intern year: a nocturnal perspective

Wow it's been a long time since my post about coffee in Ethiopia. I have good excuses about the past three months but none for the end of medical school except to say it was a time of not knowing... very little to write about except fear of the unknown, worries about matching, then moving to a brand new place away from family and apprehension about what intern year would really be like. Natural fears, and probably well warranted... but also not productive fears in terms of making the transition any easier.

Thank goodness for the amazing support of my family and friends! So, a bulleted summary of the time since I last wrote, by month:

• I travelled all around Eastern Europe in February (you can see Valary's blog about those adventures). My favorite country was Montenegro, although I also really liked Bosnia as well as Istanbul and Cappadoccia in Turkey.

Kotor, Montenegro

• I matched at a great combined community/academic program on the East coast in March.
• In April I finished up my academic requirements for med school with a Capstone course (or "intern year crash course") and a business of medicine elective that was super interesting, as well as found a place to live in my new area for the next 4 years.
• In May I graduated from medical school and received that "MD" which felt both somehow well deserved and strangely foreign, with a vague combination of pride in the privileges that suffix affords me and fear about the extreme obligation/responsibility it demands.

From my white coat ceremony at the beginning of med school

Graduation... oh how things change in four years!

• Gracie the cat and I moved to a brand new place in June, where I knew no one except a co-intern from medical school who also matched at the same program. I also bought a new car, a blue Mazda 3 which I love - it makes me happy driving to and from work each day!

New car! Having a salary is awesome :)

• In July I began with working the first 33 calendar days of my intern year. I worked Monday through Thursdays during the day, then Friday and Saturday nights. In my "spare time" I fought with Ikea on the phone in multiple attempts to get my furniture delivered. By August my apartment was finally set up and I got a weekend off for the first time! It was glorious. 

Gracie thinks the new place is okay, as long as she gets food

I'm now 3 weeks in to my third rotation of intern year, "night float." What night float means is that you take care of laboring mothers, respond to any emergencies, especially stat Cesarean sections, as well as cover the pager for all post-partum (after delivery) and gynecologic surgery service patients. It has been both truly rewarding and one of the hardest experiences of my life. It's strange how those two things come together so often in medicine.

I've been able to deliver so many babies, both to happy and distraught new parents. I had to "ride the bed" when one of my patients had a cord prolapse, meaning that the umbilical cord falls below the head and the baby could die if you don't lift the head off the cord and do an emergency Cesarean section to deliver the baby. The physician (me!) doing the vaginal exam at the time has to stay on the bed lifting the head with a hand during the surgery until the baby is delivered. This week I did my first Cesarean section as "surgeon," meaning that I was the one performing the skin incision, the hysterotomy (incision into the uterus), and delivering the baby through the incision in the uterus. Getting to do that for the first time was amazing!

The hours are brutal. I work from 6pm to anywhere from 8am to 10am some days. Sleeping during the day is difficult, even with black out curtains and a face mask. Sometimes I have so many patients, so many tasks, and my pager just won't stop going off... About half the time I don't have time to eat, and when I do it is often around 3 or 4am. I was having a particularly hard week this week because it was just super busy and there were some sad patient outcomes, and then I found out I had misunderstood the vacation/call schedule over Christmas and I just about fell apart. Thank goodness for my mom, letting me call her on the drive to and from work and just cry because I'm tired and sad and don't know how it's possible to work this hard sometimes.

Then at night I had to go back in even though I barely slept and I was really upset because I miss my family so much. The night started off with a scheduled Cesarean section that had been delayed because the day team was dealing with other emergencies. It was a really beautiful C section (if I do say so myself) and I was able to deliver the head for the second time in a row (which is often the thing interns are unable to accomplish) and I was starting to feel a lot better, when the attending and the pediatrician realize that the baby has features consistent with a disorder associated with learning problems... which was completely unexpected for the family. (I'm trying to be super vague to protect patient privacy, which is also why I'm vague about the program where I'm at on this blog.) So as this is explained to the patient, she begins crying. I have to sew up her fascia while her abdomen is actively heaving with her sobs. I cannot imagine the sorrow of finding out that you and your new, beautiful baby girl are going to be living a much harder life than you imagined. It was just so sad. The medical student afterward said "I don't know how you and [the chief resident] did that... you kept operating in such a sad situation." But that's just what we had to do. You stand there and you operate and whisper "that sucks so much" to each other but you keep taking care of that mom no matter how terrible the situation is. That poor mom and family really put my situation in perspective at least. My life may be really hard sometimes but at least I had the privilege of taking care of that woman in that moment, of trying to make her incision look the best that I could even when that was the least of her worries. I may not get the vacation I want or as much time with my family as I want, but in the end the reason I'm even here, working as a doctor, is because my life has been extremely blessed.

