Sunday, August 24, 2014

The White Coat Brigade

Although I wasn't running late, it still felt that way. It was my second day of residency and a meeting with the psychiatry training director had me intent on arriving early. At my hospital, residents have access to a parking garage, unlike lowly medical students. Having been one of them for so long, the garage looks to me like the Taj Mahal. Anyway, after driving round a couple of minutes and coming up empty-handed, I spied an empty space marked, "Physician Parking Only." Wouldn't you know it? I thought, may as well have Dirty Harry guarding it. I started to drive past when the lights came on. 

"Wait a minute, that means me."

If there was a single thing typifying the impact of residency thus far, this incident depicts it. Over and over something happens -- entering the resident's lounge for the first time, hearing my name called with the title "doctor" appended to it, having other residents smile in greeting -- something happens to remind me I'm not in Kansas anymore. Medical school really is finished, I really did graduate, and I really am here, at long last.

It's kind of funny, when you think of it, the way reality creeps up and sinks in. I don't know if it affects other people like this, but I can't help thinking about how everything feels. Maybe that's why I'm in psychiatry: just being here isn't enough; I have to take it in and digest it. And unlike some third year rotations I was glad to bid farewell to, I want these first six months of inpatient psychiatry to poke along at pace that would make a snail impatient.

It's weird, though.  I feel like a buck private who's been given a battlefield commission. Only a few years ago I was an enlisted man, now I'm at the opposite end of the food chain -- or chain of command, as the case may be. Sort of. As a first year resident, I'm little more than a medical student with a title. But the people I work with didn't know me back then or in my life before that, on the front lines of mental health care. They only know me as I am now, a member of the White Coat Brigade. It's up to me to let my behavior spell out what I learned while serving on their side of the coin. 

Nothing is automatic, but it's all as pleasurable as it is satisfying. Especially sitting down with patients for therapy knowing it's partly what I'm getting paid for. I'm here to learn everything I can, but I'm also here to work and at this point, psychotherapy is something I can do quite legitimately. It's one of the tools I've had rattling around in my backpack the past few years, waiting for its time to come.

(Creative Commons image by Kids_Safari2 via Flickr)

Thursday, June 5, 2014

His Final Breath

The invitation was a Father's Day special that read, "What did your father teach you or how did he inspire you with regard to medicine?"

It would have been much easier had it been, "What did the Old Man have to say about the Big Slab (biker slang for the interstate)?" Then I could respond, in my best gravely ZZ Top growl, "He had me on a Hogg before I could walk. Why, he and mom almost named me 'Harley,' you know, as in Don Henry's song, Harley?"

There was a motorcycle mama and her man
With a wind-burnt tan and a Harley
Roarin' through Bakersfield when her water broke
They pulled into a hospital and for a little joke

They named him Harley
They bought a sidecar
And a small bandanna band
And they loved their Harley

Leaning closer and jutting out my long ZZ Top beard, I'd look at you over the tops of my Ray-Ban sunglasses and whisper with mock menace, "You do know Don Henry --  don'tcha?" 

But, that wasn't the question and my father never owned a Hogg or any other kind of motorcycle, much to my distress as an adventure-seeking teenager. Much to his relief, I might add.

Nope, my father didn't teach me a thing about motorcycles except I could get killed riding one. I came close one Fourth of July weekend, racing my uncle's beat-up Vespa scooter round his property as fast as first gear would take me. A patch of soft soil brought an end to my dirt bike career. They say speed kills, but in my case, it just knocked me out. No, I wasn't wearing a helmet -- in those days we didn't worry about head injuries quite so much and besides, my uncle didn't have one, anyway.

Dad did teach me a great deal about horses, though, mostly how to love them like your best friends. For a tough guy -- not a gruff guy -- he had a soft spot for horses. I remember the night he woke me up and led my mother and I out to the barn where we watched a baby colt being born. It was my first "childbirth." There was poetry in his relationship with horses and he taught me how to write my own over the years.  

