Days 179-180: Existential Crisis

I am so close to the halfway mark for my hospice and palliative medicine fellowship, and have finally reached the point of breakdown.  I've had one about every year of training since the beginning of medical school.  For the most part, I've dealt with it on my own.  As I think I've blogged about before, one of the biggest hurdles many people in the medical field combat is themselves.  Especially in higher training, we all feel like we aren't good enough for what we do.  We feel like we've conned our way into the position we are in.  Sometimes, that burden if doubt is enough to completely stop us in our tracks.  We lost faith in our abilities, and we quit.  Sometimes life-changing quits (changing career) and sometimes catastrophic quits (suicide).  While, I've never reached serious contemplation of leaving my career or life, I still have self-doubts.  Inevitably, there is a point in my training where I feel like I cannot keep up with what I'm supposed to be capable of doing.  During geriatric fellowship, the break occurred in September when I lost faith in my ability to be a good clinician due to severe issues with efficiency and timeliness in clinic.  I sat in my fellowship director's office and cried.  Then she told me that she had been in the same place I was when she started on faculty and wanted to work with me to make sure when I graduated, I would be able to managed my efficiency without issue.

This year, went beyond the typical self-doubt and impostor syndrome.  A great part of hospice and palliative medicine is sitting with people who are at the end of their life.  They go through the process of determining the impact they had during their lifetime.  They try to find meaning in their life and in their death.  While yesterday evening's sob fest seemed to come out of nowhere, a clear mind notes that the breakdown was inevitable with the weight of this career choice.  I went from thinking I was only a fraud in my career to a full on review of my life.  I couldn't understand what I had done to deserve the loving and supportive family that I have or why I was gifted with the care for three cats and a dog.  I didn't feel like I was worthy of a man who cares more deeply for me than himself.  His care showed yesterday in his sixth sense that there was something more going on than just my usual frustration.  He sat silently with me while I folded laundry, knowing that I would eventually breakdown into tears, need him to hold me, and then have him listen as I rambled on about how there was no logical reason for why anyone in my life should care for me.  He listened to me cry about how I didn't do anything to deserve the life I have.  How I couldn't comprehend why I have what I have.  I went through a life review, trying to find meaning to how I'd ended up at this point.  I'm about the get married and start my career within three months of each other.  Right now, I still feel daunted by the tasks ahead.  I'm looking forward to when I can get excited again.

Days 175-178: Bedside Manner

Tuesday through Thursday at hospice were busy but fruitful.  One of the admissions I did was of a patient I did a consult on while moonlighting on the palliative care service at one of the local hospitals.  I had a family meeting with the patient and about 15 family members.  At the end of it, I was convinced there was no way she would end up going with hospice.  And then two days later, she enrolled in hospice.  And six months later, she ended up in the hospice facility due to severe shortness of breath.  I was very thankful to be able to help with her comfort this time around, more so than the last time I saw her.  It was really sad, though, to find out how much she had been struggling at home prior to admission.  I can understand how hard it is for a family to lose their loved one, but I would never purposefully put someone I love through suffering for my benefit.

At the end of the day Thursday, I went to check on all my patients before leaving since I won't be back until the end of February.  I was talking with one of my patient's family member's who was struggling with the need to go back and finish up work at home instead of staying with the patient.  We talked about this guilt, and how everyone understands that life doesn't stop simply because a loved one was admitted to hospice.  That the best anyone can do is make sure their loved one knows that they are loved and appreciated.  At the end of the conversation, the loved one looked at me and said, "you know, you should teach bedside manner.  I have had a lot of encounters with many doctors through all my other family, and you blow all of them out of the water with your bedside manner.  I wanted to make sure you know that."  It always gets me when something I do as almost a reflex has such an impact for the people under my care.  I am thankful for the continued education in communication, but I'm also glad that the love I have for my job shows through.  Even though I live constantly stressed about most everything, at this point, I can still show my compassion in the moments where I can focus my energy on the people in front of me.  That is so vitally important.  And while it is nice to be recognized on it, I would rather know that my patient and their family are able to find some peace than take time from themselves to compliment me.

Days 170-174: Traditions

There has been so much to happen since my last post.  Thursday was a rough day at work.  It started with the death of one of my patients whose family was not completely ready for his death.  I felt for his family.  They fall in the category of patients that I truly feel were "my patients".  One of the difficulties of being a fellow is the fact that there are situations where, with being in training, patients don't see me as their doctor but as "the doctor working with my doctor".  This family saw me as "their doctor".  Not to the extent of the beautiful family I cared for in October, but still more so than some of the other patients I've cared for in the last couple of weeks.  This means that they lost a loved one four days before Christmas.  Then, another patient passed away a couple hours later that one of the medical students was supposed to pre-round on.  This was followed by the patient I thought I'd be getting home for Christmas being found unresponsive and actively dying.  Finally, I was confronted by the wife of my patient that we'd been planning on getting home all week who said she refused to take him home because she couldn't care for him.  This left me having to let the patient know what was going on because from a medical standpoint, he was stable for discharge.  It was an emotionally draining day.

I am thankful I was able to take off Friday to binge watch cheesy Hallmark Christmas movies.  It was relaxing and gave me the chance to decompress after the tragedy that was Thursday.  The Hallmark movies have become something of a game, trying to figure out what the major plot was going to be since the majority are the same: two single, attractive people meet after some unrealistic event that brings them together a week before Christmas.  There is some flirting, they do traditional Christmas things together, they fall in love.  Then one or the other thinks that the other person has lied to them OR one or the other is called away by work OR one or the other already had plans to leave and isn't willing to give it up and stay.  So they separate only to realize that they were happier together and at the last minute come back together to find they both feel the same way.  And they live happily ever after.  I have probably watched about 10-12 of them since Thursday night.  It's been wonderfully mindless and silly and really a good way to get away from some of the difficult situations of work.  A nice little four day escape.

Saturday, LOML and I went to have Christmas lunner (dinch?) with my parents, grandparents, sister, cousin, and aunt/uncle on my mom's side.  It was really nice to get to spend time with them, laughing and being silly.  We'll get to see parents, sister, her husband, and my brother and his girlfriend again this coming weekend.  We spent Sunday with LOML and his family on Sunday.  It was a little chaotic.  Everyone opens their presents at the same time which is very different from how my family has always done things.  We usually each open a present so we can see what each person has received.  We talk, we eat, we take all day to open presents and enjoy each other's company.  That's what I always loved about my memories of Christmas, was getting to spread everything out over the entire day.  It's blissful.

LOML and I did that today.  LOML had to go to work for a couple hours, so I woke up, fed the animals, ate some English muffin bread with peach marmalade (homemade courtesy of my daddy).  LOML got home around 9:30.  We opened a few presents, put them away, ate some breakfast, opened some more presents, FaceTimed my parents to thank them for a beautiful ceramic bowl for LOML to use when he makes bread.  Then we FaceTimed my sister and her husband to open the rest of their presents to us (one of their major presents was an amazing, homemade, pine cone wreath.  It is stunning, and will likely be an indoor wreath because I don't want the elements to mess up its beauty). They also got us super awesome Christmas socks and handmade soaps in amazing scents (bergamot, lavender-honey, coffee-vanilla, tea tree-charcoal, and rosemary).  It really was a very special day.  I got LOML some of my favorite board games from when I was younger, so we spent part of the afternoon playing games.  It was so much fun.  I enjoyed the quality time we had together after a busy month when him working every weekend since Thanksgiving.

The thought of having to go back to work tomorrow is difficult, but I'm glad to have another four-day weekend coming up.