Being an intern is really hard. Harder than I could have imagined even after watching others go through it as a medical student. You are expected to do a ton a bitch work even though of all the people available to do that work, you are currently the slowest and most clumsy about it (because the other people are dealing with much more complex situations). You want to be really good at everything you do but you just aren't. You literally can't be. There is no amount of trying hard that will magically make you into a good doctor, at least on a day to day level. And patients are most likely hurt from it sometimes... usually in minimal ways if you have enough supervision, or in ways that are debatably your fault, but it is very easy to internalize every bad patient outcome, no matter how minor, as somehow your fault. It is so difficult to figure out how to have confidence when the majority of the time people only find it worthwhile to give you feedback when you did something wrong (which is constantly) or missed something you should have done, such as write a note or put in a certain order. If you don't have confidence and try to be proactive and manage patients somewhat independently, then you will earn a reputation of being slow and you will struggle more later on in residency when this is expected that you act independently. But if you make decisions about patients without confirming them with a superior first, then you are more likely to make the wrong decision/will end up having to stand up for yourself in terms of why you made that decision. This leads to more negative feedback than otherwise, and you can earn a reputation of being over-confident, or worse, you can actually harm patients by making unwise decisions. The trick is finding a balance between actively managing patients yourself and knowing when to ask for help.

In summary, it is very difficult to have self esteem as an intern. Add in the emotional burdens of sleep deprivation, trying to make new friends/being alone in a new place, and feeling compassion for your patients who are dealing with tragedies and you maybe start to get a picture of what intern year is like. Oh, and then you have a medical student following you around watching your every move who you are expected to teach and have patience with at every moment, even when you yourself are learning and struggling.

I hope this wasn't too negative of a post. I just really needed to write out what I've been experiencing. I waited until after I'd slept about 17 hours over the past 24 so that I would hopefully sound less terribly emotional and dramatic. I will try my best to blog more often during intern year, but based on my blogging history during medical school I'm sure that promise falls flat...

In the end, I think intern year is just something to be survived, with the hope that I will come out of it with a thicker skin yet more compassionate heart and as a better, more knowledgeable and skilled physician. And hopefully make some friends at some point... oh, the little things :)

coffee

For a coffee lover like me, Ethiopia is a dream come true. It’s no wonder, though – legend has it that the coffee bean was discovered by Kaldi, a goat herder in Ethiopia. Kaldi noticed that when his goats ate this certain berry, they acted really wired. So he tried it himself and felt the same way. He shared his discovery with a local monk who brewed the beans in hot water to help him stay awake through prayers, and coffee as we know it was born! Frankly, it doesn’t matter to me whether or not this legend is true, because Ethiopian coffee is the best damn coffee I have ever tasted. 

All coffee is served in small, concentrated espresso glasses. Besides plain coffee, the main other drinks are tea and macchiatos (coffee served over milk). I have also seen an espresso shot served with tea instead of milk (which I haven’t tried yet because I’m not sure I would like it). All of these drinks are served with a ton of sugar, which is placed in the bottom of the glass before pouring the coffee. You are also often offered extra sugar to add if you like. This is the only sweet I have had in Ethiopia so far, so even though I prefer my coffee black, I’m getting more used to it being served with sugar.  I also still haven’t figured out how to say “no sugar!” yet so there’s that…

Ethiopia is also unique in that they are the only culture (that I know of) that has a traditional coffee ceremony. I have heard of traditional tea ceremonies is various cultures, but never a traditional coffee ceremony. So far, I have only experienced one traditional coffee ceremony, which was randomly served when I was “on call” with Dr. Ismael, by a couple nurses and “porters” (which we call transport staff). The ceremony starts with an offering of popcorn, then coffee (with sugar) is served in at least three successive rounds. From what I understand, it takes a long time to learn how to prepare the coffee properly. In the lower right side of the picture, you can see the coffee pot on top of a jebena (a small charcoal oven). Elsa is fanning the oven to heat the charcoal. The coffee grounds are in the bottom of the pot and then water is added and boiled in this fashion. When the water is the right temperature (I think judging this is one of the hardest parts, although Elsa made it look easy), the coffee pot is removed and tilted, allowing it to cool for a certain amount of time. Some of the smaller pieces of charcoal are placed in a small stand (near the popcorn platter in the picture) and sprinkled with incense. The coffee is then poured over sugar and served all around. There are blessings associated with each round of coffee. 

