Sunday, June 26, 2016

Opting out

“You’re shitting me.” Brief pause. “You’re not kidding? I can’t tell if this is a really intense joke or if you’re being serious right now.” 

So far this has been my favorite response to telling someone that I am quitting residency.

It is a decision I have been working on for several months for reasons I will discuss at length momentarily, but I’ve made my peace with it. Better than that, I’m even excited about it.

I have already passed the point of no return and selected the path that will allow me to complete intern year and get my license to practice medicine as a general practitioner. As much as I dread a few more months of being an intern, I still want to change the world and treat the sick – even if it is in a different way than I had recently envisioned. My resignation is pre-dated for when my rotations are complete and already signed and submitted. My hearing in front of the Graduate Medical Education committee to discuss my resignation is already scheduled. (I have no idea what to expect from this, I anticipate that they will ask me “You sure?” I’ll say ‘no’ – they will exchange uncomfortable looks because this is a big decision to make if you aren’t sure. And then I will elaborate… probably saying much of the same things I’m about to share here… although if I don’t feel eloquent, I may just say YOLO. Or Jesus take the wheel. … Probably not the best idea.)

So here I am. It’s happening. Now I get to tell the people at work. I’ve played my cards pretty close to my chest regarding this decision because it’s a big deal. I really wanted to be sure. By now I’ve realized that sure isn’t something you get often in life. Its an easy thing to appreciate in hindsight but is rarely clear in advance. So I’m not sure, but it is happening anyways. … Is this the right time to use YOLO?

 It is a taboo thing among other residents to drop out- people aren’t sure what to say. Should they should apologize or simply change the subject? Like I’ve been excommunicated. Led astray. Seduced by the possibility of more sleep and free time.

I amuse myself by dropping this factoid into random conversations with colleagues without any real build-up at all. They will see me, in the office or around the hospital in civilian clothes (for all those who don’t work at military hospitals, this is akin to wearing a large sign around my neck that says “I’m not scheduled to work now, but I’m here anyways!!”) and they will often ask “Oh, day off?” or “Are you post-call?” or “are you working tonight?” because those are the sole explanations in the world of residency as to why I would have free time. I reply, “actually I’m quitting residency”.

It says something that the most common retort by far is laughter, followed by “Me too.” Or “I know how you feel”. Or a more subtle form of agreement “Right?!”.

I wonder what patients would think if they realized how quitting is a fantasy for nearly every resident that takes care of them?

Of course, most with this fantasy don’t actually do it. They remember that residency is temporary. They remember that these 80 hour weeks will only last for a few more years. Maybe they remember that they’ve already gotten this far to be a doctor, no sense turning back now. They remember their passion – that small but powerful encouragement when a patient refers to you as their doctor. How it feels to understand a treatment plan. The sensation of literally bringing someone back to life.

Those moments may be plentiful or they may be few and far between. Regardless of their number, it is up to each individual resident to decide if they are enough. Enough to make up for long hours, sleepless nights, stacks of paperwork, and being the lowest man on the totem pole. Enough to make up for subjecting yourself to pimping, questioning, criticism veiled as ‘professional feedback’ and smiling through it all. Enough to make up for frustrated patients, overworked nurses who walk a touchy line with new interns, and slow pharmacies that you get blamed for. Enough to make up for the guilt when the decision you make is wrong, the sadness when the treatment was too little or too late, and the despair when there is nothing you can do. Enough to make up for sacrificing relationships, working on Christmas day, and not making an appearance at the funeral of a dear family friend. Enough to make up for getting home from a 12 hour shift and still having to read about work, for spending your only night off working on a presentation, and for beginning preparation questions for boards years before the actual test.

Just now, that list of downsides is far longer than the rewards, which was unintentional. Being a physician requires a lot be forfeited, but the remuneration may be equally lengthy – it is just much harder to put into words. As I said, we must each choose our balance. If the good outweighs the cost – brilliant. Bully for you, you amazing and miraculous person. In my case, it simply cost more than I was willing to give.

After they realize I’m not kidding about quitting residency, the mood quickly changes to apologetic and embarrassed. As though some mental breakdown has led to my current situation, which in a way, I suppose it has… But only in the sense that it gave me the clarity and distance to make the right decision for myself.

It is like the end of The Office. (I can relate most things in life to an excerpt from the office, but bear with me). Andy Bernard (who essentially filled the shoes of Michael – someone had to be the self-obsessed, socially unaware, buffoon of a figurehead) has an emotional breakdown during an audition for a reality TV show. It is caught on film, ultimately goes viral and becomes a source of public humiliation for him. When he returns to Scranton in the final episode, his coworkers go over the top to tell him they still like him and everything is okay. They all feel as though his life is now derailed and he is clearly suffering from his choices. However, Andy has utilized his newfound internet fame to get a job he wants and is actually quite happy with where his life has led him.

My situation is different in that I didn’t undergo public humiliation but similar in that I often end up convincing the people around me that this is a good thing. I’m happy about not completing residency. Honest. I've thought about this.  Decided. Chosen. I haven’t gone off the rails. You don’t need to worry about me.

I’m still going to finish intern year then quit. Resign. Or, in my preferred diction, I’m opting out. It’s not that I can’t do this. I’ve been soldiering on (no pun intended) for the last 5 years through pretty miserable circumstances. As anyone who has attended medical school or done any part of intern year can tell you – it’s not for the faint of heart. No, I’m choosing something else. Opting for something better.  Honestly, I’m not sure what that entails at this moment. But I can tell you that it will not be unending work weeks with “it will be worth it someday” tattooed on my soul as I waste more and more years of my life being less happy than I could.

I was dreading intern year before it started. Everyone was. Transitioning from 4th year med student where attendings are often surprised when you show up on time to the responsibility your own patients and real (ish) power is a rude awakening. Fourth year of medical school includes time purposely scheduled as empty to allow for students to make up any outstanding work, travel to interviews and after matching to new cities to find homes and set up lives. It may not be intended also as a partial vacation to give mental relaxation before the marathon that is intern year (or an indulgence more similar to a favorite last meal for a death row inmate) but that is what I used it for. As early as the end of third year I was having doubts that I was on the right path, that I wanted to be a doctor, that I could maintain this marathon of studying for the rest of my life.

Cue fourth year. Laid back rotations (an hour per day in the pathology lab, anyone?), time off. I did a rotation in Uganda and then went on safari with some friends I’d met there. After that I went to Europe by myself and was met by a close med school friend and we lived like gypsies, carrying all our belongings on our back and enjoying what it felt like to be young and responsibility-free.

I hadn’t taken time off between high school and college, nor college and medical school. In undergrad I had multiple various jobs, grueling schedules often packed with over 20 credit hours so I could fit in the various classes I wanted to take in addition to the ones I needed to take. Needed – for med school. Because I had decided that was my path.

Flash forward and I’m 25 and experiencing my first real sense of being an adult – I had rent and a roommate and a cat, but beyond that no real obligations. My time was my own and I could travel and do as I pleased.

Perhaps a similar hiatus from the demands of higher education earlier on could have given me a much needed break to refocus and return energized. Perhaps I simply would have learned sooner that my trajectory was unstable and ultimately misguided. But those things hadn’t happened, and I was trapped.

I became deeply depressed and called my parents tearfully and explained that I didn’t want to be a doctor.

I realized that if I dropped out of medical school, it would be rather sad not to graduate with my classmates. (My ever-wise father also pointed out that since fourth year is the easy part, why bail out now? No sense quitting the race when the finish line is close enough that you could crawl to it) So I graduated.

In the graduation program, they list the residency where you will be continuing your training. I did not want the space below my name and picture to be blank. (Although, in my opinion, they could have left the picture out, thank you very much – why don’t professional and flattering ever coincide?) So I swallowed my doubts and I matched at the Walter Reed National Military Medical Center in Pediatrics.

I had gone to medical school for four years cost free thanks to the Army Health Professions Scholarship Program. The deal was – I go to med school, they pay for me, then I do residency with them and work for them – paying back a year of active duty for each year of my life they footed the bill. Given the prohibitive cost of school and having never owed a dime in my life as a college senior, I jumped at the opportunity. This was clearly the logical next step in my pre-determined trajectory. Things were simply falling into place.

