Why I Chose Radiology

One night, months or years ago, my husband looked up from a collection of short stories he was reading, and said, “This one is interesting. The protagonist is a radiologist.”

To this, I laughed out loud. “Why would the protagonist be a radiologist?”

Judging by the lukewarm reactions I’ve received this year when I’ve told people that I was going into Radiology, I suppose most people feel the same way I did: that there is nothing interesting about a radiologist.

Don’t get me wrong, I absolutely adore Radiology and honestly feel that I’ve made the best possible career choice. But, given that my interest in Radiology did sneak up on me at the last minute after I’d already changed my mind half a dozen times between other specialties, perhaps I owe everyone an explanation.

In the beginning, as I’ve mentioned, my intention was to be a neurosurgeon. I never felt like it would give me the life I envisioned, but the work sounded challenging and heroic, and that was what brought me to medical school. I quickly realized that being away from my family for 120 hours a week was even less tolerable than I imagined. The neurosurgeons I met on my Surgery rotation, though very nice, made it clear to me that working one-third time (a normal 40-hour workweek) was not acceptable, even for a woman. In fact, I got the impression that having ovaries was entirely incongruent with Neurosurgery—people simply didn’t make time for babies and lives in that field. A Surgery resident gave me this valuable piece of advice: “Is there anything else that you like besides Surgery? Because you should do that instead.”

Then I thought for sure I would be a psychiatrist. I loved brains. Surgery was invasive, but Psychiatry was also invasive. Coming from a Psychology undergrad, analyzing people was second nature to me. The patients were interesting beyond belief, and I found plenty to write about, so I knew it would make an entertaining career. In particular, I felt at home with the idea of being a child psychiatrist—I had a knack for working with children, and I was inspired by their ability to heal and overcome. But I did not know just how difficult it would be. Halfway into my Child Psychiatry rotation, I was exhibiting symptoms of PTSD. I begrudgingly admitted that I did not have the mental resources to cope with the side effects of being a child psychiatrist.

Next on my list of “brainy specialties” was Neurology. I considered it only briefly. It wasn’t part of the curriculum, so I didn’t get a fair chance to explore it beyond my dealings with stroke and seizure patients. From what I gathered, the diagnostic aspect of Neurology was highly complex and elegant. But the treatment aspect was almost non-existent—for all the time spent figuring out exactly which part of the brain was damaged, there was usually nothing to be done about it.

From there, Pediatrics was a no-brainer (you guessed it—pun intended.) Cute sick kids, stuffed-animal stethoscope covers, doctors acting goofy in exchange for a peaceful listen to the heart and lungs. The idea of being happy all the time won me over almost instantly. Plus, this opened a new slew of possibilities for subspecialties: Pediatric Cardiology, Pediatric Endocrinology, Pediatric Whatever-ology. Since each of these would entail an additional three-year fellowship after residency, I was secretly buying myself more time to really decide what I wanted to be. (What? I like to dilly-dally over life-changing decisions!) It was a great plan, and I felt confident enough to start telling everybody about my decision. This was mid-January of my third year, and many of my classmates were jealous that I’d made up my mind so early. I went forward with it, collecting recommendation letters and setting up visiting internships, until August.

Because I kept telling myself that I loved children and hated adults, as pediatricians tend to do, I thought I was destined to hate my Internal Medicine rotation. As it turned out, I loved Internal Medicine because it was the first rotation in all of my medical training where I felt like I was personally and legitimately a doctor. Much of that feeling came from being introduced to the systematic approach to reading a chest X-ray. We were taught by a pulmonologist whose hobbies happened to include Radiology and Physics. He opened his first lecture with a discussion of radiographic density. I believe “density” was the word that changed my destiny—it activated my inner Physics geek and thereby illuminated what had previously been a black box.

Radiology is glossed over in medical school. This is a mistake, because Radiology is ubiquitous and crucial to the practice of medicine—rarely is a diagnosis made without some kind of imaging. I may not have considered radiologists to be real doctors at the time, but I wasn’t about to call myself a full-fledged doctor if I didn’t have a proper understanding of Radiology. So I scheduled two full months of it right in the beginning of my fourth year.

