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Chief Residency

It has begun.

On June 30 I officially ended my Internal Medicine Residency. Well, maybe I should say that I completed it.

On July 1 I walked up to my brand new office. As I stood in front of my door, with key in hand, I read the new nameplate on the door. It was awkward.

Residency ended without much fanfare or closure. My program, for whatever reason, does not have a “graduation” ceremony. They did have a “graduation banquet” in May but I was on a pre-planned family vacation during that time. Maybe that’s why I felt like I lacked any real resolution to the residency phase of life.

So far there has been anxiety, confusion, frustration, and fatigue. I’m hopeful that the year will be one of professional and personal growth. I just hope that the growth does not require much pain.

On July 1 I attended the mandatory “new hire” orientation. After completing all required paperwork, I went to HR to pick up my new ID badge. As I already had a picture on file, I just waited in the lobby for them to bring out the new badge. After what seemed like 20 minutes, someone came out to deliver it. Instead of “Resident Physician” under my name, it now said “Attending Physician.”

Looking at my badge, almost 1 month later, it still seems weird to see that.

I don’t know what this year will bring. I’m sure it will be challenging. I’m sure it will push me.

So for those of you who have followed this journey through this blog, I invite you to continue with me.

And for those of you who have just found this blog, well, you’re invited too.

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An “A” for Effort

We’ve all heard of getting an “A” for effort. At least it was an “A,” right?

But how meaningful is that grade if you still fail?

I remember a patient I shall refer to as David.

I didn’t know David very well at all. He was a patient in the Medical Intenstive Care Unit (MICU). He was not on my team. In fact, I didn’t really have a team. I was cross-covering the patients who were already admitted for a strech of 6 nights.

At the start of each shift, the primary team would hand me a list and “sign out” their patients to me. They would tell me about pertinent, active issues. They would also try and anticpate what could go wrong and let me know what to expect. Also, if there were any studies that were pending they would let me know if I had to check on the results.

David was one such patient. What I knew about him could be written down on just a portion of a full letter-sized paper. He had previously been diagnosed with cancer a little over a year ago. He had underwent treatment with surgeries and chemotherapy. During this visit to the hospital he came because of pain. As the ED completed their workup for the cause of the pain, they discovered he had a clot in his leg and multiple clots in his lungs. They also saw a large mass in his abdomen that appeared to be malignant.

In the ICU, the primary team was treating his multiple blood clots with a heparin infusion. Heparin is frequently referred to as a “blood-thinner.” It’s purpose, in this case was to prevent further clots from developing and to prevent the current clot from growing.

When patient’s have blood clots in their lungs (usually called a pulmonary embolism or PE) this is usually the treatment. However, if a patient becomes unstable (blood pressure or oxygen levels drop) there are more drastic treatments that can be attempted. One such treatment is thrombolytics. A thrombolytic is a medication whose purpose is to break down a clot. It is reserved for the unstable patients because they are quite risky. There is a risk for bleeding and one must always consider if a patient has any contraindications for this therapy.

On this particular night, David’s nurse called me. While he had been fine for the last day or so, he was now appearing very uncomfortable. His respiratory rate was increasing. His blood pressure was trending down. His oxygen levels were also trending down.

After spending a few minutes watching him, I made the call to Anesthesiology. I explained the situation and told them that I thought David would need to be intubated as he was in respiratory distress. Within minutes they were at the bedside and preparing to intubate.

Contacting the family was my next order of business. There was a daugther listed as the next of kin in his chart. My first call went to voicemail. I left a brief message asking for her to call me back.

Within a few minutes David’s daugther returned my call. She was understandably concerned. I had to explain what had happened. I then began asking some detailed questions about David’s medical history. I needed to know if he had any contraindications to thrombolytic therapy. The answers I got were reassuring. David was stable, though, after intubation and initiation of one vasopressor. We would wait until she arrived and we had a chance to speak in person before going forward with thrombolytic therapy.

In the meantime I would have to place a central venous line and an arterial line in order to continue administering medications and monitor his hemodynamics. In between these two procedures I found out that his hemoglobin was dropping. I had no obvious source of bleeding. My heart sank as I knew I could no longer use any thrombolytics. There was enough evidence to presume he had a bleed and I had no way to rule it out at that time.

