All-Or-Nothing Hell

I’m writing this on a Sunday morning. Feet up and cozy in my fuzzy slippers, steaming coffee in hand. I’ve got my clear plan for studying this morning, but first I need to address an issue I keep hearing about from those who have asked me to help them on this journey.

One of my student mentees emailed me this morning: Please help. I feel like I’m floundering. I don’t want to study all the time. I’m in ‘all-or-nothing’ hell and don’t know how to get out of it, and right now its stuck in ‘nothing’. Help!

Can I ever relate to that feeling! As a super intense and driven person absolutely intent on achieving goals that some say are “unrealistic” (whatever that means), it took me awhile to find ways to keep myself going, keep the study schedule even on boring days or overwhelmed days or just blah days. There’s some switch in my brain that turns to the OFF position sometimes, and it used to make me absolutely twitchy until I figured out what was going on and a few effective work-arounds.

If you’re stuck in all-or-nothing hell, here’s some ideas to help.

  1. STOP COMPARING. Stop comparing your insides to someone else’s outsides. We all know students who appear to never struggle with study motivation. But those who seem the most confident are sometimes the ones who struggle the most – silently.
  2. USE TIME AS YOUR BEST FRIEND. I’ve learned that what works best is to study every day for a set amount of time, taking regular timed breaks so my brain is more efficient. This will help you avoid procrastination and those frantic last minute cram sessions (that really don’t work anyway).
  3. DON’T CHECK IN SO OFTEN WITH HOW YOU FEEL. While it is vital to do what you need to do to stay emotionally healthy, you can waste tons of time asking yourself if you feel up to the next study marathon required. Just DO IT. Just pick up the books, grab the q-bank, review the Powerpoints, run through some flash cards as if you absolutely felt like it.
  4. TRICK YOUR BRAIN. Everyone’s experience is unique. Some people need to find ways to push themselves, others need to find ways to justify taking breaks or finding balance. Try setting up rewards for consistent daily studying – like a favorite snack after an hour of intense study, or checking in on social media at the end of a productive study day, or imagining you’ve got a reality-show camera documenting your good study habits. It may sound hokey, but these mental exercises do actually work!
  5. GIVE YOURSELF PERMISSION. To have a blah day. To feel unmotivated. To even feel like you’ve just spent four hours studying and can’t remember a single thing. Just like the weather, your feelings will change. Clouds are replaced with clear blue skies. Sunshine follows rain. Snow melts. Blah days end and brain-fog lifts. Rather than feeling frantic when those down-days happen, remind yourself that the feelings will pass.
  6. SCHEDULE JOY. Medical school is intense. There’s an enormous never-ending volume of information to learn and retain. Since this is a life-long learning journey, start NOW to schedule JOY into your life. For the rest of your life, you’ll be busy. For the rest of your life, you’ll be learning. Don’t put off joy.

I promise you, every single human being experiences blah days, days when the motivation runs dry and the “off” switch seems stuck. Stop comparing, use time as your friend, ignore the unmotivated feelings and just study anyway, trick your brain, give yourself permission (to be human!), and make sure you intentionally incorporate JOY into your daily life.

This path we’ve chosen is exciting. And boring. And overwhelming. And worth it. You can do this!

The Myth of Multitasking

Its not real you know.

Whether you’re a man or a woman, there truly is no such thing as actual multitasking – literally doing more than one thing simultaneously. Researchers have proven time and again that what happens is a fast switch between multiple activities or mental exercises instead of actual simultaneous action.

But I’ve got to tell you, I come as close as humanly possible to that illusion. And one of the most frequent questions I get is some version of: “How in the world can you do everything you do and still be successful in medical school?!”

Well, consider this. There are about 18 hours of productive time in every day (while I may not like the interruption of productivity, I do need my six hours of sleep every night in order to keep up with all my super cool activities the rest of the time). I routinely study 12 hours daily, this includes lecture hours, seven days a week.

So what about the rest of the time?

Aha! This is where some folks fall down on the job. They’ll feel exhausted from their major tasks and think that what will serve them best is to just “veg” for awhile. Those six hours, usually in the evenings, are typically filled with mindless tv watching and socializing. And weekends are usually filled with many hours of “rest” that accomplish little.

Now please don’t misunderstand. I’m not one to advocate activity just for activity’s sake. I’m perfectly content to be still, to rest, and to connect with friends. I’m a human being, not a human doing.

Yet I’m also super creative.

Along with being in med school, I’m also a business and parenting coach, a social media marketing manager for a doc’s practice, and a ghost writer for various other businesses. I’m working on setting up an independent lab research project for a potential PhD program in Biology (because, well, I want that degree too). And I’ve always got several home-improvement projects going.

