Looking Ahead to 2012

I have posts brewing about the year in review and about my resolutions for the new year, but they'll have to wait until I emerge from the fog of holiday ward coverage.  In the meantime, I was inspired by a post by Larissa at Thoughts Simply Arise about the things that she isn't giving up in 2012.  Too often resolutions focus on sacrifice and self deprivation, so it's nice to remember that there are many things that we should continue to enjoy.

So here, in the spirit of enjoying the new year, are the things that I won't be giving up in 2012:

• Lazy post-call days spent cuddling with my cats and watching trashy tv.
• Solitary breakfasts at my favourite diner.
• Chocolate.
• Time with my two adorable nieces.
• Cozy pjs.
• Long visits with friends over food and coffee.  (I already have dim sum booked for my next weekend off.)
• Excessive amounts of Coke Zero while on call.
• My housekeeper, who keeps me from living in squalor.
• Travel funded by my line of credit.  (Looking ahead to Mexico and maybe Newfoundland in the upcoming year.)
• Grilled cheese made with sourdough rye bread from my favourite local bakery.  (Also known as crack bread because it's so addictive.) 

• Sleeping in whenever humanly possible.
• Blogging.

Wishing you all a Happy New Year.  Wish I could be there at midnight, clinking champagne glasses and kissing people I love, but I'll hopefully be dozing in my call room.

Breaking Bad News Revisited

Thanks to everyone who commented on my previous post about the worst possible way in which to tell a patient that he has cancer.  Although I obviously can't go into much detail because of patient confidentiality, I wanted to clarify the situation a bit so that the person I took over from doesn't come across as being a terrible doctor who withholds information from her patients. 

As is often the case with cancer, the patient's diagnosis wasn't made instantaneously, but rather became increasingly clear over a series of days as more and more test results came in.  Even at the time that I spoke with the patient, the final diagnosis wasn't entirely certain, although we had a pretty strong case for the most likely diagnosis.  For right or wrong, every doctor has his or her own way of dealing with this diagnostic uncertainty.  As I've progressed in my training and grown more comfortable with my knowledge and understanding, I've made a conscious decision to try to involve patients in the diagnostic process as much as possible.  I try to communicate results and my thoughts about the diagnosis on an ongoing basis, even when the diagnosis isn't yet 100% certain.  But this is a very difficult thing to do, and it can lead to situations in which patients are told about a possible diagnosis that ultimately proves to be wrong.  And so some doctors will choose to defer telling a patient about the most likely diagnosis until they've reached the point of certainty, as was the case with the patient whom I inadvertently told about his cancer diagnosis.  In fairness to his previous doctor, she had already told him that there was a chance he had cancer, she just hadn't delivered the news with quite as much certainty as I did.

Cartoon Character made a very good point in her comment, in which she stated that she typically asks patients "what have you been told about your diagnoses/treatment?" before talking to them about what's going on.  Although this can be tiring and frustrating for patients, as Anonymous pointed out in his/her comment, I think it can be an important tool for avoiding situations like the one that I got myself into.  I do typically try to ask that question, particularly when I'm taking over a new patient, but with this patient I was rushing and didn't take the time to ask.  In retrospect, big mistake.  If I'd just taken a few minutes to clarify the patient's understanding, I could've delivered the news of his diagnosis in a much more compassionate and sensitive way. 

I have many more thoughts that have come out from the great comments on my post, but at the moment I'm post-call from covering both a medical ward and the emergency room, so I'm not certain that I even have the mental energy to finish watching TLC's "Say Yes To The Dress" marathon.  Hopefully more to come once I get some much-needed rest.

Breaking Bad News - A Cautionary Tale

Today was my first day back at work post-holidays.  My ward has about 20 new patients with whom I needed to familiarize myself, so I spent my day diligently reviewing charts, checking blood work, and introducing myself to all of the new patients.  At the end of each meeting, I gave each patient a summary of his or her treatment plan, both to bring the patients up to date with what's going on and to reinforce the plans in my own mind.

So it was that I found myself discussing the plan with a patient who was diagnosed with cancer just a few days earlier.  As I talked to him about the new medication we had started, I noticed that he was looking at me quite strangely.  His expression grew even odder when I mentioned the further testing that we had planned.  When I told him that the oncologist would be coming by to see him later in the day, his expression turned to one of complete and utter shock, and I finally clued in to what was going on.

No one had told this man he had cancer.

And I, someone he'd never met before, had nonchalantly walked into his room and started talking about his cancer as if it was no big deal.  From now on, whenever this man thinks back to how he found out he had cancer, his memory will be of some random stranger delivering the news unceremoniously and without the slightest bit of compassion.