An hour later, Tonya, her mother, and two other siblings arrived. They were ushered into the conference room. I gathered what little notes I had about David, took a breath, and walked into the room. I made sure to hand off my hospital handset to the Charge Nurse so that we wouldn’t be interrupted unless absolutely necessary. She would screen the calls.

The family took in the grave prognosis with great composure. I explained that I could only support him temporarily. I could not treat the clots with thrombolytics. I could no longer treat his clots with heparin either. I could only place a band-aids. But considering the clinical picture, I expressed my doubts that David would survive into the following day.

David’s wife, though, seemed to persist on telling me what happened throughout his battle with cancer. I tried to politely tell her that we needed to address the issues at hand — not his constipation or abdominal pain that he experienced a year ago after the initial diagnosis and treatment. I couldn’t tell if this was her way of coping. As I allowed her to continue re-telling the events of last year, I looked at each of David’s grown children. They knew what was happening. They seemed to just want to let their mother go through this in her own way, though.

By the end of my shift David would eventually need 5 different vasopressors concurrently. He was maxed out on the ventilator. He had received over 3 liters of fluids and 4 units of blood. I knew it was only a matter of time. I had done everything I could. David died before I came in for my next shift 10 hours later.

There are times in the hospital when doing everything you can — when doing your best — is just not enough.

And those times suck.

Period.

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Helpless

I can remember a string of particularly busy nights. I was on the ICU service — sort of.

During our training, we have one month where we are assigned to “MICU NF.” The month has been described to me by previous residents as the worst month of your entire residency. There are two 3rd-year Internal Medicine residents assigned each month. They alternate weeks as the senior resident admitting patients to the medical intensive care unit (MICU). On the week you are not admitting at night, you spend your days in clinic. On the week when you are admitting at night, you spend 5 straight nights working. The last two days of the week are covered by other senior residents on their elective months so that you have a couple days off.

To be honest, the nights are “hit or miss.” After all, you cannot predict what comes through the door of the emergency department or when patients will decompensate on the wards. In addition to fielding calls from the ED for admission, you are responsible for carrying the Rapid Response pager. A rapid response can be called for any patient already admitted to the hospital. A staff member, usually the patient’s nurse, can call a rapid response on the ward when they feel their patient is decompensating and requires rapid intervention and/or transfer to the ICU for higher level of care.

On this particular night I was coming in to my 3rd night in a row. As I arrived I went to speak to the on-call MICU attending to find out our bed and team capacity for the night. She told me I had room for four patients. I nodded and went to the call-room.

Later that night, after I had already admitted one transfer patient I was sitting at my computer when the admission pager went off. It was the ED and they asked if I had a bed available. I answered “yes,” and proceeded to take down the information.

When I arrived in the Emergency Department I found “my” patient. I shall call her Dinah. She was intubated and off sedation. I glanced up at the monitor above her bed; her heart was racing. Her blood pressure was acceptable. I glanced over at the IV pumps, though, and noted that she was on levophed1.

I spoke with her RN to get a bit more detail about what had transpired since Dinah had arrived in the ED. I also spoke with Dinah’s husband (whom I shall refer to as Husband from here on out).

Dinah was young. She was in her late 30s. She and Husband had a couple teenaged children at home. For the last week she had been under the weather. But it was not totally unexpected. Others at home were also sick. They probably all had the same bug going around. But a few days prior she developed a productive cough and shortness of breath. These two symptoms did not improve and finally she agreed to come seek care.

When she arrived, she was hypoxic indicating that she wasn’t getting enough oxygen. She was started on supplemental oxygen and then subsequently was tried on BiPAP. Unable to tolerate that, the physicians in the ED decided to intubate her in order to mechanically ventilate2 her.

By the time I was called and arrived in the ED to evaluate Dinah, she had already coded once. That complicated matters even further. She had not woken up after the cardiac arrest. But it was difficult to tell at that point if this was due to the arrest itself or the medications that had been running to keep her sedated while she was on the mechanical ventilator.

Soon after arrival to the ICU, Dinah would code again. The team worked efficiently performing chest compressions, recording the events, and pushing medications as I called them out. After ten or so minutes we got a pulse back.

