Last Day

Today is my last day as an R1, which officially marks the halfway point in my rural family medicine residency training. I find it amusing that I have to have my orders and prescriptions reviewed and see patients in a parallel consulting style today, but once the weekend is over, I don't. It is a magical weekend I suppose wherein all the wisdom of my R1 training will culminate and crystallize to make me safe on Monday morning in a way that was different from today. Ha!

I laugh because this is almost as ridiculous as the fact that a year from now I could go to sleep on Sunday night as a resident and wake up Monday morning as an attending (well if it weren't for the extra training I'm planning in surgery).

These days seem, like all other milestones, eerily anticlimactic. It is exciting though in some ways to feel that sense of independence slowly developing, to find myself feeling slightly more confident with certain things that were so scary and daunting a year ago (my first order as a doctor was for a chest x-ray and I remember being completely freaked out when I wrote it! How pathetic is that?!)

Maybe today to mark the occasion ALL my patients will get chest x-rays! (I'm kidding, of course.)

Onward and upward, amigos!

I See You

My first year of residency is winding down and I've been in my last rotation, internal medicine. 

I've been taking care of a patient who has given me a glimpse into how horrifically a human can hurt another, humiliate another, destroy another. I've had forms to fill out, phone calls to make, family members to meet with. All of this has provided enough busy work to keep my mind from drifting into actually processing the things I see in front of me. It has kept me from considering, for more than a fleeting moment, what my patient might possibly be going through...what the family might be going through. I feel borderline selfish even, getting upset over it, shaking my head over it, because it seems indulgent...like I am making it about me and not my patient. We're all drained, we all want to look away.

I come home, I want to talk about it yet I don't want to say a word.

The manager of the ICU sat beside me yesterday at the nursing station and said, "you are obviously passionate about your job, you obviously chose the right profession". I took it as one of the highest compliments I've received, but as she said it I nearly burst into tears. I thought about how much I hate this job sometimes and the things it shows us, about ourselves and about others. I feel weak when my work upsets me, and I feel jaded when it doesn't.

As I drove home today I felt angry about this job, I thought about what an awful line of work it can be. I watched the bobcat driver roll up and down our front yard, the heat beating down on the metal roof. Back and forth, spreading the dirt out.

My dad used to do work like that, he worked construction and road crews. As I got older I felt sorry for him, that this was his job. I continued to watch the methodical work out my front window and couldn't tell if what I felt was pity or envy.

May Day

Not exactly sure where April went. Well it involved a holiday to the UK, then buying a house and writing my QE1 exam. Oh, OK, that is where April (and the beginning of May) went.

Since residency started I feel that I am standing on the platform of a subway station. The days go whizzing by, past my face, at a speed that leaves everything a trailing blur. Then for a moment, the subway stops and people pour out, and pour in, bumping past me. Some linking eyes, some carrying on, some talking, some silent. I remain still and the chaos moves briefly around me, then the doors close and everything speeds up again. There are these blips of human interaction that stand out, but much of it remains a blur.

I kick myself for not writing, even just for myself, every night. I really ought to try and start doing that. Maybe that will be my mid-years resolution.

Things have been in a state of flux. I recently went through yet another soul searching time in my post-graduate training. I am gearing up to apply for my +1 year (in Canada GP's can undertake extra training in things like emergency medicine, anesthetics, surgery, obstetrics, palliative care, sports medicine, etc). I always knew I wanted to do this +1 option but I've gone around and around with what area to specialize in. I thought for a long time that it would be emergency medicine, but if I am honest I am getting to be COMPLETELY over EM. I am just tired of all the abuse that goes on in the ED, in every realm: patients abusing the system by going to emerg for non-emergent presentations, patients abusing the physicians and nurses, and then the specialists abusing us when we call to consult them. I still love a sick patient, a surgical patient, a procedure-needing patient, but that is about it. I just don't want to do it full time. A shift a week - sure! Everyday? Shoot me now.