Days 168-169: Sleep

Apparently I have been quite sleep-deprived for a long time.  I have been feeling more and more tired out without really finding a way to reboot.  I have thought I've been going to bed at a reasonable time, but not enough to fully recharge.  I think the emotional drain of palliative care is requiring more of my energy than I realized.  I finally couldn't do anymore and slept 10 hours last night which required me to go to bed at 7:30 PM.  I'm thankful I was able to do that.  I still feel like I have a ways to go before I feel like myself again, but I definitely felt a little more alert today.  I'm fading this evening.  My creative juices are low.  I am also surrounded by sleeping animals which does not help.  Looking forward to no work on Friday!  I'm taking two four-day weekends in a row and hoping to recoup some more.

Day 167: Counseling

Today, I had a patient who was what we call "transitioning" which means that he has started the journey toward death but isn't actively dying.  His sweet wife of 50 years is struggling.  She wants so badly to savor every minute yet worries herself over every little change.  Most of my day with them was spent explaining what we were seeing and what it meant.  It's one of those conversations that I feel I can help alleviate some anxiety with but is also really difficult.  Today, I was telling a wife she was losing her partner in crime from the last 50 years, the majority of her life.  I was telling a daughter she was losing her daddy.  Nieces and nephews, their favorite uncle.  He was a loved man who even in suffering is kind and gentle and patient.  This man's wife waits by his side, forever dedicated, and living to the "'til death do us part" vow is met.  She is so alone for most of the day, sitting and watching, worried about everything that's different.  Thankfully, we have a group of wonderfully sweet medical students this week, and one took the time to be present with this patient's wife this afternoon.  I am so thankful for the dedication of the medical student.  Her heart is so full, and that's just what the family needs.  It truly is a blessing to know that the right people are in the right place at the right time.

Days 164-166: Cats and Dogs living together...mass hysteria

Julia and Alex went to the vet yesterday.  I've been at the vets every three weeks since Oct. 14.  I am glad Banfield is open on Saturday and, hands down, has the best staff and veterinarians I've ever encountered.  It has made what can sometimes be a very stressful visit as de-stressed as possible.  Alex has a "hot spot" or "wet dermatitis" which is the cat version of exudative cellulitis in humans except it is sometimes due to self-inflicted wounds.  He got an antibiotic depot and deworming medicine which has left him very cuddly today.  If I am sitting, he's sleeping on me.  It's been a blissfully relaxed day.  I love getting to just "be" with my animals.  

Julia had an X-ray that showed moderate asthma which was not surprising, but was otherwise clear.  We are continuing with regular dosing of her inhalers.  She otherwise looked much better than she did at her last visit.  She should be able to undergo a teeth cleaning in about 6 months and get microchipped at the same time.  Hopefully by the end of the year, we should have all the animals microchipped and registered on PetLink.

I am very thankful to be able to provide for my animal babies.  They have a roof over their heads, heat, good food, and fresh water.  I could not imagine life without them.  I can't understand the people who throw animals away like they're objects that aren't any good if they don't behave the way people think they should.  Chewy, my first cat, was tossed aside when his owner's wife didn't want to take care of him anymore at the age of 10, despite the fact that they'd bought him as a kitten and moved him from Flordia to Winston.  Boris was surrendered when his family didn't want to deal with his dietary issues.  Odie was left for dead in his crate because his owner just didn't want to take care of him anymore.  And Alex was thrown on the side of the road and left to fend for himself.  Each of our babies was rejected by other people, and I love them all dearly.  They are wonderfully perfect in each of their own ways.  I love my life with them in it.  There's no other way I'd want to live than surrounded by sweet animals.  I'd give my love to all the unloved animals out there, but my house and paycheck are not big enough.  So I will love the little creatures I do have right now with LOML on our little island of misfits who all found each other.

Days 162-163: Heat

So, I like to think I do a decent job of maintaining my car.  I take it for regular oil checks and major maintenance when it's time.  However, I forgot that not every place checks all the fluid levels regularly without asking.  Which became an apparent issue this week.  For about the last month, I've noticed that the heat in my car barely works.  And by that, it only worked when I was driving about 50 mph.  This meant that the majority of my commute to and from work was spent in a very cold car.  I just wrote it off as being due to the fact that I do not have a garage anymore.  However, I finally got fed up enough that LOML called the mechanic.  The mechanic was very concerned, like the level of concern I get when I'm worried a patient has cancer.  He said to check the coolant level and then get it to him to check.  So LOML checked the coolant level, which was low, took me to work, and then put a liter of antifreeze into the coolant system before taking it to the mechanic.  We spent most of the day on pins and needles.  Naturally, I began searching the internet and found horror stories of many 2004 Honda Civic's having similar problems and all ended with blown head gaskets.  I freaked out, started planning for buying a new car, and working out plans with my mom and LOML mom for transportation and bargaining for a good price on a new car.  Fortunately, the mechanic called back and said the car was fine after dumping a bunch of coolant into the system.  He did not see any leaks, and the head gasket was fine.  He said all we needed to do was check the coolant level weekly and have it checked every time the oil was changed.  Thank goodness.  Added bonus was having to turn the heat down in the car because it was too warm on the way home.  Definitely a first world problem, but when so much of my job is based on my ability to get myself independently from one place to another, it's an important problem to deal with.

Day 161: When the student becomes the teacher

I started back on the hospice inpatient unit yesterday, and have taken over some of the teaching duties for the medical students.  Sometimes, I can't believe how far I've come.  It's also hard to believe that it will be five years since I graduated medical school this coming May.  So much has happened, and I will be starting my first job in the summer.  I'm excited and nervous.  I will always feel like I have much to learn.  I have the opportunity to do more teaching with the medical students.  I am working on handouts for them to try to help with some of the quick tips and tricks they will hopefully find useful for some of their other rotations.  I need to get some time where I am observed teaching so I can improve my skills, and my hope is that I can have multiple opportunities for different people to observe me.  I also need more times for feedback on my communication skills.  My goal will be to offer the same to the medical students.  I can't believe I was in their place six years ago.  I was realizing at the time that I was interested in hospice and palliative care as a career.  I have several really great job offers, and will hopefully have time around Christmas to really decide on where I will settle for my first years of my professional career.  While I knew that I would get to this point, it is surreal to finally be here.  The baton is passed, and suddenly the student becomes the teacher.

Day 160: Anxiety

Over the years, I have become more and more of an anxious person.  I think, in part, due to the fact that the stakes get higher the further along in training I get.  My actions do not effect me alone.  They effect sometimes many, many people.  While as a physician, I am still fallible, I don't know that everyone else remembers that.  There is a different level at play.  My mistake or bad day could potentially cost someone their life.  Along with carrying the weight of the lives of the patients I care for, there's also the educations of the students, residents, and fellows I work with.  It's more than just me.  I'm still in awe that I am even in this position.  I'm not sure what I did to deserve the ability to have my dream career.  I worry on a regular basis that I am not going to be able to do what everyone thinks I'll be able to do.  It's like watching college athletes move on to professional sports careers.  Some excel and are the start players on their teams, and some peter out, ending up on the D-team.  I wish I knew if there was a way to tell who would become which player and whether a similar algorithm could be used for other careers.  I don't want to let everyone down, and I want to be great at what I do.  I worry I won't.  I worry I'll be a let down or that I really don't have what it takes.  I worry I'll need too much help or not enough or not know when to ask.  I worry I won't maintain my energy.  I worry I'll let my family down.  I just worry all the time about everything (or so I say to LOML)...

