Sunday, February 27, 2011

Surviving Board Exams Revisited

According to a handy-dandy little application provided by Blogger, Google's blogging support system, one of my most commonly read posts is Surviving Board Exams, written last summer after attempting boards for the second time. I've thought about this post and its popularity, and it seems to me the title is mildly deceptive, though certainly not intentionally so. It sounds like strategies for getting through medical licensing exams when in fact, it was a reflection on my post-exam experience at the time. And that's the important thing to remember, because, as it turned out, I was to take the that portion of our osteopathic boards once more before gaining a passing score.

Veterans come in all shapes and sizes. There are those who've served in the military, those who've come through hard times -- veterans of addiction, abuse, or grief and loss. I've even used the term to refer to the bond that develops between medical students or between residents in the course of their training. Just this past week, while visiting with a friend who had lost a parent, I mentioned the word "veteran" describing those of us who have lost one or both parents. My friend looked me in the eyes and said, "It's just that way, isn't it?" And it is.

Some things are so profound that our endurance of them can only be fully comprehended by one who has been down the same dark passageway in one way or another. We do our best to empathize in these situations, calling upon our personal histories with suffering, but "you had to have been there" is a phrase pregnant with truth. This doesn't mean we ought to throw up our hands and throw in the towel, abandoning persons in distress to their own devices, but empathy has its limits and we do well to recognize them, while offering the very best of the empathy we have to share.

My perspective on board exams, like that of many other medical students, is colored by trial and failure, as well as success. Looking back a couple of years, I can see how I fell victim to pressures exerted by the expectation that medical school follows a predictable time line. The longer I'm immersed in this process, the more I realize predictability is a delightful fiction. Circumstances appear that no one can anticipate, altering one's time of arrival at the railway station called "Graduation." And it happens more often than most people realize.

For me, surviving board exams became a reality as a direct consequence of attending the PASS Program in Champaign, Illinois last fall. There I learned how my previous attempts were pretty much doomed to failure because I, like most students, had misunderstood the nature of boards. I thought they tested what I knew and in reality, they test what I can use. 

Since the first two years of medical school focus on the accumulation of medical knowledge rather than its clinical application, when we face boards for the first time, we're at a distinct disadvantage. Failure is so devastating because we're inclined to take it as a judgment upon what we know, suggesting we either haven't learned enough or our learning mechanism is faulty. Both damage self-esteem and erode self-confidence, the very qualities we need to hold onto the most.

In my experience, after receiving a failing grade on boards, the first thing students do -- and I did -- is engage in a more intense review of the material they studied the first time around. Usually they supplement an already massive amount with notes, charts, and review books, on the presupposition their previous preparation was inadequate. That approach, however, perpetuates the misconception that boards test how much you know. In many cases, we already possess sufficient knowledge for the task, we just don't know what to do with it. Learning how to think clinically and discern the patterns in medical science is the critical chapter in Beggar's Survival Guide for Medical Board Exams. 

But even the experience of failure and discovering how to approach boards successfully has been a valuable one for me, because I've been able to share it with others in similar straits. Having a failing grade on boards, according to the common wisdom, is a liability when it comes to obtaining residency placement. I'm not saying it's not, but I am saying grace has a way of seeing us through when we fear there is nothing that can. When we refuse to call any experience wasted and take it instead, as something to hold in reserve until we can use it to help someone else, the benevolence of the universe, the grace of God -- whatever you wish to call it -- has a habit of acting on our behalf.

Maybe we don't get a premier spot in the most competitive and prestigious of residencies, but when we use what we have to help others we gain their love and appreciation. We grow in our capacity to give, we become better persons, and all of that is so incredibly worthy, the day can come when we are grateful for every time we've stumbled, fallen, and gotten back up along life's way, because without them, we'd never had the privilege of helping someone else.

(Creative Commons image by ross6606 via Flickr)

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Saturday, February 26, 2011

Lost in the Slots

Can you believe it? Here I am, somewhere on the upside of maturity, however old that is, and I've never even seen the inside of a gambling casino. Not unless you count Oceans 11, Rain Man, Leaving Las Vegas, and Viva Las Vegas (on television, that is), and I'm not sure that counts for much. Now, this may not sound like anything to be concerned about, except I've got friends who're younger than me by at least three or four centuries and they've all boldly gone where I've never gone before.

