Sunday, January 13, 2013

Mid year update

(Note: posted on night 7/8 of night float, as it took me a while to get to blogger from the hospital)

I am on night two (of 8 shifts total) of night float. Essentially, that means that two interns cover the majority of the medicine patients in the hospital. Right now, I am carrying the load of 12 interns overnight. That is intimidating and also completely unreal. I am almost exactly halfway through my intern year, and I figure now (at 2 AM, no less) is as good a time as any to reflect. At least until the next nurse pages me :)

Some of these I have reflected on already, but maybe time has given me more perspective. No time for run-throughs now, just a list...
-Infectious disease
-General medicine (VA)
-Primary care (VA)
-MICU (absolutely hated this rotation!)
-Neurology (disliked, thought it was pointless)
-Urgent care/ MICU coverage (VA)
-Night float

Big changes: I was in the MICU when I realized I didn't want to do cardiology anymore. Honestly, I had been slightly unimpressed with it as a medical student. I attributed that to just following people around, as well as having one community physician not quite be the model that I would prefer (think typical cardiologist stereotype). I was on general medicine when I watched a procedure in the cath lab and thought, "well, I could do this if I had to, but I'm not very excited about it." When I was absolutely hating my life in the MICU, I thought about the fact that the cardiology fellows had up to five months in the CICU, as well as several months in the cath lab. And they were constantly on call--which was not going to change much once they were attendings. I thought about my interests, and then I thought about what I want out of life. I think cardiology has very interesting research potential, but clinically, it leaves me a little cold. And a three year fellowship that was equal if not more time consuming than intern year? I knew I would really have to love something to commit to that. And right now, cardiology isn't it.

I have several friends and colleagues considering heme/onc for fellowship. Superficially, this seems to hit the big points for me: patient centered care with continuity, a patient-physician partnership, research potential, fairly decent work/life balance, and a bonus of getting to use some of my undergraduate chemistry background for chemotherapy.  It's still on the list, and I feel that it needs a chance. But after a month on the inpatient cancer service, I don't know if I have the emotional stamina for it. And two nights of night float have me seriously concerned. I had so many end stage patients, many of whom passed away within days to weeks of discharge. Granted, most of the people we admit have widespread disease and are admitted for management of their advancing cancer, so they usually come in with a poor prognosis. What bothered me most were the young patients, many with families, who are at the end of their lives. We had multiple women in their early 40s with children pass away from cancer. And in the MICU as well as on the floor, I have either covered patients or had patients covered by other members of my team with end stage cancer in their early 20s. It absolutely breaks my heart to think about these people, who a matter of months (or sometimes weeks) prior were going about their lives. Most of these patients passed away within months of their initial diagnosis. I am sure it hurts because it is so close to home. I see myself, or Tim, in these patients. I can't even imagine not being there for my kids.

And I think all of my introspection about my mortality has really affected my thinking about what I want to do. I have spent the last ten years of my life busting my butt to do what I am doing now. I realize that intern year is tough for everyone; I am not fixated on how difficult this year has been and continues to be. But I think about the next step: in 2.5 years, I will be moving on. I will either be starting a fellowship or starting a job as a physician. My life has been about delayed gratification; in just a few short years, there is potential to start reaping the rewards of my sacrifices. What do I want to do? And has it all been worth it?

I feel a great deal of guilt that I spend so much time away from my family. While I am on nights, I get to see my kids for about 45 minutes per day. I am so thankful that night float is only two weeks long at a time, but it really makes me think. I've broken my life up into little chunks just to get myself through it. Only 6 more night float shifts; before, it was, "only two more weeks of MICU" or "only three more long calls." I feel like my life, and in turn my family's lives, are just moving by. I know that this schedule is not unique to me. And it also was not a surprise. I wonder though: what will it take to make me feel that all of this sacrifice has been worth it? What is the measuring stick? Money? Really, that has never been important to me (hence why I could give up cardiology so easily). We have made do on a student's stipend, and residency pay is laughable considering the actual hourly wage when you calculate it. So if not money, then what? Prestige? I don't care. Making a difference? There are lots of other ways to do that; I really enjoyed teaching, and that would have been a viable alternative. Academics? Research? I really don't know.

