Moments in Medicine + Motherhood

One of my all-time favorite quotes comes from an address given by Theodore Roosevelt that is colloquially known as “The Man in the Arena” speech. You’ve undoubtedly come across it; it’s just that good. When I started residency, I wrote this quote out in its entirety on a Post-It note and taped it to my bathroom mirror. It stared me straight in the face on many an early morning during intern year until the steam-dry cycle of my shower left the note in a damp, illegible heap. Although it no longer greets me in the morning, I quite often pull this quote out of my metaphorical back pocket during residency’s most trying moments. It is in these moments that I find myself repeating the first several lines of this quote over and over again in my head:

“It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again…”

These words re-center me and keep me going, and from these words I have derived a new rule for myself: I gladly accept constructive criticism from individuals who are also in the arena, but I no longer listen to those who fancy taking cheap shots from the comfort of the cheap seats – very à la Dr. Brené Brown (huge fangirl right here).

As I near the end of a five-week stint in the medical intensive care unit, working alongside nurses, respiratory therapists, patient care technicians, physical therapists, speech language pathologists, and other physicians who have been taking care of patients with COVID-19 for far longer than I, I am nothing short of amazed by the sheer resiliency of this group of individuals. My experience is but a drop in the overall bucket of this pandemic, but even in my short time, I have witnessed the absolute devastation that this disease has caused for so many patients and so many families. I would ask you to try to imagine what these patients and their families have to go through, but I honestly don’t think that’s a fair ask. Because even after having been physically present within the fluorescently lit rooms, struggling to auscultate hearts and lungs over the humming of the machinery temporarily installed to retrofit previously normal ICU beds into negative pressure rooms, I can’t comprehend it myself. The pain and suffering that must accompany dying alone or waiting at home knowing that a family member is dying alone are unimaginable. Period. And for this reason, I make no claims to understand this experience. I have, however, had a brief glimpse into what it means to be a healthcare worker amidst this pandemic – witnessing this suffering, worrying about the capacity of your hospital to care for your community, and perseverating over whether or not you are exposing yourself and your family to this disease just by doing your job. I have experience with this. I am in this arena, and since there seems to be an increasingly boisterous commentary – both via words and via actions – ringing loudly from the cheap seats, I can no longer stay silent. I must speak out.

This pandemic is getting worse. Period. Hard stop. Do not pass go. Whether you are someone who views this pandemic through a scientific lens or not, the capital-T truth (insert shout out to David Foster Wallace here) is that there is a finite capacity to everything that we are currently relying on to take care of patients with this disease. Ventilators. Hospital beds. Healthcare workers. All finite, precious resources. Stating this isn’t a scare tactic. It is, quite literally, math – and simple math at that.

Today I’m speaking out on behalf of patients. On behalf of patients’ families. On behalf of the healthcare workers that I have had the honor and privilege of working with over the past five weeks. On behalf of all healthcare workers across this country who are working tirelessly day in and day out to take care of patients. Taking care of patients – it’s our job. It’s why we’re here. It’s what we do. But. And this is a big but. Given that this pandemic and something as simple as wearing a piece of cloth on your face to protect yourself and others have been politicized, it is now not just a choice to speak out, it is also our job. We must speak out against the misinformation and the behavior that are undermining the attempts at controlling the spread of this disease such that we never have to experience the outcomes that shortages in our finite resources would bring. I won’t waste my time listing here what all human beings should and should not be doing to be community-minded citizens committed to helping to control the spread of COVID-19. The public health measures have been so broadly publicized that it’s nearly impossible to imagine that anyone is not doing their part simply due to a lack of knowledge. This isn’t a knowledge gap. It’s a behavior gap. A selflessness gap. An empathy gap. This is a gap that needs to close – and soon

As I sit at my kitchen table this morning, freshly off of an overnight shift in the medical intensive care unit, I open my internet browser to learn that there were 6,023 new cases of COVID-19 in my home state of Pennsylvania yesterday – up from 4,098 the day before. That is a nearly 150% increase in the number of new daily cases that quite literally took place overnight. This is numbers. This is math. This is fact. More importantly, this is what we call unsustainable, and this is precisely why my silent observation of the critics outside of the arena ends today. As healthcare workers, we are in the arena, and for this reason, we have more than earned the right to speak out. As this pandemic unfolds, however, this becomes less of a right and more of a moral obligation. Like the man (or the woman) in Roosevelt’s speech, we must strive to do the deeds – for our patients, for our patients’ families, for our colleagues, and for our communities.

