Medical Types

I've become, in my old age, a consumer of watching people. I really listen now, really absorb who is right in front of me, and try to seek understanding of who they are. And in a teaching hospital, it is quite the array of personality types.

But I think I've distilled it down to it's basics at this point. It seems there are three "types" of people involved in the practice of medicine.

Dr. User
They seem to always want something from you to assist what they are doing, but rarely (if ever) offer something to you. They reach out when they identify your strong points, to augment their weaknesses. But they are the first to run for the hills if you need them or you demonstrate weaknesses yourself. If you are in trouble, these folks can't be relied upon or even trusted with your issues. They certainly aren't bad people or clinicians. But they are fearful, insecure, self-centered and driven to achieve little beyond what serves them best and first.

Dr. Standby
I'd say most of the people I encounter in medicine are "standby" folks. They wait in the wings. They don't come forward in hard or easy times. If you get into a jam, they wait silently close by and watch to learn from your mishaps, but are willing (although not excitedly) to assist if you ask. They aren't easily made friends of, but once they do accept you, they are all in. They are good people to know and have access to, but they aren't very committed to you or anyone else.

Dr. All-In
These folks are totally committed to everyone and everything around them. They don't hide in self serving practices and aren't shy about committing to you if you are open to it. They are accepting of everyone, every patient, every situation without a whimper. They are there for you when you need in hard and good times. They seem to approach more readily when they sense distress. They never appear burned out or disturbed by the people we live with or serve. They stand by you in good and bad times. They are likely the best friends to have in the long run and have the potential to be totally honest with you when you need it most.

I'm a Standby right now, a bit cautious. I strive to be an All-In. I think it's all about moment by moment focus, stress management, being there and approachable in good and bad times for colleagues and patients. It's about daily renewal and openness to the possibilities. Paging Dr. All-In, Paging Dr. All-In.

Cocaine

"Cocaine can constrict blood vessels in the brain, causing strokes. This can happen even in young people without other risk factors for strokes."

I've read that statement in countless books in school and journals studying the use of cocaine. I've always had a interest in the effect of drugs on the body growing up in South Florida where it's always been available. I've been interested in the effects since my days working in trauma and seeing the aftermath of use and abuse. I've seen people try to fly off balconies on LSD. drive into walls on alcohol and drive too fast for the curve on coke.

But nothing is more devastating than a deep brain bleed in a young person from a snort. It leaves the person alive but with greatly reduced function, with bills they can't pay, rehab that will never get them close to the way they were, and loved ones taking care of the rest. So sad.

Heros All Around

My new hero, Kayla Harrison ,78 kg of "kick ass". Great lesson; Don't get mad at the past, just GET GOLD! Awesome, amazing performance after years of total bullshit in her life. Way to go Kayla!! Absolutely inspirational.

First Month Done

Oh thank God it's August! I can finally sleep in my OWN bed... the simple pleasures of life.  The first month of residency is officially over and I've broken the ice on the "rest of my life". Beyond the cognitive decline of an aging clinician, I think I held up pretty well for an old guy.

Still the yungins are really, really sharp and I can tell already it's going to be a challenge to make the grade and keep up in some respects. We shall see. It's one day, one patient at a time. But for now, it's (I hope) a realy good nights' sleep in my own bed.

Ready for the End

This is the last weekend of my first block. It was challenging. 319 hours in 4 weeks, just one short of a violation. Over 400 pages for services to the floor. Untold number of scut monkey activities and moments of potential humiliation by upper class folk and attendings sprinkled with a solid 1/2 dozen moments of amazing connections with family and/or patients.

And it's those few moments that fuel my love for what I'm doing and yearning for more. I think I can put up with almost anything as long as those moment continue. And I know that that part of the equation is up to me. Because I know I have little control over any of the rest of this madness and mayhem they call residency, filled with strange rules, hours, notions, myths and activities.

Yet at the end of any brutality is the notion that one can survive almost anything. And then onward to the next block of work, education and hopefully more time for me. Remarkably, I am about to survive and this is my last weekend. And, I think I'm ready!

