Day 27: Listening

The most powerful one person can do for another is to listen.  Yet listening is more difficult than talking.  One can talk without saying anything.  The gab can come without thinking.  It can be as mindless as eating or breathing.  It can fill up time without providing any importance to the activity.  One doesn't have to work at talking.  But in order to listen well, one must be active in the exercise.  Good listening is work.  It's not thinking about what you want to say, but rather what the other person is saying.  It's determining the meaning and emotion behind their words.  When your own emotions are high, it makes it more difficult to set aside what you want to hear what the other has to say.  Sometimes, it can illuminate the point of disagreement as a simple misinterpretation.  One meant one thing while the other thought something else.  In listening actively and responding to the emotions, it can level the playing field and build the trust bond.  It is not easy.  It is something that I am still working on.  I tend to be able to listen to my patients better than my loved ones.  Active listening, that is.  I think because it is part of the training for being a physician.  We are taught that good physicians are good active listeners.  Sometimes, when tired and emotionally drained from a long day at work, it is hard to carry over those skills.  We want so desperately to have the people around us be the active listeners so we can unload the baggage of the day.  Perhaps the approach we should take is that of The Trouble Tree so we can continue to be active listeners for our loved ones.  In turn, it might help them learn how to be active listeners for us.

The Trouble Tree

The carpenter who was hired to help a man restore an old farmhouse had just finished his first day on the job and everything that could possibly go wrong went wrong. First of all, on his way to work he had a flat tire that cost him an hour’s worth of pay, then his electric saw broke, and after work his old pickup truck refused to start.

His new boss volunteered to give him a lift home and the whole way to his house the carpenter sat in stone silence as he stared out his window. Yet on arriving, he invited his boss in for a few minutes to meet his family. As they walked toward the front door, he paused briefly at a small tree, touching the tips of the branches with both hands. When he opened the door, he underwent an amazing transformation. His tanned face was one big smile as he hugged his two small children and kissed his wife.

Afterwards, the man walked his boss to his car to say thank you. Now on their way out of the house, the boss’ curiosity got the best of him so he had to ask the man about the tree on the front porch. He said, I noticed when you came up on the porch before going into your house you stopped and touched the tree, why?

“Oh, that’s my trouble tree,” he replied. “I know I can’t stop from having troubles out on the job, but one thing’s for sure – my troubles don’t belong in the house with my wife and children. So I just hang them up on the tree every night when I come home. Then in the morning I pick them up again.”

“Funny thing is,” he smiled, “when I come out in the morning to pick ‘em up, they aren’t nearly as many as I remember hanging up the night before.”

Days 25-26: Cracked

This weekend has been less than fruitful.  I had these high hopes for what I would be able to accomplish for work.  I wanted to actually feel like I was on top of things.  Instead, I broke our internet.  Or the router, at any rate.  Then my computer went on the fritz.  Had this been years ago, it would have been fine because most everything would have been on paper anyway, and I would have been able to still complete my work.  Due to the technology of today, I was fairly useless.  I was able to do some board review questions, but beyond that, I was immobilized.  I got very frustrated with the entire situation.  While things seem to be going better, I am disappointed in myself for not being able to keep to the schedule I wanted to keep for the weekend.

In line with this, I had to complete a self-care assessment and set up a plan for self-care going forward.  Based on my score, the description was either "congratulate yourself for doing a great job or you might need to loosen up as your obsessive compulsive tendencies are showing".  I think I likely fall in the later and this is what has led to my disappointment in myself.  I created a schedule for what I should be able to get done by when.  For example, I am supposed to blog from 8:45-9 every night.  Since it is 9:24 now, that was not able to happen due to the aforementioned breaking of the internet.  I probably do need to cut myself some slack, but that is hard in light of the derailing of productivity that happens when I do so.

In other news, I have had the chance to read for fun, including completing a book (The Hound of the Baskervilles).  I am going through and reading all of the Sherlock Holmes books.  I find them fascinating.  I love the details and the twists.  Since watching Elementary, I now, in my head, read Holmes's portions of the books in Jonny Lee Miller's voice which makes it easier to follow the dialogue for me.  I have not yet reached the episode based on the Baskervilles, but I am looking forward to it.