I attended BOLC (it's an acronym, but, in typical army fashion, it reads as a word, pronounced BO-luck) before medical school even started. There, we were indoctrinated into the army. A bunch of wimpy medical students and new doctors, the hardened cadre were there to whip us into shape. My memories of BOLC are rather hazy and incomplete – I spent a good chunk of our field training time with an IV in my arm due to heat stroke, dehydration, and starvation. (Vegetarians are rare and mysterious creatures for uncle sam. I think he systematically eliminates them via the Veggie Burger MRE – for those of you who disagree, I dare you to eat one.) That is as close as I came to the real army for all of medical school.

Point is, there were two major transitions happening at the beginning of intern year: 1. Student to actual doctor and 2. Girl in her mid twenties with purple hair and a nose ring largely unaffected by military tradition to same girl – sans colorful hair and facial decoration who is now wearing the rank of a Captain and expected to act accordingly. Add to that I said goodbye to many friends in Toledo who I had lived my life with for the past 4 years and considered family. Add to that I was moving far away from my actual family who had always been a short car ride (read: if I felt homesick enough to cry, it was only a reasonable drive home to hug my daddy and momma). Add to that my recently treated depression and poor responses to major life changes. In this perfect storm of ingredients, a negative reaction isn’t entirely outside the realm of possibility. Perhaps I should have seen it coming.

My program director did see it coming. There were many attempts to reach out to the interns and all residents as the year unfolded. It is no secret that intern year is a trial even for the most content and well-adjusted of future doctors. It is hard on purpose – because you can’t do it half-way. As an attending, you may have fewer hours and a better lifestyle, but when you are in the hospital and your name is on that chart – that is where your soul focus needs to be. You will not leave until the patient is stable, regardless of whatever storm you are weathering in your own life.

There is no way to know if this is the most effective method to produce compassionate, intelligent, innovative and driven new physicians. But I suppose I can see the logic… although the reasoning offered as explanation more often is simply, “that’s just how it has always been done.” Truly, I hope that the people who use this as their rationale are doing so simply because it is a short and quick way out of what deserves to be a far more in-depth conversation. Given the long-term psychological effects on those involved, and the high suicide, depression and burn-out rates among physicians today, “how it has always been done” is clearly failing us.

I digress.

I want to make it clear, my program reached out to me, my co-residents reached out to me. I was in absolutely the best possible program to face crippling depression because it was identified and I was then told that my mental health, my sanity and my existence matter more than another name on the call sheet. In any crowd, there are people you work well with and those you don’t. People you enjoy and those you … don’t. (As a child, I remember hearing a pastor in a sermon refer to these people as ‘dipsticks’ – they function to test your patience. Similar to the stick you use to dip into the oil in the car to see that it is adequate… My best friends mom referred to these people as peons. Don’t know the logic here but the mental image that I’ve peed on them adds at least 30 seconds to my ability to interact civilly.)

So, as the days grew darker and colder, we heard frequently “look out for each other”, “check in on each other”, and “depression is very common during residency and this time of year”. Cool. I knew I was depressed but didn’t see how telling anyone would do anything about it. I knew I needed time and space, but both of those things are hard to come by. I couldn’t imagine that if I were not available to take call how the others would re-adjust to shoulder the weight I had dropped on them. I was a burden.

In med school we rotate through all the basic specialties – to give us a taste of each as well as a working knowledge of their general diagnoses and treatment. For instance, we all know that “In the past two weeks, have you felt down depressed or hopeless?” and “Do you ever have thoughts of hurting or killing yourself or that the world would be better off without you?” are screening questions for depression and suicidality. When you check daily, or almost daily or really anything except never – something is going to happen.

I didn’t care. I was at the point where something was going to give, and I did not have the strength to fake it – even to this stupid form that was part of a study regarding how information is best received during rounds. The questions were snuck in and irrelevant to the study data. The form was blinded, so only my ID number connected me to it. The researcher would have no idea who number 8 was. (I was not number 8… it was a 6 or 7 digit number that I don’t remember. 8 would have been better. Rhymes with Kate. … close to Katie. Maybe not so blind after all, good thing I wasn’t 8.)

Given that it was a cry for help, I continued to spiral downward after checking whatever I checked. I waited to see what consequences lay in store for my honesty. I slept and cried and did my best to fake it. I was short tempered and moody. I lost interest in family and could barely summon the energy to spend time with them.

I mentioned this to a co-resident on one of our fairly regular phone calls. We would often discuss whatever had annoyed us about work on that given day. These venting sessions were extremely therapeutic and we trusted each other to keep the conversations between us. I told him how I didn’t care that my family was coming. That I wanted to sleep forever. That I didn’t care about a lot of things I used to care about. That I didn’t know what they meant when they said ‘look out for being depressed' when there was absolutely nothing that could be done about it.

He told me I needed to tell someone. I did... that someone was him. I made him promise that like many other things I had told him, it was in complete confidence. He gave me his word.

I faked it. Until I couldn’t. Until one day, I was called to an office for a meeting about “important feedback regarding my performance”. “It needed to be addressed before the holidays”. I wasn’t busy at that moment and left what I was doing immediately – heart pounding as I sprinted across the hospital. What could I have possibly done so wrong?

The content of the meeting turned out to be: my hair is sometimes not in regulations and sometimes I wear an earring (act of forgetfulness – not defiance). Something snapped. Really? I had been working my whole life to get to this point and it seemed that all I had heard since arriving was negative. I knew I interacted well with patients and families, but was told my sense of humor was too much (by people above me – not those in close proximity or patients or families). I knew I had a long way to go as far as learning curve but was told I was way behind my co-interns (a comment that has been disputed by many now). I knew my case presentations at morning report were humorous (Which I embraced because 1. IT'S EARLY. 2. This was as close as I would ever get as a doctor to doing stand up comedy #bucketlist), but I was told “remember not everyone appreciates your sense of humor”. I knew I was comfortable talking to attendings but had been told I was too non-chalant. Unprofessional. Didn’t care. Shirt was once wrinkled. Did not have her ID on. Her white coat was not buttoned. Hair was messy. Once sat on knees in front of patient (I wish this one were made up, because...seriously?). Appears youthful. (...I'm 26, but I dyed my hair grey so maybe that will help) Overall message: you don’t belong here.

This was not all from one meeting or one person, but that initial meeting was the tipping point. I broke down and ugly cried in a super unprofessional manner in front of my mentor who was apparently only trying to help me by sharing how I was being perceived. “Do you need to talk to someone?”… What do you think, lady? “Yes, that would be helpful, ma’am.”

Many of my co-residents are fantastic people who I am so lucky to call friends and I know (now) that if any of them truly understood where I was mentally, things would not have been the same. But I didn’t know that. I didn’t have energy to talk or bond. I withdrew.

As anticipated, after checking the box, consequences played out. But they didn’t start until several months later. When you answer the red-letter questions (euphemism, they aren’t actually in red letters) in ways that you aren’t supposed to, your name and number get matched up. Someone, somewhere gets told. The cogs begin to turn and the system churns to life.

At that point I had already been referred to the physician wellness clinic – a group of physicians specifically intended to treat other physicians in the hospital: to identify burnout, stress and depression and intervene in a timely fashion.What came of my appointment was the declaration that I was still functional, and capable of doing my job adequately. What I received from it was “until you make a mistake that hurts a patient, we do not need to do anything”. It was disheartening and I felt more alone and isolated than ever.

So when I had a separate meeting where I was asked about checking the box (finally), I was worse than I had been initially. I was offered time off which I rejected – how could I do that to all of my co-residents? They would have to work so much harder. Take more call. Carry me. I could not do that to them.

That same day I had received my feedback from my clinic month. A difficult month for me given that outpatient is not my ideal setting, but I had worked hard to be pleasant and learn the ins and outs. Well baby visits are a conundrum and I’m never sure what I am supposed to be asking if the baby is eating, sleeping, peeing and pooing appropriately. Small talk is vital to clinic – it is how you make families like you. I was doing my best, but was unable to summon the vivacious chatty darling that we all know I can be. I avoided the dipsticks as I could and tried to work with attendings that were good teachers and also managed to make me feel like I was not a complete idiot. It was akin to patching a sinking canoe with duct tape – it isn’t pretty and it is only delaying the inevitable but at least you are still moving forward, right?

Wrong. What I was told regarding my performance was again contrary to how I felt I had been doing. Too informal. Doesn’t take it seriously. Doesn’t want to be here. (That last one was actually true for a whole myriad of reasons beyond the actual work involved, but that is beside the point and probably would not have helped my case.) This is a paraphrased version of what was said to me, but I was told: you are clearly not the typical army resident, things may go more smoothly for you if you value what they value and try to be less like yourself to fit in. You know, just for a few years.

