Education of the Un-schooled Kind

I was really frightened many years ago, helping take care of my first cerebral palsy (CP) patient. There was this really grotesque looking and acting child with muscle spasms, head shakes, twitches and writing sitting in a wheel chair. I thought he would break. I thought I might break. But that was many 10's of 100's of patients ago and I've heard and taken care of CP, cerebral palsy, patients forever. It's not a new name or category of care for me. But I've been schooled this past month. I really didn't know CP at all.  

Then I met and really hung out with a bunch of CP affected folks and their families. I really appreciate the experience and am so grateful for being able to hang with some of the most phenomenal but individually different CP folks ever. Everyone different from the next. Somewhere during the last few weeks in that experience there was a "click" of information (my anatomy, physiology and neurology) with reality. And after this intense month of talking with and experiencing these amazing young people, I now realize how diverse this group of patients is.

Cerebral palsy is considered a condition but it's really a waste basket term for everyone suffering from injury (usually some form of anoxia, low oxygen, at birth). It's more often thought of as a group of disorders that involves injury to the brain. But the problem is that the physical manifestation of the damage depends on which part of the brain and it's pathways are damaged. As a result, no two patients present the same and have differing combinations of functional deficits in movement, learning, hearing, seeing, and thinking. Each one is different.

The brain is huge and has between 10 billion to 100 billion neurons organized into cortices, pathways, areas and regions. Imagine all the different combinations of connections between those neurons and you have a number that is representative of the true nature of CP and the number of possible presentations.

So the first patient may have sight problems and motor control on the left side of his/her body. The next patient may have lower extremity problems and normal above the waist up. The next may have speech creating deficits and be unable to walk or hold a fork in the right hand but can with the left...and on, and on, and on go the variations.

But what I really learned I learned by hanging out with them and hearing their stories, successes, triumphs and fears. They are creative, fast thinking, smart for the most part with incredible senses of humor about themselves and others. They are dedicated, and grateful since they don't know what they don't have...they never had it. They are sincere, loving, hard working and diligent to find their niche in life while serving others. They really are, as one mother put it, incredible kids often trapped in bodies that just don't work. I really have been schooled...and I really am a better student, provider and person for having done so.

Tis the Season

Tis the season, not to be jolly, but to apply. And so it begins...the 2012 Match ERAS season. This is the start of what will be the long months leading to the that fateful March date when everyone I know will be fighting for residency positions and hoping someone says to them..."we want you". I don't know if I'll make the 2012 match, but I'm going to give it my best shot.

It's a frightening process filled with more sources of information, speculation, advice, land mines and unknowns than I care to envision. All the elements must fall together in a pattern of "presentation" so the director of said residency programs feels you are a "match" with his/her vision of his/her specialty in his/her community. Dean's letters, letters of recommendations, tokens, Step 1 scores, supplemental  applications, Step 2 CK and CS scores, grades and evaluations from rotations, etc etc. And then how to decide which specialty, at what program, where in the world?

Having watched good friends go through this process, it's really awful. It's not a system that really matches proportionally to the many factors that a person has. In many cases, your personality and bedside manner never see the light of day if you are a struggling test taker. Getting the interview..that's really the goal. And hopefully figuring out where your best chances of "match" are before you click "send" the applications out to the many programs.

And so it begins. I'll try to figure out this process and hope that each day I'll inch toward that letter of "we want you" and it'll be a place I really want to be. Marriage was easier. Actually, pulling that ice pick out of my leg was easier.

Humanism

Sometimes within the madness, mayhem, schedules, rushes, indignities, cost over-rides, dissatisfaction, liability, pain, suffering, aggravation, selfishness, greed, industrialization, government oversight and processes of medicine...there are moments of pure giving, love, joy, healing, service and art.

I don't want to miss any more of those moments. Glad I didn't miss this one. It is the fuel for moving onward, even if I have to battle the testing beast soon. It a real honor to be involved in the relationships that have become my profession.

Transparency in Medicine

Transparency

1. free from pretense or deceit
2. easily detected or seen through
3. readily understood
4. characterized by visibility or accessibility of information especially concerning business practices

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I am regularly struck by how much research patients often do before coming to the doctor. The Internet provides a full gateway of information and, unfortunately, misinformation about diseases, treatments and the system of medical practice. The Internet has been an effort to provide greater transparency in how we practice medicine and deliver healthcare. The written word seems to hold great validity to patients.

