S8E1: Facing Challenges in Medicine

Lilly: . . . our cold open.

Austen: Full disclosure, I don't even really know what a cold open is, and this is the second season that I'm on. Is it related to the podcast, or is it just a random question?

Lilly: No, it could be totally unrelated.

Austen: Has anyone heard "Wood" by Taylor Swift?

Lilly: Let us know, guys, in the comments what you think of Taylor Swift's new album. But hello, Bundles, and welcome back. We are so excited to come to you through the virtual studio and introduce Season 8. I cannot believe we're saying that. Season 8 of "Bundle of Hers."

For those of you who've been listening for a long time or those of you who are new listeners, I'm Lilly. I was a new host last season. I'm continuing on. I'm a second-year resident in neurology. And I'll let everyone else introduce themselves as well.

Austen: Yeah, I'm Austen. I was also a new host last season and I am here again. So hopefully you're not sick of me. And I'm a fourth-year medical student. Weird to say. I just submitted applications, and so I am currently always internally freaking out, but that's fine. We live and we learn.

Lilly: Woohoo.

Austen: And this episode, me and Lilly are joined by our new host, Sanila.

Lilly: Yay.

Sanila: Hi, everyone. I am excited to be here. And like Austen, I am also a fourth-year medical student. I just applied OB-GYN as well. So that's exciting.

Austen: Oh, yeah.

Lilly: We have so many OB-GYNs.

Austen: Yeah. It's fun. We're taking over.

Lilly: I love this for us.

Austen: We're doing what we can.

So this season, Season 8, our theme is going to be growth through challenge. And as always, we'll bring our own individual flare to that, but I think it's so incredible that we get a season to talk about growth. We get a season to talk about difficult times in medicine and medical education and our training.

I was just having this conversation the other day with a friend. Medicine is not for the faint of heart. No part of this is easy, because day in and day out, you're faced with something difficult. You're faced with something that really tests your limits as far as physical exhaustion, mental exhaustion, emotional exhaustion goes. I think it just really provides us with an opportunity to grow and to change continuously, and that I think can be a huge draw to medicine.

So I'm glad that we get to explore it a little bit, the good and the bad of the challenges that we face as we learn and as we become the doctors and the physicians that we want to be.

Sanila: As well as what Austen said, we also want to recognize that challenges aren't setbacks, but oftentimes they can help us grow and learn, and we really want to talk about both the good and the bad when we make these episodes. So today, we'll kind of be focusing on all of it.

Lilly: Before we dive in, we just want to give the disclaimer we give on all of our episodes. Just reminding everyone who's listening that everything that we share on this podcast is our own thoughts and our own opinions, and that they don't represent any of the institutions that we work for or study with. We just want to be mindful of that as we share our experiences.

So I'll kind of start off, because I think this theme fits in so well with how I feel. I was just telling Austen before we started the recording that this is the year of challenges, I'll be honest.

Being a second-year resident in neurology is notoriously known as the hardest year of residency, and I'm really starting to feel that pretty intensely. I've noticed that I'm feeling challenges not only in my medical career and professional life, but also in my personal life more so than I ever felt in med school or even in my intern year.

Starting off with the professional setting of being in the hospital as a second-year resident, in neurology, you go from doing a year of medicine to now being a subspecialist in neurology.

I mean, it literally switches over a day. You go from being an inpatient IM doctor to the inpatient IM doctor paging you the next day being like, "Hey, what are your thoughts on this obscure weakness that we can't localize in this patient that has so many things wrong with them?" And you're expected to show up and figure it out.

My first call day at the VA, I got home and I was like, "Okay, I'm ready for any pages." I was eating lunch and I got a page about a patient that was in status epilepticus, which is basically a seizure lasting more than five minutes, and they had been in it for like 20 minutes.

So I am freaking out, throwing on my shoes, and calling my senior. She was like, "Drive safe. Take your time." But in my head, I was like, "Oh my gosh, this patient is seizing. I need to be there now." Just a lot of panic-filled times.

