Monday, August 31, 2015

Finals Stew

Don't have a lot of time to spend on dinner? Try this speedy recipe for a hearty stew. Sure to stick to your ribs and help you sail through finals.

Serves: 106
Cooking time: 1 week
Skill level: Easy
Dietary Considerations: Kosher

1. In a large cast iron skillet mix two parts abject self loathing with one part denial. Bring to a boil and cover.

2. While that's cooking, stir together 4 Chipotle burritos, 6 chips you found on the floor of your car, the blood of the guy who is talking on his phone in the library and 6 Venti drip coffees. Slowly mix in half a bottle of Pepto Bismol to taste.

3. Chop dreams finely and add to wine- drink while cooking for best results.

4. Add candy, candy canes, candy corn and syrup to skillet. Insulin optional.

5. Pour 1/3 of a cup of tears into denial/self loathing mixture and swirl while complaining.

6. Grease baking sheet with blood, sweat, tears and syllabus pages 394-471.

7. Allow ingredients to stew in their own regret and shameless procrastination.

8. Remove from stove and transfer to oven for the length of 3 episodes of The Bachelor in Paradise.

9.  Garnish with the dust of white board pens.

10. Serve

Monday, August 24, 2015

Trouble the Water

Its 2am. I’m lying in bed, wide awake having exhausted my Netflix playlist. I try to close my eyes, but sleep won’t come. I stare up at the ceiling and my mind turns to worry as it is apt to do every night around this time.

“Am I using too much water?”
“Is this mole cancerous?”
“What’s that noise?”
“What am I going to wear tomorrow?”
“Am I studying enough?”
“Did I talk too much during doctoring?”
“Do people like me?”
“Do I like me?”

Around and around and around….worry grips me.

I have always been a worrier. Ever since I was a little kid. I can remember telling my mom how much I was worrying. Apparently, its normal for children to worry. And no wonder, young souls have such little control over their lives, worrying seems like a good option. But I thought it would get better in adulthood. I thought I would have things figured out.

We have precious little control over our lives. If anything has helped to make that clear, its being in medical school. People get sick and die and there is so little we can do about it.

When I do fall asleep, I dream that I am in trouble. I have paid my rent in chocolate coins and the landlords are not happy about it. I try to explain that I didn’t know, that I thought it was okay, that I wasn’t trying to hurt anyone. I wake up covered in sweat with dragon breath, as the sun pours in my window. Thank God it was just a dream, (note to self, chocolate money is evil but delicious).

Thanks in part to my psychiatrist mother and my Marin County upbringing, I like finding deeper meaning in my dreams. Take home message—I am wound way too tightly. I have so much trouble letting go of the grip of my anxiety that Kara found testing my reflexes impossible and we had to use Jack instead. I can’t relax in mind and apparently not in my biceps muscles. If I do, then surely it will all go to hell. So I’ll stay up worrying, guarding the night, in case it all goes horribly wrong.

I am so scared I’ll mess up my time here in medical school. I worked so hard to get here, I couldn’t bear to watch it all come tumbling down like a house of cards with the slightest movement of air. So I don’t dare breathe at all.

“Hurry up and graduate,” my dad said to me over lunch yesterday. He’s tired of paying my rent (in real money I might add) and footing the bill for my coffee/wine habit.

I want to hurry up and graduate too. I want to get out before the devil knows I’m here. Before they see the only sensible thing to do would be to kick me out. But part of me knows this is only the start.

"Will I get sued?"
"Will I kill someone?"
"How will I know how to make someone better?"
"How do I break bad news?"
"Will people like me?"

Will I ever sleep again?

I wish I was better. Smarter maybe. Skinnier for sure. A better writer. A better friend. Maybe then I could relax. My fears are real. And I can't find my way out. Fear keeps me safe. And motivated. And afraid. I both relish its presence and curse it. I wonder what it feels like to live without it, but its such a part of me I'm not sure I want to. 

When I was really little and my parents would wake me up in the morning I used to say, "Its a beautiful sunny day." Even when it was pouring with rain. I wish I could go back to that--channel my inner carefree 2 year old.