Metaphorically, I've hung around Vegas on numerous occasions, since having been both a minister and a psychotherapist, I'm privy to confessional secrets. You know, what happens in Vegas, stays in Vegas? In other words, whatever you do while you're here, your secret is safe with us. Sounds confessional to me, more or less. Anyway, that and the movies are as close as I've gotten to the real thing until this past Wednesday.

No, I didn't hop a quick flight west after my last patient and gamble the night away, only to show up at my preceptor's office on Thursday, bleary eyed and broke. What I did was drive up to Bangor to see some friends from medical school who are on rotations at Eastern Maine Medical Center and stopped by Hollywood Slots, a real live gambling casino on the edge of downtown. It seemed like a perfect opportunity to take a look at what for some, has been the River of No Return.

The first thing I discovered was, it's difficult to just look because the place is an experience in sensory overload. Walking through the glass entry doors, the sound of slot machines clicking over their tumblers dominates all else. Naturally, there was music, a nondescript form of contemporary rock and roll, but no one was dancing like they show in the movies. The gamblers, almost all of them retired persons, were far too busy doing what they came there to do and, besides, the Muzak wasn't likely their cup of tea, anyway.

The next thing I noticed was the lights. Lights from the machines, from fixtures in the ceiling, bright enough to avoid tripping, but not so bright as to take your attention away from the all important one-armed bandits which, it turns out, don't have arms anymore. I suppose that's more of a throwback to the original Oceans 11 with Frank Sinatra and the Rat Pack, still worth renting for a date night at home. The "bandits" they use now are like computer games and operate with the touch of a button.

It rather reminded me of Percy Jackson and the Lightening Thief, though there weren't any pretty girls in skimpy skirts and low-cut blouses offering me magic mushrooms -- talk about bad luck. There were waitresses serving drinks all right, but their uniforms were unremarkable. Either the casino owners assumed male gamblers would be too busy to notice or too old to do anything about it if they did. Curiously, there were no windows in the gambling area, nothing to mark the natural passing of time. A person could get lost in the slots for days and until their money ran out or they fell asleep, they'd never realize what had happened.

As I walked around row upon row of slot machines, I noticed that's all there was. No cigar smoke-filled room with high stakes poker players, no classy roulette table with a tuxedoed James Bond and gorgeous babes hanging on both arms. Maybe I'd misunderstood, but that was my conception of a gambling casino. Slot machines for the low-risk, low return gambler, and gaming tables for the high rollers. I was disappointed. Not that I expected James might call me over and ask if I'd hold his place, using his chips, while he slipped off to the loo -- any winnings were mine to keep -- but stranger things have happened.

At one point, I stopped walking and stood still, listening. At first all the sounds blended together like coffee, chocolate, milk, and sugar in a gigantic Mocha. But then, one by one, first chocolate, then milk, and sugar were flung out of the swirl and I could hear them individually, against the undertone of the machines -- about an A above Middle C on the musical scale. The stereo was three dimensional and the only word I know to describe it is hypnotic. The sound throws the mind's gearshift into neutral, turns off the switch, and drops the key into its pocket, not yours. One instant you're reaching for the key and the next, you're wondering why you wanted to in the first place. And that's how it happens. That's how you forget where you are.

It almost happened to me. My tour had brought me back round near the entry and like someone who's had too much to drink, I fairly staggered out the doors and up the stairs to my car, hoping I had the presence of mind to locate the exit. I headed for Tim Hortons, two doors down, for a bracing dose of sugar and caffeine to clear my head. The pastries tasted better than magic mushrooms and the coffee was all of 92 octane. With scarcely an instant of regret over the thousands of refined sugar calories I was consuming, I slugged down the Joe and drove off into the sunset, though not, unfortunately, like Percy Jackson and his friends, in a "borrowed" Maserati. I guess you can't have everything.

(Creative Commons image by L. A. Nolan via Flickr)

Sunday, February 20, 2011

Pink Hats 28: Like Arrowsmith

"If Barack Obama had yo' hair colah, the two uh you could be twins."

"Ted, I've got three inches and twenty pounds on him, not to mention the other, rather obvious differences between us. You think my hair color matters that much?" Bob asked, grinning.

"No, I mean you both have or soon will have beautiful wives and two daughters, and that's a fin
e comparison to make, wouldn't you agree?" asked Ted, dropping his ethnicity for emphasis.

"I would, indeed, though as much as I admire him, I wouldn't trade jobs for love nor money. Difficult as mine is now and then, I'd rather be in hell with
a fractured spine than have his. Though I suspect he'd say the same."

