Thursday, November 27, 2008

Thanks Giving

Thanks for LIFE. I get to walk out this morning, into the cool air, and see the work of God all around me.  4201 "kids" don't get to do that since they died in Iraq, and Afghanistan.  Holly McGeogh, 19 y/o died whenimage her vehicle was hit by an explosive device in Kirkuk, Iraq (Photo: Holly & Mom).  

Thanks for health; the kind that sometimes is puzzling as people my age get sick or die. I shouldn't complain about the cool water temperature...I get to feel it.

Thanks for family and the love and support I feel from them every day.  I am blessed with both my parents, my brothers and their families and an extended family that surprises me daily with unconditional love. I can never repay the support I have felt from them, even when they didn't feel like it. I can only hope to do the same for them.

Thanks for food.  I never go to bed hungry. I never have to worry about where the next meal will come from or if it's really safe to eat. I have access to clean, drinkable water. The United Nations estimates that 1/2 of the worlds population has no access to clean water within a day's walk.

Thanks for shelter and clothing. I am covered from the elements and then some. Thanks for intelligence and good grades. Thanks for motivation, sanity, and foresight. Thanks for forgiveness.image

When a sense of gratitude enters we allow memory of the thousands of fortunate moments and blessings in our lives.  It's not always easy, particularly with the bad habit tendency to remember the bad things.  Thanks giving should not be a one day event. It is a skill that must be practiced every single day of our lives.  It can be benefit throughout the year and rightfully should be.

I'm sorry that I won't be home for Thanksgiving and spend it those that I love. But I am so thankful no matter where I am or who I'm with.

Wednesday, November 26, 2008

EUREKA Moments!

The rush of studying medicine, or any science that takes more than one course, is those moments when information from one area, time or place "merges" with information from another area, time or place and becomes the consummate OMG moment.

It happens with increasing regularity for me as I merge 25 years of education, knowledge, information and experience together in this doctorate experience. I realize that the more I learn, the more I am able to see. The more I am able to see, the more different patterns of doing something becomes evident.



Monday, November 24, 2008

Tough Times

The reality is that the financial crisis in the U.S. is not isolated. It is a world-wide problem. The effects on small universities and economies like islands is dramatic. While the cost of fuel goes down here too, the cost of everything else is rising. There is almost constant talk from locals about the cost of everything from electricity to food. I don't doubt my rent is going to go up in the near future. Food cost is out of control.

I think schools in general, but particularly small schools, are being hit the hardest. The cost of doing business in utilities, rent, taxes, salaries, benefits and the like is going up, Incomes are going down and there is little if any money available for loans. It's a crunch being felt by small medical schools too. I think this place almost shut down at one point, but we have been assured that we are ok for now. Evidence of cost cutting is everywhere and there is a renewed sense of getting thru the most difficult period that this school has experienced since inception. It's not over though.image

For the moment, it pays to just do the day to day, study diligently, focus on the end goal, and control those things I can...releasing the rest to the Gods (I choose Thor this month). Finals will be here soon, then a break to sort of recover...can't wait. For the moment, my attention is fixed on amino acid metabolism.

Friday, November 21, 2008

Case Based Learning

It's all the rage as an alternative method of teaching, and thus, learning. It has been advertised as the best of the best to have students learn to reason out problems and come up with solutions. But it is not an easy thing for teachers to do. It takes planning, and and understanding of the process. Most professors fail to recognize that and believe that it is something they "just know" because of their PhD, or teaching experience, or whatever.  image

The skill is based on the concept that a discussion has to unfold among students with appropriate use of resources to ask about unknowns. In the proper execution of problem based learning, the professor is NOT one of those resources and is a "guide on the side" mentor of the process, NOT the authority or expert.

