Non-traditional Doctor in Training

Eating for Health

2012-01-19T16:16:00.001-04:00

I just watched a man down lunch at Burger Prince. I guessed he was 6 foot and about 250# based on gross comparison with my own frame. He ordered a meal while I was behind him on line (I got a diet soda to help down my vitamin pack). He ordered 3 items including a triple whopping burger, a large potato fry and a large brown soda. Being in health care and being very curious about and actively seeking information on nutrition and health, I looked up his meal to calculate his intake.

Besides the incredibly high amount of salt, his meal was over 2000 calories. I'm currently on a program that allows 1500 cals for the whole day and he downed more in one setting. His triple burger alone was worth 1250 calories all by itself.

So I started a conversation with him about his company (insignia on his jacket) and introduced myself. His company is locally famous and I was fascinated with their success, policies and such. I wanted to know more (really). Somehow I got him interested in me in some meaningless way and he asked me to join him while he finished off his voracious attack.

The niceties of what we did, our holidays and New Year's progressed to resolutions. He told me he wanted to lose weight and get into the gym. Shocking, right? So when I noted to him that my diet soda was part of a larger plan (and caffeine injection) and a goal of 10 pound weight loss, he was interested. His face turned to stone when I told him about his now almost finished ingestion of over 2000 calories and such, and I didn't even include the 6 ketchup packs (filled with sugar) he doused his fries with.

We are just used to big everything and think it less value if we don't get it. And when we get it, we convince ourselves we have to eat it. Now at the price per calorie his meal was an incredible value, but to what end? I made a friend and potentially a future patient today, but I know he's going to think twice before he stops for that "value meal" again. At least that is my prevention hope. I'm confident though that the drive-thru will lure some unsuspecting traveler another day.

Job security, even if nobody can pay for the work. Except perhaps the very profitable Burger Prince.

The Last Christmas

2011-12-31T21:12:00.001-04:00

I'm not sure when it happened, but sometime during the 2nd year of medical school, I began to map out my trek on 3 very large, picture calendars. You know the kind...photos of national parks, huge vistas that you ad to your bucket list as you flip the pages. Awesome to look at as I moved onward.

As I progressed, I marked key dates, deadlines and points of interest in this process called medical school. I remember looking at December 2012 back then and marveling that it would be the last holiday break before graduation if everything went on time and schedule. And while there have been some blips, it came.

It was a great holiday with many wonderful memories created with family, friends and places. But it did feel different. It was the first one I wasn't studying for something in earnest. And it's that pensive time before Match is announced. It was a time of reflection too...have I done everything I need to do? Is there anything I need to do? Are my last rotations all set? It's been a very busy 2011.

And so this part of the process will end very, very soon. It's the last of the clerkships and laid back learning. I wish I could figure out how to do 4-8 week rotations for the rest of my life, but alas it doesn't pay well :) It's a great time to hone skills, be truly present with patients and get better at communication and decision making. It's a great time to reflect on the experiences thus far and try to envision the future to come. It's an exciting time.

And while I may have been out of my mind to jump off into this abyss, it's been a great experience and I'm looking forward to the next stage. And that will be here before I know it. I can see the light at the end of the tunnel and graduation is on the horizon.

And the congregation said "yea".

Now, if I could only get my preceptor assignment for Monday.

A Numbers Game

2011-12-25T07:15:00.000-04:00

The frightening thing is the information doesn't seem to be out there. It's gone largely noticed as I talk to established physicians. The reality? As medical school class sizes grew and new medical school opened on top of more foreign medical students applying...many will NOT match in 2012.

Expectation - There will be approximately 24,000 PGY1 positions available this year in ALL specialties. There will be nearly 50,000 applicants this year (U.S. and FMGs plus graduate MD's from other countries). There are going to be over 25,000 U.S. grads alone....more than the number of PGY1 slots. Any with funding questions swirling, there may be less positions even as the number of applicants increases.

The Problem: A tremendous need for primary care physicians in this country (pediatrics, geriatrics, community internal medicine, general surgery, family practice, women's health, etc)

The Myth: Expansion of medical schools will increase physicians, particularly in primary care. This is the biggest lie of the entire health care discussion, and medical school have largely bought into the idea by increasing class sizes and opening new programs. Physicians are "built" in residency, NOT medical school.

A Simple Solution: Unmatched graduate MDs and DOs want to continue training and practice medicine...being part of the solution.

How about providing a route for all unmatched physicians who have passed Step 1 and Step 2 enter into a "apprenticeship" agreement for training with any licensed physician? In exchange "training reimbursement" through Medicare, Medicaid, Insurance etc including payment for services as if the trainee was a physician.

Why is this so outlandish? A Physician Assistant can graduate PA school after 2 years, and enter into a work agreement to "practice medicine with supervision" right away. Why shouldn't a 4 year trained physician be allowed to do the same? It make so much sense to create this alternate pathway to create primary care and needed specialty physicians as a methodology to create the solutions health care really needs in this country.

The question, is there anyone in medical leadership willing to champion the effort. Are Boards of Medicine willing to be creative enough to fulfill the needs of it's citizenry as physicians retire, leave medicine, and refuse to accept Medicare and other payment programs?

We really need solutions, not more roadblocks. How about bringing the community apprenticeship training model back? It's worth looking at!

Emerging from the Rabbit Hole

2011-12-15T14:32:00.001-04:00

Time flies when you are having fun or doing interviews for residency. I was doing the latter. Doesn't seem to matter how many times I sit across a table from another human being for an interview, it never gets any easier. I'm sure my facade is glowing calm, but my insides are churning of sweat and sheer panic. I realize that it's not supposed to be that way, but the pressure of presenting yourself to one person or another in a short amount of time is brain busting. Combining a rather long history with honesty and trying to highlight the important qualities that fit the setting = nerves. At least the suit looked good.

But then, once in awhile there is a merging of the minds, a synchronous dance of perfect symbiosis and "Tsaheylu" is formed. I jump up and down inside when that happens. It's a moment in the interview time, place continuum when you know you are answering the questions easily, appropriately and becoming one with the interviewer. The portal into this rabbit hole could be something simple like a highlight from your past that fits their future view of the program. It could be a shared venture outside of medicine or a key word or phrase. It could be a testing struggle you both shared. And there doesn't seem to be any rhyme or reason and certainly no way to Google it in advance.

But I'm not asking for much, just a chance. A chance to show how passionate I am about medicine and patient care. A chance to prove beyond my average test scores that my clinical skills, honors rotations evaluations and experience means something beyond the sheer numbers. Match is what this last 4 years has been all about, and it's about to happen; As soon as these interviews are all over and the rank order lists are submitted. This is the nerve wracking season of medical education for MS-4's and graduate MD/DO's everywhere.

Since the 80's the number of applicants for the Match is growing at a faster pace than the number of spots available. This leaves the clear picture to many that residency is not possible. Everyone doesn't match. So more and more applicants are vying for a proportionally smaller number of post graduate training program spots. That's a recipe for a nervous interview season.

And so it goes. About 3 months after the holiday season, everyone will know their fate and where they'll be going come July 1. Could be family medicine in Florida, surgery in South Dakota or dermatology in Des Moines. The future of medicine is in the hands of a few powerful men and women interviewing a few very nervous applicants.

The Stream is VERY Full!

2011-11-02T11:23:00.001-04:00

When you have a hammer, everything looks like a nail. when you are in the match, everyone around you looks like a match applicant.

Recent article in the news applauded medical schools for increasing the number of first year medical students; Up almost 2,000 slots this year. That means in 4 years there will be 2,000 more students in the match process for residency positions.

But once again, the truth of the news is lost in the tragedy of the ineffectiveness of the process in the U.S. There were NOT 2,000 more residency slots created to accommodate those graduates. Add to that number the increase in foreign medical graduates like me, and the number of immigrant physicians who want to practice in the U.S. (all required for the most part to do residencies) and you see the bottleneck.

The fact is that there is a rapidly expanding disconnect between graduate medical education (residency) and the medical school "feeder" system. There is much money in expanding medical school and ERAS residency application slots, but not much made available to programs to expand residency positions. This is only going to get worse in the coming years as the new medical students graduate. It's a real problem as the U.S. tries to solve the primary care crunch as the baby boomers age.

I just want to practice "hang the shingle" primary care adult medicine. Why is this so hard? It shouldn't be at this stage.

Well, I've made it this far

2011-10-31T11:30:00.000-04:00

Just heard! I have officially passed Step 1, Step 2 CK and Step 2 CS. I now can graduate and get the coveted MD degree. Now that and $1.95 may get me a cup of coffee at McDonald's (maybe), but it is done...and that's a GREAT feeling!

Next step...3 sometime in the next couple of years. In the meantime, residency apps, interviews (hopefully) and placement. It's a long road, with many twists and turns, but I can see the light.

Could be a train, but I see the light.

Waiting for Scores

2011-10-15T00:58:00.000-04:00

Another Step, Stepped Upon

2011-10-04T19:43:00.000-04:00

"Father, into your hands I commit my spirit." - Med Student speaking to the ceiling fan with vague reference to NBME

"Boy, that was worth it. Such value in learning and educational assessment. $2 per answer!"
-Med Student III to me

"Remember what you learned for Step 1 and Step 2? Now forget it. It's useless, meaningless and has no place in this house of healing!"
- Residency director to new PGY-1s at orientation

Now just have to wait for the results.
Just in case, application to What a Burger submitted.

"Hey boy, you want fries with that??"

Sucking Sound

2011-10-03T20:04:00.000-04:00

That sucking sound you'll hear is a large medical testing organization insuring I have nothing left.

Today is the day

2011-10-03T00:44:00.000-04:00

The next "step" happens today. Step 2, part 2. This day marks the end of a long process that, while not quite over, was the pinnacle I could see off in the distance.

When I return, it will be done.

Tomorrow, onward to Internal Medicine.

Terms Everywhere

2011-09-27T00:39:00.001-04:00

It's all about vocabulary.

Anything protected from outsiders must have a code that only the insiders know. That vocabulary of terms is the "fair maiden", protected in the towers by the knights in white smocks with black rubber tubes of grail around their necks and in their ears. To know "the words" is to be a member of the secret society of potions and spells that few are permitted to use or allowed entry.

And when the attacks at the gates by nurse practitioners, physician assistants, chiropractors, pharmacists and the many "non-knights" becomes too brutal, the knights convene and invent new words, new exams, new "steps", new rules, new regs, newances...and they smile broadly.

Pneumonoultramicroscopicsilicovolcanoconiosis

Mu ha ha!!

