There Be Dragons Here

I can't say I've gotten hooked, but I will admit to having become fond of the television show, Criminal Minds, about a team of FBI profilers who attempt to unravel the criminal mind from week to week. For one thing, it's refreshing to see a depiction of psychiatrists and psychologists that doesn't place us in compromising positions. For another, I enjoy their portrayal of what it means to "look into the darkness" of human experience and struggle with its effect on the characters.

I've was thinking about my post yesterday when I realized I ought to own up to my proclivity for drawing attention to problem areas within relationships. It's an occupational hazard since, most of the time, people don't come to someone like me when things are going well. It's true, former patients will drop by or write to let me know how they're doing, but that's different. When we first meet it's because they aren't doing well.

Sooner or later, if you've done enough of this kind of work, you start wondering if there might a way to "head things off at the pass," and engage in some preventative care. Wellness is what we call it in medicine, i.e. taking better care of oneself, eating right, and getting proper exercise. The same things our mothers told us would keep us as healthy as great, great, great granny, who outlived five husbands and is still playing golf in Florida.

The thing I've discovered is most people don't intentionally get themselves into a painful situation. Willfully, yes, in the sense they've made their own choices, but not intentional in a way that suggests they always knew what they were doing. In retrospect, they see it, but in prospect, they didn't and came to wish they had. When I'm not helping pick up the pieces, I think about those things and try to put them into words a disinterested party might read and say, "Mm, that makes sense." It's my way of looking into the darkness, placing a light at its brink, and to paraphrase Dante, saying, "Weary traveler, beware, there be dragons here."


(Creative Commons image by kizette via Flickr)

Good Girls and Bad Boys

If you hang around men long enough -- I've been doing this all my life, by the way -- one question that almost inevitably comes up is, why do some women date guys the rest of us guys wouldn't have as a friend if we were paid for it. Another way of putting it is, why do really nice women seem to end up dating first class jerks (and being miserable) when they could have someone like us (and be happy)? Something tells me if I really knew the definitive answer, I could write a book and finally afford that condo in Aspen. As it is, I have a couple of ideas, and fool that I am, I figure why not give it a go?

First of all, I don't think most women set out, consciously and deliberately, to land a jerk. Instead, they'd like someone who, among other things, is interesting, relatively nice looking, and comfortable with himself. In short, he exudes confidence and seems interested in them. At this, bad boys excel, at first. The trouble is, arrogance can be very good at masquerading as confidence and the attention these types offer lasts only as long as it takes to turn the conversation toward themselves. By then, however, a woman may have convinced herself the fellow she was initially attracted to is hiding, shyly, beneath the bravado and all she has to do is uncover him.

It's possible to spend a long time -- perhaps a lifetime -- digging. Wedding bells ring and children come along, while she's gone through spade after spade and keeps coming up empty-handed. Meanwhile, all the good guys she could have dated have either moved on or, if any are still footloose and fancy-free, she's wondering why they couldn't nab her attention. We wonder that, too.

Partly, it's due to the fact that nice guys don't generally present much of a challenge. Because they're nice, they're approachable, genuine, and considerate. Us guys like them because they're easy to get along with. Women also find them easy, though in a different way, and this is one reason why they say nice guys finish last. Women generally prefer men who are worthy of them, and since they don't wish to appear overly-eager, they don't want a man who's standing next to the boat with the net in one hand, placing the hook in his own mouth with the other. Too-easy-to-catch looks too much like too-fearful-to-stand-up-for-yourself, and if a man can't do that for himself, a woman doubts his ability to do it for her. Women like courage.

A "bad" guy is a wild horse waiting to be tamed for the woman who finds the idea of being the "horse whisperer" an ego boost. Others enjoy basking in the radiance of his manliness, on the odd assumption that manliness is demonstrated by being a butthead. It's really not, but it fits a certain stereotype. There is also the stereotyped nice guy with a raging bull underneath all his respectability. Neither one would most of us men want for a friend -- they just aren't trustworthy.

So, where does this leave us? Not too far from where we started, actually. It's a real dilemma. It helps a great deal if a guy can develop some confidence and learn how to use it to his advantage. One way is to practice not being desperate. I'd suggest a guy work on his "I find you attractive but that doesn't mean I need you" skills. A woman who's got to have a bad boy won't be satisfied with anything else, so don't waste your time or hers. The one you want is the one who wouldn't mind at all being with a good guy -- just so long as you don't have to lean on her in order to stand on your own two feet.


(Creative Commons image by Toni Verd via Flickr)

Baby Steps: Knowing Where to Start

"I don't know where to begin," she said, "so much has happened. It gets jumbled together in my mind, you know, like those rock polishing machines? You've seen them, haven't you? No? They have a little plastic container about this long and this wide (she gestured with her hands), and you drop rocks into one end, add water, and seal it up. Turn on the switch, the container rotates, and the rocks get polished by bumping into one another. My problem is, I don't know which rock to choose."

"It's hard to figure out where a story begins," I said, "especially when we're midway through. Sometimes it helps to start right there -- in the middle, where you are -- and then we can pick the other 'rocks' as we go along."

Feeling frustrated or confused about where or how to begin, is something with which most of us can identify. I came across a wonderful piece of advice the other day from Forrest Church, a Universalist minister in New York. "Our lives will end mid-story, so why not begin there? Don't wait around for the perfect starting pistol. Or until you are ready. You may never be ready. No reason to wait in the grandstand for some official to guide you to the gate. Jump the fence, Enter the race in the middle. Here, now, as you are, doing what you can, with those who are closest to you. By turning the page."

There's nothing so paralyzing, I think, as the feeling that you can't make a move until everything is just so. The stars have to be in perfect alignment, we've got to do this or that, and when we're finally ready, the opportunity has passed and we're wondering why we delayed. I'm not suggesting one ought to be precipitous, careless, or impulsive, but neither do we have to rewind our lives and find the point at which things went wrong in order to change direction. Wherever we happen to be in life is a good enough place to start the process of change.

One of the rules of prescribing medications for older adults is "Start low, go slow." In other words, start at a low dose and increase it slowly because older adults metabolize medications less efficiently. It has to do with the aging liver. The point is, when making changes in our lives, it doesn't hurt to begin with small ones and move deliberately. That sure is less stressful, and when we're contemplating change, it's stressful enough as it is, right? Why not cut ourselves a break, take life one day at a time, and eventually we'll get where we want to be. Baby steps: sometimes that's how we start.


