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Okay, so this isn’t a blood draw needle, but you get the idea.

I’m thinking of creating a version of the Who Said It game called “Medical Students or Burgeoning Serial Killers?” Here are some approximate quotes I’ve collected over the past several months.

  1. “I’ll just keep all of the blood vials in this basket here until I can figure out how to dispose of them.”
  2. “Skinning a human cadaver is harder than I expected.”
  3. “We should get some pig’s feet to practice on. It’s more like human flesh.”
  4. “He gets all the supplies by telling the clinic staff we’re planning to practice blood draws.”

Okay, since I don’t actually know any serial killers in training (I hope),  the game is pretty one-sided for now.

For a bit more context (lest you think perhaps a quick call to the FBI might be in order), this week marked our foray into cadaver dissection, and also the third so-called phlebotomy party.

The phlebotomy parties came about around Thanksgiving after a primary care conference where students were able to practice skills like suturing and blood draws. I wasn’t there, but from what I heard, many of the blood draws were not terribly successful.

I don’t know about my fellow students, but practical skills in medicine make me nervous. I know that I can memorize pages of information and answer multiple choice questions with reasonable accuracy, but none of that guarantees I will be any good at basic medical skills like lumbar punctures or taking blood pressures. The latter I can practice whenever, at least. Mostly of my family and friends have been subjected to me brandishing my stethoscope and sphygmomanometer. But the stuff involving needles? At best you might get to practice them on a dummy, which is really not going to prepare you for a terrified patient, angry at being used as a training tool.

Blood draws, at least, are fairly straightforward. So with a few donations from a local clinic, one of my small-group classmates with some phlebotomy training gathered together everything we might need and had six of us over for dinner and bloodletting. After all, if you’re going to mess up poking someone with a needle, it might as well be someone who is planning to stick you right back.

The first stick is, in a word, terrifying. There was this moment before I slid the needle in that I was thinking to myself, “I can’t do this. How could I ever think that I could do this?” Then bam, a minute later I was triumphantly holding a full vial of blood, my heart pounding in my chest and a general feeling of “Holy crap, I can’t believe I just did that.” Then I turned around and offered my own arm up for some first-time needle sticking.

Our first session was such a success that the host has had two more since. They are well-attended and it is a relief to watch everyone go through the same spectrum of emotions each time: terror, followed by determination, and then elation at their eventual success. We can do this! It’s for real.

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Uh…now what do we do with it?

A friend of mine pointed out that as physicians we probably won’t be taking a lot of blood. That is more the purview of nurses and techs, even if we will eventually learn the skill. Still, it is a relief just to know that I can handle the basics. For the first time I was able get past the literal barrier of the skin, into the parts of a living person that we generally never see. I don’t expect this will make me less terrified or apologetic when I finally do have to practice on a stranger for the first time. But at least now I don’t have to wonder if I am even capable.

And, even if it’s only the barest of comforts, at least I can say, “I’m new to this, but I’ve done it successfully a few times before.”

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Well I’m down to the wire with two schools still in the running and one big decision to make. Where am I going to medical school next year?

The truth is I’ve decided to take the easy way out and let the money decide. Before too long I will know what my financial aid packages will look like and how much debt I can expect to be in when I graduate (read, a whole, stinking lot) and whichever number is slightly less terror-inducing will be my school of choice.

For students with slightly more discerning tastes, however, there is Second Look.

source: PSD Detail

Second Look is a chance for prospective med students to return to whichever schools have accepted them and have a, you guessed it, second look around. It’s a more casual setting than the interview and the pressure to impress is mostly gone. Now it’s the school’s turn to make a pitch (not that they weren’t doing that during the interview, but the utter terror of the day can make it hard to pay attention.)

Really what Second Look ended up being was two days of meeting many many new people and not remembering a single name.

