Thursday, July 31, 2008

Book Support Bizarreness

"I have never tried to convert medical students into textbooks. If we did, we would clearly be forced to lower tuition since the best composite of medical knowledge can be purchased for about $150." (Steadism #166, p.55)

I cannot believe what I just heard. The instructor, in a desperate attempt to justify this lousy course, used the textbook choice to justify it. The author himself says the text is geared for "resident physicians studying for post graduate boards." We are first year medical students.

That is, however, completely beside the point. This is the most ill conceived, poorly designed, busy work infested courses I have ever taken in my educational career. But arguing about it is absolutely futile. God, give me the strength to just get through this...please!

New Storm

Tropical depression could form near Cape Verde Islands

A low-pressure system in the Atlantic Ocean approaching the Cape Verde Islands could become a tropical depression before moving over cooler waters on Thursday, the US National Hurricane Center said Wednesday afternoon.

NOAA graphic - disturbed weather near to the Cape Verde Islands just off the coast of Africa

The system was moving to the northwest at 10 to 15 MPH and could cause heavy rain and gusty winds over the Cape Verde Islands later Wednesday and Thursday, the NHC said in its 2 p.m. EDT report. If the system strengthens into a tropical storm, with winds of 39 to 73 mph, the NHC will name it Edouard. The weather models showed the system would reach the middle of the Atlantic Ocean in about five days.

Hang Loose

There are qualities about island cultures that would best learned by medical students. We are thrust into a process of mind altering dimensions and told to relax. We are threatened with tests and future boards and told to chill out. We are constantly drilled on the need to learn every little detail or we may "kill the patient" but told that medical school is just medical school. The mixed messages aside, the environment can be stressful and some perspective is almost mandatory.

Such was a note I got today from a friend, physician, former physician assistant, and all around great guy. He said..."Guess what? It doesn't get a whole lot easier but don't get discouraged. Don't sweat the small stuff. It's all going to be worth it in the end. Keep pluggin' and remember why you are there.  Be cool."

When embroiled in the "stew", under the fire of learning the details, it is sometimes hard to see the "why" I am here. I know it's all worth it in the end. I've seen the end. I won't get discouraged. It'll only get more interesting and clinical. But, I really need a break.


Sunrise & Sunset

Each passing day, allows renewal and reflection. We live in a beautiful world, full of blessings, if we are willing to look for them, and see them for what they are. When we are consumed with finding the negative, what's wrong, faults of others...we'll find them. When looking for beauty, blessing, positives...we can find that too. A friend and colleague reminded me of that when she sent this photo, from her boat, of sunset in the Florida Keys.


Just finished 45 slides of head and neck content. Who knew there we so many holes, grooves, fosses, curves and angles in the base of the skull (I actually did, but forgot most of them). A neurosurgeon handed me a drill one day and let me start the craniotomy going after a subdural hematoma (likely middle meningeal artery disruption from a fall). I wish I remembered more about the anatomy of the skull, and less about the excitement of being able to participate in neurosurgery. Got some time today between classes to study the last 3 lectures. Noon conference is on evaluation of the cranial nerves. Looking forward to that.

Wednesday, July 30, 2008

Then Don't Ask!

I learned a lesson many years ago. As an instructor, if you really don't want to hear what is on the mind of students, don't ask! Once you ask, you invite commentary...and damn if that isn't exactly what they got today. The anger in this class is so palpable related to public health, with a strict division between those that performed well, and the many more that didn't on the last exam. And the latter let it rip today!

It is remarkable how everyone in the world knows what's on the boards, and uses that as justification for everything. The bottom line is that nobody has a clue what will be on their boards. I believe that I can rest comfortably knowing that I won't have to pick out the Pearson Correlation Coefficient formula from a list of formulas.

And using a book designed for public health resident MD's to study for their specialty boards for a first term public health course is total INSANITY. So don't justify the course by the book, or the bad questions used from the question bank that came with the book. What a crock!

P.S. I didn't open my mouth today. Everyone else did it for me.  I'm not justified by their comments. I am very sad that this is one of the worst classes I have ever taken post post high school...I actually like public health, and population healthcare. Worse, I am dismayed that many of my colleagues will view public health thru the discolored, distorted lens of this class.  It soon will be over, and not a moment too soon.

Tuesday, July 29, 2008

Ready, Set, Go

We are endowed by our creator with certain in PICT0025alienable rights. Among there are life, liberty and the pursuit of being able to wear anything we want during Summerfest Carnivale. And so it was. Everyone brought out their most visual frockages for the last parade, marking the near end of this festival season on Statia. It was hot. It was loud. The beat was strictly for hip movement and "jumping". And now, it is least for another year. I found it difficult to study in the silence, without the music in the background. One of the utility truck's carrying more speakers than band set up right outside my apartment. But study I must.

image End of Summerfest brings the start of the last push for finals. Looks like histology is actually going to finish new content early and then actually do a final exam test prep for the last week or so. That is a great relief. Anatomy will consume most of my time between now and then with all of the pelvis, genitalia (male and female), and head and neck with all the intricacies. I am reminded of the 8 hour "face-ectomies" I first assisted in back in Daytona Beach, with all the nervous structures to preserve while dissecting out massive tumors in tobacco smokers and chewers. "Pinch and cut, pinch and cut"...long hours working in a 6 inch and 6 inch space. Dr. S was a great surgeon though. You'd think I'd remember all that anatomy then.

Yesterday I plotted my strategy and tried to find a psychological worm-hole to the end. Day by'll be over very soon. Oh, did I fail to mention public health? Today was the review for the last exam. My only saving grace is that they noted that the performance on this exam was the worst they had ever seen on any previous exam in 6 years. I'm comforted. I've got my study-game-face on. Finals here we come!!


Monday, July 28, 2008

Last Block

The 5th term party was last night as well as a potluck dinner with a cross section of the classes. It was nice to see everyone in those non-school venues and relaxing together. Besides, the potluck food was great (I brought Macaroni salad). The 5th term party was a "send off" for those about to leave the island.  For the next several months those folks will study and take the USMLE part 1 and then begin rotations in the U.S. and the U.K. They all look relieved, happy and very excited about their futures. They should be.

