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Thursday
Mar212013

the ER--part 2.

*Please note, the names and details of patients/staff/friends/family have been changed to ensure anonymity.  I have attempted to stay true to the nature of the stories in as much as their identities can be concealed.

Since the last one was kind of a downer, I am going to relay a (semi) uplifting story next. 

There are a surprising number of people who come in with 'vaginal pain' as their chief complaint.  Aside from being quite vague, it's almost always an indicator that the case will be a doozy.  People don't just come in to the ED with vagina questions--they come in because something went wrong.  Down there--as they say.

I actually like these cases.  I am not a huge fan of doing pelvics (probably because I am also not a big fan of getting pelvics!), but I love women's health and I am always eager to improve my skills.  I want to learn how to make an annual exam as painless as possible--and that requires practice.  Sorry ladies of Southeast MI, I do appreciate you letting us learn how to be doctors.

This particular woman came in with 'eye pain,' though.  When I went to see her, she was sitting perfectly comfortably on a bed, playing with her cell phone.  The nurse had already alerted me that this young lady was also worried about some kind of STI.  I understand--you're embarrassed, but you might as well get it out of the way by being up front in triage.  In any case, I went to see her in an area where we had absolutely no privacy.  I alerted nursing that we would be needing one of the individual rooms to perform a pelvic exam. 

"So, eye pain?" I asked, with some intonnation that I knew about her other issue.

"Uh, yeah." She looked me up and down.  I was probably only about eight or nine years older than her.  I was also not looking particularly good.  I don't do the best job of getting dressed when the uniform is scrubs; it's like the comfort of wearing such slouchy clothing spills over into my hair and my face and I just look terrible for months.  

I introduced myself as the med student that would be taking her history and performing her exam.  I told her that an attending or resident would be supervising the pelvic and that if she had any questions, there would be someone to answer them.  I also let her know that we'd be moving to another room for more privacy.  

Once we were alone in the other room, I was surprised to hear how cheerily she reported that she wanted to get tested for STDs [sic].  I asked her if she had any particular concerns and she explained that she had recently suffered her first bout with genital Herpes and she wanted to get tested for "all the other ones."   I asked if she was worried that she might have something else and she shrugged, muttering that she was not all that concerned. 

"Do you use protection during sex?" I asked.

"No," she said.  Her response came quickly, was straight-faced, and unapologetic.  I am not saying I expect an apology on behalf of all health care providers, but I mean, wow.  This is one bold young woman, I thought.

"May I ask why you don't?"

"I don't know.  I never have.  And I have never gotten pregnant.  I don't think I can get pregnant.  But now I got these warts and I'm all like, damn.  Maybe I should get tested."

There were so many things that I wanted to address in what she said.  I chose to ask another question first.

"Do you use any kind of birth control?"

"No, and I ain't never been pregnant." 

She confirmed my worst suspicion.  By her history, this young woman had been sexually active for about five years.  She has had numerous partners and has never used condoms.  The possibilities that ran through my head were chilling.  Is this really the first time she's been tested?  EVER?!  What if she has some advanced cervical change?! Does she truly believe she can't get pregnant?  Why did her primary care doc not address these issues?  All the while I am trying not to let my face convey my fears.

"I know you have probably been told this," I said, "but you're taking some pretty big risks by not using protection.  I am concerned about a number of things.  First, you can get pregnant.  Unless you were born without a uterus and ovaries, you can definitely get pregnant--there's a first time for everything.  If you don't feel like now is the right time to have a baby, you should really think about some kind of long-term contraceptive.  Second, having unprotected sex--the kind without a condom--is putting your health at risk.  HIV rates are growing for young women in Detroit, and herpes, Chlamydia, and gonorrhea aren't going anywhere.  Has anyone talked to you about the Gardasil shot?"

"No, what's that?"

"It's a vaccine, kind of like the ones you get when you are a kid, that protects against the four most common strains of HPV--two that cause warts, and two that can lead to cervical cancer.  It's like my favorite vaccine ever!"

