You Are My Sunshine

Check out this article in the March issue of Incite Magazine. Thanks to Jeremy Henderson for editing this. 

On Hallowe’en Night 2006, I dropped by Shoppers Drug Mart to pick up some candy for the slew of trick-or-treaters who’d soon be arriving at my door. I tied up my dog, Sunny, to a post outside. Unfortunately, my mind was so preoccupied with candy and costumes that I returned home without the dog. Suddenly realizing what I had done, I raced back to the shop… only to find her gone.

No one – not my neighbours, the shopkeepers, nor Animal Control – had seen a trace of Sunny. She had simply vanished. That’s when I launched a major search and rescue operation, plastering the whole neighborhood with “LOST” signs and offering a $250 reward for her safe return. About three days later, a woman called me, reporting that she’d seen a young man walking Sunny on Dalewood Avenue. I zeroed in on the neighborhood, leafleting every house with signs. Finally, I got a call from a man who said that he had picked up the dog because he’d thought she’d been abandoned. Within minutes, I was at his house and recovered my pooch, who nearly knocked me over with excitement..

This whole ordeal proved to me the strength of my connection with Sunny. We had been through everything together. When I first arrived as an immigrant from India, she was my only friend for a while, and never failed to comfort me with her wagging tail. When I would have a tough day, she’d always lick away my tears. Sunny woke me up in the mornings with the cold tip of her snout, demanding food and patting, and would later run with me through the forests.

By all accounts, it was a miracle that Sunny was ever born. Her mother was a huge German Shepherd, while her dad was a tiny spaniel. But somehow they mated and produced a perfect blend of their genes – a beautiful, medium-sized golden pooch with a very sweet temperament.

Nowadays, I find myself thinking more and more about Sunny. It’s been a year since she died of a stroke at age 14, and the urn of her ashes sits desolately on my bookshelf. Beside it lies a big silver spoon that I used to feed her sips of water as she lay on her deathbed.

As the frosts of winter thaw and the spring comes in, my family plans to plant a small tulip garden in our backyard, where Sunny loved to play. My mother wants me to sprinkle her ashes all over this garden. A part of me feels like holding on to the urn forever, and that losing the ashes would mean finally letting go. But I know in my heart that Sunny’s ashes are not her lasting legacy. The person who I am today was shaped and molded by her constant presence throughout my childhood. She helped teach me the meaning of play, of joyfulness, and most importantly, of unconditional love.

And so I will go out this spring and spread her ashes, watching with a mixture of sadness and joy as the barren soil blooms into vibrant reds and yellows.

Chasing Dreams

“So where do you see yourself in ten years?” asked my supervising resident pointedly. It was a Friday afternoon and we were sitting across from each other at The Barton Bean, the main coffee shop in the Hamilton General Hospital. Exhausted from a busy afternoon clinical shift, we were happy to cap off our working day with steaming lattes. Since our conversation thus far had been fairly light, this question struck me by surprise.

Medicine offers over fifty different specialties and sub-specialties, ranging from heart surgery to nuclear medicine. Before graduating, McMaster medical students complete five foundations in the study of the body and disease, followed by an 18-month “clerkship” period that, in my case, starts this November. As clerks, the students work full time in the hospital, rotating through various specialties to narrow down their own area of interest.

Then comes the “CaRMS” process, the bane of every med student’s existence, whereby they compete with one another for limited specialty spots. They have to fly all over the country, interviewing at different hospitals and clinics with the hope of being accepted into their first choice. Some specialties like plastic surgery and dermatology are highly competitive, while others (like psychiatry) generally accept all their applicants.

As a high school student, I was sure that I wanted to be a surgeon of some sort. The challenging and stimulating environment of the operating room as well as the opportunity to directly fix problems appealed to me. But as I’ve progressed through my first year at medical school, my interests have shifted to neuroscience. The brain – the hardware of the mind and soul – is by far the most complex, indecipherable and fascinating organ of the body.