Let the games begin

I think medical education is constant search for diversion and distraction punctuated by the complete lack of sleep. Let the games begin!!

Love the Ralph Lauren USA garb, made in China :)

Dragon Speaking

"ice on a dill" = lisinopril

Voice recognition dictation can be so so entertaining

Loving what you don't like

It's inevitable. Experiences in medical education, or in life for that matter, that you file away in "I'm sure I don't like that". And then you set about a way to avoid it, to the best extent possible. But still staying politically correct, snuggling to the correct person, and stating the most obvious sarcasm you can muster... "I love this [thing you really hate]!" Although hate is a strong word, certainly something you will try to avoid. It just feels wrong.

But somewhere in the political correctness, the lies about what you say you like but don't, is a spiritual nirvana and real message in the "hate". We learn what we don't like but still take away a greater knowledge, experience and appreciation for that thing or experience.

And so is the life of an intern. Moving through the motions of learning so you can be a working physician, figuring out what you like and what you don't like, but still learning...always. Every skill, every nuance, every opinion, every fact; Adding to the knowledge base that is your toolbox for the future practice of medicine and patient care. Always with the knowledge that there isn't anything that they can do to me in one rotation that I can't get over. But a positive lesson on something, even if it's negative, every single day.

------------------------------------

There is no way possible to fix the current medical system quickly and easily as long as it's core is made up of professionals that believe that the old way is the only way. Sadly it's those old ways that have brought us to this broken, unenviable place in U.S. medicine.

Cost of doing bad business

She said "I ran out of my medications" and couldn't afford to get them.

Cost of medications for the month not covered by insurance, $85

Cost of the Emergency room visit for the hypertensive crisis plus the ambulance ride in, $2800

Does this make any sense to anyone?

It's not mine

There are few things that are more disturbing than to hear those words from physicians who are in the business of attending to and working with patients..."It's (referring to a live, breathing patient) not mine"

Let me get this straight. The patient needs your services, but "it's not yours?" And the it, ...that's Mrs. Bernstein. I know you are tired, so am I. I know your reimbursement won't be maximal, but who's is. But she is yours. You are a neurologist with expertise in meningitis, you are on call, and she does have meningitis.

So it, her brain and it's surrounding meningeal structures, are yours.

Healing in the modern era

This has gotten so complicated. Financial issues prevent or alter access. Why not use the ER for your primary care. They can't turn you away, even if you don't have the co-pay. So, so broken...

Luxury

Nothing too good for our residents. I have the luxury top floor penthouse suite

Letting Go

Medicine is a strange training ground. So much pressure to compete. So many lost opportunities for real collaboration and real team work. Mix that with sleeplessness & stress and you have a potential challenge.

Letting go of the tendency to hold ourselves up to other people’s standards, and letting go of the belief that we need to compete and win, doesn’t mean we don’t believe in doing the best job we can.

I love baby Pandas.
But I digress.

Reality

The hospital ED has a way of dealing reality to both patients and providers.

Reality: that which you were formerly clueless on, becomes clear as a bell.

Value

Without good teaching and teachers the process of learning in residency can become disheartening and destructive. But with good mentors and teachers, it holds promise and value to be both gratifying and productive. We shall see.

First Days of Residency

The first days of work were a little challenging with the hours, demands and (most of all) the reactions of the patients. Do you think it had anything to do with my shirt?

Survived

First of anything are usually a challenge. It certainly was my first night on call as an intern. They said it wasn't too busy, but it felt like an avalanche to me. Fortunately all the patients did well and the only faux pas on my part...walking into a "isolation" room without a yellow gown. I learned to read door signs more carefully.

Of course the patient load/calls were compounded by not knowing how to get places, how to use the electronic medical record, or the "norms" of the hospital and staff. It was challenging to integrate medical school and my experience into the work of getting through the night. But I survived. Barely. I fell asleep after my 14 hour shift during morning report before going home.