That'll keep them to the other side of the mote.

The fair maiden is protected again.

Cluster Headache

2011-09-26T14:50:00.000-04:00

Pretty darn bad, apparently.

A cluster headache is one-sided head pain that may involve tearing of the eyes and a stuffy nose. Attacks occur regularly for 1 week to 1 year, separated by long pain-free periods that last at least 1 month.

They are "episodic" (most common) with 2 or 3 headaches a day for 1-2 months, brief HA free period and repeating pattern after that. The other type is "chronic" is about the same but without a period of sustained relief. Both are more common in men, and often feel like " an ice pick in the eye."

Of course it's always a good idea to see if the patient actually does have a pick in the eye before treating.

Sorta Just Snuck Up On Me

2011-09-24T09:03:00.000-04:00

The patient struggled to the table. "This has been progressing for a few months and is getting worse. It just sort of snuck up on me, a little more each day, week.

I've had tingling over my body in different place. I'm numb here, here, here and here (pointing). I can't seem to keep my balance on uneven surfaces and have been falling a bunch. My legs and arms feel so weak and my vision is getting worse, almost daily. I've been seeing double and it's very blurry."

"How old? I'm 48 doc. I'm very active; at least I was. I drive a tuck for work and love to hike and bike with my wife and kids."

[pause]

"Lets get a MRI and see you back. I have an idea what this is all about, but I want to be sure."

"I'll want to run a few more tests but I'm sorry, it is what I thought. You have M.S., Multiple Sclerosis. I'm afraid you may not be driving anymore and while we have some treatments that will help control the episodes you have been having, this may get worse over time."

And that's how it is. One day young, active, hiking and biking...the next, struggling to get up from a chair or climb stairs. And the presentation, signs and symptoms are as varied as the stories with many different nerve maladies affects:

Multiple sclerosis is an autoimmune disease that affects the brain and spinal cord (central nervous system). Symptoms vary, because the location and severity of each attack can be different. It usually happens in "episodes", period of time with symptoms and many patients can be kept in remission with various therapies, medications etc. Episodes can last for days, weeks, months....or forever.

For me, after my neurology rotation, it will always be the "just sorta snuck on me" disease.

Get rid of my headache doc, and I'll give you my daughter!

2011-09-21T15:45:00.000-04:00

Migraine headaches suck! That would be an understatement to those really having them. Migraines create great dysfunction in life, work, relationships, mood, self esteem, eating habits, traveling habits and almost every other area of life.

So when a patient finds a cure, usually through a provider that's willing to walk the combinations of medications (both rescue and suppression), other therapies and time... patients are ecstatic. Now they don't normally give away daughters and other parts of their family, but they do make grand gestures.

"How are you headaches going Mr. Jones? We've had quite the challenge with these, haven't we?"

"Doc, they are GONE!! I love you!! That combination of [select from the buffet - Amerge, Axert, Frova, Imitrex, Maxalt, Sumavel, Treximet, Zomig, Botox, Migranal, Ergomar, Caffergot, Amitriptyline, Atenolol, Diltiazem, Doxepin, Verapamil...just to name a few] did the trick!"

"That's great Mr. Jones.I'm thrilled for you and that we could finally get you some relief. By the way, I love you watch. It's very nice. Ok, so I'll see you back in about 3 months to see how your doing."

"Sounds good doc. Here take the watch. It's just an old thing anyway. Enjoy it!" And with that, he handed the doc the watch, and walked out.

Thankful just doesn't cover the gesture.

Furiously Filling Fat Full Fast

2011-09-12T19:28:00.001-04:00

I am so full of knowledge at this point, I'm afraid to learn anything new for fear that it will force something out that I might need later for exams, practice or human conversation. I don't think there is any room possible for any more. I'm almost completely full.

And just in time too. Nearly done with this phase of study and the next exam coming soon. It's anticipation and future relieve rolled into a tight package of anxiety. The ultimate performance anxiety.

I've met some interesting folks these past weeks of intensive study; all on the same mission. We all have our strategies for success and they couldn't be more different from each other. But the ultimate goal is the same. Fill up just enough to not push anything out the other side of our brains and promptly regurgitate what we know or think we know at the appropriate time, in the appropriate exam moment so we can onward to the next "Step".

I pray for no leakage of any vital information, including my name.

His story, Her story

2011-08-30T10:28:00.001-04:00

Everyone has a story. Everyone has tales of woe and triumph about this abortive process called medical training. The stories are all about the trials and tribulations, the attendings, the rotations, the schools, the classmates, the exams, the sleep (or lack thereof), the process, the residencies, the hours, the longer hours, the memory (lapses). And we all seem to have the same response on any given day...one day at a time, moving closer to the goal, whatever that is for you. It's a daily slog.

And it's so great to find those of use who relish, thrive and look forward to the learning day. There are great mental triumphs and "oh wow" experiences of eureka, mind blowing understandings of new, or newly incorporated knowledge. And it's those that force people to answer the question, "how are you?" with "I'm EXCELLENT!" :) and really mean it.

The process can be a great challenge.

But, today, I'm EXCELLENT.

Thanks Ceriman, the waiter, for reminding me of that simple fact. It's not what happens to us, but how we respond to what happens.

Mortality

2011-08-21T07:43:00.000-04:00

I've learned to equate "clinical trials" of medications on people with illness as a terminal event, one step closer to death. It's just the places I've hung around, people I've worked with and things I've seen, but the the two -- Clinical trials & terminal -- just seem to go hand in hand.

One of my friends from way back when I was too smart for my own good, just told me she's in a "clinical trial". I felt sick...for her, and her family. She's so upbeat, so positive, so able to move through the day with a huge smile on her face. That same smile way back when, won her awards. Now they hide the sad fact that disease is ravaging her body.

I'll pray, I'll hope, I'll stay positive for her when we speak. But I've become acquainted again with mortality.

One, more, STEP

2011-08-19T07:15:00.000-04:00

Seems like I've been studying medicine my whole life. Oh wait, I have! And it seems that it really all comes down to this set of two exams...Step2 "clinical knowledge" CK, and Step2 "clinical skills" CS. The entire reason for being comes down to two day of exams, one live with patient actors (and I use that term very loosely), and one "dead" day with a computer for 9 hours. Then sometime this fall, two email messages, and attached PDF's announcing the fate...Yay, or nay, to have the opportunity to graduate, get the MD in hand and move forward into the next part of training, the residency.

Rotations have been great. I'm in my element. I love the patient, the clinic, the learning, the relationships with staff, the smells, sounds and activity around healthcare. Lots of people are disgruntled in the field of healthcare, but I largely ignore them. Rotations are signs of things to come, residency and practice beyond. This really is the essence of why I did this in the first place. I am encouraged.

I thought she said "your ass" when I first heard the description of "what next" from one of my classmates. Actually E-R-A-S (residency) application. It is truly time consuming, but a necessary evil and it too continues getting ready for the 2012 match with 35,000 close medical friends who will also apply. Letters, documentation, work history, blah, blah, blah. Seems like I've been filing paperwork my whole life too. Oh wait; I HAVE!

So I study, and study, and study some more. It's a race against time, knowledge attrition, creeping dementia, boredom, mind numbing fear and a touch of ADHD. It's a balance between sitting for long hours, exercise, sleep, eating right and knowing just how much caffeine I can bear without overdosing. It's keeping an eye on the prize and doing what it takes, even if I should have found "another career" (- career counselor, 1977). This 2nd step isn't the last step, but it's the one that really counts and "bookends" the process of the past 4 years. It's exhilarating, and frightening in one well wrapped package. My date with destiny coming very soon. Emails forthcoming.

The Cycle Begins

2011-07-16T21:17:00.001-04:00

It's that time of the year that those shooting for Match 2012 in March begin the cycle of paperwork, processes, letters of recommendation, applications and interviews begins. The cycle starts now, in July, and ends the day the "matches" are announced in March.

It's worth reflecting how the process ended in 2011. Match Day 2011 there were 30,589 "active" applicants, and 23,421 PGY-1 slots available. Over 7,000 walked away with nothing after many years of hard work and the effort. Many will apply again this cycle, but likely many will walk away into other fields of work and study.

It is the bottleneck. It is the part of the system that is the real problem with the system. Medical schools are expanding their class sizes even as new programs are created for new students, both D.O. and M.D. But the sad fact is that the number of positions in residency are not increasing as fast. Thus, more and more physician graduates will not have post graduate residency positions to enter. And the problem is only exacerbated by the number of physicians immigrating into the U.S. each year, also in the hunt for those positions.

And so the environment I enter now. I'm so impressed how little information is out there that is consistent to help make the many decisions that have to be made in the next months. I'm on a haywire way up high without a net. This "fly by wire" is a rush, but it be the first step back to waiting tables too!

Education of the Un-schooled Kind

2011-05-23T19:58:00.001-04:00

I was really frightened many years ago, helping take care of my first cerebral palsy (CP) patient. There was this really grotesque looking and acting child with muscle spasms, head shakes, twitches and writing sitting in a wheel chair. I thought he would break. I thought I might break. But that was many 10's of 100's of patients ago and I've heard and taken care of CP, cerebral palsy, patients forever. It's not a new name or category of care for me. But I've been schooled this past month. I really didn't know CP at all.

Then I met and really hung out with a bunch of CP affected folks and their families. I really appreciate the experience and am so grateful for being able to hang with some of the most phenomenal but individually different CP folks ever. Everyone different from the next. Somewhere during the last few weeks in that experience there was a "click" of information (my anatomy, physiology and neurology) with reality. And after this intense month of talking with and experiencing these amazing young people, I now realize how diverse this group of patients is.

Cerebral palsy is considered a condition but it's really a waste basket term for everyone suffering from injury (usually some form of anoxia, low oxygen, at birth). It's more often thought of as a group of disorders that involves injury to the brain. But the problem is that the physical manifestation of the damage depends on which part of the brain and it's pathways are damaged. As a result, no two patients present the same and have differing combinations of functional deficits in movement, learning, hearing, seeing, and thinking. Each one is different.

The brain is huge and has between 10 billion to 100 billion neurons organized into cortices, pathways, areas and regions. Imagine all the different combinations of connections between those neurons and you have a number that is representative of the true nature of CP and the number of possible presentations.

So the first patient may have sight problems and motor control on the left side of his/her body. The next patient may have lower extremity problems and normal above the waist up. The next may have speech creating deficits and be unable to walk or hold a fork in the right hand but can with the left...and on, and on, and on go the variations.

