CAPO Review

It is the first Monday of the month and the last Medical Monday until September. Whoo. Time to check out some medical minded/affiliated blogs at the link below.


I am going to use this as an opportunity to expose you to some of the awesomeness I saw and learned about at the conference I went to this past week for the Canadian Association of Psychosocial Oncolology.

All last week, while at the conference, I was so excited, I wanted to tell the internet world about it, but resisted the urge in order to keep people from hating a million small updates about things that may not be as thrilling to everyone except me. But now, I will give a digest of some of the cool videos, tools and ideas that captured my attention at the conference and that I think might appeal to a wider audience.

First of all, every single keynote speaker pointed out that physicians are burnt out and that leads to poor communication, missing compassion and other issues. They also all cited a study of Internal Medicine residents showing that 76% displayed symptoms of burnout or depression. This made me feel depressed. Mostly because I know it is true. Also because I wanted to know what information was out there. So, I found a decent review article (IsHak et al. 2009) on the topic citing burnout rates to be anywhere between 25-76% and that self-care, counseling and system changes might help the residents and in turn improve patient care. Fascinating.

We have a system of health care, but not a system of caring.

Dignity is huge. Studies have shown that the factor that was seen as the make/break point in maintaining dignity was how the individual thought they appeared to others. Feeling dignity is supported if they feel they are being seen as a person and as a WHOLE PERSON, not just a disease.

One speaker talked about a thing they were doing at their hospital where they asked new patients to the palliative care service an additiona question, “What should I know about you as a person to help me take the best care of you that I can?” It changed care for many people.

Breast cancer risk is increased by smokng. But, interestingly, that risk is most increased when people smoke during periods of breast development. So, a group in BC designed videos targeting teens to try to make a change in this behavior. And it is working!

ReThink Breast Cancer is a nonprofit all about young women with breast cancer. They have support groups and events and all that good stuff. They even have a blog.  They also promoted a super cool publication in the form called Cancer Fabulous Diary, which is a book with coping tips and musings for young some with breast cancer.  It is written with the blogger from Cancer Fabulous, which is basically the experience of a young woman named Sylvia Soo who is a breast cancer survivor diagnosed at the young age of 24.

The Canadian Cancer Survivor Network has a webinar series on Thursdays about things like advocacy, drug funding and really relevant political/medical issues. Who knew? They aren’t the only ones though. Lots of other non-profits in cancer care have webinars with relevant topics.

No man is an island.

I went to a series of talks on decision making in older adults with cancer. About how they make decisions, how people get information and how they enroll in trials. Many people factor in their age, even more than providers sometimes expect. Family members are often divided into two categories, the super involved and the not involved. Both can have their pitfalls. Also, subtleties in communication with the provider influence the decisions a great deal. Sometimes the appearance of interest of a physician in a clinical trial will convince someone who was on the fence. Also, older adults cope better with a cancer diagnosis and treatment decision making than younger adults.

I saw a really cool video documentary on sexuality in young adult cancer survivors that addressed a lot of big issues.  The maker of the video is designing a website and taking the show on the road.  Unfortunately, it isn’t up yet, so I can’t show you.  But, it was very real and honest and not sugarcoated like a lot of stuff out there these days.

Psychosocial oncology is cool!

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Feeling anti-writing (and proud of my cat grass)

This week (or two) has been an anti-writing week.

I just haven’t felt like writing.  Sometimes I have ideas, but I can’t bring myself (or find the time) to sit down and actually write.

I can’t say I’ve had a particularly bad week.  Or even a crazy busy week.

My days are full.  I am on Palliative Medicine, so I am in my happy place.  I’ve been keeping up with the gym and we spent the weekend at home visiting family.

All good things.  All tiring things.

My big physics exam is coming up.  I need to prep a manuscript for the university research day.  I need to prep a manuscript for publication.  I am presenting at a conference next week.

