Sunday, July 3, 2016

You've got to want it

Day two. Certainly feels like I’m back to work. On call on a holiday weekend cross covering a busy(ish) ward full of patients with whom I am unfamiliar. Pager chiming constantly with questions I think I can answer. A pocket full of papers covered in numbers and scribbles reminding me of vital signs, lab values, pending tests and what to watch for. I remember this.

First days are the worst – filled with awkwardness and uncertainty. I've now had two, first day back to clinic and first day back to a call shift. New people, new roles. Add to that the drama of a return to the fold – the prodigal son returns but without all the hoopla. I’m constantly explaining to people where I stand. I am the solitary person in a peculiar void between year one and year two, standing just between two clearly demarcated boxes. I am still an intern, but I am not a day one fresh-faced gomer. There are things I can do as reflex that would have given me palpitations on July 2 last year. I can pull numbers, prepare for rounds and perform a history and physical with the best of them. At the same time, I am not a senior resident. I’ve got to say, the only thing worse than being an intern is still being an intern after July 1st. Thanks to my extended hiatus from medicine, I feel like a rookie again. The note format has changed, I have forgotten extensions that I used to know by heart. I’m nervous that I’m going to make a mistake. I have nightmares and wake up in a cold sweat- certain that I’ve missed a page, forgotten to check a lab, ignored a vital value. It is unnerving to know that when I walk into a patient room wearing my white coat and introduce myself as a doctor, people expect that I know more than they do. From where they’re sitting, I have wisdom, knowledge, experience. From where I’m sitting, I’m a girl in her twenties who never uses Neosporin and didn’t even take her malaria prophylaxis in Africa. I eat food that has probably gone bad and shrug off a lot of concerning things regarding my own health with “it will probably be fine”.

I’m a fraud.

It is like that episode of New Girl where Nick and Jess get in a fight about something or other (oh, you mean all of them?). I’m really not sure what his point is with this statement, but at one point Nick says “I’m not convinced I know how to read, I think I’ve just memorized a lot of words.”

That’s how I feel about medicine. I’ve just accumulated a lot of useful clinical pearls. At one time or another I just happened to answer a relevant USMLE practice test question and a little fact glommed itself onto a neuron somewhere. When I’m certain of what to do, it's often anecdotal – a previous similar patient is stuck in my mind. I knew the warning signs for appendicitis long before attending medical school because of family experience.  I had some understanding of the benefits and limitations of CT scans and MRIs because of my dad's experience programming them.  Treating diabetic ketoacidosis always triggers thoughts of the first time I saw it – in a comatose teenager with blown pupils and a blood sugar of 1200. I remember the labs we tracked for her, what we monitored; that same checklist still guides me every time.  I'll never forget that hypothermia causes a paradox in which the person suffering it feels extremely warm or that altitude sickness results in an abnormal breathing pattern known as Cheyne-Stokes respiration where you alternate between breathing deeply and rapidly for several seconds and then not breathing at all for several seconds.  Especially problematic at night when you repeatedly wake up, gasping for breath.  It can be treated with a diuretic called Diamox.  I may have learned all of this in medical school, but it was solidified when I experienced it myself.  

It reminds me of the book Moonwalking With Einstein by Joshua Foer. In it, the author details his quest to win the U.S. memory championship. (This is a real thing… google it! Shout out to this year’s champion, Alex Mullen: I know nothing about you and you don’t know anything about me, but if you ever learn it you’ll never forget it! That’s a bad memory joke.) In these competitions, the participants perform seemingly impossible tasks such as memorizing 1,000 random digits in a specific order within the 60 minute time limit or the order of a shuffled deck of cards in less than 2 minutes. This seems like a mundane and rather absurd pastime but there are people who enjoy watching golf on TV so clearly there are things I will just never understand. Foer becomes a worthy competitor in these events by training his memory using what he calls memory palaces: he visualizes a place he knows well and in his mind’s eye fills it with strange images to help solidify the place of these random images in his mind. Clearly he explains this better but in an attempt to salvage this trainwreck of a comparison and at the risk of rewriting a significantly shorter and considerably less informed version of his book, I’ll provide an example.

What I used for a memory palace is my parent’s house. I know every inch of it. So if I needed to remember a random string of objects, such as: cast, punch, beak, hymn, bamboo. (Full disclosure, I used a random word generator online and of the options provided chose only nouns for simplicity of explanation. ) Here goes. To remember a cast, I’ll start at the beginning of my memory palace – the driveway. I’ve put my cast there. To make it memorable, it is hot pink. My dad is wearing it on his arm – I don’t think he would select this color on his own, so the image is amusing. Got it. Punch. A child sized swimming pool is further up the driveway filled with punch and my aunt (famous for her punch making skills) is swimming in it. Beak: My mom is wearing a beak over her face as she sits on the front porch. I can hear the “caw-caw-caw” of her pretending to be a bird. Hymn: it works out rather nicely that there is a piano immediately after you enter their house, but to solidify it, there’s my brother in full choral robe singing in an operatic voice. Unforgettable. Beyond him, in the room my family refers to as our library, is a full bamboo forest, complete with panda bear, sitting on the carpeting munching on bamboo as he pages through a book. If I have done my job and made each of these images absurd enough – then mentally walking through my parents house is the same as watching a video in my mind of triggers for that I need to remember. Try it – it is surprisingly effective and even kind of fun!