I updated the family who was still present at the hospital. The number of people had grown. Watery eyes looked at me for something — anything. They wanted hope. I wished that I could have confidently given that to them. But I couldn’t. By this time there were signs of multiple organ systems failing. She wasn’t producing any urine. She was in shock requiring vasopressors. She was in respiratory failure with a machine breathing for her. She had yet to show any signs of waking up after the cardiac arrest earlier despite being taken off medications that would sedate her.

I knew the prognosis was grim. I tried to explain that to them. I then asked if there had ever been any discussion of end-of-life care. Would she want to be on all of these machines? But it is very rare for a person in their 30s to have serious discussions of this nature. People don’t talk about dying — at least not their own deaths — at this age. They talk about growing old together with someone they love. They talk about watching their children grow up, go off to college, get married, and have children of their own.

Husband confirmed my suspicion. They had never discussed these issues before. For now, he insisted, we would continue doing everything we could — including keeping her a Full Code3. I didn’t argue with the decision. Had Dinah been 95, I may have. But Dinah was in her 30s. She was supposedly healthy just a week ago.

Thinking back to that night I am not sure when I started to sense my own helplessness. I think it hit me after Dinah arrived on the unit from the ED and I started counting up the organ systems that had failed. It definitely hit me after she coded again.

For the rest of the night she continued to decompensate. She was dying in front of me. And all I could do was throw temporizing measures at the situation. Her oxygen saturation kept dropping. The respiratory therapist kept increasing the support provided by the ventilator. Her blood pressure kept sliding down, slowly but surely. I kept ordering additional vasopressors until she was maxed out on 4 different ones. I think the helplessness hit me with each vasopressor I ordered.

Of course, the helplessness hit me every time I turned to the family to offer an update. Every update was negative. I don’t think I delivered an ounce of “good” news that night. I watched as family streamed into the room two-by-two (per ICU policy) with tears streaking down their faces.

Before my shift ended Dinah passed away. She did so with her family present, surrounding her hospital bed.

And I stood by, helpless.

  1. Levophed, or norepinephrine, is an IV medication classed as a “vasopressor.” It helps by raising the blood pressure in a patient with hypotension or low blood pressure. This class of drugs is often referred to as “pressors” for short. []
  2. Mechanical ventilation involves an advanced airway, typically a tube that goes in through the mouth and passed the vocal cords. This tube is attached to a machine — a ventilator — that is able to breathe for a patient by pumping oxygenated air into her lungs. It can also sense when a patient is trying to take a breath and assist. []
  3. When a patient’s code status is “Full Code,” in the event of cardiopulmonary arrest, a Code Blue is called. Chest compressions, shocks (if appropriate for the cardiac rhythm), and medications are administered in the hopes of “bringing the patient back.” []
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The Silence

The following is a post I wrote in medical school that I never published.

*****

“C’mon,” my resident called out to me, “Let’s go do something.”

“Ok,” I replied as I half-jogged to catch up with her.

It was a slow night in Labor & Delivery. I wasn’t doing much. Most of the patients I saw that night during Night Float (shift from 5:30 PM – 7:00 AM) were patients in triage with various complaints. Most were women who had been feeling contractions that day. I think most were sent home that night because they weren’t yet in labor. (Labor is defined as contractions plus cervical change. Since they had contractions without dilation of their cervix, they were not going through active labor.)

The resident and I walked to triage. The nurses had told us that there was a patient in triage who was still in the early part of her 2nd trimester. She came in complaining of decreased fetal movement. The experienced ones on the unit didn’t think much of it. They wondered if she had even felt movement before this time as it was early in the pregnancy. But the patient was here; and so we went to see her.

As we walked into the room the nurse was trying to find fetal heart tones with the handheld Doppler Ultrasound device. (A Doppler Ultrasound is a handheld device that allows one to hear the fetal heartbeats.) She muttered something about the equipment in the room not working, about her doppler’s battery running out. She could not pick up any heart sounds; her probes were met with silence. This should have been my first warning sign. The nurse then left the room to allow us to do our exam.

Our patient was lying in her hospital bed. Her husband stood by her side. Their toddler sat in a chair, amusing himself with a toy. The patient explained to us that she understood it was early to feel movement. But she had started feeling movement a couple weeks ago. However she noticed that it was significantly less a few days ago. That day, though, she had felt none. She wondered if it was just because she wasn’t noticing it. After all, we often advise expectant mothers to sit still in a quiet place when they try to do “kick counts” because it is easy to block the movement out when the baby is still small.

