Well Packaged Fear

I've gone and done it. I've signed up for the first national  exam to practice medicine in the U.S. What a fear inducing process! It's all online and with a few simple clicks, it's done. $700 later, I look to the horizon for three months or so hence to sit down and take this beast on. I've got some time to prepare, but being the most important exam to date is daunting.

So what do I have to do now? Study. I need at least the national average 225 or so to be competitive for rotations and residency. I need to blow this thing out of the water if possible so I can compete against the twenty somethings for those coveted spots. I hope that I'm not putting too much pressure on myself, but I don't have a lot of second chances left in me.

For the moment, just keep swimming!

I Want to Teach When I Grow Up

I'd really like to teach again, at least one on one with an interested health care student. I miss the interaction and the cognition of the "ah ha" moments in others. I've missed seeing that here since it so rarely happens. And this sabbatical has really shown me a lot about good and bad teaching.

Good teaching is about passion, as well as reason. It's about motivating without coercion. It's about teaching others how to learn and making that lesson relevant, meaningful and memorable. It's about substance and treating students as consumers. It's about staying on top of the information you teach, and teaching relevant practical points over useless "I know more than you" knowledge. It's about bridging the gap between theory and practice. It's about listening, being responsive and questioning if necessary. It's about pushing students to excel with reasonable expectations while being human, and respecting the student. It's about not having a fixed agenda, being too rigid but instead being flexible, and fluid. It's not about "finishing" the material. It's a creative balance between being a dictator and being a pushover. It's about style, entertainment and still filled with substance. It means working the room and addressing every student directly in that room. It's about recognizing individual learning styles, and proficiencies and working to address them. It's about not taking yourself too seriously and a sense of humor. It's about caring, nurturing and devoting time...not just to test and presentation creation but to the student. It is supported by strong visionary leadership with a strong vision of what is appropriate and necessary.

Having had REALLY good teachers has been a great blessing and a great curse. I cherish the interactions and the learning, but despise the level of expectation it has created in me. I think I miss out on opportunities because of that prejudice and I don't think I'll be able to accept less than the quality I've come to expect in others, and myself.  One of the dangers of being an older dude with a history.

Missing It Already

I know I'm going to miss this experience at some level. I've enjoyed the overall environment and the people. This was a good choice, and I'm sure, heralds a wonderful future to the last part of my life. The learning has been wonderful, albeit difficult at times. The living has been challenging, while still inspiring.

Most of all I'll miss the natural beauty. It's part of my  soul, even before I got here, that I'm connected with nature around me. I love the water and the land. I appreciate it all. Best of all, it has been my sanity when there seemed to be none left. It's been my balance when the imbalances piled up. And I know, someday soon, I'll know how much I miss being here despite roaming animals, water shortages, absence of real culture or burgers, the mosquitos...

At some point we have to slow down, take stock and ready for the next day. That's what I've done here, and I hope that I can continue that work no matter what or who is around me.

The End is Nearly Near

Hard to believe that the end of this part, the first part, of training is nearly over. We are making preparation for leaving the rock and readying ourselves for taking the most important board of our careers to dates. I'm stunned at how quickly it feels we got here, but I relive the daily slog thru the 567 days in my mind regularly. But who's counting.

After taking the sample boards, and realizing how much we have to study for the next months before the national exam, we are finishing up our experience in the hospital. It's been great. I've really enjoyed watching the local physicians do their magic without the common conveniences I've come accustomed to appreciate. There is no x-ray, no ultrasound, no major labs, no surgery, no CT/MRI, and no EKG machine. Diagnostic is basically bedside combined with amazing low tech skills and lots of experience. It's not sophisticated, but it is magical in a way and a pleasure to watch.

We have engaged in some interesting discussions as well about what's coming with clinical rotations, and testing and such. Mostly I've enjoyed the discussions about the future and choosing a practice specialty. I'm particularly interested in that for my own sake and choosing a balance between practice and private life, while still providing a much needed, core service. I still envision being that "anything that walks  thru the door" doc in the hinterlands.

