Memorable Preceptor Quotes #1

“Where do you want to do your Family Med Residency?”
“I don’t think I ever told you I was thinking of Family Medicine?”
“No, but you have the personality for it… You’d be good at it.”

I couldn’t hold my grin back.

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I Don’t Know

I’ve spent the last year of preclerkship on the greatest roller coaster of my life. It’s been filled with ups and downs, and it’s been an incredible thrill.

But as I sit back and really think about it, I don’t know if that would be the best way to describe it anymore.

Pre-clerkship felt more like the initial entrance into the amusement park. You’ve waited in line buy your tickets, and you are excited. Finally, you get a well deserved reward for all of your hard work. Your hard earned money and time off… it all went into this one ticket into the park. Once you enter, it’s a whole new world. You pick a ride, and you go for it. But first, you have to navigate to the ride, make a couple of wrong turns, get a little sidetracked, and then wait in line. Finally you get there, and you’re excited. You are ready for this! I mean, that is why you’re here after all. You get ushered to the seat, and you buckle yourself up. There’s someone who tugs on your belt to make sure it’s secured, and then you are off. Pre-clerkship was the learning experience, trying to figure things out. Things start to culminate, and there’s an intensity building in your chest. The coaster is climbing up the highest point, and your heart is pounding. You know it’s coming, but you can’t help but feel scared. You’re so high, you know the fall is going to be exhilarating. In that split second, you can see everything below you, and you admire the beauty you have come face to face with.

Clerkship, I think I would describe that as the initial fall and the rest of the ride. It is horrifying. It’s going to be exciting and enthralling. I know that there’s going to be ups and downs and twists and turns and sometimes I don’t even know where I’m going. I’ll scream and I’ll laugh. Maybe I’ll cry (probably, I’m quite emotional), get a tension headache or terrible neck pain. Maybe I’ll doubt myself, then quickly realise I shouldn’t be doubting myself because this is awesome.

And this is the part where my comparison ends because I don’t know how it’s going to end.

I don’t know, but it’s okay.

 

Grief

Serene sea waves
I am content
Then the quake begins in my mind
Shaking, shuddering as the memory appears
Explosion of thoughts
The emotions spread
Receding waves taking the happiness away
Wrenching pain tugs at my heart
Tsunami crashes and the emptiness comes
Pangs pounding in my chest
Destruction, dragging me away from shore
Joining you soon
A gift from the sea


The DSM V describes grief as having feelings of emptiness and loss, dysphoria occurring in waves, and preoccupation with thoughts and memories of the deceased. The waves are also known as “pangs of guilt”. Naturally I thought of the waters, and how the tides typically recede before a tsunami. I imagine grief as a tsunami, so horribly destructive. Yet somehow, the deceased hide in this tsunami, and as terrible it is, we are drawn to it, and lose ourselves in the waters.

Standardized Patients

Standardized patients (SP) are people recruited by the medical program to act as our patients to practice on. The tasks range from taking a history (they are given a binder script), to completing physical examinations. I remember reading an article or two about the possible ethical dilemmas associated with this job. There was also this one story about how an abdominal aortic aneurysm was discovered and the SP’s life was saved. Sometimes they have findings, sometimes they don’t. I don’t know much about the paperwork they have to do, or the training they receive with regards to us making accidental discoveries (which I do hope is present). But I’ve had many encounters with SPs that I’d like to share.

In my undergrad, I took a communications course which allowed us to work on our interviewing skills with standardized patients. The acting was impeccable. During the interviews, I forgot that these were actors for the 12 minutes, and felt like I was submersed in a whole new world. Seeing these actors around later was very strange. It was hard to dissociate them from the context in which I knew them… the girl with diabetes, the abused housewife, the suicidal boy… And I would wonder if any of their stories reflected their own lives. It’s almost like forgetting that your favourite actors on the movie screens are simply actors. Like teenage girls who associate the on-screen romantic heartthrob with the person’s personality.

