Merry Christmas! You have cancer!

Trauma CT

 

When bad things happen, radiologists tend to be the first to know. Anytime you ski into a tree, or drop your baby, or have a stroke, anytime you go to the ER and get an X-ray or CT or any kind of imaging, you are being seen by a radiologist who makes the diagnosis behind the scenes. In fact, with the exception of psychiatrists and dermatologists, I really can’t think of any doctors who could practice medicine as they know it without radiologists.

As a radiologist, my X-ray vision is skewed toward negative outcomes. Day after day, bad things happen to (presumably) good people. This year I worked the weekends of Thanksgiving, Christmas, and New Year’s, and I got to thinking about how many people had their lives ruined during the holidays.

On Thanksgiving, I saw a guy actively bleeding out from complications of a botched gallbladder surgery.

On Christmas Eve, I had to call several patients to tell them that they had breast cancer. I did my best to offer support and give them a plan for moving forward, but in the end there is just no appropriate way to say, “Merry Christmas! You have cancer!”

On New Year’s day, the first case I opened up was a head CT for a lady who went to sleep on New Year’s Eve and never woke up. She had a brain bleed larger than the brain that she had left.

Why do so many bad things happen on holidays, and especially on my shift? Because they happen every day. If I simply show up to work on a holiday, I am guaranteed to meet unfortunate people. And I’m also bound to interact with hospital staff who are grumpy about having to work on a holiday.

You can imagine that this can turn some radiologists pessimistic and paranoid. Our experiences tell us that skiing, horseback riding, and shoveling snow from rooftops are rash, often fatal, activities. So are pregnancy, driving long distances, and even walking down the street minding one’s own business. In our work, we never meet the thousands upon thousands of skiers who do not ski into trees.

Since I started radiology residency a year and a half ago, I haven’t done much writing about my job. I’ve been missing the meaningful interactions I used to have with patients as a medical student and Internal Medicine intern. No one who’s been through the process would say that medical school was a happy time, yet I wrote a book about all the times and places I found joy. Happiness was a commitment I made on a daily basis. I was really good at being happy!

The past year and a half have slowly taught me that even the most grounded and solidly-learned of lessons can be forgotten with disuse and complacency.

One of my Christmas cancer patients, on hearing the bad news, nevertheless told me how lucky she felt that I had been a part of her care. She said, “Dartmouth should be very glad to have you as part of the team. If you hadn’t been looking at my mammogram, who knows how much this cancer would have grown in another year.”

It had been one of the rare circumstances when, as a resident whose job is largely to duplicate the work of supervising physicians, I caught something subtle that my supervisor had missed. I had been feeling particularly ambitious that day, reading about twice as many mammograms as residents normally do in a day. I just felt an urge to push through all the patients that had been scanned that day. This patient came up near the end of my list. The “normal mammogram” report had already been sent out. We immediately called her back for further imaging and then for a biopsy, and sure enough, it was cancer.

It was the first time since starting residency that I thought, “Thank goodness I came to work today!”

I’ve since tried to take that attitude more often, acknowledging and valuing the good that I can bring to the patients who will never know I have been evaluating them. When I’m asked to interpret a study that feels too difficult, or contains a bad outcome, I try to remember that I may be contributing something that no one else can. And more often than not, I’ve felt grateful to have been there for that patient.

In 2016, I would like to renew my commitment to being happy in the things I have to do. Happiness is truly a choice. As I’ve learned, it’s a choice we must continue to make time and time again, no matter how well we think we’ve got the hang of it.

 

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Happy X-Ray Day!

On this day in 1895, Wilhelm Conrad Röntgen discovered the X-ray.

V0029523 X-ray of the bones of a hand with a ring on one finger

He was a physics professor in Germany, and had been working with cathode rays. His experiments involved discharging streams of electrons through various vacuum tube apparatuses. In one of these experiments, cathode rays were allowed to exit the vacuum tube through a thin aluminum window. He covered the aluminum with black cardboard to shield the fluorescent glow, yet he still noticed the beams escaping onto a barium platinocyanide detector plate several feet away. Figuring he had discovered a new form of radiation that could penetrate opaque objects, he called it “X,” the mathematical designation for the unknown.

After various repetitions of the experiment with different tubes and metals, he went on to take the first clinical X-ray: a picture of his wife’s hand. The produced image was of her skeleton, as X-rays could pass through human tissue but not through bone. When she saw the picture, she exclaimed, “I have seen my death!” This turned out to be a prophetic statement, as she and most of the scientists who played with X-rays in the early days would eventually die of cancer.