But what I really learned I learned by hanging out with them and hearing their stories, successes, triumphs and fears. They are creative, fast thinking, smart for the most part with incredible senses of humor about themselves and others. They are dedicated, and grateful since they don't know what they don't have...they never had it. They are sincere, loving, hard working and diligent to find their niche in life while serving others. They really are, as one mother put it, incredible kids often trapped in bodies that just don't work. I really have been schooled...and I really am a better student, provider and person for having done so.

Tis the Season

2011-05-22T20:14:00.000-04:00

Tis the season, not to be jolly, but to apply. And so it begins...the 2012 Match ERAS season. This is the start of what will be the long months leading to the that fateful March date when everyone I know will be fighting for residency positions and hoping someone says to them..."we want you". I don't know if I'll make the 2012 match, but I'm going to give it my best shot.

It's a frightening process filled with more sources of information, speculation, advice, land mines and unknowns than I care to envision. All the elements must fall together in a pattern of "presentation" so the director of said residency programs feels you are a "match" with his/her vision of his/her specialty in his/her community. Dean's letters, letters of recommendations, tokens, Step 1 scores, supplemental applications, Step 2 CK and CS scores, grades and evaluations from rotations, etc etc. And then how to decide which specialty, at what program, where in the world?

Having watched good friends go through this process, it's really awful. It's not a system that really matches proportionally to the many factors that a person has. In many cases, your personality and bedside manner never see the light of day if you are a struggling test taker. Getting the interview..that's really the goal. And hopefully figuring out where your best chances of "match" are before you click "send" the applications out to the many programs.

And so it begins. I'll try to figure out this process and hope that each day I'll inch toward that letter of "we want you" and it'll be a place I really want to be. Marriage was easier. Actually, pulling that ice pick out of my leg was easier.

Humanism

2011-05-03T16:58:00.001-04:00

Sometimes within the madness, mayhem, schedules, rushes, indignities, cost over-rides, dissatisfaction, liability, pain, suffering, aggravation, selfishness, greed, industrialization, government oversight and processes of medicine...there are moments of pure giving, love, joy, healing, service and art.

I don't want to miss any more of those moments. Glad I didn't miss this one. It is the fuel for moving onward, even if I have to battle the testing beast soon. It a real honor to be involved in the relationships that have become my profession.

Transparency in Medicine

2011-04-26T19:19:00.000-04:00

Transparency

1. free from pretense or deceit
2. easily detected or seen through
3. readily understood
4. characterized by visibility or accessibility of information especially concerning business practices

----------------

I am regularly struck by how much research patients often do before coming to the doctor. The Internet provides a full gateway of information and, unfortunately, misinformation about diseases, treatments and the system of medical practice. The Internet has been an effort to provide greater transparency in how we practice medicine and deliver healthcare. The written word seems to hold great validity to patients.

Transparency is fundamental to the creating of trusting, nurturing relationships with each other, particularly between clinician and patient. If for a moment the patient believes that communication and information provided is full of pretense, lies, or is not understood, there is immediate breakdown of the relationship and (if medical social scientists are correct) the cooperation of the patient in his/her care or "compliance". So the real question, is there transparency in medicine?

The reality is that transparency is scary to clinicians and the system as a whole. There are elaborate efforts to fully but not completely, reveal the secrets of medicine and medical practice. The Internet has done major things to this "gap" but rely on patient understanding, so would seem to violate "readily understood" transparency. Has the Internet then helped or hurt?

Transparency in the system is really up to the clinician. It's not the patient role or within his/her ability to force transparency through the Internet or available information sources. While it's all "out there", it may not be all understood and may actually contribute to damaging the relationship between physician and patient as they often believe what they read over what is being said.

So in that lies the greatest opportunities for improving patient care, trust and compliance...creating transparency with each patient we encounter. Yet there are risks in doing so as magnified by the legal system. However, taking risk offers great rewards. We should embrace our fear with honesty and transparency. But that would be in the perfect world with tort reform, liability caps and a system that supports that perspective. I'm not optimistic.

Another surgeon quit working this week. Tired of dealing with being questioned by everyone about how he practices. Another good surgeon, out to pasture.

Service

2011-04-24T04:13:00.000-04:00

One of the unsung, unmentioned perks of medical education is the access to quality experiences of service. These opportunities come in small packages, like tiny and discreet words with patients or families. And they come in larger packages related to hearing about real community needs. I had the chance for a sort of large one, more medium in scope, but VERY LARGE in effect. I helped a family clean out an apartment of a family member who died from suicide after a long, long battle with cancer, drug abuse, alcoholism, cirrhosis, pancreatitis, heart failure, kidney failure and emphysema. The physical, emotional, intellectual, and spiritual benefit of this day long effort was tremendous.

But one of the most striking elements of this event was the short list for "shopping" the deceased had created before his death. He simply wrote on a small, pink Post-it note: "comet cleaner, scrips, beef w/barley."

I've been trying to wrap my head about around the whole experience and the grateful family for stepping up when few others did except to come salvage personal belongings of the deceased.

Cleaner, drugs and soup seems to punctuate the simplicity, commonality and routine of a life in great pain, alone, struggling in the end to find a reason to live, clean the apartment and eat, until it became why bother.

Surgerizing

2011-04-22T14:41:00.000-04:00

I am REALLY in my element.

A chance to cut is a chance to cure.

But the pathology is so, so devastating.

I am so blessed to be whole, and not have someone leaning over me wielding a scalpel.

Really looking forward to Easter weekend and the last days of Passover week. A great time to pause and give thanks.

How to Value Medical Students

2011-04-21T22:38:00.001-04:00

Teaching is more than a business in medicine. Medical students, interns, residents and fellows have real needs. We all do. Address the needs and you make a friend for life and influence the future of medicine in a meaningful way. Such are the qualities of good clinical preceptors, teachers of medicine and surgery. I've had some good ones.

So what needs did he or she address? Certainty, variety, significance, connection, growth and contribution.

Learners want to know what's expected of them (certainty), experience a cross section of pathology (variety), feel they are important (significance), be a part of the team and treated as such (connection), learning (growing) and feel as if they have helped in a meaningful way (contribution).

It's hard to teach the importance of basic human needs to teachers,... individuals who are often struggling to have their own needs met.

Patient - Clinician Relationship

2011-04-19T01:05:00.001-04:00

I have met some really good clinicians lately; Individual who create great environments of trust, communication and cooperative healing with patients.

It's really pretty simple. There is ALWAYS a gap between what we expect of our patients, and how they act. I've noticed that the most disturbed clinicians assume the worst about that gap. Positive, happy clinicians seem to believe the best, come to the defense of their patients, speak directly to the patient (and not in the hallway to others) about those gaps, and create REAL trust with the patient so he doesn't feel judged or persecuted when they come to visit.

"Do unto others (patients) as you would have them do unto you (if they were the doc)"...We should protect, trust, hope and persevere more.

It really is pretty simple and probably applicable to the rest of our relationships, even outside of work.

Still Engaged

2011-04-13T01:11:00.000-04:00

Whenever I engage solo or groups of physicians I really listen carefully to what they say about this profession. I try to discern what it is they do, how they feel about it and what they believe the future to be. I'm constantly reminded of how many physicians are unhappy with what they do and why. I hear complaints about patients, insurance companies, the government, systems, and on and on. I'm convinced that there are more unhappy people in medicine than any other profession, but I don't interact with any other profession (sampling bias).

So the other day I met a very interesting surgeon, visiting the area. He practices in a small country in Africa and is the chief of surgery in a large (by African standards) teaching hospital. Listening to him speak you would have thought he had been given the gift of levitation. The pride and happiness almost oozed from his pores. It was a refreshing view into the life of a physician who really was happy with life and wholly feeling the "honor" of being a healer in a country desperately in need of healing on many levels.

One thing I'm certain of. I'm happy as a little clam. I love the content, the work, the patients, the material, the environment and the comrades. I'm learning to ignore the bitching and see past the complaining to the value in what we do and how we effect others. It's refreshing. Just hope I can maintain it thru this amazingly retarded system they call medical education.

And the surgeon, he invited me to do a "rotation" in Africa. Why not? I don't think Medicare is a discussion point there.

And exactly how do we know little clams are happy?

Don't Eat the Eggs

2011-04-12T00:56:00.000-04:00

Two days of lecture have me whipped. Sitting is becoming my least favorite activity in the mode of learning. Learning by doing (preferably walking, running or actively moving in some anatomical way) is my preferred. But the content was good and a reminder of how much I have to study before my next big exams. I need those subtle raps in the head occasionally. But what I didn't need was the rap to the GI tract. Note to self: Don't eat the eggs at a medical conference.

Inconvenient Truth

2011-03-28T18:49:00.001-04:00

The truth is surgery has a terrible time clock, and doesn't respect time in any way. Things happen good and bad that alter the "clock" and have things start and end when they weren't supposed to, or expected. It's just the way it is, and everyone around us is supposed to know that, honor that and just bear with it. But still, it never feels quite right.

And so it begins again. My absolute and complete love-hate relationship with the discipline, or lack thereof, of surgery. We cannot escape the barber-istic past. So let the anesthesia begin.

Sanity Defined

2011-03-23T17:47:00.000-04:00

Sanity is being judged "of health & sound mind" and being to make well judged choices. The appearance of sanity seems to be the one thing everyone wants but really can never get when we finally understand the real truth, the whole truth and nothing but the truth...We are all a bit crazy. To the extent that that crazy affects your home, work, professional or other (activities of daily living) life is the extent that you are judged insane by professionals as guided by criteria set up in the Diagnostic and Statistical Manual of Mental Disorders (DSM).

And now changes are coming to the DSM and the 5th edition is to be published for use in 2013. Seems that the science (practiced now mostly as a subjective art in community practice) has been propagated by researchers who have generated a wealth of knowledge about mental disorders, biochemistry of behavior, the influence of genes and heredity on mental health, and other factors begging to be described and included in the new book.

It's been 18 years since the last revision (the one currently in place) and begs the question. Will what is now sane become insanity or will what is now insane become sanity with this revision? It is theoretically possible that patients deemed "normal" now will suddenly find themselves not so normal after the publication of a book. Fascinating!

And then, the psychiatry rotation was over. And God said it was good. And before he created the next rotation, he contemplated the sanity of man and deemed woman a pre-existing condition. Man seeking his sanity discovered electricity and ECT was born. Man chose electric shocks over woman. And all was good again.

Joan, Jane, John etc...Meet Dr., Dr. Dr.