She laughed and looked pensive.  We performed the exam, which was pretty painful for her due to her herpes induced neuropathic pain.  Though the outbreak was waning, it was still quite evident.  In addition, she had some yellow discharge that looked more pathologic than physiologic.  We ran all the necessary tests, the attending put in his two cents, and he left the room.

I was about to leave to, but as I reached the door she said: "What do it mean?"

"What does what mean?" I asked.

"Herpes.  Like what do that mean.  Is it gone now?"

Her doctor hadn't bothered explaining anything about her disease to her.  He just gave her the acyclovir and sent her on her way.  We talked for a long time.  She had so many questions--it was as if she had been waiting for someone to talk to her about her body.  We talked about a bunch of STIs, her risks, the rise of HIV in Detroit, how these diseases are transmitted and why women are more vulnerable.  I asked her if she had ever asked a man to use a condom, and she admitted that she had not.  When she was younger she just wanted someone to show her affection, and sex ended up being a way to fill that space in her heart.  Unfortunately, these encounters had only lead to unhealthy relationships with most of the men she'd been with. 

Eventually, a nurse knocked and gave me a look that said, "what is taking so long?"  I had kind of forgotten that we were in the ER.  I had reverted to my primary care persona, taking too much time.

It was a really revitalizing conversation though.  In light of having matched it made me so happy that I would have the chance to be a family doc. 

Oh yeah, I matched!  Not only did I match, I matched into my first choice, a Family Medicine/Psychiatry residency in Pennsylvania.  It's a dream.  I will be able to ride that line I love so much.  Jess is relieved that we are going to her city of choice--she loved it when we visited during interview season.  I am still having to remind myself that it's actually happening!  We're going to look for houses in a few weeks.  WHOA!

Thursday
Mar212013

the ER--part 1.

*Please note, the names and details of patients/staff/friends/family have been changed to ensure anonymity.  I have attempted to stay true to the nature of the stories in as much as their identities can be concealed.

A lot of people have been waiting for me to post about my experiences in the ER.  Or maybe I flatter myself--maybe no one said that at all.  Regardless, it seems like everyone wants to hear crazy ER stories.  There are plenty to share.  Perhaps too many.  However, the joy I normally take in sharing patient stories is pretty much demolished by the pervasive desperation and abandonment I sense when I am there. 

No, I will not get off my social justice soapbox. 

There are a few stories I can share (with critical changes made to protect privacy) that really illustrate why I have found this month so hard. 

On one of my first evening shifts this month, I was sent to see a man whose chief complaint was "arm pain."  We get a lot of pain visits.  I think everyone knows that the ER becomes a regular haunt for many people who are addicted to various forms of prescription meds.  I don't find this as frustrating as my colleagues, though it can still be challenging to deal with addiction--especially in an acute care setting where the only thing that separates one patient from another is a curtain.  We all have our perceptions, but I would argue that we need to do a better job of interrogating those perceptions--does this assumption come from a place of fear or lack of knowledge?  Does it come from a place of privilege or stereotype?  Or does this assumption come from pattern recognition (a really important tool in the doctor world)? 

This particular man was not even lucky enough to get a bed.  *Mr. Henry was sitting in a little row of chairs, cradling his painful arm with his other arm.  He looked ragged and exhausted.  He was an old black gentleman who had spent the past six years on the street.  He had the odor of homelessness that I have become so familiar with--a mix of urine, dirty underwear, and sweat.  I do not say this to add some sort of 'ick' factor, but to share with you how hopeless the patients' situations can seem. 

When I sat down I could immediately tell that something was indeed wrong with his arm.  It was swollen and warm, the skin was tense, and there was an area that appeared to be a locus of infection.  This was one of the times the pain was completely legitimate.  Legitimate pain happens more often than most people want you to think.  Especially people who are suspicious of the poor and programs like Medicaid.

As I talked with Mr. Henry, I noticed he had a blunted affect--which basically means his face held no expression, it was blank and never reacted to his own pains or my questions.  He also made little eye contact and appeared to be ... down.  As I went through the list of questions we ask all patients, we came to a section on substance use and he cut me off, saying he had a drinking problem, quite emphatically.  Considering his previously limited range of expression, this stuck out to me.  Maybe he wasn't just here for his arm--though it needed attention very badly.