So I went home and I mulled (Read: cried – that happens a lot in this post, wow., ate my feelings – smores poptarts anyone?, and drank some wine – malbec pairs well with poptarts for future reference). I wandered through my next full week of clinical responsibility in a daze. I couldn’t remember answers, I didn’t know diagnoses, I could only hear my program director saying over and over again “it would not be that difficult for you to take time off”. I was coming up on my call-free block – the one month per year which I would not have to work any weekends or cross-cover on any other units. If I was going to get breathing room and there were only bad times, this was the best bad time to do it.

I was referred to psychiatry, reassuringly it turns out they still want to see you, even if you haven’t hurt a patient. I was started on medication. I slept for probably two days in my new found leisurely lifestyle. Then I started painting. I went to therapy. I went for a run. I started boxing again. I spent time with my friends outside of work. I visited my family. Things were looking up.

Until I had to address my return to residency.

I think I can pin it down to the moment when the tables turned. A mere 4 months later after the fateful checkbox, there I was, on a now-extended leave of absence from my first real grown-up job and sitting in psychiatrist-recommended therapy. Given my progress, the topic of discussion in therapy was my return to work. This particular topic froze my stomach and induced unparalleled anxiety. Trying to explain this to her, I stated “the only thing that appeals to me about returning to that job is that I will get to see my friends (meaning the co-residents) more often”.

There was a loaded silence for a few seconds as we both digested what I had just said. I don’t know that even I realized it before I said it, but after I did it was more clear to me than ever that I didn’t want to go back.

It’s quite the realization to discover that what you have been working toward for the better part of your life is not what you want to do. It is alarming and freeing all at the same time. On one hand, I sure have wasted a lot of time and money getting somewhere I don’t want to be. On the other hand… well, it feels a little like getting out of a cult. Here you are in the place where everyone else believes is the best place and wants to be there… and you just want to escape. It feels like getting off of a conveyor belt. Breaking ranks.

That realization. That moment: I haven’t been the same since.

When I was a child, the movies I was allowed to watch had very clear “good guys” and “bad guys”. There was also the “in-between guys”, which were neither good nor bad but served to further delineate the other two categories. These were Disney’s best approximations of societal pressures associated with doing the wrong thing, included to further emphasize that the “good guys” often didn’t have it easy.

For example, Belle, in Beauty and the Beast. At the outset of the movie, the authors go to great lengths to establish that she is different. She likes to read, does not care about the attention of the neighborhood hot guy (although, he has a pretty gross ponytail in her defense) and all in all spends her time happily lost in her own little world where she sets her own standards and lives her life according to what she deems right.

This seems to be a common childhood moral: be true to yourself. It’s seen in the ugly duckling, who doubts himself but later grows into a beautiful swan. Also in Robin Hood who breaks the law in order to serve the greater good. Even in the movies I indulged in later in childhood, the Disney channel original movies where the girl plays the boys sport and succeeds, or the unlikely friendship thrives in the face of apartheid / social circle differences, etcetera.

Given the extent to which it is engrained into our minds as children be true to yourself seems to be an important societal value that will serve you well in everyday life as an adult.

So, when I found myself in a situation in which I was told to not be myself, it was extremely demoralizing. In fact, it felt that the life I had been promised: a life of success, self-acceptance and happily ever after as my cheerful monologue plays while the end credits roll was all a farce. It was as though I had toiled away my years to get back to ‘GO’ only to find out, I would not get the $200 payout I had been counting on. I didn't know why I was doing it anymore.

Thus, I’m opting out. Time to reset my focus and select new standards. Still me.  If residency is not helping me meet the goals for my life, then it is not a place I need to be.

This is who I am: I have always wanted to make the better place. I have no idea on what scale or to what extent, but I believed that medicine was the route to do that. I have always wanted to work in a place that seems forgotten by the rest of the world: where people die of treatable diseases simply because no one cares or knows enough to get the medicine to them: where saving a life may be as simple as stopping the bleeding or starting an antibiotic. Maybe the Congo. Maybe Syria. Maybe India. Maybe isolated areas in the U.S. It is terribly sad that as our technology grows more advanced and the earth becomes smaller these places become more abundant, not less.

I find freedom in traveling to new and exciting places where I don’t know anyone even though it is simultaneously terrifying. I believe that I owe it to the world to do the things that awaken my passion. The things that make you feel alive and free and afraid all at the same time are absolutely things that you should keep doing.

I believe that material wealth is not the key to happiness. If I have to live in a shack and take a daily bucket shower to be where I want to be, I am okay with that. It may mean being in close proximity to spiders that I feel are much larger than spiders should be... I’m actually not okay with that, but I will deal with that as it arises.

I believe that what you do matters more than how you look while you do it. I understand that the army is governed by very strict rules to regulate appearance so for the next several years of my contract I will do my best to fulfill my duty and honor the agreement that I have signed. I hope dearly that none of it becomes engrained in me and when I shed my required fashion choice for the final time and shake out that final hair headache (a very real and painful problem) I will lose all sense of the culture where someone’s status is literally emblazoned on their chest. In my experience, many times when someone is messy it is because they have been working too hard to clean up.

I believe that if you have the means to help someone, then you should do it. Regardless of their ability to pay, their enrollment in your practice, or if they are on your side. We have enough division, violence and hate in this world already – if you have a beating heart, I have an obligation to you. It’s part of an oath that I took one day and intend to honor, as I can, to the best of whatever ability and training I acquire.

I believe that life itself is a team sport. I don’t know why residency has such a cruel streak – the pimping, the bullying. There are people I’ve worked with that I feel go out of their way to make it more difficult. Hopefully, I am not one of them.

I am so thankful for all for all of the co-residents I’ve worked with and owe special thanks to Mike for the endless vent sessions, bro time and keeping our standards for nights off high. Thank you especially for encouraging me to seek help when I was getting really low and respecting my privacy when I chose not to. To Molly for the beautiful card you wrote me on an especially bad day encouraging me to “keep doing you, never ever change, and show those Bitchez what an amazing doctor looks like” (it included much more, but this line was my favorite). I will treasure it and your friendship forever – so lucky to have a kindred free spirit in a place where free spirits are often unappreciated. To Jenn who would constantly express the sass that I kept bottled up inside: Thank you for taking up my fight and for standing up for me or next to me as the time called for it (and for giving me the emotional breaks needed like watching Bridesmaids during one of our not busy shifts). To Claire for playing devils advocate when I would focus on one terrible thing, for encouraging me to keep trying and to not let them get to me. Thank you for walking the fine line of humor and professionalism and being an excellent role model. To Katie for being there on Monday afternoons and shouldering 50% of the questions directed at “Katie” even when they might not have been intended for you. Thank you for commiserating, reaching out, listening and just being you. And for making a fantastic Moscow mule. To LC for being easily the most positive person in our program, for taking more than your fair share of inpatient rotations and not complaining. Thank you for finding non-medical things to talk about and sharing stories of your adventures – can’t wait to travel to Africa together next year (hopefully!) To Kara for being the best ward senior I could have ever wanted: embracing talk like a pirate day, throw back Thursdays and making the ward a fun place to be. You never made me feel like I was a lesser member of the team or not important in any way. Thank you for unbuttoning your jacket during your CPC, a small but powerful act of solidarity. I am really sad to have not been around for the last few months of this year because I really enjoyed working with you. I may come visit you in California – whether you want me to or not! To Bethany for the endless late night NICU talks, for putting up with my obsession with Frederick Douglass and for always being game for a fro-yo run. Thank you for your patient teaching, gentle encouragement, you’ve been such a good friend and I’m glad you will be in the area but sad you won’t be at Walter Reed. To Katrina for your sarcasm and time spent puppy bonding. Thanks especially for the hug after the Lola-Niko run in – easily one of the worst moments of my life, thanks for asking if I was okay and reminding me it wasn’t my fault. I really needed that.

If I keep going, this post would be endless because of all I could say, so to Meg, Topher, Grant, Dimas, Abigail, Jim, Steph, Sebastian, Jason and the rest of the WRNMMC peds residency, you have all been fantastic to work with in your own ways. The best aspect of this year by far has been the people I have spent it with. While I am not going to be a pediatrician, I will know that there are some fantastic ones out there. Thank you for your dedication, commitment and service. You all are amazing.