Transparency is fundamental to the creating of trusting, nurturing relationships with each other, particularly between clinician and patient. If for a moment the patient believes that communication and information provided is full of pretense, lies, or is not understood, there is immediate breakdown of the relationship and (if medical social scientists are correct) the cooperation of the patient in his/her care or "compliance". So the real question, is there transparency in medicine?

The reality is that transparency is scary to clinicians and the system as a whole. There are elaborate efforts to fully but not completely, reveal the secrets of medicine and medical practice. The Internet has done major things to this "gap" but rely on patient understanding, so would seem to violate "readily understood" transparency. Has the Internet then helped or hurt?

Transparency in the system is really up to the clinician. It's not the patient role or within his/her ability to force transparency through the Internet or available information sources. While it's all "out there", it may not be all understood and may actually contribute to damaging the relationship between physician and patient as they often believe what they read over what is being said.

So in that lies the greatest opportunities for improving patient care, trust and compliance...creating transparency with each patient we encounter. Yet there are risks in doing so as magnified by the legal system. However, taking risk offers great rewards. We should embrace our fear with honesty and transparency.  But that would be in the perfect world with tort reform, liability caps and a system that supports that perspective. I'm not optimistic.

Another surgeon quit working this week. Tired of dealing with being questioned by everyone about how he practices. Another good surgeon, out to pasture.

Service

One of the unsung, unmentioned perks of medical education is the access to quality experiences of service. These opportunities come in small packages, like tiny and discreet words with patients or families. And they come in larger packages related to hearing about real community needs. I had the chance for a sort of large one, more medium in scope, but VERY LARGE in effect. I helped a family clean out an apartment of a family member who died from suicide after a long, long battle with cancer, drug abuse, alcoholism, cirrhosis, pancreatitis, heart failure, kidney failure and emphysema. The physical, emotional, intellectual, and spiritual benefit of this day long effort was tremendous.

But one of the most striking elements of this event was the short list for "shopping" the deceased had created before his death. He simply wrote on a small, pink Post-it note: "comet cleaner, scrips, beef w/barley."

I've been trying to wrap my head about around the whole experience and the grateful family for stepping up when few others did except to come salvage personal belongings of the deceased.

Cleaner, drugs and soup seems to punctuate the simplicity, commonality and routine of a life in great pain, alone, struggling in the end to find a reason to live, clean the apartment and eat, until it became why bother.

Surgerizing

I am REALLY in my element.

A chance to cut is a chance to cure.

But the pathology is so, so devastating.

I am so blessed to be whole, and not have someone leaning over me wielding a scalpel.

Really looking forward to Easter weekend and the last days of Passover week. A great time to pause and give thanks.

How to Value Medical Students

Teaching is more than a business in medicine. Medical students, interns, residents and fellows have real needs. We all do. Address the needs and you make a friend for life and influence the future of medicine in a meaningful way. Such are the qualities of good clinical preceptors, teachers of medicine and surgery. I've had some good ones.

So what needs did he or she address? Certainty, variety, significance, connection, growth and contribution.

Learners want to know what's expected of them (certainty), experience a cross section of pathology (variety), feel they are important (significance), be a part of the team and treated as such (connection), learning (growing) and feel as if they have helped in a meaningful way (contribution).

It's hard to teach the importance of basic human needs to teachers,... individuals who are often struggling to have their own needs met.

Patient - Clinician Relationship

I have met some really good clinicians lately; Individual who create great environments of trust, communication and cooperative healing with patients.

It's really pretty simple. There is ALWAYS a gap between what we expect of our patients, and how they act. I've noticed that the most disturbed clinicians assume the worst about that gap. Positive, happy clinicians seem to believe the best, come to the defense of their patients, speak directly to the patient (and not in the hallway to others) about those gaps, and create REAL trust with the patient so he doesn't feel judged or persecuted when they come to visit.

"Do unto others (patients) as you would have them do unto you (if they were the doc)"...We should protect, trust, hope and persevere more.