How is this relevant to what I was talking about previously? Excellent question, given that lengthy trip down that rabbit hole to explain a rather minor point… In his book, he is able to remember individual facts by making it personal and relevant to him by using a place of familiarity to lock it in. I fear that my medical knowledge is secured in much the same way, the stories that struck a chord with me have locked themselves inside my memory. Like I have been building a tower with individual jenga blocks while everyone else has full blueprints of their carefully designed and constructed houses. Maybe everyone feels this way and I am not alone, perhaps jenga towers eventually solidify with the addition of time, the guidance of superiors and the glue of experience.

I have been constantly afraid that some vital component of my knowledge is lacking. I’m behind. I don’t know enough. When I expressed this concern to my program director earlier this year, he taught me about imposter syndrome.

“Imposter syndrome can be defined as a collection of feelings of inadequacy that persist even in the face of information that indicates that the opposite is true. It is experienced internally as chronic self-doubt and feelings of intellectual fraudulence.” (I got this from the Caltech website and will include the URL at the end of this post to ensure that the writer gets credit for their well-stated definition.) The website goes on to explain that there are three sub-divisions of this phenomenon: feeling like a fake (e.g. the only reason that I wound up at my top choice hospital is because they had to take me because I’m army), attributing success to luck (the only reason I passed the step exams was because I was able to guess well on the questions I didn’t know) and discounting success (anybody could have done this, I’ve just had easy classes, lenient graders, easy rotations etc).

They might as well name it Katie syndrome. I’m not saying I’m the sole person in the world to experience it, rather that I am fairly certain that the person who wrote that description could see into my psyche.

It’s worse after being away from the hospital for three months. I have spent the last several months gaining balance and perspective and occasionally studying for step III. I have done nothing related specifically to pediatrics except test questions that happen to involve a child. I have forgotten things. In a very small way, I bet this is what dementia feels like. I know there are things I’m supposed to know that I simply don’t know. I can see my own shortcomings ever so starkly.

At the beginning of intern year, everyone tells you it is going to ‘click’. That you will keep feeling like you don’t get it until one day, you just do. They’re not wrong. I see it now. My former co-interns who speak with confidence to patient families, hand out diagnoses and treatments with certitude, answer questions from nurses with clarity and poise. It’s like they all grew up without me. I am the kid in Flight of the Navigator who returns to his childhood hometown, after being abducted by aliens, only to discover that all of his friends have aged eight years. In the meantime, in the midst of whatever sci-fi logic applies, he has not aged a day. He is ten and his friends are eighteen – a huge difference in an instant. They ‘clicked’.

I had mixed feelings about coming back to work. Dread about returning to the career I’m essentially abandoning. Sadness for the aspects of the job that I like and will miss. Nostalgia for returning to a place where many friendships were formed. Awkwardness of facing those who added to the ‘con’ column in my decision making. My emotions about watching my friends advance to bigger and better things are equally mixed. It is intimidating how good they are now. Their confidence is daunting. It seems that our difference is insurmountable. I will be the eternal intern, they will proceed, onwards and upwards. Bigger and better things. I can’t help but compare myself to them – line us up side by side. After all, we all started from the same place, right? There they are: succeeding, excelling, advancing. Then there’s me: stalled out. Restarting. Stuck. I think they sense it too, the newfound chasm. They’re hesitant to give me assignments or tell me what to do. Our mental ranking system puts us at the same level, but the graduate medical education ranking system is not so forgiving. I cover the junior shifts. My notes need cosigned. I warrant supervision.

I had the same starting line and the same requirements. All evidence points to the fact that I should be there too. I should be finishing one year and starting another, advancing in my responsibilities and knowledge. But I’m not. I’ve fizzled out. They have made it to the finish line and get to celebrate. I found out there is still another lap. Did I sell myself short? Could I have pushed it a little farther? Suffered just a few months longer? Look at where I could be… This isn’t a fair game to play. If depression is a deep hole, I bet everything looks better once you’ve managed to climb out. Regardless, it is hard not to be a little disillusioned when you see how close you were to the oasis.