Seeing the same SPs as a medical student helped. When they are recruited for physical examinations, they become less of a character, and more of a person to practice on. (Unless you count examination situations, then I don’t even have time to process my own feelings towards them in the midst of being incredibly nervous.) For tests they will have make up on or some “findings” put on by the school, but in the practice setting, they are who they are. It is like practicing on my classmates, except they are paid by the school. Sometimes it is just that simple. Sometimes thoughts creep into my mind, and I start to wonder about their own stories.

Depending on the group, we sometimes pair up and practice on each other, and the odd person or group can also practice with the SP.

One time, I was practicing the musculoskeletal exam on an SP. It was of the upper limb and back, and they were wearing a T-shirt. I went through the examination, then I noticed wisps of scars laid across her forearms. They were faint, but they were present. I would be able to recognize that anywhere. I had a couple of friends who practiced self harm in high school, and over the summer, I had an elective in Psychiatry where I had seen this practice in the extremes. I had flashbacks of the girl lying on the bed in the hospital, her arms filled with so many scars you could hardly find a spot that wasn’t scarred. At first, I thought they were blonde strands of hair on her arm. I don’t think I will ever forget that image. This SP, her scars were faint, from years passed. I don’t know if she knew I noticed them. I didn’t ask her about them. I think I may have asked if everything was okay if the scars were fresh. But they were so faint… What if they were just an impulsive decision that she wanted to forget? I didn’t have any actual conversation with her, and in the busy clinical exam room with pairs of students practicing was not the best place to ask. That night I went home, and I slightly regretted my choice to leave it alone. Would it have been intrusive or relieving for her? Sometimes I wonder how she is doing now. I haven’t seen her again since then.

Another time I was practicing my fundoscopy exam on an SP. I am not very well versed in the exam, as are most medical students, and it took me many tries until I was able to find the optic nerve. When I pulled away, he asked me if something was wrong, and I explained to him that it was quite difficult. He apologized and explained that he had been crying today, and wondered if that could affect it. I quickly reassured him that it wasn’t him, it was me. Then I asked if everything was okay. He told me there was a death, and he was quite upset with that, among other things. I told him we could stop if he wanted to go home, that I could practice on someone else. He told me he was okay to proceed, and I asked him if he was feeling okay. He smiled and responded that he is doing fine. Then we continued the exam. I think after that point I made a conscious effect to be more vocal and dynamic. I told more jokes, I tried to make him laugh (and he did). Sometimes I wonder how he is doing now. I haven’t seen him again since then.

Sometimes thoughts creep into my mind, and I wonder how the next chapters of their stories are going.

Starting Second Year

I cannot believe I can finally call myself a second year medical student. As I see the pictures and posts pop up on my Facebook newsfeed, it feels like just yesterday when I was in their shoes.

The past year was one of the most amazing experiences I could ever ask for. I’ve grown tremendously as a person, and I don’t ever want to stop this process of learning. I haven’t been documenting the process throughout the many units since I’m already writing reflections for school. In other words, I was pretty dry of words. Now I think it’s a good time to look back.

Having the summer months in a clinical setting was quite the change. Instead of studying constantly, wait, no, I was still studying constantly. But this time, it was reading about things I saw during the day (or night), and filling in gaps in my knowledge. It sounds even more exhausting than being in school all day, but it didn’t feel that way. After a long day seeing patients, I would come home and read some more. If I had a long day, I had some time in between to read up about things before managing their care. Don’t worry, my supervisor kept a good watch on me at all times.

I’ve been on a constant journey to try and better myself. Each day, I’m pushing my limits even further. I’m speaking my mind when I want to, and I have become a more daring person. I challenge people when I don’t understand, I ask questions and I take criticism.

I wish some things had gone differently. I wish I spent less time on academics and more time on extracurriculars. I wish I had more time for my hobbies. I wish I took on more leadership roles. I wish I did earlier placements. I wish I networked more. I wish I had more hours in a day. But all of that doesn’t matter, because wishing isn’t going to change anything. This year, there’s going to be more doing. More acting. And if I can’t do it all this year, I’ll keep going, and I won’t stop. I’ve got my foot on the gas pedal and I’m revving up. But I’m still a responsible adult so I’ll be cautious of the speed limit and other traffic on the street. I don’t want to crash and hurt anyone.