Röntgen initially continued his experiments in secret because he feared for his professional reputation if his observations were in error. He published his initial paper, “On a New Kind of Rays,” in December 1895, and by January 1896 the news of X-rays had swept the world. Soon commercial fluoroscopes came to common usage in such unlikely places as carnivals and shoe stores. At the same time, X-rays found their use in various clinical settings such as surgical operations and diagnosing bone fractures.

Röntgen was awarded the first-ever Nobel Prize in Physics, and is recognized as the father of Radiology. Indeed, the whole medical specialty grew up surrounding his technology, now encompassing fluoroscopy, computed tomography, mammography, ultrasound, nuclear medicine, and magnetic resonance imaging.

Level Up

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On my first day of Radiology residency, I was assigned a pager and a white coat with my name embroidered on it. I chuckled along with my fellow first-year radiology residents. “What are we supposed to do with these? Does anybody ever page a radiologist? What, will they want us to carry stethoscopes too?”

Now two months later, I find myself clinging dearly to any remnant or semblance of my former doctorhood!

It’s an abrupt and humbling change of pace, becoming a radiologist. Of all the medical specialties, this one is hands-down the hardest because it really is like nothing I’ve ever done in medical school, and I’m starting from scratch with minimal foundation from my previous education. I remember the daunting, sinking feeling I had while being told during orientation, “Don’t give up. You will see your senior residents nonchalantly spewing out diagnoses that you have never even heard of. Just keep studying.” After being at this so intensely for 5 years, how could there still be anything in medicine that I’ve never heard of?!

Only a couple weeks prior to this, as an Internal Medicine intern, I was running the hospital, making big decisions, receiving thanks left and right for saving patients’ lives, and frequently being reminded by my attendings how I was wasting my talent by going over to “the dark side.” Then all of a sudden, I was stripped of all my glory and confined to a dark room all day, doing something I sucked at and being told again that I was entitled to stupidity. To make matters worse, my first rotation was Fluoroscopy, which is not even like the rest of Radiology. The work involves acrobatic photography and heavy machinery; learning it is like learning to ride a bike in Boston during rush hour. Everyone was kind in helping me, but I couldn’t help anyone. My only dignity rested in micromanaging the lives of the Internal Medicine interns calling me for consultations; it was a pittance of consolation.

Since the beginning of July, I’ve been aching to be a good doctor again. All the studying is helping, but there is something more to be gained by experience—and in that regard, the years can’t pass quickly enough for my taste.

Thankfully, the learning curve is insanely steep, which means that I am constantly reaching new summits as I clamber my way up. It seems that every couple days I can look back and say I am drastically better than I was before. I owe a lot of this to the help of my senior residents; I am so impressed by them, and I’ve improved so much while trying to emulate them. The long list of things I’ve come to terms with over the last few weeks includes: abdominal radiographs, operating fluoroscopes, dictating reports when other people can hear, shouting out answers in large conferences, and talking to surgeons.

And lumbar punctures! Four weeks ago, I asked my neuroradiology fellow if I could observe him doing a lumbar puncture. An hour later, he insisted that I get right to performing my first lumbar puncture. I struggled through the next few, usually trumped by attendings who had the nasty habit of jumping in to complete the procedure. One attending asked in front of an already-nervous patient, “Does she even know how to use the fluoroscope?” I filed away these notable memories and kept asking for more. I just wanted to be good at something, even if it was something everyone else considered simple. In the second week, my goal was to do one without any physical help, and then without verbal help. In the third week, I started teaching my medical student to do the procedure. In the fourth week, I got to teach an attending who was out of practice. I went so far as to cut my own umbilical cord, telling my neuro fellow that I didn’t need him anymore (which I only hoped was true, knowing he wouldn’t let me live it down if it wasn’t). On my last day of the rotation, I did the whole thing alone within ten minutes, surprising an attending who had walked away expecting to see me still struggling when he got back.

Back when I first chose Radiology, I was attracted to “the intellectual challenge of having familiar concepts swept out from under my feet,” and now I get exactly what I wished for. Fluoroscopy is over. On Monday, I’ll be starting out as an idiot again; new rotation, new learning curve. I expect the stupidity cycle will continue for about six months before I get to revisit something I already know. At this rate, I guess I am starting to see how, in four years, I could totally be nonchalantly spewing out unheard-of diagnoses too.

Radiology Personal Statement

Two years ago, I embarked on the exhausting and exhilarating journey known as the 4th year of medical school, where residency programs and applicants court one another for a season and dreams are made or broken. As the newest generation of 4th year medical students (including a few of my own “doclings”) now bravely set forth on this path, I thought it would be appropriate to stand with them by doing something brave, too—publicly posting my personal statement. After all, it was through writing this personal statement that I became convinced I needed to apply for Radiology. I hope my words will prove helpful to at least a few people who feel, like I did, doubtful and overwhelmed at the start of a long year.