Managing Discussion and Debate Effectively
  • The problem solving part (the "answer") must be delay long enough to clarify the facts, frame analysis, evaluate, make judgements, ascertain recommendations. This take TIME...minutes, days, weeks perhaps.
  • It is imperative to shift points of view of the student (thru the problem or the mentor professor) to see things from the perspective of the anatomist, the physiologist, the pathologist etc. At this stage the student evaluates the case from those perspectives and compares the dynamics of the perspectives (after some research)
  • Consideration of benefits/disadvantages of a position; for all sides. Again takes time to acquire the evidence based knowledge.
  • Fully consider time, ethical, moral, other science, system, cost and risk/benefit issues.

After discussion, the process requires time to research the issues, discuss further, come back to class for clarification and guidance, and then further develop to final conclusion. This all takes guidance and TIME.

How Not to Teach with Cases:

  • Have no clear goals other than arriving at an answer from an A thru E list.
  • Don't know what you want to accomplish in the case, what facts, principles, viewpoints the students should cover.
  • Provide little, if any, time to work thru the discussion.
  • Provide no direction, guidance or resources.
  • Do not allow class discussion to follow its own course.
  • Provide instant answers to questions based on your inner depth of knowledge or your PhD dissertation.
  • Don't provide enough class periods to discuss the case, and go off to do the literature searches, and research necessary for the next discussion.
  • Don't mentor or encourage preparation before discussion and out of class prep time.
  • Don't take time to get good at learning how to write, lead and execute a case based class.
  • Just throw a case up on Powerpoint, and say "OK, discuss this among yourselves,"
  • Expect miracles if you do the above...cause if any learning will be.

This process cannot be done in 2 minutes in class. This process should provide the framework for learning, not for creating additional stress...especially right before a huge exam. Why is it that professors believe that their science knowledge provides them the knowledge of teaching, particularly when the opposite is true? The arrogance is so palpable sometimes.  Teaching is actually a great role and responsibility than being a clinician, yet it is taken so lightly by so many.

Teaching is an unnatural process. It's not natural for most.  Teaching requires real attention to learning how to do it, and being open minded enough to learn how to do it...for the good of the student, and optimization of learning. In the end it will only help to create better providers and shift to teaching students how to be life long learners. Some of the nicest people, most accomplished professionals (doctors, scientists, etc) are the WORST teachers. But they never think so :)

Thursday, November 20, 2008

You want to be a what?

Been a great "recovery" week after exams. Now the final push to finals for the term. Lots of stuff for sure on a cumulative (everything since the start of the term). but I've got some time. Catch up on errands for sure this weekend...image

Very encouraging eh?  You have to be 1 chromosome short of a quadrisomy to want to go into a profession that half the people doing it want "out". And with a looming shortage and decent income, you would think that job security would be enticing. But no! The system is so broken, the strains so vast, the paperwork so onerous, the insurance situation so intolerable, that 1/2 of family physicians would LEAVE the practice of medicine if there was a suitable alternative.

For me, and the new generation of docs, it may be more a matter of creating a different practice world, not have expectations of the unpredictable future, and playing an active role in recreating the system that has been so revolting to so many who are doing it.

Monday, November 17, 2008

Reflections on Statia America Day

It really was a hoot being an American on Statia/America Day yesterday. To see 4 flags flying over the fort, including the American flag was exciting. To see the U.S. Coast Guard in Oranjestad Harbor was amazing.

Statia / America Day was celebrated in grand style on Sunday. It is amazing that St. Eustatius was the first "nation" on earth to acknowledge the independence of the United States in 1776 with a cannon "salute" to a passing U.S. warship way back when.

Early Sunday, uniformed troops marched to historical Fort Oranje in Oranjestad for the opening ceremony. Many dignitaries from Statia, other Netherlands Antilles islands, the U.S. and Holland witnessed the festivities.

The highlight of the Sunday program was a recreation of the now famous cannon exchange salute. It started with the first shots by the U.S. Coast Guard cutter. A return volley of shots rang out from the fort a short time later. I've never actually heard the gun fire from a Coast Guard vessel...a first for me.