The resident fired up the ultrasound machine and started probing. She was going to try to assess for fetal heart rate since the nurse hadn’t been able to with the Doppler.

“There’s the head,” she said as she pointed it out on the screen. She continued moving the probe around, sliding it over the jelly-covered belly. I thought I recognized the chest wall, but I was so bad at looking at ultrasound images that I didn’t think much of it when the resident kept moving.

“I usually find it really quick. But maybe the baby is turned away,” she told the couple. Again, throughout the ultrasound, only silence.

My resident then turned to me, “Can you call Dr. A on the unit? She might be better at this.”

Dr. A was our senior resident — less than a year away from becoming an attending. It made sense that she would be better at this. But this was also my second warning sign.

I left the room, but instead of getting on the phone, calling the unit secretary, and asking for Dr. A, I ran to the unit myself. I didn’t want to waste time. Besides, since I didn’t know the unit’s extension, I figured I could run to Dr. A faster than I could call.

When I returned with to the room with Dr. A, she politely introduced herself and replaced the resident at the ultrasound machine. She took her turn at the machine. Within a minute, though, she turned to the resident and quietly asked her to page the attending physician on call. And there, accompanying the silence, was warning sign number three.

The resident and I walked out. She paged Dr. B. In the hospital, they don’t like paging the attending unless absolutely necessary — especially when it is at night.

I was surprised at how fast Dr. B came. I remember thinking that the call room must be really close.

Dr. B, the resident, and I walked into the patient room. Dr. B introduced herself as the supervising physician and took over for Dr. A at the ultrasound machine. After a little bit she turned and asked us to turn the lights back on.

“I’m sorry,” she began as she looked at the patient and her husband, “there is no heartbeat.”

—–

I don’t know if I still remember the mother’s face. I think I do. But it isn’t a very clear picture in my head. I didn’t want to stare as the tears started streaking down her face so I looked away. It was tough. Labor and delivery is usually a unit of such joy. The patient’s are generally young and healthy. They leave with brand new bundles of joy.

But that night, instead of joy and new life, I came face to face with silence.

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Stomach Pain: It Continues – Part II

Part I can be found by clicking here: Stomach Pain: It Starts – Part I.

*****

We sat quietly waiting in the waiting room. Again, we found ourselves in an odd position of being on the patient end of things. Allison, my wife, is a registered nurse. At the time she was working as an RN on a cardiac unit and I was at the end of my second year of Internal Medicine residency. Also, before this GI appointment, Allison had made a 2nd visit to the LLUMC ED. On that second visit they had decided to admit her to the Family Medicine service since her primary doctor was from the Family Medicine service. They did what they could but in the end agreed that she would need to be followed by with GI and proceed with the EGD. They did offer her more medications to try and help control the pain.

After finally seeing the gastroenterologist and sharing the events of the last two years, he sat quietly typing on his computer. He explained that he doubted it was an ulcer and that her description sounded more like the pain was biliary1 in origin.

Although he thought an ulcer was less likely to be the cause of the pain, he recommended proceeding with an esophagogastroduodenoscopy (EGD) to rule out peptic ulcer disease. He also ordered a HIDA scan for her to evaluate gallbladder function.

During her visits to the Emergency Department they had done ultrasounds. One of the findings noted on the ultrasound was that there were no visible gallstones in the gallbladder. There was also no signs that a stone was stuck in the common bile duct (CBD) that connects the gallbladder to the small intestine. Her lab results also did not scream out that something was stuck in the duct resulting in an obstruction.

A week or so later we were back in the hospital, this time for the HIDA scan. I don’t remember what service I was on at that time, but I remember being able to accompany Allie to the procedure. I went with her to get checked in. They took her back; but Allison returned shortley to tell me it would take a few hours to finish. Rather than waiting in the waiting room, I went to the cafeteria and got some breakfast. I returned a few hours later to pick Allie up and take her home. She said that during the test she did feel some pain and it was similar (but less intense) to the pain she had been feeling during her episodes.

Is it strange to think that I hoped the test was abnormal — that I had hoped that it would find something wrong? I suspect my wife was also quietly hoping the same thing. Because if we had a diagnosis, we could start looking for a treatment.