This last block of testing took the wind out a bit. This was recoup weekend with planning for how to get through the last part of the term. Feeling a bit more energized today as I begin to hit the new anatomy, contemplate the other. It is time for that final push toward finals and that is going to require attention to deliberate study on my part. I'm ready.

"Do not dwell in the past; do not dream of the future, concentrate the mind on the present moment." --

Saturday, July 26, 2008

Dive Wonderful


To celebrate the end of the exam period and the five year anniversary of it's sinking, a GREAT dive today. It? The Charlie Brown...former ocean going cable laying ship, and one of the ten largest wrecks in the Caribbean. It is almost 350 ft long, and sits at about 100 feet underwater. It was a nice break from school reality to dive there this morning. Just 4 of us (one dive master) and all experienced divers (I think I was the least experienced)...great time.


It is truly an amazing experience to dive such a huge wreck.  After tying up to the buoy at the aft of the wreck, we suited up.  We then backward entered into the water from our Zodiac and moved quickly to deflate our vests and descend. The current was amazingly strong today and pulled hard to get us to move away from the buoy marking the wreck. The quicker you go down, the better...I did. I've learned that if you don't, the struggle to swim back "up current" is hard work. What I didn't know is that in our position, the current was the strongest as it moves toward, up and over the wreck...I vaguely remember the principle of flow over a surface.

We swam over to the buoy chain line, and began the descent into the deep, deep blue. Then, there it was...the propeller at the end of the buoy chain.Prop of Charlie Brown

Imagine the view from the back....a full football field in front of you, the massive ship laying on it's right side on the sandy bottom. IMPRESSIVE. MASSIVE. And it was so quiet.  I could only hear my breathing (thank goodness) and the sounds of the occasional beep of my dive computer. I strained to The Highwayhear other sounds like a far off humpback (wrong season) or creaks of the ship. I don't ever remember a silence like this, but my mind was pretty fixated on the ship.  Among the highlights: penetration of the ship in the large hallway called "The Highway", a face to face with a 5 ft. barracuda (mostly teeth), schools of Horse-Eyed Jacks, nudibranchs all  over the surface and a drive-by with a turtle who came up to me to check me out.  I never tire of the beauty of this part of the earth below the surface. I'm thrilled that my biology background has come to some usefulness.

To me the Charlie Brown is Statia wreck diving at it's best. She is a wonderful addition to the artificial reef program here, as well as to my dive log.  I am so blessed to have the opportunity to dive here and truly enjoy what it has to offer. Beyond the recreation of it, a chance to relax after a hard exam period, and relish in the beauty that is life of the seas.


300, Failures in Stats


I recently had a very short, yet interesting, and revealing discussion with the instructor of our stats class. Apologetic even for the exam and the annihilation of many students, but quick to point out that it "served those right" that never come to class (and I would agree). Unfortunately many did poorly that are there everyday, get extra help, attend the review and tutor sessions and work their assess off. What about them?

To have anyone with under 30 out of 100 would be tragic let alone statistically important. But to have as many as we did on this exam, it is truly problematic. But like the foe of Sparta, if you perceive yourself as a great, kind teacher, and God of knowledge, then there is only carnage and repeat of the gesture for future classes. There will be no learning here without intervention. I hope quickly for the sake of future classes, and our futures. And by the way, it shouldn't be those that scored well that are consulted about how the experience went. Administration would be best suited to ask all those that scored the average or worse, below the parametric low mean, in the left handed tail.  For in their descriptions will be the truth of what happened here (or what didn't happen), and what apparently has happened before in this class at the "Hot Gates" of Statia.  We brought many warriors. They only brought bad questions and a truly skewed perspective on what it is we are doing here.killerexams

Summer-Fest Carnival

Almost on cue after exams...It's a holiday on Statia...Summer-Fest.  I celebrated donation of my body parts to the exam process by going to the Summer-Fest parade today.  It started at the end of the airport runway, and wound it's way around the island "villages" and neighborhoods.  With 5 truck-pulled floats, 2 police trucks, 5 groups or was considered a successfully, big turnout for Statia.  The Adventist weren't there's Sabbath today. Did I mention one of the biggest populations here is 7th Day Adventists?

Carnival here is part religious, part cultural, part debauchery...a mix of fun, party, theater, folklore and a good excuse to close all the stores and leave work.  PICT0073 Hard to tell the origins but best I can tell it is a manifestation of the celebration before Lent, from the Catholic, 'carnevale'-which means "to put away meat." Somewhere along the way during the rape, pillage and conquest of the islands, Catholic Europeans involved in the slave trade brought carnevale here. Here it has almost become a celebration of emancipation and is celebrated with festivals year round.

PICT0080 Carnival, as it is called now, or Summer-Fest here on Statia, is celebrated on all the islands. Substance beyond the senses is not present, but not meant to be anything more than African rhythms, dancing, music, food, drinking, bands and parades.  Important to the Caribbean festival arts are the ancient African traditions of parading and moving in circles through villages in costumes and masks. The parade today was just that. As it wound through the streets of the island, it is meant to bring good fortune, to heal problems and chill out angry spirits.

There is an amazing amount of creativity that goes into PICT0070the costumes and band floats. I've seen people working on them for weeks before today.  The "groups" walking behind a band float wear the same costumes. The band floats are mostly speakers and drown each other out as the parade passes by. Clearly the one with the most "amps" wins.

PICT0077 If you try to search for deeper meaning, you waste your time. That is not what Summer-Fest is about. It's about the joy of living.  Mostly what I saw was friendly, care-free street partying, where people smiled, joked and forgot the ills of living on Statia. In any event, it was a fun time away from the books for an hour or two and a wonderful celebration of the end of exams. Only 27 days left in the term.