“It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat.” – Theodore Roosevelt, Sorbonne, France, April 23, 1910

These views are my own and do not reflect those of my employer.

I had every good intention of keeping up with this blog at the beginning of intern year. This was supposed to be an outlet for processing what I knew would be a challenging experience. But as it often does, life had something else in store for me.

Let me first start by acknowledging that being an intern is, in and of itself, some seriously hard work. The learning curve is something steeper than exponential, and the day-to-day can be all-consuming. Looking back on this past year, I can finally start to recognize the tremendous amount of growth that occurred while I stumbled through my days, but had you asked me about said growth in the moment, I likely would have adamantly denied its presence. The work is tough, the hours are long, and the time allotted for decompressing can be sparse.

After finishing my first four weeks of general medicine wards followed by two weeks of night float, I was ecstatic to emerge on the other side led by two glimmers of hope: weekends off and the upcoming closing on our first home. My husband and I closed on our home on a Wednesday, and the following Saturday, we set off for our alma mater for a day of tailgating with family and friends and college football. After the game, my husband continued his eastward travel across the state for a business trip, and I settled into a friend’s car to head westward towards home. Little did I know that it would be during this car ride that the trajectory of our year would forever change.

From the backseat of my friend’s car, I nervously opened the news article to find shaky cellphone footage of flames surrounding the house that we had closed on no more than 72 hours beforehand. The following hours unfolded in a blur during which we learned that our house had caught fire after a natural gas explosion occurred at the home next to ours, but it wasn’t until the following day when I was finally allowed to enter our home that I understood the magnitude of the damage. From the outside, it appeared that the house’s brick façade may have protected it from the heat and fire, but inside of the house, the charred interior told an entirely different story. After facilitating the boarding of the windows and the tarping of the roof that first day, I had to wash my hair an innumerable number of times to remove the lingering scent of smoke.

I will pause here to point out one of the many lessons that I have learned during this process which is that we never really know how a person is doing unless we ask and are trusted enough to receive a true and honest answer. As humans, we have a way of prioritizing our self-image, and I am no exception to this rule. Had you stumbled across my social media in the days and months that followed this life-changing event, you would have seen photos of happy, smiling faces on the day of our closing, but a single image that revealed the true and honest reality that we were living you would not have come by. No, no – it’s all rainbows and butterflies over here, thank you. Carry on.

As the immediate shock began to fade, my husband and I were faced with a new reality that would ultimately come to fill all of the aforementioned sparse time for decompressing. This new reality looked something like this. I would go to work as an intern during the day. My husband would balance working from home and fielding calls from the various stakeholders involved in processing a very large home insurance claim. When I returned home at night, wanting nothing more than to just sit and to breathe, we would reconvene to strategize in the fight for what we were rightfully owed. (I don’t use the term “fight” lightly here, because that is exactly what we had to do in order to receive what was contractually ours.) This new normal was cyclical and exhausting and always demanded our full attention; as almost anyone who has graduated from medical school knows, you come out with two new letters after your name, but you also leave with some pretty sizable debt. From firsthand experience, I can tell you that it is nearly impossible to sit upon the combined debt from medical school and a mortgage on a home that no longer exists without at least some level of smoldering anxiety during moments of inactivity and rest. In short and to no surprise, figuring out a path forward became our number one priority.

Now, I’m sure that there are individuals out there who could have simultaneously juggled the stressors of being an intern and dealing with a personal struggle without compromise, but I was not one of them. In order to continue moving forward on both fronts, I sacrificed just about everything else in my life. I stopped meal-prepping and exercising. I stopped forming new relationships and nurturing existing ones. I stopped pausing and checking in, and in doing so, I became a shell of myself. As a shell, I was in survival mode all of the time. I felt like I was carrying the weight of the world. I felt paralyzed and unable to reach out for help. I felt awkward and unworthy and undeserving, and this, dear reader, is what we call shame. Shame. I am bad. I am inherently flawed. I am spending my time figuring out my personal life when I should be reading more and learning more and growing more as a physician.

I have held off on writing about this for months now, because I knew deep down that there was something more that was meant to come from my pain; I just hadn’t quite figured it out yet. As I write this, I am still very much working actively to remove my shell and to regain my stride, and some days are better than others. But do you know what? That is okay, because what I do know for certain is that what I have felt is not unique to me. Shame is not unique to me. In fact, I believe shame is quite intertwined with the process of becoming a physician. As an avid consumer of Dr. Brené Brown’s research, I have learned that shame thrives in silence and shrinks in the presence of vulnerability. I have written about the value of vulnerability in the past, about the importance of showing up just as you are. I have talked the talk when it comes to vulnerability, but I have not always walked the walk. In sharing my story, I hope to do so. In medicine, in particular, this is important for ourselves and for our patients alike, because we can’t pour from empty cups. And right now, more than ever, I wholeheartedly believe that this work is essential – in my professional life, in my personal life, and everywhere in between. There is strength in vulnerability. There is courage. There is power. More on this to come – stay tuned.

