On surgery and confidence

I recently read an excerpt from Mindy Kaling’s upcoming book, “Why Not Me” in Glamour.  (At first, I skipped over the links on my facebook feed because in my mind I was like “Glamour?!” but when a few of my thoughtful friends reposted it I thought to myself, well, I might as well be informed.)  The article delves into Mindy’s secret to confidence:“Work hard, know your shit, show your shit, and then feel entitled.”

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This past year has been a steep learning curve for surgery.  Learning to use both hands in a tiny space and controlling the machines with my feet was fun on some days, and torture on others.  Over the months, there was a pattern in some of my feedback, where I was told that I was too “hesitant” or too “tentative” – all words pointing to this underlying thing: lack of confidence.  It wasn’t until my midterm review, when I brought it up, that I got a new perspective on it. I was reassured that I had good hands, but instead of focusing on how I would demonstrate confidence – my preceptors advised me to focus on anticipating the next step. Because, not everyone’s personalities will be the type that exudes confidence.  Some of us will work hard, will know our stuff, and yet – it can be detrimental, or a distraction, to focus on “showing confidence.”

I took their advice to heart and started to think about what my next steps are each time I was about to complete a step.  It reminded me of the multiple piano recitals and competitions growing up, where you build up a fluidity in the piece you’re performing because while your fingers were playing, part of you were thinking about the section that came next.

And so, I’ve started to build up a fluidity to surgery, and have noticed a change in my performance.  I am really thankful to teachers who are not only dedicated to teaching the surgery, but also teaching the student.

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If anyone asked me about confidence, I would add to Mindy’s advice.  It would be to know yourself, or talk to someone who does.

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On forgetting

I stumbled upon my own “facebook note” dated Mar 2009.  I wish I had included the people’s names I was referring to at each of the item when I wrote this note, almost eight years ago, because now I have forgotten.  I took a look at the list of people that I had tagged in the note, many whom I still talk to, but many whom I’ve lost touch with over the years.   I feel regretful that the details are faded now, and in some ways, even my words sound a bit like they’re coming from a stranger (I mean, why would I ever care how old Al Pacino is? And who would ever call me princess?)

But the note reminded me of all the things to be thankful for.

Thankful for those years of such warm memories and thankful for the many friendships that were the reason for them. Thankful for old friends and seeing each other grow.

I’ve included the note below.  If this little list brings back any good memories, send me a message!

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Dear Loo Friends,

Thanks for…

– calling me “princess” in a loving way
– preparing a lovely dinner of “sweet sensation” steak and red wine and skipping CCF
– staying up till 4 am playing bonanza, watching trailers on itunes, and googling how old Al Pacino is
– french toast, bacon, and scrambled eggs breakfast plus girl talk
– warm sunny saturday afternoon in williams chatting about everything
– classy dinner @ wildcraft including adventures in bosc pears, stilton cheese and lollipop cheesecakes; interruptions of blackberries and iphones, and bantering about the most INANE things
– chauffeuring me to and from my parties at 2 am
– visiting me in your pj’s even though you’re running a fever and coughing (and helping me with biological warfare by contaminating the asparagus)
– making me cook asparagus in the kitchen by myself while everyone else is eating dinner
– absolute spectacular party at sunnydale and fubar (Happy birthday dearest!!)
– giving up your room for two nights and sleeping on the couch
– a last minute road trip with one of the bestest filled with awesome conversations (mostly in point form)

 

On hitchhiking

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For two months I was at a loss of what to write. For me, writing begins with a story, and for some reason, my heart did not find itself a story.

But a few days ago, while we were stranded in the middle of nowhere waiting for a cab that was forty five minutes late and MIA, a story unfolded. One of my co-residents, in desperation that we were going to miss our flight, asked a local driving by if he could give us a ride. He was rejected. Unabashed, he asked another stranger, and this time the stranger agreed.