"Maybe, maybe not. Sometimes I think he'd like to be a healer, but some of his 'patients' are recalcitrant-prone."

"Mine only have tantrums."

"So do his," Ted said, with a wink and a nod, "
especially the ones in Congress."

"You know what a tantrum is, don't you?"

"After four kids, not including yours, and nine grandkids, I'd say I have a fair idea.

"It's what he must feel like having when he wishes he could lay a few of them across his knee and apply the hand of cooperation to the seat of partisanship. And that's why I wouldn't want his job. You can make kids stand in the corner, but senators and congressmen?"

"Besides that," said Jessie, handing each of them mugs of steaming peppermint hot chocolate from a tray Halley was holding, "the only 'White House' I want to live in is the one we're buying. Any political aspirations will have to wait until all our children are grown and I'm tired of having you underfoot."
She leaned over and kissed him sweetly. "Don't count on that happening anytime in your lifetime -- or mine, understand?"

"Oh, yes, ma'am, I do," Bob said, solemnly. He turned toward Ted, "I'm practicing saying that, both 'yes, ma'am,' and 'I do.'" Ted roared with laughter.

They were relaxing in the Green Granite Inn's lounge at Cranmore Mountain Resort in North Conway after a day of skiing punctuated by Bob's first snowboarding lesson. He and Jessie had taken turns with Halley and Ted, babysitting and occasionally pulling the girls round the lift area in a miniature sleigh Jessie and Halley purchased on a recent shopping outing. It was the same day Jessie also found a navy blue wool sweater woven with a reindeer across the back for one of Bob's presents. "He loves reindeer," she confided to Halley.

The Holiday was a week away and the Inn had been transformed with
wreaths on every door, pine bows, poinsettias, a traditional solitary New England candle in each window and a huge Balsam Fir, wrapped entirely in star-blue lights brushing the ceiling, near an equally huge stone fireplace. After all that had gone on in the past few weeks, the couples decided a day and a night away was certainly what any doctor with a healthy dose of common sense would order. Jen and Chuck, fast becoming an item after meeting two weeks earlier at Bull Feeney's, offered to take care of Sam.

"So, did you decide on the giraffe, Bob?" asked Halley.

"Shh, make sure the twins are still asleep, first."

"They aren't going to understand you, not yet at least," she responded, drawi
ng the blankets back from each of the unconscious pair in their carriers, "Yes, they are, now did you?"

"Come Christmas morning, Sam is definitely going to have a surprise waiting next to the tree, and the girls? Well, I know it will be a few years before they can really appreciate it, but one look and I couldn't resist." He was referring to a five foot tall stuffed giraffe he and Jessie had seen at Tree Top Toys in the Old Port. Far too big for anything but occupying space at the moment, it grabbed his attention when they walked in and he couldn't leave without it.

"They say having children is a chance to re-experience our own childhood, do you believe that, Bob?" asked Ted.

"I don't think it's our own so much as it is seeing the world as an adult through the eyes of our children, but in either case, it's something I've missed, I know that much. And, I'll tell you this, I'm deeply grateful life doesn't hold grudges when we don't get everything right the first time."

Jessie reached up and stroked his hair. "I got an email from my dad this week and he said something I think you'll appreciate. He said relationships like ours do far more than simply give us second chances. They give us the ones we've never had. You could say -- and I'm definitely saying it -- this is our first, at long last, and I'm going to make sure neither of us misses a single minute of it."

"Like Arrowsmith? You don't want to miss a thing?"

"Just like Arrowsmith."

(Photos copyright 2011 by the author)

Saturday, February 19, 2011

The Credit Limit

For a generation of men raised wearing oxford cloth shirts, what I'm about to say may come as a surprise, but I was in high school before I developed my life-long affection for the button-down, all-cotton variety. Why so long? It's not because they hadn't been invented yet. That took place in the nineteenth century when English polo players discovered the basket weave pattern provided better ventilation during a match. The buttons were added when someone complained about collars flapping in the breeze.

Growing up, as I did, the son of a cowboy-saddlemaker, my father's shirts and mine were made of broadcloth and had snaps on the front and cuff plackets. Patterns were more popular than solids in Western-style shirts, and the truth is, you really can do a lot more with broadcloth when it comes to designing shirts in patterns. Don't believe me? Take a look at your Land's End catalog for men sometime. Brooks Brothers, Joseph A. Bank, you name it. Stripes do fine with oxford cloth, especially pinpoint, but the Scottish plaids, paintbrush styles, and paisleys (if anyone wears those anymore), are generally made of broadcloth. It just takes the dye better.

