Category: Reflection

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Education Informal-curriculum Lessons Medicine Observations Reflection

Guiding Principles for Medical School.

Dear Jane:

Thank you for asking me about my perspectives on medical school. Here are some general principles that you might find useful in your own training:

View everyone as your teacher.

Everyone you encounter will teach you something. Be open to what they have to offer.

Yes, your professors and attendings, the “official” teachers, will educate you. Patients, however, will often be your best teachers. Listen to what they say, watch how they react to what you do, and acknowledge and accept the feedback they give to you. Their teachings are often the most useful and valuable.

You might see a physician condescending to a patient and decide that you never want to do that. You might see a nurse offer quiet comfort to a patient and decide that you want to mimic that manner. You might witness a technician help a patient feel less anxious before a procedure and decide that you will steal that technique. You might talk to a physician on the phone and decide that you will adopt that professional and kind manner when you talk to other physicians.

In this way you can be a student for life.

Reflect on your experiences every day.

This can take many forms: You can keep a journal. You can talk with friends. You can meditate. You can go for a ten-minute walk around your neighborhood. You can sit in a chair and stare out the window. It doesn’t have to be a big thing.

Reflecting on your experiences will help consolidate what you learn so you can apply that knowledge in the future. This applies to “book” knowledge (physiology, pharmacology, etc.) and “non-book knowledge” (how to redirect a patient or your colleague, how to manage your emotions in the face of disease and death, etc.).

There will be times when you will feel overwhelmed and cannot or choose not to reflect. That’s okay. It happens.

You will see terrible things.

You will see people suffer. You will see people die. You will hear hospital staff say derogatory things about patients. You will see your colleagues lie about things they should not lie about. You will see everyone—the patient, nurses, doctors, technicians, family members—work as hard as they can and none of it will help the patient. You will see people who need help, but don’t want it.

Remember the discomfort you feel when you see things you don’t like. These experiences are your teachers, too. They will help you stay human and humane. Medical training can steal that from us.

You will do terrible things.

You yourself will do things you will not like. (Hopefully infrequently.) You will snap at patients. You will be snarky to staff. You will bend the truth, if not lie, because you won’t know what else to do.

You must reflect on these events so they don’t become habits.

Connect with physicians who do not work in academic centers.

Some physicians in the community will have practice patterns and work in systems that will appall you. Some will inspire you. While academic medicine does happen in the “real world”, it’s often different from what is in the community.

Exposing yourself to the non-academic world will help you learn about a greater variety of patients, creative and innovative developments in health care, and provide more context about medical care in the world. Even if you end up working in an academic center, these experiences will shape your practice.

After you decide what kind of doctor you want to be, take rotations in every other specialty.

Medicine is compartmentalized, but people are not. Your patient with high blood pressure may become pregnant… develop a painless red eye… fracture a bone… have her gall bladder taken out… or develop an alcohol problem. Learning about a variety of conditions will help you take care of people, not just diseases.

The most useful guiding principle for me during my training (and now) is to remember that your work is to take care of the patient. It’s not about the letters after your name, long titles, or how big your salary is. Medicine isn’t about you. It’s about the patient. That attitude will keep you humble, curious, and grateful.

Congratulations on your admission to medical school! May you find the work rewarding and meaningful.

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Lessons Observations Reflection

Length of Day.

The long, glorious days have arrived in Seattle. The sun rises shortly after 5am and sets after 9pm. We’ve savored the warmth of the sun on our faces; the sky has been more blue than grey in the past few weeks.

The tradeoff is that, in the winter, the days are short. The sun rises close to 8am and sets before 4:30pm. Furthermore, the pewter clouds and rain blot out the light of the sun. The days are dark.

These cycles, though, are predictable. We celebrate what light we have during those winter days as we step through puddles and under naked trees. During the summer, we relish the long days as we witness the alpenglow of the sleeping volcano, hike the verdant mountains, and squint at the sparkling waters of the sound.

Life is not predictable. We do not know if our lives will be like a day in December or June in Seattle. We only know the length of day after the sun sets, after someone dies.

When his mother died, my father followed the custom and wore a black braid around his left bicep.

“How long did you wear it for?”

“Ninety days.”

He gave me four pieces of black yarn. While on the plane I created an uneven braid with the yarn and wrapped it around a black armband. I will wear it until August 20th.

The thing about death and dying is that, even though you know it will happen, it’s still abrupt.

This is why it is vital that you say what you need to say and do what you need to do while you still can.

You don’t know when someone you love or care about will die. If you have stuff you need to tell someone—your apologies, your love, your hopes, your affection—tell them now.

We regret those things that we could have done, but, for whatever reason, chose not to. Regret sucks.

And even if you do say everything you need to say and do everything you need to do, know that it may still not be enough. For those that we love, we can never tell or show them enough how much we love them, how grateful we are for them, how much we want them to have happiness and peace. When they die, that ache of regret may still persist: You wish you could express your love to them one last time.

It will be too late.

