This is how it often is

We met on her second day of hospital admission. She was in her early 30s with a newly diagnosed leukemia. Her symptoms had been mild to start, and now she was here, admitted with cancer, about to begin chemotherapy. She had a six year old daughter at home. The walls were filled with artwork, family photographs, the annual Christmas card.

This is how it often is. You don’t have cancer until you do. The symptoms are mild at first – “I thought I had a terrible virus”, “I was so run down but I had been working so hard”, “My back was aching something terrible but I had just started CrossFit”. You’re living your normal life until it shatters.

I am a dermatologist who sees patients in the hospital when they experience side effects from cancer treatment, or have had a bone marrow transplant with skin complications, or have skin disease in either setting. This is not the role we usually envision for dermatologists. When I was an intern at a renowned academic teaching hospital, the ICU attending skipped over me while we were reviewing a chest X-ray on rounds. “You don’t have to know how to read this – in a few months you’ll just be doing Botox.” I was sleep-deprived, short on caffeine and the low woman on the totem pole, so I swallowed my tongue and folded it up as an anecdote I would later share with my own residents. As one of my mentors always says: you have to show skeptics your value, not tell them about it. Eventually they’ll come around.

The things I love most about medicine – the connections I have with my patients, the trust they have in me, the things I learn from them – are sometimes the hardest part of medicine. Patients often share their hopes and fears. They tell me things they have only told their closest families and friends. I had unprotected sex with someone who wasn’t my husband. I tried to kill myself. I don’t want to die. I never wanted to have children. I grew up in foster care and never had a family who loved me. It’s heavy. There is never any judgement, just a deep understanding of how complicated our world is. There is so much loss and pain, and on the flipside so much beauty and love.

Many times, my patients are soon in remission. The cancer was removed surgically, the cancer treatment worked, the bone marrow transplant gave them a new chance at life. I often don’t see these patients again, but some continue to visit me each year for a routine skin check, or because of a new rash. Those are joyful visits. I receive updates on wedding anniversaries, growing children, grandchildren, vacations – general life excitement.

Other times they never leave the hospital. Or they arrive to the hospital a different person. The complications pile on, everything goes wrong. Soon there is a planned discussion between oncology and the patient’s family. How aggressive do they want to be if new complications arise? Is it time to transition to comfort care? Whereas the first time we met they were sharing photographs of their families and explaining the artwork on the walls, they are now hooked up to machines and unable to communicate beyond a blink. I still talk to them when I enter the room. I repeat who I am and what I am doing – “I will be taking a look at your skin. Your oncologist is worried about the new blisters on your legs. Is it okay if I lift up your sleeve?” The syllables fade into the air, surrounded by assorted alarms. I finish my exam, say good-bye.

The next day we arrive to round and the family is huddled around the bedside, family members spilling into the hallway. The daughter is there. This is usually a sign that the patient has a few hours to live. It is a terrible moment for physicians. I wish I could shield my residents from it, in the same way I yearn to shield my children from the terrible things that happen in our world. We move on to the next patient but there is a heaviness in the air. A six year old is about to lose her mother, a husband is about to lose his wife, parents are about to lose their daughter. The hospitalization ends here but the repercussions of this loss will resonate for eternity. Eventually it will be explained as my mother died when I was six, but there were days and weeks and months and years leading up to that moment which were filled with all of the details that make our lives rich.

I sign into the hospital’s electronic medical record at home that evening to finish notes. I see that our patient has died. My children are sleeping in their beds and my husband is working on a deadline next to me but a mother has died. I move on to the next task, almost in slow motion. This is how it often is. You don’t have cancer until you do. You’re breathing until you’re not. You’re alive until you’ve passed.

What I’ve learned is this: there is nothing to do but to keep moving. Cherish the small things in life, keep your family close, take care of your health. Tomorrow is not a guarantee, trite as it may sound. Wealth and accolades will not shield you from disease and death. At the end of the day, we are all left with nothing. Ashes to ashes.

To my fellow physicians-I see you in the trenches, trying your best to keep your academic hats on while retaining your humanity. To patients everywhere-your doctors truly care about you. They think about you long after you’ve left their office and often long after you’ve left this earth.

I still remember my patients who have passed. I keep the trinkets they gave me, write down their quotes and life lessons, and have stored away the memories we’ve shared. Medicine is broken in so many ways – out-of-touch administrators with unreasonable demands, insurance companies refusing access to care, astronomical cost – I could go on and on. But all is not lost as long as the purity of the patient-physician relationship remains.

Bad news

This month has been hectic. It started with a lovely get-away (without kids!) for my husband and I. It was lovely. We were away for a week and were able to sleep 10-12 hours per day, finish both our conversations and our meals, lounge leisurely by the pool (under an umbrella, of course), walk along the beach, read, and simply be.