A career in neurology, the study of the brain and nervous system, would obviously be the most logical career path. And yet, in my experience, the real clinical work of a neurologist consists mostly of treating a narrow set of conditions over and over again; migraines, seizures and strokes. It also requires the completion of the internal medicine residency, probably one of the toughest available. This residency involves several difficult years of stress and sleeplessness borne out of regular 28-hour shifts. Then come additional years of training specifically in neurology.

When I try to envision my future, I'm not sure I would want to continue training in the hospital past the age of 30. By then, I’d like to be settled in a beautiful red-brick house somewhere in Toronto with a big, overly-friendly dog, a loving spouse and maybe even a kid or two. For me, the true substance of life is family and friendship, adventure and exploration. I'd want to be sure that whatever career path I chose allowed me enough flexibility to cherish these aspects of life. 

Lately I’ve begun to consider family medicine as a possibility. Its flexibility and broad scope of practice appeal to me. I could imagine myself running a busy clinical practice, as well as doing some teaching, writing and travelling. Undoubtedly, I have many tough decisions ahead … But if I make these decisions based on true values and interests, then I think I’ll be just fine.

Heart to Heart

"Raman, it's time to see your first patient. Interview and exam," my supervisor said firmly, placing a thick file in front of me. It had already been three weeks since I started my hematology elective, and although I'd relished every moment, I had kept declining to see the patients on my own. The very thought of it made my stomach queasy. But now my supervisor, convinced that I was ready, was throwing me in the deep end.

I slung on a stethoscope and headed to Exam Room 6. The patient, an elderly woman in her 70s, was suffering from a rare blood cancer. Her chart had informed me that she'd recently come back from a skiing trip to the States, and so I broke the ice by asking her about her trip. Both she and her husband enthusiastically recounted their adventures on the slopes.

Flipping back to the medical interview, I started off with open-ended questions that became more and more focused. There was a beautiful moment in our conversation when I forgot my anxieties and fell completely in lockstep with the patient. Each question flowed naturally and spontaneously one after the other until I gained a deep understanding of her case. For those few minutes, I was fully immersed in the interview, all my attention focused on her words and expressions.

Communicating with others has not always come naturally to me. As a little boy I immigrated to Canada with my family and was at first painfully shy. Every time I tried to talk to someone outside my immediate family, I would become consumed with my own fears. As a result, conversations with strangers were uncomfortable and I would avoid them, becoming isolated and lonely. Someone in Grade 3 called me a "loner" ... racing home, I looked up the definition in the dictionary, hoping it was something good. After realizing what it really meant, I just lay on my bed feeling sad and frustrated. 

Once I hit middle school, I finally started to make more friends. But I've never forgotten the pain of shyness, and still consider the ability to connect with another to be one of the most miraculous aspects of life. In the clinic that day, I felt a strong connection with the patient, turning what could have been a series of routine questions and answers into a heart-to-heart discussion. While a mere medical interview is scripted and emotionless, a true "heart-to-heart" is spontaneous, imbued with trust and mutual respect. It builds the foundation for a productive and rewarding doctor-patient relationship.

After I completed the interview and physical exam, my supervisor walked in. "So how did he do?" he asked. 

"Oh he did just fine," the woman said. Her face lit up into a warm smile. The doctor nodded approvingly and handed me the next patient file. This time, I felt genuinely excited. 

By the end of my shift, dusk was falling. I had to hurry home to have a bite to eat before heading out to a medical school party. Over the course of the next four hours,  I managed to make new friends and also master the art of "beer pong". The hostess, a second year med student, affectionately dubbed me "Noodles" after the popular "Ramen Noodles" soup brand. As I chatted with my friends, we connected easily through laughter and stories ... person to person, heart to heart.

The Lost Decade

My great-great grandfather, William Ashburner, was a master English shipbuilder in the late 19th century. He specialized in schooners, swift racing vessels propelled by up to seven masts. A shrewd businessman and innovator, he earned himself a small fortune, investing it in a mansion for his family in the North of England.

