Surviving, achieving and living

Well. It's been a while since my last post - shocking! (not)

So what have I survived since the last post? I officially finished all of my required clinical rotations (in med speak - I'm done with third year!). It's an odd time at Penn Med because this is the second semester of my third year, yet my "courses" now are equivalent to what 4th years take - the first 2 years are compressed to a year and a half = the clinical years get an extra 6 months.

I did a month of Radiation oncology (omg lazors), and a month of Ophthalmology (eye balls are awesome - seriously).

Took 2 months off to study for and take the USMLE (US Medical Licensing Exam) Step 1. The old saying is - you take 2 months of step 1, 2 weeks for step 2 and a #2 pencil for step 3. That saying is a slight exaggeration, but that's how it tends to go: the later tests are far more clinically focused - so you've probably seen it / taken care of a patient who had it.

Then came my sub I in Emergency Medicine. Sub I = Sub Internship. The first year of any residency is called / considered your intern year. A subi is a month where you show you're capable of filling the shoes of an intern when it comes to taking care of patients.

What have I achieved since the last post? I did well on Step 1 and I've decided to pursue Emergency medicine. A pretty big decision! Then again, if I've learned anything from my life - it's that I should be prepared to be surprised. I usually have a plan and a goal I'm working towards, but I almost always end up doing something radically different. So we'll see where this road leads.

And now? Now I'm living. I am still taking electives, but it isn't a crazy marathon sprint (yes, that's what third year is). I get to stop and smell the roses (less metaphorically put: visit friends outside of medical school, say hi to my parents in person for a change). It's frightening to realize that I'll be an MD in just under a year. It's also a scary personal realization that most of what I'll learn in medical school (like 90%) I've already learned. When I look back, there's no doubt that I've learned an immense amount of information. The reason I'm scared is because my 3 years of medical school have taught me how much more there is to learn. And there's a ton of it yet to learn...

Looking back at my third year, I started to carefully think about what the three words: surviving, achieving and living mean. Obviously they mean different things to different people. Asking a kid who goes to Princeton what his/her definition of surviving is will get you a different answer than someone from the war-torn Congo. Putting all of that aside, and throwing in my own personal philosophy into the mix, I think these are 3 completely different mind sets. But they get mixed up quite often - especially in the Asian / Jewish / immigrant culture.

I can't speak to the Jewish culture but I know from an Asian and immigrant background that survival was our foundation. Our parents (or our parents' parents) had to work their butts off just to get by. Some of them got lucky and ended up with the ability to give you way more opportunity than they (or anyone else) had.

And don't kid yourself. The world isn't fair. They got lucky.

There is something to be said for making your own luck. There's a saying that goes: "I don't know what can guarantee you success, but I know what can guarantee failure - and that's not trying". Ok, even that may not be true because some people are just so damn lucky that they don't fail despite not trying. But let's leave those people out for a minute.

Putting all of that together - our parents/family push us to try very hard. I am lucky enough to not be in the "survival" situation they were in. I don't have to worry about making enough money to put food on a plate. Or worry that we won't have electricity tomorrow. With the way medical costs are going, I may have to worry if I can pay for my medical care - but that's a digression for another day.

Our families take what they know (survival) and channel it into something that is more situation appropriate: achievement. If you aren't achieving, you've failed. And in the survival world, failure is not an option. Thus the push to achieve. All. The. Time. It's a pain in the butt, but it works: Asians and immigrants are increasing their presence in top schools.

But here's the problem with all of that: what about living? Many Asians and immigrants will tell you all they've seen their family do is work hard. They aren't sure if they've ever lived. Now, let's not start arguing about what it is to "live" - there are more opinions on that than every discussion above that I've shelved combined.

I think living is the opposite of achieving. Ever heard of delayed gratification? In the classic experiments, you'd get the rewards, even delayed, within a reasonable timeframe. Now - we are expected to delay gratification for years, or maybe even a decade (*cough* medical training *cough*). Where does it end? When do you get to live?

