Dear Intern

Dear Intern,

It will be the best of times and it will be the worst of times.

And what a special time this will be. This will be a time of learning. You will learn the details and nuances of clinical medicine — the diagnostic features of sarcoidosis and the second, third, and fourth line treatments for community acquired pneumonia. You will learn how to learn, and you will forget what you learned, only to learn it again. You will sometimes wonder if your brain can possibly store any more information. And often it can’t. But sometimes it will.

In the beginning of the year, you will find that although internship is about learning the secrets of disease, it is equally about learning the secrets of yourself. When an insurance company refuses to cover an important MRI, you will witness the intensity of your anger. When your hearing-impaired patient misses her appointment because she cannot find transportation, you will feel the depths of her sadness. And on the eleventh day of a twelve-day call block, you will wonder why anyone would choose to do this work under his own volition. Why would you attach your life to the suffering of others, why would you hide yourself in the shadows of illness? But then while cleaning your desk on a quiet October night, you will come across your medical school application essay. You will be struck by the curiosity in your voice and the excitement in your thoughts. But you will be saddened upon realizing that in your relentless pursuit of tomorrow, you have forgotten that today contains everything you have desired.

In these moments of insight, you will realize that happiness is a choice, and that medicine like anything else is a mix of awe and awful. You can choose awful. You can choose to hear the screams of suffering patients, mock the outdated technology, and avoid the rooms filled with the scent of staleness. But you can also choose awe. You can choose to remember the stories that make you tremble with emotion, like Mr. J the thirty-two year-old singer who you will admit to the ICU for a life-threatening abdominal infection. His parents will tell you that he was supposed to get married that week, and the sadness in their voice will make it difficult for you to sleep. You will look for someone or something to blame, but instead you must find someone or something to believe in, because good things can happen to good people. Four weeks later, you will stand by his hospital bedside with a beaming smile as you watch him, the handsome groom, be married to her, his beautiful bride.

During the harsh winter, you will sometimes resent your friends in other professions. You will see pictures of their new homes and weekend getaways, and you will want to get away. After a tiring day at work, you will propose that your team go out for dinner. But the entire conversation will be about the very job that you came to dinner to get away from. In moments like these, you will realize that you never really wanted to get away, that you may have chosen this profession, but by now, it has also chosen you.

By March, you will have learned to never underestimate the recovery of the human body or the resilience of the human mind. You will have repeatedly observed that the best predictor of a sick patient is a worried nurse. And you will have found that when you are tired, anger comes easy and kindness takes effort – especially kindness toward people who are not kind toward you.

As the sun returns in April, you will begin to feel burdened by the looming expectations of a new year and a new role. Some mornings, you will walk into the hospital feeling like an imposter – as if you stole your badge, stethoscope, and medical degree from someone else. You will inevitably make mistakes, some of which may harm patients. And when this happens, you will hate every cell in your body. You will promise to never see a patient again. But hopefully you will remember that time as a medical student, when Ms. G, the homemaker from Santa Rosa California, told you that you will make a kind and thoughtful doctor one day. You truly it believed it then, and it is important that you believe it now.

As the year comes to a close, you will begin to accept that this job is unfathomably difficult, although your attendings will make it look remarkably simple. You will envy their intuition about patient care and their ability to manage difficult conversations. You will envy their schedule. They will arrive at nine in the morning with a bag of bagels and cream cheese, and you will want nothing more than to one day be an attending yourself. But perhaps, when that day comes, you will arrive to the workroom and see your team, surrounded by unfinished notes and finished cups of coffee, and you will want nothing more than to be a resident again — when it was ok to not know, when every diagnosis felt new and every emotion felt raw.

Finally, I would like to congratulate you. From now until forever, the letters M.D. will follow your name. But I would also like to caution you. Please remember that medicine is not who you are, it is simply a thing you do. You are a brother, a Hindu, a Rockets fan, a best friend, a tennis player, and for some days of the week, a physician. So do not let these letters get too close. For if the M.D. erases the name that precedes it, you will become indistinguishable from many others who practice this profession. And you are too young and it is too early to let that happen.

