Preliminary academic calendar

Finally, a preliminary academic calendar for the first semester has been posted. They have broken it up into two blocks:

1) Human Body: August 17 - October 19
2) Molecules to Medicine: October 20 - December 14

It's a relief to have concrete information so as to mentally prepare for what's in store, beyond the abstract "It's gonna be a lot of work."

Taking time for the self on the path to becoming a doctor

A friend forwarded me this NY Times article, "Taking Time for the Self on the Path to Becoming a Doctor," which addresses some very deep concerns that I have about how I will cope with the immense stresses of medical school, which another friend of mine aptly refers to as "dehumanizing." I think it's important to remember how vital it is that I have an anchor to reality, to sanity, throughout medical school and beyond.

By PAULINE W. CHEN, M.D.
Published: June 18, 2009

Over the next two weeks in hospitals and medical centers across the country, new medical school graduates will begin their internship. Among their many worries — moving to a new city, meeting new colleagues, adjusting to medical training — is a more profound, existential concern that had once plagued me.

Do I have to lose my self in order to become the doctor I want to be?

I learned the answer to that question partway through my internship. Not in the hospital but in the checkout line of a local grocery store.

The customer in front of me was an older woman — she wore a faux camel-hair coat and had hair dyed a matching color. I remember that she had wanted her groceries bagged in a particular fashion, but the sales clerk, a young woman with impossibly long pink acrylics, was perplexed by the woman’s demands.

I felt as if I had stepped into an avant-garde theatre production. Each time the young woman bagged the groceries, the older woman admonished her and asked her to go through the process yet again. The muscles of my jaw tightened with each round of bagging, and even though I was off for the day, all I could think was: I’ve got sick patients to take care of, I can’t wait for this!

Unable to bear it any longer, I stepped forward and bagged the woman’s groceries myself, shoving the plastic bags into her arms while resisting the urge to push her on her way. I imagined steam rising from my head as I ranted. But a part of me was as shocked as the people still standing in line. I had never lost my temper in a store, and I had never raised my voice in public. Now, a few months into internship and with a three-minute provocation, I had the capacity to act like a grizzly bear sprung loose from a trap.

I walked out of the store horrified. That night thinking back on the event, I grew more ashamed of my behavior. But I also realized that it was not the first time I had snapped. Over the previous months, I had thrown myself into my work and shunned everything I once enjoyed and nearly everyone I loved. I believed I needed to do so in order to become a surgeon.

But I had lost my self in the process, and the stress made me irritable. I was no longer the nonconfrontational person I once was.

I had, for example, raised my voice a couple of days earlier at a receptionist in the radiology department when she couldn’t schedule my patient for a CT scan. I had scolded a nurse who had had the misfortune of being the fifth person to page me as I scrambled to finish a procedure. And only a week prior, I had squabbled with my family after my mother innocently asked, "Why do you have to work so hard?"

According to a study from the Johns Hopkins University School of Medicine in Baltimore, I am far from the only doctor who has behaved this way. The researchers interviewed residents, or doctors in training, from seven different specialties and found that they set themselves up for burnout by accepting, even embracing, what they believed would be a temporary imbalance between the personal and professional aspects of their lives. While the young doctors interviewed defined well-being as a balance between all those parts, many felt that their medical training was so central to their ultimate sense of fulfillment that they were willing to live with whatever personal sacrifice was required, even if it meant a temporary loss of a sense of self.

I spoke to the lead author, Dr. Neda Ratanawongsa, who now practices general internal medicine at San Francisco General Hospital and is an assistant professor at the University of California, San Francisco.

“It’s partly a coping mechanism,” Dr. Ratanawongsa said. “We tell ourselves that we can do everything but not at the same time, so we are going to put off the thing that defines us as a person — time with children, running a marathon, painting, playing music — in order to get trained because being a doctor is also rewarding.”

That delayed gratification works well initially because residents believe it is only temporary. “A lot of what matters to residents at this time is the sense that they are learning to care for patients well and growing as doctors. They feel that what they are doing is going to be worth it.”