I guess things are kind of adding up.  And possibly, some of the feeling overwhelmed from that is keeping me from writing (or working on those things, for that matter).  Hopefully, it passes soon.  I kind of want my groove back.

On a brighter and unrelated note, the cat grass is growing… A lot.   And the cat doesn’t eat it.  He just sniffs it and bats it. Basically, we have a pot of freakishly tall lawn.  I think I might trade it in for coriander at some point soon…

 

Unique

The Top Ten Tuesday topic this week is the top ten unique books you have read.

Sounds cool.  Too bad I spent my evening trying to finish up my presentation for the conference I am going to in a few weeks.

Yes, I am that keen.  But, the real reason I am getting it done now is because I want my research supervisors to give me useful feedback and the only way to ensure they give me said feedback is to give them a fake deadline much before it is actually needed.

So, I spent much of my evening curled up on the couch with my laptop listening to the leak drip (yes, we still have that leak, although it has slowed) and watching television while creating a powerpoint presentation all about my research.  Which then reminds me I need to start working on my manuscript, but that is a challenge for another day.

My current “unique” is that I know a lot about current research around cancer support groups, education programs and mood scales.

In other “uniques,” the only book I could think of for the list in question was The Book Thief by Markus Zusak.  Because I LOVE death as the narrator.

I start my palliative medicine rotation tomorrow.  I am excited because I really like palliative medicine.  Also, it is the first rotation I have looked forward to since the Fall.    That makes me and it kind of unique.

The cat is unique.  He has a strange love of Q-Tips.  He carries them around and chews them and finds them a particular delicacy worth digging through the garbage for if they have ear wax on them.

I am uniqued out now.

“Never withdraw care”

We should never really withdraw care.

This was a quote from a fabulous talk I went to today about communication.

It is true.

In medicine, we often say things like “withdrawal of care” and mean things like withdrawing life support or stopping “extreme” or “heroic” measures.  Sometimes it is even about things like stopping active treatment for incurable disease.

Taking those things out of the picture does not equate not doing appropriate supportive care.  Everyone needs supportive care.  Always.  Just in different ways.

But, if you are a family member, it can sound like you are taking everything away.

Like the health care professionals don’t care.  Like hope is gone.  Like they are being left to die.

That is where this quote came in.  How the language we use can really portray the wrong message.  Context is everything, but really, we need to try to keep context out and keep things clear.

And no matter what, we should still care.   It is in the term healthcare.  It just makes sense to care in medicine.  Medicine is a caring profession. Because sometimes caring is all you can do.

Care is always in the equation.  The definition of care is what can change.

Sometimes the most caring thing you can do is to stop intervening beyond basic symptom management and emotional support.

It isn’t giving up, it isn’t even always changing focus.  It is about context.  It is about our humanness.   It is about care at the root of the word.

Just some food for thought.

1 in 4: Lessons in reality on the transplant unit.

I have spent the last almost month now on a bone marrow transplant elective.

I always throught I would like to be involved in transplantation.  I get that in my field, it is a small role, total body irradiation for certain indications, but nonetheless, it is a contribution, and I thought being a part of that team would be fascinating.

I have obviously been working more from the hematologist (and thus, the more involved) side of things.

I love it.  I might end up stuck at work late most nights and skip meals because it is too busy to eat properly (but really, how is it that much different from most rotations), but it is fascinating stuff.

The thing is, it is different from what I expected.

My perspective of bone marrow transplants is romanticized.  When I thought transplant, I (despite my previous criticisms of the realism of the books) pictured something from the pages of My Sister’s Keeper or one of Lurlene McDaniel’s books.  I saw them as tough and filled with complications, but also as a cure and this glorious saving grace.

Transplants are these things.  But, there is so much more to them than what the books suggest.  I feel like books and movies make them seem like a cure-all thing, but they aren’t all the time.  And although complications are addressed, I feel like they aren’t portrayed as the potentially fatal things they can be.

