Published by
Stanford Medicine

Author

Medical Education, Patient Care, SMS Unplugged

Dreaming vs. doing: How my definition of compassion changed during medical school

Dreaming vs. doing: How my definition of compassion changed during medical school

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

dreamingI woke up gasping for breath. My patients had died, and I was dying with them. Gradually, my mind unclouded and I realized that it had been a dream, but that realization didn’t soothe my worries. I lay in bed wide awake, anxious. I was picturing the woman who couldn’t speak due to a stroke, who squeezed my hand and raised her eyebrows urgently, asking me for something I couldn’t identify. Then I was remembering the very sick elderly man whose wife brought homemade soup to the hospital every day, and who always had a warm smile and a flurry of gratitude in Mandarin for anyone who entered his room. Their faces swam through my mind for a long time before I returned to sleep.

I was in the midst of my first clinical rotation. After two years focusing on the basic science of medicine, finally caring for actual patients was exhilarating and all-consuming. Even after long days in the hospital obsessing over what else I could do for my patients, I would talk about my clinical experiences on the phone with my mom, on runs with my friends, and over dinner with my husband. I lived and breathed my new role so completely that in my dreams, my patients’ deaths were synonymous with my own.

Now, two years later, I still love my days spent caring for patients in the hospital and clinic, but I don’t dream about my patients anymore. I rarely talk about my work over dinner. This wasn’t a purposeful change, and sometimes I wonder if it means I care less than I once did. I worry that I am Exhibit A for the predictable erosion of empathy that we’re all told to expect by the time we graduate from medical school.

In my more self-forgiving moments, I tell myself this change in how I experience patient care means that I’m learning to compartmentalize my experiences to survive the many emotionally demanding years ahead of me in the medical profession. Based on what I hear in the periodic group reflection sessions that we have in medical school, many students, as well as senior physicians,  agree that this kind of compartmentalizing is the key to avoiding burnout. After all, being completely present for the patient sitting in the room with me means learning to put aside other concerns – including thoughts about my other patients. The same goes for my ability to be present in the rest of my life as a wife, mother, or friend. However, in spite of all this, there is still a part of me that wonders if my growing ability to mentally put my patients’ problems aside will translate into a decline in empathy and passion for my work. After all, I didn’t come to medical school just to survive it – I came to medical school because I believed caring for patients was my calling. What does it say about me that I can so easily leave that passion at the door of the hospital?

Continue Reading »

Medical Education, Medicine and Society, SMS Unplugged

The woman in the elevator: dealing with death in medical training

The woman in the elevator: dealing with death in medical training

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

flowersAlmost every patient I meet gives me the gift and curse of forcing me to confront a new side of my own vulnerability. I see new ways to die, new ways to suffer, new kinds of setbacks or losses. Of course, very little of this knowledge is technically new: My mother taught me that everyone dies, life isn’t fair, and so on. But since starting clinical training, what is new is the intimacy with which I live that knowledge.

On my neurology rotation, I was sent to examine a little boy in the ICU who had become unresponsive. I will never forget what I saw when I lifted his eyelids. His right pupil was rapidly changing shape from lumpy oval, to diamond, to a slit like a cat’s eye.

I alerted my attending, who somberly explained that that the boy’s brain was probably herniating – in other words, it was under so much pressure that it was being pushed into places it shouldn’t go. A few minutes later, a CT scan showed massive bleeding in his brain. The neurosurgeons were called, but determined they couldn’t save his life. As we left, a curtain was pulled in front of the room.

A few minutes later, already back to work in other parts of the hospital, my team stepped into an elevator. Before the door could close, a young woman ran in behind us. As the elevator ascended, she sunk to the ground and wailed, “Am I going to lose my baby? Please don’t let me lose my baby.” When the doors opened, she sprinted toward the ICU. With horror, I realized the woman was my patient’s mother. Her baby was already gone.

The next morning was a gorgeous Saturday. I had the weekend off so I put on my grungiest clothes and headed to my community garden plot, determined to separate myself from the week’s experiences. Weeds had crept in during a few especially difficult clinical months. I placed a shovel in the dirt, put all my weight on it – and it didn’t budge. I tried again, but the soil wouldn’t yield. I discarded the shovel and reached to pull a huge weed. The dead branches crinkled off in my hand, roots still entrenched in the hard, dry California earth. I sat down among the weeds, defeated, face in my hands.