I told my mother everything I wanted to say in the six months between the time of her diagnosis of cancer and her death. She took advantage of the time, too, and shared her hopes, fears, dreams, and wishes with me.

I thank her. And I miss her.

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Blogosphere Nonfiction Reflection

My Brief History on the Internet.

The first time I posted my writing on the internet was in 1997. I created a website about The Evolution of Mickey Mouse. It was based on a report I wrote in high school about the small mammal. My research for this report entailed several visits to the library to scroll through multiple rolls of microfilm (do kids these days even know what microfilm is?) to find articles that described the mouse during his heyday. I decided to put my findings on the internet so other people wouldn’t have to dig through canisters of microfilm. That Mickey Mouse website did well: For a short period of time, back when the Yahoo! search engine reigned supreme and Google was new, the site was ranked #2 with the search terms “Mickey Mouse”.[1. Disney.com, of course, came up first if you searched for “Mickey Mouse”.] Children from the world over sent me e-mails with instructions to “say hi” to Mickey Mouse. The internet was a sweet and innocent place.

My first blog was hosted on Open Diary. It was late 2000 and I was a medical student. I used a nom de plume that now causes me some mild embarrassment. I wanted to record my experiences in medical training. This was not a new practice for me: In junior high, high school, and college, I filled the college-ruled pages of dozens of spiral-bound notebooks with my thoughts. To my knowledge, there weren’t many medical students blogging at that time. Other Open Diary users read my writing, seemed to enjoy it, and expressed interest in what happens in medical school. Writing for an audience was fun. The internet was a social and friendly place.

Open Diary used fixed templates. While I knew that the substance of the writing was paramount, I wanted more style on the screen. That’s when I moved my writing to Blogger (still owned by Pyra Labs at that time) and adopted the title “intueri: to contemplate”. That would remain the name of my blog for six to seven years. I dropped my nom de plume and started using my first name. No one could figure out who I am with just my first name, right? And even if they do, who’s gonna care?

I wrote about my experiences in medical school… and then about my experiences in residency. My blog moved off of Blogger and I bought my own domain. I used MovableType for a few years. I then tried WordPress and have used it since. I read Instapundit and he posted an e-mail I sent to him. Ezra Klein, before he became Ezra Klein, called me “one of the web’s most graceful prose stylists“. I hosted Grand Rounds a few times.[2. If you know what Grand Rounds is, that shows your blogging age.] I started meeting people who read my writing online. The internet was a dynamic and exciting place.

I started feeling ambivalent about writing online. I closed down comments because anonymous people left statements like, “ALL PSYCHIATRISTS SHOULD DIE” and “YOU’RE A PSYCHIATRIST, YOU KILL CHILDREN”. A physician who wrote a blog under a pseudonym was revealed in court. I worried that my writing wasn’t fictitious enough, that maybe my stories weren’t purely coincidental. My mind generated catastrophes: Someone might read a story and think I was talking about them! They would sue me and I would lose my license! Other doctors would judge me! I would never recover! Even if I did, one of those commenters who hate psychiatrists would then kill me!

So I shut down that blog. The internet was a scary and dangerous place.

I moved to New York City. A man who was living there had been reading my blog for a few years. He suggested that we meet. We dated. We eventually got married in Central Park.

I couldn’t not write. Nearly two years had passed since I had posted any of my writing online. I decided to start another blog, though I did not want to write in fear. In White Ink revealed my full name. (Nothing bad happened.) The first post appeared there in 2010. The internet was not dangerous place, though not an innocent place, either. The internet was a place to learn.

I purchased this domain name, mariayang.org, that same year. Would you believe that it took nearly four years for me to build the courage to finally occupy the space?

Next time: Occasionally asked questions about blogging as a physician.

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Nonfiction Observations Reflection

Sea Lions.

The sun was beginning its ascent into the sky, though it had yet to peek over the horizon. An occasional harbor seal poked its round head through the surface of the dark water in the marina. The twinkling stars overhead were starting to fade.

Dozens of sea lions were piled on top of the rocky pier. The males, some weighing close to 700 pounds, barked and snarled at each other. A loud splash occasionally cut through the din when, during a quarrel, one of them fell into the water.

My friend and I walked along the platform. The wood planks creaked under our weight as we followed the path back to the shore. We spied a sea otter, curled up and snoozing, at one end of the dock.

My friend stopped walking.

“What?” I asked.

He pointed. My gaze followed his finger through the purple darkness.

Not six feet away from us on the pier was a heap of eight or nine sea lions. The smaller ones were farther away from the main walkway. A blubbery male, teeth showing and head raised, was seated on the platform. He was looking at us.

“What if he attacks us?” my friend whispered.

Some of the other sea lions turned their heads and cast a wary eye upon us. The corpulent male guarding his tribe barked. My friend leaned back into me.

“He won’t attack us. They eat fish,” I reasoned.

“That thing weighs like 700 pounds,” he said. “He could crush us.”

The distance between the fleshy sea lion and the other edge of the platform was about three feet. There was no other way back to the shore.