Those two months were tumultuous. I started out with a lukewarm feeling: The work was engaging to varying degrees depending on who was teaching me, and sitting in a dark room all day was marginally tolerable. I often felt like I was watching other people play a video game that I didn’t understand. That is, until one of the radiologists handed me a textbook to leaf through when times were slow. It was the best book I’d ever read in medical school, and I was raving about it to my husband when he asked for the millionth time if I was going into Radiology already. (My husband is himself a huge fan of Radiology.) I retorted that I did not come to medical school just to sit in an office and be nobody’s doctor. But as I became more and more intrigued by what I was learning, I found myself in a dilemma. I started to question my commitment to Pediatrics, and indeed my whole paradigm of doctoring.

It was at this time that I re-read some of my old blog posts to start compiling this book, and I came across a piece I’d written about how to choose a specialty, called “How To Make Lifelong Decisions: Don’t Compare Apples to Oranges. Just Make the Lemonade.” I had forgotten all about this, and it took me completely by surprise. Apparently, I had figured out at some point that choosing a specialty wasn’t about the nature of the work so much as about the kind of person I wanted to be—and I knew, undeniably, that radiologists were exactly the kind of people I wanted to emulate. Besides being the smartest of the smart, radiologists were sensible, sociable, happy, and generally wonderful to work with. And they all loved their families very much.

So then my gears were churning frantically. I only had a couple weeks left to submit my residency applications, and I had everything set up for Pediatrics. Radiology is a much more competitive specialty, and I frankly wasn’t sure if I would be able to get in, especially with such little preparation. I finally came to the Dean of Student Affairs, Dr. Dupey, whom I consider the “Sorting Hat” of my medical school and to whom I give full credit for ensuring that we all match into residency. She looked at my credentials and gave me the thumbs up! I still wasn’t 100% ready to burn the bridge on Pediatrics, so she challenged me to write a personal statement for both (which I’ve included in the following pages.) I found it extremely easy to say why I wanted to go into Pediatrics; that essay took me about an hour. The Radiology one took me an entire weekend. I thought really hard, I got frustrated that my writing was inadequate to express my feelings, and I cried a lot. But when I emerged from this process, I was convinced that, one way or another, I would be a radiologist.

Seven grueling months later, I opened an envelope that fulfilled all my hopes and made all the trials worthwhile: I am going to Dartmouth to become a radiologist!

Advertisements

Woohoo! I made 3 sales!

I must admit, being an author is pretty awkward!

The book was launched this week, as many of you know. But then again, many also don’t know, because I’ve been absolutely terrible about spreading the word. That is my flaw #1 as an author: I am afraid. I tremble at the thought of anything that resembles self-promotion in any way. Instead, I expect everyone I know to read my mind and to ask me about my book so I don’t have to be the one to bring it up in conversation. Anyone who doesn’t read my mind in this way, I assume would not be interested in reading my book.

I even had a book signing! I was told a little bit beforehand about what this would be like for an unknown author. Basically, I would be sitting at a table with my pen and stack of books, and people passing by would try their best to avoid eye contact. Well, my event was part of the medical school graduation festivities, sponsored by a local health foundation, and took place at an art gallery; each of these organizations brought in guests who obviously took a special interest in the art of healing. There were three other medical students showcasing their works of art as well, so we all had families and friends in attendance. Notwithstanding the unusually safe and supportive environment, I still at times had the experience described above.

What I find so dreadful about this new experience is the constant guilt about “selling something,” EVEN THOUGH I’m donating all of the proceeds to charity and I won’t see a penny of it myself! I have loved writing and sharing my stories over the past two years, and I am extremely proud of having accomplished one of my lifelong dreams of writing a book. It was a tremendous amount of work compared to writing blog posts. But suddenly, I’ve turned from an awesome writer to a saleswoman. Seems a little counter-productive, doesn’t it?

