Chapters 25 and 26, "The third year, uncertain directions" and "It gets better"

 

Chapter 25: The third year, uncertain directions

I returned from my Japan trip feeling refreshed. I would start my third year of medical school in Spokane, WA. I had moved in to a house with my Friends Laura and Kevin. My first rotation would be OBGYN. I was both nervous and excited. In second year I had spent time with a  family medicine physician at a maternity clinic, and a small part of me thought that I might go into OBGYN. I felt somewhat ready because of that extra time. I scanned the syllabus and schedule to try and get a sense of what my life would be like. It looked like there was a combination of clinic, surgeries, and labor and delivery. The fist day would be a brief orientation. I was thankful for that, because it would be much lower stress. I looked up the recommended texts and study plans—there would be a large test at the end of the 4 week rotation. After mentally preparing and visualizing what the next morning would look like, I went to bed. The following morning I had a quick cup of coffee then drove to the hospital. I met up with the other students on OBGYN, I knew most of them, then the clerkship director introduced himself and began explaining how the rotation would work. We were all partnered with different clinics. For me, I would come in each morning and work with one of the attendings in the clinic. There was a scheduler we were to check in with the afternoon before to learn about any surgeries happening in the morning prior to clinic, and we were encouraged to sign up for as many as we wanted, and talk to the specific attending before so that they knew we were coming. They told us that to be allowed in surgery we had to have evidence that we studied both the surgery and the patient beforehand. It seemed reasonable. We were then each assigned a different two weeks in the labor and delivery unit, then informed that every week would be assigned a call day with an attending, where we could be called in at any time for surgery. Call days were 30 hours long. The clerkship rules from the school informed us that if we were up all night for surgery or delivery, that we should not come into clinic the next morning and should sleep instead. Several of the attending physicians around me told me that I should ignore that rule, and that the other doctors would look poorly on me if I followed those instructions. I was confused because I was fairly certain that the hour restrictions were through the American College of Graduate Medical Education, and that schools had to follow those rules in order to maintain accreditation. I was beginning to worry about this rotation. That afternoon I check in with the scheduler and find out that there will be a hysterectomy the following morning with a Doctor B. It’s one of the surgeries I’ve watched before, and so I sign up. I find Doctor B afterwards and let him know. He’s a curt bald man who tells me that I better be familiar with the procedure and the patient and that he’ll throw me out of the operating room if I am not. I try to sound agreeable. Then I gather my stuff and get ready to go home.

              When I get home I make a quick diner and grab a beer and start studying the procedure and patient, as well as some common OBGYN clinic problems. I start to feel ready and comfortable about tomorrow. I watch a video briefly of a hysterectomy on youtube to review before going to sleep.

