Chapter 2: Outpatient Internal Medicine


Love, Sanity, or Medical School

Chapter 2: Outpatient Internal Medicine

July 29: Monday

7:10 am: I will not cry today. I will not think about my breakup with Casey. I am sitting at the Starbucks at The General Hospital and I will not cry. So far so good but it's only 7:15am. Off to my first morning at the internal medicine outpatient clinic. Remember, no crying.

7:50 am: There are two other medical students present when I arrive at my first assigned clinic site. A nurse shows us our schedule for the day. Looks like our first patients will be arriving in ten minutes. Ok. Turns out this is the student clinic where we are expected to see our own patients, take a patient history and do a physical exam (aka the H&P), then develop an assessment and plan. Just like grown up doctors. This is all well and good, I just had no idea I would be having my own patients right now this second.

9:15 am: I took my worst history ever. Probably a combination of being caught off guard with this situation of walking into a student-run clinic, having my own patients, it's Monday morning, and I'm still distracted from everything that happened this weekend with Casey. Sad. No, no, no, not going to cry. Not here, not now. This patient's history was made particularly difficult because the patient recently had a stroke and his residual deficit is memory impairment.

Me: “Sir, how long have you had diabetes?”

Patient: “I have no idea.”

Me: “Ok, what happened when you had your stroke?”

Patient: “I don't remember.”

Me: “Do you take all of your medications every day?”

Patient: “Yes.”

Me: “You take every one of your medications every single day?”

Patient: “Well...”

Suffice it to say that the visit did not improve from there.

4:30 pm: I used to live in Chicago and I loved it there. I moved there on a whim after graduating from college. If not for Casey I never would have left Chicago and I’m aching to go back there at the moment.

6:15 pm: I'm about to leave for dinner with The Boss, my trusted advisor and confidante. When I first moved to my little Midwest city, I desperately wanted a job at The General Hospital to increase my chances of being accepted there as a medical student. Casey searched around the hospital and found out that The Boss, one of the senior attending physicians in the emergency department at The General Hospital, was thinking about taking on a premed student to help her with a new research project.

I emailed her out of the blue and basically wrote, “Hi, my name is Silvia, you don’t know me but you want me to work for you.” She wrote back the next day with something like, “I have no idea who you are, but I'm intrigued.” Shortly thereafter I began working for her.

We quickly developed a productive and trusting working relationship. She became my premed advisor, helping me navigate the application process, prepping me for my interviews, and even writing one of my recommendation letters. Once accepted into medical school she became my academic advisor. Years later, our working relationship has grown into a friendship as well. Upon hearing of the breakup with Casey she immediately offered to take me out for dinner and drinks (aka get me super drunk). So, off I go to dine and drink with The Boss.

Midnight: I'm a couple of beers and martinis deep right now. The Boss and I talked for hours and she informed me that when I am ready to date again that I will have no problem meeting new men. Her explanation went something like, “It will be just like Zappos, you will have an array of options and you will pick the one you want.” I told her that mostly I am unhappy but a part of me is a little angry, a little disappointed, and oddly, a little relieved. I offered that if she wanted to, she could be a little mean to Casey when she runs into him at the hospital. In a professional way, of course.

July 30: Tuesday

10:30 am: I have no clinical responsibilities today, just afternoon lectures, so I spent the morning moving my stuff into the guest bedroom. My outpatient medicine schedule is very light compared to inpatient medicine. I work two half-days at the student clinic, three half-days at Far Away Clinic, and one half-day in a cardiology clinic.

I'm ok until someone asks me if I'm ok. I feel like a life I had been planning for years just died.

July 31: Wednesday

7:30 am: Back at the student clinic, then this afternoon I'm working at Far Away Clinic, a fair distance away from my little Midwest city. I'm not sure what my responsibilities will be this afternoon.

9:43 am: It turns out that patients frequently do not show up to their appointments at the student clinic. I have yet to see any patients today.

10:15 am: When I'm upset, I lose my appetite. Everything tastes like cardboard. When I went through Hurricane Katrina during my senior year in college I lost almost twenty pounds in just a few weeks. Fortunately, it was right after my junior year studying art abroad, and most of those twenty pounds were souvenirs from my months spent in Rome and Paris. Stories from college are for another time, perhaps another book.