Days 158-159: The Tree-Cat

As some of you may know, I moved in to LOML's "bachelor pad" in March of this year.  It's a quaint little cottage that really does not have any space for a full size Christmas tree.  Plus, with the discovery of Alex the kitten jumping out of a tree to us in October, I figured a full size tree would be his next big adventure.  So LOML and I found a little 3 foot tree that could be placed on one of the bookshelves.  Seemed safe enough.  Alex couldn't climb all the way into it.  Plus, we secured it to the bookshelf, so all would be just fine, right? Wrong... So very wrong.  Alex has been trying to get into the tree since we put it up after Thanksgiving.  He had pulled ornaments off of it regularly.  Finally, tonight, he figured out how to pull it off the shelf entirely.  Thankfully, all the ornaments are plastic so no shards of broken ornaments in anyone's toes.  I also realized that Alex was getting these sores on his neck.  At first, I thought they were from him rough housing with the other cats, but none of them seemed to actually use their teeth or claws on each other.  Plus, there were never any visible puncture wounds.  When I thought the spots would start to heal, they seemed to worsen.  It dawned on me today that he was likely getting them from rubbing up against the rough ends of the fake Christmas tree branches, and getting superficial wounds.  Needless to say, the tree is out where he can't get to it anymore.  Fortunately, I have multi-colored lights around many of the windows where I can see them, and enjoy them.  I have a Christmas Bob the Minion statue that has replaced the Christmas Tree, and will likely remain our "Christmas Tree" for a long time.  Will have to start thinking of a new tradition since trees are out with our early tree-cat this year.  Who'd of thought we would be worrying about a cat-proof Christmas?

Days 154-157: Exhaustion

Tonight, I feel drained.  Not because there has been an abundance of emotionally straining family or patient encounters.  Not because of the weather or time of year.  Predominantly because there are some major life events coming in 2018, and the planning for many of them is all combining right now.  LOML and I are getting married in April.  While there isn't much we're having to do this moment, planning is always at the back of my mind.  There are things that need to be taken care that are coming up as time goes on.  I feel bad that it is on the back burner in some ways comparatively.  I just took the boards for geriatrics in mid-November, and yet am already having to think about boards for hospice and palliative medicine.  The number of things to be done for fellowship feel like they keep increasing.  Then there's the job search.  I have completed several interviews, including one today.  I loved the few programs I looked at.  I am excited about some of the possibilities. I am always worried that I will not be able to meet the goals I set for myself or attain the perceived expectations of others.  I want so badly to do well, and am worried that I will hold myself back due to my low self-confidence.  While writing it out here makes it seem like far less I have to balance, I feel like there's more I'm carrying around.  There's likely the component of self-doubt that is included in this.  Am I really ready for all these responsibilities?  Will I be able to do everything effectively?  Will I be able to grow into the role like I need to?  Will I be able to admit when I need help or if I am floundering?  Will I be able to become more assertive?  Will I be able to move on as faculty from being the learner?  Will I be able to relax at some point?  The list of questions goes on and on.

Days 149-153: Onc Clinic

I have been rotating with different oncologist for the last week.  Today, I got the sense that I offended one of the oncologist.  I saw one of his patient's in the pall care clinic a couple weeks ago.  The patient wanted to rediscuss treatment options.  I, of course, told the patient that everyone had said that the treatment options weren't available.  However, I, as a non-oncologist, was not believed.  So my attending asked me to email the patient's oncologist to let him know what the patient wanted.  Apparently, even though the oncologist swore I didn't offend him, I offended him.  He was like, "you made it look like I didn't talk with the patient about anything.  Didn't you read my note?  Why didn't you refer him for a second opinion?".  Because 1. The patient didn't trust my opinion because I wasn't an oncologist 2.  He didn't want to go anywhere other than Wake and 3.  I can only read him the note the oncologist wrote because I don't know the algorithms for cancer treatment plans.  Anyway, he swore I didn't offend him but then brought it up multiple times that I should have written my email to him in a different way.  Or told me how I should have interacted with the patient during my clinic visit.  Then, he asked what I was supposed to be doing with him in clinic, and I explained that I needed to learn about chemotherapy/immunotherapy and its side effects.  Immediate response from him, "treatment doesn't have side effects"...  I play along, and then spend four hours being pimped on how to choose adjuvant therapy and what adjuvant therapy is and how to choose treatment.  And then how to calculate the relative benefit of each treatment and how to stack them.  Thanks for listening to what I needed to know and spending our time together talking about anything but what I needed to learn about.

Days 146-148: The Zoo

Right now, I feel like LOML and I are zookeepers with the three cats and dog that live with us.  Boris, the oldest cat, is on a special diet for his grain/gluten allergies (shows up like celiac and IBD at the same time) so we're having to make sure he doesn't get the other animals' food.  Julia has asthma which comes with the need for inhalers and a weakened immune system so she's now requiring regular ear drops and washings.  And because it's not safe for her to go under anesthesia, I'm having to learn how to brush her teeth.  Alex, the newest kitten has the same amount of energy as Hammy the squirrel from "Over the Hedge".  He requires at least two 30-minute play sessions per day.  He has to be fed three times per day, and is also super food-motivated so we're constantly having to distract him while the other animals eat.  When he misbehaves, he has to go into time-out.  He tries to get in the shower with us.  And unfortunately for our Charlie Brown Christmas Tree, he occasionally goes back to his original roots as a "tree cat" and tries to play with it.  He is an adorable, and sometimes mildly frustrating, ball of energy.  Then there is Odie, the lone dog in the pack who is not thrilled to be out-numbered by cats like this.  When it was him, Julia, and Boris, it was fine because Julia and Boris tend to leave him alone.  They each have their spot and no one bothered the others.  Now, Alex has completely flipped the routine.  He is into everything, and this lack of reserve bothers poor Odie.  It also upsets the other animals that they spend so much time vying for my attention.  When I get into bed, I tend to wake up with Odie under the covers on one side of my feet, Boris above the covers on the other side, and Alex up by my face.  I can't roll over or move because they all want to be near me.  I have no privacy or personal space anymore.  While sometimes I wish I could hide away, I am glad to have all of them.  I hope Alex slows down sometime soon.  And I hope Julia learns that the toothbrushing and the ear cleaning make her feel better.  She doesn't have to like it, just reach the point, like the inhaler, where she tolerates it.

Days 140-145: Self Criticism

I am always overly critical of myself.  I had my quarterly review this past week, and I'm apparently right on track.  I have some areas to work on for chart reviews for clinic, and improvements in advancing my communication.  However, I feel like I am so far behind the curve ball.  I feel like I am incompetent.  I feel like there is no way I will be a good faculty member or assistant program director.  I feel like I have fooled people into thinking I can meet expectations.  I seriously have an issue with believing in myself.  It makes it really hard to see myself excelling in any role, even when others can.  I still try my hardest to be the best I can, but I set my goals for myself way higher than is sometimes attainable.  I haven't figured out how to get rid of my perfectionist ways and be content with where I am in the now.  I need to work on some of the self-care activities I'm supposed to be doing (ie. the mindfulness and yoga I'm supposed to have done last month and this month, respectively).  I have a million ideas for some of the things I could do for the narrative medicine/wellness curriculum as faculty.  I have to get myself to believe that I can actually do these things I have ideas to do.  I am thankful to have a support team behind me.  I need to believe the things they say about me.

Days 137-139: Moonlighting

I occasionally spend a weekend here and there working with the palliative care group at the other local hospital in the area.  During geriatrics fellowship, it was a nice way to spend more time in the field I love.  I spent what may become my last weekend of moonlighting this past weekend.  While I will get to spend more time with the team during the month of April, it is, in some ways, different being autonomous versus being a learner.  At any rate, this weekend wasn't too bad other than a rather bizarre encounter.  I usually try to use my communication education when running family meetings.  I still have a lot of room for improvement, but feel like overall I do a decent job.  This past weekend, I had a situation where I felt like my empathy actually made the situation worse rather than better.  I can't say I've had that happen before.  Every time I used an empathetic statement, it made the patient and family more irate.  It finally came down to me be blunt and borderline rude to be told I was making more sense.  I was told I was clearly several steps behind everyone else there.  I was told I was talking down to them.  I was told I was trying to hide something.  It was almost to the point that I wish I had another provider in the room to make sure I wasn't being any of those things.  The only consolation were the few family members who understood that what I was saying was what everyone else in the room was also saying.  I can't say that I've had an experience like that before.  Had my initial encounters been during the week, I would have had the supportive care nurse or palliative counselor with me to help make sure I was communicating as best I could.  I realized several times I became defensive, and I probably should have taken a breath and calmed down before continuing.  I supposed now I will hopefully know better when something similar happens in the future.  Until then, I keep reminding myself that I used the communication tools I was taught and conveyed the information to the best of my ability. 