He also taught me a lot about hard work, accepting responsibility, taking risks, and following your heart, all of which he exemplified regularly. It's been sad that he didn't live to see me through medical school. I would have dearly loved to share the folly and fun of my daily efforts to become a physician with him. Some of the situations I managed to get myself into would have had him laughing until he cried. Others wishing he could board a plane, despite his illness, to stand alongside his son when he experienced hard times.

If my father taught me anything about medicine, apart from how to "doctor" horse injuries. it was that I never knew as much as I thought I did. People will surprise you. His own life-long struggle with chronic pain resulting from a back injury at age 19, made him a model of endurance that earned the admiration of his physician. He worked through pain that would have laid me out and did it every day. His determination to wave off the beating wings of the death angel until his final heartbeat was a testimony to his disbelief in the word, "quit." 

So, what did he teach me? Where do I start? He taught me everything worth knowing and then some. He taught me about his fallibility, his fears, and to accept and overcome my own. He taught me to tolerate what I couldn't change and change whatever I could. He taught me how to face the worst life has to offer by going through it with me until I was ready to go through it alone. 

And that's when he took his final breath.

Happy Father's Day. 

(Creative Commons image of Billy Gibbons of ZZ Top by Filipe Neves via Flickr; "Harley" words and music by Don Henry who owns the copyright)

Sunday, June 1, 2014

Warm Days and Woodchucks

I hate moving. I used to think I was good at goodbyes, but you want to know the truth? I
suck at it. It doesn't matter whether there's a really good reason for riding into the sunset, I still find reasons for wanting to stick around long past closing time. Days I couldn't wait to resign my job in Colorado turned into days I loved it, even though I was leaving for medical school at last.

It's the same way now, even though I'm leaving to begin residency, also at long last. Only this time, I don't have to look for reasons, they're all around me. For instance, about ten minutes ago, the dogs and I were making our afternoon rounds along the edge of the hayfield when my big dog pulled up suddenly. I looked down and he was nose to nose with either a big woodchuck or an equally large beaver. They resemble one another and despite my friendly greeting, he didn't seem inclined to introduce himself, so we hurried on.

But things like that make it hard to move.  Cool, quiet, starlit nights, immune to the sounds of the city. and breezes off the freshly mowed hay, later in June, are things I'll miss. Yes, I'll get to see the Detroit Zoo and perhaps hear the Detroit Symphony, but my roots are in the country and I'd gladly trade the zoo for the porcupine that lives under the barn or the woodchuck in the hayfield.

I know this is my "big chance," as they say in show business, and I'll be glad to settle in and get to work. Time passes quickly, I learned in medical school. Residency will, too, and sooner than I imagine, I'll be packing again, to come home. In the meantime, though, warm days and woodchucks make me appreciate the life I've had, here on the farm, that much more.  

(Photo copyright 2014 by the author)

Thursday, May 22, 2014

The Secret Life of Walter Mitty

Beauty doesn't ask for attention. ~ Sean O'Connell

My friend and co-author, Dr. Lynn Smith and I used to talk at length about what we called the "Walter Mitty personality type." Risk-aversive, detail-oriented, traditional (though not necessarily conservative), and inclined to play by the rules. Good, solid people like Bilbo Baggins, who aren't likely to rush out their front door in pursuit of adventure. Their secret is, they'd like to. They dream about it, but they can't let go. Until they have to.

This is the story line for the marvelous film, The Secret Life of Walter Mitty (2014), starring Ben Stiller. By day, Mitty is a quiet, unobtrusive supervisor in the photographic negative department of Life magazine. At any other time, his imagination may have him miraculously rescuing damsels in distress or besting arrogant, narcissistic asses like the one in charge of transitioning Life from a print to online format. In daydreams, he's everything he's not from 9 to 5: creative, brave, articulate, and appealing. In life, he can't even bring himself to speak to the woman who's stolen his heart.

