Loneliness of Visiting

Article in New England Journal of Medicine by R. Srivastava
This hit home with me and thought it was thought provoking and put words to the tension and frustration of medicine and of the care of the sick.


“The problem is the poor chap is lonely. If they sat with him a little more, they wouldn't need to call us as much!” My harassed intern is venting her frustration with Mr. Wilson's relatives. The 76-year-old man has languished in the hospital for the past 3 months, a resident of practically every major unit in turn. He was first admitted to Surgery for an emergency laparotomy, which revealed bowel cancer. From there, he went to Rehab for a short stint. But he developed pneumonia and was transferred to the Medicine unit, where he needed an isolation bay. When he became agitated, the night resident gave him haloperidol. But he became sedated and, unable to find his call bell or attract anyone's attention through the closed doors, he got up unassisted — and fell, fracturing his hip. Ortho took him to the operating theater, after which he returned to Rehab. Two weeks into Rehab, his abdominal wound dehisced. So he is back in Medicine for antibiotics and wound care.

We, his medical team, sense another disaster lurking around the corner. His notes have spilled into another volume; his name tops the list of long-stayers, and although we try not to contaminate him with our sentiments, a certain pessimism clings to us. Just yesterday, I found myself telling the medical students, “Every day he spends here he is at risk for a new complication.” It was the most relevant teaching point I could come up with.

Mr. Wilson belongs to the diminishing category of people who have “never been to the hospital until this happened.” Now, he feels battered by his circumstances. He has no appetite. The wound is malodorous. His arms are bruised from regular IV changes. The repaired hip feels stiff. To the well-meaning psychiatrist he carefully explains the difference between being depressed and finding the situation depressing, though lately he seems even more withdrawn. He answers in affable monosyllables. Often he just listens passively, not bothering to protest or engage. His transformation from active citizen to dependent patient is complete.

Mrs. Wilson, though pleasant and concerned, is an old 85, troubled by an osteoporotic spine. Her daughters used to drive her in and sit with their father, but the visits have gradually become shorter and fewer. They have full-time jobs and families.

“Why don't they come anymore?” I ask the intern.

“I don't know,” she muses. “It's almost like they have stopped caring what happens.”

What happens next in my life seems to have occurred almost by design: “I have bad news,” an acquaintance phones to tell me. “Brad had a stroke — he's in the ICU.”

I have known Brad since my student days. Alarmed, I rush in. He lies in intensive care, intubated and senseless after undergoing emergency neurosurgery for a brain hemorrhage. His head is bandaged, and there are tubes everywhere. The ventilator displays reassuring numbers, but an intubated patient dependent on a machine to draw breath seems the epitome of vulnerability. His blood pressure is precariously high. A drain tube snakes out of his skull. A urinary catheter hangs off the other end of the bed. There are multiple IV lines, a nasogastric tube, bulky compression stockings on his legs, mittens on his hands. Even with his substantial build, Brad seems dwarfed by the surrounding paraphernalia.

Visiting on the days that follow, I edge my chair close to his bed. I say a few words, self-consciously wondering whether he can hear me. His extubation is the first opportunity to assess recovery. To everyone's disappointment, he exhibits unilateral neglect and excessive agitation. Within a day, he is diagnosed with pneumonia. It is impossible to ascertain whether he is agitated owing to pain, pneumonia, or the stroke.

The fog in his head seems dense. Even without sedation, he can stay awake only for minutes. If you stand in front of him, his gaze might meet yours, but it takes the eye of faith to read recognition into it.

“Take my hand,” I urge. Sometimes I imagine a weak squeeze in return, but other times his hand falls limply to the side. The effort of turning in bed is too much. His face becomes red and flushed as he rests back, defeated.

An uncomfortable witness to his situation, I reach reflexively for my phone. But I had to turn it off, so I cannot go through my messages and pictures, which are months old and of no consequence but would make for an easy distraction. My newspaper is unwieldy in the small space. The precautionary gown and gloves makes it even more impractical to hold Brad's hand. A touch through powdery gloves feels slippery in practice and intent. I look up, but there is not even a muted television screen to stare at mindlessly. The nurse busies herself with the next round of medications, and we make small talk. I tell her Brad and I go back 20 years. “That's special, Brad!” she enthuses. He looks at her blankly and innocently. My heart sinks. It seems unkind to leave but painful to stay.