So, that brings us to high school. Somewhere along the line, my mother came home with three oxford cloth shirts, two of which were all-cotton, the other a blend. We had our shirts laundered at the time because you could have that done for a song, unlike today when it costs a symphony to get them out of hock. It was quite a while before I figured out why the all-cotton ones took starch so well and the blend, no matter how much starch was added, hung on me, limp as a banana peal. Polyester may help reduce wrinkling, but it can't absorb starch, and it's due to the fact that polyester is petroleum-based and starch has to be mixed with water.

I'm thinking about all of this today because I have freshly starched shirts drip-drying on hangers in the shower. It's part of my weekend routine. Come home from my rural medicine rotation with a bag of laundry, starch the shirts, dry and iron them. It's a habit I got into several years ago. I used to think having shirts professionally laundered was the way to go until learning about the process itself changed my mind. Because shirts are draped over a form-fitted model and steam is shot through the fabric, professional laundering tends to break down the fibers and as a result, shirts wear out faster. Since the steam is hot, they also tend to shrink a little each time. I don't know about you, but being on a medical student's income, there are limits to my shirt budget. Besides that, once I find a shirt I like, I'd prefer it to last a while.

I suppose one could argue laundering, starching, and ironing takes time and time is money. That's true, but the time I spend doing all of this is not time I'd spend making money, so in the long run, I'm saving it. Also, you have to consider how, once you've learned to iron and iron well, you get faster by sheer practice. If you iron while watching television, you can do two things at once and it cuts down on boredom.

Now, before the male members of the audience start thinking this is "woman's work," I'd like to suggest a couple of things. First, never, ever use the term "woman's work" around the opposite sex unless you want to limit yourself to first dates, because that's all you're going to get. Just because mom used to press your clothes, don't entertain the fantasy that girlfriends do likewise. Second, one of the secret benefits I've discovered about doing my own ironing is, women find it attractive. I'm not kidding. If you're a man, you already know there are things cooking in the minds of women that you won't understand if you live to be a million, so stop trying. This is one of them.

Still, I'll hazard a guess. I think women find it attractive because it suggests to them a man is secure enough in his identity and masculinity, that he can do domestic chores without thinking twice. They take it to mean he takes pride in himself, his appearance, and knows how to be responsible. A man who can do these things can also take care of them. Not that they can't take care of themselves, because they can, but you get the idea. It means a man is dependable, mature, and especially, confident. He's got the stuff money can't buy, no matter how high is his credit limit.

Oh, and if you'd like a good recipe for homemade starch, drop me a line.

(Creative Commons image, "The Morning Routine," by Mike Schmid via Flikr)

Thursday, February 17, 2011

The Lucky One

I'm home again after another amazing week in rural Maine. I gave my first tetanus shot yesterday and identified, if not actually diagnosed, my first case of outpatient pneumonia. The latter was a biggie for me since we didn't have a chest x-ray to rely on; instead, it was a matter of taking a careful history and listening to our patient's breathing, then asking what was the most likely explanation for their presentation. As I've mentioned previously, I can't get over how much more akin to internal medicine this rotation is turning out to be.

In part, this is due to the fact that my preceptor's patient population is, by and large, an older one, so the colds, flu, measles, and chickenpox that show up in family medicine don't walk through his door too often. It also stems from his comfort level, dealing with difficult and challenging cases. He won't admit it -- something I admire about him -- but he's a careful and astute diagnostician. He takes his time with patients and encourages me to do likewise and make certain I offer well-reasoned and thorough explanations for what we're doing and why.

More than accurate explanations, he wants to make sure we provide ones that are comprehensible. This appeals to me strongly because it's the same principle my friend Dr. Lynn Smith and I followed when writing our book. We wanted to communicate effectively, not impress readers with the extent of our vocabulary, something that often characterizes academic writing. "It's not what you say or do," my preceptor reminds me over and again, "it's what people think you said," that matters. For this reason, you want to make certain what they think is the closest approximation of what you actually said, as possible.

So, for example, when urging a patient to take a complete course of antibiotics and not stop once they begin feeling better, he'll say, "It's like wolves who attack the weak and sickly in a herd of deer and then go after the strong." An antibiotic kills off the weaker members of a bacterial population in the initial few days of taking it, but you've got to finish the prescription in order to get the ones that remain after you've started to improve. Makes a lot of sense, doesn't it?

