he has some peculiar ideas. he vehemently counsels teenagers that they are not allowed to go on any dates until they graduate from college (so glad that i never asked him what age he gives the HPV shot! - the anti-venereal-warts shot, which is really the first anti-cancer shot, approved for girls starting at age 9). his version of "anticipatory guidance" (did you know that primary care doctors are all supposed to provide all parents and kids with 'anticipatory guidance'?) is to give a short list of things that are "bad." "don't watch television: television is bad." (i couldn't agree more, but i wouldn't, you know, say it like that - and i doubt he'd endorse my anticapitalist motivations.) "and no computer. stay off the internet." and he tells all parents, at the 2-month baby visit, that when the baby turns four months old they will have to "put baby in the crib every night and let them cry themselves to sleep. that's how they learn self-soothing." and he explains, "you have to do it before they start to get separation anxiety around six months." his patients are all white, upper-middle-class, breastfeeding, and somber.
not surprisingly, it gives me nightmares. i mean literally. i have bad dreams every night. just like when i was "learning about pediatrics in the inpatient setting."
i take my little girl, aged about 5, to my parents' house, where she is to stay for a while because i have an overwhelming workload in becoming a doctor that i have to try to get caught up on. she's playing on the floor while i'm getting ready to go, when she suddenly says, 'mom, can you look at my arm?' and when i look i see that that there's a little ulcer on her elbow, with a little bit of pus coming out, and as i examine it, the skin of her upper arm starts to split open, starting from the ulcer, and i can see the muscle and bone. i try to hold the split together with one hand, and the skin on her lower arm starts to split open, too. i tell her to wait here a minute, not to move a muscle, and i go running down the hall, calling to my mom that i need the car, i have to take her to the emergency room right away. as i run i see that the carpet is all rotten and ripped up, and there's a place where the plywood underneath is all torn up and broken and the wood is soft - you could punch a foot right through it - it's because there's a leak dripping from the ceiling above it, with a huge brown watermark; the railing along the stairs has fallen down and the rusty shards are sticking up like teeth; and even though it's an emergency, my parents just stare at me from the other room with their mouths open; something's wrong with them; they don't understand a word i'm saying.
i dropped out of the "behavioral medicine" track of my program.
i'm still studying it - independently - but i can't devote my few remaining months of training to observing people with terrible psychiatric illnesses that i will never treat, in (terrible) hospitals where i will never work. which means i can't complete the requirements for the track. which means i dropped out. i also dropped out of the maternity-care track, a few months ago, after doing the math and realizing i will never be able (as an MD) to do the kind of (non-hospital) maternity care i could in conscience do. i'm still studying it independently, because it's cool. i don't need to keep struggling, to earn an honorary certificate (which is all you get for pursuing a specialty track).
it all makes sense; it's not a big deal - except when i'm dreaming.
i'm living in a dilapidated mansion, as usual, and i've tried to grow a garden. it hasn't gone well. i've planted corn and green beans and tomatoes and, optimistically, flowers, all along a hedgerow. i figured they could use the support. i did not expect the hedge itself to rear up over them here at the end of the summer, thorny and dense, blocking out the sun. so i'm out there in the rain, trying to see if anything's salvageable; i'm getting wet while the ground under the hedgerow stays bone-dry; the plants are brown and stunted; none have borne, or obviously ever will bear, fruit. my advisor, the psychologist, is walking along, breaking off brittle dry stems of vegetable matter, saying, "how did you ever expect this to grow here?" i am very much ashamed.
i think about starting my own practice all the time. i'm so far in the closet, it's hard to even imagine finding the door. why a closet? because this desire, to be a solo-solo doctor, without even any nurses to handmaiden me, with a patient population so small i could fit them all in my backyard for a party, spending an hour at a time helping them figure out how to deal with their illness, or how to regain their wellness, is treated as naive and flower-child-y at best, and suspiciously disloyal at worst. it's not the "real medicine in today's economy" that i'm being trained for.
currently, as someone who is "almost done" (you can say that again), i'm trudging through days and days and days of fifteen-minute appointments with people who are really, really sick and scared and needy, trying not to dump a ton of the scutwork that i actually do need to learn (clean out this ear! repeat this blood pressure! show this patient to the lab!) on the nurses - as we're admonished over and over again to do, "just like you would in real practice." so i don't have time today to tell you that you're going to need a biopsy - or not need a biopsy - because i have too many fifteen-minute appointments today, and will be running two hours behind by the end. i'll try to call you tomorrow, even though i know you're sitting by the phone right now. it's not just you - multiply yourself by a hundred. or make that, multiply yourself by 2,465.
i keep catching myself asking myself how i can stand it. how, after all, do i do it? how do i keep from cracking under the pressure? or am i cracking? is this how you can tell you're cracking? when you start wondering how you're going to make it? not mention when you start asking yourself, daily - several times daily - if this whole idea was a terrible, terrible mistake.
i can't believe in it. i can't commit to this shitty level of care. i can't imitate my teachers. can't, can't, can't - but must, must, must - which in my psychology quickly turns into won't, won't, won't. and what if something goes wrong, and i can't open my own practice? then what? more of this? even more?
i'm at work and i see that my schedule is full with appointments for a family of ten, all who have achondroplasia (dwarfism). all are angry at being made to wait, because as usual i'm running behind. the first patient wants a prescription for testosterone to make his muscles bigger. i tell him i don't know if that is safe with his condition, but i'll do some research on it and get back to him, and finally flat refuse to write a prescription; he leaves even angrier than he arrived. the next patient is a kid, with his mom, who wants him to get growth hormone, and i tell her i don't think it will actually make him any bigger, and she's very VERY angry, and we have to talk (i talk, she argues) about it for a very long time. i check my schedule again, and see that the next patient, also with achondroplasia, is here for "acute chest pain," and has been waiting now for half an hour, and i look down the rest of the list and just despair.
i was on call on monday night. i got to the hospital at four in the afternoon, and found i was on with a medical student. this meant i would do all the work as well as show her how to do it as well. she would do work too, but none of it would be part of the medicolegal events of hospitalization, so it would be double the work instead of, as if i were on with an intern (who has a medical degree), half.
for some reason - the medical student said, "full moon?" - our little community hospital was doing land-office business. lots of interesting cases. "land-office business" and "interesting cases," to ordinary people, of course, mean a tall building chock-full of people engaged in their worst personal nightmares. to me, it meant that every two hours the emergency room called me with another admission, half to the intensive care unit.
let us all count our blessings that we do not have acute-on-chronic kidney failure plus flash pulmonary edema (how can you get the water out of the lungs, if you can't pee it out?), nor a (putative) busted arterio-venous malformation in our small intestine (the blood keeps pouring out the rectum, and we keep pouring it back in the vein - a jugular line, the last one that works), nor sickle cell disease rendering the blood supply to our lungs painfully ("painfully" in the literal sense) useless.
we've got THAT going for us, at least.