Maybe tomorrow will be more productive...

Day 24: End of Week Four

I have completed my fourth week of HPM fellowship as well as my second week of hospice inpatient.  I so enjoy working over there.  I love the people I worked with, and the patients I cared for.  It was a tough two weeks, though.  The end of last week culminated with the passing of over half the patients.  The mass exodus.  It made for a quiet week this week, which was nice.  It gave me the time to talk about career and life.  I got some great pro-tips, and some new information to mull over.  I feel like I still have so far to go in what I need to accomplish from an academic standpoint.  There are some things that I feel comfortable with and others I am still working on.  All in all, I am closer to settled, although I still need to work on a better schedule.  But I needed this past week to catch up on sleep.  Tomorrow, LOML and I are going with his mom to finish the last few things that need to be done before putting his grandfather's house on the market.  We will be coming home with a large hutch that used to belong to his grandparents.  I am excited about having it in the front room.  I think it will look nice and make the space look bigger.  Until next time...

Day 23: Delight in the Midst of Suffering

Each month, I will have a different narrative medicine prompt to write about and poems or short stories to read. This month was reading A Brief for the Defense by Jack Gilbert:

Sorrow everywhere. Slaughter everywhere. If babies 

are not starving someplace, they are starving 

somewhere else. With flies in their nostrils. 

But we enjoy our lives because that’s what God wants. 

Otherwise the mornings before summer dawn would not 

be made so fine. The Bengal tiger would not 

be fashioned so miraculously well. The poor women 

at the fountain are laughing together between 

the suffering they have known and the awfulness 

in their future, smiling and laughing while somebody 

in the village is very sick. There is laughter 

every day in the terrible streets of Calcutta, 

and the women laugh in the cages of Bombay. 

If we deny our happiness, resist our satisfaction, 

we lessen the importance of their deprivation. 

We must risk delight. We can do without pleasure, 

but not delight. Not enjoyment. We must have 

the stubbornness to accept our gladness in the ruthless 

furnace of this world. To make injustice the only 

measure of our attention is to praise the Devil. 

If the locomotive of the Lord runs us down, 

we should give thanks that the end had magnitude. 

We must admit there will be music despite everything. 

We stand at the prow again of a small ship 

anchored late at night in the tiny port 

looking over to the sleeping island: the waterfront 

is three shuttered cafés and one naked light burning. 

To hear the faint sound of oars in the silence as a rowboat 

comes slowly out and then goes back is truly worth 

all the years of sorrow that are to come.

Over the last two weeks, we have had two groups of medical students rotate through the inpatient hospice facility.  Each week, I have been asked how I compartmentalize or deal with growing close to people who are going to die without becoming callous or emotional all the time.  It's a reasonable question.  The fact is, while I know my patients are dying, I don't see them that way.  I try to see them for the person they lived their life to be.  I enjoy learning about the experiences they had growing up, the careers and improvements they made in the world, the people they touched, the love they have for their families.  I find delight in my job by being able to help with the reminiscing while working diligently to decrease their suffering to the best of my ability.  It is an honor to be able to care for them in such a vulnerable and intimate time of their life.  I get to meet some very fascinating and wonderful people, even if only for a brief period of time.  I enjoy getting to know them and connecting with them and their families.  That is a hugely important part of my career as a doctor.  I don't always know how to best explain, but I know that I am not saddened by making the brief connections but gladdened to have learned a little more of history through their part in it.