You don’t just go getting transplants all willy-nilly.  They are for people meeting specific criteria.  For people who are otherwise healthy and for people who have some baseline reserve.  They are generally for people who are at risk of dying from their disease sooner rather than later if they don’t go to transplant.  They are serious business.  And continue to be long after the transplant is done.

The bone marrow transplant hematologist I am working with this month is cautious to remind us regularly that there is a good chance any one of our patients could die.  Even if we do everything right.

He says it is one of the toughest parts about doing transplants  1 in every 4 or so people he develops a relationship with dies.  This is tempered with some lower risk transplant variants where it is only 1 in every 10.  But still, average that out and you still have 1 in every 5 or 6 dying.  And there is still the risk of relapse and such in the long term.

Kids do better than adults.  These odds are adult odds.  Kids tolerate everything better.  That is just how kids roll.  They can take so much more than adults can.  I am glad for that.

I know, this from the oncology resident who loves palliative medicine where 99.9% of people die.  But, you know that going in.  You know there is no cure.  This is a potentially curative treatment.  That is tough to go through and a good chunk of these people die.

I am okay with the odds.   I get that the odds of survival in transplant in the setting of malignancy are better than the odds of surviving their disease without treatment or with other treatments.  That is the only way you can really justify going through it.  People are referred for transplant only when survival post-transplant are higher with than without it.

Plus, flip the odds around… 3 in 4 survive, 9 in 10.  That sounds decent, I think.  Especially compared to what it would be without treatment.  Tough stuff, but realistic stuff.

I have watched people do well with transplants.  I have seen people come in with brutal side effects and consequences of transplant.  But, they are alive.  I have had people horrendously sick one week come out of it looking great and running into me on the street after they get out.  I have had others who came in looking great and have tanked.

Known risks.  Known benefits.

Everything in life is like that.  In the oncology world, these risks and benefits can be extreme.  Sometimes the odds and the risks blow my mind.  Seeing us making people so sick with toxic doses of chemotherapy and then saving them with stem cells.  Watching someone hover at risk of infection, of bleeding trying to keep them comfortable and safe and hoping that their body recovers their blood cells before things get out of control.  Watching someone recover their counts and their life day by day.

When it comes down to it, when you look at the data, some risks are worth it.  And there are always those who defy the odds in either direction.

The transplant patients I have worked with have been some of the toughest, bravest and nicest people I have worked with.  That is probably part of why I shudder when my staff doc reminds me again that there is a chance the person won’t survive, even if I do everything right.  At least, I am learning how to do things right.  And be realistic while being supportive and caring.

I am glad for this experience.  For the realistic perspective I have of bone marrow transplants I have gained.  And I still want to be involved with them because they save lives and buy time for so many.

Sometimes, I still wish it somewhere near as simple as it seems in fiction books.

Morphine and Hand-Holding… When the word “fix” changes meaning.

Sometimes, we, as humans, are helpless.  Subject to the needs of our biological bodies and in a position where we are doing well simply to breathe.

Babies, despite being tough little cookies are helpless.

And sometimes, when we are critically ill or dying, the same phenomenon can take place.

Life comes and life goes.  That is how we were made.  Our Earthly bodies are finite.

We celebrate birth, but fear death.

Birth and death are not two different states, but they are different aspects of the same state. There is as little reason to deplore the one as there is to be pleased over the other. –Mahatma Gandhi

I have been covering call for the internal medicine floors.

I love internal medicine.  You can help a ton of really sick people with complicated disease get better.  The thing is, lots of sick, complicated people don’t get better.  At least not in the sense that most doctors or other people, for that matter, want to see.

I got called a couple times overnight to see someone.  A new admission.  Who had recently been admitted, but got better and went home.  And was now sick again.  Sicker.  This person had decided after past experiences to refuse intubation or other breathing assistance aside from oxygen.  So, we were treating the underlying disease and hoping for the best.  Otherwise this person would be in ICU on a ventilator.

I went to see this person, curled up and looking tiny in the big hospital bed.  Just breathing.  Breathing with every muscle in their body despite the high percentage of oxygen mask on their face.

