Chapter 1: Intersession I

Chapter 1: Intersession 1

June 24: Monday

8:24 am: “Welcome to third year!” a smiling Dean of Something Educational boomed across the medical school’s packed auditorium. I didn’t hear many remarks past those beginning words of the requisite welcome speech because I became distracted in catching up with my friends. I’d recently returned from vacation with my longtime boyfriend, R. Casey Jones, and had not yet seen anyone. Aside from all my friends looking expectantly at me to share news that I do not have to share, while not so subtly glancing at my left ring finger, it is wonderful to see everyone.

9:17 am: All medical students are warned that the third year of medical school is the most stressful, exhausting, and confusing year in the whole process of becoming a doctor. I first learned this a few months ago when reading a 2009 study published in Academic Medicine entitled “The devil is in the third year: a longitudinal study of erosion of empathy in medical school.” Some disturbing phenomenon happens during this year where medical students morph from cheerful, motivated, optimistic future doctors into bitter, cynical individuals. Since reading that article, I’ve come across multiple other studies and reports highlighting the horror that is the third year of medical school. Even just last week I came across an article in Slate magazine ominously titled “The Darkest Year of Medical School,” which discusses how third-year medical students experience a dangerous rise in depression, suicide, and substance abuse.[ii]

I’m curious about how this happens and to what extent it will happen to my classmates and me. I intend to record this entire year on my iPad mini, which happens to fit comfortably in the pocket of my short white doctor’s coat. My goal is to subtly jot down notes throughout the day using the app “Notability.” I’ll be recording events not only as they unfold in real time, but also capturing how I interpret these events and how I react to them. Medical student secretly turned gonzo journalist!

At most schools, mine included, medical students spend the first two years hunkered down in hiding, memorizing textbooks. We learn basics such as chemistry, immunology, pathology, physiology, anatomy, etc. In stark contrast, years three and four of medical school are spent rotating through the different medical specialties, letting us try out each one for a month or two. Every medical student in the country completes the same core rotations: surgery, internal medicine, family medicine, neurology, psychiatry, pediatrics, and obstetrics and gynecology. The goal is to expose us to each of the major specialties, helping us determine which medical field we will enter.

10:30 am: Oh, I should probably listen now, the speaker is explaining how third year will work for us. There are three blocks of rotations this year; each block is 16 weeks long. At my school, the students are split into three large groups, and each group rotates through each of the blocks. Kicking off each block is an intersession week, where I am right now, designed to prep the students for their upcoming rotations. As my first block consists of internal medicine and surgery, my lectures this intersession will review common medical conditions (heart disease, diabetes, etc.), basic surgery skills (such as suturing and tying knots), and anatomy. There will be two other intersession weeks this year. Intersession two will precede my block of family medicine, neurology, and psychiatry. The third intersession week will be before my final block of pediatrics, and obstetrics and gynecology.

11:45 am: Immediately following the welcome lecture, we were treated to a talk about not letting residents and attending physicians physically, emotionally, mentally, and/or sexually torture you. Apparently, many med schools have poor track records when it comes to abuse of third year med students. At least my school is aware of this issue and is preparing us for potential exploitations? The speaker also casually mentioned that we’re not supposed to work more than 80 hours in a week or more than 28 continuous hours.

June 25: Tuesday

12:35 pm: In general, doctors all wear white coats. However, there is a well-established hierarchy in medicine and not all white coats are the same. Atop the totem pole is the attending physician. The attending has completed their entire medical training and is in charge. Next down are the fellows. Fellows have finished residency and are completing optional specialized training (one to three years) before becoming an attending. Fellowship is not required, and most residents go straight into being an attending.

The residents are next down on the ladder; residents are licensed physicians. The first year of residency is called intern year. Interns and residents see and examine patients, write orders for lab tests and prescriptions, and make decisions regarding patient care. The resident has more power than the intern, though the attending has the final say on all matters. Interns are more heavily supervised than other residents and tend to do the most scut work. Throughout residency (which is three to seven years, depending on the specialty), a newbie intern develops into a senior resident. Supervision gradually becomes less and less, with the senior residents having the most freedom.

Medical students are doctors-in-training. We have not yet graduated medical school, and we do not yet have our medical licenses. We can see patients and perform procedures under the supervision or direction of an intern, resident, fellow, or attending. First and second year medical students aren’t even on the totem pole since they’re locked away studying.

Visually, the totem pole looks like this:

Attending physician


Senior resident

Junior resident


Fourth year medical student

Third year medical student (my current location)

Teams are led by a single attending, but may include any combination of residents and students. Hospitals with residents and medical students are referred to as teaching hospitals.

2:15 pm: FYI, all medical students and residents move up the medical totem pole by one rung on July 1. Always. If you’re a patient, you may want to avoid teaching hospitals in July. We’re all new to our respective roles.

3:23 pm: Learning how to gown and glove for surgery is surprisingly more complicated than it appears.

7:22 pm: Ouch. Rough afternoon. I spent the afternoon hours in anatomy lab being pimped by surgery residents and attending surgeons. “PIMP” stands for “Put In My Place;” it is a technique used throughout medical training whereby it is established that the superior has more knowledge and expertise than anyone below them on the totem pole. Pimping stems from the Socratic method of questioning a student, with the goal of leading them towards a correct answer. If the teacher poses questions in a logical and progressive manner then the student should ideally be able to work through the problem and come to a conclusion on their own, even if they did not initially think they knew the answer. The College of Medicine endorses the use of the Socratic method. Pimping differs from the Socratic method in that the goal of pimping is to point out that the student does not know as much as anyone senior to them. A student is asked questions repeatedly until they answer one incorrectly, at which point the teacher (be it a resident, or attending, or even a fourth-year medical student, if they’re being a total dick) can point out how little they know, deride them for not studying enough, or otherwise embarrass them. Ultimately, the student is reminded of their lowly stature on the totem pole. So yes, today I was pimped during anatomy lab.

