Greatness Prescription

We all with for mentors in life that embody all of the characteristics of greatness to observe and emulate. Sure greatness is a perception of one's self, but it is a composite of learned skills and discipline that provides the pathway to, even private, greatness. I see those characteristics in the many medical professionals around me: colleagues, administrators, attending docs, nurses, physician assistants, pharmacists and other health care professionals. I've even seen it in the non clinical staff...campus security, maintenance, housekeeping folks. Some of those characteristics I've noticed:

1. Relaxed confidence - It's both in skill and emotional maturity that relaxed confidence exudes. More than a look or feel, it allows one to think logically, respond appropriately and overtly remained balanced in this unbalanced life.

2. Knowing what's really important - Se never learn this skill in school but some learn it on the street or at home. It's the ability to honestly follow one's heart, mesh it with education and experience, and figure out what's really important. More than anything, this allows releasing anger or frustration for those thing that aren't really important.

3. Focused activity - I've heard it indirectly referred to as "doing what's important" but it's really doing those things that feed what's important once you've identified that (see #2). When we become in "other" things we are distracted from the path to that success we seek.

4. Play - You've heard work hard, play harder? Well more than having the capacity and finding the time to play, it's also about seeing the fun in the everyday. It's easy to focus in the negative and what's wrong, but when we consciously understand that bad stuff happens, and deliberated search for the "present(s)", the good, the playful, the fun... our whole outlook improves and we become better at playing in the off time.

5. Positive expectations - A program director MD has never complained about what's not. But he constantly searches for ways to positively identify what's possible in the future. His expectations are verbalized in his statement of every problem that arises, offering solutions and positive outcomes as a probability.

6. No excuses - "I couldn't because..." is not helpful. Identifying what needs to be done and understanding our limitations, expressing them to others, is conquering over ego and stubborn pride. Excuses are mental obstacles that keep us in the past.

7. Balance - Life at home, work, play, gym, eating etc...all in balance. If it's not "peaceful" than you are out of touch with what's the right reality for you (from a nurse who smiles all the time).

And so it is, I've got lots of work to do.

Viral something

Yep, you got the flu or that flu like thing or could be flu lite or viral this or that.

Yes, could be plague or burbonic or consumption, or rheumatiz. Sure could be the blight too. What? You saw the river "part" on your way to the hospital? Ya, amazing.

Nope. No antibiotics. Just lots of fluids, a hot water bottle, chicken soup, ibuprofen or tylenol for aches and fever, sleep and time in bed...time.

And throw away your toothbrush when you start feeling better.

I know. I got the vaccination too.
Bless you! Oh, that was a cough? I take back the blessing then.
Don't want to waste those.

Flu-like what?

Sick Kids

Pediatrics is a funny place. Mostly I have found we just humor the parents until the kid gets better. Expectant hand holding, saline mist, bulb suction, and lots of talk about poop, wet diapers, vomiting and breast feeding. Any people get paid for this?

But every once in awhile, a really sick kid comes in and the real art comes in. I'm blessed to have seen some really keen artists practice this craft, separating the patient from the ranting parent, and actually make a cool diagnosis and heal sick kids. I gain greater respect for pediatricians every single day.

God bless YOU!

A room full of doctors. One sneezes. Several say "God bless you". The sneezer says "thank you". All totally without thought, automatically. For those who claim to practice evidence based medicine, there is little evidence that saying "God bless you" provides any healthful benefits that we know of.

History says we have been saying "God bless You" since about AD 77. There are lots of theories where this came from and no real consensus on the origin. Could be from the lavish blessings Pope Gregory 1 in AD 590 ordered to fight the bubonic plague when sneezing was thought be an early sign.

Or it could be to bless a person to prevent the soul from being thrown from the body during a sneeze....a shield against evil. Another theory says that saying "God bless you" restarts the heart, thought to stop during a sneeze. Or maybe, it's just a reaction to feeling like you have to do something when you don't know what to do or say.

So next time I hear "God bless you", I'll know the plague is prevented, the soul is retained and the heart will continue to beat.

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**Level I: Scientific evidence is lacking, of poor quality, or conflicting, such that the risk versus benefit balance cannot be assessed. Clinicians should help patients understand the uncertainty surrounding the clinical service, and stop saying it around other clinicians.