Unfortunately the advent of steamships doomed the schooners to irrelevance and he quickly went bankrupt. He looked to the colonies for employment, quickly setting his sights on South Africa. He moved his family to the city of Johannesburg, where he took up work in the gold mines. Life was tough in this rugged new environment, but he and his ten children managed to thrive.

Unfortunately, his wife Anne did not. According to family legend, she went to her bed and “wept for two years”. She’d simply lie there all day, every day, crying constantly and barely able to do basic tasks like folding her own clothes. She was inconsolable, and the family was naturally devastated.

Reflecting back on this story over a century later, it's plainly evident that Anne suffered from clinical depression, a biological illness that affects millions of people. While effective treatments are available today, back then, all William and the children could do was watch their wife and mother languish in her bed.

I was reminded of this story last month after meeting a young woman, call her Katherine, who had been struck by severe depression for nearly a decade. She used to live a normal life, full of rewarding friendships and a meaningful career, but things changed after she delivered her first child. She would just spend day after day lying in bed feeling exhausted and empty. She couldn’t understand why; after all, she had a loving husband and a healthy new baby. On the surface, everything was wonderful in her life.

Doubtful about mainstream medicine, Katherine did not seek any treatment. Instead, she tried to plunge herself into a vigorous exercise routine, went on expensive vacations and devoured self-help books. And yet her depression raged on year after year until her life gradually fell apart, losing her job and falling back on a small disability pension. Where once she was an outgoing person, she now found it hard to even smile.

I met Katherine shortly after she was placed on a “Form 1” by her doctor, an order that forced her into a psychiatric ward. She had attempted suicide, an unsurprising consequence of a decade of suffering.

Her doctors quickly diagnosed her with clinical depression and put her on an SSRI, a potent class of medication that normalizes brain levels of serotonin. Within a week, Katherine reported a “burning” sensation of warmth in her chest when she saw her son. She was taken aback by this new, unusual feeling. But then she realized that it was actually the sensation of joyfulness, something she hadn’t felt for years.

Since then, Katherine has been discharged from the ward and her life has blossomed. She has reconnected with long lost friends and rediscovered her energetic, outgoing spirit. Whereas her eyes had seemed distant and glazed over before, they now sparkle with a happy expression, as if they are smiling right alongside her. For so long she had defined herself as an antisocial, sad person, while in reality, her real self had been imprisoned by mental illness.

Along with recovery comes reflection. Katherine looks back on the past decade with a deep sense of regret. So many years wasted, so many opportunities for new friendships and experiences lost. So many beautiful memories that could have been made. She barely knows her son, since she has been emotionally absent since his birth.

And yet Katherine could have avoided all of this suffering if she had just sought treatment at the first signs of her depression. What went wrong? While she herself may be blamed for her initial stubborn distrust of mainstream medicine, that decision was influenced by our society’s stigma of mental illness. So many patients fail to seek psychiatric treatment out of shame, feeling that it reflects some inherent character weakness.

But there shouldn’t be any shame. Just as diabetics must take insulin, so must clinically depressed patients take antidepressants. Both are biological illnesses in which pharmaceutical treatment is necessary.

In the past, the mentally ill were often crippled by their condition for their entire lives. Now, with appropriate treatment, Katherine has a bright future. She looks forward to doing all the things that she missed out on over the years, especially getting to know her son.

For the first time in over a decade, she truly feels alive. 

Grace Under Pressure

note: Any private details have been changed/removed.

The Juravinski Cancer Centre is a massive glass and steel building that dominates the Eastern part of the Hamilton mountain skyline. It is a hub of cancer-related activity, including research, treatment and supportive care. A massive 75 million dollar fundraising campaign has allowed its administrators to get their hands on every cancer specialist's dream machine: the CyberKnife Radiosurgery Robot, which can kill tumors with sub-millimeter accuracy.