Today was my last day of medical school. I wish I could say that it was in some way magical, but to be completely honest, the whole thing was the textbook definition of anticlimactic. No fanfare. No confetti. No champagne. Just me, a computer, and an exam timer quietly ticking down from two hours and 45 minutes, the allotted length for the standardized end of rotation exams, to zero seconds. I packed up my belongings and made my way out of the library, feeling for one final time the warm air on my face and the inevitable wave of untethered freedom. How many times have I felt this post-exam feeling before? I have completely lost count. For the greater part of my 29 years on this earth, my life has been divvied up by exams. I remember throwing myself onto my bed in first grade with hot, salty tears streaming down my cheeks and blubbering over my assessment that I would never be able to correctly spell words such as “and” and “the.” The testing continued, and some of the more vivid experiences have been seared into my memory forever. A pre-test on fossil fuels in third grade. An algebra exam in eighth grade that was preceded by a failed class-wide attempt at revolting against taking said exam. “Group tests” during senior year physics. Engineering exams that I passed with flying colors and engineering exams where I was ecstatic to answer 65% of the questions correctly. An anatomy practical where I lost my place amongst the numbered body parts and experienced a panic so great that I thought I was going to syncopize face-first into a cadaver. An exam so unfortunately fate-determining that I barricaded myself inside of a library nearly every day for six weeks on end. With my head down and one foot in front of the other, I slowly ascended this mountain of exams until today at noon when I somewhat abruptly found myself at the top.

In his infamous last lecture entitled “Really Achieving Your Childhood Dreams,” Randy Pausch introduced the concept of a “head fake” by making an example of children playing sports. The idea goes something like this. Parents do not necessarily set out hoping their children learn about *insert any sport you can think of here* when they sign them up for the local sports league. Instead, parents want their children to learn about teamwork and sportsmanship and perseverance. That’s the “head fake” or the indirect learning that takes place without the individual even realizing it. In reflecting back on my education to this point, it is glaringly obvious that the “head fake” applies to the process of achieving a medical degree just as well. Doing well on exams requires you to learn the material. It requires that you focus on yourself. On your foundation of knowledge. On your preferred study method. On your exam grade. But as we slowly but surely climb the metaphorical mountain, the most beautiful thing that we can learn is that it’s not about us at all. We don’t learn the material to learn the material. We learn it because our understanding of the pathophysiology, diagnosis, and treatment of disease will one day directly impact the outcomes of our patients. We don’t take the exams to get the grades. We take the exams to demonstrate that our patients will be safe while they are under our care. We don’t seclude ourselves and miss out on opportunities in vain. We make these sacrifices because practicing medicine is a privilege that is, in many ways, earned.

Now, I would be lying if I said that I recognized this privilege early on in medical school. I didn’t, and I don’t necessarily fault myself for that either. It’s hard to realize the wealth of opportunities your white coat affords you when your days are spent tucked away in a library carrel, slumped over a textbook. It wasn’t until I started interacting with patients on any kind of regular basis that I really started to understand what it means to take care of other human beings, what a unique vantage point we are given, and what a tremendous amount of trust is implicitly offered to us. With the mountain that was medical school behind me and the mountain (Mount Everest?) that will be residency in front of me, I hope for many things. One of the things that I hope for the most, however, is that my understanding of the medical training “head fake” continues to grow in order to allow me a fuller understanding of what a blessing it is to serve as a healer through the practice of medicine.

Medical school is almost over, and if you’re anything like me, endings have a way of bringing #allofthefeelings to the surface. And to intensify these feelings, medical school was hard. Really, really hard. And while I clearly have no first hand experience in what it means to be a resident, I feel confident wagering the educated guess that residency will also be really, really hard. Anyways, back to things that I do know for sure: if there’s one thing that I’m good at (not unlike most people, I’ll add), it’s making my life appear like it’s all rainbows and butterflies via the curated images that are social media. Here, for example, is a photo of my husband and I looking really, really happy on Match Day.