6:15 pm: I didn't sit down the entire afternoon at the Far Away Clinic and I barely had time to write my notes. I really enjoyed the pace as well as Dr. Pearl, the physician with whom I worked.

Dr. Pearl would send me into the patient's room to do an H&P, after which I would present the patient to her and then offer my ideas for what we should do. She would then step into the room for a few moments to greet the patient and clarify anything that was unclear. I was immediately trusted to see patients and give my opinion on their care. This is a first on this rotation. Dr. Pearl apologized for all the running around, but I loved it. She doesn't know I spent a lot of my days on inpatient internal medicine sitting and studying.

One of my patients this afternoon was a tall, dark and handsome man, who arrived in his manly uniform. He sprawled out on the exam table, nearly naked in just red and blue striped briefs. He was too tall for the table and his legs dangled off quite a way. He was lying on his side, head propped up on his hand as if posing for the annual Midwest uniformed man calendar. Unfortunately, his whole body was colonized with the bacteria called MRSA, which left him covered in painful abscesses.

Being so big and tough, he didn't come in until the lesions were huge and he could barely get dressed. Some medical terms I used in my note on him include: indurated, fluctuant, erythematous, purulent, and malodorous. He was lying on his side because that was the only comfortable position for him. Why was he naked? So that we could drain the larger abscesses on his hips and thighs. Not so sexy. Sorry. At least I’m learning proper medical terminology.

August 1: Thursday

8:45 am: I’m waiting to see the human resources folks at the Cardiology Clinic to get my ID badge. Tonight, will be my first time seeing Casey since our breakup last Saturday evening. We… wait, no… now it's “I”, I need to take myself off the shared cell phone family plan we're on. The car and renter's insurance needs to be separated. He'll be moving out soon and I'm going to need to move on with my life. Not easy. Not fun. I thought he was going to be my husband and the father of my children. Time to delete the Pinterest wedding I had planned.

10:34 am: Finally done with obtaining a Cardiology Clinic badge.

12:45 pm: Back up in Far Away Clinic.

It's very different working for a physician that does not trust you. The doc I am working with today is a young Indian man named Dr. Gupta. Just like yesterday, I would go into the room, report back to him, and then he would go in. However, unlike Dr. Pearl, Dr. Gupta would then proceed to re-ask every question I had already covered. Patients must get annoyed answering the same questions repeatedly. It certainly annoys me because it means he either wasn't listening to me, didn't care what I said, or didn't trust the information I reported. Every single patient. Not every physician will operate in the way that I, the third-year med student, wants him or her to. Oh well.

Dr. Gupta is lacking a bit in the interpersonal skills arena. For example, a new patient arrives at the office to establish care, she has ripped shoulders and arms, is dressed in workout gear and running shoes, and I'm guessing she will leave the office and head straight to the gym. While getting a history from her Dr. Gupta queries, “do you ever work out?” Um… really? He couldn't be like, “oh, I'm guessing you're a runner?” Or something equally appropriate?

The patient and I exchanged glances and then she politely responded, “Yes, I do work out.” There were several moments like that with other patients throughout the afternoon.

August 2: Friday

7 am: I miss my family. I need a hug from my momma. My sister Olivia is due to go into labor with her twin boys at any minute. I’ve been secretly painting a Winnie the Pooh themed piece for the twin’s future bedroom. I wish I could be in NY right now.

11:15 am: Interesting patients today at Far Away Clinic.

Noon: I have a new appreciation of the word hypochondriac. Into clinic this morning walked a healthy-appearing young woman with a multitude of concerns. Her vitals signs (meaning her heart rate, blood pressure, respiratory rate, and temperature) were normal, and even though she frequently visited the office, she did not have any actual medical conditions listed in her chart. She ended up getting four referrals to various specialists, all at her insistence, and we addressed several other concerns unrelated to the referrals as well. Several of the docs informed me that with some patients, it's easier to give in and let them have whatever referrals they want. Not sure how I feel about that.

2:13pm: I’m getting antsy, I can't take it anymore; I have to get out of this city.

5:10 pm: I’m trying my best to not sit around wishing that I had never left Chicago. I loved it there so much. Professionally, I'm in a great place. I love my school and my friends, I'm going to be a doctor, and I know that I can leave this shitty little city in less than two years. That's gonna have to be enough for right now.

August 3: Saturday

4:24 pm: Almost finished the Winnie the Pooh painting for my sister.