I politely ask how the person is doing.  I knew the answer.  It was written all over their tired face.  They couldn’t breathe.  And as the med student behind me said later, we really weren’t doing much about it.  Some oxygen, some steroids, puffers and antibiotics and crossing our fingers.

I don’t know if you have ever not been able to breathe.

I have.

It is a terrible feeling.

So, I can only imagine how terrifying it would be knowing that you may very likely die from this distress.

We listened to her lungs.  Held her hand.  Asked if there was anyone we could call.  The answer was no.

I went back and looked at the orders.

Nothing for anxiety.  Nothing for pain or to ease the struggle with the breathing.  The plan was ICU until very recently.  And other issues until the situation became more grave made the use of anxiolytics and narcotics not the best idea.  But now, as the nurses said, they basically sent her to the floor to die or get better, whichever came first.

On-call residents are not supposed to change the management too much.

But really, sending me a possibly dying patient without palliative orders is unfair.

Not using invasive measures to sustain life does not equate giving up.  It just means that we don’t violate the pulp out of a person for what may be a non-existent benefit.  However, people who do not have CPR or ventilation often still receive other treatments to help their underlying problem by treating infections, diseases or symptoms.

Sometimes we withdraw everything except for comfort measures. But this decision comes with even further discussion with the patient and family and looking at other things in the picture like the stage of the disease and the goals.

At this point, this person was having their disease treated.  They still had a small but reasonable probability of recovery with treatment of the underlying problem, although their chances of coming off of a ventilator were slim.  We were also managing some symptoms, but they were still having significant difficulty.

I wrote an order for Ativan and for Morphine.   I had a good chat with the student about providing comfort care regardless of the prognosis, but especially when people are end-stage.  I showed her how the blood gases showed the patient was tiring out and medically needs intubation.

I looked in on the patient before heading to bed.  Still curled up and puffing away, but asleep.  I whispered a prayer and went to bed.

I was called to that floor a few more times over night.  Never for that person.  But, a few others with more “fixable” problems.  Things that feel miserable like shortness of breath and nausea, but that are often managed easily with some reassurance that the medications we ordered with soon kick in and they will likely feel better.

There is something satisfying about the easy fix problems.  Knowing that they likely will get better.  Knowing the next step if they don’t.  Or that someone else probably does.

Plus, easy fix problems are ones that can be resolved quickly or at least easily and thus we all get more sleep.

Even in people who are at a point where their problem cannot fix, there are easy fixes.  Sometimes, a simple change can resolve the unpleasant symptom, like the feelings of smothering.  Or holding IV fluid overnight in someone who is beginning to go into heart failure because their kidneys have now stopped working.

There is also something satisfying about seeing someone sleep after a night of feeling like they were dying, even if you likely didn’t change anything big.  At least you gave them some peace while you wait to see if the other solutions will work.

But, there are things that aren’t easy fixes.

There are the obvious difficult situations like complex critical illness, people who are so sick you can’t leave their side, those that need monitoring and multiple medications.

Even once people are beyond those things, there are still tough fixes.  Like fear.  Or loneliness.  Or the knowledge that death is imminent and you are scared.

Sometimes staying awake after a simple call and holding someone’s hand while they breathe and sleep is more satisfying than reviewing the second chest pain (that almost always is nothing) of the night.

The patient was still alive when I went home.  Still looking terrible, but less anxious and ever so slightly better on paper.

Things are complicated.  People surprise you.  People you expect to die live and vice versa.

We are all human.  We all deserve good care.  Even if it is the end of life.  We put tons of money and time into babies (and we should).  But, why not our elderly too?

I love internal medicine.

We get to fix people.  Even if it isn’t always in the way we conventionally use the word “fix.”

Any job in the world…

I recently saw the question somewhere “if you could have any job in the world (and be fully qualified to do said job) right now, what would it be?”  It got me thinking.

