Part of the Solution

I really don't know what I want to do when I grow up. I've had a fascination and attraction to many of the disciplines in medicine and surgery over the years.  When I was first assisting hand replant surgery, I loved hand surgery. When I was assisting taking out a parotid tumor and dissecting around the facial nerve, I loved HEENT. When I was injecting knees with viscosupplementation solution, I loved orthopaedic medicine. When I'm sitting at the bedside with a patient and her family,  I love hospital medicine.  

So I have this great curse of not really knowing what I want to do when I grow up, but a clear knowledge that I want to do it. For me, medical school goes well beyond the access to the field of medicine. It is about deciding what to do with the rest of my life, literally. One thing keeps coming to the surface...being part of the solution. And what that seems to mean is being part of primary care, and increasing care and access to care for the general population.  Family Medicine keeps coming to the surface.

Family Practice is the medical specialty that provides continuing and comprehensive health care for individuals and families. All behaviors, sciences, sexes, ages, organ systems and clinical processes are a part of the practice of family medicine. The patient-physician relationship is a key feature of family medicine, but is this view more hype and ghostly shadows than reality?

I really would like to care for people of both genders and all ages. I'd love to be able to diagnose and treat 90 percent of all patient problems, including biological and mental health concerns without the use of specialty referral.  I have grand visions of treating conditions of all organ systems rather than limiting their practice to specific organ systems (although I won't throw out my 20 year experience in surgery and orthopedics). I believe that treating the whole patient by taking into account all the medical, social and mental health concerns of the individual is not just important but imperative. I believe that family medicine has the best chance of practicing  disease prevention and health maintenance in addition to treating illness.

So is it family medicine? I can only hope to be part of the solution. Actually, for the moment, I'd just like to pass biochemistry. Per chance to dream.

Best Hopes

I have great confidence in the generation of physicians getting ready to come out in the next 10 years. Being one of them, I'd better be right? I'm excited to be a part of this wonderful group.

The psyche of the modern medical student has changed over the years. After being a party to conversations over the many years, I can say that most students are getting into this field for the right reasons. Some of the more important observations about we medical students (and the future doctors getting ready to take care of the world):

We can be a bit quirky but we are intelligent and highly motivated by intellectual challenges.  We are creative and highly imaginative, and express ourselves in unique ways.  We have high energy and strive to meet challenges with enthusiasm and enough skepticism to keep us safe.

We are intuitive and can sense the needs and feelings of others if we actively engage and listen.  We are resourceful, and can devise ways and means to accomplish things.  We are warmhearted and enjoy doing things for others for the most part.

We are humorous and have an ability to make others laugh.  We are hardworking and have a never-say-die approach to life.  We are willing to take risks and see risk-taking as a form of excitement.

We are loyal, honest, and trustworthy.  We are flexible, and adapt easily to change for the most part. We are change-agents, and like the intrigue involved in change as long as it doesn't hinder our progress.

We are good observers of the world around us, and are able to find quick solutions to complicated situations.

We are productive and effective if we like what we are doing. We are forgiving as long as we haven't lost a limb.  We don't mind the goats and the chickens, the mosquitos and the rain, the lack of everyday pleasures in the U.S. to become the best doctors we can be.

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It's raining on the West Coast of Florida where we are.  Needless to say we are not able to enjoy the beach here.  We are getting feeder bands of rain all the way up here every 10 minutes or so, but I get to write and my daughter is doing her homework for school next week. This storm is huge.  Hurricane Gustav is now a Category 4 and is strengthening and heading toward the west of Cuba, and New Orleans. Katrina was a Category 3 when it hit and flooded over the levies. God help them.

Ageless Value

I recently heard a national speaker talk about age and life. He said "Never make a decision based on age. The spirit is ageless and eternally youthful. You can do at 85 what you can do when you are 35, except now you can do it with some wisdom.  The power of the self in our spirit is of ageless beauty." One can only hope. I believe that for the first time in a very, very long time that I am living of the spirit and not of the aging flesh. That is a great relief. I can only hope for the wisdom to do what I can, not do what I can't and know the difference when I get there.

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There has been a recent rash of articles in the newspapers and journals about the "broken healthcare system." I'm thrilled to be training to be a part of such an environment. I think about the complete irrationality of my decision daily in the face of a system that is totally broken. Having just recently had to apply for health insurance, that brokenness was really brought home to me. I'm healthy, active, and without pre-existing conditions, but was made to feel like an absolute criminal in the pursuit of health insurance to cover me in case I get hit by a wild bull or crazy goat.while going to school. Estimates of the number of uninsured and underinsured are rising daily in the U.S. and we are quickly becoming the model of what to avoid by other countries.

The Pentagon is spending nearly $5 billion per month in Iraq and Afghanistan, a pace that would bring yearly costs to almost $60 billion. Those expenses do not include money being spent on rebuilding Iraq's electric grid, water supply and other infrastructure. Imagine the value of investing that $5 billion per year in the underinsured and uninsured, coordinating health care costs across the country, stabilizing infrastructure and manpower in healthcare...just imagine. At the very least, $60 billion would completely fund a system of national insurance for all uninsured and underinsured and help bail out the struggling emergency room system that is now that population's primary care.

