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.