/facepalm

Welcome back from holidays, Solitary Diner.  I feel like just about the biggest jerk to ever exist.  Excuse me while I go and extricate my foot from my mouth.

Christmas Recap, In Pictures

Wrapping presents, with my favourite Christmas special in the background.

Christmas Eve dinner at my brother's house.  Very tasty pork-stuffed pork.  Mmmm.

Homemade (by me) creme brulee for dessert. 

A surprisingly well-behaved canine visitor.

A kitty cat, curled up to spend Christmas Eve with the nieces.

Christmas morning "proof" that Santa had paid a visit.

The most essential component of Christmas morning for the adults.

Presents!

A Christmas scavenger hunt, by my five-year-old niece. (Love the spelling!)

Christmas morning breakfast.

More pork. Mmmmm.

Boxing Day morning at my Mom's house.  As pretty as the sunrise was, I didn't need my Mom to wake me up for it.

Boxing Day dessert (homemade pavlova).

So good.

Homemade dainties (to make sure we maximized our caloric intake).

As you can see, there was a lot of very tasty food and multiple celebrations over the past five days.  It's been wonderful to have time off and to get caught up with people, many of whom I haven't seen in months.  My only regret is how quickly the time went by.  It seemed like I was constantly rushing to get presents wrapped and creme brulee made and dishes washed.  Tonight is the first time in this vacation that I've had nothing to do*, and I'm enjoying relaxing on the couch with a kitty cat and my laptop.  I would happily take another week of this, but unfortunately there are 30 or so patients in need of care, so it's back to work tomorrow.  After five such wonderful days, I really shouldn't complain.

* By "nothing", I mean finish my laundry, cut up the peanut butter marshmallow squares that I made to take to work tomorrow, put dinner away, do dishes, and pack a bag for tomorrow.  But I'm ignoring all of these things in the interest of some down time.

Christmas With The Nieces

Seven-year-old niece:  "Auntie Solitary?"
Very tired Auntie Solitary:  "What time is it, J?"
Niece:  "7:13."
Auntie:  "Seventeen more minutes, J."
Niece.  "I know!  That's what Daddy said!  But, but, but....Santa was here!  Aaaaaand....the stockings are full!  Of presents!  And there's more presents under the tree, but I didn't go down there, because Daddy said I wouldn't get the presents from Santa if I peaked at them.  But I think they're there, because the stockings are full, and Santa leaves the presents when he fills the stockings.....aaaaaand....is it 7:30 yet?  Cause Daddy said we could open the presents at 7:30."
Auntie:  "It's 7:15.  Almost there."
Niece:  "Ohhhh.....I think I'm going to EXPLODE!  I'm SO EXCITED!  It's CHRISTMAS!"

It's Christmas indeed.  Hope Christmas has been as exciting and joy-filled for everyone reading this as it was for my seven-year-old niece.  And now I'm off to have a nap with the kitties before rounds two and three of the celebrations begin.

Holidays

Sorry for the whining in my last post.  Unfortunately, it was reflective of what I was feeling at the time - overworked, harried, tired, frustrated. And yesterday, if anything, was worse.  As wonderful a time as Christmas is in the outside world, it's a miserable time inside the hospital.  There is too much work for too few people, staff are putting in their maximum effort just to meet the minimum standards of patient care, and there's an air of resentment that comes from being in a hospital when the rest of the world is eating Christmas baking and drinking eggnog in front of a fire. 

The worst part of this season, for me, is feeling like there is no possible way for me to be the doctor I want to be.  I pride myself on taking time with patients, being on top of their issues, and being a calm and pleasant person to work with.  Neither "calm" nor "pleasant" described me yesterday, as I muttered swear words under my breath or banged my head against the desk (literally, more than once) in frustration.  Everyone has their breaking point, and while mine is high, it is reachable.  Trying to lead a team of two to excellence is beyond my breaking point.

But, the ward is now out of my hands (despite still pervading my dreams), and I have five glorious days of vacation.  My two paragraphs of ranting behind me, I'm now going to try to forget about work and just enjoy all of the magic of the season.  I have today and the first part of tomorrow all to myself, and as usual I'm debating between giving in fully to relaxation and trying to accomplish the hundreds of items on my to-do list.  Hopefully I'll achieve something in the middle.

Fortunately, my to-do list does not include "go to the mall".  Thanks to everyone's suggestions to do my shopping on-line, I managed to get all of my Christmas gifts with minimal stress and without setting foot in a single mall.  And I think I even achieved my goal of getting somewhat meaningful gifts for everyone.  See what you think:

Mom:  A crock pot to replace the one that she broke earlier this year.  Not all that exciting, but it should help her with the daunting task of cooking for one.  And it will hopefully translate into some tasty meals for me when I find the time to visit.