Day 22: Wellness

Wellness is a constantly moving target.  Sometimes, I think I'm doing great, and then I falter; work ebbs into life, I stop taking time for the things that are important to my mental health, and I fall into a rut.  I don't think I'm alone in this constant waxing and waning of self-care and wellness.  I am so goal driven, though, that when I start to lose footing, I begin to become self-critical.  I see myself as a failure for not being able to maintain a proper balance.  I forget the words of my medical school mentor.  She said that there is no such thing as work life balance; it's about what needs more focus in the current moment.  Sometimes, you have to focus more on work, and that's okay.  There will come a time when the focus can shift to life again.  And so the cycle goes, like an ever swinging pendulum that never gets stuck one way or the other.  The focus is less on which way the pendulum is swinging but knowing that there is only a fraction of a second that it hangs purely on one side or the other, that there's always a little life when it's swung toward work or always a little work when it's swung toward life.  It's never fixated at one extreme or the other.  So I continue to think of ways I can leave a little time for life right now, and know that soon, I will have less work to take up my time.

Day 21: Career

Today I had the chance to sit down and talk through some of the pros and cons of the job search, of looking for employment outside the confines of where I've been training for the last nine years.  It's so tough.  I feel like I'm letting people down by not staying as I'd been saying all along I would.  Part of me is still so worried about everyone else.  The other part realizes that I have not really seen what medicine outside of one health system looks like.  There are learning opportunities everywhere I go.  I am excited and nervous for what the future holds.  Each new experience gives me insight into my interests, my career goals.  I have come to realize that, while clinic might one day be part of my future, I want to explore inpatient care both through palliative care and hospice.  While my skills as a geriatrician may weaken with this goal, it means I will have to work harder to keep using them.  I do not see myself defining my career by my research undertakings.  I never imagined having to base my salary on grants or promotions on publications.  I want to be an educator, but am hard pressed to see myself having take a pay cut to fulfill this part of me.  My 5-year plan involves buying a house, potentially a new car, and having children, all of which require some level of financial certainty.  In the following five years, I may want greater time flexibility.  The focus is either financial or time, one gives for the other; it's a matter of what is of greatest importance at any given time.  Who knows what is in store for me in the coming months of the career search.  For now, the focus is on creating a cover letter, finding professional references and finding out what's out there.

Day 20: Clinic

The clinic is not my world or my cup of tea.  Yet it seems to wind its way into the other parts of my life.  I look forward to my time at the hospice inpatient facility.  I actually want to get there early.  With clinic, I get excited if someone cancels.  I don't think that's right at all.  With the inpatient palliative unit at the other local hospital, I don't mind getting in early or staying late.  I want to do research on how to better care for my patients.  I look forward to my weekend rotations there.  I feel like clinic is useful, but I don't like the anxiety of the time constraints and then the infinite things to follow up over the course of the year.  It's the work on top of work.  It's the fact that it never lets me go.  I'm always having to interrupt something else for the sake of the clinic.  I've literally only had one day in clinic so far, and am not excited about the next year's worth of it.  I know there are worse things out there.  I know that I do still help patients.  It doesn't really feel like palliative care sometimes.  Certainly some patients have symptoms other than pain, but most of the time it's pain.  And then the calls are people that didn't listen when the pain contract was discussed and ignored the fact that if their pain worsens, they are supposed to call us, not suffer in silence until they've run out of medications.  It's going to be a long year.  I hope I can work on finding more meaning in the utility of clinic.  So far there seem to be few people how have any semblance of optimism.

Days 18-19: Faith Restored

I worked extra shifts this weekend on an inpatient palliative care unit/consult team.  While it does help with building my financial savings, it also replenishes my emotional and spiritual reserve.  I love learning, but I also love being able to feel like I can put my learning to work.  This weekend was a test to my communication training from just a week ago.  I had a patient with dementia that had been all but discredited for having input into his own care.  Certainly, he cannot make his own medical decisions, but he still has thoughts and the ability to assent or dissent.  He deserves to have his voice heard, and feel like he's worth listening to.  We all forget that when someone can't understand us at our level.

On the other hand, I had a family who was worried about the decisions they had made about their loved one, and wanted someone to walk them through how to get from the hospital back to the facility without a hiccup.  I used "I wish..." statements, and NURSE (Naming the emotion, Understanding, Respect, Support, Empathy) to show empathy.  I made an effort to show respect.  I gave my personal opinion.  I think it helped because the family seemed much more at ease today.  I felt like I made a difference simply by listening to the family's concerns and addressing them.