And I think that the hardest thing about going into your second year, advancing in your years, whether it's in med school or residency, is really just how much more responsibility you get.

Our program here at The U is nice in the sense that we have senior backup for the first two and a half months of residency. So you have someone that will go to the code strokes with you. We call them brain attacks. Or they'll help you in managing your patients and getting through the flow of how you're putting in orders, and just thinking through different differentials and things like that.

That has ended, so I am officially flying on my own. And that's been really, really challenging for me because I still feel like I'm getting the hang of it, going from treating heart failure and COPD to now taking care of patients with strokes and seizures and myelopathies. It's really scary because I haven't been seeing it for over a year.

For example, today I'm on the stroke service and we had four brain attacks in two hours. So I was quite literally running around the hospital from CT scanner to CT scanner, reviewing the images on my own, talking to the radiologists, figuring out what I want to do, and then calling my attending and being like, "This is what I want to do. This is what I'm seeing on the images," which a month ago I probably wouldn't have even known how to scroll through a CT on my own and look for the stroke.

So it's scary and it's a challenge in the sense that you really feel like someone's life is in your hands and you need to make the right decision for them. There are a dozen nurses and techs and other residents in the emergency room staring at you and being like, "Can we get the patient off the scanner? Can you call off the brain attack? Is it still going on?" And you're sitting there having to figure out all these decisions and keep a level head to make good medical decisions.

So that's really overwhelming as a resident. And sometimes I'm like, "I'm just a girl. I don't know. I just want to have my time to scroll through and really get a good history."

As a med student, you guys are so good at your histories and you really get all the niche details of their life. I still want to do that, but I'm quickly learning, I just quite literally do not have the time . . .

Austen: You don't have the time.

Lilly: Yeah, to sit there and get their whole history. So that's something that I'm really struggling with, is this new responsibility.

There are times during the day that I'm on call totally by myself, managing all of our seizure patients, all of our inpatient general service, our stroke service, all of the consults, and anything can pop up. Anyone can page neurology and then there's literally one person.

It's kind of funny when the ED pages us and all four pages go to me, and I'm like, "I'm just one person. I'm going to make my way down, but it's going to take a while."

So it's kind of scary going from such a large IM class to now a very small neurology cohort. But at the same time, I'm doing lumbar punctures on my own, I'm doing nerve blocks on my own, and I am running a brain attack without a senior there.

So although it's challenging, and I'm also not really realizing it, but thinking about it, I'm like, "Oh, wow, I'm actually doing that by myself," which was a terrifying idea or thought three months ago, which is wild.

Austen: No, that's so crazy.

Sanila: I will say I am also not enthused about getting thrown into residency, because I feel like at this point in fourth year, I'm kind of getting used to sleeping in a little.

So it does kind of make me nervous, that transition from medical school to now having responsibilities, and being in charge of patients, and having people rely on you, which are all skills that you kind of build on throughout your medical school third-year clerkships. But for some reason, it just feels a little more serious as a resident. I know we have our transition to internship coming up, but it still feels like I'm going to be thrown in the deep end all over again.

I will say on my OB rotation during my third year, I was working the month that the new interns had just started.

Lilly: Oh, man.

Sanila: And seeing the new OB intern that was on labor and delivery nights with me and kind of watching her ask for help and learn things over again and make mistakes, but also grow from them, was really refreshing. It made me feel a lot better to know that no one is going to expect you to be an attending as soon as you get into residency.

And I think there is a little bit of wiggle room in terms of training and people being there to support you. I mean, I think that's why you have a cohort and people who are supervising you. So that makes me feel a little bit better.

Do you feel like you've had that safety net, Lilly?

Lilly: Yes, I definitely agree with the asking questions. I'm one of those people where I'm not ashamed to say, "I don't know. Can you teach me or can you help me with this?"

