One Down, Some To Go

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

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

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

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

No Wonder

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

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

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

 

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

Epiphany

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

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

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

Open Mouth, Insert Foot

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

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

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

Rule #234 of OB/Gyn:

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

Scowl

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

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

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

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

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

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

Not A Great Way to Start the Day

"And the baby was born dead"

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

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

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

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

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

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

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

From Vaginas to Interaction

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

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

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

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

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

 

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

Rotation Success

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

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

Focus on the success pathways in rotations.

Avoid the potholes.

Where Do Lonely Ex-Professors of Medicine Go?

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

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

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

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

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

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

 

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

First rotation bleeding

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

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

Some causes:

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

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

Preparation is the key. Preparation it'll be.

 

 

 

Blighted ovum

What do you want to be?

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

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

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

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

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

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

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

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

hypersensitivity to the drug

pregnancy, known or suspected

undiagnosed vaginal bleeding

thromboembolic disorders

cerebrovascular disease

hepatic tumors, benign or malignant

hepatic disease, active

papilledema

retinal vascular lesions

sudden onset vision loss or changes

 

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

Day #1- Babies and Insight

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

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

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

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

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

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

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

Rotations Begin

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

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

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

Let the Adventure Begin

“Enthusiasm is the greatest asset in the world. It beats money, power, and influence.” -Henry Chester

It's New Year's Eve and I've driven all day. The drive was smooth, traffic free, and provided plenty of time to think about the year gone by and the year (or so) to come. I just assume that 2010 didn't happen as it did, but both successes and failures provide great lessons. I've certainly learned a few this past year. Hope I don't repeat the bad ones. I've misjudged some people and situations, and underestimated my weaknesses. But I'm beginning to understand my strengths more. I hope that serves me and my future patients well.

2011 is a new beginning in many ways. Most of all, it's the beginning of the end of school and the start of rotations. I've been here, done this before. I mostly know what I need to do and will fake or figure out the rest. It's exciting yet frightening to realize that applications for residency start soon and Step 2 looms in the horizon. And so, it begins WITH ENTHUSIASM ...the other half. NO curbs allowed!

 

Settling into new living quarters the next few days, dinner with friends, New Year's Day with old college buddies and then Monday arrives with obstetrics, gynecology and more fun than you can possibly have with a tie and white coat on.

 

Wishing family, friends a Happy New Year! It's going to be a GREAT year!

The Spirit of Christmas

“And someone says, look, the animals, they are adoring the baby. Adoring, hell. They’re wondering why there’s a baby in their food.”

----------

 

We need not find the exact same meaning in the Christmas story in order to join in the celebration of it's virtues of love, forgiveness, hope, peace, goodwill, faith and charity.  Respecting another's beliefs does not mean that you have to agree. But understanding the virtues and viable beliefs that benefit all mankind is noble and in all of our best interests. This is a great time to go inward and assess how we treat others, and how we treat ourselves. Even if the baby is in the food.

Happy Hanukah, Merry Christmas, Happy Kwanzaa and Happy New Year 2011 to everyone. It's going to be an amazing year! Let's vow to love, forgive, hope, create peace and be charitable to others. It's the season of "not about me" and all about others.

We are the Bastard Step Children

Once again a group of medical establishment types are upset (sort of a feeding frenzy) at the foreign, particularly Caribbean medical school system.  An article recently appeared about a "feud" between NY State medical schools and foreign medical schools.  Seems that NY State medical schools are waging "an aggressive campaign to persuade the State Board of Regents to make it harder, if not impossible, for foreign schools to use New York hospitals as extensions of their own campuses."

It appears to be about clinical training positions, rotations for students and residencies for post grad MD/DO training, at NY hospitals. They say that there are 2,200 foreign medical students training in NY hospitals, nearly 1/3 of the total population of medical students.

All sorts of accusations have resurfaced, and I've heard them all, but it seems to be mostly about turf and jealousy. While there are many, many examples of quality physicians practicing in the U.S. with such an education background, the focus seems to be on the fact that these private school are for profit. After all, regardless of "school location" the essence of practice in the U.S. is passing the same U.S. boards, an approved residency and the full license scrutiny of state medical boards. Are they are stellar examples of Ivey League institutions? Absolutely not, but it's education none-the-less.

The real issue seems to be about St. George's School of Medicine and their 10-year $100 million contract with the city to send its students to NYC hospitals. Is it possible there may be some jealousy? Since the U.S. needs more primary care docs and the pathway to becoming a doc in the U.S. is essentially the same, could the problem really be about the willingness of St. George's to pay for good education for it's students?

While I know how hard I'm working toward this goal of becoming a physician, I know I'll have to deal with the perception of the Caribe medical school system and my preparation. But in the end I hope that I'll be judged no harsher than my U.S. counterparts. As a St. George's graduate and now emergency medicine resident at Stony Brook NY & foreign medical school grad said, "we have something to prove, as opposed to the sense of entitlement that some U.S. medical students might feel." I feel the same that I have something to prove but then I've felt that most of my career.   I hope that the U.S. medical school "machine" recognizes that there is plenty of illness and room for everyone. NY, you should be flattered that so many want to come there for quality clinical education.

Clarity, VIA horoscope

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

2010: A Year of Change

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

------

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

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

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

- Dr. Grey

Moving Onward

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

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

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

Mentors

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

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

Brain Cell Recovery Process in Progress

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

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

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

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

Steps

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

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

Over the peak

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

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

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

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

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

Sweetest word: "Passed"

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

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

Onward to clinical rotations and Step 2!

Relief

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

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

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

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

Amazing Stories - A break from study

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

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

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

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

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

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

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

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

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

Time to Study Again

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

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

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

I'm certainly out of mine.

And there it is

One simple word "fail".

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

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

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

Feels pretty sucky though.

Almost Here

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

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

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

One more week...

Dutch Health Themes of Service

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

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

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

The Spill That Keeps on Giving

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

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

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

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

What a tragedy.

Impulse

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

Getting Closer

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

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

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

The Trek

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

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

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

USMLE Solo

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

Drowning is NOT an option.

The Placebo Effect

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

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

RESCUED!

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

OOH "Out of Here"

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

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

Happy Kingdom Day

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

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

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

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

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

Never Saw it Coming

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

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

It never is, is it?

The Mind Protects

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

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

Respect and Stuff

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

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

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

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

 

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

Privacy

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

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

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

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

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

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

HIPAA Privacy; apparently, just a formality.

Competent Culture

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

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

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

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

Cleared, the Sweetest Word

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

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

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

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

Well Packaged Fear

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

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

For the moment, just keep swimming!

I Want to Teach When I Grow Up

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

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

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