Sunday, January 30, 2011

Rural Medicine and Splitting Hairs

Kennebec riverSo, tomorrow begins my rural community health rotation, which basically means private family practice in a rural area. I've always thought that was a bit of an inside joke since the entire state of Maine is classified as rural, but I'm probably splitting hairs. From the standpoint of population, my last rotation was actually more rural, since tomorrow's is only six miles from a town of eight thousand. I'm probably splitting hairs, again. I think the idea is to get me somewhere off the beaten path.

You might be wondering why I'm doing a rotation like this in the first place. The most obvious reason is because, well, I have to. While rural medicine is an elective at other medical schools, mine requires it. We train mostly primary care physicians and the average patient, if we decide to practice in Maine, will likely resemble those we see on this rotation. It's also a way of getting students out of their comfort zone, though for me, rural life is like biscuits and gravy. I was raised in the country and practically learned "down home" before English.

As to what I'm expecting, it's going to be family practice. Lots of colds, flu, and diarrhea. There may be opportunities to learn how to suture cut fingers and I suspect, like most family docs, my guy is also the local shrink. That will be fun. I'm hoping for a chance to get my physical exam skills back up to speed and use the OMM skills I've been practicing the past month. And I hope my preceptor eventually feels comfortable enough to allow me to work up a few patients on my own.

For most students, rural medicine seems to come along later in the rotation cycle, so they've had a chance to learn a few things before showing up at "Doc Hollywood's" front door. Because I had to retake boards, my cycle is slightly different, so rural medicine is my opportunity to get into shape before diving into the hospital madhouse routine. I'm not sure one way is better than the other, it's simply the way things are. I'm just glad to have boards behind me and be seeing patients for a change.

From the perspective of my dog and cat, this will be a lot easier than the PASS Program. Last fall, as you may recall, I was in Champaign, Illinois for eight weeks and the three of us chewed up the phone lines every night. This time, I'll be out of town four days out of seven, but it's only a two hour drive away, and I'll be home on the weekends. We'll go for walks, watch movies, have morning snuggles with the cat on my lap, and bake cookies before I head back on Sundays. Pretty much life as usual. Considering subsequent rotations may send me further afield and for longer periods, this will be a good transition for them. And for me.

Anyway, there will be more to come and we shall all see how it goes. Oh, and yes, I'll take photos.


(Creative Commons image of the Kennebec River by qnr via Flickr)

Friday, January 28, 2011

Call It Fiction If You Like

Front of yellow Splenda consumer packet.Evenly yoked, that's how my friend and fellow blogger from Australia, Crystal Mary Lindsey, puts it, referring to an ideal romantic relationship. Her image is of two oxen paired in a yoke, pulling together instead of pulling apart. Matching them is the challenge, finding two of similar strength and temperament that permits placing them side by side to achieve a common task. Since Crystal's comment is related to the fictional characters, Dr. Bob Z and Dr. Jessie Livingstone from Pink Hats and a Mack Truck, I've been thinking it might be a good idea to take a look at their relationship and see what makes it exemplary of being "evenly yoked."

The first thing that comes to mind, for me, is the freedom they experienced from the very beginning. Jessie described it as something that allowed her to feel like a woman. She never got the sense Bob needed her to be a girl or mother figure. This is important because we often take on roles in a relationship that we unconsciously perceive the other person needs or wishes us to fulfill. Her faculty adviser explained how Bob was obviously comfortable with Jessie being herself and for Jessie, this meant feeling like a mature equal. It was present in their first contact, when she laid her hand on his arm and suggested he try Splenda instead of sugar in his coffee.

Bob describes their freedom as the permission to be genuine and spontaneous, and it's exemplified by his almost flirtatious, "Hi there, Splenda gal," when they ran into each other the following day in the parking lot. He wasn't flirting, he was simply being ingenuous and very much himself. He didn't know her name as yet, but he was willing to be friendly and open with her and she felt, once again, like a woman. Freedom is contagious -- one has it and another catches it. With Bob and Jessie, however, it seems they felt it at the same time. But she demonstrated it first and he couldn't help but follow her lead.

They also have "chemistry," that vague and difficult-to-describe attraction that makes some relationships go romantic and others remain friendships or merely acquaintances. It's like sodium and chloride. There's a quality to these elements that makes salt whenever they're in close proximity to each other. Put sodium nitrate in a solution with potassium chloride and water (don't try this at home -- inorganic chemistry was never my strong suit and for all I know, the combination may be explosive), and darned if the sodium and chloride don't find each other, making salt once again. They can't help themselves. That's how it's been with Bob and Jessie.

Chemistry is what makes their relationship interesting. We're drawn to them because they're drawn to each other in ways we'd like to think we might be drawn to someone. There is respect, admiration, and playfulness -- they aren't simply in love, they truly like each other, and liking is as important as loving. Liking reflects chemistry and it's hard to imagine stable, dependable, energizing romantic love without a healthy dose of it.

And then there is the matter of the twins. This is a huge issue for Jessie although she doesn't seem to make as much of it as we might imagine. In part, this is because she's already dealt with the issue of Bob's age. The freedom she's experienced enables her to trust her own judgment and view him as a whole person, inclusive of the age differential, and decide whether she's willing to engage or back off. That she chose to pursue him, so to speak, is based on several factors, including her highly positive relationship with her father and her desire to be with a man who possesses a considerable measure of maturity. She knows being with him will likely entail becoming a mother right off and her decision to go ahead draws, not only on her love for the twins, but also upon her knowledge that he is going to be a package deal, period. If she wants him, she has to adjust her expectations to include Hannah and Clara. As Chuck says of her, she really is a remarkable young woman and honestly, I admire her courage and integrity tremendously.

What I've noticed about Bob and Jessie is how their relationship has developed with ease. A friend of mine and regular reader of this blog once told me "easiness" is an irreplaceable quality. While I didn't quite understand her at the time, I have come to appreciate the subtleties of her comment far more in recent years and I believe she was exactly right. Relationships like the one between Bob and Jessie aren't like trying to fit a size 13 foot into a size 12 shoe. Oh, it can be done all right, and maybe the shoe feels okay in the store, but once you walk around a bit, your toes start to rub and it's time to bite the bullet and go back for the right size.