I feel like each day I learn something new that improves my skills as a physician.  I'm excited to go to work.  I feel rejuvenated.  I'm also excited about the fact that I get to work at the inpatient hospice facility for another week before I head off to intervention pain management.

Day 17: Death

This has been the week for death.  Or rather, the last 3 days have been days full of death.  At KBR, we have had almost 4-5 people die every day.  It's been somewhat unnerving.  While I realize that I am at a hospice inpatient facility and death is common, I don't think I've had as eventful a week as this has been.  We start to get into the superstitions, trying to figure out if it's a full moon or new moon or some other celestially driven circumstance.  I am thankful that the patient's I cared for were at peace.  They did not suffer at the end.  Their loved ones knew that I cared deeply for everyone who entered the room.  I was supportive and compassionate.  I can't say I was perfect at everything I did, and that I didn't need help.  I know, though, that I put forth the best effort that I could in caring for each patient I managed this week.  There wasn't one that I felt I somehow hastened their death, nor did I feel like any of them were allowed undue suffering or prolonged course.  I was thankful for the support I received from the nurses, nurses aides, chaplain, social worker, and the other doctors and NP I worked with.  It was another wonderful week of working with incredibly passionate caregivers.  I am so thankful for the experience.  I love what I do, and am thankful to work with others who love what they do just as much.  I'm almost sad that I only have one more week there before transitioning to another team at the beginning of August.

Day 16: Exhaustion

I would never for a minute give up my chosen career, but I have reached a profound level of exhaustion that stems from the constant emotional and mental pull of working in hospice.  It consists of many conversations with family and friends of people who are dying.  It comes from caring for the dying and working diligently to prevent suffering.  It stems from constantly working to show empathy, acknowledge emotions, compassionately share information that the family or friends want.  It is by no means easy.  For me, there is the added pressure of being in a fellowship with high demands of outside reading and personal development.  It is the fact that even going home does not afford me the decompression time needed from a emotionally, physically, and psychologically stressful job.  I am thankful that LOML is so understanding and willing to deal with the exhaustion.  He makes me dinner every night and helps with the animals.  He listens to my day, even if he can't completely relate.  He is more than accepting of me as I am, for emotional better, worse, or downright punch-drunk (which happens when I am beyond exhausted).  I am thankful to have his steadfastness, even when I do a poor job of showing it.  I am glad he forces me to have some level of life outside of work, even when the scale tips precipitously toward work.

Day 15: Sparkles in the Sun

Today is about the little things.  As I was driving to work this morning, the sun caught the beads in my earrings, and the sparkles danced across my steering wheel.  It was pretty and made me smile on my way in.  Prior to that, I had run a sprint mile faster than I had previously.  At lunch, during journal club bootcamp, I really felt like I understood the articles we had to read.  Lecture this afternoon was held in the 8th floor conference room which has two walls of windows.  At the end of lecture, we were able to see the downpours in different parts of the city.  On my drive home, the sun cut through the clouds in a beautiful beam.  I was greeted at the door by my sweet little poochie and the love of my life.  LOML made a delicious dinner, and helped coach my little sister on job search and interviews.  I got to congratulate my sister on passing the very big certification exam she took today.  LOML and I got to watch an episode of the new Hulu show we're watching together over dinner.  The little things matter as much as the big things.  I am thankful I am able to appreciate them.