But when the imbalance persists for longer than initially expected, professional growth is not enough to sustain most young doctors. “The ones who are happier,” Dr. Ratanawongsa observed, "are the ones who have held on to one or two things and have said, ‘I’m not just another resident. I play the guitar, I run races, or I go home to family.’ They don’t do these things to the same extent as they did before residency, but they do them enough to maintain a sense of self.”

Residents who don’t find this balance are at risk of burnout, clinical depression or, more commonly, subtle forms of stress. “These residents may feel that even if they can give excellent care most of the time, there are times when they snap at a patient or don’t order a test fast enough because they are so burnt out."

Although her study focused on doctors in training, Dr. Ratanawongsa sees the same challenges among doctors who have finished and are currently practicing. “There is always this expectation that at some point things will turn around. The interns say, ‘When I finish internship and become a second-year resident, things will get better.’ The residents say, ‘When I finish training, I will finally have balance again.’ And doctors in practice may believe that they will find more balance once they have retired.”

The danger is that physicians may end up leaving the work force or will become less effective caregivers. Dr. Ratanawongsa suggests that doctors learn how to create a better sense of balance in their lives from the moment they begin training. “We are taught to put our patients before ourselves; it’s in our charter of professionalism. I agree with that, but I also think there has to be some sense that I matter, too, at some point. If something important is going on with our loved ones or with ourselves, we need to be able to advocate for ourselves. And we need time to reflect on who we are and where we are going.”

In the months after that incident at the grocery store, I continued to devote my life to my training — there was no other way to become the surgeon I wanted to be — but I also learned to find time for myself. Even 18 years later, I can still remember those moments away from work well — late morning breakfasts with the Sunday Times in hand at the greasy diner down the street from the hospital, glorious springtime drives in a friend’s used convertible, afternoons running on a boardwalk and walking along the beach. I lost a few extra hours of sleep each time I did something for myself; but in the end I, and my patients, would gain much more.

“My belief,” Dr. Ratanawongsa said, “is that doctors will have a greater capacity to know their patient as a person if they know themselves. That kind of knowledge requires a sense of balance and an understanding of why they chose to become a doctor. It comes down to their capacity to be an empathic, caring and compassionate provider; and it comes not from their medical knowledge but from their soul.”

“This is something we should never sacrifice, even temporarily.”

Financial Aid 2009-2010 Award Offer

I finally got my financial aid package, and man what a relief it was to know that my school is paid for. The package consists of a mix of Federal Subsidized Stafford, Unsubsidized Stafford, and Direct Grad PLUS (.PDF) loans.

None of these three loans require repayment while I am a student. Stafford loans subsidized by the government have a fixed interest rate at only 5.7% and do not start accruing interest until after graduation. Unsubsidized Stafford loans do not have this delayed interest accrual benefit, and their fixed interest rate is higher at 6.8%. Both Stafford loans have a 6 month grace period after graduation and before repayment starts. Direct Grad PLUS loans have the highest interest at 7.9%, also fixed, accrue interest immediately like the Unsubsidized Stafford loan, and its repayment grace period is only 2 months.

After my initial relief at knowing that the loans came through wore off, and after I took some time to crunch the numbers, the sheer magnitude of debt that I will be facing broadsided me. But my medical education is essentially a high stakes long-term investment in my future. I think it's important to keep that perspective, focus on my education, and not allow myself to get bogged down or stressed out by the numbers.

The orphanage and the dump

Today was a study in contrast.

La Casa Esperanza, The House of Hope

Our first stop was Casa Esperanza, an orphanage that lived up to its name. We drove down a winding dirt road to a hillside suburb of Tegucigalpa with Dr. Claudio, who helped found the orphanage and has been involved in Rescue Task Force and its new sister organization World Emergency Relief.

I asked Dr. Claudio more about the orphanage. There are currently 26 children living there. Casa Esperanza started some years ago with an initial investment of $320,000 and now costs about $3,000 per month to maintain. That covers all costs, including feeding the children and paying staff. It simply amazes me that more than two dozen orphaned children could be comfortably supported by such little money. The orphanage is currently at capacity, but Dr. Claudio wants to build another dormitory, which would raise capacity to about 50 children and operating costs to about $6,000.