              The next morning I wake up, drink my coffee, drive to the hospital, ad proceed to the OR. I introduce myself to the OR front desk. They show me where to get changed and which room Doctor B will be in. I change and go to the room. The techs and nurse are outside. I introduce myself and explain my role. They ask me if I’ve ever scrubbed into an OR before. I tell them yes. The tech insists on watching me to ensure that I do it correctly, then ask what glove size I am. I tell them 6.5, and then begin the ceremonial scrub. The tech is satisfied by my technique. Then I enter the room and the tech dons me in a gown and gloves. Doctor B is not here yet, nor the patient. I stand in the corner of the room, being sure to keep myself sterile. Eventually Doctor B enters. I tell him good morning. He asks me if I introduced myself to the patient already. I told him no, that I just came to the OR and tried to get ready. He told me that I needed to introduce myself to every patient I would operate on. I ask him which room the patient was in and that I could go do it then. He tells me not to because it would waste sterile equipment. So I wait. Eventually the patient is rolled into the OR with the anesthesiologist. She’s already starting to fall asleep. I walk up to her and try to introduce myself and explain my role. She tells me that she’s OK with me being in the room and I thank her. Then we begin prepping for surgery. Lines are placed, clothes removed, antiseptic scrub applied, instruments laid out. I’m told to stand off to the side and not get in the way. Doctor B asks if I studied the surgery. I tell him yes. He asks the first steps. I answer correctly. He asks what structures need to be avoided. I tell him the ureters. He then asks me about the patient, why is she getting this surgery? I tell him endometrial cancer, which is true. Despite this he seems unsatisfied with my answers. Finally we’re ready to begin. It will be a laproscopic surgery—small incisions and cameras. Doctor B makes some quick incisions, the patient’s abdomen is filled with gas to create a cavernous space to maneuver the cameras in. Doctor B inserts one of the cameras and then hands it to me to direct. He explains how to move the camera and its controls, as well as which structures to focus on. On the screen a mass of intestines and organs appear. The intestines are fatty and oily, sitting lower down in the middle is the uterus, with a ball shape ovary on either side. IN contrast to the intestines it is deeply pink. I move the camera as directed. Doctor B begins cutting with the long metal laparoscopic tools. They use cautery, and the smell of burning flesh soon fills the room. He asks me which structures he’s cutting. I answer correctly. He starts to move his tools and I follow with the camera. He yells at me and tells me to only move when he tells me. I hold the camera steady. Then he moves to the next structure. He lets go briefly of one of the tools and slaps the top of my hands and tells me to make sure I follow his movements and always keep the tools in the center of the screen. I tell him I will do that, and he asks another assistant to take over the camera movement and I’m relegated to the side. I’m now in charge of the suction, to collect the excess smoke from cautery to make sure the field is clear at all times. It’s a relatively easy job. The surgery continues. I’m asked more questions. Eventually we get the uterus out. It’s placed in a large plastic bag and removed through one of the larger initial incisions. I hold it. It’s warm and lumpy and bloody. It feels strange to hold an organ that was minutes ago a part of someone. Next it was time to close up the incisions. Doctor B asks me if I’ve sutured before. I tell him yes. I had actually practiced a few nights ago and felt rather capable. He told me he would sew up one incision, and that I could do the next if I did it exactly the same way. He sews up the largest incision. Then hands me the tools and points to the smallest to do. I thank him, and begin to prepare, but immediately he slaps my hands and tells me “I thought you knew how to suture?? Is that how you were taught to hold your instruments?” He grabs my hands and tries to reposition the instruments in my hand, aggressively. After some more yelling I’m allowed to place one suture, and then Doctor B finishes up, doffs his sterile gear, and states he’s going back to clinic. The Tech looks at me and tells me not to worry, and that Doctor B is always like this. I thank her. I help them clean up the room, then doff my sterile gown and start heading toward clinic. I grab a cup of coffee along the way. When I get to the clinic, Doctor B is at the counter. He tells me I’ll be working with him and hands me a patient list. He tells me to interview the patient then present and then we’ll go in together. I sit down at the student laptop with my coffee and begin reading about the upcoming patients. Doctor B grabs my coffee and throws it in the trash and tells me that I can’t drink next to the computers, stating that a student once spilled on them. The nurse over the counter retorts that that was actually one of the other attendings. Doctor B snorts. Tired, I continue to read up on the patients. Then Doctor B turns to me and says, “whatever you’ve heard, I’ve turned over a new leaf with medical students.” I am doubtful. The fist patient comes in, it’s a third-trimester general check-up. She’s up to date on her vaccinations and all prepared for delivery in a few weeks. She and her husband are excited. I present the patient. The Doctor B goes into the room. I follow. He gives the patient an enormous large and tight warm hug, nearly caressing her whole body. Telling her how great it is to see her. The husband appears mildly uncomfortable. Then he peppers them with questions about the baby. Have they decided on a name? Are they feeling ready? Do they have everything prepared at home? Etc. He asks if they have any questions, they are wondering about delivery date. He tells them a few weeks, then informs them that a different physician in his clinic will be on call on the expected date so he will not be able to personally deliver the baby. They ask if they can make it happen early or delay it in order to have him deliver because he is who they have seen the whole time. He tells them they could try inducing birth early, then talks about risks and benefits. They decide to just wait, and then the visit is over.

              I see a few other patients before the day is over. I learn that Doctor B is an incredibly spiteful and mean man to medical students. I reach out to some of the upper class-persons I know who inform me that this is actually a pattern for him and that he had been previously banned from interacting with medical students. I thought to myself, how did I get so unlucky? With such a stressful and important process, how could the school allow for such a terrible instructor to continue to teach its students? I hoped that I would never work with Doctor B again; however, I would not turn out so lucky.

…

              The remainder of the three week rotation is similar, although I have a chance to work with kinder and more professorial attendings, for which I’m grateful for. The two weeks of labor and delivery are torture. There is no direction or supervising attending physician. I work with the family medicine residents, who are competing for procedures, patients, and births, and so I receive little hands-on or teaching experience during the rotation. By the end of the three weeks I am so disappointed by the OBGYN community that I want nothing to do with the subject ever again. I’m disappointed because in second year I truly thought it would be a potential career path. I take the clerkship exam at the end, which goes fairly well. I feel validated that I actually learned something, despite the malignant doctors that I had to work with. After all is said and done I receive my evaluations for the rotation. I get a pass, the equivalent of a C, I read the comments and I recognize Doctor B’s voice in them. I’m angry and feel betrayed. I put in good effort and learned a lot, but couldn’t do anything about the personalities I worked with. Elizabeth suggested I filed a complaint and a grade change given Doctor B’s history with medical students. I considered it, but eventually decided that it would be too much effort for worth. I was angry and I felt like there was nothing I could have done differently to change the outcome. In retrospect I likely should have challenged the grade. At the time I did not realize that that first low grade of “pass” would leave a prolonged, lasting impact on my medical future and my options in career and residency location. I felt so angry that one vindictive man could have such a tremendous influence on an individual’s future, and wondered how someone so cruel had gotten into medical education. When our futures our decided by single persons based on what feels like nothing objective, it’s no wonder that medical students become dejected, depressed, and defeated, and later vindictive. There was a culture in the medical education system of rigor and cruelty that needed to change, but none of us could do anything until we worked up the ladder. At that moment I decided that I wanted to end up in medical education, and to be a positive, kind influence on the whole system as best I could. And alas, I feel ashamed that I was unable to achieve that goal. And so I hope that others reading this feel a similar drive to improve medical education in my stead. Thank you.

