The Night Before Step 1

Less than 12 hours away from the 8 hour beast. I feel like the armor-clad protagonist facing the final villain with only one “revive” potion left. As I look back at the past two years (all the 25 miles *nod to Allison’s post*), I seriously can’t believe I’m finally here. There’s no way I’m really taking the Step 1 tomorrow. Right? My emotions cycle between fear, anxiety, confidence, anticipation, and back to fear. Deep breaths, Eunice. Deeeeeeeep breaths.

Now that I’ve done all I can to fit two years worth of information in my worn-out brain, all that is left to do is to leave the rest to God. Do I trust that God has everything in control? Do I trust that He has the best planned for me? Sometimes I sincerely question. And even now, I still have lingering worries about tomorrow and the rest of my future. Yet in spite of all my failures and mistakes in the past, He somehow always helps me back on my feet to try again. He somehow teaches me to be still, to listen, to be patient. I think I can trust Him to do it again this time.

A few of my classmates and I met together before the big test to talk about our fears, pray together, and encourage each other. We also crammed in a quick anatomy review sesh! Thank God for good friends who remind me of what’s really important and who see fun in everything. A passage we read was from Psalms 118:

The Lord is with me; I will not be afraid.
    What can mere mortals do to me?
The Lord is with me; he is my helper.
    I look in triumph on my enemies. [STEP 1!!]

13 I was pushed back and about to fall,
    but the Lord helped me.
14 The Lord is my strength and my defense;
    he has become my salvation.

25 Lord, save us!
    Lord, grant us success!

29 Give thanks to the Lord, for he is good;
    his love endures forever.

Pre-Step 1 – ready to be 3rd years!

See you on the other side of Step 1!

My Hidden Curriculum

Ryan, Third Year Medical Student

So here’s the problem with 3rd year: I suddenly have so many stories to tell, but not nearly enough time to tell them! That said, the type of “busyness” that 3rd year has been providing is so, SO much better than what I experienced in the preclinical years.  Check this out, one of my patients turned out to be a widely published author; she gifted me one of her books:

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Pretty cool! I’ll probably reemphasize this notion throughout the year, but simply studying medicine is nothing compared to seeing it all come together in the clinic.  These experiences are all part of a “hidden curriculum” of sorts.  While tests still need to be taken and papers still need to be written in order to obtain a license, it’s the unofficial learning objectives I feel shape us med students into the doctors we are to become.  They may not be listed anywhere, but they are just as important.

Let me illustrate this with a short story.  After finishing my medicine rotation, I moved on to psychiatry.  Most psychiatric medical conditions are cared for in an outpatient setting, meaning the patient won’t stay overnight in a treatment facility.  However, when someone is sick enough to require hospitalization for a psychiatric emergency, this means that they are acutely a danger to themselves or to others. My rotation site was solely an inpatient setting, so all the patients I helped take care of fell into that second category of “danger to themselves” or “danger to others.”

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My Home for the Last 6 Weeks

While working on the adolescent unit in the Loma Linda University Behavioral Medical Center (LLU BMC), I found myself quickly growing frustrated at some of the situations I would encounter.  Not frustrated in an “I’m going to lose sleep over this” kind of way, but frustrated in the way I feel most doctors get when they wish they could change something, but know that it exceeds limits of how they could help.

Now, I realize that kids who have grown well in to their teens are fully capable of making their own decisions. But the thing that frustrated me about most of the patients I encountered is that most of the time, his or her psychiatric hospitalization was due to something beyond control. I’m not just talking about “bad genetics,” as is the case with patients who develop things like cancer or diabetes; I’m talking about things like poor decisions made by parents or abuse from peers.

So there I was, on the fourth day of my psychiatry rotation, when I met Craig*.  At first glance, he looked like your everyday average 14-year-old, but to the trained eye, one would have noticed his small sized head, flattened cheek bones, smooth upper lip, and other subtle facial abnormalities. Police had brought in Craig to the BMC after he had punched a family member multiple times for “annoying him.”  As a medical student, it was my job to talk to Craig and try to figure out why he needed a stay at the BMC and how we could help him.  This is done through the traditional process of interviewing to hear a patient’s story.

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Preparing to Take a History

Craig seemed like a nice enough boy, but shortly into the interview, I could tell something was not right.  He acted very embarrassed by the incident, claiming that it was “no big deal” and that he just wanted to go home.  When I carefully explained that he would not be able to leave until we were sure he was doing ok, he asked if he could instead visit with his girlfriend, who just happened to be living on the girl’s side of the same psychiatric unit. Surprised, I probed for more details about this girlfriend, but Craig suddenly changed subjects to talk about his 8-month-old daughter, who was already walking around and speaking in full sentences. He went on to tell me about his career as a rap star, how he was the captain and star running back of his school’s football team, even how he managed to single handedly subdue a drug dealer at gun-point.