The purpose of our visit, aside from playing with the children, was to survey damage to their dormitory from the recent earthquake. There were several large cracks in the building, but thankfully, the damage seemed to be relatively minor and the building still safe to use (not an expert´s assessment).


I was greeted with a BIG hug from a little boy even before I got out of the truck. We handed out candy and balloons, watched their grammar lessons, and took lots of photos. From that first little boy´s hug welcoming me, I was overwhelmed by the positive atmosphere. To be honest, this magnitude of positivity caught me by surprise since I typically think ¨Oliver Twist¨when I think of orphanages. But to these children, Casa Esperanza is a true home in all senses of the word. Though I know that they have already seen their fair share of hardship, it filled my heart with joy to watch these children enjoying the innocence of childhood, a rarity here in Honduras.

The Dump

Our second stop was the dump. I cannot adequately communicate the desperation and desolation of spirit that I saw there. People live there, they live at the dump: children, women, whole families. Some of them get paid 50 cents per day to sort and haul recyclable materials, while others fight over trash that they can sell or trade or eat.


A garbage truck arrived while we were there. When it dumped its load, a hoard of people descended onto the pile of trash like the hundreds of vultures circling overhead. At the top of the pile of trash was a little boy holding up a recyclable cardboard box for a toy scooter that he would never have, but he smiled with his spoils as if he were holding the actual scooter. Then I saw a little girl, who couldn´t have been much more than 8 years old, lugging a sack of trash larger than herself. It was only later, when I was looking at a close-up of a picture I took of her, that I noticed she only had one shoe and wore just a sandal on her other foot. Such is life for these children, robbed of their childhood and their humanity.

There were vultures everywhere, not just circling above. They hopped in and out of the crowd digging through the trash, and they lined the crest of the hillside overlooking the landfill like bandits waiting for an opportunity. As I was taking pictures, Richard (our Honduran guide who accompanied Andrea and me to the dump) abruptly said that it was time to go. Later, when we were back in the car, he told us that a couple men showed him knives and flashed gang signs at him. Esos no son solamente banditos, son malditos. They are not just thieves, he explained, they´re very bad men who are dangerous in their desperation, and they just wanted us to go away. So we went.

I never felt like I was in any immediate danger, but the atmosphere was unambiguously threatening and guarded: every person living at the dump literally fights each and every day for their life. Andrea showed me the dump because she wanted me to see for myself the base depths to which human existence can sink. ¨This is about as bad as I´ve seen it,¨she says. ¨People just don´t want to know, they don´t want to know that this is happening right now, but it is.¨ I don´t want to know, either, but I feel it is my responsibility to know. What can I do about this, though? What can anyone do about such an atrocity when it´s buried and forgotten as easily as tossing your leftovers from dinner in the trash?

Reflections: Honduras earthquake relief mission

We drove back from Puerto Cortez to Tegucigalpa all day yesterday. That 8 hour drive gave me some time to unpack my thoughts and feelings from my first experience in immediate disaster relief, responding to a 7.1 earthquake in Honduras.

We found a group of families whose homes were destroyed by the earthquake and gave them food and other supplies that would help them through the disaster. Rescue Task Force typically responds to bigger disasters, like the 2005 tsunami or Hurricane Katrina, where there's a great need for the immediate presence of doctors and medical supplies. We didn't really know what to expect, going in, and it turned out that no one - amazingly - was in need of medical attention.

These people were very poor to begin with, so losing their home was a catastrophe. I'm glad that we were able to help in what little way that we could, and knowing what I know now I would do it all over again. But I also recognize that the help we were able to give is only temporary, and that at the end of the day, these people still have no home to return to and no resources to rebuild.

Unfortunately, this represents deeply rooted sociological problems endemic to Honduras that a relatively small outfit like Rescue Task Force can't hope to tackle. I strongly believe in the service that RTF provides, acting as first-responders to natural and man-made disasters throughout the world (they say this somewhere on their website), and I will continue to do what I can to support them, including volunteering for future missions. Even so, it's still difficult for me to see these systemic problems and know that there's nothing that RTF can do about it despite its resources, both in the form of money and volunteers with the will to help.

I'll write more about my outside-the-box thoughts on how to address these systemic problems in a later post.

Today, we will visit the orphanage.