Breaking up

I was listening to This American Life last week, and the episode was about break ups. It was a strange and amusing episode to listen to, and I know that I have felt the same way at times, but it seems like when we talk about break ups, it’s usually the perspective of the dumpee rather than the dumper. It is the dumpee who is all alone, pining for a nonexistent future.

I can certainly sympathize with the dumpee, seeing as that has been my station in life. Being dumped sucks, and after the last time, I have no desire to go through that again. It is all about being hurt, tossed about like in the wake of a passing ship, and while the dumper is getting on with life, the dumpee is stuck in a continual relationship post-game report.

You know, after a football game, the commentators all sit together and break down the game play by play, finding all the faults and mistakes and errors. “In the 2nd quarter, he was far too clingy and came off as desperate. In the playback, you can see he was doing a LOT of hand holding. I think that this is where the momentum turned.” You get the idea. Maybe you even know what I’m talking about. And inevitably, a sick kind of hypothetical game comes up. Maybe if I did this, it would’ve been different. Maybe if I was better about that...

The sick twist to being dumped is that your own self-worth goes in the toilet. Here this person whom you loved and respected has determined you are unlovable, and so that becomes your own self-image, that you actually deserved this, because who could love you? It takes a long time to get back to even keel, and you dream of the day when everything stings a little less.

I for one am sick of this mental torture. I do not want to ever find myself in that place again, full of anguish and self-pity, tortured by the echo of love. I think that if I am in a relationship I see going downhill, next time I will be the dumper. I will be the one to cut my losses, rather than the one left stumbling in the dark.

I am not a mean person, and I don't relish the thought of hurting other people, but it is an issue of self-preservation. A person can only stand so much heartache in a lifetime, and I've had more than enough.

Dear Rhona

I listen to a lot of medical podcasts, in an effort to try to keep pace with the changing medical world. I find that the podcast is the perfect bite-sized piece of information and, with an ipod, can be played just about anywhere while doing just about anything. I listen while I cook or clean, and I've been doing okay except for The Lancet, which is a difficult podcast to follow because of the sheer volume.

But recently, I got a most pleasant surprise: the soft, lilting, Scottish accent of Rhona McDonald, a substitute for the regular Lancet podcaster, Richard Lane. I was actually listening attentively. I have never seen this woman before, and know nothing about her, but I have to admit, I've got a little voice crush.

It reminded me of a girl I knew in college who was a very attractive Chinese girl, but the amazing thing about her was that she had this smart British accent. She grew up in Hong Kong, and spoke proper British English. It's funny how something as silly as an accent can carry so much weight in our minds.

Along the same lines, I had one friend who had such a pleasant, wonderful voice, and whenever she talked to me, I felt all warm and fuzzy. I wanted to have her record my answering machine message. I was so enamored with her, just by her voice, but apparently, since pretty girls are my Kryptonite, I never could manage to say more than 3 words to her at a time, and I haven't seen or heard from her in years. But oh, what a voice.

Practical advice for the new MS1

It's time for the brand new medical students to embark on a long and treacherous path towards being a doctor, and I think of this time as amazing. It is both scary and exciting. It is mysterious but beautiful. It is also one of the first times in your life when you are finally among equals. I thought I might provide a little advice to any MS1's out there on my thoughts about the first year.

On first draft, I wrote about principles and value and being a better human being, and you know what, I don't think you'll need that. You will get it from everyone, and tons has been written about it already. Just google "Advice for new medical students." Instead, I will give some very practical advice.

Unless you have a PhD or were a financial analyst, the first year of med school will be one of the hardest things you've ever done. If you want to do well, you have to ensure that your time is productive.

(1) Figure out how you study best (smarter, not harder). Some need to write it out. Some need to hear it. Some need to read it over and over again. Whatever works best.

(2) If you like to study in the library, you gotta get there early to camp out in a good spot. You have to get a good spot, not only to help you study, but by getting a good spot, your academic cred will go up, and smart people will want to study with you.

(3) Have a study buddy. Not someone you study WITH, but a person you study NEAR. So you can take study breaks together, chit chat. Also, with two people, more chances of getting the good studying spots.

(4) Work hard, play hard. After every test, we'd go to the bar. In med school, that whole waiting till noon thing goes out the window.