The day wouldn't be complete without speeches from the various political dignitaries. This is a transition time for Statia as it goes Dutch once again, and the speeches reflected both the excitement and pure fear that is here. This is, for some, a huge step backward for Statia as they progressed closer to independence over the last 200 years. But becoming a "municipality" of the Netherlands makes Statia little more than a "city" of a larger, more dictatorial system called the Netherlands. While it's been "Dutch" for some time, as a protectorate of sorts, Statia was not really subject to the stringent processes and rules, and regs. Now they are.

Some some of the speeches were...defiant. They proclaimed a strength to resist the negative effects of the "motherland" Netherlands. The changes were enumerated by many....constitution, rules implementation, land purchases and transfers, budget reorganizations, etc. Statia wants the economics benefits of the new union, but they are very cautious about the effects of being part of a large, capitalist nation...Holland. One politician from the island proclaimed "Obama" as a battle cry, that anything is possible from a small island nation's people. The meaning was not lost.

This was then the last Statia / America Day where Statia is not fully integrated into Dutch society. Next year will likely be somewhat different and it will be interesting to watch over the next year. I'll be almost done with this phase of my education by then, but I'll leave with a sense of "Statia Pride" even if I don't really "belong" here.

Re-memoversary FL131

Beth; Born: February, 1977; Died: today, 2007

The mark of a life is in the imprint on those left behind. I can only imagine how Jorge feels now after losing his mate and friend, but those you coached, touched, supported, Beth...RIPprompted, propped... hugged, we'll miss you Beth. In our mini breakthroughs and stands for what we believed you revealed parts of ourselves that can never be turned back over to "the nerd" again.

Your life was too short, but your work will live on forever in the lives you touched and the skid marks you left on some hearts.  You revealed that love, contrary to what most people think, is not a commodity to be saved, traded, or bargained for. It is available to all and how we all should "walk".  When looking up "walking in love" in the dictionary, it says, "See Beth". Many of us are where we are partially because of what you did for us.  We "barely knew anything" but you helped to clear up the fog a bit.

And I think I understand what you did now. Sometimes it's not why, but why not. Rest in the great peace and  you created in the short time you were here Beth.  You are missed and will never be forgotten.

Sunday, November 16, 2008

Happy Dutch-American Heritage Day

Statia plays an important role in the history of Dutch-American relations. On November 16th, Dutch-American Heritage Day, 8 million Americans of Dutch descent celebrate their heritage and the contributions they and their ancestors have made to the economic, social, political, and cultural life of the United States.

The Dutch began relations with America in 1609, when Captain Henry Hudson of the Dutch East India Company sailed up the present-day Hudson River looking for a shorter route to Asia. Although Hudson did not find his route, Dutch traders began to exploit the riches of this wild country and in 1614 established Fort Nassau (near Albany), the second European settlement in America. A few years later, the Dutch Governor Peter Minuit bought Manhattan Island for 60 guilders, the famous $24 bargain.

A large portion of the eastern U.S., stretching from New Jersey and Delaware through New York and from Connecticut and Long Island to central eastern Pennsylvania, was settled by the Dutch in the early-1600s. The area was once known as New Netherland, and many places--Schuylkill, Catskill, Brooklyn, Staten Island, Harlem, Wall Street, Coney Island, to name but a few---trace their names from this Dutch period. Over the next two centuries, several waves of Dutch emigrants settled in the United States and, today, most Dutch-Americans are concentrated in ten states: New York, Michigan, California, Florida, Pennsylvania, Iowa, Washington, Texas, Ohio and Illinois.

Linked by traditions of intellectual and democratic freedom, the Netherlands became the first country in the world to recognize formal diplomatic relations with the United States in 1782. These relations have never been interrupted, and thus the Netherlands can boast the world's longest record of continuous friendly relations with the U.S. Benjamin Franklin once wrote: "In love of liberty and in the defense of it, Holland has been our example."

