the good life, let's go on a living spree

Some days are horrible and some days are wonderful and some days are neither, and I guess the thing is just to remember that it will always be thus. My friend AP, who is now two years behind me in training, text messaged me excitedly today to tell me she received honors for the first half of her first rotation. She was so happy, and I was quite happy for her. But I also wanted to tell her not to get too high. I remember having the exact same experience, I remember the elation, and then I remember the feeling of complete failure when I didn't honor something else three months later. Looking back on it now, I see it was all arbitrary and anyway not something one should use to measure one's self worth. I wanted to tell her not to get too high, or at least to know that, should she get less-than-stellar marks next time around, she should simply shrug off the negativity.

It's easier to have a horrible day as you get older, I find. I was out cultivating a drinking habit after call one evening with my fellow intern, a sweet, well-intentioned, good-hearted young intern. She was telling me that she had come to dread going into work every day. She was worrying and admonishing herself for things that weren't her fault. She was worried she was less than everyone around her. She was not competing with anyone, but she was seriously concerned that she didn't measure up. And the reason is that she is so well-intentioned, so good-hearted, and so young, that she takes every mention of criticism, every snappy remark to mean that she is a bad doctor. When in fact, she is a great physician, and probably will be one of the better ones among us. It's sad what the system does to us.

I feel sometimes like I have a forcefield though. Sometimes I get criticized and I take it quite seriously and use it as motivation. Other times, it is quite clear that someone had a bad day and I'm the lowest rung on the ladder, so here comes that dung that rolls down hill. And on those days, I get annoyed and probably my resting heart rate and blood pressure are higher than they should be. But I go home and bake cookies or cupcakes, or I knit a round, and I remind myself that tomorrow will be a better day. Or if not tomorrow, then soon. Nothing is eternal.

Unfortunately, not even the good days. Like this one, in which I woke up after a pleasant night of drinking, and the weather was so perfectly temperate that I walked to AP's house, then the two of us walked to a lovely brunch and then walked back. Then I ran a few errands. And then I baked a caramel cake.

Believe it or not, I don't have many opportunities to bake cakes these days. Most of the times, I am stress baking, and as such, I have to make things that are portable and easily consumed. So I've baked a metric ton of miniature cupcakes, a bajillion cookies. But rarely a cake. Tonight I'm going to a barbecue though, and it's a friend's birthday. I suspect she may already have an actual cake (she's a relatively new friend so not altogether aware of my cake-mania and insistence that I bake any and all birthday cakes for friends), so I wanted to make something easily consumed, a snack cake of kinds. Caramel cake indeed. I've made this before. It is the kind of simple cake that people pick at, one small square after another, until, tada, nothing but a few crumbs and a lace of caramel on a plate. It's sweet, but not cloyingly so, rich but not like a brick that sits in your stomach. It's maybe not entirely summery, but it keeps easy, so I know if I bring it, my friend and her boyfriend can have at it for the rest of the week.

I know days like this won't last either. It's just a temporary lull, a respite of happiness and fun and drunken shenanigans. There's always some stressful situation afoot, that much is guaranteed in residency (and maybe life in general). But as long as I remind myself that such days as these exist and will return, everything feels quite tolerable.

don't call me daughter

I probably shouldn't write this post. I'm tired, I'm post-call, and this is sort of the opposite of my general philosophy on posts. But I'll try not to be vitriolic.

So it's Mother's Day. And Mother's Day, well, I find it a strange day. It's sort of a Message in a Bottle (song, not movie) situation, I suppose. You think you're an isolated case, but it turns out there is more than just you in this boat.

I'm not going to go into details, because that is not my style. But I don't have a great, or even a good relationship, with my mother. All these years later, I can understand the decisions she made, the great strain she was under when she raised me and my brother, the burden of unhappiness she's always had to carry. All of that empathy allows me to let go of what I lacked in the past, and makes me slightly better equipped to accept what I'll never have.