And so it begins. The residency learning process in the face of overwhelming responsibility, not enough time, not enough staff and a learning curve as steep as Mt. Everest. But I'm determined to make the climb, one step, one day, one patient, one decision, one new EHR skill, one nap, one admission, one order at a time.

July Effect

July 1 each year is the start of residency for several thousand medical school graduates. That is the where the term "July Effect" arises. I am, starting July 1, part of that effect.

My colleagues in law, and business get so excited when they speak of internships. Companies with big names and even bigger reputations are discussed freely. Visions of suits, handshakes, networking breakfasts, long hours and potential job offers to follow usually accompany those discussions.

But for those of us in medicine, internship is more akin to a form of indentured (or edentulous) servitude. It is that first year when you have no sleep, no very little, have high amounts of activity, and no opinion (at least none that matters to anyone). On the food chain, even medical students are treated better (they go home early usually). It is a very different look and feel.

So now it's my turn to become part of the productive, or dangerous, time called internship. For the next year, beginning on July 1, I will become part of the 1000's of first year, PGY (Post Graduate Year)-1, residents... aka Interns. I'm scared, excited, worried, elated and I'm hopeful to be at least able to find my way around this massive medical center.

I am also going to become part of the "July Phenomenon", that time when experts have said to stay healthy and avoid the hospital due to up to a 10% rise in medical error. That is the first month that "we" are there, doing our doctor thing, in the very first month of our training practice. There have been arguments over the years if the effect actually exists, but from the looks of the PGY-1 class around me, I think the world is safe... as long as they are continually hovered over and supervised.

And so it begins. The years of medical school have led to this point in time. You really can't do much with a medical school diploma so this is where the rubber meets the road so to speak and we translate our knowledge into real, tangible patient care.

I'm scheduled for a opening schedule of 160 hours over the next two weeks with only one day off in the next 14 (not a violation of the new GME hours rules).

Ready or not hospital, patients and staff,

HERE WE COME!

Longevity: 4 Years and 1/2 way

It's really been a long gestation, but I birthed the credentials that I've been working toward for the past 4+ (depending on how you count the years) . In no particular order:

1. M.D. diploma
2. ECFMG certification of education
3. Residency match offer/acceptance
4. State M.D. resident license

It's a slow, slow delivery with much frenzy in the last year, but the "quads" have been birthed. And as I start my unpaid orientation for residency, I'm excited to be at the 1/2 way point "finish" of my education and training as a physician.

Throw on top of that a new hospital I.D. card, some new embroidered coats, and it becomes an "ahhhh" (like right after the baby delivers) moment

This point in time was a distant dream when I first got accepted to medical school and began this trek. And I say 1/2 way because given a 4 year (maybe 5) residency/fellowship course of study to follow, I've literally only completed 1/2 of the necessary hurdles to full medical practice licensure and board certification.

The process to get to this point is truly amazing, on so many levels.  It's been a cascade of emotions, effort, trials, schedules, deadlines and processes. It's hard to believe sometimes that anyone actually completes this process, but with one day at a time, enjoying every single moment, it is possible and feels great.

Literal Bible in Practice

I’ve read this several times in the past. It’s not new and it’s not mine, but it still tickles me. Sometimes we just have to step back and really assess what we believe, why we believe it, and the mass effect on the community and culture around us as we strive for cooperation, peace and a world we can proudly leave our kids.

Dear Dr. Laura;

Thank you for doing so much to educate people regarding God's Law. I
have learned a great deal from your show, and try to share that
knowledge with as many people as I can. When someone tries to defend the homosexual lifestyle, for example, I simply remind them that Leviticus 18:22 clearly states it to be an abomination. End of debate. I do need some advice from you, however, regarding some of the other specific laws and how to follow them.

1. When I burn a bull on the altar as a sacrifice, I know it creates a
pleasing odor for the Lord - Lev.1:9. The problem is my neighbors.
They claim the odor is not pleasing to them. Should I smite them?

2. I would like to sell my daughter into slavery, as sanctioned in
Exodus 21:7. In this day and age, what do you think would be a fair
price for her?

3. I know that I am allowed no contact with a woman while she is in
her period of menstrual cleanliness - Lev.15:19-24. The problem is,
how do I tell? I have tried asking, but most women take offence.

4. Lev. 25:44 states that I may indeed possess slaves, both male and
female, provided they are purchased from neighboring nations. A friend of mine claims that this applies to Mexicans, but not Canadians. Can you clarify? Why can't I own Canadians?

5. I have a neighbor who insists on working on the Sabbath. Exodus
35:2 clearly states he should be put to death. Am I morally obligated
to kill him myself?

6. A friend of mine feels that even though eating shellfish is an
abomination - Lev. 11:10, it is a lesser abomination than
homosexuality. I don.t agree. Can you settle this?

7. Lev. 21:20 states that I may not approach the altar of God if I
have a defect in my sight. I have to admit that I wear reading
glasses. Does my vision have to be 20/20, or is there some wiggle room here?

8. Most of my male friends get their hair trimmed, including the hair
around their temples, even though this is expressly forbidden by Lev.
19:27. How should they die?

9. I know from Lev. 11:6-8 that touching the skin of a dead pig makes me unclean, but may I still play football if I wear gloves?

10. My uncle has a farm. He violates Lev. 19:19 by planting two
different crops in the same field, as does his wife by wearing
garments made of two different kinds of thread (cotton/polyester
blend). He also tends to curse and blaspheme a lot. Is it really
necessary that we go to all the trouble of getting the whole town
together to stone them? - Lev.24:10-16. Couldn't we just burn them to death at a private family affair like we do with people who sleep with their in-laws? (Lev.20:14)

I know you have studied these things extensively, so I am confident
you can help. Thank you again for reminding us that God's word is
eternal and unchanging. Your devoted disciple and adoring fan,

Jack

It’s all about the paper

Classmates are beginning to receive and subtly (or not so) gloat about their new diplomas. They are beautiful, large and completely satisfying to look at. Hard to believe that this is what it has all been about…the paper.

The slog of medical school is certainly about learning. It certainly is about figuring out our place in patient care and the future of medical care in this country. It’s most certainly about compassion, healing and care of those in need. But mostly, it’s about the “ticket”, the paper, sheepskin,….the diploma.

Those large ear to ear grins I see from classmates are of total joy in accomplishment and surviving where many have not. And it helps to have a diploma in hand when doing so.

Can’t wait to get mine. I’ve been patient all of these years. I can wait a few more weeks if necessary.

Time flies when you are having fun!

Exactly 4 years ago today, I was getting on a plane and traveling to school for the very first time. I remember seeing my island home as we approached and wondering what would be in store. I had no freakin' idea what I had gotten myself into. Yet, here I am. I've actually survived the 4 years of school and am graduating.

A lot has happened since then with classes, course and national exams, clinical experiences and life. I've made it to the logical conclusion and graduation from medical school with an invitation to residency training for another 4-6 years, depending on my route of travel.

And so, in weeks it's here. I am almost a doctor. I've just about finished my requirements for school, all the national exams, and all the stuff that is crammed into the process. It's frightening how much I had to do to get to this point, but it's here, finally, 4 years later. Funny I don't feel any smarter.

About the only think left is having the degree actually printed, in hand and sent off for recording and certification by the appropriate bodies and organizations so I can begin post graduate training and clinical practice. It's a time of renewed fears, amazing possibilities and wonderful memories assuming I suppress the bad ones and add a healthy dose of psychotic denial, delusional projection, fantasy, passive aggression, acting out, intellectualization, reaction formation, dissociation, displacement, repression, humor, sublimation, suppression, altruism and anticipation.

It's great to be here at year #4. And I'm not sure what being an M.D. is really all about yet, but I'm hopeful I'll perhaps get a nicer table at my next restaurant reservation when I say "doctor". Nah, more likely nobody will notice. But that's ok. I survived.