So, I did what I do when anything gets me thinking.  I asked Patrick.  He wasn’t entirely sure.  Maybe likely actually teaching, but maybe journalism or something.

The thing that blew my mind was that I am actually doing that job (sort of) and am at least on my way to being fully qualified to do that job.

Actually, at this moment, as I sit in the hospital in hour 13 of 24 hour weekend surgery call, I question that a little. But really, even now I am mostly in my element.

If I could do anything in the whole world, I am pretty sure I would still do medicine.  Even despite the fact that I love to write and teach and such.  I feel like medicine gives me that and more.  And yes, I think I would still do rad onc.  And I would want to be doing it in combination with doing some palliative care.  An ideal split between the two would be awesome, but even just doing some part time coverage of a hospice would be amazing.

Obviously, I would love to be done with the whole residency thing.  I mean, it is a great learning on the other side, it seems.  The grass on my side is quite alright, though.

Nonetheless, I am working towards my happy place.  And realistically so is Patrick (at least he likely is).  I am glad we both are.  I think it would be just dreadful to be in a place where everything I was doing as not satisfying and nowhere near where I want to be.  I meet people who regret their choices and seem very unhappy every day.  It must be miserable.

I remember having a high school physics teacher (who was a touch on the crazy side with his handy dandy protractor and such) who told me one day that he became a teacher because he didn’t know what else to do with his physics degree.  Had he known about what became my undergrad degree (Nuc Med), he might have done that and enjoyed it more.

I also remember doing clinic with a very old pediatrician who was amazing at his job.  He is kind of a guru in his field.  We all respect him immensely.  At the end of clinic, he asked me what I wanted to be when I grew up.  I told him.  He asked all about it and my reasoning.  Then, he looked at me and said if he could go back 50 years, he would have done what I am doing.  I asked why.  He said that he picked something that was great and he would like, but really, he didn’t think he was smart enough (totally wrong) to do the other field, didn’t want to move to train and when he realized he could, it was too late.  He enjoyed his career.  His life is fulfilled.  But there has always been a piece of him that wondered “what if?”

Sometimes, I wonder if I will look back and wonder “what if?”  But I don’t think so.  At least not to the point where I think I would be unhappy.  It is a scary thought in some ways.

The good thing is that your job or where you live is not the key to life.  And you can make happiness as much as you can find it.  True happiness and satisfaction comes from so many places, namely God.

I may not be in my happy place (work-wise) yet, but I am getting there.  And grateful that I am on my way.  And that I know where that place is unlike many people in my age bracket.  Plus, the way to my true happy place is pretty darn happy most of the time, I must say.

This reminds me of a delightful Proclaimers song that I love to sing…

Tomato-Tomato: Answering some questions of distinction from the world of medicine.

Image from mentalfloss.com.

“You say tomato, I say tomato.”

You know the saying.  So, did my delightful teacher in Nuc Med, Debbie.  Except when she said the saying she pronounced tomato identically both times.

It cracked us up.

In life there are some things that sound the same but are different, some that look the same but are different and some that are indeed the same, but sound different.

Confused yet?

I have been asked a few awesome questions about some medicine-ish sorts of things by my readers and patients and family and have decided to answer some of them now.  These are answers to some of the “what is the difference between” sorts of questions.

Question 1: What is the difference between a ward clerk and a clinical clerk?

A ward clerk is the lovely person who takes care of all of the administrative things on the hospital ward.  They are the sunny face that directs people to rooms, answers phones and keeps the place organized.  They get paid for this job.  A clinical clerk, also known as a senior medical student is someone who is in their last couple of years of med school and is rotating through the hospital learning in a hands on sense how to be a doctor.  They are different from residents or interns.  They are NOT doctors (yet).

Question 2: What is the difference between an intern and a resident?