"May I ask you how your mood as been lately?"

"My mood?" he asked.  He seemed genuinely confused.

"Well, you seem a little down to me.  Is there anything in particular that's on your mind?" I asked.

"I just... I'm just ... tired.  I'm a bad man," he said while looking away from me.

I proceeded to ask him why he thought of himself as 'bad,' and he went on to list the various ways in which his alcoholism has impacted his life.  He explained that he is no longer on speaking terms with any of his family and he has never met his grandchildren, that he is homeless and sick all the time, and that he has no friends.  If my heart was capable of breaking, it broke right there in that hallway. 

As I've stated in previous posts, addiction is a disease like any other.  MRIs and CAT scans have shown that there are physiologic differences between the brain of an addict and that of someone who is not prone to addiction.  Studies have even shown that the offspring of addicts react differently to various pleasures than those who have parents without any history of addiction.  But when you are hospitalized as a result of alcoholism, no one visits.  No one brings flowers.  Even the nursing staff seem to write you off.  It's a disease that only burns bridges, and one for which there is no cure. 

I asked Mr. Henry if he was interested in ending his relationship with alcohol.

"Yes, oh God yes.  It's just that every time I try I get those seizures and have to come here only to get bumped back out again."

Mr. Henry is talking about the DTs, Delirium Tremens.  The DTs are one of the more ominous signs of alcohol withdrawal.  These seizures, which can be preceded by irritability, rapid mood changes, confusion, and hallucinations, can actually cause death.  These symptoms are typically in full force 72 hours after the patient's last drink.  Many alcoholics become familiar with the symptoms that lead up to these seizures and end up drinking--even though there is a strong desire to quit--simply because they feel so terrible and there is a fairly easy solution: alcohol.

What Mr. Henry wanted was a supervised withdrawal.  The first few days after a person stops drinking are the most dangerous.  If one is able to pay (insurance or cash), they can withdrawal in a hospital where medications are administered in a step-wise fashion to help ease the transition and avoid seizures.  Typically, Benzodiazepines are used in this process.  Benzos, another addictive substance that works much like alcohol, act as a substitute for the booze.  As the body adjusts to a new normal, the benzodiazepines are stepped down and eventually stopped.  Of course the biggest challenge comes when the patient leaves the hospital and encounters all his old haunts. 

Mr. Henry seemed ready, though.  I believed that he was truly interested in quitting his habit.  After a quick physical exam, I went and reported the case to my resident.  Of course, I mentioned the arm and the antibiotics we could likely use to treat the infection, but I was much more interested in discussing this guy's willingness to quit.  I was shot down.  Hard.  Apparently it's not the ER's business.  I mean, I get it, it's not like this hospital has a ton of social workers available to find resources for this very desperate population, but still.  This man wanted to improve his life and we were essentially saying, "OK, good luck with that!" 

The man left with a prescription that he probably doesn't have the money to fill.  Before he went, I looked up a few resources in the community for handling addiction.  I gave him my sincerest wishes for luck in the process, but I knew that's not what he needed.  He needed money and agency--an ability to advocate for himself.  Both of which he didn't have.  I sat down in a chair and watched him limp out.  I felt like I had given up on him.  It was terrible.

That's when I knew that ER wasn't right for me. 

 

Thursday
Feb212013

privacy & patient stories.

There are a lot of reasons I write about my clinical experiences.  The main reason being: I enjoy it.  Writing has always been cathartic to me.  It is my only art form.  It is the way I express myself and the way I understand the world.  When I was in the third grade, I wrote a masterpiece.  Or so I thought.  It was 42 pages--a lot for your average third grader.  At that point, I thought writing was about being prolific.  It is truly difficult (and horrifying) to read "Angela Ben and Jen" now, but I am glad I have this little piece of my own writing history.  It reminds me of how passionate I have always been about the written word--no matter how little I truly understood of its power. 