Incidentaloma

And sometimes they just walk in, a bit weak, with a migraine like headache...

Neurology always amazes.

Often nothing when presenting as severe.

Less often, life changing when presenting as minor.

Inclusive Leadership

I've worked for more health care organizations than I care to remember or admit to. But while the traditional world of "gold watch" retirement scoffs at the notion of changing employers, I have found it as instructive to my professional and personal life as anything I've done including graduate school. This has been most instructive in the area of leadership and management of those organizations; The ones ostensibly directed at taking care of people. As long as those people aren't employees.

Now I certainly don't want to dismiss all health care organizations as insensitive to the people who work for them, they aren't. But there are many in the ranks of healthcare who are. And more importantly, those who believe that such treatment should be the norm. This is particularly true of larger organizations who become too large for management to comfortably adjust sensitivity into the mix. In many cases it seems that such management is part of the training of healthcare managers who see employees as little more than worker ants in their "hill", or line-up.

Every once in awhile I run into an organization that breaks the mold. One that specifically addresses the gap between employer and employee in an active, specific and dynamic way. I'm so relieved to have experienced Inclusive Management and Leadership - A type of management that deliberately includes all members of the team in the evaluation of the past, execution of the present, and planning for the future. Wow! What a concept!!

So what does that look like? I was standing at the physician's desk, working up a patient's chart and the lead physician walked over, called everyone over and created an "instant meeting" over a particular issue he needed immediate input on. I likened it to a soccer team huddle right before kick off (flashback to my goal-keeper days). An instant meeting, including everyone (including the clean up crew) to address a specific situation, and plan for the future. Can't get any more inclusive than that. Everyone had input, and everyone walked away from those few minutes feeling like they had a voice and part of the organization.

This was just the tip of the iceberg. The management has made specific (not accidental) and deliberate (with intention) efforts to include everyone. This has made created a loyalty to the organization and management that I can't even describe in this short essay.

This is a really enjoyable place to work. Everyone knows the failures and shares in the successes. Opposing points of view are appreciated and encouraged and never end up in contention, firings or retribution. Everyone has value in the working of the practice and becomes an "expert" to consult in their area. There are meetings and huddles, with the time and space to be sure that all elements of opinion are worked out and implemented as necessary. Management is about finding the resources to implement ideas not about creating top-down decisions. The lead physicians and managers are always available for drop in meetings and problem solving.

I can't tell you how refreshing this type of health care environment is and how happy the sick patients seem to be as a result. They really enjoy coming here.

Migrating to Residency

A new anesthesiologist, Dr. Kristin Forner, recently wrote an article about stepping off into the abyss of practice after residency. As I read, I contemplate the abyss of residency after medical school. I appreciate here perspective from a center of fear, and moving toward more and more comfort and calm. I've moved those stages through school to now. Being surrounded by really smart people will humble one into fear of what you don't know.

Her points and challenges:

It's important to "embrace the breath-stealing terror that comes with knowing you are it." Now that's not a reality for residents starting out, but there is no turning back into the comfort of student rotations where, one preceptor told me, "we don't depend on you for anything except to show up." There is a certain fear that comes with increasing responsibility and I see it just over the horizon. It's different than operating as a dependent anything.

She relates that we should "doubt decisions you never doubted, and invent questions you never had".  It seems that the more I learn, the more I know, the more I question. It seems to be grounded in "the more I know, the more I don't know" phenomenon. I seem to ask questions now that I've never asked before, and likely I should have.

Forner instructs the reader to "go back to the basics". This seems to be a haunting task given the enormity of the core of basic sciences that contributes to what we do every day. It seems that many around me attempt to make the practice of medicine more complicated, or more likely, they are inspired to do so by laws, rules, guidelines, directives, legal decisions, risk, liability and on, and on, and on. There seems to be a fine balance between practice that honors the basics and the addition of complexity that has become the practice of medicine.

