Real Talk: The long white coat

As a medical student, I often yearned for the day when my short coat would be replaced with a long one, my name embroidered with an “M.D.” after it. I would gaze longingly at my residents and attendings adorned in their Capes of Knowledge, flitting about the hospital in their flowing white garment dispensing Ativan and reassurance like candy and wine. (Just kidding, candy is bad for you).
Well, I am half-an-intern-year wiser and I’m here to tell you: The Establishment has you duped. They have carefully cultivated this illustrious image of the Long White Coat (LWC), but what they aren't telling you is that it is not worth its weight in anything except maybe Robbins Pathology textbooks.

I know, I know, there are things people actually like about their LWCs. It’s a shining beacon of authority! (Especially the day after Laundry Day). It serves as an extra layer of protection from hospital subarctic temperatures and bloody vomit, sometimes simultaneously! It comes with pockets for carrying Very Important Stuff like energy bars, the purple book of wisdom, and an IV kit for mainlining caffeine!

The most tragic dupes of The Establishment are women, who have been brainwashed for years upon years by the fashion industry into being thankful for the pockets, since every other garment leaves them (us) deprived. It’s a massive conspiracy that’s been playing out for centuries! But that belongs in a separate article that I will never write because fashion is so far from being my thing.

Okay, so the benefits pretty much end there. Now for the drawbacks, with some suggestions sprinkled in:

The Coat Mass Index

• It is a couple feet longer than our student coats, which just means extra inches to iron (ha.) and keep clean. Ain’t nobody got time for that! Those are precious minutes that could be spent sleeping, or stealthily scarfing down lunch in the bathroom where no one can find you.
• Those extra inches also mean you keep rolling your chair over it, which means it gets dirty, which means you have to wash it again (maybe), which means you have to iron it again…you see where I’m going with this.
• More square inches = greater surface area to cover in miscellaneous fluids, including but not limited to: blood, emesis, printer ink, stray pen marks, etc. Cue vicious cycle yet again.
• New and improved length blocks universal scrub back pocket access! Making for awkward moments when you hike your coat up to fish out your phone.
• Extra length means the stethoscope in your pocket is now at perfect door-snagging length. Excess fabric is more than happy to co-snag with the stethoscope, making it difficult to maintain a semblance of dignity and authority while cursing at a door knob.
• Yes, they come with nice, roomy pockets. But as with any benefit offered to a capitalist society, you’re tempted to ‘make the most of them’ and stuff them chock full of Very Important Stuff, which makes for sad shoulders and a sad back.
• I hear the Pocket Capitalism Effect tapers off as you go up the ranks, since eventually you will be a bad-ass attending who only needs to carry around your brain and a pen to scrawl chicken-scratch on the souls of your minions.

Just for kicks, how cool would it be if white coats grew on their own? Lengthening by a percentage of your height per year of experience – eventually, they will all be like awkward, collared and buttoned, infected wedding dresses.

Fashion Commentary

• The fabric is hot. And I don’t mean the kind of hot that gets you all excited. I mean the kind of hot that gets you all disgustingly overheated and uncomfortable. You’d think they would have discovered a more breathable material by now. Can we get Under Armour on this?
• Also: Why aren't LWCs fluid resistant yet??
• Maybe instead of white, they should come in shades of body fluid, the ultimate camouflaging technique. I’m not entirely sure how this could best be engineered. A swatch for each type of fluid? A fancy cloth mosaic?
• The LWCs are inherently sexist! I’m sure this shocks exactly no one (see fashion industry mini-rant above).
• Guys don’t get a slimming band across the back. Why not? They have as much right to a tapered fit as the rest of us.
• Gals don’t get pocket-accessing side slits! I mean, it’s bad enough we usually get gypped on the pocket square footage front, but now we can’t even get to them!

 The [unwelcome] Genius Effect

• People think you actually know stuff. I mean, the coat even says “M.D.” on it. This is dangerous.
• It comes free with a 15th century pager. Run away! This is not a good deal! Silence your inner capitalist!

Cargo scrub pants are the great equalizer. Everyone should have to wear them all the time whenever they’re in the hospital. The end.  

Lows and lows

"Nothing is permanent in this wicked world - not even our troubles."

- Charles Chaplin

It was my last Friday on the wards for this go-round, the last day our current two teams would spend together before all the non-interns switched over. And from noon onward, it turned into an emotional roller coaster I struggled to navigate.