(5) Get a study group together. Meet regularly. Our study sessions were great fun, and are some of my best memories from med school.

Enough about studying. Let's talk about life for a minute. You will not have one. So you should take some steps to ensure that your life will not be completely joyless and pathetic.

(6) When you hear about this party or that party, go. Go to every single party. Party hard. Enjoy. You'll need to get all your fun in now, to make up for later.

(7) If you're not studying, you'd better be having fun. First year is all about gas pedal or brake. No neutral.

(8) Have some friends who are just friends, and you don't need to worry about a study session breaking out. I had a group of friends who met every week. It was fantastic fun.

(9) Join a million clubs. It'll help to fill up your non-productive time.

(10) Your med school colleagues will form their entire opinion about you for the next 2 years based on the months of August and September. If you have to be an asshole, don't do it the first two months, huh?

Your expectations of med school have to be a little realistic, and you will find that med school is nothing like any academic activity you've ever done, because it is the best of the best. It's like you've joined the academic equivalent of the Navy SEAL's.

(11) Don't try to show off. No one cares about your MCAT score, because we all know that the MCAT doesn't mean shit anymore. In my class, I was in the top ten for MCAT scores, but I was never again in the top ten for anything throughout the rest of med school. No one cares about the MCAT.

(12) A lot of med schools are pass/fail, but I have heard stories about people not sharing notes or giving out false information to try to game their class rank. This is SO NOT COOL. You will get a reputation for shit like this, and guess what, reputations don't go away so easily any more. Eleven years later, some blogger like me will be writing about how Mousy was such an asshole because she wouldn't let me copy a lecture handout, because she didn't need anything from me, and how much satisfaction I got when she wanted to switch calls with me during 3rd year, and guess what, I didn't need anything from her.

(13) Don't start drama. I have known people who've gotten into fist fights in class, or yelled at a professor. That's just ridiculous. I mean, really.

(14) A lot of schools have a 'med school for dummies' kind of extra study session for students underperforming. Don't make fun of these people. That's just fucking rude. I had to go to one of these sessions. It is already one of the most humiliating things that can happen in med school. Your mockery is not required.

Romance in medical school is possible, and I would encourage you to pursue a love life, but there are some definite pitfalls and caveats to keep in mind.

(15) Med school is a small world, so if you end badly, expect repercussions to follow. And do me a favor. As a guy who was turned down at least twice with the line, "Oh, I'm not going to make the mistake again of dating someone in med school," when you do get into a relationship, don't take out your frustrations with med school out on the other person. Med school is a stressful time, but it's never okay to put other people down to make yourself feel better.

(16) For the guys, most girls in med school are in their early twenties (like you probably are), and are still essentially the same girl who turned you down in college. If you are striking out in the med school world, try the working world. That same 23 yr old girl has developed very different priorities after working for a living. For you ladies, c'mon. Boys never change. We hit our maturity peak at 16. He's not going to grow up and act his age, even if he's going to have MD after his name.

(17) Although most med schools are about 50/50 boy girl now, the number of single men to SINGLE women is still vastly disproportionate. In my class, it was somewhere around 5 to 1. If you like a girl, don't do what I did and wait around. Move quickly, because there are 4 other guys with the same idea.

A little advice for the ladies: dating men in medical school is like car shopping. Do a little research. Figure out what you want from a relationship, what are the deal breakers. Take a test drive. All of med school is your oyster. If you can't find anything good in your class, try one up or one down. However, keep in mind that med school selects against bad boys and heavily favors nice guys. You might want to look outside of med school if dating jerks is your thing.

I have some miscellaneous pieces of advice that don't quite fit into the categories I've set up, but are worth mentioning, because some are extremely practical.

(18) First chance you get, steal a pair of scrubs. If you have access, start wearing scrubs regularly (just not to class). You'll save money on laundry.

(19) Become the 'Go To' guy for something. I had a couple friends who invested in a kegerator. Guess who got invited to every party? Even I had my own 'thing' for med school.

(20) You will be poorer than ever before. Save your pennies. Eat ramen noodles.

(21) Whatever you may think about Drug reps and docs whoring themselves to Big Pharma, the only decent meal you're going to eat for weeks is being provided by the drug rep, free of charge. Swallow your pride and take free food whenever it is offered. You can have standards when you get paid.