And so it is during repeated visits to Brad that I realize just how difficult and lonely visiting a patient can be. In fact, the sicker and needier the patient, the harder it is. Sitting with Brad, with neither conversation nor technology to distract me, I am forced to consider the vagaries of life. There we were, only 2 weeks ago, relishing lunch on a patch of green and watching my children bounce on the trampoline. For all I know, we may have had our last full conversation. As I take in his tired body, I fear what lies ahead for him. Will his pneumonia worsen? Will his hypertension abate? Will he be able to recall the countries he has traveled to and the books he has read? No doctor knows. No test can tell. To be in the powerhouse of medicine and yet be stumped by these questions is maddening. Brad's fate could be anyone's fate — it is an introduction to one's mortality, and it gives pause for thought.

And slowly, I see why it might be easier to just make phone calls from the safety of one's home than to be witness to a seemingly unending stream of medical misfortunes. Or why it might seem like a good idea to slow down the visits or find a dozen other things that take precedence over visiting someone in the hospital.

In response to my expectant eyes one day, Brad's doctor summarizes his progress. Her first five sentences are laden with medical jargon, which I follow silently until she halts. “I am sorry — are you a doctor?”

“Yes, but I am here as his friend.”

“OK, so you understand.” She relaxes and continues her summary.

In fact, I have many questions and even more worries, but with her feet already pointed toward the door, I feel like an intruder.

I would like to deny it, but in her, I see a reflection of myself and my colleagues, and it makes me feel ill at ease. I wonder if we become so accustomed to speaking in jargon that it becomes the dialect of first choice. How little must patients and their relatives really understand of our attempts to communicate with them. How many cues are missed on an average ward round? Could the way we talk make relatives feel uncomfortable instead of involved?

My mind goes back to the Wilson family. Their reticence now seems somewhat easier to understand, their silence easier to sympathize with. I can't remember the last time someone arranged to sit down with them, although many teams diligently flock past his bedside every day. I am confident that our pessimism is matched by their lack of empowerment. I realize that their puzzling reaction to illness is not so much selfishness as self-insulation.

I am not quite sure yet how I will teach my young intern the difference, but I feel lighter for knowing it myself.

Little children

So.. after my first day of 8 weeks of pediatrics, I can say almost with certainty that pediatrics is not my passion. I like kids in real life. just not in the medical field. The commotion during the history, the crying when you're doing a physical exam, and not actually being able to talk with most of them... when it comes to medical stuff, I just think I like adults.

I found myself fascinated by the parents today:

The father who I immediately judged as I walked in the room by his loosely fitting pants perilously hanging from his hips, the long hair and the unsmiling demeanor. But as I watched him throughout the interview I was impressed with how loving a father he was. He seemed to always know what his nonverbal daughter needed~he suctioned her airways, he managed the feeding tubes and he lifted her weak body into his arms to hold her safely to himself. I saw his stressed and sick child crumple peacefully in the security of his arms.

Another mother came in with her 4 year old daughter. She was a single mom, frazzled, sleepless with dark rings around the eyes on her bare face. Her hair pulled back in the pony tail that tells the tale of a woman with no time for herself. She was harassed and short tempered and had unending exhaustion. I wanted to take her aside and know how she was doing. How she was holding up in the chaos of her life... And I wondered what happens when she lost her last straw of sanity...

I think I would be a pretty sucky pediatrician.

Thank you for remembering that I'm a person too

Patients desire their healthcare workers to treat them like humans. I am the first to understand this importance. My family was blessed with incredible doctors, nurses and others who took care of my brother and our family, who explained and who sympathized and who treated our family like human beings.