Brother:  A bottle of port.  Every year on Christmas Day, the male relatives in my sister-in-law's family sit around smoking cigars and drinking port, so I figured this was as good a gift as any for the brother who has everything.

Sister-in-law and nieces:  Tickets to the Nutcracker ballet.

Growing up, one of my friends would go to the Nutcracker with her single and childless aunt every Christmas, and I was always jealous.  All of my aunts had their own brood of children to care for, and my mother was far too frugal to ever spend money on ballet tickets, so I had to content myself with watching the ballet on tv.  When I found out that my sister-in-law was pregnant with a girl, one of my first thoughts was that I would take her to the ballet as soon as she was old enough.  I took my nieces for the first time last year, and it was a bit of a disappointment as the younger of the two (four at the time) was terrified of the mouse army and wanted to leave at intermission.  But when I asked the nieces what they wanted for Christmas this year, they both said "Nutcracker!" and proceeded to dance around their living room in a joyful and silly interpretation of ballerinas.  So Nutcracker it is.

Older niece:  One of the hazards of online shopping is how easy it is to buy more than one needs.  So despite having just bought ballet tickets, I decided that my nieces needed a physical gift to sit under the tree and open on Christmas day.  So I bought the older niece Ramona Quimby age 8, which was one of my favourite books when I was her age.

I also bought her Pictureka because *ahem* I still owed her a birthday gift from July.  I had initially decided to take her out for a "Day with Auntie Solitary" in lieu of a gift, but apparently Auntie Solitary hasn't had a day to spare since July, so a gift it is.  My niece loves the Where's Waldo books, so hopefully she'll enjoy a similarly themed game.

Younger Niece:  The Nutcracker by Susan Jeffers.  I adore Susan Jeffers's illustrations, and I've bought my youngest niece one of her books for Christmas every year for the past two years.  This seemed like a good choice to accompany the Nutcracker tickets.

Miscellaneous people I will see at Christmas:  Normally I try to buy something small (chocolate, a cute mug, bath products) for the distant relatives and neighbours who join us for Christmas celebrations, but it always feels like such a waste of money.  So this year, I decided instead to make a donation to a local food bank and just give cards to people.  (I even have multiple boxes of cards that have never been sent sitting in my Christmas box, so I'm all set in that department.)  Hopefully no one will be offended that they didn't receive a $5 trinket from me.

Looking at this list, I'm reminded of how fortunate I am to have these people I love in my life and to be able to afford to buy them things they will enjoy.  I get a bit cynical at times about the materialism of Christmas, but it is nice to watch a five-year-old's eyes go wide with delight as she rips the wrapping paper off something she loves.

And now, off to the UPS store to pick up the Amazon package containing that something for the five-year old.  I hope that all of you reading this have a wonderful holiday with those you love.

And lots of chocolate.

Christmas Math

The internal medicine wards at the hospitals where I work usually have 30 to 35 patients divided amongst a team of four to six residents and medical students.  Medical students are responsible for half as many patients as residents, leaving medical students with three to five patients and residents with six to ten patients, on average.  It makes for a busy rotation, but the patient to trainee ratios are still low enough for trainees to get to know their patients well and to stay on top of their medical issues.

Enter Christmas.

Subtract from the team two or three medical students, who disappear from the ward for two blissful weeks of holidays, and one or two residents, who get five short days of holidays to spend dreading their return to work.  Then toss in one or two off-service residents, who can barely hide their bitterness about being pulled from the cushy world of oncology clinics to cover 30-hour-long call shifts on a busy and understaffed medicine ward.

(I know this from experience. I was the bitter resident who was pulled from oncology last Christmas.)

The end result is those same 30 to 35 patients, now being managed by a grand total of three residents.  And one of those residents is post-call every day, meaning that there are two residents on the ward at any given time.  Two.

Although this delightful system doesn't officially begin until Friday, I got a preview of it this morning, when my team of three residents was reduced to one thanks to a resident leaving post-call and another resident being on half day.  Between myself, the poor family medicine resident who is five days into his internal medicine rotation, and the ever cheerful pharmacist, it took us five hours to round on the ward (normal time is two-and-a-half hours).  By the time we saw the last patient and promptly sent him back to the ICU from whence he came, my heart was filled with despair and I was contemplating alternative career paths.  Unfortunately I've yet to identify another career path that would allow me to pay off my six-figure debt.

(And I love my career.  Honestly.  Or at least I will after five days of holiday drinking.)

I'm trying to think of something wise and insightful to add as I lounge half asleep on my couch, but all I can really think about is how happy I am that tomorrow is my last day of work before Christmas.  I am so very ready for it.  I reviewed all the patient charts and checked all the blood work before leaving tonight, so the ward is in the best shape that it possibly can be.  My Christmas gifts are all bought, my apartment is decorated, and there's enough chocolate in the cupboard to put me into a hyperglycemic coma.