Slavery, today?

It is hard to believe that it still exists. Millions of working "slaves" in farming, domestics, manufacturing, sex trade and other industries around the world today. All forced to work without basic rights, compensation, freedoms or care. All ages, all continents. Struggling to find a way out but feeling there is no help. But there is help.

January is National Slavery and Human Trafficking Prevention Month. It is our duty to identify and stop human trafficking in the world.

Distress

Studies have shown a higher lifetime prevalence of depression in those who go through medical training, perhaps as high as 30%. With propensity, family history, genetics, prior history or other precipitating factors, maybe higher. Choose the wrong specialty, location, or institution and the chances are good it will ensue.

Is it any wonder why I see so many unhappy people around me?

Learning to Fly

Imagine you are learning to fly a very large, passenger plane. You aspire to be the captain and make the daily decisions to fly and (hopefully) land the plane. You start with smaller planes and work your way up over time. But imagine after getting your private pilot license in small 2 seat small planes, your instructor, who has never seen you actually fly the plane, hands you the keys to a 747 and says "have a nice day". He assumes you know everything there is to know about flying because you finished entry level pilot school. And assumption that will likely be fatal to you and everyone on board.

I don't want to be dramatic, but that is essentially what often happens in residency training programs where the instructors are as lost as I am. Professional medical educator often make assumptions and are so lazy they can't begin to solve the problems at hand and truly mentoring and training future medical professionals. Now I know they are all not like that. And I know many who are extremely good, but I am dismayed at the number of inferior faculty members in medicine today.

On several occasions I've been "handed the keys" without a word of education, mentoring, direction or anything resembling teaching and told to "start the engines". Nothing quite 747ish, but certainly in a class I've never flown before. Assumptions of my skills, knowledge, education, morals, ethics, decision making, memory of clinical practice guidelines (checklists to the pilot) etc have been largely "assumed" inaccurately and brushed off with a "well you went to medical (flight) school, didn't you?" I've been careful, I've plodded through each situation with care, but not without error and certainly not without trauma (to me especially). The system, at least my part of it, is very broke.

If other industries worked as ours does, the country would be in shambles. Planes would fall out of the skies as pilots, who never practiced on a simulator or in an otherwise safe environment, muddle their way through piloting encounters. Vehicle accidents, caused by police/fire/EMS driving fast to calls, would be common as drivers muddled their way through it without the benefit of an emergency driving course or similar. You get the idea. We gain expertise by mentored practice and infusion of knowledge working first in safe environments with simulators, training courses, etc. Not on people.

This is silly. This is dangerous. It was the best of time, it was the worst of times. And I have to go back to the planes tomorrow. I doubt I'll even be greeted by a hello, let alone meaningful teaching of any kind. But I'll do my best to park the 747 and not hurt anyone. Particularly me.

Public Violence

Another day, glued to CNN, watching a tragedy unfold. A small town. A small elementary school just weeks before Christmas and the New Year. There is not going to be any explanation that will make this event understandable on any level. Certainly not for the parents of one of the many children killed. The grief of the parents can't, won't be understood.

As time begins to reveal the true scope and causes much discussion will ensue about how to protect public buildings in the U.S. from this type of incident. Imagine a mentally unstable individual, dressed in camo or black fatigues, with a bullet proof vest on, armed with several weapons, gaining entry into any public building...determined to do harm. What really must we do to protect many from the one or two? This happens so quickly that even with armed officers on the premises, tragedies like this will happen.

I don't even pretend to have any prevention answers but the answer is not in gun control. We are well beyond that and this is more about people control. The real prevention must come at getting better at hearing and heeding the warning signals that may have preceded this and other tragedies. Threats, notes, comments, texts, tweets and other communications often precede such events and foretell that "something" is going to happen. Prevention is pro-active and requires investing time and resources. But it may be our best hope. Although I realize, there is no real way to totally prevent this from happening ever again. And likely it will. So, so sad.

My "parental" heart goes out to all those families who are grieving the very pre-mature loss of their children as well as those who have lost adult victims in this tragic event. CNN is reporting "closer to 30 killed at school" but it is still unfolding and the victims families are in the process of hearing for the first time that their child won't be coming home.

