Space

I just started my third week of a Psychiatric rotation down in Bend OR, which for those of you not from around here, it's about three hours southeast of Portland, which has great significance in terms of the weather. Bend is east of the Cascade range of dormant volcanoes, which means that it doesn't rain nearly as much as it does on the west side of the Cascades, and more importantly for me, the SUN is out every day!!!

The first week of the rotation was rough, because the hours were so normal (8-5) and the people here so damn nice. Rough? Yes that's right; my adrenals were in such overdrive after 5 weeks of surgery that I felt an uncontrollable urge to work more and longer and harder than was expected. One day during the first week, the manager of the inpatient treatment center I'm working at saw me at my computer at 5:30 pm and asked with incredulous eyes, "What are you still doing here?" I thought that maybe I was on a different planet, or that maybe it was really midnight and not just 5:30pm! It turns out I am surrounded all day by social workers who clock in and out, never staying beyond their eight hour shift, and to them, it was unusual to see a "doctor" there late. One of the benefits of becoming a psychiatrist - the hours are such that you can actually have a life outside of work.

The truth is that I didn't know what to do with myself after leaving work, coming home to a cute little apartment I am living at right next to the hospital. Sure I would make dinner, clean up, listen to an online lecture, study for a bit, but then there would still be HOURS left before it was time to go to bed. And there was no rush to get to bed early, since my alarm wasn't going off at 4:30am anymore, and I could get up at 7 am, and still have time to dress, eat, and walk across the street to the hospital. I was quite neurotic that first week, and only now am relearning how to fill my "free" time. I've been doing yoga, walking/running, hiking, and even picked up a novel, which I have not done in I can't remember how long. I also have a lot of extra time since my family is in Portland during the week, and only come down to visit me on the weekends.

Now that I am more comfortable with the new "normal" schedule of work, I am faced with all the thoughts and feelings that come with working with a mentally ill population. This has been a frightening experience at times, a humbling one, and definitely an emotional one. I still have yet to master not letting my eyes tear up as a patient is pouring out their pain. And there is so much pain in psychiatry, as there is in all medicine, but this seems different to me somehow. Maybe it's just because I have to be open enough with my patients to really care about their well-being, but not so open that I feel their pain. It comes back to boundaries, and I just haven't learned how to do my job as a medical student, to listen to these painful stories, and not take in or take home the depression, anxiety, hopelessness, or even craziness.

Maybe it's also because in some ways I empathize with the patients; I can imagine their experiences, based on my own mental health history. I have never been sick enough to need inpatient care, but I know what depression feels like, what anxiety feels like, what it feels like to not want to be alive. It's been a long time since I've felt these things, but talking to these patients is a reminder to me of where I have come from, as well as a humbling realization that I never really had it that bad. Not even close.

I connect much less with the psychotic patients (thankfully I've never experienced hallucinations, delusions, or paranoid thinking), to the point that they scare me a little bit. I've had patients who believe many bizarre things like aliens operating on them in the daytime and nighttime, or a big machine with wires connecting to the palms, trying to upload a new consciousness, or even a clan of white robed people on roller skates living in a patient's house. There has also been a few manic patients who are really really intense, with no personal boundaries, and they get right up into your face, either talking nonstop, or just staring really intensely. I have to break eye contact with these patients because the intensity is so uncomfortable for me.

I try to be open minded, to see them through the light of someone who is severely mentally ill, but the truth is I have the same internal reaction that anyone else on the street would have - a feeling like there is definitely something wrong with this person, followed by a strong desire to get away. And then you throw in a patient who is both psychotic and angry, and I swear it takes everything I have to not turn and run. The seasoned psychiatrists tell me to make sure they do not sense your fear, because they feed off of it, and I'm thinking, How the hell do I do that?

Maybe it comes back once again to the whole boundary thing. If I have stronger boundaries maybe I won't get emotional when a patient cries, or feel heart ache when someone shares their pain, or feel scared when a patient gets intense or angry. But what if the process of forming these strong boundaries closes me off so much that I can no longer connect with the patient? That is my fear, and why I would not choose psychiatry as a speciality, because I do not want to see what would happen if I started to close myself off that way.

I've watched 4 psychiatric doctors here practice their skill, and I see each of them interacting with the patients in different ways. 3 of them I believe have perfected the art of having good boundaries; they come in, do their job, prescribe the medications that will hopefully change the person's brain chemistry in such a way so that they can make the changes necessary to lead more productive and successful lives. I know that they care, but I don't feel that they do, and I wonder what the patient thinks and feels.