August 4: Sunday

I really need to be studying but I'm still so distracted. It is weird to think of myself as single after all these years. One of my friends asked me if I would be willing to date a guy who has kids. Huh? I don't know, I hadn't really thought about it. Yes? No? I have no idea.

Noon: I will be an auntie exactly twenty-four hours from right now! Olivia’s soon-to-arrive twins have no idea how much they have already helped brighten my life this past week. Every time I have felt sad this week, I imagine her and my little nephews. I can't help but smile and think that one day, with the right guy, I will know that happiness too. Is it possible to have tears of pure joy and abject sorrow at the same exact moment? Let’s not find out right this moment though as I’m sitting at my neighborhood Starbucks and it would be really awkward if I started crying right now. I have to stop writing for a moment.

Interesting article for those so inclined: there’s a NY Times opinion piece from August 3, 2013 entitled The Trauma of Being Alive by Dr. Mark Epstein, in which he mentions the Kubler-Ross stages of grief. In thinking about my breakup, I can see how the stages apply. I think I spent the last year in denial about my relationship being over. I am starting to feel a little angry, but mostly I am still just sad. I don't know how bargaining will play into this, and I certainly am not at acceptance yet.

I have a lot of experience with grief and trauma but I am already emotionally wrecked about Casey so I won't torture myself or depress my audience any further right now with thoughts of those other haunting experiences... Stop. Redirect. Babies. Think about my sister's babies and how I will have a photo of them tomorrow. Focus on the happy stuff. See, I'm already smiling.

August 5: Monday

12:30 pm: I'm struggling with how much to include here because I set out to record my experiences as a third-year medical student, not to share the details my love life. Well, here goes nothing. Casey and I had sex last night. Our evening started off innocently enough but, as tends to happen whenever we are left alone, we can't stay away from each other. He hasn't moved out yet, so I knew I was in a high-risk situation. I couldn't remember the last time he had seemed so interested or passionate. It was incredible. I cried afterwards.

I keep trying to blame myself for our relationship falling apart. I think if I weren't so stressed with school the past two years and so focused on us getting engaged then maybe we would've kept the fun lightheartedness in our relationship that had always been present. But I remind myself, if he had proposed a year and a half ago then maybe I wouldn't have gotten so down and serious in the first place.

I don't understand what went wrong, or what wasn't right enough for him. We had a really happy relationship. He treated me so wonderfully; he was affectionate, cooked for me almost nightly, and routinely helped me study in med school. The sex was always incredible. But, after seven years he still wasn't 100% certain that I was “the one.” I couldn't give him any more years of my life. I had to end it. I need to stop. Dwelling on this will only make me mopey and weepy again. I just wish I knew what it was about me that wasn't good enough for him.

1:00 pm: As I sit here feeling depressed and eating my Greek salad, I am also checking my phone every two minutes, awaiting updates from New York on the progress of Olivia’s delivery. At this very moment she is in a hospital in Manhattan getting an epidural. Babies will appear soon. Within an hour, perhaps?

2:34 pm: I am creating tracks in my carpet from all my pacing back and forth. Olivia went down to pre-op about twenty minutes ago, and her hubby Alejandro was called down to meet her in the OR a minute ago. Here we go!

3:04 pm: Olivia’s cesarean should be almost done, right? The babies should be out by now and her Ob-Gyn should be stitching her up. I want to see their bitty faces and give them kisses and thank them for helping me through the week.

3:08: Two healthy, beautiful baby boys have arrived! Welcome to the world my little nephews Jackson and Henry. They are, in a word, perfect. My momma, now known as grandma, sent me adorable photos. Olivia, now known as mommy, and her babies are doing well.

PS: Yes, I saw patients today at the student clinic. No, I don't really remember what happened.

August 6: Tuesday

8:00 am: Another day with no patient care. Outpatient internal medicine is not what I expected. At least we have a clinical skills lab today.

My friends and family seemed surprised and impressed when I tell them that I broke up with Casey, and that I told him to move out. Everyone guessed that I would be the one to move out. As I explained to Casey, I was the one who already did everything. I left my beloved Chicago for him, I worked my ass off to get into the only medical school in this little Midwest City, and I spent every day of the past year and a half trying to figure out how to make our relationship work. I'm done being the one to do things.

So, Casey is the one moving out. He didn't argue, he agreed. His move out date is about three weeks from now. Maybe once he moves out we'll stop having sex? Oh, and for the first time in seven years he left a hickey on my neck. I feel like such a teenager.