June 26: Wednesday

11:15 am: Cancer, obesity, and genetics. A thoroughly depressing day of lectures. 

2:10 pm: During lunch I received my schedule for the next eight weeks. I start with four weeks of inpatient internal medicine, followed by four weeks of outpatient medicine. Inpatient means the patient is admitted to the hospital and stays there overnight. Within the hospital, the sickest patients go to the Intensive Care Unit (ICU). Slightly less sick patients are in the Step-down unit; which is one tier less intense than ICU-level care. The most stable inpatients are on the floor, and are called floor patients. On the other hand, outpatient typically means a clinic, where a patient goes for doctors’ appointments or checkups. This may seem obvious to some people, but my mother, who has no medical background, has informed me that I need to explain these distinctions.

5:25 pm: Afternoon lectures on wound care provided us with some nasty images of pus-ridden infections and made me excited for my surgery rotation. I’ve never fainted at the sight of blood and guts, but we were just warned that third years happen to faint with alarming regularity. The professor informed us that it usually happens on days when we’re feeling really sleep deprived and haven’t eaten, drank, or sat down all day. Which apparently are most days of third year.

June 27: Thursday

11:53 am: Morning lectures were chock full of review about viruses, bacteria, and other infectious diseases.

5:43 pm: I decided to go to medical school at age 24. After studying art history and studio art in undergrad, I earned a master’s degree in counseling psychology and art therapy. I then worked at a top-notch hospital in Chicago. My mornings were spent on the inpatient psychiatry ward and in the afternoons I did bedside counseling and art therapy with children and young adults. Most of my patients on the various medicine wards were severely ill, often staying in the hospital for weeks at a time. I developed wonderful relationships with my patients and would inevitably bond with them. I mourned them when they died, attended their memorials, and cried with their family members; it felt as if my friends were routinely dying. I hated my job but loved being at the hospital, so, the abridged story is that I decided to go to medical school.

I left my job and forged ahead into the world of medicine, completing my pre-medical school requirements at Northwestern University. Casey matched to a teaching hospital called The General Hospital for his surgery residency. We packed up our lives in Chicago and relocated to this random Midwest City. I applied to medical school and was accepted to The College of Medicine, which is the medical school affiliated with The General Hospital. So now here I am. I’m a 29-year-old artist-former-counselor-turned-medical student from Long Island, NY, living in a random little Midwest City, about to start my third year of medical school.

June 28: Friday

7:30 am: I’ve kept journals since I was five years old. I have over 20 journals lined up on my bookcase, all penned in my terrible handwriting. I’ve never shared them with anyone. The idea of writing for a potential audience to read is terrifying.

However, writing a book has also been a lifelong dream of mine. Capturing the events of third year by journaling electronically seemed like the perfect set-up. To provide some distance, I’ve decided to refer to myself by a pseudonym, almost as if I am recording someone else’s story and not my own. After spending much of the week deliberating, I chose the name Silvia for myself in homage to my favorite song by the band Miike Snow.

12:15 pm: An all-morning review of the pharmacology of immunology is precisely as boring as it sounds. But no matter how boring, I have to know this stuff. At each rotation’s end is a multi-hour, nationwide, standardized flogging, politely known as a final exam. Our grades are used to compare us not only to each other, but also to all the other third-year medical students across the nation.

We also get graded on our clinical skills. This includes how well we interact with our patients, our competency doing procedures, and if we go above and beyond the requirements of the rotation. Our overall grade combines our exam score and our clinical grade for a final mark of fail, pass, high pass, or honors. Our grades influence our class rank, and where we will be able to match for residency. In order to get a residency spot, or ‘to match’ into a specialty, one must be a competitive candidate. As there are now more medical students graduating each year than there are residency positions, medical students tend to get über-competitive when it comes to grades and class rank.

2:15 pm: We’re back in the auditorium, sitting through a ceremony officially welcoming all the third-year students to our clinical years. Everyone looks prim, proper, and eager in freshly laundered white coats. We’re reciting the oath we took at our induction into the field of medicine at the start of medical school. Instead of reciting the Hippocratic Oath, a few students wrote an oath to represent our class and what entering medicine means to us at this time and place in our lives. The Dean of Something Important is back at the podium, spewing more warnings about third year. Right now she is reminding us to rely on each other and help each other through the year. She is telling us to reach out if we are drowning and need help. “Suicide is not the answer,” she informs us. I look at my closest friends, Piper, Sophia, Jane, and Maggie, and get the feeling I have no idea what I’m in for but I’m glad these women are sitting on either side of me. The Dean of Whatever concludes her speech with, “Congratulations on making it to third year. Thank you for listening, and good luck.”

Ipad in hand, down I go into the rabbit hole of third year.

Chapter 2: Inpatient Internal Medicine

Love, Sanity, or Medical School

Chapter 2: Inpatient Internal Medicine

July 1: Monday

1:00 pm: They just handed me a pager. Now what?

I’m sitting in a barren, windowless classroom tucked away on a top floor within The General Hospital, surrounded by a small group of newly-minted third-year medical students. It’s our first day on the wards. We are waiting for the senior residents to collect us and distribute us to the various medicine teams.

2:15 pm: Still waiting…

3:30 pm: Turns out that the senior residents didn’t know that we, every medical student in the entire College of Medicine, were starting today so we sat there until three pm. We tried calling them. We tried paging them. Finally, an attending physician randomly passing by came to our rescue and located the seniors. They seemed pleasantly surprised to see that we’d been patiently sitting there for hours.

3:55 pm: I met my team, comprised of a fourth-year medical student, an intern, and a senior resident, and then was dismissed. Everyone seemed welcoming.

July 2: Tuesday

7:01 am: I have no idea what I’m supposed to be doing.

