The Longest Shortest Time.

One of the most complex emotions to embrace as a parent is the simultaneous push and pull of realizing your child doesn't need your help in some facet of their life.  My son and daughter charging fearlessly out into the world, getting rid of training wheels or that last goodbye hug at school drop off  shows me they're flourishing.  Yet as happy as I am in those moments, the mother lizard brain wants more time, more chances to nurture.   We are caught in this conflict of days being long but the years being so short.

As an educator, I can easily see comparisons to a parental role - especially when your job description emphasizes the assessments, career counseling and wellness for all of your learners.  The latent feeling of having 50 extra children becomes fairly explicit on occasion.

I worry about them.  I celebrate with them.  I get a bit emotional and take lots of photos at graduation, as any proud parent would.

Of course, I also love teaching them; someone lighting up when a concept gets explained on rounds keeps me going as much as the endless cups of coffee.  I hope to make an impact on the trajectory of their careers, maybe to someday be that voice in their head when they remember to double check that the young female patient with Diabetes on the ACE inhibitor is still on her birth control.

The unique experience of training residents means that you as the educator have to figure out when you've become redundant, when you get to check off the "Ready for Independent Practice" box.    That same push-pull.  You have these longest, shortest years to try and get them ready for everything that Medicine can throw at them, always wishing for the chance to pass on one more clinical pearl.

I rarely have that big moment of redundancy in clinic.  Especially one that was already a busy, being understaffed with residents and faculty getting pulled to other commitments.

Mrs. J didn't get the memo that it was supposed to be a chill day.

She had what sounded like classic menopause symptoms.  Sweating, and florid, possible hormonally driven anxiety (well documented in her chart) - but with some chest discomfort as well.

And because clinic was slammed, my resident already ordered the "Just in case" EKG as I was half listening to the story they were going over with the med student.  It was a reasonable tack, maybe a bit cautious but with all the times I had told them "you've got to consider the can't-miss diagnoses, even if they're not likely"  I wasn't going to change the plan.

And so I finally caught up with them, went over the case with the student.  We reviewed expected menopausal symptoms, indicated treatments and discussed whether or not she merited an outpatient stress test "just to be sure", going over modalities and risks of false positives given her pre-test probability.

They were already triaging the next patient when I decided to just poke my head in the patient's room, confirm the history and look at the EKG our nurse was finishing up.

The words "So here's the thing about hormonal therapy for the control of menopause symptoms..." vanished as my eyes fell on the ST elevations, the classic sign of heart muscle in trouble.

Happily "I'm going to go show this to Dr. A and talk about how we're going to get you feeling better" came out instead of "Oh, Holy Shit."

And so I showed it to Dr. A, the one who made the right call.  The one who listened and thought about the "just in case" when all I had was overheard history.  Who saw the mild hypotension and didn't write it off  as just volume depletion.  The one whose eyebrows about hit his hairline when he saw the tracing.

And so it was his job to talk to the patient and explain what was going on.  I carried the cup of water and the 4 baby aspirin.

Of course, he may not have been thanking me in the moment - how exactly do you open the conversation of "I'm pretty certain you're having a heart attack" with your 10:30 clinic patient?

But he did it.

Sometimes, I have to bite my tongue when I stand back and have my residents run the show.  These are still my patients after all; I have to know the point is getting across, that we've done everything to ensure a good outcome.

I almost jumped in when the patient started to push back against the need for them to Go Directly To The ER (Do Not pass Go, No $200 for you.)

But then I watched him kneel next to exam table, consciously altering the physical dynamics of the conversation and change the patient's ability to feel in control of the situation - exactly as I would have done.  Soften his tone and word choice enough that it was the patient making the decision instead of being forced into it.

There was nothing for me to do except pitch the empty cup of water and watch as he crossed the T's and dotted the I's of a rapid ER transfer, all while assuring the patient that things were going to be ok.

It's good to be redundant.  For tying shoes or managing Myocardial infarctions.

The necklace

On the gen med floor, we take care of adults.  We get used to extensive questioning during intake histories, shared decision making for our care plans, daily updates of progress and explaining test results.

Ryan is definitely not our usual.  Because he can't talk to us, we are forced to make do with reports from caregivers to understand when each symptom developed, to rely on numbers to figure out if what we are doing is making him better or worse.