It's difficult being in a place where you are surrounded by sick people all the time. It skews your perception. And being in a tertiary care center, these patients are SICK. When I was in the MICU, outside hospitals would transfer their complicated patients to us because they were too critical to manage at the other facility. And these patients would come in more stable than some of the patients we safely manage on the floor. So, the patient population notwithstanding, working in a hospital affects your perspective. I've seen young and old people who are sick, critically sick, terminally sick, and many of them die--despite our best efforts. It makes you wonder how anyone can be healthy, how anyone lives to a ripe old age. I am 32; I have had patients younger than me die. It doesn't matter if patients have families, or if they were in school, or if they hadn't finished what they set out to do in life. Disease didn't care. And it makes me fearful for the people I know and love.

I know that the statistics tell us that most people will not die young. However, now having seen it and almost having it feel common, it makes me scared. What if? What if I'm the one that gets cancer next? What if someone I love gets the resistant infection? Will I regret how much (or how little) time I have spent with the people I love? Will all of the decades of delayed gratification really be "worth it"?

One of the attendings that worked on the cancer service offered very good perspective on the patients we see in the hospital. He said that heme/onc is 95% of the time an outpatient specialty. Most patients see their physicians outpatient, get chemotherapy or radiation outpatient, and many are cured or improved as outpatients. The people who come into the hospital are the 5%. Even in his practice, which focuses on late stage cancer, most of his patients do not come into the hospital. Our inpatients are so sick that they can no longer be managed outpatient. He was the one that encouraged me to see patients in outpatient settings before I cross heme/onc off the list.

This year has been so full of ups and downs. I believe I have cried (privately, so far not publicly) on every rotation I have been on. I feel overwhelmed on a regular basis, I feel like I will never learn everything that I need to know, and I worry that all of my training will never help me be a good enough doctor for my patients. And then there are times when I cry for other reasons. I have been touched so deeply by some of my patients and their families. I have never expected recognition from my patients. Really, it's unrealistic, and you set yourself up for disappointment if you expect external validation. But on the occasions where patients or families have pulled me aside and said how much my care means to them, it absolutely moves me. It makes those long nights, those tearful huddles in the bathroom, seem like nothing. Pats on the back from colleagues are nice, but warm words from the people I work so hard to care for are like gold.

It is unoriginal and passé, but I want to be a doctor to help people. I have said for many years now that I want to be a doctor to help people on a personal level, and I want to be a scientist to help people I have never met. I know what I want my life to be like in 10 years. I want to be in academic medicine, with a regular outpatient clinic. I want the opportunity to be involved in research, either as a collaborator or a PI, on a project that is relevant to patient care. I want the opportunity to do occasional teaching, whether it be at the medical student, resident, or fellow level (I would do graduate/undergraduate as well, though I realize those opportunities are nearly nonexistent). I think several weeks per year of inpatient service are fine and would challenge me to stay up to date on more critical care than outpatient alone. And I accept that any job will have call/coverage, but I want that to be less than half of the time (and the less, the better).

I don't know what field exactly this dream job will be in. I always saw myself in a specialty, especially since I want to be involved in research, but maybe general medicine needs to stay on the table. I feel like specializing is a safety net for me, and it fits my PhD persona. I like knowing everything I can about a niche. General medicine intimidates me because it is broad; even with all of the technology available now, general medicine requires you to be a walking differential diagnosis machine. That is not a skill with which I feel comfortable yet.

I really don't know where things will go. And I know it is still a few years away, but it affects decisions now. How do I spend my elective time? With whom do I need to develop a professional connection?

I don't really get a choice about how I spend my time intern year. I took the only choice I had; I elected to change my schedule around by joining a pathway in the program that allows for more outpatient clinic. I am hoping that turns out to be the right decision. Even if I don't do general medicine, becoming a better outpatient provider will be a useful skill for any future path.

I don't know yet how I will determine whether all of the sacrifices I have made are "worth it." And I don't know how long I will have on this earth to figure it out. But for now, I just have to keep surviving for my own sanity, and I have to sneak in as much time with the people I care about as I can. Everything else is outside of my control.