Chapter 17: it gets better

              After the OBGYN rotation, I decided that I would never go into OBGYN given how unenjoyable the work environment was. And I began to wonder if I would even go into family medicine due to the OBGYN element as well. I was devastated. I felt like I no longer had direction in terms of medical career. The upcoming rotations, however, were much better. I completed psychiatry and pediatrics in Spokane. I enjoyed both. The pediatricians were very kind, and the medicine was very interesting. I admit I considered pediatrics briefly after the rotation, but realized that I did not enjoy well-child exams, which I knew would be the bulk of pediatrics. The other factor was that I learned one would have to complete a fellowship to become a hospitalist in pediatrics, which is what I would have done because I found the hospital medicine the most interesting. I was not interested in that additional training for what you should likely have learned in residency anyway because most of pediatric residency was inpatient. It seemed absurd that there should be a hospitalist fellowship, and felt to me like a money grab by the board and licensing organizations.

              Then it was time to move briefly to Seattle for my internal medicine rotation. The school would re-imburse us for lodging to offset the cost, which I thought was generous. I found a long-term air BnB that was nearby multiple bus stops to get to the three hospitals in Seattle that I would be working at (harborview, UW, and the VA). I was excited to come back to Seattle briefly and see my friends and family. I packed lightly and made the drive from Spokane to Seattle. The Air BnB was a small condo. I get there and the owner introduces himself and leads me into the space. It’s a nice, decently sized space with a small living room, kitchen, desk and work area, and a cubby-space with a bed in it. After showing the space and giving me the keys and key codes, as well as the wifi password, the man explains to me that I cannot talk to the other residents in the condo complex. He tells me that they are technically not allowed to do Air BnB through their HOA. I find this strange and ask what I should do if I encounter one. He says that I should tell them I’m a cousin staying over. I agree, although it is somewhat stressful, then he hands me a zoned parking pass for my car. We shake hands, he leaves, then I go down and move my few boxes into the condo and hang up the parking pass. Luckily I don’t encounter any other residents.

              I reach out to my brother and his fiancé, now that I’m in Seattle. They are going out for drinks tonight and then going to Ru Paul’s Drag Race. I look at my schedule, tomorrow morning I start at Harborview at 7 in the morning, and I may be on a call shift until 10 am the following morning. It’s a 40 minute commute to the hospital. I haven’t seen Zach and JP in a while and decide to go. I could always leave early, as long as I got around 6 hours of sleep, it would be OK, right?

              I meet them downtown for drinks at a Japanese bar. We have a couple, including some tequila shots that JP orders. This is definitely a bad idea. I decide not to buy an extra ticket to the show so that I can leave early. We catch up for a while, and then it’s time for them to go to the show. I tell them I’m going home and to bed. We say our goodbyes. I order an uber. I feel somewhere between tipsy and drunk. This is not good, I think to myself. Back in the condo I make myself the WHO oral rehydration solution—used for Cholera treatment—and chug it before brushing my teeth, setting an alarm, and going to bed. I had packed my bag beforehand. I felt ready. I wake up at 5:30 in the morning after approximately 6 hours of sleep. I’m very mildly hungover, just tired with a light headache. I make and drink some coffee, grab glass of water, then take my bag and head over to the bus stop. My University of Washington student card gives me free passage on the bus. It brings me to Harborview. As we cross the bridge from the north part of the city into the main city, I admire how beautiful the city and mountains are against the water and clear sky. When I get to Harborview, there are other medical students waiting just outside the front entrance. I meet up with them, we introduce each other and talk about what other rotations we’ve done. We agree to enter together to go to the orientation room. Like most rotations this one would begin with an orientation. Inside the room there is kindly-appearing older doctor, we’ll name Dr. S, wearing pride gear sitting at the head of a circle of tables, with papers laid out next to several seats with our names on them. Doctor S would turn out to be one of the kindest doctors I ever met, and would become a major reason for my future decision to pursue internal medicine in the future. Doctor S explains to us how the rotation will work. We will each be assigned to different teams and rotate every week or so. All the teams were on an every 4 day call schedule, where every fourth day we will stay overnight in the hospital for a total of 28 hours. Then he explains the lecture schedule and our other assignments. Looking at the schedule I begin to get excited. I am going to start with team B, which also happened to be the infectious disease team. During the first two years of medical school I was fascinated by infectious disease, and I was additionally interested in the social aspects of infectious disease, especially after reading the works of Paul Farmer.