These days, writing is much more to me.  Sometimes I write because I desperately want to share whatever it is I have learned or experienced--these entries are normally written hastily and in a daze.  I like the quality it gives the pieces, like a brushed-up stream of consciousness.  Sometimes I write because I want to understand something better.  I am one of those 'learn by writing' people.  I was the girl who took pages upon pages of notes in class, almost verbatim.  Something about the thoughts passing through my brain and out my hands makes it concrete to me.  When I encounter a patient that I don't understand, or a disease that really baffles me, it helps me to do a little research and share it with all of you. I also write because I have an odd fear that I will forget how to if I do not regularly exercise this part of my brain.  Doctors are kind of notorious for abbreviations and brevity in their note-taking.  While I don't think I will ever be that person (I am routinely criticized for the length of my notes--too long!), I do fear that the creative element may be lost if I don't occasionally spend some time with it. 

Today is one of those days I want to write to understand.  A former colleague (kind of) sent me a facebook message the other day suggesting that a status of mine may violate the Health Insurance Portability and Accountability Act--more commonly known as HIPAA .  Normally, I am quite careful about HIPAA.  In fact, I generally follow the same principles this guy does.  If you work in health care you know how many times you are forced to learn and re-learn its basic tenants.  Before I started this blog I poured over all of the rules and regulations about de-identifying patients, geographic restrictions, etc.  Not just because I don't want to get in trouble, but because I don't want patients to feel I am taking advantage of them.  More often than not, I ask them if I can write about their story, so long as I change identifying features.  They always think it's funny--'why would you write about me?'  In any case, I am pretty earnest about privacy.  However, I suppose I haven't been as careful with social media.  I would never write a name, or a circumstance on facebook--but when there is a truly outrageous diagnosis, I occasionally over share with my 'friends.'  Mostly because it's so strange or gross or scary.  That doesn't make it OK though.  I am glad this person pointed out the slightly inappropriate nature of my status update.  After I deleted it and processed the guilt I felt, I got to thinking: is it ever OK to share patient stories, or does this violate the doctor-patient relationship?  Is sharing a patient story that may help others (whether through education or alleviation of fear) justified in some sense?  Or do we tell ourselves that in an attempt to alleviate whatever guilt we may feel?

HIPAA is an enormous policy that covers many facets of health insurance and communication regarding health care data.  In clinical practice, the importance of HIPAA most often comes up when doctors need to share information with other doctors about a common patient.  For instance, say I went to my primary care provider because I had been losing weight.  I am 65 and I don't want to lose weight (this is truly fictional story).  My doctor runs some labs and discovers I am losing a lot of protein in my urine.  This paired with my weight loss leads her to request a CT scan for fear of a malignancy.  I am sent over to the system's radiology center (and so is my clinical data) and scanned.  A radiologist reads the scan and suspects a diagnosis of Multiple Myeloma.  This particular kind of cancer is handled by Hematology/Oncology docs.  I set up an appointment and me (and my clinical data) go see a third doctor.  The doctor requests a litany of labs that I can complete at an outpatient facility.  So me (and my clinical data) go to a third party lab, have lots of blood taken, and the results (my clinical data) are sent back to my oncologist.  He reads the results and confirms the diagnosis.  Shortly thereafter, my treatment begins.  Unfortunately, I also break my leg (multiple myeloma puts holes in your bones).  I go to an orthopod who receives all of my clinical data from the cancer workup and treatment.  This number of data transfers is actually pretty typical.  Moreover, this kind of data sharing is convenient and incredibly important. 

Taking really excellent histories is something that doctors (despite their immense knowledge) can be pretty bad at.  This collective info that is transferred to each new physician involved in my care not only increases my safety (perhaps along they way they discovered a new allergy or drug sensitivity), it makes my time in the clinic much less redundant.  Instead of telling the same painful story again and again, I am able to answer the questions that are relevant and get the care I deserve. 