(Creative Commons image by hojusaram via Flickr)

Thoughts on Familiarity

They say you never really know a person until you live with them. They also say familiarity breeds contempt. It was while researching the authorship of the latter (Aesop, from one of the fables) that I came upon a blog post in which the writer hinted the offspring of familiarity just might be a factor in the high divorce rates in this country. He went on to mention a citation from the New Testament, "a prophet is not without honor, save in his own country," as exemplary of the ways in which knowledge of a person can diminish an appreciation for their uniqueness.

At first, I wasn't sure what to think of his application. Contempt often finds a place in the litany of reasons for divorce, though usually in the sense of one or both parties feeling angry and resentful. Then I thought about "familiarity" and I've decided the writer has a point. When familiarity is taken as the tacit assumption that we know all there is to know about a person, or at least all we need or want to know, it can lead to boredom, dislike, or dismissal.

The most vibrant marriages I've witnessed, over time, were those in which both partners never seemed to cease being surprised by one another. They possess an ongoing curiosity about each other, the anticipation that there's always something more than meets the eye. You could describe this as mystery, though not at all in the sense of things you wished you'd known before you said "I do," that come round to bite you in the back 20 years down the road. It's more the sense that the person before you has depth and character and discovering how they unfold from day to day is an adventure.

In my experience, mystery is strongly related to good relationship chemistry, and unfortunately, chemistry is something that's either there or it's not. I've never found a way to put it back into a failing marriage if it was never there in the first place. Growth, however, is something to which we can contribute, and we do that by having some interests that are ours alone, as well as the ability to meet our own needs for self-esteem. Persons who rely on others as resources for self-esteem or to provide opportunities for growth, tend to wear partners out fairly quickly. If the energy for partnership isn't mutually derived, eventually the well's going to run dry for somebody.

Where there is good, solid chemistry and the feeling that a relationship is pregnant with possibilities, familiarity breeds comfort. It helps create an atmosphere in which mutual exploration is welcomed and embraced. It helps create security and an environment conducive to growth. Familiarity breeds contempt in relationships when it's been earned and though it doesn't always have to be that way, sometimes it turns out that way.


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A Side Trip into the Social Graces

"Different muscle groups," that's what a personal trainer would say, "You're using different muscle groups -- ones that don't usually get this kind of treatment -- and they're reminding you of it in no uncertain terms."

I don't have a personal trainer, just so you know. I couldn't afford one on a medical student's salary (student loans) even if I wanted one. But I imagine that's what s/he'd say when I got to the gym complaining of pain in my middle back along a line connecting the lower tips of my shoulder blades (inferior angle of the scapula, in technical terms). Of course, s/he would be right, that's precisely what I'm doing, using those muscles in ways that leave me tossing and turning all night, looking for an elusive and seemingly non-existent comfortable position.

All of this comes about from holding my arms in the 10-2 position during Saturday evening dancing class. More than that, it's holding them at angles that force my back into rebellion, while reaching for partners who are considerably shorter than me. When I first began this side trip into the social graces I was glad my dog and I walk as much as we do, because it renders the cardiovascular workout that is an hour on the dance floor, no problem. It's the skeletal muscle issue that's forcing me into new territory.

Now, this works on a couple of levels. For one thing, I tore a medial collateral ligament in my left knee a few years ago, at the same time ripping a tiny piece from my medial meniscus. Both healed nicely, but standing or, as the case may be, dancing on hard surfaces for extended periods, tends to aggravate the old injury. Couple this with the muscle pain, the morning after class I feel more like I've been playing football rather than tripping the light fantastic.

As a result of it all, I've got to get in shape. I figure practicing while holding weights in each hand will strengthen my back and remembering my knee brace will take care of the lower extremity. I can probably leave my shoulder pads and helmet at home, unless the instructor decides we need to learn a few Patrick Swayze (Dirty Dancing) moves. If that happens, we will have shifted to the arena of "contact" sports, in which case, I just may need some extra protection.


(Image of unknown licensure via Wikipedia)

Wearing Yoiur Own Skin

Whoever invented the concept of putting captions on T-shirts has got to be lying beneath an umbrella -- on their own beach -- on their own island -- off the coast of Tahiti, wearing one that reads, "Made in the Shade." I don't know where all this got started (probably California) but there are some phrases I dearly love.

"Don't trust anyone under 14,000 feet" is a quote I've worn, and worn out T-shirts bearing it, for years. The words surround a map of Colorado with all of the peaks marked that meet or exceed altitudes of 14,000 feet. It's a humorous way of calling attention to one of the assets of which we are most proud.

Here's another: "It's not the pace of life that bothers me, it's the sudden stop at the end," from a No-Fear T-shirt. I think that's great and it's perfect for medical students. It reminds me of the lyric from an old country song, "going 90 miles an hour down a dead-end street."

"Wear Your Own Skin," a piece of sound advice offered by a T-shirt-clad stranger standing on a street corner, reminds me of a chance encounter last night at dancing class. I've been sick the past two weeks, as you know, and didn't think it was right to show up, coughing, hacking, sneezing, and passing along virus particles to anyone who had the misfortune of being my partner. So, I've stayed home, hoping I wouldn't forget everything I'd learned in the meantime.

There were several new members present, two of which, it turns out, are doctors in the area. What tipped me off to one was the fact that she kept checking a pager at her waist -- doctors are wedded to their pagers, even when they're supposed to be having a good time. While she and I stood talking in the middle of the floor, oblivious to the fact that the music would be starting momentarily, the other, a physician-in-training, came up and introduced herself. In a matter of seconds, we were chatting like we'd known each other for years.

I love medicine and this is one of the reasons why. It creates an instant community among persons who might ordinarily have little to say to one another. Both of them had studied internal medicine, and of course, my area is psychiatry, but they valued the role of psychology in patient care and I'd had experiences that paralleled theirs with medical patients. I imagined we must have looked funny to the rest of the dancers, our little circle of animated conversation moving to its own unique rhythm. But it made my night and we all made new friends. Dancing class has been fun and I expect it to be a lot more, now that there are three of us, learning together and wearing our own skin.


(Creative Commons image by swan-t via Flickr; 90 Miles an Hour by Hank Snow, also covered by Bob Dylan)

Medical School: Hot or Not

I've never really sat down and told anyone what it's been like, not only being the oldest person in my medical school class, but the oldest in every course I've taken since 1998. The truth is, I'm not sure I know, because I've never really regarded age as the defining factor in my experience as a medical student. For one thing, somebody has to be the oldest, even if it's only a matter of having been first out of the birth canal by a few seconds. It just so happens I was out and about a little earlier than the rest. For a guy who's had trouble being on time ever since, this is really pretty comical.