I haven’t had any breaks, but that’s okay because I’m happy. I’m happy doing what I do. My preceptor told me I’ll never be as interesting as I am right now. I accept the challenge. I don’t ever want to stop learning and being interested in all this.

Barriers

When I shadowed a family medicine physician a while back, we encountered a patient who had made an urgent appointment with regards to a drastic change in her family life. The doctor sat back and let her speak, letting her express herself, while offering input during the appropriate periods of time. Several times throughout her expressed concern, she stopped and apologized for taking up the doctor’s time. And every time the doctor would reassure her that all was well. After the appointment was done, she made a follow-up appointment for after she consulted all the resources offered to her.

When I shadowed a midwife recently, we encountered a client who was having difficulties with her professional life in relation to her pregnancy. The midwife sat back and let her talk about all that had happened, and ask for advice moving forward. Once the appointment was finished, a follow-up appointment was made for when she had finished consulting and finding the resources she needed.

In both cases, the healthcare workers showed incredible compassion, empathy and support for their patients/clients. Somehow, the second scenario stood out to me a lot more. Why was that? I pondered to myself. They were both excellent providers, but what was different about the second scenario?

I realised the difference was in the presence of both a power differential and time constraint. Slowly but surely, we are trying to make the physician-patient relationship more balanced. As we are trying to move forward, during this period of transition, the effects of the past may still be present. It is like a trend that we slip into. The atmosphere of both providers were different: one was more office-like, the other more “homey”. Could this have allowed for something to sink in subconsciously? How can you maintain professional behaviour while trying to make the relationship balanced?

There was also a time constraint associated with the first case. The waiting room was filled with patients, and each only had a fifteen minute appointment slot. The second case? An empty waiting room, and each patient had a thirty minute time slot. Granted, the patient load of each is very different, allowing for these differences, but how does this impact patient care?

Each patient that comes in through the door deserves the same standard of care. And while we know that and try to accomplish that, they, on the other hand, are riddled with guilt and concern. How can we change this? How do the subtleties in our practice affect this? Sometimes doctor’s clinics are filled with patients, distributed through the clinic. Does this create an atmosphere where people feel rushed for time when they speak with their own provider? Or is this moreso based off of the patient/client themselves?

The two situations I described above are probably the most important scenarios I have seen. Both exemplified the skills we were taught in class almost exactly. So what are we to do? How do we address these subtleties? Or maybe these subtleties aren’t even important on the grand scheme of things? Only time will tell.

Judgment

Early in my medical student career, I was in a COPD clinic for a horizontal elective. All the patients had the same problem: COPD. Hence, they were all treated in basically the same way: inhalers, antibiotics, home oxygen… But they all had such different stories to tell.

The physician I was with was very skilled in this area. There was no doubt about it. He had these patients referred to him from the very beginning.

But there was just something about it.

It was as though he had given up.

Whenever a patient walked in, and revealed that they still had not quit smoking, he filtered out all that they were saying. He did not address any of their other concerns because he couldn’t. He told them there was nothing he could do to help them if they don’t quit smoking because that was the problem in the first place. All those other problems they were listing all stemmed from smoking.

When the appointment was over, the patient would take their prescription slip and leave, with a surprisingly neutral expression. To be honest, it seemed like the patients had given up as well. It was as though they were just part of a cycle, a cycle that strived to improve the quality of life. Even the patients who had already quit smoking could not escape this cycle. Granted, they looked happier in comparison with those who hadn’t quit, but still, it was a routine.

The idea of giving up is very subjective, so I thought that perhaps there was something wrong with me. I asked the physician about it afterwards, to which he replied “I can’t help them if they don’t help themselves.”

I was a bit shocked; it was like he had abandoned the patient and left them out on the curb to fend for themselves. Like he didn’t care at all.

It reminded me of a communications class I took in undergrad, where we had a standardized patient who was a distressed abused woman. When I went into the room, I saw her sobbing and I completely froze. I asked her if everything was alright, and if she needed a few moments to gather herself. Our facilitator stopped the interview and told me I had built up a wall with just that statement. She needed a few moments to gather herself. Suddenly it was her problem, and hers alone. This was not the right approach because she was here for support and for help.