The first evening was a reception. We entered the front room of the medical education building to find it crammed with acceptees and current students. Everyone was already sectioned off into little groups surrounding a center table with snacks and water. It was hot in the room and there was little room to maneuver. If I hadn’t had a fellow postbac buddy I probably would have turned right around and left. (Small talk is not my forte.)

Eventually we migrated to larger room and sat at large round tables that might someday be our classroom. At one point the medical school acapella group (no, I didn’t know medical schools had acapella groups either) came out and sang a few songs. There was no real end the evening; we just chatted with the folks at our table until, bit by bit, the people in the room drifted off in search of a real dinner.

The second day was a bit more organized. For one thing we had name tags this time around, which made it a lot easier to keep track of who I had already met. They also had their pitch ready to go; we sat through two panels and a classroom simulation about handling a disaster situation.

In the midst of the second panel, one of the fourth year girls described all of the amazing experiences she’d had during her rotations and I had a moment where I felt almost disembodied from my experience. This has happened to me a number of times during the past two years when it really hits me all of a sudden that I am doing this…I am going to medical school. How utterly strange. How crazy I would have thought anyone who might have claimed that this would be my future. Whether I attended the school in question, or my other possible choice, I was really, truly going to be a doctor someday.

So in some sense Second Look didn’t quite achieve its purpose. I have no clearer idea of where I want to be for the next four years, despite loving everything I heard about the school. But after nine months of feeling like I’m stuck in between steps, I’m starting to feel like maybe the race is on again. I can’t wait until August.

Here is a funny video our director sent out to us. It was made by a postbac student from another program and I think it pretty accurately depicts my life as of right now.

The current stats are as follows:

I have been invited to a total of seven interviews.

I have interviewed at six of those schools.

I have been told by one school that they do not yet know if they would like to interview me.

I have heard back from four of the schools where I have interviewed. Two are acceptances. One is “continued,” which means that they will continue to discuss me as the admissions cycle moves along. One school has me on their wait list.

My top choice is the school that continued me, which means I am in limbo for the next several months. It’s an active limbo; I can send them any information to help make my case, but that is a mixed blessing as I had planned to continue my glide year doing what I have been doing thus far. I have a slight plan of attack, but it may come down to the wire.

I sent off my last thank you letter today. It is possible that I may hear from other schools for interviews, but I am a bit worn out by the process by now. One of my acceptances was at one of my top choices, so I can afford to be selective from now on.

Which leads me to my final point in which hold @$#% I got into medical school? I got into TWO medical schools! I got into two GOOD medical schools! I. Am. Going. To. Be. A. DOCTOR!

So yes, I am waiting. And yes, I still don’t know exactly where I’m going to be come September. But I do know that I am going to medical school and right now that’s enough.

I’ve started working as an instructor at the massage school in town. It’s a position I held before starting the postbac, so although I’m in a new setting a lot of the details are the same. Meeting new people, especially in a setting so oriented around a specific career I am not a part of anymore, I’ve been explaining my story quite a bit lately.

Last week I was gathering my stuff up to go home when one of the TAs, a woman in her 40s or 50s, turned to me and said, seemingly out of nowhere, “I am so excited about your path in life.”

For a moment I was startled. “I…you mean medicine?” I asked.

“Yes! Sorry, that was unrelated. I hardly know you. But it just seems so exciting!”

I broke out into a smile. “Thank you,” I said. “I’m really excited too!”

She went on to tell me that medicine was something she might have liked to do, but that it really was too late for her now. She said this matter-of-fact, without self-pity or jealousy. It was just exciting to her, it seemed, to watch someone pursue their dream.

I love these little moments that remind me how lucky I am to be doing what I am doing. It is stressful, and nerve wracking, and right now incredibly boring. But I am pursuing my dream, and that isn’t something everyone has the luxury of doing. It is also something I nearly talked myself out of doing because it wasn’t practical.

I’ve been feeling off kilter recently because I’m in limbo. I’m not in school, but I am also not done with anything. That TA’s little burst of excitement reminded me that even though I might feel stuck right now, there is still plenty to be excited about.