Sincerely,

Muthu Alagappan, MD

Intern 2016-2017

 

 

*Published in a slightly different form on KevinMD.com at http://www.kevinmd.com/blog/2017/07/dear-intern-advice-first-year.html

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What I wish I had said

Mr. J, I first met you soon after an attack,
The cancer had spread to the bones of your back.
I tried to be calm and offer you hope,
but I had just lost a loved one, and was struggling to cope.
I asked how your day was and you answered me kindly,
and then you asked about mine, and it helped to remind me 
that a doctor’s hope is to heal and for that we rehearse,
but if we are hurt too, then our roles may reverse.
I wish I had thanked you for your compassion that day,
And told you that kindness is how most memories are made.
I wish I had asked about your grandchildren’s names,
As they laid by your side, engrossed in their games.
I wish I had promised you that good days were ahead,
To package the past, and look forward instead.
I wish we had talked about the source of your tears,
For medications ease pain, but only words can ease fears.
But I was busy that morning, and left it to fate,
Hoping that later, wouldn’t be a few hours too late.
My regrets are not many, but they replay in my head
Of conversations past, and what I wish I had said.

Crash

It’s 3 AM on a Tuesday night and despite being surrounded by patients, I am alone in the ICU. My mind drifts to memories from my childhood — to half-day Fridays and packed lunches, to weekend sleepovers and backyard football. I smile, recollecting the truths I was taught about the world: that love doesn’t die and that boys don’t cry, that good things happen to good people and that every story has a happy ending.

But the sound of a helicopter disrupts my thoughts, and a voice emerges on the intercom: “This is Medflight #3502, we have a 50 year old female in cardiogenic shock after a large anterior wall heart attack, ETA 15 minutes.” Adrenaline courses through my body, but I pretend to be calm. The older physicians never seem nervous. I quietly slip on my white coat, pocket my stethoscope, and page my resident for backup.

Within minutes, the automatic doors of the ICU swing open and a patient is rolled in on a stretcher by several emergency personnel. We meet them at the entrance and prepare to take responsibility for this woman’s life.

I first examine our patient. She is unconscious; a breathing tube emerges from her mouth and a machine ventilates her lungs. She looks Spanish, but I can’t be sure. She also looks relaxed — years from now, she will have no recollection of the day she almost died. I am glad the mind knows to turn off during the body’s most painful moments.

To her right is her husband. The first thing I notice are his tears, which now flow freely. He is being ushered away by our support staff, but he can’t bring himself to leave his wife’s side, likely a promise he made to her years ago when they first fell in love.

I stand across from the supervising nurse who has worked in this unit for 33 years. Her hands glide effortlessly across the patient’s body, starting IV’s and pushing medications. She has infused life into thousands of critically ill patients, many who will never recognize her face nor remember her name but will forever tell stories about the angels that saved them.

The cardiology fellow stands in the corner, intently watching the vital signs monitor. With each successive alarm, she yells out more commands, “we need access… I want levo hanging and epi in the room…the anterior wall is down, activate the cath lab…” But beneath the jargon and behind the white coat, her words mean something entirely different: “please don’t go…not today, not now.”

Finally, my attention turns inward. My scrubs are wrinkled and the shoes I wear every day are starting to break at the sole. I was always eager to grow up, but now I want nothing more than to be a child again — back when love didn’t die and men didn’t cry. When good things happened to good people, and when every story had a happy ending.

Before and after

Mr. C is a kind, elderly Lebanese gentleman that I have taken care of for two weeks on the cardiology service. He has been quite sick — his heart has trouble squeezing and sometimes beats in abnormal rhythms that are hardly compatible with life, let alone comfort. There were several nights when we almost lost him. Nights when his room became a battleground for doctors and disease, while he sat motionless, caught in the crossfire. But in a manner beyond our understanding (which I am realizing is much of medicine), he has recovered and will soon be leaving the hospital.

I head toward his room, contemplating how I will say goodbye — “I hope to see you soon” sounds more ominous than pleasant, yet “it was a pleasure to take care of you” seems to imply that I found joy in his pain. I will likely just smile and say thank you.

I enter his room to find him alone, sitting near the wall in an old chair usually reserved for friends and family. He looks majestic, in a casual way. He has traded his hospital gown for a beautiful pair of faded jean overalls that he wears over an old gray t-shirt. His few belongings are packed in a small bag that he hugs tightly on his lap. With his back toward me, he is looking calmly out the window at the bustling streets of Boston. I tap his shoulder, careful not to startle him. I smile, and give him the good news. He smiles back. He looks again toward the window and points at the pedestrians rushing between office buildings — “Believe it or not, there was a time when I used to be able to walk that fast,” he says in a reminiscent tone. It is important to him that I agree, so I do.