I had a really great mentor my first year of medical school; I was taking the blandly labeled "Clinical Medicine," a course that is supposed to introduce the most junior medical students to the concepts of patient care.  In Clin Med we focus heavily on history taking and basic clinical exam skills (how to use a stethoscope, how to take a blood pressure).  My doctor, however, had a particular interest in patient narratives.  The joy he derived from patient care was really inspiring.  Nothing was more magical than a patient trusting him with their story.  He felt that understanding the patient narrative was incumbent upon all doctors who wish to do right by their patients.  For that reason, he chose to write about his patients--though under the cloak of de-identification.  I wonder where he is now, and how his writing has been.  I really looked up to him.

The subjective experience of disease is illness.  Illness is where the story lies.  How a patient describes his or her struggle with an illness can tell you almost as much about his or her prognosis as their lab data can.  A patient's medical decision making process is based more on her experience with illness than it is her understanding of the pathology that plagues her body.  For this reason, it is critical that physicians attempt to be in tune with the narrative, the story of the patient's illness.  One can recommend chemotherapy because it is the next step in a treatment algorithm, but if the patient's husband died three weeks ago, she is 95 and without friends or much family, what will her chemo experience be like?  Does it really matter that it 'buys her' three more months when those months will be marked by intractable nausea and vomiting?  

The fight in a patient is measured largely by their circumstance.  A patient that elects to forgo various therapies offered to them is not 'weak,' they have simply chosen a different kind of fight.  You can bet that a patient's decision to forgo therapy and likely die more quickly reveals a new kind of struggle--a battle to understand what it means to be dying. 

The experience of illness can be enlightening, it can be devastating, it can reveal inner strength or unknown fears--or both.  Sharing this experience, then, is one of the more intimate things a patient can do.  By revealing these corners of one's soul to a doctor, who is likely only slightly more familiar than the average stranger, a patient is entrusting you with some of their most important truths.  It's humbling.  What do you do with these truths?  Do you choose to look at the patient with your labs and clinical data--do do you choose to distance yourself from that which has shaped his or her experience?  Or do you do your best to carry these experiences with you as you consider a course of action? 

It's apparently quite easy to grow numb in medicine.  Non-compliant patients, the inappropriate use of the ER (I am looking at you, people with colds), the displaced anger of patients with bad diagnoses, and an attitude of entitlement can really wear a person down.  Especially if that person is working too many hours and worked really hard to get there.  If attendings are any indication, many harden to patient's woes much more quickly than I would have guessed.  HOWEVER: I want to give a shout out to the many doctors I have worked with in the past two years that still seem to grasp the importance of recognizing a patient's struggle.  It's so rare as to almost seem foreign when a doctor's brow furrows upon first hearing a patient's story.  These indications of humanity are reassuring. 

My dad has a screensaver on his computer at work that says, "It's about the patient, stupid!"  I think that pretty much sums it up.

 

 

Monday
Feb042013

the information age.

Right now, I am using a non-descript canvas bag that says "primum non nocere."  My dad got it for me for my birthday this past summer.  I am ashamed to admit that, despite a year of Latin and three years of medical school, I had to ask for a translation.  It means "first no harm."  You know, good old Hippocrates and such.  In the legal world the concept becomes non-maleficence (as opposed to beneficence).  My dad is very committed to this particular precept in medical ethics.  He believes, and much research demonstrates, that modern medical intervention is often of no use and is very often harmful.  Take cardiac stenting, for example.  You probably know more people with cardiac stents that you do people who have dealt with cancer.  They are like a take-home prize if you get bad results with a cardiac catheterization (a common diagnostic procedure for those suspected to have coronary artery disease).  Researchers started to question the benefit of stenting as an intervention in stable cardiac disease (read: partially occluded vessels that are asymptomatic) and found that the procedure has no benefit beyond that of conventional medical therapy. 

So why do a stent?  The total cost of a stent is about $23K, more if you are paying with private insurance.  Don't get me wrong, Cardiologists are not especially into money-grabbing.  Part of the popularity of stenting (and other procedures/drugs where there exists evidence directly contradicting the benefit of said procedures) is cultural mythology and a desire to 'do something.'  Many patients are adamant about being proactive.  If you are told that your left anterior descending artery--referred to lovingly as 'the widow-maker' in the world of medicine-- is 85% occluded, wouldn't you want to do something big, like get a stent?  Would you not feel like a ticking time bomb if you were to just pop pills and hope they were working?  There is something about undergoing anesthesia and seeing one's own blood stain a bandage that makes one think, 'well there, I took care of that.'