Days 129-136: A Week of Silence

It has been busy since my last post.  I picked out the new dress for my matron of honor, saw a musical (Company), sat for the geriatric boards, set up another interview (at Wake!), and became a psych resident (unintentionally).  Oh, and ordered tickets for the Nutcracker!

The musical, Company, was dark.  LOML referred to them as caricatures of married life.  The couple where the wife was on a diet and the husband sober but started fighting to show discourse.  Then there was the couple that seemed so happy but were getting divorced only to be more in love once divorced, literally staying in the same apartment "for the kids".  There was the bride who panicked, got mad at her fiance, told him she didn't want to marry him, had the best man propose to her, and she decided he was silly and she needed to go find her fiance who was a "good man".  There is the "loose man" and "uptight woman" couple where the typical gender roles are maintained right down to the wife's "purpose" being to make the husband a sandwich after smoking weed.  Finally, there was the woman who was on her third husband and only marrying for the money.  She is  truly the most cynical.  The girls the main character dates are also all stereotypical.  The good girl who ends up with a different guy, the ditsy flight attendant, the bad girl.  Each fits a typical mold.  The entire premise is that marriage is a trap that is a constant love-hate relationship with the person you are marrying.  While I realize that marriage is ugly and messy sometimes, it didn't come across that any of the couples in the show actually loved each other.  The main character, who was a single guy, only seemed to want to get married because it "seemed like the time to do it".  I usually enjoy musicals, but while the actual music was beautiful, the overarching story did not hit the mark for me.

As for the psychiatry thing, I am shadowing one of the geriatric psychiatrist who has me doing notes.  Fortunately, the physician I'm with does most of the orders and tells me what he wants me to write.  So really, I'm less of a psych resident and more of a note lackey.  Only a few more days and then a four day weekend for Thanksgiving.

Days 126-128: Admin Time

As sad as it sounds, I get really excited when I have a little admin time at work.  I feel productive when I get work done during the normal hours of the day.  It can get very tiring working all day then coming home and having to work until bedtime.  It gets a little old.  Having admin time is the breathing room to get work done in the office without distractions from three cats and a dog.  Once I have a to-do list, I am good to go.  There are a lot of little projects to do, and when I come home, I really don't want to do them.  I want to relax and read or write or paint or be with the animals.  I know that's not always possible, but my hope is to be able to find more time to spend with those in my life that mean the most.  There will always be a lean toward work, especially earlier on, but it will continue to improve.  Sometimes I like going full-tilt, but sometimes I want to be able to take a breath without constantly thinking about everything waiting for me to complete.

Days 122-125: Feline Leukemia

This weekend was marked by the good news that Alex, the new kitten, does not have feline leukemia which is the cat version of HIV/AIDS.  This is great news because, for the most part, indoor cats are not exposed to the feline leukemia virus, and therefore, are not vaccinated for it.  Indoor/outdoor cats are due to the higher likelihood of exposure.  Kittens are usually vaccinated for the first year due to their constant desire to escape to the outdoors to explore.  Once they are over a year and less likely to try to escape, they no longer need the vaccine if they will be 100% indoors.  Since all of our cats will be 100% indoors, they are not vaccinated.  Alex had to be kept separate from Julia and Boris until we knew he was feline leukemia negative.  Since false negatives almost never happen, a negative test is truly negative.  Therefore, we are assured he is not infected.  This has made things easier and more interesting since Alex does not have to be sequestered in the front room any longer.  Boris and Julia are not always enthusiastic about having a new sibling.  Though, cats aren't ever really excited about anything, except meals.  At any rate, they are tolerating the kitten being in the house.  He is behaved, for the most part.  We are working to train him to not use our hands as toys.  The scratches on my hands show how well we are succeeding.  I have clipped his nails once already.  He did pretty well.  Boris and Julia have hissed and growled and smacked him around, but his kitten energy levels and his obliviousness have made the situations relatively comical.  Boris will pop him on the head, and he'll turn around and bite Boris on the ear.  He tries to get Julia to play, and she'll sometimes play along.  Odie sometimes tolerates him.  Overall, I think we'll be in a better place in a couple weeks, but introductions are going well at this point.

Days 119-121: The Difference

There are a few families and patients through time that will forever shape a doctor.  While I have had many wonderful patients, there are two that stand out the most.  One was a little girl I took care of who had cancer.  She passed away from complications from her chemotherapy.  I still carry the picture she drew for me, and occasionally listen to the two voicemail messages she left for me to "check in".  She was special because when she felt her worst, I was the only "doctor" she wanted to see.  She would let me talk about the hard stuff with her because I knew she was always listening and absorbing what we were saying, even if the residents on the team didn't think so.  The second is the patient that I took care of on the palliative care unit last week.  He was such a sweet man, but his family, and especially his daughter that made medical decisions for him, grew to trust me like the little girl from 5 years ago.  I am not sure why they felt I was the one to trust.  I am completely humbled by the faith they had in me.  But it carried them through his death a few days ago.  To the point, that his daughter came to the palliative care unit to find and tell me of his passing.  I am thankful I kept an eye out for his obituary so I could go to the visitation.  There are only a few patients whom I have felt I needed to say goodbye to the patient and family.  He and his family are one of the them.  His daughter kept introducing me as her "daddy's doctor".  It is beyond humbling.  I never really know what to say in those situations.  Before I left, his daughter told me that she would never forget me.  I hope that she realizes that I will also never forget her, or her siblings or father.  It was one of those doctor-patient relationships that forever sticks to your spirit as a reminder of the gravity and importance of what I do.  I hold those moments dear to help act as a beacon when I start to lose faith in my abilities to care and support others.  They truly hold a special place in my heart.  I hope they know how much they mean to me.

Days 114-118: Need Slo-Mo

Sometimes I wish there was an option to slow down time or pause everything else put yourself.  I'd get more sleep, study more, read more, write more.  If LOML was unpaused with me, we'd get more time together.  Quality time.  We make quality time for each other, but it never seems to be enough.  I always have something looming over me that needs to be done.  I wish that weren't always the case.  I wish I had time to actually be in the moment, not just tell myself I'm in the moment but really have my mind on other things I need to get done.  One of my mentors in medical school used to say that there is no such thing as work-life balance, it's a matter of what needs more of your focus at any given time.  Some days, work takes precedence.  During medical school, residency, and fellowship, work takes most of the focus.  At some point, the pendulum will swing, and a focus on life outside of work can be at the forefront.  What's really difficult are the times when both need attention at the same time.  That makes it even more stressful because neither receives the full attention they need so either one or the other isn't done to the best that's needed.  It can be frustrating.  Right now, I want to be able to take time away from everything I have to do for work to actually enjoy life.  I know my time is coming, it's just frustrating in this moment.  It helps that I have a very supportive family.

Days 112-113: Pent Up Anger

I can't believe it's already October and I've completed yet another narrative medicine prompt.  There was what seems to be a lot of pent up frustration and anger in this one.  More than I think I realized I had.  I hope it does not offend.

Prompt: Write your own poem in the spirit of Rafael Campo’s exploration of the difficulty of certain relationships in medicine, like with his patients

You never seem happy.

Every day, you talk to the wall,

Almost refusing to acknowledge me.

It seems to annoy you that I come each day

To check on your mom, my patient,

And offer no answers you want to hear

About how things will go.

You already know, you say.

You don't need me to tell you.

You want to tie her to a chair

So she can't continue to fall.

You claim she is your mom

Yes ask for her to be treated

Like an abused animal.

And when I try empathy,

It only makes you more perturbed.

I can't take the dementia

Or broken wrist

Or broken hip away.

I can't make her less impulsive.

I can offer supportive care,

And understand I will see you all again

The next time she falls

Because she isn't ready to die

Even though hospice isn't just about that.

You ask for support

Then turn it away.

I can't keep the energy for this

Day after day.

I'm tired and want to care for my patient

The best that I can

Without dealing with the anger

And frustration

And callous statements

Coming from you every morning.

Days 105-111: Missing Week

I can' believe we are in the last full week of October.  This month has flown by!  Last week was particularly rough.  The husband of one of my patient's unexpectedly died last week.  He came faithfully every day for the first week, and then stopped showing up early last week.  We finally asked police to go for a safety check to his house, and they found that he had passed away.  It is tragic and heart-breaking.  I enjoyed getting to sit and talk with him each day.  It gave me insight into his wife who has dementia.  He cared so deeply for her and loved her more than he was able to express.  It showed, though.  Boy did it show.  He was faithful and steadfast, and she's noticed that he isn't coming by anymore.  I'm sad that I don't get to talk with him anymore, too.  I know his family is grieving.

I had a patient come back to the hospital after being discharged.  In any other case, I might have felt responsible, but the current situation is not one that lends itself to being able to prevent rehospitalizations.  The patient has dementia and a broken hip and thinks she can still walk.  Naturally, she is going to fall.  I did what I could to try to prevent it, but it still is going to happen regardless of what we do.  The daughters realize it, but are frustrated with a system that is not designed to be supportive of the aging population.  It's unfortunate, and I wish we had more options.

Today, I had to have an in-depth conversation with a patient's family member over the phone.  Her stress was palpable, but I showed her respect for what she had done.  Through that, I was able to support her through some tough decisions, and ultimately help her better care for her loved one.  I don't think I ever imagined having some of these conversations over the phone like this.  I still have a lot of room to grow.  I feel like it's a huge compliment if the patient's daughter was able to sense through the phone how deeply I care about my patients and how much I love my career.  Despite being tired most of the time, it seems like I'm still able to show more empathy than I realize.  That's a really good thing.

I'm looking forward to finding a time when I can take a deep breath again.  Until then, I'll keep trucking along.

Days 102-104: Stress to the Max

This weekend has been crazy!  So, as noted in the previous post, a kitten jumped from a tree into my arms.  We named it Alex, and then weren't able to get the kitten to the vet until Saturday.  So Saturday morning, LOML and I do our third Walk to End Alzheimer's together in the morning.  Before kitten's vet appointment, our sweet Chiweenie, Odie, injures his paw while out running.  So we have a vet appointment for the kitten at 2:30 and for Odie at 5:30.  The kitten's appointment goes well.  We find out Alex is a boy (as I'd surmised), about 10 weeks old (a little older than I thought), covered in fleas, and with round worms (none of which are a surprised).  He's mildly underweight, but all energy and just as sweet as he can be.  Boy does he love staying right by my feet.  I've tripped over him a couple times now.  At any rate, we've got him on kitten food that he loves, the worms are gone and so are the fleas (and we are happy for all of that!).  His orange is getting darker each day, and his stripes are starting to come in.  Here are some pictures:

So after we finish at the vet with Alex, we practically turn around with Odie to have him evaluated since he is now limping on his right front foot.  After an assessment, the vet needs to give him hydromorphone to get him to relax enough to where they can examine him.  He went from this about 10 minutes later:

To this about 20 minutes later:

He was so out of it until Sunday morning.  Fortunately, no fractures in the foot.  He's on an anti-inflammatory which seems to be helping.  Minimal limping.  Only having to work through the associated constipation that comes with the use of narcotics.  It's so strange getting to see that medications I prescribe at work used on my animals.

Finally, we have the other cats, Julia and Boris, who are trying to stick together to phase the monster (AKA Alex) on the other side of the door.  Alex is off limits to them for the next couple weeks in case he is feline leukemia positive.  Hopefully he isn't and we can start introductions after his next round of vaccinations.  At any rate, the gray babies are trying to avoid the meowing baby.  I don't know how excited either will be when finally introduced.  Here are the other babies:

We have a house full of animals, but I wouldn't have it any other way.  It is hectic and stressful at times, but LOML and I are a team, and frankly, they're all really easy animals to take care of.

Days 100-101: When Kittens Fall from the Sky

Yesterday had an interesting end to it.  LOML and I went on our usual evening walk with the dog.  It takes us along the busy road we live on before we turn into one of the nearby neighborhoods that is a little quieter for the pup to do his business.  On one side of the side walk are a bunch of trees and bushes that act like a barrier to absorb some of the sound of the road to protect the neighborhood.  As we were walking by one of the trees, we hear what sounds like to loud meows.  LOML looks at me and says, "does that sound like a cat?"  I agree with relief knowing that I'm not actually hallucinating it, and then begin to search for the cat because that's what I do in these situations (disclaimer:  I did not know what I'd do in this situation until yesterday when it happened).  I look up, and about 3/4 of the way up one of the trees is a little orange kitten face.  It is so excited to see people, it partly climbs, partly falls, and partly jumps out of the tree and into my arms (after I'd flung the dog's leash at LOML).  As I'm sitting there holding it, looking bewildered that this is real life, LOML looks at me, sighs, and says, "we just adopted another cat didn't we?"  "Yep."  I have no idea how to care for a kitten despite having now parented three cats.  All were adopted on the older side (first kitty was 10, second was 6, and third was 10 months at the time of the adoption).  This little guy or gal is maybe 6-8 weeks old.  I'm not sure.  S/he ("she slash" as LOML referred to the kitten) was covered in fleas, but otherwise alert and active.  S/he purred the entire way home, as I feverishly called my family to figure out what to do.  My sister gave me some tips as did my dad (2 of my parents 3 cats were also "found".  One was in my dad's garden, the other was on the side of NC route 64.  Clearly this "finding cats" thing is genetic.).  So we got supplies, the kitty ate (although looks like s/he may have worms), and now will have its first checkup Saturday.  Definitely unexpected, but as one of my co-workers said today, "if the cat comes from the Heavens, you have to keep it".  And that's just what we'll do (despite LOML's trepidation at another cat, he is learning to love it...and let s/he fall asleep on him).

 Me and the kitten next to the tree it climbed out of

Post bath with Dawn to try to kill some of the fleas

(It really works! Dawn ftw!!)

Days 98-99: Time doesn't Slow Down for Nobody

I feel like time is flying by, yet it feels like forever until I take my geriatric boards.  I actually hate that I'm devoting so much time to geriatrics right now that I can't work on stuff for palliative care.  I genuinely wish I could study notes for palliative medicine.  For now, I can focus on palliative care during the day and geriatrics some nights and weekends.  I'm hoping things will settle down to where I can get a better routine in place.

I am trying to intersperse all the work with some fun/downtime.  I went to see the Russian Ballet perform Swan Lake this past weekend.  It was so good.  I love ballet, and was glad to get to spend the time with my parents and Drew.  It's also unreal that we are starting to do serious planning for our wedding.  With wedding, job, and potentially house on the horizon, I feel like in some ways time is flying by.

Weekends in October are full as are the weeks.  I barely feel like I have time to breathe.  I don't remember working this hard and enjoying it this much in the past.  It's exciting and daunting to know that I am going to be starting my first job as a physician in a short period of time.  It's surreal to be on this ledge ready to fall over.

Days 94-97: The Anniversary

I am woefully behind on blogging, mostly due to catching up on sleep and spending time with family.  The weekend will be covered tomorrow (hopefully).  Today is dedicated to yet another instance of delight in the midst of suffering.

One of the patient's I cared for last week celebrated her 67th wedding anniversary on Friday.  She was on the palliative care unit and we had discussed her impending death and referral to hospice only the day before.  Her family would be meeting with the hospice liaison the following day.  But Friday was her anniversary, and it was truly a celebration.  I started my morning watching her play with her granddaughter and great-granddaughter.  I came back to do her exam an hour later to find her covered in balloons and asking for a straight pin so she could start popping them.  Her family put up the balloons and streamers all over her room and her door.  She smiled from ear to ear as her husband asked her to marry him again.  She said yes.  A picture was brought in from when they were married in 1950.  They were a stunning couple in black-and-white.  There was cake and other snacks.  So much joy and fellowship mixed with periods of sadness knowing that it would be their last anniversary celebrated together for some time.  But the joy on both husband and wife's faces was unmistakable and unshakable even in the face of profound sorrow of the reasons for her hospitalization and the status of her discharge.  It was an honor to be allowed into such a tender, joyful moment.  It was a great reminder for what palliative care and hospice are supposed to look like.  Not the person dying and groping for closure, but the patient celebrating what life is left to live.  It was beautiful.

Day 93: Difference

Today, I was referred to as "awesome" and "a genius" which was preceded by comments of accolade and people wanting to work with me once I finish fellowship.  It is still beyond my comprehension that people really do like working with me and see me as someone worth pursuing for a colleague.  What's even more fascinating is the fact that I don't see myself as doing anything extraordinary.  I feel like what I do is inconsequential.  One of the medical students yesterday, during our debriefing, said that she reminds herself that what is mundane and part of our daily job is usually the most monumental day for the patient and their family that we are caring for.  As a medical student, I remember thinking how different it is that I got to leave the hospital of my will not someone else's.  I worked with two wonderful families who had arrived at the same place by different means.  Both had loved ones who are dying (one more quickly than the other).  Both wanted dignity, respect, and comfort above all else.  One family needed more hand holding and gentle guidance, and will continue to need that.  The other was more certain.  Both had chronic diseases that had slowly been changing their lives.  One had a catastrophic event.  Even though I spent more time with one of the families, both left feeling relieved that someone had heard them, met them where they were, and helped them to the next step in the journey.  I don't know that I could have ever imagined being at this position in life.  I knew I liked to talk.  I never imagined the difference I could make with being able to talk better.  It's very surreal at times.

Day 92: 13 weeks

I can't believe I am over 3 months into fellowship.  Some days I feel like I'm still back at the beginning.  I am humbled by how much faith patients and their families have in me.  I also can't believe I'm looking for my first job out of training.  It is surreal.  I don't always feel like I'm ready to take that step.  I worry that I am not good enough.  I worry about how to choose my next job.  What if I make a decision and then realize I want something else?  What if I'm not ready?

I got to hear Patrick Kennedy talk today.  He is a huge advocate for better mental health care in the US which I think is phenomenal.  He really is passionate.  It was exciting to know that he continues to be a huge advocate and use his sway to try to gain more support for the cause.  I hope that he can work to change the current system so that mental health is not stigmatized but viewed as a disease like diabetes or hypertension.  It sounds like he wants to start the process in North Carolina and then spread it to other states.  I am appreciative of the opportunities I have gained through this fellowship.  I hope I do a good job of showing my thanks.

Days 87-91: The Wedding

I think I am still recuperating from all the excitement of my sister's wedding this past weekend.  It was so great to see all my family and meet all of my sister's husband's family (that is so weird to type!).  It was a stunningly beautiful weekend, and my sister was radiant.  It was a little nerve-wracking to be the maid-of-honor, and sometimes I wish I had taken in the day more than I did.  There are certain images that will forever be with me, but it truly is hard to really take in all the moments.  I was so afraid that my wedding in 6 months would overshadow hers, but we were able to celebrate hers and still know that we would see everyone again at mine.  It didn't seem to detract from her happiness at all.  I am so thankful to have the sister that I have, even though we sometimes don't see eye-to-eye or fight over things we can't even remember (yep, that has happened).  She is funny, energetic, sweet, supportive.  I hope that I conveyed all that in my maid-of-honor speech.  I spent so much timing stressing over that darn speech!  It is so strange having the complete joy and delight of her wedding bracketed by days full of talking about death and prognosis and serious illness.  While that is going to be my job for life, it was such a stark contrast.  It's also strange going from saying, "I'll worry about [enter item for my wedding here] after my sister's wedding" and now it's after my sister's wedding and I have to start worrying about these things.  I'm excited, but the over-planner in me is a little nervous.  Wish I could take a page from my sister's book and sit back, relax, and enjoy whatever may come.

Days 85-86: Extremis

September narrative medicine prompt: Write a poem about a patient you took care of in the ICU that was challenging for you, describe that experience, how it felt, images you saw.  Why was that particular case hard/challenging for you?

It was an elective surgery
Replacing a worn hip
So she could keep up with the grandkids.
She was a young 80-something year old,
The matriarch of her family,
So alive before her surgery.
When I first met her,
The tangle of cords and tubes
Shrouded her beauty,
No longer alive but not yet dead.
Waiting.
Waiting for family from far away
Wondering why they are saying good-bye.
She wasn't supposed to die.
She was supposed to go home the day after surgery
With a walker and home health.
Instead, she lay in the MICU with tubes
Coming out of natural and unnatural orfices.
How did this happen?
Surgeons claim aspiration pneumonia.
Op note is useless.
So many questions I couldn't answer.
I don't know why she didn't go home.
I don't know how she ended up with me.
Tuesday, post-op day five
The ventilator and pressors are stopped.
She was dead before the epi wore off.
She didn't go home,
She went to the ME
Because we still had no answers.
I listened to her silent chest,
Telling the family she was gone
Even though I knew she was gone
Before she came to the MICU.
I left for clinic,
Feeling empty
And useless.

Day 84: The End

She lays there
Unmoving,
Surrounded by cords, her halo.
Alone,
Her eyes won't follow you:
Unseeing.
She stands in the other world
Crying,
Tethered here by a trach.
Restless;
Why won't he come see her
Dying?
Why won't he let her go
Peacefully?
She no longer lives
Vibrantly,
Mere blips on machines
Marching
Across the blackness:
Vitals
Of a woman who has died
But keeps on living.

Days 80-83: Family

This coming month is going to be all about the family, and it started this past weekend.  My little sister is getting married next weekend which means I'm sweating bullets over the MOH speech I haven't written... It also means I get to spend a lot of time with my awesome family.  This past weekend, I got to be there for the final dress fitting for my sister and go to lunch with her, the moms, and one of her other bridesmaids.  We had so much fun despite the biker rally right outside the door of the restaurant.  Then it was running around getting all the various supplies for welcome bags and jewelry.  Saturday was spent cracking up about "deez nutz" and random scribbles on the backs of pictures.  It was so much fun.  What's even more exciting is knowing that Friday night will be all the siblings and their respective significant others under the same roof.  It is going to be so much fun.

I am thankful for the time I've had this past weekend talking with my little sister and my mom.  I miss getting to hang out with just them sometimes.  I can't wait until LOML and I have a house where we can have guest over to visit.  I want my family to be comfortable coming up to see us, knowing that they'll have their own space.

On that note, I am suddenly nervous about applying for my first job.  What if I'm not as good as I should be?  What if I get too easily distracted?  What if I'm not as competent as people think I am?  The impostor syndrome is kicking in again...

Day 79: Fear

Fear was a running theme today.  There was the family that was afraid of their loved one dying and hanging on to every last bit of control they might have over the situation.  There was the patient who was afraid of how her mother might do without her once she was gone.  There was the fear of admitting that I might have different ideas of the ideal job from what I'd professed even six months ago.  There's the fear that my CV and cover letter are not good enough to send out.  The fear of rejection.  Of not saying the right things at the right times to the right people.  There's the fear of not telling everyone flat out what my goals for my career are.  The fear of how it will be taken.  The fear of being cornered and pushed into doing something I don't necessarily think I want to do right now.  The fear of what expense comes with being true to myself.  The fear that I won't be supported by my mentors or will looked down on for not choosing what they want me to choose.  I am so afraid of not being accepted or being told that I'm turning my back on who I am.  I want to feel like I can choose my own path and still be loved for that, even if it's not what others had dreamed up for me.  This all compounds the fear that I don't take enough time to do all the work I need to do and haven't studied as much for my boards as I think I should.  I base my image of myself on my expectations of myself and am left disappointed when I don't reach the lofty goals.  I keep saying I'll do better tomorrow and then tomorrow never comes.

Days 77-78: In My Element

The last couple of days, I have been back at work on inpatient palliative consults.  I feel like I am back in my element.  I tend to do better when there is more going on, so I have enjoyed being busy.  Getting to spend my day talking patients and their family through difficult situations is something most people shy away from.  I really enjoy it.  Even when I thought I was semi-good at it as a resident, I feel better prepared at this point for the communication required to sit with people through their darkest moments.  I still have a ways to go from a growth standpoint, but I am closer than I was just a few, short months ago.  I feel more comfortable with letting the family lead the conversation which is completely different from how the conversations would run when I was in residency.  In most cases, I was given an agenda for the conversation, and that's what I would stick to.  Now, there is so much more I can do by simply following the patient and their family.  It feels less forced.  I will never be perfect or an expert, but I can certainly do the best of my abilities for my patients.  That is a good feeling.

Day 76: Inner Child

I have been channeling my inner child the last two days.  As mentioned in an earlier post, part of the curriculum this year is trying different self-care activities.  August was art therapy, and I have carried the techniques into my life away from the hospital.  I will have to post some of the more recent acrylic paintings later due to the recent paintings being presents.  What I can show is that I have finally mastered the "shaving cream art" technique.  I feel like it's the adult version of finger-painting wherein you don't actually use your fingers.  You start by spraying shaving cream onto a flat surface (I purchased cheap lunch trays like from elementary school).  You then use a ruler or some other flat edge (I use a large plastic putty knife) to flatten out the shaving cream and make your medium.  Then put drops of color into the shaving cream (gel food coloring for me) and swirl it around with a skewer.  Once the colors are swirled to your satisfaction, you firmly press a piece of cardstock or watercolor paper (must be heavy paper) into the shaving cream and let it sit for about 30 seconds.  Flip it over and scrape the excess shaving cream off the paper.  I also blot the paper to remove any residual shaving cream and wet food coloring before letting it air dry overnight.  What you get is something that looks like this:

  

There were others that I did that weren't as good as these, and there is still room to improve.  It definitely lends itself to more abstract art, but it is so soothing to swirl the colors in the shaving cream to create the images.  Each one is different from the next.  I am enjoying this little piece of relaxation along with the writing and occasionally reading.

Days 74-75: Imperfection

We, as humans, are imperfect.  Our bodies are not meant to last forever.  Disease and aging occur whether we want them to or not.  Our minds are only able to show us as much as we are able to comprehend.  When bad things happen, we either project inward and wonder what we did wrong to lead to the event or we project outward and wonder how others could have done what they did to us.  We try to find blame, and sometimes even wonder if God, or a Higher Power, truly exists, and if so, how they could let such travesty befall us.  We wonder how a Being that is considered so loving could betray us and turn on us.  I, for a long time, have felt that there is no way some Higher Power could exist, especially after the things I was asked to do in the name of love as a resident.  It is truly difficult to understand how a person can, in the same breath, say that they leave it all to God and then ask us to resuscitate their 90+ year old loved one.  It seemed like abuse and a contradiction.

I have been thinking about imperfection.  My imperfections, my defects, the things that I wish I did better or had more control over.  It wasn't until the last couple weeks that I started thinking that the imperfections of humans, our toils, wars, racism, hate, and diseases, could exist in the same universe as a benevolent God.  Then, a few weeks ago, when going on home visits with one of the hospice chaplains, I realized that they can exist.  The chaplain was talking to a man who could not understand how his doting wife could have come down with a neuro-degenerative disease that left her unable to talk or care for herself.  He was angry at God, but felt guilty for that anger.  The chaplain's response was that God did not cause or allow the disease to happen.  He said that we were all made from clay, and clay is imperfect.  Therefore, we are made in the image of God but because we are formed from an imperfect medium, we cannot expect ourselves to be perfect.  He went on to say that because we are formed from clay, our bodies begin to breakdown, to return to its natural form.  Thus, we develop diseases; we age; we die.  It was a revelation for the patient's husband as well as for me to hear the chaplain talk like this, to say that the miracles of healing may not look like what we are wanting or expecting, for in death, we are cleansed of all our imperfections and our souls return to their Creator.  It was a revelation to hear that the things we do to each other are because we are made from an imperfect material and are prone to making mistakes, for doing things that are not always good.  It's in our nature to be imperfect, so why feel like a failure when perfection is not attained?  This does not mean to lose all motivation, but instead, continue to follow the rule of "love thy neighbor as thyself" and "do unto others as you would have them do unto you".  God made us in his image.  If you work everyday to do your best to meet the Golden Rule, then there is no failure for you have done the best with the imperfect material from which you were made.

Day 73: Procrastination

I have spent the last couple of months procrastinating on coming up with a hotel block for the wedding.  It seemed like a tedious task to get bogged down in, so I conveniently forgot about it until I had to actually get something done.  So my plan for today was to start calling a couple places to see what I could get, only to find out that there is a group that is partnered with "the knot" that negotiates the price for the rooms and gives you a list of bids for the hotel block.  If only I'd taken the time earlier on to find this, I would have saved myself a lot of anxiety over what turned out to be a simple task.  I also got a picture on the wedding site and made a registry.  It was relatively painless and quite a bit of fun.  Now to wait to hear back from all the hotels before making a choice, but it's possible even that will be done before next week which is a relief.  We're left with a few other details, but most can wait until after my sister's wedding in 2 weeks!  Overall, a good day of making up for months worth of procrastination.

Day 72: Euphoria

This is the late entry for Thursday.  It was such an emotional roller coaster of a day, I needed the chance to sleep on everything before thinking a touch more clearly.  I am still in disbelief.  I got my first true job offer yesterday.  I am beyond excited, too.  I still feel like I should interview a couple other places, but I so love the team where I am that it would have to be a "too good to be true" offer from somewhere else to tear me away from Winston.  It's a little overwhelming right now thinking about my sister's wedding in a few weeks, LOML and my wedding in a few months, interviewing for jobs, contract negotiation, etc.  I feel a little more confident in myself, but I think it's going to be quite some time before I feel completely settled.  I am glad to have LOML by my side through all this.  I am thankful that we have somehow balanced out when each of us are stressed so that we're not stressing out at the same time.

I also talked with the counselor at group about my worries from my last post.  He referred to my concerns as "signs of growth" and that I was the only person who had truly kept coming back to continue to grow.  I will likely finish out the month, if possible, with going to group weekly, and hopefully by that point will have completed the extra training in addiction medicine treatment that I am doing.  I am honestly not sure how I will use it at this point, but I will see where the road leads me.

Currently taking things one day at a time because there is so much that I need to do.  As they saw, onward and upward.