Thursday, July 24, 2008

What is it REALLY like

A former student of mine recently contacted me when she heard that I had gone back to medical school. I was thrilled to hear about her success in surgery and life with kids and husband (sounds remotely like a life I once knew). She asked me a simple question..."what is it really like?" She's been actually thinking about medical school for some time. I did my best to fill her in on the nuances of the learning, the process, the goals, my experience in school, the battle of memory and my choice. I think I was pretty honest about it, open about the pros and cons, balanced about the reality of this.

But then I got to think about what it's really like. It is, as I've heard before, like eating an's a lot of material to digest, in a short amount of time, and after awhile, you'd like to have another dish or something sweet to eat. And while the class is supportive and we are all in it together, in the end this is a very individual experience predicated on personal tenacity, goal setting and resolve. This is not a group experience except as we attack the elephant to eat. And trust me, if anyone of us should go down, there would be about 1 second of grief and I would become that other dish or "something sweet" to eat. I have no delusions, at least about that.



I'm pretty sure Edvard Munch was thinking about public health statistics at Statia when he painted....


I believe those are the instructors walking behind on the bridge...actually they are running, chasing...

Rumination: n.

1. The act of pondering; meditation.

2. The act or process of chewing cud.

Both good qualities I think.

Purposeful Hurdles

After the tragedy that was the last block of medical stats, I searched for the "greater picture" so as not to get swallowed up by the "Dune"like sandstorm that it felt like.  I drifted into the thought of purpose and the hurdles that are important and those that are not so important. Important 1) the practice of ethical, safe, economical medicine, and 2) Pass USMLE Step 1, 2 (after clinicals) and 3 (after residency).

It's no secret that this exercise in study and intellectual basting has a purpose...USMLE Step 1. Sometime in about 20 months, it'll be our turn. The last term folks here are studying diligently for their go sometime this fall and I've learned some things over the past few days.

Passing score is a tightly held secret by the National Board of Medical Examiners but hovers around 185 each year.   The average score, estimated from the published distribution is about 214.  While not the only factor used in evaluation and purely speculation on my part, top internal medicine programs are looking for step 1 scores of 230 or better.  That would be a great goal.  215-230 would be a fine finish given the advanced plaque formation in my Circle of Willis.


The consensus seems to be, start studying now. I thought that was what I was doing. But, it's going to be more...questions everyday. I've got many resources and many have been recommended. The key is to do a little everyday and then after 20 months, I'll be ready for this first career hurdle. I appreciate the insight of the "last termers" here and their perspective on what it will take over the next two years. In all, I've got to keep the greater picture in mind else I will truly go mad. Or perhaps I'm already mad, and that is the reason I'm here?

Wednesday, July 23, 2008

Stats and Thou

I take full responsibility for the train wreck that just happened. I am fully to blame.  Over 20 hours of study (obviously the wrong things)...I'm really sorry I wasn't more prepared for the exam today, but I don't know what I could have done different. 

I think I just passed it. What a miserable feeling.  Knowing what I know about USMLE and the use of statistics in medical practice, this class misses the mark so far afield that I probably psyched myself out. It was clearly the biggest challenge I've had since arriving I hope to never repeat. I can see clearly that statistical research is not my forte'. Best to know what you can't do, than what you can do at this point, right? This class could be so good if the focus was actually clinical preventive, public health services.

Ok, testing is over for this block. Finals looming in the not to distant future. I'm relieved, but so disgusted at the same time. Like someone said, "it's only medical school."

Just Wondering

Ever notice that "studying" is the contraction of student + dying? I love public health, I love public health, I love public has been said that as you repeat the words, the actions will follow - NOT IN THIS LIFETIME! 4 p.m. cannot happen too fast today...

Tuesday, July 22, 2008

Various and Sundry Poisons

One absolutely wonderful aspect of living in a foreign country with lots of bugs is the availability of pesticides that are banned back home. I bought some stuff the other day that is banned in most developed and developing countries (Statia is in neither category). It not only kills bugs when you take the cap off, but it peels the paint off most surfaces. I can almost feel my laboratory mouse cancer cell titer going up and my bone marrow suppressing itself as I spray. Is this a great country or what?

P.S. Got an A on my histology an hour ago...B on my combined Anatomy lab / lecture and have only Public Hell to go. I celebrated the end of today by taking a dip in the Caribbean. It was delightful.  I am confident that making it past tomorrow gets me over the hump and heading toward the end of the term....29 days to go, but who's counting? I am. Back to study so I can increase my confidence level to over 50%, one standard deviation from the mean, with an alpha=.50. Hopefully my sensitivity for detection of correct answers (positive outcome) will be greater than 80% and my false positive error rate will be low. me from the stats monster!!

Anatomy and Rectums

Well I wasn't surprised by the lecture exam. It was as challenging and pedantic as the lab. In many ways, I am vindicated by the fact that no matter how hard I look at anatomy and study the infinite details, my clinical knowledge just gets in the way of sorting the important from the unimportant. I constantly get in the way of myself in the search for practice-based knowledge.

Example, a question about the average locations of swollen rectal veins...nice to know, but in reality, you examine, locate and treat. If someone presented with complaints of hemorrhoids that didn't fall into the average location descriptions it would be inappropriate to say..." I'm sorry sir, I can't treat you because your problem falls outside of the description for the average location of this malady your are suffering from." Sometimes we are so consumed with the language and definitions in the practice of medicine that we miss the mark...those skills we need to practice. Another example...nice to know that a foreign body will likely fall to the superior segment of the upper lobe of the right lung when a patient aspirates laying down...but in practice, you go find it...WHEREVER it is! I get the "prediction" piece, but the practice of medicine is about taking care of the how things present, not falling into bad habits related to general rules and descriptions.

I am overall pleased with my performance. I'm pretty sure I beat the class average and understand the material pretty well. I get where this is all leading and I'm sure that my core understanding is solid so I can transfer these skills to my history, physical examination and assessment skill set. It would be nice to be able to practice those skills at the same time.  Call me crazy, but laying a stethoscope on a chest when you are learning the locations of cardiac valve auscultation is a reinforcing and positively educational experience. It will only require many to go back and review what we just did when we get to that point in our education. Dr. Stead was right...this process has really degraded over time. Remember, medicine was an apprentice "sport" way back learned by doing as well as reading.  Onward to Histology...