That's all I can think of for now (isn't that enough?). I'd be interested to know if anyone else has practical advice for new MS1's.

Death and failure

[SPOILERS ABOUND. BEWARE!]

I was discussing my thoughts on the book "The Spirit Catches You and You Fall Down" with a friend of mine who also read it. We were both amazed at how something so basic as caring for a sick child resulted in such tragic consequences, and it's no surprise to folks like us. We're both Asian, and we've had our own experiences with the clashes of Western medicine and Asian cultures. Neither of us are Hmong though, and it's a pretty different viewpoint.

But then my friend said something really funny to me. "It's so sad that she died, and it was all from—"

"What? Wait a minute. She doesn't die. In fact, according to the book's website, she's still alive."

"No, she died... didn't she?"

"Umm... no she didn't. She's alive."

In medicine, we equate death and failure. We can't separate them, or at least it's very hard. It's why some oncologists will wait till the very last second before sending someone to hospice. It's why we take worse care of DNR patients than full code patients. Even my previous comment is biased towards life-saving measures. Is it worse care, or is it more appropriate care?

But the truth of the matter is that in the medical field, we have a very hard time dealing with death. I have my own theories. I think when it is our own lives, they have a beginning, a middle, and an end, and although most of us are not seeking out death, we understand that it is a part of being human. And we can be content with that based on our own self-worth, which is the totality of our life's experiences.

When you're a doctor, all you see is a part of that life. You may see the beginning. You may just see the middle. But almost never do you see the whole thing. And so a doctor is not able to determine the value of a person's life based on life experiences or anything substantive. We are left with only one way to judge a life's value: quantity. We try to get people as much time as possible, with the belief that adding days will add value.

And in general, board strokes, quantity is valuable, but only to a point. For example, someone on his death bed is probably not concerned with the performance of his stock portfolio. So quantity is clearly not a definitive measure of worth, and so we as doctors are forced to rely on patients and families to tell us what a life is worth, and when it is okay to cut back on quantity, to give a little quality.

I remember one ICU patient was ready to cash out, so I talked to his son, trying to see if we could change to comfort measures. His son was conflicted. "If it was me, I'd say enough is enough. But my dad, he was real stubborn. He would never give up an inch, and I know he would want to fight to the very bitter end. What should I do?"

I could've talked him into palliation, but that's not fair, because in the end, his role isn't to play God, and neither is mine. It's simply to convey his dad's wishes. "When I talk to families, what I really want to know is what the patient would've wanted. Sounds to me like you've given me the answer. I'm gonna keep being real aggressive, and when you think he'd have hit his limit, then you let me know."

Believe it or not, I'm an optimist

I keep getting comment after comment about how discouraging I am, and how I'm all doom and gloom. OMG, please, understand one thing: I LOVE my job. L-O-V-E. Every morning, I look forward to seeing my patients. The whole 'Don't become a doctor' series is about full disclosure. It is the price you pay for being a doctor. Do you really want to read another article on how medicine is difficult, but rewarding?

I got a private comment from a reader asking me if medicine really was so horrible, and I felt a little guilty. So for those of you similarly disheartened, fuck this whole series. I have one question for you: are you in love with medicine, or are you in love with being a doctor? Because I love the medicine. I have gotten into arguments with other docs about whether a patient should be on coumadin or not. You have to be passionate about the medicine. Because you will never be passionate about getting mail addressed DOCTOR ifinding, and you'll feel no sense of fulfillment from the length of your white coat.

So for those of you who are not regular readers of this blog, understand that this blog is written for me and me alone. I do not write this blog for other people. It is my fears and concerns and worries. It is entirely about the things in my life that worry me.

And since I'm getting sooooo many detracting comments, I thought that I might give you a little... treat. Here is a quick list of all the things that make me crazy happy to be a doctor. There are so many wonderful things about being a doctor, and it is a super fantastic job, if you can deal with all the negatives.

(1) There are only a few 'sacred' professions. For example, there are only two people that a family will call to the bedside of a dying person: a priest and a doctor. Caring for the sick and dying, that is a very special kind of duty, and I feel so lucky to have met so many wonderful families, under the absolute worst circumstances, and seen just how beautiful love is. Watching a wedding is a beautiful display of love, but it cannot even come close to watching a woman weeping at her dead husband's bedside. That is sacred. We as physicians are privy to so many of these sacred moments: births, deaths, and everything in between.

