Neurology Junior Assistant Resident (JAR) Year Part 1

I am halfway through my second year of residency (first year of focused Neurology training), and I am both exhausted and thrilled to be doing what I love - saving people's brains (and spinal cords too, sometimes).

The learning curve as a JAR (Junior Assistant Resident) is much steeper. Not to mention the added responsibilities we are tasked with, including teaching interns and medical students, running to stroke codes, providing guidance to medical teams that have requested our expert advice on their patients, etc. 

As a PGY-2, I complete inpatient rotations such as Stroke, General Neurology, the Neurology consult service, the Neuroscience Intensive Care Unit, and outpatient rotations in neuroimmunology, headache, neurodegenerative (i.e. movement, memory disorders), and at the Durham VA Hospital. We also have a few weeks of elective time which we can use to complete rotations in certain sub-specialties and related areas such as neuro-ophthalmology, neuro-otology, sleep medicine, neuroradiology, and research. 

2021 was overall a tough year, what with the demands of residency and the stress of the persistent COVID pandemic, but truthfully, I am so grateful for the challenging experiences because they have made me into an even stronger and more mature individual. I am also grateful for my achievements this year, which would not have been possible without the mentorship of incredible faculty. This includes the Duke R38 Research Grant to study some of the mechanisms underlying racial disparities in Alzheimer's Disease. I appreciate the opportunity to share more about my research interests on the Duke website through a Resident Spotlight interview. I've grown more passionate about cognitive impairment over the last few years and decided to take up volunteering as a Community Educator through the Alzheimer's Association. 

I'm tired but these activities are fulfilling and honestly, they keep me going. Dr. Siddhartha Muckherjee's 2018 article in the NY Times entitled "For Doctors, Delving Deeper as a Way to Avoid Burnout" encapsulates how much the extracurricular pursuits we're passionate about can keep us engaged in our medical careers. Throughout the article, in discussing his and a few of his former medical school classmates' research pursuits, he states, "We survived, I think, by deepening our commitments to research. We tried to increase our mastery within peculiar medical niches. And powerful, autonomous interests kept us going." Importantly, however, the support of my family, friends, co-residents, and therapist has been critical for my mental health and overall survival in residency.

I cannot forget the sheer exhaustion I have experienced just over the past few months, especially during my time rotating through the Neurology consult service. I remember that one of my busiest nights was in early August 2021, a couple of months into my first year as a Neurology resident (PGY-2). Things got so crazy that I didn’t get the chance to eat for the entire night and I barely drank any water. (Truthfully, I could and should have taken a break but unwisely chose to power through). I only ate a raspberry cheesecake cookie from the Subway downstairs nearby our cafeteria. I’m not sure I even went to the bathroom. It was a busy night. We had about 5 stroke codes and 6 consults in 12 hours. I guess it could’ve been worse, but it was still bad.

By the way, just for reference, one consult alone takes a lot of time - it involves chart review, seeing the patient to chat with them about their illness and to do a physicial exam (or even contacting family members if the patient is not able to explain what brought them to the hospital), relaying recommendations to the primary team (main medical team that is taking care of the patient), assisting with the disposition (where the patient will end up, i.e. home, admission to the hospital, etc), and writing the consult note, which consists of documentation of the HPI (history of present illness: the patient's narrative), physical exam, and assessment and plan. All of this can take quite some time.

Regardless, when I am woken up out of sleep and have to drag myself out of the cozy, dark, and warm on-call room to see that 3AM seizure consult in the emergency room, I remind myself why I chose this career in the first place.... and all becomes right in the world once more. It's truly a privilege to see patients who are suffering from neurologic emergencies and conditions like stroke, seizure, acute demyelinating diseases in the brain or spinal cord, etc, and to be able to get them the treatment they need (i.e. thrombectomy to remove the clot that's causing the stroke, anti-seizure medication, steroids for the demyelinating diseases such as multiple sclerosis, etc).

Localization in neurology is also pretty cool (and scary, depending on how you look at it). Believe it or not, one very tiny stroke in a small part of the brain (i.e. brainstem) can cause multiple tremendously debilitating symptoms, such as eye problems, weakness, speech changes, sensory deficits, and/or other symptoms. 

Stroke is certainly the biggest neurologic issue that we deal with and are consulted for in the hospital. What's the biggest risk factor for stroke? High blood pressure. Other risk factors include high cholesterol, diabetes, obesity, obstructive sleep apnea, heart disease, tobacco use, etc. We have to get our blood pressure under control! Let's also get that cholesterol under control by modifying what we consume on a regular basis. Let's try to be more active in our day-to-day as well. And the diabetes? We need to keep that in check too. If you snore and are overweight, you might consider asking your doctor to order a sleep study for you (keep in mind though that sleep apnea can also occur in people who are not overweight). If you have sleep apnea, that needs to be treated. Stop smoking! Go to your follow-up doctor visits. Take your medications. It's simple! An estimated 80% of strokes are preventable. Can you believe that?

Anyway, I'll get off my soapbox now. I will try to post another entry sometime this spring highlighting some interesting cases.

Thanks for reading! :)

Reflections from Intern Year (Part 2)

Emergency Medicine

There were many patient cases I encountered during my Emergency Medicine rotation in April that left an indelible, emotional mark on me, but I will highlight a couple. 

Preserving a Patient's Dignity

I developed quite a few frustrations with the field of Emergency Medicine during my month working in the emergency department (ED), including the lack of continuity of care, the stress of the high acuity of care, and importantly, having minimal time to spend with patients. The latter prevents you from taking a thorough history or performing in-depth physical examinations. It drove me insane. I'd gotten so used to being thorough on the general medicine services; it was such a shock to experience the rush of emergency medicine. I was forced to write brief, concise notes, rather than the thorough narratives and assessments & plans I was used to crafting on the inpatient side. 

It was one 3-11PM shift (that extended until 12:30AM) in the ED that made me realize how much I hated working in emergency medicine. It was the busiest shift I ever had: I didn't get the chance to eat, go to the bathroom the entire time, or even take a minute to myself. It was very stressful, what with trying to get a patient admitted to the general medicine service, discharging about three, dealing with an unstable patient with diabetic ketoacidosis, and seeing new ones. Things got very crazy. I could feel that my cortisol levels were elevated the entire time.

One patient, an 83-year-old African American woman, came in from her nursing facility after she was found to have a hemoglobin of 5.9 (normal hemoglobin for women: about 12-15.5g/dL). I had just come on to the shift when the decision was already made to send her back to the facility after she received a unit of blood. Unfortunately, after a repeat lab draw, her hemoglobin had actually dropped after getting a unit of blood to 5.5. I banged my computer mouse against the desk in frustration. There's no way we could send this poor woman back to the facility without ascertaining why her hemoglobin was dropping. I was simply told in sign-out (information about the patients for whom I assumed care) that she had a history of chronic anemia and intermittently required transfusions. But why? I wanted to push, but unsurprisingly, this is not information that the previous intern had, and it wasn't really their fault. Emergency medicine is not conducive to obtaining a comprehensive understanding of patients' narratives and medical problems. That's what the outpatient (or inpatient) setting is for. Not the ED. (Photo from here).