Today at least, it is a beautiful sunny day. I'm not sure that it will be tomorrow, but today it is. And today matters. Today I am a medical student.

Today I will let that be enough.

Thursday, August 13, 2015

The Babadook

Ever have one of those days?

You wake up late, you can’t find any clean clothes, there’s no food in the fridge, your unread emails number in the hundreds and every logistical thing that can go wrong, is going spectacularly wrong right in front of your eyes.

Yea…I have those days too.

It can be hard to come back from a bad day without the help of your friends. And in medical school, where it can often seem as though everyone has it more together than you do, admitting that you’re having a bad day (or a bad week) can seem more like revealing your inner most fears and failures than a way back to normalcy.

Maybe we don’t give each other enough permission to well and truly embrace a bad day—for I believe that the only way to truly put a bad day to rest is to embrace it. Yes I spilled coffee all over myself, broke my computer charger and oh, is that cereal stuck in my hair? Excellent.

The only sane thing to do would be to crawl back in bed and try again tomorrow, but its just not possible with our schedules as demanding as they are. We have to show up—and I don’t think that’s going to change anytime soon. As we are thrust further and further into adulthood (when did that happen and how do we make it stop?), I am starting to realize that adults have to do things, we have responsibilities and demands for our time. And yet as medical students we do not yet have the MD behind our names nor the paycheck that comes with a degree like that, to be able to leverage it when things don’t go our way. Let's be honest, shopping makes everything better. 

We can’t escape for a blissful vacation to the Cinque Terre- because we lack both time and money. But I promise you that all is not lost Gentle Reader. You can come back from what ails you, to fight the good fight with renewed strength. You just can’t do it alone.

I recently watched an Australian horror flick called The Babadook. Frankly, its hard to be scared in a movie where everyone has such a delightful Australian accent. This film also got a lot of criticism for not having very good special effects of the monster plaguing a single mother and her son. But I don’t think it really matters, because what makes the movie so creepy is its truth.

The mother in the film refuses any help or support from friends or family and succumbs to possession by the monster who grows stronger as she refuses to admit that she can’t do it alone--as if single mothers didn’t have it hard enough. She is ultimately able to fight off the monster by accepting help from others and they go on with their lives by acknowledging the beast, but not letting it terrorize them anymore. We too must acknowledge our inner Babadook—our fear that we are inadequate and that we have no option but to solider on alone. The only way to conquer it is to let other people in. Trust the people around you enough to let them show you what it means and feels like to be loved.

In turn it is our responsibility to show up for other people. To take time to listen and to empathize. Together we can deal with bad days, snarky comments, traffic, deadlines and all of the other annoying things that life contains. It can be really difficult, but aren’t we lucky that we get to come to school each day, surrounded by people who can show us that life is a swirling together of the annoying and terrible with the amazingly beautiful and good.

We must acknowledge our bad days, our short comings and embrace the fact that we need help (and no—we don’t have it together all of the time) if we don’t--we lose the ability to deal when things don’t go our way, when we feel hopeless or angry or not enough or ugly.

Remember the good things in life when the going gets rough. Let other people remind you and show you the best of this earth when you forget. Take your cynical, overburdened self to the beach or some other beautiful place. Share a meal with people you love, pet a dog, read a good book (not one for school), pour yourself a drink of something cold. Didn't your mother tell you there'd be days like this? And just like everything else, she was right. Lucky for us, we have each other to get through this maze of chaos and crazy.

I'm not saying you'll never have another bad day again-- although I really wish I could. Rather I implore you to try to embrace that sometimes things don't work as they should and reach out to others for strength and support. 

Saturday, August 8, 2015

Let there be Light

I’m supposed to speak at the body donor memorial in September. I told Brendan and Sundip that my speech was written. “Don’t worry,” I assured them. “I have it all in my head, just need to get it down on paper. I’m a writer, it’s my process.” But the truth is that I am struggling with what to say. I’ve tried to write it, but I just end up drinking a pot of coffee while the blinking cursor taunts me.

