Missing It Already

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

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

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

The End is Nearly Near

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

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

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

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

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

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

Transition

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

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

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

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

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

True Self

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

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

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

Learning...Next!

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

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

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

Remiss

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

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

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

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

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

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

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

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

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

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

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

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

Some good applications in life too.

I'm BAAAAACCCKKKK!

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

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

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

Breaks

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

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

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

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

It is finished, almost

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

40 Years

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

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

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

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

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

Meteors

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

Finals and Storms

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

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

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

Leash Laws

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

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

The End of the Season

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

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

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

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

Quiet Weekend

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

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

I remain open to the possibilities.

40 something

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

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

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

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

It's Coming - Hide the Kids

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

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

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

Ran Out

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

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

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

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

First Case of Swine Flu

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

Harrison's Textbook of Pain and Punishment

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

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

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

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

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

Back from break

I'm back from break, but not sure that I'm ready to be. This last block was challenging as represented by the lousy grades. I worked hard, and was a bit lucky so again I fall above the bell-curve. 1/2 down, 1/2 to go till the end of term and the next break. The content is wonderful, but nothing like the scenery of break...

St. Kitts is gorgeous and filled with some of the most friendly people I've met yet. The views were spectacular, the food delicious, the relaxation about as complete as possible.

As ready as I'll ever be I guess to start back soon.

Happy Father's Day

Supportive, loving, caring, tenacious, courageous, bionic...no better Dad! Happy Father's Day today and all year round. Thanks for all you do for all of us!!

It's all about the hair

Walking home today, I past several homes with the same activity happening on the porch. Big girls, little girls..."doing" each others' hair.

I've heard it called several thousand things over the years, and frankly, I'm not sure what it's called here. It's braiding, platting, twisting, spiraling, and probably many other names. But all seems to end with beads or other such adornment.

There are more hair salons on this island than gas stations. There is an absolute dedication to the hair and being sure that it is different on a regular basis and "taken care of" even more regularly. It takes hours upon hours to "do" the average head of hair and is part of the social fabric of parts of the island. My landlord is a self proclaimed "expert".

But then, with the adorned beauty of the island, it's people, it's vegetation, there is good reason to keep the hair just right. And, to be honest, there's not much else to do, so why not the hair.

Effect and Effectiveness

It is amazing to me how one person can change the environment of a small school. Bring on a "filler", a 2nd or perhaps 3rd string to take on the role of a star, and chaos is likely to ensue. Such is the case with a small institution.

Clearly, another hiring mistake has been made in a BIG way. I totally respect experience, my elders and that dynamic of fraternal organizations called "senior" or "upper class"...those that have conquered before me. But I am also acutely aware that this position power lasts only briefly before the deeds have a chance to be planted. 100 days in the case of the President of the U.S. I suspect then that new teachers get only 10-30 by extrapolation.

He is terrible. He is chaotically disorganized. He has so few teacher positive qualities. And he is turning off students as quickly as he has come. Out of 28 registered students for one of his classes this week, 5 showed up and I suspect (as represented by the number of Facebook and IM windows I saw open in front of me) that only 1 was paying any attention at all. When student recognize low quality they walk with their feet since they can't walk with their wallets once invested in the semester.

I thought it was a aberrancy because of the GREAT teachers clinicians that I have had in my past. I believed what Dr. Stead said about the history of medicine education, that clinicians had a duty to teach. But the moral of the story is clear...clinicians can tell great stories but can't teach automatically. It is clearly a skill in classroom & time management, preparation, humility, organization, communication, planning and delivery that requires attention and deliberate learning. Even perhaps "unlearning" of bad habits. But what else are they to do? They are truly unfit to do little else, and that in lies the conundrum of hiring authorities.

And on a small campus, the implications of poor hiring are inversely proportional to the size of the campus. The smaller the campus, the greater the impact of both good, and unfortunately, poor teachers.

Junies, Happy Birthday

Seems that I have many family and friends that have birthdays in June. I hope that it is a wonderful birthday, filled with celebration, peace, love, and happiness!

Gastroculture

I was talking on the phone yesterday and one of the wonderful faculty maintenance/cleaning staff walked up to me, said hello and handed me 3 "things" that I didn't recognize. She is one of the most sweet ladies in the world and we have exchanged cordial conversation over the time I've been here. For some reason on this night, she decided I needed the gift of food? Yes, it was food. She explained, after I put my phone conversation on hold, that this was a walnut. But I know walnuts and this was no walnut. In her typically broken, Dutch-Island English, she explained that it was a fruit and that the insides could be eaten. She told me she just picked them and they were ripe and ready to eat. I asked what you could eat and she said "inside". I thanked her very much and went back to my phone call. As I did, I studied the "fruit" intensely. That's a cashew!! 