Why are we so willing, and able to pay for war, destruction, and country rebuilding in far way places and not so secure in the same spending for our own countries health. I don't get it. Maybe it's time to do as the bumper sticker suggests, "Get our troops out now. Let them win." And take the saving and invest in the healthcare of this country. I might not then finish training and enter a broken system. We might actually help the health care of Iraq and Afghanistan too. What is wrong with us as a people "earth" that we can't understand and implement what we need to do to survive, and thrive?

Working It

"The best preparation for work is not thinking about work, talking about work, or studying for work: It is work." - William Weld, Politician and attorney

Vacations are wonderful time for reflection and recharging from the work that is medical school. Being "home" with family and friends has been wonderful in the scheme of things. But, I am ready to return to work on the next phase of my education and humble myself further into the process of open-mind, open-heart learning. 

Sometimes life is harder than school. I've found that out this trip. Sometimes our intentions, our feelings are swallowed up in the assumptions of others. While not escapable in school, it is avoidable as the work shows in performance. I'm working it...life and school. I can only hope that those around me see the effort, appreciate the "trying" over the successes or failures, and recognize the importance of avoiding assuming anything.  It's a righteous purpose even with the challenges.

As God closes one door, another one opens. I'm getting to exactly where I'm supposed to be....just working it and allowing the seeds to germinate and grow. It's never too late. Moses was 80 when God called him. I'm not where I want to be, but I'm better off than where I was.

 

I'm off to a weekend escape with my daughter. I am rejuvenated by her spirit, her youth, her excitement with life anew in high school. She is a wonderful person...embodiment of the optimism and love I can only hope for. I will miss her greatly when I leave again but hold her spirit tightly in my heart as I strive to be the father, dad and man she can be proud of.

 

We are watching Gustav...not for Florida or school, but for the people of Jamaica, Caymans, Cuba and the Gulf Coastal states of the U.S. We will hope and pray for little destruction and disruption of life. TS Hanna is not far behind and has just passed the Leeward Islands. Island living has given me a renewed interest in the health, and safety of others in the path of these potential beasts.

"Remember that not getting what you want is sometimes a wonderful stroke of luck." - Dalai Lama

Disclaimer

I am totally responsible for my opinions and those expressed here. I have been made aware that some people may be offended for others whom I've referred to. While I understand that, I hope nothing is construed as a personal attack..it's not. But I recognize that there are people who invest their identity, reason for being and value from the opinions of others, and what they do for a living. I'm sorry for their perspectives and essential insanity, but I don't share that belief. So whatever I express is about me, not about them. If you get that, you get me, and understand my musings.

Statements made and opinions expressed on this blog are strictly those of the author and not other entity. Frankly no other entity would claim them or me for that matter.  No other entity, other than those unfortunate souls who have chosen to read this blog review, approve, or endorse the contents nor it the content monitored by anyone who has the power to do anything about it.  I am quite sure that it will be read if necessary to investigate alleged violations of policies, federal, state, or local laws, or the rights of other persons, including my own. I don't think everyone has the duty to agree, but hopefully everyone supports my right to express. I encourage real freedom.  If you don't support my right to express and only like reading things you agree with, stop reading this blog and find another one closer to your liking. Please.

R&R and Soon

This much needed break from studies has been really nice. I'm recovering daily the motivation for next term. That sustained, disciplined process needs renewal I think. Like the reason for sabbaticals for college professors...sometimes you just need the break to rejuvenate.  After figuring out what I need to do to be a successful student after this many years, the element of sustained thinking is the one I find to the most difficult.

Dr. John C. Maxwell describes discipline as "doing what you really do not want to do, so you can do what you really want to do". We all have the tendency to be undisciplined in the areas that we do not care to do. But that is emotion leading choice, rather than choices leading our lives. I'm learning that daily in life and school.

I've resolved to be more disciplined in three areas...thinking, emotions, and actions.

Disciplined Thinking:  Through the process of sustained thinking, I am learning to focus more on the issues at hand for the long term. Medical school makes you do that. My marriage had me to doing that.  And I don't think it is lack of skill. I think it is a unwillingness to try to master sustained thinking....focusing on the process and goals for long periods of time while engaged in the actions necessary to achieve it.

Disciplined Emotions: This is fairly difficult for most; It has for me.  I have resolved to master them more than they task me. Unfortunately our actions, particularly towards others, are manifested from our emotions. Controlling that connection is the key. I'll never stop "feeling" certain things, but it doesn't have to come out in my behavior.

Disciplined Actions: Once a choice is made (medical school) and the intention is clear thru starting the process, follow thru via disciplined action is the key to reaching the goal.

The only way I can become an accomplished physician and man is to keep growing, and learning. The day I stop growing and learning, it is finished.

I am preparing for the next term by getting things together and actually starting the reading. I've also plotted my schedule for study and review for the next term as most of the content will haunt me again on Part 1 USMLE. I learned a lot about me being a student again. Now thru disciplined action about that thought, I'll make those improvements necessary for next term and beyond. "Patience grasshopper; All will be revealed".