Was this doctor building up walls? Did he even realise it?

Then I started to wonder, truly, what is the point of these patients coming anymore, looking for change? He said he wasn’t going to do anything differently if they didn’t quit, mostly because there was nothing he could do.

But really, was there actually nothing?

At the time I agreed; quitting smoking is the number one thing that is on the treatment list for COPD patients. We had learned and been stressed that so many times.

Now, I’m not so sure. Maybe there could have been some more that he could have done. I distinctly remember one patient who said they had quit smoking, but who I could distinctly smell the tobacco smoke on their breath as I listened to their lungs. I didn’t want to make any assumptions, so I didn’t bring it up. I remember looking at some of the patients and pondering their socio-economic statuses. Perhaps they could have used some help with social work? It’s very difficult to quit smoking too; maybe there was some assistance or resources he could have directed them to? They always told him that they were trying to quit, but couldn’t. Maybe they just needed a helping hand.

And the way he said it… “Just quit smoking. You need to quit smoking. Or you will die. Do you understand that?” He made it seem so simple. In reality, it is anything but simple. It becomes a part of your life, and you are consumed by it. It is as though you cannot live without it, a reality worse than death. But maybe that’s just what they wanted to do, die. Maybe this was a plea for attention, a window of opportunity that was missed.

I don’t know what was worse, hearing those words uttered by the doctor, or the patient being so numb and desensitized to that reality.

Perhaps I am being too harsh. Perhaps he had tried to offer resources for them to quit, and that didn’t work. Perhaps years of facing these patients made him realise that typical means will not solve the problem. It would just be a waste of time, and even ineffective. Maybe in these cases they just needed to hear the truth. Perhaps this snapshot of how he treated them now was the complete opposite of what it had been years ago. Perhaps he had exhausted all of his efforts and this was a last resort.

It’s difficult to not be judgmental in these situations.

Fears

I have had several people close to me almost slip away. They were each battling a war, a war in which they were losing. I have seen overdoses (and thankfully subsequent recoveries). I have seen hospitalizations (and thankfully subsequent healthy discharges). I have seen the less extremes in those who have shared their grief and anguish in due time, in those who, with a little bit of prying, poured their hearts out about the past weeks or months gone by. I have seen those who I have had to talk to others about, in hopes that they will be able to keep an eye on them because something about their smile did not seem right. They all had one thing in common: they were too afraid to bother me with their problems, because they thought I had better things to do. I wish I had known what was affecting them, and to what extent. Nothing can ever be more intense than almost losing someone important in your life, be it the medical school admissions process or the journey through medical school.

Sometimes we are afraid to face the problems in front of us for the fear of bringing down others. We are afraid to take up too much of their time, and we are afraid we won’t be able to be accommodating. We concoct all of these hypothetical situations in our minds, each with a worst case scenario plotline:

I’m having trouble with some personal problems and I need some help. But I don’t want to ask the wellness advisor for help. What if they think I’m incapable? Maybe I should talk to my friends. But they are probably busy with school… I will take up too much of their time. It’s not important anyways, I’ll just hope it goes away.In reality, those could be truths, but they may also be completely wrong.

We spend so much time worrying about others, and then we forget to worry about ourselves until it is too late. Whatever it is, when it comes down to a twenty-four hour day in a seven day week, that moment you need is only a small fraction of time. If we get help earlier on, we can stop these problems before they accumulate and snowball into a larger, more difficult to manage situation. What if the solution was right before your eyes, hidden beneath the shadows, and you just didn’t see it? What if the solution was as simple as a lending ear? Or a hug? Or some tears that have been held in for an extended period of time?

As I have mentioned before, when you neglect taking care of yourself, those around you are affected as well. Those who care about you, and those you care about feel the same pain you are experiencing. To the same effect, then these people will never be too busy for you, because they love you and care about you. It does not do well to be afraid of being loved, or to love. In loving, we are letting those who care about us into our world, and seeing what we see. It is a sign of trust. Don’t let fear hold you back; let your strength be your guide instead. And when you face these demons, you are not alone, everyone will be there to catch you if you fall.

