For my co-residents and for little O

I am on retreat with my residency class. We are in an otherwise empty hotel on the Jersey Shore whose just-an-average-hotel-ness is intensified by the lonely quiet of the off season. I can imagine the bustle of summer filling up the space — trails of sand from little feet tracked in from the beach, brightly colored umbrellas stacked up on the deck, all the various sounds that people can make from within hotel rooms — but in the emptiness of winter the rooms seem tired. Why are hotels decorated in brown and beige? Are there people who are offended by color? Or is it just to mask wear and dust and dirt? Is the bored eye less likely to see?

There are few opportunities in my life to sleep in but today I could have slept until 8:30am, which as all parents of toddlers can attest, is the new noon. I went to bed early last night, in fact, because I wanted to experience the sensation of restedness this morning, the feeling of waking up out of readiness instead of necessity. But because the universe has both good wisdom and a good sense of humor, my eyes opened at 5:45am — the very time that my alarm will ring tomorrow morning — and I couldn’t go back to sleep. At first I was filled with a familiar sense of cynical irritation, the “why me” and “well isn’t that always the way” that residency has brought to my life despite the comforts and advantages that I enjoy. But then I thought to myself, how often do I get a chance to walk on the beach as the sun rises? According to weather.com the sun would be rising at 7:01AM. I put on several layers and slipped out of my shared room, through the muzak in the lobby, and out towards the ocean.

There was no one else in sight. I walked toward the ribbon of pink spreading up from the horizon. The hard, frozen sand up near the beach grasses gave way to the satisfying sink of each step into the wet shore. Several gulls circled and dipped. I looked for shells to bring home to E — not too small, not too sharp — and came across some of the odd hints that the ocean delivers up to us about itself. Cracked orange crab shells and dismembered legs half buried in the sand. Plant fronds of various colors and textures and widths. A foot-long brown spear that widened up to what looked like the end of a bone with some white and yellow flesh still attached — tooth? spine? tail? Breaking the smooth contour of the shoreline, a sudden small pile of sea sponge. I walked for an unknown distance. The sky became lighter and lighter beneath and around the layers of cloud. I wondered to myself when the sun would rise and what would mark the sun’s rising. I looked at my watch and it was 7:13, already past the appointed time. The part of my legs between the top of my boots and the bottom of my coat began to tingle and sting with cold and I turned to walk back to the hotel as the daylight continued to bleed into being around the edges of the sky.

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How should I say this? I am worried about the state of health care. I am worried about the state of my own heart. I am worried about the way doctors are trained. I am worried about the way health is defined. I have been in and around hospitals for almost a decade at this point and I feel like I know less and less about how to help people achieve well-being. I feel like I’m getting better and better at keeping people alive and less and less good at helping them live well. I am maybe a little depressed or to use the somewhat more socially acceptable term, burned out.

I went into medicine with a desire to be with people in life’s most terrifying and difficult and potentially ecstatic moments. I wanted to understand the body, to understand more about life and illness and death. It’s a cliche but a deeply felt one: I wanted to be of service. I also wanted financial stability and the ability to provide for my children. I wanted a job that would be meaningful even on the worst days. But mainly I wanted to form deeply satisfying therapeutic relationships — it’s what I wrote my residency application essay about and it is still what I aspire to accomplish, somehow.

Now, almost ten years later, I spend more than 90% of my day in front of a computer. Sometimes the computer is actually physically located in between me and my patients and I have to crane my neck around its unsleeping eye to see them. I type through the majority of my clinical encounters. During a typical day on the wards, I see my patients for — at most — 5-10 minutes per day each. My day is filled with entering and reentering orders on the computer, writing endless admission notes and progress notes which recapitulate information that is already recorded elsewhere in the medical record, waiting on hold to talk to primary care doctors’ answering services, calling pharmacies and insurance companies for prior authorization, calling subspecialists to address each of the body’s organ systems, and coordinating the complex behemoth of a large tertiary care center to get tests and studies done for my patients. I work up to 28 (actually more like 30 but shhhh don’t tell) hours in a row every fourth night which wouldn’t bother me except that of those hours I spend at most 2-3 in total with patients. Patients turn over so quickly in the hospital that I might be responsible for the care of over 100 patients during a given week. During clinic hours I am perpetually beset with anxiety at how far behind I am, unable to get through a well child visit meaningfully in the 20 minute time frame allotted for this purpose and because of the fragmentary nature of residency scheduling, I often do not see these patients again. I want to form relationships with my patients, but at times it feels like talking to patients just takes time away from the tasks that need to be done for them. It’s crazy, but it’s true.

Some of these issues are unique to residency, which is time-limited (though formative), but surveys of post-residency physicians suggest that as a group, we are in trouble. In a much quoted and discussed survey of 24,000 physicians by Medscape in 2013, only 54% reported that they would choose medicine if they had it to do over again. Fourty-nine percent of physicians surveyed reported at least one symptom of burnout and 40% reported that they were burned out.