 

"Motivation is very important, and thus my simple religion is love, respect for others, honesty. With proper motivation these can help humanity…" - His Holiness the Dalai Lama

It is Done

I've often had the same feeling walking out of a difficult surgical case...from intensity and brain drain to nothingness. That was the feeling walking out of my last exam this morning.  I wasn't sure what to do, where to go. So I went out to Zeelandia Beach (north shore) to watch the waves and wait for everyone to finish the test (we headed to the beach afterward). Zeelandia was a good place to commune with the Public Health Gods and offer my sacrifice of part of a diet Coke, a piece of a granola bar and a few shells. Yes, I literally cast them into the sea. An amazing feeling knowing that while the exam average was in the low 60's, my 80 something insured that I would never have to see this class again. I would just assume donate a body part. I think I did.

As I heaved the offering toward the waves (just the coke, not the can...this beach is where turtles lay their eggs), I yelled something unintelligible (was I speaking in tongues?) and scared the heck out of a cow calf nestled in nearby thicket of sea grapes. Only on Statia...sharing the beach with cows. The act was total release of the pent up frustration of a course that should have never been.

What a total waste of effort dedicated to satisfying the arrogant, misguided plan of the instructors. As a former professor, and academic director, I'm all for academic freedom, but this was academic freedom run amuck in total opposition to the school curriculum plan, expectations of the students and sound teaching theory. I doubt anything will change unless the instructors decide to leave, like at least two others in the school, for more money elsewhere. But it doesn't matter to me...never again. I just feel oh so sorry for the studs that have it next term. WARNING, WARNING Will Robinson...GO BACK (Lost in Space, circa a bunch of years ago). Forgive them, for they know not what they are doing. It is done [music fades to silence].

It is @#$%& done.

The Storm Keeps Giving

AT 500 AM EDT...0900Z...THE CENTER OF TROPICAL STORM FAY WAS LOCATED NEAR LATITUDE 29.1 NORTH...LONGITUDE 80.7 WEST OR ABOUT 20 MILES...EAST-SOUTHEAST OF DAYTONA BEACH FLORIDA.

FAY HAS MOVED VERY LITTLE OVER THE LAST FEW HOURS. HOWEVER...A SLOW MOTION TOWARD THE WEST-NORTHWEST IS FORECAST TO BEGIN LATER TODAY AND CONTINUE FOR THE NEXT COUPLE OF DAYS. ON THIS TRACK...FAY IS FORECAST TO MOVE SLOWLY ACROSS THE NORTHERN FLORIDA PENINSULA TODAY...AND BE VERY NEAR THE GULF COAST OF THE FLORIDA PANHANDLE BY EARLY SATURDAY.

The storm that spawned in the Caribe just north east of us continues it's track, or lack thereof, in northern Florida. This thing has lasted for a long time since I first saw it off the African coast and we pontificated on it's possible destructive path across the Netherlands Antilles. I suspect that any water we "caught" in our cistern from this storm is long been used for flushing and showering, but the storm continues to provide water. I'm sure that north Florida has had enough of this visit.

The student center on my side of town will officially close today to access, although the library and study center near administration will remain open over break. Today is the last, last day of the term officially. I'm taking my final final and, hopefully, will know that I've passed the term and am able to move onward later this morning. It's been a great challenge, filled with amazing highs and lows, but I know it is literally just the beginning as I move ahead. The effort was huge, but the payoffs are revealing themselves daily as I create this new life.

I am going to give myself two gifts before I leave: One - I'm going to diving tomorrow. There is something magical about the silence of the deep. The water has been amazingly clear and bright blue the last few days and has called me. Or perhaps those are just the voices in my head from the insanity that has been this last class and exam? In any event, I know that the treat of the dive will help the process of clearing my head for break and the next term.

Two - I'm going to graduation tonight. Several of my new friends, one house mate included, are leaving the island after today for clinical rotations in the US, UK, and Holland. Experiencing this act of transition will, I'm sure, inspire and give something to look forward too over the next 18 months. I'll try to store an "experience" for future reference, somewhere in my frontal lobe. I'm very excited and happy for the last termers who will be taking USMLE Step 1 in the next few months, and then starting rotations. BTW, our program is somewhat unique in that sense...You cannot start clinical rotations of years 3 and 4 without passing USMLE Step 1. Some motivation huh?

So should be an interesting day in paradise. I pray for the powers of the public hell Gods to smile their countenance upon me over the next few hours. It is done.

Instructions for Life and Medical Practice

Instructions for Life by The Dalai Lama

-Take into account that great love and great achievements involve great risk.

-When you lose, don’t lose the lesson.

-Remember that not getting what you want is sometimes a wonderful stroke of luck.

-Follow the three R’s:
- Respect for self,
- Respect for others and
- Responsibility for all your actions.

-Learn the rules so you know how to break them properly.

-Don’t let a little dispute injure a great relationship.

-When you realize you’ve made a mistake, take immediate steps to correct it.

-Spend some time alone every day.

-Open your arms to change, but don’t let go of your values.

-Remember that silence is sometimes the best answer.

-Live a good, honorable life. Then when you get older and think back, you’ll be able to enjoy it a second time.

-A loving atmosphere in your home is the foundation for your life.

-In disagreements with loved ones, deal only with the current situation. Don’t bring up the past.

-Share knowledge. It is a way to achieve immortality.

-Be gentle with the earth.

-Once a year, go someplace you’ve never been before.

-The best relationship is one in which your love for each other exceeds your need for each other.

-Judge success by what you had to give up in order to get it.

-If you want others to be happy, practice compassion.

-If you want to be happy, practice compassion.