I guess the best advice given to me on this subject was one I heard back a few years when a friend was encouraging me not to give up on my dream. He said this: “Just make sure that you don’t put the rest of your life on hold while you’re pursuing your education. Education is a big deal, and you’ll get there. But its not the only deal.”

So how about you? Besides your ‘main thing’, what are you multitasking about? What other projects do you have going? How do you fill your time and days and weeks and weekends? I don’t know about you, but I am reveling in the soul-enriching process of multitasking, being more than the educational process!

Four Upsides To Being a Non-Traditional Med Student

“Non-traditional” is the word most often used to describe medical students who took a different route besides going straight from highschool to college to med school. Those of us determined to pursue this dream when over the age of about 25 are lumped together as “outlyers”. Admission committees juggle our commitment against the economic reality of the expense of our medical education and our life expectancy. If we do achieve acceptance, our colleagues don’t quite know how to relate. Often we’re older than our professors, and the less secure among them may (subconsciously?) lash out in their need to maintain the upper hand. Residency programs aren’t sure if the time they’ll put into training us will pay off in the long run – after all, someone like me will begin actual practice at about the age many docs are looking at retirement.

But even with the jaded eyes of one who fought long and hard against prejudice and sometimes outright discrimination, I maintain that there are huge upsides to being an older student in medical training. Here are my top four.

  1. We’ve lived. We’ve lived long enough to find balance, know self motivation, and have proven commitment in real-life experiences. We don’t need to be taught compassion. We understand at a visceral level what it takes to keep going when things get tough. We don’t need hand-holding. All those “real life” lessons not yet learned by someone spending their first 25 years of life in an academic setting have already been experienced and assimilated. We’ve lived.
  2. We don’t take abuse. This is a biggie. With much focus these days on creating a medical education experience less dominated by an autocratic mentality,  I confidently say that I don’t take abuse. Its not an entitlement thing. Its a real life emotionally healthy thing. And the icing on this particular cake is that this all happens in reality – you can try to bully me. But it will have absolutely no affect on my psyche.
  3. We can relate. Having lived, having carved out our own emotionally healthy well-grounded life in the real world, we can relate deeply and authentically with our patients. We understand the fatigue of a new parent. We never forget the ending of a marriage or the time we couldn’t pay the light bill. We know the fear of a medical mystery, teenagers in trouble, and aging parents. All that life stuff our patients live with every day, we can relate with having lived rather than from reading a textbook or listening to a continuing ed guru. All that relating makes us much more effective physicians.
  4. We’re in touch. There’s a pretty good chance that we’re in touch with our weaknesses as well as our strengths. We know where our biases are and how to work around them. We know how and where to reach out for help when we get stuck. And having lived just a little longer, we’re a whole heap less swayed by the latest push to fulfill someone else’s idea of our dream. We’re in touch with our insides, our outsides, and stay fairly well in balance even when life stuff kicks our backsides.

If you’re a person with the dream of being a doctor one day, never feel like you’re “too old”, or that its “too late”.

If you’re a “non-traditional” medical student, embrace who you are and keep going. The medical profession needs you!

If you’re sitting on a medical school admissions committee, mentoring a potential med student, a med school professor or clinical director or attending, please remember that we will learn from you whether you make the process easy or hard. We will pursue our dream whether you support it or throw up every possible roadblock. And we will bring compassion and competence to our practice of medicine whether or not you see our value.

No matter what path you’ve followed in your pursuit of medicine, if you’re a “non-traditional student”, we need you. Medicine needs you. Patients need you. You’re in the right place.

This Funny Foreign Language…

I love learning.

Truly, there is some hole in my soul that is filled best by the process of learning all things medical and scientific.

However, please forgive me while I have a mini-rant moment.

After spending a few hours studying Autonomic Pharmacology, I’m convinced of just one thing: Whoever named these various processes was hallucinating, was hopelessly psychotic, or just had a sick sense of humor knowing future med students could quite easily feel their brains explode simply by having five words that meant the exact same thing.

Here’s just one example.

Muscarinic antagonists

aka antimuscarinics

aka muscarinic blockers

aka parasympatholytics

To say nothing of the adrenoceptor antagonists and sympathoplegics…

Here’s the super cool thing (realized after I went through the material four times and it actually makes sense)…

Just a few days ago I was with a patient in the ER who needed Metoprolol. Now I understand better why it was needed, how it works, and why that was the right drug choice in this case.

Then there was the patient who came in with an overdose – after today’s study session, I better understand anticholinergic toxicity, inhibition of cholinergic neurotransmission at muscarinic receptors, and why certain treatments are and are not appropriate.

Here’s the thing.

I make jokes about the sometimes ridiculous and convoluted new language I’m learning – just because its actually rather funny to me that there’s so many very long nearly unpronounceable words (and goofy awesome when I can say and spell them and describe what they mean). But far more incredibly cool for me are those moments of putting it all together – the academic details with the clinical application.