8:15 am: My attending, the young Dr. Osler, immediately comes across as friendly and enthusiastic. We discussed my goals for the rotation. His focus is on improving my patient presentation skills and teaching me to come up with broad differential diagnoses (aka medical explanations) for my patients’ problems. Sounds good. My ‘personal’ goals: 1. Avoid personal embarrassment. 2. No crying if I get yelled at. My first impression is that Osler doesn’t seem like the type of attending who torments third years, though I guess I’ll find out soon enough.

The crux of “having a patient” is rounding. Each medical student and resident takes turns presenting their patients to the rest of the team during rounds. We hop around the hospital, traveling room-to-room, until we have checked in on every patient on our list. Rounds are nerve wracking because it is imperative to know every single detail about your patient’s work up. The ‘work up’ is a generic term referring to all the data collected on a patient, including physical exam findings, daily blood tests (aka lab values, or, labs), and imaging results (such as x-rays and MRI scans). Knowing how a patient is responding to their treatments is essential, too. All of your decisions regarding their care are debated and nitpicked. If the attending finds your management of a patient to be unsatisfactory, the consequences may range from an eye roll, to an audible sigh, to a verbal berating, to being locked in a dungeon without food or water until such a time when your attending believes you can once again be let loose on the wards.

I officially have my own patient! He is in the hospital for a ginormous (proper medical terminology right there) foot ulcer. I could call him Mr. FU for foot ulcer, but let’s go with Mr. UFO instead. Having my own patient means I now have someone to present on rounds. Each morning, before the team arrives, I’ll get to The General Hospital super early to read up on any new lab studies or overnight developments in his care. This is called pre-rounding. After presenting him on rounds, I’ll write a note on his progress and goals for the day, while helping plan for his discharge. Waaaay better than being in the classroom.

12:59 pm: Every Tuesday afternoon all students on the internal medicine rotation have class together from 1-5 pm. In an effort to make these four hours of lecture more exciting the internal medicine people have coined these afternoons “Super Tuesdays.” Sure. Whatever. There are a lot of stereotypes in medicine. Internal medicine folks are known to be super nerdy. So far, so true. And unfortunately, I can’t go home afterwards because I’m on call tonight. Being “on call” on the medicine service basically means an extra-long day, so instead of leaving at 5:00 pm I’ll be here until about 10:00 pm.

July 3: Wednesday

8:43 am: People take bad news quite differently. A patient on our service was told his fiancé gave him Hepatitis C and he nonchalantly commented, “Oh well, I’m marrying her anyway so I guess that’s that.” When the fiancé found out that she may have contracted Hepatitis B from him in return, she was NOT happy. I thought she was going to punch him or break the engagement right then and there.

10:15 am: While on morning rounds we met an elderly new patient named Mr. BH, who was admitted by the overnight team. He is suffering and in excruciating pain from multiple medical problems and a broken hip. As the overnight intern started presenting Mr. BH to our team, Mr. BH began reaching out past the intern and signaling for me to come closer. I was at the end of the bed and Mr. BH persistently motioned for me to move nearer to him. The whole time he was moaning in agonizing pain and it was confusing because we couldn’t figure out what he wanted. When I finally got close enough, he grabbed my hand and held it tightly. Turns out he needed some comfort and just wanted to hold my hand. He gripped my hand tightly the entire time we were in his room. It was very sweet and very sad. Pulling my hand away so I could grab my stethoscope and perform a physical exam felt more than a little heartless.

Happy Fourth of July: Thursday

8:20 am: It’s hard to watch people in pain. A professor taught us last year that patients should never be in pain, should never be short of breath, and should not die alone. These are deceptively difficult goals. Give too many meds and they stop breathing, give too few and their pain is intolerable. My team is trying to balance controlling Mr. BH’s pain without causing a deadly respiratory depression.

Noon: My day was brightened when I ran into my Sig O, Casey. We met nearly seven years ago on a random Tuesday at a dive bar in Chicago. It wasn’t exactly love at first sight but there was definitely some spark, some attraction, so we began dating. Dating casually grew into a relationship, falling in love, and moving in together.

1:12 pm: My team is constantly busy, and I feel like I’m in the way or at least just not on their radar this afternoon. Patients are sick as shit, and I don’t know my role yet. I’m keeping myself busy by reading and studying.

2:29 pm: I tried to learn to draw blood but was informed by the intern, “Don’t waste your time, you’ll never do that, nurses will do that for you.” Only thing is, I want to learn and I’m bored because I don’t know what else I could be doing right now aside from studying.

July 5: Friday

3:32 pm: I updated Mr. UFO and his family. I answered his questions and then discussed his progress and discharge plans. It feels better than simply being out of the classroom, it feels like I am finally learning to be a doctor. Wonderful!

10:18 pm: I managed to sneak in a dinner with Casey tonight. It’s been forever since I’ve seen his red hair and blue eyes, which is impressive considering we live together and work at the same hospital. As he is a general surgery resident, his schedule is even worse than mine. His muscular former-football-player frame is still tan from our recent trip to Central America. Even with the unseasonable amount of rain we still managed to sneak in some scuba diving and visit the breathtaking Tikal Mayan ruins. Most importantly, I was able to check another box off my bucket list - I swam with sharks. It was a phenomenal experience. My love of the ocean and my most recent bucket list is not relevant at the moment though; I need to get some sleep because I’m on call again tomorrow.

July 6: Saturday

11:00 am: Four and a half hours down, ten hours to go. The problem with Saturday call is that you have to come in post-call on Sunday. This means that my first day off since starting third year will be next Saturday.

Turns out, drawing blood is a clinical skill requirement for this rotation.

Mr. UFO is doing well and is going home tonight so hopefully I’ll get another patient, maybe even two. It’s hard knowing that I am the weakest link and that I slow the team down, but there’s really nothing I can do other than keep learning and try to improve as quickly as possible. In these couple of days my presentation skills, with the help of my attending Dr. Osler, have improved a lot. However, I still suck at describing wounds using proper medical terminology.

Dr. Osler: “Silvia, how would you describe this man’s ulcer?”