Weary, Excited

Everyone looks so weary today. This morning I walked in on some folks that have been here in the study hall all night long. Today is the term #2 testing and they look haggard and really full supratentorially. I hope they do well. I think everyone is thinking about just getting this week over so they can head to where ever home is. I can't wait.

But I will miss "here" too. It's been a great first term and I sincerely appreciate this opportunity and my surroundings. Can't wait to start the next term and move yet another step closer to...the next step.

I met a new student on the beach yesterday. It seems a long time since we started, yet it has gone so quickly. His questions were the same as mine; His fears equal.  It brought back a lot of feelings that I've experienced over these past few months of renewal, and learning. I look back on them with great reverence, aw, and excitement for the future. As this term sunsets, a new one begins in about 3 weeks. (photo: The Caribbean "bay" at sunset, Saba in the distance, by me)

Time

There  comes a point in your life when you  realize:

who matters,
who never did,
who won't anymore...
and who always will.
So,  don't worry about people from your past,
there's a reason why they didn't make it to your future.

'Be kinder than  necessary
because everyone you meet is fighting
some kind of battle, some kind of illness, some kind of trial in their life.

Fay and Aunt Mae

Look like it is going to be mostly wet in South Florida the rest of today and maybe tomorrow as Fay moves over land. They are already feeling the rains in what is predicted to be 4-8 inches falling on an already soaked (from a wet summer) South Florida. But it was enough to have schools canceled and a full blown preparation order from the governor. As one official said it, "it's great practice for the big one." Those involved in disaster preparation are doing their thing, their kids are at home or with friends since the plans didn't include the storm. Hopefully everyone will be ok, and Fay will just slide by. I hope my friends in NC are watching out now...this ain't over.

Interesting development in U.S. socialized medicine today (yes dear, there is socialized medicine in the U.S.; it just doesn't call itself that).  Medicare finalized a list of types of conditions for which, starting Oct. 1, it will no longer reimburse hospitals at the higher diagnosis-related group rate. Hospitals (not the physicians who care for them) will be paid much less for these patient conditions:

• Stage III, IV pressure ulcers
• Fall or trauma resulting in serious injury
• Vascular catheter-associated infection
• Catheter-associated urinary tract infection
• Foreign object retained after surgery
• Certain surgical site infections
• Air embolism
• Blood incompatibility
• Certain manifestations of poor blood sugar control
• Certain deep vein thromboses or pulmonary embolisms

OK I get the point. Anything iatrogenic (hospital or clinician induced) needs to be stopped. Medical error needs to be curtailed and not encouraged, but there are issues on this list that are not as straight forward as to be responsive to "if we don't pay, it'll go away." I know there is going to be some debate on this, but let's just take the first one....Stage III, IV pressure ulcers. I understand that there is the perspective that they should never get to this stage, but that may be more dependent on the patients milieu for healing and not what is being done to or for the patient.

So nurses in skilled nursing homes are at an all time low...ratio of nurse to patient. There just aren't enough. The paucity of geriatricians to take care of an every growing population of elderly is significant. They are calling for 1000's needed over the next 20 years. Nursing homes are understaffed, overworked, underpaid and my fictitious Aunt Mae is there.

Aunt Mae doesn't eat well, maybe not nutritionally what she was in her 20's, and sits in a wheel chair most of the day. She is moderately cognizant of her surroundings for only a few hours a day. She is transferred periodically from chair to bed and back by the nursing assistants when they think about it, and after they feed, dress, bathe etc everyone in the unit.

Pressure sores result from sustained pressure on the body. They're especially common in areas that aren't well padded with muscle or fat and that lie just over a bone, such as your spine, tailbone (coccyx), shoulder blades, hips, heels and elbows. Because your skin and the underlying tissues are trapped between bone and a surface such as a wheelchair or bed, blood flow is restricted. This deprives tissue of oxygen and other nutrients, and irreversible damage and tissue death can occur. Though the affected tissue may die in as little as 12 hours, the injury may not be apparent for days or even weeks.

So one day, the staff, PA, NP or physician sees the damage...the start of the ulceration (because they performed an earnest, deliberate, complete examination. Best case is that aggressive care at this stage prevents further damage and the Stage 1 (early) sore heals. In most cases, it doesn't heal. Aunt Mae doesn't have the nutritional constitution or immune system to heal or fight off infection from the less than sterile conditions that are at ALL nursing homes. So, she is transferred to Geriatric General Hospital for more definitive, attentive care. She gets it, and heals.

Now, the hospital wants to get paid. Under the new rules, the hospital is made "responsible" and gets paid much less than the care provided because of the diagnosis (which provides no leeway for explanation of the events) code placed on the claim form to Medicare. Later the hospital has to make a decision about the care they will provide and decide to eliminate the "losing" diagnosis and declare that they will no longer accept bed sore patients for care, and the nursing home (the same one where the problem started) takes over long term care. The problem gets worse.

This is of course a hypothetical with real world consequences. I get what Medicare is trying to do, but they are so confused on how to get there. The system is really broken. We can't continue on this route. Medical care will continue to be costly, and increasingly ineffective if we use these methods to fix the global problems. It is time for real socialization at some level to eliminate the barriers to healthcare that have been and continue to be created. What is more likely is an interest in ways of preserving income by various and sundry methods to get paid for the work done and the material expended.