There is one doctor that is incredibly gifted; he still has an open heart, and fortunately for me, I have worked almost exclusively with him. He gets his job done efficiently, and has appropriate boundaries with his patients, while at the same time, exudes a kind and sincere compassion. He sees them not simply as a diagnosis, but a living, breathing, suffering human being, that needs not only medications, but validation for their suffering. How he does this without his own heart breaking is something I keep wondering about; he clearly has found the right path for him and seems perfectly suited to this profession. I can only hope that I too will come across the perfect match for myself, one where I will not have to worry so much about keeping space between me and my patients.

Adaptation

So I finally got through surgery, but not before having to learn to adapt to the tension riddled environment that clouds a surgical rotation. And given the feedback from my classmates that have had other surgical rotations, not at the VA with different residents and attendings, my experience doesn't seem to be unique. It was like being thrown into white water rapids without a life jacket, and I used my meager swimming skills to get around the huge rocks and avoid being pulled under.

Part of that adaptation came in the form of me just shutting my mouth. Don't ask too many questions, for several reasons: 1. because one of the attendings already said on the first day how frustrated he gets when med students ask him questions that can easily be looked up (OK, nowadays EVERYTHING can be "looked" up, which meant that when I was around him, I never asked any questions and he probably thought I was mute) 2. because one of the residents encouraged questions, but if you didn't know the answer then he told you to go home, look up the answer, and report back the answer the following day. Unless I wanted to go home and use up of some of my precious hours for studying rather than say, taking care of my bodily needs like eating or sleeping, I quickly decided to act like I already knew it all, and asked no questions.

I also learned by watching another student suffer (hey, I may as well use every survival mechanism possible right?). In this case I learned how to do more than just look up the specific answer to a question asked by a chief resident. Through watching another's punishment I quickly learned to think ahead and also gather any information about things closely related to the question asked, so that I could readily have the next question answered as well. A fellow student was asked one day while presenting her patient by the bedside, why it was important to know EXACTLY how much fluid was produced from a patient's NG tube (stands for naso-gastric - a tube put down the nose, esophagus and into the stomach, in order to suck out any excess fluid, in the cases of a bowel obstruction. The stomach has to be "decompressed" before the patient blows a hole in their bowels). Anyhow, after the student told the resident why knowing the amounts evacuated from the NG were important, she was then asked how much fluid the stomach produced on a daily basis. She did not know, and so was sent home to come back with the answer.

The whole time I was having my own flight or flight response, (increased heart rate, breathing, and sweating through that useless anti-perspirant I put on at 4:30 am), wondering how would I answer this question? 2 liters I thought, just say 2 liters, with no idea where this number came from my mind, whether it was an actual remembrance of a number memorized while learning this sometime in the last two years, or whether it was just a shot in the dark. This blurting out of some answer was something I frequently did with these residents. I always thought it was better to say something, and make it look like I was actually capable of thought, while others recommend never guessing, and just saying you don't know when you don't. My ego would have none of that; I would rather guess wrong than say I don't know, just another of my flaws.

Unfortunately for my classmate, she did not think ahead to the next logical question that would come after knowing how much fluid the stomach produces daily. The next day, while rounding on the same patient, the resident asked my classmate how much the stomach produces, to which she confidently replied, 2 liters. (Hey I would have guessed right, I must be really smart my ego thought, or just randomly lucky, my alter-ego replied). She was then asked, well, how about the biliary system? (that's your liver which produces bile), to which she painfully had to admit once again (cringe, cringe) that she did not know, and she was sent home for more research. The next day she returned with a list of all parts of the gastrointestional system and the amount of fluid each part produces (a total of 9 liters per day!), and to my chagrin was then challenged regarding the exact amounts (the resident would think it was 1.5 liters versus 2 liters), and was belittled for wherever she got her numbers from. Aaaaarrrrgh! Take home lesions: 1. Be more than prepared 2. Be prepared to never be right 3. Be prepared to feel stupid no matter what.

This never being right occured once while on call and participating in a day surgery over at OHSU. The first thing that was working against me (which of course I had no control over) was the fact that I had been working at the VA, and had not gotten to know or work with any of the residents or attendings over at OHSU. The second thing is that I had never even been in the operating rooms over at the OHSU, and like every different place that you work, everything is different in terms of where things are located. It was like the first day of surgery all over again. Not knowing where the patient was prior to the surgery; (it's imperative that you meet the patient prior to them being put asleep by the anesthesiologist). Depending on the reasons for the surgery, the patient could be found up on the floor where they had been located during their inpatient stay, or down in the pre-op area (which I had no idea where it was at OHSU), or in some special area where patients come for pre-op same day surgery. Luckily for me, I found the patient right off the elevator while going to the floor where I was told the OR was located.