The family members of our donors deserve to hear words that help them feel proud of their loved ones and let them know how grateful we are. And I dream of giving a speech that moves the audience to tears, but I can’t seem to get past my feelings about anatomy lab—most of which do not lend themselves well to a stuffy affair at the Mondavi Center.

I dreaded going to lab more than I dread going to the gym—which is really saying something. I feel ashamed and guilty that anatomy lab often filled me with horror, disgust and fear. These feelings are especially acute because I know that some of my classmates have positive memories about anatomy--feelings of excitement in getting to explore the human body and uncover its inner workings, and I wonder why I don’t feel the same.

During the first weeks of anatomy lab I had nightmares almost every night. Mostly it was the same dream over and over again. I was the cadaver. Cold and naked on the table, masked faces with readied scalpels standing over me. I tried to scream but couldn’t make a sound. Then I was enveloped in darkness as the clam shell table covers were closed and latched. I woke up covered in sweat. Every night, without fail. The dreams got so bad in fact that I started avoiding going to the lab to study altogether, turning instead to my precious books in the comfortable safety of the library.

Naturally, I was terrified the first time I saw my donor’s face- his piercing blue eyes staring into my own. The first time we cut into his flesh I squeezed his hand as Marissa plunged her blade deep into his chest. But of course he didn’t flinch. I guess that’s the thing about our donors—we can’t hurt them. Truly they are our first and most patient teachers in medical school. Available at any hour, willing to be subjected to the utmost probing, how ever did these once living souls chose to make the selfless act of willing their earthly remains to our untrained hands. Perhaps I have such a hard time with lab, because I myself could never fathom giving such a gift.

As much as I hated anatomy lab, I was shocked when it seemed to end rather suddenly. Oddly, I felt the need to go back one more time. Sadistic as it was, I told Aaron and Kim that I would help them clean up and come 9am on the day before the biochem final, I walked into lab to find all of the tables open, with all of the bodies exposed. This could have been the start of one of my nightmares, but it was near the holidays and Kim had Christmas carols playing gently in the background. “Thanks so much for coming,” Aaron says, not looking up from removing a leg from the most muscly cadaver.

Below the tables are body sized cardboard boxes. Its our job to move the bodies off of the table and into the boxes so they can be cremated. I think about running for the door. Looking around the room I have to say, this wasn’t the mitzvah I had in mind.

Kim and I approach the first body- a woman with painted fingernails in a similar shade of pink to my own lacquered fingers. I see the cards and flowers that have been left for her. Someone has taken the time to meticulously piece her back together. Apart from her leg resting a few inches from her pelvis, she looks almost whole. We come to the next table and the next, each with flowers and notes of gratitude. We are careful to lay the bodies gently in the boxes, tucking the flowers and cards in along with them. One of the lab groups visits to say goodbye to their donor in person. I watch as they hold hands and bow their heads in silent farewell.

As Kim and I work I press her for details about what is going to happen to the bodies. She patiently recounts what I already knew. They will be cremated and the ashes scattered in San Francisco Bay. I know what the cremation process looks like. I saw it in a documentary once. I know that the mass of the ashes will be less than the original mass of the body, because the matter has been converted to energy.

I’d like to think some of the energy that was released when they were cremated is in me. In my neurons that fire when I think of the brachial plexus, or the great vessels. Its in you too. When you press your stethoscope to a patient’s chest or to your own, it will be their heart you picture in your mind. When you feel for the liver, it shall be theirs you’re reaching for. And when you fall into bed at the end of an excruciating day, you’ll know exactly which muscles, nerves and sinews ache because you saw them in another.

I named our cadaver Ed. I’m not sure if anyone else in my group called him that, but to me he was Edward, the 6 foot something, skinny as a rake man who never met me, but illuminated the human body for me in ways no other could. When Kim and I finished putting all of the bodies in the boxes, I snuck back to my table. I had a note in my scrubs pocket for Ed and I pressed it into his hands.