Brain Food

I wonder if brain food will help me get through this...

1. Fish: Herring, salmon, tuna, mackerel, halibut, anchovies, sardines & other cold-water fish

2. Soy: soy milk, tofu

3. Colorful and citrus fruits: avacado, cantaloupes, watermelon, tomatoes, plums, pineapples, oranges, apples, grapes, kiwi, peaches, cherries

4. Berries: Blueberries, Elderberries, blackberries and raspberries

5. Cruciferous and leafy green vegetables: broccoli, cabbages, kale, turnips, Brussels sprouts, broccoli, collard greens, cauliflowers, radishes, spinach, onions, red peppers, lettuce, carrots, asparagus, okra, mushrooms, broccoli and sprouts

6. Chocolate: Dark chocolate

7. Nuts

8. Whole grains: whole wheat, wheat germ and bran (folate), oatmeal, brown rice, whole-grain breads and cereals, barley and popcorn

9. Peas, lentils, green beans, lima beans, black beans, kidney beans, and a variety of legumes

10. Sage: oils and tablets

11. Spices: curry, tumeric, curcumin

12. Tea: Green and black

13. Eggs

14. Calcium-rich foods: Yogurt, cheese, milk

15. Iron-rich foods: Lean red meats

16. Complex Carbohydrate-rich foods: grains, nuts, sweet potatoes

17. Supplemental: Gingko biloba

18. Water, water, water

Here we go again. I  hope 2013 brings more sanity to this process of learning. That is of course if I survive the Mayan Mayhem and 12-21-12, 12:21:12 am and pm.

And, prayers for our country and the parents of the children killed in Connecticut. So sad.

And So It Begins, Again

I had hoped I awoke post 12-12-12 at 12:12:12 am or pm with the awareness that my world had died and I had been transported to a time and place where peace reigned through the kingdom. Nah! I'm back on a too-cramped airplane to a too-damn-small airport and taking care of patients in residency. I can't think of a more painful experience except maybe having my eyelids pealed back over my forehead. Oh wait, that happened too.

I'm not backward, ignorant or a naive trouble maker. I'm not psychotic, paranoid or anxious. I'm not angry and have no grudges. But the system I return to is broke, bad. And I hope at the end of the day, everyday, I don't hurt someone.

End of Days

End of days?? Yay!! 

The story of the end of the world is fascinating and goes something like this Cliff Note summary.  Apparently the Sumerians of days gone by discovered the planet Nibiru and they surmised it was heading toward Earth. It was supposed to make impact with earth and destroy everything, including the midnight grill at the hospital, back in May 2003 (remember that?). Obviously it never happened and I started medical school and residency. So the owners of that cosmic thought shifted the date to this month.

Why this month? Conveniently the end of days event was linked with the end of one of the cycles in the ancient Mayan calendar and the winter solstice on 12/21/12. And I for one, am thrilled about the possibility of total destruction of residency and the medical system that we know and love as well as obliteration of all past memory of failed relationships, bad meals, even worse instructors, lousy chief residents, lame exams, pimping, aging, passive weight gain, car troubles, parking tickets, famine, pestilence, war and terrible frozen yogurt flavors. We, or at least I, really need a do-over mulligan.

I have absolutely no clue about Nibiru or the end of days. NASA says the planet doesn't exist and I believe the guys who put a remote control vehicle on Mars. But I am very excited to know of the possibility of total destruction or anything that will prevent me from cleaning my bathroom one more time. Peace be with each of you time travelers. May your cosmic journey be a safe one; Because I know who's on call in the ER and it won't be pretty. 

Namaste.

Inversely Proportional

I didn't discover the connection, but seem to be living it now.  On a daily basis I can't believe how much emphasis is placed on memorization in medicine. It's rewarded, encouraged and even used to flagellate others in person. It is clear to me though that the relationship is present. As the need for memorization increases, understanding decreases proportionally.

There really is no need to memorize the genus and species of microbes, or the pharmacological reactions and actions that can be easily looked up. Portable technologies and the references they provide have changed the game in clinical practice. The world of information is at our finger tips and accessible. I don't need to know the Krebs Cycle. I need to know how to use it in taking care of my critical patients though. When will medical education move from memorization to that of focus on understanding with the user end point in mind....medical practice.