I'm three weeks down in what's usually a four week rotation but I've been offered the chance to extend it by another two, and that's what I'm doing. I'm learning too much and having too much fun in the process to turn down the opportunity. Of one thing I'm certain, when I graduate, whatever kind of physician I'll become, it will be strongly colored by the weeks I've spent with this guy and his gal Friday in north central Maine. Am I ever the lucky one.

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

Saturday, February 12, 2011

Nuts R U

A Swedish box of chocolates called
I so suck at small talk. Some people are masters of the lingo and I truly admire their facility. Even with friends, sometimes I end up babbling like the little fishy dude in The Return of the Jedi. Remember him? Lando Calrissian's co-pilot on the Millenium Falcon in the final, epic battle against the new Death Star? When he spoke, it sounded like he was saying, "Blabbada, blabbada, blabbada." Well, that's me.

If only social situations were like writing. Not texting, because my fingers are so big and the keyboard on my iphone so small I have to hunt and peck with one finger. Even with text shorthand, "hi how r u?" takes so much time that my co-communicant has gone on to "nice 2 see u bye" before I'm halfway through the conversation. I mean real writing where nouns are nouns and verbs are verbs and they follow one another in the sweet company of polite punctuation. Not likely, huh?

I don't know if I freeze up inside or what, but when confronted by situations where a dissertation is inappropriate and a few choice words are poetry, my brain goes blank and my mouth takes on a mind of its own. And that's where writing would help because I could always backspace and erase a comment before hitting "enter." Not that this guarantees anything but it does allow editing. The other way, where what you say is what they hear, it's anyone's guess whether I'm going to come off like a nice guy or a goof ball.

Now, it's very true that asking other people questions, giving them an opportunity to talk about themselves, is generally a safe bet. If you can listen well, and therapists are usually pretty good at that, you're covered. Inevitably, however, there comes a point when you run out of questions or they'd like to hear about you, and then the good ship and crew are in peril.

Occasions like these make me wonder about the extrovert business. On any given day, that's me, energized by interaction, eager to engage. In casual social settings, Mr. Introvert takes over and even Forest Gump would have a better chance of making a good impression. Maybe I should memorize some of his better lines? When someone asks how I'm doing, respond, "Well, life is like a box of chocolates, sometimes you get a smooth center and sometimes it's nuts." Just so long as they don't walk away thinking the nuts r u. That would probably be bad.

(Public Domain image via Wikipedia)

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Thursday, February 10, 2011

Omega Thinking Revisited

A little over a year ago, I wrote a post entitled, Omega Thinking, describing my journey to medical school and the changes that have taken place in my life along the way. Since then, I've shared this concept with a number of people, some older, some younger, and all of them have found it a meaningful explanation of experiences they've had, and I've been encouraged to believe I may be on to something.

Let me give you a brief overview to get us all on the same page. In the photo you'll notice two Greek letters, alpha on the left, and omega on the right. While nobody's life proceeds in a straight line, for the sake of simplicity, let's say the left leg of the omega represents mine as a young man. At some point, I'm guessing about age 25, I took a left turn. I didn't realize what I was doing at the time nor did I make the turn intentionally. It just happened, like a lot of things.

For the next twenty or so years, I wandered, for lack of a better term, around the loop, attending graduate school, running a business, going through life trying to figure our where I fit in, if I did at all. Exactly when I took the second left, this time onto the right leg of the omega, is also uncertain. I think it was 1998, the year my mother died, my father was diagnosed with pre-leukemia, and I began premedical studies. In depth psychology, "left" symbolizes the unconscious and I've come to interpret the first left turn as a sidestep ultimately leading to self-discovery. The second left integrated the person I had been with the one I was becoming, and perhaps, ought to have been all along. This sounds easy; in reality, it was far from, though the details will only muddy the water, so we'll leave them out at the moment.

The complicating factor in all of this is the arrangement of the legs of the omega. Notice the point at which they are nearest one another. When someone undertakes a process like the one I'm describing, once they've come full circle, they're going to be more like the person they were when they started out. Yes, they're older, and hopefully, more mature, but that doesn't change the fact that they're closer to the starting line than the end of the race. It seems to me, for reasons only the unconscious knows and each of us has to fetter out, some of us need time in the loop in order to truly run our race to the best of our ability. Or to find out which one is our race to begin with.