Code Blue, ICU. Code Blue, ICU.

My attending and I were on our way down to the ER to see a new admission when a code was called in the ICU. The ICU staff is the rapid response team, so typically the floor doctors don't descend en masse; a few people headed over there while we two continued our trek downstairs.

Our admission was a very elderly lady with late-stage Alzheimer's who had fallen victim to a vicious infection and recently stopped eating. Her family had made her 'comfort measures only,' and she was being admitted for gentle care until hospice services could be put in place for her to receive care at home.

Spindly fingers. Raspy breaths. Vacant eyes.

Her room was crowded with family and her caretakers. Her presentation, from so many angles (minus the infection), bore strong echoes to my grandfather's last days. My attending spoke to the children as I held her hand, thinking back to when I last saw him, similarly cachectic and lost to the world in all ways except for the air his lungs still pulled in, the blood his heart still labored to pump.

After talking to the family and the ER doctor, we made our way back upstairs. Just as I was settling into my seat to work on her admission orders, a second code was called in the ICU for the same patient. They needed more hands on deck for CPR, and several of us rushed over.

1--2--3--4--5--6--7--8--9--10-- x 2 minutes

The patient's room was the one right next to the room where my patient's harrowing code had occurred one month ago, when I was working in the ICU. Half of the staff was the same that had been present that day. When I was struggling in the aftermath of the code last month, one of my medical school mentors told me, "Events like that tend to stay entrenched in your memory for the rest of your life. You'll always remember the details." It's only been a month, too soon to extrapolate to a lifetime, but I had flashbacks that Friday in a way I never had before. But there was no time to indulge (there rarely is); time to be present.

After some time, the family asked us to stop, and the code was called. Those of us who had come to help trudged back to the wards with a heavy heart, back to the grind of work. My resident had finished the admission orders for me, and I began the admission note. Soon after, my pager went off -- please call radiology.

Peritoneal carcinomatosis. Subcapsular splenic lesions. Periaortic lymph nodes.

They had CT scan results back for another one of my patients, a sweet, feisty elderly lady who had come in with intractable vomiting and unintentional weight loss. The results were grim. She had widespread metastases, likely related to a past cancer for which she had undergone treatment years ago.

I called her primary care doctor to give him the update. He came by the wards within the next hour, and we went to deliver the somber news to our patient. She took it in with her usual stoicism, giving little hint as to how she was feeling, and little room for us to explore that with her.

Olé!

What was left of the day went toward tying up loose ends and finishing paperwork. And was then followed by the final jarring event of the day -- a celebratory two-team dinner to feast to our time together, which had been scheduled since several days prior.

I wouldn't say I ran the full spectrum of emotions that day, because mostly I wallowed at one end of it, and had to play-act at the polar opposite end for the final few hours of an otherwise exhaustingly mournful day. There were too many echoes in speedy succession -- of my grandfather, of my ICU code, of my first medicine patient I had as a third-year medical student, who happened to be the first patient I had to break the news about cancer to, and the first patient I had transferred to the ICU, only to see him die a slow, sad death there.

Somehow that Chaplin quote seemed to belong with my memories of this particular Friday. When I was an MS-III with my first patient with newly diagnosed cancer, while simultaneously struggling to process my aunt's sudden and tragic death, my intern at the time would say, "This too shall pass." And more recently, as I struggled through that Friday, and some of the days leading up to it, another mentor/friend told me of her dance party with her adorable son to Taylor Swift's "Shake It Off."

How can we build in time to do that? I hadn't fully internalized what a wild, visceral ride I went on that day until over a week later. It was after I transitioned back to an 8a-5p schedule, had caught up on some sleep, and found myself with a two-day weekend to finally try and decompress.

There has to be a better structure for processing, even within the constraints placed upon us by training. How else will we stem that empathy degradation we keep hearing about?

Things to ponder. In the meantime, if you see me jamming to TSwift, all I will say is, don't knock it 'til you try it. 

An all-too-common tale

"Let your heart feel for the afflictions and distress of everyone."

-George Washington

Beware, however, of the paralysis that may follow.

Last week, I found out that one of the patients I had cared for while she was admitted to the hospital died within a couple of weeks of going home.