I'm ready Christmas.  Bring it on.

Advice to People Attending Holiday Parties

It is never appropriate to tell your husband's colleague to f@(% off.  Even if she did take the last peanut butter marshmallow square.

(Photo from Bake Eat and Grow)

It's 3 am, I Must Be Lonely

The first week or so as the senior resident on a new ward is always one of the most terrifying and frustrating experiences of residency.  With only a two- to three-line blurb on each of the 30-plus patients on the ward, I'm expected to direct a team of five trainees of varying levels of knowledge and experience to provide "optimum healthcare" to our patients.  Over the first few days, I can't possibly know more than the bare minimum about each patient, so I'm constantly left fumbling through my own notes and patient charts and computerized lab values to try to figure out what's going on and how best to address the issues that emerge in rapid succession.  I write myself long "To Do" lists of charts to review and tests to follow up on, but at the end of the first few days there are always more things left behind than checked off, and I am inevitably left feeling like a failure.

Which is why I'm awake at 3 am, much to the delight of the cat who is curled into my thigh and enjoying the unexpected middle of the night cuddles.  My dreams have been invaded by a continuous loop of images from the past two days, and I've been lying half-awake in bed going through a mental checklist of patient issues, searching for things I've missed or could have done better.  My middle of the night anxiety isn't helped by the fact that the ward has had bad luck over the past two days and, through no fault of anyone, a number of patients have done very poorly.  The continuous loop focuses mostly on the codes and the pre-codes, questioning my decisions, wondering what I could've done better or faster or with more self confidence.  Wondering if I could've made a difference for the people who won't make it home for the holidays.

This will get better.  I know this from experience.  The second day was already better than the first, as my familiarity with patients and my understanding of the strengths and weaknesses of my team members was exponentially higher.  But the whole rotation will nonetheless be stressful, four weeks of constantly feeling behind where I should be, not enough for the trainees and nursing staff and attendings and ultimately the patients who are looking to me for guidance and for care. 

When I hear or read of people who criticize doctors, who dismiss us as indifferent and money-grubbing and arrogant, I wish they could sit with me now, at 3 am.  I wish they could inhabit my dreams, which are filled with columns of lab values and images of CT scans and tables of vital signs, and know how much I think about my patients.  I wish they could feel the pain in my stomach, taste the chalky peppermint of the Tums that I chew like candies, and know how seriously I take the work I do.  I wish they could see me wiping away tears before I compose myself enough to tell a previously healthy young woman that she's dying and know how invested I am in the outcomes of the people who entrust me with their care.  I understand that there are doctors out there who are bad and uncaring, but I'm not one of them.

So now I wait, for my mind to still enough to make another attempt at sleep.  Writing this post, exposing my weaknesses and fears for the entire electronic world to view, helps.  Because I know that many of the people reading this have been through exactly the same thing, and that there are a few who are also awake at 3 am, thinking, worrying, hoping.

Signs that it's a Terrible, Horrible, No Good, Very Bad First Day on the Ward

1)  You need to comfort a crying team member before rounds have even started.
2)  You get your first patient complaint ever.  From a patient you haven't even met.
3)  In the middle of a code, the ICU attending asks "Is this the patient you wanted us to assess for admission?", and you reply "No, that would be her roommate."
4)  Two out of the three remaining team members end up crying before sign out rounds.
5)  You start crying the moment Joni Mitchell's River starts playing on the radio while driving home.

Can I go back to Hepatology now?

An Atheist at Christmas

 
The timing of this post is perhaps a bit odd, given that I just devoted an entire post to stories of alcohol-infused egg nog and photos of my Christmas tree, but this is a thought that's been weighing on my mind lately, so I thought I'd try to get it down in a post.  Before I get into any talk about religion, I want to add the disclaimer that I don't want to offend anyone with what I write here.  I recognize that these are my own personal beliefs, not necessarily the "truth", and that everyone is entitled to their own beliefs.  I don't mean for this post to be disrespectful in any way towards people who do believe in God.

This year marks the first Christmas that I've considered myself to be an atheist.  For decades, probably since I was seven or eight and heard the term for the first time, I've always thought of myself as an agnostic.  I never felt that I could know whether there was or wasn't a God with any sort of certainty, so agnosticism to me was a comfortable state of non-belief.  As I've gotten older, however, my beliefs about life and the universe have tipped further and further towards the atheist side of the scale.  Medicine in particular has done this; through my training, I've been witness to incredible unfairness and suffering that, to me, isn't consistent with the idea of a compassionate supreme being.