2011-02-28T10:07:00.000-04:00

My "Tara" experience came early in my psych experience. "Tara" is the character played by Toni Collette on "The United States of Tara", the Showtime TV show about a middle-aged, married, mother of 2 kids who has dissociative identity disorder. For the older folks this disease is aka multiple-personality disorder (MPD) and was associated with "Eve" and "Sybil", who are unknown by my 20 something colleagues.

It became apparent very quickly that I was totally ill prepared for the Tara experience with my Barbara Bates (Hx and PE textbook author), linear, history and physical examination style. There is nothing linear about the "new patient" work-up of a multiple, particularly as the personalities come out and interject, or worse, correct each other. Such was my experience.

I sat with Joan, Jane, John and some other un-named personalities for a long time hearing the history, fact, details, summaries, ranting, ravings, lies, delusions and such. It was the most entertaining hour I've ever spent in medicine and I'm a better provider for it. But my real conundrum as a provider came the moment I sat, pen hovering over the progress note page, and tried to write this encounter up in some manner that was intelligible and demonstrated my expertise as a medical professional:

"Personality #1 (called herself Jane) related a history of sexual abuse at the hand of her father and noted no other physical, verbal, emotional, financial or sexual abuse history. Personality #2 (Joan, deeper voice with faster cadence and visible tremor left hand) immediately corrected "Jane" and noted that she had been financially abused by a Texan with a big car just a few day before this visit. Personality #3 (John) then noted that Jane was Jealous, and that Jane and John were really wanting the Texan's money..."

And so it went. And who was Jealous? John was actually talking about another personality, within a personality. Apparently personalities can have names of emotions too...a variant presentation.

I have to admit, I felt a bit hoodwinked but still entertained. That's the thing about Psychiatry in general. There are no blood tests or real objective testing for many of the diseases we encounter. Such is the case with MPD, now DID. The interview is all we have. And if it is, we are totally unprepared. At least I am. But then, that was the best afternoons so far. No wonder Tara is a hit show on Showtime.

Mental Health

2011-02-16T08:00:00.001-04:00

Who we are, and how we respond to our environment as a living, breathing, interacting organism is a function of our nervous system. And that nervous system made of nerves, our spine and our brain is largely a function of chemicals...norepinephrine, epinephrine, serotonin and dopamine. So beyond limited therapies of counseling (a mainstay of psychiatric care), restraint (physical and chemical), and controversial surgical and electrical brain intervention; Psychiatry is largely an attempt to modify those chemicals. Today, 4 % of men and 10 % of women in this country are taking antidepressants at any given time according to Dr. Julian Whitaker.

So the day to day operations of a psychiatry office, and the function of a student in that environment, is the management of those drugs that attempt to modify those chemicals. The drug names of many, varied, and often entertaining....and there are MANY, with new ones coming out almost hourly. You can barely get through a TV show without seeing a commercial for one. We sell psychiatric illness and the "cure". It has become the mainstream of what we do in psychiatry and sales have skyrocketed from about $500 million to the current almost $60 BILLLION in only about 20 years. It is BIG business and the number of drug company sponsored lunches I have eaten while doing my psych rotation is testament to the amount of expendable dollars available due to these sales figures.

"The way to sell drugs is to sell psychiatric illness."----Dr. Carl Elliot, University of Minnesota Bioethicist (The Washington Post, 2001).

And while I feel well fed, and likely that some people actually need this care to survive life, much of what we do in psych is suspect at best and in some cases dangerous. Dr. Peter Breggin, M.D. says, "Going to a psychiatrist has become one of the most dangerous things a person can do", referring to the chemical approach to care.

And we continue to sell both disease and illness to a large percentage of "patients" walking thru the door, but the stories are largely of "life" and the stressors we encounter along the way. Has our ability to handle life and the massive stressors been exceeded or do we just look differently at that ability (and possible treatment)? It appears that current psychiatric practice is largely the latter.

"[W]e do not know the causes [of any mental disorder]. We don’t have the methods of ‘curing’ these illnesses yet.”----Dr. Rex Cowdry, director of the National Institute for Mental Health (NIMH), testimony before a House of Representatives Appropriations Committee Hearing

But there are some severely wounded people out there with real, significant and life strangling psychiatric issues. And it's those people that we daily struggle to help live a life with some quality and as few bumps, injuries and maladies as possible. And it's largely that hope that keeps the doors open, and the drug company lunches coming. We really want to help those in need, but we continue to invent, modify, and alter need. It is a grand experiment for sure.

"Anyone who goes to a psychiatrist ought to have his head examined."-- Samuel Goldwyn

"Biological psychology/psychiatry is a total perversion of medicine and science, and a fraud."— Neurologist Fred Baughman

"Psychiatry is probably the single most destructive force that has affected American Society within the last fifty years." – Dr. Thomas Szasz, Lifetime Fellow, American Psychiatric Association

One Down, Some To Go

2011-02-09T13:00:00.001-04:00

The first rotation is about over and time to reflect and transition to the next. I've really enjoyed the site, preceptor and the plethora of pathology. GREAT learning for sure. I also know that a constant diet of diseased vaginas, cervices, uteri and ovaries won't be my full time gig anytime in the future. Great to know that I understand the nuances of the specialty though. I'm sure I'll see much of this again.

It's been quite the tour of the female system in health and wellness from the technically specific presentation on pipette removal of egg parts and sperm chromosome modification of grand rounds, to the more mundane emergent patient presentations of membrane rupture, premature labor and peri-natal bleeding. It's also been quite the education in the finances and politics of healthcare. A sad, sad commentary on how the U.S. treats it's citizens and the right to healthcare.

I find it fascinating that while we pay taxes to keep public school running in almost every state and jurisdiction in the country, we have the most split, fractioned mechanisms for providing basic health care to the populations most at need. I find it unconscionable that we spend billions on destruction and rebuilding other countries and find it hard to find moneys' to address the core nutrition, peri-natal, and women's health care services. To be more specific would violate HIPAA and many other federal laws, but to not feel the issue at the jugular level is inhumane.

So we move through the day, one patient at a time, doing what we can do. I appreciate that there are some seasoned clinicians who have the time, resources, morals and ethics to do what is necessary, when it's necessary for who needs it most. I've been lucky to meet and work with some of them this past month. Hope the next one is more of the same.

No Wonder

2011-01-30T01:20:00.001-04:00

A recent patient, all of 16, told her story in what we call the "history". It was clear that her problem was a gynecological infection and it was just a matter of getting to the final diagnosis and treatment through some easy, in office testing.

But I found myself hung up on the social history and explored that deeper than usual. How'd it come to this, I probed. What resulted was a scenario that left me with the feeling of "no wonder."

No competent family, parents or friends available or present. No one being attentive to education and social issues. No kindness, fun or light-hearted playing. No one to be playful when possible or serious when needed. No real love, forgiveness, honesty or truth around her. No appropriate feedback, critique, direction or guidance. Mostly hurtful words, being ignored, emails and texts not returned. No real genuine interest from others for her well being or needs. Nobody to share concerns with or speak the truth with. No respect, and no hellos, "how was your day." No open hearted love or trust, but plenty of vulnerability, people walking out or away, grudges, pride and ego. Most of all, nobody walking in, when everyone else was walking out and no unconditional acceptance, love or support.

This bout of a STD may not be the worst of her problems in life. The foundation has been cast, mostly on shifting sand dunes, empty promises, unkept responsibility and unattainable dreams. Pretty sure she'll be back, maybe pregnant next time.

Epiphany

2011-01-28T09:54:00.001-04:00

There comes a moment of recognition on rotations that is hard to ignore and likely the core reason why we do this. It's that moment in time that I realized that I really enjoy learning, I've learned a lot, but I couldn't see myself doing this specialty full time. I really hope to help kick out a few babies in my career, but I'm certain I won't be doing OB/Gyn full time. That is both a relief and a hallmark moment on any rotation.

Still I need to learn all I can since I know with great certainty that while babies and vaginas are not my career passion, I will see this content on the boards I'm certain. And it has been a GREAT experience in many ways.

Case point: When 19 year old smokers come in 27 weeks pregnant with no history of pre-natal care, folic acid, nutrition / vitamin / supplement support, is it any wonder there are complications? The world of medicine if faced with very tough decisions indeed.

Open Mouth, Insert Foot

2011-01-15T12:30:00.000-04:00

There I was left alone in the office with a woman seeking care while the attending walked down the hallway. You'd think that every disproportionately overweight woman (stomach bigger than the rest of her body) would be pregnant in an obstetric practice. At least that's what I thought.

"How's your pregnancy going?" I asked to try to break the uncomfortable silence and be the caring young professional that I am.

A look of sheer horror filled her face and I knew that I had done the un-done-able. "I'm not pregnant..." she said indignantly with wide and a 40 yard stare that filled in the rest of the sentence (...you asshole).

Rule #234 of OB/Gyn:

Every overweight woman who walks into an OB/Gyn clinic setting is not pregnant.

Scowl

2011-01-14T23:41:00.000-04:00

It happened again. That scowl of judgement and prejudice. The FMG/IMG scowl from American trained physician and medical students. I'm getting used to it. But should I have to? It's amazing how it feels and how it looks, but it is my reality. There are no American born/bred IMG/FMG students in the world today (and there are many 1000's of us) that wouldn't have liked to attend a U.S. school, but there simply are not the opportunities. So out of country is the only way for us. Why the scowl?

The truth is that International medical graduates fill many of the gaps in the U.S. system of medicine, as well as those gaps in other Westernized countries. But for many reasons that is seen as a lesser calling than say Orthopaedic Surgery or Dermatology. Foreign school provide opportunities for the student and help fill those gaps. And IMG's have had a very positive effect on the U.S. system by providing care in extraordinary ways, in places that most U.S. grads can't or won't go.

There is an increasing number of U.S. citizens attending international medical schools. We are the U.S.I.M.Gs. we are the many Americans who attend schools in the Caribe, Central and South America, Mexico, Asia and Europe. We work hard to prove ourselves and return to practice in the states. We sit for the same school exams and NBME boards as our U.S. trained colleagues. We do rotations for the most part, in U.S. clinics and hospitals. We know that we want medicine, but sometimes we are not sure that medicine wants us. Yet we continue. And we endure the scowl.

Almost 300,000 IMGs, 25% of the American physician population, have entered the practice of medicine in the U.S. And about 1/4 of them are U.S. born and bred. Another 1/4 are from the Philippines, India and Pakistan. And while the history has meandered, we now all (U.S. and foreign students) take the same Step 1, 2CS, 2CK and 3 exams to gain license and practice privilege in the U.S.