I went home this weekend for my mom’s birthday. We took the ferry from Tiburon to San Francisco at sunset. It was beautiful. The sun glinted off the water as it slunk below the horizon. Despite having a hard time in anatomy lab, I feel a certain peace in thinking back on it, and I know I am forever changed—even if I still have the occasional nightmare. I lean over the ferry railing, staring into the depths of the foamy blue-green sea, I think of Ed and think of how his carbon particles have become part of the seaweed and the fishes. There was a Giant’s game in the city that night and as it got dark, we were treated to a glorious fireworks display and I remember what my note to him said.

“Oh gentle Teacher. I bring you flowers, I carry your body to the funeral pyre. May all of the structures in you that I have named and laid bare, flare. May they burst into light.”- C. Montross

Saturday, August 1, 2015

Hart like Mine

This is the story of my beautiful friend Alicia as told in her words. It needs no introduction except to say that whether you've been wearing a white coat for one day or many decades, we all need to be reminded about the kind of physicians we want to become. It is my great privilege to have her story posted on my humble blog. And with that gentle reader, I give you this week's post-- Hart like Mine. 

by Alicia Hart

It's 11pm here in Houston, Texas. As I write this my wonderful husband Rolf, is asleep in the next room. It is in these rare moments, during which I am neither caring for my husband nor sleeping, that I write to remind you how important the career you have committed yourselves to is. It is my hope to also give you insight into the patient and caregiver perspectives-- experiences I never imagined I would have.

I got married to the man of my dreams just 5 short weeks ago. One week before the wedding, my handsome, charming, strong, compassionate, loving husband was diagnosed with Stage 3 mesothelioma, an extremely rare and aggressive form of lung cancer that enveloped almost every structure in his left chest cavity.  It has been 3 long weeks since he underwent an extrapleural pneumonectomy (EPP) in which my hero, Dr. David Sugarbaker-- Yes that really is his name; removed my husband’s left lung, diaphragm, and pericardium, while infusing intraoperative heated chemotherapy in his chest and abdomen for over an hour. To put it mildly, this experience has been utterly horrifying and heart breaking. 

Our tiny, newly-minted family is now face to face with the patient experience those of us in healthcare so often distance ourselves from (and with reason). It has made me question my faith, my love of medicine; it has made us both question nearly everything from our place in this world, to the meaning of it all, to our very existence. In some ways we have grown stronger, but sadly this disease has taken so much from us. Then again, it has not taken everything: my husband is still alive. 

Rolf has been given a chance at survival because one man and his team have dedicated their lives to this orphan disease, a disease in which so few people have it at any given time that few, if any, corporations see the incentive for developing treatments. The TEAM of providers who ended up treating my husband made all the difference. They helped heal us in ways I never thought possible.
However, not all doctors are made equally, and perhaps I am so grateful for our treatment team in part because of the hopeless conversations we had with other providers we went through to find them. 

Prior to meeting with Dr. Sugarbaker’s team, my husband and I consulted with a Kaiser surgeon in Roseville, Dr. Jeffrey (there is no) Moore (I can do for you). He was stoic, cold and the first words he spoke were, “Have any questions?”… Not a, “Hello”… not an, “I’m so sorry you have just gotten this news, but we can help you,” what we got was an impersonal, heartless, “Have any questions?” Yes, here’s one…"why are you a physician?" 

Rolf and I were furious, the physician whom we were meeting for the first time got defensive, offered only palliative measures, and that was it; it was decided that he would never touch my husband. At the time we were in shock, nodding our heads, crying when he spoke of taking a biopsy of the tumors and performing a pleurodesis to help stop the nearly 3 liters of fluid surrounding his lung from re-accumulating. We left that day with a mere fraction of the hope we came in with, a horrible feeling in our hearts, tormenting imagery in our minds of what was to come, and few if any plans for the future.