I think what people who are in my situation forget (and I'm in my situation because of dumb luck - more on that in a bit) is why we work so hard. Why our families worked so hard / push us so hard. It's so we can have what they didn't. So we can have a better life. Living. Sadly, I think people often miss the forest for the trees. Achievements are easy-to-measure milestones. We are quick to count off the number of trophies in a case or the number of extra letters after a person's name. We are quick to see the size of a house and the number of cars and do an approximate net worth calculation. What we aren't as quick to see is how well they've lived, what they've sacrificed to get here, and are they happy. These are very, very difficult things because they are not quantitative like the things I mentioned before.

So, what's my point? Don't lose the forest. I'm lucky enough (like many of my peers) to have the opportunity to live your life while trying to achieve - why? Because this isn't about survival for us. Not like it was for our immigrant/Asian parents. It isn't an OR condition - you CAN have both. It's about maintaining balance. Or so I tell myself.

Now, from this spawn 2 arguments:

1. Can you really achieve to your fullest potential if you are "wasting" some of your time / energy / whatever on something else (like this "living" I speak of)? If you take it as a zero-sum game, then probably not. You can't possibly give something 100% (or 110% if you are a "good Asian") if you're doing stuff like stopping and smelling the roses. If you take it from a perspective of self-actualization, then... maybe: the fact that you are living / doing things that directly make you happy can make you better/more efficient = your output per time unit invested improves.

2. What the hell leads to achieving anyway?

I'll probably make a blog post about both 1. and 2. at some point. But I will put in a small blurb about #2 - mainly because I said I would earlier.

I agree with Ben Bernanke's talk: for those of us lucky enough to be here and to have achieved this much - it's exactly that. Luck. I could've just as easily been born into a family that wouldn't have ever left the slums of India. Would I still have found my way to Cornell, Columbia and then University of Pennsylvania? Probably not. Is that to say my hard work didn't play any role in the outcome? No, that's silly too. But, more often than not, I tend to think that luck and just plain showing up are what lead to outcomes rather than your hard work (and keep in mind, any innate aptitudes you have are also innate to you because of luck). Even if hard work contributes only 5% to the overall scheme - I'm still going to work hard.

Why? Because that's the only thing I have control over. And I'm a control freak. Well, for the stuff I can control anyway. For the rest of it - meh. At least I know I tried!

- K Dawg out.

Death and all of his friends

Hmm. I just realized that quite a few of my posts are related to death (or dying). I don't mean to be doom-and-gloomy. Seriously I don't. I hope when people read through my posts they realize I'm trying to encourage people to live their lives to the fullest, or help someone else do so. Why? Because (as I mentioned in an older post) - only one thing is truly guaranteed in life: death. So if you've got a limited amount of time - do something worth talking about. If not, at least do something fun. So on your death bed you can say "damn, what a ride". So that life was worth it in the face of all the suffering, obstacles, and annoying people you had to deal with.

Today's post is based off a video posted by the class of 2015 at Penn med. It'll likely bring tears to your eyes:

My Last Days: Meet Christopher Aiff

This is a great, well made video, but what I wanted to highlight were the Christopher Aliff's words at the end:

"When we devote our energy and time to trivial matters and choose to stress over things that are ultimately insignificant, from that point we perpetuate our own sadness and we lose sight of the things that really make us happy. And rationalize our way out of doing really amazing things."

I don't presume to know anything about Christopher, but it seems the general population doesn't seem to think about things like this till the end of their life. As the (14th) Dali Lama once said (paraphrased):
"Man [...] sacrifices his health in order to make money. Then he sacrifices money to recuperate his health. And then he is so anxious about the future that he does not enjoy the present [...] he lives as if he is never going to die, and then dies having never really lived"

It saddens me greatly, but this is very true.

So what's my take home point? Besides being doom-and-gloomy?

"Dying doesn’t need to be a bad thing – it is in fact a necessary thing. I want to be remembered as someone who did their best." - Christopher Aliff.

I intend to do my best, and be able to say "Damn. What a ride" when it's my time. But, for now, I'll be nursing my R knee's patellofemoral pain syndrome (the most commonly diagnosed knee pain! And you thought I was going to do a post without any medical context whatsoever..) while practicing my dance routine(s). 

All in the spirit of procrastinating homework assignments for school.

The calm in the storm

So blogger was kinda forcing me to update my blog's looks (apparently the template I was using isn't really supported anymore). So, after long deliberation (i.e. procrastinating studying), I decided to go with this.