We were never close, always like strangers. She could never understand the tomboy who would belligerently mow the lawn to prove her brother should have to wash the dishes occasionally. She never understood a daughter who preferred curling up with ACK comics rather than shopping for dresses. She could never console the awkward teenager who stuck out like the literal black sheep. She does not believe in heartbreak, she can not relate to it, she can only understand protection, self-preservation. She can not give advice. In the end, we are like two figures masked and cloaked and sound-proofed. We can't see, feel or hear each other.

Maybe it's for the best. She was the doubt in my head, the voice telling me I was never good enough, that dreams were not for girls, that I had been a disappointment for not molding into what she had tried so hard to form. When I really let her go, some of my dreams came true, and sometimes I was so happy that I thought I would have a heart attack, and sometimes I was convinced that I was good enough.

But of course, it would always be a little less, because she would never see.

Last year, I once tried to have a frank conversation with my mother about my life, in the hopes of making her a witness. She told me she had simply concluded, from my silence, that having chosen to go into medicine was a big regret of mine. Then she asked me if I had 'met anyone.' I didn't bother responding to either jab. It was the first time she hadn't sent aftershocks through my system, hadn't caused me doubts, hadn't launched me into a cavalcade of defensive arguments. I guess that's what my mother's taught me- to really know myself.

The next time we saw each other, we talked like strangers with a mysterious, dark past, mostly polite with a few passive-aggresive remarks.

I write this not because I feel sorry for myself. I've done just fine, and you certainly cannot blame your upbringing for every wrong you've ever been done. I really have let it go. But I suppose on a day when everyone else is extolling the virtues of their mother, I have to believe that I'm not alone in feeling less than celebratory on this day.

I won't look for a house up on a hill

See, and this is the part where it all makes sense. Two days in a row now, I've had some ridiculously long work days. Broke work hours two days in a row. There's been a real lack of harmony on the teams I've been on of late, and it sometimes sucks the joy out of working on a team.

So I came home late tonight, frustrated, annoyed, tired. And as I was in my kitchen looking at the latest hurricane that had gone through there (the result of a cupcake extravaganza earlier in the week- Mexican chocolate cupcakes with dulce de leche frosting and... of course a dab of chocolate ganache on top, thank you very much), I suddenly thought, in a fit of rage, screw you, you don't deserve any more baking!

Then, just as suddenly, I started laughing. Really, I find anger pretty funny. Especially anger that results in some kind of threat involving baked goods. It just makes it all the more clear how useless rage usually is, when you channel it into something that absurd.

And when I'd exhaled, and realized I still had some homemade pizza for dinner, I took stock of my day again, the last two days, and everything felt, well, just fine, and maybe better than fine.

The great thing about medicine is that there's always some weird yin-yang thing that happens that makes everything alright. You have a day in which you lose heart, because your patients are combative or keep repeating the same self-destructive pattern that lands them in a hospital bed over and over again. But on those days, you find some fellow resident, some colleague with whom to commiserate, and you know you're not alone. And you have a day in which you feel like all of your colleagues have lost their souls, are joyless, and are actively trying to make more work for you. But on those days, you have some of the most satisfying interactions with your patients. Today was such a day. And on such days, once you've gotten the Hulk-like fury out of your system, and set aside your fatigue, then you relax.

I relax and realize that, even though it may not always feel that way in the moment, I am exactly where I need to be.

is this the real life, is this just fantasy?

Yesterday, I received a page from a nurse that a patient was trying to leave against medical advice. Since I am not as cynical and hardened as I may sometimes come across, I went to find out what brought all of this on.

The man was fully dressed but for the IV in his arm, which was still dripping heparin, a blood thinner, into his system. The man had several clots in his lungs back in December. He was treated for them in the hospital but was supposed to take a pill, warfarin, at home for about six months to keep the clots from worsening. He forgot to take the pills here and there, and came into the hospital this time with big clots in his heart. Pretty dangerous, to say the least. Now the man was annoyed and wanted to leave.