Bob and Jessie have never had to try to fit together, they just do. As a consequence, they work out the details of life with a mutuality and obvious intentionality that places each other first. Notice how, again and again, Bob becomes concerned about one thing or another and Jessie reminds him they'll figure out a solution, as long as their relationship is their first consideration. And so, like Crystal Mary's oxen, they pull together, not apart. They're evenly and equally yoked. Call it fiction if you like, it really isn't. It certainly doesn't have to be, anyway.


(Public Domain of Splenda package via Wikipedia)

Thursday, January 27, 2011

The Last Day of My First Rotation

An infantShe was only a few weeks old and who could blame her for becoming fussy. It was warm enough in the office, but her parent had come in for treatment and that meant waiting, except babies don't generally like waiting very much. There was no television with "Barney" or "The Big Red Dog," to entertain her, so, for better or worse, she was stuck with me.

Babysitting at such times is one of the tasks that falls to the medical student. I mean, if you think about it, it makes perfect sense. Your attending can't very well say, "You deal with the patient and I'll mind the baby," especially if seeing patients is their livelihood. And that was the case today. So, when she started to cry -- the baby, not my attending -- I picked up her carrier and rocked her -- she liked that because the tears vanished in seconds. Carriers get heavy, I discovered, so I rocked her on my knee the rest of the session. I couldn't help but think of Dr. Bob Z and the twins from Pink Hats. Her parent said afterward, "You're a natural at this." Whether that's true or not, it was one of the nicest things anyone has said to me.

Today was my last day doing full-time osteopathic manipulative medicine. Rotations are about learning in the real world as opposed to the classroom or laboratory and that certainly describes the past four weeks. Like all DO students, I learned my basic OMM skills by practicing on fellow students who possess little if any somatic dysfunction. In a clinical setting, however, people come to see you because they're in pain. You can see it in the way they walk, the ways they carry their bodies, and the expressions on their faces. Maybe they've been injured, have arthritis, or a repetitive strain injury, but whatever the problem, life is miserable because of it and they expect you to help.

For me, touching real patients and learning to do so in a genuinely therapeutic manner has been a wonderful experience. I've thoroughly enjoyed this rotation and frankly, I hate to see it end. I've been privileged to work alongside my preceptor as a team member, while also getting feedback, direction, and gaining confidence at the same time. It's as though, at long last, I know what to do with the tools in my kit besides take them out and polish them occasionally. And to top it off, I got to babysit today. As my father used to say, you can't beat that with a stick. Sounds pretty good to me, dad.


(GNU Free Documentation image via Wikipedia)

Wednesday, January 26, 2011

Wrappijng Up My First Rotation


I don't mind saying, writing lately has been tough. Up early and off to the hinterlands, then back home with a mind full of "how soon can I get to sleep in order to get up and do it all again." I'm looking forward to my rural community health rotation beginning next week because I think -- I'm not sure -- it means recapturing mornings to write. We'll see.

In the meantime, tomorrow is my last 40 mile drive one-way. That may not sound like much if you're in Denver or Dallas, but up here, off the beaten path, 40 miles is a fairly serious hike. They're good roads, the one's I've been traveling, and well-kept. They have to be, since they're the primary arteries, north-south and everywhere else west of interstate 95. The traffic is generally minimal in the mornings and there are no speed traps. But the roads are winding and one section in particular, between Sebego and Naples, slows down all but the suicidal.

Anyway, like I say, tomorrow I'm wrapping up my first rotation doing primarily osteopathic manipulative medicine and I'm going to miss it. I've truly enjoyed learning how to employ this modality in the real world, with real patients who get up from the examination table, stretch and smile, then say thank you because they feel better. For readers who are familiar with OMM, either by training or from having experienced it, my rotation has focused on using soft-tissue techniques in a fairly wide variety of patient types. For those of you who have no idea what I mean, soft-tissue techniques use a lot of stretching and gentle probing to address muscle dysfunctions, though this is an over-simplification. Still, it give you an idea.

I suspect the most important thing I've gained from working with my preceptor is a greater appreciation for what it means to be an osteopathic physician. Instead of "doing things to" a patient, we've been working with patients to affect physiological changes in the way their individual anatomy operates. I think that's one of the virtues of soft-tissue osteopathy, you're cooperating with tissues that have been altered by injury, overuse, or congenital malfunctioning to restore their functional capability. It's an organic approach that requires the patient be involved as an active participant in treatment. It less about what I can do as a physician and more about what we can do as a team.


(Photo of the view toward Mt. Washington from Bridgton, Maine, copyright 2011 by the author)

Saturday, January 22, 2011

Pink Hats 26: Jessie and Atticus Finch

Screenshot of To Kill a Mockingbird(an America...Image via WikipediaIf you were to ask, Jessie would say she strongly suspected Harper Lee of being a neighbor when she was growing up because Atticus Finch was so like her father, the resemblance couldn't be coincidental. It just seemed that way when she saw Gregory Peck in To Kill a Mockingbird on television as a teenager and checked the book out of the school library the next day. It wasn't a physical resemblance, though both Peck and her father were tall and parted their hair on the right. It was his way with his children, Scout and Jem. That, coupled with the fact it was one of her father's favorite novels and he was fond of quoting it.

"Courage isn't a man with a gun in his hand," he said,
often enough that she knew the words by heart long before she found out Atticus had said them first, "It's knowing you're licked before you begin but you begin anyway and see it through no matter what. You rarely win, but sometimes you do." It must have been courage, she thought, that saw him through raising a son and two daughters alone. They had aunts and uncles and some lived close by, but for the most part, as with most families most of the time, it was him and the children. He wasn't perfect -- no one is, not even Atticus Finch -- but he raised his children respecting them and he taught them to respect themselves.
She loved the hymn, Rock of Ages, cleft for me, let me hid myself in thee, her mother sang as a lullaby, and after she was gone, Jessie imagined it was written about her father. Stable sprang to mind when she thought about him. He was firm and level and reliable when our world was rocked to the core. He showed us how to survive our grief.

She felt the same way about Bob. He was solid, too, solid and stable. He'd come through his own grief without bitterness and he loved so freely. As she got to know his friends, some going back to medical school, she saw reflected in their faces a man who'd rather die than let any of them down. One, a member of the hospital janitorial staff, said of him, "He doesn't think he's better than anyone else." And it was true, he didn't. She knew he would be there for the twins and their own children, as would she, and they'd be there for each other. Theirs was a relationship between equals.