However, lack of information about why the patient had chronic anemia caused problems during my shift when I took over. I skimmed through the prior intern's incomplete note which stated that the patient had abdominal pain. No imaging was ordered, no rectal exam done, and I did not see any mention of stool history in the HPI (history of present illness). Goodness, I would have to do all of those things in order for the patient to be admitted to the hospital. The General Medicine team would definitely need this information.

Before entering the patient's room, I began to don my PPE (she was COVID+) and while doing so, I couldn't help but stare at her through the glass window of her room in the ED. She was entirely hunched over on her right side in bed, her glasses misaligned as a result of her head pressing into the bedrail. She was eating her chicken Parmesan meal with her left hand. A prior stroke robbed her of dexterity in her right hand to use the knife and fork on her plate, so she had to resort to grabbing the chicken with her left hand and stuffing it into her mouth. She made a complete mess of herself. The tomato sauce trickled down her left arm and was smeared all over her clothes and sheets.  

I wanted to cry when I saw this. I felt a lump in my throat and tears welling up in my eyes. I was astounded. I knew we had so much to do in the emergency room and it would take a few extra moments to don our PPE before entering the patient's room, but I was sure that we could all find 10 seconds to slow down and try to preserve our patients’ dignity by simply adjusting them in bed. Let's not have them make a complete mess of themselves while they are eating their meals. It took me just a couple of minutes to adjust this patient in bed and feed her dessert while at the same time tell her about our plan for her care. Why are we not slowing down to try to help our patients? 

I explained to her that I would need to examine her backside because we were concerned she may have been bleeding there. When I turned her, I saw that she was soaking wet and had dark black stool smeared all over her backside. Again, I wanted to cry. No one had changed this poor lady for the entire day. There was no need for me to do a rectal exam. She was obviously bleeding, and probably had an upper gastrointestinal bleed causing this dark tarry stool. I still could not believe that no one had thought to look at her bottom. I opened the door of the room and asked the nurse to help me clean the patient. The nurse must have been overwhelmed with other patients because she simply replied begrudgingly, "What supplies do you need?" Well, I thought, that wasn't what I was asking for, but okay. 

I cleaned the patient up as best as I could on my own, apologizing profusely the entire time. "Ma'am, I'm so sorry that no one was able to help you get cleaned up." All the while, this sweet woman continued to say, "It's quite alright, dear. It's alright." I shook my head furiously in silence, holding back tears. No, ma'am, I wanted to tell her, it's not alright. No one should have left you sitting in your own urine and stool for this long. There were multiple critically ill patients in the trauma bays that required more attention, but they were eventually stabilized. This patient was in the ED for several hours and no one at the facility or here in the ED was able (or willing?) to change her. Again, why are we not slowing down to try to help these people? I abhor that the field of Emergency Medicine oftentimes does not allow you to slow down and spend adequate time with a patient to establish rapport and thorough plans of care that they deserve.

 

The Air Mattress

During one overnight shift in the ED (11pm-7am), I saw a 50-year-old man who came in after a terrible bout of abdominal pain. He had just been discharged the day prior after a one-month stay in the hospital for multiple bowel resections and repairment of an inguinal hernia. He came back to the ED that morning because, since the night prior, he didn't have any furniture in his motel room to lie on, which would help facilitate his healing and recovery postop. He said that his father was going to buy him a recliner and deliver it to his motel, but when he got there, there was no recliner.  His bed was taken away due to hygienic concerns, per the motel owner and cleaning staff. All he had was a chair to sit on, but even that was broken. He woke up multiple times throughout the night. He began having sweats, chills, myalgias, and severely worsening abdominal pain. 

Fortunately, his lab work and imaging in the ED did not reveal anything concerning. His labs actually looked great. His physical exam also looked good: his postop scars were clean, there was no erythema, swelling, drainage, nothing. However, we didn't want to send him home if he didn't have anything there to sleep on. I spent a while talking to social work on the phone, but they were unfortunately unable to identify a way to get him an air mattress or any other furniture to hold him over until the arrival of the recliner that his father ordered. Apparently, the misunderstanding was that his father would buy the recliner while he (the patient) was in the hospital and deliver it to the patient's home, but none of that was done. The patient could not afford to purchase an air mattress for himself. 

I offered to give the patient's father a call to ask for assistance with the air mattress, but the patient adamantly refused. "I appreciate what you're trying to do, Doc," he said, "but that's not a good idea. You calling my pops could make things worse for me. He's an extremely stubborn Jehovah's witness, the chief of our family and household. If he says that the recliner won't get to my place until another few days, then that's that. He won't like it if he finds out I've sent some doctor to go meddling in his business." I asked if it might be better to call his mother instead. "Also not a good idea," he said apologetically. "He'll find out that you called her and become angry about me having someone go over his head to talk to her." 

"Okay," I said calmly, "what about your sister, or nieces and nephews who are living with your parents? Do you think one of them could run to Target or Walmart to get a $10-15 air mattress for you?" 

He shook his head no. "None of them have any money. They go to my pops when they need cash! And then he'll find out that I'm asking them for help when he's already told me that I need to just wait for the recliner to arrive."

This was getting ridiculous. I was trying to help this patient but he seemed to knock down every suggestion I had. I began to get angry with this father of his, but I tried to stay calm because I learned that their social situation was really tough. Earlier, the patient explained that his parents were taking care of his sister (who had "disabilities") and her children, who were previously abused by their father. I understood that there was a lot going on in that household, but I still found it frustrating that the patient was scared and insistent that I not call his father or anyone in the household. I simply wanted to ask if they could spare $10 to go to Walmart or Target and buy an air mattress for him. All in the name of his physical health! Family dynamics can get so complicated.

There was apparently no one else who could do this for him either. I explored a lot of other options with him. His family was basically out of the question, and he didn't really have any other family members around who were available to do this. In the motel, he was close to many of his neighbors. I asked if it would be possible to call one of them and ask if they might be willing to get him an air mattress. He shook his head no and said, "They don't have any money either. We're all paying extremely low rates to live in the motel. No one has any money.” I suddenly decided that I would go out to pick up the air mattress myself and bring it back to the ED for him. The patient expressed gratitude for my offering to do so.

Unfortunately, after I clearly communicated to the attending and nurse that I was going to go out and buy the air mattress for the patient, I was never told that the patient was being rushed out of the ED after my attending discharged him in the system. I made a plan with the nurse that we would keep him in a waiting or hallway area until I returned with the air mattress. When I learned after sign-out that the patient was gone, I grew annoyed with the nurse for not fighting for him to stay put somewhere nearby until I returned with the air mattress. 