What I discovered right off, as the oldest, it's kind of hard to be invisible. Being over six feet tall and prone to verbal expression doesn't help; people tend to notice you whether it's intentional or not. If you're 20 something, along with a majority of your classmates, you can fade into the background. Not so for the "old guy." At the same time, this is an advantage because you don't have to worry about being memorable when it comes time to solicit letters of recommendation. You have a built-in singularity and people will remember you, for better or worse (hopefully not the case).

There are pressures associated with being the oldest or among the oldest. Since you're filling a space that would ordinarily be filled by a younger student, you have to demonstrate a genuine commitment to medicine. It could be presumed, because you're older, that you're having a mid-life crisis or merely wish to dangle your toes in the water, and since a tremendous amount of money and energy has been invested in your education, you'd better be worthy of it. Even though your presence is evidence the admissions committee took you seriously, you still have to prove yourself. There's no free ride simply because you may have been accomplished in the real world.

Then there is the question of who you'll associate with, who are going to be your friends. This is where mindset begins coming into play. If your self-image is strongly tied to your age and former social status, I think it's easy to create problems where there needn't be any. Sometimes we have to revise our ideas about ourselves to make room for flexibility. This may be highly individualized, but even before coming here many of my closest friends were younger than me, and in an environment where everyone was younger, being flexible was the only way to go, and I've had great fun as a consequence.

One question I often get is, "Don't you get treated like 'Dad' a lot?" To be completely honest, the answer is no. I don't think I'm deceiving myself here, because I've been trained to use my own emotional impressions in psychotherapy to gauge what's happening with patients. Had I chosen to act like a parent, it may have been different, but I'm not here because I haven't had children; I'm here to become a doctor just like the 25 year old sitting next to me. You get what you look for and if you expect to be regarded as a parental figure, don't be surprised if it happens. If you expect to be considered a peer and a friend and behave like one, that's generally what you'll get in return.

They say that medical school (graduate school of any sort) is a head game and whoever "they" are, they're dead right. When the going gets rough, and it does beginning day one, a person needs interior resources to draw upon. There absolutely has to be a comfort zone, a "fine and private place" within, that enables one to conceive of themselves as belonging, as meant to be here. Call it fate, desire, determination, the will of God -- we need a conviction that we're where we ought to be. Not where other people think we ought to be because of our age, gender, or any other superficial consideration, but where we know, at the core of our being, we're supposed to be. Once a person's got that, the rest is the same hard work that awaits everyone else. "Hot" or not (me).

Medical School: The Great Leveler

I wasn't exactly planning to write a series this week because, truthfully, much of what my entering class and I have gone through together these past four years is pretty provincial. They're the kinds of things one might find interesting if they'd had similar experiences, and then again, maybe not. And in fact, this morning I began an entirely different topic when the one I'm about to tackle tripped me up, demanding attention.

If you're even a semi-regular reader of this blog, you know I've talked about age in the context of medical school on several occasions. That my class was able to work through the subject so well is due in no small part to the proportion of ages represented among us. By my carefully calculated thumbnail estimate, we were about 70% under, and 30% over, 30. If I'm mistaken and someone knows the actual figures, I'll be happy to stand corrected, but I think I'm pretty close. The point is, there were enough non-traditional students to make age differences seem pretty ordinary.

That said, we still had to adjust to the idea of pluralism and this is where the educational environment actually helped us. As the great leveling influence in our mutual experience, medical school cut across social lines. Gender, age, religion or national origin tend to fade into the background when survival is the issue. Developing community is easier when everyone is overworked, stressed out, weary, and sleep-deprived.

Under these conditions, being too tired to do anything but take people as they come, enables a person to actually look at who's sitting across the table. Common concerns take precedence over perceived differences and eventually, you begin to realize the differences don't matter anyway. As long as the mutual commitment to the task is present, you come to respect, and in some cases, truly admire one another. If only the rest of the world could learn to live together as well as we did, wouldn't that be a sight?

Is what I've been describing a rite of passage? I think so. Figuring how to get past the things that render us distinct individuals and focus on what renders us similar, is something that will follow us throughout life. Learning how to accept a person for who they are rather than what we'd like them to be is one of the ways I define maturity. Looking back over four years, I think it's safe to say we became as grounded in our humanity as we have in our medical education, if not more so, and that certainly, is a rite of passage.


(Creative Commons image "Mystery is all around," by Aanas A. via Flickr)

OMM: Touching the Picture and the Frame

The Placebo Effect gets a bum rap. When you're rushing to the emergency room, as I was one night with what felt like a Bowie knife sticking in my back, you don't care about the ambiance, you just want morphine. Although I didn't know it at the time, I'd blown a spinal disk while helping deal with a psychotic patient a couple of days previously, and for all the good they didn't do, my pain medications may as well have been candy. It was the kind of pain that is so pervasive, you can't get away from it no matter what you do. Relief, to borrow from Mick Jagger, would have to be "a shot away."

It turned out, the ER I practically crawled into on my belly like a soldier ducking fire, was brand new. Between answering the intake nurse's questions with gritted teeth and wishing he'd cut to the chase and just hit me over the head, I got the impression the architect definitely knew something about the placebo effect. The decor made it clear, I'd come to the right place.

And that's what the placebo effect does: it reinforces the sense that we're in good hands. Usually, when the term "placebo" is mentioned, people assume we're talking about sugar pills. In fact, it goes far beyond that and includes such things as the physician's white coat, an efficient and empathetic nursing staff, a well-lit and organized examining room, and above all, the doctor's ability to convey confidence that s/he knows what they're doing. In other words, it promotes trust.

Think about those times when you may have walked into a doctor's office and felt like you needed a shower as soon as you walked out. Magazines in the waiting room were out of date and the receptionist scarcely looked up when she pushed a clip board toward you and said, "Fill this out." The carpets looked as though they hadn't been vacuumed in a month and not a single person smiled. You're feeling anxious before you even see the doctor and it's all because nobody paid attention to the placebo effect.

