Transition

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

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

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

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

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

True Self

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

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

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

Learning...Next!

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

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

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

Remiss

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

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

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

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

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

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

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

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

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

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

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

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

Some good applications in life too.

I'm BAAAAACCCKKKK!

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

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

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

Breaks

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

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

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

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

It is finished, almost

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

40 Years

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

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

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

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

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

Meteors

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

Finals and Storms

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

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

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

Leash Laws

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

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

The End of the Season

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

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

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

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

Quiet Weekend

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

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

I remain open to the possibilities.

40 something

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

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

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

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

It's Coming - Hide the Kids

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

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

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

Ran Out

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

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

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

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

First Case of Swine Flu

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

Harrison's Textbook of Pain and Punishment

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

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

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

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

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

Back from break

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

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

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

Happy Father's Day

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