As always, I returned home with a desire to incorporate some of that into my daily life: taking a few minutes per day to just be together, reading more for fun, enjoying leisurely meals, exercising. Except we came home to a 1 year old and a 3 year old and two full-time jobs so none of the above happened.

It’s also a busy time. I’ve been taking advantage of my second-trimester energy to complete a few projects, including submitting plans for a minor home renovation. I’ve also had a pesky cough since our time away and though it would go away but it didn’t, and the coughing would often rob me of my energy and cause me to feel even more tired than usual. To top things off, my oldest came down with hand foot mouth disease (HFMD) and was home the entire week prior to a flight I was taking solo with both kids. He was in pain and cranky the entire week (apologies to all of the moms I counseled on HFMD by saying it was merely viral and would blow over) and, the worst part of all was that he wouldn’t sleep through the night! So the first few nights my husband and I stayed up with him. And then my youngest got a fever (but fortunately did not erupt into HFMD) and then HE wouldn’t sleep through the night.

So I set off with both kids in recovery ALONE on a 6 hour flight and it was by far the worst flight we’ve ever had. My kids have traveled a lot because even though we don’t live close to family, I think it’s so important for them to spend time with them. They are usually shockingly well-behaved. I come prepared, keep them entertained, and they generally keep their crying and tantrums to a minimum. But last week was a different story. Both kids were on the mend, I felt like crap from a combination of not sleeping as well as fighting off this cough (oh and being pregnant), and they wouldn’t nap! So we kept things pretty together until the last 30-45 minutes. And then when the plane landed, all hell broke loose. Both kids wanted to be carried but I only had two hands and had to carry the carry-on bags (we only had travel backpacks with us but it was a lot to juggle!). Then my oldest started throwing a tantrum about everything – he didn’t want to let me into the aisle to organize our bags, he didn’t want his brother to sit by the window, and on and on and on. Meanwhile, I’m frantically trying to organize everything while his little monkey of a brother is climbing over the seats. My oldest won’t move from his spot so I tell him “I’m going to pick you up and sit you down here so that I can grab everything” and do just that. He loses his **** and starts yelling “Mommy you HURT ME!”. Meanwhile, I’m dying.  As calmly as possible, I tell him it’s time to get off of the plane. A very nice lady helps with one of our bags, I carry my youngest off the plane, and my oldest begrudgingly drags his bag and follows behind, complaining all the way.

At the gate, I have to find and unfold our stroller, which was a waste of effort because neither kid will sit in it (but at least I can pile some bags on it). The oldest is crying and blocking people as they walk off of the plane while the youngest just wants to be held. I hightail it out of there with the oldest hitting me on my backpack and throwing the world’s greatest tantrum. We are the last people off the plane and the pilots are begrudgingly walking behind us because (I learned on another trip) they can’t leave anyone behind when they leave the plane. Awesome. And then, to top it all off, I have to walk approximately 20 minutes with one kid in my arms and one kid whining the whole way because we have landed at a huge airport, at possibly the furthest airline!

It was a total disaster. I saw my parents at the exit, handed the kids off to them, and then walked off to baggage claim to burst into tears. I could tell the security guard knew I was going to lose it because he let my parents follow me to the baggage claim to help out with the bags.

Until yesterday, I thought that was the worst thing that had happened. Then, my ob called me. Before I left, I had a few third trimester labs drawn. Apparently, one of those labs was toxoplasmosis. I had already had this checked in January (at 7 weeks) and both IgM and IgG were negative. For some reason, my ob rechecked it. She admitted that this was controversial – that many people don’t recommend rechecking due to low likelihood of infection in our area and false positives. But then she told me that I had a new positive (IgM, with IgG still negative). She wasn’t sure what to make of it. She had spoken to the high-risk obstetrics group at my hospital and they would follow up with me and likely have me return for an ultrasound, as well as labs, maybe an antibiotic, etc. She told me not to freak out so I promptly did just that – freaked out.

Toxoplasmosis!? That’s one of the terrible infections we learn about in medical school that can cause a slew of problems in newborns. WTF!? But I don’t own any cats…and I’m a vegetarian! I couldn’t believe it. I did what I always tell my patients not to do – turned to Dr. Google, and PubMed, and every person I know who is an obstetrician or infectious disease expert. I received a slew of responses: it’s probably nothing/a false positive, you definitely should not ignore this, you need serial ultrasound monitoring, they need to test the baby, there’s nothing you can do anyway because you’re 24 weeks along.