I think some people really enjoy or maybe they think they'll learn by just struggling it out on their own and trying to figure it out. But I realistically just know I don't have the time or the capacity to spend three hours trying to figure this out if you know and you can share that knowledge with me. So I always feel comfortable asking questions.

And my seniors are . . . even though they're not on senior backup anymore, they're like, "If something pops up, you can call me or text me." So even if it's something like . . .

Because now I have a continuity clinic as well, which we didn't have in intern year. So you have patients outpatient who you're responsible for, and you might get a call or a page when you're not on your clinic rotation about them. And I'm like, "Oh, this is kind of weird. Maybe I need to send this patient for more testing."

I'll just text my chief and be like, "Hey, I'm looking at this guy's imaging. It's looking a little sus to me and I'm a little bit nervous. I think I need to send them to neurosurgery." And they'll talk it through with me and I feel a lot better when I'm sending in the referrals and stuff.

So you definitely have a safety net and a support system. And ultimately, at the end of the day, even if I miss something on the imaging or there's something on the exam that changes, there's always a senior who will eventually see them or the fellow, and then the attending will always lay eyes on the patient as well. They'll catch whatever you missed.

Austen: I feel like when both of you were talking, it made me think of a couple of things. So first, I feel like both of your experiences . . . Lilly, talking about reaching out to the senior resident or reaching out to the attending, and then, Sanila, your experience watching these new interns who probably feel like they have to know way more than they do, but then still them being vulnerable enough to be like, "Hey, I don't know what's going on," I think it really underscores how often in medicine we feel like we have to know more than we do.

We feel this pressure to just have this transition from student to now resident physician and be like, "Okay. Well, now I'm supposed to know things because I'm a doctor."

Lilly: Right.

Austen: But I feel like that is so limiting as far as growth goes, because then you end up not speaking up when you do need help, and you end up putting patients in [inaudible 00:11:47] and all of that kind of thing.

And so I think it's pretty remarkable that sometimes the key to us becoming the better physicians that we want to be and the key to us doing lumbar punctures on our own and putting in orders or delivering babies on our own, or whatever we're going to be doing, is being honest with ourselves, recognizing when we need help, and then being vulnerable enough to say, "Hey, I would love to do this. I'm just not exactly sure how to yet." And then relying on more skilled and people with more experience to just be like, "Hey, can you help me get to that point."

It sounds simple and I'm sure people listening are like, "Duh, girl, that is literally how you learn." But I feel like sometimes we don't give ourselves that space to be a true learner, to kind of relish the fact that we don't know and use that as an opportunity to grow as opposed to being scared by what we don't know and feeling like, "Oh my gosh, I already should know this. I already should be able to X, Y, and Z," and then kind of feeling embarrassed to reach out for help when literally the system is created in a way that we have that help. We have those safety nets that you guys talked about.

And so as you guys were both speaking, I was just thinking about how important vulnerability is when you are a learner. When things are hard and you don't want to be vulnerable, I think, is honestly the best time to be vulnerable, especially with the people who are put in place to support you. How else can you get adequate support if you're not like, "Hey, I need your help"?

Sanila: I think that is such a great reminder because I . . . Maybe you both feel the same, but I feel like I forget that being an expert takes a lot of time and practice, and all these attendings who are pimping me on the half-life of some drug that I've never even heard of before have probably had years under their belt of this sort of experience.

I feel like I wake up and then I'm like, "Okay, let me try and learn everything about neurology that I can today for this outpatient clinic." And it just is really hard to do that.

So I'm glad that you brought that up because it just reminds me that I can take my time and create the space to learn things while also finding a way to balance all the responsibilities I have.

And if I do need to ask for help, then that's why I have peers around me. It's okay to do that and kind of figure out how I can learn through the mistakes I make and the questions I get wrong when I'm being pimped. And if an attending tells me to look it up and present on it later, then I'll just do it and I will know something new that I didn't before.