A woman working another plot – a fellow student gardener I had never met – walked over and asked, “Are you okay?”

“I’m just not strong enough to do this. I should give up my plot.”

“I’ll help you clean it up,” she offered.

“Thanks… Sorry… I’ve just had a bad week.”

“Lots of final exams?”

“No. But I watched a little kid die yesterday.”

My new friend didn’t miss a beat. She knelt down, gave me a hug and said, “You are strong enough. Let’s get your garden cleaned up.”

I believed her, and kept gardening. I proudly told myself I had found an outlet to successfully cope and put the horrible experience behind me.

But it turns out things like watching that child die aren’t processed and compartmentalized so neatly, and can come back to haunt even the best and most personal times. A few months later, on the night before my daughter was born, my husband and I arrived at the hospital full of excitement, and stepped onto the elevator on our way to Labor and Delivery. But as the doors slid shut, I couldn’t suppress the mental image of the last time I rode that same elevator: a desperate young woman on her knees, repeating “Am I going to lose my baby?” For the thousandth time in medical school, I knew the fragility of my own blessings.

I have come to believe that coping doesn’t mean finding a way to separate “personal” life from “professional” experiences. There is no healthy coping mechanism that will let me walk away from experiences like this unaffected. Instead, I just keep telling stories like this one over and over – to myself, my friends and family, and now you – hoping that in the retellings I will find some meaning, some wisdom, some gratitude, or some peace.

Jennifer DeCoste-Lopez is a final-year Stanford medical student applying to residency in Pediatrics this year. She was born and raised in Kentucky and went to college at Harvard. She currently splits her time between clinical rotations, developing a new curriculum in end-of-life care, and caring for her young daughter.

Photo courtesy of Jennifer DeCoste-Lopez

Medical Education, Pregnancy, SMS Unplugged

The hospital becomes a different place: pregnant in medical school

The hospital becomes a different place: pregnant in medical school

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

bun_oven2“What was it like to be pregnant on the wards?”

I was pregnant throughout most of my third year of med school, so I’ve been asked this question a lot. For a while I had a habit of brushing it off. “Being pregnant isn’t extra work,” I would point out. “The baby-growing happens automatically while you go about your day.” But over time, I realized that the hospital became a different place for me when I became pregnant, both because of the mental state I brought to my learning and because of how I was treated by others. Here are some of the best and the worst aspects of my own 40 weeks living in that world.

Good stuff:

  • An incredibly meaningful OB/GYN rotation. Being pregnant when I first coached a woman through labor and delivered her baby made an already surreal, beautiful experience even more personal. Furthermore, delivering other people’s babies demystified childbirth for me, making it way less scary when it was my turn.
  • Being taken more seriously by some families on Pediatrics. Fairly or not, many parents trust other parents more than they trust the clinical training of a pediatrician. Although I wasn’t a parent yet, I looked kind of like one. So I was often granted some (unearned) credibility in their eyes.
  • A powerful reminder of how health affects everything else. I was lucky to have an easy pregnancy by most standards, but there were days when minor symptoms—nausea, joint pain, headaches I couldn’t treat with medication, or just feeling a little off—made the already draining demands of med school take more of a toll. After this experience, I try to have more patience when I ask my patients to navigate complex health systems or make major life decisions all while suffering from symptoms far more severe than the ones that brought me down.

Bad stuff:

  • Feeling like my identity was reduced to “the pregnant student” in the minds of some of my superiors. A handful of attendings thought that pointing at my belly and asking “What’s going on in there?” was totally appropriate behavior for rounds. One resident would greet me by asking “still pregnant?” when it had been only two hours since he had last seen me. Another time I was pointedly quizzed in clinic about the recommended amount of weight gain during pregnancy (not OB/GYN clinic, which would have made sense).
  • Assumptions about my professional seriousness based on my appearance. I was once scrubbed into the operating room during my third trimester and the attending surgeon asked me if I was interested in Surgery. Before I could answer, the resident blurted out incredulously, “does she look like she’s interested in Surgery?” Few times in my life have I been more aware of my gender and the barriers that come with it. The flip side of that coin is that when people found out I was interested in Pediatrics, they would often respond with a knowing nod and say, “of course, that makes sense.” I wanted to explain that I am interested in Peds for reasons that I find professionally compelling, and wanting to have my own kids is a separate decision.
  • Never being able to get my work done without having to answer well-meaning pregnancy questions. While I was pregnant, many people I had to collaborate with in the hospital wouldn’t get around to talking about the patient with me until I at least shared my due date and explained that it’s not a boy even though I “carry it all in the front.” It wasn’t the end of the world enduring some overly personal small talk, but it did sometimes get frustrating.