The use of information is much more important that memorizing it. Yet that is the emphasis found on exams in medical school and on national boards.  The emphasis on memorization in many ways determines our future by selecting out memorizers from users of information for residency based on test scores.

The reality is that medicine is controlled by memorization and performance on exams, guided by results on Step USMLE. Performance on that exam is, for the most part, the determining factor in residency selection. And that system isn't going away easily with the multi-millions that system makes.  Exam, boards and pimping performance (hallway pop quizzes perpetrated on unsuspecting learners) is the core of how medicine teaches and expect learning. But is it really learning at all? Is it really providing insight and apprenticeship to the insight of knowing how to apply the knowledge memorized?

We need more formative and summative assessment that is "application" based and less memorization based exams in medicine. We need a return to a real apprenticeship system that values moving knowledge from teacher to student in clinical practice with application in mind. As a colleague recently wrote, "medical education is failing us" all, both practitioners and patients. It has certainly failed me and gutted my passion on so many fronts.

Terror : Part of Public Health

Imagine riding a bus in Atlanta, Miami or Denver. You are going to the mall to meet your mates and hang out. About 10 minutes into your ride a "blast" rips through the bus throwing you backward. You cut your face on glass, the back of your head on the post behind you. You can't hear clearly due to the blast "ring" in your ears and you are bleeding profusely all over yourself. Your new boots are ruined. You can't find your smashed cell phone on the floor 10 feet back. The man sitting in front of you is more injured and unconscious.

That's sort of what happened in Tel Aviv today. I don't have a dog in this fight. I have no family or political ties to Israel or the Gaza Strip. But it's difficult to imagine living that way; living the reality that rockets are falling from the sky and buses can blow up at any time. This is the reality in Israel today.

And that made me wonder why my Syrian born colleague (a foreign/international medical graduate or FMG/IMG), gaining a great future in medicine training in the U.S., pondered out loud about the "villain and murdering Israelis". Why is it that some believe there should be equal mayhem and death on both sides for there to be a fair fight. That's what he explained.

So I asked our campus police, an officer at a nearby table at lunch..."Does engagement with a terrorist require that the police lose as many officers, killed, as the terrorist they confront on the street?" He laughed. And I already knew the answer. Defense of freedom, justice, democracy and rule of law does not require fair. It requires "superior force" to stop the aggressor. Center mass stops. That is what the hospital police officer said.

It is regrettable that modern terrorist organizations use civilians as shields to deploy arms. As careful as any protective force can be, injuries and death to civilians will then happen. I hate that part about modern warfare viz. a vie, Iraq, Vietnam, Afghanistan etc etc. It's the reality of urban combat and there are no easy answers. But let's not confuse who the aggressor and who the protectors are in any such conflict.

My Syrian colleague and I will remain colleagues and I trust him not to blow up the hospital. I'm not sure my colleagues in Tel Aviv today feel the same confidence in their neighbors. I pray this Thanksgiving for peace and rational clarity at what is really happening in the Middle East and in many corners of the world. I'm thankful for many things, but in this day, I'm very thankful for "superior force", a center mass mentality and safe bus rides to the mall.

Public Health: Terror

Some Stuff I Learned & Read

1. Take a 10-30 minute walk every day. And while you walk, smile; the ultimate anti-depressant.

2. Sit silent for at least 10 minutes each day. Talk to whatever God is for you. Buy a door lock.

3. When you wake up complete, 'My purpose is to____ today. I am thankful for____'

4. Eat more foods that grow on trees & plants and eat less food that is manufactured in plants.

5. Drink green tea and plenty of water. 

5a. Eat blueberries, wild Alaskan salmon, broccoli , almonds & walnuts.

6. Try to make at least three people smile each day.

7. Don't waste energy on gossip, the past, negative thoughts or things you cannot control.

7a. Invest energy in the positive present moment.