Now, I don't usually do this, but this morning, I carved up the fruit and put it in my oatmeal and ate it. What don't I usually do? I don't usually put an item in my mouth that I know nothing about on the word of another person. I got 1/2 way thru the bowl before I got on Google. Whew! You actually can eat this thing.

It tastes pretty good, but I can see that a juice or by itself, you may need to sweeten it. It tastes a little like star fruit and is often called the "star apple". And yes, you actually can make a cashew like nut from the top seed.   Officially it is the Spanish jocote de marañón, probably from Guatemala originally, and the seed at the top is the official fruit of the red pod.

But is some ways I felt the intrepid traveler and discoverer, eating something for the very first time. Can you imagine the person that first ate anything from the forest? Besides food sources, toxic poisons and medicines with profound effects were also discovered this way. I can happily say that after about an hour, I'm still breathing and have no signs of GI disturbance, but it is early. If this is my last day on earth, it's been fun!

Expectations

There are few expectations that traumatize us more than those we place on our own success or performance. I have post traumatic test syndrome (PTTS). S/S manifestation: undeniable urge to go diving and hang out at the beach. Periods of mindless TV punctuated by refrigerator raids, complete with standing at an open door trying to figure out what to concoct. Intermittent and symptomatic Rx: Napping and giving into the urge to reflect on the successes, and anticipation of the future. Few feelings like it in the world. I hope there is no cure. I did fine enough on exams to come back for block #2.

Exams and Experimentation

You would think that after over a year and 12 major exams blocks with nearly 50 exams, I'd be used to it. But I'm not. Like some vestigial, deep, primitive brain implantation, my "fight of flight" activates on the Saturday before exams. It's nerve wracking and no amount of medication, cheesecake or shock therapy seems to avert the inevitable stress of the not knowing. And the first ones of the term are definitely the worst cause we haven't got a clue how the new profs are going to test.

It's sort of a game, with some sport, but I know that it is a means to an end. Deep in side I know that it's just another hurdle and I can almost rationalize the reasons for this ancient torture called testing, but clearly this is not a good way to create physicians. My hindsight as an educator is very valuable, but also very damning. This process is just not right, productive, educational or inspiring. Thank goodness I actually love the science. And I do.

This term too is full of contrast. I'm quite sure I have both the best classroom professor I've had in a long time, and the worst. I'm fortunate on one hand, but it is unfortunate that there is still the misguided notion that great and learned physicians who are likely wonderful bedside teachers are automatically good classroom professors and course directors. To the contrary, it is almost predictable that the opposite is true. Real teaching, and course management is a completely learned, non-innate skill. It is not automatically bestowed upon the MD or DO graduate at any time during training. But as long as there is ego, and the paternalistic belief that it is automatic, we'll end up with very learned men and women, muddling their way thru being teachers. Too bad, this time, I have to be the guinea pig to testing the theory, once again.

Quake, Oil & Storms

Recent natural and natural events have quaked me out of study into writing again. I've been so slack keeping up with the blog. Which only means I've been actually studying and not been dragged hither and yon by attention diverting distractions.

I didn't really know about it until I friend, who lives in the Western U.S., asked me about it. Seems that anyone who doesn't live this way believes that the Caribbean is the size of New Jersey. Yes, we (collectively the Caribbean) got "quaked", but didn't feel it WAY out here in the NE Caribe; At least not that I know. On Thursday, May 28, 2009 at 03:24 AM, and earthquake With magnitude of 7.4 hit in the far western Caribe, off the coast of Honduras. Beyond the great rum they produce, seems that Cuba shielded this side of the Caribe from any major effects.  It was centered right offshore and did some damage including killing a several people. There was lots of talk about it here, but to my knowledge it wasn't felt at all. It did stimulate my thinking about our vulnerability to various and sundry forces. We never heard about it officially at school, no sirens were heard, not much of anything to indicate a problems at any time. And while we may never know, reports of the water level in Puerto Rico dramatically receding as much as 50 feet raised from the deep recesses of my memory all the training I got while living in Hawaii about tsunamis. We would be clearly vulnerable.