It is a very strange world in which we erupt into this phase of training and I am anxious to hear the pondering of our clinical faculty. The doctoring profession has been so mis- and devalued by what I've come to understand as "the business." It's not fashionable or profitable to be a general practitioner, yet it is our countries greatest need. I've seen an over emphasis on doing CPT coded procedures, and a sense that specialists are the only ones who know anything. Yet the patient centered "home" model where the doc knows the patient from "womb to tomb" seems to be what people want. But the finances, and legals get in the way. How to navigate that? I'm not sure, but hope to find out in the next two years.

My initial goal is to stay far afield of the financial conflicts that creep into our lives as new docs. I won't test or market products for drug or equipment companies and will scrutinize continuing medical education carefully, even though it's required. I'm not interested in serving the commercial interest Gods anymore. I recently turned down a steak dinner from a drug rep. Somewhere in this new world there is practice which is largely governed by patient advocacy, ethics and professional doctoring values in a private, not for profit realm of the wood. I'm moving thru cynicism and hopefully see clearly the "man behind the curtain." I'm sure it won't be a yellow brick road. 

But I am heartened when I see the docs here talking to patients at he beside, doing a classic Bates history and physical and actually making a sophisticated diagnosis without the high tech to depend on, or worrying about the lawyers in the hallway. There is something wonderful and pure about professional practice in the absence of profit, and a defensive posture, even if we can't get a chest x-ray.

Transition

We started making the transition from classroom to the wards today. Getting into the hospital really is exciting given the fact that we have been pretty much sitting in class for almost two years. The smell of the hospital, the patients and staff walking around...gave me the chills, in a good way.

The hospital is small and ill equipped by standards enjoyed by most westernized city hospitals. There is no x-ray, no ultrasound, no EKG, no surgery, and limited blood-work services. For anything major, patients have to be shipped out to another island. But then, the skills of the physicians here are truly amazing, and their  beside clinical assessment skills are excellent and they demonstrate that high tech can be somewhat replaced by high touch, and skill with history and physical exam. It is something I hope to remember.

But I can see that there are challenges in this environment. First is the heat and moisture. If you were going to create the perfect environment for the breeding of infection, this would be it. And then there are the mosquitos and the flies. Without A/C the windows are open and fans are blowing, but the mosquitos and flies abound. In the world of Dengue fever, and other mosquito borne diseases, this is a challenge. Lastly, the dust...it's everywhere. Diligent housekeepers are working nearly round the clock, but in the dry conditions of late, there is dust everywhere, covering nearly everything uncovered.

Certainly not ideal conditions to heal and get better from trauma and disease, but what a great opportunity to learn about hard core, basic medicine. I really missed that the first time around and hope to gain some great skills of beside clinical exam without the high tech trimmings (except maybe my smartphone). The frontier of primary care will be much more interesting if I can stay focused on that instead of all the other political and apolitical chatter.

It's really pretty exciting to stand at the doorway to the next phase of this training. It's still, and maybe more so, a rush!

True Self

People change in medical school. I noticed it one day waiting for class and found myself marveling at how one of my classmates had morphed over the past two years. Beyond the dichotomy of whether that is good or bad, it just is.

When you strip away the expectations of parents, friends, family and others; social pressures to become a doctor; and all the hype...you are left with your own values, dreams, personality and the true self. In the stress of school, particularly in the aberrant pressure and competition against others for grades (our retarded system here), that true self is subject to change.

I have found that to be one of the great challenges in this endeavor and work daily to avoid the pitfalls of what I see around me both in classmates, and in the physicians I have worked with in the past. My goal is to emulate those that maintain that true "sane" self, and don't morph into another species, burn outs, psych patients or surgeons that throw instruments at unwitting nurses and equipment technicians.