I've been talking about rites of passage the past few days, while thinking about what my soon-to-graduate classmates and I have experienced together the past four years. Some, like me, came here with backgrounds in liberal arts, and others having been immersed in the hard sciences. In both cases, we've had to undergo an alteration in thinking that enables us to view patients as an integrated persons. We've had to learn that OMM addresses physical as well as psychological dysfunction, because we can't touch the frame without touching the picture at the same time. We've had to learn to take the placebo effect seriously and use it to a patient's advantage. We've had to learn that doing so not only makes good sense, it makes for good medical practice.

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Let Your Fingers Do the Talking

I'd like to elaborate on something I said yesterday, if that's okay with you (how would I know if it wasn't? Beats me, but I wanted to be polite and include you, anyway). I mentioned that, as osteopathic medical students, we're trained to use touch in the promotion of wellness and well-being. What I didn't mention are the risks involved, not for the patient so much as for the practitioner, and this is where the water gets murky.

I can't produce the data offhand -- must have left it in my other shirt -- but satisfaction surveys consistently report that patients like working with their osteopathic physicians because of the personal attention they receive. I can't prove what I'm about to say, but I believe this is due, in no small measure, to the fact that we touch our patients. You may not realize it, but when we stand behind you and palpate the lymph nodes along the sides of your neck, for example, then run our hands across your shoulders, we're evaluating muscle tone and thus, gathering information about your emotional, as well as physical, condition.

At the same time, we're also telling you about ours -- the communication goes both ways. You might notice that we seem (feel) hurried, upset, happy, or sad by the character of our palpation, the tension in our fingers or their pressure on your skin. As much as we try to maintain an appropriate professional distance, information passes through our fingers that we can't hide. For the most part, we aren't consciously aware of what we're "saying." Nevertheless, you come away with a deeper understanding of us than either you or we realize at the time and this is reflected in the quality of our relationship.

One of my most favorite authors, Dr. Harold Searles, has written about a fascinating dynamic that can take place between patients and their doctors. He says patients have an uncanny ability to sense when, and in what ways, their doctor is in need and often endeavor to help by bringing up similar concerns in their own lives. Patient and doctor cooperate to heal the patient and in the process, heal the doctor as well. I mention this because it points out how the relationship between us, between doctor and patient, can never be entirely one-way. The element of mutual self-revelation -- conscious and unconscious -- is always present.

It is the acceptance of this risk, that some knowledge of us will be accessible to patients, that renders osteopathic interaction so very real and personal. I can imagine some of my medical school colleagues asking, what about psychiatry, isn't that the one specialty where touching patients is prohibited? Yes, it is, and for that reason we must be very good at using our other senses to reach the same goal. But Searles was writing about psychiatry, so the matter of self-revelation isn't eliminated by restricting physical contact to a handshake. The point is, using touch to evaluate and treat patients inserts another piece into the relationship puzzle and it's one of which we need to be aware.

Returning to the theme of rites of passage, OMM takes us past the obvious issue about touching another human being and into the realms of relationship and personhood. We don't dwell on what it means, this kind of contact we have with patients and one another while in training, nor should we have to. The take-home message is we're creating a relationship that goes deeper than we think, and whether we're budding psychiatrists, internists, gynecologists, or surgeons, we're actively relating even when our mouths are shut and our fingers are doing all the talking.


(Creative Commons Image by Archie McPhee Seattle via Flickr)

OMM: A Rite of Passage

Yesterday I alluded to rites of passage, those actions we undertake enabling and symbolizing our transition from one phase of life to another. For osteopathic medical students, the study of gross anatomy -- laying hands on the dead -- is paralleled by osteopathic manipulative medicine (OMM) -- laying hands on the living. Touch is not only a characteristic element of osteopathic medical practice, it is a powerful element in doctor-patient interaction. Researchers have recently demonstrated, for example, how touch is capable of communicating a fairly wide range of emotion. Learning to touch and be touched is another one of those rites of passage my classmates and I have shared.

If you were to think this should be no big deal -- people touch each other all the time -- you'd be mistaken. It is a very big deal. For one thing, most of us are accustomed to physical contact that is generally restricted to family, friends, or intimate partners. Deliberate and prolonged contact with a stranger? That's definitely something else. And when we begin medical school, even though we are classmates, we're still relative strangers. Becoming comfortable placing our hands on someone we scarcely know is as important as developing expertise with the techniques of treatment.

I imagined, being somewhat older than most and having had experience physically assisting patients, I would have an easier time with this whole thing. Did I ever have a lot to learn. During our first lab I was paired up with a younger female classmate and truthfully, I suddenly felt very shy. I tried not to let it show, but it was difficult, to say the least. I'd never touched someone in quite this way, using my fingers and palms to become aware of muscle tension, noting how the quality of the skin on the arms differs from that along the back or neck. It was really very intimate and yet, non-sexual, at the same time.

Being touched by her was just as unnerving. I'd been an osteopathic patient on several occasions, so the experience of being palpated and manipulated wasn't new. But this involved being explored in a similar non-specific manner as I had employed with her. It's hard to describe the experience; it was comfortable and yet, I felt vulnerable. Not unsafe, I don't mean that, but vulnerable in the sense of letting go of being in control. I think that's the core issue for anyone in this position and being there is how we learn to identify and empathize with our patients.

When the question is raised, what distinguishes osteopathic from allopathic physicians, the answer usually entails a reference to the practice of OMM. Although I've said that myself, it's really too mechanical an explanation. It would be more accurate, I think, to say we're trained to use touch in the promotion of wellness and well-being. Having had this experience, I sort of feel sympathetic toward MD students who don't have the same opportunity. It's so extraordinary, without it medical school would seem impoverished. As it is, we're a lot richer because of it.


(Public Domain image of students learning Osteopathic Manipulative Medicine via Wikipedia)

The Gross Anatomy Lab

The pending graduation of my entering class coupled with my own proclivity for reflection has me thinking about some of the formative experiences we've shared over the past few years. One of the earliest and very likely, most profound of these was gross anatomy. Although many of us had taken undergraduate courses in anatomy and physiology, this was the first time we would dissect a human cadaver.

It was not, however, the first time I'd personally witnessed death, having been present when my father and my mother's sister passed away. But what I found remarkable about working with a cadaver was how unlike death it was. Strange as that may sound, death, at least as I've seen it, is difficult to distinguish from sleep. When life slips away, it seems loathe to do so in a hurry, and leaves residues of itself in the texture of skin and fading muscle tone. The effect of embalming is such that all of these are removed, and a cadaver appears more like a mannequin than the remains of a person.