11:18 am: The cow eyeballs squished a bit when cutting into them. Slimy little buggers are slippery. A few almost went shooting off the exam table at our clinical skills lab. While learning about performing eye exams we were treated to some pretty horrific images of human eyeballs in various stages of injury and infection. I like procedures. As I now have a break until afternoon lectures, I should probably go study.

1 hour later: I did not go study. I talked to my sister and to my mom. Somehow Casey and I are going out tonight for dinner. A non-date, if you will. I guess it's better than ending our relationship with fighting? We're just really bad at not being together. I wonder who will pay the check.

After Casey and I broke up I tried reaching out to my girls first but everyone was out of town because we all had the weekend off. I then called Magnus, who picked me up within fifteen minutes of me telling him that Casey and I had split. He brought me to his apartment, invited over a bunch of friends, and we spent the day drinking beer and watching classic dumb comedies such as Dogma.

At some point he apologized for not being good with “girl stuff” but he added that he has plenty of beer for me, and beer is almost as good as girlfriends in these situations. I agreed. The following day I spent with Piper, Sophia, Jane, Maggie and Daria, who were also incredible. My friends showered me with love, hugs, and support. It's not that I'm surprised by how amazing my friends are, but they have gone above and beyond to take care of me. Truly incredible.

I love my friends.

August 7: Wednesday

6:53 am: My heart is still pounding from the nightmare that just woke me. There were blasts and bombs going off all over. I was with my cousin Violet. It was the day of her October 19 wedding and her hair was already done. We needed to get out of the area because we were in danger. Firefighters directed us towards safety. There were blocks and blocks of debris piled high for a far as you could see. We had to climb over the piles because there were no longer any clear roads to walk on.

The piles were made of blasted building bits and body parts. Bleeding and horrifically injured people cried out for us to help them, but we couldn't help anyone because it wasn't safe to stop. The smell of burning flesh and smoke was in the air.

Four missiles zoomed overhead so we ran into a building for cover. We could feel the heat of the blast. I thought the building was on fire and that we would burn to death inside of it. The fear choked me. Back outside, we again began climbing over the piles of bodies. A woman reached out her hand for us to help her, but the firefighters yelled at us to keep moving. I tried to apologize to her for not helping but I was rushed along too quickly. We reached a staircase and started climbing. Violent yells to me “No, I can't do it anymore.” I support her back and push her forward as we are climbing. She faints backwards onto me. I woke up screaming.

Noon: There was only one patient for me to see in the student clinic. I was hoping for a busy day to pull me out of my post-nightmare haze.

I spent my afternoon at Far Away Clinic with Dr. Pearl. Her patients absolutely love her. It's inspiring to see a physician happy and relaxed yet working efficiently.

As much as I love my two-bedroom two-bathroom apartment, I cannot afford to live here by myself. I'm starting my roommate search by posting my apartment on a website called Rotating Room. It's designed for students working in healthcare that rotate at different hospitals and need a place to stay for only a month or two at a time. This seems like the easiest and fastest way to get a new roommate.

August 8: Thursday

I shipped the Winnie the Pooh painting I made for my nephews Jackson and Henry. A relaxing morning so far, and then off to Far Away Clinic for an afternoon with Dr. Gupta.

Some days every patient seems to have the same complaint; everyone will have a cold, or back pain or whatever. Not today. I saw a spider bite that resulted in a full body rash, a rare bleeding condition complicated by a blood clot in the patient’s leg, and a post-op visit.

In response to the patient with the spider bite, one of the nurses spent a solid hour googling various spiders on her giant flat screen computer monitor. I have horrific arachnophobia and fear paralyzes me whenever I see a spider. Unfortunately, her computer screen faces my workstation so I had to crouch down behind my own screen to avoid seeing the myriad of tarantulas, wolf spiders, brown recluses, and other little horrors. Occasionally she would exclaim, “Oh that's so gross! Look how hairy! It's so big! All those eyes!” My heart is racing and my skin is crawling. I keep telling myself to take deep breaths and not look so visibly freaked out. It’s unprofessional.