Not much and yet a fair bit.  An intern is a first year resident.  All residents are doctors.  They are doing training so that they can practice independently.  It is like another gradation of training.  You can’t just get a job working as a doctor out of medical school.  You get a job working as a resident.  In many places, there is a first year of “rotating internship” meaning the first year resident has to do rotations in a number of specialties of medicine to get well rounded before focusing on one area of medicine.  That is kind of what I am doing now.  Sometimes people say interns are off-service first year residents.  First year residents and fifth year residents are very different in that the level of training is obviously different.  You learn more as time goes on.

If I didn’t hate graphic t-shirts, I would need this shirt. Image from zazzle.com.

Question 3:  What is the difference between medical and radiation oncology?

Both are oncologists (although most people only consider their medical oncologist an “oncologist”).  Medical oncologists are doctors specialized in giving systemic treatments for cancer, like chemotherapy and hormone therapy.  Their background is internal medicine.  Radiation oncologists (not to be confused with radiologists) are doctors specialized in using radiation to treat cancers, often in a more localized fashion.  One is not better than the other.  The medical, radiation and surgical oncologists all work together to provide cancer care.  Sometimes for one cancer, it responds better to one thing and not another.  Others need all three modalities.  It depends on the cancer.

Question 4:  What is the difference between radiation oncology and radiology?

There were people in my med school class who I am pretty sure thought up to the day we graduated I was going into radiology.  Because they are clearly the same thing.  They are not, although back in the day, they were.  Then a lot more oncology started happening and things got more specialized and they branched off of each other back in the 50s and 60s.  Radiology is a field in which you read diagnostic imaging (CTs, MRIs etc).  Interventional radiology is a subspecialty of radiology in which you use radiologic imaging to do some surgical procedures, like putting in chemo lines and special drains.  Radiation oncology is a field in which you treat cancers with radiation.

Question 5: What is the difference between Hospice and Palliative Care?

At surface, there isn’t a major difference.  Often, the two are grouped together.  Hospice is a type of Palliative Medicine.  Palliative comes from the word pallium, meaning to cloak or comfort.  Pretty beautiful term, if you ask me.  Palliative medicine is a field of medicine in which you provide pain and symptom management, generally to people with life threatening illness.  Being cared for by palliative medicine does not mean death is imminent, but that cure is unlikely and comfort is important.  Palliative medicine is all about quality of life.  In a hospital, there may be a palliative care unit – an inpatient unit that provides comfort care.  In the community, there may be a Hospice house or organization.  Hospice is a type of palliative medicine and a sort of philosophy.  It is home-based palliative care.  Meaning, people are supported at home through outreach teams or they can go and live in a hospice house, which is a home like setting providing palliative supports.  Often, a palliative care unit is a bit more hospital like and can provide a bit more hospital-type supports compared to a hospice house, which is basically a home away from home.

 Question 6: What is the difference between the short white coat and the long white coat?

Good question.  My first guess would be the amount of white fabric available to get dirty (I am not a fan of white coats).  Apparently it varies from school to school.  Where I came from, the short white coat was a symbol of you not being in your clinical years.  You wore it to shadow, to clinical skills and such.  It was a sign of being a rookie.  Once you hit clerkship, you could wear the long one.  In some other places, all medical students go short.  I have no clue.  I guess it depends where you are.

This image, taken from an article in boston.com demonstrates the different styles and people wearing white coats and how although long white coats are traditionally associated with attending physicians and big accomplishments, it does not mean only attendings wear them and the reverse is true of the short white coat. Bet you can’t tell who is who.

Question 7:  What is the difference between an allergy and a sensitivity?

An allergy is an immune response.  A sensitivity is kind of like a nasty side effect or irritation.  People claim they are allergic to all sorts of things they are not.  If you vomited or itched or got constipated on morphine, you probably had side effects and may have a sensitivity.   If you develop hives, intractable vomiting or difficulty breathing, then it is an allergy.

Question 8: What is the difference between nuclear medicine and radiology?