We live in an information age.  How many times have you heard that shit?  I feel like I first heard that line watching a documentary VHS from the late 80s on polyamory in eighth grade.  (I know, right?  I wonder how many phone calls the office got that night.)  The video was meant to be a glimpse at all the wild and crazy things of the future, including having several committed sexual partners.  As someone who had yet to be kissed, I remember finding the video quite titillating.  I also remember thinking, 'what the hell information age whatever, this is crazy.' 

Now that the Internet is more than chat rooms and porn--for some of us--we are often hard pressed to get away from the information age.  How many times have you pulled out your smart phone to settle an argument?  How often do you rely on Google to find you a restaurant/hotel/educational establishment?  I am guilty of this, to be sure.  In fact, it really bothers my mom that every time she says 'I wonder...' I pull out my phone and stop her wondering in its tracks.  It's compulsive, though.  At this point, I don't even hesitate.  One could argue that this is good because it increases our collective knowledge; however, recent research has shown that those of us who are so attached to our mobile devices have stopped trying to remember things.  If the Internet is there, why try, right?  Much scarier is the research recently published in the Wallstreet Journal about the rise in injuries among children as it correlates with smart phone use among caretakers. 

It seems that we are attached to these devices in a very fundamental way.  Our reliance on technology informs almost every decision we make--including health care decisions.  Prior to the widespread use of the Internet, parents relied on recommendations from close friends for pediatricians, or perhaps the recommendation of their primary care provider.  Now there are innumerable web sites with non-standardized scoring systems to rate doctors. All it takes is a person with an Internet connection and a really good or a really bad experience in the doctor's office.  I have such mixed feelings about things like this.  I love the democratizing power of the Internet, the kind of rogue airways it can provide.  However, on more than one occasion, I have been to these websites to look up the office number of a doctor I am rotating with and found that their were either a) no ratings or b) one really bad rating.  And that is when the democracy of the Internet ceases to be meaningful.  In reality: these reviews are likely written by privileged folk who have more agency and higher expectations of their doctor.  Sure, most people have some way to access the Internet these days, but do you really think a woman who is living in extreme poverty and is barely able to find transportation to her OB/GYN is going to take the time to get on the Internet and write a mediocre review about her annual exam?  No.  If she does, more power to her.  She must really believe in the importance of data collection. 

The Internet demands a new level of accountability from physicians.  No, not the ratings web sites; most physicians do not put much stock in those.  The Internet's wide spread influence requires that a physician is able to have a real conversation with his or her patient about a diagnosis.  It is rare, now, that a patient comes in without having diagnosed him or herself with some kind of bug--and it's not uncommon for them to be right!  However, and I am sure you already know this, WebMD can be a very bad thing.  It's like a very scary and bad version of 'playing doctor.' 

Many patients who come in with 'the flu' or 'bronchitis' or 'pneumonia' are wrongly sent home with Oseltamivir, Azithromycin, or Levaquin, simply because they asked for them.  Yes, this is their doctor's fault.  Yes, it is the doctor's job to prescribe the appropriate medication (which may be no medication at all).  However, this 'ask and ye shall receive' bit happens with an embarrassing frequency. 

This "Information Age" is going to require new thinking.  It's going to require a new level of collaboration between patient and physician.  I am happy to say that I think the new generation of physicians will be up to this task.  We know what it's like to see a red bump and immediately search 'red bump, groin' in Google--only to find out that it's razor burn.  Almost everyone I know has searched 'how to pass a drug test.'  Because we understand this new kind of industriousness, I think we'll understand our patients' anxieties better.  Well, I hope we will. 

Saturday
Oct272012

renaissance woman.