I don’t know what’s next. I am returning to finish intern year so that I can complete my  requirements to obtain a medical license. After that, I will be around the Capital area for a few years as I begin to repay my army commitment possibly doing General Medical Officer work,  although I have no idea what that entails.

For the first time in a long time, there are options. After my army commitment is done and I get to choose my own adventure, maybe I will try to write. Maybe I will use my license and do global health work. Maybe policy work. Maybe advocacy. Maybe I’ll work in a medical school.  Maybe it will be something completely new that has not occurred to me yet - maybe some mix of all the above.

Right now, I am okay with not knowing. All that I know is that several months ago I came too close to losing myself. I was living a life that was not what it should be. Hopefully, I’ll never be there again.

Tuesday, June 21, 2016

Twigs of Fury

“We tell ourselves stories in order to live… We live entirely, especially if we are writers, by the imposition of narrative line upon disparate images, by the “ideas” with which we have learned to freeze the shifting phantasmagoria which is our actual experience”   - Joan Didion, The White Album
Once I start writing, I can't seem to stop. As events unfold around me, they compose themselves into narratives in my mind. I have set myself a goal of writing 30 minutes per day for two main reasons. One- it's less intimidating. I don't give up after 5 minutes of staring at a blank page because I know if there is still nothing on paper after 30 minutes, I'll call it a day. Second - it limits me from writing non-stop. I am in the midst of studying for my third (and final) step exam - an especially draining task that takes a painful effort to force myself into. Literally any distraction presents a gargantuan temptation. I also have to sleep, eat, spend time outside, run, hit something as hard as I can (I promise, it's almost always an inanimate object), do yoga, and do all of the other things I need to fit into a day to make myself feel whole.

In the immortal words of Sweet Brown "Ain't nobody got time for that".

The flaw in this strategy is that things I want to write don't occur to me only during those short 30 minutes of the day. So I find myself waiting at red lights, pausing in the grocery store or stopping midsentence to commit a piece of potential prose to memory or frantically recording strings of words before they flit away.

Stories compose themselves especially quickly when I face disappointment and life does not turn out as I wish. Perhaps it is my coping mechanism, to isolate myself from the real sensation of the loss. What could have been.

I've recently begun boxing regularly at a boxing and MMA gym near where I live. Fighting has been a hobby of mine since the very first time I gloved up, first year of medical school immediately after a grueling anatomy lab session. I stank of formaldehyde and sweat and had absolutely no technical skill in the sport whatsoever. What I had was fairly good endurance from years of distance running and an unbelievably patient and enthusiastic coach in my friend, Matt Gorris. He walked me through stance, protecting myself, keeping my hands up, throwing punches and elbows, putting power behind my kicks and knees. We worked hard for over an hour. By the time I was done I was no longer stressed. I went home to study, but the repetitive blows had made my hands shake so badly I couldn't hold a pen. My knuckles were bloody and I was exhausted and starving. I knew I was hooked.

We worked out at the local YMCA together regularly. Matt, a talented Muay Thai instructor, had technical knowledge that I lacked and had appropriate pads and gear for training me. It is an amazing feeling throwing a solid punch for the first time – when you figure out that the power comes from the hips, the core, the shoulder and the legs all at once… I learned that I was stronger than I realized, that despite my diminutive stature, I could (pardon the cliché) pack a punch.

Other people in our rag tag band of workout buddies began to notice my increase in strength and began to refer to me and my skinny, visually unintimidating arms as “the twigs of fury”. (There was a group of 5-6 of us who would regularly gather to hit pads, work the bags and improve form. We wanted to form an official club as part of our med school with the name the BAMF club. Matt insisted this stood for boxing and muay thai fighting, but given the more common colloquialism associated with BAMF, we never made it very far into the approval process.)

As my newfound coach and members of our group transitioned into their next year of medical school, intensifying class work and beginning preparations for their first step exam forced our workout sessions to become few and far between. I lamented the loss of an outlet, craved the challenge of fighting. No other workouts exhausted me in quite the same way.

Coincidentally, my first medical school friend, Jeremy, had recently started training at a Jiu-Jitsu gym nearby. The gym was partnered and shared facilities with an MMA gym known as Bad Dog MMA. For a reasonably low fee, they offered classes known as MMA conditioning – hour-long workouts offered daily at the intensity of conditioning for pro fighters. In fact, several of the pros who fought for the gym also trained at these classes.

The idea of training at the same pace as professional fighters was daunting. It took Jeremy well over a month to convince me to attend a class. Even after the convincing was over, still scared, I roped two other friends to coming along with me – I didn’t want to be the sole newbie.

The class was exhausting. It consisted of many different stations, each of which was performed for a 3 minute round after running and jump roping for several minutes as a warm-up. There was weights, plyometric drills, shadow-boxing, heavy bags, ropes, mitts and so many other variations to the workout that it is hard to recall now. It was also impossible to get bored. I returned for a second class… and a third.

Bad Dog MMA at the time had only around fifteen regular attenders to the class, three of which were fighting at the professional level. Rather than falling into separate castes based on our skill level, everyone embraced a familial atmosphere. Sarcasm ran rampant and teasing was the main form of communication – it felt like home. After two months of conditioning classes, I signed up to train in MMA as well. The community of fighters was smaller even than those in the classes and as a result I learned new technique and skill under the guidance of local professional fighters.

I was still fairly new to the sport when I first experienced fight night. Several of my newfound friends were competing in a local exhibition. I was encouraged not only to come and support my “brothers” but also to sit at the table reserved for Bad Dog. Of course I went.

I had watched some MMA on TV as my interest in the sport grew and had not missed a Pacquiao fight since developing an obsession with him. Watching the sport live is an entirely different animal. The blood is real and very visible. Our table was near enough that I could appreciate the strength of a blow’s impact via sound alone. While I find it fascinating given the strength, prowess, and athleticism involved, on some level it still feels a little barbaric, sitting in a room full of people cheering each time a person is hit so hard they cannot stand.

This sensation was enhanced by my newfound camaraderie with the fighters. One of them, an 18 year old having his first public amateur fight that night had me white-knuckled for the duration of his bout. Previously unmoved by most sports competitions that I was not personally involved in, I suddenly understood the passion of fans who want so desperately for their team to win. I felt a sense of belonging. I was one of them.

He did marvelously and ultimately won his fight in a very clear decision. I relaxed slightly, and continued to watch the other fights.

Several bouts later, as a fighter tapped out, the announcer declared the winner via “trying to choke”. I was extremely confused. You could get a win by trying to choke? Why would anyone not try to choke then? I posed these misguided questions to Jeremy, who sat next to me. His laughter indicated that although in my head I had become part of this world, outside of my head I clearly had a lot to learn. What had actually happened is that the fighter won via triangle choke – a brutal and very effective choke in which the executor traps his opponent’s head and arm between his two legs, bends one at the knee, forming a triangle shape in which the head is trapped. He can then very easily and very powerfully clamp down on his opponents throat until the opponent taps or passes out.

A good ground game is crucial to an MMA fighter. Many fights are won and lost grappling via complicated holds and chokes. As exciting as knockouts are, they occur rarely. Ronda Rousey, arguably the best female UFC fighter, has won almost all of her fights via arm bars. 

Seeing the gap in my defenses, I began attending Brazilian Jiu Jitsu classes at Bad Dog. I could not find the same inspiration from BJJ that I got from upright fighting. The learning curve is steep and it was frustrating when, after learning only one choke, attending an open mat session and realizing when your entire repertoire of skills consists of one trusty move, you become pretty easy to defend against. I lost repeatedly.

Also, being small and female, I had a limited number of opponents available to me. While training to punch, it was unimportant to find someone of comparable size. In BJJ however, an challenger with even 30 pounds on me made it difficult to perform the technical moves I was learning.

Being female shouldn’t be a problem but the vast majority of the BJJ crowd was male. I didn’t know them as well as the MMA guys I had been working with. There is a certain level of trust involved in wrapping your legs around someone and grappling. Maybe it shouldn’t have made me uncomfortable, maybe there is an inherent code of conduct among members where athleticism and bettering each other take precedent over all else... Regardless, it did.

At the time I was just over 100 lbs and any weight-matched male partners were likely to be young teenagers anyways. So my training partner ended up being the one other regularly present female in the group who was a friend from medical school. She had maybe thirty pounds on me but was at least not a teenage male.