Austen: Yeah, definitely.

Lilly: Yeah. And Austen, you brought up such an interesting point too in talking about these things and how we're navigating them and the ultimate reason why it's important to ask for help or to feel like you can, which really, what we're getting at is failure, right? We're afraid of failing. That might be why we don't ask for help because we're worried. We need to figure this out. We can't fail in front of our attending. We can't fail the patient. But then also, you're asking for help because you're worried that it's going to fail or you're going to fail.

I think as med students, as residents, as people in medicine, we don't want to fail because we're so used to being higher performing, really motivated, disciplined individuals who want to get things done and want to get them right, especially in a high-stress situation where it's someone's life or someone's quality of life that's on the line.

But I think it's important to speak it out that we all will fail probably many, many times. And some of these failures will be small: not starting a home med on a patient, or getting the wrong dose in your history, or weird typos in your notes, things that aren't significant.

But other failures will be not signing out a patient well enough to make sure that something gets followed up that's detrimental, or missing something on imaging, or having a procedure where something goes wrong and a patient has a terrible outcome from it.

Especially as future surgeons and all of these things, you'll experience failure because nobody's perfect. No patient is perfect. No procedure is perfect. We'll all experience some kind of failure. And tragically, a lot of that failure may result in a patient loss or some kind of detrimental outcome that totally changes our quality of life, and how we respond and react to that will really impact the future care that we provide to patients.

Any time I've made a mistake in taking care of a patient, it has truly scarred me to never, ever make that mistake again. If I'm transferring a patient and all their medications are held and I know that's going to affect the patient's care because it's happened in the past, I quadruple check to make sure all the meds are released before I leave for the day.

If a patient's family is angry overnight because they didn't get an update, that's a failure on my end to have communicated with them before I left or to call the family or to make sure the patient understood the plan.

There are so many ways that we fail in medicine, and we're also scared to do that. But at the same time, when you're a med student and when you're a resident and when you're a fellow, those are the times to fail because you're in that learning environment. Your failure will hopefully be caught by someone who's above you.

As a med student, your pending orders, your resident is signing them. They should be reviewing the doses. They should be making sure that that's the right indication for that med.

And then for me as a resident, I have a senior and a fellow and an attending who all need to cross their Is and . . . What am I saying? Cross their Ts and dot their Is. But do you know what I mean?

Austen: Yeah.

Lilly: There are so many checks and balances in place because we're in a learning environment to where these mistakes will hopefully not lead to really negative outcomes, but they happen.

When we do our ICU rotations, we can see . . . A lot of the times, when I see patients in the ICU, I'm like, "These are iatrogenic etiologies," things that we did to patients, procedures that we did to them that didn't go well, or medications that caused certain reactions. And I know that whoever was that surgeon or that attending is going to lose sleep over that, but that doesn't mean you just stop practicing medicine, right?

Austen: Yeah.

Lilly: You have so many other patients whose lives you're going to impact.

Sanila: Going back to that theme of vulnerability, which you mentioned, I want to hear both of your takes on what you feel like is the difference between transparency, or sharing information about something, and then vulnerability. That difference between . . . Let's say someone makes a mistake. Having to disclose that mistake to, let's say, your supervisor or a patient, is that a matter of transparency or is that vulnerability?

Austen: For me, and I can be totally off base. I am not a dictionary. I recognize that. So this can be incorrect information and I want to put an asterisk before whatever I'm about to say just in case someone who has a connection with Merriam-Webster is like, "Hold on, girl, that's not right."

But for me, I think vulnerability requires transparency. I don't think that transparency always requires vulnerability.

For me, the subtle difference between the two is that both of them are kind of founded on being honest, and I think you can be honest and deliver facts and information through transparency.

But vulnerability, the way that it's different in my mind is that there is almost a personal cost when I'm delivering that information. Whether it be my pride and ego or someone's perception of who I am, it feels like there's almost a price to pay with vulnerability.