A Gift

HURRICANE WATCH IS IN EFFECT FOR THE FLORIDA KEYS FROM SOUTH OF OCEAN REEF TO KEY WEST...INCLUDING THE DRY TORTUGAS AND FLORIDA BAY...AND ALONG THE FLORIDA MAINLAND FROM CARD SOUND BRIDGE WESTWARD TO BONITA BEACH.  A HURRICANE WATCH MEANS THAT HURRICANE CONDITIONS ARE POSSIBLE WITHIN THE WATCH AREA...GENERALLY WITHIN 36 HRS.

I wrote about Fay several days ago as it approached us and move to our north. I've been watching this thing develop, as most Caribbean storms do, for about 10 days. Now, the gift of Faye move toward Florida, just in time for the start of public school with rains to an area that just doesn't need anymore. I'm sure my family and friends are preparing as we speak just in case this turns out to be a "ride" later tonight, Monday and Tuesday. Time will tell. I wish everyone all the best with this little gift from the east.

Gas Prices

Oh the joys of shopping on an island...One roll of Bounty paper towels, 2 pints of milk (sterilized unrefrigerated, in cartons), and one pint of juice (brand, unknown to me)...Total: 19 Antillean guilders ($11 U.S.

WHAT? "Ya mon" the cashier said, "gas prices you know. Even in where driving is not really an issue or gas concern, gas prices are filtering into everything...food prices, cost of electricity, tuition. My electric bill doubled from June to July and used less electricity (never have I seen that before) so I can only imagine what the school bill was. The A/C is on 24 hours a day for the study halls. And yes, tuition is going up in January so we hear to cover that expense, among others. But $11 for three containers of drink, and paper towels? C'mon!

I am lucky and very grateful for the luxury of having money to spend for essentials, but I cannot imagine how many on this island, and other islands, survive it all. No wonder many have to make choices when they have to pay for medical care. For many, and the island isn't unique, it is a matter of healthcare or eating. The medically indigent (those who work, don't have healthcare insurance or coverage, and who don't qualify for Medicare or Medicaid) are one of the fastest growing populations in the US. At least Statia has the answer...free medical care for residents.

I think it is high time the U.S. consider strongly making it's socialized medical system (what do you think Champus /Tricare, Medicaid, Medicare, etc are?) a real socialized system and stop the half-baked measures. Where insurance and cash is present there will always be opportunities for private practice, but lets get the foundation in order and begin to serve the almost 50 million uninsured. We are doing it anyway.

Back to savoring my $1 per oz juice. If I save some of it, maybe I can trade it for tuition next term?

Open Mind, Open Heart

Survey Is Healthcare Reform on the Horizon? - A survey released last week by the Commonwealth Fund says the vast majority of Americans believe the nation’s healthcare system needs fundamental changes or a complete overhaul.

It is possible that as I emerge on the other end of my medical education that the system as I have known it for the past 20 odd years since graduating PA school, will be VERY different. Basing any future plans on my past experiences, while enabling and comfortable, is not prudent. It is imperative at this stage to open my mind and heart to the possibilities, and go into this venture without any preconceived notions, for as I operate from those notions, attitudes, beliefs and prejudices...I close doors.

This was really highlighted the other night in an open forum meeting with our Clinical Education Dean. That really opened my mind to the possibilities and totally trashed my notions of what it is I need to do to get to where I am going. Better than a plan is expectation of general success in the spotlight of an open mind and heart to fully recognize the opportunities when they arise. For to imagine what those opportunities will be, and worse, to hang hopes and dreams upon them, is a total waste of time.

Crico what?

Rule #244....Never, EVER, EVER change a gut answer on an anatomy lab exam. It WAS the Posterior Cricoarytenoid muscle. I new that, wrote it and then, in true old man habit, second guessed myself and changed the answer to the wrong one. That and one brain fart about the origin of one of the uterine arteries and I would have aced this one. I'm stoked, but gotta remember rule #244 FOREVER (or at least until I land a residency).

New goal..254 on USMLE part 1. Set by one of our graduate just before he matched in his #1 choice residency slot. I believe that 260 is the highest you can get. Two years from now, I hope to get that kind of news. In the meantime, study on!!

Amazing Feeling and then NOT

Make no mistake...there so much material and so many ways to have bombed this exam. We were essentially responsible for every detail of the human body anatomy from day one of class. It could have been ugly. But is was ok and I, by any definition, succeeded. Succeeding at any assessment in medical school is a combination of preparation, memory, interest, motivation, relevance...and a bit of luck. The factors, stars and various low pressure systems in the area were aligned this morning and I nailed the anatomy lab exam. This is a great beginning to finals week and puts much less pressure on me for the lecture exam next week. I've got some time now to work on other courses, and hopefully maximize my overall learning. It is an amazing feeling walking away from a comprehensive exam actually knowing the material. I went to his office today and thanked the professor for a great educational experience. I worked very hard, but REALLY enjoyed this class.