As a parting thought, I wish other students would realize that if they would get out of the way, the process will reveal itself and that fighting it only ruins the process, and makes it bumpy at best. We have at least one person in the class who thinks he knows better than everyone else about everything. The fact that he is a total antisocial idiot and only gets in the way of our learning is my latest mental challenge. Ahhhh nammmmm....I can only hope that he is blessed with rotation attendings that not only aren't tolerant of his behavior, but publicly rebuke it. For if it continues, he will become one of those physicians who disrespects nurses, is in conflict with administrations and colleagues and treats patients as objects of his knowledge and skill. We don't need any more like him in medicine. Where do these people come from, and how do they end up in the healing arts in service to others?

Damn, Lab#3 Exam Done

There are good tests and bad tests, as defined by the testing experts. There are good questions and bad questions as well. When you merge good tests with good questions there is magic, and learning reinforcement. But it seems that all exams fall short in some way, mostly related to their construction of questions in a reactive manner to what has been presented and the dynamics of a given class. Exams should be proactively designed to the learning goals as established with the end in sight. If you want to train good doctors, the goals should address good doctoring skills. Then "test" what you need for students to know about those goals and skills.

I know how difficult it is to design good exams. I've tried and failed many times. I think overall this anatomy lab exam that I just oozed out of was a good one..challenging, educational, insightful. Everyone should not emerge from an exam thinking they did well. I don't think I did, and clearly I wasn't alone. But having said that, some of the questions outright sucked.

The sacral hiatus? C'mon, give me a break. An arrow pointed to a single lymph node on a chest xray instead of the hilum of the lung? You have got to be kidding me. We haven't even had radiology or clinical medicine yet. Laying a deflated, discolored, flat stomach on a table out of a cadaver (one we've never seen)? It looks like mesentary. Orienting a liver upside down for identification of specific left/right, up/down orientations? Nothing we would have to do in clinical practice. The logical question; why? For what purpose do these identifications feed our greater doctoring goals.

I would guess that out of the total about 15% of the questions were not only not emphasized on reviews, in lecture or in the book, but were clearly miniscule elements of knowledge that were way out of bounds of the knowledge necessary for the skills we will need in clinical practice. Not a single question about the lung segments we will soon auscultate.

I haven't a clue what grade I earned.  I studied my butt off for this one.  I hope I got my every loving B, but I do know that while overall a good exam, there were some horrible questions...and I don't think I'm alone in saying that.

P.S. (4 hours later) I love to read what I wrote after I find out my score. I did just fine, and beat the average enough to feel like my study and understanding it solid. But my gut feelings about the exam have not changed just because of my score. The more clinical the better IMHO.

Wednesday, July 16, 2008


"A master can tell you what he expects of you. A teacher, though, awakens your own expectations." -- Patricia Neal

I am continuously amazed at how good teachers inspire. Such is our anatomy instructor. There is little he doesn't  know...from memory. Truly amazing. Answers to questions, regardless of the depth or sophistication, from student are answered with nary a pause. Sometimes, he glances up or down, briefly pauses and then spews volumes of information and clinical relevancy about the topic at hand. Today, he conducted a complete review of the thorax and abdomen in the lab for nearly 2 hours, without break, breath or notes. AMAZING and inspiring. Regularly he awakens my own expectations and raises the bar higher for my own performance. Like the many I've had before him, I hope there are many more like him along the way. He makes me pay attention to the fine points of what is, the foundation of care. Dr. McKelvein, that crusty, chain-smoking, thoracic surgeon who taught me more about the human body in health and disease than most of my professors put together once said...with a complete understanding of normal anatomy and physiology, everything else in medicine is cake. I get that.

P.S. When did plastination (plastisized real bodies, like in the "Bodies" exhibit, become so integral in anatomy lab? I missed something of the technology in these past 25 years.


"The moment one gives close attention to anything, even a blade of grass, it becomes a mysterious, awesome, indescribably magnificent world in itself." — Henry Miller

Tuesday, July 15, 2008

Storm Dissipation

As of today, the new storm appears to be dissipating into the oblivion that is the waxing and waning of stormage. Of course, that could change in an instant, but complacency will likely find it's way back to the student body here in just a bit. For now, doesn't look like much more than a stiff breeze and some rain.

BTW, I went out to Fort DeWindt (Fort of the Wind) yesterday during a break (one of my favorite escapes)...just to reflect and dissipate some inner storm from "life". I stood on the wall surrounding the gun platform facing the Atlantic Ocean (where the Atlantic merges with the Caribbean). I closed my eyes and the 25 mph wind felt like it was going to blow me off. I hung suspended for a moment...almost like I was "taking off"...What a feeling! I think I heard Celine Dione singing something from Titanic in the background.


The Clueless Stage


"You aren't totally sure how you're making so much progress today, but you don't care -- you just want to keep at it!"

I'm not a fanatic, nor do I plan to integrate astrology into my medical practice, but sometimes, the daily sums up what's going on. I am TOTALLY unsure about the progress of the past few days. Funny thing is, almost everyone is feeling it and I'm beginning to believe that it is a part of the process of "conversion" from image discomfort with a mass of information, to moderate comfort. Like the birthing process, there is a sort of migration "down the tube" to the light with repetition, review, lectures, reading etc. Just keeping at it, even in the face of total clueless-ness is key. I don't care about the lack of feeling comfortable with block #3 content, but I do care about the outcome. I pray each day for the eureka experience to come...hopefully just before I walk into the exam.

Monday, July 14, 2008


"Do what you love, love what you do, and deliver more than you promise." – Harvey Mackay

It appears that the rumors are true. Three professors are leaving the university at the end of this term. One has been touted as "outstanding" by many third part sources and he will be missed. We'll have to wait and see.  One thing it certainly true in schools, nothing is more  predictable than change.

I have been most impressed at most of our professors. The really outstanding ones truly seem to love what they do, and are doing what they love. Having taught before I can relate to how they must feel. The most evidence of this is Dr. K...loves what he does, and always delivers more than he promises. I am constantly amazed at his depth of knowledge (or consistency of memory). It is truly a pleasure for him to constantly overdose us with all seems relevant.