(2) There are very few professions where science and humanity mix so intimately. You can be the best scientist in the world, but if you can't interact with people, you'll never be a good clinician. In hard sciences, you have to love the science in a vacuum. In medicine, I love the science because of the difference it makes in people's lives.

(3) Medicine is one of very few professions where you meet people from all walks of life. In medical school, I was rounding and we were talking to a patient who didn't graduate 4th grade. When we came out of the room, the attending told me, "Here we are, over 30 years of higher education cumulatively, and we still need to be in touch and accessible to this guy with a 4th grade education. I tell ya, ifinding, it keeps you humble."

(4) It's very easy to find fulfillment in your work. One of my ICU calls was absolutely miserable, and I was complaining to the nurses why does all this shit happen when I'm on call? I was getting crushed. One of the nurses came up to me and said, "Dr. ifinding, it may seem really bad, but we are so thankful that it is you on call. When I finish my shift, I can sleep easy knowing that you're doing everything you can for my patient. If it was me in that ICU bed, I'd want you by the bedside." In medicine, there is no finer compliment. Whenever I feel lost, I think of all the people I've cared for, and it's easy to find the strength to keep going.

(5) I love puzzles and thought games. Sudoku, crossword puzzles, word jumbles, all kinds of games like that. I love to take chaos and make it into order. That is how I know that I was destined to be an internist. Every patient is like a little puzzle. Do you have diabetes? What are the diagnostic features of pneumocystis pneumonia? Every day, I am mentally challenged. It is exciting.

(6) I like to take care of people. I like having my own patients who think of me as their physician. It is so flattering. I have one patient who hugs me every time she comes in. She is such a sweetheart. But on the opposite end of the spectrum, I have a patient who is a complete asshole, who after years of me killing him with kindness, he's become very cordial and pleasant! The nurses were shocked. All this medicine stuff, it's fun, but without the patients, it would be meaningless to me.

That is what I love about medicine. It lets me take care of people. It lets me do my good for the world one person at a time, and I get the luxury of seeing the fruits of my labor. It is, at its core, remarkably selfish of me, and I am not sure how selfish and selfless can exist in the same action, but that is why I love medicine.

Don't become a doctor #11 - perfection

I was in an elevator one day, and I couldn't help but overhear two neurologists talking (elevator conversations are bad! Even when it's an elevator full of doctors! Don't make me call the HIPAA police!). The only part I caught was one saying, "The PCP really dropped the ball. It was textbook HSV encephalitis."

Just as an aside, herpes simplex virus (either the cold sore or the genital herpes variety) can rarely INFECT YOUR BRAIN, and if you manage to live through that, you'll usually suffer some major neurologic damage.

I was completely stunned at the boldness of the neurologist's statement. But I'm sure that this PCP doesn't need a couple neurologists beating him up. Probably doing a good enough job himself. I know I would.

In medical school, one of my professors told me something wise. "Ifinding, I'll bet you think you should be right 100% of the time, because when you're wrong, people suffer, and maybe die. But guess what? You'll never be right 100% of the time. No one can be. We're human. In fact, you only need to be right 60% of the time. That's what the USMLE says (182 out of 300 on Step 1). I think that the most admirable goal would be 90%. If you can be right 90% of the time, then you'll probably be the best doctor you know. And when you fuck up, then you can say to yourself that you're allowed to be wrong one in ten times."

That's a really easy concept when you're a student, and the only thing at risk are your grades. It's a lot harder when you're trying to decide if it's pericarditis on EKG or an MI. And after a while, you learn painfully that you will be wrong sometimes, and the best you can do is plan for the worst.

So if you can't deal with being wrong sometimes, then stay away from medicine. I long for the days when being wrong meant losing points on my boards. Now when I am wrong, people get hurt, and people die. There aren't many things in medicine that feel worse, but the truth of the matter is that it is unavoidable. No one is 100%. No one.

Don't Become a Doctor

I have been getting a LOT of links lately, and I appreciate the traffic, but I've come to realize that most of the links are for the 'Don't Become a Doctor' series, which I enjoy writing (I am still writing it), but I can see that there probably should be some sort of table of contents or main link page for ease of navigation and for the sake of links.

