I'm not a huge fan of getting screamed at~ particularly when I did nothing wrong. This was my day on Wednesday. The patient had refused a rectal exam when we admitted her ('cause really who wants to get a rectal exam?) and it wasn't too important with her presenting symptoms so I didn't encourage it ('cause really, who wants to give a rectal exam?). When her Hgb dropped 2 points the next morning, I bit the bullet and told her that we really needed to rule out a GI bleed before we discharged her later that afternoon~ make sure it was just dilutional. So began my search for a hemoccult card. For those of you who haven't had the joy of being a surgical medical student, these card are simple little pieces of cardboard that you smear stool on, turn it over, and then squirt some chemical fluid on. If the paper/cardboard turns blue, there's blood in the stool. Really, really basic 'technology' and really really standard for the physical exam (depending on your attending...). Anyways, I asked the floor nurses for one, because at my last hospital they usually had them on the floor and would grab one for you out of their secret stash. I was met with an indignant "We don't keep those on the floor!" No problem, I thought, I'll just order them up to the floor (another standard option at the hospital I was at before, and what one of the residents told me to do). 3 hours later, there was no hemoccult card to be found. I cheerfully asked the unit secretary where I would find it if it got sent up, only to be literally yelled at~ telling me that they weren't ALLOWED to have hemoccult cards up on the floor. I went back into my patients room to do some diabetes education and could hear this woman complaining about my request to everyone around her. I ended up having to go to the lab, in the far corner of the hospital and literally BEG them to give me one. "I guess I will," the lab tech eventually told me, "but put in in your pocket and don't let anyone see that I gave it to you!"

Frustrated, I asked my resident why they keep such basic material in the dungeons under lock and key. It boils down to money. It's so frustrating when the bureaucracy and money game gets in the way of patient care. I know this was a taste, but I have a feeling that those moment of unrelenting frustration will only multiply as I progress through my education. I want to take care of my patients. I want to do the best thing by them. I want them to not live in the hospital, but I want to be as thorough as I know how to be as a medical student. Now I'm starting to realize that I'll be battling uphill to maintain this philosophy and I'll be fighting against a system that has to put other things first.

being the bad guy

I stood there next to the hospital bed with chart in hand as the patient answered my questions through hysterical tears. "Please just call my pain doctor" she sobbed. I tried to explain that I can't call an attending about a patient I know nothing about. I calmly appealed to her to answer my questions and tell me about what was happening. I knew going into the interview that this patient would get no pain meds. She was being managed by a pain clinic which tied our hands to the ability to alter her pain regiment. As this painfully uncomfortable interview progressed, I learned that she had stopped the medication for her peripheral neuropathy and after we ruled out acute reasons that would justify a hospital admission, it was clear that this woman would be going home. I knew she was lonely, I knew she was uncomfortable, and I knew she was unhappy. But does that justify a stay in the hospital? Here was a 400lb woman who can't ambulate with an exacerbation of a chronic illness that needed to be addressed in the outpatient setting. If she was admitted she wouldn't have left the next day. She risked DVTs, pneumonias and all sorts of other hospital acquired illnesses.

I walked back into the room knowing that the conversation would end poorly. She had already fired physicians this year when they told her that she was getting better and I figured she'd have no qualms about yelling at a medical student. As I explained that we ruled out a DVT and cellulitis as possible causes and told her that we wouldn't be able to give her any additional pain medications, as I calmly told her that her pain doc recommended discharge and followup in his office, and as I told her there was nothing that necessitated her being admitted, the anger struck. And it was at me.

As medical students, the residents and attendings usually shield us from the anger of the patient. This was the first time that I and I alone was delivering news that was unwelcome. As I apologized that she felt so unhappy with her care and told her what the doctors said, I was the bad guy. I wasn't the smiling happy medical student that the patients love because we are the innocent bystander. I was the one she was mad at. I was the one she was criticizing and yelling at.

As a people-pleaser, this bothered me and made me uncomfortable. It made me feel that I wasn't taking care of the patient. That we were missing something. But then I brought myself back to reality. While I don't feel like I did anything good for my patient, I felt like i was acting on the principle "do no harm." It sucked and I felt awful that I couldn't make her pain go away. That I couldn't make it all better. But I guess this is life. Sometimes I'm going to have to make tough calls that aren't what my patients want in the interest of preventing harm. It was an uncomfortable feeling.

dove promise. and other random reflections

I love dove chocolate. I really do. And I love the cheesy little sayings on the wrappers. I went on a 5 mile run this morning and obviously the first thing I did when I got home was to have chocolate :) The wrapper read "What would you try if you knew you could not fail?"

This is the second time that this question has surfaced in the past year and it's one that sticks with me. I've realized that I'm a human dictated by fear and timidity much of the time. I live in indecision because i don't want to risk making the wrong choice. The main criticism from my last rotation was that I needed to be more confident and assertive. I'm trying hard to take the risk of saying something wrong or stupid. To push myself to put myself on the line. I know I need to do that in order to be a good doctor, but for some reason I'm petrified of looking stupid. Thursday night when I was on call, I tried to be decisive, to be assertive, to not freak out when the resident handed the phone to me to give report to the attending at 2am. To give my opinion even when I knew it was wrong. I feel/hope it will facilitate better learning and adequately prepare me to be a decisive, confident physician who my patients can trust.

So in light of this new goal in my life, I once again ask the question "What would I try if I knew I couldn't fail?" What does my dream life look like? Is it policy, international medicine, working with youth? Is it something grand, or is it something that'll be a piece of the puzzle? Do I not attempt because I fear failure or because I'm overwhelmed by the possibility?

I miss India. I miss the dreams that it inspired in me. The goals and direction that it gave my life. I want to go back to that focus, that direction, that intentionality. "You get a strange feeling when you’re about to leave a place, I told him, like you’ll not only miss the people you love but you’ll miss the person you are now at this time and this place, because you’ll never be this way ever again.” Reading Lolita in Tehran. It describes my transition exactly. I miss the flexibility in my life, but also the intentionality and discipline that were present in my relationships, my quiet times, my exercise and my reading. How do I bring those pieces of me into my busy and distracted life here in the states?