Me: “Um...” And I’m thinking to myself, well it smells really foul and looks super gnarly, as if someone took an ice cream scoop and scooped out a portion of the man’s heel, leaving behind a bloody, smelly, pus-filled hole. Hmm… need to learn how to translate that into words a grown-up doctor would utilize.

I was right about Dr. Osler though; he is not one to torture medical students. He gives detailed feedback and frequently checks in with me. Even better, he has not once threatened to throw me in the brig! So far, so good.

Noon: The family of Mr. BH, the one who held my hand, updated his advanced directives to solely comfort care. Everything will be done to manage his pain but nothing else - no other medical interventions, no CPR, no life support, nothing. His family believes that his quality of life will never again be at a point that he will find acceptable or enjoyable. In order to effectively manage his pain, we need to increase his meds. Any time we did that in the past few days he would get drowsy and hard to awaken so we’d back off on the dosage. However, alleviating pain is the only goal now. We increased his pain meds once again, which means he’ll likely go into respiratory depression again, which means he will die.

3:30 pm: I was assigned my second patient. She’s admitted for an intentional drug overdose that caused her liver to fail. I know quite little about liver physiology, but I’ll be able to put my master’s degree in psychology to use so she’ll be a good patient for me.

July 7: Sunday

8:58 am: Nope, no I take that back, she is no longer my patient. Turns out her psychoses and medical management are too far beyond my meager third year skills. It sucks to realize that my master’s degree in psych is not useful at all; I had envisioned being successful with psych patients but no, just like everything else, I have to learn from scratch. Instead, now under my care is a sweet young girl named Barbie with a nasty eye problem.

It’s weird waiting for someone to die. A resident from another team casually inquired, “So, has your guy Mr. BH died yet?” It wasn’t asked in a disrespectful way either, merely run-of-the-mill resident lounge conversation.

For the first time, and this may not happen again for a while, the senior resident on my team conceded, “You were right about your patient.” I’d asked if Barbie could have some anti-anxiety medication. He’d firmly replied “no”, that she doesn’t need any. She is young and healthy and shouldn’t be given anxiety medications because they’re addictive and potentially dangerous and blah, blah, blah. He then went and saw her in person and decided yep, Barbie is indeed super anxious and would benefit from a little Ativan. A small victory for the med student!

Barbie has a horrific eye infection and must have eye drops placed every 30 minutes for 48 hours. A nurse will go in her room and literally pry open her sleeping eyes every 30 minutes for two full days. Wow. The alternative is she risks vision loss from not treating her infection properly. OMG she is going to be a zombie from lack of sleep!

Speaking of zombies, there is another patient on my team with a leg infection that reminds me of a zombie wound every time I see it. You know those decaying zombies where it looks like strips of skin got peeled off and it’s all beefy red underneath? That is exactly what this woman’s leg looks like. Creepy.

July 8: Monday

11:48 am: There are three, nationwide standardized exams that have to be passed throughout medical school in order to get one’s medical license. They are referred to as the boards, and are composed of Step 1, Step 2, and Step 3. Step 1 is taken just prior to starting the third year of medical school. It’s a beast of a test and our scores are coming out soon. If you fail Step 1, you are immediately pulled off rotations and are not allowed to continue with third year until you have a passing score. Yikes! While I don’t think I failed, I know I will be incredibly relieved to see a passing score…

I picked up another patient today, a young woman named Ms. AI, with a difficult to control autoimmune disease. I didn’t actually offer to pick her up; she was assigned to me. No one on the team wanted her because she is known to be super bitchy and argumentative. Amazing how quickly patients develop reputations. Ms. AI is emaciated from a string of recent illnesses. My goals are to help her gain weight, get her strength back, and get her labs under control. I wonder if she sensed my distraction while we spoke. No offense to her but my brain is entirely consumed with thoughts of my Step 1 score posting soon.

3:12 pm: I keep offering to my team to let me do things but they keep saying, “It’s ok, we’ve got this,” or, “Thanks but no thanks.”

July 9: Tuesday

6:30 am: Uh-oh. Apparently, Ms. AI has been moved to Step-down, a more acute care wing of the hospital. That’s bad. She became unresponsive overnight and a “rapid response” was called (not quite a code blue like when your heart stops and you’re actively dying but still really bad, and people are concerned that you might die). Scary. She seemed fine when I left last night…

11:00 am: Surprisingly, Mr. BH is doing well. Sure, we amped up his pain meds and risked killing him (at his family’s request, of course) but he pulled through. He has even been moved from Step-down to the floor. I’m too new to know whether or not this is an unusual occurrence. All I know is my team felt fairly certain that this guy was going to die a couple of nights ago.

11:55 am: Barbie’s eyes are doing well; it looks like she may be able to go home tomorrow. It’s too soon to know for sure, but it doesn’t seem that there will be any long-term vision problems.

3:50 pm: Very interesting Super Tuesday lecture today. Really, not sarcastic. Our discussion today is on death and dying. Upon walking into the classroom, we were promptly asked, “How do you want to die?” We all responded with ideas such as: at home, without pain, quickly, surrounded by family. Then we discussed the brutality and futility of CPR. We were told that only about 10%-20% of patients who get CPR will live to be discharged from the hospital. Additionally, we were informed that about 75% of people on TV shows survive such ordeals. Yes, I am typing while sitting in lecture. Shh… don’t tell; it looks like I’m taking notes. Anyway, talk about false hope and unrealistic expectations!

People with terminal diagnoses, who have time to plan their deaths, have a higher likelihood of dying at home, surrounded by family, compared to those who die suddenly. I wonder whether or not physicians also have a higher likelihood of dying at home because they know the poor outcomes that result from aggressive life-prolonging treatment. Hand is going up…

My professor really liked the question and suggested that I do a research project on the topic. I nodded noncommittally. I do find it interesting, so maybe I’ll get to it one day, like when I’m done with my book and my bucket list and my current painting and the ten other things I always have going on at once. First month of third year is not the time to start tacking additional tasks onto my to-do list.