On the receiving end of medical care both as a patient and as a loved one advocating for sick family members, I know what it’s like to receive care from a system of overwhelmed and/or burned out providers. Test results are not communicated. Small details are missed. You wait 7 hours to speak with the doctor, then that person does not know some of the basic details of your case. The care you receive addresses a symptom or a part of the problem, but rarely the whole problem, and rarer still, you as a whole person. I fear being that kind of provider yet I have been that kind of provider despite my fervent desire to avoid it. There are just too many patients, too many data points, too many notes to read and write. There is so little time for relationships to form. There is no magic there.

Doctors are a hard group to sympathize with. Once we finish training (it’s long, but let’s face it, life is longer) most of us land in the top 10% if not the top 5% or 1%. Training is hard and the hours are long but we choose this life with full knowledge (as much as you can have full knowledge) of what we are getting into. We hold a lot of societal and political power and on an individual level,  in hundreds of thousands of exam rooms across the world, we have the power to examine, to question, to diagnose, to prescribe, to get it right and heal or get it wrong and harm. But if we as a society want to get the kind of health care that not only cures but heals, we are going to have to look at how doctors feel, how they are trained, how their work-life is organized, what we ask of them, and how we support them in their work.

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If you work around sick children long enough, there will be a death that crushes you, that doesn’t let go, that you can’t let go of. Little O came into my care last month and a few hours later passed away under the most difficult of circumstances. Oddly enough, I don’t remember her name — perhaps because the intensity of our efforts to keep her alive and the adrenaline coursing through my body erased it from my data banks, perhaps because I have been afraid to reopen her chart. I think of her as little O, the little O of her mouth, the round moon of her little face which I saw for weeks every time I closed my eyes. If I will it, I can hear her mother’s screams in my mind’s ear as vivid as the sounds of my household humming around me as I write: “No es justo! No es justo!”

I want to make contact with her family, to tell them that I feel for them, that I think of her, that even though our lives touched for only a few short hours, I feel the weight of their loss. I have never done such a thing before and I’m not sure if it is even appropriate. Who should I ask? Do I need to get permission from my program director? Do I need to run it by risk management? In the end, the question comes down to one of the nature of my relationship to that baby and her family. Was there one? And if so, what was it? I have been training for many years but have received no apprenticeship in this most important aspect of my profession.

So many hundreds of children pass through my life and I through theirs and we are like ghosts to each other. There are so many layers between me and my patients, layers of bureaucracy, legality, scheduling, vulnerability and power traded back and forth in a complicated dance. Was this always so? Sometimes I fantasize about becoming a small-town doctor, about being part of the community I serve, of knowing my patients and allowing them to know me.

I will likely never send a card or see little O’s family again, but this is what I would want to tell them: I will hold your daughter in my heart forever.

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Meanwhile, back at retreat, I am surrounded by the loveliest people. My co-residents are intelligent, accomplished, funny, and kind. To a person they are motivated by the desire to be of service. They are scientists and humanitarians who hold as sacred the trust placed in them by children and their families. They are also spouses and parents and children and friends who struggle to balance the commitments they have made in so many domains in their lives. I feel lucky to know them and I think children are lucky to have them as their doctors.

What I wish for them and for myself as doctors, what I wish for myself as a patient, for my patients, and for my loved ones who are someone else’s patients, is a system that allows us to be healers, that helps us to heal. I want a system that allows me to express my compassion, that gives me the space and time to care for people in a meaningful way. Unrealistic? Selfish? Possible? I plan to find out.

I haven’t posted in so long, it’s hard to know where to start. There is lots to say on such topcis as the New Year, death, illness, stress management (, the failure of), the Total Money Makeover, residency (which currently has the upper hand in the battle for my soul — think Sauron before Isildur cuts off the one ring). But I’m going to start with the smaller quotidian battles of toddlerhood that have been playing themselves out on our stage of late.

E has been into Curious George recently. There is lots to talk about with Curious George (e.g. colonialism, class issues in Manhattan, why everyone from crane operators to hot-air balloonists seem unphased by interacting with a talking monkey) but what has been striking me most is the way The Man with the Yellow Hat’s parents George, the ultimate toddler. The typical episode of Curious George begins with George causing a minor calamity, like covering the entire apartment with wet toilet paper, burying The Man with the Yellow Hat’s important papers in twenty-seven different holes in the ground, or inviting a family of doves to reside in the bathroom. The Man with the Yellow Hat’s response is unformily thus: A brief expression of displeasure (“George! My new bedspread!”) followed by an attempt to see things from George’s point of view (“You were just trying to figure out how toilets work.”) followed by a turn toward the practical (“We’ll just have to go to the hardware store and find a new handle for the refrigerator.”). Never once does The Man with the Yellow Hat yell, put George in time out, or refer to himself in the third person (“The Man with the Yellow Hat is very disappointed in you, George!” Um, no.). The Man with the Yellow Hat seems to understand that a) George has good intentions, and b) he is a monkey and there are limits to his capacity for understanding.