She was watching him, asleep next to her on the couch, his collar unbuttoned, his tie loosened and straying off to his side. He'd thrown one arm over his eyes and draped the other around her. Now and then he'd release a soft, low snore, and she smiled. Her thoughts wandered back to dinner, his proposal, walking along the streets at night, the drive home, falling asleep together with Sam. There was a quality of serenity about it all, a peacefulness she'd felt around people who were right for each other. And we have it, too.

She sighed and reached over, undoing a button midway down his chest and slid her hand beneath his shirt, feeling his heart beat. "You have such a good heart, mister," she whispered, "it's why I love you so much. Your heart." She sighed again and he opened his eyes.

"Good Morning, Sunshine," she said.


(Public Domain image of Gregory Peck in the role of Atticus Finch via Wikipedia)

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Tuesday, January 18, 2011

Pink Hats 25: Good Morning, Sunshine


Unlike many, when Bob received his membership card in the Newly-Divorced Club, he resisted diving head-first into the singles scene. Singles bars had never been his cup of anything, even when he was younger. He had opportunities to date and even Halley had offered to fix him up with a friend of hers who was a social worker and former Miss Maine. But by then, it was too late, he'd already met Jessie. After that morning in the Alfond coffee bar, there would never be anyone else. Not for him.

She had fallen asleep beside him on the couch in front of the fire, with Sam curled up next to her. Halley's comment about getting a room might have its appeal, but not tonight. This was an evening for romance. Besides, they'd already settled the other question. It was the Friday evening they'd watched Avatar when Jessie broached the subject.

"Do you know how attractive you are to me?" He opened his mouth to speak, then closed it, not certain how to answer. "I put my hand on your arm that day in Alfond because it seemed the most natural thing to do. It's...our chemistry. You could have taken me in your arms and swept me away and I'd have gone willingly."

He ran his fingers through her hair. "I can't tell you how many times I've wanted to do that since."

She smiled and said, "I know, me, too. But there's something else I want for us. I want to wait. Not because I enjoy waiting or because I have reservations -- I don't. It's ...if we were to marry, like we've talked about...I want that to be the most wonderful night of our lives. And with you, I've never felt like I had to hurry."

"I've been thinking the same thing. I know it's probably not what couples usually do and yet, I feel like it's right for us..."

After toasting their engagement with champagne and receiving congratulations from nearly every table at Twenty Milk, they gathered their coats and walked outside into the night air, his arm around her shoulders, hers around his waist. There's just something about kissing the woman you love on a cold and snowy night, he thought, as they stopped at a corner and he kissed Jessie beneath a dimly shining antique street lamp and brushed flakes from her hair. He said he'd never seen her more beautiful.

They drove to her apartment, announced the news to Sam who responded by leaping onto his hind legs and licking both of them, then lit a fire and snuggled next to one another, sipping Grand Marnier from a pair of crystal snifters she'd inherited from her grandmother. A few moments later, she laid her head on his shoulder and closed her eyes. He took the snifter from her hand before it nearly fell to the floor. She smiled in her sleep and softly murmured his name. We've been so easy, so 'natural,' like she said. Maybe John was right, maybe we were meant to be.
He thought about all those times he went home alone, having seen her at a residency seminar or following a quick, innocent lunch in the hospital cafeteria. That piece of it had been hard. There were occasions he nearly slammed on the brakes and turned his car around to race back for her. Those were the hardest. When they were finally free to spend time together, he imagined it would be impossible to keep his feelings under wraps any longer and allow their relationship to unfold on its own. It wasn't though, and instead, it felt to him like falling in love with her all over again.

He set down his snifter, stretched his long legs toward the fire, and drew her close. He hadn't intended to fall asleep but the next thing he knew, her face was next to his, and she was smiling at him. "Good morning, Sunshine. Sleep well?"

He noticed the light streaming in the windows, looked at his watch and back at her. "Like I haven't in years, if ever -- so much for our 'first night' together."

She stroked the ring on her finger and kissed him. "It's not going to be our last."


(Photo of winter sunrise on Sabego Lake, copyright 2011, by the author)

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Sunday, January 16, 2011

Pink Hats 24: "Yes," Was All She Said


Ordering an engagement ring from Boulder's Cronin Jewelers the Monday after Thanksgiving was easy. A phone call with a Visa card number and ring size was followed by the promise UPS would deliver it by next-day air. Bob wished the rest of his life was as simple.

Attending group education classes as part of the adoption process added an evening complication to his already busy schedule, though Jessie joined him when her's permitted. Since he was going to be, at least initially, the legal entity in the process, he was the one who had to show up for these meetings without fail. But he was surprised at how much he was learning about blended families, helping children who eventually wish to know their biological parents, and so forth. The things they don't teach you in medical school, he thought.

Following the Monday evening group, he was at Halley's, seeing the girls."So, are you finally going to turn me loose on the hospital gossips or what?" she asked. "I still keep up with my sources and they've been chomping at the bit since I retired to take care of Hannah and Clara." Bob and Jessie had decided to name the twins Clara, after her mother, and Hannah, after his.

"Wait a few more days, okay? I haven't proposed and it's always possible Jessie could fool me and run, not walk, as fast and as far away as she can get."

"Oh, come on! You know that's never going to happen. You're more likely to get cold feet than she is."

"I know, I know." He said, chuckling. He looked down at the baby in his arms and said, "It won't be long before we'll be rocking away every night in your very own room." He stroked her palm gently and she wrapped tiny fingers reflexively around his.

Halley watched them, father and almost-daughter. "Little did we know, that afternoon in the ER."

"Nope. Chuck called them a 'Mack Truck' heading my way. It was the best auto-pedestrian encounter I've been involved in."

Halley smiled and nodded in agreement. "Have you thought about where you're going to propose? You have to plan this, you know."

"I've made reservations at Twenty Milk Street in the Portland Regency for Friday evening. Ted took you there for your anniversary last year, didn't he? Seems to me he said he did." She nodded in assent. "It's all done up for the holidays and I'm thinking drinks in the Armory Lounge and then dinner. You remember the fireplace at Twenty Milk, right? I've arranged for one of the tables next to it and champagne to be served at my signal -- if all goes well, that is. With snow in the forecast, the Old Port should be magical, like it always is at Christmastime, and we can walk the streets afterward."

"Or get a room?" Halley said, with an arched eyebrow.