The type of person who makes it as far as medical school – through the science-heavy undergraduate curriculum, scientific research, volunteering, MCAT exams, interviews, applications and essays – a competitive personality is heavily selected for. Those attending medical school are used to being the best of the best, because that is the only way to get where they are going.

I was hugely relieved to find that this thinking did not prevail at Toledo. While a few outliers were grossly competitive and cutthroat, the general attitude of the class was co-operative. We shared notes and study guides, pneumonics and advice.

Although it hadn’t been made obvious to me at that point, my friend fell into the more traditional pattern. Highly competitive without much thought to the outside appearance, she worked hard to get what she wanted. This isn’t a fault - it has served her and many like her very well. However, it was contrary to my approach and an unideal quality in a training partner for a beginner.

She was one of the first friends I invited to the gym – part of my insulation against being the sole newbie at a conditioning class. My mentality was that we were there together first. Us against the world. For awhile it worked.

In our BJJ training, when we would learn a new choke, I would purposely allow her to achieve it. As I said previously, it is not hard to defend against a particular move when you know exactly what move is coming. The point of learning these chokes, in my opinion, was to learn them, practice them and develop the muscle memory so that when presented the opportunity to use it in a fight it has already become second nature.

She took the approach that no one should ever get the best of her. Even in training, when I was the aggressor, practicing a newfound skill, she would defend against it relentlessly, running out the clock before I had enacted it at all. Admittedly, this is a fantastic quality in a fighter. A warrior spirit which can never be beaten. I bet if Jack Bauer were training in BJJ, he would have exactly the same philosophy.

I wanted a friend to learn the ropes with and I quickly grew disgusted with this approach. My limited opportunity to practice and narrow choice of partners led to frustration and ultimately cessation of my BJJ career.

Shortly thereafter, personal conflicts among other members of the gym became public and the whole environment became a toxic place. I lamented the loss of the family atmosphere and friends that I had made and went back to training on my own with friends holding pads whenever they were available.

Bestie and I in our YMCA training days.  Toledo, Ohio
This served me well up to the end of medical school. Through third and fourth year, I was never in one place long enough to warrant joining a gym.

Intern year started and I redefined for myself what ‘busy’ truly meant. It looked as though my gloves would be relegated to the dusty crawlspace in my house. Set aside to be reclaimed, maybe someday. I continued to exercise on the rare occasion that I had enough time and energy at the end of the day – and frantically more often as Army Physical Fitness Tests loomed near on the horizon.

I began to notice that something was wrong around the time of my first NICU block. For a few weeks, I compensated with running nearly every day, but this left me no time to eat before bed and it drained my limited physical reserves rather quickly. I began to lose interest in food and would consume only a fraction of my needed intake.

Were it not for the amazing residents I work with, I am certain things would have hit a critical mass much earlier on. As it was, shit hit the proverbial fan during my first clinic block. It is no secret that clinic is my least favorite of all the rotations we have to do during intern year. Add to this that I was very depressed and doing my first clinic block late in the year, (when you are already expected to understand the basic diagnoses and functioning of the clinic… even if you have worked there) and essentially you have the perfect recipe for a poor experience.

Long story short, I fell off the bandwagon. I lost interest in largely everything I once enjoyed. I would come home at the end of the day around 5 PM and immediately cry myself to sleep. I had trouble faking it at work – once people started to ask me if I was okay, I was no longer able to pretend I was.

This led to a much-needed hiatus from residency. I was given time to think and refocus.

It had been ages since I’d had the luxury of time.

It was an overwhelming void. What was I going to do with myself?

When this question was posed to me by a friend, I blurted out "Join an MMA gym" without having previously decided to do so. I surprised myself and decided now that it had been said, I had to put my money where my mouth was.

Entering new and ambiguous situations has always induced anxiety for me. Ironic, given that I enjoy traveling where I know no one and nothing… Regardless, this made finding a new place to practice MMA a rather intimidating task. After a few weeks of online searching, I found Champion Boxing and Fitness. It was conveniently located and had a few good testimonials. That was enough to make me think I had found “it”.

One day, after summoning my courage, and making plans in the area, I went to the gym. I arrived and forced myself to walk in and inquire about joining before my courage left me.

The owner of the gym happened to be manning the front desk. He was amiable and pleasant. We took a walking tour of the gym, he outlined membership and what was included. Fitness classes and unfettered gym access for a monthly fee. For slightly more each month, I could train with “boxing team” which included pad work, sparring, conditioning. “What do you want to get out of it?”

That was a question I really hadn’t asked myself previously. “To get better.” I answered before thinking.

“Yeah, the classes are great for getting in shape. Women especially like boxing because it just tightens everything up.” He responded, misconstruing my answer. “The boxing team more works technical skill- the art of fighting... and they do a lot of conditioning – each workout starts with a long run together. Pretty team oriented, very intense. They focus more on teaching you how to box. I think you will really like the classes.”

“Actually I would like to learn more of the art of fighting.” He looked a little surprised by my response. But recovered quickly and began walking me through the options of renting gloves and buying wraps.

“Oh, I already have my own wraps and gloves.”

“Boxing or fitness gloves?”

“I have both boxing gloves and fingerless MMA gloves.”

Clearly he wasn’t anticipating that I would already own my own gear. In his defense, I had shown up at the gym after meeting up with friends, so I had makeup and glasses on and no bag with me. I suppose it could have looked like I had wandered into the gym by accident, mistaking it for the nail salon next door.

A large African-American male sitting behind the desk, previously engrossed in wrapping his hands for a workout suddenly looked up and assessed me. “Oh yeah, she’s a fighter” He said.

His appraisal of me helped me feel legitimate. As if previously, I too had been considering the possibility that I had wound up there by mistake. 

We finalized the deal, paid necessary fees and I left with a schedule in hand.

Selecting and attending my first class was equally intimidating. I wished that I had roped people into coming with me. The gym is laid out such that when you walk in, the front desk is immediately to the right. To the left is a full – size, roped in boxing ring. Directly ahead, beyond some weights and machines there are approximately 30-40 heavy bags suspended from the ceiling in regular intervals forming a regimented rectangle. This is where the bulk of the classes are taught.

I showed up 10 minutes early for my first class, laid my bag against the wall and put my gloves under a bag as I had been instructed. Then I waited.

No one else hovered by any of the bags. A man worked the speed bag to my right. Another ran on a treadmill. A pair of people were sparring in the MMA cage. I chewed my nails and looked around, waiting for instruction or some idea that I was in the right place.

“Do you need help wrapping your hands?” A man of about forty years old asked from a few bags away.

“No, I don’t think so.”

“Okay, I just didn’t know if you knew how or anything.”

Annoyed by his assumption, I yanked my wraps out of the bag and began quickly wrapping my hands. I had grabbed my shorter, Everlast wraps which are unfortunately bright pink. Paired with my electric pink running shoes and the fact that I had lipstick on, I am sure this did not suggest that I belonged.

A woman in her early forties arrived and strode directly to a bag near the windows, towards the front corner of the room. Her black hair was tied into one ponytail with multiple rubber bands down its length. She looked confident. She, for one, had clearly done this before.

The only thing I dreaded worse than looking like a complete idiot was looking like a complete idiot at the very front of the classroom. Unfortunately, given the layout, the very front of the class was an unclear location. I approached this woman – who clearly knew things and asked which way the front of the class was. She indicated that it was the wall with the mirrors, but that it was hard to see from the back. I reassessed my positioning and selected a bag near this woman – I figured I could just copy her if I had no idea what was going on.

She explained that the instructor for today’s class usually had easier workouts. An hour of intense bag work, push-ups, jump-squats, burpees, and wind sprints later – dripping sweat and getting only limited oxygen to my brain, I tried to talk myself into a new hobby. Knitting sure passes time – no one feels like they’re going to die after an hour of knitting.

After catching my breath, I reminded myself for the millionth time since starting this sport – You love this.

Some weeks later, I found that Lisa (black ponytail) was right – those classes were the easy ones. They began to feel easy to me too. It was about that time that I decided to attend boxing team for the first time. They workout for two hours together and at the time I joined the gym, that would have been impossible for me. However, I had improved endurance and felt ready for the new challenge.

It was this moment – my first attendance of boxing team, that begged to be written, even as it was happening. It has taken a lot of backstory to get to this point, but here goes.

It was around 5:50PM on a Tuesday night as I walked into the gym for my first boxing team session. It was packed with children and adults alike. It seemed as though every punching bag was currently occupied while an instructor yelled out combinations from the front of the room. A dozen more people worked out independently on treadmills, lifting weights and the speed bags. Children ran screaming and laughing through the room. It was chaos.