Let me just say I’m really glad that I have a real job where I earn a living by showing up and doing what I’ve agreed to do. If my life were to depend on me selling my writing, I’m confident that I would just starve to death.

Trauma, Death, and the Big Picture

In reading this eulogy of Steve Jobs written by his sister, I was tickled to learn that on his ICU bed, Steve was inventing hospital gadgets.
One time when Steve had contracted a tenacious pneumonia his doctor forbid everything — even ice. We were in a standard I.C.U. unit. Steve, who generally disliked cutting in line or dropping his own name, confessed that this once, he’d like to be treated a little specially.

I told him: Steve, this is special treatment.

He leaned over to me, and said: “I want it to be a little more special.”

Intubated, when he couldn’t talk, he asked for a notepad. He sketched devices to hold an iPad in a hospital bed. He designed new fluid monitors and x-ray equipment. He redrew that not-quite-special-enough hospital unit.

For the really big, big things, you have to trust me, he wrote on his sketchpad. He looked up. You have to.

By that, he meant that we should disobey the doctors and give him a piece of ice.

I just came off my first overnight call in the Trauma ICU, after working 31 hours straight. This sketch of Steve is just like the patients I’ve met this week: can’t eat, can’t breathe, can’t move, but would like to go back to skydiving ASAP.

I think there are generally two types of ICU patients. There are the vegetables subsisting on life support, and the rest are feisty. The bull-rider with multiple spine fractures insists on bull-riding again the next day, even as he struggles to sit up. The teenager, whose ATV accident required brain surgery, asks me every hour whether we can take out the tube draining the bleed within his skull: “Will it be later today? Not ’til tomorrow? I can’t sleep with this thing coming out the back of my head.” As I write this, a man whose brain is exposed by gaping holes in his head, is trying to pull out every IV and monitor and walk right out of the hospital.

It seems as though these patients have an entirely different set of priorities than their doctors have for them. We want to manage their fluids and electrolytes. We want to make sure they have an airway. We want to save them from dying of pneumonia, of ischemic bowel, of cardiac arrest. But all they want is to continue whatever they were doing that landed them in the hospital in the first place. Don’t they learn from their mistakes, and don’t they realize that they can’t live without these devices and measures we are taking for them?

But as damaging as it can be to a doctor’s ego, I get it. I don’t believe our work is more important than the lives we save. We bring out the defibrillators and ventilators to make people continue living, but that is not what I consider “saving a life.” People don’t live to have normal potassium levels measured in their blood. People live to bull fight, to dirt bike, to invent computers, to be home with their family.

Obviously the basic needs have to be met in the hospital. It can be a cruel process, and patients may not get that ice cube after they’ve already starved for days, but we take great consideration in the treatment plan and believe that what we’re doing is for the best. But after the healing is done, when bodily functions return to baseline, then what? Our story ends with the hospital discharge.

But the hospital discharge is the beginning of a longer road to recovery and life. Lots of changes and arrangements have to be made at home. The patient may be a burden to their family for a long time yet. That is why, beyond getting to leave the hospital bed, my hope is that these patients can survive to the next time they can do what brings them joy, whether it’s strapping on a parachute or bouncing their child on their knee. To me, that’s when their life has truly been saved, not a moment sooner.

Passage

A husband and wife were about to bring their baby into the world. She lay across the surgery table. He sat with scrubs, cap and mask, anxiously waiting by her side. She grinned, even as her eyes glistened with tears. He spoke reassuringly as he squeezed her arm.

They had imagined this day over and over. Within minutes, with this birth, their lives would change forever.

A curtain of sterile draping fell between her head and abdomen, separating the excited parents from the hectic operation about to take place on the other side.

It was my first day in the OR since Anatomy dissections. She looked strikingly like a cadaver, except that she actually bled—multiple suction tubes flooded with blood. The OB with a flock of residents were frantically cutting, digging, and cauterizing.

“This is the uterus,” they held up something huge and nodded at me. When they pierced it, amniotic fluid gushed out as if a hose had exploded.