It really is pretty simple and probably applicable to the rest of our relationships, even outside of work.

Still Engaged

Whenever I engage solo or groups of physicians I really listen carefully to what they say about this profession. I try to discern what it is they do, how they feel about it and what they believe the future to be. I'm constantly reminded of how many physicians are unhappy with what they do and why. I hear complaints about patients, insurance companies, the government, systems, and on and on. I'm convinced that there are more unhappy people in medicine than any other profession, but I don't interact with any other profession (sampling bias).

So the other day I met a very interesting surgeon, visiting the area. He practices in a small country in Africa and is the chief of surgery in a large (by African standards) teaching hospital. Listening to him speak you would have thought he had been given the gift of levitation. The pride and happiness almost oozed from his pores. It was a refreshing view into the life of a physician who really was happy with life and wholly feeling the "honor" of being a healer in a country desperately in need of healing on many levels.

One thing I'm certain of. I'm happy as a little clam. I love the content, the work, the patients, the material, the environment and the comrades. I'm learning to ignore the bitching and see past the complaining to the value in what we do and how we effect others. It's refreshing. Just hope I can maintain it thru this amazingly retarded system they call medical education.

And the surgeon, he invited me to do a "rotation" in Africa. Why not? I don't think Medicare is a discussion point there.

And exactly how do we know little clams are happy?

Don't Eat the Eggs

Two days of lecture have me whipped. Sitting is becoming my least favorite activity in the mode of learning. Learning by doing (preferably walking, running or actively moving in some anatomical way) is my preferred. But the content was good and a reminder of how much I have to study before my next big exams. I need those subtle raps in the head occasionally. But what I didn't need was the rap to the GI tract. Note to self: Don't eat the eggs at a medical conference.

Inconvenient Truth

The truth is surgery has a terrible time clock, and doesn't respect time in any way. Things happen good and bad that alter the "clock" and have things start and end when they weren't supposed to, or expected. It's just the way it is, and everyone around us is supposed to know that, honor that and just bear with it. But still, it never feels quite right.

And so it begins again.  My absolute and complete love-hate relationship with the discipline, or lack thereof, of surgery. We cannot escape the barber-istic past. So let the anesthesia begin.

Sanity Defined

Sanity is being judged "of health & sound mind" and being to make well judged choices. The appearance of sanity seems to be the one thing everyone wants but really can never get when we finally understand the real truth, the whole truth and nothing but the truth...We are all a bit crazy. To the extent that that crazy affects your home, work, professional or other (activities of daily living) life is the extent that you are judged insane by professionals as guided by criteria set up in the Diagnostic and Statistical Manual of Mental Disorders (DSM).

And now changes are coming to the DSM and the 5th edition is to be published for use in 2013.  Seems that the science (practiced now mostly as a subjective art in community practice) has been propagated by researchers who have generated a wealth of knowledge about mental disorders, biochemistry of behavior, the influence of genes and heredity on mental health, and other factors begging to be described and included in the new book.

It's been 18 years since the last revision (the one currently in place) and begs the question. Will what is now sane become insanity or will what is now insane become sanity with this revision? It is theoretically possible that patients deemed "normal" now will suddenly find themselves not so normal after the publication of a book. Fascinating!

And then, the psychiatry rotation was over. And God said it was good. And before he created the next rotation, he contemplated the sanity of man and deemed woman a pre-existing condition. Man seeking his sanity discovered electricity and ECT was born. Man chose electric shocks over woman. And all was good again.

Joan, Jane, John etc...Meet Dr., Dr. Dr.

My "Tara" experience came early in my psych experience.  "Tara" is the character played by Toni Collette on "The United States of Tara", the Showtime TV show about a middle-aged, married, mother of 2 kids who has dissociative identity disorder. For the older folks this disease is aka multiple-personality disorder (MPD) and was associated with "Eve" and "Sybil", who are unknown by my 20 something colleagues.

It became apparent very quickly that I was totally ill prepared for the Tara experience with my Barbara Bates (Hx and PE textbook author), linear, history and physical examination style. There is nothing linear about the "new patient" work-up of a multiple, particularly as the personalities come out and interject, or worse, correct each other. Such was my experience.