In the American War of Independence, the American revolutionary cause found both sympathy in and support from the Netherlands. In 1779, John Paul Jones wrote "The Dutch people are for us and for the war." In 1782, John Adams, the first U.S. envoy to the Netherlands, secured the first loan for Congress from three Amsterdam banks. Between 1780 and 1794 the Netherlands lent 30 million guilders to the U.S., a small amount by modern standards but at the time it equaled the entire foreign debt of the U.S. After the 1941 attack on Pearl Harbor, the Netherlands was one of the first countries to ally itself with the United States. The landings of the 82nd and 101st Airborne Divisions in the occupied Netherlands, which began the liberation of the Netherlands in September 1944, are still celebrated today.

Statia's Part: In November 1991 the U.S. Congress proclaimed November 16 as Dutch-American Fort Oranje SunsetHeritage Day. November 16th was selected because on that day in 1776 Dutch forces on the Caribbean island of St. Eustatius returned the salute of the American brig-of-war "Andrew Doria," thereby making the Netherlands the first country to officially salute the flag of the newly-independent United States.

Thursday, November 13, 2008

Alive and Well, Old


So if you've never been to school, as an older (politically correctly called "non-traditional" full time student, you just can't relate, but I'll try to paint the picture. The age gap is alive and well. Medical school is not hard, it's just a lot. And when you put together "a lot" with 20 some-things, you get stress. And when you are 20 something and you want to's usually a combination of eating, drinking, frivolity, nakedness (both public and private), sleeping and maybe some more drinking. I've been thru all those stages in the past but occasionally it's fun and bonding to get together with classmates during and after stress filled weeks of content being thrown at us (hoping it'll stick).

I've been wondering lately about all the invitations for dinners and get togethers that I'm not getting when the 20 some-things de-stress. Now I don't feel that I'm being excluded but have wondered about the dynamics (I've written about them before). It is different.  So I was talking to someone about it yesterday and said something about my perception of the gap. She (a verified 20 something) was very clear....

"Don't take this wrong or in a mean way, but would you want to party with someone older than your father?"

No I guess not. Leaves more time for study. But in my mind, I am 20 something.

Wednesday, November 12, 2008

CDC on Dengue


Outbreak Notice Update: Dengue, Tropical and Subtropical Regions - Updated: November 10, 2008

Dengue fever is the most common cause of fever in travelers returning from the Caribbean, Central America, and south central Asia. This disease is caused by a virus spread through the bites of infected mosquitoes. Many countries reported high numbers of dengue infections during 2007. This trend has continued in 2008, with large outbreaks reported in Brazil in March and April and an increase in cases reported in the Caribbean in October.

    * March 28, 2008: The Brazilian Ministry of Health reported a national total of 120,570 cases of dengue fever, including 647 cases of dengue hemorrhagic fever and 48 deaths.2
    * April 10, 2008: Health officials in Rio de Janeiro reported that 75,399 cases of dengue fever, including 80 deaths, have occurred over the past year.
    * November 5, 2008: Health officials in the Netherlands Antilles reported an increase in dengue cases on the islands of Saint Martin, Saba, and Curaçao in late 2008. More than 500 cases of dengue fever have been confirmed on Saint Martin and nine cases of dengue fever have been recorded in Saba. Saba officials say this is the largest number of dengue cases reported on the island in the past 30 years.


No vaccine is available to prevent dengue, and there is no specific medicine to cure dengue. Those who become ill with dengue fever can be given medicine to reduce fever, such as acetaminophen, and may need oral rehydration or intravenous fluids and, in severe cases, treatment to support their blood pressure.

Symptoms of dengue include

    * fever
    * severe headache
    * pain behind the eye
    * joint and muscle pain,
    * rash.

Sorta like I feel the week before exams...Watch the skeeters! And BTW, Florida has just been lucky...It's in the zone.

