I write a lot about surreal happenings in and around the hospital because I feel like if I don’t get them down on paper, maybe, they didn’t happen, and in my head, I know that they did, so I must create some solid proof of this fact. I have said this before, and I’ll say it again, the only thing that makes this job survivable is the surreal unrealism that surrounds us on a daily basis.

When I was a third year resident, I rotated through a certain infamous state institution as the “medical senior,” which sounds really fancy, but is secret code for “the bitch.” Said state institution is one of those places that stands isolated atop a scenic hill, amidst beautiful greenery, and has murky urban legendry and old wives’ tales floating in the moat that surrounds it.

It’s block shaped, and made of solid red brick, the walls lined with beady barred windows. Inside, it’s clean, but decorated very a la 1950s. Puke green dotted epoxy festively adorns the floors, and the walls a covered by a sensible washable matching tile – in case someone does, indeed, puke. I imagine.

The place had 8 different kinds of psychiatric units. You’d never know there were that many, but once you start listing them, it makes all the sense in the world, for all the different flavors of crazy out there: regular lock down psych; geri psych; med-psych (when they have a medical problem too); behavioral psych; addiction psych… these are some of them.

The crown jewel of the place, though, was the prison ward.

A tiny window with a push-out pull-in drawer marked the spot right next to the steel door with one of those wheels on them. You’d hand in your ID – why? Oh, so that in case there was a hostage situation, the police would know who’s in there – and your phones before going in. Once that was done, the door would open, and you’d step into a tween room. The door behind you would close, and the metal bars in front would then open. Then, the guards would lead you down the hallway halfway, with a second set of guards taking over at the halfway point to take you to the end.

The guards were special. As a relatively cute girl, I wasn’t sure whether to be more afraid of the guards or the prisoners, but I generally wore my best pajamas and buttoned my white coat from toes to nose. Just in case.

Once, there was a female prisoner. She didn’t look much like a female, but she came from a ladies’ prison, so I know it has to be true. She needed a special convoy, and bathroom accompaniment for her activities of daily living. I guess that makes total sense, but it’s bizarre in the moment.

Another time, there was a young man, not a prisoner, who’d sneak out to the corner, or rather, to the bottom of the scenic driveway, where there was a known druggie pit stop, and sell off hoarded percs to the folks getting out of the methadone clinic.

Another young prisoner would lick and spit into his IV thereby inducing horrendous life-threatening bacteremias, which ended up in him developing a severe case of endocarditis, but at least it kept him out of jail. We figured this out after the third episode of shaking chills and profound sweats, and MRSA in the blood, directly temporally related to placement of a central line catheter. Lo and behold, IM antibiotics put an end to the problem.

My favorite case of me not being able to keep my mouth shut was when a prisoner arrived with epididymitis (testicle infection), which is basically an STD. So, you’ve yourself an STD, I told him. His response? How’m I gonna have that, I been incarcerated for 2 years. I think I said, Well, stop having sex in prison…. I may have said, “ass sex,” I’m not sure. Sexual harrassment doesn’t apply in the prison hospital.

The prisoners were pretty funny, but so were the nurses. The most common answer to any question in that place was, “yes, I think I remember somebody said something…” in a distinct tropical accent.

One day, we all got to talking. As the “medical senior,” I lead a crack team of 4 random interns collected from indentured hospitals in the area, 1 PA student and several pharmacists around, and technically answered to an attending, most of whom were questionable at best, and therefore best avoided. But this one day, we all got to talking; we were discussing tatooage. The prisoners’ tattooage. The subject of that omni-present tear tattoo came up, and I said that it means they’ve killed someone. The attending just would not believe me. She just couldn’t. You see, because our delicate medical sensibilities must be protected, we weren’t really allowed to know what our patients did, lest we allow personal feelings affect our clinical sense.

(This worked most of the time, except when you’d be taking care of the sweetest little old man and his cancerous prostate, and then suddenly find out that he’s been incarcerated for the past 40 years, and has 40 more to go. What does one think in those circumstances?)