The American health care system relies on IMGs to supplement an ever-increasing demand for health care, particularly in light of the baby-boomer generation entering their geriatric years. Only 40% of primary care positions (internal medicine, pediatrics and family medicine) are filled by U.S. grads. But that tide may change as the number of slots for medical students in U.S. school is rising (up to 30% increase over the next years). For the recent past and future, IMGs will continue to fill those gaps.

So the scowls continue, but seem to based on an old system of prejudices that hang on for dear life. Discrimination has been felt by many in my position as we are seen as less competent or able to practice medicine. And I'll do whatever it takes to counter that old argument.

Not A Great Way to Start the Day

2011-01-14T19:06:00.001-04:00

"And the baby was born dead"

I can't imagine a worse way to start the day in obstetrics. Over the past few days, while we were out, one of our near delivery patients discovered that her baby wasn't moving. For two days she worried, and hesitated to contact the doctor or the hospital. And when she did, she was instructed to immediately go to the emergency room. Immediately it was recognized that the baby was at least in trouble, at worst wasn't alive, and an emergency C-section was performed. Too late. The baby was born deceased; 37 weeks gestation. A full grown human baby.

This teaching moment, this tragedy, became the topic of our morning rounds discussion. What exactly would you say to the mother? How would you deliver the news? What would your pre-caesarian "informed consent" sound like? I really struggled for the words, but "passed" the test in theory. But the mother wasn't there to hear my answers.

The loss of a child in the peri-natal period is considered to be one of the greatest losses a mother can experience. There is profound feeling of loss, lack of control, and totally being unprepared. Compound that with the feelings of responsibility and of blame, and the loss becomes magnified. In the Kubler-Ross Death and Dying model of recovery, all of the emotions of anger, denial, etc can be felt. The hardship and difficulties psychosocially have been described but are immeasurable. The remarkable thing is that the literature recognizes no real difference in the grief process or response between mothers losing a baby by stillbirth (as this was), miscarriage, or pre-term death.

As providers we are aware that patients who suffer such losses need for us to acknowledge the loss and express the consideration, sensitivity and compassion they yearn for. We need to provide the support services personally and arranged. Most of all we need to avoid any tendency to blame, chastise or lecture. And it is remarkable how easy it is to slip into this thinking when in your gut you know you could have saved the baby if the mother had done as she should have.

Today my gut reminded me of my own struggle with death and dying...and loss. I flashed back to the teenage blonde lying still, in pieces, on a gurney at a Spring Break city after attempting to jump into a swimming pool from a 4th story hotel balcony. I saw a vision of a 10 year old boy draped across the hood of a car after an accident when I was playing paramedic. And there were way too many others. It just doesn't get any easier to contemplate. But I seem to be getting better at generating the mechanics of dealing with the issues surrounding the events. At least when pimped for the verbal answers to the questions. I wonder how I'll do in real life. I hope I never have to face that situation.

And then the clinic day went on. Future mother's were waiting to be seen.

“For death begins with life's first breath And life begins at touch of death” - John Oxenham

From Vaginas to Interaction

2011-01-12T17:11:00.001-04:00

I got bored with studying the nuances of gynecology, speculum exam and the various presentations of vaginas & cervices in clinical practice. While potentially an exciting subject and surely one to be on the boards and in clinical practice, I guess being cooped up for these days awaiting "thaw" has over-drenched my brain with the subject. I think too I inherently fear any content that has so much focus on estrogen, vagina and babies.

So I moved on to read some journals and stumbled upon one related to the psychosocial aspects of clinical care. And phrase caught my attention: "judging days"; Those days and times when we are too busy analyzing our own actions or the actions of others instead of just focusing on doing good, what's best and what's right.

Seems like such a subtle perspective, but it's really a dramatic one I think. From judgmental to just providing the best care possible. The system seems to train into young minds being judgmental because inherently the system is such. Every action we take is assessed, graded, scrutinized, commented on and judged by others in some way. It would be difficult to assume that new providers wouldn't be the same with each other, staff and patients.

But in the system comes the choice. And that may be the greatest advantage of being an older dude in this educational process; making the choice to do what's right, and just serving...thinking less about the judgement of others, and more about doing the right thing. It means abandoning the "what about me" mentality that seems so pervasive in medicine and the world in general. It's about abandoning a core selfishness that seeks to provide personal gratification and satisfaction over the needs of others.

But then I've always tried to do that even in my private life. And I hope that it extended to my practice life so that the "judging days" are way less than the just "doing the right thing" days. It's a daily, even moment by moment, choice. And just knowing that makes the choice easier and more clear. Even if it makes navigating the process of medical education more challenging. In this case it may be more beneficial not to "go with the flow."

“Everything that irritates us about others can lead us to an understanding of ourselves.” - Carl Jung

Rotation Success

2011-01-09T07:37:00.001-04:00

There really is no magic to doing well on rotations and getting through with minimal trauma imposed by attendings, coordinators and residents. There are some things that one can do (and I have to constantly remind myself of these often neglected facts) to insure success on rotations in the 3rd and 4th years of medical school.

Exclaim loudly, "This is my favorite rotation/specialty and what I want to do when I grow up." Without that gut wrenching enthusiasm, you look as if you aren't interested. Enthusiasm goes a LONG way.
No bitching about anything. Indirectly you are commenting about the environment that your superiors have chosen to work (and thus commenting on their mental capacity). Besides, does complaining help? Moreover, there is nothing they can do to you in 4, 6, 8 or 12 weeks that you can't get over.
Lead, don't wait to be lead. Figure out on your own what needs to be done and do it. Short of practicing medicine, try to anticipate the scut work that needs to be done and just do it!
Help your fellow students, interns and residents SHINE! If they look good, you look good. Nothing off your back if you help them succeed. Keep them up to date about their patients. That's your job.
Be inquisitive and ask good, thought out questions. Your curiosity stimulates teaching, and your own learning. But don't ask questions that are easily searched on your smart phone. Ask questions that are about the how and why things are done in the mind of the attending or instructing physician.
If you don't know, say "I don't know". It'll likely stimulate a conversation or explanation...or at worst, a "go look it up and tell us about it tomorrow. BTW, more chances than not, they'll forget to ask you about it tomorrow.
Make the nurses, techs and other clinic and hospital staff love you. Alienating a trusted staff member of the attending/physician is rotation suicide. They'll be there long after you are gone and are more likely to be defended as "family" by others working with them.
Show up early, stay late. This shows your respect, interest, dedication, and ability to organize your life around the most important things at this time...the rotation, your attending, and your learning.
Try stuff you are frightened of within the parameters of your learning. Sit down and create a treatment plan based on your assessment and run it by you supervising doc. Test your knowledge regularly without waiting for the doc to do it.

Focus on the success pathways in rotations.

Avoid the potholes.

Where Do Lonely Ex-Professors of Medicine Go?

2011-01-07T21:48:00.001-04:00

This week was an exciting re-entry into the world of medical education. Lots of great highs and very few lows as the drug of education entered my veins again.

One of the more interesting events was being corralled at the hospital by a former professor of medicine, now retired, who seemingly was just "hanging out" and l;kely interested in the free breakfast. Before I knew it, he was sharing his expertise on everything from IUD's to hospital politics...before I could even say a word.

So many teachers of medicine, who spend way too many hours at the hospital during their careers. They lose their families to the effort and have only hospital based friendships. They end up hanging on and around way too long. This guy obviously had no place to go except to the hospital, dressed in his sparkling whites. He carried a briefcase filled with articles for instant access to hand to any unsuspecting "short coat" student of medicine like me.

Fact is, I didn't know him and he didn't know me. He barely allowed me enough time to recite my name. But in my zeal and zest to be early (or at least on time) I had some time to kill before rounds one morning. And there I was trapped with Dr. Retired.

He began discussing his history, and it slowly progressed to his expertise. I wasn't allowed to say a word, so it appeared. He droned on about the subject matter as if imparting the great wisdom of the Pharaoh's upon me. It was filled with history, inaccurate assumptions, and pharmacy company rhetoric. And while I learned some things about the subject matter, I learned more about the ego, loneliness, and pomposity of retired pseudo-Ivy professors who spent way too much time proving himself to students, residents, fellows, chairmen, promotion committees, curriculum directors, research boards/IRB's, deans and pharmacy sales folk. He repeated his appointment title at least 10 times during the conversation as if to emphasize his height and weight over me. And while I appreciate his interest in me and my education, this was nothing more than sad.

But such is the mental challenge of academic medicine and the individuals in it. There are great teachers, researchers and mentors, and then there are the others. At the end of week one, I remain humble, open to learning, and eager to create value in my education for me and my future patient's. I've been exposed to amazing minds this week and I know this is where I belong once again.

And as for my brush with Dr. Retired? I'm on this side of the lectern now. And I know I won't ever go to the hospital, free breakfast or not, when I'm retired. Mostly because I may run into some nudnik like me.

First rotation bleeding

2011-01-06T08:49:00.001-04:00

It was just a matter of time before I was assigned a topic to review for the attendings and learn-lings on the service. It's sort of an apprentice right of passage to be able to present a topic in a concise manner and defend or support the information when questions are asked. I've seen this before and presented a ton, but somehow this first one feels different.

The topic? Bleeding in the first part of pregnancy, also known as "first trimester bleeding". First trimester bleeding is any bleeding during the first 12 weeks of pregnancy, and it is one of the most common symptoms to send a woman to her obstetrician and is never really considered to be a "normal" thing. And while bleeding is frightening at any time for any reason, most of the time it's nothing serious for the newly pregnant woman. It is reported that ~1/4 of all women who deliver healthy babies experience some bleeding in the first trimester.

Some causes:

Cervicitis / Vaginitis: any inflammation of the cervix or vagina, usually from trauma or infection causing bleeding from the inner lining of the mouth leading to the uterus (womb);
Infections of the vagina or cervix: yeast, gonorrhea, chlamdia, trichomonas, Gardnerella
Cervical polyps
Tissue dislodgement from uterine lining (must r/out tissue from pregnancy)
Miscarriage: doomed genetic mismatch or similar genetic reason (blighted ovum, etc); 1 in 5 chances; Mostly associated with cramping pain; Can be complete, incomplete or threatened.
Ectopic pregnancy (outside of uterus implantation of fetus)
Embryo (future fetus) implantation bleeding when ovum initially implants into uterine wall
Hormonal changes
Aggressive placenta growth & implantation with trapping/release of blood from behind placenta
Intrauterine fetal demise
Molar pregnancy (a type of cancer)
Post coital bleeding from having sex during pregnancy
Other "trauma" to vagina, vaginal wall or cervix

I've got lots of work to do to be sure I understand that topic completely, but just the act of this cursory research has me more aware of the work up for bleeding in the first trimester. And that may be the greatest value of this exercise...my awareness. We'll just see how much I impart on my fellow learners in the process and how I avoid death by questions I can't answer. I've got the weekend for that, the gym and study for boards.