I look up and six hours have passed. I know far more than I did six hours ago (even if the way-too-long words are ridiculous), and there’s still so much more to learn. Now on to the indirectly acting cholinomimetics (AChEIs)!

I Don’t Know

Working the ER last night, I had one of those realizations. You know the kind – that moment that rocks you back on your heals and makes the breath catch in your throat. The moment when you realize that some of your basic assumptions about medicine are simply false.

I can’t begin to tell you the times I’ve said I don’t know over the last few months. Working alongside my clinical mentor gives me the opportunity to observe diseases and treatments that I haven’t studied yet, and frequently my mentor will ask simple questions that I just don’t know the answer to.

Take last night for instance.

A patient came in complaining of “just feeling ‘off'”. She was tachycardic (124), had elevated blood pressure (181/110), and her face was flushed. Afebrile, no diaphoresis, no nausea, no chest pain or difficulty breathing. In fact, her physical exam was completely unremarkable. This patient exercised regularly, drank no caffeine at all, and pretty much thought she was healthy. After blood work we still had no better idea of why… cardiac enzymes were normal, d-dimer normal, TSH levels normal, nothing helpful on the EKG… Still, after two hours in a quiet darkened room, her symptoms remained precisely as they presented initially. Metoprolol magically lowered her heart rate and blood pressure back within normal ranges, and my mentor and I went to see how she was doing.

And then I had that moment.

Dr. J looked at me from the other side of the patient’s bed and asked, What are we worried about?

MI, blood clots, PE or other pulmonary issue, perhaps metabolic disorders….. my voice trailed off as I realized I simply didn’t know anything beyond that, and I looked forward to hearing his explanation to the patient. Possible causes of her symptoms. Treatment options. A concrete plan going forward.

But what happened was much different than what I was expecting.

We just don’t know what caused your symptoms. Three months ago you were here with similar presentation, and at that time the doc who saw you thought it might be that you were drinking too much caffeine. But you’re saying you cut caffeine completely out of your diet so it can’t be that. All your tests came back normal so we’ve ruled out the life-threatening issues, which is a good thing. We’ll provide you with a prescription of a beta blocker to help prevent your heart rate and blood pressure from spiking, then get you in to see a cardiologist asap.  

Whoa. So me not knowing wasn’t only about my clinical inexperience or being in an early stage of my education…. Even my mentor didn’t know.

Que huge shift in my thinking.

Medicine isn’t necessarily about absolutes. Even highly educated and experienced physicians will often not know what’s causing a particular set of symptoms.

And that’s okay.

I write that’s okay as if it is. I’m surprised at how uncomfortable those two words make me. I want medicine to be an exact science – enter in symptoms, spit out a diagnosis and concrete treatment plan. But that’s not reality.

And in those times of not knowing, I’m learning how vital it is to treat the patient with compassion and competence. Regardless of the storm of discomfort aroused by that I don’t know conclusion, our task as physicians is to provide as much reassurance as possible to the person actually experiencing whatever it is that has us baffled.

I’m well aware that it is impossible for me to ever know everything about everything in the medical realm. But moments like I had last night hugely motivate me to learn more, know more, understand more, minimize as much as possible the times I must say, I don’t know. And with that, its back to the books for me, oh so grateful that this upcoming block of lectures covers cardiac issues and I’ll gain a little more knowledge to help minimize those I don’t know moments.



I’ve been bored. This week after New Year’s was filled with fun stuff like lunch with family, catching up on laundry, playing with my pups and previewing next week’s classes powerpoints. But by yesterday afternoon I was painfully bored.

So I sent off a quick text message to my clinical mentor: Are you working this evening? 

Thirty minutes later I had changed into scrubs and was in my local emergency department examining a patient with extreme edema, an exacerbation of CHF.

This woman with such a sad smile looked up at the ceiling as I asked her how she was feeling.

I’m very tired you know. My doctor suggested I come in to the ER tonight, maybe just so I could get one night of real sleep. Please please don’t send me back there tonight.

Her responses to my questions were spoken barely above a whisper, with long pauses. My heart hurt a little as I asked her, “Why do you not want to go back to the facility tonight?”

Very long pause.

Its not that they don’t provide good care…

An even longer pause. I held her hand gently and simply waited.

Well, actually, yes it IS that they don’t provide good care. Its just – I guess its just that I don’t have anyone who cares at all.

After a consult with her Cardiologist and the Hospitalist, we finally got approval to admit her for the night. She would get at least one night of good sleep. And tomorrow, she’ll meet with the hospital social worker to see if maybe there is a different living situation that would provide her the level of care that she needs.