Nuclear medicine is awesome.  That is the clear difference.  Seriously though, nuclear medicine involves imaging radioactive tracers as they behave within someone’s body (physiologic imaging).  For instance a bone scan images a tracer that acts like calcium and binds to bone.  Areas of fracture, wear and tear, infection or cancer appear brighter because that bone is turning over more quickly.  Radiology generally involves external radiation projected onto a film through the body.  It images anatomy only for the most part.   Think x-ray.

Upper left is a bone scan of a hand with a fracture of several carpal bones (with pins in place). Upper right is an x-ray of the same hand). The bottom left is an example of a fusion image with the two modalities showing how activity can be localized to an anatomic site.  Image from HERMESmedical.com.

There you go.  Eight awesome questions I get relatively often about things that seem very different or kind of the same.  Let me know if there are more questions.  Or more answers.  Either are delightful.

Why Oncology

I have been asked by various blog readers of late about my interest in oncology and why on earth I chose it as my specialty of choice.  I have written before about how much I love Palliative Medicine, dislike surgery and all that good stuff, but never the specifics on the whole oncology thing.

Image from pingram.me.

Thinking back, it seems silly that I have never written on the issue.  I think part of it has to do with me being in the midst of the CaRMS (residency selection) process when I started blogging and I needed to tell everyone about it in the real world.  Another piece is that the story is rather complicated and has a lot of back story and honestly, I am not sure how far to go back.  And I glossed over it in my CaRMS explanation because it just feels too personal and too cliche.   I picked some key incidents, but seriously, some of them make for posts of their own, which will likely appear in the future with further explanation.

To get the full context, I am taking you back to when I was a kid and my Aunt (the one I always say I am just like) was just diagnosed with lymphoma.  6 year olds don’t get much except that someone is sick.  And she was always sick.  Over the next couple of years I learned about chemo.  I learned that people on chemo lose their hair and their nails and get very sick.  I learned that you can become immunocompromised.  In my head at 7, this meant that you, even as a grown up could get chicken pox.  And that is bad.  I saw the inside of the chemo room.  I tagged along to doctor’s appointments.  I learned how to go into isolation rooms.  I understood the word coma. Things that no kid should ever have to learn about.   But, to me, that was normal.

She died when I was 8 and ½.  I will never forget the days leading up to and following that day.   Never.

It sounds cliché, but the experience changed me.  Little 8 year old me.  I knew death was real when most of my friends didn’t.  I knew what cancer was.  I found it all fascinating.  I read medicine books.  I needed to know everything that could kill me and my family.  But, I wanted nothing to do with it, or at least that is what I thought… My, how things change.

I have had other losses.  Some have really shaken me, like my classmate this summer.  I learned that I can’t avoid the things that hurt you.  And that sometimes death just happens.  But, I think it still shapes you.

They say death is hardest on the living. It’s tough to actually say goodbye. Sometimes it’s impossible. You never really stop feeling the loss. It’s what makes things so bittersweet. –Meredith on Grey’s Anatomy

Time marched on.  I discovered I loved physics and biology and such in high school.  I got sold on doing Nuclear Medicine as an undergrad thanks to a few friends.

I had minimal interest in working with people.  I thought being a researcher would me my area of interest.  It just seemed I didn’t like the touchy feely stuff like my friends… It made me uncomfortable.

It wasn’t until I started university I even considered medicine.  I somehow fell into the job at the Hospice.  I applied to it and several others.  I never thought I would get it.  It worried my family and friends… Me being around all of that death.  I loved it.  I can’t explain it, but it was home.  And it just made sense.  I was comfortable.  I wanted to help these people.  It really clicked.

I did Nuc Med.

During my undergrad, I changed.  I found God.  I found people.  I discovered I had a passion for people in the difficult times in their lives, through crisis and illness.  I continuously had things pointing me towards medicine and towards people.

In the end, I graduated and went to med school (though it came in to question repeatedly throughout my undergrad with all kinds of self-doubt and such).  I wasn’t sure what to do once I got there.  Oncology was on my brain, but so was Nuc Med… I loved it so much.  Then, there was the whole Palliative Medicine thing.