Day 14: Dreams and Such

I can't believe I've hit the official two week mark.  I can't believe I've had the honor to learn and be part of this field.  I never dreamed that this is where I would be or this is what it would feel like.  Today, I had the chance to talk with medical students about new and different ways to communicate with patients as well as how to take care of themselves.  One of the things that we discussed was recognizing the hidden curriculum and how to address when someone's cynicism goes too far and spills over into patient care.  It was a raw and important conversation that we rarely have.  We tell medical students to "do things to prevent burn out", but we don't truly talk about what that means.  There's little conversation about how to recognize burn out, and how to compassionately approach our colleagues who become cynical and unsympathetic.  We aren't given concrete ways to address our concerns for ourselves and others without being made to feel inferior.  If we are to improve as a whole, we need to be able to recognize emotional burn out in ourselves and others, and feel safe in reaching out a helping hand.  We need to be able to have ready access to resources for our comrades.  If we can't care for our own, how can we expect to work as a team to care for others.  I think today, I figured out what my focus will be going forward.  I want to create a curriculum to actually teach people how to be resilient in medicine, and how to help promote self-care in themselves and others.  How to recognize a faltering colleague and help bolster them rather than assume they'll know how to help themselves.  I guess it's time to start the curriculum research...

On a completely different tangent, I had a strange dream last night.  Most of the time, I confer too much meaning to my dreams, but this one cut a little more deep than others.  Last year, one of my friends from medical school, Kay*, committed suicide.  It was devastating.  Last night, I dreamt I was at a baseball field with the rest of the group we hung out with at medical school.  Every time I'd turn around to talk to one of my friends, I'd see Kay in the background.  I'd get excited, and tell the other girls I was with, but by the time they'd turn around, it would be someone else.  Kay never approached us, but I saw her three or four times in the crowd behind us.  I'd get so excited thinking that she was still alive, that it was progressively more heart-breaking each time it turned out to be a false alarm.  I think this is a reminder that her loss will be with me for the rest of my life, that I still wish she were here because she was such a great doctor.  I miss her dearly.

*Her name has been changed for the sake of her privacy.

Day 13: A Good Day

Today was a good day.  I started my two week rotation at the local hospice inpatient center.  I wouldn't say that I did much.  I met one family, I wrote a note, I saw how the other doctor I was working with approached making her comfortable.  I worked on my communication skills, trying to actively listen, use open ended questions, learn more about the patient as a person.  It felt natural.  I worry some about whether I'm doing the right thing when it comes to communication, but I worry less than I used to.  I will never be perfect or the best.  There will always be room to grow.  But I also did not feel like a failure.  It was nice being able to see a patient on my own without following behind the attending like a new medical student.  When I'm not truly given the chance to try on my own, I feel used, like an over-educated administrative assistant.  When I actually get to see the patient, formulate my own plan, and present it to the patient and/or family, then I feel like I am actually a doctor.  I don't pretend to have all the answers or know exactly what to do in every situation, but I don't learn well if I'm not learning by doing.  I'll shadow when in a field that is not my own, I want to try things out on my own to figure out what my style will be within my own field.  I know it will get better as the year goes on.

Day 12: Sunday

This weekend has been something of a breath of fresh air.  While I still spent a large portion of my time readying articles for fellowship and studying for geri boards, I did not feel the same crunch for time that I did last weekend.  While I am still somewhat behind, I was relatively consistent at setting time aside for work and time aside to relax.  I am so thankful to have a loving and supportive family, especially my Drew.  He has been steadfast through it all.  I spend a disproportionate amount of time anxious about whether I'm letting people down or not the person I am expected to be (whatever that actually means).  He is always there to remind me that I am.  He has food on the table when I get home from work.  He helps share in taking care of the animals.  He does his best to help keep the house straightened up.  I am so appreciative to have him by my side.  He is very special to me, and I hardly think I do a good job of telling him this on a regular basis.  I hope as I get more comfortable with fellowship, that I will be able to spend more time with him than studying.  Until then, we share in the decisions that are best for the moment in time we are sharing in the present.

Day 11: Anxiety

Anxiety
Gnaws away
Like a cancer inside,
Making every movement
Feel foreign.
It takes away the ability
To know when to jump
And when to settle.
Is this how it's supposed to feel?
The empty hollowness
Surrounded by frenetic noise.
Pull and pull,
Like a tug o' war.
When will I snap?
When will one side fall,
And I go limp?
The fight all gone,
And I'm left slack, flaccid,
Tied in useless knots.
I might get my feet back under me,
But for now, I lay quiet,
Patiently awaiting the inevitable.