July 10: Wednesday

I experienced my first two rapid responses today. When you’re the “on call” team you carry the code pager. When the shrill rapid beeping starts blaring, you immediately stop what you’re doing and race toward whichever room is listed. Both turned out to be nothing but it was thrilling to head toward an unknown emergency. When people see you running, with your white coat flapping behind you and your stethoscope bouncing on your neck, they jump out of the way, flattening their backs up against the wall to let you pass while craning their necks to see what medical crisis you’re off to fix.

To clarify, neither time did my own pager go off, I just obediently followed behind my team when they started running. There is a fundamental difference between people who get excited when they hear a code pager and those who cringe. Turns out I fall in the camp of people who get super excited. The rapid responses were great distractions from worrying about my Step 1 score and also broke up the monotony of rounding. Turns out that rounding lasts for hours and is pretty darn boring.

10:45 am: Passed my boards! Barely.

While of course I wish I had scored higher, I can’t help but be so, so, so relieved that it’s over and I am moving on with my classmates. My insightful mentor, The Boss, firmly stated in her email to me earlier today: “Do not be worried. You will excel in the clinical environment.” I trust her advice and input implicitly, so I will not worry. We’ve previously agreed that my strength is working with people and has never been, nor likely ever will be, taking multiple-choice tests.

2:30 pm aka 1430: I removed an internal jugular central line from a patient, which is a large IV that is placed in a patient’s neck. This marks the first time this rotation I have touched a patient other than during a physical exam on morning rounds. While the internal med folks are all really friendly (bordering on non-confrontational), I don’t see myself being in a specialty with so few procedures. I like getting my hands dirty.

Ms. AI was moved out of Step-down back to the floor. Good.

Turns out many end-of-life studies have been done and a greater percentage of terminally ill physicians die at home with no aggressive interventions compared to the average layperson. I direct interested parties to the article, “How doctors choose to die,” published in The Guardian by Dr. Ken Murray. Intriguing. I think I will fill out a living will someday soon.

My intern and senior resident both let me draw blood from them. Bloody good fun. We were doing this in the break room and received many odd looks from people passing by in the hallway.

En route to see a new patient, my senior resident shares advice that was given to him upon receiving his own Step 1 score: “Do not let your score influence your level of confidence.” I really appreciate hearing that, thanks. It was like he could read my mind and knew I needed a boost.

A patient disappeared today. Kind of impressive considering he is paraplegic and has minimal upper body strength. The patient is well known for screaming, weakly flailing his arms, and spitting at any staff member who enters his room. Additionally, he also refuses to put on a hospital gown, so he has been lying in his hospital bed covered in strategically placed washcloths. To sum up, not just a paraplegic but a naked paraplegic managed to escape off of the floor this morning. Strong work floor staff.

July 11: Thursday

10:11 am: I have so much to learn.

11:42 am: I often ask patients what they understand about their medical conditions. Many of them have never had anything explained to them in terms they can understand and they have no idea what is going on.

4:05 pm: The naked paraplegic was found and returned safely to the floor. Apparently, he wheeled himself to the hospital courtyard where he was eventually found and brought back up to his room. I’m not entirely sure if the goal was leaving permanently or just temporarily so that he could have a cigarette.

My poppa (my dad’s dad), the singing NY cab driver extraordinaire, escaped from a hospital once. After one of his many heart attacks, he left the hospital without telling anyone, got into a cab dressed solely in his hospital gown with his ass hanging out, and then had his girlfriend pay for the cab when he arrived at home.

I just realized I never described the patient on whom I removed the central line. Through a series of unfortunate events the patient had both hands amputated, and in their place they now have intricate hooks. The dexterity and speed with which the patient maneuvers their hooks is pretty incredible. You try tearing open a sugar packet, pouring out just half into your coffee, deftly using a stirrer, then picking up the cup and drinking without spilling! I don’t know if it’s inappropriate to be so impressed. Maybe that is the typical level of functioning for someone with those types of prosthetics?

July 12: Friday

11:43 am: Tried going on rounds today without a stethoscope. Such a rookie.

Mr. BH has been discharged. Alive. Not a celestial discharge. Still in pain, still with a broken hip, but alive nonetheless.

3:12 pm: Ms. AI started throwing up blood. She is in constant pain. I don’t know how to help her.

July 13: Saturday

Fifteen days in and my first day off since starting third year.

July 14: Sunday

6:43 am: Back at work. On call again. The internal medicine residents always seem nervous and hesitant to do things. We talk and talk and talk about patients and when we’re done talking, we call a consult or two and then talk some more. A consult is when you ask another medical specialty for their opinion about your patient. For example: if a patient has a seizure, you might call for a neurology consult; if a patient develops chest pain, you might call for a cardiology consult; or if a patient feels depressed, you may call for a psychiatry consult. I know these patients are complicated but commit to a choice and do something! I’m guessing their hesitancy is compounded by the fact that it is July, and they are all probably scared to do something that could kill someone. I guess that’s understandable.

It’s hard to give patients awful news. Every time we do I think I see a dark look cross the patient’s face. It’s as though they’re rethinking all the poor decisions they have made throughout their life that led them to this point in time.

4:30 pm: The intern is too trusting. A patient came in with a pus-filled infection on the dorsum (top) of her hand, which ostensibly developed after she fell off a bike one week ago. She has no other injuries, not a scratch on her. She swore up and down to the intern, and myself, that she does not do drugs. After leaving her room I commented to the intern that I thought she was probably lying about her drug use. Her injury looks suspiciously as if she was injecting heroin into her hand. He replied, “No, there is no reason not to trust her.” Sure. We’ll see about this one. The intern and I present the patient to our senior resident and our senior agrees with me that yes, she is probably an IV drug user. The intern sticks to his guns. Again, since one else wants her, she has been assigned to me. Let’s call this new patient of mine Ms. BA for bike accident.