I job shadowed in undergrad.  In all of those things.  I realized I loved people and that Nuc Med (as a physician) made me want to gouge my eyes out.  I loved Palliative Medicine, but didn’t want to be a GP.  Medical Oncology required an Internal Medicine Residency.  Radiation Oncology was like the optimal combination of the things I liked leaving out some of the bits I disliked.  Research, as it turned out was not really my thing at all.

So, Rad Onc became my new focus.  I did the electives.  I applied to the program and I got in.  I am sufficiently anal retentive and organized to do the job.  I love physics.  I love the details.  It is fascinating to see how quickly things are changing in the field and how team oriented and patient focused things are.  I am comfortable in oncology.  And I find it fascinating.  There is something strangely amazing by the way cancer cells can just take over.  The physiology.  And even more so, it is amazing how we combat those cells.

It is a strange pick.  A small program.  A piece of the hospital that is a black box to most people.  In fact, it is hardly taught in medical school.  Some of my classmates didn’t know what I was going into when we graduated.

Sometimes, it takes moving forward to really understand how where you come from makes you who you are.  If it weren’t for those experiences, for that by chance summer job, for my undergrad degree, I am not sure if I would have even done medicine let alone picked my career of choice.

And we know that God causes everything to work together for the good of those who love God and are called according to his purpose for them.  -Romans 8:28.

Forgiveness

Forgiveness is something we all need.

I am referring not only to forgiveness for all of the terrible things we do from day to day that God needs to forgive us for, but also the terrible subset that we do to the people we care about.

Marriage was created by God and is often used as a model for the relationship between Christ and the church.  And the thing is you often screw up and hurt the people we are closest to.  Like God and your spouse.  But, they forgive you.

Forgiveness is an amazing concept.  It is something that is full of love and grace.  Like parents who continue to love and forgive their children time after time.

Some people say they can forgive, but they can’t forget.  Sometimes, I question if that is true forgiveness.  I am not saying that forgetting is easy.  That is what God does for us through Jesus… And it is big.  So big.  But, for the rest of us, just forgetting a deep hurt is not easy.  We remember, we relive it…. It sticks with you as a part of things.  But, I think even though you remember, there is a difference between not forgetting in a remembering sense and not forgetting in a still not letting the person get away with anything and making them and yourself feel terrible.

I am not belittling big hurts in life.  I have had a big hurt or two.  The kind that haunts you. I have friends who have lived through more than most people can imagine.  Forgiveness was a struggle.  It continues to be a struggle to deal with some aspects of it.  But, with God and through love, forgiveness comes.

When you love someone, sometimes the hurts sting more.  You want so much to understand and yet you want so much to have the person know how it made you feel.  But, we are taught to forgive.  I think love helps with the forgiving process.  When you love someone, you want to forgive, no matter what the hurt.  Maybe not instantly (it probably should be, but it is not necessarily).

Marriage is for life.  So, you might as well forgive and work through things.  Otherwise, it is going to be a very long and unhappy forever.  God gave us the capability to forgive and the example through His Son because He loves us.

I have seen people who have carried big hurts their whole lives.  And sometimes it takes until they are unwell and dying before the truth comes out.  More times than I would like to see, I have seen parents ask for children they haven’t seen in years.  I have heard people voice regrets about forgiveness and hurts that cannot be resolved person to person at this point.  Honestly, it is a good reminder to me to forgive people and maintain relationships.  It is also wonderful to see resolution, but heartbreaking to see people’s anguish when the resolution does not come.

Forgiveness is something that I think we brush off sometimes.  But, it is quite significant.

I have been going through a bigger than usual Classic Crime phase and have re-listened to this song. 

It talks about love and forgiveness in relationships.  I quite like it and feel it does relate to my relationship and that of many others.  We screw up, we confess and we forgive.  Forgiveness is part of real love.  Thank goodness God really loves us.