I just want to be absolutely crystal clear to the new readers out there, as I have gotten a lot of comments and mail about how pessimistic this series is, and how I must hate my job. I LOVE my job. I could write 40 posts on why someone should become a doctor. That's not the point of this series. Because you don't need help coming up with a list of reasons why being a doctor would be great.

To reiterate the purpose of these posts, I think that people spend a lot of time talking about the admirable qualities needed to be a doctor, and the motivations. We talk about the nobility and altruism of medicine, but rarely do we ever talk about the faults and shortcomings. So, I created this series as a guide, so that the eager pre-meds of the world can see the downsides too. And there are good sides, and it can be great, if it is what you want. But if all you are looking for is prestige and money and an easy life, I hope you might reconsider.

But please don't be too disheartened though. If anything I say actually discourages you from being a doctor, post a comment and let me know. I have no right to take your dreams away. I should be accountable for that. And if your dream truly is to be a doctor, I'll be more than happy to give you a litany of reasons why I think medicine is wonderful.

(1) The very worst in people
You only see the very worst of the world. Those are the folks that need our help.

(2) The doctor is OUT
it is very hard to be emotionally available for the people in your life, because you've learned so very well how to suppress it.

(3) There is no cure
We can't cure crap (literally and figuratively)

(4) A cruel mistress
It finds its way into every part of our lives, and continually pulls.

(5) Thou shalt not opine
Your professional opinion is not something to just throw around or wear on your sleeve.

(6) Laughing at the pain of others
What's the alternative? Go home and cry our eyes out every day?

(7) Thankless
All too often, I've taken exceptional care of someone, and been thanked with curses.

(8) Constant change
Some people like fields that are understandable and consistent. Medicine is not such a field.

(9) It's all your fault
Somewhere along the line, we decided as a society that the buck would stop at MD

(10) Hate me
If you want to be a doctor for the prestige and admiration, you're wasting your time.

(11) Perfection
No one is 100%. No one.

(12) Limited Resources
Distributive justice is a harsh reality.

(13) You know too much
You cannot help but assume the worst, because you have seen the worst.

(14) Uncertainty
In medicine, there is uncertainty on all sides.

(15) Guilty
Shouldn't someone be held accountable? And if I'm the patient's doctor, shouldn't it be me?

(16) I've got a secret
Patients have told me things, dark and secret things...

(17) A checkered past
Being a doctor does not come with a clear white coat.

(18) Meaning
the ugly truth is: a job is a job.

(19) Biased
He is still human, and still deserves to be treated like one.

(20) Treating the source
The diseases I am treating are not the principal problems of her life.

(21) Haunted
doctors are always haunted by so many ghosts.

OCD

The medical school admission process selects for people who border on OCD. I would be one of those people. The reason why is because medicine is so damned detail-oriented. It's like putting together Lego's, except you read the instructions once, see it done once, and then you're expected to do it from memory. So having people who are a little neurotic sometimes helps.

And sure enough, when I'm doing my thing, I've got it down to a T. I'm ordering 5,000 labs, getting x-rays, quizzing students on the diagnostic criteria for hemochromatosis. Beware my Doctor Fu. I'll check back on things, and I'll hear, "Oh that Dr. ifinding is so thorough!" But where this spills over into my personal life can be a little annoying.

I can never remember if I locked my car. I will go back from my office or from the hospital to check and make sure I locked my car. Even now, just talking about it, I want to go and check. Even worse, my front door. I am always so glad when I have a place where the door automatically locks.

I am always worried that I left my burners going on my range, or left the toaster oven on. Every day before I leave, I have to check both to make sure they're off. This might even sound somewhat reasonable till I tell you that I've been doing this daily, but I wasn't cooking for about 2 weeks. That's right, I was checking burners that I hadn't used in 2 weeks.

I have a pathologic fear someone is trying to page me and I'll miss it. Weekends, at night, my pager is always on. It's really, really hard for me to turn it off. I'm even worse with my cell phone.

And I can't pack like a normal person. I was gone for a weekend, and when I finished packing for the trip, I had 5 days of clothing packed for a 2 days. I had packed sweaters, jeans, boots, and a jacket for 90 degree weather.

I need help.