And not in a "It's impossible to be vulnerable. It's this huge Herculean task," or anything like that, but I think typically when you are vulnerable, you are kind of exposing yourself in a way that you are open to someone's judgment. Someone's perception of you could change. The way that someone views your training and experience could change. So many things, I feel like, could alter because of the information that you're delivering.

And generally, in times when I'm being most vulnerable, it's been times when I've been like, "You know what? This is really hard for me. I don't know what's going on, and I am sorry if I should, but I don't. Can you please help me?"

That feels more vulnerable to me than just being like, "I don't remember the side effect of this drug." That feels like, "Okay, nor do I, girl. It's fine." I mean, maybe not "it's fine," but that's information that . . . not everyone is expected to know X, Y, and Z or keep all of that random minutiae in their brain.

But I think when it's like, "I don't know this," or, "I'm confused," or, "I'm scared," or, "I'm depressed," whatever your vulnerable truth is, it feels a little more precious, I guess.

And that sounds maybe weird and cheesy, but that's my take. Those are my two cents.

Lilly: Austen, that was beautiful. I love how you described it as coming to a personal cost, because I think that really emphasizes the meaning of vulnerability. And every example I can think of when I was vulnerable with a patient is probably something that someone else who doesn't feel like being vulnerable with patients would think is inappropriate.

For example, I did a palliative care rotation and some of the family members were telling the provider I was working with that they were really nervous about going to rehab and getting the care there, and it would be so different because they're not in the hospital technically with tons of nurses and doctors checking on them often.

She said, "My dad actually went to that rehab hospital and I was also really worried about those things. Here are all of the wonderful things that he was able to get being there, and really focusing on his rehabilitation and getting stronger and things like that."

She didn't share any of his personal medical history, she didn't go into too much detail, but just being able to say that, "I've also had a loved one in this type of situation and we had a really good experience there," helped those patients so much.

And now as a resident, I was helping a patient navigate kind of end-of-life care with their family. I think it's important to just recognize that this isn't so procedural and explaining, "This is going to be hard. What questions do you have? How can I support you?" And a lot of times, patients will say, "Will they experience pain? Will there be suffering?"

Transparency is telling them, "No, they won't experience pain or suffering because we will give them medications to try and reduce any pain that they will experience. We'll make them comfortable. We'll be able to tell from their breathing and their heart rate and things like that if they are in distress."

And then I think vulnerability is sharing, "I've had a loved one go through this and I know how uncomfortable it is to feel like you're not doing everything you can for them." And we should hold space for that.

Every time that I've opened up with my patients just a little bit . . . I obviously don't dive into my family and my own background and history and tell them every minute detail of their healthcare, because ultimately, it's not about me, it's not about my loved ones. It's about their loved one that's in the room experiencing the worst day of their life. But it really does humanize the experience and I think patients see us as people and not just someone who's in and out of their room doing a procedure.

That's the kind of vulnerability that I feel like has really built rapport with patients before when I've been vulnerable.

And then some people hate crying in front of their patients and things like that, which I don't think you should be blubbering in front of your patient, because ultimately they need the comfort more than you do. But I think it's also unreasonable to say, "We're going to sit in this family meeting about end-of-life care, and you're going to be stoic too."

Sanila: I think to your points, transparency is probably more about the act of just sharing information. And I definitely agree that vulnerability has more of an emotional impact as well. You're kind of sharing something that places you in a state of emotional uncertainty. By sharing something personal, you're giving up a sense of personal safety, for better or for worse, which can be really hard to do.

So I guess my follow-up question is how do we give up that sense of safety? And how do we begin to embrace learning and growth through challenge and being willing to share all these emotional parts of what challenges look like?

Austen: I think someone . . . actually, Sanila, I think it was you. A few minutes ago, you talked about how attendings are experts and they're experts because of the practice that they have, the experience that they have. And I think the same thing can go for vulnerability.