5:45 pm: The urine drug screen on Ms. BA came back positive for all sorts of good stuff including opioids, cocaine, and marijuana, and that’s not even the fancy drug screen that picks up designer drugs. Called it. Another win for the medical student.

July 15: Monday

It’s shocking how many people have nasty foot problems from diabetes. The prevalence of diabetes makes me concerned for my dad - the disease is nearly ubiquitous among overweight Americans. My dad is out of shape, a former smoker, and has already had one heart attack. He is the poster child for a future diabetic, and I worry about him constantly.

I just found out Ms. AI is being presented at M&M today. Why? M&M, or, Morbidity and Mortality, is a conference where a patient who had a complication or who died, allegedly due to a preventable medical error, gets presented to all of the medicine teams. The teams then pick apart the case. The goal is to identify the cause of the problem so that it won’t be repeated by anyone else.

In theory it’s a non-accusatory forum to address life and death errors, but I’ve heard it can get pretty heated. Not quite like the TV show coming out called Monday Mornings, but something to that effect.

Noon: Morbidity and mortality conference. Here we go.

12:55 pm: Sitting in M&M while your patient is being presented is the worst thing ever, and I’m not even responsible for making decisions regarding her care. (I mean, I like to think I am, but really the residents make all the decisions and I just write her daily progress notes). The roomful of docs was provided with a barebones overview of her case, missing many of the details regarding the complexity of her condition. Then they start talking condescendingly about how they would’ve handled her case differently and perfectly. I wanted to yell out, “No, you don’t get it, she is crazy unstable!” but I sat there quietly and watched my team face the firing squad while I hid in a corner.

July 16: Tuesday

7:53 am: Feet smell powerfully bad. Especially right after morning coffee.

9:14 am: Ms. BA is still swearing up and down that she does not use drugs. We keep going along with her story about the bike. No one will confront her. I don’t think she should get more narcotic pain meds because she is drug seeking. Her abscess isn’t even that big, and it’s healing really well. Hopefully she doesn’t go home and inject more heroin into it.

2:20 pm: Super Tuesday lectures are made infinitely more bearable by the presence of my closest guy friend, Magnus. We share a dry sarcastic humor and hold similar views on many issues ranging from patient care to football to the importance of bacon.

Magnus and I became close because he dated my bestie Piper all throughout first year. The three of us would sit next to each other every day during lectures and hang out whenever not in class. Piper broke up with him right after first year ended and fortunately, they never once tried to put me in the middle of any of their drama. It was a messy breakup and they did not speak to each other for the entirety of second year. Piper and Magnus are still two of my closest friends; I just have to hang out with them individually now. They’ve had shared custody of my friendship since their separation.

July 17: Wednesday

This morning I walked into Ms. BA’s room to find her lounging in bed, quietly watching TV. She waits until a commercial starts, then looks at me and deadpans that her hand is killing her and she is in 10/10 pain. Not to be insensitive, but if you can calmly and clearly tell me about your pain while watching soaps then it’s probably not 10/10. Actually, it’s definitely not 10/10; 10/10 is more like childbirth to an extra-large baby without an epidural, or having a broken bone sticking out of your body at some weird angle, or having your leg bitten off by a shark with dull teeth. Those are examples of 10/10 pain in my book. I’m sure it hurts but really, I think she’s drug seeking again and I have no interest in giving her more meds.

Ms. BA is getting under my skin because lying is a pet peeve of mine. While growing up, my parents told my sister Olivia and me that they would never lie to us because once you catch someone in a lie, their word can never be trusted again. To this day, I still trust my parents; they’re awesome. Ms. BA sucks.

1:00 pm: We have a patient on our service with a three-week-old wound in the back of his head. There were stitches and staples put in initially, staples all down the middle with one stitch at the top and two stitches at the bottom. His staples were removed a week ago, but the stitches were forgotten about for reasons unknown. I offered to remove the stitches because they had been in too long (scalp stitches are usually kept in for 10 to 14 days). My team agreed this was a good idea, but my intern wanted me to consult the trauma surgery team first. Umm, no. Bad idea.

Calling the trauma team for their permission to remove THREE stitches on a well-healed wound would result in me either getting laughed at or yelled at by the trauma team. I explained that I wouldn’t call. The intern retorted, “Yes, you have to.” The intern then left to go do something else. I normally do not defy my superiors but this was ridiculous. To appease my intern, I called Sophia (my dear friend and fellow medical student), who is currently rotating with the trauma surgery team. That way I could aver that, yes, technically I did call the trauma team. She didn’t answer (because the trauma team is always busy, which is why I didn’t want to call in the first place) and then I went and removed the stitches anyway.

3:00 pm: My intern is not happy with me. Fortunately, the senior resident jumped in and defended me by explaining, “No, no, no, we do not consult trauma surgery for little things like that.” Phew. Yet another example of internal medicine people being terrified to do anything without the explicit permission of as many people as possible. Or another example of July interns being terrified to kill someone. Either way. But really, if you have three three-week-old stitches holding the back of your head together then you have way bigger problems in your life than a rogue med student.

July 18: Thursday

One of the patients got me sick. It hurts to swallow. My throat is on fire. My tonsils are disgustingly swollen. It feels like strep, but it’s likely something viral floating around. Ugh.

Night team gave Ms. BA more narcotics. Will people please stop increasing the pain meds on my drug-seeking patient? The senior resident reluctantly admitted to me that he had increased her dose. He explained that it was to make the night nurses lives easier. Fine, I get that, but isn’t there any other option?

I would like to have an honest conversation with Ms. BA about her behavior before she leaves. I want to tell her that she really needs to stop using needles, especially dirty ones, because she will get more abscesses. My team informed me that the nature of medicine is to treat and not bother addressing problems for which there can’t be follow-up. Ok, but what I don’t understand is this: I have the time, I have the training, and I’m still naively optimistic enough to think that I can make a difference in her life. What is the harm if I go over options for treatment programs? Either way she is going home today.