"There's a chance he might still be out in triage or in the waiting area," the nurse said. I ran out to the waiting area but he was nowhere to be found. I tried calling the cell phone we had on file for him, but it turned out not to be his number. Someone else's voice and name were on the voicemail. The motel he mentioned had multiple locations, so I tried the one located closest to the hospital. No one by his name was staying there. I tried calling a couple of the other locations multiple times, but no one ever picked up. Perhaps because it was 12AM? I hung up the phone after trying the third location for the 4th time and sighed in frustration. I felt horrible. I felt like I really let this man down. I made a promise and I wasn't able to fulfill it for him. I worried that he would probably bounce back to the ED in the days he was waiting for the recliner to be delivered to him. 

I tried to make myself feel better by saying, well, I tried. I really did. But I still felt terrible. This poor patient was alone in what I imagined to be a dark, moldy motel room with a broken chair as his only furniture. He would almost certainly develop severe abdominal pain again after another night of immense discomfort. I was very sad that we couldn't solve the simple problem of getting this poor man an air mattress.

Intern Year Rewarding Experiences

Not all of intern year was stressful. In fact, it was mostly rewarding. Dare I say that I favor residency more than medical school? This is because I am deep in the trenches of patient care. This is why I became a doctor! To serve others, provide healing and comfort, and to fulfill God's purpose for my life. 

I'm grateful to have been selected as a recipient of the Duke NIH R38 CARiNG-StARR (Creating Alzheimer’s Disease and Related Dementias Researchers for the Next Generation–Stimulating Access to Research in Residency) grant at the midpoint of my intern year. I am studying the impact of adversity on epigenetic regulation in the development of Alzheimer’s Disease in African Americans.

It's been rewarding in itself to reflect on many other experiences and patient cases. I keep a notebook in my EverNote app that is dedicated to reflections throughout the year on difficult patient encounters, points of major growth in my training, teams that I worked well with (or didn't work well with), my growing passion for Alzheimer's, etc. It is at the end of these 12 months that I recognize more than ever how much I value the doctor-patient relationship. It is truly a privilege to serve patients in this profession.

Reflections from Intern Year (Part 1)

I am at the end of my intern year of residency. I completed a year of Internal Medicine, which is required for Neurology residency training. I will then begin my Neurology focused training in a couple of weeks, which will last for 3 years.

First day of Intern Year (Orientation)
June 25, 2020

This past year was arguably one of the most challenging and rewarding times of my life. I knew that internship would be difficult, but I never imagined that my experiences would leave me feeling all of the following: humbled, beaten down, furious, shocked, depressed, exhausted, laughing so hard I was clutching my stomach, overwhelmed, stressed out beyond belief, and ultimately, even more passionate about becoming a competent, empathetic physician for patients.

It has been a whirlwind. A surge of random memories is sweeping over me (many negative I realize haha, but I have more positives to share later): getting cursed out after my 28-hour call by a frustrated patient at the VA who demanded more information about his upcoming orthopedic surgery. Feeling so exhausted after working a non-stop 12-hour overnight shift in the Emergency Department that I found myself walking around the parking garage for a good while because I'd forgotten where I parked (I made it home safely). Getting swung at by an angry patient during my night shift on the Cardiology service because the day team had forgotten to re-order his pain medications. Witnessing the "n" word get thrown around by a drunk, older white woman in the ED. Also in the ED, caring for an acutely psychotic patient who used to lead a drug trafficking ring. In clinic, seeing an Arabic-speaking woman whose agitated son demanded that I prescribe a 3-month supply of narcotics for his opioid-naive mother without any clear indication for them. 

If you haven't already guessed, residency can be quite an entertaining time. The aforementioned experiences taught me the importance of maintaining a calm composure in high-stress situations. The stories certainly don't end there. And they're not all negative either! It has been amazing working with remarkable, selfless co-interns and residents at Duke. I also can't express enough how wonderfully supportive and encouraging the leadership has been (program directors, Chief residents, other faculty). I have been pushed to learn and grow in ways that I truly didn't think were possible. I deeply value the relationships I've been able to build with my patients in both the inpatient and outpatient settings. I am so grateful to one of my senior residents who showered me with affirmation early on in my intern year, generously sharing that I had one of the best bedside manners he had ever seen by any provider. I embraced opportunities to mentor both medical and PA (physician assistant) students, all of whom were valuable additions to the medical team.

I'd like to share a few stories and highlights from my intern year in this entry. For the sake of organization, I will break it up into challenging experiences then I'll end briefly with the rewarding parts of my training thus far. 

To ensure HIPAA compliance, personally identifying information has been omitted/changed and certain details of these encounters have been modified to protect the patients and their families.

Intern Year Challenges

Imposter Syndrome: Being at the Bottom of the Trainee Totem Pole

First-year residents (interns) are fledgling physicians who just finished medical school. We are on a steep learning curve throughout the year. Sometimes I found myself wondering: what in the world would I do if I didn't have [insert name of upper level here] around? Fortunately, I gained more confidence and autonomy as the year went on, but I certainly experienced extreme Imposter Syndrome at the beginning. (Photo from here)

First Day of Intern Year                       

I'll never forget my very first day of intern year: I started off on the Stroke service (Internal Medicine residents at Duke complete a few weeks of Neurology every year during their training). Looking back, it's embarrassing to think about how little I knew at the time. I never got paged as a medical student, so when my pager went off for the first time, I didn't even realize that it was mine. 

As a medical student, no one will yell at you for accidentally leaving your pager at home, or for forgetting your stethoscope or other examination supplies one day. As a resident, you wouldn't dare leave anything behind. In the mornings before driving to the hospital, I got into the habit of double-checking to make sure that I had my hospital ID, pager, stethoscope, face shield (when it was still mandated we wear them), alcohol wipes (to clean my stethoscope), and most importantly, my phone, which is always a lifeline at work. 

Anyway, my JAR (junior assistant resident; second-year resident) had to tell me that it was my pager going off. When I silenced it, I didn't even know how to work it to read the entire message. I internally scolded myself for not fiddling with it ahead of time to figure out how to properly navigate its functioning. The page was about my patient who now had low blood pressure and was feeling symptomatic (lightheaded). His other vitals were fine. I stared at the page. It suddenly felt like all knowledge I may have had about hypotension washed out of my brain. I also didn't know this patient very well as it was my first day on the service. I was finally able to move my feet to find the nearest phone to call the nurse back and ask for more information. She sounded so calm. I was so nervous. 

"Hey Dr. Rose, Mr. E's blood pressure is 86/49 after checking it three times. He says he's feeling a little lightheaded but is otherwise stable. His other vitals look fine. Do you want to give him fluids?"

I froze. Wow, she just called me Dr. Rose. That's me. I pinched myself to re-focus. I had to make a decision. But I wasn't sure what to do! I turned around to see that our team was still rounding. The attending was teaching about common stroke etiologies and the medical students, nurse practitioner, and JAR were listening intently. Crap, I didn't want to pull my upper level away to ask for her help with something this simple. I wracked my brain for what to do next. The nurse, sensing my hesitancy through my silence, offered, "We can give him fluids. They gave some when this happened before. How much do you want to give?" 