Tuesday, November 11, 2008

Dr. Pepper, Paging Dr. Pepper

I'm a pepper. Wouldn't you like to be a pepper too?

I'm not only a pepper, but I'm going to be Dr. Pepper!


I love pancakes, in moderation. One of my fave places to go at home is a pancake house I love. I heard a great analogy the other day (actually a You Tube Video) about medical school being like eating five pancakes a day, everyday. Some days you don't feel much like pancakes, but you have to eat them so you save them for tomorrow...and then you have to eat 10....and so on. The only problem is how many people can eat 5 pancakes a day, everyday?


Last push for exams. I'll never be ready. I've tried to eat my 5 pancakes a day, everyday for the term, and I'm barely able to swallow any more. I know I'll have to regurgitate all the pancakes I've eaten since the last exams next week, but I don't think they'll all come back. We'll see. Needless to say, I'm a little sick of eating pancakes.

Saturday, November 8, 2008

Uncoupled Reaction

Thermogenisis...the ability of the body to create heat, in the absence of any. Humans have largely degraded this process over time with the use of heaters, clothing and such, but our animal brethren do it quite well. Think about the hibernating bear in the cold cave. The body senses the need for temperature increase secondary to regulation to keep the optimum temperature in the body for core physiologic processes. Temp drops, and the cells "scream" for increase in the heat (like banging on the pipes) to they can do their work of cell division, and protein synthesis (among others). The body kicks in with and "uncoupling" cascade that puts the normal processes of the cell on hold, to divert to the "brown fat" heat production machine...we using ADP for ATP energy, produce heat, and then "stop" when the cells have had enough. Thermogenin is the protein largely responsible for that action, but the system can also be triggered by dinitro substances, thyroxine, bilirubin and long chain fatty acids. What a mahvelous machine eh? Brown fat...who knew?


So why would I share such "interesting to me but useless to the rest of the world" information? It took 2 lectures, umpteen Powerpoint slides, and hours of intention to get me to that understanding. I've been short, but the number of steps to get to this point in the "reaction" is 20 or 30 or so, with lots of side steps in between. The minutia of medicine and body science. Far greater minds have determined the value, but I wish somebody in clinical medicine, at the front lines of headaches, nausea, cancer, and diabetes would tell me how does this make me a better physician? I've heard all the rationale about mechanisms for drugs and all, but those can be summarized in quick fashion for everyday use. It's about accumulation of more information for information sake, isn't it?

Worse, the time element that this takes away from really knowing what is important. We spent hours on this, and only 1 on EKG reading. Paramedics get more intensive EKG training (and thank God for mine). The real reaction in learning is:

Time + content = memory & recall

There probably is an enzyme involved to stimulate this reaction. Some, et. al. have suggested coffee, Red Bull, Twinkies, apples, Monster and other such substances are effect catalysts. I think the studies were biased and unfortunately written up by those taking the substance. However, there is a formula for effective memory and recall, assuming that all AcH and GABA neurons are firing correctly in the brain to allow learning and retention (the problem in Huntington's disease for instance..oh no! Do I have Huntingtons?...aside: While learning diseases processes, it is imperative that the learner rule out that he/she has that disease)

Manipulation of the raw materials of this reaction is also important. Modify time (spend to little or too much) and learning is modified. Manipulate content (make it too hard or too easy) and learning is modified. So the mix of right time, with right content (at the control of the "teacher" receptor) = optimal learning. I can manipulate the time, and there is NEVER enough. So it is truly up to the teacher. This is not it's his/her fault rhetoric, it's simply the truth. I don't believe that most teachers fully understand that distill content and thus delivery, to optimize the use of time (limited supply) in learning what we need. We CANT learn it all, so why try to deliver all?

I sometimes forgot this simple fact when I taught. I totally understand wanting to share all you know, but in the speed to deliver, there lies the fundamental problem with lectures in general, and lecturing too fast in order to jam in all the stuff. The problem is compounded given the geometric growth of the information database in medicine. It's simple too much to learn in two years. But do we have to? Is it necessary?