Refreshed and Revived

2013 was a big year for me: I finally attained a goal that I had been striving to reach for a very long time, that I had dreamed of ever since I was a little girl. Finally, after having dreams, being hit with reality, and then taking a leap of faith, it had happened. Somewhere in there I found self-confidence in the midst of chaos, and found within me a sense of calm I hadn’t felt in a very long time. In the midst of all this stress and responsibility, I have somehow found happiness, and I hope that will carry me through.

2013 was a year of admitting. Admitting my true feelings, admitting my faults, admitting my limitations, admitting my fears. I know that I will come across many patients who will exemplify something I have battled with myself or someone close to me has battled with. I’m going to have strong feelings, and that’s okay. I’m going to feel helpless, and that’s okay. I’m going to feel scared of my past haunting me, and that’s okay. 

2013 was a year of thankfulness. I’m so thankful to have so many people around me who care for me. I have learned from my past mistakes to not shelter or wall myself away. I have learned to not take the kindness of others for granted. 

2013 was a year of forgiveness. I have forgiven all those around me who have hurt me in the past. But more importantly, I have decided to finally, and truly, forgive myself. Because sometimes it’s not all your fault. You can’t take responsibility for someone else’s actions. I’ve forgiven myself for my own actions, because you can’t always be perfect. Things are going to affect you in your daily life. The important part is being able to recognize your faults, and improving.

2014 is going to be a year of surprises. Being surprised at what I know (and more importantly, don’t know), and being surprised at what the world has to offer.

2014 is going to be a year of change. I’m going to continue the lessons learned in the past, and be a better person. I’m going to remember that confident and happy girl who walked into that interview that day. I’m not going to be scared anymore, because I know I have friends, family and a wonderful boyfriend who are going to be there for me. I’m not going to dip back into the past. I’m not going back to the dark that had once existed in my life. 

2014 will be a year of insanity. Near the end of the year, I will be on clerkship, and that is going to be one hell of a stepping stone. In the meantime, I’m going to make the best of my medical school days before they are gone. 

End of Unit One

Even though it’s only been a mere three months since I began my journey into medical school, I feel like I’ve changed so much.

If you asked me to pinpoint why or how, to be honest, I really don’t know. I don’t know how I’ve changed, but I feel like I’ve changed so much. I know this sounds quite vague and like I didn’t say anything at all, but really, it’s the truth.

The other day I was shadowing a doctor, and I had the opportunity to talk to a patient with a mental health issue. It was heavy. I thought it would be easy– I mean, I myself have struggled with mental health issues in the past– but no, it wasn’t at all. My experiences were nothing compared to theirs. We talked for about half an hour. It was amazing. They spoke to me about their life, their experiences, their struggles, and how far they’ve come today. I’m incredibly happy for them, and I hope that they will be able to continue this journey onwards, but coming out of that experience I felt this sudden weight on my shoulders. I know I shouldn’t be carrying this with me, but I don’t know how to get it off, other than keep telling myself to get it off my mind, or just with time, or just doing some other things to get my mind off of it. I don’t think I will ever forget this patient.

I also moved into a new place. I had a lot of conflict with the management, and I felt that none of it was deserved on my end. It was moreso due to a lack of communication on their end. But suddenly, they apologized to me. It was odd, strange, but also made me kind of happy, knowing that I can be respected as an adult. Growing up, I don’t think apologies were ever given to me. Like, real apologies. Not the, oh sorry I bumped into you. Real apologies. Well, I guess we can include when my boyfriend apologizes after I get upset, or that one time my friends in high school apologized for how things turned out with a guy I was dating back then (essentially I pulled a stupid move and ditched my friends for him, but to be honest, both sides were at war and I had to pick a side when both sides were wrong). In any case, it was odd, but a good kind of odd.

And so ends unit one: resp, cardio, and heme. I feel like I still don’t know everything I need to know about these topics. But then again, that’s okay. It’s perfectly okay. This knowledge base will keep on expanding. I just have to make a mental note to come back to the old while learning the new. A difficult but not impossible task.