The main point of the coffee ceremony, as well as just asking others for coffee (or tea), is community. The people here never seem to rush. I like the cultural tradition of taking time to talk and socialize – making it a priority. Coffee and talking to people – what a wonderful fusion of two things I love!

transportation

Although this isn’t something the first thing that struck me when I first left the airport, I think the first thing to say is that there are no addresses in Mekelle. It is a relatively large city, the second largest city in Ethiopia after the capitol, Addis Ababa, and home to around 200,000 people. There are paved streets (which were apparently installed in the last 2 years by the Chinese government), but there are no street names and thus no way of directing people to a particular location. For example, we were near the downtown area with some OB/GYN residents getting coffee after lunch yesterday, and we walked by this restaurant called “Pizza Jerry.” The residents pointed it out and said “we have been wanting to go back there but we couldn’t find it!” It is hard for me to imagine directions without the premise of street names, but it seems like everyone gets around just fine.

The next thing I should explain is our main transportation, the bajaj. A bajaj is similar to the tuktuks found in Asia and India, I am told, but it is essentially the motor and wheels of a moped with a metal car built around the structure. Inside, the driver sits in the front and steers like you would with a motorcycle, and the passengers sit in the back row. You can fit 3 people in the back, maximum, but it is a tight fit! The bajajs basically function as an American taxi does, except there are no meters – you must ask for the price to your destination, negotiate, and determine the price before the driver takes you there. We are obviously foreign so we are often charged more, but we still pay somewhere between 25-35 birr for three of us to ride downtown, which is about $1.50. 

There is another form of public transportation which are called taxis here. It is a larger van that has 4 rows of seats. They pile about 13-15 people in the van and drop you off at predetermined destinations. It costs 1.5 birr per person, so 7 cents. We’ve only taken a taxi once, and it was an interesting experience because we were told to ask for “ketema” to get to downtown, but we ended up in a place that was more like the local market, with rows of shops selling spices and flour and necessities – we looked very out of place (although that’s really nothing new I guess). Also, we had variable opinions of the taxi depending on who we sat next to…

Wealthier people here own cars like you would see in Europe. One resident, Dr. Ismael, told me he is preparing to get his driver’s license in anticipation of being able to afford a car as an attending. The most desirable cars, according to him, are Toyotas. In order to obtain a license, you have to attend a month long course and then take a written and practical exam. There are also 5 levels of driver’s licenses depending on what type of vehicle you would like to drive. A “landrover,” which is basically defined as a truck or a Bronco type vehicle, is level 3 and requires a higher certification, level 3. I think tour buses, etc are part of levels 4-5. Ismael wants to get a level 1-3 license so that he can drive between cities. There are sedans here, but those are really only appropriate for driving within town, and would not be adequate for driving in between cities. Also, you can’t buy a personal car in blue because that is the color of the bajajs and taxis!! 

We walk back and forth from the hospital, but otherwise we take bajajs everywhere. We are weak (I’m blaming it all on the fact I’m still getting used to the altitude!) and also directionally challenged foreigners!

Oh and I completely forgot to mention that there are also many horse-drawn carts and goats being herded through the streets. Oh, and random donkeys wandering around!

hike up a hill in photos

A Ethiopian geologist, Philmon, who we met through a professor, offered to take us on a hike up a hill.

It was harder than we thought... again, blaming the altitude.

The breathtaking view of Mekelle. They light a huge bonfire from this spot on the holiday "Meskel." You can see the fire from the city, as well as people walking down the hill with torches.

We found goats!

I almost touched the sun!

No words.

We walked back down as we watched the most beautiful sunset I have ever seen.

selam!

As an addition to the travel blog linked with my previous post, I’ve decided to post my observations about Ethiopian culture and medical practice. We have only been here three days and already I have observed and experienced so much that I want to share! From transportation and introductions to surgery, food, and the very concept of time, I have learned so much about Ethiopian culture. My goal is to post short blurbs about individual topics. 