We are close to leaving this term. The new anatomy tutors have begun to show up to learn their new job starting in September with the new term #1 students. In about a month, this term will be a memory and we'll move forward to the next challenge, term and professorial line up. I hope they all love what they do.

I Am Pumpkin

A recent reading outside of medicine, stimulated some thinking about the environment in which I find myself.

"There is an old story about a traveler who finds a pumpkin that has just started to develop. To protect the little pumpkin against the elements, he slips it inside of a jug. Then he goes on his way and forgets about it. When harvest time comes, the pumpkin has grown only as large as the jug. The jug that once protected it, eventually limits its growth."

photo of pumpkin fieldThere seems to be commonality among older graduate students in residential graduate programs. We have "stories" as to what brought us to this point in our lives. I notice how nobody questions the 20 somethings what brought them here. It is acceptable, even expected, of them.

I on the other hand found protection and shelter in a life and belief system I had before medical school; One I really believed in.  For a time that life and those beliefs offered comfort, acceptance and protection, but soon lost relevancy and usefulness. That life was my "jug" and stopped growing and started to lament about my condition.

The reality of the pumpkin in the jar is that eventually the pressure from growing against the glass will eventually cause the pumpkin to rot. I was imagetrapped in my jug, my career, my life...and had to break the jug; Or, have someone break it for me; Which is ultimately what happened. I am now out of my jug and growing again.

What I had done, starting with a errant recommendation from a professional career counselor many years ago, was based decisions on limiting beliefs, seeking acceptance and avoiding risk. It was a set up for "jug rot." Now I use my beliefs to propel me daily to avoid rot and hopefully, create a wholly new approach to the practice of medicine.

Now, how do I say that to a 20 something without sounding like an ax murder?

Sunday, July 13, 2008

I'm Not Bored....Just Boring

When I speak to my parents, I feel so boring. I'm a graduate student. My life is basically....sleep



...occasional run, hike, pushup, or dive (and I use that term very, very loosely)


Nothing very really exciting happens or new for that matter, except in my head (a very active place). The intellectual challenge is amazing. I love the medicine and the pontification. I love watching other suffer and struggle with concepts that they have absolutely no basis to learn or understand (just kidding). But I am...


Prognostication at p=.005

I just like to use the terminology I don't understand. That is the beauty of statistics...a language unto it's own, and nobody has a clue what you are talking about. Why is it that so many bogus research papers end up in prestigious journals each year? Excellent use of statistical terminology. Someday I hope to author a quality bogus piece of research detailing the brain suffocating qualities of statistics education. In the meantime, I'll use my software and sea-going police talents to estimate the position of this newest storm as of this coming Saturday. Too fun...SURFS UP DUDE, at p=.05!


Hurricanes and Exams

"Tropical weather system 94L has emerged midway between Africa and the Lesser Antilles. 94L has the potential to develop during its westward track, perhaps affecting weather conditions in our area by next weekend. An update on 94L will be posted here on Tuesday at the latest, assuming minimal development. More rapid development, however, will necessitate an earlier update. Members of the University community are advised to remain alert to updates on 94L."


It's been ominously hot lately. Largely weather like this keeps people inside the school or at home studying. Something to say for adverse living and weather conditions that provide no diversions or relief....You get to study. But that brings storms...and one is coming this way. Friday, 8 AM this new one is slated to be just offshore, as we walk into our anatomy exam (predicted position - photo above). Looks very WET!

Study Week: Once again, for the third time this term, the tension is mounting as tests begin on Friday. We are hopeful in first term to survive anatomy (all of thorax, abdomen, and pelvis) as well as the other courses. The one that seems to have preoccupied my cerebral lobes has been medical statistics (I shutter each time I hear the words). I can only pray one thing...get thru this, and NEVER take a stats class again as long as I live. But then, that could be a very short time as the storm approaches. Just kidding (my mother is wincing now). But the possibility of postponement looms. More study time (or time to get more neurotic about it...depending on your perspective).

Thursday, July 10, 2008

I'm Not That Smart

"I'm not smart enough to know what this man has, but I am smart enough to know when I need help." (Steadism #341, p92)

There is no way in this world that any one person can know everything there is to know, off the top of his/her head, in all situations encountered in the practice of medicine. So why is there this culture of memorization in the face of evidenced-based practice, technology assistance, and a knowledge base that seems to be growing before my very eyes? I am regularly, daily, moment-by-moment amazed at what I don't know, what I have forgotten and what I will likely never know. I've had at least 5 "eureka" experiences today...realizing what I didn't know when I was actually practicing the craft and muttering to myself, "ohhhhh that's why that was [such and such]." I get that we are supposed to have a grasp of the concepts and become facile with and in the terminology, but in the words of one of our 4th term colleagues (getting ready to start rotations), "I barely remember what day it is..."

I think the goal of this process is to find a niche...a practice, with a collection of patients, in an area, that you can remember enough to not hurt someone, and still fool the majority of the lawyers that you remember everything...knowing good and well that you can't remember everything and might hurt someone if you aren't diligent about your practice and refer when you are smart enough to know when you don't know what you don't know. Whew! Then of course, the referral will have to be approved by a reviewer at an insurance company that is trying to pull off the same. I may have to Google that to be sure.


Wednesday, July 9, 2008

Skewed? I Get That!

image There is a simple education principle for instruction of adults in professional education (my education education surfaces frequently being a student). Instructional design must start with the end-point in mind. In other words, design the education for the intent of the education. If you train car mechanics, you have to understand the real world job of the car mechanic and work backwards from those "needs."

Take medical statistics for example. What is the role of a clinician? 1) Understand and apply the "evidence" presented in the medical literature (research primarily) to the practice of medicine, and 2) take care of patients in an efficient, effective, and ethical manner without doing harm. Given that end point, what is the value of statistics?  Instruct us how to read the literature, how to interpret the literature, and how to judge the value of the results of the literature. Instruct clinical application of statistics in normal ranges of lab values, predictive values of differential diagnosis, and the many core patient care and decision making processes. Show me that 95% confidence intervals can be applied to the understanding of lab ranges on my hospital lab printouts. It is very simple. Make it applicable to the function.