I asked him why. He said the hospital was stressing him out and all he wanted to do was go out and smoke a pack of cigarettes. I tried to explain that smoking was the most likely culprit for his clots forming in the first place, and certainly we couldn't let him wander off to smoke while he was hospitalized. He said that was fine, but then he wanted to be discharged immediately. We stood there at an impasse, despite several volleys of arguments. I was the evil physician vilifying his smoking, and arguing with him even though his mind was made up. He was the uncooperative patient who did not seem to care that he had a life-threatening condition that could kill him if he left the hospital. I tried to strike up a compromise and offered him a nicotine patch. He laughed in my face and offered me this compromise- 'if I'm still alive, I'll come in tomorrow, and you can admit me again then.'

Since we don't run a prison ward, I had to let the patient leave of his own accord. It was extremely frustrating. But it struck me that this seems to be the quintessential dilemma, always, everywhere. Two versions of reality. Both of us convinced the other is deluded. I recalled so many times I've tried to change someone's mind. I'm not saying one shouldn't try- some things are obviously wrong (Kutcher, I'm looking at you). Still, when I think of all the heartbreaks I've had in life, they are all boiled down to someone not understanding me. Yet really the problem was that those people did not agree with me, did not see things my way. And as much as I can claim to see things from the other side, to empathize and relate, it doesn't really matter, because on some things people are simply of two minds and they cannot be reconciled. That's what I'm trying to accept.

As for the man, I just hope he lives to return to the hospital, truth be told.

don't let them change you or even rearrange you

Well, time flies when you're not having fun. Or when you are. Pretty much either way. That's the thing, isn't it?

Anyway, it's funny, this stupid blog. It just sticks around and takes up space, and I am often remiss about posting to it. It's foolish to write a blog like this, so turned inward and self-absorbed, for anyone else. So most of the time I write assuming no one is reading anymore, and it becomes a place to have a conversation with some conjured up version of myself.

All of that is true, and yet it always seems like magic when I find someone is reading all of this, following along with all the silliness. I can't explain why exactly but it means a lot.

I definitely reached my limit last month, and now I am recovering. The catch with medical training is that you want to change. In some ways. You want to become more competent, more confident, more facile with figuring out a diagnosis, better at having difficult conversations, more efficient. You want to become a good doctor, or at least a better one. But as you strive for that, in residency, there are dark forces at work that seek to change you in other ways. Outpatient clinics filled with patients with a million problems they have no interest in fixing and coming to you because they want a prescription for pain medications or want someone to fill out disability paperwork. (All of that would probably be a lot more tolerable if you were not so stretched thin for time that you can not give any of it your proper attention) Uninsured patients who get admitted to the hospital over and over and over again because they can't get any proper medications or care outside the hospital (good job, US healthcare, once again- very cost efficient). Attendings who treat you like you're a sucker and a sap for spending more time talking to a family about their mother's desire not to have invasive measures taken rather than spending that time running medications like pressors to keep a patient's blood pressure artificially normal when their heart has already decided it doesn't have the energy to do it anymore. And, most recently, patients who actively use methamphetamines, develop a variety of heart problems, which you spend time treating, only to be assured that the patient will reverse all of your work and return to the methamphetamine use as soon as you discharge them from the hospital.

Very dark forces.

I fell victim to them last month, and it was disheartening. I'm hoping I'll never feel that way again- never feel that frustrated with patients and my work. It's as much the fault of the powers that be. The cardiologists treat patients like all they are is a heart- they don't look at the whole patient and their context and what they will and won't be able to do when they leave. On the other hand, maybe they shouldn't. Everyone should have access to care, which includes medications they need and clinic visits that are required when they leave the hospital. No doubt, it would save money to the system in the long run. But then, and this is the very dark part, but you are basically deluded and Patch Adams-ing it up if you do not acknowledge this- there are a small subset of patients who just don't want to take care of themselves. They will drive you insane because despite your best efforts and myocardial infarctions and stents and scares, they will leave the hospital and go right back to self-destructing, and show right back up at the hospital a short time late. You have to face that fact and accept it and choose to treat everyone anyway. Ultimately, that makes you a better doctor, I think. But it's certainly not easy.