So I thought about anesthetics. 9 months in the Big City and then 3 months in my current city. I like the procedural side of anesthetics, and I love airway management, but I am not a detail oriented, thinking person. I am a cook, not a baker, if you can appreciate the vast difference between the two personalities. I can force myself to be detail attentive but it requires a lot of mental energy. I realised that I was choosing this option more because it has greater portability and demand currently in Canada. It wasn't what I truly wanted to do in my heart of hearts.

Thus, I decided to apply for the Enhanced Surgical Skills program (ESS). It is one year of surgical training that is divided between 6 months of obstetrics and 6 months of general surgery. In the obs component you learn c-sections, essures, tubal ligations, instrumental deliveries, and other office procedures. In the general surgery component one is expected to become proficient in performing hernia repairs, appendectomies, lumps and bumps, scoping, and any other procedure you feel you ought to provide to your community (some do tonsillectomies, carpal tunnels, etc).

So now I am pumped. I have found an accepting community that will give me privileges in this scope of GP-surgeon practice. The applications are in the fall (for a July 2015 start) but I'm already trying to get as much experience as I can with these enhanced skills. It's been great, having loads of obstetrical procedures here as well as being scaffolded up on basic surgeries...all by kick-ass GP-surgeons!

It's weird feeling like things are possibly falling into place. I've had so much internal conflict and so many questions about what I ought to do with my career. I have always felt that family medicine was an uneasy fit for me since I started residency, mostly because there are many things about FM that I do not love. THIS feels like a fit, it feels like something I can hold on to and mold into what I want it to be in the future. I hope.

Life Goals = Check

So for the first time since June, I feel somewhat ready for the week ahead. For the past 10 days or so my main life goal has been to empty the dishwasher. I thought, if I could pull that off I might even lift my game and wash the sheets on my bed.

Well, done and done.

You might be thinking that this is THE most boring post you've ever come across but honestly, I feel this deserves to be put down in the history books. My food for the week is made (mulligatawny stew, curried cauliflower soup, and some slow-cooked peanut chicken), the sheets are fresh, the floors are vacuumed/washed, my bathroom is clean, laundry is done, bills are paid, dog food is stocked, and the fridge is sparkling. Oh it is sweet. This is what happens when I get two whole days off!! (Ok, I was post-call on Saturday so I slept until 1415h, thus making my achievements even more impressive, as far as I am concerned).

This week will be busy, I have volleyball tomorrow, am on call in the ED on Tuesday and on call for anesthetics on Wednesday but then on Friday I am flying home for Thanksgiving!! I can't even remember the last time I spent Thanksgiving with the family. It's been at least 10 years for sure. I am ridiculously excited...and prepping my elastic waistband pants in advance. Ah screw it, I'll just wear scrub bottoms the entire weekend.

In other GREAT news, Duncan finally gave his notice at work which means that the Manfriend will be joining me here shortly on the bald prairies. Yes, he is leaving his job and house on the ocean in BC to move here. It must be love.

Let's hope he's still smiling come February...

It's going to make such a difference having him here in the shoebox-sized rental. Residency has been a heavy go and a lonely road so far, and it's definitely been tough to keep the fires burning long-distance. Hopefully his tender British hide doesn't get frostbitten during his first REAL Canadian winter. Eep. Yeah, he's been in Canada for four years but Vancouver Island winters really don't count. We had a long discussion about vehicular modifications required for -40 degree winters, phrases like "block heater installation" and "winter tire purchases" were thrown around. I think he is still processing all of this. I get random questions like, "So...do people plug their cars in at work??" in the middle of a conversation about running shoes.

Yessssssss.

I am currently on my combined gen surg/ortho rotation. It is...meh. I really enjoy being in the O.R but my program has really changed up our rotation so that we spend most of our time in ambulatory care and surgical clinics. Which, I suppose, is nice for the people who hate being in theatre and who plan to have mainly GP clinic based practice. (In case it isn't already painfully obvious I don't plan on having a predominately clinic based practice). I recognize that this approach makes sense in terms of what family medicine residents need to know from a surgical rotation perspective - I just wish I had some more time getting to assist and do procedural things. Which is probably why I LOVED LOVED LOVED my anesthetics rotation (but that is a whole other post). Did I mention, I LOVED ANESTHETICS?!?! 