“Just don’t make eye contact and keep walking,” I said.

He didn’t move. Shrugging, I slipped around my friend, kept my eyes down, and walked past the bulky creatures. My fingers could have patted their heads; their flippers could have smacked me into the water.

When I was about eight feet past the sea lions, I heard hasty footfalls behind me. My friend, unscathed by the animals, appeared by my side.

“That was scary,” he murmured.

“They could have eaten us!” he exclaimed once we were on shore. “They weigh a lot! Did you know that sea lions can run on land faster than humans can? Can you imagine a 700-pound sea lion tackling you? Into the water?”

“But they don’t eat humans. And we weren’t going to fight him for that dock or his clan.”

After a few moments of silence, he said, “You’re brave. You walked by them as if they weren’t there.”

I wondered about this later. My friend is not timid, nor is he nervous. Why did the sea lions rattle him so much?

The construction workers across the street shouted at me.

“Hey baby! Wanna gimme some sugar tonight?”

He was sitting on the stoop when I walked by.

“Konichiwa. An nyoung. Ni hao,” he called. “You speak one of those, right, honey? How do you say ‘I love you’?”

While I was waiting to cross the street, he came up to me and said, “You’re pretty. You’re pretty. You’re really pretty. Asian woman, you’re pretty.”

He waved at me from across the room. “Hey, doc! Do you do sex therapy? I want to learn more about that… from you.”

Of course. I am a woman, he is a man. What have I done in the past when I got attention I didn’t want, when I wanted to disappear?

“Just don’t make eye contact and keep walking.”

Categories
Nonfiction Observations Reflection

Michael.

Everyone noticed him before we boarded the plane. He asked the airline representative at least three times to confirm that he had a seat. He looked like an adult, but the tone of his voice was that of a child.

“Yes, you have a seat, Michael. It’s 7B.”

Grey cargo pants covered his short legs. The sleeves of his striped polo shirt collected below his elbows, making his arms look even shorter and his hands even smaller. His neck hid inside his collar. His fingers were short and thick. His glasses magnified the creases in his eyelids. Because his nose was flat, it made his mouth look wide.

The elderly man in the aisle seat had asked the flight attendant to stow his cane. Wrinkles burrowed into his forehead and surrounded his eyes. They revealed a lifelong habit of frowning. The elderly man heaved a sigh of resignation when Michael took the seat between him and me.

Michael sat down with conviction, then stood up and adjusted the nozzle so more air blew into his face. After sitting down again with resolve, he picked up the seat belt.

“What is this?” he asked, his fingers poking the thick padding. When no one responded, he turned to me and said, “This isn’t a normal seat belt. It’s weird.”

As other passengers filed past us, he greeted every third or fourth person.

“Hi! Hi!” He thrusted his arm forward across the lap of the elderly man. Without realizing what they were doing, many people found themselves shaking his hand.

“Hello! My name is Michael! Who are you going to see? I’m going to see my dad. He bought my plane ticket for me.”

“Oh… that’s nice.”

The elderly man sat back, leaned away from Michael, and sighed.

Michael turned off his cell phone. Turning to me, he saw me send a text message.

“You’re supposed to turn off your phone, like this, see?” He waved his phone at me like it was a baby rattle.

Shortly after the plane took flight, Michael reached his hand in front of my face and pulled down the window shade.

“Too bright,” he said as he looked back at the television.

The flight was about two and half hours long. Twice, Michael announced to the elderly man, “I need to use the bathroom.” The elderly man said nothing, pushed himself out of his seat with his arms, and stood in the aisle with sorrow on his face as Michael ambled his way to the lavatory.

When the pilot announced that we were approaching our destination, Michael reached over, grunted, and pulled the shade up halfway. Through the double-paned window we saw the Pacific ocean, its waves rolling towards the coast in a never-ending parade. A squadron of pelicans glided over the water. Small boats left frothing white wakes atop the blue-green swells.

Michael reached over again and pulled the shade up a little more. We both continued to look out the window.

When the plane arrived at the gate, Michael bolted out of his seat, reached over the elderly man, popped open the overhead bin, and pulled down his backpack.

“I’m going to see my dad!” he announced.

An airport attendant boarded the plane and called Michael’s name. He raised his hand with the enthusiasm of a child who wants to answer a question first.

“I’m Michael!” he said. “Are you going to walk with me off the plane?”

I saw Michael a few minutes later outside the terminal and witnessed his reunion with his father. His father did not share physical characteristics with Michael; Down syndrome is not heritable.

They hugged each other and both smiled with joy. The extra copy of chromosome 21 did not diminish the love father had for son.

“How was your flight?”

“It was great,” Michael said. They began to walk away together, his father’s arm holding Michael close to him.

We judge ourselves by our intentions, but we judge others by their actions.[1. This quote is attributed to several different people, including Andy Andrews, Stephen Covey, and Ian Percy.] For people with overt disabilities or deformities, we are more forgiving of their behaviors because we are more charitable about their intentions.

Why do we not do the same for those people whose deformities or disabilities are not visible?