"Use your imagination," he said, "it's active enough for both of us."

WGME's chief weather meteorologist did not disappoint when, five nights later, the Old Port resembled the North Pole, replete with decorations and a light snowfall adding to the accumulation that had been piled along the edges of the sidewalks, turning them into corridors in front of the shops. Bob and Jessie had foregone the valet parking in favor of a walk, arm in arm, along Fore Street, and were now deep into New York Sirloins by the fire at Twenty Milk.

"I've been thinking more and more about your 'house,' Bob said, "The real estate broker called this week, apparently the owners liked us and suggested they might be willing to deal. I told him I'd like to sell my place first and when I mentioned the location, he said he might actually have a buyer. He wants to bring them by for a look sometime next week. If all goes well, we could be moving after the first of the year."

Her fork halted in mid-air. "Are you serious? Oh, Bob..."

"Serious as a heart attack, Babe. Eventually we'd have to add a bedroom or two, but right now, there's plenty of space, as we saw when we toured it, and I really do like the idea of living in the country again."

"So do I," she said, and reached across the table, laying a hand on his. "It would be a dream come true."

After dessert of Pumpkin Bread Pudding with pecan pralines and cream, they sipped coffee and let the nearby conversations drift away.

"There's something I'd like to talk to you about," he said, taking a deep breath, "and honestly, I'm not entirely sure how to begin."

She set down her cup as this time, he reached across the table, taking her hands in his.

"Ever since we met, though I didn't fully realize it at the time, my life has been different. I know I keep saying that, but it's true. The next day, when we ran into each other in the parking lot, I could tell."

She smiled, remembering. Hi there, Splenda gal.

"The funny thing is, when class was over and I got into my car to head back to Portland, I knew exactly what I wanted to say to you, and of course, I couldn't and wouldn't for reasons you already know. But I knew it anyway. I've thought about how to say this, over and over, tried to imagine being more eloquent, and all I can come up with is this."

He let loose of her hands and she watched him slowly stand, then kneel down on one knee in front of her. "Jessie," he took another deep breath, "my sweet, sweet Jessie, I love you like I've never, ever loved. You're all I want, you're all I could want if I lived forever. Will you," his voice trembled and he swallowed, "will you please marry me?" Her eyes swam, but before she could answer, he reached into his jacket pocket and took out a small velvet-covered box, opened it, and set it down in front of her. Inside was a diamond ring with the Flatirons carved along either side of the stone.

The room had been growing quieter and quieter and all eyes were turned toward a couple near the fire where one knelt before the other. A waiter serving food stopped as if frozen. A dropping pin would have made more noise. Jessie took the ring, slipped it on her finger, and looked at it for a second that seemed to him like hours. Then she framed his face in her hands and kissed him.

"Yes," was all she said.


(Photo of Portland's Regency Park Hotel copyright 2011 by the author)

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Friday, January 14, 2011

Pink Hats 23: Conspiracy Theory


Holidays at the Livingstone House were a crowded, cacophonous intermingling of three generations, at least one dog, and abundant good food. This year, the din was periodically disrupted by squeals coming from the twins, "on loan" from their foster parents, who already had a house filled with their own children and grandchildren. Together, it made for the happiest Thanksgiving Bob could remember in a long, long time.

Following dinner, he drew Jessie's younger sister, Jennifer, aside on the pretext of discussing her family medicine residency at Central Maine Medical Center. "Jen, I need your help," he said, whispering and glancing at Jessie to make sure she couldn't overhear, "I'd like order an engagement ring for your sister, but I have no idea what size. Do you know what she wears?"

Jen, nearly a carbon-copy of her sister with the exception of auburn hair instead of Jessie's blond, said, "Of course, the same as me. We've always exchanged clothes and jewelry. I wear a six -- this is so much fun! When are you going to ask her?"

"Soon. There's a jeweler in Colorado -- I visited his store last year while attending a conference -- who has a design with filigreed mountains along the sides of the ring that I'd like to get for her. Let me show you." He took out his iphone, opened Safari, and turned to the page he'd marked. "What do you think? Too modern? Not traditional enough?"

"Bob, it's perfect! Jessie will be thrilled -- she's loved Colorado ever since she spent a summer out there working at a camp near Estes Park while she was in high school. You've got to get this for her!"

"She mentioned that but I never made the connection. I called this past week and they have sixes and sevens in stock -- so, anyway, we can count on you for family medicine, right?" He changed the subject as Jessie approached.

"What's the confab, you two? You look like you're acting out a scene from Conspiracy Theory," she said, taking a seat next to Bob and pulling him close.

"Shh. We're plotting to take over the medical school," he replied, with a wicked gleam, "by loading the clinical faculty with friends and family. I'm sure Chuck would love to get his hands on psychiatry, so that makes four of us and Halley makes five." She looked at him quizzically. "Someone has to run the place, can you think of anyone better?"

She covered her mouth, laughing, and shook her head as Jen looked from one to the other, asking, "Who's Chuck?"

"Oh, he was a student of mine during his first rotation. We're becoming friends over time. He's two years behind you -- "

"-- and he's single, good looking, and," glancing at Bob for his confirmation, "distinguished," said Jessie.

"Mm, 'distinguished.' By that do you mean 'older'?"

"Older than some, younger than others," Jessie said, with a playful but tantalizing tone. She's circling the bait, she thought.

"Older like, um, Bob?" Jen persisted, giving him a deliberate and appreciative appraisal. Now she's smelling it.

"Close but not quite," he said. "Honestly, I never asked his age, if you can believe it. I guess it's something guys don't think about. I'd say he's a few years younger than me." Then he added, "He did ask me if, uh, Jessie had a sister..." He ducked his head sheepishly and blushed.

"I see," she said, straightening in her chair and squaring her shoulders as though she was an elementary school teacher preparing to scold a misbehaving student. "Well. If he's anything like you, it sounds like you'd better tell him she does and she's interested." Aha! I've got you now!

"I don't know how much he and I are alike, but we are becoming friends, like I said, and I already did, the first part, that is."

"Then will somebody please tell him the second part while he's still interested!" she said, exaggerating for effect.

"Why, certainly," said Jessie, assuming a prim and proper demeanor, also for effect, "I'll get right on it. Now, what were you two really talking about?"

This time Jen came to the rescue. "Christmas presents, if you must know, now drop it before Santa puts you on the Naughty List!"