Systems based care

A while ago, I attended a social event with some of the support staff. I was actually quite surprised to be invited. After all, the staff and the physicians sometimes don't get along so well, and so there's can be a little tension. We talked quite a bit about the different residents and doctors, and it got me thinking about multidisciplinary care, and how sometimes we judge each other on everything but medical ability.

My mom is a nurse, so she always told me that I have to be nice to the staff, and I should always be on my best behavior, and never mean or rude. She would always remind me of my pediatrician growing up, who was a saint of a man.

So I've always tried to be on my best behavior with the nurses and staff, because they are not paid to put up with attitude from me. And I believe that people who like you will help you. Case and point, when I was rounding in the hospital as a resident, one of the interns was presenting, "The patient hasn't had a bowel movement in 2 days and—"

"Wait a minute," I broke in. "Tracy told me that he had a BM yesterday evening, and now he's got diarrhea! I asked her to send a sample." Sure enough, we walk in the room and there is that wonderful smell of melena. The intern asked me after rounds how I knew the patients so well. "The nurse spends all day with the patient. You should try talking to them."

Anyway, back to my original point, whenever I hear nurses complain about doctors, I'm always surprised, because it is often things that the doctor didn't even realize that have earned him such scorn. There's an asshole surgeon who walks around with a coffee all the time the nurses would mock him and his coffee cup behind his back. When I talked to him one day, he thought that he was beloved.

One social worker thanked me profusely for meeting with a family, because another resident was supposed to do it but was called away. Why was she glad it was me? Because the other resident comes from a culture where you don't make a lot of solid eye contact, so he doesn't look patients or family in the eye. And everyone thinks he's pathologically shy or else trying to hide something.

I have seen excellent physicians hated, and incompetent physicians loved by staff, as well as the converse: I've seen great nurses despised and horrible nurses loved by doctors. It took me a while to realize that our ability to interact productively with other health professionals is a skill in and of itself, and multidisciplinary care isn't something you can just assume (so much so that systems based care is part of all residency curricula). So for my part, I try always to be polite and cheerful, and only to be critical where it's appropriate.

And sometimes, when I'm not sure, I'll call my mom. One time, a nurse called me with a low BP of 87/53 (so obviously a machine value, since people almost always report even numbers or multiples of five), so I asked if she rechecked it. She acted like I asked her to part the Red Sea. "Why don't you get up here and recheck it?"

When I got home, I called my mom and asked her, "This nurse called me with a low BP on a patient, and so I asked her if she rechecked it but—"

"—and she didn't recheck it, right? Well, I'll bet she didn't check it the first time either. The tech probably did. She probably didn't do a manual either. That's just plain lazy." I love my mom.

Truer words

Hmong in California by yankeepez

I have been reading "The Spirit Catches You and You Fall Down" which is a book about Lia Lee, a Hmong infant with a terrible seizure disorder, and the culture clash between the American medical system and the Hmong people. I am instantly wary of all such books, because 99% of them are about how stupid the American medical system is, and lay the blame squarely at the doctors' feet.

This book is remarkably fair, and showcases the completely divergent cultural attitudes. I was discussing this book with a colleague, and remarked, "This story is horrible. I almost wish it was malpractice, but how much worse when everyone has the best of intentions, and still they cannot do something so basic as care for a little girl."

There are two things about this book that got to me though. One is that the book talks greatly about the Hmong people. It helped me to understand a lot about the Hmong patients I have seen, but the thing that got me the most is how the author talks about Hmong culture, but in reality, I have discovered something on my own quite in opposition to the book.

The problem with immigrant cultures in the US is not just one of assimilation. It is that the culture of the Old World is stagnant. It cannot grow. All change is viewed as corruption from the American way of life, and these transplants who were once the most liberal of their generation become the most rigidly conservative. And for me, the way of life that I was taught I now understand to be archaic. I am a man living a dead culture.

The other bit from the book is a line from one of the Hmong people, Jonas Vangay, a French educated man who helps the Hmong community to navigate the American bureaucracy. He utters this aphorism: "I am always the one who laughs last at a joke. I am a chameleon animal. You can place me anyplace, and I will survive, but I will not belong [sic]. I must tell you that I do not really belong anywhere."

I have never read a line that I have felt is a more appropriate description for myself. And I can't help but think to myself that truer words have never been spoken.