Whatever author James Thurber originally intended, this particular film version depicts a journey of the soul. Mitty is an ordinary guy who's become a worker bee. He contributes, he's efficient, he does his job very well. His life has purpose but no passion. He'd like it to and his daydreams are filled with it, but he's ambivalent. Even his e-Harmony profile is incomplete. He's at a crossroads and needs a guide, a mentor, someone who can show him how to make his own choices and live his own life.

Enter Sean O'Connell, played by Sean Penn. O'Connell is a photographer of the old school. He still uses film and submits his photos for publication by snail mail. He doesn't own a cell phone and would probably misplace it if he did. He's unpredictable and follows his own rules. As it happens, he sends Mitty a roll of film with instructions indicating the last negative on the roll is his preferred photo for the final cover of Life

The problem is, Mitty can't find it. It wasn't enclosed in the packet containing the rest of the negatives. Nearly at wit's end, he notices a photograph of O'Connell and imagines him beckoning for him to follow. Without warning, Mitty dashes out the building and boards a plane for Greenland, O'Connell's last known location. No baggage except a briefcase, no clothes except for what he's wearing on his back. 

Unable to hook up in Greenland, he follows O'Connell to Iceland, and on to ungoverned Afghanistan in the high Himalayas, where he stumbles upon him, photographing the elusive snow leopard. O'Connell explains the negative was in a wallet he sent Mitty as a gift. Ironically, the negative was in Mitty's possession all the time, but he was so focused on where it ought to be he couldn't consider where it might be.

O'Connell thought he was being "playful," assuming his partner would get the joke. Mitty saw it differently. Sixteen years and millions of negatives made him good at his job but lousy at spontaneity. In the course of things, he'd forgotten how to play. He's not alone; a lot of us are like that. The pressures of life and work build until we take everything so seriously. We turn to alcohol or drugs to unwind, but they don't help, not really. They disinhibit, that's all. Play is something more basic, more in touch with what makes life worth living.

Observing O'Connell refuse to take a shot of a snow leopard because the moment itself is too precious, Mitty realizes some things are too special to be captured. They can only be experienced. Moments later, playing soccer with a group of young Sherpas, he learns that play and transcendence are linked, and both can find expression in the work we do. Mitty knew all about work. What he needed to learn was how to play once again.

On returning to New York, Mitty confronts the arrogant narcissist in a way that, unlike his earlier fantasies, doesn't involve physical violence. Having rediscovered himself in O'Connell's company, he is able to speak as a mature man with a secure and certain center, to a spoiled and self-centered child. No longer fearful and timid, being with the archetypal "wild man" has changed him. He commands respect and his words carry weight. 

Does Mitty ever get the girl? You have to see the film to find out. Sorry, I'm only willing to leak so much. Besides, you do want to see why that bloody negative was so important, right? Most of all, The Secret Life of Walter Mitty is worth seeing for a contemporary glimpse at the ultimately spiritual journey to earn and achieve maturity, to become confident, to feel truly capable as a human being. It's a study in contrasts, too, between Mitty, who is willing to undertake the journey, and an arrogant narcissist who for all his posturing, has not and probably never will. 

(Creative Commons image by Sheng Wang via Flickr)

Sunday, May 18, 2014

Narcissist or Antisocial?

Following-up on my last post, "Mirror, Mirror," a reader wrote and asked if I might address Antisocial Personality Disorder in contrast to pathological narcissism. There was a time when I thought doing so was pretty straightforward since antisocial personality disorder was usually associated with a criminal history. I've since realized that's too simple because narcissists who become violent can end up with criminal records and antisocial types can be attractive and charismatic in the same way we usually think of narcissists. 

The picture becomes even more complicated when you think about other features they may have in common. For instance, both are well-known for being manipulative, self-centered, and resistant to feelings of guilt and remorse or responsibility for the damage they cause. "Lack of empathy" is how we describe this professionally, but in simpler terms, it means they can't imagine how it feels to be on the receiving end of their behavior. If a person's ability to empathize is impaired, they tend to act without considering the impact of their actions on others. The way this is expressed gives us an idea about how the narcissist and antisocial type differ.