I am going to write these posts offline and then upload them at times when my iPad will connect with the internet, which is unfortunately only occasionally… but I at least have a SIM card! It was a very lucky find in Addis Ababa because it allows me to communicate with people here and connect with the internet. I wish I were dextrous enough to compose an entire blog post on my phone, but a mini keyboard is so much easier. So I hope to post frequently, but this is my forewarning that it may not happen or I may potentially post multiple sections at once. 

I was told before I left that the pace of life was just different here. I thought I understood what that meant, but I think you can’t really understand until you experience it. I am definitely learning what patience truly is, and what life is like when you have very few distractions (although I have actually felt very busy these past few days). I feel so blessed to have the opportunity to be here for a month in a town that is not used to tourists. Walking to and from the hospital every day I am greeted by children who wave and giggle whenever you wave back like it is the funniest thing in the world. They also love giving high fives. I think I might show them how to fist pump next time! I am also overwhelmed by the generosity of the Ethiopian people I have met. Whenever I eat with an Ethiopian person, they refuse to let me pay for anything! I have also met many random people who, although we literally only have the word “selam” (hello) in common, laugh and smile easily. 

I know I will learn so much here, and I just hope I can give a little back!

interviews, rank lists, and ethiopia... almost

So I return to the blogging world after a long hiatus to explain what I was doing during November and December and to introduce my next big adventure!

Mostly, I haven’t blogged in a few months because I was busy flying all over the country to interview at a bunch of different OB/GYN programs. The way doctors get their first jobs (called residency training programs) is through a process called the “Match.” The basic gist is medical students apply to a bunch of programs in their chosen specialty, receive invitations to interview, and then are expected to pay to fly and stay in hotel rooms for at least 10 programs in order to have the best probability of matching. The applicants and residency programs then create "rank lists" of each other which are put into an algorithm and then you are magically matched! It is nerve racking to fly all over and navigate new places, but I also loved staying with friends I hadn't seen in a while and getting to see cities in the US that I'd never been to before. It's funny that the most anxiety-provoking aspect of interview season was not the actual interviews - it was making sure I got to the random meeting rooms in hospitals I'd never been to before, parking in the correct garage, etc, and making sure that I was always 15 minutes early!

I am excited about the next four years and I can't wait to find out where I will be spending them on March 20th! I definitely have some favorite programs but those will remain secret. :)

And now for the pressing news that is even more exciting than decisions about my future - I'm going to Ethiopia! I will be doing a rotation in obstetrics and obstetrical fistula repair at Mekelle University in northern Ethiopia. There are two hospitals in Mekelle, Ayder Hospital and Mekelle University Hospital, and I will also be spending time at the Mekelle University Fistula Clinic, which is associated with the famous Hamlin Fistula Hospital (http://hamlinfistula.org/) in Addis Ababa (the capitol city of Ethiopia). I am so excited for this experience - I know I can't fully anticipate its significance in my life, but I know I will learn so much and be stretched in so many ways. Then, after a month in Ethiopia, my friend and I will be traveling around southeastern Europe for a few weeks!

This adventure has turned out to be overwhelming in so many ways: first with doing the last minute prep like applying for a visa and getting my brother to give me a yellow fever vaccine in between interviews, then with attempting to pack for hospital dress clothes in warm Ethiopia and warm layers for winter in Romania all in a tiny carry-on size backpack. But little could I have imagined how a relatively small snow storm in Chicago could lead to a whirlwind of standing in customer service lines in the middle of the night (I may or may not have burst into tears in front of a United customer service rep at 3am today), countless phone calls, frantic flight searches on phones, and sleeping in an airport. You can read more about that adventure on the blog I'm sharing with Valary at  http://www.travelpod.com/travel-blog-entries/valaryr/3/1420828752/tpod.html. 

We are currently in a hotel in Toronto (hey! we made it out of the country!) and hopefully leaving on a direct flight for Addis Ababa in the monring. I am planning on updating this blog occasionally but will mainly be focusing on that travel blog during these two months. 

four things about fourth year

After a few requests, I return to blogging again with apologies for my recent absence! I really wanted to write a recap of third year - this transformational year in the life of a doctor - but I kept putting it off while studying for Step 2 and thus missed my window... but now I bring to you my thoughts about fourth year of medical school after approximately 2.5 "sub-internships."