I have always enjoyed looking at the world through the writer’s eye; seeing the story that exists behind the framework of daily life. This article, which comes via a friend in publishing, finds similarities between Grimm’s Fairytales and the patients seen in the hospital. The author comments on how medical training seldom provides insight into the context of an individual’s ailments. She is left with these haunting images and the questions they provoke. And yet my sense is that, simply by viewing these patients through the lens of a storyteller, she is probably gaining a greater insight into their illness than the physicians who don’t bother to wonder. If nothing else, she is likely more invested in her patients if she can invent a narrative for their lives; a way to pick out individuals amid the blur of cases that crowd into a day’s work.

It’s probably not the sort of thing one says in polite company, but I really like doing dissections in biology lab. It brings out the little kid in me, that part that loves to take things apart and see how they work, that finds the squishy insides of the animal to be both totally gross and totally fascinating at the same time.

The first dissection I did was in high school freshman biology. We studied frog anatomy, and the day before the dissection we were charged with observing “external characteristics.” This basically meant that right before we sliced into our specimens, we were given an entire lab period to bond with our frogs. One of my friends couldn’t take it and spirited her frog away by stashing it in the front pocket of her backpack. We released him into the creek behind the school; I have no idea if the environment there was at all suitable.

I expected to have a real problem with the actual dissection. It just didn’t seem like something I should enjoy. The frogs had their brains (literally) scrambled beforehand, meaning that their hearts were still beating when we opened them up. My group was made up of two other girls, both very tentative about the whole process, so I ended up taking charge somewhat against my will. I remember cutting my frog open very carefully and watching his heart beat inside of his spread rib cage. I was amazed. I knew that hearts beat, but I had never envisioned how violent it was; this ball of muscle twisting and writhing just behind a few layers of muscle and bone.

Since then I’ve always claimed to love dissections, and couldn’t wait to start cutting. We worked our way up slowly; first an earthworm, then a crayfish and an enormous cricket, then a squid and a clam. Of course the day we started on the fetal pig, which I had been looking forward to since we first went over the syllabus, I was in the midst of my aforementioned plague and spent most of the lab feeling nauseous from the stench of formaldehyde and trying not to cough on our specimen. It probably didn’t help that we were looking at the digestive system, which, even in a fetal pig, involves a lot of organs filled with fluids you would rather not contemplate too closely.

This week we tackled the circulatory and respiratory systems. Having moved out of the gunkier areas of the body and feeling more energetic, I recalled why I loved dissections so much. The heart lay in the center of the pig’s chest, shiny and strong; not beating in this case, but impressive nonetheless. The lungs weren’t fully formed, but it was easy to  see each individual lobe as it curled almost protectively around the heart. Ironically one of the things that gave me the biggest thrill was pulling back the connective tissue around the trachea and larynx; I was stupidly suprised to find that they looked just like the pictures.

Looking inside a living organism, particularly one as similar to humans as a fetal pig, feels special to me. I always imagine that pictures and diagrams are simplistic; a rough estimate representing a non-existent every-man. It surprises me to realize that it all actually looks like that when you get inside. The liver really is smooth and rounded, the aorta really does loop up over the top of the heart, the trachea really does look like rings stacked on top of one another. It’s a cliche, but inside we really aren’t so different after all.

We have one more biology lab before we’re done (I think a sheep’s brain might be involved). I’m not going to miss it exactly, but I will say that I’m not dreading cadaver lab in med school one bit.