Thank the gods I thought, I can visit and introduce myself to the patient. One test I knew I would pass when inevitably asked by the attending whether or not I had met the patient. This may sound trivial to you, but the ability to find a patient's location in the hospital is not as easy as you think. I can't tell you how many times I headed off to the pre-op area to meet a patient, was told by a nurse "they were just moved to the OR", and I would scramble to try and get there before the attending did, so that I could do the appropriate introduction. Now this is not a trivial matter. Of course you need to meet your surgeon prior to him or her cutting you open; but how important is it to meet the third year medical student who is scrambling around trying to act important, but is actually totally insignificant in the operating room? Will you remember the name of the medical student who told you they were going to watch your surgery? Of course not, but again this was one of the insane expectations of the surgical rotation which I think is meant to set you off balance. (an it worked)

But balanced I would be for this surgery, because I MET the patient, and got her story, without spending hours reading all of her past medial records in the computer (OK computers are not really my friends; I use them because I have to, but if truth be told, I fight them, and long for the days of simple pen and paper - a true English literature and writer's confession). So I go with the patient into the OR, feeling all smug, only to be quickly shut down during the surgery by the attending. First, let me tell you what it's like to be standing next to 4 other human beings and to be completely ignored. It makes you feel crazy, but in a surgical rotation you just learn to live with it. You expect to be treated like you are invisible and don't exist. You are merely there to watch, learn, and listen to those that are oh so much smarter than you, even the surgical scrub nurses, who bitch at you for not wiping your hands correctly. It's so ironic to me to be upset for being ignored, AND to also wish to be ignored, so that you aren't berated or pimped to the point of feeling stupid.

So there I am just counting down the minutes, looking so forward to the end of the surgery, when the attending decides he needs to give me a lesson in how to use scissors. So I allow him to teach me how to correctly cut the sutures (after the chief resident has tied the knot, I come in and cut them). Not a very difficult thing to do, but obviously I could use some help with cutting, so I accepted the advice of the surgeon (thank you, you arrogant ass I'm thinking). A few minutes later, during which time the the surgeon is talking to the scrub nurse (she's in the club too, also ignoring me) about the prices of condos in the Pearl district, he decides to teach me an even more important skill - how to hold the scissors in the palm of my hand. I guess I'm just acting way too eager with the scissors all ready to cut the next suture, and I need to non-chalantly rotate the scissors around my index finger, lay them in my palm, so that I can (his words) do "something else" with my hands! I wanted to laugh out loud! Like they are going to let me do something else other than hold the suction device! Of course I accept this advice with total humbleness, and continue counting down the minutes that I have to suffer this man.

A few moments later, the chief resident grabs the scissors out of my hand (she has also obviously decided I don't know how to cut sutures adequately), and cuts the suture. Of course the attending has turned to laugh and make some joke to the scrub nurse again, while the resident sets the scissors down in front of me. At this exact time, the attending turns back to the surgery (how annoying the surgery is interrupting his most important discussion of the real estate market, and the cute little condo he just bought his spoiled daughter), and he sees the scissors down and NOT in my hand. Strike number three - I am told in a stern voice that I need to HOLD the scissors, to be ready to cut the next suture. I think I mumbled something about the chief resident using them, but it didn't really matter what defense I may have made on my own behalf, or even if the damn resident had stuck up for me. In their minds, I was just the useless and stupid med student.

When I walked out of that surgery I told myself that I wouldn't do surgery with this group of people ever again no matter what. And sure enough, the next and last time I was on call, I told the residents that I would answer the trauma pager, and go to the ER when patients came in, but that I wasn't going to go to surgery that night. It's my education right? I'm paying the $50 K per year, I know that I can learn a hell of a lot more about surgery sitting in my call room, rather then scrubbing into another humiliating surgery. I can't believe that as students we either have to 1, put up with it or 2, participate in it, in order to be accepted into the clan. I saw that happening with my classmates, the ones that hope to go into surgery. They made excuses for their residents, attendings, and their atrocious behavior, saying things like, "they are really stressed out and tired." They bragged of 8 hour surgeries, and nights without sleep. They seemed to love, or at least, become adapted to the abuse. Not me. No way. Yes, I will adapt in order to survive the ordeals and trials of medical school, but I swear I won't let it destroy my humanity, or the basic standards of kind treatment of other people. If I loose that, then I will truly loose myself.