But there's something to be said for patients treating their healthcare professionals like humans too. I didn't realize it until I was taking care of this gentleman with end stage lung cancer. Our team almost fought over who got to see him. He might be the only patient on our service who had every one of the residents come and visit him in the morning. I tried to explain it later that day, and the only way I could, was to say that this man and his wife treated us like people. There was no fast interview. Before I could get any questions out about shortness of breath, they were asking questions about me and how I was doing. It was actually awkward at first. He was so active and at peace with where he was in life. His goal was to maintain mobility. His wife's goal was to love him and surround him by family. They were realistic and didn't expect us to be miracle workers. As selfish as it sounds, they invested in us and it was profound.

Dialysis

Dialysis is a sobering place. And in the last several weeks it's come to stand for irreversible illness. I see people tethered to the area, unable to escape even for a few days, because on Monday they have to be back hooked up to the dialysis machines. Those lines connecting them to machines filtering out the toxins that threaten to be so deadly.

I guess I should start by telling you about the patient that has triggered my feelings towards that windowless room at the ground floor of Akron City Hospital. I first met Jane in the emergency room at 11pm one night when my team was admitting. I had just finished another patient's admitting orders when my senior resident got a call about her. "Umm... while I finish up this paperwork, take a look at her lab values and see what you think!" When residents have said this before, they usually mean some subtle lab difference that I'll never pick up on, so I was surprised when the Creatinine level of 21 jumped out at me. Normally, Cr is below 1 and I honestly didn't know it was possible for someone to have a level that high! I quickly glanced at the patient's age and looked over the list of other diseases she had, completely expecting some 90 year old lady with diagnosed (yet uncontrolled) end stage renal failure. But no. Jane was 51 years old and had no diseases that she had been diagnosed w/ or was being treated for. By her own accounts she had always been healthy. As I began to take her history and she told me her story, I learned that she had had a workup at the other major hospital in Akron which had proved to be inconclusive, and Jane, frustrated, stopped following up. I stood there in her room as she told me about her symptoms, the stress of a recent job loss, and the frustration of her persistent nausea and vomiting. I was in the suffocating ER as Jane laid in that inhuman excuse of a room, partitioned off from the next patient by 3 curtains protecting her privacy. As the word "dialysis" was stated as a likely possibility, I was there to watch the the instant reaction on the face of Jane and her daughter.

I saw her the next morning as resident after resident, and attending after attending visited her to talk about her prognosis. I observed the light slowly drain out of her eyes throughout the morning as she approached the catheter placement. And I visited her nearly every morning of her 10 day hospitalization. You've never felt so much peace as you walk into a room. Here was a woman with deathly low kidney functioning telling you how important it was for her to wash up every morning and "get ready for the day" so she could continue to feel human through this all.

And when she started dialysis, I went there to get her history morning after morning. I talked about how her body was responding and listened to her lungs and heart as the dialysis machine whirled on and on in the background--pumping blood in and out of her body as she lay there confined to her bed as that machine worked to keep her body from shutting down.

But I'll never forget that one conversation. I was pretty annoyed that morning, and I had 2 hours to see just one patient. But Jane was that one patient. I headed down to dialysis to do my usual check in. By this point she was only in the hospital to wait for medicaid to kick in and we really were doing nothing more than dialysis to manage her medically. But I still went to say hi. And I asked her how she was really doing. I find that's quite a different question that "how are you doing this morning?" And she answered me. I leaned against the counter in that crowded little space as Jane poured out her heart about the devastation of the diagnosis. How one day she was healthy with a job and a life and a future, and the next she's tethered to Akron and to dialysis. How will she work when she needs to be in that windowless room 3 days a week? Her dreams of "someday getting around to traveling" are over. She's here. Her health has now become her life. Her renal disease now dictates all of her activities and functioning.

I was, in short, humbled by this conversation. Here was a woman who was independent. Who lived life. Who had a family, had a job, and functioning completely as her own person. And yet she wasn't beyond disease. It made me re-evaluate how I live my life. It reminds me of my own conviction that I never want to wake up one day and realized that I've forgotten to live. I want to live. I want to love. I want to invest in relationships. And Jane reminded me that nothing is certain. That there are no guarantees in life.

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?

Mortality

I layed in bed last night with my mind racing. Planning how I would react if I got in a car accident on my way back to Youngstown this evening. Walking through what I would do and how it would feel to be in a trauma bay with my classmates in the room as I lay on the bed with my clothes cut off and tubing being shoved down my throat. As I was lying there, I remembered my drive home from the hospital on Thursday. How I played through the same scenerio. How I pictured the humiliation of being wheeled into the trauma bay at St. E’s with all the residents and attendings that have been my colleagues and teachers for the last few weeks.

These are new thoughts for me. Working in the ICU with teenage patients, healthy 40-something year olds and college students who have been taken out by a car accident, ATV crash, or any other freak accident you can imagine seems to have brought me to terms with my mortality. Seeing previously healthy people being knocked down by accident and illness with no prior hints has been humbling to me. Who am I to think that I’m above a freak accident? Who am I to think that “this” could never happen to me?

I had my first patient who was actively dying on Friday. It didn’t phase me much at the time. I was engaged and interested, but not really bothered by the idea that this man most likely could be ‘expired’ by morning. But then this morning at church we were singing “Sin has lost its power, death has lost its sting” and it all of a sudden hit me. I wondered if I could really rest in God's assurance that he's bigger than death. While I feel death carries no fear for me, can I say the same thing for my patients? For the human lives that I work with that aren’t walking with Christ? This has the makings for an interesting year.

In the back of my mind, I always wondered if I'd love medicine and being at the hospital as much as I thought I would. You sit in classrooms and pouring through books for years anticipating that one day you'll be with patients and it will all be worth it. The funny thing is that it's a mere hope; that at the end of the day the years of work and the $100 thousand that you've invested in your education will be worth it. Well, last week proved that I do love medicine every bit as much as I thought I did. I think it's a good sign when you spend 30+ hours straight at the hospital and aren't counting down the hours till you can go home. I love the patients (as crazy as they can be), I love the residents, I love the smell and feel of the halls of the hospital. I love suturing, and procedures, and even being confused. I can't believe I'm lucky enough to go into a field that I'm this passionate about.

the book that I love.

For 6 months I've carried around this book. It's not intimidatingly overwhelming from the outside--no more than your average textbook. It has "First Aid" plastered in large font over the front cover, implying a simpler topic than what's below it "USMLE Step 1". But it contains 80% of the information (in abbreviated form) of what I need to know. I've lived with this book for months. I've read through each page 3-4 times now. I've noted each bullet point that is representative of an hour of lecture. I've highlighted and I've neatly printed elaborating notes and important points in the margins. The pharmacology pages are neatly marked with post-its. This book has almost become an extension of myself. My own handwriting throughout. My own notes. My own emphasis on important points, or on points that for the life of me I can't remember. As much as studying has been tedious, I still love this book. I love the knowledge that it holds. I love the centuries of research and discovery that this little book opens to me in simple statements.

I've complained that it's tedious and a bit monotonous, but I had a realization on Saturday. Numbers 11 talks of how the Israelites complained about the manna--how there wasn't enough diversity and that they were "bored" of the manna. And while I know there are great spiritual depths here that i have left unexplored, what struck me was their ingratitude for a blessing. This was convicting in the wake of my life of studying. I've always said that my education and the pursuit of medicine was something that was a huge blessing to me. One of the greatest gifts that God has given me. Why, then, am I complaining for living in "only" this blessing for the time being? Shouldn't any blessing of God's be blessing enough? So the next morning when I opened my books, I had a new perspective.

Ok, that was a good study break--back to the books :)

And here comes the sun

What I've noted about transitions over the years is that they are often accompanied by regret for the path we're leaving, and fear of the path we're approaching. But for some reason I've had neither emotion as I approach this particular transition. I have an appreciation for where I am now and where I've been for the last 15 years of classroom education. I can enjoy (loosely used term) the next two months of studying on my own schedule and taking breaks when I feel like it. I've learned what discipline is (and how bad I often am at it). It's been a fun type of freedom and has allowed me to invest and build relationships and gave me time to wrestle with things outside of my profession.

But just beyond is a new type of learning. Just on the other side of this transition is a practicality and a set of skills, not just knowledge, for me to learn. On the other side is the immersion into why I've worked so hard towards for the last decade. And as scary as it is, there's a hope and an excitement of remembering regularly the calling that God's given me which is so easy to forget amidst books and papers and projects. I'm not naive. I know that next year is going to bring its whole set of challenges, humiliations, frustrations, inadequacies and sleepless months. But it stands for something. And for that reason, the anticipation and the hope far outweighs the fear.

Since this blog is mostly for myself anyways, I feel like I need to save this devo that was sent to my inbox mere days after the previous post. Who can accuse God of not knowing what we need to hear.

Be Perfect, therefore, As your Heavenly Father is perfect. Matthew 5:48

Bob sat across from me at our monthly McDonald’s breakfast time together. We saw each other almost daily, rushing past each other in the hospital, but this was our scheduled time to be friends. He was struggling with an issue in his life.

“I was raised to do everything well. That got me through medical school and it has worked well to build my practice. But I’m dropping all kind of balls lately. I have a patient I was working up for back pain. Before I could get the tests done, he was paralyzed from a cord compression, a cancer in his spine. I have another patient with a mammogram that was positive; the report was lost and I didn’t see it for three months. She was not at all happy. I missed my daughter’s gymnastic competition because an emergency came in. I feel like I’m failing everywhere.” I answered him the best way I knew how, “So, you want to be perfect, like me?”

As doctors we are hardwired to be achievers. God placed within us the character to do our best, to get things right---for His glory and for mankind’s benefit. As doctors, mothers, fathers, spouses, church members, we are called by God to excellence; and we expect that from ourselves. But sometimes we carry that expectation too far. Sometimes we expect perfection from our efforts and make perfect performance into an idol. If we choose to do so, at some point that idol will topple over on us and cause us great pain, for we will never be perfect in this life.

There is a clear distinction between excellence and perfection. Excellence is measured by great effort. Perfection is measured by results. God cares about our effort but He does not expect perfect results. When Jesus calls us to be perfect in Matthew 5:48, He is not asking for perfect results; He is calling us toward wholehearted devotion to our Father in heaven. He wants us to do all things well for His glory (Col 3:23), to pour ourselves out in sacrificial service. He wants us to serve Him with our very best, but He expects for us to leave the results to Him (Phil 1:6).

We are called by God to strive for excellence by remaining well read and well skilled, by disciplining ourselves to do our best with each patient and with our families. God smiles on us when we pour ourselves out to serve Him with our best in all areas of our lives. But as we do, we must continually hand the results of these efforts back to Him. Only He knows how to use them well to write His story of redemption.

never good enough

Perfectionists. The sad breed of humanity that feeds off of affirmation and action-oriented accomplishments. What drives these people to such a self-torturing lifestyle? Why the need to prove themselves? Why the need to control? I guess I should acknowledge the good in perfectionists. They're hard working, determined, motivated, disciplined and reliable. But they can't just let things be.

Group projects are the bane of their existence. "Just scraping by" isn't an option and inevitably they become the "mother" of the group emailing about deadlines, tracking people down and making sure everything gets done. All the while thinking to themselves "I could get this done SO much faster by myself."

I'm glad to say that my perfectionism has softened in the years of medical school (..and college...) I've learned to delegate, to rely more on my leadership than on my compulsion to do everything myself. I've learned that perfection is unattainable in a class of 115 of the brightest students. I've learned that I will never be able to learn everything that I need to know. I've learned the impossibility of knowing everything and being the best and being perfect. More than that, I've learned that I don't want to be perfect. I want to make mistakes in my life. I want to be stupid occassionally. To screw up. To have to admit that I'm human. To risk rejection. To really truly allow people to love me for who I am instead of loving me for the perfect image of myself that I try to project.

But every once in a while the perfectionist inside me gets the best of me, leaving me frustrated, discouraged and insecure. Knowing that as an M2 (2nd year med student) I should have certain competencies and I still feel incompetent. That I still can't do an effective physical exam with any level of confidence of what I'm trying to find. That I still get awkward when taking histories and get nervous and embarrassed in front of my attendings. That I can't remember diseases and criteria that i learned weeks ago. That my brain is just to small and my skills are too limited. The feelings of inadequacy flood over me and plague me with self-doubt and insecurity.