Day 10: Impostor Syndrome

I feel like an impostor most days.  I don't think I'm good enough for what I do.  Sometimes, though, I also feel like others are being nice to me out of obligation.  I think this is an even deeper set belief.  Ever since I was a kid, I never really felt like I belonged.  I was always the "weird kid".  I was nerdy but also had ADHD so sitting still wasn't something I was good at.  I had buck teeth, and got glasses in 4th grade.  I felt like an ugly duckling.  I didn't really have many good friends when I was younger, so I tended to hang out with my parents and younger siblings.  When we moved after my 9th grade year, this became even more prominent especially since I went to high school 45 minutes away.  There are very few people I feel like I truly connect with.  I'm incredibly insecure and over-analyze everything I say or do.  I feel like I either say too much, say the wrong things, do the wrong things, offend people and they're too nice to correct me, etc.  The list could continue endlessly.  I feel like I try so hard, and then end up 10 steps backward from where I started rather than anywhere near my goal.  I can't shake the feeling.

Days 8-9: Communication is Key

Communication is part of humanity.  It is integral to every aspect of our lives.  Today was my first formative feedback for the first two weeks as a palliative medicine fellow.  While overall good, I feel like I have so much to try to improve on in an infinitesimally short amount of time.  I need to learn how to communicate the role of palliative care, on identifying and responding to emotion, on giving patient's and their caregivers the respect they deserve.  There's dissolving conflict and providing prognosis.  There's discussing goals, values, and how these play into future care.  There's discussions of physical, psychological, spiritual pain.  Of any type of symptom a person can have and how it affects their quality of life and what we can offer to address it.  The list goes on and on.  Communication is the key to the palliative medicine fellowship, and I feel like a baby making its first few coos in an attempt to figure out how to form words.  I feel like I am so far behind and have so far to go to be able to remember everything I'm supposed to say, when I'm supposed to say it, and how I'm supposed to say it.  I hope I will improve.  My worry is that each time I practice to improve one skill, I will forget another.  My brain is fried. 

Days 5-7: Crunch Time

I will skip Sunday as a day of rest which was really a day of feverishly working to prepare for Monday and Tuesday.

Consults has been tough.  Not by volume, but by the incredible learning curve that comes with each new one.  I thought I knew a little palliative care.  I was wrong.  Devastatingly wrong.  In the vast swath of knowledge that goes to palliative, I know a minuscule amount.  Each day, I add to the list of things I need to read up on, only to find myself swimming in a sea of topics.  I am too slow of a reader to make it to the top again.  Not for lack of trying, mind you.  I think one of the biggest hurdles is the mentality that pervades other areas.  A mentality, mind you, that I used to have: that of the "end game" being to get the patient and/or family to do what you want them to do.  The selfish mentality that the only "right" decision is your decision.  Despite the fact that we aren't the ones who have lived day in and day out with a terminal disease.  I realize the frustration with having to continue what feels like futile care for a dying patient, but at the same time, I can't imagine any of us would be convicted enough to sentence a parent or sibling to death who had only been healthy what felt like a few days prior.  I also can imagine that any of us would feel guilty, as a young parent, if we were faced with leaving our children to fend for themselves without us around.

I sometimes do feel like a hypocrite, preaching that I can't make anyone do anything they don't want to.  I feel like, as a resident, I tried and failed to make people see what I saw only to be frustrated when things didn't go the way I felt they should.  I have begrudged the family that forced many hours worth of resuscitating their loved one on me, despite the fact that my team had it within their power at that time to say that the patient was no longer able to live if resuscitation had not brought her back to life without CPR.  I feel like I've aged in just the year of geriatrics.  While not necessarily wiser, less bent on forcing people into a corner.  Is it the fact that I'm not the one directly dealing with the daily repercussions of a person's imminent likelihood of coding?  Is it knowing that I will be asleep while the other team anxiously awaits the need to intubate?  Is it the fact that I'm not on the other end of the phone when a patient transfers to the ICU?  I hope not.  I am thankful I am no longer the one with sleepless nights in the hospital managing ill patients on a skeleton crew, but I hope I have not become so distant from that time.