 

I am so happy to be choosing Radiology as the path to becoming the kind of doctor I’ve always envisioned: smart, cooperative, and compassionate.

I love that Radiology is “brainy,” requiring great mental power and flexibility. Radiologists are central to the practice of medicine, as diagnoses and treatments so often pivot on the proper understanding of imaging. Of course, as a proper Physics geek, I am intrigued by the technology that continually increases our ability to know more and diagnose more. But what I love most about being on the cutting edge is the intellectual challenge of having familiar concepts swept out from under my feet. It’s not enough to memorize the pathognomonic patterns—those may change along with advances in imaging modalities. For radiologists, there is a real advantage to reasoning by principles and not by rules; the difference being that a rule may forbid stepping off the roof, but the principle of gravity also extends to not jumping off a cliff.

I want to be a good colleague, one who uplifts and brings out the best in others. I’ve seen how a good radiologist can turn others into better doctors. During my Internal Medicine rotation, a very patient Radiology lecturer introduced me to the Physics principles of imaging and systematic approach to reading films, which opened my eyes to a new level of reasoning and sparked my interest in becoming a radiologist. In learning how shadows translate from densities, and densities from pathology, I finally began to illuminate what I previously saw as a mystery in medicine. I realized that there is an order and logic behind the shadows, revealing the answers to those who understand. I am excited not only to gain the diverse knowledge and skills that radiologists employ when consulted by physicians of all specialties, but also to continue working as part of a diverse team.

I want to be a good person, one who respects other people regardless of where they stand in the hierarchy. I love that Radiology, far from being an antisocial desk job, requires clinical skills and bedside manner. I was impressed that of all my mentors, it was a radiologist who stressed the importance of cleaning up my own sharps and treating nurses with respect, and who, in answer to a 90-year-old lady asking if he would recommend the thoracentesis, considered his own wife. Even though it may be easy to dehumanize the dozens of scans that populate the computer screen each day, I will not abandon my philosophy of what it means to be a doctor: to heal and affect positive change through personal relationships. I’m happy to know that a dark cubicle does not preclude this, but rather makes it even more important.

As I reviewed my experiences to choose my future, I realized that the answer lay much deeper than, “Do I like thinking or cutting? Do I want to treat diabetes or gallbladders?” What it took for me to love all my rotations was a good attitude, a strong work ethic, and a commitment to being happy. I know these qualities will serve me well in the difficulties that I will undoubtedly encounter in my career. Ultimately, my decision is based on the kind of person I want to be, and I look forward to residency as the next step in shaping that person. In this regard, I am seeking a program that will expand my boundaries, where I will grow intellectually, work as a productive member of a supportive team, and provide excellent patient care.

YOLO

Heralded by screaming lights, a man was dropped on our doorstep. Sepsis. Diabetic keto-acidosis. The brink of death.

He was also cachectic from decades of drug abuse and malnutrition, and didn’t have much reserve to fight the illness. He was struggling to breathe. He looked on with hollow eyes. We knew right away he wasn’t going to make it through the night.

Because the foreseeable outcome was so extremely grim, we were upfront in asking this man exactly what he wanted from this hospitalization: How did he want to die? Would he have us pave for him a comfortable end? Or would he have us wring out every last drop of frail existence before throwing in the rag?

To our surprise, he didn’t give us permission to let him go. In previous months, his life had been repeatedly spared in hospitals. But each time, he was restored to lessons unlearned—if he was better, he was better enough to overdose. So said his family, but he didn’t believe it.

So onward we fought.

These are Medicine’s most trying moments. I have sent off many people from this world, now—always when they’re ready, and sometimes when they’re not. It’s humbling and gratifying to be the last friend in a well-lived life, the one to bestow a parting IV and hospital blanket in the final glow of sunset. It’s frantic and dissonant to be the desperate arm over the cliff, the one obliged to hang on until the last futile chest compression. So often I’m assigned the latter role by patients with too many regrets in too little time.

Miracles are doled out too, in small packages of insulin and antibiotics. This man survived to wake up tied to a hospital bed, and—this is the miracle—to think to himself, “This ain’t me.”

The next few days were excruciatingly painful. We gathered everyone—patient, family, and doctors—to have a big heart-to-heart. The man expressed his resolve to come off all narcotics forever. The family had heard it all before. The medical team decided to test his resolve by taking away his pain medications gradually. We had legitimate reason to be skeptical, as he had legitimate reason to be in pain. Every morning, I asked about his pain. The answers went from “Okay” to “It’s 8 out of 10, but I can get used to anything” to “It was more than I could take last night, but I’m bound and determined to do this.” I don’t know how, but every day his smile grew wider and he was able to walk farther. All the while, his severe joint deformities were a constant reminder of his strength in coming face to face with this pain for the first time in so many years.