In either case, once a person has exited the loop, they may find themselves out of step with members of their age-group generation in terms of interests and life tasks. While you were "in the loop," those who weren't, moved on ahead, and now, in a very real sense, your generation is not the one you were born into, but one you dropped into when you stepped out of the loop. Sounds like a time warp, doesn't it? But that's how people I've talked with describe it.

It can be genuinely confusing, when you find yourself in a position like this, and for most of the past year, I've wondered if there was a corollary to Omega Thinking that might verify I was on the right track. Something more than the validation I'd received from others who liked the idea. This week, I found what I was looking for. It surfaced while chatting with someone in recovery from alcohol dependence. The nature of recovery forces a person to confront issues that have been hidden for years, blunted by their drug of choice. Doing so can be difficult, painful, and yet, have the effect of creating the feeling that one is alive for the first time. Once you dare draw the curtains wide, there's no telling what you'll see. Although our histories were different, the pattern we followed was extraordinarily similar.

Was my initial left turn a mistake? Was it like this man's first drink as a teenager that made him feel like an adult and kept him drinking for thirty years? I'm inclined to say it wasn't because of the value I've come to place on the things I've learned and the relationships I've established along the way. The unconscious leads us where we need to go, even when we think we're in charge. I certainly thought I knew what I was doing at 25. If there was a mistake involved, it stemmed from trusting an omniscience I never possessed and relying on judgment that was untested and unproven.

I'm not about to say I'm older and wiser, now. Older, yes. Wiser is still ahead, somewhere down the road, or at least I hope so. But even the "older" piece of it is relative. It helps, having a grey hair or a wrinkle here and there, when trying to convince a patient to take better care of themselves. But I'm still a student -- 25 or 50 plus, it doesn't matter -- and I must come across as one because some of my patients treat me as though I've got a lot to learn. And they're absolutely right, I do. What I've learned already, by sidestepping into the omega loop, is how to pay closer attention to what life has to teach.
(Creative Commons image by Leo Reynolds via Flickr)
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A Word of Thanks

Before settling in to write, I'd like to offer a word of thanks to everyone who's come by to read this week. I'm up to my neck in family medicine and by the time I get back to my temporary digs for the evening, my brain is swimming with diagnoses, treatment options, and reading assignments I've got to complete. Despite all my good intentions, writing has had to take a back seat the past few days, whether I like it or not.

Aside from that, however, the week has gone incredibly well and once again, I've seen conditions that one rarely sees, if ever. For instance, I've gotten to chat with a patient who has Whipple's Disease, an extremely rare condition that has been diagnosed only about five hundred times since its discovery. Most students never have an opportunity like this and I'm extremely grateful for the chance to have heard what it's like from one who's clearly suffered a great deal with it.

Patients are truly the best instructors and today, one of them was a five year old with hair as red as Ron Weasley's. His mother came in for an exam and while she was ensconced with my preceptor, "Junior" and I went out into the waiting room and looked at story books and talked about great adventures. When it came time for his wellness check, I was his pediatrician. It was my first time at bat doing a physical on a child and he was wonderful. I couldn't have ordered a better instructor if I'd had a list to choose from.

And then, there was an opportunity to do some osteopathic manipulative medicine on a patient complaining of back pain. Face-on, he was standing a bit crookedly; when turned around, his spine imitated the "S" on Superman's jumpsuit. His story was typical for this time of year. He was shoveling snow, leaned down, twisted, and yikes! It was his sacroiliac, as osteopathic students are probably guessing, and I was once again glad for a month of OMM practice and review before coming to northern Maine.

Anyway, now you know what I've been doing when I'm not writing, and hopefully, I'll make up for it fairly diligently this weekend. In the meantime, thanks once again.

Sunday, February 6, 2011

Coping with Both/And

Doug RossImage via WikipediaWant to know what the hardest thing is about family medicine -- for me, that is? Explaining to family doctors why I want to be something else. And doing so in a way that doesn't hurt anyone's feelings or give the impression I'm not interested in medicine. Trust me, this is no mean task, especially when doing a family or internal medicine rotation. You see, as a student, I want to get the best education I can. But this tends to create confusion because, somewhere along the line, psychiatry has gotten the reputation of being the discipline for those who don't have the hots for medicine. Making it tricky for those of us who do.

Like most generalizations, this one doesn't hold true in every case. Still, it holds true in enough of them that it becomes necessary for the rest of us to try to overcome the stereotype. But here's the rub: if I act motivated to learn physical medicine, it calls my commitment to psychiatry into question. If I act like all I'm interested in is psychiatry, then I may not be taken as seriously as the student who identifies with Marcus Welby, Ben Casey, Doug Ross, or Alex Karey, MD or DO, depending on which generation of television doctors you follow. Damned if I do and damned if I don't.