Hope you like it! Overall, minimal change from the previous layout - what took me the longest was figuring out the background image. Lots to choose from, but I liked this the best.  Now, most people will jump and say - "obviously you picked this - you're Indian!" Yea well, ok that might have played a part in it. But more so, I like the image for what it represents in my mind: hope. The light of hope can be very small, like the lamp in the background, but it provides a gentle warming glow. This warm glow is just that - a warm glow - if you see with just your eyes. But if you open up to it, open your soul to it if you will, there is so much more you can see. To me, lamps and candles have a glow that brings a sense of calm. The glow encourages me to persevere. To not look for a calm in the storm, but to be the calm in the storm of life.

I find it interesting that Doctors can be the storm and the calm in the storm for patients. I can't imagine a storm worse than walking into a 22 year old patient's room, telling her she has lupus, and that she has severe consequences from it too like alveolar hemorrhage. This can potentially be a very dangerous complication - fatal even. And then you have a choice. Do you leave them in the storm, or do you help guide them through the storm? It frustrates me that so many doctors are not trained to do this. And trained they should be for 2 reasons:

1. The more obvious reason: it's part of our job. The human factor of medicine is what brought me here, and I'll be damned if I didn't learn this very important aspect of it. Gladly, Penn has an extensive Doctoring curriculum that does just that. And, for the most part, my attendings and residents are great about being the calm in the storm for our patients.

2. You aren't born with these skills. First instincts differ, but in general reacting on instinct doesn't help the patient. The worst first instinct is that doctors feel like a failure and very quickly try to draw out a plan for what to do next. Well and good, but that shouldn't be the first step. Or they try to grasp for false hopes. Or just don't know how to handle it and turn it over to people who they think will be more helpful (of all "inappropriate" reactions I've seen, this is arguably the lesser of the evils).

Interestingly, this was not going to be the point of this post. A friend of mine (let's call her Nandi):

was surprised I was "frustrated on multiple fronts" - she asked "aren't you doing great in everything?"

My response was along the lines of: "hah, no, the one thing I learned from working in pharma is to fake it. And I fake it damn well".

The point I was trying to make was - life's a storm. Everyone's life. It's not always easy to see because you aren't in their shoes. The question becomes, what do you do about it. For me, I can't possibly try to optimize everything and have the best outcomes on every front - I know and accept that. Doesn't keep me from trying though (which I'm sure is a catalyst for my frustration). So what's my solution to life whenever it feels like things are spinning out of control and I can't possibly keep it together? To stop myself from being a failure?

"When you're going through hell, keep going" eh?

And that is why I started off this post by talking about:

Hold tightly to the things that calm you - your friends, your pillow, your family. Because only you can be the calm in your storm.

In the end

As medical professionals (and soon-to-be medical professionals), we deal with death.

As living beings, we deal with death.

The one thing you are always guaranteed the moment you are born, or even the moment you are conceived, is that you will die. (depending on where you go, you can even avoid the paying taxes bit of "death and taxes").

As part of my Family Medicine clerkship (which is a subset of the 3 month medicine block) we have a hospice experience. I have an issue that the general public (and a good part of healthcare) associates hospice with death. As in hospice = you are going to die. Or hospice is where you go to die. I hate that. That's not all that hospice is. A very important aspect of what hospice provides is end of life care. But that's like saying the purpose of a car is to have air conditioning. The true spirit of hospice revolves around palliation. But I'm not sure I even agree with the all-knowing wikipedia definition of hospice.

But, as always, I digress.

As part of our hospice experience, we have to write a short paper on either:

- What was the most meaningful part of the experience?

- What surprised you the most during this visit?

My paper addressed the second question. I'm sharing that paper with you below. As always, I've scrubbed out all identifying patient information. And, as always, these are my opinions. No one else's. It is not meant to reflect or imply any parties share the same feelings etc. This is also not a completely accurate description of what happens in hospice - this is just a slice.