I wanted to kick myself. I didn't even know what to tell her for how much or what kind of fluid to give.  "Um... how much fluid did he get before?" I finally got some words out. 

"One liter of normal saline," she replied.

"Okay, let's do that," I told her, happy to have resolved this so I could return to rounds with the rest of the group.

"Sounds good. Would you mind putting in an order for the fluid?"

I froze again. I didn't know how to put in that order! Darn, I didn't know how to do anything. I felt so incompetent. Fortunately, my upper level had by now broken away from the team to see if I needed help. She saved me by showing me how to put in the order. The patient remained stable and his blood pressure improved slightly with the fluid bolus, but later that afternoon we explored and aimed to address the reasons why his blood pressure was intermittently dropping.

Now, one year later, I know exactly how I'd approach this situation differently. After getting the page, I'd call the nurse back while reading through the patient's chart to get information more quickly. I would ask for the other vital signs. If they're unremarkable, I'd clarify where and how exactly the blood pressure was measured. Sometimes the read is inaccurate because the blood pressure cuff is not tightened properly or it's placed on the patient's forearm or leg (yes, this has happened before). I would then, in no particular order, and while reviewing information in the chart, inquire about where the patient's blood pressure usually runs (i.e. is the 86/49 reading just slightly lower than a baseline of 90s/50s?), if he was mentating well or experiencing any other symptoms, if there were any concerns about an infection, if he had a history of heart failure, advanced renal disease, or cirrhosis (to determine how much fluid to give him), etc. The nurse would probably be able to answer most if not all of these questions. I would then fill in the gaps with my chart review. It's important to gather and synthesize information quickly to determine the next steps.

If there was any indication that the patient was acutely unstable, such as other concerning vital signs (i.e. needing oxygen to breathe, very fast heart rate) or looking unwell (i.e. pale, perhaps frank bleeding from a clear source such as the rectum), I would not waste time reviewing his chart. I would immediately go to the bedside to evaluate and stabilize the patient. 

I hope to grow in these other important areas as I continue on in my training: 

• Pathophysiologies: My co-interns and I worked our butts off in medical school to solidify our understanding of numerous pathophysiologies that underlie disease processes. As an intern, though my many patient encounters helped hone my knowledge base, I still felt much of this mastery slip away because I wasn't using certain concepts. Lord knows much of the minuscule basic science details we needed to master for Step 1 have dissipated from many residents' minds. I remember more from my Step 2 studying, and perhaps even more from Step 3, but the knowledge I am not using or cases I'm not seeing often (i.e. biostatistics concepts, management of certain cardiologic emergencies such as pericardial tamponade, specific infectious diseases, etc) has inevitably faded. Fortunately, this knowledge is revived and sharpened with more experience and patient encounters.

• RRTs/Codes: (RRT = Rapid Response Team; a patient is unstable, Code = code blue; a patient's heart stops). Throughout the year, I was involved in multiple RRTs and a handful of codes in the inpatient setting, but I led few. I aspire to emulate my senior residents who are confident leaders in emergent situations such as these in the hospital. It takes tremendous skill to calmly, efficiently, and effectively lead a team of clinicians (nurses, respiratory therapists, pharmacists, etc) to achieve optimal quality of care for an unstable patient.

• Goals of Care discussions: Leading conversations with families and patients with terminal illnesses about life-sustaining interventions is such an important skill to hone as a provider. My uneasiness with goals of care discussions stems from a traumatizing experience on the general medicine service: I cared for a patient with terminal bladder cancer who we planned to discharge to home hospice per his wishes. However, the day prior to discharge, he developed major clotting in this bladder that we presumed eroded into a nearby artery, causing massive bleeding. This was completely unexpected. My attending swiftly and gently led a discussion with the daughter about the possibility that the patient could pass away that evening. 

Unfortunately, he died sooner than that evening. After our conversation with the daughter, the attending and I exited the room to place comfort care orders, but not too long after those orders were signed did we hear the daughter scream. A nurse came rushing over to the work station. She tapped me forcefully on the shoulder then waved me over. "We need a doctor, we need a doctor!" She then rushed back into the patient's room. The attending and I were on her heels.

When we entered the room, the daughter was still screaming. Her knees buckled, her head bowed and grazing her father's face, her hands tightly gripping the head of the bed. "Please know that I did all I could!" she cried. The patient looked very pale; he was staring into the distance with lifeless eyes. The nurse looked at me and the attending and shook her head gently before averting our gaze, as if to say, "He's gone."

Another nurse grabbed hold of the daughter before she lost her balance. She was then led out of the room. That was the first time that I pronounced a patient dead. I heard the daughter's screams in my sleep that night. I remember waking up in a panic to those screams, distressed and heartbroken.  

Moving forward, I know that I will lead more goals of care conversations with patients and their families. It is important to be able to do so with deep empathy, candor, and compassion.

Halfway through Intern Year

I cannot believe that we are halfway through intern year and approaching the end of 2020. 2020 overall has been an emotionally overwhelming and stressful year, needless to say: the COVID-19 pandemic, social isolation from our loved ones and peers during the quarantine months, the racial tensions and social injustices running rampant in our nation, the 2020 presidential election (though the outcome was a relief)... it has overall been an absolutely crazy year. Let's not forget the deaths of famous individuals such as Kobe Bryant, his daughter, and Chadwick Boseman. 

It has been stressful as well. I hit an overall low point in November when I worked 14-hours most days on one of the busiest services in the hospital: General Medicine. I was pushed over the edge, however, when a couple of other stressful events took place in my personal life, including with my family. I went into a depression during this time and made it a point to reach out to my therapist and someone through our Employee Assistance Program. I was grateful to also have the support of my PD, co-residents, and other administrative staff in the program.

General Medicine was the hardest rotation I worked on all year because of the long hour days and immense amount of information that quite frankly, I'm still trying to master. It was an exhausting couple of weeks. Intern year so far has taught me tremendous humility and resilience. 

After General Medicine I was scheduled to be on Geriatrics for a couple of weeks before a one-week Christmas vacation. The New Year will bring another 2.5 months of the General Medicine rotation, and a few weeks here and there of Ambulatory (clinic), Rheumatology consults, Pulmonology consults, Cardiac Intensive Care Unit, and Emergency Medicine. 

Hoping for a fresh, new start in 2021 :) Thanks for reading this short udpate!

Beginning of Intern Year

I am two months into my intern year and it has already been a whirlwind of an experience. So far, I completed three weeks of Neurology (Stroke, Gen Neuro, and Neuro consults), several Ambulatory (outpatient or ED) weeks, and 1 week of Gastroenterology consults.
I also just finished working 12 days straight on the General Pulmonology service. Hours were 7AM-7PM (or 5PM, but mostly 7PM). I alternated short (7am-5pm) and long (7am-7pm) call days with my co-intern. He had already worked 12 days straight before I arrived, so I was willing to do my own stretch of 12 days before getting a weekend off. 