In the great scheme of things, the way Stanford Med handled my pregnancy gets an A+ in all the most important, practical ways. My mentors and advisors were overwhelmingly supportive, I was never penalized for having to attend medical appointments, and I was granted a huge amount of control over my academic schedule and timeline. Nonetheless, the learning environment was undeniably different because of my pregnancy. I hope that by speaking openly about it, I can help future students in my position experience more of the good lessons that came with pregnancy on the wards, and less of the negative assumptions.

Jennifer DeCoste-Lopez entered medical school at Stanford in 2010. She was born and raised in Kentucky and went to college at Harvard before heading to the West Coast for medical school. She currently splits her time between clinical rotations, a medical education project in end-of-life care, and caring for her daughter, who was born in 2013. 

Photo by Chip Harlan

Medical Education, SMS Unplugged

Please stop calling doctors "newly minted"

Please stop calling doctors "newly minted"

coins

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

Many friends from my original med school class will graduate and officially become doctors in just a few weeks. I can’t believe I’ll be at that point in only a year, and I’m incredibly proud of my soon-to-be-doctor friends. This time of year there’s always a lot of talk surrounding graduation, and in light of that I have a small request.

Please stop calling med school graduates “newly minted doctors.”

In the past few months I’ve read about “newly minted doctors” dozens of times. The snappy but overused phrase is sprinkled across articles about the residency match, health-care reform and medical education. Every time I read it, I think about a gift my parents used to give my brother and me each Christmas: two envelopes of uncirculated coins, one from the mint in Denver and the other from Philadelphia. The perfect, shiny coins were sealed in plastic and presumably untouched by dirty human hands. My set of coins was indistinguishable from my brother’s, since all were cast from the same mold.

Then I picture myself and my classmates, and it strikes me that the ubiquitous metaphor of medical graduates as cold hard cash is ironic at best, and insulting at worst.

We don’t bear any of the luster or newness of those shiny, uncirculated coins. We’re tarnished and grubby. We have shoes in our closets with our patients’ blood soaked into the leather. We’ve been endlessly passed around, trying to keep our heads above water in the culture of a new medical specialty every few weeks. We are permanently marked by the human hands that have touched our own: patients begging us for answers that we don’t have, mentors guiding us as we perform a procedure, loved ones comforting us when a patient dies.

And we certainly aren’t all cast from the same mold. Some of my classmates were the first in their families to go to college, while others come from several generations of physicians. Some had previous careers – as teachers, businesspeople, lawyers, musicians, writers – which shape how they approach medicine. Some have published their research in top scientific journals. Others devote themselves to improving health within the most marginalized populations. My colleagues aspire to become leaders in fields as diverse as science, policy, public health, education and technology. We are anything but interchangeable.

We chose to forego years of income (and many of us took on considerable debt) to enter the profession where we believed we could have the most positive impact on people’s lives. While past generations might have viewed med school as a ticket to prosperity, we knew better – there are many faster paths to greater wealth. And yet here we are, training to be doctors anyway. So evoking the greedy image of clinking coins to describe us is pretty far off the mark.

In short, what bothers me about the phrase “newly minted doctors” is that it’s both dehumanizing and de-professionalizing. It downplays the years of life, learning and human connection that take place before we ever write the letters “MD” after our names. It chips away at our professional identity by reducing young doctors to an interchangeable commodity rather than individuals who have devoted years of education to become thinkers and leaders in their communities and areas of interest. Of course, I acknowledge that what new doctors do with their lives is a question of economic importance – but it is much more than that. And because the language used to refer to us influences how patients, policy-makers and society at large view us, I ask that people pause before suggesting that graduating doctors could be molded, cast and distributed as if from a mint.

