put in my time and I'm good at what I do. I even enjoy it. But that's not the same as having meaning and fulfillment.

There's no meaning in my life. I don't know how you go about fixing that.

Addendum to delivering horrible news

After talking to some friends about the process of delivering horrible news, I need to add a few things. When I say horrible, I mean there's no chance for recovery. If there is a chance for recovery, albeit slight, you have to tread a little more carefully.

But there are certain things that must be avoided. Never use the following phrases:

"We'll keep fighting"
"Do you want us to give up?"
ANY sports analogy
Quit, throw in the towel, give up, stop trying, surrender
Never make it a choice between life and death

I say this because it's important to understand that letting someone die peacefully takes a lot of courage. It takes a strong will to say, 'No. S/he wouldn't have wanted this.' Because you're not asking for a family to decide if their loved one should live or die. That's just not fair.

In most cases, you're asking the family to see that the focus of treatment needs to change, that treatment isn't making the patient any better, and so we must redefine what 'better' means. Better can mean cure, but better can also mean at peace or comfortable or right with God or any number of things, and it's important to help a family realize that if we can't make a person medically better, we need to think about these other better's and maybe think more about that.

I'll admit, I get palliative care involved very early in a case where the patient is in my opinion without hope for recovery. And it's important to know that palliative care isn't about giving up. It's quite the opposite. It's a determined and concerted effort to make someone feel better.

The limitations of a delicate soul

When I was little, I would eat my french fries without ketchup. This was because I was too scared to go up to the counter of McDonald's and ask for ketchup. It was easier just to eat the fries. Occasionally, one of my parents would realize this and make me go up to the counter and ask. I'd wait in line (for ketchup!) and then, in this meek little voice, "can i have some ketchup please?"

I was very easily embarrassed as a child, so I'd avoid all kinds of social situations in an effort to avoid assured humiliation. Every now and then, I'd find myself in a terrible spot, and I'd turn some freaky shade of purple. My friends never realized that it was possible for someone to blush that much.

Some of my friends were unbelievably cruel to me when they realized this. They'd shamelessly flirt with me, and watch me flush. it became a contest. Some people might view this as fantastically lucky, to have girls flirting with me, but it was utterly anxiety provoking.

I stopped watching the evening news after the riots in LA from the Rodney King verdict. I saw people hurting other people and sat in front of the TV weeping. It was traumatizing. Since then, I barely watch the news.

It was sometime in high school that I realized that I have a delicate soul. Since then, I've been trying to desensitize myself. I would ask questions, poke and prod, talk to people at the grocery store randomly, I would flirt. I would try to meet new people. I learned to open up and try to connect with the world.

And now I don't blush so easily anymore. I'm not afraid to ask for what I want. I can interact with the rest of the world normally. But I never learned how to defend myself. There are things that we do to defend ourselves from situations. But my solution is always the same: withdrawal. I pull back, pull away, never let anyone in. And it's worked out surprisingly well. But the problem is that it's not really any different from that five year old who was too afraid to ask for ketchup so he ate his fries without any.

Evil, soulless cupcakes

Going to church on Easter Sunday is like torture. It's when all the lapsed Catholics decide today's the day. At mass today, at a service where I regularly have room to stretch out, I was forced to stand even though I was 10 minutes early. I used to be very resentful of this, to the point where I always think about skipping Easter Sunday mass, since I do go to Easter Vigil anyway.

I was always bitter because these people show up for a day, get to feel all Catholic for an hour, then go back to their lapsed life. Why bother with Catholicism? There are untold numbers of Protestant demoninations that do this an call it normal. Why do they force me to stand on Easter, which is one of my favorite days to actually go to church?

But how bitter of me is that? I mean, here I am spending nearly every Sunday in church, and how can I be bitter that I have to stand one Sunday? These people are coming to church and trying to reconnect with their faith, and I'm annoyed? It's a beautiful thing. It's people trying to find their place in the world, trying to make terms with God. I'm not so bitter anymore. I'm happy for them, even if it's only for one day, or two counting Christmas.