So with all that couching out of the way:

------------------------------------------

During my hospice half day, I got the opportunity to watch and help two families through the loss / inevitable loss of their loved ones. In the first situation, the patient had quickly slipped into a bad state of health secondary to late stage esophageal cancer. He had only a few months with his wife after his diagnosis. He  quickly slipped into a state where he couldn’t make his own decisions. His wife was very distraught at having to make the decisions – having to read his mind, to guess what he would’ve wanted. 

The second family I worked with had a different dynamic. An older patient went through multiple treatments for breast cancer, but the cancer recurred. It started to invade her heart. As of the time I saw her, she was still in relatively good health. She had a large family – she had 7 children (who all had children of their own). The kids were all in the room when we started discussing hospice. 

Her kids were leaning towards doing everything to prolong their mother’s life whereas the mother (the patient) simply said “no, that’s not living. I don’t want that. If it’s my time, it’s my time.” What surprised me about the whole encounter is how a family wants to deal with the end of their loved one’s life vs. how the loved one (the patient) wants to go through it. It seems like when we see the pain the patient is going through, we want to help. The first instinct for an outsider (and this seems to include family as well as health care professionals) is to act – to do something to extend their life. 

Whereas for the person actually going through the pain – for someone who has actually had to face their mortality, their perspective seems different. I am sure that many patients who are going through the stages of grief have a hard time accepting that they may pass soon and want everything done in a bid for gaining as much time as possible. I am not here to make any character judgments. I do have my own personal thoughts on the matter, but that is not the focus of this paper.

I guess what surprised me was how calmly some people approach the end of their life. This second patient was very sad about everything that was happening. She wasn't cheery about the idea of dying. About leaving her loved ones behind. But even though she teared and cried, she was still calm and direct about her wishes. It was also interesting to see the interaction in the family. There was no question she was the matriarch –  what she says goes. No arguments. No back talking. 

Encounters like this reinforce my strong feeling that patients with grave diseases need to have these difficult conversations earlier rather than later. If the inevitable does happen, leaving the loved ones / family members to deal with making final decisions is a horribly difficult burden. Death is difficult for everyone. Planning for end of life care ahead of time - whatever those plans may be - lets people focus on what matters most near the end.

---------------------------

I don't mean to be fatalistic, but the end comes for us all. Thinking about it (in a healthy, productive way) doesn't make it come any sooner or delay it any longer.

Going through documents like "5 wishes" helps people have these difficult conversations. Even more - it helps to quickly draw up paper work for what you want health care workers to do for you. So that your wishes are respected and carried out. 

Ok, now my lunch break is over. Back to seeing patients!

Clinics and perspective

I started my clinical rotations in January (2012). Here's a few random thoughts about what's been happening. I did 3 months of "Surgery" - 1 month of emergency medicine, 1 month of GI (Gastrointestinal) surgery, 2 weeks of plastic surgery and 2 weeks of orthopedic trauma surgery. I then completed 6 weeks of pediatrics (3 weeks inpatient at CHOP, 3 weeks outpatient at Cherry Hill), and now I'm about to start my second week of my OB/GYN rotation (which lasts 6 weeks as well). 

During clinics I've been completely awed by medicine. On the one hand I'm saddened by the limitations of medicine, but on the other hand I'm amazed by how much we can do and how many people we can help. It's just plain awesome - and it's amazing I get to be a part of it. I'm actually starting to help people now! In a very, infinitesimally small way - but hey we all have to start somewhere eh? This is something I've been working towards for a long time, and it feels great to see tangible progress. 

Recently on pediatrics I actually had one of these moments:

(I listened to and found many heart murmurs and accurately diagnosed them! Then again, the residents and attendings had already beaten me to the punch (obviously) - but it was still cool!)

At other times, I legitimately feel like this:

This was especially true during my month of Emergency Medicine. Obviously they don't let me do the initial triage of someone in severe distress, but one patient encounter stands out for me. He came in after passing out at a bar (he wasn't drinking, and this happened the day before too) and I got him to admit a history of cocaine use. While I was finishing up my initial questions, the EKG tech had just completed getting an EKG and I looked over at the strip as it was coming out... and rushed it over to the attending and said "room __, looks like a STEMI - atypical presentation" (the patient was having an ST elevation myocardial infarction - a heart attack. The cocaine use fit the picture because it increases your risk of having a heart attack even if you're young - which this patient was).