This whole time she thinks she’s pulled one over on us. She thinks she is so clever and has successfully tricked the medical team into believing that her abscess is from a bike accident. In addition to paralyzing hesitation to do things, there is also a large amount of confrontation avoidance among the internal medicine people. Beyond frustrating. I’m too action-oriented and straightforward for this specialty.

A couple of weeks prior to coming to The General Hospital, my other patient, Ms. AI, had a nasty infection that almost killed her. She had to be intubated. This involved placing a breathing tube in her throat and connecting it (and her) to a ventilator, a machine that breathed for her. This is akin to being placed on life support. She has extreme anxiety and nightmares about that hospital visit and she is terrified about the prospect of going to sleep, decompensating, and waking up intubated again. Her solution to this is to not sleep. She looks painfully tired and is fighting falling asleep.

Her previous hospital experiences have been pretty traumatic. Another horrific experience was during one of her pregnancies, which resulted in her requiring an emergent cesarean delivery. She shared with me about being whisked away into a bright room, being surrounding by people in yellow gowns and having a mask put over her face. When she awoke, she learned her baby had not survived the delivery. Poor Ms. AI. I want to give her a hug. If you know her, you probably don’t want to give her a hug because she’s pretty bitchy with the rest of the staff, but she’s chill with me for reasons unknown.

July 19: Friday

About an hour ago I received a text from my intern to go check in with Ms. AI because she is in a lot of pain. My mission was to figure out what was wrong and comfort her but offer no pain medication. After about two minutes of chatting she told me that on top of everything else going on, she is having really bad belly cramps and muscles aches from starting her period. She is also suffering from severe anxiety and depression. I talked with her a bit and regretted that I had nothing to offer her. As I was leaving, an idea popped in my head. I randomly asked her if she would like to speak with our chaplain about her anxiety and for some spiritual comfort. She loved the idea. Found a way to support her and no meds required. Take that, intern.

I am feeling more and more ill as the day goes on and my energy is gone. I just want to bury myself in my bed, under layers of warm blankets. How sick do I have to be before I can leave? We were jokingly (?) informed during orientation that we would have to require IV fluids and IV antibiotics in order to be considered sick enough to not be at work.

July 20: Saturday

10:31 am: I kind of have the urge to check Ms. AI’s medical records from my home to see how she’s doing but I am off for the weekend, so I will resist. It’s only my second day off from work in 20 days and my first full weekend off since I started third year.

My head is achy, I barely have the energy to sit up, and my ever-running nose is red and irritated from constantly being rubbed by tissues. I am not moving off my couch today. I wish I felt better so that I can enjoy my days off. Casey is on call, so I have the apartment to myself. I don’t think we’ve spent any real quality time together in days. Or months. It’s getting hard to tell whether this can be blamed on our schedules or if something else is the cause.

July 21: Sunday

11:43 am: After sleeping most of the past 24 hours I feel infinitely better and ready to leave the confines of my apartment.

It was so gorgeously bright out today that I decided I needed to spend the day outside. I was in luck. Once a month the LGBT group at my medical school hosts a potluck dinner and as a mostly-straight ally, I try to attend each month. The hosts for this month are the brilliant Dr. Neuro (who I adore) and his partner. Upon arriving to the party, Dr. Neuro took my best friend Jane and I upstairs to the balcony overlooking his pool and backyard. From this vantage point he pointed out each of the physicians and their specialty, so we would know whom to best target for networking. After about ten minutes of playing who’s who, two more people entered the backyard. Our professor confided to us, “Oh, look, that’s the medicine attending, Dr. Osler. He’s started coming out to family and friends last week, but he hasn’t come out at work yet. It’s been really difficult for him. This is his first time ever attending the potluck. I’ve assured him it’s a safe place where he can be comfortable and open.” Well, I guess there’s no safer place to run into your own med student than at an LGBT potluck/pool party?

I’m fairly certain Dr. Osler almost ran from the pool deck upon making eye contact with me. We chatted briefly and then each went about our own business of drinking and relaxing.

July 22: Monday

11:35 am: There was a mandatory CPR recertification class this morning resulting in me missing morning rounds again. It feels weird to be away from my patients three days in a row.

11:46 am: Ugh… the chaplain never checked in with Ms. AI on Friday! So much for that idea. On top of that, it turns out Ms. AI had a fall and developed a new infection. Why is she getting worse and not better?

2:35 pm: Ms. BA has been discharged. I wonder how long before she returns with her arm infected and requiring an amputation à la Requiem for a Dream.

July 23: Tuesday

6:50 am: We have a new attending today so farewell to Dr. Osler. He was easy-going and laidback, making my transition to third year smooth. I’ve heard rumors that our new attending is borderline neurotic in how she likes things done and can be a real stickler about pretty much everything.

9:26 am: Many patients seem distrustful when we talk to them. They and their families often query: “Do you know what you’re doing?” “Why am I not better yet?” “How old are you?” “Are you sure about that?” “I checked Google and I think I have xyz…” I keep thinking, “We’re doing the best we can and don’t worry; our attending keeps a close eye on us.”

11:46 am: Ms. AI has diarrhea so prolific right now that she has taken to wearing diapers. She tearfully admitted to me how embarrassing this whole situation is for her. We’re not that far apart in age. I really, truly can’t imagine being in her position; it must be so, so terrible.

2:23 pm: Super Tuesday! Hold the super.

3:12 pm: My personal life is falling apart. Can I keep ignoring that right now?

July 24: Wednesday

11:49 am: We have a patient in his 90s who is likely not making it out of The General Hospital alive. His name is 95. His daughter, who is my parent’s age, made this realization while we were rounding yesterday. She broke down crying. Not just crying, but really sobbing. We witnessed the moment where she came to understand that her father is not only mortal but is dying. My team left me with her during rounds to comfort her and I am so glad they did. I let her cry it out for a bit, then encouraged her to talk about 95 and her family. After a while, we discussed coping, strength, and surviving events we believe are insurmountable. After spending so many hours of so many days wishing I could be of service to my patients and my team this felt wonderful. This will certainly be a most memorable patient encounter.