(Creative Commons image by alvy via Flickr)

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Road Hazards

Writing a story in installments can be as tricky as trying to navigate Southern Maine during a snow storm. There are plenty of road hazards. When I finished Pink Hats chapter 22, "A Different Drummer," not only did I screw up Chuck's education, I realized this morning I also managed to pretend the calender was non-existent. To anyone who noticed and then overlooked this discrepancy, thanks for being gracious. Anyway, I've made some necessary corrections in order to eliminate any confusion and get the characters into a right relationship with time. Now to get on with the story.

Thursday, January 13, 2011

Talk About Being Hard-Nosed


We were chatting about various issues, don't ask don't tell, the nature of relationships, and of course, politics, and how he imagined I might feel about them.

"I kind of expected, you being a man of the cloth and all, you'd think differently," he said.

"I'm sorry, but what does being a minister have to do with it?"

"Well, you know, the Bible says certain things just aren't right and I figured you being a minister, you knew the Bible better than most, and therefore you'd be pretty hard-nosed about those things."

He'd made a reasonable assumption, I just didn't happen to share it. To explain why, I told him the following story.

Once upon a time, there was a woman who had been caught, I assume by her husband, with another man. At this particular time in history, it was common practice to drag the woman out into the street, humiliate and then stone her to death. No one asked whether she had been abused or neglected and no one offered to represent her in court. As a matter of fact, there was no court except public opinion and in that one, she was guilty as charged.

Things were looking bad for the woman when Jesus happened by. The townspeople told him what was taking place and asked his opinion. He thought about it a minute or two and said, "Anybody who's never done anything they're ashamed of can throw the first stone." One by one, the people walked away. Then he said to the woman, "Looks like nobody's left to accuse you and neither do I. From now on, though, try not to get yourself into another situation like this."

"Yeah, but I'm talking about stuff that's unnatural," he said, "men and men, women and women. You got to be either for or against that."

"I don't have to be one way or the other on anything," I said, "because the One I work for wasn't. He dispensed with passing judgment except on those who thought they had a right to judge others. That didn't sit well with him. If he was here right now, you know what I think he'd tell us? Stop worrying about what other people do, whether it's right or wrong, natural or unnatural, and start being compassionate because some day you may need it as much as anyone else. And if you don't show it, you have no right to expect it."

Talk about being hard-nosed.


(Creative Commons image entitled "Hard-nosed" by Peter Giger via Flickr)

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Wednesday, January 12, 2011

Making a Difference


Doctors don't get snow days. Neither do students on rotations, but today is an exception and instead of driving through forty miles of cold, wind-blown confetti, I'm sitting here by the fire, comfortably watching it fall. Ordinarily, and that includes tomorrow, I'll take a winding country road that skirts Sabego Lake (photo) north to a small town in the foothills of the White Mountains, from which Mt. Washington, the highest point in New England, can be seen on a clear day. There, along with my preceptor, I'll work my hands around, under, and over sore muscles, tender points of lymphatic congestion, and arthritic joints, learning how to translate osteopathic manipulation from a classroom exercise into a meaningful therapeutic experience.

In a lot of ways, that linguistic process underlies everything we do in medicine as students, whether we still sign our names MS-I, II, III, or IV (medical student plus our current year) or append the long-dreamed-of counterpart, PG-I, II, III, IV (post-graduate or resident and the year) to a quickly and sleepily scrawled signature. Yes, even residents have classwork, homework, journal articles to read, and papers to present. It's not all hands-on.

But the translation is the best part, I think, or at least it is for me, right now. I like working with the structure and mechanics of language -- grammar, syntax, the nuances of word meanings, the distinctions between dialects. Learning the language of medicine is a student's first task and it takes two years to become vaguely familiar with the vocabulary. But it's like my first year high school Spanish class. We memorized dialogues and repeated them as though they meant something, but in the real world how many times can you ask, "Hola Juan, donde esta la biblioteca?" before people start avoiding you?

I'm not opposed to learning those dialogues -- next time I'm in Cancun I'll have no trouble finding the library, as long as the guy I'm talking to is named John. Anyone else and I'm in trouble. Language has to be applicable to be meaningful. And getting the hang of meaningfully applying what we've faithfully tried to memorize -- or better yet, learn and understand -- is ongoing. It's like the pursuit of virtue according to the fourth century Church father, Gregory of Nyssa. He said the process is eternal and we never arrive at a point where there isn't something else just ahead. Thinking you've got it made is proof you don't. Continuing to try is how we ultimately get to make a difference.


(Photo copyright 2011 by the author)

Monday, January 10, 2011

Rotations and the Wisdom of Scarlet O'Hara


The upside to being the only student in a rotation is you have unfettered access to your attending physician. They have the experience, you don't, so now's your chance to make like a sponge and absorb as much as you can. The downside is when s/he asks a question and there's no way on earth you can stand there with your hands in your pockets, staring at the ceiling, hoping someone else will speak up. See, there is no one else. Your attending knows the answer, the patient doesn't care, and the spot light is all on you. Oh, the joy, the rapture.

Oh, brother.

And that describes my day. Not once mind you, but twice I was pimped -- which has nothing to do with prostitution, by the way, though sometimes it may feel like it -- once regarding an anatomical structure (muscle) and once about a patient's response to a similar structure (another muscle) when it was palpated. And did I know the answers, you ask? Well, pilgrim (John Wayne imitation), did I know the answers! To the first, I was certain the muscle existed because I'd heard about it, read about it, and seen it with my own beady little eyes. Could I tell where it attached to the bone? (Gulp) Uh, no.

Okay, everyone gets a second chance in Jeopardy, right? So, did I know why our patient responded as if tickled when the second muscle was palpated? (Gulp, again) Uh -- gee, doesn't everyone act like that? In other words, no. My first encounter with destiny sent me running for Netter's Atlas of Anatomy between patients -- better late than never. My second left me feeling like the poor dumb schmuck I probably looked like.

There's nothing wrong with feeling like a poor dumb schmuck or even looking like one because I'm a student and students aren't supposed to know much of anything at this stage. At least in theory. When they're pimped, then it's either blather like an idiot, admit you don't have the faintest idea, or maybe, if you're lucky and the universal tumblers on the one-armed bandit that you're convinced you just pulled all click into place, you may actually come microscopically close to the correct answer.

Just not today.