A cheerful start to spring break would be a little obvious, don’t you think? Instead, here is an article by Atul Gawande about hospice care:  http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande#ixzz1FvNCGNpM

The article is long, so here are a few excerpts that stood out to me. First on the role of hospice and the distinction between prolonging versus improving a person’s life:

“The difference between standard medical care and hospice is not the difference between treating and doing nothing, she explained. The difference was in your priorities. In ordinary medicine, the goal is to extend life. We’ll sacrifice the quality of your existence now—by performing surgery, providing chemotherapy, putting you in intensive care—for the chance of gaining time later. Hospice deploys nurses, doctors, and social workers to help people with a fatal illness have the fullest possible lives right now. That means focussing on objectives like freedom from pain and discomfort, or maintaining mental awareness for as long as possible, or getting out with family once in a while. Hospice and palliative-care specialists aren’t much concerned about whether that makes people’s lives longer or shorter.”

This second excerpt is about Stephen Jay Gould, who was diagnosed with abdominal mesothelioma, which statistically has a survival rate of about eight months:

“Gould was a naturalist, and more inclined to notice the variation around the curve’s middle point than the middle point itself. What the naturalist saw was remarkable variation. The patients were not clustered around the median survival but, instead, fanned out in both directions. Moreover, the curve was skewed to the right, with a long tail, however slender, of patients who lived many years longer than the eight-month median. This is where he found solace. He could imagine himself surviving far out in that long tail. And he did. Following surgery and experimental chemotherapy, he lived twenty more years before dying, in 2002, at the age of sixty, from a lung cancer that was unrelated to his original disease.

“I think of Gould and his essay every time I have a patient with a terminal illness. There is almost always a long tail of possibility, however thin. What’s wrong with looking for it? Nothing, it seems to me, unless it means we have failed to prepare for the outcome that’s vastly more probable. The trouble is that we’ve built our medical system and culture around the long tail. We’ve created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets—and have only the rudiments of a system to prepare patients for the near-certainty that those tickets will not win. Hope is not a plan, but hope is our plan.”

And finally, how medical science makes it impossible to give up hope completely, even when the outcome is all but assured:

“We imagine that we can wait until the doctors tell us that there is nothing more they can do. But rarely is there nothing more that doctors can do. They can give toxic drugs of unknown efficacy, operate to try to remove part of the tumor, put in a feeding tube if a person can’t eat: there’s always something. We want these choices. We don’t want anyone—certainly not bureaucrats or the marketplace—to limit them. But that doesn’t mean we are eager to make the choices ourselves. Instead, most often, we make no choice at all. We fall back on the default, and the default is: Do Something. Is there any way out of this?”

The overall message is that talking about death is difficult, but the skirting the issue only makes it harder in the end. Patients look to their doctors to guide them through the process of staying alive, not to help them come to terms with death. Meanwhile the doctors themselves are only human and they hardly want to be the bearers of bad news. Gawande describes getting caught up in the optimism of his patients, of questioning whether he has any right to destroy their tentative hold on hope . It’s easier to give in to that sense of possibility; the idea that this patient is the one holding the winning lottery ticket. It’s much harder to reach past that optimism and change the conversation from, “What do I do next?” to “Where do we draw the line?”

I take this article as a warning. Away from the immediacy of such a confrontation, I like to think that I would take a sympathetic but practical approach to talking about death. The trouble is, death is not practical and neither are the emotions that go along with it. The situation Gawande describes is all too familiar; that desire to turn away from an uncomfortable topic toward a more agreeable fiction. I could easily see myself unwittingly embracing the false hope of a patient determined to fight to their very last breath. It’s the stuff of great stories and no one wants to play the part of the doctor who gave up before the fight was over.

In the end, though, it is the doctor who needs to be the one who doesn’t succumb to the convenient fiction. Hope is a good thing in medicine, but false hope will make the reality that much more difficult to bear. I hope that by anticipating the difficulty I will face when talking about death, I can prepare myself not to shy away.

A year ago I was a few days past my interview with the postbac program I eventually decided to attend. I was working two jobs; one as a massage therapist in a wellness center, the other teaching anatomy and physiology at a massage school. I had been volunteering at a trauma center for about three weeks and was nervously eager to continue. I was half excited, half skeptical about my future and what the upcoming year would bring.