Day 4: The Funeral

Saturday, I went to the memorial service for my high school chemistry teacher.  Several times, the Reverend leading the Episcopal service repeated this message based on the words of Henri-Frederic Amiel: "Life is short, and we do not have much time to gladden the hearts of those who make the journey with us.  So be swift to love, and make haste to be kind."  By the church filled to bursting yesterday, the tears of joy and sorrow, and the number of students present, it was obvious that, despite his curmudgeonly ways, Dr. Mosley had done just that.  He gave all of himself in the short time he blessed us who were on the journey with him.  In thinking back on my few, short years at Spartanburg Day School, I realize now that, while he was occasionally frustrated with us, he was never truly ever angry or cruel.  He was sarcastic, but underneath that was someone who truly believed that each student was his own child to guide and mold into a model adult.  My hope is that he can reflect now and say that, even if there were many projects he would like to have seen to fruition, he does not regret anything he said or did in the time he had with us.  My hope is that he feels like there is nothing more he could have done with the time he had.

It got me thinking about whether I would feel the same if I were to die suddenly.  While a somewhat morbid line of thinking, it's what helps in pushing to making sure each day is lived fully.  Can you answer "yes" to the question of "if I died tomorrow, did I do all I would have wanted with today?".  Certainly we all have things we want to do in the future, but would we see missed opportunities in the past that we regret or didn't act on like we wanted?  I can say that, while there are many, many things I hope to be able to do in my life, if I were to die tomorrow, there is nothing I regret about my life to this point.  I have a wonderful fiance that I've had two years of living fully present with and loving more than I will ever be able to express.  I have a supportive family that I care for more deeply each day.  I am proud of the man and woman my brother and sister have become.  I have friends that have become more and more like family with each passing season.  I have three darling animals that are special and dear to me.  While I am still in training, I have had the opportunity to pursue the career of my dreams.  I touched my patients souls in ways I can't even imagine.  I can say that even now, while there is so much to learn, I feel complete with what I have.  If I were to die tomorrow, I would be sad at the opportunities that have not yet come to be, but glad in what I have accomplished to this point.  I cannot imagine feeling any remorse for who I have become to this point.

So I end as I began, a reminder to all who read this: "Life is short, and we do not have much time to gladden the hearts of those who make the journey with us.  So be swift to love, and make haste to be kind."

Day 3: Communication 101

Being a doctor is about communicating information that is nowhere near common knowledge in a way that makes sense to people who have never read a medical textbook.  It is tough.  It takes a lifetime to even consider being remotely competent in this skill.

I had the chance to go through the communication workshop last year which made this year slightly less nerve-wracking.  While I felt like there were areas I did better in, there is still so much that I can learn and work on.  The underlying theme though, in most cases, is "less is more".  Less in the sense that, there is only so much a person can process at any given time.  There is a way to provide difficult information so that people are given space to absorb and process.  If it takes us 7+ years of training to even be allowed to work as independent physicians, why should we expect our patients and their families to be able to hear, process, analyze, and decide on some of the most difficult decisions in their lives in less than an hour?  It's selfish and cruel.  I can't imagine many people go into medical school saying "this is all about me; forget the people I'm taking care of; they only matter if they do what I want them to".  And yet, that is almost what we do when trying to make people make life-altering decisions in a blink of an eye.  On top of that, we forget to give them the respect of getting to know them and what's important to them before dropping bombshells of information on them.

The challenge of this year will be disseminating the message that a palliative medicine consult isn't about "getting the DNR" or "making someone hospice".  It's making sure people are informed to the best of our ability and provided recommendations on further treatment based on their hopes and goals.  Emphasis on the Patients and their Families hopes and goals, not ours as the team.  Our agenda is second to what is best for the patient and family.  And especially if the patient isn't able to communicate and it falls on the family to speak for them, the family needs to be comfortable with each step.  If they're loved one dies based on the decisions they made for their loved one, they need the peace to know that any decision they made was in their loved ones best interest.  We move on to the next living patient, the family's world stops turning for some time as they cope with the loss of someone important to them.  Our hope is that we were able to guide them through the complicated decisions to a place where in their grief, they know that did everything their loved one would have wanted for their medical care.