The comforting thing about being Catholic is that it's not a very judgemental faith. I've been approached by other Christians and been told that I'm going to Hell and that my faith is misplaced, blah blah blah. To be fair, I think that about them too (ha ha ha), but who am I to shit upon someone else's faith? I think that the thing I like the most about being Catholic is that I do my thing, I do my good works and follow my path in the world. And other people, it's not my place to judge. It's not my place to condemn.

Today, in order to celebrate a wondrous Easter, I wanted a cupcake. The cupcake really is the most wondrous treat ever, a hand held confection that is cakey and wonderful. The last cupcake I had was in New York City, at Magnolia Bakery. A friend of mine felt like walking a little, and we were in the area, so we trekked over to Magnolia's West Village locale and indulged in a cupcake each.

It was a good cupcake. It was soft and moist, and the frosting was rich and decadent. But it was just a cupcake. It was something that I could get from any bakery that would so dedicate itself. The simple fact of the matter is that most bakeries in NYC are far too specialized to do something so trivial as cupcakes: bagel shops, bread bakeries, or ethnic bakeries, there are so many iterations.

And that cupcake meant nothing to me, until I started watching some television. In the few months since I've had that cupcake, I've seen 4 references to Magnolia, and I haven't seen one episode of "Sex and the City" (which is the most evil show ever, btw).

People put so much value into the name of things. People want Starbucks coffee and Black Angus beef and Heinz ketchup and Krispy Kreme donuts. Who cares? so Magnolia Bakery, you make an awesome cupcake, but in the end, it's just a cupcake.

Asking for trouble

Every year, I go to the Easter Vigil service (it's a Catholic thing). My current church has a very nice ceremony. It's always a wonderful mass to attend. After weeks and weeks of Lent, alleluia! It's such a touching and beautiful ceremony, I'm always surprised more people don't go. Maybe it's the fact that it's 3 hours long...

But what always surprises me is the number of people who want to become Catholic. Easter Vigil is when adult seeking to join the Church are initiated. I have a hard time understanding it. I really didn't have a choice. I became Catholic because my mom made me. Not that I mind. It's just that if I was an adult, and was posed with the idea of becoming Catholic, that'd take a lot of convincing.

Because after all, there's so much suffering involved. There's all the guilt. It's not fun. It's a lot of work. It's church every week. It's holy days of obligation scattered throughout the year. It's all this responsibility.

But I guess there are good things about being Catholic. There's so much tradition. But the thing I like the most about being Catholic is that it's work. There's no lip service. Being Catholic is all about getting your hands dirty. It's doing good in the world.

So congratulations to all those new Catholics out there. It's time to get busy.

Pre-med season

Lately I've been hanging out in coffee shops, and as April comes to a close, it's only natural to see the MCAT books out. There are pre-meds everywhere full of hope, still virginal and uncrushed by the world. They haven't even begun to suffer. In their minds, doctors are noble, the captains of the world.

And it's because of these bright-eyed college students that I've been doing these "Don't Become a Doctor" posts. Because none of these guys know what it means to be a doctor. So many people want to be a doctor for the prestige or the money or the power or whatever stupid reason that isn't what being a doctor is.

And I know this because I'm no different in my motivations. I didn't know what it was to be a doctor when I was a pre-med. And it took 4 years of medical school to figure out what it is to be a doctor.

For me, the reason why I applied to medical school was selfish at heart. I saw medicine as my salvation. It was a profession where I could dedicate myself to working with the sick and suffering, God's work. It was a noble reason to exist, rather than converting oxygen and sugar into carbon dioxide.

And nowadays, I look into that sea of cafe tables covered with MCAT study books, and wonder to myself if they know what they're getting into. And I'm glad that so many of them will fail in trying to be a doctor, because it's better to find out that medicine's not for you before spending $150,000. Four years of college, four years of med school, and at least three years of residency is too long and too painful to do something you don't love.


In my life, I have a strong sense of self-respect. I have dignity and a great desire for justice. However, in spite of all this self-respect, I have very little self-esteem, which is almost ridiculous, given that I have so much to be proud of.

So, if you'll excuse me for a minute, I wish to simply espouse what in my life that I am proud of, and why I should have some self-esteem, because I really should. Any normal person couldn't help but be proud of the achievements I've had in my life.