A year from now I will have finished the postbac program, taken the MCAT, completed two rounds of medical school applications and likely many interviews. I may have been accepted to a few places. I may even know where I’m going to be next year. I will have a glide year job or two that I will be expecting to leave come fall.

Instead of making new year’s resolutions, I’ve decided to limit my sights to the end of the postbac year. Most of my resolutions beyond that would be a foregone conclusion; get into med school, don’t screw up the MCAT etc. Right now my mind is still trying to wrap itself around part three of medical boot camp; so I’m keeping my resolutions small and short sighted. Incidentally, a disproportionate amount seem to involve food.

The Resolutions

  1. Stop complaining so much about physics
  2. Cook something each weekend that can be consumed throughout the next week
  3. Update the blog at least once a week.
  4. Find the perfect portable sandwich to bring to school. Or better yet, discover a few different options so I don’t end up completely sick of it by week three.
  5. Stop complaining so much about physics.

I anticipate having the most problems with resolutions one and five. I trust you, my beloved readers, to keep me on track if the ranting gets out of control.

Here’s to a happy  and healthy (but not too healthy) New Year to everyone!

We had a speaker come in and talk to the postbacs last Wednesday, and for the first time since I started this program a doctor stood before me and said in no uncertain terms that we were all in for a fantastic ride. I hadn’t realized until that moment how much I was missing exactly that statement.

There are a few major reactions I get when I explain to people what I’m doing. Usually the first reaction is surprise; especially people who have known me for awhile give me a look that says, “You? Really? But why?” They quickly get with the program, though,  and enthusiasm abounds. I’m good at selling my story at this point; the journey from English major and writer to aspiring physician. It all sounds wonderfully adventurous, and the reality of years of schooling, debt and lack of sleep can be ignored for the glamour we’re shown on shows like Grey’s Anatomy and House

Next the conversation drifts toward the many controversies in medicine; the high rate of infection in hospitals, health insurance and the health care bill, that one doctor who did that really unethical thing that was in the paper the other day. I draw on my limited knowledge of medical politics and become the informal representative of the doctors perspective. We talk about the problems in the medicine today, we talk about the futility of finding permanent solutions. In my head I vow to do better someday, but deep down I wonder if that will be possible.

One of the fellows I worked with when I was shadowing listened to the tale of the postbac program and nodded thoughtfully at me. “That sounds good,” he said, “You still have time to change your mind.”

It wasn’t the first such statement I had received from various attendings, residents and medical students at the hospital, but it brought me up short.

“I don’t think I will,” I answered slowly. “The longer I’m in the program the more I’m sure this is what I want to do.”

He looked skeptical but said, “No of course not. It’s a wonderful profession,” as though he didn’t really believe himself.

The comment was unsettling, but it wasn’t until another postbac showed up bubbling with excitement over a meeting with an MD/MPH that I realized how much the consistent negativity was getting to me. “This woman,” she exclaimed, “She loved her job. I haven’t met any doctors who seem to love what they’re doing.”

I opened my mouth, ready to protest, but found that I couldn’t. The statement wasn’t entirely accurate; I’d met many doctors who seemed quite happy with their choice of careers and who have been supportive of my own efforts in that direction. But I also could not point to a single example of a physician who had bubbled over with excitement the way my friend was describing. How frustrating, I thought. I’m still so sure this is what I want to do with my life, but everyone around me seems to be supporting me more out of habit than out of a genuine excitement for the journey.

It was, therefore, perfect timing when this particular speaker came to talk to us that afternoon.

He sat at the front of our classroom with a smile on his face and said, “You will love this profession; you will have so much fun provided one thing: that you want to do the things that doctors do.”

He went on: “Medical school will be so much fun. It will be like going to Hogwarts; you’ll get to do potions, you’ll look inside people’s bodies. You will do magic. You will get to help people, which is the greatest gift of all. There is nothing more rewarding than when a patient gives you a hug or thanks you for helping them.”