Except we’re both kind of really, really terrified inside. Because, seriously, what even does that little letter that I’m holding actually say about our future whereabouts? But alas, happy we appear. I’m kind of getting ramble-y here, but there’s a point, I promise. The point is that we are all starting a new chapter, one in which we will experience the highs of medical training as well as the lows. Furthermore, we’ll all probably want to look like we have it all together while simultaneously having a constant need to ask for help. For a lot of things. For a lot of really, really basic things. But guess what, that’s okay. Because that will kind of, more or less, be our jobs. To ask for help. To learn. To learn and then re-learn and then, realistically, re-learn again.

So, where exactly am I going with all of this? Well, here’s the other thing. Burnout or, more aptly, moral injury, is also real. Really, really real. And also super multifactorial. And probably not solved by #wellnessinitiatives alone (but that’s a story for another day). One thing that makes me feel like burnout and moral injury are not the end of the road for the medical profession is the fact that Dr. Brené Brown, the amazing affect researcher that she is, is slowly but surely making herself known in the medical community. And for good reason, by the way. She’s kind of the penultimate form of realness. She was recently interviewed on #thedoctorparadox podcast, and she dropped this brutally honest nugget of truth.

“…the biggest shame fear, at least when I interview physicians, is not even about what patients are going to think. It’s about what their colleagues are going to think. It’s about what other healthcare professionals, who they believe they have some control and power over, are going to think. Many physicians that I have interviewed are comfortable being more vulnerable with their patients than they are with their colleagues. And I’ve got to tell you, as someone who’s done a lot of grand rounds in medical schools, that is absolutely by far the most shame-based, competitive environment that I’m ever in.”

So, why does this matter? Because we are the future of medicine. We are the people who get to set the tone, set the stage, set the agenda. We get to create the spaces within the hospitals where our colleagues will feel comfortable speaking up, sharing their weaknesses and concerns, asking for help. Sure, that might be tough to do as interns, but this is work that I truly believe we have to do. We have bring #vulnerability into the medical training milieu. We have to stop hiding behind perfectionism. It’s not good for us, and it’s not good for our future patients. Burnout is a big problem that will undoubtedly fall to our generation of physicians to solve, and don’t get me wrong, it will require a multifaceted approach. But don’t underestimate the power of vulnerability, the power of being a human being. Bring your perfectly imperfect but wholly human self to work. For your future patients, for your future colleagues, and for your future self. Oh, and also, check out this podcast episode. It’s the realest.

Medical training is often described as being an exercise in delayed gratification. This concept more or less implies a trade of instantaneous satisfaction for a (hopefully) larger reward down the road. And in so, so, so many tangible ways, this is spot on. You give up the free time, the weekends with friends, the vacations, the new car, the home ownership, the whole 401k thing. The list goes on and on (and on and on). Ironically enough, however, there are moments in medical training that all but forcefully shove right into your own two hands one of the most important, most elusive entities that I think we as human beings are all chasing:  a gratitude for the present moment.

I would estimate that the great majority of medical training is spent just trying to stay afloat. To keep your head above water. That has been my experience, at least. If it’s not a project or an exam, it’s a patient presentation or a challenging diagnosis. A battery of questions from an attending during rounds or in the OR. An outside hospital record that you can’t seem to get faxed (Yes, we in medicine still rely heavily on the antiquated thing that is a fax machine). There is so much metaphorical treading of water. It can be exhausting, and I’m fairly certain that I’m only scratching the surface of a mountain of fatigue as a student. But tucked snuggly away, in between the studying and the rounding and the assessments and the plans, there are some serious moments of clarity. Moments when you see good health taken away too quickly from people who were too young, too unprepared, too kind. These moments are filled with tears, with sideways looks to loved ones when the term “cancer” floats audibly into the open air for the first time, and with long, drawn out silences.

It might be the unabashed fluorescent lights under which these conversations so often occur in the hospital or the weight of the words themselves or, most likely, a combination of both. But in these moments, the important things become crystal clear. True gratification is not and never will be derived from the things that we think we’re giving up, the tangible things. Being healthy. Being alive. Being present. Having our loved ones around, healthy and alive and present as well. These are the things that we’re all chasing. These are the things that matter the most. I know I’m not alone in saying that I fail to realize this on a daily, if not hourly, basis. However, if medical school has given me any one thing, it is a position to be reminded of this important lesson on a semi-regular basis. The reminder usually comes on a particularly challenging day, during a particularly challenging week, when you’ve felt like you’ve seen enough human suffering to outlast a lifetime. These reminders are so important, so invaluable. They are part of the reason why it is an honor and a privilege to practice medicine. May we all, be we in medicine or not, allow ourselves to more often remember the important things. For instant gratification’s sake.