That is NOT what I'm hearing. I am getting, for the umpteenth time in my career, another lecture in the mechanics of statistics. WHY!! Tell me how statistics is valued in clinical practice, patient care and the literature. Tell me what I need to know for the boards. But if I need more, I'll hire a statistician or a research firm to do this. Clinicians don't need another stats course. We need to understand how to make good decisions using stats.

Academic freedom: the misguided perception of instructors that they can do whatever they want to do because they, in their infinite wisdom, believe that what they teach is important or they are interested in without due consideration for the end-point of the instruction in which they are involved. Equivalent value = tenure. Range: Useless to more useless.

"Education must satisfy a person's needs and wants, and in a way that it makes the person ready to use it." (Steadism #173, pg 56) I don't need this. I don't want this and I won't be ready to use it without the help of the Department of Research or a journal staff, if I ever write again. Sometimes I wish I didn't know so much. I'm so skewed...probably left.

Next Storm


Looks like another low has rolled off the coast of Africa near the Canary Islands. People that live there have "first warning" for storms it seems, if anyone lives there. This one rolled out more south than Bertha, so we watch these more carefully here and in Florida. This one has lots more rain in it too. Good for the water supply here, but good for mud slides too. Moving land is one of the largest killers in storms around the world, not the wind or the rain. Dry dirt becomes mud and run-off very quickly.

It is hot (so what's new) and sunny today.

Tuesday, July 8, 2008

It's Only Medical School

"It is a neurotic goal to try to learn everything. One must pick and choose." (Steadism #178, pg 57)

Last night we desperately sought to work through and understand the core concepts of medical research, and using evidence based medicine. My perspective of this material given my former life practice and teaching preventive medicine is that the approach is all wrong.  "They know not what they do." To memorize and digest gobs of equations that only statisticsstatisticians, and masters and doctoral public health professionals enjoy is absolutely useless in clinical practice. We need to understand the literature... absolutely, but it is absurd to have to know how to perform the operations of statistics...the math. If you drive a car, you need to understand the laws, be capable at using the car everyday and know when you need to get a consult from a professional mechanic. But do you need to know how the car was assembled or how it was engineered? Absolutely not. This is no less valid in medical statistics. Tell me the "laws". Help me understand how it basically works. Teach me how and why to get a consult from a professional, but this approach is useless with a capitol U. I need to understand the literature and the value of a randomized, double-blinded (or even triple for the purists) controlled study, but do I need to be able to check the math? I don't think so.

So I'm standing at the board trying hard to understand the formula for the area under a normal curve distribution of a sample (I'm sure all imagephysicians will recognize that they need this skill daily in the care of, say, diabetes...NOT). I'm stuck at the point of creating knowledge about the formula for area, and an upper classman walks in to assist us. He gives is a once over, puts his two cents in (very helpful I might add), steps back and say, "listen; don't worry about it, it's only medical school."

There was a certain magic in his words. It IS ONLY medical school and we can't know everything perfectly. This one point, likely never to be seen again after the next test (except maybe one on the USMLE boards) is not that important. Medical school is an exercise of sifting thru the volumes of material and realizing that you can't know it all. You cannot understand it SESOM Lab perfectly...try and move on. He said something too that I've heard before..."What do they call the person who graduates medical school with the lowest test scores and GPA? - Doctor."  Now I have no plans to graduate last in my class...quite the contrary, but without some reminder of this fact and the cognition that it's only medical school, one would become neurotic eating this elephant. Sometimes you just need to know when to spit it out because you are down to bone, or when to add mustard for taste. While I do take this very seriously it is, after all, only medical school.

Monday, July 7, 2008

It Don't Apply Here

I overheard a conversation today by someone who has been here for over a year...and is entering the last term next term. This is the 4th term for this person. I garnered that he has never had any healthcare experience and that life before this was certainly different. He said something very interesting..."what I learned in life, doesn't apply here."


I have sensed an increasing anxiety here over the past few days. I'm not sure what it is, but with 50-60% of the grades still "out there" on tests #3 and #4 coming, I am starting to get a sense of that. But I've had some experience in life and have a mental scaffold to place this information in. I still have to study. I still have to spend time memorizing long lists of facts, but I "get" where it goes in the practice of medicine and surgery.

I realize and more each day, that having the scaffold is an amazing value and likely should be a prerequisite for medical school. Without that framework, one constantly asks themselves what is this about? In general, life does not prepare one for this experience of managing information and life. Is it any real wonder why many physicians become the way they are, because of this experience? I'm very lucky. What I learned in life, including my private life, did prepare me for this and does apply. In fact, it may be the fuel.

Sunday, July 6, 2008

Islam and Acupuncture

It was a really great weekend here at school with two wonderful events. Saturday night was the Muslim Student Association annual introduction to the Islam religion and potluck dinner. The room was packed and I learned a lot about the Islam religion from speakers and presentations made. One of the great values of being in a truly international setting is the exchanges that happen with information, and this was a perfect example of that.  I didn't realize certain things about the origins of Islam, the tenets of the Muslim practice, the writings, Mohammed and many other aspects of imagewhat it is to be Muslim. It was very interesting to hear of the origins of Islam on Statia as well. I think we all walked away with a greater than CNN understanding.  Every time I realize what I don't know, I gain value as a person and future physician. This, to me, is truly what the continuing quest for cultural competency (which never really comes) is all about. I'm more convinced that it is more about cultural appropriateness. It's even more insightful that Jews, Christians and Muslims may be pray to the same "one" God. I didn't know that the Qur'an describes Jesus, Moses and Noah as Muslims..."submitters to God." There is even a book of Mary! There is probably more things alike than different.  There are nearly 1.5 billion Muslims in the world today. Someone said, we are really all blood related from back when....heck, we were all Jewish back when. The buffet pot-luck was amazing...I've not been that full in some time.