Now there are some important differences between The Man with the Yellow Hat’s situation and that of the average parent of a toddler: George is not expected to progress in his judgment or life skills whereas a child will eventually have to be left alone in the room with a stove, drive a car, and remember their social security number. George’s escapades also seem never to result in injury whereas real life is not so kind. Finally, The Man with the Yellow Hat has no apparent job and yet has an unidentified soure of endless cash and thus is able to seamlessly absorb even the most property-damaging and time-consuming calamity. Still, as the parent of a delightfully curious and sensation-seeking toddler, I find myself at those critical moments of toddler parenting asking myself: WWTMWTYHD?

I love E beyond the beyond and this phase of emerging language and the ability to describe her thoughts and desires is full of magic. At the same time, it can be — how should I put this? — challenging. Putting on a sweatshirt can take 45 minutes. Bedtime can take much, much longer. There are days when I feel my interactions with her largely involve saying “no,” speaking her name in an exasperated tone (awful), coming up with feasible yet appealing (?) rewards and consequences (“if you put on your diaper, we can go downstairs and [pause for dramatic effect] MAKE OATMEAL!”), and showering her with praise for things that don’t matter like lying down long enough for me to put her pants on. Is there not a better way?

Here are some things that I have learned from the Man with the Yellow Hat:

1) Tell me when you are ready. Despite the fact that George’s speech is entirely unintelligible, The Man with the Yellow Hat almost always prefaces an activity or decision by asking George’s opinion or asking if he is ready to go. He doesn’t just take George’s hand and lead him out of the house. When there is a task to be done, instead of trying to wrestle E into doing it when she has no interest or negative interest, I ask her to tell me when she is ready and then pretend to busy myself with something else. At which point, she will busy herself with something else and then 10-30 seconds later inform me that she is ready. This works about 25% of the time and is only useful when there is no looming time limit.

2) Abandon all hope of things remaining clean and tidy. It is clear from The Man with the Yellow Hat’s repeated decision to leave George unsupervised at home that he does not mind cleaning up messes. I am not so evolved. It is hard for me to watch E use the questionable dish sponge to “wash” the dried banana off her shirt or drink milk from her cup by carrying it in a spoon across the kitchen and sipping what remains of it while facing the backdoor. Every cell in my body wants to say “no” and redirect her. But really, who cares? The clothes she starts the day in stay on unless they smell or are so wet as to put her at risk for hypothermia on the way to school. Everything else is just part of toddler life and I don’t waste my conflict chips on them. Or rather, I try not to.

3) You break, you buy. Or rather, you break, you help with the cleanup. When George breaks the museum’s most precious dinosaur display, he has to work with the museum director to glue it back together. Similarly, if E throws rice all over the floor such that archeologists centuries from now will still find its marks under what is left of my cabinets, she has to help clean it up. This teaches natural consequences and also occupies her so that she doesn’t have a chance to create another disaster while I’m cleaning up the first disaster. This works about 10% of the time but when it works, it just feels so good.

4) When you mean no, just say no. As a Generation X/Yer, I find the ethics of parental authority challenging. But does the Man with the Yellow Hat worry about scarring George by exercising his authority and setting boundaries? He does not appear to. This may be due to his troubling sense of colonialist mastery over George, but I’m gonna to see the glass as half full and assume that he is just comfortable asserting himself in situations when his judgment is more developed than George’s. Instead of cajoling and bargaining and negotiating with E, when I mean no, I just say no in a firm and case-closed kind of way. I’ve been getting better at this and it actually seems to lessen the toddler madness. Well, about 50% of the time. On a good day.

5) When you are with the monkey, be with the monkey. The Man with the Yellow Hat sometimes leaves the house to do things (what we never know) but when he’s with George, he and George are engaged in the same activity, whether it’s going to the hardware store or staring at birds or exploring the chicken coop. You never see The Man with the Yellow Hat trying to answer email or polish the family silver while George is jumping up and down in the background. I find the most personally frustrating times to be the times when I am trying to accomplish something that has nothing to do with E while she is trying to engage my attention in whatever she would prefer to be doing. This is sometimes inevitable (aka: everyday at dinner time) but I am trying to be a better planner so that I have enough time to myself (thank the lord for babysitters and grandparents and the fact that children sleep more than adults do) and can be more present when I am spending time with E. Also, like the Man with the Yellow Hat, I involve her in whatever I am doing, from cooking to shopping to folding laundry. This makes us all happier.

Then there is the little piece of advice I kinda wish I could give to the Man with the Yellow Hat: You are expecting too much of your monkey! The Man with the Yellow Hat leaves George unsupervised all the time despite repeated evidence that he cannot be trusted to avoid disaster. Seems like George needs a babysitter! The (often unattainable) key to toddler parenting is to figure out what where your toddler is developmentally and then set your expectations accordingly. It doesn’t make sense to leave a toddler in a room with a small pile of swept up dust while you go to find the dustpan and expect them not to touch the tantalizing pile of dust (um, just a hypothetical example from, oh, yesterday). The exasperation I felt upon my return was 0% E’s fault and 100% the fault of my own faulty expectations. The great thing about a toddler is that, instead of putting the swept up schmutz in her mouth, E tried to make a dustpan out of a sheet of paper and sweep it up herself. What would the Man with the Yellow Hat say? “Good job, George!” And that’s what I said.