After listening to Craig’s stories for about a ½ hour, I knew I would need to call his family for more information.  We ended the interview on a pleasant note, and I walked away trying to make sense of it all.  Though there’s always the slight possibility a patient is telling the truth when sharing elaborate stories such as these, there’s a good chance he or she is confabulating, and so extra information must be obtained from family (a process known as obtaining collateral). Confabulation refers to when a patient makes up memories or experiences, without intentionally trying to deceive. If you try to point out inconsistencies in these stories, the patient often becomes frustrated or defiant, insisting he or she is in the right.

I called up Craig’s primary caretaker, who turned out to be his first cousin.  The conversation began with Craig’s cousin answering various questions about his history, but quickly turned into a venting session as her own concern and frustration began to flow.  She explained that Craig’s behavior had always been highly unpredictable, and as he had grown bigger and stronger, this behavior had become increasingly disturbing and violent.  She listed some fairly horrific examples, including torture of animals, destruction of property, bullying other kids at school, and being a general terror around her home.

These examples made me instantly think of a diagnosis known as “conduct disorder,” but when I asked about Craig’s parents, a diagnosis didn’t seem as concrete. According to his cousin, Craig was the unwanted outcome of a one-night stand.  His mother used drugs heavily during her pregnancy, a pregnancy which was complicated by poor prenatal care and an improper delivery outside of a hospital.  The cousin said that after Craig’s birth, his mother wanted nothing to do with the child, so he was given up to his biological uncle, a man trying to raise 9 other children on a poor income. She explained that to help her uncle care for Craig, she watched over him during the school year.

At this point, I could tell Craig’s cousin was becoming tearful as the full gravity of her situation bore down on her. I attempted to provide some consoling words while reassuring her we would do everything we could to help Craig, ending the call. I took a deep breath as I tried to make sense of everything I had just heard, removing my glasses to rub the confusion out of my eyes. How could this have happened? What exactly was going on?

It was at that moment, my attending physician walked into our small workroom. Almost forgetting to say hello, I launched right into Craig’s story, hoping she could provide some insight.  She listened patiently as I recited back my presentation, glancing down at Craig’s chart every so often.

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Me with my Residents and Attending

“Well Ryan,” she began as I finished up, “this is an example of what happens when someone uses drugs during pregnancy.” She went on to explain how the frontal lobe of Craig’s brain, the area of the brain responsible for a person’s impulse control and personality, was likely severely under developed. Due to his exposure to drugs while he grew inside his mother’s womb, he couldn’t develop as in a normal pregnancy. This lack of impulse control lead him to do whatever tiny idea crept inside his head, set off by any kind of stimuli. If someone annoys him, he punches him or her. If a cat meows too loudly, he’ll throw it across the room. If he wants to plant a big sloppy kiss on a girl he passes at school, he’ll do it. “He lacks the basic control that you and I take for granted,” my attending said, finishing up her explanation, “he’ll struggle to live a normal life.”

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Brain Lobes!

As we discussed potential treatment options to help Craig control his impulses, I couldn’t help but feel so frustrated with the whole situation.  How is this fair? It’s not fair that Craig’s brain didn’t have the same chance to develop like mine did, it’s not fair that Craig’s cousin has had to live in fear of her own cousin’s impulses… it’s just not fair! And I don’t know the story of his biological mother, but what if she is the continuation of generations of drug abuse and abandonment? How is that fair to her?

Craig’s story is just one of many. I saw kids who were considering ending their own life because their parents called them “worthless” and “stupid.” I saw kids with terrible eating disorders because they were being bullied at school. I saw orphaned kids with no parents to teach them right and wrong, already so addicted to drugs it seemed like sobriety would only ever be a fantasy. And I saw kids who were terrified of other human beings because a family member abused them both sexually and physically. How is this fair?

As a Christian, I believe that sin runs rampant throughout the world, and that doesn’t seem very fair at all.  But I also believe there is a reason for this: God could have created us as mindless drones who loved Him by design, but instead, He gave us the gift of choice, something that makes our ability to love genuine, but something that has also resulted in consequences.

Whether you are religious or not, I believe that humans have a tremendous ability to love and care for those less fortunate.  There’s going to be a lot we see in life that “isn’t fair,” and we have to be able to accept this, showing compassion in spite of the circumstances.  And I’m not just talking about health care professionals; this applies to everyone!