Preparation is the key. Preparation it'll be.

Blighted ovum

What do you want to be?

2011-01-05T18:17:00.001-04:00

"When I come back, I want to come back as a vagina or uterus. It's the center of life"

After today I sort of agree with Dr. G about his wanting to come back as a female body part. For my moment in time, they are royalty. Today the female organs were elevated to new heights of medical science and clinical applications. The full gamut of discussion from CD36 markers on macrophages of the peritoneal cavity and their role in endometriosis to family planning with IUD's making a come back. Deeper discussions in the politics of female health capped with social commentary about single young females getting pregnant and cutting off their lives at the knees ensued.

The uterus and vagina were, at least today, the center of my life and universe. Seems that it will be my life for the next several weeks.

Day #2 - It's all about what you give

2011-01-05T06:31:00.001-04:00

"Let me introduce you to 3 of my students. Two of them are smart. Can you guess which one?"

It doesn't matter how smart or accomplished you are in this field. Teacher's of medicine can find ways to "pimp you" into submission and the recognition that you don't know squat. And that seems so easy in my case. Even simple questions seem to throw those willing to work hard to prove themselves in clinical education.

"What is the single factor in determining specialty choice by student physicians?" he asked. "Passionate interest" M said. "And you?", the instructor asked pointing to me. "I was going to say passion", I said. Did that really come out of my almost a doctor mouth? And with that, I moved to the top of the shit list and received a public lashing. Of the 1000's of words in the English dictionary, I couldn't think of one additional reason? What a maroon!

I must be the dumb one. At least I know where I stand, sit or mutter. My position on the lowest wrung of the scut dog ladder is insured. And it doesn't help that I stick out like a sore thumb in this sea of youth, dark hair and essence of "smart as hell". But then, I did know the breast cancer contraindication to the use of estrogen/progesterone in women. And the other reasons likely to show up on some board exam in the future?

hypersensitivity to the drug

pregnancy, known or suspected

undiagnosed vaginal bleeding

thromboembolic disorders

cerebrovascular disease

hepatic tumors, benign or malignant

hepatic disease, active

papilledema

retinal vascular lesions

sudden onset vision loss or changes

I do have lots to learn, and I'm sure there will be many more "dumbass" moments in my clinical education. I think that's why they make us wear the short coats.

Day #1- Babies and Insight

2011-01-04T00:26:00.000-04:00

Today was the first day of my first rotation and it started like most days of a new job filled with anticipation, fear and trying to figure out how to beat the traffic. Luckily school is not back from holiday break yet, so the traffic was relatively good and I made it to the clinic for our first meeting with plenty of time. Before I knew it, the orientation meeting was over and I had new friends in the 6 of us students starting today.

By noon, I thought the day would be over. There were no patients in clinic, the doc was on call and exhausted from overnight, and we had finished what we needed to finish. The clinical coordinator in the clinic had us finish the last paperwork, handed us our paperwork for hospital badges, and that seemed to be it...until she said three of us would be on call. Guess who was one of the three?

Call? First day, first night, first rotations? Really? My consciousness had to suck it all in and up, and my id wrestled with my ego for a bit, but then I realized I've done this before. And as a medical professional, I've sort of kind of done this stuff before.

I had 4 hours to kill before the shift started at 6 PM. I ran to the hospital, got my picture ID done and headed "home" (or at least my temporary corporate housing home). At least I could get a short work out and something to eat before I had to be back. I did both. And before I knew it, I was back at the hospital, searching for parking.

Meeting the doc for the first time was not without some advance preparation. I'd heard about Dr. G but nothing could prepare me for his energy, insight, stories and calling to teach. I think I am the 1900th or so student he has "mentored" and it shows. His interest in students is amazing. He genuinely cares, and said so in no uncertain terms and his discussion on the practice of medicine not being about him, but about his patience, was truly inspiring. I can see already, this is going to be an amazing learning experience as long as I keep open, present, eager and not worry about the infrastructure that is living in a new city, with new staff etc. But then, I've done that before too.

And just when I thought the day would dash my anticipation, nervousness and excitement with fairly routine, "It" happened...

One of the patients on the floor birthed a baby human. And even though I've seen 100's of babies being born, participated in many myself including emergency, life saving C-sections, this still felt amazing, and very new. And in a small way... 5 lbs, 6 ozs small...reminded me what this is really all about. And it's not about me at all. But then, it never was.

Rotations Begin

2011-01-02T16:14:00.001-04:00

It's hard to believe that it's actually here, but I am firmly geographically implanted and ready to start OB/Gynecology in the AM. I've not really been involved in OB since the birth of my child, but it's an area that I've enjoyed, learned about, and worked in in the past. Setting my mind in gear and pre-reading the content is a bit frightening, but I realize that nobody has ever died from "first day of rotations" either.

And so it begins in the morning. I've got my instructions. And beyond handling any emergencies that may come up tomorrow and the future in patient care (although highly unlikely I'll have to worry about that), I'm more concerned about the traffic, parking and finding the clinic. Then the daily experience of the work and schedule will begin to take over and I'll start the steadfast move to the end of rotations and school. Ready to learn!

Note to self: Don't drop babies. They don't like it. Or at least, catch them on the first bounce.

Let the Adventure Begin

2010-12-31T21:42:00.001-04:00

“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

2010-12-25T14:34:00.000-04:00

“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

2010-12-24T09:58:00.001-04:00

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

2010-12-23T08:10:00.001-04:00

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

2010-12-19T15:32:00.001-04:00

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

------

"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

2010-12-19T15:20:00.002-04:00

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

2010-12-15T23:29:00.001-04:00

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

2010-12-08T13:48:00.001-04:00

"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

2010-11-25T08:20:00.001-04:00

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

2010-11-20T11:25:00.000-04:00

"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"

2010-11-19T09:15:00.001-04:00

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

2010-10-27T08:16:00.000-04:00

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

2010-10-20T10:29:00.001-04:00

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

2010-08-22T22:26:00.004-04:00

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

2010-07-14T13:38:00.004-04:00

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

2010-06-02T17:39:00.001-04:00

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

2010-05-28T18:02:00.001-04:00

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

2010-05-11T06:06:00.002-04:00

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

2010-05-10T22:53:00.001-04:00

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

2010-05-10T03:37:00.003-04:00

"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

2010-04-27T07:32:00.002-04:00

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

2010-03-08T09:39:00.001-04:00

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

2010-03-04T10:57:00.001-04:00

"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.

RESCUED!

2009-12-19T13:38:00.000-04:00

They've seen us!!! We're RESCUED!

OOH "Out of Here"

2009-12-19T10:38:00.000-04:00

All my bags are packed, I'm ready to go. I'm standin' here outside Winair. I hate to wake the goats up to say goodbye. But the dawn is breakin', it's early morn. The dog is waitin', he's barkin his horn. Already I'm so elated I could die. Cause I'm leaving on a prop plane, I don't know when I'll be back again...

This is it. Got my passport, and one-way ticket home. It's been a journey and a half, and I'm hopeful I've learned enough to make it to the next Step. But for now, it's travel and some welcome R & R before starting the push for boards and my date with destiny. Another long day, but I know the drill by now after 6 runs. Hopefully all the bags and flights are on time, and together. Can't wait to be home again.

Happy Kingdom Day

2009-12-15T07:57:00.001-04:00

In the islands, there is only one thing more predictable than the weather... holidays! Today is 'Koninkrijksdag' or 'Kingdom Day'. it's a national holiday here and in the Netherlands and happens every December 15. It celebrates the signing of the Charter for the Kingdom of the Netherlands by

Queen Juliana on 15 December 1954. The charter deals with the relation between The
Netherlands and the overseas territories like the Netherlands Antilles (soon no longer to be in existence).

So today, nothing official can get done. I'm quite sure though that the green bottles will flow, and political conversation will spew. Or will the bottle spew, and conversation flow? As this place goes back to the kingdom, while most countries seek independence, the celebration will likely be the last one. In 2010, the last of the "overseas territories" will be gone, and all will either be back in the kingdom (not just a territory), or independent (like St. Maarten, Curacao, etc). This really is very historical but likely will not get the appreciation it deserves.

And I will continue to get ready to depart, also for the last time. Knowing that the next time I come to visit, if and when, I'll be entering a new place with more rules, regulations, organization, services, and taxes. It's bittersweet leaving now, but I'm a bit happy I won't have to live through the challenges that likely will be when the transition actually occurs.

So as we go back to the rule of the kingdom, Happy Kingdom Day!

Never Saw it Coming

2009-12-13T10:00:00.000-04:00

"The toughest sacrifices are the ones we don't see coming. When that happens, when the battle chooses us, that's when the sacrifice can turn out to be more than we can bear."

Hard day. And I thought it was really out of my mind.

It never is, is it?

The Mind Protects

2009-12-12T07:34:00.001-04:00

The mind has an amazing way of protecting us from the traumas of our lives. We experience great stresses and like the small animal injured in a fight, the mind squelches the event and moves us forward to new challenges and new risks. Such is the experience of the past few days and months.

The memories are becoming buffered by the action of the mind and everyone speaks of the "good times", and great friends, and wonderful experiences. But if you listen closely, you can hear the remnants of some of the trauma hidden by the artificial expressive aphasia imposed by the mind. For speaking the truth in many cases, while factual, only resurfaces the wounds. And while those truth traumas are really there, we have to thank the brain for doing it's handiwork.

Respect and Stuff

2009-12-09T22:50:00.001-04:00

Coming to the 1/2 way point of this monster, I realize that I've learned so much since I hit the start all bright eyed and bushy tailed. Not that I'm any less bright and bushy (cuz I'm not), but I've had some sense knocked into me for sure. I'm so thankful for the wonderful mentors and teachers along the way here. They are the reason I came and stayed in spite of the processes that threatened to derail us.

I came on faith and the recommendations of my friends who graduated from here now directors, practicing docs, residents and interns. They said that the campus was filled with role models, respect for the students and a pathway to the goal I sought. So I came, and learned.