Jennifer DeCoste-Lopez entered medical school at Stanford in 2010. She was born and raised in Kentucky and went to college at Harvard before heading to the West Coast for medical school. She currently splits her time between clinical rotations, a medical education project in end-of-life care, and caring for her daughter, who was born in 2013. 

Photo by Grand Canyon National Park

Medical Education, SMS Unplugged

Med school friendships from classroom to clinics

Med school friendships from classroom to clinics

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

SMS-4-9-14My first two years of medical school – the “pre-clinical,” mostly classroom-based years – were an intensely shared experience with my classmates. At the stethoscope ceremony initiating us into med school, their heartbeats were the first I listened to upon being presented with my stethoscope. A few days later, we all nervously huddled together as our anatomy lab cadavers were undraped for the first time. We drew each other’s blood, percussed each other’s spleens, and ultrasounded each other’s abdomens.

Outside of class, my med school friends remained a constant presence in my life. We volunteered together on weekends to mentor pre-med students, give flu shots, or work in the student-run free clinics. A group of us would meet up for regular games of “Fridayball,” a completely made-up sport that we nonetheless took pretty seriously. I trained for and finished my first half-marathon and triathlon with a few of my classmates, which I never would have done without their encouragement. We went hiking and camping together. We helped each other move, gave each other rides to the airport, and cooked each other comfort food.

Then the pre-clinical years ended, and suddenly our paths diverged. Many of us jumped straight into clinical rotations, where we were scattered across dozens of clinical teams at five different hospitals. The MD-PhD students (my own husband among them) stepped out of the medical curriculum to dedicate the next few years to their research. Others took a year or two to pursue a research project or a second degree. Although I have continued to see my friends pretty regularly to catch up over lunch or coffee, go for a hike, or celebrate a birthday, school no longer brings us together on a daily – or even weekly or monthly – basis.

I miss being constantly surrounded by my friends as part of my daily routine, but I guess I can’t really complain: Most adults don’t get to see their friends at school every day. As it is, I am thankful to have found incredible friends who still go out of their way to be there for me, even now that our schedules don’t easily match up. Like the friend who skipped class to drive me to the doctor when I was sick. Or the friend who answered the phone late at night to help me recover important files I had accidentally deleted from my computer. Or the friend who stops by every month or so just to bring us a giant pretzel from his favorite bakery.

I think I will always have some nostalgia for the natural, easy closeness that came with the first two years of medical school. But maybe the time we spend together now is meaningful precisely because it isn’t as easy to come by.

Jennifer DeCoste-Lopez entered medical school at Stanford in 2010. She was born and raised in Kentucky and went to college at Harvard before heading to the West Coast for medical school. She currently splits her time between clinical rotations, a medical education project in end-of-life care, and caring for her daughter, who was born in 2013.

Photo courtesy of Jennifer DeCoste-Lopez

Medical Education, SMS Unplugged

8 reasons medical school debt won't control my life

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

debtAfter my recent post about choosing to start a family while in school, a friend and student at another med school responded:

At least for me, another thing that comes into play is the debt load… I myself will be carrying a debt load akin to a mortgage by the time I graduate (not by choice; my tuition and fees alone work out to $55k/yr) and as someone who will most likely [be] in his mid 30s… before he starts making real money, this has really hit close to home.

Fair point. According to this nightmare-inspiring AAMC fact sheet (.pdf), the median graduating debt for U.S. med students is $175,000. That debt undoubtedly looms large in major career and life decisions such as specialty choice, where to live, and when to start a family.

Thankfully, my debt will be nowhere near that figure, and I’d like to share the reasons why. I hope this will encourage those of you applying to medical school to think broadly about factors that will impact your debt at each school on your list. When I began the application process I never would have guessed that Stanford, with a “sticker price” of $65K per year in tuition, would be my most affordable option.

Of course, everyone’s situation is different, and I can only speak from my own experience. However, it is telling that our average debt is consistently among the lowest in the country, despite our location in a region known for its sky-high cost of living.

So here’s a few of the reasons why my household of two med students and a baby will graduate with a very manageable debt burden:

1. A solid need-based financial aid package
The packages Stanford offered to my husband and me were comparable to those offered by peer institutions. That means tens of thousands in grants, plus loans that don’t accrue interest during training.