This same week, a potential unnatural disaster also happened. We had an oil spill. On Saturday, May 23, there was a large oil spill originating from a tanker vessel moored at the Single Point mooring just outside the Northern Reserve of the Statia National Marine Park.
The mooring is used by large tankers that are too large to moor up to the Terminal pier to receive or deliver crude oil. It happened at 1:45pm , and it ultimately got pretty big...4 km x 500 meters.

And then, it happened AGAIN, just 3 days later! On Tuesday, May 26, at 5:30am, there was another spill originating at the Single Point mooring. This one much smaller, but it really brought home how much impact this oil facility could have. A major spill could have serious effects for the island's environment and economy. The same spills, with currents running a different direction could destroy the reef here.

And to further my joy, hurricane season is about to start. Reminds me I have to stock up on water again since I almost ran out during a 5 day suspension of port services after our almost direct hit from Omar the hurricane. The storm blew in tons of sediment into the harbor and we couldn't get nothing from no place, no how. We truly are dependent on the lifeline of barges, and shipments.

But I have first major exams of the summer term, another potential unnatural disaster, to keep my mind off of spills and quakes. Is this a great island, or what??

Deliberate Though and Creation

Sometimes life feels like a train wreck.

But from the ashes often arises great knowledge.  If you don't go willingly, away from the tracks, life experience and education beats you into submission...in a good way. It's actually a pleasant surprise once you recognize that the "change" and growth is both beneficial and welcomed. At the terminal stages of this process, you begin to recognize and develop abilities to handle life factors slightly better than before. I've seen that reflected in the many students and faculty around me over the past year. The most successful appear to be those who can think specifically and deliberately , communicate that thought to themselves and others, and create a different reality for themselves and those around them.  They have become "authors" of their lives.

But to create something in the physical world, it is imperative to create the idea in your mind. Those people who best contribute to the whole in this microcosm of school, have the ability to create the reality in their mind first, they effectively create whatever it is they are thinking in the world around them. This deliberate thinking becomes the tool to create the physical reality, because to create something in the physical world you first must create an idea in the mind...getting the mind "right" or thinking straight about that thing.

But thinking straight isn't a right wrong thing. It's not about thinking in alignment with others, or consistent with any dogma or belief system. It's merely making decision in creating our reality on what is the best thing for everyone involved, conducive to peace, consistent with empathy and identifying the humanness in those around us in which we slog thru life. Thinking straight maybe making decision even when risky given the current state of affairs in the "apparent" world.

I understand that not "thinking straight" and making wrong decisions leads to failure. Those thoughts are usually not "created", not made; We just manage to fall in to them because of our laziness and willingness to fall into the thoughts of others or circumstances around us. If thinking is straight the chances of making wrong decisions are greatly reduced. Deliberate, straight thinking is thought we actually and specifically create.

Deliberate, straight thinking is not about memory and creating thought from our experiences and past. It is not about thought created of our fears of the future. It is about the deliberate creation of though based on our best selves, greatest wants for the greatest number of people, and our yearning to be more directing of our lives. It is about becoming the source of our thoughts and thus our lives.

When you are the "source" you are creating thought. It doesn't have to be original or profound except to you. The only rule, it must be you creating the thought. Once you start this process, you remove yourself from the world working on you and your thoughts and you begin to work on the world with your thoughts...you become the source.

You can originate a thought that is neither a response nor a reaction to anything that has happened or gone before. Deliberate thinking, like any ability, improves with practice. It has been the goal of various meditative practices for years.

If you think you're beaten, you are.
If you think you dare not, you don't.
If you like to win, but think you can't,
It is almost certain you won't.
If you think you'll lose, you're lost.
For out in the world we find
Success begins with a fellow's will.
It's all a state of mind.
If you think you're outclassed, you are.
You've got to think high to rise.
You've got to be sure of yourself before
You can ever win a prize.
Life's battles don't always go
To the stronger or faster man,
But sooner or later the man who wins
Is the man who thinks he can.

So how do we tackle this thinking problem and straighten it out? How do you get your thinking straight?  We are all capable of deliberate thinking, and source awareness. When we step out of our ego (brain based, emotional, indoctrinated by others, physical perceptions, imitation, survival) we can move steadily toward the creation of though deliberately, and being more of the source in our lives...generate creation in the physical world.

Start small. "I feel the best I've ever felt." Work up. I am going to be a competent, confident, versatile physician.

And on we go

Up the river I course like Blue Man...

It's really strange seeing people who I know getting ready to leave school and move into the world or the next "step". They seem to be everywhere here, hanging out with little to do except study for the big exams coming. That will be me soon, but I don't think I'm ready. But on we go...