The tipping point for me came while reading The God Delusion by Richard Dawkins while on holidays in Hawaii earlier this year.  (Because apparently I'm incapable of reading light, mindless books, even when surrounded by some of the most amazing natural beauty in the world.)  I won't get into the relative merits or flaws of the book (there are 1751 customer reviews that address them if you're interested), but what struck me about the book was Dawkins's comparison between a belief in God (or belief that there isn't a God) and a belief in a scientific theory.  To paraphrase badly, Dawkins says that a person will claim a belief in a scientific theory not because they know with 100% certainty that it's true, but rather because they feel that the balance of evidence is strongly in favour of that theory.  Similarly with atheism, a person doesn't have to "know" that there isn't a God to be an atheist, but simply needs to feel that the balance of evidence is strongly in favour of there not being a God.  Reading that, and believing that the balance of evidence was towards there not being a God, was enough for me to switch from calling myself an agnostic to calling myself an atheist.

All of which is a long way of getting to my point about being an atheist at Christmas.  Being an agnostic at Christmas wasn't all that hard, because even though I wasn't convinced about the religious significance of the holiday, I was still open to the possibility that it was true.  I could still go to church and sing Christmas carols and participate in the holiday with some spiritual meaning behind what I was doing.  But as an atheist, that's gone.  Suddenly a holiday that I've celebrated my entire life feels devoid of any meaning to me.  In some ways, I feel like a fraud to be celebrating the holiday at all; it's as if Christmas isn't really mine to celebrate anymore.

Surprisingly, to me at least, this feels like a huge loss.  Christmas has always been one of the most magical times of the year for me - a time of sparkling lights and favourite homemade treats and endless visiting with family.  And while none of the external aspects of Christmas have changed, the internal purpose and feeling behind it has.  I wish in some ways that I could rewind time, unread The God Delusion and unsee the suffering of my patients, so that I could go back to a point in time when I still wasn't convinced that God existed, but I also wasn't convinced that God didn't exist*.

Heck...while we're at it, I'd like to rewind to a point in time when my Dad was still alive.  Because to me, nothing epitomized Christmas more than sitting next to my Dad on the couch, egg nog in hand, as he put the scratchy John Lennon album on the record player and played Happy Christmas (War Is Over) for the first time of the holiday season.

Happy Christmas Dad.

*I realize that this is one of the most awkward sentences ever written.  It sounded good in my head when I wrote it, and now I can't come up with a better way of phrasing it.  Hopefully you'll forgive me and my tired brain for such terrible writing.

It's Beginning to Look a Lot Like Christmas

My Mom came over for dinner and tree decorating tonight.  And maybe a bit of egg nog.  I didn't have any rum, so I used Bailey's Irish Cream instead.  Very tasty.

I'm starting to feel much more Christmassy after listening to some Christmas music and putting up the tree.

Here's the very tasty dinner of short ribs that I used to bribe my Mom for her services:

Some of the ornaments (old and new) adorning my tree:

A handmade ornament made by my mom decades ago:

And one made by me:

An angel made from sea glass:

It's me!

A reindeer from the Little Travellers Project in South Africa:

Very tired kitty cats after such an eventful day:

I'm now enjoying the last few minutes of my weekend with a cat at my side and a tree shimmering in the corner.

If you celebrate Christmas, how are your preparations coming?

Another Reason to Love Hepatology

I'm on hepatology home call for the weekend, and I finally understand why it's called "home" call.  I haven't been paged once.  I can hardly begin to describe how welcome an entire day without work is right now.

When I woke up this morning (at 9:30!), I got inspired by Sarah's post at the SHU box and wrote myself an ambitious "To Do" list.  Look at all the productive things that I was planning to do!

In the real world, however, I didn't get much farther than lunch with A, who is out of the hospital on a pass again this weekend.  We spent about two hours at a favourite breakfast spot (not this spot, but just as good) and then wandered across the street to a coffee shop where we spent another two hours drinking candy cane hot chocolate.  It was divine.  I haven't seen A in two weeks, so there was a lot of catching up to do.  She's looking better than the last time I saw her, and she's feeling more hopeful, all of which is good to see.

I did get the meal plan written and the groceries purchased.  I decided to keep the meal plan pretty simple this week (i.e. mostly leftovers) because I have about a month's worth of frozen dinners in my freezer that I need to start eating.  It's wonderful to have some backup food so that I don't need to depend on takeout for nourishment.  Here, for your reading pleasure, is my meal plan for week #7.