I’ve been placed as an elective student with a hematologist, a specialist who works with disorders of the blood. I’ve been so impressed by his vast knowledge base, his compassion and skill in communicating with patients. A woman will come in with rapidly advancing leukemia, and he will sit down with her for twenty minutes and explain her entire disease in layman’s terms. He wants his patients to know exactly what's happening in their body, and you can just tell that they really appreciate him. 

The most inspiring case I’ve encountered so far has been a middle-aged woman with advanced multiple myeloma, a deadly disease that ravages the bones. Her skeleton is rapidly deteriorating, compressing her spinal vertebrae so that they squeeze against her spinal nerve, causing excruciating pain. She can barely walk and keeps falling, splitting open her lip on numerous occasions. Meanwhile she suffers from a serious mental illness.

And yet her husband takes care of her with incredible devotion. He sets an alarm to wake him up twice a night to take her to the bathroom, makes all her meals and drives her to appointments. He manages all her medications and has even taken temporary leave from his work to care for her full time. Unfortunately her pain and stress have destabilized her mental illness and her mood is a rollercoaster, flipping from severe rages to extreme dispair. But her husband doggedly sticks by, enduring her temper while continuing to provide care.

When I think of a superhero, I usually think of a muscly manly man dressed in tight spandex, but in my opinion, this slender, bespectacled gentleman is indeed a superhero. When he said that he would stick by his wife through “sickness and through health” on his wedding day, he really meant it. At that time, his wife was a healthy, beautiful woman. He certainly couldn’t have expected her to be ravaged by mental and physical illness. But he stayed true to his wedding vows, even while many marriages end because of far less serious problems.

What motivates him? Is it a sense of obligation wrought by religion, family values or culture? Or is a sense of loyalty innately embedded in his personality? Clubbing at Sizzle on Friday night, I looked over at all the hotties on the dance floor and couldn’t help but wonder: How do I differentiate the genuine from the superficial? And would I have the fortitude to stick by my spouse through years of illness? Looking at the husband, I can just sense a gentleness and wisdom in his expressions and words that tells me he is a caring person to his core. 

Seeing this couple struggle together through this hardship has also given me a sense of perspective on my own problems. Honestly, I've been complaining way too much lately. Yes, I’m sick again with a fever, stressed out and dealing with an inordinate amount of work, but my problems pale in comparison to theirs. They've truly shown “grace under pressure” and I hope I can find a little bit of this grace in myself as I deal with major challenges over the next few weeks. 

The Weird & the Wonderful

As my second semester or "foundation" here at McMaster comes to a close, I'm finally getting a good handle on my stress. I've returned to eating and sleeping well and doing other things besides working. For one, I bought an XBOX 360 and have now converted my bedroom into a gaming centre slash personal gym. After a hard day's work, I enjoy an hour or two of playing video games or pumping iron (not that it's had any effect on my measly muscles).

I've also taken up an elective in the anatomy lab, and now spend an hour with an anatomist every Wednesday afternoon. It's led to some weird and wonderful experiences.

"Raman, can you hold this for a sec?" the anatomist asked me last week, handing over a human brain. It was heavier than I expected and nearly slipped out of my gloved fingers. Eeek! Although at first I was paranoid that I'd drop it, I was also awed by the fact that I was holding a real brain.

The anatomist disappeared into a backroom and came back with a big plastic box. She cracked the lid and peeked in. "Ah perfect," she commented. Uh, what the heck was in there? She then popped off the lid and pulled out a whole human head, its features all squished together. Oh great! At that moment, I was second guessing my decision to take on this elective.

Oblivious to my discomfort, the anatomist launched into a lecture about the pituitary gland. Meanwhile I was wondering what to do with the brain; had she forgotten that I was still holding it? One of her colleagues passed by with a big smile. "Great weather out there, eh?" he said happily. The anatomist returned the smiled and nodded. Wait, here she was holding a human head, and all her colleague wanted to talk about was the weather? Only in the anatomy lab.