I walk into the room of another patient and notice that his face and ears are speckled with large blood vessels called telangiectasia. He has a rare bleeding disorder called HHT. I forgot what it stands for... Hereditary hema... Something. Basically, it's a vascular disease with related bleeding and clotting issues. He presents with leg pain that is very concerning for a blood clot in his leg. We sent him for an emergency ultrasound of his leg and several hours later got bad news: he leg was full of clots from his ankle to his mid-thigh. Blood clots in the thigh are dangerous; a little bit can break off and go to the lungs, causing a blood clot in the lungs, called a pulmonary embolism. Typically, you can give blood thinners to people with clots. But, giving blood thinners to someone like him would likely cause potentially fatal bleeding. Kind of a catch-22; treat the blood clots and risk him to bleeding to death or don't treat the blood clot and he will likely get a fatal pulmonary embolism. What to do?

HHT is an autosomal dominant hereditary disorder. One side of his entire family is affected. While HHT is not fatal in and of itself, it puts you at major risk for bleeding out from minor trauma. There is variable penetrance, so some family members get it worse than others, and there is no way to tell how bad it will be for a particular person. The first sign tends to be recurrent epistaxis... aka lots of nosebleeds. His children have recently begun to have nosebleeds. His story makes me wonder, with a dominant and potential deadly genetic disease, I don't know if I'd willingly have children. I say that as someone who may be a carrier of a 100% fatal recessive disease.

August 9: Friday

Countdown to the weekend.

8:40 am: Two nurses are working today. Let's call them GN and BN for Good Nurse and Bad Nurse, respectively. BN was sitting at her desk picking her nose. GN was calling patients with test results, while BN made a personal call. Not that I'm against personal calls, I couldn't care less, but BN came across as lazy while GN was working.

8:55am: GN asks, “BN, why haven't you gone through your pile of papers yet?” GN points to a stack of papers next to BN, a pile of lab results and other things that need follow up.

“Wait, what? Why didn't you tell me earlier that I had work to do?” BN rolls her eyes and audibly sighs before she stops picking her nose and starts to go through her paperwork.

Another afternoon with the young Dr. Gupta. He still repeats every question I ask. Today one patient replied to a question with, “I already told your med student...”

To which he countered, “Yes I know, she told me.” Awkward.

11:30am: BN is sitting at her station assaulting my ears with her singing. I can't.

12:38 pm: Off to the Cardiology Clinic.

Today started off with Dr. Heart, a world-renowned cardiologist, offering that I could work with her for the afternoon. Very, very exciting and intimidating.

One of her patients today was a spry100-year-old man, named 100, who had come in for a checkup. Although he had no complaints, Dr. Heart completed a thorough physical exam. This is going to sound so nerdy, but her exam skills are mad impressive. Using the tips of her fingers and her palm, she was able to feel a subtle murmur, determine not only that the heart was enlarged but specifically which chamber of the heart was enlarged, and to figure out that 100 was in the early stages of heart failure.

She explained findings to me as she went and tried to have me copy her maneuvers so that I too could reach the same conclusions. I don't think I have ever felt more inadequate as a medical student. To confirm her suspicions, she decided that 100 needed a few lab tests and an electrocardiogram (EKG). Of course, all of her suspicions were spot on. Damn, she's good.

August 10: Saturday

I spent my day cabrewing with a bunch of my classmates and other random people. For those unacquainted with cabrewing, it is basically canoeing while drinking a lot of beer. I am mostly sober now and need to get some sleep. It was great to get out of the little Midwest City and do something different. I also met a lot of people. A super cute blue-eyed guy named K Canoe got my number. I'm not interested in him, or anyone at the moment, but I thoroughly enjoyed that a tall and handsome stranger flirted with me. Flirting and all that is still novel to me at this point in my breakup recovery. Too bad I didn't meet him a month or two from now when I'll hopefully be ready to start dating again.

August 11: Sunday

10:30 am: The Winnie the Pooh painting arrived while on Skype with Olivia and the twins. She loved it and is going to hang it in their room.

1:24 pm: Blehh… studying. If I studied as much as I painted and journaled, I think I would be a phenomenal student. Every move I make hurts as I am sore and covered in bruises from all the times my canoe flipped over onto me yesterday.

Casey and I ended up going to a super fancy dinner together last night. At least we didn't sleep together afterwards. Progress?

Off to get my hair done. I need a new look. It’s time to go from being a bland brunette to a fiery redhead!