Despite their belief that they are independent and need no one, narcissists really are very dependent upon others. The arrogant type needs admirers and the covert type, someone to use as a resource for self-esteem. As a consequence, in the initial stages of forming relationships, these individuals are seductive, conveying the image of the perfect friend,  colleague, or significant other. What they want is something else. Like the vampire's victim who willingly exposes her neck again and again, they want your trust, availability, and eager compliance. Only when you've been finally worn out, do they toss you aside like a wrinkled, faded newspaper.

Antisocial types can be seductive, too, but their goal is to obtain something specific and move on. Once they have it -- your money, property, virginity -- the relationship is over. You could say the narcissist invests for the long-term and the antisocial for short-term, immediate gains. A classic example is the retirement scheme that drains seniors of their financial resources, operated by the "pleasant young man who was so eager to help" and has skipped town with the money. Antisocial types consider people too much trouble to spend a great deal of time on them -- it's what you have that they find interesting. Narcissists want you and that's why they are so appealing.

Notice how both types can use people freely without the inconvenient interference of Freud's Super-Ego or conscience. Covert narcissists may be vaguely aware that others consider their behavior wrong or hurtful, but ultimately, how others feel doesn't matter to them. Arrogant narcissists and antisocial types simply don't take morality or conscience into account; they are ruled by pure self-interest. 

All three types are inclined to excuse their behavior on various grounds and criticize their victims for any negative consequences. Instead of internalizing blame and feeling guilty or ashamed, like most of us, they externalize these feelings and try to make it sound as though you're the one with the problem.  Techniques like "gaslighting," making up information in order to prompt a victim to doubt their perceptions or sanity, are commonly used to cover their true intentions. The antisocial type doesn't care whether their behavior violates the law; the idea may even be exciting to them. Arrogant narcissists can't imagine being held responsible for their actions since their natural superiority places them above culpability. Covert narcissists are convinced no one would even consider thinking of them as blameworthy in the first place. 

The reason covert narcissists feel immune to blame is due to their adeptness at creating a facade of innocence and using it to conceal their ulterior motives. Many find it hard to believe such a sweet, caring and ethical person could be deliberately deceptive. And, of course, this is precisely what the covert type is counting on. Their carefully-crafted, false persona enables them to operate surreptitiously, sometimes going undetected for years. Publicly, they don't wish to appear bothersome; privately, they are extremely high maintenance, intentionally draining others of their energy and well-being. 

In a sense, antisocial and narcissist exist on a continuum with the antisocial type lying more towards the asocial extreme and arrogant narcissists on the extroverted, social end. More introverted, yet also socially-oriented, the covert narcissist lies somewhere toward the middle. All of them exhibit an absence of regard for the thoughts, feelings, and values of others. All of them find it easy to lie and all of them are predatory to some degree. 

Predatory is a strong word but it gets to the heart of the matter. The individuals we've been describing are serial users. Whether they appear innocently grandiose or intentionally deceptive, they view others as resources, as means to an end. Adulation is just as important to an arrogant narcissist as ill-gotten gain to a criminal antisocial type. A covert narcissist plans his emotional ambush as carefully as a master thief. To them, the rest of us are sheep waiting to be sheared or resources waiting to be tapped. That we might be anything else never crosses their minds.   

(Creative Commons Image of Narcissus by Tiago Costa Nepomuceno via Flickr)

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Thursday, May 15, 2014

Mirror, Mirror, On the Wall

Bond:  "You're cleverer than you look."
Q:  "Mm, still, better than looking cleverer than you are." ~ Die Another Day (2002)

As most readers already know, I'm a fan of 007. For several years, Timothy Dalton was my favorite -- he possessed a certain darkness that rendered the "killer" aspect of Bond's character believable. Well, move over, Timothy, Daniel Craig does it even better and with a conscience thrown in for good measure (Skyfall, 2013). I like that best of all: Bond is capable of empathy, he is not a narcissist.