This is not to say dissecting a human cadaver isn't emotionally draining, because there are other things, nail polish for example, that remind you what you're about. Some individual or family, however, donated this body specifically for the purpose of teaching medical students. They intended us to dig deeply, they dared us to discover the secrets of the body they once inhabited. That's why it's here.

One afternoon in October, I stayed late to assist one of the professors in removing the brain for use in the next year's course in neuroscience. As he cut through the cranium with an electric saw, and I followed up with a hammer and chisel breaking the bone free to expose the tissues beneath it, I couldn't help recalling a line spoken by Dr. Leonard McCoy (Star Trek IV: The Voyage Home) regarding 20th century medicine, "What is this, the goddamned Spanish Inquisition?!"

Anatomy can be a brutal process and I told my professor so. He said, candidly, that was quite true; we don't have time to be gentle and sometimes it isn't necessary. The dura mater surrounding the brain, is as tough as garment leather. The bones forming the cranium are thick and hard; later that evening my hands ached from the afternoon's effort. Gross anatomy is hard work and it should be. It would be dishonoring to those who've entrusted us with their bodies if was anything less.

What I've noticed about students, myself included, whenever we've come back to the gross lab, is a quality of -- well, honestly, of reverence. It's more than respect, it's the recognition that this is where the rites of initiation occur. It's where we first began to become doctors. What happens here changes a person, and from what I've seen, it changes us for the better.


(Image of unknown license via Wikipedia)

Medical School: Becoming a Family

For years, breakfast around my house was a hasty affair. While living in Boulder and driving to work in Denver, it was reduced to a sandwich on the highway. Lately, however, I've gotten back into a rhythm of taking a few minutes to cook hash browns and egg beaters and eat calmly. As a result, some interesting thoughts surface when I least expect them.

Take this morning, for instance. I was thinking about graduation for my entering class on May 22 (hope I got that right), and felt a sense of abandonment that surprised me. I guess I've been holding it at arm's length, as I typically do with such things. Anyhow, it must have crawled right up my sleeve, because there it was, perched on my shoulder like a pirate's parrot and whispering in my ear. "Your class is moving on and you're going to face the next two years alone."

Now, this is not at all true, strictly speaking, and I tried to be understanding. After all, it's the nature of fear to take on unrealistic proportions, so it wasn't being wicked or mean, it was just being itself. My job, at times like this, is to point out the distortions in order to restore some inner balance. And that's when I thought about Popeye.

Not Popeye the Sailor Man of cartoon and movie fame (Robin Williams, 1980), but Robert "Popeye" Wynn from Band of Brothers. If you're familiar with the HBO series or have read Stephen Ambrose' book, you know Popeye was wounded on June 6, 1944. Shipped back to England for surgery and recovery, he went AWOL and left the hospital before his wound was completely healed, in order to rejoin his unit.

A recurring theme in Band of Brothers is the intense connection formed by the men of Easy Company, particularly those who went through basic training together. In several blog posts I've tried, similarly, to conceptualize the relationship we established as members of an incoming medical school class. I keep coming back to it because the reasons remain elusive.

For me, these 125 persons represent the context in which my dream of becoming a doctor first began to be realized. They are my witnesses and when the demands are great and the obstacles huge, they remind me of the truth: I'm going to make it. In some indefinable way, what we've created transcends friendship and I really don't know how we did it. You can't predict the way genes will combine during the crossing-over phase of meiosis and what happened with us may not have been something anyone could have predicted either. We were just the right people at the right time in the right circumstances who, like the men of Easy Company, became sisters and brothers -- a family -- without even knowing it.


(Creative Commons image of Popeye and Oliveoyl by norwichnuts via Flickr)

The Unseen Pages

Once again, I'm indebted to a fellow student who's called my attention to the obvious. Two days ago, when I excused myself from writing due to sickness, it's treatment, or both, he suggested I have another essay or two in the bag for just such an occasion.

I've been reflecting on his comment and the amount of material that never makes it onto the finished page every day, and a quote from Elie Wiesel that I keep in my journal came to mind: "There is a difference between a book of two hundred pages from the beginning and a book of two hundred pages which results from an original eight hundred pages. The six hundred pages are there. Only you don't see them." I feel certain this is something with which my friends and fellow writers Crystal Mary Lindsey and Garnet of Maine can easily identify.

My mind is like sheep -- if I don't keep an eye on it, next thing you know, it's wandered off. In the course of settling on five or six paragraphs each day, there are another ten or twelve that never find their way onto "paper." Sometimes they look very good in themselves but within the context of wherever it is you think you're trying to go, they're inconvenient distractions.

When putting our book together, Lynn and I went through this process hundreds of times, asking whether we'd covered a topic adequately or if there was "one more thing" we could say only to find we'd already said it elsewhere. So, at some point, you say to yourself, this is as good as it's going to get. Additions and deletions aside, you imagine yourself like a skydiver, standing in the doorway of the plane, hoping you land on soft turf -- or at least something vaguely intelligible.

One if by Land, Two if by Sea

I was doing okay until the Park Service Ranger said something about a column of British soldiers approaching the bridge held by Minutemen. That's when I heard the sound of drums and a chill ran down my spine. I reached for my musket, an English-made Brown Bess, but it wasn't at my side. I looked around almost in panic, the Regulars closing fast enough to feel the ground tremble from their numbers, and then I remembered this was a reenactment. The day was right, April 19, but the year was wrong -- it was 1997, not 1775.

The crowd of onlookers with cameras and children didn't help much, because as the column marched past I felt an urge to charge into their midst, bare-handed, shouting invectives and threats against the Crown. I don't know if I was channeling some young, idealistic Colonial ghost from nearby Sleepy Hollow Cemetery or had just gotten caught up in the moment, but time and reality suddenly felt very fluid.

The night before, Paul Revere had ridden to the home of Dr. Joseph Warren in Lexington, to warn John Hancock and Samuel Adams of the movement of British troops. In the cold, misty dawn hours, Minutemen met Regulars on Lexington Green, an open, grassy space in the heart of town where farmers grazed cattle, and gunfire was exchanged. From there, it was on to Concord, where I stood, waiting, hoping for a miracle.

That's what my first Patriot's Day, the equivalent of a national holiday in Massachusetts, was like. For all practical purposes, it marks the beginning and end of the Revolution in northern New England, since most of the fighting took place in the Mid-Atlantic and Southern Colonies. You wouldn't know it, however, on Patriot's Day. People crowd historical sites like the Old North Church, gazing up at the steeple where lanterns indicated one if by land, two if by sea. It may have taken another year to be formalized, but if you ask anyone this day, America was born in Boston on April 19.