August 12: Monday

11:15 am: We had eight patients scheduled for the student clinic today, three showed up. Each student got to see one of them. At least I was done by 11 am. My one patient had stitches on the back of her head, left behind by the trauma team. No, I did not call a trauma consult to ask their permission before I removed them.

It's weird to give nurses orders. Even weirder when they do what I request without question. I've read that some women tend to have a harder time commanding others to do things. Turns out I'm one of those women. Maybe it's because I don't feel like I know enough yet, coupled with the fact that I'm giving orders to people much older and wiser than me and more established in their careers. I guess I’ll just have to get comfortable doing it.

Off to go study. For real this time as I am running out of time to procrastinate. At the end of each rotation we must take a final exam. These exams are nationwide, and the scores end up in our residency application, so they are high stakes. The exam is in less than two weeks!

August 13: Tuesday

Studied all morning. Go me. Off to Super Tuesday afternoon lectures.

My first lecture covered a ton of interesting material in an engaging way. Now, we're halfway through the second lecture and the new lecturer is monotonously reading her slides of black text on a plain white background. My mind is starting to wander, not to anywhere specific though.

I'm thinking about my upcoming test, my amazing new auburn hair color, dinner with Casey, my classmates, starting my surgery rotation, and wondering how badly I'll be suffering from lack of sleep. Basically, I’m thinking about everything except my current lecture. I wonder if and how I'll manage to write during my surgery rotation. I guess I’ll try to at least jot down a few thoughts each day and go back and expand on them as I have time.

Glancing around the room, everyone seems pretty spacey. A lot of students are typing on their iPads and laptops. I'm guessing they're ‘taking notes’ just like I am right now. Magnus is sitting next to me on his iPad, alternating between Facebook and researching players for his fantasy football team. Ok, her lecture should be ending soon. My classmates are squirming in their seats.

Our lecture has already run a couple minutes over. Oblivious to our lack of interested, the professor announced, “You guys seem to get it, I could probably leave right now, but I'll go ahead and go through the next two cases anyway.” The crew is getting restless. There may be a mutiny soon. I am trying to keep a neutral, pleasant looking face. Magnus is sitting next to me practically jumping out of his seat. I appreciate informative and engaging lectures. I don't like lectures without any new information, without pictures, and that run long. Oh the next lecturer just poked his head into the classroom and gave the current lecturer 'a look'. Message received, she just wrapped up. Finally.

Now this is a lecture: clinical decision making tailored for new third year medical students, using a common disease as an example but easily applicable to other medical conditions. Words of wisdom from this lecture: use evidenced based medicine but never betray your gut.

I have no cell phone service in the lecture hall. As soon as I walked out of the classroom my phone beeped with a text from K Canoe, the guy I met cabrewing on Saturday. I was kind of hoping he wouldn't contact me because I feel bad ignoring him but I'm definitely not ready to date yet as I’ve only been single for two weeks.

August 14: Wednesday

At the student clinic once again. My patient is a soft spoken and kind young man who has a genetic condition causing high blood pressure, diabetes, and severe heart failure. Clearly embarrassed, he revealed to me that he couldn’t afford all of his prescriptions. We sat with the attending and went through every single prescription, picking out the most important ones. The whole time, I felt incredulous that there was not more that we could do for him. The attending noted how this is not an uncommon situation for many of the poorest people in society.

Another patient I saw today also has multiple medical problems. This patient cannot afford his medications either, but it’s because he keeps spending his money on cigarettes, alcohol, and cocaine. Sometimes, I wonder how to impress upon people that they must take care of their bodies.

6:30 pm: Casey told me he found an apartment. I guess that's a good thing. Back to studying.

August 15: Thursday

1:56 pm: Studied all morning, and now I'm back up at Far Away Clinic. I examined a soldier in army fatigues with a mysterious rash. We have no idea what it is or where it came from. Seriously. I have yet to figure out which rashes and skin conditions can be examined without wearing gloves. Dr. Gupta ran his hands over the little bumps covering the soldier's body. I guess he figured it wasn't contagious. I'm going to stick with gloves for now... always. Just to be safe. Apparently, dermatology is not for me.

2:05 pm: I'm in between patients, waiting for my 2:15 to arrive. When I look at the patient census for the day, all I see is a chief complaint. For my 2:15, the chief complaint is “butt pain.” I have all sorts of ideas as to what could be causing that particular chief complaint. Of course, my mind immediately imagines a guy limping in, looking incredibly embarrassed and refusing to sit down while a faint buzzing sound hums in the distance. I don't really imagine that being a Thursday afternoon kind of chief complaint though. That is probably something more likely to show up in the emergency department on a weekend. I'm guessing it will be something way less entertaining.