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Fellow Classmates, Working Hard…

Rotating through the adolescent unit at the BMC has helped show me how to deal with these kinds of emotions, struggling with my natural inclination to defend the defenseless, yet show my concern in a professional and empathetic way.  As I mentioned at the beginning, this kind of training isn’t necessarily listed in a curriculum somewhere, but it’s experiences like these that provide the best teaching.  It’s definitely one of the things I’ll remember as I continue my education, hoping to touch the lives of others in a positive way.

Well, my psych rotation is ending this week, and even though it seems I was just there, I’m headed back to Kettering, OH for another short three weeks to complete my neurology rotation.  I was hoping to catch a Cincinnati Reds playoff game or two, but unfortunately for my poor team, they got eliminated in the first round (for the 3rd time in 4 years!).  I’m looking forward to seeing my family again, and maybe I’ll get to see the Bengals play instead haha. Until next time! (I feel like I need a catchy sign off phrase, any ideas?)

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My Wife & I in Oak Glen Over the Weekend

*Names have been changed to protect privacy.

Burnt

Leanna, Third Year Medical Student

Frankly, I’m not sure how to phrase this post. For a month or two now I’ve been wanting to write about feeling burnt out. Yet each time I’ve started an entry, it becomes a bit of a downer, and not representative of who I am as a person or as a medical student. Becoming a physician is difficult in all sorts of aspects, and with every phase of medical school there are new joys and rewards, as well as disappointments and frustrations, but for some reason this stage of school seems to have beaten me down a little more than I would’ve imagined. And so, recently I’ve been challenged to really peek around in the recesses of my mind to fully process every single thought I’ve had regarding school.

If I could say any one piece of advice to anyone, regardless of what field he or she is studying in, is that you must live for something bigger than yourself. I suppose this is something cute that could be written on a refrigerator magnet or on a social networking profile, but you must, must, must give deeper thought to it. With each day’s new challenges and unknowns, it seems to me that as humans we get so frustratingly focused on ourselves. I see this in myself tremendously––coming back to my apartment at the end of the day I find myself exhausted, whether emotionally or physically, and I start to dwell on all the things in my little life that I wish were different. A different attending physician. More opportunities for practicing procedures and having more responsibility for patient care. Placement at a different site. More time off. A better understanding of the future. More time with my boyfriend/family/friends. As you can see, I could go on and on, and still, not all these things I’ve listed are wrong to hope for. But really, they revolve around I, I, I, me, me, me, and when my life does not reach the standards and expectations I’ve set for it, it falls short into a place of frustrated futility, tiredness, and intermittent self-pity.
However, back to my point––you must be far-sighted, you must have a great purpose for why you want to be in medicine (or in whatever field you have chosen!). Not because the day-to-day rewards are so fun, although they sometimes are. You need to come home at the end of the day, and whether or not you were treated unfairly, or spoke to condescendingly, or feeling personally rejected and exhausted, there must be a clear focus as to why you are in medicine and not in something with more immediate, comfortable benefits. I can’t stress the importance of loving, adoring, and treasuring the field you’ve chosen, making sure that it something you want for the rest of your life and something with a greater purpose than yourself.
Speaking of myself, I am in medicine because I cannot see myself being satisfied doing anything else. And I’m not saying I’m in it by default––if you knew me, you would know that my passion for what I am studying is enormous, and that it’s the undeniably perfect fit for me. It’s ironic and amusing, how in the days and hours I feel most exhausted there is some unexpected form of encouragement and support further acknowledging the fact that I am indeed in the right field. There are many hobbies and topics that catch my eye, and yet at the end of the day I know that nothing would bring the same feelings of gratification as restoring people’s health to the best of my ability––or doing my best to prevent disease in the first place, and as a Christian, hopefully using that as a vehicle to show God’s love and kindness towards broken humanity.
So, at the end of the day, all that said, remember the big picture––whatever your big picture is for you personally. With everything that you are, love what you do, and make sure you are in it for the right reasons, for the long haul, even when at times the day-to-dayness of it becomes less than thrilling!

Thankful

The holiday season is by far my favorite time of year.  It’s the time for snuggling up in cozy sweaters and warm blankets, sipping peppermint mochas, spending time with friends and family, and celebrating all that we are thankful for.

This year, the holiday season comes during a hectic and harried time.  According to our second year predecessors, our upcoming exam set will be the most difficult exams that we will face all year.  This is made evident by the fact that I have been sorely neglecting my duties as a student blogger because, let’s face it, I’m busy being a student!  Yet in the midst of studying heart sounds, respiratory physiology, genetics, anatomy, biochemistry, and immunology the holidays remind me to pause and appreciate the things that matter most in life.

So, as I sit here snuggled up in a blanket, sipping a warm cup of tea on this last night of Thanksgiving break, I thought I’d share just a few of the things that I’m thankful for this holiday season.