But the tear tattoo really got under this attending’s skin, so she went as far as to ask of the patients. The one she picked happened to be a young kid, who was in after having been caught “partying” by the cops, and while at the pound, or the holding cell or whatever they call it, he was discovered to have an IV line from a previous hospital stay somewhere else, unclear exactly what happened there, but we can only assume that the “partying” took place directly via the conveniently placed IV access.

The kid was a punk. I gotta say. Skinny weasly little punk, whose main problem and crime probably WAS his punkedness; I can’t imagine that his ass killed anyone, but there it was, a distinct tear tattoo. So, when she asked him if it’s true that it meant he’s killed, he acted mostly embarrassed and refused to talk. Then, we googled it, and much to her chagrin, yes, it was true. The punk kid, though, I’d bet he was a poser.

This story has not point other than the fact that if a whole place can be one giant iceberg of surreality, maybe there is still hope for survival.

As physicians, we have to become relatively hardened to the misfortunes of others because if we don’t, we will fall apart. Again, it’s like that Ray Bradbury story about the being who’d morph into someone you lost to make you happy; eventually, too many people needed him, and he melted…

Every once in a while, though, someone just gets to you, the barriers collapse, you stop seeing them as a patient, and start seeing them as a person. I hate when that happens.

When I was an intern on Onc, I had a patient who had colon cancer; he was in for… something… I don’t recall. He was a nice man. Halfway through his state, he suddenly lost his eyesight – temporarily – as a side effect of his chemo. He was extremely distressed about that, obviously. He kept saying, “But I’m an engineer!” His wife was a nurse in the PACU, and she’d come visit him, and chat with the floor nurses. He was just like any other patient.

Until one night I was going home, dropping off the last of my notes at 6 or 7 o’clock, and I wanted to pop in and check on him. I found him sitting up in bed, lights off, watching Law and Order, and eating something out of a Glad Tupperware, with a plastic knife and fork. I said something along the lines of, oh, homecooked meal? “Bonnie made it,” he said. “She knows hospital food isn’t great.” And he smiled kind of awkwardly out of the corner of his mouth…

That one moment, it just killed me. I felt such a squeezing, aching empathy? vicarious pain? intense discomfort? that I had to back out of the room quickly to hide my tears. Cried on the T on the way home. Why? nothing changed; he was still the same patient. Something about that moment, though, where I saw him from a more private, unguarded angle… It hurt.

I don’t know what happened to him.

I now have another patient, who has a pretty bad illness. I think he reminds me of a family member. Something about his profile. He’s been cheerful and pleasant; he walks up and down the hall with his IV pole, dragging the johnny strings on the floor behind him. But he’s having complications after complications. The ERCP that was done to relieve his symptoms made him worse, and he can’t get treated for his original illness because of it. He said yesterday, when I asked him about his great attitutde, “I know I have cancer. But I don’t feel like I have cancer.”

I suddenly felt that very same pinch and ache. And I just don’t think I can deal with it today.

I need to know right now why it is that no one seems to feel obligated to do their work. I mean, I’m SORRY if I called in a tech to do a procedure, and the patient is having chest pain, so the procedure is delayed, and the tech has to sit around and wait. You can just go right ahead and save the eye rolling and under-your-breath swearing for your mother, ok? You’re on call and you get paid for this, paid EXTRA, I should say, while the attending and I are here, and we don’t leave until everyone is tucked in.

The worst part is, I have this overwhelming urge to pander and apologize, so that everyone likes me again.

What should I have done? Tell the patient not to have chest pain? Get the cardiologists to drop all their other patients with heart attacks to come see this one? Or just go ahead and undertake a risky procedure so YOU can go home on time??

I mean, fuck, we’re talking about taking care of people! So unbunch your panties, please, and grant us with the favor of doing your job!

This title is totally tongue in cheek, in case you couldn’t tell. It’s like those books: “What to expect in pregnancy.” As if all the things that could happen in pregnancy can be neatly rolled into a 300 pages of printable cuteness!

Well, medical school is definitely not cuteness, and definitely cannot be summarized in 1000 words or less, but all med schools across the US have a similar skeleton and anatomy (get it? I know, I crack myself up too), so I thought I’d outline it.

MS1
The worst year. It repeats a lot of your college courses, such as biochemistry and physiology, but in more detail and with more multiple choice.  The infamous anatomy lab where you will play with the pickled people takes place this year.  