2:16 pm: He's still not here so I began thinking about the rise in emergency department visits related to women getting Ben Wa balls stuck in them and needing removal after 50 Shades of Grey was released.

The 2:15 walked in limping but it is most likely sciatica, not a true “butt pain.” Oh well. I think Dr. Gupta is also secretly a little disappointed at the anticlimactic visit. Our patient however found the situation entertaining as he kept repeating, “I have a pain in my butt, haha.” No sir, you have hip pain that shoots down your leg. Let’s not exaggerate and get the medical staff really interested for nothing.

6:01 pm: My brain is a bit fried from studying. I'm in a bad mood about Casey finding an apartment. I’m not doing well today.

August 16: Friday

An email popped up a moment ago that someone in New Orleans is interested in my apartment. I'm about to call her. Hopefully it works out.

An hour later: After a phone call, some emails, and a price negotiation, looks like Zooey will be my new roomie. She is a speech therapy student doing a three-month rotation at The General Hospital, from September 13 to December 10. The timing will be interesting. She will basically be moving into my guest bedroom as Casey is moving out of the master bedroom and while I'm moving my stuff from the guest room back into the master bedroom. I'll be on surgery until November, so I don't even know if I’ll see her that much. Who knows? This year is already quite different than I thought it would be.

August 17: Saturday

This time next week I'll be in NY visiting my baby nephews. I am so beyond excited.

August 18: Sunday

10:00 am: Woke up in Casey's bed. Oops, how'd that happen?

7:18 pm: Another one of Casey's married friends is pregnant. I am happy for them but so jealous. My life has been pushed so far away from being at that point. I don't want to be married and having children with someone just for the sake of doing so, but I thought I had found the person with whom I would share my life. Starting over sucks so bad.

August 19: Monday

Every morning at the student clinic I have to walk past the pediatric exam rooms to reach the medical student office. In the pediatrics hallway is a Winnie the Pooh height chart and every time I see it I smile and think of my baby nephews.

One of my patients gave my attending a completely different history than the one she had given me. Now I look like an ass. Thanks.

3:15pm: Zooey and I have a Skype appointment at 4:00 pm. She sounds fun and bubbly and I’m excited to meet her. Maybe she'll be my new BFF.

5:01 pm: I don't think Casey realizes that he still calls me ‘honey’ when he’s trying to get my attention.

August 20: Tuesday

Studied outside on my deck all morning. Sunshine felt wonderful and brightened my mood.

I'm not sure how prepared I actually am for this final exam. Best go back to studying.

12:24 am: After I finished studying around 10 pm I sat down with a suture kit and practiced tying knots for two hours. I am getting really psyched for surgery.

August 21: Wednesday

6:44 am: Last day of outpatient medicine. Last day of my internal medicine rotation. Finally.

8:05 am: It's suffocatingly hot in the student clinic today. Neither myself nor the two other med students are interested in internal medicine and we're all thrilled that the rotation is nearly over. Before the fellow arrived, we started the morning wishing that none of the patients would show up.

Done with the student clinic. I can leave here forever once I get my final feedback. Then off to Far Away Clinic for my last afternoon with Dr. Pearl.

Fun afternoon at Far Away Clinic:

My first patient is a big, badass biker here for his annual physical exam. He is sitting in an itty-bitty paper gown, covered in tattoos, with a black skull-patterned bandanna atop his shaved head. Even the toughest among us need medical care. My favorite part of the encounter was when Dr. Pearl and I informed him that he was due for a vaccine. He gaped at her wide eyed and whined, “But Dr. Pearl you know I hate needles!” It was adorable to see this big beast of a man showing trepidation about getting an injection.

A healthy and fit lady in her early seventies came in for an annual physical. She had been traveling for the past two weeks with her hubby and some friends. During their adventures she informed us how they all went hiking, biking, and did other outdoorsy activities. In the next week or so she will be off to Europe for a couple of weeks.

Immediately following her was another lady of the same age. However, this patient could barely walk from years of metabolic disease and various other illnesses. It was so striking to see them back-to-back. It makes me think I need to start working out again. I know I usually eat healthy but I'm really scrawny right now. I could use some muscle. These women really have me thinking about health maintenance.