On another note, 95 is one of the healthiest patients on our service: no diabetes, no cardiovascular disease, and no obesity. The senior resident informed me that if someone makes it to their 90s, it’s because their life leading up until that point was likely healthy. Evidently his health status is not surprising to anyone else on the team.

1:15 pm: My intern is off today, my senior is at clinic, and my attending is not here. I’m going to be a bad/lazy med student and go home. I really need to go food shopping and take a shower. It’s been awhile.

July 25: Thursday

6:52 am: As I pre-rounded today, Ms. AI told me to not be so nervous when presenting in front of the new attending. I was touched to realize that this patient, someone so sick and brittle, had noticed how my bedside presentations changed with the new attending. She is absolutely right. This new attending definitely makes me jittery. I just wish my team could do more for Ms. AI. She appears to be fading before my eyes, every day more pallid and frail than the day before.

11:52 am: My team went into 95’s room during rounds. While discussing the plan for 95, his daughter walked into the room. When she saw me, she walked right over and gave me a big hug, then looked me in the eye, thanked me, and told me she’d never forget me. Great way to start the day! It would have been just as wonderful if my team wasn’t present to witness her gratitude, but having the team there was a bonus.

7:35 pm: As part of my end-of-rotation evaluation I was scrutinized while taking a patient history and doing a full physical exam. In general, the feedback was positive. My attending taught me how to properly palpate the spleen during the physical exam. From now on I won’t have to awkwardly pretend as if I know what I’m doing during that part of an abdominal exam. My attending remarked that I am skilled at quickly developing relationships with my patients. It’s nice to feel that I’m good at something since most of the time I am fairly lost. Patients do not act the way we were taught they would.

There’s a NY Times article about patients developing post-traumatic stress disorder (PTSD) after ICU stays. Patients at higher risk tend to be young females. I wonder if PTSD is plaguing Ms. AI during her hospital stay.

8:36 pm: I am actively ignoring the fact that Casey told me on Monday night that he doesn’t know if he ever sees us getting married.

July 26: Friday

11:30 am: Turns out that 95 is a trooper. He’s doing great and will be going home tomorrow. Yet another patient this rotation that my team had written off for dead but will be going home very much alive.

2:15 pm: I had a final feedback session with my senior resident today. He said he was pleased with my progress and went on to explain, “I don’t want to use the word aggressive… No, your assertiveness in offering to do and watch procedures was great.” I told him I tried to keep an open mind during the rotation, but we agreed that internal medicine probably isn’t for me. Like in any way. At all. Ever.

I’m happy it’s my last night of call with inpatient internal medicine and tomorrow is my last day at the hospital. The next four weeks will be outpatient internal medicine.

Since tomorrow is my last day, I really need to go say goodbye to Ms. AI.

3:35 pm: Timing. Not a minute after typing the previous sentence the code pagers went off. I took off running and was halfway down the hallway to the patient’s room before it clicked that I was heading towards Ms. AI room. She was unresponsive, so a rapid response was called. Then she started posturing, with her arms and legs extended stiffly at her side. The doctor pinched her skin and tried other painful methods to rouse her. I wanted to yell at him to stop. I stood frozen near the doorway of her room and watched her get intubated while the residents discussed whether or not she may have developed a bleed in her head.

The scene played out exactly the way she described to me that she was afraid it would happen. Masked, yellow-gowned docs swarming around her bed and shoving a tube down her throat. She was sent for an emergent head CT, so I went with her, and then I followed her to her new room in the ICU. I kept vigil at her bedside for some time, unable to imagine how I would feel if one of my nightmares came true. One of the attending docs stopped by and asked me if I was ok. He kindly updated me that her CT scan was normal. I’m usually good at hiding my emotions but this was too much to witness. She can’t die. She can’t. Of all the patients… not her. Please not her.

5:45 pm: Time does not stop and our team is busy. There is a new patient for me and I almost vomited in his room because of the stench emanating from him.

6:50 pm: Lots of new patients are rolling in, including two who are psychotic. Psychotic patients are fascinating to me, and today they are also distracting me from thinking about Ms. AI. One new patient kept yelling at me and calling me Bessy. The other one is intensely paranoid and believes she is part of an FBI conspiracy and film project. She seemed relieved (though I think slightly disappointed) when I told her firmly “no” we are not making a movie about her. Though, she will get a part in my book. I didn’t tell her this.

July 27: Saturday

6:45 am: Today is my last day on inpatient medicine. I would’ve said goodbye to Ms. AI but she is still intubated in the ICU. I will, however, go and say goodbye to 95 and his wonderful family once we’re done with rounds.

1:30 pm: Wow, what a great note to end on. I spent nearly 40 minutes sitting with 95 and his wife of forever. They have many children and even more grandchildren and great grandchildren. 95’s wife revealed to me in a conspiratorial tone, “Every time he thought I wasn’t busy enough he got me pregnant again.” My favorite exchange went something like this:

Wife: “I couldn’t have found a better man, I am so blessed.”

95: “You could’ve found a richer man.”

Wife: “I guess so.”

95: “Eh, but he probably wouldn’t have you let you spend all his money the way I let you spend all of mine!”

The two of them busted out laughing.

95’s wife asked me if I had a boyfriend. I replied “yes,” and she told me that he better be treating me right. She added that he must be worried all the time about other doctors hitting on me. I’m not so sure about that, but I just nodded and smiled and left it at that. There were lots of hugs and well-wishing when I left the room. I am in awe of their relationship. You could see the love between them, radiating from them. My grandparents, my mom’s parents, were like that. Hugging and kissing and holding hands up until the day my poppa died. My relationship with Casey isn’t like that; it hasn’t been like that in a long time. Maybe in the past, but not recently. I’m dreading going home today and discussing the state of our relationship, but I can’t put it off any longer.

Before I leave the hospital and officially finish inpatient medicine, I go turn in my pager that never went off.

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