I was directed to the boxing team coach, Mike. I had never met him previously. He sat on the edge of the ring, watching two fighters spar and occasionally shouting out guidance. He shook my hand and indicated that I should sit down.

He had grey hair with occasional dark pieces cut in a short, military-esque fashion. He had long 5 o’clock shadow on the sides of his face and his chin. His eyes were a sharp steely blue of extreme intensity. Overall, his appearance gave the impression that he should be aboard the Pequod, wearing a weathered sweater and swearing up a storm.  Wizened. Fierce. Tough.

He seemed pleasant enough though and asked me to tell him about myself.

That is quite possibly the most annoying inquiry on the face of the planet. I never really know what to say and often just report my name and something the person asking already knew about me. For instance at the start of intern year – when every new attending posed the same question. “Hi, I’m Katie. I’m a doctor. I’m from Ohio.”

Where I’m from gets thrown in there surprisingly often too – as though it will convey some innate sense of who I am. Oh, an Ohio girl. Right. So she likes the buckeyes and says pop instead of soda. She will complain about the snow, but if anyone else does – they have NO idea how bad it could be.

I should really come up with a more personal response to that question… Unfortunately, I think it would give the person asking far more information than they actually want to know. “Hi, I’m Katie. I say a lot of mean things but they are usually quotes from movies or TV shows that I don’t intend to be taken literally.” … “Hi I’m Katie, it’s possible that I spent over 20 minutes putting on make-up today and unlikely that I know the last time I washed my hair.” … “Hi I’m Katie, I consume more coffee than is actually advisable and this only enhances my ability to speak non-stop when I’m nervous, usually about things no one cares about and I could probably go on but you look bored and now I’m uncomfortable and feel as though I’ve alienated you even though that was the opposite of my goal here.” Or, perhaps more fitting for a boxing gym, “Hi, I’m Katie and it is one of my life goals to get in a fight. Not a scheduled match, persay – but I’m not ruling that out either. I want to be in a real fight where I’m the one clearly in the right, defending an underdog or my honor or whatever and the other person is much bigger than me but because of my skill and my will to win I still manage to floor him or at least draw some blood such that I’m clearly the crowd favorite by the end.” (Like when Mr. Miyagi shows up to defend Daniel in The Karate Kid. Clearly, he should be overmatched given that he is older than his opponent and outnumbered, but he still manages to wipe the floor with them #goals.)

At the time, I hadn’t considered all the potential answers to this question and simply responded in the typical fashion. Katie. Ohio. Want to get better at boxing. (Why on earth would I be in a boxing gym otherwise?!) Blah blah blah. 

His response was not what I anticipated, although, in retrospect it is the crucial moment in any boxing movie where the protagonist faces adversity.

He explained that this is a team approach, if I decide to do this, which I probably shouldn’t, I need to be on time. “If you want to show up, ten minutes late, not take this seriously, then I don’t care about you. You might get better, but you probably won’t. I’ve got kids in there competing in real fights. If this is just a hobby for you and you’re not going to make this the number one priority in your life, then I don’t care. I don’t need your money, I don’t need you to like me. I’m an asshole and I’m okay with that.”

Essentially, we aren’t going to pay special attention to you. “I’ve got about twenty kids – some of them can’t make a fist and some of them are pro level.” He went on to explain that at the beginning, boxing is about repetition. Training your muscles to punch properly and training your cardiovascular system to keep up with the demands of a several-round fight. It’s boring and painful and I would probably hate it. “There is a beginner boxing class starting up – start there and they will go through the basics with you and then you can come to my team after you’ve learned all that.”

I didn’t respond immediately. His rant had persisted for several minutes and was a lot to digest. I had wanted this since day one of joining this gym. Boxing team had been my goal and I worked hard to get “good enough” to be here. Embarrassed by my own apparently overly generous assessment of myself and my skills, I sat in silence, wanting nothing more than to slink away.

I’ve never had a good poker face when I’m upset or hungry and at this particular moment, I was both. Mike must have seen this and softened I guess. He told me to sign up for beginner’s boxing, that it would help me and then I could come back and try again with him. I shrugged it off as best I could and thanked him for his time. (Nothing like thanking someone after they’ve spent 10 minutes telling you “You’re not good enough”).

Having suffered enough to get this far, I went to the front desk and inquired about beginner’s boxing. I waited for awhile behind a middle aged man who had an inordinate number of unnecessary questions about the fitness classes offered. (Did I mention that I was hangry by this point?)

As I was waiting, the boxing team gathered and went outside for a talk from coach Mike followed by a run.

Finally, I had the attention of the person at the front desk. She explained to me all that I needed to learn in order to be good at boxing. I cut her off because I was not interested in the syllabus at this point but simply wanted to know days and times.

“Oh, it’s just starting up. We haven’t actually scheduled it for any days or times yet.” … Awesome. She acquired a piece of paper, wrote on the top ‘Beginner’s boxing class’ and underlined it. She asked for name phone, phone number and email. I provided them as requested and left. By now the boxing team was no longer encircling the front door and I wanted to be long gone by the time they returned.

As I sat in my car, processing (and figuring out the closest place to pick up food), the boxing team ran by in several clusters. The guys in the front of the pack were clearly strong runners and keeping a quick pace. The stragglers were dragging and I had no doubt that I would not be bringing up the rear. Jealous that they were “good enough” and I was not, I went home and poured myself some wine.

When I returned to the gym the next day for my regularly scheduled classes with an instructor I knew well, Coach Mike happened to be there as well. Of course. I had not laid eyes on him prior to my embarrassing meeting the night before, but now I was going to see him everywhere. Statistically- unlikely; anecdotally- that’s how my life goes.

I was late and had only managed to wrap one hand during the drive. (A practice that always gets entertaining reactions from other drivers). Coach Mike was working with a fighter whose name I don’t know right near my usual bag. After an awkward unintentional eye contact, I smiled tersely and set about wrapping the other hand. Mike came up and asked if I was able to sign up for that class. I guess this was as close as I could expect to encouragement? “It hasn’t been scheduled yet” I informed him. He replied “oh, this week or next for sure” and refocused on the important task at hand.

Anger and embarrassment does for my fighting the same thing that coffee does for my thinking. It speeds it up, gives it clarity and accuracy. An edge.

Mike was around the gym for the duration of the class. I let it all out on the bag, his words from the previous night still stinging in my ears.

The fighter he had been working with – easily 6’5” and over 200 lbs (with super intimidating dreadlocks to boot) came over to work the speed bag that happens to be right by my spot. At this point, I was engrossed in my workout and working hard to breath. I didn’t pay him much attention. After letting a particular combination fly, I heard him exclaim, rather loudly, “OWW. Dang.”

I looked at him and was surprised to find that he was watching me. His exclamation had not been a personal expression of injury but instead a commentary on my combination. I nodded at him and went back to work.

Joppy, the instructor, came over with the punching mitts and worked some combinations with me. While hitting the bag is rewarding and exhausting, it does not compare to the sensation of hitting the mitts. Responding to the calls in real time, ducking as needed, maneuvering around to follow the coach and maintain distance while protecting yourself from real blows… it’s a whole new level.

When the bell finally chimed signaling the end of the round, I was sucking in air like I had just sprinted up a mountain. “High knees, go.” Joppy commanded and we all obeyed, panting and bouncing as though our lives depended on it. “Hmmrhginf hdn hd” He said something else, but much softer, clearly directed at me and not the class at large. At that point, listening, thinking and bouncing were not three things that I had the capacity to do at once. I stopped so I could breath and hear him clearly, “What?”

“Have you considered one on one training?” He asked me. The nearby fighter commented something along the lines of “She’s legit” or “she’s got stuff”. Honestly I could barely hear him, but from the expression on his face and the way Joppy nodded assent I knew it was intended as a compliment.

“Honestly, I really want to start and I’ve tried, but…” I trailed off, certain he didn’t need to know the full story.

“After class, we’ll talk. I would train you really cheap.” Brief pause as I stared at him, a little dumbfounded. “High knees.” He reminded me and I got to it.

Twenty minutes later, after completing our abdominal workouts and finishing stretching, I unwrapped my bleeding knuckles as I approached him. He walked me through what training would entail, the importance of endurance, and asked what I wanted to get out of it. Flashing back to all of the times I had been asked this previously and misunderstood, I tried to answer with more words. I explained that I wanted to be a good fighter, to be able to handle myself in the ring, to learn how to slip punches and work combinations without thinking about them. He nodded.