One of those "low" storm's southern edge is hitting us right now with intermittent winds and rains. It's pouring now. This is likely a foreshadow of "nasty" things to come and the horrific experience that will be the public hell exam next week. No interest, no motivation, no relevance to anything that I'm here for and a slew of bad luck on prior exams follows me into this event. No wonder I'd like for it to just go away.  Hardly bodes well for success. But I will make progress the next few days that I tackle the path to finding success in this course, in spite of the professors. They have done what they can, given their complete lack of knowledge of what we need, lack of clinical experience and total disdain for the class as a whole. Throw in some of the most problematic teaching, communication and delivery techniques I've ever witnessed and you have a course of instruction that failed miserably for no reason. It needs oversight, direction, and complete gutting to rescue it from a likely repeat next term with two more classes of students who will unwittingly enter with great hopes and expectations. I wish them well and hope that some semblance of interest in public health remains for those who survive this total abortion. I was actually very interested in public health, taught several sections on the topic as a professor, and had hoped to make it part of my advanced/graduate training at some level. I don't think there is enough mouthwash on this island to get the bad taste out of my mouth.

Difficult and Teaching

The process of learning is an independent event from difficulty. Why is that concept so hard for instructors. Just because you make a course hard doesn't mean more or better learning will take place. In fact, making a course difficult without connection to learning is called hazing and is considered torture in some countries.

There is a triangle of  organization to good learning, like the triangle of combustion, that provides a framework for quality education given a instructor lead event. Now I mention "instructor led" because some have suggested that independent or student centered "group" learning may be more effective than the lecturer/learner model.

But let's assume that the "rules" of engagement for the institution require contact time with the instructor. The triangle suggests that quality education is instructors, connecting students with content in a meaningful way to facilitate understanding and long term learning.

If the teacher can encourage independent exploration of the content, all the better. But when the teacher fails to stimulate the student, fails to connect the student with the knowledge (via lectures, or notes, or books, or whatever), learning fails. I think this is the major weakness of "talk at you" teaching (lectures), but worse with instructors that try to make courses difficult with absolutely no intention beyond making it so. Such is the case with at least one of my classes.

But where this has TRIUMPHED is anatomy. Dr. K is a master of presentation, the content, and connecting the student with the content in a way to stimulate more contact with the material beyond the classroom. That is a gift, and with all the trauma that being an adult learner can bring, kudos are in order for this wonderful man, class and learning experience. I only wish he had taught the other class. I will miss anatomy in many ways beyond the lab exam tomorrow and the lecture (with embryology) next week. It was challenging, difficult in fact, but an amazing learning experience. THANKS!!

Stormage

Pretty much tells the story....#1 is heading toward and just north of us, and #2 is right behind it.  I doubt any major organization is going to happen so likely more wind and rain than anything. Wave height is about 6 feet out there now. Should make for some interesting shore views.

I've got enough water to sink a ship, a gas stove and plenty of canned goods...so if worse comes to worse, I'll be fine for a few days. Should make for a fun Thursday AM when we are scheduled to take our final exam.  I can see it now, braving the winds, rain, flying debris to finish a class. Talking about major commitment !

Abuse

Finally, some real attention to a real problem. An article appeared recently about doctors acting out. The article details one hospitals program, and an "emerging effort to crack down on what some call healthcare road rage. The push is inspired by a growing body of research suggesting that swearing, yelling, and throwing objects are not just rude and offensive to co-workers, but hurt patients by increasing the likelihood of medical errors."

I've known about this problem for years. This industry is totally stressed out. Add egocentric, type A personalities to the mix and you have frustration, anger and acting  out. I've been the victim of these madmen for many years, one as recently as my last job. If I did, what this and other physicians I've worked with had done, I would have been fired, or even arrested. But nothing happens to them. Why? They are high earners and have mustered political clout. They seem to have the ability to fend off critique and punishment even with horrific stories of behavior. I've witnessed more than my fair share.

I'm thrilled to see that is changing and vow never to become one of them. I must always remember where I come from and be cognizant of the scars left by those physicians before who left them. Never again.

Stigma

It has begun. The discussion of the big white elephant in the room that everyone thinks they know, but don't speak about. Why a Caribbean medical school?  After all, we don't want to be penalized for coming here. I am personally aware of many international medical grads that are doing just fine in practice. It is much less an issue today than in prior years like when my friend went away. I still remember how strange it was to hear of his adventures. But now he is doing just fine in practice in Florida.

The discussion is hot here. The confluence of two forces merged yesterday...a comment from a teacher and an article in the NY times.  The comment was simple, off-handed and disturbing. One of our instructors said we "weren't smart enough for U.S. medical school." The article was about another Caribbean school landing a contract with NY hospitals, paying an exorbitant amount of money to exclusively send clinical students there. Apparently the discussion brought a furor among the medical intelligentsia of U.S. schools that send their students there.

I really don't know the truth of the whole, but for me it was a simple matter of not wanting to take MCATS again, and not wanting to repeat undergraduate courses that were "too old" according to many U.S. school.  Frankly, I wish there was a forward thinking hybrid medical school that accepted only nurse practitioners and physician assistants to train...one that dealt with practitioners in a different way than the average medical school treats it's students. That was one of the visions of Dr. Stead before he died.

Truth is my overall GPA, after a bachelors, masters (actually two of them if you count the non-accredited one) and a nearly finished doctorate (crapped out at the thesis stage during my break up)...was a solid 3.45. Ok so brain surgery is out. I'm not the smartest on the block, but my passion is there and the political system of entry into U.S. medical schools for older students is challenging. This provided open access to an education "door" that U.S. medical schools simply don't offer at this time. As long as I can build on my clinical knowledge and sit for USMLE and "match", I can get to the same end point. By the way, this is the entry to every scholar of medicine who trains outside of the U.S. and the numbers are staggering. For every position in residencies not sought by a U.S. grad, there are 5 international grads willing to accept an offer. And with the shortage of physicians now and in the future in the U.S. this phenomenon is only going to increase. I just have to stay above the fray, perform well, particularly in the clinical setting, and overcome.