A young woman came into the office for an annual physical and I am really jealous of her. She recently returned from a several week around-the-world trip, next week she is moving to an awesome city to start a new job, and she looks like a Barbie doll. Seriously. Not fair. I hope she realizes how lucky she is. I know absolutely nothing else about her, but I am judging her entire life on those three things because I am jealous of all of them at this moment.

My last patient is a chatty and jovial woman who is a couple of years older than me. Her blood pressure normalized after being high for some time and she no longer needs any blood pressure medication. Turns out her blood pressure dropped once she finally divorced her husband and stopped dealing with the stress and anxiety of being in a bad relationship. She told me about the years of angst that came with trying to make a relationship work that wasn't right. Now she is finally relaxed.

She talked about starting over in her early thirties with a hopefulness and positivity that I have yet to find. I wanted to thank her, to tell her that she gave me hope for happiness in my own future, but I just listened and congratulated her on her improving health. I find it entertaining when patients share their stories with me, but I have yet to figure out if and when it’s ever ok to share any snippets of my own life with them.

I've really enjoyed the wide variety of patients I've gotten to see at the Far Away Clinic. Young, old, black, white, healthy, sick, rich, poor, and from all walks of life. I'll have to keep that in mind when choosing where I want to do residency.

August 22: Thursday

7:30 am: Study, study, study.

The library is blissfully quiet right now but freezing. I'm completely incapable of studying at coffee shops or anywhere there are people walking by or when there is any noise. I have major difficulty sitting still and studying for extended periods of time. On the opposite end of the spectrum, I could paint for hours without realizing any time has passed. And of course, I can sit and journal pretty much anywhere without noticing any chaos going on around me.

7:30 pm: Back in the privacy of my apartment. In the past, my home was more of a clothing-optional type of place. Being proactive, I instituted a clothing-mandatory rule about a week ago to decrease the likelihood that Casey and I have sex again. It seemed logical to me that the more clothes we are wearing the less likely they are to come off. However, Casey is ignoring my rule. Right now, he is wandering around the kitchen without a shirt on and with scrub pants barely covering anything. How can I be expected to concentrate on studying with him wandering around all tanned and half naked? It's asking too much from me. Oh well. I tried.

9:39 pm: Final push. I have one more section to review and then I quit. If I haven't learned it by now it's not happening.

August 23: Friday

6:30 am: Walking out of my apartment this morning the sky was dusky blue and a few stars were still twinkling. It had been raining all night and the humidity in the air was drenching, creating a foggy aura. The crickets and bugs sounded a large chorus. It was like being in the blue lagoon at the Pirates of the Caribbean ride in Disneyland. I headed off to my exam this morning humming, “Yo ho, yo ho, a pirates life for me.”

Post exam: That exam was terrible. Everyone walking out looks completely shell shocked. I have three weeks until I get my score. One of my hardworking and studious friends just came up to me and told me she thinks she failed. At least I'm not alone?

2:34 pm: At the moment I am sitting at the new wine bar at the airport. My flight to NY leaves in about an hour. I'm sipping on a glass of Pinot Grigio hoping it will lessen the pounding stress headache I got from thinking about this morning. I would have been at the airport earlier, but I got stuck behind some slow moving farm equipment on the highway. Welcome to the Midwest.

My feedback from Far Away Clinic was uniformly positive and I earned excellent clinical grades. The doctors collectively thought I did a solid job presenting my patients and coming up with a differential diagnoses for them. Dr. Pearl told me I should consider internal medicine as a career, which I take as an incredible compliment coming from her.

My feedback from the student clinic was not so great. The fellow informed me that I started out a little scattered, didn't seem very enthusiastic, and did not go above and beyond, though I improved a lot over the course of the month. It might be more accurate to say that I was barely functioning during my first day at the student clinic, which was not even forty-eight hours after Casey and I broke up.

Overall, she gave me average marks and I could not disagree with her assessment of me. At the same time, she cut me zero slack for not being on top of my game in my post-seven-year-relationship breakup state because medical students are expected to perform at our highest potential all the time, no matter what. I'm still learning how to turn my emotions off when I walk through the doors of the hospital. I'm not sure if I'll ever be able to do it.

Two years and two months of med school down, twenty months to go. Off to surgery.