Well, that is enough rambling for one night. I just thought I should check in with the odd happy post from now on so that people don't think I am scouting highway accessible bridge abutments.  

Also. My dog rules.

Wake up and pet me dammit!!!

Roll on, Monday. 

Medicine Giveth and Taketh Away

My relationship with medicine has been a complicated affair. Depending on the day I can feel anything from anger and resentment to gratitude and love for it. It's been this big, ambling, shuffling entity in the background and foreground of my life for as long as I can remember. At times it is all encompassing, at times it disappears to a pin hole in the distance. Some days I find medicine grounds me, makes me feel like I have a better understanding of the world and what is truly important. Other days I feel that it warps my perceptions so much that I have no idea which direction is north.

I took two days off this week, leading up to an emergency medicine conference that I am attending (in Whistler - if any of you are also going to be there, come and say "hi!")

Having a couple of days to breathe (and by 'breathe' I mean 'finally catch up on paperwork, presentations, research assignments, leave requests, and emails') has given me some time to think about the last few months and my initiation into being a physician.

The weeks fan out behind me, some moments are vividly etched, the others already faded and gone.

Like finally being able to eat at the end of a 15 hour shift, with my only option being the last bowl of chile in Subway. I mean why did the guy have to tell me that it was the last bowl of chile? He could have just said, "Here is a delightful bowl of piping hot chile!" not "you got the very LAST bowl".

Or having to appear interested and awake during post-call re-enactments of Duck Dynasty episodes by an attending. Informing a patient that there is no such thing as a "butt cast" for her pain following a hard landing on her derrière. Holding a fibrillating heart between my fingers and squeezing, squeezing, squeezing until there was nothing left to do but wash off the blood that had managed to seep under my sterile gloves. There were unexpected flowers at the hospital on my birthday from Duncan. There were babies that came into the world, chubby and screaming while yellow-gowned, O.R capped men proudly stroked their wife's hair. And also the grey dishwater colored ooze and rotting flesh stench of necrotizing fasciitis, and countless miles spent walking the rotary trail with my puppy, Monty, while I tried to make sense of it all.

So many moments. Tumbling. Flashing before my eyes while I try to fall asleep. Those nights when the sweetest feeling ever is having your feet at the same level as your heart. That bone-tired exhaustion surpassed only by the relief that the day is over. On the especially bad days Monty is allowed up on the couch with me. His scruffy face and propensity to lick my socked feet are enough to make me laugh and take my mind off whatever transpired at the hospital that day.

 

Which is why I am never sure of how to answer the question, "How is residency going?" My mind floods with all of the images of these moments. Some hilarious, some disturbing, touching, rewarding, enlightening...humbling. So I suppose the best answer to that question is, "it's complicated".

Blog Readers, I Salute You

This is just an aside. A short note to say that I really appreciated the folks who took time to send comments and emails my way in response to my last post.

It pleases me greatly that people still read this blog (which is...ok maybe not in asystole but certainly a life threatening bradycardia - forgive me, I had to). It also is humbling and thought provoking and reality checking to hear the thoughts of people who have been reading this blog (or who know me / are related to me). I appreciate that I can be (somewhat) candid and honest. Which is what I would want if I was reading story of someone who was chasing a dream.

I think that too often we get to the goal and the story is over. Happily ever after. But really, everyone knows, deep down inside that this isn't true. My mother reminds me that what doesn't kill you makes you piss on your shoes and that the people who got their dream residencies in their dream specialties are pissing on their shoes for many reasons as well.

So thank you all, for your thoughts and notes and perspectives and wisdom. I had intended to end the blog after graduation but it seems there are still people out there who read it, and even enjoy it!  And I think I still have a lot to say about medicine and this journey which continues to unfold in strange and challenging ways.

In a completely unrelated note: today while the pediatrician was listening to the lungs of my 3 year old patient the kid gave his mum a thumbs up. I swear I am laughing as I type this. Even though I am looking forward to my next rotation (anesthetics) I will miss certain things about peds. Though, I will not miss the daily cough in my face routine that occurs.