I'm compassionate. I feel very strongly for my patients. I'm thoughtful and considerate. I'm conscientious and hard-working. I don't shy away from tough spots. I I'm sensitive and kind-hearted. I have a strong sense of morals. I appreciate art and literature. I'm erudite and classy. I can swim in all social circles. I hold a BS in a hard science and an MD. I'm in the profession that consistently ranks #1 in prestige.

I have so much to be proud of, and you'd think I'd take a little pride in it. I wish I did.


I don't give out compliments. I don't. Anyone that's known me for a while can attest that getting a compliment out of me takes something pretty impressive. This isn't because I'm a jerk. Okay, so I may be a jerk, but that's not the motivation behind not complimenting anyone on anything.

I always feel so uncomfortable with compliments. People try to compliment me, and I know they're trying to be nice or whatever, but instead I feel very awkward. I'm like those elves that cobbled shoes at night. I'm don't do anything in my life aiming for recognition. These days it's not so worrisome for me, and I can even take a compliment with a modicum of grace, but it's not like I seek out compliments.

This is entirely different from thanks. It's not difficult to accept thanks. Thanks is praise for work that has been done. There was effort, there was expense, and there is thanks. It's only natural.

The thing about compliments are that for the most part, it's opinion and conjecture, and so very different from thanks. Whether you look pretty or not today is opinion. Whether you're a hard worker is a fact.

So, these days I give out a series of non-compliments, things that people interpret as compliments, but really are more like observations.

"You changed your hair."
"Is that a new tie?"
"You look very dressed up today."
"Is that a new perfume?"
"You must've gotten a lot of sun on vacation."

And people can take them for what they will. Most people take it as a compliment, and thankfully leave it at that. Some people (women) will fish for the compliment. "Oh yes, I went to a new hair salon! Do you like how it looks? Hmm? Do you? Huh? What's that?"

And sometimes, I let a compliment slip. Like I was walking past my favoritest hot nurse, and she was very dressed up that day, and as I passed, I said, "My, you look beautiful today." And about a minute later, I thought, "Did I just say that out loud?" I'm sure it's only a matter of time before I have to attend sensitivity training.

Why I didn't do oncology

When I was in medical school, I was rounding on the internal medicine service, and our afternoons were pretty light. I was checking up on some tests and how my patients were doing, when I ran into Dr. Lanky. As you might expect from the nickname, he was tall and wiry. We was also the chief of oncology and generally well-respected.

"Hey, IF, I'm rounding on consults. If you're not busy, you can come along if you want." He sipped his coffee and motioned me along. I had planned on hiding in the library for the rest of the afternoon, but I liked Dr. Lanky. He was always good with students, and since I was interested in Heme/Onc, this would be a great afternoon for me to learn, and if not to learn, then at least to schmooze.

Regardless of whether you liked or hated Dr. Lanky, everyone respected him. He usually rounded on consults by himself, and so getting to round with him was a distinct privilege. I didn't need much convincing. He also knew I was interested in Heme/Onc so he thought he'd show me the life.

"What about the other students?" I asked as I chased after him in the hall.

"Where are they now? Nah, let's just do you and me." Wow. Face time with the chief of oncology. I felt pretty good. So, I started seeing his consults with him, which amounted to me following him around. I did a little bit of scut, but not what you'd expect for a medical student rounding alone with a division chief. We read charts, checked labs, looked at films, and reviewed path slides. Finally, it was time to see patients. All along the way, Dr. Lanky explained the pathophysiology, the natural course, the prognostic factors. But it all meant nothing until we talked to the patients.

In one afternoon, we talked to 5 patients and families, and we told them that they had terminal cancer. He offered many tissues, held many hands. Room after room, it was one terminal diagnosis after another. Some were offered palliative chemo, possible palliative radiation. Some were offered a Hospice referral.

None of it was easy. One patient was a peek and shriek from the surgeons. They'd done an ex lap only to find diffusely metastatic colon cancer. Another was a 46 y/o lady with stage 4, poorly differentiated, non-hormone responsive, breast cancer. She had her two little daughters sitting on the edge of her bed. One was a 78 y/o gentleman with unresectable pancreatic cancer. His wife burst into tears and grabbed her husband's arm. "Please, please don't leave me," she cried. He tried to smile and comfort his wife. Then he thanked us.