It was a crazy whirlwind of patients last night. But that patient I examined when I first got there has stayed with me. Modern medicine can’t fix her heart failure. As time marches on she will get progressively worse, and at some point her heart will simply give out. In the meantime, I hope that her interaction with me, a student doctor, gave her at least a brief moment of assurance that yes, there is indeed someone who cares.


I Am More

There’s a lot of focus lately on things like physician and student doctor “burnout” – that demoralizing realization that the grind of the job isn’t worth the price paid. That crisis can show up as everything from mild depression to a major job or life change to suicide attempts. While some are lobbying strongly for major changes in both medical education and medical practice, I’m thinking more how this works at the individual level.

From my position as an “older” medical student, I ache for the students and practicing physicians who experience such crises and believe they have no options. But its not just about empathy.

Its far more than that.

Over the few decades I’ve been an adult, I’ve had a few crises of my own. Having dealt with severe depression in my 20s, I know intimately what depression feels like and what it takes to move forward. I also know how insidious depression can be. And with the perspective of experience, I’d like to share a few things I know.

Its kinda like being halfway up Mt Everest, reaching back to the climbers following to share the potential pitfalls they’ll encounter and how best to keep climbing.

  1. I know that horrified moment of waking up realizing I’m in an abusive relationship – both an abusive personal relationship, and an abusive academic / work relationship. When I was younger, I would just “take it” for awhile. As I got older, I got to know my insides a whole lot better. I learned to stick up for myself, and I learned when it was important to walk away. You’ve got to be willing to walk. (Having done that – walked away from an abusive med school – I can absolutely promise you that it doesn’t have to be that way. Your dream of medicine is not over if you walk away from an abusive academic situation or an abusive practice situation.)
  2. Tough is fine. Abuse is not. Wherever you are on this hike up Mt Everest, you’ve put in the time to know that its a hard climb. Long hours. Not always warm-and-fuzzy colleagues. Unrealistic expectations. But here’s the thing. We expected tough. We knew it would be tough. We prepared for tough, and even with that preparation we get blindsided now and then. But abuse is NEVER okay.
  3. The law of attraction… with a twist. The field of medicine doesn’t just attract those of us who want to make a positive impact or heal suffering. It also attracts narcissists. There are a few other fields that have a higher than ‘normal’ percentage of self-centered jerks, but oh boy howdy medicine – both academic and practice – sometimes seems to only rarely attract those able to keep their gentle altruism intact through the training process. Remember that when you’re struggling, and don’t expect your colleagues to necessarily be the best people to lean on.
  4. You MUST have people. By that I mean, people you absolutely feel safe with and can lean on. People you can share your horrid day with an awful professor or attending or colleague without them judging you or walking on eggshells. People who will really hear you when you question your sanity or want to just throw in the towel. For me, this always means someone I pay for their ‘friendship’. Maybe that sounds a little cold, and I do have a wonderful family and great friends. But the only place I let my heart feel completely safe to be that real is with a therapist.
  5. I expect myself to lose perspective. For instance, I know ahead of time that right after an exam, I’m sure I failed. When I say “I don’t know” to my clinical supervisor, I’m sure he is fed up with me and wishes I would stop wasting his time. Your triggers will be different, but you must take time to understand what they are and anticipate them.
  6. Protect your career / reputation while you’re saving your life. I considered not even including this point, but what the heck, I’ve lived through this one. Its a reality that many within the field of medicine / academia have little patience with or understanding of the inherent soul-shriveling nature of the field for many. When you run into a professor or supervisor or colleague who’s own wounds mean they lash out to wound you, protect yourself. Until the culture changes, if you’re feeling overwhelmed or unsupported or abused, just remember that your school / boss / supervisor is likely not the place to go for help. Remember #4, you must have people. Choose your people wisely.
  7. Turn left. There is always a different option. No matter where in the process you are, there is always a different path than the one you find yourself on if it isn’t working for you. This isn’t about some weird entitlement attitude – you’re not entitled to always feel giddy with happiness in this grand field we have chosen. But serious ‘burnout’ – hitting the wall and hating your life – is entirely different. Don’t be embarrassed to admit you feel stuck, or overwhelmed, or exhausted, or depressed.

I’m tough. I’ve put a lot of energy and a few decades into becoming very good friends with my insides and understanding what it takes to keep my soul intact even in super hard circumstances. What I’ve discovered is that I AM MORE.

I’m more than my chosen profession.

I’m more than my job.

I’m more than what others think I am.

I’m most definitely more than what I DO.

And I will continue to protect WHO I REALLY AM with every fiber of my being while I strive to keep climbing up this grand mountain we’ve chosen.

If you’re in that place of feeling overwhelmed, realize you’re losing perspective, or just ‘can’t stand it anymore’, reach out. Please. There is always hope. And WHO YOU ARE is so much more important.