1. Fourth year is great! As I've been told all along, fourth year is the light at the end of med school tunnel vision.

One thing that makes fourth year great is the vacation time. I actually took my first month off to take the USMLE Step 2, which is the second round of sitting in front of a computer for 8 hours straight. This time, I did not even come close to having a panic attack (which is probably my biggest accomplishment so far this year) and happily, I did way better this time around. I think that is a combination of the test being more focused on clinical knowledge than basic science, which is much easier for me to study, and simply having a calmer attitude about the whole thing. Despite the fact that my Step 2 score actually matters as much if not more than my Step 1 score, there was so much pressure surrounding Step 1 that I think my score primarily reflected that stress. Anyway, moving on - vacation! After taking Step 2, I had the amazing opportunity to go to London, Cinque Terre (in Italy), Nice and Paris with my family. When lying on the beach in Nice speaking French with my former host mom, I truly wondered why in the world I had chosen to go to medical school! But in the end, it was a great time to spend with my family and a refreshing reminder that the world is much bigger than the 10 minute walk between my apartment and the hospital! I am going to have a lot more time off this year to spend with my family and friends, and I will also be going to Ethiopia and traveling around Eastern Europe in January and February! This year is going to be great.

Another - much more medically relevant - aspect of fourth year that is awesome is my role in the hospital. I have truly loved my sub-internships (or "sub-Is" as we call them) this year. A sub-I is a month long rotation in the specialty you are going into where you are supposed to act as the intern, aka the first year resident. They serve two main purposes - to prepare you for intern year and to impress the people in your specialty in order to get letters of recommendation. I have loved my sub-Is because I'm finally getting to do what I love - OB/GYN - and I'm actually decently good at it. Gone are the days of feeling completely lost and worrying more about where the stapler is than how your patient is doing. Now I can actually give confident advice to patients about their problems and even give preliminary diagnoses without running it by the attending first. I'm trusted to do more procedures and have more responsibility. I also have more time to connect with patients. Although there is still so much more for me to learn and so many skills for me to perfect, I feel like I actually know how to be someone's doctor. :) It's an amazing feeling. It confirms my hope that I will truly love my job and look forward to going in to work every day for the rest of my life.

2. Fourth year can be kind of frustrating. It is mainly the sort of legal/logistical aspect of it, but essentially, I am no different than I will be at the time (almost exactly 8 months from now) when I will graduate and have an MD behind my name. Unfortunately, I will not be any smarter or much more knowledgeable than I am now. Especially during my inpatient rotation on Labor and Delivery, it was frustrating how I couldn't help more simply because I'm not legally allowed - for instance, I can't sign prescriptions, put in official orders, or write certain notes. In some ways, I'm happy I don't have those responsibilities. I'm glad I did have this time to learn more because that will help me be a better intern eventually. And it's nice to avoid any flack when something goes wrong... :) But it also kind of feels like I can't really learn until I'm fully responsible for something. Which leads me into my next point...

3. Fourth year makes me afraid for intern year.

I think I've gotten a pretty good picture of what it will be like to be an intern, both from doing my labor sub-I and from hanging out with the interns, and it scares the heck out of me. Intern year is this perfect storm of an enormous increase in responsibility, consistent sleep depravation for month after month, and having to adjust to a new city and make new friends. All while working 80+ hours/week. And wanting to be perfect at everything I do right away. And at work I will suddenly be responsible for everything that I was just whining I can't do now - without any more know-how than I currently have. It's truly birth by fire. In many ways I think intern year will be amazing. I'll go from having delivered 8 babies to delivering hundreds. I will finally have the privilege of being the primary surgeon on a case. I will learn an amazing amount about patient management. But these past few months are the first time I really contemplated what interns lives are like and it is truly a fearsome thought.

4. Fourth year is full of fear of the unknown. In addition to fear of the known (I know I will be doing intern year somewhere next year and it will be difficult) fourth year is also a year of unknowns and possibilities.

Tomorrow is the first day I can turn in my residency application. While I am looking forward to flying all over the country and experiencing what different programs are like, this senior year is just like the other two in that I have no idea where this year will take me. Either it hasn't really hit me yet or I have been talking about the Match for so long that the idea doesn't seem crazy to me anymore, but on May 20th I will open a letter in front of an auditorium full of my classmates and find out where I will spend the next four years of my life. At this point, I feel very peaceful about all this and believe that I will end up where God wants me. I think I will be happy with whatever program I match at. I have a feeling, though, that the anxiety and fear will increase as I go along this process, so that's why I included this last point. Also because I like the symmetry of having four points for fourth year.

Sorry again for my relative absence (especially following such a morbid post last time) but hopefully I will be able to keep up a lot better now!