I am post call. I worked thirty hours in a row with 20 minutes of “sleep” (aka answering pages while lying down). I am in the pediatric intensive care unit these days and the number of pieces of data to interpret, management decisions, pages to answer, and things to worry about are all a hundred-fold moreso than anything I have ever experienced. Is there a word for feeling simulateously more energized, more exhausted, more competent, and more incompetent than ever before? And sadder. I fantasize all day and all night of escape, yet when we finish rounding in the morning and I am relieved for the day (relieved!), I find I cannot leave. I walk around to the rooms of the children who were sickest overnight and listen to their lungs again, exchange a few words with their parents, make sure their nurses don’t need any orders to be put in. I have carried these children with me for thirty hours — or have they been carrying me? I have worried over them literally breath to breath to breath, watching the loops of their inhalations and exhalations on the ventilator for clues on how to help them. It feels wrong to leave. I can slip out of the PICU and re-enter the unbroken world but they cannot.

The hours after I return home have a strange emotional architecture. Everything is superlative: If I eat a cheese sandwich it is the BEST cheese sandwich I have ever eaten. Then I take the BEST shower I have ever taken. My bed has NEVER felt so good. My house and my loved ones radiate an aura of perfection. Could the light coming in through the kitchen window be more golden? Then suddenly my stomach clenches with the memory of a mistake I made or that I think I might have made on one of the patients from overnight. I want to turn on my laptop and log on to the electronic medical record and check but I don’t because that would mean crossing a certain line in the sand that I cannot cross if I want to recover enough to go back to work tomorrow. “The patients are fine,” I say to myself, half believing it. I take a nap for a couple of hours then E comes home and shrieks with delight as she climbs into bed with me. I am filled with an almost painful degree of adoration for her every feature and action. I can’t stop touching her cheeks, her elbows, her cute chunky thighs. She points to a picture of a cup on the back of the New Yorker and says “cup” and I am convinced that she is the SMARTEST toddler that has ever drawn breath. It’s 4pm and I should be taking her out to the park or reading her a book but my body feels like the nerves are no longer connected to the muscles. I can’t. We turn on a movie and she watches it while I close my eyes. She is incredibly wiggly and I find myself wishing she would just be still for a few minutes. A voice inside my head whispers “You are a terrible mother.” I know I am not a terrible mother, I know it to my core, but every time I am post-call, my exhausted head fills with this same toxic thought. “You are a terrible mother.” I have been apart from her for too long, I think. I feel like crying but don’t. I am so fucking tired.

In summary: Euphoria –> anxiety. Euphoria –> guilt. Exhaustion. Et cetera.  Do other people experience this?

C makes my post-call afternoons and evenings feel celebratory. She says, “I am going to make you a special dinner” and even if she makes the same tacos she might make on a different night, I feel like they are directed towards me especially, patching the holes with love. I am acutely aware from moment to moment of how lucky I am.

On this particular day, C puts on music during dinner, Bach’s Piano Concerto in G Minor (the second movement of this performance by Glenn Gould is crushingly beautiful). The familiar first chords hit me as if from the distant past, as if delivered via gramaphone from some deep phylogenetic place.  I can feel each harmonic shift and small arrival in the music zinging down my spine, up through my neck. I am vibrating. E, perceptive of her parents as all children are, grabs my hand and C’s hand and starts pumping our hands up and down with the beat. I remember myself suddenly, the person who is capable of wonder and pleasure in beauty and intimacy and gentleness.  It’s like the poem by Yehuda Amichai: “Forgetting someone is like / forgetting to turn off the light in the backyard / so it stays lit all the next day. / But then it’s the light / that makes you remember.”

How long has it been since I was myself, I wonder. Hours? Days? Months? Minutes? I’m too tired to remember. At work, I walk fast and feel resentful when people start taking too long to do something. By necessity I am always doing more than one thing at once and a part of my brain has taken on the role of air traffic control, evaluating the tasks that need to be done and figuring out ways to get them done more efficiently. I page a consult while calling back a nurse who has just paged me, calculating that I will be done with the current conversation before the consultant calls me back. I send a document to the printer and stop by a patient’s bedside to give a parent an update on my way to the printer. Sometimes things are so busy that I don’t get to see all the patients I am taking care of overnight and they remain just headers on sections of my to-do list.