Day 2: The Letdown

I had high hopes for my first day and my ability to prove to myself that I was ready.  Even with having done every rotation in hospice and palliative medicine I could up to this point, and having just completed a fellowship in geriatrics, I still have so very far to go.  I realized today how little I know.  The mountain only got higher.  I know I will get closer to the top by the end of this year, but it still feels like I slipped a little today.  It's all in the name of learning, but I am prone to tearing myself down when I feel like I've let those around me down.  I hope that, even after today, they feel like it was worth matching me into the program.

Today, though, it was even more difficult learning that my chemistry teacher from high school passed away suddenly yesterday.  It got me to thinking about what I really remembered.  I took chemistry my 10th grade year which was also the first year I was at Spartanburg Day School.  He would have us write summaries of each chemistry chapter, including writing the definitions of each important word or topic and outlining each section as well as completing the questions at the end of each chapter.  To save paper, I would write in this tiny handwriting (as in, I would fit two lines of text in each space on college rule paper) so that each chapter's outline wasn't more than a couple pages.  Having no friends in Shelby, and going to school 45 minutes from my house left me with lots of free time.  At any rate, I remember that he made my outline the example for how the rest of the class should do theirs.  I remember the time he asked me to go through the answers to a chapter's questions while he had to help with something outside the classroom.  I think I remember that day more for the fact that my friends stood up for me when others felt it was easier to bully me.  I remember his constant sarcasm, but underneath he cared deeply for each of us.  After the chemistry exam, he had everyone make a tie dye shirt.  He was seemingly a part of everything at SDS.  I can't even imagine going there and he not be there.

I feel like I had been sheltered from death when I was younger, and now, it feels like death is an everyday occurrence.  I realize that it is a part of life, and a large part of my career will be peppered with it.  However, it seems like I've lost more people in the last year and a half than I lost in the 28 or so years before that.  My friend, Kim, committed suicide last June; We lost Drew's nephew, Jaxon, last January; We lost grandfather this January; Now Dr. Mosley joins them.  I don't want to become embittered, but of those losses, grandfather's at the age of 93 was the only one where I felt like a full life could truly be celebrated.  All the rest were too young and too soon.  I can only imagine the possibilities of what their legacies could be.  In the darkest recesses, when I let me guard down, I fear the loss of my own, yet to be born, children before their time, the uncertainty of the length of their lives on this Earth.

Day 1: A Day Late

July 5th was my official first day of my hospice and palliative medicine fellowship, the last leg of my medical education journey before entering the world of full physician.  It's exciting and daunting at the same time.  I doubt that I will ever feel fully prepared for my career.  I think the fact that it is ever changing makes that impossible.  I am slowly coming to the realization that, so long as I work to the best of my ability, and am able to admit my shortcomings and then work to improve in those areas, I will be able to go home each night knowing I did all that I could for my patients that day.  It is not going to be easy.  I did not pick my areas of passion by the ones that would get me home early each day.  I was drawn to them.  It's still surreal sometimes to even be here, learning in the field that I knew from the time I was 13 would be my calling.  That time seems like a lifetime ago.  There have been and will be days when I don't feel like I deserve the honor of my career.  I realize that I am not alone in these insecurities, sometimes it's harder to convince myself of this than other times.  I have been tasked to post something each day for the entirety of this fellowship.  Some days will be ramblings like this one.  The thoughts that flit through my mind as I sit at my computer.  Some may be reflections on a difficult day through story-telling.  Some days may be a poem if moved to that level.  There may be days I post more than once as I am given writing assignments.  Just as I only have a glimpse of the peak of the iceberg that is this fellowship, I cannot say what the year will hold in terms of my writings here.  We shall see what today, day 2, holds when I set myself down to write tonight.