I’m also a bit annoyed at my ob. Why did she check it if it’s controversial? Her exact words were “I’ll probably change my practice after this”. And I am not entirely sure she knows exactly what to do at this time. She referred me to the high-risk ob, and that person called me, but I’m traveling and can’t be seen tomorrow, and she’s going to be out of town next week. The ID expert I spoke with told me to get labs ASAP, but the ob told me it wasn’t time-sensitive. Her exactly words were “I’m going to be blunt with you because you’re a doctor: if this is a true infection, there’s not much you can do at 24 weeks”. But shouldn’t it matter if it’s a true infection?

So I’m just waiting here, anticipating the worst. And it’s made me realize that I’m done having kids. I always thought I wanted a fourth, but pregnancy is too tenuous and stressful. I think about the experiences I’ve had with my kids – my pre-eclampsia scare with my first and him being in the NICU after birth (the briefest NICU stay ever, but seemed like the longest to me), my positive first-trimester screen with my second and having to see genetics for additional screening to rule out a chromosomal abnormality, and now this with my third. I pray that he will be healthy. That this is either a huge misunderstanding (false positive) or that he does not catch this infection. I’ll have an ultrasound in one week and hopefully will have some additional information at that time – and hopefully it’s all good news.

Vulnerability

I don’t write much about being a doctor because I do it every day and I prefer to write about non-medical topics, but my absolute favorite part of doctoring is meeting different people and hearing their life stories. I’m admittedly slower than I should be because I love hearing about people’s families, childhood, histories, etc. With my return patients, I always ask for updates and love to learn about what’s new.

Doctoring is a lot like waitressing – another job I really enjoyed. It can be tough on an introvert and draining after a long day of multiple patient visits. It can be taxing not only because of volume and patient turnover, but also because of the heaviness of the stories I hear. I am so honored that my patients share with me the things that they do. I keep these stories with me and often recall snippets years down the line.

Many years ago, one of my patients gave me a shark-tooth necklace. He was dying and making necklaces during his time in the hospital. I still keep this tucked away in my jewelry box, almost a decade later. It was my first gift from a patient, and he was one of the first patients I encountered during medical school.

Similarly, snippets of conversations weigh heavily on my mind. I think about my treatment plans – was everything correct? What will that one outstanding test say – will it change my management? How is my patient who just left the hospital – has she improved? Being a doctor is a tough job to leave at work. I can rarely escape it.

When I was growing up, my father would say: “Don’t become a doctor to make money.”

When I was in medical school, people would say: “Medicine isn’t what it used to be.”

I have known people who have dropped out before medical school, during medical school, after medical school, during or after residency. It’s not for everyone. You don’t clock in at 9:00am and clock out at 5:00pm. My husband will ask “How come if your last patient was at 4:00pm you didn’t come home until 6:00pm?” and it’s because medicine is messy and patients can’t be tucked neatly into 15 minute appointment slots. Also because there’s a load of electronic documentation that has to be done – but that’s a story for another day.

It’s rarely easy but I love what I do. The hours fly by in a blur. The patient encounters invigorate me. I learn something new every day and I come home with the knowledge that I have had a positive impact on someone’s life as well as their health.

What I would say to someone choosing a career in medicine: it’s so hard to know whether you will love it. And it’s true that so much has and will continue to change within medicine. But if you love science, interacting with people, and healing, it’s a great career choice, so don’t focus too much on the naysayers.

 

Just okay

These two articles really resonated with me. One from today’s New York Times and another from a blog, written some time ago.

Am I okay with a mediocre life? All of my life I have been an overachiever. In fourth grade, we were assigned a state and we had to write a paper on that state by the end of the year. This was in the early days of the Internet. In order to write a paper, you actually had to go to the library, use the Dewey decimal system, find your books, take notes, and then write. I vividly recall freaking out in December because I was worried that my paper, due in May, would not be completed in time.

One of my earliest friends recalls a transportation presentation that I blew out of the park in sixth grade – she still talks about it to this day, and it is probably the only reason we became friends.

In eight grade, I swept the middle school award assembly – my name seemed to be called after every category. It was almost comical.

I could go on, but in sum: everything honors, AP classes, SATs, Ivy League, MCATs, medical school, matching into a competitive residency, academic practice.

And here I am today: a husband, two kids, a home of our own, great careers, good health. I’m happy, but I’m not sure if I should be wanting more. I see people around me opening up their own practices, starting their own companies, becoming Insta-famous, working as media experts, creating ground-breaking innovations, involved in amazing research, and on and on. It all looks and sounds great but sometimes the thought of it just makes me tired (it may be the thought but also highly likely that it’s the kids). I like my quiet life: quality time with family, taking great care of my patients, teaching residents and medical students, barebones social media presence, just trying to be better every day.

Is this enough? It sure feels like it, but does this mean that I am done being an overachiever? When is it okay to stop wanting more? For someone constantly in motion, when is it okay to stop and just be?