Okay okay okay!

So today my friend Rob posted this on my FB page, "I feel like the blog is circling the drain.. like an end stage nephro patient. Write more stuff!!!" 

Which is fair enough. I've had a lot of posts or snippets of posts floating through my head since I started residency but for a number of reasons I feel like I can't write them. 

For one, I live in a pretty small town and I have an ever-increasing paranoia that I am violating patient confidentiality by writing about things that happen at work. Also, for some reason I feel slightly more duty-bound to pretend that everything is fantastic because SHAZAMMMM! I am done medical school and am actually a doctor now - i.e. life goal has been realized and therefore I should be rolling through a field of tulips with an ecstatic expression on my face. 

Truth is, I am actually not that happy. But I mean really, the cards are stacked a little against happiness right now. 

I just moved to a new town and have no friends. I just started a new job which is always stressful. The herniated disc in my back is unrelentingly painful and restricting my activity (thus quality of life). I am broke as a joke. My boyfriend still lives two time zones away because Canadian immigration moves slower than maple water in an ice storm and his permanent visa has yet to be granted. This town is ROUGH. I could go on and continue to list another dozen first world problems but I will stop myself there. 

I am a positive person, I really am. I always try to find the silver lining in things. I try to think that everything happens for a reason and that the universe puts me where I need to be. But I just can't seem to go there in my mind right now. I am not a person of regret usually but right now I regret so many things. I regret studying abroad and the financial repercussions as well as the professional ones. I don't want to be here. Am I allowed to say that? I can't wait for the end of the day (or night) when I can be home watching "Parks and Recreation" reruns in the quiet darkness of my curtain drawn living room. 

Transitions are hard, and I know that. I remember being nauseated and sleepless before every shift when I first became a nurse, and gradually that faded. I just suppose that I am frustrated too that I didn't anticipate these growing pains. I (erroneously) believed that I knew what I was getting into, coming into medicine from a nursing perspective. But I realize now, more than ever, that every stage of life brings with it some joys and some sorrows, some stimulation and some tedium. Becoming a doctor hasn't allowed me to transcend that reality. It's just given me more waking hours to experience all of it.

Multi-tasking

I picked up the kid's chart. It wasn't a simple consultation as he had been referred to the pediatric clinic for ongoing investigations of chest pain and palpitations. It was a busy clinic and so I was trying to juggle reading referral letters, getting histories, and writing notes all at the same time.

I was sifting though the documentation while a sweet, round faced lad swung his legs against the examination table - non stop kid-style stream of consciousness monologue pouring forth. So while I'm seeing ECG's and prescription refills and trying to elucidate the history from his mom, ignore the chatter and read through a holter monitor report from the cardiologist he says, "Excuse me, excuse me..." I realise that I am not emulating the appropriate 'doctor/patient/parent' interaction so I stop mid sentence in the specialist report and say, "Yes?"

"Did you know that lemurs have opposable thumbs?"

No kid. No I didn't. I'll just add that to the seemingly countless other things I do not know in this world. I laughed and made a mental note to start dropping more non sequiturs into conversation.

Now back to that pediatric cardiology referral.

At the end of the consultation I told him he was one sharp kid and he agreed adding, "and a curious one too".

Yes indeed. 

Blood spurting!! Life saving!! Code calling!!

No. That wasn't at all how my first day went.

It was all very dimly lit and civilized. It was all about how to fill out forms for vacation requests and travel, how to submit log books, finding computer passwords and parking instructions.

I still have a few days of orientation ahead of me. Today I purchased a propane tank, a Co-Op membership, and maple syrup. I am feeling very 'rural Canadian'.

These transitions are tough. Tonight while I was making homemade ketchup I was thinking that it has been a long time since I've been a new person in a new town. There has always been a safety net of friends or well known colleagues in my previous nooks and crannies. I know I'll be on my feet soon but I know I am stress-condiment-making (I am not a baker, so I cannot stress-bake).

Right now I am melting in the >30 degree heat, in my house that has no AC.

Next Tuesday is my actual first day on the job. Eeeep! For now, I will bask in the paperwork.