To be fair, I'm sure it must be the same for students whose stated intention of becoming "doctors" is complicated by an interest in patients' psychiatric conditions. Both/and isn't the easiest thing to cope with on the best of days. Now, it's entirely possible that those appear medically-ambivalent might actually be happier with advanced degrees in psychology. I don't know, I'm just saying. You can definitely count on medicine involving you with patients in ways you don't have to think about as a psychologist.

Take this past Thursday, for example. The only other time I've performed a male (why do we call it that? I mean, is there any other kind?) prostate exam was in lab one evening a little over a year ago. On the same occasion, I did my first female breast and uterine exam, both with actor-patients to whom and for whom I will be eternally grateful. As you may know first-hand, exams like these are a very intimate, for doctors and patients alike. And they're things a psychologist doesn't ever do.

It's true, psychiatrists don't routinely do prostate exams or pap smears, but that's not the point. They receive this kind of training because they're in training to become doctors and therefore, approach the brain-mind-behavior interface from the standpoint of one who practices medicine, not psychology. As an aside, this is one of my objections to allowing psychologists to prescribe psychoactive medications, but that's for another day. Call me narrow-minded, but I don't think one can be a competent psychiatrist without being a competent physician for the very reason that psychiatry is the medical discipline whose task is to tread the no-man's land between mind and body.

St. Augustine, Bishop of Hippo (not of hippopotamuses, though I certainly have no objection to the idea -- ever attend a blessing of the animals on the Feast of St. Francis of Assisi?) in Northern Africa during the fourth century, prayed, "God, deliver me from the need to justify myself." I guess I'm not there, yet, but God knows my heart and I think my preceptor in rural Maine does as well, because he surely gives my desire to learn physical medicine the same attention he does my interest in psychiatry. It's just a matter of coping with the stereotype in subsequent rotations and I guess that involves being gently and respectfully honest and letting the chips fall where they may. It's nice to know Augustine struggled, too. I feel like I'm in good company.

(Fair use of a copyrighted image of George Clooney as Dr. Doug Ross from "ER" claimed for the purpose of identifying the character in question with no commercial intent and in the absence of a similar, free image)

Friday, February 4, 2011

Family Doctors -- The Default Psychiatrist

I thought there would be lots of colds, flu, and diarrhea in my rural medicine rotation, remember? Ordinary, boring pathology that mom could treat as well, if not better, than the doctor. This week, I've seen shingles (a burning, painful rash that sometimes hits on those who've had chickenpox), polycystyic kidney disease, a transient amnesia that I thought represented a transient ischemic attack and may still prove to be, and a boatload of psychiatric issues couched (no pun intended) in the guise of daily life. To my friends in family medicine, I can only say, you were right and I was wrong -- family med is anything but boring.

It's easy to create the impression that "rural" automatically means "country," especially when referring to communities like the one I've been describing. Well, it does and it doesn't. My preceptor practices in a small town of about 1200 persons but his patients come from miles beyond the town limits. It is country, no doubt about it. But rural really means under-served more than anything else. For instance, in a community that numbers, including outlying farms and communities, a population closer to 12000, the yellow pages lists one psychiatrist.

True, patients could drive to Augusta or Bangor or even Waterville, but that's hardly a realistic expectation when gas is $3.19 a gallon and the average family limo is a four-wheel drive truck that drinks gas faster than you can put it in the tank. Even if they have insurance, considering the limits placed on psychiatric care by most policies as well as sky-high deductibles, having insurance doesn't simplify the problem of paying for ongoing care.

That's what "rural" really means. Limited access as well as limited services to begin with. It's almost easier for a dairy farmer to make a living in these more remote areas than it is for a mental health clinician. For that reason, because doctors also have to put food on the table and payment can be uncertain, it's difficult for a community to keep a psychiatrist in practice even when they find a willing victim.

So, what do you do? You either keep your depression, anxiety, tormenting internal voices, or suicidal thinking to yourself until they get out of control or you go see the family doc who takes care of your high blood pressure. But, lest this sound like a good deal, it's not really. Family doctors function by necessity as default psychiatrists, but their training has its limits, as does the psychiatrist's. It has to be that way because no one can possibly learn everything. Not even doctors.