“None of that will come without sparring. None of it is real until you are taking blows as well as throwing them. That’s really when it all comes together. You would wear pads and stuff, but we need to get you in the ring. I think you have potential and I would just train you like an amateur fighter and we would go from there. See where it goes.”

He went over the cost of a personal training session and gave me his card. I heard none of it. My mind was already envisioning myself in the ring (and, as after every workout, imagining what I would eat next). Joppy and the fighter near me (whose name I still don’t know, but if he features in another story ever, I’m just going to refer to him as ‘dreadlock’ because this is getting rather cumbersome) reaffirmed my faith in myself. I wasn’t wrong and I do have what it takes.

This is a super long story with a rather clear moral. No one else determines your skill, your value and your worth. Mike took one look at me and decided I was not right for his class. I wouldn’t be able to cut it. Honestly, he may have been right. But the real failure was when I agreed with him both internally and externally. When I didn’t stand up for myself and say you may be right, I may be in over my head, but I’m still jumping in. When I left the gym without giving that first session a try, simply because I was told to.

Maybe everyone else has already learned this and didn’t need to relive my humiliation to affirm it. I’ve dealt with the same general theme in other aspects of my life – relationships, jobs, etcetera. It is something that Disney seems to engrain into us as children – you can be whoever/whatever you want to be… Just be true to you! In fact, I think we comprehend it more clearly as children; once we are adults burdened with pride and social graces and some sense of our limitations that we are so willing to settle for the box that someone else has set us in.

So, I’m going to train with Joppy. He believed in me. I’m going to go back to boxing team too. I’m even going to go to beginner’s boxing – it can only make me better, right? My arms may only be twigs… but what doesn’t meet the eye is that they are twigs of fury. Look out world, because someday when there is a bully picking on an underdog or a guy making sexist remarks or forcing a girl in a bar to put up with his drunken stupidity… #bucketlist, I’m probably gonna ask him nicely to stop. When he sizes me up and sees that I’m a small, insubstantial girl with no way of enforcing my request and ignores me… Well, then that will certainly be a story I will write about.

Champion Boxing & Fitness, Rockville, MD
-Empty on rare occasion

Friday, June 17, 2016

Be brave with your life

I watched the movie Everest with my parents this weekend - which they spent a good half hour selecting from the redbox while I was waiting for them. To their credit, they did not know I was waiting for them in the parking lot given that I no longer live near home and hadn’t planned on visiting them soon.

It took them awhile to select a movie because in addition to finding a movie that met the rigorous standards of being appealing to my parents, it also had to be a *blu-ray*. My brother, ever the favorite child, surprised my dad with an early father’s day/ birthday / continue to love me more than my sister gift of a new blu-ray player.

My counter move to this ploy was to simply show up, unannounced and then expect them to feed and entertain me for a few days. Jimmy: 1. Katie: …enchiladas?

Anyways, if you haven’t seen the movie yet, its inspiring and terrifying and definitely worth watching. Initially when watching, I decided I wanted to climb Everest. By the end, I’ve decided to maybe set my sights on a smaller mountain. I suppose that was a bit of a spoiler alert, but come on, you knew that it was going to end badly… a movie of people walking up and walking down probably wouldn’t be that interesting. ALSO, it happened in the past and the 1996 Everest disaster was (I think?) a fairly publicized catastrophe. Similar to someone watching the Titanic for the first time… I don’t feel bad if I ruin it for you by sharing that the ship sank and I really want to know how you’ve made it your whole life without ever hearing the fate of the Titanic.

I digress.

Long story short: good movie, I’ve started reading the book, Jon Krakauer’s Into Thin Air.

The author was present on that expedition due to an interest in climbing as well as talent as a writer. He was sent by the magazine to write a feature piece. No one anticipated how big the story would ultimately become. There was no initial intent to write a book. He explains in the introduction that this book served as a catharsis for him – he hoped, to get Everest out of his system. He doesn’t say if it worked.

What strikes me about this book so far is how honest he is about the characters in it. It is clear from his writing that he is a reporter. He shares the truth with unapologetic clarity. The characters in this story are not characters but actual people and described as such. He includes both flaws and idiosyncrasies that might be considered embarrassing to the people involved. The survivors are people he has shared a life-altering experience with, whether he considers them friends I will never know. Several of the people introduced early on ultimately die and yet he is still able to paint them accurately. The book does not read like an obituary where those passed are angelic, heroic people who simply had some bad luck. It is harshly honest.

Perhaps this resonates with me because I feel this is a skill I lack. Only recently have I begun to be more honest with the people in my life about what I want, about how I feel. Admittedly, its probably only recently that I started being honest with myself.

I have difficulty describing people with the same clarity as Krakauer because I want people to like me. It's not an overwhelming obsession where I cater to the desires of everyone around me, but rather buried deep inside me. I avoid confrontation. I gloss over flaws. I repress anger. Frustration. Sadness. It has occurred to me that I apologize for things I have no reason to be sorry for.

New goal: to write with honesty.

“You own everything that happened to you. Tell your stories. If people wanted you to write warmly about them, they should’ve behaved better.” – Anne Lamot

I owe it to myself to describe things exactly as I see them, as I feel them - even, in some cases if that is not the way they actually are.

People especially need to be written in their full spectrum. Live is lived in shades of grey, not in black and white. Good people hurt feelings. Well-intentioned truths break hearts. Bad mistakes make good stories. There is beauty in the tragedy of life. It is messy, unfinished, broken and lovely all at once. It’s a field of wildflowers - untamed. It is magnificent despite the lack of direction – or perhaps, because of it.

Step one in this new process I suppose is to allow myself to feel and express whatever I want to actually feel. For instance, that I will no longer be a pediatrics resident after this year. By choice.

The story of that decision is a much longer monologue for a different day. It may be the wrong decision and it may be the best decision I have ever made. Either way, it is mine. Life is too short to be lived in a situation that inspires constant unhappiness. My path is not as straight as I once thought it was. It is okay though, I haven’t reached the end of my story yet. The only requirement of life is that you get from point A – birth, to point B- death. Everything in the middle, you get to decide.

I have a painting on my wall that reads “Be brave with your life”. It is quickly becoming my new mantra. Dropping out of residency feels akin to getting off the highway to exit the safety and comfort of the car and being walking through the forest. It is terrifying and exciting all at the same time. Is it brave? Who knows. Bravery and stupidity look the same initially – which one results depends on the consequences.

Here goes nothing.

Thursday, June 16, 2016

Christmas 2015 - part 1.

I have decided to begin a new initiative in my life to improve my writing. Or, more accurately to improve the volume of my writing. Whether this will make any change in the quality of my writing remains to be seen.

I don’t post to my blog often because I tend to write only when I feel I have something to say. However, often times when I feel words coming forth and begin composing lines in my head I am not sitting near a computer or pen and paper so those words are lost and along with them an important piece of me. That’s not to say that I am walking around with little thoughts flying out of my head left and right as I just shrink smaller and smaller and slowly disappear. I think their loss affects me only. As they disappear, I lose touch with my thoughts and my feelings and it becomes harder to express myself simply because I am out of practice.

So, thus begins the new plan to write for 30 minutes per day, regardless. Timer set, words out. I am not going to edit. I am going to try not to edit. The goal here is to simply put thoughts on paper (well, simply put thoughts out of my head) and not produced some finished piece.

Yesterday, I had an interesting idea for a book. I want to compile a bunch of short stories from intern year. Writing the whole year as a narrative would be terribly boring for anyone to read. (Countless hours of note writing, article reading and crying to sleep). But there are a few instances where time slowed down and the stories etched themselves on my mind. The baby that was born Christmas morning shortly after I arrived for what I anticipated would be a quiet day in the NICU – that terrifying sensation of running into a room where CPR is being done on the still pregnant mother and realizing that two lives literally hang in the balance.

On TV, the codes run smoothly, there is some yelling and arguing for dramatic effect, but what you don’t see is the realistic crowd of people. In the hospital, codes are commotion. They are paged via the overhead paging system and the rule is that someone from every department has to go. Not someone – a doctor. That is because when a heart is stopped, every second matters. And when it happens – it happens anywhere. Who knows who will reach them first? That’s why the best bet is to have someone running from every direction. Because no matter what someone will be there in moments.