It's been a typical start this term. Shaking the cobwebs of the lazy break attitude and getting into the swing of studying again this weekend will be the first hurdle. It's already building to volume that I know are challenging to many, but I still hear things I "know", or at least vaguely remember, from my practice and former education. Amazing how some things stick.

Yet too, I am continually amazed at how much I don't know, never learned or did by menu or guideline instead of understanding the real "why". Such is the more technical education of my past. I don't think I put anyone in danger, but the "oh wow's" seem to come with greater frequency...or am I just paying more attention? I don't know but I'm loving this part of the learning.

I have to admit that learning at this stage is simply more economical, efficient, and profound. I'm more ready to learn and more excited about learning, than ever before. I never got this excited about my education in education. I walk out of class now and feel energized, jolted into what can be, what will be...and that is just a pure, unadulterated rush. One that I'm sure many, many cannot, will not ever feel in their lives. Poor souls.

And so it begins...

I am poised on the great precipice of summer term and yet another battle for academic excellence and survival with the great "it".  Muhahaha! It is "me" against "it"!

I feel like if I make it sound like the great novel I'm more likely to pursue it with the passion it deserves. Actually I'm hoping it all comes together, there are enough students to pay the bills another term and that there is yet another delay in the implementation of the Netherlands taking over this paradise. It is a race against time, money, politics, power, learning, teaching skills (or the lack) and that which I know not (or know and have forgotten).

More Studying

The most important educational factor in medical school this term will likely be what organism? Algae! That little green plant stuff too small to make a decent salad.

The headlines tell the story...

Algae Plume Reaches Caribbean

This one "plume" is big and covers a wide expanse of Caribbean water. So big in fact, that it can be seen on satellite images from space.  It started in early April and appears to have begun as nutrient rich runoff fresh water flow from South America...likely from the Orinoco River, which exits Venezuela's northeast coast or directly from the Amazon river further south. 

While difficult to notice from the surface to the untrained eye, the water is eerie green around the island. Upon entering the water it feels like you are descending into pea soup...cloudy green water noticeable to those of us used to swimming normally in crystal clear blue water. "They" say it is starting to break up, but you'd never know it.  A short swim yesterday proved "them" to be wrong. The water is still too cold to cause up/down currents in the water to break up the mass. "Them "must not be swimmers or divers.

It is dramatic how the color of the water has changed. I dove a wreck in 90 feet of water about 2 weeks ago and it was really thick green. Pretty interesting to dive in different conditions on a wreck, but I wouldn't want to make a habit of it. You can see the now (Left, green) photo of the prop and one before the plume about 3 months ago (Right, blue). The photos are at the same depth, with same camera, with same settings and almost exactly the same lighting conditions. Dramatic effect on visibility and feeling of the dive.

And the fish LOVE it...it's a buffet! So while the diving and swimming visibility is less, the amount of fish on the wreck is especially high. The little ones love the algae and the big ones love the little ones. Hunting and eating for fish is further enhanced at the wrecks and ledges of reefs. So while the clear inviting waters are gone for the moment, we are seeing fish we've not seen in some time. NICE! One dive master said, "so thick we had to physically push them out of the way".

So as the plume (or bloom as many call it) continues, and makes swimming a bit more dangerous (sharks, and barracuda love to feed in the murky waters), studying may be the natural alternative to getting eaten by a confused carnivore. I am glad though that I could experience the conditions at least once, but I am looking forward to clear conditions again.

Break

It's not Saturday Night Fever, or Dengue Hemorrhagic fever...it's Rock Fever. "Rock Fever" is a subtle combination of subjective and objective signs and symptoms that often are not truly experienced until you separate from the source of the fever...the island. Once the possibilities of drive thru burgers, steaks of known origin, and other such comforts take hold, the true nature of the fever becomes apparent. I miss access.

It's not really the getting that is so important, but the knowledge that access is possible is often enough. I walk thru Costco near home, and I understand that the possibility of buying and devouring one of those wonderful cakes is possible. The mere possibility is better than the eating, digesting and the effects of the high blood sugar to follow (well maybe not completely better).

Access is a quality of life that is universally experienced at some level by all free people. Access is only denied to those incarcerated by the judiciary or by the geographical situation they find themselves. The latter contributes to the disease of Rock Fever.

So I drive thru where I might not drive thru otherwise, and stuff my self with the Taco Bell knowledge that soon again I won't be able to do so. My fever will then return, and I'll be immersed in the near end of my time on the rock...one of the most wonderful experiences of my life. And I can't wait to get back and get started again.