The Pulm service had me on an emotional rollercoaster. There were things that I loved and hated about my first inpatient Internal Medicine rotation as an intern. Overall though, the experience forced me to practice more independence and ownership over my patients' care. Two patients in particular had a great impact on me and pushed me to new heights in my independence and confidence as a fledgling physician.

To ensure HIPAA compliance, personally identifying information has been omitted/changed and certain details of this encounter have been modified to protect the patients and their families.


Chest pain without a clear cause

We admitted to our General Pulm service a sweet 27-year-old woman with idiopathic (no clear cause) pulmonary hypertension (elevated pressures in the lungs) and a number of rheumatologic diseases (i.e. lupus, systemic sclerosis, etc). 

She presented with chest pain that radiated to her upper back and had gotten worse over the past month. Her EKG showed sinus tachycardia (fast heart rate), and her D-dimer (a fragment produced during the degradation of a clot) was elevated. She was at high risk for a pulmonary embolism (blood clot in the lung), so we sent her off to get a CT angiogram. It was negative. We also sent her for a right heart catheterization to evaluate the pressures in the chambers of her heart. She also underwent a left heart catheterization when we learned that her troponin (cardiac enzyme) was elevated. The pressures in her heart were relatively stable from her prior catheterization during a previous hospitalization, and the left heart catheterization showed that her coronary arteries (which supply the heart) were completely normal. She also underwent an Echocardiography (ultrasound of the heart) that showed heart failure with preserved ejection fraction (seen on prior Echo during a recent hospitalization).

After all of these tests and some additional workup it was still unclear what exactly was causing her pain. Given her extensive rheumatologic history, it was likely of multifactorial etiology. It may have been partly due to costochondritis (inflammation of the muscles between the ribs), pericarditis (inflammation of the membrane surrounding the heart), or even esophagitis (given history of systemic sclerosis and patient's endorsement of some heartburn in the past). We decided to ask Rheumatology for their recommendations. We continued to treat our patient for her severe pain with oxycodone and other multimodal therapies, including an anti-inflammatory patch to put on the chest, a medication to prevent heartburn, and a lidocaine patch for the pain in her upper back. 

While we continued to treat and find the cause for our patient's pain, other issues arose during her hospitalization, including recurrent bouts of supraventricular tachycardia (SVT), persistent nausea and vomiting (which she blamed on the veletri), and constipation (likely opioid-induced).

On the fifth day of her hospitalization, she went into SVT while using the bathroom. Her nurse sent me an urgent page to come quickly and evaluate. Her heart rate rose to the 190s. My co-intern and I rushed to her room. Both of the Pulmonology fellows were in clinic, so my co-intern called the attending while I talked to the patient and her mother to understand what was going on. The patient was on the toilet, crying in pain. She'd just received oxycodone an hour prior but was still experiencing significant chest pain, as well as a burning sensation in the joints of her fingers and toes. I encouraged her to perform vagal maneuvers to slow down her heart rate (i.e. blowing into a syringe and bearing down). A couple of nurses then helped her get from the bathroom back onto the bed for further evaluation.

We'd called for adenosine to be prepared and brought to the room in case it needed to be administered. While our attending was still on his way, another attending from the MICU (Medicine Intensive Care Unit) stepped in to see what was going on. One of the nurses quickly filled him in. He turned to me and my co-intern and asked us loudly if we'd ever given adenosine for SVT before. Dread filled me. I was terrified. No, I'd never administered adenosine before. I was also appalled that he would ask me this question in front of my patient's mother who was standing on the other side of the room nearby the window, but within earshot. I told the attending the truth, in front of my patient's mother. 

I felt like a fool. For the past week I gained a sense of ownership over my patient's care like never before. Her primary concern of this hospitalization was the chest pain, but other issues arose that I began to manage independently. These included her persistent nausea and vomiting, constipation, poor appetite, and intermittent burning pains in the joints of the fingers and toes. I initiated therapies for all of the aforementioned at the consultation of my supervisors, of course. However, over the course of the week I did so less and less, making adjustments in her bowel regimen, nausea treatments, and analgesic therapies (for the burning sensation in the extremities) as appropriate. I worked hard to gain the confidence of both my patient and her mother. During my initial encounter with the mother, she was justifiably furious about her daughter's pain and the unclear answers to what could be causing it. I walked them through our thought process. I spent a lot of time with them during that week, updating them on the discussions we've had as a team and the anticipated next steps.

I felt confident that I'd built much rapport with the patient and her mother, as well as instilled confidence within them in the competency of our medical team and myself as a physician.
But I felt that that was stripped away with the one question asked by that attending about my ability to administer adenosine to my patient who was in SVT. I felt very embarrassed. "Great," I thought afterward. "Now the mother will wonder what in the world this incompetent woman who calls herself a doctor is even doing taking care of her daughter." I couldn't even bring myself to look at the mother.

Fortunately, our patient's heart rate went down to the 120s, and the EKG showed sinus tachycardia. She was given a one time dose of 1mg of IV dilaudid for her pain, and we immediately started her on a beta blocker (metoprolol) to slow down her fast heart rate. After putting in the orders for the additional IV dilaudid and metoprolol, I rushed back to my patient's room. Things had calmed down significantly. The crowd of nurses and techs that were gathered outside of her room had dispersed. My patient had just received the dilaudid, and her eyes were shut tightly in an attempt not to vomit into the grey emesis basin in her lap. Her mother was sitting quietly opposite her in a chair against the wall, staring at her daughter with furrowed eyebrows the entire time, concern filling her eyes.

I waited a few moments before speaking. I explained the nerve-wracking events from earlier, apologized for the scare, and expressed how relieved we were to know that she was okay. I reviewed the next steps of her hospitalization, and the main goals we were working on before discharging her home. Both had a lot of questions and I spent some time answering all of their concerns.

"Please don't hesitate to let us know if there is anything else we can do for you," I said to my patient and her mother after our chat.

My patient opened her eyes for the first time during this encounter and met my gaze as I rose to leave. "Thank you," she whispered.

Born with cystic fibrosis

Picture from here

Another patient we admitted to our service was a 30-year-old man with cystic fibrosis (CF). He was hospitalized many times before due to poor compliance with therapy and substance use. 

My patient presented to the emergency room with worsening shortness of breath, wheezing, and increased coughing over the past couple of weeks. He was not consistently compliant with some of his treatments (i.e. chest physiotherapy for airway clearance of the mucus buildup (see above picture)), and he was using substances such as cocaine. We started to treat him with antibiotics for the bacteria that were isolated on his sputum culture. The plan was to keep him in the hospital for the duration of the antibiotic therapy. Previously, he was discharged with a PICC (peripherally inserted central catheter), but had put heroin into the line, so for every admission after that he remained hospitalized until the antibiotic course was completed.

He taught me a lot about standing firm and showing confidence as a provider. He was hospitalized innumerable times in the past, and because of this he often tried to run the show by demanding certain changes or new additions to his management. One of the biggest challenges of this hospitalization was his anxiety. He would demand ativan a few times, but we were very strict about no benzodiazepines because of his current suboxone use (suboxone is used to treat opioid addiction). Concurrent use of suboxone and benzodiazepines can lead to adverse effects, including respiratory depression. We made it clear to him that we could not prescribe benzos. 