First year sucks because it is a far distance away from actual medicine or actual doctoring for the most part, although you do get to take some classes that allow the medical school to advertise “early clinical exposure!” (that is what everyone looks for when applying, and after starting, try to avoid so as to be able to concentrate on actual studying…)

Interesting classes you get to take:
1. Introduction to clinical medicine – here, you will learn how to properly interview a patient hitting all the important points of the medical history, and how to present in rounds without sounding like a blabbering idiot. PLUS, and this is an added bonus, you learn how to be an attentive and sensitive physician. (keep an open posture, lean slightly forward, never cross your arms. Nod your head, and once in a while, say: “This must be very frustrating/difficult/painful/confusing to you. “)
2. Human sexuality – I’m serious! We had a professor who was just perfect for teaching human sex. His name was Bernie Bernstein; he was an elderly Long Island Jewish guy in a tweed jacket and a (usually crooked) bow tie. I can’t think of what beats hearing him explain the stages of the “Female ooooogasm.”
3. Medical ethics – this course is a brain twister. Like a tongue twister for the brain. It hurts. No answers, just philosophizing. Discuss euthanasia… discuss HIPPA… discuss Terri Schiavo (well, she wasn’t around when I was taking this course, but something similar was discussed).  Discuss discuss discuss… ad nauseum discuss.

MS2
Slightly closer to what you hope to be allowed to do one day, so more interesting and relevant, but also, much more vast and voluminous. The amount of information you have to read and internalize is staggering. Really. I wouldn’t be surprised, for example, if the pathophysiology of athersclerotic plaque formation replaces, say, your best friend’s date of birth. Or if cephalosporins, their mechanism of action, spectrum of coverage and various generations, take over the space in your brain previously occupied by your phone number and address.

This is when none of your time is actually yours; anything you do that’s not studying, is taking away from studying.

Of course, there are some people who might not have had that exact experience. In fact, I have one specific frenemy in mind. We accidentally met the summer after first year, each at a different school, and I said, expecting commiseration, although, honestly, I don’t know why I would: “So, that was overwhelming!” Her answer: “I don’t know why people say medical school is overwhelming. Whatever! I wanted to work hard! I knew I’d be working hard! And I am always done studying by 8.”

Hint: NEVER EVER say stuff like that to other medical students, or they will kill you. If not with their bare hands, then with their look of death.

Step 1
The United States Medical Licensing Examination has 3 and a half steps. Step 1 is taken between 2nd and 3rd years, ie before you make the move into actual clinical medicine. Step 2 is taken after your clinical years and Step 3 at some point in your residency, probably after intern year. These tests are 8 hours of pure computerized hell.

Let me digress for a few minutes. I had this friend, and she turned out to be the first of my friends to have a baby when we were still pretty young. Naturally, I was curious about how bad is it, really. I mean, when the baby comes out, your poor vagina, that’s gotta hurt like hell!!

She answered, “Oh, no way, pushing the baby out is a pleasant relief, like a good bowel movement! It the contractions that suck…”

Back to my story. Sitting at the computer taking the test is pleasantly relieving, like having a baby, or a bowel movement. The studying beforehand is what really sucks, especially for step 1.

MS3
You’ve passed step 1! You’ve been allowed on the floor. The main job of a third-year medical student is to follow their intern around. They’re encouraged to ask questions, but if they do, often, it’s turned right around and they’re given an assignment. You have to do the core rotations: Medicine, Surgery, Psychiatry, OB/GYN, Pediatrics and Family Medicine. The trouble is, unless you’re extremely good at faking interest, the rotations you don’t like are painful. Because you HAVE to look interested. The third-year medical student’s biggest sin is to not look interested. Or motivated. It’s a joke by now: “An interested and motivated individual would…”

MS4
A secret ploy to get us to pay more money!! You’re required to do some rotations, usually, you’ll do ones that pertain to the actual field you’ve chosen. But you end up with up to 5 months of nothing to do. Some people (ahem, gunners) will do useful things, like research. Others (ahem, moi) eat junk food and watch Law and Order. Yet others procreate. Tons of girls had babies at this point. Probably not a bad idea.