I suppose, depending on the expectations and theories one associates with being hospitalized, this could come as an expected eventual outcome. While I'm not feeling particularly profound or philosophical, I suppose it's worth conceding that the eventual outcome is always death. Except this sweet, unfortunate, confused lady was not here for any acute health issues, but rather, a worsening of many chronic ones. And her true cause of admission? A complex constellation of social symptoms. Her "eventual" death came too soon.

Her true illness was joblessness, near homelessness. No health insurance. No resources. Limited supports. A language barrier. A profound degree of not just health illiteracy, but illiteracy, period. The overwhelming combination eventually brought her path to intersect mine for a brief interlude. In theory, I cared for her and made her feel better. But I had no remedies, none at all, for the true causes of her multiple diseases. My prescription pad was useless in more ways than one -- not only could I not write her for a home, or a paycheck, or a family, but the few medications I could write her for, she would be unable to take due to lack of comprehension.

We try, with incredible efforts from our social workers and case managers, to set up safe discharge plans for our patients, but in so many ways, our hands are tied. She left our hospital bed and returned to her familiar ground. Within a few short weeks, she died -- ostensibly of medical causes, but actually of so many social ones. And since then, I've wondered what more I could have done to prevent this, and what more I can do for the next incarnation of her confluence of social issues who crosses my path. I've yet to come up with any answers, and am left feeling miserably inadequate.

This is not meant as a social commentary, though the situation deserves one. I have no groundbreaking insight or ideas on how to remedy this story and the multitudes like it, at least not just yet.

This is an outpouring of grief and regret. Of failure.

I'm sorry. 

BAU to the Rescue

"Things are not always what they seem; the first appearance deceives many; the intelligence of a few perceives what has been carefully hidden."

-Phaedrus

(spoken by Hotch in "Paradise," 4x04, Criminal Minds)

Most who know me know I am a loyal Criminal Minds fan. Every episode is book-ended by quotes. I don't believe they have ever repeated a quotee (apparently this is actually word) within or between episodes, but don't quote (ha) me on that. But I digress. 

In senior year of college, I began to struggle with blogging, especially as difficult things were going on at home, combined with the encroaching sadness of leaving college behind and separating from a lovely, if insular-to-college, community. So, I turned to my favorite TV show for inspiration -- I picked an arbitrary quote from one of the openings/closings to help me focus my thoughts whenever I struggled to write. And it worked!

When I started my med school blog, I felt I was 'better' than that. I could manage my own inspiration! I was in such an inspiration-rich environment, what could possibly be lacking? Quite a bit, apparently, the most significant of which was focus.

I changed blogs from college to medical school because I thought carrying the same one forward would encumber the process of identity growth. But I'm keeping the same blog for this transition, from medical school to residency, at least for now. Why?

a) I never quite gave it a fighting chance, and feel responsible for giving it another go.

b) Transition and growth is a gradual incline, not a stepwise leap from one standpoint to another.

c) Let's face it, it's kind of an awesome name. (That's not arrogance speaking -- I didn't come up with it!)

But I think it will take a different form. I hope it will.

In medical school, I shied away from expressing too much of myself or my opinions. My friends will probably scoff at this. I should clarify -- this was mostly true in public environments/forums, maybe not as much one-on-one. I don't think this was a new trend; I'm a somewhat conflict-averse person, though I've been known to pick my battles.

I also somehow became of the opinion that I was only worth taking seriously if I processed my experiences into story-form prose. I'm still struggling with this, but I'm starting to consider that to be false. And the duality of self gets tiring to maintain. The intention to maintain it here began to translate into maintaining it in person. And that really gets tiring.

It seems kind of goofy to think that writing this will somehow affect a significant change in behavior. But maybe I will at times be more successful in holding myself accountable. And hey, I'm kind of goofy at baseline -- who knew? (Spoiler: My sister definitely knows. Better than any other human being alive. This will probably make her feel validated in some way. Just for you, M.)

Identity.

I am a

-daughter

-sister

-cousin

-granddaughter

-friend

-learner

-educator

-mentee, and dare I say, mentor

-reader
-alien

-[select] TV show junkie

-coffee addict

-Bollywood fan (though the 90s make me cringe)

-PJ extraordinaire

---> Some will think this stands for pajamas. Others will say poor jokes. They would all be correct.

-writer

The list is both incomplete and in continuous flux. Now I am also a psychiatry resident, resolving to work harder to find a truer me even as I help patients do the same. And all this with the hope that I will come out a better care provider and individual for the effort.

(Leave more identities in the comments! Yours or mine. The more absurd the better, of course.)