And for a few magical seconds, I was there.

(GNU Free Documentation image of the statue of Paul Revere behind the Old North Church via Wikipedia)

Sex: Abandoning the Field

I'm not sure, but I may be playing around with Pandora's box and we all know what happens when someone lifts the lid. Pandemonium breaks loose. Did you know, by the way, that John Milton coined the term in 1667? Pandemonium is the capital of Hell in his epic poem, Paradise Lost. I didn't know that either. Anyway, at the risk of paying a visit, I'm thinking about sex.

It came to mind while recording The West Wing this morning. Actually, it wasn't the program that got me going, but a commercial for a product intended to make the "big moment" feel like an ocean cruise liner blowing its horn. The physiology alone boggles the mind. Now, it's not that I don't think this is a humorous commercial, because I do. It's also a rather creative use of slang and metaphor.

Then there's the one about the guy who couldn't get a date if it was arranged, having at last become a ladies man because of male enhancement. There are also serious commercials promoting treatments for ED. Tongue in cheek, it's enough to make you feel sorry for anyone named Edward. Don't get me wrong, I'm not opposed to freedom of information nor am I being prudish or moralistic.

Advertising being what it is and people being who they are, sex sells. What concerns me is, wherever we're going with all of this, we're don't seem to be doing so with conscious intentionality. The proverbial frog, when dropped into a pot of boiling water promptly, and sensibly, leaps out. Placed in a similar pot of cool water while the heat is turned up, he's dinner before he notices the water is boiling.

What I mean is, when we talk about our children developing ideas about sex that reflect respect for persons, we ought not abandon the field to Puritanism at one extreme, or wholesale sexuality at the other. If education can be the silver bullet, as West Wing's Jed Bartlett is fond of saying, then adults ought to begin with themselves. Is there a reasonable limit to the degree we wish to have sex portrayed on screen and if so, what is it? How would we prefer to have sex displayed and in what contexts? Can we arrive at a consensus? If we want Madison Avenue to make these decisions for us, it will be more than happy to do so. Somehow, I just don't think that's what most of us have in mind.


(Creative Commons image of Queen Mary Smoke Stack by biofriendly via Flickr)

My Horse and His Boy

 
The following is a piece I've dabbled with, off and on, for several years. It borrows from my own youth and yet, it is still a work of fiction. The horse, however, and our relationship was very real. I hope you enjoy this tidbit and will leave a comment or two.


Psychiatry hadn't so much as crossed my mind at 13, but I suppose its seeds were there. I discovered quickly that my freshman year in high school wasn't going to be much fun. I made few friends, and despite my efforts to fit in, felt like an outsider. I realize now I was an outsider and for good reason. My classmates were the children of professional parents -- many were faculty at the university nearby -- and had grown up in the insular society that wealth and intermarriage create.

My parents owned a small farm and I grew up in the shadow of the Indian Peaks, a range of mountains that rises 13,000 feet above the plains of Eastern Colorado. From my upstairs bedroom window I could see the morning sun strike above the snow line, transforming them into flames of fire in the western sky. My earliest memories are images, really, of fields of snow with horses crowded together to stay warm, icicles hanging from the porch roof, and the sunrise on the mountains.

It was a different world from the one of my classmates, and while I won't say it was a better one, still, it was mine. Having a world of your own is important at 13. For me, returning home from school meant a long walk down the dirt road that passed in front of our house. It was nearly a mile from the bus stop on state highway 119, and in the fall, the huge cottonwoods that lined the fields shed their leaves, transforming the lane into a river of gold. When I came within sight of our pasture, I'd stop and whistle to my horse, Dandy, and his head would rise from the grass in response to a signal that was ours alone.

Sometimes I'd cheat the distance to the house by slipping between the fence rails and crossing through the field, eying Dandy as he trotted to meet me. The difficulty I had making friends at school stands in sharp contrast to the ease in which my horse and I shared such a simple, unpretentious intimacy. In the few years we had been together he knew me better than I knew myself, and at the same time, knowing him enabled me to know myself. He was my best friend and I was his boy.

There is great solace to be found in a relationship that places no demands on you to be or do in a manner foreign to yourself. There is a freedom in it, too, that allows you to give according to your capacity, only to find your capacity increasing with the giving.

As I look back on it, that's the way it seemed to be between Dandy and me. I felt there was an understanding between us that didn't need language for expression. On warm summer days I'd climb onto his back, and without saddle or bridle, nudge him with my knees toward a smallish elm tree that grew against the north fence line of the pasture. There, in the shade, I'd strip leaves from low-hanging branches and hold them by my knee while Dandy twisted his head round to gently nab them from me.

We'd do this for hours, him growing fat on elm leaves, me growing fat on love. Whenever I would approach anything approaching bliss in my later life, the memory of those summer days would surface, as if to remind me how I ever learned to recognize bliss at all.

(Creative Commons image by garryknight via Flickr; Text copyright 2014 by Patrick W. Conway, all rights reserved)

Dispositional Authenticity: True to One's Self

To thine own self be true, and it must follow, as the night the day, thou canst not be false to any man. ~ Polonius, Hamlet, Act I, Scene III

I got hooked on Hamlet as a teenager, drawn in by the idea of a young man conspiring with the ghost of his father to expose the truth of his murder. As a son whose father has died, I can relate to Hamlet far more now than ever before, but that's a subject for another post.

This morning I'm thinking about the advice given by Polonius to his son, Laertes, who is about to depart for France. On the face of it, Polonius sounds like a father preparing his son to relate to the world as an adult, and concludes his speech with the famous quote above. In point of fact, he reveals that throughout life, he has been true only to himself, and as a result, being false to any and everyone, when the occasion required it, has been easy. You might say he has been authentically inauthentic and he doesn't even know it.

I'm mentioning this because researchers at Ohio State University have been conducting a study among heterosexual couples examining the role of dispositional authenticity -- the proclivity for being true to one's sense of self -- in romantic relationships. It appears that individuals who are self-aware, and who live up to what they know of themselves, behave in ways that are more intimate and less destructive with respect to their partners.

My father would not have been surprised. He used to say waiting until you're involved with someone to begin the process of self-discovery is like repairing the fence after the cattle have wandered through. "You can't very well figure someone else out, if you haven't figured yourself out first." As obvious as this sounds, it's very revealing when you think about some relationships.