He is brutally honest; he's willing to do pretty much whatever he has to in order to get the job done, but looking clever means nothing to him if it's not real. Were he a narcissist, on the other hand, looking clever would be everything. Furthermore, he would think himself exceedingly clever, even though he was not. It's difficult for me to imagine Bond gazing dreamily at himself in a mirror and saying, "Mirror, mirror, on the wall, who's the cleverest of them all?" He hasn't got time for such nonsense; a narcissist has nothing but time for it.

That's one of the many problems with narcissists: they believe their own press. They think they're far more intelligent than the rest of us, true or not. They're wise, we're foolish, they're cosmopolitan or sophisticated, we're naive or impressionable. If a narcissist appears to admire someone, it's because they covet what the other possesses. Admiration is a cover for competition and narcissists are poor losers. 

Ironically, the narcissist's intelligence tends to be less lofty than they'd have us believe. Engage them in a discussion and you'll discover their knowledge base frequently represents a collection of disconnected assumptions and quotes selected from sources they consider influential. Original thinking is not their strong suit. They're like Mockingbirds, whose song is a chaotic repetition of all the other birds in the sky. What matters is not what they think but how impressive they sound, citing statistics and references, and leaving you breathless in their presence. At least this is the case for the arrogant-type narcissist.

Covert narcissists are less willing to risk their fragile self-esteem by trying to impress you with how much they know. Instead, they prefer to listen, treating you like an amazing conversationalist who has them hanging on every word. In the process of winning your trust, they're actually searching for those points at which you are most vulnerable. The time will come when they'll use those points to your detriment, revealing themselves to have been a cunning adversary clad in the guise of a friend. 

It probably sounds terribly unfair, if not unkind, to draw attention to the predatorial aspect of pathological narcissism, but it's necessary in the same way we have to recognize the killer aspect of the James Bond character. The difference lies in the fact that Bond doesn't kill indiscriminately. He's not a cold-blooded murderer despite the numerous notches he might carve into the handle of his Walther PPK. He only shoots (or stabs or drowns or blows up) those who have it coming. There's either justice or necessity in his sights.

Narcissists are rather indiscriminate. Anyone is a good enough target if they're vulnerable and nearly all of us are, to some extent or another. Narcissists wish to demonstrate their self-assumed superiority and doing so is their ultimate value. We are either their privileged audience or an unwitting resource for supporting their self-esteem. We are never individuals worthy of respect and dignity. We are things and for a narcissist, one thing is as good as another, as long as our life blood lasts and we don't realize what's happening to us.

Prevention is the best defense and discovery our key strategy. Learning to recognize the wolf in sheep's clothing is hardly a waste of time. You can't avoid a predator if you don't know what one looks like or how s/he behaves. My four-footed neighbor, Freddy the Porcupine, has only one natural enemy, but you can be certain he knows who that is and how to steer clear of his habitats. In the same way, learning how to identify pathological narcissism and its practitioners is the way we sidestep being reduced to the level of "things" and retain our humanity. Trust me, this is definitely worth the effort.     

(Creative Commons image of Bond and Q by Andrew Becraft via Flickr)

Sunday, May 4, 2014

The Uncarved Block

In your heart, you already know.~ Zen saying

Depending on the space we happen to be in, the heart's knowing can be a curse,  blessing, or one more unanswered question. The hard part is getting our head into alignment with what we already sense, intuitively, to be true. A Zen master would probably suggest meditation might help, but that just puts me to sleep. Besides, I'm more an uncarved block kind of guy.

The uncarved block is a concept expressing naturalness and the oneness with nature embraced by Taoism. You may be familiar with the delightful book, The Tao of Pooh, in which the author, Benjamin Hoff, describes Winnie the Pooh as the uncarved block. Simple, uncomplicated, genuine -- these are words that describe Pooh. A complex bear he'll never be. His most severe problem involves getting his head stuck in a honey jar. Unlike me, unlike most of us.