I try to imagine what he was like when he was 26 — long before his heart had failed and his body had weakened. I hope he sang loudly at concerts and danced wildly at weddings. Like me, I bet he hated flossing, loved road trips, and feared public speaking. I imagine he worked hard at his job and cared deeply about his family. And I am sure he used to walk fast.

As a young physician, I often wonder what my patients were like before they entered the dreaded doors of the hospital. I suppose it is our curse that we do not get to know their former strength or their future dignity. But perhaps it is a blessing that we meet them when they need us most.

Stanford School of Medicine – Commencement Address 2016

“Thank you for this unbelievable honor to speak on behalf of the SMS graduating class of 2016. We sit before you today not because of our test scores or accomplishments but instead solely because McKinsey refused to hire us and our part-time startup didn’t pan out. This may be the only institution where dropping out is considered more successful than graduating. Of course, I’m only kidding. We could not be prouder of how far we’ve come nor more excited for what lies ahead.

I think it’s only appropriate to begin by saying thanks. First and foremost, thank you to the admissions office. We all make mistakes, and I’m certainly glad that you do as well. But on a serious note, we know that hundreds of others applicants deserved this opportunity as much as we did, so we are humbled by our good fortune. To the administration, Dean Minor and Dean Prober, thank you for your world-class leadership. With your vision, Stanford’s future appears even brighter than its distinguished past. To the faculty, you surprise us. How do you know so much about mitochondrial regulation of NADH in the Krebs cycle yet so little about Microsoft Powerpoint? But to be fair, you also inspire us. We hope to become 1/10th as knowledgeable, creative, and kind as you are today. To our dedicated E4Cs, your mentorship has been invaluable and one of the few constants during our time here as medical students. You are the only ones who truly understand how little we knew as first years and still how little we know as graduates. To our advising deans Drs. Ladd, Sibley, Knox, Salvatierra and especially Dr. G, thank you for your guidance throughout this journey. To my classmates, you continue to amaze me. You are without a doubt some of the most intelligent, caring, and hard-working people I have ever met. With you on our side, we will always have a chance in the fight against disease. To our parents, significant others, siblings, roommates, and friends, this day is as much about you as it is about us. You cared for us when we lost ourselves in the care of others, and that means everything. Words alone will never be enough to express our gratitude And to everyone else, this day is a manifestation of a lifetime of good luck and positive influences — from our great grandparents to our little league coaches, from our childhood neighbors to our loving uncles and aunts. To the teachers who encouraged us at a young age, the classmates that shared our enthusiasm for science, and the friends who taught us the value of being kind – we thank you. At my undergraduate commencement four years ago, the speaker, Senator Cory Booker told my class, “don’t act like you hit a triple when you were born on third base.” This day is a celebration, but it’s also a recognition that in one way or another, we were all born on third base. We are blessed beyond belief. Fellow graduates, would you join me in standing to thank everyone that made this day possible for you.

You may be wondering what we are feeling on a day like this. Honestly, we’re a little worried: are we ready for the real world? What if we get sued, or even worse, file for bankruptcy? Actually never mind, those things have happened to people before us and they’re doing quite well, in fact two of them are the nominees for president.

In just a few days, we will venture out into hospitals all over the country, but before we go, let’s spend one last time looking back at the road we traveled.

For many of us, our first medical school experience was the SWEAT camping trip, where we split into groups of 10 for a backpacking trip in the mountains. On my second night there, I found myself in a tent with two classmates, staring up at the secrets of the sky, losing myself in the wild expanse of the stars and silently thinking “I hope a bear doesn’t kill me.”

Next came the preclinical years. After our very first medical school exam, I distinctly remember opening an email titled “exam results.” After seeing my score, which was lower than expected and lower than many of my classmates, I thought there must be some mistake. As it turns out, there was a mistake, actually many mistakes, 24 to be exact. Apparently, I had learned close to nothing about the biochemistry of protein synthesis, but I had learned that I was now in the company of brilliance – which at times can feel intimidating, but mostly feels inspiring.