Love it. 

Medical school? Clinics? My initial response:

And I'm still going strong. High five for awesomeness.

Now having said that... there are many, many, many moments of:

This is how I feel when it comes to applying my (extremely limited) medical knowledge to the real world. And this is definitely how I feel when I take the Shelf exams (they are the "final exam" for a clinical rotation block). Clinics aren't all rosy. The patients can sometimes be difficult. The people you work with can be difficult - some bitch all the time, some have a bad day and decide to pick on you to no end. Almost like they are trying to prove how little you know. And, of course, some people are just plain mean - almost like they've forgotten how it feels to be in our shoes. Finally, the hours can be horrendous (4:45 am - 7pm regularly for multiple weeks). 

Often, this is how I feel like when my "higher ups", exams or patients ask me questions:

But for those who know me, you'll know I like to focus on the positives. There's crap to deal with in every aspect of life. 

The question is: is there a reason for to put up with it?

This is why I try so hard to remember why I decide to medicine in the first place. I want to help people. I am not here to chase a grade. I am not here to impress my residents or my attendings. Or that hot chick at the end of the bar (I've definitely tried that last one multiple times... being a med student doesn't work as well as TV says it would). I'm here to be learn as much as I can so I can be the best damn doctor I can be. Why? Because I want to save people's lives. I want to alter their course from just surviving from day to day to living each day to its fullest. 

People warn you that it is difficult to maintain that humanistic perspective as you go through medical school - especially clinics. Things conspire to beat your compassion out of you (not on purpose, but it is unfortunately what happens). Quite a few people are bitter residents by the end of medical school (but it seems to improve a bit when they become attendings).

Anyway... I digress. The main reason I decided to take some time out from "studying" and make this post? Because of a video I saw this morning. It's for the reasons depicted in the video that I work so hard. The reason why I'm here. Here's hoping I can help kids like this some day.

And in other news, a special shout out to my good friend Anna - we are all excited about your pregnancy and I wish & pray for the best for you. You and your husband are awesome people and I can't imagine a couple more deserving of a little bundle of joy than you guys.

Starting the Obstetrics part of my OB/Gyn rotation Monday. Let's catch some babies!

A very special Christmas

Merry Christmas and an early Happy New Year to everyone!

I'm a firm believer the world won't end in 2012, but I guess we'll find out soon enough.

This is not a regular Christmas for me. The end of this year symbolizes a small (but important) transformation in my life. Starting January 3rd, I'll be "working" in the hospital for my clinical rotations. Gone (mostly) are the lecture halls and didactics that have been my home for more than a decade. Now, I start my on-the-job training.


I've mentioned this a couple of times before - the clinics are something I've looked forward to for a long time, something I've worked towards for many years. But it also creates a lot of anxiety. I feel woefully inadequate to take care of patients. But people reassure me that the training I've received so far is much more comprehensive than I realize. That I am more prepared than i realize. That small consolation goes a long way.

Then again, I guess this kind of anxiety is a good thing. A little bit of stress does improve performance... but more importantly, it harkens back to an important lesson from my differential diagnosis class - don't assume you know everything about the current situation. This is the cornerstone for a good differential diagnosis: you always keep your mind open to other possibilities, and you force yourself to think of counter example - what else could it be?

By walking into clinics assuming I know less than I do, I'll force myself to keep my eyes and ears open. It forces me to be on my toes just a bit more. At a personal level, this means I'm hungrier to learn more. But the more important (and bigger) effect it'll have will be for my patients: I'll be taking second, third and even fourth looks over their plans, histories, results... the works! I'm hoping this second guessing will make me a better student now, and (eventually) a better doctor.


So here's to the end of a beginning and the start of a new phase in my education. On the job training isn't something new to me - I worked in the corporate world for 5 years before coming to medical school. But this is a very different animal. Sappy as it sounds: lives are on the line.

There will be many more "ends of beginnings" to come, I have no doubt of that. But I believe recognizing and respecting milestones (like this one, even though it's a small one) is crucial to the learning process.

This is a bit tangential (and if this is your first time reading my blog, you'll realize that I almost always have tangents in each post), but times like this remind me of what it takes to be a good doctor. For some reason, whenever I think of that, I'm taken back to a scene from Scrubs (one of my favorite shows).