On the day that his PICC line was placed, he requested ativan for the anxiety and fast heart rate he "knew he was gonna feel" during the PICC placement. Before I could respond, he said brusquely without taking his eyes off of the TV, "I already know what you're gonna say. I want to speak to Dr. K instead." I didn't argue. It wasn't worth the energy. If he demanded to speak with my attending then so be it. Unsurprisingly, my attending said that we could not give ativan (a discussion we'd already had both as a team and with the patient), and I was told to relay this to him. I headed back to the patient's room to tell him this, and just caught him as he was leaving his room to walk a few laps around the floor. 

"Hey there!" I said, "I see you're about to go for a walk. I'll come back and we can have a chat afterwards."

"What is this about? You can tell me now," he said impatiently.

We were standing out in the hallway. Nurses bustled on by and other patients were walking around with their gowns hanging open and IV poles pulled alongside them. This was not at all the best place to tell him he couldn't get what he was requesting. I didn't want to risk dealing with an outburst, which was likely to happen given his volatile behavior. 

"Let's go ahead and step into your room so we can talk. It'll be quieter in there," I told him.

"Is this about the ativan?" he demanded.

"Why don't we step into your room?" I suggested again.

"No, why can't we just talk about it here?" He spat. "What are you, scared?"

I was stunned that he would ask me such a question and I chuckled nervously. Instinctively, I quickly sized him up. He was about my height (5'8), of an average build, and his ambulation was somewhat limited by a lame left foot. He was wearing a boot brace on the foot. He had surgery done on the left ankle from an injury sometime ago. 

I suppose I was being overly cautious about relaying this "bad news" out in the hallway, but at the same time I didn't want to cause an easily preventable disruption. No matter how gently I spoke to him, he would still become angry. I didn't realize I'd paused for so long until he started to walk away in frustration. As he limped away he turned around to shout at me, "You know what, I'm not gonna talk about this anymore. I know what my heart does when I get those PICCs put in. You can't tell me I don't need the ativan!"

He never got the ativan and he did just fine.

During the second week of his hospitalization, his nurse paged me to evaluate him for a new-onset tingling all over the body and a gripping, knot-like sensation in the chest that made it difficult to breathe. He was sitting up on the edge of the bed, anxiously rubbing his hands together. His systolic blood pressure was elevated to 179 but came back down to 150 by the end of the encounter. His other vitals were unremarkable. When I asked him to describe what he was feeling, the symptoms fit the description of a panic attack. 

Once again, we could not give benzos (i.e. ativan) given his suboxone and opioid use history. We discussed seroquel, but patient refused, stating that the last time he took it he was "knocked out for 3 days straight". Hydroxyzine was not mentioned this time because of his prior extreme agitation at the suggestion (reports feeling suicidal on this medication). Finally, he said he did not wish to speak anymore because he was "gonna refuse everything" offered, but he still continued to discuss his personal issues outside of the hospital that were causing him great anxiety and stress. After talking for a bit about these concerns, he sat back in the bed, appeared calmer, more relaxed, and said with a smile, "I feel better now." 

He was a difficult patient in terms of compliance and lack of decorum at times. I found myself balking often when I first met him as he tried to make the case for medications (i.e. ativan) that we simply couldn't give to him. He's taught me to be stricter and firm in my and our medical team's carefully thought out decisions, regardless of his temper tantrums and disrespectful responses. It is important to stand firm and demonstrate resolve when dealing with patients like this. I will carry this on with me throughout the rest of my training and career.

Thank you for reading!

~*~*~*~

Transition from medical school to residency during the COVID-19 pandemic

Black Lives Matter

These last few months have been absolutely insane for our country (and world). These shaking events include the worsening impact of the COVID-19 pandemic and the protests that have arisen in response to racial injustice and police brutality in our nation. George Floyd, Breonna Taylor, Ahmaud Avery, and the death of many other African-Americans has incited rage and anger across the US, especially among communities of color. It is absolutely infuriating that we are still fighting racism and social injustice in the year 2020. It is sickening. These issues have stirred up immense frustration and anger within myself, because I cannot stop imagining that each of the black individuals who died unjustly at the hands of a policeman could have been one of my own family members.

Why are we not more actively working to address the underlying issues that have stirred up fury and violence in the streets to begin with? We need to take the time to listen to each other, especially to communities of color because our voices have been suppressed for much too long. We cannot have peace or begin to work towards a solution to the chaos until we acknowledge why the black community is outraged.

An anticlimactic end to medical school

The COVID-19 pandemic has upended everything. My medical school pulled us from our clinical rotations in mid-March, and we finished up the rest of the semester virtually. Everything was canceled, including Match Day, graduation, weddings, meetings, flights, conferences, everything. I had many travel plans for the spring, but unfortunately, they were all canceled.

I took advantage of our extra available time to work and earn some money to help finance my move to North Carolina. I started working for Renewal Care Partners, an organization that provides home health and companion care services in the Chicago and New York City areas. Their services were considered essential when the shelter-in-place orders were instituted, so I was able to work multiple shifts per week for about three months while finishing up my final rotation of medical school and preparing to transition to residency. I was paired with a client with Alzheimer's Disease who needed daily assistance with routine day-to-day activities. Her husband took care of her but needed some help during the quarantine with the daily activities (i.e. dressing, bathing, cooking, cleaning, etc). 

Photo from here

I wouldn't have traded the experience of working with Renewal Care Partners for three months at the end of my medical school career for anything in the world. During medical school, we learn everything about diseases: how they manifest, what can cause them, how to treat them, how to prevent them, etc. We also learn to listen to and educate patients empathetically about these same diseases. However, we are never fully exposed to the real-life challenges that patients face within their own homes while they are ill (or as a result of their illness). As a Care Partner, I worked directly in the home of our client and her husband, completing different tasks throughout my shift such as laundry, cooking, cleaning, bathing my client, feeding their cat, and running errands. This job gave me a unique, intimate view of the challenges that my client and her husband faced on a daily basis; this is something that I otherwise would have never gotten the opportunity to experience, and it has been absolutely invaluable. 

The next time I am on a medical team that takes care of a patient who has just suffered a stroke, for example, I need to challenge myself to constantly think about how this brain injury can possibly leave the patient seriously disabled. Who will take care of him when he leaves the hospital? Will he be able to make it to all of his physical therapy sessions? Does he need help with activities of daily living? Since medical school, I remember hoping and praying that I do not become a burned-out, bitter, and beaten down resident doctor whose main care in the world is to simply get through the day and turn patients over to another supervising medical team. One of the main reasons why I went into medicine was because it is a deeply humanistic profession. I am not doing my job as a doctor if I am not giving my all to my patients and serving them as compassionately and empathetically as I can.