Ted (the stranger) got his car right away and went to an airport 25 miles out, in a not-too-familiar place. On the way we all chatted about our backgrounds, our hobbies, our stereotypes of each others’ countries (of course, being Canadians, we were diplomatic and didn’t say anything negative. Plus we didn’t want to risk getting left on the side of the highway). Thanks to him, we got to the airport on time.

His simple gesture restored my faith in humanity but also gave me pause. I can’t say confidently I would’ve done the same. I suspect it is a mixture of fear (I’m a tiny girl if you haven’t noticed) and this slight, nagging sense of an immense inconvenience/disruption to my otherwise-uneventful-but- oh-so-important day.

The second moment of inspiration, or the first, really – was my co-resident asking for help. I was too embarrassed/in denial/fearful of strangers to really believe he should be asking for a ride or that it would even work. But it did.

So I conclude the post that comes after my two months hiatus with two words for two instances: be brave – in giving and receiving help.

On aggression

Incident #1: 3 am.
CC: Rule out globe rupture.

Intoxicated 20 year old man, when told he didn’t need surgery called the resident a “f-ing ch-nk” and threatened to “sue her”.

Incident #2: 2 pm.
CC: Decreased vision “post-op”

45 year old man, punched a resident without provocation.

Incident #3: 5 pm.
CC: Can’t “focus” after head injury.

36 year old man told that his “nystagmus” was voluntary and not physiological. Yelled at the physician to go back to school. Shouted to the patients in the waiting room he wouldn’t even bring his dog here.

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These incidents happened at different times to different people. Thankfully, there was no lasting damage. But it quietly shook the (perhaps, naive) implicit trust I had in the physician-patient relationship, that somehow, because you are trying to help someone, they would not deliberately harm you or be hostile towards you.

In my sheltered world, I’ve never heard a racial slur said to me. And I never thought that I would hear it while providing medical care to someone. But the words were the least of it, he had torn his hospital gown off, and he was towering over me and I was all alone. And after security came, after he returned to ER, after all the detailed documentation in his chart… The overwhelming thought was not – how can someone do this to me or what consequences should he bear or even that the emergency department did not do due diligence to warn me… But blaming myself for being vulnerable.

I had tucked away this incident that had happened more than a year ago. But after witnessing incident #3, not as the direct target of those comments, I was reminded of that moment when I was powerless. Although my staff knew in advance that this was a potentially challenging situation and had asked me to stay in the examination room, all he could do after the confrontation was spend half an hour documenting what had happened.  He was clearly shaken, but he went on seeing the remaining patients.

In medical school, the only “training” I recall in dealing with these situations was a brief clinical exam station in diffusing an “aggressive” patient. The station always ended with the patient being calm again, and you got full marks for remaining professional….But no one ever touched on the aftermath.

Admittedly, these are rare encounters.  It is hard to prepare for them, and hard to process after.  Perhaps, the approach should be similar to what my staff did.  Be aware of potentially risky situations, be objective, and focus on the other patients who need your care.

 

On maintaining normalcy

I recently saw a man in follow up.  He had lost vision in his left eye progressively over the course of a few months, associated with pain, and he was told it was cataracts.  On follow up with his cataract surgeon, it was noted that his vision could not be improved more than counting fingers.  He was referred and assessed urgently for giant cell arteritis/temporal arteritis.  He had a known history of prostate cancer with metastases to the spine.  When I assessed him, he had more than just vision loss.  He was proptotic and had restricted motility.  Urgent imaging was ordered for him.  It was found that he had multiple mets to the bony area around the orbital apex, a region where important nerves for vision and eye movement emerged.

But when I saw him again, his primary concern wasn’t the cancer that was causing these problems, or that he was on palliative radiation and chemotherapy, it was on how the cataract surgery looked. When I told him that his lens was nicely in place, he said, “Good, can you write that in a note to my optometrist? I’m going to see her next week and I’d like her to know.”