I'm obviously very early on in my training, but when I have been vulnerable with patients or when I've been vulnerable with residents that I've worked with, when I've been like, "I don't know what's going on. Can you help me?" and knock on wood that this doesn't change, but it's never really come back and bitten me in the butt.

It's not like I have a patient who, if I'm talking to them and I'm like, "I have a sister with chronic illness. It's really hard. I want to recognize this is really hard," or however I'm being vulnerable with them, I've never had a patient who's like, "Can you shut up?" or, "Stop. That's not what we're talking about."

I think more often than not, I've had patients who feel like they are better understood and better seen when I try to be vulnerable with them.

Like Lilly mentioned, most of the time when we're meeting patients, it's the worst day of their life. Sometimes it's not, but most of the time it is. And just by being there, they're in an incredibly vulnerable position.

And so I think it makes it easier for them to be vulnerable when they feel like they're not the only vulnerable people in the room. And I think it makes it easier for me to be vulnerable because I know that they are also vulnerable. Whether it's by choice or not, they are very vulnerable, and so it makes it easier for me to kind of make that sacrifice to be vulnerable with them.

But then again, just practicing it, trying to be vulnerable with people . . . I mean, it's not like every person you encounter, you're going to be like, "This is my deepest, darkest insecurity. Here it is on a platter." But the more comfortable we are with being uncomfortable, the more comfortable we are with being vulnerable, the easier it'll be to become vulnerable with other people or to give ourselves those opportunities to grow through vulnerability.

But again, who knows? I could have a terrible experience in a couple of months and be like, "You know what? I never want to be vulnerable again." And that'll be another challenge I'll have to work through, but it's all part of growth. No growth in the comfort zone.

Sanila: Yeah, I definitely think it is a little bit of exposure therapy, trying to do little things that maybe you're not as comfortable with. And I agree, don't go around sharing your deepest, darkest secrets, but I think just starting by saying, "This is what happened. This is how I felt. Here's what I learned," or, "I'll do XYZ in the future," and starting with little things, after time, some things will probably become easier, hopefully.

Again, easier said than done. So to our listeners, please don't come after me for giving unsolicited advice, because this is still something that I'm practicing as well. But I guess in my mind, that's what I would think is one pathway to trying to become more vulnerable.

I also agree, Austen. I think it can enhance patient care, especially when you start to build trust with patients and you take away the paternal aspect of medicine, and you talk about this kind of shared decision-making and shared healing and emphasize a more community aspect rather than an individual one. I think that can be really beneficial for folks.

Austen: Tying it back to challenges and growth, I think learning to master being vulnerable and recognizing vulnerability in others helps us become better physicians at the end of the day, better able to connect with other human beings, better able to care for other human beings.

When you genuinely care about someone and when you recognize what's going on with them, it's easier to then care for them. As we kind of explore growth and challenges this season, I think that'll be probably a theme we'll come back to, is vulnerability.

Lilly: Yeah. And just normalizing the struggles and sharing your experiences of your mess-ups and your failures so that others know that it'll happen, it's okay, we'll work through it, and we'll learn from it is really important.

As we kind of wrap up this episode, some things that I want all of our "Bundles" listeners to think about is what challenge has shaped you the most? Where have you found unexpected growth in medicine or in life? And share that with us in the comments on our Instagram, on our website, on the podcast.

We'd love to hear from you, engage with you more, get to know what your experiences are like. You get to listen to us chit chat, but we also know that you have your own lived experiences that are so important to share as well.

And we always love meeting you all in the hospital, on rotations, in clinics. So please, whenever you see us, let us know so we can say hi and chat some more.

In the meantime, you can subscribe to "Bundle of Hers" on Spotify and Apple Podcasts and join our conversation and drop a comment. And you can also follow us @bundleofhers on Instagram as well. We look forward to chatting with you all soon. Bye.

Austen: Bye.

Sanila: Bye.