Getting to hold that brain was just one of the weird and wonderful things I've done in med school since returning from the Christmas break. Last week, my clinical skills supervisor brought out a life-like replica of a pair of human buttocks to practice rectal exams. "Just come from the side and slip your finger in," she explained, demonstrating the technique. Apparently I had quite the expression on my face, because she looked straight at me and said, “Hey, I didn’t make you choose this profession.” I was just relieved that I could learn the rectal exam on a model, and not on a real person ... but that too will come in time.

I've also been introduced to the unpleasant concept of “Fetor Hepaticus.” The doctors suspected that one of my patients had chronic liver disease. To help confirm the diagnosis, my supervisor asked me to smell the patient's breath. When the liver is dysfunctional, the breath takes on a characteristic "rotten and sweet" smell - "Fetor Hepaticus" literally translates to “breath of the dead.” In this case, my nose would literally become a diagnostic tool. Leaning in toward the patient, I took a good whiff ... Yep, diagnosis confirmed.

Like any job, medicine comes with certain downsides. Yes, those downsides may be smellier and stickier than what you’d encounter as say, a lawyer, but the upsides (like getting to hold that brain) are pretty awesome too.

Facing the Firing Squad

Yesterday was one of the worst days I've had in medical school so far. The week leading up to it was extremely stressful, packed with tutorials, studying, electives, shadowing experiences and other major time commitments. I found myself leaving the house every day at the crack of dawn and returning by 9 or 10 at night, grabbing a quick bite to eat before starting tutorial review. And then I would get a few restless hours of sleep before dragging myself out of bed to start another day. For whatever reason, all my major commitments happened to coincide to create the week from hell. 

On Monday night, I finally collapsed into bed at 2 am and decided to take a sleeping pill to ensure I got a good night's sleep for my clinical training the following morning. I rarely use such pills, and so it came as a shock when it totally zonked me out. I was asleep within minutes. It took every ounce of motivation to drag myself to the hospital. Our task was to do a basic interview with a “standardized patient”, or in other words, an actor hired by the university who pretends to be a patient. All the students (nine in total) sit in a group with the two supervisors and critique one another's performance. It's a little intimidating to be doing a mock interview as eleven people watch your every move (albeit, very nice people).

I happened to be the last to go. After three hours, I think everyone was a little bit impatient for the session to be over. My “patient" presented with severe exhaustion, but I'm pretty sure I was more exhausted than she was. I started doing a basic history, asking about when the problem started, what was happening at the time, what she had tried for relief, etc. etc. I had trouble concentrating and my interview seemed to veer way off track. I hadn't even gotten on to recommended treatments by the time the timer rang, abruptly ending the interview.

I looked to my left, at the assembly of nine students and two preceptors, all looking thoroughly unimpressed. Oh crap. The students had been instructed to be honest and critical in their feedback; after all, how else would you improve? Judging by how much I had just bungled up the interview, I felt like I was facing a firing squad.

Let's just say, I took a battering - a polite, Canadian-style battering - and it was totally deserved.

Right after class, my fever returned with a vengeance, and I had to drag myself through the rest of the day. It was exhausting and demoralizing.

Now I'm sitting at my laptop with a hot cup of tea, recovered and rested. I think the most important lesson I've learned from this experience is that, in order to be a good care provider, I really need to take better care of myself. A burned out individual exudes a negative energy that turns people off and may make patients less willing to open up about their problems. When I'm very stressed, I find it harder to feel and show empathy, and is that really fair for the patients? Sure, I can still do a good history and physical exam, but medicine should be about more than just checking the boxes.

So I'm putting myself on a regular sleep and exercise schedule, cutting down on unnecessary commitments and finding time to decompress every day. With any luck, this exhausted, burnt-out Raman will be replaced by a rosy-cheeked, smiling Raman within a couple days. And then I can hit the next interview out of the park and redeem myself. Fingers crossed.