The Match
The match is a service that will literally match up residency programs with appropriate respective applicants. The AMCAS rears its ugly head. Once you’ve picked a field, secured 3 recommendation letters, and written a personal statement (My Korean grandmother didn’t understand that I wouldn’t be seeing patients. But for me, radiology is the noblest field.), you pick out the programs you want, click click click, and await interview invitations.

Interviews are more fun that the medical school interviews. For one thing, everywhere you go, you get food. Secondly, residents will try to suck up to you. Third, you get time off rotations to interview, so score!

Then, once you’ve had enough, and they’ve had enough of you, you fill out a rank list. I have known students to become literally suicidal over their rank list. Playing tricks with the list, trying to figure out if they can trick the match protocol into playing more into their favor…. But trying to guess the match protocol is like…. Trying to figure out the proverbial mysterious ways in which god works. It’s like that giant prophet from A Hitchhiker’s Guid to the Galaxy. After years and years of hard work and blinking lights, you get an answer. 4. How that answer came about, no one will ever know.

Match day is an exersize in restraint. Everyone gets together in the medschool auditorium. Tension is so palpable, and the air so thick, you can seriously cut it with a knife. Let’s just say, to make it through, we brought giant Nalgene water bottles filled with orange juice [and vodka]. You’re handed an envelope. Once everyone has theirs, someone says: GO! and everyone opens at the same time. The noise that follows is deafening.

Once that happens, you’re indentured for the next 3-6 years…

Well, if I get an audience, maybe there are some laypeople in said audience, who would like to be enlightened as to the process of becoming a doctor.  The process is long and rather painful, and often, people ask me how I can do it, and if I’d do it again.  Well, truth is, yes, it’s difficult, and you do end up losing some folks along the way.  But when you’re thrust into what’s basically a huge community across the entire country – and world – and everyone is doing the same thing you are, you sort of just… DO it.  Complaining and martyrdom become superfluous and unnecessary, because we’ve all been there.  And about those people you’ve lost?  No matter.  The ones who are worth it tend to stick around, and the weeds get… well… weeded out.

First things first.

Step 1: College
Carefree time to explore and find yourself, right?

Wrong. As a college student, you’re supposed to already know your calling into the medical field, and you’re supposed to start making waves about getting yourself there by taking pre-requisite classes. This is called being pre-med. The official purpose is to give you a scientific background; the real purpose is to get rid of those who didn’t really mean it, those who didn’t think it through, and those who just can’t hack it. The most powerful machete that chops off the most significant chunk of weaklings is Organic Chemistry (twitch twitch). I still (twitch) have a (twitch sleepless night twitch twitch) serious tick when I think about it (alkane twitch).

If you did not think that far ahead, and decide to go to med school after college, there are special post-baccaulaureate programs available that offer the same pre-med courses. Some come with a master’s degree, others don’t, but the bottom line is the same: more studying and more money. A year in a post-bac costs more or less the same amount of money as a year in college, plus an unspecified amount of stress, nerves and years off your life. The pressure of being around only other pre-meds who want to knock you down so they can take your spot in line to medical school can really really get to a person. So I’ve heard.

Step 2: the MCAT
The MCAT is the big entrance exam med school hopefuls endure around junior year of college. It basically reviews all you’ve learned via the pre-med courses, plus, it has a daunting verbal and essay section, which, again, is a setup to get rid of those who can’t hack it. “Loose lips sink ships.” Write an essay which will 1) explain the meaning of the phrase. 2) agree with the phrase and explain why. 3) offer reasons to disagree with phrase. 4) argue against those reasons.

Ready to stab yourself in the eye yet?

Most people will shell out good bucks to pay for a prep course. In my day, it was around $700; by now, I’d think it’s probably more like $1500.

Step 2a: Extracurricular interests
The weedout process works well. In the end, those who are left are all smart, motivated individuals who will all do anywhere from acceptably well to exceptionally in their schoolwork. So, you have to do something else to make yourself seem especially motivated, mature and doctor-like.

May we suggest, volunteering at a hospital? Doesn’t really matter what you do. You can be bringing cookies to junkies, as long as you’ve got the word “hospital” somewhere, you’re good. Research works, too. Doesn’t have to be anything great. You can be washing test tubes as an undergrad, but you put yourself down as a research assistant and you’re golden. Gotta fluff up the CV.