Residency

Photo from here

I left Chicago at the end of May and drove to my sister's in Maryland. It was a 10-hour-drive, and surprisingly it wasn't all that terrible. I'd stuffed all of my belongings into my small Mazda Mazda2 sport (well, not all of them; I had to donate and throw away a bunch of stuff). I did all of the moving on my own. It was exhausting, but I saved hundreds if not thousands of dollars that I otherwise would've spent on movers and a truck. I spent most of the way listening to the Dr. Death podcast. I was engrossed in the series. I stayed with my sister in Maryland for a couple of weeks before heading down to North Carolina to get settled in. My family came with me to help me move my things in.

I'm still in slight disbelief that I will be at Duke for the next four years. I am a Neurology preliminary intern this year, and will be working alongside the Internal Medicine interns. They are quite a diverse cohort, which is fantastic. As for the Neurology preliminary interns, all 7 of us are women. We are Duke's first-ever all-female cohort of Neurology residents. 

I officially start residency in a few days, and I am a mix of anxious, excited, nervous, and a little apprehensive. I have not formally taken care of a patient since January during my Infectious Disease elective. So it's been about five months. That is crazy to think about. In February I was in Ecuador assisting in a Neurology outpatient and inpatient service, and for the first two weeks of March I was on an Ophthalmology elective, which was essentially shadowing. After that, we were pulled from our clinical activities. It's been a while since I've formally taken care of a patient, but I'm confident that I'll be able to get back into it okay. Hoping to emerge from my first day unscathed. Fingers crossed. Updates to follow.

Thank you for reading!

Neurology Residency Interview Trail (Part 2)

NOLA - Beautiful weather, amazing food, and microaggressions?

Photo from here

I took an overnight Megabus on a Saturday evening from Atlanta to New Orleans for my next interview. It lasted about 8.5 hours. I had a horrible headache the entire day I was in Atlanta at my friend's place and I had no idea why. I'd eaten regular meals, drank a lot of water, napped for a couple of hours that day, and even took an extra-strength Tylenol but nothing worked. I was so afraid that the headache would continue into the following day and worse into Monday during the interview (unlikely, but I was still paranoid). I slept pretty much the entire bus ride except for the couple of times we stopped in Montgomery and Evergreen, Alabama. The headache went away completely by the time we arrived in New Orleans, thank God. 

Once I arrived, I dropped my things off at The Quisby (a fantastic hostel in the area nearby the hospital and bus station) and took a walk around the area. The weather was absolutely gorgeous (60s) at 7AM on Sunday, and the streets were empty. For some reason I felt like I was in another country with the palm trees, warm 'foreign' weather (I'm used to Chicago and NY's nasty winter), and the smell. I can't explain it, but there was something about the smell of the city that tricked my mind into thinking that I was in a more tropical place, like Jamaica.

Photo from here

I stopped at a popular brunch spot called Surrey's Cafe & Juice Bar. I ordered their Bananas Foster French Toast. It was to die for. It felt like heaven in my mouth after the first bite. It was certainly pricey but I wanted to try a popular local meal. 

The staff at this cafe were great. The locals also seemed friendly, but something (smallish) happened that made me think a lot more about microaggressions (Google definition of microaggression = a statement, action, or incident regarded as an instance of indirect, subtle, or unintentional discrimination against members of a marginalized group such as a racial or ethnic minority). 

A white couple came into the cafe with their daughter (who couldn't have been older than 2) and sat at a table next to mine. The girl was jabbering and squirming around in her high chair. A key fell from the table underneath the high chair. I was close enough to grab it so I picked it up and handed it over to the mother, "Here you go," I said with a smile. The woman didn't even look at me, mumbled, "Oh, thanks", and snatched the key from my hand before snipping at her daughter to sit down properly in the chair. I went back to perusing a list of fun things to do in the area. I figured that both parents were preoccupied with keeping their daughter from hurting herself. 

The girl continued squirming and a pacifier went flying and landed on the floor nearby my table again. I actually didn't notice it until an older, white woman from another table reached under my chair to pick it up and hand it back to the mother. The mother looked at the woman and said with a big smile, "Thanks so much!" Then she turned to her daughter and said, "What do you say sweetie? Say thank you to the nice lady."

I didn't really give this interaction much thought until I left the cafe. That's when I chuckled and thought to myself, "Wait a minute... That was weird. Does that situation count as a microaggression? Is it possible that the mother was kind of impolite to me because of...well you know....? And maybe she just didn't realize her own actions at all? Am I overthinking this??" I never play the race card, and I honestly don't ever really think about how my race might play a role in the way I am being treated by someone. I'm a human being, that's all that matters. Who cares if I have a little more melanin than you? 

My parents grew up in a country (Jamaica) that is predominantly black, so the issues of racism, prejudice, and micro/macroaggressions were certainly not pervasive in society. The United States is another story, needless to say. Growing up with parents who were not familiar with or had not been exposed to racism or prejudice during their own upbringing, I think this had a lot to do with my oblivion to micro/macroaggressions for most of my life. I have not been aware of them, or perhaps they just haven't happened to me as often as they would in places like the south or say a random majority-white, small town in Wisconsin, for example. Let's be honest. I'm now more aware of microaggressions because I've been having more conversations with friends and family about them. 

Tchoupitoulas Chicken
Grilled chicken breast topped with a Louisiana crawfish
tasso cream sauce and smoked mozzarella cheese, served
over whipped potatoes and asparagus
Photo from here

Anyway, later that day I was able to finally check in to the hostel and head over to Tulane's pre-interview dinner. We went to a place called Superior Seafood. The food was out of this world. It was without a doubt the most delicious food I'd eaten while on the interview trail (and possibly ever). I ordered the Tchoupitoulas chicken (I have no idea how to pronounce that). I also ordered bread pudding with a delicious caramel sauce and whipped cream on the side. Amazing. I felt bad about eating so much but I tried to make up for it by walking 30 minutes to and from the interview the next day. (Weather was in the 60s!). If I could fly back down to NOLA just to have this same meal I would.

Houston - talking politics on Greyhound and learning about the most diverse city in the US!

On the Greyhound bus from New Orleans to 

Houston, I was sitting next to a Louisiana

Photo from here

native, a middle-aged white man with a strong Southern accent who worked as a truck driver for many years (let's call him "Steve"). I was hoping to both nap and read "Kennedy and King" during the 6-hour drive, but I didn't mind taking a break, albeit long, to talk to Steve. We ended up chatting for a few hours about a number of things, including the attractions of Louisiana, alligators, "swamp people", New Jersey (my home state), his family, my career goals, and we ended the conversation discussing politics. It was a respectful, genuine conversation about our feelings regarding Trump's policies and his administration. We also touched on Obama's policies a little bit. (I admitted upfront that I don't know a lot about politics and I don't follow it very closely, so I spent much of our conversation Iistening to Steve). It probably won't take you by surprise when I say that he was a strong supporter of Trump's policies, but he wasn't crazy about "Trump himself".