The learning curve in the preclinical years was steep, but we managed to find our way. We persevered through microbiology, physiology, anatomy, and immunology. And we also picked up some real world skills. For example, we learned that watching a one hour lecture on 2x speed is the perfect way to take a 30 minute nap. We learned that the four biggest risk factors for heart disease are hypertension, diabetes, smoking, and eating lunch at the VA cafeteria. And we learned that when professors say: “this is my last slide,” it means you have reached the halfway point of their lecture. These first two years were also marked by several moments of awe and inspiration. The human body is an amazing machine. To sustain life, millions of intricate mechanisms work together in perfect harmony. Our heart must pump, our lungs must oxygenate, our brain must process, our nerves must sense, and our immune system must defend… all so our eyes can mindlessly watch the Bachelor on a Tuesday night. But we also look back at moments of levity, where the footprints show us tripping, stumbling, and often falling directly onto our face. As a second-year, one of my classmates presented a patient as being allergic to NKDA without realizing that NKDA stands for no known drug allergies. Another time, in a cleaning reasoning session, a friend suggested treating a hypoglycemic patient with “4 dextrose”, which is actually pronounced “IV dextrose”.

It was on clinical rotations that we really came of age. Slowly, we acquired our quintessential “firsts” of medical school – our first real patient, our first suture in surgery, our first newborn delivery, our first code, and our first death. On the wards, we went from classmates to teammates, standing side by side in the trenches as we withstood the onslaught of disease, drug names, and didactics. We banded together, sharing tips and strategies for survival. One time, an older student pulled me aside to share that there are two ways to impress an attending 1) memorize the signs, symptoms, diagnostic workup, treatment, and natural history of every disease in their specialty, or 2) ask them about their research. There were also moments that affected us on a deeply emotional level. I had one of these experiences on my labor and delivery rotation as part of OBGYN. Our team was taking care of an expecting mother, and due to an unforeseen complication, we had to deliver her twins immediately. The room rushed into action and the attending assigned me to the role of holding the first infant while she would try desperately to save the second. In less than a minute, a baby girl was born and placed in my outstretched hands. The attending turned toward me for a brief second to say “Muthu, you got her?” and all I could do was nod my head. The physicians turned their attention to the second child, who was in critical condition, which left me alone by the bedside holding a 10 second old baby girl. I was the first person she had ever seen. I had my right hand behind her calf and my left hand behind her neck, and in that moment, not even an NFL linebacker could have taken her away from me. A few minutes later, both newborns were out and in the capable hands of a world-class neonatology service. Looking back, literally all I did was hold a 6 pound infant for three minutes without dropping her, but I was physically and emotionally exhausted. I disposed of my gloves, wiped my eyes, and thought to myself, everything was worth it. And that brings us to today, where I can confidently say those four words, everything was worth it.

There is this overwhelming perception of medical school that it’s stressful, tiring, and unforgiving, and at times, this is absolutely true. But I can’t imagine a better way to have spent these past few years. We made memories we’ll never forget with friends we’ll always have. And in a few short few years, we gained a lifetime of experience. We witnessed the resilience of a cancer survivor and the decisiveness of a trauma surgeon. We saw the unrivaled joy of a new mom and the devastating sadness of a new widow. With our stethoscopes, we listened to the first breaths of a newborn and the final breaths of war veteran. We live in a time where we are constantly reminded of what we don’t have, of what we must acquire to be complete – a bigger house, a faster car, more likes, more followers, more friends. It was in the hospital that I learned that we need none of these things to feel alive. All we need is hope and someone who cares about us. And as physicians, we can provide our patients with hope, and we can be the one that cares. It was in the hospital that I learned that while many questions can be answered by experiments and data, life’s most important questions can not: is it time to let go, will tomorrow be better than today, and what makes you happy? In fact, in a world so enamored by data, it’s interesting to note that data can only forecast, it can never foresee. It can predict what is likely to happen, but never what will happen. Data didn’t predict that many of us would have been admitted to this institution. It certainly didn’t predict that I, someone who had a speech impediment until middle school, would be speaking before you today. And it won’t predict the future for any of us.

So on this day, as we celebrate the road we traveled, let us also celebrate the uncertainty of the road that awaits. Let us do everything in our power to make tomorrow better than today, let us be conscientious and compassionate, let us care for our health and the health of others, let us never stop learning, and let us never stop questioning. But despite our best efforts, when the future undoubtedly throws us a curveball, let us rejoice, because as the saying goes: “life isn’t about waiting for the storm to pass, it’s about learning to dance in the rain.””