I have a long history of being able to suffer through temporary pain – what comes to mind instantly is getting my wisdom teeth out without anesthesia. The only analgesic they used was Novocain. Fun fact: when you have a local infection, such as when a wisdom tooth becomes impacted and some bacteria are allowed to gather and propagate, the surrounding tissue becomes acidic relative to its usual functional pH. Another interesting fact is that Novocain does not work as well in acidic tissue. I learned this in my second year of medical school in an “organ systems” lecture – a lecture designed to present physiology – normal function of a tissue, pathology – when a tissue stops functioning normally, and pharmacology – which medicines we use to treat it and how they work, all together. I hate pharmacology. There has to be at least nine million drugs out there, each with a brand name and a generic name, both of which must be learned. Nothing is named intuitively – Celebrex sounds like an umbrella you use for celebrations, not an arthritis medication. What about “ibuprofen” indicates that it will treat a headache? Viagra should be a place you visit or a type of fancy wine… I’ll take a bottle of your finest Viagra (…Well I guess that line works on two levels.). There are mechanisms, intended effects, side effects, interactions and dosages. A million individual facts… there is a reason that pharmacy school is just as long as medical school.

Regardless, I learned that Novocain does not work as well in infected, acidic tissues. I don’t remember why. I likely would not remember this tidbit at all except that when I had my wisdom teeth out the Novocain did not work in my infected tissue. It took 7 or 8 shots (7 or 8 times the usual dose) to make the area even semi-numb. Another example of anecdotal knowledge that has shaped my medical proficiency.

A more accurate depiction of what I mean by pressing through temporary pain can be captured in a long-distance race. In high school, I ran cross country. I loved the team, the coach and the practices. I vehemently hated the races. I dreaded them because I knew how painful they were. The first mile is the worst – before the numbness sets in and you still feel every stabbing breath. You know how much farther there is to go. It’s going to have to hurt. Eventually, you learn to ignore the screaming of your lungs and the thumping of your heart. You tune in to your brain instead: “faster. farther. keep going.” You learn that pain is temporary and that this too shall pass. You can see the finish line and keep propelling yourself towards it, even if you still have miles to go. Our team mantra was “You’ve got to want it”. Essentially, decide that your results are worth the temporary suffering.

This mantra became ingrained into us. We wore it on bracelets, had it on our newsletter. Our coach would say it to us before every race, after we finished reciting the law of the jungle. It probably served to further establish our reputation as a cult throughout the rest of the school. It is a one-sentence phrase that only has meaning if you’ve put it there, otherwise it’s just a hallmark greeting. Something you might find in a fortune cookie.

It has meaning to me. It has gotten me through an untold number of endless workouts, marathon study sessions and low points in life (when others are headed to the beach or vacation, and I’m holed up in the hospital). But it is not an all encompassing, get through everything phrase. The word “want” is a very important choice there.
Sure, “You’ve got to want it” serves as inspiration when you have forgotten you want something. Mid-race when you’re about to throw-up and every sensible fiber of your being is telling you to just ease up a bit. Slow down. It would be so easy. Then you remember, you want to strip those seconds off your time, you want to pass that girl wearing the bow on her ponytail, you want to see exactly how hard you can push yourself. You force yourself to remember what you want. Mind over matter. However, It can also serve as a counseling device as you are selecting your life priorities. “You’ve got to want it.” You have one hourglass in life. The sand will keep slipping out of the upper bauble regardless. If it is something you don’t want, don’t waste your time. I could learn to compete in memory competitions, just like Foer did for his book. I might someday have some bragging rights and an arsenal of impressive party tricks but those alone would not be worth the effort I put into it. If you’re not interested in the end, the means becomes just a distraction from everything else you could be doing.

Last but not least, it is a reminder that only you are in control of your life. You get to pick what you want and what you don’t want. You have got to want it. Initially, I focused on the finish line of residency, a distant three years away because that is what I was supposed to do: a coping mechanism.  That’s the next step when you get out of medical school and it's how you get to where you are done. A step back gave me fresh perspective to realize, I simply don’t want this. I may want to want it, because everyone around me does. I may want to want it because the sensation of finishing something might be more rewarding than walking away- then I could check the box rather than leave it empty. I may want to want it because I do like some aspects of the job. I like resuscitating babies that haven’t quite figured out how to live just yet. I like handing parents a healthy baby and walking out of the room with a mic drop feeling as though I’ve contributed. In the moments where I am struggling with the fact that I have thrown in the towel and opted out, I have to remind myself that no, I want this – I want my life to be my own. I want to find a way to incorporate medicine into everyday life in a way that it will serve me instead of break me. I want my spirit to survive. The struggle is not worth it if the end result is not where you want to be; your sand is more finite than it seems.

Unfortunately everything is much more clear from the end than from the middle. The others in my class have reached a chapter's end whereas I’m still toiling away in the middle. If hindsight is 20/20, then my best bet to see this clearly is to look back on it. Press on.

I am two days in, with the better part of three months to go. I have no idea what is in store for me, what challenges I will face, what diseases I will treat and what my ups and downs will entail. But the finish line is in sight, I just have to keep my head above the water, learn what I can and accept where I am. My ending is still a long ways away.

Here’s where I got my definition of imposter syndrome

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