Getting to the lowest common denominator in my own life has been a challenge and continues to be. Circumstances don't always cooperate with the effort and making a move in any direction can stir up a beehive of complications. The uncarved block, fortunately, isn't a way of living as much as a way of being. It's who we are more than how we live, though right being ought to result in right doing.

Living on this farm the past five years has been an exercise in simplicity and one that I've cherished. I've learned to consolidate errands because "town" is twelve miles away, down a curvaceous country road. Walking my dogs around the hayfield is a pleasure I can scarcely describe and gazing out the front window at a barn dating to the late 1770s is a childhood fantasy come true. I've never gotten past the sense that some late night I'm going to encounter the shimmering remnant of a colonial someone who lived here long before me.

When a person's focus is directed externally, it's difficult to be simple. The world does everything it can to tell us we've got to keep busy lest we be left behind. Complexity isn't the template for the uncarved block. A piece of wood that has yielded to knife and sandpaper no longer depicts its untouched state. The uncarved block must be seen with the mind's eye.

It's like that with people, when we intentionally overlook skin color, clothing, distinctions, differences -- foreignness. When we allow the potential for relatedness to take precedence over presumption. Turn on TCM (Turner Classic Movies) sometime when The Russians are Coming, The Russians are Coming (1966), is on the schedule, as it was last evening. It's a comedy depicting a Soviet submarine that runs aground in a small, New England harbor. The residents of the town are up in arms because it's the era of the Cold War and instead of the British, the "Russians" have arrived at their doorstep. Townspeople and Russian sailors forget national pride to help rescue a child and suddenly, they're no longer enemies. 

A year ago, when bombs went off in Boston, Islamic-American doctors risked their lives alongside European-American doctors and first-responders to help everyone they could. The uncarved block was all that mattered. Getting simple enough to see that, all the time, is hard, especially when the voices of paranoia crowd the media, warning us one false step is only a single step away. Paranoia isn't a guide; it's psychosis, it's madness. Taking each other as we are is a better one. I'm quite certain, Pooh would agree.

(Creative Commons image "The Uncarved Block" by Beth Hoffman via Flickr)

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Friday, April 18, 2014

My "Thing" About Shoes

Lib in boots
I've got a "thing" about shoes. I never knew I did, not until a few minutes ago. Someone from a far place on the other side of the world read, "Wearing Mom's Shoes," last night -- though it was really this morning for them -- and that's when it hit me. I've written about my aunt wearing my mother's shoes, me growing into my father's, some that fit and some that don't. I've referred to distance runners and sprinters and they wear shoes of one sort or other, or most do.

In my only reasonably successful track event, I ran in stocking feet because the Converse "tennies" we wore at the time were worthless in a sprint. Once the weather warms up and I get the lawn freshly cut, shoes will get traded for bare feet. It only seems right, living in the country. Once I've traded life on the farm for a sojourn back in the city (residency training), that will seem slightly odd. Bare feet are for country boys, penny loafers for city mice. I know that's not strictly true, but it fits the stereotype.

But back to shoes, I notice them. What people are wearing and when, and I wonder why they've selected the ones they did. The big, block-like, square high-heeled sort that's back in style, pumps, boots, and so many kinds of tennis/hiking shoes an accountant couldn't keep track of them. If clothes make the man, shoes reflect the person. Too out of style and we're nerdy; too "in," and we're overly fashion-conscious. Most of us are in the middle, trying to get around without our feet hurting.

That's why I still love Skechers Shape-Ups, despite all the hype about false advertising. They're comfortable and good for long days on the hospital floors. My only complaint is they're not made anymore and finding the leftovers in my size (big) is a challenge. The company has a new one made with memory foam -- I may have to resort to those, if I can remember, that is. Maybe the shoes will help.