The other event was the "Integrative and Complimentary Medicine" Workshop today. For all of the morning and part of the afternoon, we learned about the integration of traditionally non-allopathic therapies with allopathic practice.  I've been interested in these concept for many years, but it was nice to hear some new therapies and different approaches. I've been of imagethe opinion for some time, that if it doesn't hurt, or make you worse, then "why not." Patients are using alternative therapies anyway...we need to gain trust and find out what they are so we can help patients make educated decisions about what they spend their money on. There are herbals out there that interfere with mainstream medications too. I think the key is knowledge and information so you and your patients can make the best choice, without making the situation worse. This workshop helped to do that.

Great weekend! Going running to the beach now. Hope it's not raining.

Bertha Update

Looks like the closest the storm Bertha will be to us on Statia is Tuesday or Wednesday. We are likely going to see some wind, rain and wave action on the north shore.


Saturday, July 5, 2008

Bertha Update


Looks like Bertha is going to strengthen to hurricane force at or about the time it passes us to the north. We may get waves and rain so the forecast says now. We are almost halfway between the storm and Florida. Trending is difficult. Last storm that headed straight across from this approximate location was named Andrew. Not all storms drift north. So now, save any movement straight across or (even more remotely) south, we'll miss a hit.  I'm not a betting person and will continue to stock up on canned goods, water and watch it.

Friday, July 4, 2008

Bertha...still lingering


She's out there, but moving gradually moving north, north west toward open water. It'll pass us before there will be any thought by the mainland U.S....that's how far out east we are. Should be a nice breeze and wave show on the north shore Tuesday or Wednesday. Need to try to get out to the shore to see.

Driver's License Process

We are so, so spoiled with convenience in the states. For a driver's license in Florida: Go online to the State web site for driver's licenses, enter DL number and identifying information, enter payment information, click enter....find DL in mailbox in about a week. Contrast....

Statia: First, go buy official letterhead stationary from the tax office and write a letter to the Lt. Governor of Statia for permission to obtain a driver's license. Wait two weeks for a reply (per instruction), but none comes. Police Car - Statia They don't reply. Permission is forwarded to the Police  Department and sits there until they call you, or you make the calls yourself (after 2 calls to find out who to call). APPROVED for application. Go to tax office window #1 to purchase medical clearance form. Stop by window #2 to purchase tax stamps for census office and police station. Stop by window #3 to purchase driver's test permit for each vehicle you want (motorcycle, car, ATV....each class requires separate one).  Take medical form to hospital for physical exam Hospital Statia Receptionand signing of the medical form (and pray the doctor is in, and that the line isn't too long to see him). Take tax stamps to census office for official verification form to verify temporary resident status. Get two passport photos. Take completed medical form, census verification letter, police "stamps", photos and evidence of testing fees paid to police station for processing. They'll call when the license is ready (I'm doubtful). 11 stops, 3 full weeks, and one of the hottest days of the year today to finalize the documents. Amazing. And I'm still not done or have my license in hand.

Killer Bees on a HOLIDAY?

"We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights that among these are Life, Liberty and the pursuit of Happiness." -- The Declaration of Independence

It is July 4th on Statia. Nothing is closed, we had class and seemingly there is no difference in the day. Walking to class this morning I decided to experiment. Everyone I saw that was local was greeted with "happy holiday", and no explanation. 100% of the subjects (N=11) had a look of "what kinda crazee is he?". Now admittedly this was a random sample without blinding the researcher (can you tell I'm doing medical statistics now?), but it was fun none the less. There was a big student party at the beach this afternoon with volleyball, ETOH and food, but I didn't stay long or drink...too much to study. Happy 4th everyone...lots to be thankful for; Life, liberty and the pursuit of happiness.

So walking around town today to get my paperwork completed for my driver's license (see separate entry), I met another local challenge, Africanized Bees.  I'm sure my mother will be thrilled to read this one. I rounded the corner and saw a local man pacing in a very strange way, just in front of me near the street. I kept walking toward him. He SCREAMED! Kijk uit! Bijen die kill! (Look out! Killer bees!) Damn, I just got over the possibility that I ate a dog. And on a holiday? Give me a BREAK!

Yep...they are here! Those dreaded creatures that we were warned about on the mainland U.S. (but made it to Texas and other states anyway). Fears of people dropping dead like flies were in my head back then. Well the are here in the Caribbean. Oh joy!


image Africanized Honey Bee (Killer Bee) Order: Hymenoptera (Bees and Ants) Family: Apidae (Bees and Allies) Scientific name: Apis mellifera scutellata -

Some brain surgeon introduced these aggressive creatures to Brazil in 1957 to help reinvigorate the Bee farming industry there. They have been hybridizing and spreading from South America northwards, leading to horrendous adverse effects in the islands (we are really close to South America), Mexico, Central America and the U.S. "Killer Bees" are able to eliminate the queen and take over colonies of other bee species. But their claim to fame is that they are amazingly aggressive toward people to protect their territory. They swarm frequently and disperse readily. Their aggression has caused deaths of humans.

Thus the cause for alarm and the funny pacing of the man I met on the street. I stopped in the middle and then started to run. He quickly reminded me ("DON'T RUN!!) that this was exactly the wrong thing to do...I kept running. None followed. Now one more thing to compete with my quest for knowledge...The price we pay for being future healers.

Thursday, July 3, 2008

It's Official

We are officially in "Caribbean Island Hurricane Watch Season" with the development of the first tropical storm. I actually could see this thing form before I heard it on the news, Weather Channel or online with a piece of software I learned about when I was a Marine Patrol officer.  It's really helpful to scan for pressure, rain and wind changes at the surface of the water. Sailors use it regularly to see conditions and look for "good wind."


These systems form near the Cape Verde islands off the African coast as hot, circulating dust storm (more simplistic than reality, but you get the idea).  At the end of the blue arrow is us. The big blue blob to the right with the the storm (blue = rain; red flags = higher than normal winds, circular lines = lower pressure..the hallmark of these storms). This one is tentatively forecasted to go north of us, but we are hopeful for some cistern filling rain out of it. And in the future, this where we'll be looking for such events.  As I've said before about hurricanes, I'm just sensitive. Better go stock up on canned goods and water, just in case.