It's OK to like many things.  I want to document this for the sake of posterity.   Sometimes, it feels like it's not; societal or academic pressure may lead you to believe it is better or more advantageous to become a super-specialized _______, and conquer a tiny corner of the planet.  This mentality is evidenced everywhere--doctors are increasingly choosing specialties over general practice, colleges are developing an infinite combination of majors and minors--our country's ever-passionate love affair with the division of labor has conquered business and is doing its best to invade academia. 

This philosophy made quite a bit of sense around the Industrial Revolution, divide labor and we can all have more and make more.  I am not suggesting we should regress to doing our own gardening, knitting our own clothes, and teaching our own children (though the choice is valid for those who want it).  I am simply suggesting that the extension of the division of labor into academia is anything but natural and is limiting for some folks.  Myself included.

I remember learning about Renaissance Men when I was in elementary school (the absence of Renaissance women did not escape me, thankyouverymuch history books).  I was fascinated by the concept of someone who could write, formulate beautiful mathematical theories, compose symphonies, and heal the sick on the side.  It seemed an endlessly stimulating way to live life.  When I was in elementary school I often let my mind run rampant with daydreams about the myriad ways I would change the earth.  From the simple and superficial (more glitter on everything) to the ideas with more gravitas (the importance of understanding the existential duties of citizenship became a fascination in high school), I generally felt free to explore that which made me tick.  My parents, being the well-rounded and incredibly well-read people they are, can be given all of the credit for this.

My inability to keep all these balls in the air didn't strike me until college.  At any given point, I generally had two of three majors.  I took the maximum number of credits each semester and threw myself into the joys of academic masturbation.  Academia was something I excelled at--with significant personal effort.  I was a student in the James Madison College, a residential pseudo-honors college for public policy.  For that reason, I took a LOT of social science courses.  Our requirements outside the college were minimal: a few pathetically watered down general education courses in science and history, a math requirement that my high school pre-calc got me out of, and economics if I remember correctly.  While I found these general education courses something only to be endured, most of my classmates celebrated their freedom from the objectivity of science and math.  

I wasn't satisfied.  I was in college, for God's sake, shouldn't I at least take calculus?  And chemistry?  What about philosophy?  Oh!  And statistics!  And so went the course of my undergraduate education.  I treated MSU's academic offerings as an unlimited buffet of delicious brain candy.  I took so many courses outside of James Madison that by the time I graduated, with one degree mind you, I had collected somewhere around 160 credits.  The requirement for graduation was 120, I believe.

I don't write about this to brag.  I am quite proud of the diversity of my education, but I am also in more debt because of it.  Moreover, I was made to feel like my decision to diversify my education was foolhardy and done out of indecision rather than curiosity.  I believed that for a time, too.  I believed that until I came to medical school. 

When I started medical school, I realized I wasn't cut out for specializing... in anything.  Not just within medicine, but in life.  Probably one month into medical school I knew that I wouldn't be satisfied being *just* a doctor (whatever that means).  That's actually when I started my first blog (RIP, thehoneypot [dot] com).  I needed to write and reflect.  I needed to share and analyze.  Short of some very fun lunch table conversations with my motley crew, there was no room for reflection.  In fact, I discovered quickly that any kind of dissent or questioning would get a person in to hot water quickly.

And that's kind of how sciences are--if you collect a large group of people so invested in objectivity, dissent becomes impossible to conceptualize.  We do what the data says, end of story.  It was a very harsh black and white world for someone who loved hanging out in the gray.  For the sake of survival, I learned when to shut my mouth (which was most of the time I wanted to talk).  I realized that I could not successfully question authority as an undergraduate medical student.  For this radical, it was a hard pill to swallow.

One of the reasons I realized I loved Psychiatry was the importance placed on ideas on and nuance.  Psychiatry not only embraces diversity, there are many schools of thought under it's big, fun umbrella.  In Psych, it's not dangerous to be different and have a difference of opinion.  Discussion and personality are welcome and crucial to the learning process.  It is a field that feeds me, a field that restores my hope in medicine. 

For now, to maintain my sanity, I write.  I read, I question, I vote, I talk, I get lost in music, I enjoy debating the merits of art, I nurture my interests in business management.  I am determined to become the Renaissance woman I once dreamed could exist.