I could write ten blog entries on different tidbits of wisdom I picked up over the course of that talk. “Start thinking about why you’re doing something before you start thing about how to do something.” “There is great value in learning something you didn’t know you wanted to know; there is great value in a lack of specificity.” “Learn to follow every statement with the word ‘because.’ ‘I think the patient has pneumonia instead of a blood clot because….’”

And yet it was that first declaration that I think I needed to hear more than anything else. Yes, I thought, That’s me. I want to do the things that doctors do! More importantly, I want to be excited to do the things that doctors do.

I’ve found very few people who passionately love their jobs in a way that is palpable, and many of the people who do have jobs that hold little interest for me. I don’t expect every doctor I meet to brim with excitement at the prospect of another day on the job, just as I doubt I will ever be a shining example of optimism in the face of difficulty. (Well, maybe on paper sometimes. I hope.) I refuse to take any of it as a sign that I’m on the wrong track. But it was a relief to finally hear someone stand up and say, “You’re in for a hell of a ride, and it is going to be AWESOME.”

There are a couple of students in my program who are considering PA (physician assistant) school instead of medical school. For anyone interested in primary care and, oh I don’t know, having a life outside of work this is a pretty practical option. The requirements to get into school are slightly different (no physics, for example, which right now sounds like a magical possibility where candy grows on trees and unicorns carry your books to class for you) and, unlike the physician path, the time/money commitment is not as intense. All in all I see the appeal.

Yet for some reason the option of PA school makes me profoundly uncomfortable. I think this is because it’s forcing me to confront the reasons why I’m not choosing to go that route.

I’m an intensely logical person. I’d like to think that is a good trait in someone planning to be a doctor, yet somehow I keep coming back to the unsettling fact that becoming a doctor is not a logical process. The system is archaic; there’s been little change to medical school and residency structure since medical schools first became standardized. The time commitment for training is unreal; even if I condensed all of my future schooling into the shortest time period possible I won’t be a practicing physician until I’m thirty-two. Not to mention the financial commitment is extremely long term and I can probably expect to be paying off student loans most of my foreseeable future.

Why then, I keep asking myself, would any logical person put themselves through all of this when there are dozens of other health service positions that require less time, effort and money?

In an earlier post I mentioned that in biology, the function of most molecules follows from their structure. If you look at the structure of the medical training system, it’s not hard to see why we have a dearth of primary care physicians. It’s not that the interest isn’t there; I think the problem has far more to do with cost benefit analysis. When you sit down and weigh your pros and cons, I imagine a lot of students wonder if maybe they wouldn’t like time to have family someday or start earning a decent living before they hit thirty. I can’t blame them.

So once again I ask myself, why am I not going that route? And uncomfortably I have to answer that some of it just comes down to pride. For a long time I didn’t believe myself capable of being a doctor; medical school was something that really smart people did, not people like me. Even now that I’ve had a taste, there’s a little part of me that just doesn’t believe I could ever be worthy of the Dr. title and I desperately want to prove that part of me wrong.

Is that a good enough reason to eschew the practical path and to subject myself to a second glorious semester of physics problems and MCAT prep? Well, on its own, no, probably not. I do want to help people, and I do crave knowledge for knowledge’s sake. And for all that the prospect of facing a semester and a half of bewildering physics equations fills me with a very special kind of dread, I welcome the thought of immersing myself in the practice of medicine in the coming years. I never want to look back and wonder if maybe I could have done it.

Perhaps addressing my own doubts, naming them as an old psychology professor used to say, is a good thing. No, I’m not going to go to PA or nursing school, and not because I think it’s an impractical choice. Rather, it’s a little too practical for me right now. Just because I’ve put my dreams of living big as the next great American novelist on hold doesn’t mean I’ve stopped dreaming. And if that dream involves a long white coat and more student loans than any sane person should accumulate, then it’s worth it. Logical or not.