The following story is adapted from an essay that I wrote at the end of my 3rd year of medical school. It is written in loving memory of my father, who passed away later that year.
It was the summer after my 1st year of medical school when I got the call.
“I have some bad news,” my sister started.
Our dad had been having some difficulty swallowing lately and had unintentionally lost about 20 pounds over the course of the last 8 weeks. That afternoon, he had gone to the hospital for an upper GI endoscopy, and they found a 5-centimeter mass in his distal esophagus. Listening to her describe it, I couldn’t help but think back to the previous fall, when our anatomy instructor had summoned the class around a cadaver in the anatomy lab to examine a particularly impressive example of esophageal cancer. The spidery black tumor had been plastered across what was left of the cadaver’s posterior chest wall. It was like looking at a Jackson Pollock. My conversation with my sister was punctuated by silence, neither of us knowing quite what to say. Finally, after a particularly long pause, I told her that I loved her, hung up the phone, and promptly broke into tears.
The next few days were a blur. I sent a frantic email to my mentor to inform him that I had to suspend my summer research. Little did I know, I wouldn’t come back to it for another year and a half. I booked a one-way ticket home for later that week and spent the next few days just trying to distract myself. At 3am on the morning of my flight, I sat in bed weeping while I drafted an email to my friends, explaining the situation. It had been five days since I had gotten the news, and I was still shell-shocked. I hadn’t been able to work up the courage to tell them in person, knowing that I would dissolve into a blubbering mess if I even tried to answer the question “How are you?” with any semblance of honesty. Typing it out for the first time was excruciating. I always thought that it was just some stupid cliché, but putting my dad’s diagnosis into words for the first time really did make it all feel so much more real.
In the coming weeks, we would learn his official diagnosis: stage 3 esophageal adenocarcinoma of the GE junction. My sister and mother are both doctors, so like the diligent evidence-based medical providers that we are, the first thing that the three of us did was perform a literature search on PubMed.
Weird, I know.
Over the next two weeks, I learned more about esophageal cancer than I ever wanted to know. I read about the risk factors and complications, the treatments and recurrence rates. I pored over videos of esophagectomies being performed using different approaches and techniques—open, minimally-invasive, transhiatal, Ivor Lewis—and read about their relative advantages and drawbacks. I looked at survival curves, extrapolating that based on his staging, the likelihood of my dad surviving another 5 years was optimistically somewhere in the neighborhood of 30%. It struck me that he probably wouldn’t live to see me graduate from medical school. Those numbers still make me tear up sometimes, so I try not to think about them very much these days. But that’s the problem with working in medicine. You know too much.
To say that my institution wasn’t of much help during this period would be a bit of an understatement. At the start of the school year, I reached out to a few administrators to tell them the news. When I asked about my options moving forward, they gave their polite condolences, using a script that I would quickly learn had little meaning: “We are sorry to hear about your father’s health. Please let us know if we can be of any assistance.” In hindsight, I realize what an odd thing that is to say to a student. When you don’t even fully understand the emotional, academic, and professional challenges that lay ahead of you in your training, you don’t know what kind of help you’re going to need, much less what help is available to you. How could I have known what to ask for?
Over the course of the next year or so, the depression hit hard. Watching your father lose 20, 30, 60 pounds while his only form of sustenance is pumped into him through a jejunostomy tube will do that to you. It is not easy to watch someone you love quite literally wither away before your very eyes. Eventually, you stop recognizing them altogether. That’s when the real pain sets in.
In a lot of ways I was a classic case study for reactive depression, with a few servings of anxiety on the side to keep things interesting. My dad was still alive, but I was grieving his slow downward spiral, imagining his death a hundred thousand times over—trying to inoculate myself against the inevitable. I spent the better part of my days just trying to keep my head above water. I found myself keeping this wacky sleep schedule, sleeping 13 hours some days and pulling all-nighters on others. I would start to cry while doing inane tasks like washing my dishes or walking home from class because those were the times when my mind could wander...and it would wander back to him. I rarely had the energy or mental capacity to study, so when I did, I was just cramming for final exams, spurred on by the fear of failure alone. I don’t think I really learned anything all year: every month, I would receive the results from my latest exam and when I saw that I had just barely passed, I would heave a huge sigh of relief. Then I would go back to feeling empty and miserable. This continued until the end of the year, when I was confronted with the reality that I was woefully unprepared for Step 1. While most of my peers dedicated just six to eight weeks to studying for the boards, I took four full months, trying desperately to teach myself everything I was supposed to have learned that year. I passed, but I’m still not particularly proud of my score. When I finally joined my peers on the wards, I remember feeling like such a fraud, like everyone could tell that I wasn’t as smart as them.