The problem with this is that once the page is sent, there is no page revoking system. So once the first person arrives on the scene, the second person usually arrives seconds later. Then the third, then the fourth, then the fifth, then the sixth. All this help is fantastic at first – one person does CPR, one person manages the patient’s airway (gives breaths with a bag and mask or puts a tube in the patients throat if necessary) another person is responsible for medications – drawing up the correct dose and administering it when called for (this same person also usually starts an IV and gives IV fluids), another person is responsible for writing down everything that happens. Hospitals have special paper forms for this with the usual medications listed and a basic structure outlined. More often than not, these rough timelines are scribbled onto the back of whatever the person has in their pocket or nearby. It could be a patient list from a completely different day, it may be the notebook they have been using to record lab values, and sometimes its just paper towels pulled from the dispenser.

Another person is responsible for “running the code”. They do none of the above functions, but rather stand back and observe the whole scene and direct, similar to leading an orchestra. It doesn’t matter if you are a fantastic bassoon player and the bassoons are doing a terrible job… if you step off of that podium to take over for them, the whole thing will become unraveled rather quickly.

So, in a perfect world, a code with approximately 6-7 people is ideal. Everyone has their roles and stays in their lane while simultaneously helping the person in charge look for things they may have missed.

When a real code happens, there is usually 20-30 people in the room. 20-30 well intentioned people who have been trained to save lives. People who know that the patient currently in the eye of the hurricane is in dire need of help. People who have chosen their career path because they want to help.

In real life, you may have 6-7 people performing their roles perfectly, but you also have about twenty onlookers, with all the best intentions, valuable expertise and relevant training who, quite frankly, are just in the way.

The average person not in the healthcare field has no reason to see that scene generally unless it involves them personally or a loved one. I assume in those instances, they are fairly distracted from the crowd of faces present.

Initially, my idea was to tell multiple stories like that one. (Well, that really wasn’t the story… I guess just a long set up to explain why I felt the story needed to be told).

I told this idea to a dear, dear friend of mine who expressed encouragement and then unexpectedly shared her own version of the same story. I had forgotten she had been there that day as well, on a different floor, uninvolved in any of the previous care of the patient… and then she got the page, and, as expected, took off running, realizing on the way that her day had just completely changed course.

When I walked (ran) into the OR in the labor and delivery unit, I knew already that this baby was not going to have a long life. It had been diagnosed prenatally with a genetic condition that would support life for a year at most, but even that long was unlikely. I knew the mom was at full term, baby was appropriately sized, it was her first baby and apart from the known condition of the baby, she had previously had a healthy pregnancy. All that said, I had all sorts of reasons to be reassured that this mom was going to be okay and also a general feeling of foreboding that baby was not while at the same time feeling (terrible as it may sound) relief. Relief that this was not my fault, that even if I gave this child my 100% best effort and all the medicine and work and life-saving efforts… it was not going to die because I had failed.

Emotions tend to take a backseat walking into a code scenario. The only thing to feel at that point is adrenaline and instinct. That is why we practice, why it is drilled into us as medical students, doctors, nurses, respiratory therapists… A. B. C. Airway, breathing, circulation. If you can only think of one thing, you know where to prioritize and simply let instinct take over.

When I arrived in the OR, the pregnant mother was on the operating table – unmoving. A teenaged enlisted sailor in the navy was doing chest compressions. OB-GYN nurses were at the bedside in a cluster. Someone was yelling into the hallway “Call a code blue! Call a code blue!”. An anesthesia resident – clearly designated by his blue scrubs was at the head of the bed, drawing up meds. The staff anesthesiologist appeared only seconds later.

The code blue was paged. Within seconds, 40 people were in the room –OB-GYN providers in their cranberry scrubs. Pediatrics in their cranberry scrub bottoms, festive shirts and Christmas headbands. Anesthesia from multiple units with blue scrubs and colorful scrub hats. Other specialty providers in the uniform of the hospital – dark green scrubs, and the occasional civilian nurse with fancy patterned scrubs that are only really noticed in a hospital where everyone else is required to wear the same thing.

When I walked in… it was chaos. Despite my background knowledge of the patient, the reassurances that mom was previously young and healthy and fully expected to have a normal delivery, I was overwhelmed.

Dr. C. My friend scheduled on the pediatrics floor that day, walked (ran) into the same scene, but from an entirely different vantage point. Her responsibility for the day was to the patients three floors below. The patients whose charts she had spent the morning reading and learning.

It was hearing her story that triggered a new idea in me. For all of the stories of intern year that have stuck with me (except for one terrifying scenario involving a limp, blue baby) there have been other doctors involved – from various specialties and at various training levels. It would be interesting (to me anyways) to compile short stories, but from multiple vantage points. The pediatric intern (me) in way over her head. The pediatric upper-level resident familiar with code scenarios but with no knowledge of this particular patient. The upper-level anesthesia resident who came running from a different floor in response to the code blue. The teenaged medic responsible for the chest compressions. Another pediatric intern was not present for the code, but was there with the family when later that night, the baby passed away.

These moments, they affect us. Even if we have seen them all before and will see them all again. It’s hard to explain to people who haven’t been in that scenario. My parents, visiting for Christmas, came to the hospital to have lunch with me. I barely was able to sneak away as we were still trying to stabilize the baby, 5 hours later. When I told them the story of my morning, explained my tardiness to meeting them for lunch, my mom had only one question. “Is the baby going to die?”

“Yes. Honestly, I am surprised she hasn’t already.” We had explained to the family it was fruitless. The child was terminal regardless and x-rays from shortly after birth demonstrated minimal lung tissue. Whatever they had been promised regarding taking their child home, we were not going to be able to give to them.

At that point, I was frustrated with the family, because despite all the information we could give them about their child’s prognosis and timeline, they wanted all possible life-saving measures taken. (For non-medical people, that means we are keeping this baby alive no matter what. There was already a tube in the baby’s throat with the machine breathing for her, but if her heart were to stop, we would begin chest compressions and do everything we could to bring her back.)

We had other sick babies in our NICU. Non-terminal babies that also needed our time and attention. It all goes back to medical ethics and resource allocation and how do I justify spending hours trying to save this baby that is definitely going to die and ignoring this baby that is sick but will likely live?.

I tried to explain this to my mom, who was a bit taken aback with my non-chalant answer. “Put yourself in their shoes” she begged “would you want to just let your child die?”.

What she didn’t understand was that I had thought of that, and that I couldn’t now. I can’t imagine that baby is mine right now because I need to know what that baby’s lab values show, and how fast her heart is beating and the settings on her ventilator. I need to know about the 8 other babies I am responsible for – what is their blood sugar, how much have they urinated today, does their white blood cell count indicate an infection, is their chest x-ray getting worse?.

What I couldn’t make my family understand is that my heart was breaking too. Separately, silently, because I had to go back to work. I had to talk to the baby’s father, a non-medical 19 year old. I watched his face as yet another doctor told him his daughter was going to die. I noticed he had on athletic sandals with socks. He had a lanyard hanging out of his pocket. Apart from the OR hat he had forgotten to remove, he could be an average high-school student heading up to the basketball court to shoot some hoops.

He was so young. His face indicated no understanding. His daughter, just recently born and yet barely alive only three feet away. His wife, downstairs in the intensive care unit, still unconscious and not breathing on her own. I was older than him. Yet I had nothing that I could even come close to relating to his life experience at that point. I wanted to hug him and cry for him and at the same time I wanted him to leave, because I had work to do.

So I guess that’s the goal in telling my story and the stories of others. I don’t have the skill to succinctly explain everything. I can’t make you understand what I feel without walking you through these moments that I will never forget. Even when I’ve been through millions more just like them.

This baby was born around 7:30 AM. We spent all morning fighting to keep this baby alive, trying to manage the other patients, worrying about the state of the mother, and of the other physicians in the room. Talking to the new father and grandmother. Fielding questions from nurses. Examining other babies. Attending other deliveries – these with healthy babies and happy families with their Christmas miracles. Trying not to resent them and feeling as though their happiness was almost offensive, in light of everything that had happened, but instead cooing over the new baby saying for the millionth time how he was absolutely beautiful. A healthy baby boy. 7lbs 5 oz. Perfect size. Normal. You should get to take him home in only a few days. Congratulations. Then, I was eating lunch with my family, trying to explain how my day was going. Trying to be pleasant because it was Christmas, after all.