Being true to oneself implies the presence of a self to begin with. At the very least, this refers to a stable and enduring core enabling one to grow, contribute to the well-being of others, and cope with loss and frustration. Among individuals who employ a "false self" as compensation for insecurity, or who rely on a contrivance that has little or no basis in reality, dispositional authenticity is compromised. Like Polonius, their expression of self is situation-dependent and who they truly are, from moment to moment, is uncertain.

For partners who are accustomed to being honest with and about themselves, interacting with the dispositionally inauthentic is perplexing and sometimes, downright crazy-making. Consistency is important, especially where intimacy is concerned, and it helps immensely to be able to interact with someone who is "always home." When your partner's identity is as variable as spring weather in Maine and they are unwilling or unable to examine themselves to find out why, the whole concept of being in relationship is called into question.


(P.S. Thanks, everyone, for your patience yesterday, I appreciate it.)

Absent With Leave

Dear Readers:

I have to beg your indulgence today -- whether it's the medications I'm taking, the virus I've got, or a combination of the two, my brain cells are absolutely in rebellion. I just can't seem to put a noun and verb together today to save my life. If you'll accept my apology, I promise tomorrow I'll be better, back in the saddle, with something I hope is worth reading. In the meantime, have a good evening and stay well.

Thanks so much,

Beggar

Too Real for Fantasy

Thinking about the roles we adopt in relationships, one I've never really been comfortable with is that of a fantasy lover, an idealized version of some long-gone Mr. Might-Have-Been or worse yet, a father figure. I've got too many warts -- blatant evidence of my card-carrying membership in the human race -- to be anything but real. Besides, there are too many unspoken expectations associated with being a fantasy, it's too much to live up to. I have a hard enough time just being me, most days.

This is not to say there's no appeal in being imagined as perfect. The problem comes about when something like this cold turns me into a hacking, draining, dribbling mass of gunk only my dog can tolerate. I hate getting sick, I'm a lousy patient, and all the coughing renders my normally sexy baritone a rasping imitation of the frogs that proliferate in the forest this time of year. Sexy -- see? I even approximate delusional when I'm feeling lousy.

The rest of the time I'll take the truth any day of the week and twice on Sunday. What I mean is, I prefer being with people who wouldn't know entitled from the end title sequence of a movie. They might deserve special treatment but they'd turn it down if it was offered. More interested in accepting than being accepted, they consider appearances as meaningless. They'd be "forever in blue jeans" if the alternative meant disingenuity.

It's okay for a while, reflecting a projection you've been handed like canapes on a party tray, but sooner or later a person wants to be seen for who they are. I think sooner is better, though it doesn't always work out that way. Sometimes you have to wait until the projection breaks down like a worn-out car on the highway. Once that happens, if there was anything real in the relationship to begin with, it will survive the shock. If not, well, there's always fantasy, but that has its liabilities, like this croaking cold. Pardon me while I go blow my nose -- again.


(Creative Commons image by purplemattfish via Flickr; Forever in Blue Jeans by Neil Diamond)

Dancing with a Petri Dish

An antibiotic won't help at this point, not even if our mothers said it would. Most upper respiratory infections (like the one I presently have) are caused by a virus, not a bacterium. As a matter of fact, indiscriminate use of antibiotics is one of the reasons for the existence of antibiotic-resistant bacteria. We've inadvertently trained these guys to survive in the presence of medications intended to kill them. It's like a scenario straight out of a 1950s science fiction film.

To paraphrase Jimmy Buffet, it's my own darned fault. I've got a little carpal tunnel syndrome working in my right hand and I've been wearing a wrist stabilizer to decrease stress on the median nerve -- that's the one that gets compressed in carpal tunnel. So, because it's a pain to take the stabilizer off to wash my hands, I've kind of cheated a bit lately, and probably rubbed my eyes or some such thing and infected myself.

As a consequence of being lazy, I get to feel crummy off and on -- another sign this is viral and not bacterial. And since it's an upper respiratory tract infection, I not only get to practice coughing, but also my nose-blowing skills. For the most part, an over-the-counter antihistamine has been fine to keep me breathing. Last night, however, the mucous cells in my nasal passages went into overtime and breathing while lying down was impossible. In desperation, I took a nighttime cold remedy that had a little bit of pseudophedrine in it as a decongestant. That's how this post almost got written at 3.00 in the morning.

Since I've managed to stay well for the past couple of years, I'd forgotten that pseudophredrine may cause drowsiness or excitability, depending on the person who takes it. Me, I get wired. So, there I was, baking brownies and wondering who of my friends was on-call somewhere, also wishing they could sleep. But at least I was breathing for a change.

This morning, a trip to the store has added nasal spray to the mix and I'm more or less functional. If this lasts another ten days, it's probably got a bacterial component and I can get a script, but I'm hoping for recovery before then. As for dance class, I think I'll sit this one out tonight. Dancing with the stars is one thing, dancing with a Petri Dish for a partner is quite another.


(Creative Commons image of common cold virus via Wikipedia)

Narcissism: Unmasking the Victim

 
When talking about narcissism and relationships, one question that almost always comes up is, what kind of person would choose to become involved with a narcissist? This is a sensitive subject; no one wants to come off as critical or blaming, yet it's a question that needs to be broached, if for no other reason than the fact that former significant others ask it of themselves. What was I thinking, how could I have been so naive, so blind. 

To begin with, those who've been in these so-called "relationships" were looking for, and honestly thought they'd found, someone who was genuinely caring. It's terribly difficult to admit to yourself -- much less anyone else -- that the woman or man of your dreams is really a nightmare. It's also true that partners usually aren't dragged, kicking and screaming, into hooking up with a narcissist. There is the aspect of being an accomplice that must be addressed. That said, I don't believe someone who gets involved with one of these individuals necessarily does so with conscious intention. Unconscious motivation can be a powerful underlying factor in one's choice of romantic partners. 

Narcissists are smooth. In the early stages of a relationship, it's nearly impossible to conceive they could be fraudulent. They're too considerate, attentive, supportive, and affectionate. They appear utterly smitten, unable to get enough of us. It was love at first sight and they make the most of every opportunity to remind us of it. 

The narcissist's regularly repeated declarations of affection, however, are what is called "love-bombing." It's one of many techniques employed by narcissists to weaken and break down a potential partner's defenses, rendering them emotionally receptive. Before we know it, they're talking about moving in, sharing an apartment, getting married and having children. Our family loves them, our friends love them; we're living a veritable fairy tale. Until Sleeping Beauty starts to awaken, that is.