Days 70-71: 10 Weeks

I have been the hospice and palliative medicine fellow for 10 weeks now.  I have so much left to learn and so little time left to learn it all.  I have a research and an education project.  Surprisingly, one of the areas of interest to me is determining how to best care for patients on hospice who have concomitant substance use disorder.  I did not think this would be an area of interest.  I thought I would spend my life trying to fend off individuals with chronic pain or substance use issues.  There is this mentality that they are headache patients, difficult to care for, and uncooperative.  I can imagine when practicing outside of hospice, it is hard because the data points against the use of opioid medications for chronic pain.  Many doctor shop for the ones that will give them what they want.  It is not always an easy group.  But there is still the possibility that these people will end up with a terminal disease or cancer and potentially getting referred to hospice.  Right now, there is little data and even less infrastructure in place to address the best way of caring for this population on hospice.  Here we find ourselves in a situation where the best treatments for pain are narcotics, and the likelihood for developing pain is high.  Hand-in-hand with caring for a patient with addiction is the concern for family or friends diverting medications from the hospice patient.  How do we make sure undue suffering does not occur at the end of life?  How do we best address the issue compassionately and safely for all involved?  While the numbers of patients we will see that fall into this category are low, they don't deserve to suffer anymore than anyone else.  There is a lot of information that outside of the fleeting euphoria that comes with using, most of the time is spent feeling alone, depressed, and craving the drug of choice.  It is not a happy or peaceful life and compounds the suffering of dying.

I have to admit that I was jaded by my residency.  Many of the people I saw with addiction were not in treatment.  They were angry at the world, and more specifically me, because I was the one who was refusing to feed into their addiction.  I modeled those I worked with who typically took the strong stand of not prescribing any opioids.  Harsh words and curses from the patient were met with the strength of the offensive line in football.  Neither side would give and no one was happy with the situation.  It will harden and embitter anyone.  My hope is that with new training in compassionate communication, I can at least bridge the gap, show empathy, but still be firm in the limitations we define for the care plan.  My goal is to not let someone suffer in their last days, but at the same time finding safe ways to provide them appropriate treatment for their end of life symptoms.  I don't think this is something I am going to figure out in the first five years of my career.  I hope I don't become jaded again.  Addiction is a disease not a choice someone makes on a whim.  Most don't have control over themselves.  It needs the same steadfastness and care as any disease we can tangibly see or test.  I hope I continue to remember that when faced with the devastation of the wake from the disease.

Days 67-69: Work from Home

I am infinitely less productive when I work from home.  Between the animals and chores around the house, there is always something to distract from the work that needs to get done.  Fortunately, I left wiggle room on Tuesday and Wednesday so I can make up and get back on track (only to end up behind again).  This week is my last week of the research rotation for this half of the year.  I am going to miss the extra free time to do things when I want to do them.  I wish I had more time like this.  Sadly, this is not real life.  I have come up with a quality improvement project.  I am not to a point where I am ready to discuss it here, but I am glad I figured one out, and it is one that I had thought of, not someone else.  I think despite it's seeming simplicity, it will likely be more complex than I think.  It will have to be done in pieces.  I also need to get the ball rolling on applications.  I need a couple more people to review my CV and cover letter.  I am nervous and excited.  I feel like there are so many things I need to work on and next to no time to do so...

Day 66: Storm Prep

Hurricane Irma is heading for the east coast, starting with Florida.  While it is unclear what the course will be after landfall, there is concern for lots of rain here.  Fortunately, I feel quite prepared with my "raining cats and dogs" umbrella.  While our likelihood of losing power is low, LOML and I have stocked up on essentials.  We have enough nonperishable food to last us about 3 days, water for us and the animals, and food for the animals.  We've filled up the gas tanks to get into the following week.  It's probably overkill.  The important part is knowing that I am stocked up for working on my hobbies when I'm stuck at home.  Or mentally preparing myself if I'm somehow needed for extra staffing at the hospital should we become part of the evacuation strategy for other hospitals.  I'm banking on the former.  This coming week is going to be very interesting...

Day 65: Higher Power

Today, I think a Higher Power took hold and put me where I needed to be this evening.  I have been in a funk, worrying that I've said the wrong things at the wrong time to the wrong people and completely ruined any chance of getting a job doing what I love in a place I love.  So after getting myself all bent out of shape this afternoon, despite most things pointing to the contrary of my current thought trail, I was contemplating forgoing group this evening.  It is the first time in the last three weeks I hesitated when leaving the house to head out the door.  But I figured nothing would be lost in going.  The caveat here, is I am going on an invitation after my week of addiction medicine.  I am apparently the first person who has taken them up on the offer.  I find it to be my moment of peace in a busy week.  I don't have to be on my phone.  I am present.  There are no expectations, although, I have spoken up the last two weeks.  I get seriously nervous doing it.  But I do it.  And tonight was the first time I really felt like I made a difference for someone.  Someone who was adding to the grief of losing a loved one to dementia.  It was something I could speak to, I could support through naming the guilt and fears, showing a deep respect for the time it takes to care for the loved one, for the strength it takes to be that person's voice.  I could give hope that the person did everything in the best interest of their loved one, and hopefully be able to see that when the darkness of grief had parted.  It was the proverbial 2x4 from the Higher Power that my calling is caring for dementia patients.  That this is where I can do the greatest good for the world's greatest need.  It is such a difficult, dark place sometimes, but to be able to have these moments of deep connection.  The opportunities to educate and support abound.  My sense of self-deprecation and doubt was gone.  The anxiety of the nebulous "I can't do anything right" was replaced with the nervous of speaking up in a group of strangers and yet doing so for something I am so clearly compassionate about.  In the same breath of saying I hate giving the diagnosis of dementia, I could be finding ways to provide hope.  It's hard to see that in the moment of taking away someone's identity and independence, but there has to be some way to shine light in the darkness.  Even if the light only comes from the smallest of candles.

Day 64: Success

This is how I feel right now.  I feel like I can't keep up with all I need to do.  Fortunately, I think if I just start doing what I need to do, and doing the best I can, I will succeed.  I just need to get  into the right mental space.  I'm at the point where I am second guessing my every move.  This happened during geriatrics fellowship, too.  I think it's more pronounced this year because it is the last year of training before I'm set free on the world.  That is the most exciting and most terrifying thought there is right now.  Part of me realizes that there will still be oversight and people to talk to about difficult situations, but there is still a level of gravity to the knowledge that it won't be the continued direct supervision.  I feel like I will never know enough.  Blessing and curse.  Blessing in that a small level of discomfort will keep pushing me to provide the best I can for the people I'm caring for.  Curse is that I will be in a position to potentially never overcome the constant self-doubt.  I need to find a happy medium between constantly tearing myself down and pushing myself to do the best I can.  Until then, I will just keep at it.

Days 60-63: Where Do I Belong?

This weekend was a wonderfully relaxing weekend.  I was able to spend Friday helping out my family when my baby brother's girlfriend developed appendicitis and he needed all our support.  I spent Saturday with my grandparents which I enjoy doing, especially since it's hard to know how many more times I'll be able to do that.  Sunday, LOML and I hiked Pilot Mountain which was a fun little adventure for the two of us.  Monday was spent doing some work and then painting the evening away.  When I was in high school I used to paint spiderwebs on the backs of the AOL CDs.  This time around, I painted a stained glass window which looks similar to the spiderwebs I used to paint, expect the stained glass window is a little more detailed.

It was definitely fun painting it.  I have so many ideas for other paintings to do.  I wasn't sure how it was going to turn out, but am glad it turned out decently.

As for today, well, it was a bit difficult.  Clinic was busy, as usual.  I had to leave early to spend time with an interviewee.  Then went to drinks with some of the faculty which was a little uncomfortable being the only one there that wasn't faculty.  It was another moment where I felt out of place, like an outsider.  I didn't quite feel like I belonged.  I don't know if part of it is the fact that I'm a fellow and not privy to much of the faculty stuff or if it's  something to actually do with not fitting in with the group in general.  As my best friend from college says about her post-doctoral program, got to take it one day at a time.