Still, according to the wisdom of Scarlet O'Hara, "Tomorrow is another day."

Um, does anyone have any aspirin?


(Creative Commons image of Vivian Leigh as Scarlet O'Hara by Madmoiselle Lavender Lou via Flickr)

Sunday, January 9, 2011

Oops!


Well, I made a mistake. In "Medical School Hopscotch," I said Chuck had virtually no medical training prior to beginning his pediatrics rotation with Dr. Bob Z and in yesterday's post, he suddenly has six weeks of internal medicine and two of radiology behind him. Oops!

So, which is it? "Hopscotch" has the record correct, pediatrics is Chuck's first rotation and will be followed by internal medicine, a radiology selective, obstetrics and gynecology, and then, his long awaited psychiatry rotation. The purpose of yesterday's post was to reveal how his experiences with Bob, Jessie, and the twins, as well as his other patients, have triggered the desire to blend psychiatry with children and their parents. He thought his life was planned out nicely, but the past four weeks have introduced a change and now child-adolescent psychiatry is apparently on his horizon.

Chuck's role in Pink Hats has been twofold. First, he provides some necessary continuity with the events of chapter one. As time went along, it struck me as incongruous that we should only encounter him once, particularly since, without him and his dog, we wouldn't have a story at all. Second, he's given me an opportunity to talk about psychological issues that would naturally surface with Bob's desire to adopt the twins. For instance, why would a 62 year old man wish to put himself through everything having children entails? Chuck's an unbiased observer, allowing you and me to see how things look inside the male mind from the perspective of an outsider.

At the same time, being an older student, Chuck is far more likely to develop a relationship with Bob that smacks of peerage and thus, permits us to see Bob in a different light. With Chuck, he can be a teacher as well as a man who asks questions about himself and his motives. In a sense, Chuck is the closest thing Bob has to a male friend and confidante, though in fact, this is not the case. Bob has friends, but with the exceptions of Halley and Ted, none of them have made an appearance and since we're nearing the climax of the story, I doubt any of them will. We're getting to the point where introducing anyone other than very minor characters would be confusing.

So, my apologies for failing to keep track of the details. Although the Holidays are over for us in the real world, they're just around the corner for Bob, Jessie, and everyone else, and I think they're going to be a lot of fun. If it all works out like I hope, you'll want to have a hankie or two handy.


(Creative Commons image of The Book of Changes by Nikki L via Flickr)

Saturday, January 8, 2011

Pink Hats 22: A Different Drummer

After-hours coffee and Danish from the Nook and Cranny had the earmarks of becoming a ritual between friends. Despite his pediatrics rotation having been complete around mid-September, Chuck continued drop by Bob's office throughout the first of his two required six-week internal medicine rotations and now an elective two weeks in radiology. On the other side of four more in OB/GYN lay psychiatry, at last. What he didn't expect was the residual effect of his initial month with Bob, Jessie, and the twins on his future.

"I keep thinking about that child-adolescent fellowship and it's all your fault," he said, hanging his head and faking misery.

"I've been blamed for a lot of things," Bob replied, ruefully, "including a baby when I was seventeen that I had absolutely nothing to do with -- and couldn't have even if I'd wanted to because I was on a Scouting trip during conception -- but this is a new one. Tell me."

They were sitting in Bob's office with their feet propped up on opposite sides of a massive roll top desk he'd inherited ten years ago from his pediatrics instructor who, at 80, decided it was a good time to retire and sail around the world. He made it, by the way, and now, he and his wife were trekking in Nepal, in celebration of his 90th birthday.

"Well, I thought I had everything planned out. Adult psychiatry was my bailiwick. Sure, I loved kids, just like you, but I enjoyed psychotherapy so much it was hard to see myself in another role. Then you came along -- and Jessie -- and the twins -- and the next thing you know, I couldn't get enough of pediatrics. Especially the kids with ADHD and parents who're going nuts trying to cope, the occasional bipolar disorder we've seen, and the substance-abusing teens. And frankly, I miss them. I feel like saying, along with the prophet Isaiah, 'Woe is me, for I am undone.'"

Bob pursed his lips and nodded, as though he had anticipated the news. "I had a feeling we were going to be a bad influence. It's even worse when the kids like you, and clearly, they do -- that's a trap waiting to be set. Top it off, when you can get teenagers talking -- well, all I can say is, you are in way wicked trouble, my friend." He broke into an appreciative smile.

"Looks like it. I don't know all the details yet, but I've got plenty of time -- see? You can't get rid of me, can you? Now, about the dream you mentioned a couple of days ago in passing, the one you had on the way home from Concord --"

"-- yeah, what did you think of that?" Bob asked, interrupting.

"It was a good one, especially coming on the heals of meeting Jessie's father."

"You're saying a dream's timing is as important as its content?"

"From the perspective of interpretation, yes. Dreams are one thing, the way we view them afterward, is another. My impression is, this one is suggesting you have your own rhythm. Kind of like Thoreau's comment, 'If a man does not keep pace with his companions, perhaps it's because he hears a different drummer.' In your dream, the bass drum was a stethoscope -- you're maintaining the 'beat' of the music all right, but in your way. Timing enters the picture because, from what you've told me about Jessie's dad, it sounds like he's inclined to do similarly. It's probably another one of the benefits of you being older, allowing the two of you to establish a more mature connection."

"I agree, but that didn't make it any easier. Sure, we were more likely to develop a peer-type relationship than would have been possible if I was nearer Jessie's age, but he's still her father and truthfully? I felt like I was 22 once again, sweaty palms included. I guess none of us are as 'together' as we'd like to believe."

"That holds true for me, I'll tell you. One thing you can definitely count on is your relationship with her father making life a great deal easier for Jessie."

Bob was in mid-bite on his Danish. He stopped, put it down, and said, "I would assume that's a 'given.'"

"It is, but there's more. It tells her she doesn't have to love one of you at the expense of the other. It gives her a deep, abiding sense of security about two of the most important relationships a woman can have with men. And a woman like Jessie, who clearly wants someone with more maturity than a guy closer to her own age might possess, has the unspoken expectation that whoever she brings home, should be someone her father can respect as well as one who respects him. You already know this, but she's really an extraordinary woman -- I hope I get half as lucky." With a gleam in his eye he added, "Wait a minute. Didn't you tell me she has a sister? Anyhow, looks to me like you hit this one out of the ballpark. When are you going to pop the question?"