Saturday:  Pork Pie with Oka Mash (from Canadian Living).  Yum, yum, yum.
Sunday:  Short Ribs with Mushrooms and Red Wine Sauce (also from Canadian Living).  I'm trying something fancier than usual, as my mom is coming for dinner.
Monday, Tuesday, Thursday, Friday:  Leftovers!
Wednesday:  Birthday dinner (not mine) with friends at a local Asian fusion restaurant.

The pork pie involved a lot of peeling and chopping and sauteing and baking, but it was definitely worth it in the end.  Way tastier than standard shepherd's pie.  I made it with smoked gouda instead of oka cheese, as my regular grocery store doesn't carry oka cheese, and I was not willing to drive half an hour to go to a store that does.  I think it was a perfectly acceptable substitute.

Everything else on the "To Do" list is going to have to wait, as my brain and my body are both in need of some recharging.  Rather than tackling my pile of dictations or heading to the mall (ahhhhhhh) to shop for Christmas gifts, I'm going to watch the Big Bang Theory and eat dessert.

Here's hoping that there are no hepatological emergencies tonight and that everyone is enjoying their weekend as much as I am.  This is definitely a day that I'm not going to wish away.

Unexpected

I'm currently eight days into a thirteen-day-long hepatology elective.  When I was signing up for electives at the beginning of the year, hepatology was near the bottom of my list, something I ranked at all only because I'd heard the teaching was good and because it sounded far less boring than many of the other choices.  (I'm looking at you geriatrics.  And allergy and immunology.)  When I saw that I'd gotten hepatology instead of some of my higher-ranked choices, I was a bit disappointed, but I didn't think too much of it.  I figured it would be a good chance to brush up on my approach to liver enzymes, and the slower pace would be a nice break after two long weeks of night float.

I had no idea how much I'd enjoy it.

The patients we see on consults are far more complex and interesting than the straightforward alcoholic/viral/autoimmune hepatitis patients that internal medicine routinely manages on the wards.  They often have multiple processes contributing to their liver disease, such as accelerated cirrhosis from hepatitis B and D co-infection, or from ongoing alcohol use on top of chronic hepatitis C infection.  Or they have multiple complications of their liver disease that make treatment challenging, such as a patient whose blood is clotting too much, causing clot formation in his portal vein, but simultaneously not enough, causing him to ooze blood from his iv sites.  The complexities of the field are far more exciting to me than I expected.

What I'm enjoying even more though are the social issues that come to the forefront in hepatology.  I've always had a strong interest in how factors outside of the healthcare system, the so-called "determinants of health", influence a person's health and well being, and I'm reminded of the centrality of these factors to health in my weekly viral hepatology clinic.  Most of the clinic patients are hepatitis B-positive, usually as a result of being born in an endemic region where crowded living conditions and lack of access to healthcare perpetuate the spread of disease.  And now that they've emigrated to Canada, their ability to access appropriate care is impaired by their lack of understanding of the system and the fact that they speak a different language from the healthcare providers.  (Note to self, learn to speak at least rudimentary Tagalog.)  The remainder of the clinic patients are hepatitis C-positive, usually as a result of either brief experimentation with iv drugs at a time when hepatitis C was common in North America or long-term heavy iv drug use.  As I read through Gabor Mate's In the Realm of Hungry Ghosts, I'm reminded of the many societal, familial, and personal factors that lead a person into drug use and, unfortunately, to complications such as hepatitis C.

Reflecting on my brief stint in hepatology, I'm realizing that it has many of the things I'm looking for in a career.  Intellectual challenges.  A patient population that I enjoy working with.  Opportunities to influence healthcare policy and systems on a larger scale.  I'm enjoying it so much that the wheels are turning in my head, pondering whether this is something I could do long-term.  It's a bit of a shock to me to be in this position, as this is the first time in residency that something other than oncology or hematology has really caught my interest and made me question the path I'm on.

Ironically, I officially started telling people that I'm going to apply for an oncology fellowship about two weeks ago.

Ah...isn't life interesting?  If nothing else, it keeps us on our toes with its never ending twists.

Anticipation

I am happy to report that, minutes after publishing my previous post, I crawled into bed and slept uninterrupted for 10 hours.  It was glorious.  I awoke the next day feeling somewhat alert and capable of intelligent thought for the first time since I finished night float.  It's amazing the difference that rest makes.

Despite getting somewhat caught up on sleep, I'm still eagerly awaiting my next day off (currently 9 days away).  Every morning I do a quick tally in my head, counting up the days behind me and the slowly diminishing number of days to come.  And I long for it to go faster so that I can have a day without alarm clocks or patients or attendings or piles of charts to dictate.