*****

A few weeks later she went in for her EGD. She was told that she had to come with a driver, per policy, as she would not be able to drive home after receiving sedation for the procedure. Fortunately I was assigned to a service that was at the main University hospital so I was near already. It was also not a very busy service so I was able to be her designated driver. This was the first time in our relationship that I had to be her designated driver too.

After the procedure was completed (it did not take very long), I was called back from the waiting room to join her. She was coming off the effects of the moderate sedation2. She was quite talkative but I could tell she seemed a bit “off.” As I watched her talking away to her RN, the GI doctor handed me a printed out report that included pictures from the procedure. As I scanned down the report, he told me that the exam was normal. There were no signs of any peptic ulcer disease. In fact, the whole procedure failed to find any abnormalites. Considering the EGD was normal and that the HIDA scan showed some decreased function in the gallbladder3, our GI doctor decided to place an outpatient consult to Surgery. We would follow up with GI in 3 months.

I tried to stay positive. At least we had ruled something out. Allison tried to stay positive as well. As we digested the fact that she had completely normal results we started shifting our thoughts to a biliary cause of the pain. We hoped that the surgeons would take a look at her case and be happy to operate on a young, relatively healthy woman.

*****

Life continued. I finished my second year of Internal Medicine residency. Allison, spending what felt like most of her time on the freeway, began looking for work that was closer to home. She looked at positions in the outpatient setting. She looked at patients in the inpatient setting. She sent out multiple job applications. Replies were slow. It was during this time that we made another trip to the Emergency Department due to another paralyzing episode of abdominal pain.

Again, this pain came out suddenly and again, the pain started in the morning. Allie really did not want to go to the Emergency Department again. She was frustrated with being in the emergency department for pain medications. We already knew that the tests would come back normal. I think she also did not want to be looked at as someone who was seeking pain medications. But I convinced her to go, if only to have the episode broken so that she could gain some relief.

This time, we sait in the waiting room for almost 7 hours. The local county hospital had received some sort of threat, or so the rumors swirled. And all of thier patients were being diverted to the University Medical Center. All the while, she sat there in the waiting room crying until her tears ran dry. At one point a concerned patient who was also waiting her turn came over to pray for her. We eventually got in to be seen. First, though a medical student interviewed her, then the resident, and finally the attending.

They wanted more tests.

Eventually came the talk we knew so well. They had run the tests and everything had come back normal. Since the pain was improved, they wanted to send her home. They were assured that the pain wasn’t due to some emergent situation requiring some intervention or hospitalization.

I finally expressed my own frustration that night. I told them how we were awaiting a surgical consultation as an outpatient. I realized that this was not an emergent surgical case. No surgeon would be rushing her to the operating room. So I asked why they did not at least consult surgery to speed things up? Why not have her seen in the ED so that the surgeon could come by and write in the note to follow up as an outpatient? At the very least, I asked, could the ED just recommend that we follow up with surery soon — like within a week?

The resident said he would see what he could do. Within the hour, though, a surgery intern was at our bedside to evaluate Allison. We went through the entire story again. We talked about how GI felt that the problem was biliary despite normal ultrasound and “normal” HIDA scan. The intern said she would return with her senior.

Within the next hour the surgery senior arrived. We actually knew each other from medical school. He shared that they were not convined that this pain was of biliary origin due to the numerous “normal” tests. However, if they GI felt it was biliary, we ought to follow up with them. We also discussed surgical intervention. I asked if he had any recommendations on which surgical attending to see in clinic. He recommended someone I will refer to as Dr. S, stating that he would be more lenient with his requirements to go to surgery and may be willing to try a surgical intervention to see if it would solve the problem.

We thanked him for his time and recommendation.

Almost 24 hours after we arrived, Allison was discharged home. It was Saturday morning and we were exhuasted.

On Monday, Allie made her an appointment to see Dr. S in surgery clinic. She also made a follow up with her GI doctor.