I am more appreciative everyday of scholars like Dr. Eugene Stead who suggested that medical school was so far off base that the problems we see in the clinical practice and the system at large, are largely predictable and of our own making. And it starts at the lecturer/learner level. And as long as we fill our classrooms with instructors of great knowledge, but of little ability to fully understand their role in manipulation (after full analysis and consideration) of the content arm of this reaction, the reaction will always yield what it continues to all it's glory.


Experts beyond the island call what is happening in the US family medicine specialty a "crisis." Recent "match" results show that of the 2654 family medicine residency slots available, 250 went completely unfilled (nobody in place in those slots for training). More importantly, only 48% of the "filled slots" were filled by graduates of US based medical schools. The rest, 52% of the 2404, were filled by graduates of international medical schools. imageIs there any wonder why offshore schools are booming? There is a need to be filled, and international medical grads are filling them. And this phenomenon is not just in the US. Those slots are likewise being filled in Australia, the UK, Canada and other westernized countries.

We are not turning out enough general practice physicians in the US for the future needs and not filling the slots of available training slots for the ones we are turning out. Crisis? Not sure. But certainly a challenge, and an opportunity....if I can get thru this term :)

Friday, November 7, 2008

To Netherlands or Not

image We are sort of Dutch and sort of not. Most of the transitions on this island happened violently, but not this one. As I walk past the fort, I glance regularly at the flag poles to check where I'm living. Right now there are three flags there, but likely in the near future, there will be only two. I'm sure there will be great fanfare and some sadness, but at some point the flag of the Netherlands Antilles (we are one of the "stars" now) will likely come down leaving only the flag of Statia, and that of the Netherlands.


You can see and feel subtle signs of the transition coming. It likely is going to be a slow, drawn out, "island-time" process; well at least until the Dutch get really involved. After the discussion of Obama settles, locals are split on what might happen at that point. There is fear that the island will be too full of rules and regulations and lose it's outlaw mystique. Some welcome the infusion of European money, and possible development (including a possible resort). Some fear rapid rises in the cost of living (more than now??) and inflation. But one thing everyone can agree on, it will be different.

School is undergoing it's national (Dutch) accreditation site visit soon and the topic of value invariably comes up in conversation. I think the consensus there is, who knows. One thing most sure is it may open a gateway to European community rotations, residencies and employment. For some that is a real concern and issue. We shall see.image

P.S. Word from a senior (year 4) Statia student about ready to graduate and get the coveted MD...he passed USMLE part II. It is now in my cross-hairs.

Thursday, November 6, 2008

Just dreaming...


No reason...just dreaming. I know it can harden my arteries, encourage insulin resistance, boost polyp formation in the colon, and precipitate cholecystitis, but I'm willing to take the risk.

No Way!!

It's about 1300 miles away, but I can't believe that another storm, "Paloma", has evolved in the Caribe. Should be a Cat I by the time it hit's Cuba. I don't think we'll get anything here, but I feel pretty sorry for the soaked region that it is about to hit. They really have been brutalized this year. Our prayers...


Wednesday, November 5, 2008

OMG At Work

Sunsent Statia Oct 2008 after storm (8)

Most photographers take time to frame the shot, find a good location, eliminate the electrical wires :) LOL ...but this sunset was too good to pass, and the sun was setting quickly. Amazing, vibrant colors. Truly God at work!

Now what?

Ok, now start fixing the mess! Make the US a better place for our kids...


Tuesday, November 4, 2008

Post Pottery Booty Analysis

Post 'Cane Booty Arggghhhh! Avast mateys! All this treasure hunting on the west coast before and after my afternoon swims has yielded some interesting finds.  Photos got reviewed by our local expert.