Step 3: Enter AMCAS
American medical colleges applications service. Back in my day, this was a disk, nowadays all is done over the internets. The hard part is to write your personal essay: “Ever since I was a little girl, I used to count pills in grandma’s pillbox, and now I want to be a dermatologist.” The second hardest part is to collect worthy recommendation letters. Shameless pandering ensues.

The beauty of AMCAS is that you can just click on the schools you want, so you can basically shoot for the stars. Harvard, sure! Yale, Standford… umm West Bumfuck as safety… Hawaii because I like the ocean… Colorado because I enjoy skiing… But realize that after the initial black amount of $, it costs an addition blank amount per checked school. I paid around $500. It might be more now.

Then, and this is the best part, the schools send you what they call “secondary applications,” and what we lovingly christened “blackmail.” Technically, it’s so that they can find out more personal information about you, having already discounted some people that would not be getting in that year. In reality, these get sent to everyone. The basic premise of the secondary application is this: “Send us more money.” Sometimes, in fine print, it also says, “for show, please also answer this question: It takes a village to raise a child. Do you agree?”

Once you’ve done that, you sit and wait for interviews to come around.

Step 4: Interviewing
Buy a black suit. No, really. Black. At most, navy blue or dark grey. Other colors set you apart as “nutty.” And back in my day, the ladies, we had to wear skirt suits. That’s what everyone said. Apparently, a woman in trousers… is offputting.

Never ever answer the ubiquitous question, “Why do you want to be a doctor?” with the wishy washy “I want to help people.” [you wanna help people?! Help old ladies cross the street!” Come up with something original.

Interviews range in malignant potential. Some are friendly chats, and others are horrible. One of my interviewers grilled me: What does the surgeon general do?

Step 5: Hurry up and wait
Self explanatory.

Now you’re in. What did you get yourself into?

Stay tuned…

When I was an intern in the MICU, we had a tragic case of a 40 year old Cambodian woman who died from a pulmonary hemorrhage due to an underlying malignancy (I think, a lymphoma). She died just around 7 am, when the team was arriving, and preparing for that morning’s rounds. We found the post call team wild-eyed and exhausted after trying to save her all night.

So, the team, including the big attending, the smaller fellow, 4 residents, 2 interns, 1 medical student, 1 pharmacist, 1 pharmacy intern, and a dietician is gathering around to start rounds. Suddenly the door swings open, and down the long MICU hallway, two men literally carry in, feet dragging on the linoleum floor, an older woman, and another man. The dead woman’s family, her mother and husband. As they drag down the endless hallway, they wail. Absolute bone chilling cries of grief, pain, loss and despair. They wail in their native language, but it doesn’t matter, because all of us understand the international language of pain. Plus, it’s their culture. Outward grief.

Rounds can’t go on like this because no one can think.

We have no choice but to watch this sad procession – and it so happened that the dead woman’s room is all the way at the end of the hall. Other family members start to peek out of other patients’ rooms, and stay there, because no one can look away.

They keep dragging the wailing man and woman like rag dolls down the narrow hallway to the end.

They make it to the room. The nurse has barely had time to clean up signs of the night-long fight for the woman’s life… there is still crusted blood around her nose and breathing tube. The mother falls to her knees. The husband throws himself on the bed. The other two family members – they’re actually teenage boys, the patient’s sons, stand back, lowered gazes. The screams turn even more shrill. The nurse judiciously shuts the door and curtain, and the sounds become muffled, but by no means disappear.

Our team is speechless. I’m nauseous. This is month 3 of being a doctor. This is hour 1 of a 30 hour call. No one says anything.

“Do you ever become inured to this?” I finally ask the attending.
He says, “No. And if you do, it’s really time to call it quits.”

This blog’s beginning lies in the fact that I realized how vast and ridiculous my experiences with the medical field have been.

How insane, touching, infuriating, frustrating, cynical, difficult, all-consuming, rewarding, educational, unique, uniform, colorful, fascinating….  my life has been.

I can’t believe I have only shared it in small pieces.