Smith

[ ] Call social work

[ ] Check urine output

[ ] AM labs

At the same time, there are hot spots of tragedy and horror that I have to suppress in order to function. A toddler who fell into his family’s pool while his father ran in to answer the phone and is now neurologically devastated. A baby who was shaken and is now neurologically devastated. Otherwise healthy children who have been maimed or paralyzed in accidents. Babies with cancer. And at each bedside, a parent whose desperation and fear is barely contained.  I want to throw my stupid to-do list away and hug them. I want to wail and keen and pull all the tubes and lines out of their tortured bodies and give them some peace. What I certainly do not want to do is lift the dressings and view the wounds, literally or figuratively. But I must and so I do. I calmly check my to-do list boxes and manage the smallest of details. I know cognitively that this is in their best interest, that what I am doing is helping them. But sometimes it doesn’t feel that way.

Now, at the dinner table with the people I love most in the world and vibrating to the music I love most in the world, I find myself crying. “They are suffering so much,” is all I can say. They are suffering so much. I am both contributing to and palliating their suffering and I have to live with that. It feels good to feel something.

E looks concerned so I wipe away my tears and we get on with having a marvelous evening together. We have a dance party. We tumble on the couch. We read books in bed. We take a bath together. Gratitude. Joy. Endless gratitude and joy. I try not to think about whether or not there are any potentially cancerous cells lurking somewhere in her bone marrow. I mostly succeed. Later C and I eat ice cream sundaes (see above re: C’s ability to make the ordinary seem celebratory) and then turn on a movie. I am asleep before the opening credits end.

It was a good day (that was also two days). Maybe there are some people for whom the hard stuff and the amazing stuff can be separated out, but for me they always bleed together, each arising as a result of the other.  I dream of a life that is easier, less complicated, containing fewer contradictions, less work, and less ache, but not really. What I really dream of when I sleep is my daughter, running down the sidewalk beside my partner, kneeling in the grass, picking up a perfectly round stone and looking up at me with amazement. I dream of the ceaseless oscillations of heart beats on monitors, lab values that I have to understand, the bodies of my patients, swollen and wounded. All of these things are bound together by love, by the best that I have to offer the world. This is the life I have chosen and perhaps even the life I have been chosen for, depending on what you believe.  I am grateful for it.

Well, intern year ended. Second year began. For me the transition has been gentle. I have spent the first month of second year on a primary care rotation, where there isn’t much difference between the role of an intern and the role of a resident. Though I will probably not go into the field, I love primary care. The triumphs are not always dramatic (aka restarting a heart) but they are profound: helping the family of a boy with behavior problems identify the anxiety disorder that is causing his outbursts, seeing the patients I met as 4 day olds last summer toddle in on two legs for their year-old check-ups (really there is nothing like it), hearing from one of my patient’s mothers that her husband quit smoking as a result of the discussion we had at our previous visit. In primary care, you never know which of the thousands of stones you throw (Put the baby to sleep on her back! Include a book in your bedtime routine! Brush your teeth! Wear a condom!) will cause a ripple of positive change in the life of a child, so you just keep meeting your patients with an open mind, ready to throw as many stones as you can in the time allotted (20 minutes or 40 minutes which always turn into 60 minutes).

Meanwhile, in what feels like a parallel dimension, my fellow second years have started the rotations that will define this year: NICU, PICU, onco, cardiology. They are caring for sicker patients and doing so without direct supervision from senior residents. It reminds me of the line from the Sound of Music (showing every night at our house from 6:30-6:45pm, bring your lederhosen!): When the Lord closes a door, somewhere He opens a window. Except in medical training it is kind of the opposite: When the Lord opens a door, somewhere He closes a window. That is to say, as soon as you are comfortable, you are pushed back out of your safety zone. On the one hand, the absence of direct supervision is scary, on the other hand it is the only way to learn while the safety net of fellows and attendings is still there to catch you.

Over the course of the month, I have gotten to meet some of the new interns as they arrive for their first and second primary care clinic sessions. They are eager, tentative, and still appear moderately well-rested. Though I am sure it isn’t written on my face, I feel a world of emotion for them: fiercely protective, sad that they have to go through the hard moments of internship, excited for the greater mastery and confidence they will feel as a result of their experiences, worried that something in their spirits will be lost in exchange. On the first day of the vacation that ended my intern year (almost a month ago now – hard to believe!) I started a letter to them. There was so much I wanted to tell them about what to expect, how to cope, and how to thrive. Now that I’m about to start three months of 28-hour call every fourth night, I figure it’s time to send it, before the lessons of last year are replaced by the lessons of this year. So, this is for you, new interns, both here and everywhere. Thanks for showing up and taking over!

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Dear New Interns:

Welcome to residency! Much advice will be given to you in the coming months about how to do intern year. Everyone who has gone through the process of becoming a doctor has his or her own insights and advice. Some of these will resonate with you now, some may suddenly resonate at 2am on a hard night of call, and some may never resonate. Everyone experiences residency differently.  That said, I feel compelled to share with you some of the insights I have gained, in the hopes that they might help you navigate the year ahead.