While there is the tendency to go it alone, Dr. F encourages asking for help. It's so fortunate that the source of help has really expanded and I'm grateful for learning how to use them. There is so much information on my smart-phone, on my Kindle Fire, on my laptop in the online world...there is no reason not to check, ask, and test theory with database information of experts. I've become a devotee of "Up to Date" and other sources of quality information. I think I've matured a bit from my Wiki-medical-school approach to "asking for help".

Much of what we do depends on others. Medicine is a team sport, whether you want to be on the same team or not with the person you stand with. It is extremely important to "understand the value of knowing the people with whom you work".  Much of what we end up doing in practice is dependent on the actions or inaction of others. I've seen that time and time again as a PA. I'm sure it'll be more clear and important as a resident.  It's important to regularly identify those you can depend on to assist you when you need it most. Those reliable sources of guidance, direction, support and lead can make or break your practice.

As in life, medical practice is based on discernment and knowing what you know when you know it. She points out that it's possible that you may "actually know more than some of your older, more experienced colleagues". Being old may limit application of that perspective in my case, but I'm hopeful. I know I won't stand back "out of quiet respect" but I hope I recognize what I do know, and what I don't know. That speaks to "trusting instincts and listening to them". But then, that inspires great fear at times too.

Her last point speaks to "wanting to teach." This is easy for me. I believe that (as one supervisor once told me) I shouldn't "die with knowledge not passed on" to others coming behind me.  For me too, teaching is a learning tool and I need to get ready for a few more exams before this process is all over. I have much to teach and much more to learn.  And even in the fear, it's exhilarating to be moving forward into the abyss.

 

 

 

Thanks to Dr. F, I have more rappelling gear to get out and use.

Almost there

Graduation is coming. I can see it. I can taste it. I can feel it. There are few of us left who started this trek together, both faculty and students.

Who knew it would look, taste and feel so good.

2 more months, officially, and my folks will be able to say "my son the smiley face doctor". Whew!

Match Stats for IMGs

24,034 PGY1 spots offered in 2012 Match

Of 11,134 IMGs in the 2012 Match, 4,886 (43.9%) matched

6,828 IMG, not U.S. citizens, 2,775 (40.6%) obtained first-year positions

4,279 U.S. citizen IMG, 2,102 (49.1%) matched to first-year positions

Although majority of PGY-1 positions in the are filled through the Match, a significant number of IMG applicants obtain positions outside of the Match or pre-matched (as high as 2400 in past years)

Lecture Notes - Eating for Weight Loss

Seems so simple to eat right, until we start that migration in the back and forth loop called the grocery store. I'm struck by how little there is to eat that is really good for you and that was emphasized by a great talk I hear tonight on eating for nourishment, weight loss, health and longevity.

Besides working out every single day to assist the body musculature to burn calories and circulate nutrients, it's important to know what you have to have and what you can't have in your consumption.

Proposed possible "program" diet for weight loss (when added to exercise) with dense nutritional value:

Daily eats: nuts (Brazilian and almonds mostly, roasted ok, salt free best), dark greens (kale, turnip, dark lettuce, etc), carrots, green tea (loose coffee pressed with a small hit of agaves to sweeten, hot or cold, Japanese), whole grains (soluble fibers in oatmeal, barley, tabouli, quinoa, and brown rice) and fruits (darker, purple the better; blueberries, strawberries, grapes, melons, papaya etc)

3x per week: Oily fish (sardines, mackerel, tuna, wild salmon, black cod or rainbow trout; U.S. and fresh or frozen best; no Asian seafood), yogurt (mostly milk products and bacteria, limit extras, organic Greek), sweet potatoes (grilled, roasted, baked or dehydrated), avocados, broccoli, cauliflower

1x per week: red meat (includes chicken and pork), white starches (breads, rice, potatoes, etc), desserts, ETOH, almond milk (unsweetened)

NEVER, EVER: canned soups and stews, processed foods, fast foods, "diet" anything (especially diet drinks), regular milk (accomplice food for other foods like cookies and cakes), added granular sugar, added "processed" salts

Then benefits of loosing weight are tremendous and potentially can improve cardiac disease, diabetes, metabolic syndrome, insulin resistance, sleep apnea, cancers, etc., etc.