Bob laughed, "One at a time. First, yes I did and she's available, but I think it would look better if Jessie played matchmaker. A professor setting up a date might appear as unfair advantage. As to the second, I haven't quite decided, but I'm thinking around Christmas. It's our favorite time of year and even a romantic moron like me can pick the right place. I need to find a ring and I haven't figured out how to get her size without coming out and asking. I could do that, I suppose, but then the cat would be out of the bag and I'd like this to be a surprise. Not that we haven't talked or at least alluded to it. I just want very badly for her to have the 'fairy tale,' you know?"

"Yes, I do, and she'll love you for it."


(Creative Commons image by Allie's Dad via Flickr)

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Friday, January 7, 2011

Osteopathic Psychiatry: It's Time to Smell the Roses


Medical Students and physician review a techni...

In August of this past year, the House of Delegates of the American Osteopathic Association passed a resolution supporting the use of osteopathic manipulative medicine (OMM) for the treatment of psychiatric and neurological patients. In some circles, this might be viewed as a controversial decision and for non-medical readers, I need to explain why.

To begin with, we're not really talking about neurological patients since OMM has long been used in their treatment. With psychiatric patients, however, it's another matter. You see, psychiatry has traditionally been the one medical discipline in which practitioners, apart from a polite handshake, generally tried to  refrain from touching patients as a matter of principle. Psychiatric relationships are already complicated due to their subject matter, why risk complicating them further by introducing physical contact into the mix?

Not all psychiatric writers agree, however. Irvin Yalom, MD, for example, argues physical contact shouldn't be rigorously avoided; rather, when touch has been appropriate, the next step is to talk about its meaning for the patient (The Gift of Therapy, 2003). There is a wise saying, Everything is grist for the therapy mill, which means everything that takes place between doctor and patient should be discussed as a natural part of the patient's psychotherapy. But OMM involves more than placing a comforting hand on the shoulder of a grieving patient, which is why the decision to employ it has the potential to generate controversy. From my perspective, the issue has as much to do with history as with theory.

The practice of psychiatry as it's usually conceived can be traced to the work of individuals who were adherents, so to speak, of The Indiana Jones School of Psychiatry, i.e. they made it up as they went along. That's legitimate, by the way, when you're quite literally going where no one else has gone before. You sort of have to find your own way because there isn't anyone who's done what you're about to and can advise you to take up a hobby instead, or better yet, just get a dog.


In those days, psychotherapy was the psychiatrist's primary, if not only, tool -- it would be years before lithium became the first psychiatric medication on the scene. I studied under a psychiatrist who completed her training prior the advent of psychiatric medications and I asked her what that was like. She said being thrust into a ward filled to the brim with actively psychotic patients with nothing to use but psychotherapy was a hopeless endeavor, but as they had nothing else, what else could they do? 

According to the pioneers in the field (Jung, Freud, and others), the cure to neurosis was found in the resolution of the transference (the idea that a therapist unconsciously reminds a patient of another key figure in their lives, a parent for example, and by working through their feelings toward the therapist, they are actually working through painful feelings toward the parent; past and present meet in the transference). I can't say that psychiatrists and patients didn't ever touch because there are records to the contrary; it just wasn't a formal element in the process because it was feared touch might interfere with resolving the transference. The relationship between patient and doctor, therefore, was primarily cerebral and words were relied upon to render it incarnate in flesh and blood.
 
For the most part, the osteopathic community has focused its interests on the application of OMM to promote wellness and treat physical illness, especially in the context of primary care medicine. There are references to its use with psychiatric patients in the literature, but these are few and far between. Many, if not most, osteopathic (D.O.) psychiatrists have been trained in the traditional hands-off model and hence, experience a natural reticence about using touch to any great extent as a treatment modality.

Now, here's the problem. If osteopathic medicine represents a similar but also different approach to medical practice, it only makes sense that osteopathic psychiatry should represent a similar but also different approach to the treatment of psychiatric illness. As long as our methods are identical, however, it's kind of hard to see how anyone can point out a distinction between us and our MD colleagues. If you want to claim your degree confers a measure of "something else," it's only fair to ask what that might be.

In response, many have been inclined to say, we're interested in the whole person. But here's where I run headlong into my own experience. I've trained side by side with M.D. psychiatric residents and witnessed how much they care about their patients. They may not use the mind-body-spirit terminology that is the heart and soul of osteopathic medicine, but they care and that's what matters above all. What I'm getting at is, whatever differences exist between us, they have to be real, measurable, and not based solely on a well-worded principle, as critical as it may be to osteopathic identity (see Mission Impossible, 2/5/2014).

I realize I may be treading on thin ice and not all my osteopathic colleagues are going to be comfortable with the prospect of introducing therapeutic touch into the psychiatric mix. But times change. Physicians can undergo sub-specialty training in alternative medicine. The diagnosis and treatment of psychosomatic illness has its own subdivision within the American Psychiatric Association. The landscape of psychiatry is becoming far richer and far more complex than our forefathers and mothers could ever have imagined when they invented the talking cure. I think the House of Delegates is telling us it's time we woke up and smelled the roses.


(A follow-up essay may be found here)


(Public Domain image via Wikipedia)

 

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Wednesday, January 5, 2011

Rotations: Day Two


There's no question about it, I'm definitely enjoying this rotation. For one thing, as a friend reminded me yesterday, the techniques tend to come back once we start using them. I think muscle memory plays a role here, the hands remembering things the mind thinks it's forgotten. An understanding supervisor makes a tremendous difference, her ability to recall what it's like being in shoes similar to mine drives away the tension. Forgiving patients who tolerate my fumbling efforts and offer thanks when leaving, make me think there's hope for me yet.

Something I'm noticing more and more is how common some types of dysfunction tend to be. One patient has a rotated pelvic bone and then another and another after that. In lab we see this sort of thing in isolation from daily life. They're exercises rather than the lived experience of someone in pain. And for the most part, a rotated pelvis isn't the primary consideration, but addressing it enables a person to walk with less stress and strain, placing fewer demands on the rest of the body to compensate. When my supervisor tells me to examine and treat what I find and then returns later to check my work and responds with a pleased, "Mm," it's gratifying to say the least.