From the chaos they pulled out a small bundle. The nurses rushed to it with a bulb syringe and sucked the fluid from its mouth. Then it began to cry.

The dad stood up when he heard the sound. First his head emerged above the curtain, and then a video camera pointed in our direction.

I gasped. Everyone froze. Without missing a beat, the doctor held up the baby, smiling at the camera. Nurses quickly wiped off the blood. Then they swept the baby off to a table along the side of the room, and the video camera followed.

Work on the mother resumed. Placenta out, uterus closed, skin stapled.

The whole thing only took about 20 minutes. Nothing went wrong. It was a great case for a first-time medical student. And I found it to be horrific.

Only a thin veil separated the family’s experience from ours. For them, a beautiful beginning of a new life together. For us, cutting and sewing and blood and guts. I almost felt it was out of place to say congratulations.

This is how I was born into the world of Medicine. I was thrown in headfirst, unprepared and alone. I would learn, over the years, that some of life’s most precious experiences—birth, healing, death—are gruesome. I would witness many more than my share of such moments, again and again, as part of the routine of my career. I would struggle to find the beauty in the madness of this reality. Yet I would find it.

Running With IV Poles

I wish I could show you a picture of this young couple huddled over the side of a crib. Their faces were clouded with deep concern. Their baby had spent the greater part of 4 or 5 years in various hospitals, for treatment of a multitude of problems. His endocrine problem, which brought us into the treatment team, was the least of these. Even though we were only monitoring one lab value, we came by to check on this little patient every day. Every single time, we walked into this same scene with his devoted parents huddled over his crib.

I wish I could show you a picture of this child. Like so many Pediatric Endocrine patients, he was tiny for his age. He lay floppy in his bed, barely able to move his claw-like limbs. And he had these fascinating buggy eyes that seemed to stare in opposite directions.

Parenting is complicated, of course. There are many tremendous tasks associated with caring for a child, and despite excellent efforts, children don’t always turn out as one hopes or predicts.  But, seriously, no one could have been prepared for this! And yet, I have never seen any parents who loved their kid more than these brave people loved this poor child.

Pediatrics can be a tragic, heartbreaking field to work in, especially at a tertiary care center like UCSF (where I’m currently visiting). Every patient has several big problems. Too many will die shortly. Families have to split time between the hospital and the life they want. Parents put off their education, their careers, their relationships, their other children. They drag on in these horribly straining circumstances for months, years, indefinitely—until their trials end abruptly in the death of the little one. So many times a day I wonder how all these families make it through such times.

The beauty of Pediatrics is getting to be a part of these stories, to see example after example of courage and resilience, and to help bear these huge burdens in some small way. It’s the little head poking around the IV pole, shouting, “Excuse me, Doctor, I can’t see the TV!” It’s the five-year-old grinning when asked about his new diabetes, then running over to bite his brother’s head. It’s the sigh and nod of a tired mother writing down the dosages of yet another new medication regimen. It’s the gorgeous young couple huddling over the crib of their severely-deformed son.

The beauty of Medicine in general is seeing people in the most unimaginably horrific circumstances, and realizing, they are just people. They are not a list of diagnoses. They are not limited in their ability to be happy.

To Fight

Have you ever had a doctor break down and cry with you as you received bad news? Sometimes I have to work really hard not to be that doctor.

Each day in Oncology clinic, I see all the stages of grief. Everyone battles cancer completely differently, and I get to experience it all as one giant roller coaster.

One minute an old woman comes in after her last round of chemo left her hospitalized. She absolutely insists on taking another round. Her doctors hesitate to give her more chemo and radiation than she could tolerate, yet she refuses to go to the grave without having pulled out all the guns. The defiance in her eyes is contagious. I want to shout, “Yeah!! Go get ’em!”