I hate that I'll have to deal with people looking down their noses at me for going to a Caribbean medical school, but frankly I've been dealing with that prejudice for a long, long time as a PA. Only then it was, "when will you be finishing medical school honey?" As a PA, the answer was always a long explanation of what I did for a living. Now, I can say simply...soon.

A Beginner's Mind

"In the beginner's mind there are many possibilities; in the expert's mind there are few."  -Shunryu Suzuki, "Zen Mind, Beginner's Mind"

Within the depth of my age, experience, former education and need to be right, I am searching diligently for a "beginner's mind." It is amazing how receptive real teachers are to that mind, as it creates the willingness in others to share what they are experts about.

Storm Update

They say this thing is heading a bit north of us, and struggling to get stronger...so maybe just a rainy, bit windy storm on Wednesday / Thursday. Here's what it is supposed to look like on Thursday, the morning of our lab final:

We are at the end of the arrow, and the circle is the center of the low pressure of the storm. The blue "clouds" are rain. Walking in the rain isn't new to us here lately, but a deluge with wind will be interesting. I'm hopeful that it won't change the exam schedule and throw that off. We shall see.

Tis' the Season

It is the season. It is something we live with everyday in the tropics. I've lived in the path of tropical waves for many years, but the thought of one coming still gets my attention. I guess that is what is supposed to happen though. Tropical wave 92L has formed in the mid-Atlantic. Early indications are for a weak-to-moderate tropical storm to reach our area by Wednesday or Thursday. However, it remains possible that 92L will strengthen to become a weak hurricane in the days preceding its anticipated arrival. Students and other members of the University community have been put on alert to watch the storm and be alert for 92L. That figures because is the start of finals :(

It is here...finals will begin in 3 days. This is going to sound bit schizophrenic, but it has been a long, long term that has gone by very fast. I realize that length and depth of a thinking season has nothing to do with the perception of the passage of time. So maybe not so schizophrenic after all ? I can't believe what we have accomplished, and glad it is coming to and end. Terms actually fit my personality and my attention span. Or maybe it is the habit I formed as an instructor. I enjoyed the flush from term to term, and from class to class. In any event, it's almost four months...the end of the my attention span. Time for a "flushing" of the old and on with the new. It is a renewal each and every term start. That process begins on Thursday with the first final and ends next week with the end of Public Hell. I then mount a plane and head west to civilization, my family, friends, Dairy Queen and sundry drive thru diversions.

It has been a successful semester in many ways. It has begun a new chapter in my life and that of my classmates. It has been filled with emotion, spiritual,  intellectual and psychological triumphs and cognition. It wasn't just school for me and likely will permanently change my view of myself, and the world at large....all in a good way. So as we move closer to the flush, I am reminded that beyond the deeper meaning, later this week, the world will come down to one, specific event..."what is this pin stuck in, and what is it's origin,insertion, nerve inebriation (or is it innervation?) and action?" Is it possible to have a global, mind-altering experience in a collection of such a minute tasks or sets of tasks? I think it is.

"Kids, you tried your best and you failed miserably. The lesson is, never try." - Homer Simpson

Doubts

"There is clearly a difference between the physician who has doubts about his interest in clinical medicine, and the physician who has doubts about his ability. I have always had much more patience with the latter." - Steadism #63, pg. 33

For many in the early stages of medical school, there is an inverse with great confidence in ability that does not exist, and no interest (or clue) about clinical medicine. Conversation abounds around school about the amazing abilities that are, in reality, not present; Statements of fact, that in fact myth; Confidence, where real performance has not proved....and absolutely no interest in clinical medicine.

But I take heart in the knowledge that that interest will develop in many with increasing baseline knowledge and the move to clinical rotations in two years. As we progress in this mind-numbing process, confidence decreases as you realize how really little you know. And, interest in clinical medicine either does or does not emerge from that decreased confidence.

Thus one of the most important features of being an older, healthcare experienced medical student. I know I don't know anything (and I'm very confident in that), and I have an amazingly strong interest in clinical medicine. In that combination is the humility that makes the clinical years so much fun and something to look forward too. But before then I am daily tested by the teacher in me, to exhibit the humility and reverence to "the process", which at times can be so painful. And so the conundrum of the older student. It is a daily walk to judge not based on the past, be open to the possibilities, and just let it all flow over me so I can get to the clinical years. It is, after all, only medical school.  

Anatomy Survival

Ok, you can shut the fire hydrant off now! I've had enough to drink and my sippy straw is sorely damaged and my brain (likely supratentorial irritation). The instructor just announced that we would be getting new material until the day before the final lab exam. Just when I thought it was safe to think of anything other than anatomy. I know what I'll be doing this weekend and the rest of the week. But I'm sitting in a good position and while I think an A is out of the question, I'm ok with that. But how much can one brain hold...and worse...I'm kicking myself for forgetting all this since I last took the class, albeit 24 years ago. I get it. I'm a moron.