He later told me of the transformation that came over him. The morning light was breaking through the blinds. He was strapped at his waist. The nurses were eerily quiet in the hallway. He thought of what we had told him, that we expected him to die from the consequences of his habit. “I haven’t been scared since I was in Vietnam crawling through the jungle. But that night, I was ready to put on my street clothes and run!”

I don’t know if all this will last. But thanks to him, I’m willing to give a second chance to many more of my future patients. I wouldn’t have believed that, with either his body or his mind, he would make such a recovery. Now I’m starting to think I’m in Medicine to be proven wrong—and, in the process, to be made better.

Graveyards In A Hospital

I survived my first week of doctorhood! And, more importantly, so did my patients!

During one of our orientation lectures, we were told that as interns, we are “entitled to stupidity.” Despite all that we’ve been doing the past 4 grueling years, no one expects us to know anything right now. Therefore, we should take advantage of this time to ask questions and make mistakes… you know, as long as we don’t kill anybody.

Well, that’s awkward! In any other profession, I feel like “Don’t kill anybody” would be setting the bar pretty low. Granted, outside of medicine, customers generally aren’t dying to begin with; when people walk into a grocery store, they aren’t complaining of chest pain. But I’ve read enough textbooks and passed enough exams to know how not to kill any given patient, don’t you think?!

I changed my mind at about 3AM today.

My first shift covering the hospital’s Medicine service was overnight on a weekend, after a full regular workweek. Having never even pulled a true all-nighter in college or medical school, I had no idea how this would go. At 7PM I showed up to meet my day-shift counterpart. He was holding a handful of lists, and after about 5 minutes of brief introductions, all 25 or so patients on those lists became mine. That was a chilling moment!

I took the lists, and a slow deep breath. I asked, only half-jokingly, “Are you sure you trust me with all your patients?” He said, “Of course I trust you!”

By midnight I had admitted a couple more patients from the ER, written a handful of orders, and successfully fielded several pages from nurses. I’d finally gotten used to introducing myself as “Dr. Meservy,” and I was starting to feel like it too.

At 2AM, my fellow night intern and I were sitting side by side, typing up our notes on the new patients we’d admitted. I was trying to read up in the literature about my patients’ conditions so I could incorporate good reasoning into my notes. I was constantly interrupted by the pager. Neither of us could stop yawning. We agreed that pulling a life-saving all-nighter was just about the craziest thing anybody had ever expected us to do.

Shortly after 3AM, I received 3 consecutive pages from the same nurse. A critical lab value! Something might kill a patient! After calmly telling the nurse that I would call her right back, I ran over to my senior resident and asked, “WHAT ARE WE GONNA DO?!” Together we made a slew of fast decisions that ultimately reversed the danger and stabilized the patient. This was followed by more deep breaths and more note writing.

In the morning, our management was met with both praise and criticism. We did the right thing overall, but we overlooked some minor details and we didn’t meet everyone’s preferences. In the daylight, our little mistakes became blatant. But in the moment, we were scared and tired and didn’t have much time to act. If the situation had been more critical, with less room for error, maybe it would have made the difference between life and death for that person.

This all leaves me wondering, was it in a hospital that they came up with the term “graveyard” shift? Now I know: if somebody were to get killed, this is probably how and why!

Kids Say…

Shortly after my book was published, I was invited to speak to an elementary school class about what it takes to a book. I talked about plot creation and the publication process, and shared some of my stories.

The kids surprised me by writing some PRICELESS thank-you letters! Here are some of my favorite lines:

“I really like how you overcame being called a nerd and made fun of because you are Chinese. I think it is really awesome that you helped save a man from dying just from your knowledge in Chinese. That is very inspiring. Go nerd kids!!!”

“You showed me to be proud of who I am.”

“I am so thankful that you presented to our class about the most crucial elements to writing a book and how to go about it. It had fascinated me for months previously and I had been wondering how, and I had absolutely no idea at all!”

“How you incorporated your stories in with duck features, such as ‘worked my tail off,’ was great.”

“I do hope you become a famous author, or even a famous rich author!”

“I liked the story about the thought-to-be-crazy Mandarin person. I liked how you could save him from psycho treatment.”

“The stories that you told about the man who lost his tongue yet every day found something to smile about was sad and had a good morale. I hope I every day have something to smile about.”

“My cousin is in medical school. It sounds hard for her and it must have been even harder for you.”

 

So, it’s been a month since the book was launched, and I happen to know that roughly 200-300 people own copies of it! Has anyone finished reading it yet? What are your thoughts?