Meat Missing. Call Owner.

Medical school in the Caribbean is quite different than, let's say, Harvard Square or Miami, or Los Angeles.  Now, I'm pretty sure the content is very similar, but clearly the environment we are in adds something Chained up dogspecial.   Besides being Dutch (which is not a bad thing), it is the West Indies.  This is clearly a different culture when it comes to animals for instance. They treat their dogs like hell, and I suppose are doing things with them that I'd rather not know about. One of the regular issues I have here is lack of  sleep at times due to barking dogs that are chained up in the back of yards near my place. It's pathetic, and frankly just wouldn't be tolerated in the U.S. Oh well, this isn't the U.S. (I hear that a lot). I'd like to go on a rampage one night and release them all.

So I just got back from lunch.  I ordered chicken at one of our local eateries and I'm just not sure that is what it was. The meat is always suspect on an island that has shipping as it's primary source (warms up sitting on the docks), but the added reality of roaming animals on the island, a large feral cat population, and the manner in which dogs are treated...anything that doesn't look exactly as advertised is suspicious. The chicken, if that what it was, was cut up at suspicious angles thus obliterating the natural landmarks that tell the brain via the eyes that you are in fact eating a bird of some kind.

In reality, I've eaten dog and cat before, but I'd prefer not to repeat the experience. It wasn't by choice. The cat came in the form of a "plate lunch" from a family owned Filipino restaurantimage in Hawaii. I wasn't sure at the time I was ingesting feline, but they were "cited" by the health authority sometime later for doing just that. I couldn't believe they weren't closed down. The dog I ate was totally a surprise. I got invited to a hapa (half) Hawaiian family backyard event and ate dog as one of the main courses...I thought it was pork as it was laid out. I was informed later of my mistaken belief. Too was already somewhere in my colon by then. Actually, and I hate to admit, it was pretty good. Rice/vinegar fed...

But again, I'd rather not repeat the experience and hope to hell I didn't just eat somebody's yard chain ornament or one of the other roaming creatures. One of the risks of being here I guess, and people have survived this experience and gone on to successful medical careers. Oh well...Back to studying for my last midterm in about 3 hours. I hope I've digested by then.

Impromptu Reading

Suares Outside Patio I was leaving study hall last night and ran into one of the locals who live in the area. She's a really nice lady who I see all the time, but never have spoken to. She was in my path toward home so it was moderately unavoidable without great effort to round her with obvious change in my tack and course.

I said "good evening" and shrugged a half wave as is almost habit now as this is a smile and wave culture. Everyone honks, smiles and/or waves here when they pass. Not doing so is considered rude and almost viewed as an act of aggression. She acknowledged and asked me something about if I was studying. I realize this was a way to start a conversation as I can't imagine anyone, leaving a medical school study area at 10:30 PM is doing much of anything except study.

The talk was superficial and vague as we gradually got to a path leading to spirituality and, strangely, astrology. As an Adventist (a large population here) and astrologer, she fancied herself as having all her spiritual bases covered. She asked about my sign, never asking about my religion. Thank goodness for that because right now, my religion is school and my bible is Netter's Anatomy. She would have been appalled at who my God is Goats of Statia(Professor K) and where my worship is held (the anatomy lab).  "Capricorn", I exclaimed, as if almost proud of the fact that my sign, the goat, wanders freely on the island. And even though I show no resemblance or  propensity for their deeds I find some satisfaction in knowing that George Burns, James Belushi, Paul Newman, and Alan Alda are all Capricorns.

She noted that Capricorn reflects earthy qualities and that we were mostly cautious, confident, strong willed, reasonable and hard working.  She noted that I often Church stained glass depicting Capricornwas aloof, shrewd, practical, and generally responsible.  She talked about the endurance, whatever it takes attitude, of the goat and the reliability and diligence work although we tend to lack originality and often follow traditional plans even if it doesn't satisfy our inner needs. I've still not said a word at this point.

She then asked for my hand and as she held it in a long hand-shake said that the previous life I had was over and I needed to grasp that. The jobs I've had before were not for me and that I was never really grounded as whatever it was I did before this time. She admonished to continue to tread this path as further grounding would occur and that my satisfactions would in fact come true with discipline, persistence and effort over the long haul. I heard her Adventist kick in when she concluded that living life with compassion, letting go, love for all creatures, especially myself, would be my salvation.

Anatomy didn't seem so important as I walked home. I did realize I have one more and then we are officially half done with this term. Only 50 day or so left.

Wednesday, July 2, 2008

Don't Drink and Drive

Random's been a long day.

"You are crazy to go to medical school," one of my former employers admonished in an email. This physician had the chutzpah to try to talk me out of my choice. As a sign from God,  a good friend of mine who is a Caribbean medical graduate and successful family practitioner in Florida praised the effort...Thanks JL!

But we are crazy. Really. And we substance abuse as well.  The prevalence of mental illness among medical students, including substance abuse, is higher than the general population.  Medical students use alcohol and prescription opiates at a higher rate than similar age-matched cohorts.  As for other forms of mental illness, an 8-year study at the University of Louisville revealed that approximately 20% of their medical students sought psychiatric consultation and treatment, for reasons such as adjustment, mood, anxiety, compulsive and dependent personality disorders, and marital problems.  It is something to consider.

Caribbean beer consumption ranges from 24 to 45 liters per person, and Statia has one of the highest rates of Heineken consumption (and the Trinidad brew "Carib", partially owned by Heineken) in the islands. On most days you can find crates of the stuff stacked up at the port. It is more likely to find beer at the port than fruits or vegetables in fact. The sad fact that the temptation to drink is here and readily accessible. In fact, many local rums are cheaper than the water.

imageI may be crazy, but I am going to have a beer after this term (maybe before it's over). Clearly it is important to not gain any additional pathologies while I am here, but so easy to see how this happens.

Back to anatomy. We are doing the thorax this week.