"Better to smoke and eat better than to eat horribly and not smoke" might be a slight stretch, but we are increasingly what we eat and it's really high time we integrate this in a significant way into our culture and our practice of medicine.

X-ray Eyes, Hands, Shoulders...

(Radiologist): "I feel like hell. My shoulders and wrists are killing me..."

I've been a scut-dog. I was one of the junior staff of a hospital radiology department (for a short time) whose sole job was to serve the senior physicians with whatever they needed. And in radiology, that meant chasing films, finding films, locating jackets, checking in and checking out films and at the most critical time...find a lost film, STAT!!

Then it was necessary to put the film on a large, floor to ceiling box with rollers to "view" the film. It could take minutes, hours sometimes to have a film read and reported to the person ordering the x-ray test. It felt like so, so much work. And it was.

Zipppppppppppppppp...

Fast forward to today. I sit in a dark room, reading radiographs with a senior at lightening speed. And we sit for hours. No chasing films, no looking for jackets, no checking or checking out....those days are long gone. No more long term x-ray storage, processing, chemicals or accounting. We read hundreds of images today that would have taken weeks before. The efficiency of radiographic interpretation and the technology is one of the greatest revolutions in my long medical career. Picture archiving and communication systems (PACS) have taken over imaging. It's all about the computer.

 

Now, a radiologist can generate so much work, they can barely keep up with the demand. Computer overuse syndromes are so common among radiologists that some wonder about the value of the average $384,421 per year salary they can receive in exchange for the lifetime of pain in the shoulders, elbows, wrists and hands. The pace is fantastic and it's truly amazing to watch a modern radiologist "whir" through the day.

I walked away today, as other days, with a total "oh wow" experience and an ah ha moment that I could never sit in a dark room, for hours and hours on end, with little human contact, reading radiographs with little insightful information about a patients history, physical exam or differential diagnosis. And a little carpal tunnel to boot.

(Radiologist): "I feel like hell. My shoulders and wrists are killing me...but for $8,000 a week, I'll figure out a way to make this work"

Humbled, again

What a great day of learning!!

It's difficult to go very far in medicine, and not encounter people who are way more smart; filled with retained information, facts and experiences. It seems to happen regularly for me, but sometimes it's just more profound than usual.

Such was the other day, standing at the X-ray box.  And while it's not really a "box" anymore (my grasp at historical anchors), the experience is no less profound. Maybe more so given the technology and "wow" factor.

But the impressive thing to me is that I'll never have those 20-30 years of experience that create profound insight into a craft. That daily slog through medical care, and moreover, dealing with the failures and complications, brings a level of knowledge and skill that cannot be duplicated any other way.

And when one person who has attained this pinnacle shares it with me (or pimps me), I am so, so humbled. And so sad that I there aren't enough days in my career left to attain that. I should have started earlier is the only answer, but "shoulda" doesn't really cover it enough.

In any endeavor in life, practicing the craft is everything to becoming truly facile with the information and application. It's true of fine furniture makers, and true of physicians. The practice is what it's all about. And the more you practice, the more you have to give.

Great knowledge is learned at the X-ray box...uh, I mean the triple screen, color, high definition PACS display unit with the IPad controller and animated 3-D integration technology.

Matched

It's simple. It's straightforward. It's almost inane.

"Congratulations, you have matched".

That's mostly what it said and now we just wait until Friday to hear of the "where" of the equation. There's no telling where it'll be or when it'll start, but knowing that this phase is over is wonderful to know. It's been a strange, at time difficult, amazing journey so far these past 4 years, but it's literally the beginning of the second 1/2.

This is likely going to be an amazing time filled with new learning, new levels of responsibility and renewed view of the past, present and future. It's the thing we have been working for and what it's really all about.

But like any "match", it could be just the beginning of a new fire.