Recently, it got me thinking to the fact that I spend a lot of my time longing for time to go faster.  During the week, I long for the weekend.  During a rotation that I'm not enjoying, I long for it to be over and the next one to start.  And I'm always longing for vacation, which at the moment is almost 3 months away.  I'm always looking ahead, always wanting to be through with the current moment so that I can move on to something better.  And in the process, I seem to be wishing my life away.

I don't know if there's any way to stop this.  I want to be more present in the moment, to appreciate the things that I'm doing now, but it seems to be human nature to always long for something better.  It doesn't help that I seem to always be tired, and stressed, and overwhelmed.  Days off are like tiny islands of calm within the turbulent sea that is residency, so I suppose it's not surprising that I'm always wishing for one.  But I wish sometimes that it didn't have to be this way.

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Now that I'm somewhat more rested, I've been trying to stick to my December goal of limiting my electronic media to 1 1/2 hours per day.  And I've been failing miserably.  I tend to read blogs in the morning while eating breakfast, to watch tv while eating supper, and to watch tv/read blogs/write blog posts at the end of the day as a way of destressing, all of which adds up to more than 1 1/2 hours.  I debated stubbornly pushing ahead with my goal, but I realized that doing so wouldn't free up that much extra time, as most of my electronic media time overlaps with things that I have to do anyway.  So, in the interest of my own happiness, I'm abandoning that aspect of my December goal.  I am, however, sticking with what I think is the more important aspect of my goal - to stop checking emails/Facebook/blog stats while doing other things (like studying).  I think I lose a lot of efficiency and waste a lot of time by frequently interrupting my studying, so I'm hopeful that this will help.

Aaaand....I seem to be losing all capacity for intelligent thought as the sleepiness hits me once again.  Time to watch the end of Project Runway (no intelligent thought required), pack some of my leftovers for tomorrow's lunch, and then go to bed.

Consistency

Today marks the fifth evening in a row that I've fallen asleep on my couch, and the third night in a row that I've done it in front of Parenthood.  Either I'm really tired or the show is really bad.  I wouldn't know, as I'm usually out before Bob Dylan starts singing the theme song.

More interesting and coherent posts to come when I get caught up on sleep.  See you all around Christmas.

What Meal Plan?

Normally I can handle tired.  After all, a person doesn't make it to their second year of residency without learning how to push through sleep deprivation.  But the post-night float tired is a completely different beast from ordinary tired.  When making the transition back to a normal sleep schedule, my body, having become fully accustomed to sleeping during the day, will simply ignore the will of my conscious mind and fall asleep whenever there's a lull in activity.  During a talk on airway management.  While waiting for dinner to heat up in the microwave.  Five minutes into the recently downloaded pilot of Parenthood.  The last two days have been about the closest thing to narcolepsy that I'll (hopefully) ever experience.

As a result of this nearly irresistible urge to sleep, I haven't kept up with any of my goals.  My lovely and not overly ambitious meal plan for the week has given way to dinner out with my mom, McDonald's, and takeout from a local Italian market.  I have probably kept to my 1 1/2 hour per day limit on tv and internet, but only because I fall asleep whenever I try to do either.  If sleeping in front of the tv counts, I'm definitely over.  I hate this.  I want to be able to follow through on the goals I set for myself, or at least be conscious to enjoy some of my free time this weekend.  Grumble, grumble, grumble. 

Ah well...this will be over soon.  By the end of the week, I'll be sleeping at night and awake during the day like a normal person.  Hopefully then I'll be able to cook myself real food and open a textbook without inadvertently using it as a pillow.  And write a real blog post - I have dozens of half-composed posts on interesting (to me at least) subjects bouncing around in my head, but I haven't the mental focus to get any of them down.  In particular, I started reading Gabor Mate's In the Realm of Hungry Ghosts while awake during the night last weekend, and it has me ruminating on issues of addiction, resource allocation in medicine, social justice, and others.  Hopefully some of these thoughts will make it onto the screen before too long.  (Of course, I also have about four posts in my brain that stemmed from the Women In Medicine evening I attended over a month ago, so these new posts may not see the light of the internet until the new year.)

How is everyone out there in cyberspace doing?  Still bearing with me despite my recent posts in which I use a lot of words to basically just say "I'm tired and grouchy"?

This Day Brought To You By Caffeine

As excited as I am to be done night float, I hate the transition back to a normal sleep schedule.  Being a recalcitrant insomniac means that I don't adjust well to changes in my sleep schedule, and as I've said here before there's no bigger adjustment than switching from days to nights.  Having worked night float gives me a whole new level of respect for nurses and other people who work shift work on a regular basis.  I'm very glad it's you/them and not me who does this all the time.