I think I will survive this and come next Thursday I'm sure I'll know (how profound). This was about constant, hard work, and dedication beyond my feeble memory. It is about hearsing and rehearsing, petition and repetition...until the brain says, oh yea, I get it. It was about immersing myself in the biohazard that is the lab, and rooting around to gain those amazing tactile memory cues I need and thrive on as I walk from station to testing station feeling my own body (the only cheat sheet you can bring to an exam). But even with all that, know deep in my epiploic foramen what was the key to my survival?

Altoids. Thank goodness for Altoids (cinnamon, my fave) and the hazardous gas neutralizing effect of sucking on those wonderful candies during lab. I don't think I could have done it without them....Thanks to an emergency shipment from my mother, I was saved and was able to spend the time I needed to make this happen. As those pungent flavors tantalized my olfactory nerve, and the anterior 2/3 of my tongue with both mandibular nerve (V3 branch of trigeminal) and facial nerve sensations, I was able to transition many, many facts from short to (hopefully) long term memory. Well at least as long as a week or so.

Why Not?

"Think big, start small." -- Patricia Fripp

I don't know what it is about age and medical school but the constant query of "why now" seems to percolate into every first encounter conversation. When I say I'm at the medical school to locals, and others I've not met yet, they always assume I teach there. I get that. Then the next seemingly logical question...student? Why now?

In my head, it's always "why not now". I had the life I wanted and hated it. I was a second class citizen in my marriage and my professional life.  The only person in my life that actually brought me peace and joy (most of the time) rejected me. Now I don't want this to be a sob, poor poor pitiful me story...it's not. It was the springboard to thinking bigger and starting somewhere. In medicine that mean starting small again. So the real question, when left with few choices in the field I love is, why not? The interesting thing is that for most older medical students, I suspect that is the case while the story may change slightly. At least that is what I've heard.

But the value of doing it this way is indisputable to me now after one term in school. I am better off as a student for having had the history I had. It makes me appreciate it that much more. It also has provided me a foundation that I appreciate every single day...Today it was as simple as a discussion of NG (nasogastric) tubes. While blank faces around me look in total awe and confusion about aspects of bedside care, internally I'm raving with joy...been there, done that.

My only regret is that I'm almost too old to do any long term residency in the areas of study I so enjoy. As the cranium was opened today, I realize how much I love neurosurgery (although I am so retarded at mastering the concepts). But with one of the longest residencies in medicine, neurosurgeon is clearly not an option.

So in my "why not", there are still many "whys" and it is nearly a daily event to sort out the why's from the why nots. Perhaps an exercise in futility, but a great exercise none the less.

T-minus 7 days 'til the comprehensive lab exam. May the anatomy Gods be with me. This is my "small start".

"If you try too carefully to plan your life, the danger is that you will succeed--succeed in narrowing your options, closing off avenues of adventure that cannot now be imagined." - Harlan Cleveland, Educator and statesman

It's Only Temporary

Capricorn

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"Work or school is all-consuming right now, however you define it and that may cause some friction with friends or family. Reassure them that it's temporary and then get on with it. " - Daily Horoscope

It is sometimes hard for me to believe that all the world is not in medical school. Aren't they? LOL. This is so all consuming, particularly as I face cumulative finals. Again, the elephant is being consumed, and I only have a spoon. Lab exam for anatomy is in one week covering everything since day one (I can't even remember last Friday) and all the new content. It is overwhelming sometimes, but I don't want to neglect family and friends...it is only temporary.

BTW, a new study was recently release about health, eating, drinking and language.  After an exhaustive review of the research literature, here's the final word. The Japanese eat very little fat and suffer fewer heart attacks than in the U.S. Mexicans eat a lot of fat and suffer fewer heart attacks. Chinese drink very little red wine and suffer fewer heart attacks than us. Italians drink excessive amounts of red wine and suffer fewer heart attacks than us.  Germans drink beer and eat lots of sausages and fats and suffer fewer heart attacks than us. CONCLUSION: Eat and drink what you like. Speaking English is apparently what kills you.

The question is which to speak to gain the most benefit in health and life. I think I am going to start speaking Hindi. Since there seems to be a large number of Hindi speakers in school and many in U.S. residency programs, it may actually benefit me in school and in clinical practice in the U.S. it seems.

U.S. HIV cases 40% higher than previous estimates

The CBS Evening News (8/2, lead story) reported that healthcare officials have announced that "the AIDS epidemic is worse than we thought." Apparently, for many years, the "government has underreported the number of people infected by the AIDS virus."

The problem with statistics is that they are only as good as the input of data. With flawed data of any kind, estimates are guesstimates and paradigms are useless. What is the primary care physician to do? We are at the mercy of the data we are provided and then ultimately held accountable for any faux pas that occurs in our individual practices related to that data.

Clearly underestimating the number of HIV cases in a practice is not jugular to practice success, but consider the effect of reporting a "normal" lab range (supposedly within the 95% confidence interval of a normal population) with flawed input data of those normal observations? At worst diseases are missed or overlooked. So the application of statistics to medical practice, and understanding the data as is presented in the medical literature is a key skill for clinicians, But can we really grasp the reality of flawed data?

Note to public health teacher...the data is everything, the concepts are important...the calculations are useless. I suspect too that HIV is a more important clinical public health problem than the formula for finding the Pearson Correlation Coefficient.