Be graceful about what you know and what you don’t know. Over the next year, you will be asked approximately 700,000 questions you don’t know the answer to. These questions will come from attendings, fellows, senior residents, your fellow interns, nurses, case managers, people looking for directions around the hospital, and most frighteningly, your patients. The good news is that there is one right answer: “I don’t know, but I can find out.” It will be tempting to fudge, to change the subject, or to guess. If someone is signing out a patient to you and they use an acronym like LFSGA-Beta (totally made up), don’t assume that you should know this and feel embarrassed to ask. Ask! It is an opportunity to learn and also a patient safety issue. My first day in the well baby nursery, I had to ask what “AFOF” meant. Turns out it means “anterior fontanelle open and flat” which I have subsequently written upwards of five thousand times. I felt a little sheepish having not known something so simple, but I was free to focus on more important things and all my little babies got their fontanelles appropriately documented using as few letters as possible. The same goes for calling consults. If you don’t understand the rationale for a treatment plan or just plain don’t understand what the heck the person said, don’t be afraid to ask for clarification. On the flip side, when you have heard crackles on a lung exam or feel strongly about which elements of the history are most important or did four years of PhD research in a particular disease, don’t be afraid to stand your ground or teach your colleagues. To use a tired but true cliche, medicine is a team sport and you will serve your patients best by leaving ego aside and doing your best to learn and teach.

Accept help: Throughout the first six months of internship, I felt annoyed and defensive every time my senior resident asked if I needed help. I saw this as an indictment of my ability to complete my staggering to-do list. Every time my senior resident asked to “run the list,” I felt ashamed if there were tasks that I had not done, even if I had been working non-stop since the morning. About two months before the end of the year, I realized that offers of help are just that: offers of help. Our jobs are hard and there is often more to do than one person can do, though there are many days when one person has to do it all. So when someone asks if they can help, just delegate a few tasks and be grateful. (Exceptions include medical students and your fellow interns who have already signed out who are using “Can I help you with anything?” as code for “Can I leave now?” in which case the answer is: “Nope, I got it! Have a great night!”)

Make time to see your patients: Right now, you might be thinking – this is crazy advice! Of course I’m going to see my patients! But the truth is that you will spend much more time in front of a computer than in patients’ rooms this year. There may not be an intuitive moment in the day to re-visit your patients after rounds, especially if you are on a day-float, night-float system where there is pressure to sign out your colleagues. In the time you do spend with patients, you will feel pressured to focus on medical stuff. But unless you are a person who doesn’t like people, in which case rethink this whole endeavor, practicing medicine without meaningful interactions with your patients will lead straight to burnout. Here is what worked for me: On long call nights after signing out, I would spend 15-20 minutes visiting with one of my patients in a less goal-oriented way. Even though I was tired, and didn’t see my daughter on those days, they were my favorite doctor days.

Looking up stuff on uptodate is also reading: I spent most of intern year feeling guilty and nervous about how little “READING” (those are lofty quotes, not scare quotes) I was doing. But I was looking up a ton of stuff on uptodate and emedicine in the course of my days and nights taking care of patients. Surprise! This counts. If you learn something you didn’t know by reading, it counts as “READING.” If you remember it the next time you encounter it, it counts as “LEARNING.” If you don’t remember it, which will happen often because (listen up creators of medical training schedules everywhere) sleep deprivation impairs your ability to learn and remember things, just look it up again. It’s like double reading points!

Lean into your weaknesses: If you are afraid of procedures, volunteer to do them. If a patient on the floor scares you because they are complicated or have a challenging family, visit them first. If a disease process is unfamiliar, seek out patients with that disease even if it means an extra admission on a long night. Volunteer to lead mock codes. This is your golden opportunity to get comfortable while you have a safety net.

Learn to accept the fact that you will make mistakes. Everyone who you admire in medicine has made mistakes and everyone has made mistakes that harmed a patient. When this happens to you, try to forgive yourself while at the same time learning from your mistake. Learn to sleep well again. This takes a lot of maturity.

Embrace the 24-hour day: In normal-people world, breakfast happens in the morning, dinner in the evening, and fun things happen on the weekends. In the world of medicine all 24 hours are fair game and you need to learn how to squeeze the things you need into the crevices available. Spending twenty minutes getting food from the cafeteria with one of your fellow interns at 3:30am counts as friend-time (would calling it happy hour be too much of a stretch?). Stealing an hour post-call to have breakfast with your significant other counts as date-night. Walking to work one day instead of riding the bus counts as both exercise and an opportunity for reflection. Writing this, it sounds depressing, but I’ve actually found it to be kind of fun, to inhabit the whole space of time. I’ve also become more productive, because I am not waiting for someone else to tell me what activities to do when in my day.