Next thing we see a young man whose cancer had no business interrupting the course of a well-plotted life. He’s already nauseated just worrying over how the treatments will affect his family. He and his wife raise a slew of questions, exploring every crevice of every possibility. Our uncertainty makes them visibly uneasy: Curing cancer is a numbers game, from our perspective. But for each individual patient, we either achieve a cure or we do not—and the side effects are definitely not worth it for a not-cure. I wonder if he might talk himself out of getting any treatment at all.

Then we get a happily oblivious patient, a guy with brain tumors so far gone that he no longer has the capacity to understand his own plight. We try to explain that he needs to take his chemo pills diligently. He smiles pleasantly and agrees, indicating that he clearly won’t do anything of the sort. While this is truly terrifying to me, part of me also thinks that perhaps, for a cancer patient, he is in the best of all worlds.

The tearful patient really gets to me. Someone had given her false hopes about her prognosis, so then it became our job to set the record straight. The doctor apologizes profusely. The patient retreats into heaves and sobs as she begins to mourn her own death all over again. In her mind, we have just killed her. I hand her a box of tissues—inadequate for the gravity of the situation. Yet she smiles briefly as she takes the box from me. We continue the conversation as she empties the box. Pagers ring, and we silence them without answering. Occasionally I stare at the ceiling so the tears won’t crash down.

Where in my medical training was I supposed to learn how to let a patient die? How do I tell the dark news, and then, how do I react? Do I grieve the disease, or do I fight it? What does the patient need to hear? Is it inappropriate to laugh with them? To cry? Is it unprofessional to admit that the cancer, in beating the patient, is also beating the doctors?

What is a good doctor?

How My Book Got Its Name

I wondered for a whole year what I was going to title my book, and suddenly, “The Ugly Docling” came to mind. I think it’s fitting on many levels.

For one, the Ugly Duckling is the story of a nerd kid who grows up to be a doctor (or engineer, or astronaut, or member of any profession that draws from the smart kid pool.)

I’ve been a misfit since elementary school. First it was because I was an immigrant, had an odd name, wore different clothes, and didn’t speak the language. But even after I grew accustomed to American culture, I still struggled with being a nerd. I tried so often to dumb myself down so I could be accepted by other kids. I wanted people to know that I was a musician, a poet, and a tennis player, but I would be mortified if anyone found out that I was in MathCounts or Academic Olympics. And though I spent way too much time trying, I never had nice hair. For me, this one was tough; high school is all about the hair.

Fast forward to medical school: Everybody is a smartypants. Everybody is charismatic. Everybody has nice hair. Well, almost. When we tell people that we are going to be doctors, they react with kind words of admiration, appreciation, and respect. (And then they show us skin lesions for diagnosis.) Yet, when I found my old MathCounts roster and pointed out that a couple of my classmates were on it, they were mortified. It really is bittersweet to look back on those years. But hey, let’s face it: doctors don’t just pop out of thin air; they were Mathletes when they were little! Nobody makes fun of a doctor. So why are American kids taught to make fun of nerds? I consider this book to be a big hug for my young self—and for nerd kids everywhere. Nerd kids: It gets better!

But my personal Ugly Duckling story continued even after I met up with the other swans in medical school.

Perhaps because of our common unspoken background as nerds, the culture in medical school is reversed. We admire and compliment each other for knowing the right answer at the right time. We fear being laughed at when we act ignorant or incompetent. Some may brag about how they never study, but they are either lying or willfully endangering lives and mocking the practice of medicine, and the rest of us know in our hearts that we would never refer our own patients to those individuals.

It was in this culture that I realized I may still be a misfit. Yes, of course I have studied my tail off, and of course I want other students to think of me as being a stellar student. But to the degree that I still have gaps in my knowledge, I question my doctoring skills. When I get an answer wrong, I question if all my classmates are smarter than me, if I can be a good doctor, if other doctors will want to refer their patients to me. For the first couple of years, I focused so much on test scores as measures of my doctoring skills. But then, when the exams were over and I was thrown into the real world of hospitals and clinics, I was humbled to learn so many things that were never taught in the medical classroom. These are the things that I felt moved to write about.