Interpersonal psychology suggests partners of narcissists are inclined to have dependent or masochistic personality traits. Either because they prefer relationships to being single or because they possesses an unusually high tolerance for emotional pain, they don't tend to make waves when they're unhappy. Instead, usually out of a sense of loyalty, they excuse their partner's behavior, even when others find it troubling. As long as a partner is relatively comfortable mirroring the narcissist's imagined superiority or insistence they've been ignored, overlooked, and misunderstood, things go fairly well. But there is nearly always some sort of verbal or emotional abuse that goes along with preserving the relationship. Safety and security come at a high price.
 
Partners are convenient targets for the arrogant narcissist's (what we usually think of when we hear the term "narcissist") verbal or physical abuse when they feel embarrassed, slighted, or has failed to receive the respect and admiration to which they feel entitled. Covert narcissists, in contrast, rely on complicated, carefully planned and executed strategies of manipulation to control others. Under severe stress, they resort to passive-aggression as their normally sweet, harmless demeanor disappears and the pent-up rage we rarely see begins surfacing. As a result, they can be as unpredictable and unsafe as their arrogant counterparts. When partners have finally been drained of their usefulness, they're often surprised to discover the narcissist has already chosen their replacement and has them waiting in reserve. 

While not always true, partners of narcissists have generally been trained well. One or both parents possess narcissistic traits and thus, unconsciously identifying similar individuals for intimate relationships is second nature. Recreating the atmosphere in which a person grew up feels familiar. I've heard it said, "I can find a narcissistic predator in a room filled with good women with my eyes closed. It's like my radar is tuned their frequency." Masochism, in the interpersonal sense, doesn't refer to the enjoyment of suffering or pain; it simply means we've learned from parents that abuse is to be endured as part of the relationship landscape. 

None of this is meant to hint that partners are somehow psychologically flawed. On the contrary, they possess considerable psychological strength, as demonstrated by their ability to survive a great deal that is truly unnecessary. Unmasking the qualities that render a person vulnerable to "narcissistic possession" is critical to recapturing one's feelings of self-worth and reinforcing the ability to protect oneself, emotionally, in the future. Failure to do so only increases the likelihood that having been hurt by a narcissist once, we may be hurt again, and that's something truly worth avoiding.

(Creative Commons image by Riccardo Cuppini via Flickr)

Doing It Like Nemo

I have a friend who will, by the end of this day, have completed her last day of medical school. Admittedly, I may have several friends in the same boat, but since she is the only one who's schedule I know with certainty, she gets the spotlight. If any others are reading this and today is also yours, don't hesitate to take a bow, you've earned it. What sets my friend apart is the fact that, in another world, she would have graduated last year.

I've mentioned, on several occasions, how we begin medical school with one set of expectations and proceed to adjust them as we go. One may become a teaching fellow or do research for a couple of terms. Academic or personal problems may interfere with our progress and we need an additional year to complete our studies. I lost a semester this past fall but gained a published book in exchange -- it was, as Wind in His Hair from Dances with Wolves would say, a "good trade."

The upshot of making adjustments in our time line is, the process we began in community, we sometimes complete individually. The identity established as a member of an incoming class is altered by circumstances, resulting sometimes, in a feeling of displacement. Like Nemo, who was snatched away from father and home and thrust into an alien environment, we have to learn to adapt. But this is not a bad thing, because in the real world of medical practice, adaptation is our daily bread.

When it seems like the rest of your class is passing you by -- and let's not sugarcoat it, they have in a real sense -- it's easy to start ruminating over all the "What ifs." That, however, only gets a person into a rut and as the Sunday School director in my first pastorate was fond of saying, "A rut is nothing more than a grave with both ends kicked out."

Medical school, like many things in life, is a head game and if we can envision our experience of it as maturing, we're closer to the truth, because that's precisely what it is. I don't mean changing our thinking to render external reality more palatable, I mean recognizing the intrinsic nature of the thing. Once we've done that, our approach to it becomes as individualized as the outcome. There is no right way, no wrong way, no better or worse way, there's only our way and if we hang tough, eventually, we'll find our way through.


(Creative Commons image of Finding Nemo by San Diego Shooter via Flickr)

Sociopathy: The Loss of Humanity

About all he said was, "I'm seeing a patient for medication management and I'd like you to do some therapy with him. He's had some legal entanglements, but I don't think he'll try to hurt you. I'm eager to get your impressions."

My usual glad-to-be-of-help expression must have turned slightly pale because he quickly added, "Don't worry, if you get in trouble, just shout and we'll all come running."

Oh, that's very comforting, I thought, and just how am I supposed to do that with his hands around my neck? "Thanks, I'll be sure to call your name loudest," I said, irony dangling around the rim of my smile. They call this supervision?

Legal entanglements was putting it mildly. He had a record that went back to high school and was currently awaiting arraignment on charges of assault and battery. Of course, my patient said, it was all trumped up, he'd done nothing of the sort, and besides, the police didn't like him because he was Irish. I refrained from mentioning that, in Boston, being Irish could almost be considered a prerequisite for a position on the force.

Suggesting we assume for the moment, that the charges were genuine, I asked what might be the reason for them. He explained a fellow car salesman had cheated him out of a deal and then waved the contract in his face, daring him to do something about it. "I tried to reason with him," he said, "but he laughed and called me a coward. It was his own fault, he shouldn't have provoked me."

"So, you did assault him, is that right?"

"No, I didn't touch him," he replied, conspiratorially. "He stumbled and hit his face on a car. I was trying to help him when someone called the police. They said they saw me hit him, but they lied -- they were all in on it."

Later that afternoon, my supervisor informed me that my patient had been diagnosed with antisocial personality disorder. "He's sociopathic, has essentially little or no conscience, and refuses to accept responsibility for his actions. He's charming, narcissistic, and he'll have you believing the moon is made of green cheese if you're not careful." Over the coming months, our "therapy," if you want to call it that, involved a weekly recounting of the offenses other people had committed against him, thereby justifying any retribution he may have exacted. Our final session ended much like the first one had begun, with him denying he'd harmed his coworker in any way.

I never felt I was in danger, but neither did I ever feel completely comfortable. The normal feeling sense you get with another person was absent with him, as though he had little emotion to begin with. He denied having been abused as a child but when he talked about his parents, he might have been describing strangers. Working with him was a learning experience without question, and one that I'm generally disinclined to repeat. It was too much like trying to help someone who'd lost his humanity and had no interest in going to look for it.