I've mentioned at least a few thousand times before that I'm a psychiatric guy. I see patients with physical problems and can't help but look at their facial expressions and listen for the energy or the lack of it in their voice and speech patterns. How does pain affect a person in ways we can't see? And how do these signs change as treatment progresses? I love the friendly banter my supervisor engages in with patients and encourages from me. It's a chance to loosen tight muscles by drawing personality into the mix.

The beauty of working in an established practice is you get to work with patients who aren't new to OMM. They're accustomed to having relative strangers touch them in really quite intimate ways and I marvel at their trust. I'm grateful for this, especially, because it helps me think of myself as a medical clinician, doing the best I can to help them feel better, while learning as I go. Their willingness to allow my unfamiliar fingers to probe and manipulate is turning each day into one marked by self-discovery, by the process of finding the healer within me that I have so frequently admired and sought to emulate within others. I don't know how they do it but I'm very glad they do.


(Creative Commons image entitled "M is for Muscle Memory" by stuant63 via Flickr)

Tuesday, January 4, 2011

Rotations: The First Day

Montage of Family MedicineImage via WikipediaWell, I've completed the first day of my first clinical rotation and I almost feel a little guilty because things went so well. My instructor/supervisor and I seem to enjoy working together and all of our patients left feeling better than they did when they arrived. All in all, I think we can call this one a success. So far, that is. I still have plenty of time to screw up, though, believe me, that's not at all my intention.

The setting for this rotation is a private practice in neuromuscular medicine utilizing osteopathic manipulative therapy. Unlike one in family medicine, for example, where I'd see patients with a variety of medical as well as psychiatric conditions, most of the patients in this rotation have some kind of somatic, i.e. physical, pain resulting from injury, repetitive use/misuse, or age-related degeneration. OMT involves using one's hands to apply prescribed techniques for the relief of pain and restoration of normal functioning.

The good thing about starting off with a neuromuscular rotation is, I'll get a solid basis for using OMT in other clinical settings, something I've wanted very much. At the same time, it's a reminder that I've been so focused on boards the past few months, I've forgotten some skills and need a serious refresher.

Even better is getting immediate satisfaction for your work. In psychiatry, we learn to defer gratification because psychological change occurs incrementally over time. With OMT, patients often show visible improvement at the end of a treatment session and it feels good knowing I've had a "hand" in that.

Best of all, the awareness that I'm not simply in the office for a day, but will be around the entire month is wonderful. It means I'm not asleep, I'm not dreaming, and I'm not going to wake up in the morning to find boards still looming in the distance. And that feels really, really good.


(GNU Free Documentation image via Wikipedia)

Monday, January 3, 2011

Triage


Besides the noble art of getting things done, there is the noble art of leaving things undone. The wisdom of life consists in the elimination of non-essentials.~ Lin Yutan

In medicine, we call it triage, the process of prioritizing patients according to the severity of their condition. Around New Year's, we use the term "resolutions." For me, it comes down to rotations beginning tomorrow and the painful recognition that, once again, time is going to be a precious commodity. I had hoped Pink Hats would have been done by Christmas. Fat chance. Well, I had good intentions, anyway.

So, now, seeing as how my days are going to be taken up by working with patients 40 miles and an hour's drive away, I think it's probably reasonable to say Pink Hats entries are going to more likely appear on the weekends. In between, I'll try to focus more on what it's like, doing a clinical rotation, show you some photos of the countryside, and get back to life in general. At least that's a workable plan. Like all the best laid ones of mice and men, things frequently go awry, and if they do and it's fourth down, we'll punt.

Unless we're close enough to run the ball into the end zone, in which case, who knows how things will turn out?!


(Creative Commons image entitled "Triage" by lamont_cranston via Flikr)

Saturday, January 1, 2011

Taking the Hit


When I was a kid, New Year's meant the Tournament of Roses parade and football afterward. It also meant Christmas break was almost over and I'd have to face the prospect of going back to school. It was really hard to get excited about a holiday with that kind of baggage. I've never been one to "party hardy," so as an adult, I tend to spend New Year's Eve at home, explaining to my dog and cat why New Year's is such a big deal. They usually end up falling asleep somewhere in the midst of my soliloquy and I don't blame them.

Last night, however, I got an unexpected treat when the 2006 film Rocky Balboa showed up on commercial television. I hadn't seen it in quite a while and all I could recall was, Rocky is an older, retired fighter who has a chance to come back and tackle a younger and presumably, hungrier opponent. I'd forgotten some of the things that made it such a moving film the first time.

Mostly, I'd forgotten Rocky's impassioned speech when his son appeals to him to turn down the invitation to fight the reigning world heavyweight champ on the grounds he has felt eclipsed by his father's name and reputation. "The world ain't all sunshine and rainbows. It is a very mean and nasty place and it will beat you to your knees and keep you there permanently if you let it. You, me, or nobody is gonna hit as hard as life. But it ain't how hard you hit; it's about how hard you can get hit, and keep moving forward. That's how winning is done. Now, if you know what you're worth, then go out and get what you're worth. But you gotta be willing to take the hit, and not (be) pointing fingers saying you ain't where you are (or wish to be) because of him, or her, or anybody."

Listening to Rocky's character, I couldn't help but think about people I've known (and know, by the way) who've had experiences that lead others to ask, "Haven't you had enough? Isn't it time to rethink your options?" And instead of rethinking anything, they find a way to keep moving in the direction they've chosen. Not stubbornly, mindlessly, without regard for life or limb, in the name of an overblown sense of pride. But out of commitment to something larger than themselves, a dream, a vision of their future they're unwilling to abandon simply because the way has gotten tougher than they thought it might.

I'm impressed by their determination, but especially by their integrity. When they've called or written to say they've taken a hit, they don't talk about how they've gotten a bad break or who's to blame for their situation. They consistently tell me what they've done and how their actions have resulted in what they're facing now. If they blame anyone, it's themselves, but not in an off-handed way that suggests they think someone else is responsible after all.

These are the people who keep me going. When I'm tempted to feel sorry for myself or think I'm all alone in a big blue sea of things that didn't go right, they're out there, swimming against the tide instead of treading water. The waves wash over their heads, they sputter, clear their faces, take another breath, and keep on going. They know land is ahead whether they can see it or not and refuse to quit until their feet touch solid ground. If they can do it, so can I.

From my dog and cat, Dr. Bob Z, Jessie, and all the rest -- including me -- Happy New Year!

(Creative Commons image by Lord Henry via Flickr)
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