Yesterday I had the brilliant idea to sleep less during the day in the hope that I would sleep more during the night.  Not so much.  I got about 3 hours of sleep during the day and then spent my evening in a grouchy fog, trying to be a civil daughter to my Mom who had driven into the city to visit me.  I put on a decent show, but internally I was annoyed by things that normally wouldn't phase me - the poor service and loud music at the restaurant we went to, my Mom's perfectly reasonable request to look something up on my computer, my Mom's lack of interest in Tuesday night's Glee episode.  I was just cranky.

Going to bed, I initially did well thanks to utter exhaustion and a few sublingual melatonin pills.  But after about 4 hours of sleep, I was wide awake with no hope of drifting back into dreamland.  I lay in bed for a full three hours, hoping that by "calming my mind" and giving it time I would eventually fall back asleep, but it wasn't happening.  So here I am, a full 1 1/2 hours before I need to wake up, writing a blog post.  As much as I enjoy blogging, I would definitely rather be sleeping.

Looking forward to the next few weeks just makes me even grumpier.  This weekend is a two-day mandatory ICU course, which doesn't count as a "work weekend", so I'm on call the following weekend as well without being in violation of the call limits of our contract.  And then the weekend after that is part of the next rotation (and therefore next set of call limits), so guess what?  I'm on call.  Yep...coming off of nights, I'm now working a 21-day stretch with only one day off before Christmas.  Grump, grump, grump...

I will get through this, but it's going to hurt.  I hate the fact that mandatory exams and educational sessions don't count as "working weekends".  As a result of this loophole, I haven't had a weekend off except when I've been on night float since I got back from holidays in September.  And I still won't have a weekend off until the five days of Christmas holidays, when I will do my best to drink enough caffeinated beverages to be pleasant around my family.

Anyway...I have nothing more profound to say than that I'm not looking forward to this stretch and that sometimes I hate the demands that are placed on us as residents.  I understand fully that I signed up for a demanding career path and that this is just part of what is required of me, but I don't think I'm being unreasonable by wanting some time to sleep.  Or at least free Starbucks gift cards as a bonus for having a stupid call schedule.

Edited to add:  Knot Telling - one of my newer commenters and someone whose blog I read regularly - wrote a post inspired by my recent post about my pigeons of discontent.  It's a great post about becoming happy despite one's life circumstances, and I strongly suggest reading it and dropping her a quick comment on it.

On reflection, it's kind of ironic that I wrote a post recently about being fundamentally happy, while today I'm writing a grouchy post about working too much.  Apparently being fundamentally happy doesn't fully protect a person from the ups and downs of life (or of their inner psyche). 

Dedicated Snacking

3 am on night float (last one!):

1. Thought:  "I feel like chips.  Salt and vinegar kettle chips...mmmmm.  But I still haven't been to the bank, and I've exhausted the supply of loose change at the bottom of my school bag."
2. Walk from 6th floor internal medicine ward to residents' room on 5th floor to get bank card. 
3. Walk from residents' room on 5th floor to bank machine on 1st floor.
4. Take out $20 bill.
5. Walk back to 5th floor vending machine.  Discover that there are only Sun Chips and Smarties in vending machine.  Disappointment!
6. Remember that there is a vending machine on the 1st floor.  Right next to the bank machine.
7. Walk back to the 1st floor vending machine.  Discover that there are only Sun Chips, Old Dutch potato chips, and Hershey's chocolate bars.  Feel sense of despair.
8. Remember that there is a vending machine on the 3rd floor next to labour and delivery.
9. Walk to the 3rd floor vending machine.  Discover salt and vinegar kettle chips.  Success!
10. Discover that 3rd floor vending machine does not take bills.  Contemplate kicking in glass of vending machine out of desperation.
11. Remember that there is a drink machine on the 1st floor that takes bills and gives coins as change.  Hatch a new plan!
12. Walk back to the 1st floor and visit the drink machine.  Discover that it only takes $5 and $10 bills.  Suspect that the universe is mocking you.
13. Walk back to the 5th floor vending machine and discover that it takes $20 bills.  Yay!  Buy a box of Smarties to hide in your backpack for a future date and cradle the precious change in your hand.
14. Walk back to the 3rd floor vending machine and buy the hard-earned salt and vinegar kettle chips.  Success!
15. Walk back to the residents' room on the 5th floor.  Gleefully crack open the bag, anticipating your first bite of salty, sour, crunchy goodness.
16. Curse the universe when you're paged stat overhead to a code before you get to eat a single chip.  Defiantly shove three chips into your mouth and try not to choke while running down the stairs to the code.
17. Try not to think about chips while giving orders for resuscitation. 
18. Drag self wearily back to residents' room after code. 
19. Gaze lovingly at chips.
20. Finally eat chips.
21. Realize you weren't actually craving chips, you were just bored.
22. Realize that you're still bored.
23. Eat Smarties.