8. Eat breakfast like a king, lunch like a prince and dinner like a college kid on a budget.

9. Life isn't fair, but it's still good.

10. Life is too short to waste time hating anyone.

11. Don't take yourself so seriously. No one else does.

12. You are not so important that you have to win every argument. Agree to disagree.

13. Make peace with your past so it won't spoil the present.

14. Don't compare your life to others. You have no idea what their journey is all about.

15. No one is in charge of your happiness except you.

16. Frame every so-called disaster with these words: 'In five years, will this matter?'

17. Forgive everyone for everything.

18. What other people think of you is none of your business.

19. GOD heals everything - but you have to ask Him.

20. However good or bad a situation is, it will change.

21. Your job won't take care of you when you are sick. Your friends will. Stay in touch!!!

22. Envy is a waste of time. You already have all you need.

23. Each night, complete "I am thankful for______. Today I accomplished_____."

24. Remember that you are too blessed to be stressed. 

25. When you are feeling down, start listing your blessings. You'll smile.

26. When in doubt, start with #1 again. Repeat often.

27. Listen more to your heart, gut and less to your head.

Professional Education

There is a science called education.

There is a psychology of communication and information.

There are well tried adult learning tenets.

Medical educators, for the most part, don't know them & don't practice them.

Happy Diwali Fall Festival

Happy Diwali to all of my Hindu colleague brothers and sisters!
सभी मेरी कत्थई भाइयों और बहनों के लिए हैप्पी दीवाली!
For Hindus, Diwali is one of the most important festivals of the year and is celebrated in families by performing traditional activities together in their homes. Diwali marks the attainment of moksha or nirvana by Mahavira in 527 BCE.
Studying and working with many Hindus these past years, Diwali has become part of my Fall Thanksgiving celebration. We should all attain Nirvana and celebrate life and "colors and many sparkles" around us.
Happy Diwali - हैप्पी दीवाली

Gender Regrets

I don't have many regrets in life. I don't regret things I've done that have failed; Still learned. I regret not doing medical school earlier in life. But I don't regret the decision to go late in life. But today I have a new regret.

Where I am, medicine is a man's world. It's dominated by male attendings and women who think they are men or have to make pretend they are periodically. So when a female joins the ranks, you tend to notice. Such was the case recently when a new medical student joined rounds with us boys.

There she was, 5 foot something, with curves from her pony tail to her painted toes all reddish-blonde with a cute Southern accent. All the boys made sure they mentored, led, guided and pimped her. She got more attention than the last Krispy Kreme donut in the nurses break room. She remembered kool little factoids about medicine from her recent reading and studying for Step 2 and was sure to walk briskly with the attending so everyone behind could see her, uh, ya...see her. The boys loved it. I didn't get spoken to, pimped or looked at the whole day. I got no new patients and didn't have to present the few I had. There wasn't time. She was there.

So my regret? I regret not being born reddish blonde, 5 foot something, with curvaceous curves, a cute Southern accent and a decent memory for medical text factoids. Maybe my next life?

Uncertain Certainty

"The problem in medicine is, the body is complex and our knowledge is incomplete. People who want certainty – physicians or patients – are kidding themselves"

The patient perspective is sometimes sobering.

E-patient Dave deBronkart, writing online from the patient's perspective, grabbed my attention with "Expecting Doctors to be Perfect is a Setup for Dysfunction"

And the corollary from the e-doctor perspective is "Expecting ourselves to be perfect is dysfunctional", yet it is the core of performance in post-doctoral training. And with so any being intellectually perfect, the stakes are higher and more significant.

Mr. deBronkart quotes a study involving after death autopsies stating that 10-15% of "cause of death" and "final diagnoses" are actually incorrect. I'm not surprised. We have so much technology but so little real insight into disease particularly when it involves multiple systems. It's not that we don't care, or don't want to do good...we do. But..."the body is so complex and our knowledge so incomplete" that we can't be certain at all.

But the system deals regularly in absolutes, teaches great certainty, extolls the virtues of greater insight into our belief system. It's a mismatch with the true reality of what is. And it's what makes learning in this bad system even worse. I'll go out and do my best today, with the limited knowledge I have, about the complex systems we deal with, and try to make sense of the environment that creates uncertain certainty. At least, I'll certainly try to be as certain as uncertainly possible. Of that, I'm certain.