  1. Biliary pain is pain that originates in the biliary tree/biliary system. The biliary system includes the gallbladder and the bile ducts connecting it to the small intestine. See here for more. []
  2. For the EGD they used moderate sedation. This means that Allison was not completely knocked out like one might be for a surgery in the operating room. She was given enough medications to make her very sleepy. Usually, though, patients are still able to follow simple commands during this type of sedation. This is actually preferred because they need her to swallow the scope. []
  3. While the radiologist had said that her gallbladder function was normal, our GI doctor noted that at 25 years of age, Allie’s gallbladder function shouuld be significantly higher than it was. She was hovering at the very low end of normal. This would be expected for a senior citizen. Instead, she should have been at the higher end of normal. []
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On Teaching

The following is something I wrote in 2009 while still a medical student:

Teaching is a hard thing. By teaching I don’t mean explaining or instructing. Take, for example, teaching basketball to someone. Telling someone the rules of the game is not, to me, teaching them how to play basketball. Explaining what the rules mean and how and when they apply is not teaching either. Teaching involves more. It is showing someone how to dribble the ball, demonstrating the correct form, and then helping the student develop these skills. Teaching is not merely conveying knowledge. It is imparting excellence — or, at the very least, competence in a particular area or field.

Teaching involves lifting a student up with compliments while simultaneously providing criticism that is at the same time constructive, painful, and humbling. Delivering these two — compliment and criticism — can be tricky. How does one find the right balance? It’s unfortunate that there is no formula. Each person is different. The combination of compliment and criticism that motivates and inspires one student could very well devastate and discourage another. Maybe the truly amazing teachers are able to read their students and expertly walk that fine line.

In the absence of truly amazing teachers, or truly amazing teachers with plenty of time to spend with us, a student must resort to other means of attaining competence. One alternative is learning from multiple teachers. Good teachers have different methods, techniques, and personalities. Each one can provide a different, yet helpful angle.

As this academic year inches closer and closer to an end, my mind seems to frequently wander to the future. One of the things I think about is my position as one of the chief residents next year. I hope that I will able to be a good teacher. I may even be willing to settle for an “ok” teacher too.

Maybe I am getting ahead of myself. Maybe I should just concentrate on learing as much as I can as a resident.

Teaching, I feel, is such a great responsibility. Especially when you are training people to take care of patients. The good thing is that I won’t bear this responsibility on my own. I will merely be a cog in a larger wheel; I will only be one part in a larger system. There will be plenty of seasoned attendings who will gladly teach the residents, and I am sure myself as well.

Teaching, I hope, is something that one can learn. And I hope that through the next year I will be able to develop my own teaching style. I’m sure I won’t be able to develop in a year — it’ll take time. But I do hope I am able to make a significant evolutionary leap in my development as an educator and teacher.

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Three Wishes (published on The Differential)

The following is a post I wrote during medical school.

******

Questions are powerful. They stimulate thought. They encourage discussion. And sometimes, they do so much more.

During my time on the Adolescent Psychiatry unit, one of my favorite questions to ask my patients was “if you had 3 wishes, what would you wish for?” or some variation thereof.

It’s not an exact science. But I felt like the question gave me a little bit of an insight into their minds. I had frequently heard the child psychiatrists ask this question of the tiny tots. I didn’t hear them ask this of the adolescents. I’m not sure why.

I remember one patient telling me that one of his 3 wishes included destroying the place we were in. As far as I could tell, I took this answer in stride. I asked him why and he admitted that he didn’t feel like the facility was very helpful. He just wanted to get out of there and go home. A couple days later, when I asked him again, I was glad to hear him say that he had changed his mind. He realized that value of the psychiatric unit and didn’t want it torn down and destroyed anymore.

Another patient told me of her wish to buy her mother a big house. It’s probably safe to assume how and why a wish like this would begin to take hold in the mind of a young person. Other teens also voiced their own desires for material items.

Regardless of the wish, big or small, I felt like it was a backdoor into understanding a little bit more about my patient. And in psychiatry, you take whatever you can get — at least that’s how I felt about it.

What happened to me, though, was that I began to look introspectively. I would like to think this sort of thing happens more often than not to students rotating through psychiatry. I began to think about what I would wish for if I were given 3 wishes. In fact, I was pretty much forced to think about it for myself when one of the patients turned the question back on me after he had answered the question himself.

If I remember correctly, I think I answered that I wished 1) to be done with my schooling and 2) for a lot of money. I told him I’d save the 3rd for later. He thought it was clever. But in looking at my first two wishes, I realize that I’m not that much different than the patients I was seeing. I seem to want physical and financial freedom just as much as they do. I just word it a little bit differently.

And that’s how one little question helped me feel closer to the patients I was seeing each day.