Once we got away from that place, we discussed our experience, vowing not to return to a man who wouldn’t take the time to see the man behind the disease: my amazing husband Rolf Friedrich Unterleitner. As Rolf grew anxious waiting for a plan, I sent out a call over facebook to my fellow classmates for help in scouring the literature for a glimmer of hope; we got something so much more: Dr. David Sugarbaker. He is a CT surgeon who’s been treating patients with mesothelioma for over 20 years, and to top it off, he’s an author on nearly every research article looking to improve survival rates via innovation in surgical techniques.

On June 12th we were married, sailing off on a cruise to Alaska with our families. It was gorgeous and just what we needed to get our heads in the ring, to muster up the motivation and courage to fight this thing. Although it was a beautiful wedding and breathtaking honeymoon, the disease was always there with us, like a black rain cloud hovering above, threatening to soak us to the core. We returned home to California and in less than 24 hours we were off again headed this time to Houston to see what Dr. Sugarbaker had to offer.

It was amazing what they had planned for us that first day. A breakfast and informational session at the clinic with three other families who also had a loved one diagnosed with mesothelioma. At first, I thought this was some sort of sales pitch and then I knew what it was, the TEAM approach to medicine. In your medical education and career you will hear the word “team” thrown around, yet I’m not sure how many of us will either truly embrace and/or understand it until we experience it for ourselves, first hand; it’s incredibly powerful.  Every member of the team was just as valuable as the next, from the social worker that spoke that morning, to the nutritionist, to the chaplain, to the NP, to the physician, each helped us heal in extraordinary ways. Yet the thing my husband and I remember most vividly from that day is Dr. Sugarbaker saying, “I’m in this for a cure.” It was not a promise for a cure nor a pretentious claim coming from somewhere on high, but an affirmation that we selected the right doctor to help Rolf. We went from Dr. Moore telling us, “Well, the options are all bad” to, “I’m in it for a cure,” complete opposite ends of the spectrum; both doctors, yet only one role model. 

And in this part of our journey I found what I hope for all of us who study medicine--hope that we will invest ourselves so fully in our patients that we too will throw our hats into the ring to look for their cure no matter how much others in our field doubt us, no matter how far off that cure may be. Part of what I believe makes a great physician is someone who has the capacity to see and do what others cannot. Let us act as a team of innovators, dreamers armed with knowledge, as pioneers with the will to do the research that will ultimately save our patient’s lives.

I don't mean to sound grandiose or naive. I know the average life expectancy for stage III mesothelioma is less than a year. Yet, I am confident this will not be my husband as so many have pulled together to do the research to get us to a physician who, through innovation in the field, has had such success that 10+ year meso survivors exist! 

Going through this with my husband has taught me so much about the kind of doctor I hope to become. And you bet I would trade every awe inspiring lesson for this not to have happened to us. I do not wish this upon anyone, but I do hope that the lessons I carry with me from “the other side” can be shared with all of you without you yourselves having to experience this immense pain. I have no doubt some of you have already experienced horrible loss and I am so sorry, my heart goes out to you and your families; still, let these moments guide you over the next four years and for the rest of your career, let them remind you of what it’s like to be a family member of a loved one experiencing illness.

I shall leave you with one last story from our time spent in the hospital…a story that touched our souls:
For days following Rolf’s surgery he was NPO, not allowed anything to eat or drink, and was experiencing extreme dryness so much so that he developed sores in his mouth. Finally I asked for a consult with the physician on call to see what could be done about it. After explaining my concerns, the physician--I never did find out his name, said he was going to place an order for Lifesavers to help alleviate Rolf’s discomfort. I asked the nurse when we would be able to get them and she replied, “He can write the orders, but the hospital doesn’t stock might want to go down and get some at the gift shop.” No problem, off I went. When I got down there, I could not believe what I saw, his doctor in line purchasing Lifesavers for him!  I’ll never forget how my heart melted that his compassion touched our family at a time when we needed it most, how his selflessness reignited my desire to serve others in this way.

It has been through these experiences that I have discovered the kind of doctor I aspire to become: a knowledgeable, caring, team player who is in it for a cure.

Join me.

Alicia Hart is a medical student at UC Davis. She can be reached at