Clarity, VIA horoscope

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

2010: A Year of Change

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

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

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

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

- Dr. Grey

Moving Onward

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

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

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

Mentors

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

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

Brain Cell Recovery Process in Progress

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

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

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

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

Steps

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

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

Over the peak

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

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

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

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

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

Sweetest word: "Passed"

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

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

Onward to clinical rotations and Step 2!

Relief

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

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

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

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

Amazing Stories - A break from study

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

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

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

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

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

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

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

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

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

Time to Study Again

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

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

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

I'm certainly out of mine.

And there it is

One simple word "fail".

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

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

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

Feels pretty sucky though.

Almost Here

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

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

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

One more week...

Dutch Health Themes of Service

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

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

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

The Spill That Keeps on Giving

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

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

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

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

What a tragedy.

Impulse

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

Getting Closer

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

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

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

The Trek

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

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

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

USMLE Solo

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

Drowning is NOT an option.

The Placebo Effect

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

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

RESCUED!

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

OOH "Out of Here"

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

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

"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

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

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

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

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

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

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

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

For the moment, just keep swimming!

I Want to Teach When I Grow Up

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

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

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

Missing It Already

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

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

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

The End is Nearly Near

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

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

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

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

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

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

Transition

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

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

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

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

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

True Self

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

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

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

Learning...Next!

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

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!

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

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

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

"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

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

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

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

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

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

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

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

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

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.

Harrison's Textbook of Pain and Punishment

The study of human disease is chronicled in great textbooks with names that every student of medicine knows...Sabiston's (Textbook of Surgery), Nelson's (Pediatrics) and Harrison's, Textbook of Medicine. As I study, I pick up these volumes regularly to get the full expose' of the disease rather than a summary analysis or "Diseases Made Ridiculously Simple" version. I regularly pick up Harrison's.

I love the extensive nature of the discussions. This is on the verge of a diagnosable mental disease in itself as most avoid books the size of mountains. But the descriptions are so complete, and so vivid, that it is difficult not to learn something. I only wish I had more time to read it so I can become the doctor I dream I will be.

But Harrison's, and the legacy of it's original editor (Dr. Harrison) is part of my problem with medical school today. I have said this before, but I was very lucky to have had some of the greatest professors of medicine in the world during my education as a physician assistant. I have been schooled by some of the best tactical clinical teachers who learned their craft from the best of the best. Dr. Harrison (of the textbook) taught one of my professors while he was the chair of Cardiology at the University of Alabama. I walked by a building named Harrison. So indirectly, I've learned from Dr.Harrison. Or at least I've had a glimpse of that greatness in the teachers I've had. I am reminded of that as I read the text.

But it is with that history, that I struggle with the sheer madness that is medicine teaching today. As if the art hasn't been practiced and has wonderful theoretical and practical foundations, I feel daily experimented upon...today, once again, I am the victim of disorganized thinking and presentation, random musings of the inappropriate, and painful presentation styles reminiscent of torture.

I will survive this because there is a grand goal, but I am totally understanding of the reasons why many people leave this experience angry, frustrated, bewildered and so willing to forget that this ever happened. I hope that is not the case for me. I do not want to fall into the that hopelessness of a failed romantic, still beaming with a love for the art of teaching in medicine, and the writings of wonderful teachers of teachers. And I can only hope that such wonderful teachers will continue to enter, and force out those that shouldn't be...back to research, or taking care of patients, or whatever it was they did before they took up the hobby of teaching.