Steve opened up a lot to me and shared that I was the first black person he'd had a genuine conversation with in over two years. In all of that time he adamantly refused to speak to "another black person" because of the negative encounters he'd previously had with them. He gave an example of a time in 2016 when he was the only white person working a construction job somewhere in the south among several other older black men. The black men were having a heated conversation about Trump, and Steve said that he was trying to avoid getting involved. After some more taunting from the men, he couldn't help himself and told them that though Trump was an "a**hole, his policies are sound." The other men boiled it down to a race issue and immediately dismissed Steve, calling him a "racist hillybilly redneck".

I cringed when he shared this. "Ever since then I ain't never spoke to another black person the way I'm speakin' to you. They always say I'ma hillybilly racist and it ain't true! I notice they also always seem to be makin' excuses for not moving forward in life."

I was speechless for a while as I tried to gather my thoughts to formulate some words. I tried to explain to Steve the point of view of the black men, including their anger, the pain they and their families experienced over the years with racial injustice, and the frustration they feel when they encounter a white individual who supports Trump, because it is difficult for the white community to even fathom what black individuals have gone through in our nation's history (and even continues to go through today). At the same time, I tried to comfort him and agreed that the men's dismissal of Steve as a "racist hillybilly redneck" was uncalled for and cruel. They didn't give him a chance to explain himself and that was very insensitive on their part.

Personally, Trump's inflammatory language was enough for me to dislike him from the very beginning. His rhetoric has been mysogynistic, ableist, and incredibly racist over the years. How can one possibly ignore that? For example, referring to Haiti, El Salvador, and a number of African nations as "s***hole" countries during a meeting with a bipartisan group of senators at the White House is absolutely disgusting and vulgar. These words came from the mouth of the President of our country.

I have to admit that by the end of the conversation I grew a little frustrated with Steve but I maintained my composure and didn't say any more to incite an inflammatory discussion. It became obvious that he wasn't bothered by Trump's nasty rhetoric and he wasn't sensitive to or knowledgeable about the ethnic minority's experience. He was very respectful, don't get me wrong, and he certainly opened up my eyes to another perspective. I became more aware of the shortcomings of the Obama administration and the strengths of Trump's. I admit that I don't often have in-depth conversations with supporters of Trump, but it's not because I avoid them; it's honestly because the opportunity doesn't often present itself. I am always open to having a discussion with someone who is willing to gently share their opinions and respect my own.

Houston, TX
Picture from here

When we arrived in Houston in the afternoon, I rushed to get ready for the pre-interview dinner and information session. I learned quite a few nice things about Houston, including that it is now the most diverse city in the country! I didn't know this! It was also nice to be able to tour the hospitals a little bit and see the gorgeous skyline of the city.

We went to a restaurant called Third Coast with the residents. I ordered the Tagrialini (I think this was the name) - it had pasta, shrimp, bacon, and some veggies. It wasn't bad, but I started to wish that I ordered the parmesan chicken instead.



(Okay I'm going to try to make the rest of these interview stories quick!):

Providence, Rhode Island - Freezing weather

I arrived in Providence at 1AM the day before my interview. I had a layover in Charlotte, NC (from Houston) and the flight to RI was delayed. Right before we boarded our flight in Charlotte I heard someone say, "If it's 30 degrees here in Charlotte it's probably 10 in Providence!" I chuckled when I heard that but the person ended up being right. It was 15 degrees in Providence when we landed. When I ran outside the airport to catch my Uber, the icy cold air hit me with a fierce slap in the face. It was such a stark contrast to the pleasant 50-60 degree winter weather of the South, and I was so annoyed to be experiencing the cold at that moment. To make matters worse, according to my Uber driver, the airport recently mandated that travelers grab their Lyft or Uber in a parking garage that was a bit of a walk away from the airport. Quite a few people were sprinting through the cold to catch their rides. I was frustrated at this new mandate and the crazy cold temperature that night.

Nashville, TN

Nashville is a great music city (not just country music). The food is great, people are friendly, and it's relatively diverse. Interestingly, Nashville has the largest population of Kurds in the country. The Kurds are a community of people who have migrated from Middle Eastern countries like Turkey, Iran, Iraq, and Syria. 

Vanderbilt has so much to offer, and I really enjoyed meeting the Chair, Program Director, Associate Program Director, and residents. They truly have a wonderful team. 

I stayed in Music City Hostel for one night before flying to New York the following morning. While there I shared a room with three other women (it was very cheap). 

New York, NY

NYC is a stressful place. One morning, on my way to an interview, I walked into the wrong subway station and didn't realize it until after I already swiped my MetroCard to get through the turnstile. That was a waste of $2.75. I exited the station and stood at the corner for several minutes trying to decide what to do. It made me a little anxious to stand there as people rushed by. If I took the next train at the correct station I'd arrive just on time, but if I ordered an Uber/Lyft, I'd get there 10 minutes early though it would cost lots more money. I ended up ordering an Uber because I didn't want to risk arriving late. 

To be honest, as I walked through some of the neighborhoods of Manhattan during the several days I spent there, I couldn't help but wonder why NYC is such a glamorized place. So many people smoke, unfortunately.... and spit! Right on the sidewalk. Also, I wouldn't be surprised if some of the small puddles on the sidewalks are actually urine. The streets and subways are absolutely filthy. At times I had no choice but to put down my duffel bag on the floor of the trains. When I returned to my friend's place at the end of each day I wanted to burn the bag.

I suppose NYC has some nice aspects: it's extremely diverse, Times Square is gorgeous (my friend who I was staying with lives nearby there), and people mind their own business. Although I suppose the latter isn't always a good thing. When I was on the train heading back to my friend's place from an interview one evening, an older woman nearby me was coughing profusely. I was standing and holding on to the handrail. Another young lady sitting next to the older woman frowned, pursed her lips tightly, and tried to scooch away from the woman. The woman furrowed her eyebrows and looked around apologetically. She pulled out a tissue and let out a loud, hacking wet cough, filling the tissue with mucus. The young lady next to her looked absolutely disgusted and quickly turned her head away from the woman.

I scolded myself for not having another tissue or an extra water bottle on me to offer to the woman. Out of all days to forget a bottle of water! I wanted to kneel down, rest a hand on the poor woman's shoulder, and gently ask her, "Are you alright ma'am?". The young lady's behavior towards the woman also bothered me, and I wanted to set things straight by showing her how to treat strangers with compassion.

Let's be patient and kind with strangers. The woman could have had lung cancer, and people were looking at her with disgust on that train. It was so heart-breaking to see. What in the world happened to empathy? Let's do unto others as you would have them do unto you.

Rochester, NY
During my two days in Rochester, I met up with a really good college friend who is currently in medical school at the University of Rochester. It was so nice catching up with her, eating her phenomenal home-cooked Cameroonian food, going to her local church, and binge-watching the first season of "You" with her on Netflix.

Rochester is a nice city. It's fairly diverse, the cost of living is great, and the Neurology residency program has been directed by one of the leaders in Academic Neurology for a while now. I enjoyed my time there.

~*~*~

Thank you for reading this long post! I hope you enjoyed it :)