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

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

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.