Along those lines, do not underestimate the power of the small gesture. This year you will be so busy, so pulled in so many different directions, it will seem impossible to take care of the relationships that matter to you. There will not be much time for long coffee dates with friends or trips to visit family members in distant cities. You may even miss a wedding or a baby naming and it will not feel good. The good news is that there will always be five minutes here and there and you should learn to use them to sustain your relationships (and take care of yourself, but more on that next). Send flowers to your girlfriend or mother as you are walking to the subway. Write little emails to friends if you don’t have time to write long emails. Take your child to the zoo at 9am for an hour before your ED shift. Call your friend from college as you are walking to the cafeteria to grab dinner. Don’t wait for a better time, take the time you have and keep your social connections as alive as possible.

Find ways to take care of yourself: I’ve heard many people describe their strategies for staying healthy and sane during intern year. There are as many strategies as there are people. But I think the path of self care during internship is a combination of making peace with the fact that you will be tired and stressed a lot of the time, while finding ways to relieve that stress in the time you have. Lots of people will tell you to exercise and eat right and I’m sure that’s not the wrong answer. I personally didn’t exercise intentionally even once during the year and ate more dessert than I would ever admit, but I spent many wonderful hours being lazy with my daughter, and a few hours each month writing in coffee shops, which is what makes me feel happy and centered and renewed. Choose 1-2 things that keep you grounded and make time to do them when you start to feel distant from yourself or burned out.

Everyone is your teacher: You will work with dozens if not hundreds of different people this year. Some you will love, some will rub you the wrong way. But all of them have something to teach you. At the end of the year, looking around at my fellow interns and the graduating seniors, I can honestly say that I learned at least one valuable thing from every single person I worked with, whether explicitly or by watching them practice. So don’t let a personality conflict get in the way of learning from the people around you.

When it comes to bullshit, don’t be a sponge and don’t be a boomerang: When someone treats you poorly, it usually means they are insecure, tired, burned out, or being pushed beyond their limits. When you are having an interaction that makes you feel like shit, refocus the other person on the well-being of patients. In that moment, you have the opportunity to help that person rediscover his or her best self. Here are two lines that have worked well for me: “I’m worried about this patient for xx reason and I need your help” and “Please help educate me.” Then again, some interactions will just go poorly. When that happens, resist the temptation to take it personally (sponge) or to have your own anger outburst (boomerang) and just try to get what you need to take care of patients.

Help each other honor your personal commitments: I’m not sure this needs much explanation. If your co-intern is getting married or it’s their grandmother’s 99th birthday party or they are the best man in their brother’s wedding and you are free to switch shifts or stay long, do it. Then don’t be afraid to ask for the same.

I will end by saying that for me, intern year was hard. It was hard to be a beginner, hard not to know the answers all the time, hard to be so sleep deprived, hard to be apart from my family and friends for so many hours and weeks and months. It was also hard (but good) to learn to make decisions that affect patients, to deal with uncertainty and my own anxiety about making mistakes, to attempt procedures for the first time, to fail and learn from failure. But there are also the successes, the camaraderie with fellows residents, the growing sense of competence and confidence, and the incredible feeling of making a difference in the life of a patient. The best advice I can give is: Face it with courage, self awareness, and kindness. Good luck!

Today is not mother’s day, but it’s my mother’s day because tomorrow I will be working a long call. I will not see E awake at all unless I accidentally on purpose wake her up when I get home which, *blush*, I have done more than once. Before I had a baby, Mother’s Day seemed like a forced over-sentimental construct. Now it is more important to me than Christmas (ok, I’m Jewish), Hannukah (ok, that’s not really an important holiday for Jews), or my own birthday (as an adult, birthdays are kind of eh). It’s the holiday we mamas EARN! Cause being a mom is amazing but it is a shit-ton of work, and the most arduous work is done in the years that the child won’t even remember, so bring on the chocolates! Excuse the profanity, but this Mother’s Day I’m feeling a little feisty. Why am I am feeling feisty? Because everyone is buying their mothers flowers and making them breakfast in bed, but America is still the developed country in which it most sucks to be a mother.

Here are some of the countries that currently offer women paid maternity leave: Rwanda (12 weeks at 67%), Sudan (8 weeks at 100%), Haiti (100% for 6 weeks), Bangaldesh (8 weeks before delivery, 8 weeks after, how cool is that?), Somalia (14 weeks at 50%)…. the list goes on and on and on and on. Here are the only three countries that do not: the United States, Swaziland, and Papua-New Guinea. Our lack of support of mothers (and fathers!) is even more embarrassing when compared with countries that are more our economic equals. French women get 16 weeks at 100%, rising to 26 weeks at 100% for the third child. They are eligible for 104 weeks of unpaid leave which can be shared with the father. In Canada new mothers get 50 weeks at 55% and fathers get 35 weeks at 55%, some portion of which is shared with the mother’s 50 weeks. Why have all but three of the world’s countries decided that women should be paid to stay home and care for their new babies? Could it be that having and raising babies serves an important societal function?

