Relief

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

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

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

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

Amazing Stories - A break from study

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

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

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

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

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

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

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

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

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

Time to Study Again

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

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

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

I'm certainly out of mine.

And there it is

One simple word "fail".

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

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

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

Feels pretty sucky though.

Almost Here

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

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

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

One more week...

Dutch Health Themes of Service

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

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

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

The Spill That Keeps on Giving

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

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

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

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

What a tragedy.

Impulse

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

Getting Closer

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

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

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

The Trek

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

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

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

USMLE Solo

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

Drowning is NOT an option.

The Placebo Effect

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

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

RESCUED!

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

OOH "Out of Here"

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

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

Happy Kingdom Day

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

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

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

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

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

Never Saw it Coming

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

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

It never is, is it?

The Mind Protects

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

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

Respect and Stuff

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

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

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

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

 

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

Privacy

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

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

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

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

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

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

HIPAA Privacy; apparently, just a formality.

Competent Culture

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

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

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

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