I've learned that respect is something that is earned, not demanded. I've learned that quality is created, not accidentally stumbled upon by filling up slides. I've learned that quality doesn't have to be packaged in a pretty building. I've learned that our students are some of he most tenacious, focused learners in spite of great adversity and forces willing to impede progress. I've learned that not all change is good change, and can be dangerous if not recognized as such. I've learned that often little things create the greatest footprint of impact and effect. I've learned that, at times, doing the right thing is just walking away.

In retrospective sum, I see the great things accomplished, but I'm sure that my brain is deliberately hiding from me the traumas we were subjects of. I appreciate the experience so far, my classmates and the opportunity. And I'm ready for the next phase of the learning and hopeful I didn't learn too much, or too little.

Cause the next "step" is coming....and it's a doozie!

Privacy

2009-12-08T19:52:00.001-04:00

HIPAA Privacy Rule - protects the privacy of individually identifiable health information

I have to admit, I'm a novice when it comes to experiencing health care delivery beyond the borders of the U.S. So this Caribe healthcare experience has been truly "new" in many, many ways. But one of the most amazing to me, it the protection of privacy. To the extent possible, the providers do their best, but in a population of less than 5,000 where everyone knows everyone, is that really possible?

Further exacerbating the situation is the rather free flowing way that care is delivered and how patient privacy is protected, or not. One encounter truly summed that up for me the other day.

I am sitting with the doc in his private office. There are 3 doors entering the room from the hallway, the next door treatment room, and an adjacent patient room.

A patient walks in with another person and sits down near the physicians desk. I thought the other person was family or close friend. Au contraire! They hardly knew each other. It was the "next" patient in line, sharing the space. But it didn't seem to matter to the patient. Just then the door flies open and a nurse from the hospital, and the hospital administrator walk in. They engage the physician in a conversation about a patient and his family (by name) needing assistance. During the conversation, the nurse next door enters another door and announces that Mr. So and so is ready to see the doc in the treatment room. When the midwife walked in to consult the doc about Ms. such and such and her baby, a phone call engaged the doc in a conversation about Mr. Some and such coming back on island after seeing a specialist.

I looked around. There were 7 of us in the room, and the doc on the phone. Everyone heard everything about everybody. The patient, patiently awaited attention to be turned back on her and her headache.

HIPAA Privacy; apparently, just a formality.

Competent Culture

2009-12-07T19:50:00.000-04:00

One of the buzz phrases of medical education has been the concept of "cultural competence." Loosely, cultural competence in health care services is the ability of individuals, and the systems they are a part of, to provide health care to patients with diverse values, beliefs and behaviors.

When I taught this class in an earlier life, I used the CLAS standards as the model for the behaviors that organizations and individual practitioners should use as a guide. Although the CLAS standards are primarily directed at health care organizations, individuals can use them as a guide to make their practice of medicine more culturally and linguistically accessible. This is becoming more and more important as populations become more blended with individuals of diverse backgrounds, religions, nationalities, races, sects and...most importantly...health care belief systems.

I cannot imagine a better place to learn the practice of culturally appropriate health care than where I am. I realized in clinic how far I've come to understand the Caribe culture, and language. First, most would say it's really English, but I say ney ney, ya? Iz der speak aw bra! (nothing to do with lingerie). Me bellie ben hurtz whir I coo coo (nothing to do with psych). Da water ist burn offa me git upa bed. After a few hundred patients, I'm actually beginning to understand most of it, but find myself totally baffled at times. I'm sure I have this deer in the headlights look when I nod as if I know all that is being said. I'm sure I laugh at the wrong times occasionally. The Caribe-English can be quick, choppy, rhotic, glottal, accented, sporadic with influences from Jamaica, Barbuda, Africa, Netherlands, the UK, France and Wales. Ah, but iz Stashia mon!

But then the culture falls away to the frank ills of this land. The charts stack up with the same chief complaints I hear in the U.S.: Diabetes, hypertension, obesity, poor nutrition, sexually transmitted diseases, teen pregnancy, cardiovascular disease, breast cancer, stroke, COPD, asthma, emphysema, flu, cataracts, glaucoma, melanoma and other cancers. Illness is a non-judgmental taker of life and health, without prejudice. Disease respects no boundaries or artificial segregation. It is truly equal opportunity. The subjective descriptions by the patient just sound a little different.

Cleared, the Sweetest Word

2009-12-05T20:31:00.001-04:00

It's been a hectic last few weeks getting ready to complete basic sciences and move onward to the next phase of training. With all the gloom and doom discussions, and continuous drone about school, I'm ready to move onward, and not a moment too soon. Lots of discussion about exams and such. It's such an inane conversation, truly an arbitrary system. Amazing how dogmatic people can get about this stuff. It's so contrived.

On that note, If large number of students are failing exams, that's not education...it's ego; teacher ego. Either the exam is too hard, or is poorly written. It is about ego creating an us vs. them mentality, adversarial instead of cooperative and mentoring. It is the creation of the antithesis to team work in healthcare. Students are not dumb, but teachers can be so vain and full of their position power that they succeed in seeing students as dumb, and working diligently to prove the point on exams...their only weapon in the great fight. Worse than having this environment is having it be supported by leadership. The greatest disappointment in school is when students recognize problems, and leadership is unable, or unwilling to move beyond "I know better" into "how can we make it better". There are no easy answers, but there are easy efforts. And in many cases, the effort and the process is more important than the reality.

Back on track...out of here. One of the last events of the process is getting away from the island, cleared of all "crimes and misdemeanors", bills, debts, cusses and discusses. It's basically a signature and pretty stamp scavenger hunt concocted by who knows who. But in a little less than two days I had my done and I was "cleared"...Cleared to leave without risk of being detained in some manner. What a sweet, sweet word.

So I've officially (or mostly) survived this part of my education and learning (very different and sometimes mutually exclusive terms). I've navigated the right to move forward and onward to the next phase and for that I am grateful. As wonderful as parts of this experience has been, I'm very excited about getting off the rock and integrating back into some sense of civilization, sanity and clarity. Patient care soon, soon.

Well Packaged Fear

2009-11-22T11:39:00.001-04:00

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

2009-11-21T13:09:00.000-04:00

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

2009-11-19T13:25:00.000-04:00

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

2009-11-18T16:19:00.001-04:00

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

2009-11-09T18:05:00.001-04:00

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

2009-11-02T19:29:00.001-04:00

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.

Learning...Next!

2009-10-04T20:39:00.001-04:00

I've arrived at a threshold in my learning process. I can tell that it's time to leave this environment and move on to the next. What was a portal is now a steep spiral staircase with obstacles and challenges, many unnecessary. I've never felt more like a child; Completely counter to what I know to be good educational and administrative processes, filled with arbitrary rules, emotional directives and regulations, based on outmoded ways of thinking, immaturity and inexperience. It's far from the "adult education" that Malcolm Knowles speaks of in "Modern Practice of Adult Education: "At its best, an adult learning experience should be a process of self-directed inquiry with the resources of the teacher, fellow students, and the course itself being available to the learners but not imposed on them." It seems like an imposition now. I think they would be shocked to know that our potential is far greater then the expectations they impose upon us.

But as long as that isn't a train coming toward me, I can see the light at the end of the tunnel. It's coming to the end of this part of the process of becoming a doc. I've always thought that basic sciences is more of a fraternal hazing than anything, but I've come to appreciate the baseline of knowledge that it is, and the reasons for that foundation in the future. The hurdle is not way out there anymore..it's right around the corner. I just need to navigate this last stage of basic sciences and the imposition that it is.

I've learned so much. I've eaten so many pancakes...many overdone, some underdone, some not even looking like pancakes. Now it is time to spit them out and finally be done with this phase. I know the learning isn't over, but I'm hopeful that life beyond this stage is a more an adult learning experience filled with self direction, mentors that lead and direct, and learning that is for the sheer joy of it, rather than the huge imposition that it has become. I have great faith since I've had such experiences...and I can't wait.

Remiss

2009-09-28T08:06:00.001-04:00

I've been really remiss lately, getting embroiled in life around me. I've recently become focused again, "woke up" by reality of why I'm here. It's not too late, and the timing couldn't be better. Hopefully I'll peak in time for the national boards and the most important test I'll likely take in my life...thus far. Truth is, school has been really interesting and although voluminous, fascinating too. Example, a recent discussion on "angry patients"...

I was having this conversation the other day, so this is for that person, but worthwhile for anyone about to deal with patients.

I've had my share of really angry patients over the years...

* Keep your perspective straight. The anger usually isn't about you — even if the patient believes it is.

* Assess your safety. Do you need a witness? Should you leave the door open? Is this a matter best handled by security or the police?

* If at all possible, sit. Sitting tells the patient you have all the time in the world to solve this problem (although we all know you do not).

* Acknowledge the anger. "I feel like you are angry," is an honest way to start the conversation. Alternatively, "I feel our communication has broken down" can help the patient feel heard and steer the conversation toward resolution, and not just go-nowhere venting.

* Get to the real source of concern. Did the nurse have to stick the patient three times for venous access? Is he afraid he will die? Probe gently but persistently to get to the core issue.

* Then, stay silent and listen. The complaint may be 100 percent valid, completely insane, or — more likely — somewhere in between. But you won't know unless you let the patient talk.

* Ask what he would like for you to do; then negotiate. If he demands high-dose morphine PCA, offer a p.r.n. narcotic or NSAID. If he demands instant test results, offer to call and find out when the final report may be available. Don't do anything medically unreasonable or inappropriate. You are, after all, the doctor.

* Offer an alternative outlet. Depending on the issue, you may not be the appropriate person to resolve your patient's anger. The office manager can often help the patient feel his concerns are being addressed.

* Once again, remember that the anger isn't about you…most of the time anyway.

Some good applications in life too.

I'm BAAAAACCCKKKK!

2009-09-08T19:05:00.001-04:00

Break was way to short. It always is. But I think it was the best that could be expected given the time frame. Great time with family, friends, food and foolery. Mentally rejuvenated and 10 pounds heavier. Ready to tackle even the most challenging....WHAT? A test!? The first day of class, covering everything we have ever done since we started learning? Tell me you are kidding. Tell me where the ibuprofen is!

The new term brings new students, new hopes, new fears, new schedules, new rules, new faculty, new leadership, new money...you can just feel the "newness" ooze from every wallboard pore. It's the same old island; Nothing ever changes for the most part. But the attitude and environment on campus is palpably different. We just don't know what to expect, but are hopeful none the less. I am back. And dare I say, we are back.

I hope I passed the test today. It's going to be a long haul to that infamous Step 1. I can feel it getting closer. I can see the light...but then again, it could be that train coming at me I keep dreaming about.