Here is a more personal statistic. We pay $309/week for high quality but no bells-and-whistles day care. That’s $16,068 per year. We’re lucky, because we make enough money to also afford rent and food and gas and car insurance and health insurance, but just barely. If I were a single parent or had two children, I actually don’t know how I would afford to work. Then there is school to think about. It is hard to get into a high quality public school where we live, so I’ve priced out the private schools in the area. $28,000/year for first grade? Yes, that’s right. They are even offering parental loans for elementary school these days, so we can look forward to an era of stacked student debt, in which parents are paying their own loans and their children’s loans. This is not sustainable. Then I think of all the children who do not have a choice, who waste years of their lives in schools that do not offer a real path out of poverty, that perpetuate the cycle of violence, underachievement, and early childbearing.

As a parent in America, you get the explicit and implicit sense that having a kid is kind of your own fault. You break, you buy! Having a child is a lifestyle choice, like buying a European car that is expensive to service. No one is going to pay you to stay at home while your perineum heals — no one forced you push a baby through it! No one is going to let you go first in line when your toddler is screaming their head off in the supermarket line (um, why can’t that mother control her child?). No one is going to find creative ways to fund improvements in education (here’s a thought: make everyone and every company actually pay taxes on their income). But an economy cannot survive without people in it. I’m no economist, but it seems to me that it is in the best of interest of our economy for human beings to continue to exist. In other words: Dear America, You’re Welcome! Love, Mothers. Icing on the cake if these up-and-coming citizens are not drug addicts or criminals and if they can hold down a well-paying job such that they can buy stuff. Who will be paying into social security when you and I are shuffling to our retirement home mailboxes to pick up our social security check? And how can we continue to be successful in the global economy when 26% of high school graduates cannot read at their grade level? The decision not to invest in children will be the death of the American experiment. There are some things people just can’t do by themselves, and being born, surviving the first few years of life, and learning complex subjects like calculus are some of them.

So tomorrow — find a place of heartfelt gratitude and while you are there, call your mother. She did a lot for you that you can’t even remember. For example, you pooped on her more than once. Then, next time someone tries to tell you that there isn’t enough money to support mothers (or fathers) as they do the grunt work of keeping the next generation of Americans alive, don’t believe them. If Burkina Faso can do it, so can we.

I am so tired that I am drifting off in the midst of my task, so tired that I can barely write a sentence that has a beginning, middle, and an end. Last night it was hot for the first time and since my body is tuned to sleep only when the room temperature is between 68-72 degrees, I did not sleep. Where was I again? Oh yes, the task. The task is to do something writing-related between the hour of 8pm-9pm tonight, no matter how fragmented and befuddled. It’s 8:37 now.

Stephen King has said, “Writing = ass in chair.” You just have to sit there consistently and put words on a page, regularly, for a long time. This is a concept I’ve been struggling with my whole life. As a child, I was talented at music, but never wanted to practice. I was a diligent meditator and it enriched my life and my inner world immensely, but one day I stopped doing it every day and I slowly became a stranger to that part of myself. I toyed with making a go of it as a writer in my early twenties, but feared that I lacked the self-discipline to do the whole ass-in-chair thing. Well, the stakes are a lot higher now. As it turns out, I too will one day die as all beings do. And there will never be a perfect, protected time to write. It will always be woven in and through other things. I fantasize about having a writing room with sun streaming in through two huge windows, having as my sole work of the day the task of feeling the world into words, having at the end of the day the satisfaction I feel only when I have written something to a point of new understanding. If I want to have that even for one day a month or one day a week or one week a year, let alone a more substantial part of the time, there is only one way to get there: ass in chair, no matter how tired or bored or frazzled I am, no matter how many sleeveless onesies need to be purchased for a certain pig-tailed dervish.

I went to the dentist this past Monday (it’s my vacation. Aren’t you envious?!) and it turns out I have 4mm pockets in a lot of places and even two 5s. This means that I am in “THE WARNING ZONE” as an ominous poster on the wall read, the zone where I am in danger of all my teeth falling out or needing thousands of dollars of periodontal care, or both. The dental hygienist was as politic about this as any oral health professional I have ever encountered. “You need to floss every night and brush your teeth after every meal. And let’s get you in for cleanings a little more frequently” (aka more than once per presidential term of office). I have been treating oral health kind of like I treat writing: it happens when I am well rested and in a good frame of mind, which is to say not often. I brush every day but floss only here and there and like I just said: not a lot of dentist visits. But now I have to floss my teeth EVERY NIGHT and if I don’t, pain and suffering and poverty will dog me the rest of the days of my life, so saith the dentist.

I surrender. I am almost 33 years old, the Jesus age, and I guess it’s time to learn to do some things on a daily basis. It’s 9:11 and I’ve outlasted my hour by 11 minutes and of course I have lots more to say now that I’m on a roll, but instead I’m going to go downstairs and cut friend eggplant into tiny pieces so that E can eat them for lunch tomorrow. Then I’m going to fall into bed if I make it back up the stairs. But first I’m going to floss. Then I’ll come back tomorrow night and try again, one hour at a time.

Here is an Onion article on this subject that is just so true and sad and funny.