His bedside staff has the most difficult job - even for folks who are skilled in the arts of cajoling, compromising and winning the trust of a person in pain.  But trust is a poor word for what allows our patients to let strangers do incredibly personal and invasive things to their body knowing they are acting in good faith.

Ryan's trust is an incredibly fragile thing - gone in a moment, displaced by older and more primal emotions.  Worse, you only figure out the trust is gone when the shouting or hitting starts.

It's hard to see scared through loud and unpredictable and not your usual.

"Careful, he likes to grab."  Everyone was warned to hide badges, stethoscopes.   I adhered to the warnings, but forgot the necklace one day.

Tiny silver links with filigree crosses.   Long.  Long enough to grab easily, strong adult fingers wrapping around it in a moment.

The fact that I managed to lean in instead of jerking away is something I'm still grateful for.  To respond with gentle chiding "Ryan, you know that's not nice" instead of raised voice or clipped tones.   I credit the amazing colleagues who taught me how to interact with folks whose brains work in ways different from what we're used to.

Because when I leaned in, I saw the eyes of my two year old looking back at me.   The one who gets frustrated and bangs on a table because he can't put words to "My world is ending because you gave me the green plate when I wanted the blue one"   The one who is morally obligated to do the opposite of what you tell them to do because testing boundaries is an appropriate developmental milestone.

And so I kept leaning in.  Held hands whenever I could.

It would have taken no effort for either of us to break that chain, to sever the attachment instead of deepening it.

The most rewarding breakthroughs I've made with my children, my patients, my residents were the times that I moved closer to the off-putting person or behavior instead of away.   It's a leap of faith in a fellow human when you force yourself to get to the root of anger and see the hurt, guilt or fear.

 In this instance, we both took the leap.  We each had something to hang on to, as insubstantial and transient as that link was.

So now I have a tangible reminder of that moment, something to wear when I need to appreciate the fundamental truth of my practice.

Our test scores, our data, our outcomes and guidelines mean exactly squat without the connections we make.

God help me if Michelle isn't good enough

We scrambled.

Yes, it's called something different now.  But it's still a scramble.

For those just tuning in, US medical residencies attempt to fill their open spots through an arcane voodoo ritual called "The Match" that links hopeful applicants with their new homes.  Unfortunately, in a high stakes game of University programs versus Community, urban vs rural and future fellowship goals... not everyone matches or fills. 

Everyone who gets bad news on the Monday of Match week starts to roll out their plan they quietly created and then studiously ignored, hoping they wouldn't have to use it.

In the regular interview season, there are careful metrics, scoring rubrics and invitation protocols.  Those all get... abbreviated in the mad dash to find a position that isn't Fairy Tale, but at least short of a Horror Story.   Programs sift through literal piles of referrals and politics over who gets a shot at being considered.

There's a certain brutality to it - having to go on the professional equivalent of speed dating hours after being told "It's not me... it's YOU."  The folks that you put on your best face for - they wanted someone else more than you.

You question your value, your recruitment program, how you look to folks that don't understand just how great the cafeteria burgers are, or the set of extra comfy chairs in the sunny corner of that lounge on 6 north.   You question it extra hard being the junior faculty who took their first shot at making the interview and rank order list, wondering if your director is going to give you another chance next year.

So of course my solution in this scenario is to dust off my skates and put myself back on the track with Veterans of Detroit Roller Derby who had been skating every week while I had been interviewing and shuffling applicant folders.

Past Kat is pretty savvy.  She knew that in the event of a good match, it would be a welcome celebration, affirming that yes, I am still Badass-adjacent.

She also knew that during previous dark times, Roller Derby had Saved My Soul.

So I drove down I-75, mentally reviewing the edit to the edit to last version of our rank list my partner had sent and listened to Michelle Obama tell her story "Becoming".  The story about how she wasn't enough.  That she was an impostor just waiting to be found out and dismissed as unworthy. 

It was a moment of liberation.  The knowledge that no amount of Ivy League Education, professional accomplishments or position of authority is every going to quiet the tiny but ugly voice in the back of your head.

So you better just strap on 8 wheels and get to hitting.  You scramble with everyone else and find your missing people to spend the next three years with.  You fake confidence and certainty that the choices you're making are the best available.

And then, sometimes.... you make it.  Detroit Roller Derby practices are going to be a welcome escape from the next interview and match season - which I'm of course, already prepping for.