I sat with Joan, Jane, John and some other un-named personalities for a long time hearing the history, fact, details, summaries, ranting, ravings, lies, delusions and such. It was the most entertaining hour I've ever spent in medicine and I'm a better provider for it. But my real conundrum as a provider came the moment I sat, pen hovering over the progress note page, and tried to write this encounter up in some manner that was intelligible and demonstrated my expertise as a medical professional:

"Personality #1 (called herself Jane) related a history of sexual abuse at the hand of her father and noted no other physical, verbal, emotional, financial or sexual abuse history. Personality #2 (Joan, deeper voice with faster cadence and visible tremor left hand) immediately corrected "Jane" and noted that she had been financially abused by a Texan with a big car just a few day before this visit. Personality #3 (John) then noted that Jane was Jealous, and that Jane and John were really wanting the Texan's money..."

And so it went. And who was Jealous? John was actually talking about another personality, within a personality. Apparently personalities can have names of emotions  too...a variant presentation.

I have to admit, I felt a bit hoodwinked but still entertained. That's the thing about Psychiatry in general. There are no blood tests or real objective testing for many of the diseases we encounter. Such is the case with MPD, now DID. The interview is all we have. And if it is, we are totally unprepared. At least I am. But then, that was the best afternoons so far. No wonder Tara is a hit show on Showtime.

Mental Health

Who we are, and how we respond to our environment as a living, breathing, interacting organism is a function of our nervous system. And that nervous system made of nerves, our spine and our brain is largely a function of chemicals...norepinephrine, epinephrine, serotonin and dopamine. So beyond limited therapies of counseling (a mainstay of psychiatric care), restraint (physical and chemical), and controversial surgical and electrical brain intervention; Psychiatry is largely an attempt to modify those chemicals.  Today, 4 % of men and 10 % of women in this country are taking antidepressants at any given time according to Dr. Julian Whitaker.

So the day to day operations of a psychiatry office, and the function of a student in that environment, is the management of those drugs that attempt to modify those chemicals. The drug names of many, varied, and often entertaining....and  there are MANY, with new ones coming out almost hourly. You can barely get through a TV show without seeing a commercial for one.  We sell psychiatric illness and the "cure". It has become the mainstream of what we do in psychiatry and sales have skyrocketed from about $500 million to the current almost $60 BILLLION in only about 20 years. It is BIG business and the number of drug company sponsored lunches I have eaten while doing my psych rotation is testament to the amount of expendable dollars available due to these sales figures.

"The way to sell drugs is to sell psychiatric illness."----Dr. Carl Elliot, University of Minnesota Bioethicist (The Washington Post, 2001).

And while I feel well fed, and likely that some people actually need this care to survive life, much of what we do in psych is suspect at best and in some cases dangerous. Dr. Peter Breggin, M.D. says, "Going to a psychiatrist has become one of the most dangerous things a person can do", referring to the chemical approach to care.

And we continue to sell both disease and illness to a large percentage of "patients" walking thru the door, but the stories are largely of "life" and the stressors we encounter along the way. Has our ability to handle life and the massive stressors been exceeded or do we just look differently at that ability (and possible treatment)? It appears that current psychiatric practice is largely the latter.

"[W]e do not know the causes [of any mental disorder]. We don’t have the methods of ‘curing’ these illnesses yet.”----Dr. Rex Cowdry, director of the National Institute for Mental Health (NIMH), testimony before a House of Representatives Appropriations Committee Hearing

But there are some severely wounded people out there with real, significant and life strangling psychiatric issues. And it's those people that we daily struggle to help live a life with some quality and as few bumps, injuries and maladies as possible. And it's largely that hope that keeps the doors open, and the drug company lunches coming. We really want to help those in need, but we continue to invent, modify, and alter need. It is a grand experiment for sure.

"Anyone who goes to a psychiatrist ought to have his head examined."-- Samuel Goldwyn

"Biological psychology/psychiatry is a total perversion of medicine and science, and a fraud."— Neurologist Fred Baughman

"Psychiatry is probably the single most destructive force that has affected American Society within the last fifty years." – Dr. Thomas Szasz, Lifetime Fellow, American Psychiatric Association

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.