One solution involves dual-tract medical education: family or internal medicine slash psychiatry. If you're fortunate enough to match in one of these highly competitive residency programs, you're ahead of the game because at least you can count on physical medicine to help subsidize the psychiatric care you deliver. But Maine doesn't have a dual residency program and students tend to practice near their training site and that leaves us, once again, out in the cold.

It's a dilemma that needs serious attention. And we've got to do something because the needs of patients in outlying areas for psychiatric care are overwhelming and as things stand, there just aren't enough of "us" to go around.

(Photo of a park in the snow in Skowhegan, Maine copyright 2011 by the author)

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Thursday, February 3, 2011

A Real Country Doctor

A patient having his blood pressure taken by a...Image via Wikipedia
Well, I'm home for the weekend, having gotten away early, following a short day in the clinic, and I've got to say I'm enjoying this rural medicine rotation immensely. In part, I'm sure it has to do with the fact that I'm personally getting to see at least a couple of patients each day on my own before we're joined by my preceptor, and today there were three, all in a row.

I can't begin to tell you how good it feels to do this once again, after such a long dry spell. It's been four years since my little cubbyhole of an office in Denver where I sat with patients, argued with managed care, and dreamed of being a doctor. Walking into an examination room, now, and greeting someone I've never met, asking them what brings them to the clinic, is so much like coming home it's almost beyond words.

What has surprised me about the experience thus far is how much fun I'm having. Previously, my encounters with family medicine have been so-so. Not bad, but not great, either. This time, I can hardly wait to get to the office at 8.30, about the time the nurse-receptionist-office manager-cheer leader in residence and anything else you want to call her, arrives. She's got a wry sense of humor that is wonderful and she knows medicine inside-out. I told her today that when her boss retires, she may as well forget about retiring herself, because I'm hiring her next.

By nine, my preceptor arrives, and the first patient shortly thereafter. If we having breathing room, we'll see this one together. If it's like this morning, the nurse has one lined up for both of us and I'm in heaven. Thirty minutes later, I report to him what I've found and we round on the patient together. There is always a teaching moment somewhere in the mix and I'm amazed at how much he knows and how much I'm learning. And this has only been the first week.

I'm glad to be home, to have a chance to walk my dog and cuddle with the cat, to clear the fresh snow away from the barn and dig out my mailbox that's buried forty inches deep with more snow on the way. But you know? I honestly can hardly wait for Monday to come. I'm seeing diseases I've only read about the past few years, evaluating patients with a growing confidence, and learning about medicine in a way that makes me wish I could scan my preceptor and his nurse into my iphone and carry them with me right through residency. He's a real country doctor and I'm a country boy who's having the time of his life.

(Pubic Domain image via Wikipedia)

Tuesday, February 1, 2011

Rural Medicine Rotation: Welcome to Grady

I wish the sun had been shining when I took the photo accompanying this post, because things aren't nearly as bleak as they look, but this is north central Maine, it is winter, and the sun doesn't shine all the time. That doesn't seem to make a great deal of difference to the residents of this little community on the Kennebec River. Five miles away lies Skowhegan, where student housing is located in a private home. Skowhegan leads the state in maple syrup production. Fun facts about New England to know and tell.

The storm paralyzing the mid-West at this moment, gets a matter of fact greeting this far north. The closest we'll come to recognizing the weather is to show up for work tomorrow in boots and jeans instead of slacks. And forget about wearing a tie. People who aren't born here, move here because they want to live as far away from anywhere a tie might be considered normal attire.

Five miles separate the comfortable basement where I sit writing and the first floor doctor's office in the yellow Victorian above (photo). "Welcome to Grady," I said to myself yesterday morning as I walked into the waiting room. Grady is the fictional location for the film Doc Hollywood -- this was the first of many Michael J. Fox moments I think I'm going to have over the course of the next four weeks.

I mentioned Sunday I hoped eventually to have the chance to see patients, relatively speaking, on my own. Eventually came twice yesterday and was repeated as many times today. It may have been a while since I've done a physical exam, but apparently I haven't forgotten nearly as much as I feared. And nearly every day, I'm grateful for Dr. Francis and the PASS Program, as my patients reiterate something he taught and real life imitates.

A rotation like this is a gift. Seriously. How often do you get to drop into someone else's life? But that's essentially what I've done with my preceptor. This is his town and I'm a visitor. He lives here and I'm passing through. That he, his nurse, and their patients treat me as though I'm anything but just another student is pretty darned amazing, because they sure don't have to. And yet, that's exactly what they do.

(Photo copyright 2011 by the author)
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