Five cases, all equally tragic, each one enough to destroy a man's faith in God. After the last one, I left the patient's room in tears. Dr. Lanky finished up his note and turned to me.

"You okay?"

"Yeah. It's just that... it's so tragic." What tipped me over the edge was the breast cancer lady, who upon hearing the bad news grabbed her two, beautiful little girls and clutched them so tight. The confusion was all over their faces. "Mommy, why are you crying?" It was too much to bear. I had to leave.

Dr. Lanky put a hand on my shoulder. "We're not made of stone. We're people too. You shouldn't feel ashamed to cry. I'm proud of you. Compassion is a noble thing."

That one day rounding with Dr. Lanky cemented in me the desire to do Heme/Onc. It only took one afternoon to win me over. Playing such a sacred role in people's lives usually requires vows of chastity and obedience.

And over the past three years since that afternoon, I've come to understand that Dr. Lanky was the exception and not the rule. I've seen the handiwork of oncologists, and I want none of it.

All through medical school, we learned about informed consent and patient autonomy. Then something like oncology comes along and all that medical ethics stuff is in the shitter. 'Oh, I don't tell them they're dying.' 'Oh, you can't give them statistics.' 'She'll be dead in 6 months, but if I tell her that, she'll be miserable.' And some of it even sounds reasonable till you meet a 54 y/o woman with stage IIIb small cell lung cancer who's talking about whether her grandkids will go to college when they grow up.

'You can't destroy their hope,' is the universal cry. How dare I tell a patient that her radiation is strictly palliative. How dare I explain that the five year survival for pancreatic cancer is zero. To me, it's like being on an airplane where all its engines are out, and we're about to crash. Then, the flight attendant says over the speaker, "Now, as you may know, we're having some engine difficulty, but we're doing our best to work on this problem, and we're implementing some procedures that have worked in the past. I'm confident that we'll come through this okay."

Oh, it's not lying per se, but it's not really the truth either. And no matter how calm it may make me, I don't want to be balancing my checkbook when I die. My last thought would be, "That lying bitch! We're crashing!"

And seeing the world of oncology, offering up so much false hope, and seeing how different this was from Dr. Lanky, I couldn't bear it. I cut Oncology out of my career plans and re-excised for margins. I'm not saying oncologists are bad or anything like that, but this idea of not destroying hope is pervasive throughout oncology and all medical specialties that deal with potentially life-threatening disease.

I was talking to an ethicist a while ago about this, and he said something profound: "We are always hoping for cure, and view death as failure. But just because we can't cure, that doesn't mean we can't give patients real hope." There's so much to hope for other than cure, but that's all we've ever cared about, and we've ignored all that other stuff.

I think Dr. Lanky would be disappointed that I'm not pursuing Onc, because he knows as well as I do that I could never be one of those false hope oncologists. I'd tear myself apart. But by the same token, the idea that I could ever be involved in such a case, even once, is more than I could stand.

And so, the oncologists that take care of my patients every now and then will criticize me for talking to my patients about what lies ahead, but as much as they yell, my patients always thank me for giving it to them straight. I'm not mean about it, or hopeless. But I feel that in their hearts, people want to know the truth. So I give them as much truth as they want. And at night, alone in bed, I can sleep with a clear conscience.

Addendum - I'd like to note that I do not go about trying to dishearten my patients or destroy their hope. I simply find out what they know and don't know, what they'd like to know, and provide whatever information and support that I can. Sometimes, it's telling a patient that chemo is rough, but can have good results. Sometimes, it's telling a patient that the chance of remission is very slim. And when I was working with Dr. Lanky, we weren't out to crush people's hope. Each case was very much terminal, and even then, we offered most palliative options, and some even hope for remission, albeit with long odds.

I don't want you to think that I'm out there, ruining the work of good oncologists who give their patients truth, and in that, deserve trust. I simply wished to say that what I see from a lot of doctors is an unwillingness to be truthful about prognosis. What's the point in knowing prognosis if we never share that? And to those oncologists that work hard to treat their patients respectfully and not patronizingly, cheers.

As far as my unwillingness to do oncology, I've come to realize I have a delicate soul, and I could not suffer the weight of deception. In all things, I strive to be square with God. And the thought that one day, I could become like those oncologists I despised, that thought was too much to bear.