2. Teaching assistantships
The TA program is one of my favorite things about Stanford Med! The opportunity for students to teach is integrated into our curriculum and encouraged in a way that, as far as I know, doesn’t exist at any other school. We serve as very well-paid TAs (regardless of financial need) for both core preclinical courses and fun electives. As an aspiring educator, this is a dream come true. I develop my teaching skills, reinforce my knowledge of important material, get to know the students in the classes below me, and work with faculty mentors who are passionate about education – all while dramatically lowering my debt.

3. Med Scholars program
Med Scholars supports student scholarly projects (anything from working in a lab to writing a novel), by granting tuition support and a living stipend. Assuming we write a solid proposal, there’s enough funding for every student regardless of financial need, so we’re not left scrambling for scarce outside research funding.

4. Outside scholarships
My husband and I have both benefited from generous outside donors, to whom we are immensely grateful.

5. Never having to buy my lunch
In the preclinical years, rarely a day went by that I didn’t get free lunch (and sometimes dinner) through seminar series, elective courses, or student group meetings. During clinical rotations, the feast continued: Many departments have daily seminars with lunch provided. For the rare day when I don’t get fed, I can always pack my own simple but nutritious lunch for about $1.50. So there is really no reason to spend my student loan money on expensive cafeteria food.

6.“Odd jobs”
Our flexible school schedule gives me time to earn extra income through jobs like babysitting and tutoring.

7. Biking everywhere
Stanford and its surroundings are super bike-friendly, making me healthier, happier, and blissfully unaware of fluctuating gas prices.

8. Groceries from The Milk Pail Market
At this quirky little store within biking distance of campus, I can fill up my cart with enough veggies, fruits, beans, and grains to feed us for a week – all for less than $20. My medical advice is to skip their unpasteurized milk, though!

Jennifer DeCoste-Lopez entered medical school at Stanford in 2010. She was born and raised in Kentucky and went to college at Harvard before heading to the West Coast for medical school. She currently splits her time between clinical rotations, a medical education project in end-of-life care, and caring for her daughter, who was born in 2013.

Medical Education, SMS Unplugged

Permission: Learning to thrive in medicine by breaking my own rules

Permission: Learning to thrive in medicine by breaking my own rules

SMS (“Stanford Medical School”) Unplugged was recently launched as a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

Jennifer D

“Just so you know, I’ll probably start crying any moment,” I warned. I could already hear my voice cracking, a Pavlovian response to this sort of meeting. After all, this would be the sixth faculty member whose office I had cried in since starting med school less than a year before.

“That’s fine. You crying won’t stop us from talking.”

I had permission to cry, so I went ahead and started crying.

I had spent my entire adult life so far striving to succeed in pre-medical courses, clocking long hours in lab, and tirelessly volunteering – all because I felt called to become a doctor. I wasn’t just going through the motions: I loved my pre-med activities and I loved medicine, and my first year of med school only strengthened that passion.

But I was just beginning to fully grasp the commitment I had made. It was unbearable to think that a decade of training would pass before certain aspects of my personal life would be within reach. These worries grew, and I sought advice from faculty mentors – hence, my tearful tour of six professors’ offices. Some offered stress-reduction suggestions: “Have you tried yoga or meditation?” (Yep, this is definitely California.) Others thought I hadn’t found my true passion yet and tried to help me tease it out. I was incredibly appreciative of the time they spent strategizing to make my path more bearable, but none of it got to the root of my anxieties.

In Faculty Office Number Six, my heart raced as I built up the nerve to confess the extent of my treason against the medical profession.

“I just worry I won’t have time for other things. Like my garden…”

But of course, I could bear not growing vegetables for a few years.

“…And getting exercise…”

This is not a plausible problem to cry over. She wasn’t buying it. ‘Just say it,’ I thought.

“…And actually… I think I want to have a baby. ”

Typing these words three years later, my heart is in my throat remembering how it felt to confess to a department chair at the School of Medicine that I wanted to have a baby. Having a baby in med school is Just Not How It’s Done. It is irresponsible, presumptuous, and especially inexcusable for someone in her mid-twenties who could easily wait until after residency. I braced myself for her reply.

“Then why on Earth don’t you have a baby?”

Not the answer I expected.

Continue Reading »

Stanford Medicine Resources: