Let the Adventure Begin

“Enthusiasm is the greatest asset in the world. It beats money, power, and influence.” -Henry Chester

It's New Year's Eve and I've driven all day. The drive was smooth, traffic free, and provided plenty of time to think about the year gone by and the year (or so) to come. I just assume that 2010 didn't happen as it did, but both successes and failures provide great lessons. I've certainly learned a few this past year. Hope I don't repeat the bad ones. I've misjudged some people and situations, and underestimated my weaknesses. But I'm beginning to understand my strengths more. I hope that serves me and my future patients well.

2011 is a new beginning in many ways. Most of all, it's the beginning of the end of school and the start of rotations. I've been here, done this before. I mostly know what I need to do and will fake or figure out the rest. It's exciting yet frightening to realize that applications for residency start soon and Step 2 looms in the horizon. And so, it begins WITH ENTHUSIASM ...the other half. NO curbs allowed!

 

Settling into new living quarters the next few days, dinner with friends, New Year's Day with old college buddies and then Monday arrives with obstetrics, gynecology and more fun than you can possibly have with a tie and white coat on.

 

Wishing family, friends a Happy New Year! It's going to be a GREAT year!

The Spirit of Christmas

“And someone says, look, the animals, they are adoring the baby. Adoring, hell. They’re wondering why there’s a baby in their food.”

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We need not find the exact same meaning in the Christmas story in order to join in the celebration of it's virtues of love, forgiveness, hope, peace, goodwill, faith and charity.  Respecting another's beliefs does not mean that you have to agree. But understanding the virtues and viable beliefs that benefit all mankind is noble and in all of our best interests. This is a great time to go inward and assess how we treat others, and how we treat ourselves. Even if the baby is in the food.

Happy Hanukah, Merry Christmas, Happy Kwanzaa and Happy New Year 2011 to everyone. It's going to be an amazing year! Let's vow to love, forgive, hope, create peace and be charitable to others. It's the season of "not about me" and all about others.

We are the Bastard Step Children

Once again a group of medical establishment types are upset (sort of a feeding frenzy) at the foreign, particularly Caribbean medical school system.  An article recently appeared about a "feud" between NY State medical schools and foreign medical schools.  Seems that NY State medical schools are waging "an aggressive campaign to persuade the State Board of Regents to make it harder, if not impossible, for foreign schools to use New York hospitals as extensions of their own campuses."

It appears to be about clinical training positions, rotations for students and residencies for post grad MD/DO training, at NY hospitals. They say that there are 2,200 foreign medical students training in NY hospitals, nearly 1/3 of the total population of medical students.

All sorts of accusations have resurfaced, and I've heard them all, but it seems to be mostly about turf and jealousy. While there are many, many examples of quality physicians practicing in the U.S. with such an education background, the focus seems to be on the fact that these private school are for profit. After all, regardless of "school location" the essence of practice in the U.S. is passing the same U.S. boards, an approved residency and the full license scrutiny of state medical boards. Are they are stellar examples of Ivey League institutions? Absolutely not, but it's education none-the-less.

The real issue seems to be about St. George's School of Medicine and their 10-year $100 million contract with the city to send its students to NYC hospitals. Is it possible there may be some jealousy? Since the U.S. needs more primary care docs and the pathway to becoming a doc in the U.S. is essentially the same, could the problem really be about the willingness of St. George's to pay for good education for it's students?

While I know how hard I'm working toward this goal of becoming a physician, I know I'll have to deal with the perception of the Caribe medical school system and my preparation. But in the end I hope that I'll be judged no harsher than my U.S. counterparts. As a St. George's graduate and now emergency medicine resident at Stony Brook NY & foreign medical school grad said, "we have something to prove, as opposed to the sense of entitlement that some U.S. medical students might feel." I feel the same that I have something to prove but then I've felt that most of my career.   I hope that the U.S. medical school "machine" recognizes that there is plenty of illness and room for everyone. NY, you should be flattered that so many want to come there for quality clinical education.

Clarity, VIA horoscope

Horoscope - December 23, 2010 Although the intensity seems to be dying down a bit, there's still a lot going on in your personal life. Thankfully, you're not as distracted today, making it easier to follow a clear path toward your goals. Visualize your destination, make a plan to reach it and then set out toward your target. Keep in mind that shortcuts won't help you get there any faster now, so prepare to take the more traditional route that consists of hard work & determination. How do it know? Almost ready to move and start rotations. Can't wait.

2010: A Year of Change

I'm opening my fingers, loosening my grip. going with it and it feels like pure adrenaline!

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"When we say things like "people don't change" it drives scientist crazy because change is literally the only constant in all of science. Energy. Matter. It's always changing, morphing, merging, growing, dying.

It's the way people try not to change that's unnatural. The way we cling to what things were instead of letting things be what they are. The way we cling to old memories instead of forming new ones. The way we insist on believing despite every scientific indication that anything in this lifetime is permanent.

Change is constant. How we experience change that's up to us. It can feel like death or it can feel like a second chance at life. If we open our fingers, loosen our grips, go with it, it can feel like pure adrenaline. Like at any moment we can have another chance at life. Like at any moment, we can be born all over again."

- Dr. Grey

Moving Onward

The discussion about who, what, where, when and how is now intensifying as school has received requests for rotations and my packet of information necessary to move on. I'm hopeful for something warmer than not during this winter start, but I'm ok with anything that might move me toward the goal of graduation and my degree. Our affiliations are fairly extensive and looks like I'll be able to do all of them in the U.S. Other options include some in Europe. That might be interesting.

The process was interesting for sure. I was relieved to learn that I am not wanted for crimes and/or misdemeanors in the U.S., I'm immune to most childhood communicable diseases (need to follow up on one I actually got vax'd for), and don't have HIV or Hepatitis. I was screened, prodded, invaded and stuck more times than I care to share, but it is nice to know I'm starting off healthy and a bit more "patient wise".

So now the process of nailing down the location and start date will happen in the next week. I'm already anticipating that with some packing, storing, clothing assessment as well as early search for housing in the areas proposed. With a Jan 3 start, I'll likely have to move this or next week to get there on time. Should be a whirlwind of activity for sure. But it's all good! I'm officially an MS-3, and loving it!

Mentors

I don't take the concept of mentors lightly. I've had a few really good ones over my life in medicine. I appreciate someone who can, regardless of their position or degree status, appreciate where others are in their pursuit of excellence. They are consummate listeners. They drift into long silence as they analyze your needs. They respond quickly when needed and slowly when necessary. But overall, they believe that they can help you create the best you and not make the same mistakes they made.

Thanks to the Mentorship Program at the ACP, I've found such a person. The most amazing phone call today about my pursuit of medicine and the future of being a physician. With all that knowledge and experience, it was hard not to feel awed by this physician's commitment (even in the short time of a phone call) to my success. And thanks for making Internal Medicine more than just a bunch of fat, smoking, hypertensive diabetics who don't comply anyway. Thankfully, another myth dashed.

Brain Cell Recovery Process in Progress

"Your brain has more than 100 billion cells, each connected to at least 20,000 other cells. The possible combinations are greater than the number of molecules in the known universe." - Brian Tracy

A little over a month since the board and I'm finally seeing the light at the end of my isolation, and brain cell recovery. I believe that cell # 99 billion, 756 millionth is waking as I write. This really has been a process of recovery, readying to dive into the next phase of this education process. Hope to have all the paperwork in shortly to officially move into clinical rotations and actually seeing patients again...or at least watching someone else see patients. That may be more the point. In this age of health care reform, it should be interesting for sure. Didn't have that element the last time I did this.

Hard to describe how lonely the process has been, particularly as I was systematically abandoned by everyone who is not blood or a classmate. My friends and family have been great, particularly in the past few months. But I guess it's not very fashionable being associated with a medical geek. And a geek, to be sure, I've been. But this repulsion of some seems to be a magnet for others. I can't tell you how many strange proposals, attempted fix ups, bizarre encounters I've had in the last few months. I've ignored or blow off them all. Likely future patients.

So I'm gradually moving into full brain cell and personality recovery and contemplating the move away from "here" to "there". My spawn continually reminds me that it's not that long before I'll be walking away from this process with my degree in hand and wondering why I thought it was so hard. She's right though. It won't be long. Just hope I survive with more of the billion brain cells than not.

Steps

It's all really just a bunch of "steps", one after the other, to become a physician. Like a steeplechase race, jumping through or over each hurdle without fumbling or falling. I understand the game even if playing the game seems skewed from it's purpose. So onward, and upward to the next Step.

Truly a happy Thanksgiving this year. Much to be thankful. It's a great time to notice. And I do.

Over the peak

"We must find a way to demystify medical education..."

I remember hearing a champion road bike racer in Europe describe the feeling at the end of a massive cycle climb upon reaching the top. He described the hard, slow, intense, rhythm that builds from the bottom of the climb and the feeling of peaking, and going over the top to the other side. I could almost feel that instant moment of "ahhh" when I read the results last week, but with the full knowing that on the other side of the downhill was yet another peak. Such is the "time trial" of medical school it seems.

And as I feel the "ahhh" of reaching this peak and having Step 1 behind me, I realize that there are other peeks ahead to build toward. And just knowing that, and understanding better what's necessary to make the peak somehow less tall, lessens the challenge. My training is getting more focused, more intense, and more efficient I think. But finding the joy is sometimes evasive.

Dr. John R. Minarcik said that "Learning medicine should be a JOY, not an ordeal." I've recently felt both the joy and the ordeal on this climb. Reaching this "ahhh" moment, I'm beginning to better understand how the process of medical education beats the joy out of a person who likely started the climb in full joy of the ride.

Ride on! I think I'd prefer a Harley though.

Sweetest word: "Passed"

Whew! I can't imagine a better Thanksgiving gift. I truly give thanks. Step 1 is now in my rearview mirror, and I'm onward to MS III and rotations. The work isn't done, but I know that I've gone over a huge hump when I didn't always feel like I would, or could. I probably won't land an orthopaedic residency with the score, but it's good enough for me.

The last year has been grueling, emotional, and filled with highs and lows. I have been supremely humbled by the experience, and so, so thankful to many family and friends who encouraged, screamed, cajoled, and supported me thru this phase. Thanks everyone who mattered. You know who you are.

Onward to clinical rotations and Step 2!

Relief

It's often the case that in times of great stress, you don't notice, until the stress is relieved. It's amazing how much relief there has been in the past 24 hours since writing the exam. Hopefully this is the charm. Now the waiting begins.

In the meantime, I signed up for some YouTube video subscriptions to keep my head in the game. One I signed up for was on Pathology; a series of vids on the basics of path as we learned in medical school by Dr. John R. Minarcik, MD. Should be some nice entertainment. More interesting was the automatic note sent from Dr. Minarcik, when you sign up. He writes:

1) Medical knowledge is an intrinsic right, NOT a commodity to sell.
2) Learning medicine should be a JOY, not an ordeal.
3) Everybody learns according to their own best style and convenience.
4) The Hippocratic oath issues of patient privacy, compassion, and FREE sharing of knowledge have to be honored.
5) Medical schools have to be in sync with board exams, or one of them has to go.
6) Medicine is too important to be tainted by corporate profiteering, government bungling, deceitful politics, or personal egos.
7) Exam and grade anxieties are the CANCERS of medical education. If your school admitted students which they feel need to be whipped, the SCHOOL has failed, not YOU!

From a medical school pathology professor. Profound to me. My new hero.

Amazing Stories - A break from study

I have spoken to so many people about the USMLE examination process. And I am continually amazed at how many single and multi "fails" are out there in the world from Step 1, 2, and 3. It seems to be the unspoken truth of many until they realize you are part of the tribe, then the stories flow. It's like a private fraternity/sorority or secret society that you have only heard vague rumors about.

The universal truth seems to be that finding out you didn’t pass your exam is universally traumatizing, stress inducing, and a slap to the morale. Everyone seems to feel a universal "what now", and a level of self examination that can be described as "to the bone." It's hard to talk about with anyone and seems that everyone is interested in how you did, adding to the stress. I have heard stories of losing touch with close school friends after knowing the news. I heard of at least 2 people that lost significant others as a result. One person said his girlfriend, in no uncertain terms, told him...if he wasn't going to be a doctor, she couldn't be with him anymore. They had been in a loving, committed relationship for nearly 2 years.

There is also a universal search for reasons, blame, why's and how's, particularly those that come very close...within 10 points of passing. I've heard about lousy education, crappy teachers, retarded exam process, unrealistic expectations, cultural bias, incoherent questions, lack of clinical correlation, pedantic knowledge, details that have no connection with reality or clinical practice and those testing "bastards". Then the self deprecation starts to flow from the stories: I'm not smart enough. I can't remember shiite. I'm not a good test taker. I'm too old. I'm too young and inexperienced. I have ADHD, Bipolar PD, Borderline PD or PTSD. I should have stayed at home. I was having my period or migraine. My mom, dad, sister, brother, aunt, uncle or dog died. I had a bad, bad day.

But there is universal agreement that the fact is, it's decision time and you can either attack the problems by really identifying the reality of the situation or bail and do something else. The thought of never being able to overcome the hurdle forces many to scrap the attempt and seek alternative careers. I've heard from more former medical students, now science teacher or medical assistants, than I would have ever imagined.

Choosing to stay in the fight, getting help becomes a great challenge. If you have real mental health issues, you have to seek appropriate assessment and real counseling or medical help. Dextroamphetamine and amphetamine seems to be the most commonly used as part of attention deficit hyperactivity disorder, claimed by many. Alcohol comes a close second.

I heard of one story of how an individual, studying for his 3rd attempt, got dismissed from a review course. How does one get dismissed from a review course? Bring beer to the lectures. Unbelievable. Apparently, according to the story teller, he is on his way to becoming an expert in fatty liver, esophageal varices, portal hypertension and ascites.

And if you stay engaged in this bizarre process, you have to study again. That may be the most overriding theme. And many choose that course. The challenge becomes what to study? how? with what materials? in what order? when to introduce questions? in the test/tutor/times/un-timed mode? Which bank? Which books? Which tutor? What review program? Which city? And for how long? Use NBME as a guide? I've not heard much consensus on any one approach; It's so individual. And there in lies the conundrum. You become your own analyst and expert to figure it out, and you are the worst person to make that determination.

So everyone does what they can: talk to friends, contact school and profs, call review programs, contact mentors, ask the clerk at the grocery store. At this point, any opinion will do. And most everyone tells you something different about the "how they did it", but says the same things about the what: You can do this. You can make it happen. You'll be fine. It'll all work out. Fact is, it may not. But you have to get things in order and do what you can.

It's not horrible. Everything happens for a reason. It presents an opportunity to realize your deficits and work on filling them. It allows time and space to hone knowledge so you can be a better clinician. It provides insight into study skills, memory, learning. personality traits, tenacity and dealing with success/failure. It's a unique perspective to be stripped down to, and can be beneficial regardless of the final outcome. And in the final analysis, what doesn't kill you makes you stronger, or...forces  you to join the peace corp.

Time to Study Again

It is time! I am off and running, or diving, into study again for the 2nd round. Getting excited about it again, after a brief gut punch.

I'm amazed at how many people come out of the woodwork with USMLE stories once they know your trials and tribulations. So my attack is renewed, revitalized, and on course again.
Down, but not out.

John Maxwell said, "If we're growing, we're always going to be out of our comfort zone.

I'm certainly out of mine.

And there it is

One simple word "fail".

This process has been exhausting. I've heard just about everything to do, not to do, from people that know, should know and know nothing. I worked as hard as I could given my skills, time, emotions, psych...and just missed....by one point. 1 point. Hard to believe that the last two years is punctuated this way. Just this side of the barbwire fence. But it might as well be 10,000 miles away. Probably just 1 or 2 questions.

I guess in the ebb and flow of events of life, there are always 'low tides'; those times when we are tested. This is one of them for me for sure. Perhaps my early counselors were right...maybe just not "cut out for this". I've ridden the waves into shore for glorious rides in the past, but this feels like the riptide, sucking me to deeper water...and I can't stand. I have to remember that, like the rip-tide, focusing on the little things will get me out.

I need to stop, take account and use my intuition to chart another long-term course. Need now to find out what my options are without becoming emotionally invested in this setback. Rash decisions, actions will be unlikely to work. This is an excellent time to refine existing abilities or develop new talents or, at best, discover subtle influences I can exert.

Feels pretty sucky though.

Almost Here

The culmination of a couple of years of study happens in about a week. Daunting. I have a keen sense of my own value and feel worthy of success, but the uncertainty still looms. I can feel as competent and confident as I want, but if the skill set and test taking mastery isn't there I won't fulfill my obligations. I may need to reassess my goals.

Without the activity of life, I would have never considered this option to begin with. I put aside this dream for a long, long time in exchange for trying to make other parts of my life work and the insecurities. I have rediscovered and resurrected those dreams and am taking the necessary steps. But there must be capacity and capability too. Not so sure about that.

I truly believe that I am deserving of and capable of achieving happiness in this career and have obviously been driven to pursue more expansive goals that many have said I'm not capable of. If you add those who have said how crazy I am to do this, there are few on my side. It boils down to having sufficient faith in myself to at least try and take this necessary evil road. I didn't turn down this opportunity and am giving it my best shot. But is it enough? It is said that believing in your worth is the key to achieving your goal, but in this case, I'm not so sure.

One more week...

Dutch Health Themes of Service

As I again intertwingle with the U.S. health care system, I realize how much I like the Dutch approach. The Dutch health services are world known in some circles because of their approach to care based on fourteen themes: Five general themes, nine themes related to special groups of patients and public health problems -

1. Competition - it can stimulate innovation without being a negative.
2. A strong primary health care - gatekeepers and longstanding relationships with patients
3. Transparent hospitals and other institutes
4. Strong patient unions advocating for the patient
5. Dissemination and implementation of successful experiments - Evidence in practice
6. Centers for youth and family - overweight, autism, ADHD, depression, violence, abuse
7. Safe hospitals with strict patient safety mgt systems
8. Integration of emergency services of ambulances, GP's and hospitals
9. Integrated care programs for chronic disease: DM, COPD, heart failure, stroke, cancer
10. Disease management in mental health services promoting recovery
11.One access to long term care
12.Flexible long term care
13.Professional addiction care
14.Legislation on medical end of live decisions with strict ethical systems

Anything even remotely successful must have strong leadership, allocated resources (taxes in the Dutch case), advocacy at all levels, and integration into new professional training. It's worth a look.

The Spill That Keeps on Giving

On Day 22 of the tragic oil spill from the drilling rig in the Gulf of Mexico.

Oil continues to pour into the Gulf from the undersea well at about 200,000 plus gallons per day. The pink, orange oil is now near the shore and has begun to wash up "balls" of oil on beaches, and a national wildlife refuge and nesting ground for sea birds. All sea wildlife is at risk. Shrimping may never recover.

And, there has been no success in stopping the flow of oil. It keeps on coming.

Beyond the direct effects of the oil, has anyone considered the effect of the nearly constant spraying with dispersant? Do we have any idea what the 1000's of gallons of dispersal solution can do to the environment and to human health?

What a tragedy.

Impulse

Why do we, at times, feel ourselves being compelled to improve ourselves, not only for our own sake but for the sake of a higher cause that we sense yet can barely see? What is that soft vibration that tugs on our hearts and beckons us to courageously leap beyond the small confines of the separate self sothat we can participate in the life-process in a much deeper and more
authentic way? - Andrew Cohen

Getting Closer

"It's not much longer". "You'll do fine". "You got this".

I know people are trying to help, encourage and insure my success, but they may be up for a fall. I know I don't have much longer. I'm watching the calender too. I've paid the fees, scheduled the date. But I don't know that I'll do fine, and certainly not sure if I got this. But I am hopeful...that people would just stop trying so hard to say the right thing when there may not be a right thing to say.

Onward into the dark night, the recesses of leukemias, anovulatory mechanisms, lung function, and tumor markers. I don't "got this" yet.

The Trek

It's really hard to get out of bed some days because I know that what faces me is another block of hours of study. I may be being hard on myself to do the best I can on this upcoming exam, but that's the beast that is medicine. I laugh inside when people say I'm "type A" or an overachiever or some such. Not sure I'd want a PA or physician or surgeon taking care of me who wasn't. But that internal motivation to succeed at this is none the less the thing that does actually get me out of bed. Although love for the study content, and for people, doesn't hurt.

I'm nearing the end of the first 1/2 of study with the exam some weeks away. I'm gaining confidence but still not performing up to the demands of my motivation. The mini eureka experience I have daily help, but I know that there is much to do, more to come. It is, like life, a day to day existence and discipline to keep mentally, spiritually and physically healthy while continuing the self motivated effort to ingest and retain as much of this elephant, these pancakes, as I can. Some day soon, I'll have to regurgitate it back, on cue.

I wish people wouldn't keep telling me that this is the hardest test in the world. Or that they wouldn't be doing this if they were me. Neither is good motivation. I get it.

USMLE Solo

Studying for USMLE Step 1 is a very lonely experience. While I see many others "doing it", still the highs and lows of study are lone and solo. The camaraderie of suffering thru class, while still painful, is somewhat blunted by the fact that there is a room full of people sharing the same experience. And while I know there are many 1000's of persons doing what I'm doing, it's hard to connect beyond it just being me vs. the ocean of content that is the mostly non-patient orientation of Step 1.

Drowning is NOT an option.

The Placebo Effect

"There is an effective treatment for your condition and the prospects for recovery are excellent"

Sometimes it's not what we do in medicine that matters, but how and what we say.