Breaks

2009-08-29T16:06:00.000-04:00

Break...between terms. A great time to take inventory and figure out how to regroup for the next assault. And the next one will be one for sure. The pinnacle of processing thru the first two years of medical school is the "first" Step exam (part 1)...an assessment of knowledge since starting medical school. It is daunting at best, for even the smartest 20 something. For me, it seems like a beast. But I am blessed with some insight, motivation, and at least a sense of what I need to do to get ready for it. I'm sure I'll be as ready as I can be after the next few months, but I have to stay focused on the goal and the path to success that lies in service to others without expectation of reward.

The other inventory taken during breaks is that of the "other" life; often the one we leave behind when engaged in graduate school. That other life seems more uncomfortable and I feel as inept in it as ever. For nerds like me there is comfort in the one on one study that is medical school. With only me against the process and the knowledge. It is what it is, and so be it is what it is. My worry about it won't change it, or make it feel any more comfortable. Why is it that those so close have the propensity to do the most harm and show the least respect and most disregard? I should cherish and even revere their "honestly", but I don't.

I go back to school more hopeful than ever about the learning, the environment, the stability of the institution, the faculty, and the organization as a whole. The rest, as it has been so eloquently stated, is up to me and I accept that challenge. It's far easier than real life in that regard, and there are no photo reminders of more brutal times. Bearing it alone is so better. A shame I wasn't born in the Aussie "Outback". I believe it's time for a walkabout.

"Without hope of reward, provide help to others. Bear suffering alone, And share your pleasures with beggars." - Nagarjuna, "Precious Garland"

It is finished, almost

2009-08-13T23:19:00.001-04:00

Summer term is OVER! At least the lecture, classroom part. Final exam are next week and they can't come too soon. I'm really already ready for them since I come in with pretty good grades and have been keeping up, but wait I will. And then break, and home. Can't wait. YAY!

40 Years

2009-08-13T22:22:00.001-04:00

"And it's one, two, three, what are we fighting for? Don't ask me I don't give a damn..."

In the hills of New York state, 40 years ago, there was a failed concert. There were too many people, no organization, too few services and some of the worst rainstorms of the season. But it was an event that probably changed many people. Today is the anniversary of that concert.

I'm pretty sure at the age of 12 that my parents wouldn't have let me go to Woodstock, but it influenced my choices in music for the rest of my life. I still have some of the greats on my IPod: Santana, Jimi Hendrix, Ten Years After, Sly and the Family Stone, John Sebastian, Jefferson Airplane, Paul Butterfield, Arlo Guthrie, Crosby Stills Nash and Young, Richie Havens, Country Joe and the Fish, Joan Baez, The Who, Joe Cocker, Sha Na Na (yes, "Bowser"), and Canned Heat. The first real album I heard and owned in college was Jefferson Starship. I still get silent listening to a full rendition of the Star Spangled Banner by Jimi. Am I still listening to Santana's music after 40 years? Amazing! And when I met Stephen Stills in Hawaii I was speechless.

But the real effect was the thread of spirit and thought it laid down in future friends, camp counselors and bunk mates, relatives and in my heart, and the sense of rebellion it kindled in my psyche. I'm not sure that is all a good thing, but it's there none the less and I'm still marching to a different drummer after all these years. Happy 40th Anniversary!

"And I get by, with a little help from my friends..."

Meteors

2009-08-11T19:28:00.001-04:00

Looking NE just right of St. Maarten around midnight thru the early morning we should have a nice view of the Perseid (the constellation) meteor shower. They predict several 100 per hour and I'm sure I'll be able to find a lonely location far from city lights. Oh wait, we have no cities! COOL!

Finals and Storms

2009-08-10T19:09:00.000-04:00

I'm getting into that mental frenzy called finals prep, but I don't feel to panicked at this point. I guess I'm either delusional that I know this stuff, or I'm just getting used to the routine. This is, after all, the 16th barrage of block exams. Maybe I am just getting used to it. I still have about a week to study. Plenty of time by standards, if I've been keeping up, and I have....eating those pancakes everyday. can't wait for break though.

The only imponderable in my otherwise drab island existence of study and island life is the impending storm season and one particularly interesting one just coming off the African coast to our east. It's got no name, but it's heading our way. This is the predicted Aug 16 position based on my trusty sailing wind predictor.

At that rate, and if it continues its course and path of development, it will strike the island when I'm safely in Florida. But that could be good or bad. I'm going to have to watch this one. I don't like the idea of a "big one" hitting when I'm not here, but nothing I can do about that now. Waiting, watching, studying....

Leash Laws

2009-08-09T19:34:00.000-04:00

I think you can judge the level of society sophistication and progression by it's leash laws. I am officially in a 4th world country. I got attacked on the beach by a vicious dog today. No worries...no blood. Fortunately as I emerged from the water, I had my mask and snorkel in hand and as the beast leaped for my calf I hit him with the mask. He was pissed, but I wasn't hurt. Statia is no place to get bit. I'd probably have to be airlifted to a 3rd world country for treatment and that would suck just prior to finals.

What is it about places like this and their attitudes toward dogs? Dogs are mistreated, chained to car bumpers, running wild killing sheep and attacking humans...and there doesn't seem to be a care about it. A place can truly be judged by how it treats it's animals.

The End of the Season

2009-08-03T09:30:00.000-04:00

The end of summer, and my time here, is almost over. Summerfest ends today. The parades this past weekend heralded the end of the Carnivale season and the end of summer. Only a few weeks more til finals this term and I can already feel "break" ahead. Time to really hit the books hard for cumulative final exams.

It is also nearly the end of my "season" here. As I left immigration with my new annual "license" to be here, I realized I've been here over a year and that my time is coming to an end. The tell tale sign? My old immigration permit was punched with three huge "invalidation" holes punctuate the end of one year. National U.S. boards will be upon me soon enough and clinical rotations will begin the trek toward M.D. hood.

It was a busy weekend with lots of end of summer events, some amazing diving and lots of thoughts about life beyond Caribe medical school. It's been an amazing experience. I'll miss it.

There was a series of amazing "fly overs" this past weekend of both the shuttle (before in landed) and the Space Station. The night is so dark and filled with stars that the view was amazing. Note to self: Walk up slowly on free ranging donkey encountered on night time walks to view the Space Station flying by. They spook easily, protect their young, and don't like humans much.

Quiet Weekend

2009-08-02T18:08:00.000-04:00

Our perceptions about the world around us, and how we interact with the world, are filtered through the perspective of who we really are and what we thrive on. As I watch the sunset, sitting on my Caribe island, studying the depths of human physical illness, I've discovered (again) a tremendous pleasure that I can only enjoy when I am alone, therefore the desire to be with people or to run after things or position or title has vanished away by itself again, as I have been here.

More importantly I prefer it to anything else. It will be a challenge to reintegrate into the real world, and my recent brushes with the real world hasn't been too pleasant. Question: How do I combine my love for the healing arts, and contributing to the elimination of human suffering and creating more health while being true being alone and not running after things or positions? Is there such a position in medicine?

I remain open to the possibilities.

40 something

2009-07-10T16:58:00.001-04:00

It seems that right after any major break, there is a sigh of collective relief and then a counting down. That hasn't changed the entire time I've been here and the countdown has begun for the term. T minus 40 something days. I don't keep up to the day, but there are people here who know it to the minute. I have to admit I'm ready to be done to and with next exams 2 weeks away, it's only a matter of a few quick weeks before term break. I'm thrilled.

This block is a voluminous one filled with details and content, much either new to me or buried so far down in the recesses that retrieval is impossible. As always, I'll come up with what I need to succeed in two weeks, but this part of the process is so nerve wracking. Oh the pressures we put on ourselves.

But I have to admit that this stuff is great. I love the study, and the path has been particularly engaging with an interested, vibrant, totally engaging professor. Although I can't say that he has much competition...the others suck. I hope I didn't suck as bad when I was teaching. It's all I can do to stay awake and many, many of my colleagues have chosen to just stay home and study. One day it was me and 5 others in class. Frankly I don't blame them for staying home. Think the prof would get the message? Nah! There is only one thing worse than being an uneventful, uninspiring, boring professor...not knowing you are. It's sad. But our new dean says if they keep it up, they are out of here. They should be. It's amazing how much medicine you can teach yourself, and lecture is such a terrible way to teach and learn anyway. I think I see the med school of the future :)

So we are on the down hill to the end of term, the rains of summer intermittently green up the lands and fill the cisterns, the heat is radiant off the poorly constructed cement streets. Thank good ness for the Caribe, the water and the small town diversions to keep me sane in the meantime. TGIFriday and the weekend promises some respite, catch up, and focus. Nothing much changes on an island, except maybe perspective.

It's Coming - Hide the Kids

2009-07-09T17:25:00.000-04:00

Hey it's fun but it's a distraction none the less...it's Summerfest time! Impromptu parades that interrupt the neighborhood, lots of drinking and way too much gyrating...but you can't stop it. There are events for the next several weeks, filled with music, beer, parades, more beer, madness, mayhem, animal sacrifice...maybe not the animal sacrifice part. And don't you know that it coincides with exams. How much fun can a medical student have?

The more interesting thing about Summerfest is the costumes. Seems that some work on these objects of fashion for many months preceding the events. No wonder! Probably takes several trips to St. Maarten, and Duggins Market (upstairs of course) to get everything you need to create one. They are masterpieces of how to reveal as much skin as possible without being naked. They seem to fuel the sexual energy that pervades the event. And age has no limit....even the young are all decked out. And they wonder why the teenage pregnancy rate is soaring.

Ah, Summerfest...just another island excuse to not have to go to work, drink beer from green bottles and wander around half naked.

Ran Out

2009-07-08T17:06:00.000-04:00

Only on Statia....I wen to the immigration office for this country island to renew my resident card (so I can stay on the island and finish my studies).

Guess what? They are out of ID cards and don't know when they'll be getting any in.

As I was leaving the clerk mentioned that maybe they should just issue a vehicle license plate to me that I could wear around my neck.

I don't think she was kidding. Whether I can stay or not, is still being discussed.

First Case of Swine Flu

2009-07-06T16:43:00.000-04:00

When you are in a city of millions, a case of H1N1 is news. When you are on an island of 2500, it's fear inducing. So was the first case of H1N1 on the island, recently confirmed by the health department in the Netherlands. And while he has recovered, he is now teaching in the school, and I shook hands with him yesterday...before I knew he was previously infected. I can only hope that the salty waters of the Caribe are hostile to H1N1. I went swimming shortly after meeting him. I patiently await signs of the flu.