Faith – The trials of medical school have taught me that faith is a crucial component of remaining grounded in what truly matters.  I am so blessed to attend a university that encourages me to grow not only in my knowledge of disease processes, but also in my knowledge that we are not the ones who do the ultimate healing.  We may suture wounds and treat diseases, but God is the ultimate healer and only He can offer eternal life.

Family – This Thanksgiving I got to spend time with my sister in Davis, California.  She is a fourth year veterinary student at UC Davis and her clinical responsibilities make this the first Thanksgiving that she has been forced to be away from home.  After not seeing her for months while she’s been away at school, it was amazing to be able to visit her in Davis for a few days.

Friends – One of the things that has made medical school the phenomenal experience that it has been thus far is the people that I get to spend each and every day with in my class.  I have made some of the most incredible friends along this journey and I couldn’t be more blessed.  Moreover, my long-time friends from years past have stuck with me through this time. Although I hardly get to spend time with them, they continue to support and encourage me.

Holiday Shenanigans – Part of the fun of the holidays is all of the holiday festivities!  This year our class had a Thanksgiving Potluck in the park to start off the holiday season right.  A special thanks to Theresa Tran and Lauren Parker for helping to plan this event!  We have a few more fun holiday parties planned for the class so stay tuned for more updates!

Life in the Cracks

Everyone always tells you life’s a journey. I can’t begin to recount the number of times I’ve heard it likened to a path, a road, a process. Running a race. My nose wrinkled up a little bit yesterday morning when I had a similar thought. I’d always thought myself more creative than the safe, vanilla “life is a journey”-ers; but this time clichés got the best of me.

I hate waking up, but am in love with mornings. Days are one of the only occasions where I firmly believe that crust trumps filling; the beginning and end are so much more lively than the flat landscape of mid-noon. Sometimes I think my bias comes from missing the ocean; watching the waves come and go—finding a soft beauty and dynamic in the ebb and flow. The mixes of dark and light dancing into dusk and dawn remind me of the sea.

There’s something to be said for the mountains. Brave and jutting, imperfect and cragged, still not afraid to stand post above the skyline. I think the hills are my favorite—there’s something soft about hills; maybe it’s because they’re gold and dressed in tall grasses. Or that I’m fairly certain if one looked long enough they’d find a few hobbit homes tucked between their creases. Even valleys demand respect; low and unpretentious, the downhill slopes are protection. Always compared to hardship, heartbreak, and questions. How fitting then, that God would raise up walls around them on all sides to protect from the wind; valleys aren’t pits, they’re baskets.

I’m a super ADD runner. I rarely let my iPod make it through a song before I’ve queued the next. Sometimes I rip my ear buds out all together and let the tempo be my own. Either way, my mind is always going a thousand miles a minute. Sometimes I can corral my thoughts along the lines of whatever I’m listening to. Other times it revolts against the prodding and stubbornly insists to do its own thinking. There are a few constants to my runs, though. The first is that one of my shoelaces WILL come untied. Something about my footfalls is enough to unnerve even the bravest double-knots. The second is that I think about God. There’s some sort of weird synchrony between being outside and just running—letting yourself go without much purpose except not to stay still—and spirituality. The same rings true for lying down or siting in complete quiet. Maybe God likes morning and night and seashores best, too. The times where there is movement, and change, and rest all bundled into one. The third thing I cannot escape, besides running out of breath, is looking around. Sometimes I feel like I’m life’s spectator to a ping-pong match—my gaze darting around, displeased until it’s attempted to take it all in. Maybe that’s why I think about the mountains so much. And the hills. And hobbits. And the sea. And find myself agreeing with the kind of overused lines about journeying lives that should be found lining a tacky picture frame or bookmarks in the Christian bookstore.

My agreement comes from looking down. Checking my shoelaces. Making sure I don’t step on cracks. Scouting for crackly leaves to tromp down on. It brings my vision back to my own two feet—rhythmically moving on the cold, hard grey. The metaphor of medical school—a path of flat monotony with little strips of breath, and change, and non-fluorescent outdoor, natural light shoved in between. Life lived in the cracks. I’ve never been so appreciative of the dirt and weeds and wildflowers that make their homes between the concrete slabs. Their beauty is lived by context; they are no more or less alive because of their placement, but their resolve to stay, to blossom between the rock, makes me smile.

Medical school is not an easy road. And I have a sneaking suspicion that things don’t get easier as the white coat adds more threads. This life is full of concrete slabs. But it curves around mountain faces and the backs of hills and into lowlands in the pit of God’s palm. Waves wash over this road, sometimes pounding, sometimes softly pooling around my ankles. This life is full of concrete slabs, but there are flowers in the cracks.