Overall I got some refined earthwares:
-Creamware 1760s-70s
-Pearlware 1770s-1820s
-Tin Enamelware (often incorrectly called Delft) 1550s-present
-Canaryware 1760's

I got some Stonewares:
-Frechen (Bartman Jug) 1580s-1680s
-Fulham 1600s
-Dutch/German water/gin jugs 1700s

And some Coarse earthenwares
-Afro-Caribbeanware 1500-present
-Black glazed Earthenware 1730s-1760s

Not a bad haul for a part time beachcomber and archeologist. Pretty cool stuff got kicked up by the storm who shall not be named.  My searching will have to slow as the volume of molecular biology, genetics, biochem and physio begins to expand beyond the boundaries of my inner space.  But is was fun to think that one of my treks would yield the great treasures of pirates gone past. Blue glass was a great substitute.

Sunday, November 2, 2008

Evidenced-Based Voting

אנא להצביע בעד הבחור השחור!


We can't take 8 more years. They tried, and failed.  Just look at the issues, and dissect the hype from the reality. The diagnosis and treatment is clear. Just use the historical past as the evidence. Calculate the mean, median, mode and standard deviation for the population the Republicans experimented on. Use the evidence.

Saturday, November 1, 2008


I almost didn't believe it. It isn't striking or particularly pretty.  The dot of color with the hole in it, rising above the large rocks, pale browns, tans, and blacks of the beach.  My eyes looked but my mind didn't quite register the reality. Thought is was another peace of blue pottery. I actually walked right by it, then paused, and walked backwards to look again.  It was in the most unsuspecting place. Like a friend told me, "no rhyme or reason." And with the seas constantly changing the coast since the storm, more are likely to "come up."

Like Hawaii, there is a Kamaaina (person of the land) thing that happens when you "connect" to the land through something native.  I believe now I am wired into the luck of the land of Statia.  One can only hope that it will help on future exams :)

blubeed (2) blubeed


I am continually challenged by people. Isn't it amazing how selfish some people are? I love the specimen of human being that feels put out if they have to do something they don't want to do,  but is offended when you won't do what they want to do.

image Bible Parable: There was once a girl who wanted to go snowboarding. She'd never done it and was intrigued by trying. So she decided to travel to a place with great snow to do it.  When she announced her intention to her traveling companions, they decided they didn't want to snowboard but encouraged her to go and enjoy the experience. They were happy for her adventurous spirit. She did go and became offended by the fact that her companions didn't want to go.

Later the companions decided to they wanted to go do something else, and asked the girl if she wanted to go. She did go, but in her mind became offended that is wasn't what she wanted to do. She wanted to do something else. She walked around angry the rest of the trip, and then stored away the painful experience to draw upon later. <end>

This specimen of human will now be "double" offended and "put out" in their own minds and begin building a It's all about mecase against others for why they don't want to be with you, or serve you graciously, or take care of you. They are unforgiving, cold hearted, selfish people inside, even though they may be light, cheery, smiling on the outside. This person is so put out by others beyond what they want to do and how they want to do it, and totally neglect the needs of others around them. Worse they judge others by that measure and see people who are flexible and serving in negative terms as "wishy washy" and "soft".

No it's not snowing in the Caribe, but that specimen of human being is alive and well here. In this "what about me" mentality, it rarely matters what other people do, it's never good enough and mostly "wrong". It is amazing how many of those people like that are attracted to medicine. And it's not just here. Recent events and contacts in my life just reminded me of how many there It's all about me, deal with it!actually are in the field of medicine, pretending to serve others, when they are really just serving themselves.

I'm not trying to build a case for not being in this field. To the contrary, it motivates me to further explore those elements of myself that prevent me from really giving to others in this last part of my life and create a new reality for dealing with patients, staff, and colleagues. It is NOT about me, and never was or is. And it's not a cute "bunny" trait in others. It is totally opposite to empathy, sincerity, serving others and commitment to other in spite of how we "feel".  Living by those feelings is never reality, only the reality we invent.