For a long time, I couldn’t figure out why medical school had become so challenging for me. But I slowly learned that in many ways, it wasn’t structured to be easy for anyone. For example, I learned the hard way that there’s really no such thing as an excused absence in medical school. On the day of my dad’s esophagectomy—a lengthy surgery with a notoriously high mortality rate—there were two PBL sessions scheduled for that morning. I had hoped to be with my family on the day of his operation, but despite being “very sorry to hear about [my] father’s health,” the course directors informed me that if I chose to leave, I would need to write a paper to make up for each absence or risk two failing grades. After all, these small group sessions were oh-so-crucial to my education, so much so that attendees regularly fell asleep. Their suggestion was routine, but caught me off guard nonetheless. Weren’t these people doctors? Didn’t the so-called “art of medicine” involve being compassionate and empathetic to other people’s needs? Didn’t they see how counterproductive it was to excuse an obviously distressed student from work by giving them more work? I felt outraged at first, and then, ashamed. Was I weak for needing help? Was that not normal? And if I couldn’t handle the stress of an illness within my own family, was I even cut out for a career in medicine at all? That insidious thought was reinforced time and time again, no more so than when I was told that because of how I was struggling academically, I shouldn’t even try to become a surgeon anymore—I was much better suited for primary care.
No one tells you how to navigate situations like this: Who has the power to help you? What kinds of resources are out there? How you can optimize your academic career moving forward? There isn’t a manual for being grief-stricken and depressed in medical school, no algorithm or decision tree. And when you don’t know who to turn to, it can often feel incredibly isolating. It even becomes difficult to ask your peers for advice. After all, most students have never dealt with the death of a parent, and if they have, they’re not usually too vocal about it. And who can blame them? There isn’t the time or the space. The chilling sensation of confronting your own mortality doesn’t usually come up in polite conversation.
So no one showed up at my door one day to warn me about how hard it was going to be. About how exhausting it would be to lie every day, pretending for my patients and classmates and attendings like nothing was wrong. No one prepared me for the confusion I would feel when I slowly began to hate all of my friends, how I wanted to scream at them when they couldn’t seem to understand why I might be having a bad day. I even started to resent my classmates for their accomplishments, though rationally I knew that they deserved their success. They don’t know how lucky they are, I would think to myself. How unfair is it that they have the luxury of focusing all of their energy on school while I’m over here trying to juggle a dying parent and a family that is falling apart at the seams? And now residency programs expect me to compete with them? Seriously?
I began to hate how angry and self-centered I had become.
Through trial and error, I slowly found little ways to fight back. I tried my best to compartmentalize and forgave myself for the days when I couldn’t. I learned that I can (and should!) push back when administrators tell me “no.” I made conscious efforts to shift my perspective and each day I would force myself to write down one thing I was proud of accomplishing or one thing I’d witnessed that had brought me joy. Most importantly, I stopped bottling everything up inside of me and started talking to the people I loved about what I was going through.
So for those students who are struggling, I need you to know that you are not alone. That may sound obvious from the outside looking in, but when you’re in the trenches and fighting for your life, it can be hard to look beyond the obstacles in front of you to recognize that there are others fighting by your side. And it’s okay to lean on them. Today, in 2017, 1 in 4 medical students is depressed. So that feeling of loneliness? Like no one can relate? It’s an illusion. A lie. Complete and total bullshit.
But here’s the kicker: only 16% of us will ever seek professional help. That number seems to surprise the deans of medical schools across the country, but it really shouldn’t. After all, it takes courage to admit that you’re struggling. And it takes energy and strength that you don’t always have to ask for help. Like me, you may also feel conflicted when you realize that we as medical students can also become our own biggest obstacles. There’s so much pressure to outperform each other (and ourselves!) in medical school: to have the highest board score, to get Honors & AOA, to showcase our dedication by being the first people to arrive in the morning and the last ones to leave. But there’s not much talk about how that mindset can really harm us in the long run. For example, I didn’t seek help for my depression until nearly a year after I recognized that something was wrong. I remember knowing that I needed to talk to a psychiatrist, but not being able to fathom how I could even fit a doctors appointment into my schedule as a busy 3rd year medical student. Can I just leave rounds? Is that allowed? What if my resident thinks I’m being lazy? Or what if that’s my only day on service with a particular attending? How will they be able to grade me if I’m not there? I put so much pressure on myself to be “the perfect student” on paper that I had also put off the task of working through the one thing that was holding me back. Little did I know, I actually did have the time to see a therapist. Really. On a Wednesday afternoon, at that! I had the time to start taking an antidepressant. I had the time and the power to delay a shelf exam or request an extra study month. If nothing else, I had the time to get help. I only wish I had learned that lesson sooner.
Six months ago, my dad was diagnosed with metastatic disease. He’s on a palliative chemotherapy regimen that on average maintains efficacy for about five months, so in the back of my mind, I’m just waiting for the other shoe to drop. For his CEA levels to rise. For his ascites to return. After two years, I’ve grown used to the uncertainty of it all. For now, he’ll keep getting his biweekly infusions. Eventually those drugs will stop working, so we’ll move on to the next one and then the one after that...until we run out of options altogether. I can’t afford to use any more vacation months to go home and see him, so I’ve taken the next year off and joined a research program instead. I don’t mean for that to sound so calculated or bleak. It’s just the truth. It’s the reality of trying to be a full-time daughter within the pillared constraints of medical education. So we’ll manage his side effects for now and brace ourselves for what’s to come. We’ll continue to live each day. We’ll watch. We’ll wait.
So it goes.