At first I thought, he just doesn’t get it.  Then I realized, no, it was me – I didn’t get it.  I didn’t get that he was maintaining a normalcy in his life – of caring about the seemingly-irrelevant details and of going to appointments that aren’t centred on his cancer.  If I were in his shoes, I probably would let my illness and my prognosis define me.  But instead, this man went on as best as he can with “normal life” – knowing that one day it would end  – but why let it end now by obsessing over the inevitable?

 

On dying

 

My grandma passed away in April of last year.  The first question many people ask is, “Was it unexpected?” In fact, it wasn’t.  It was inevitable, she had spent the last year dying.  Shortly falling a hospital admission for suspected TIA, she then suffered a hip fracture.  Even though the hip fracture was repaired immediately, she never recovered.

In medical school, we were  taught that there was a 50% one-year mortality rate following a hip fracture.

She was the one, in one in two.  She was bed-bound, then developed pressure ulcers, and somewhere in between she stopped eating.  On most of our visits over the last year, she rarely acknowledged us.  Only nodded, said our names, and then drifted back into her sleep.  It was inevitable, but the permanence of death is always shocking.

My last memory of her was four days prior to her death.  My mom had just come back from her one month trip.  When we got there, the nurse was trying desperately to clean my grandma but no amount of artificial air freshener, or the biting cold wind that blew in from the wide open window, could mask the stench of diarrhea and decaying flesh.  That day, we stood silently by her bed, willing her to acknowledge us with a word, but she was too weak.  In our overly bright voices we exclaimed, “Grandma, we’re here to visit you, we’re here! we’re here!” She opened her eyes, nodded, and closed it again.

My grandma, speechless and immobile, weighing forty-five pounds.

My grandma, who loved to eat.  Who would always order way too much at dim sum.  My grandma, who had random zingers, like the time when my uncle had injured his leg playing hockey and she said, “don’t you think you’re too old to play with those who are half your age?” My grandma, who despite having very poor vision would take the ttc on a weekly basis from Finch/401 to chinatown.  My grandma, who once got lost, and speaking no English at all, found herself at a police station in whitby and produced her church bulletin so that the police officer could call her pastor and arrange for someone to pick her up.  My grandma, who didn’t seem to remember much except all ten grandchildrens’ and four great-grandchildren’s birthdays every year.  My grandma, who baby-sat my cousins and I when we were babies.  My grandma, who had no money, but would fight to pay for the meal and be ready with a generous red pocket for every birthday.

My grandma always said, I’m ready to go anytime, but I hope I could die in my sleep. 

It speaks to what a rich life she had lived and how she had no regrets.  And this is how I will remember her.

To pause

One of my “goals” this year is to write at least once a month.   Residency has been such a whirlwind, and days have become weeks, become months, and a year and half after my last entry, I realize I have been drifting through experiences without processing them.

Last week, I bumped into a first year on my way to do an enucleation.  I was pleasantly surprised by her enthusiasm to join me, as I myself was dreading the awful smell and cold of the morgue. There is a medicine mantra of see one, do one, teach one – so after I showed her how to do the enucleation on one eye, it was her turn.  As she struggled to put in the eye speculum and was mortified at her own struggle, I was struck by how easy it was to forget.  To forget, how the “simplest” things are the most intimidating; to forget, that the thought of “they’re-judging-me-even-though-they’re-not-judging-me-and-it’s-all-in-my-head” can keep circling in your mind over the silliest manoeuvres; to forget, that it’s so easy to catastrophize the little mistakes of innocence and of inconsequence as a defining sign that you suck; to forget, that one day the biggest challenge may become a mastered skill and a not-so-scary thing; to forget, that the reason why residency training is five years is so you can learn and do the best for your patients.

As I approach my surgical years with great trepidation, I know that I will encounter daily moments of self-doubt and feeling defeated.  I may encounter those who have forgotten what it was like, on that first day, to be handed the instruments and expected to “do” – but here’s to hoping that I will remember that I am here to learn and to do the best for my patients.

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PS.  Also, to remember the sense of wonderment at simple things in life.  Check out this video of a fifteen-month baby girl – in the rain for the first time! http://vimeo.com/m/84802749