This is one of the most powerful scenes from the show and it has stuck with me for many, many years. A great doctor is someone who is very invested in his patients... but knows the importance of staying objective. Walking the line and keeping tragedies from debilitating your work is not the easiest thing to do, but I believe it is an important lesson to learn. Here's hoping I learn it.

Enjoy the New Years! And if the world does end in 2012 - I'm going to be very sad because I'm JUST starting the really fun stuff...

- Karthik

Let's recap

So what have I been up to since my last real post... It's interesting for me to look at this list and realize just how much happens in a med student's life in the span of a few months. This is in stark contrast to what I was accomplishing in my corporate life. I was definitely doing some awesome/fun things in my last life, but it was on a very different scale. I guess this is how I know I'm in the right place now?

1. Summer:

Over the summer I worked with inner city high school kids. I was teaching "watered down" medical science. But the main goal was to convince them to go to college. It was such a fun gig... I only worked 4 days a week (half time too!) and I got to teach! It was sweet!  The best part about the whole thing? This is how my students see me:

(the future surgeon part might be a bit of a stretch...)

2. My second year started! Each part of it sooo deserves it's own numbered bullet... As a side note - Penn Med is special - we start our clinics half way through our second year. So, starting Jan 3rd, 2012, I'll be in clinics! It seemed really close last year... and boy, it's a lot closer now!

3. Cardiology

This is one of our "tough 3" courses at Penn (the others are Brain & Behaviour, which we finished in January, and Renal - which comes right after cardiology).

And boy was it tough! For being a dumb pump, the heart is one complicated machine. Heart issues are also the #1 killer in America (and maybe the world, but I'm not sure about that statistic). It's difficult to describe, but a large part of my class absolutely loved cardiology (including me). As complicated as it is, if you really understand how the physiology works.... there's actually logic behind everything! (This is rare in medicine). Of course there are some things you just have to accept / memorize - but overall, it was so well run. There's a good chance this one course has pushed cardiology (mainly catheterization and electrophysiology) to the "top 5" things in medicine I'm considering.

4. Dermatolology

Putting dermatology between Cardio and Renal was the (second) greatest idea they had at Penn. This was a much needed break. The weird thing is, Derm is one of the hardest residencies to get into because it is so competitive; yet our class on Dermatology is only 1 week long and is pretty straightforward (the mean on the exam is a 100). They just hit us with the most salient points and keep things very simple (which is nice once in a while)

5. Renal

Ouch. I want to go back to thinking about the kidney as a black box that makes pee. I'm thorougly impressed by the amount of things a kidney does. It was pretty painful trying to learn all the things the kidney does (and the different ways the kidney does it), but at the same time - I'm so happy I've got not one, but two kidneys.

(btw, this is the third of the 3 hard courses at Penn).


5.5: Fall break!! This is the best idea they've had at Penn Med. They gave us a couple of days off after Renal. What did me (and 6 others) decide to do?

We went to the Bahamas.

Yup.

It was pretty epic! Definitely needed that.

6. Pulmonology

This is our last honors/pass/fail class before we head to clinics (we've got a microbiology review class and a class on differential diagnosis before January, but those are pass/fail). It's supposed to be easier than what we've been going through so far... I really hope it's true. For some reason, I'm just so burnt out after cardio and renal. It's also that I'm ready to hit clinics. I'm having a very difficult time motivating myself to study. If this continues, the Pulm exam will not end well for me. Here's hoping I can concentrate over thanksgiving break. If not, I'll definitely be screwed 2 weeks from Monday.

7. Clinics - wth!?

On the one hand, I can't wait, but on the other hand... I'm mortified. I've learned a lot int he last year and a half, but I've got so much left to learn. And now it's time to learn while doing. Which is kind of scary. (Who am I kidding, it's madness, but it seemed to have worked for everyone else who's gone ahead of me...)

I've always been a big fan of the quote "courage is not the absence of fear, but rather the judgement that something else is more important than fear". This is the best picture I could find to describe it (and double points because it's a harry potter reference)

But in reality... this is a more accurate picture of how I feel:

Signing off. Hoping to make another post around Turkey time.