I guess all this came about from spending my youth in my father's retail western store/saddle shop. We stocked Western and English riding boots, in limited styles and quantities. We could special order anything, but customers like to handle what they're buying, so you've got to have at least a few pairs on the shelves. 

English boots are basically made of canvas (for summer), rubber (for barnyards), or leather (for everything else) and come in brown, black, or black with scarlet cuffs around the tops (fox hunting attire). Oh, and there are the little ankle length, jodphurs; can't forget them. Field boots have laces over the instep, dress (formal riding attire) are plain. English boots are like English food: there's not a lot of variety on the table, unless you're talking about pudding and we are definitely not talking about that.

Western boots, on the other hand, thrive on variety. Some have short, shoe-like heels and others the traditional cowboy style with three-four inch under-slung heels that angle downward in the direction of the toes. Tops can range from eight inches to knee length and toes can be rounded or sharp enough to use for a hole punch. And then there's the stitching or patterns cut into the top. They're decorative, sure, but also functional. The more rows of stitching there are, the less likely the tops will wrinkle around your ankles with age and the influence of gravity. If only faces had that advantage.

Colors abound as well as kinds of leather. Cowhide, water buffalo, or waxed calf for work boots; kangaroo, lizard, ostrich, fine calf, for "dressin' up and goin' to town," boots. I have a pair made from shark skin my father ordered for me during my first year in seminary and they still look good. I used to spend hours, when the store was empty and I should have been dusting or sweeping, looking through boot catalogs, wishing and dreaming.

So, yeah, I'm a "shoe guy," as well as a "car guy," and a "horse and dog guy," but I come by it honestly. There's no fetish here. The way to my heart is not through my feet. Invite me over for dinner and my shoes will be polished, but don't expect me to bring along my kit to do yours. A sincere compliment you'll get, but maintenance is up to you. My "thing" about shoes only takes me so far.    

(Creative Commons image by BCR Librarian via Flickr)

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Sunday, April 13, 2014

Parenting in "Star Trek" and "Man of Steel"

I'm a Star Trek and Superman freak. I wouldn't go so far as to call myself a "trekkie," though I did see the late James Doohan at the University of Texas a few years ago. I was so accustomed to his Mr. Scott, it was a shock to hear him speaking without an accent. I also saw George Tekei at a science fiction convention, once. Superman and I have yet to meet, but that doesn't rule out the possibility. You never know, he might decide my hayfield looks like a homey place to stop by, en route to an adventure somewhere else. 

I'm especially fond of the reboot versions that have appeared over the past couple of years and watch them every chance I get. As a matter of fact, I was watching Man of Steel (2013) for the umpteenth time this past weekend, when I began noticing similarities between Superman and Captain James T. Kirk, particularly in their relationships with fathers and father figures.

Both characters, for example, experienced the loss of their biological fathers at or near the moment of childbirth and under similar circumstances. Kirk's dies in the process of trying to secure the safety of his wife, newborn son, and crew, while battling the renegade Romulan, Nero (Star Trek, 2009). Superman's father, Jor-El, is killed by General Zod, while sending his son to safety on Earth. Both men are subsequently raised by step-fathers, with somewhat different outcomes.

Technically-speaking, Kirk never has a "step-father" in the sense his mother remarries. In Star Trek (2009), we find him, his mother and brother, living with an uncle with whom their relationships are conflicted. Our introduction to a teenaged Kirk occurs in the scene where he "steals" a vintage Corvette Stingray his uncle claims is "his," and drives it off a cliff. It looks like a typical case of adolescent acting-out, but as the deleted scenes indicate, the car actually belongs to Kirk and his brother, an inheritance from their father. Its destruction, however, reveals how much Kirk resents his uncle and the way he treats his nephews.

Superman is raised by adoptive parents after his spacecraft crash lands on their Kansas farm. In many ways, he has a far more functional family life than Kirk. He is the child his step-parents wanted and never had. He is loved and protected from the misunderstanding that may result from the premature use of his powers and his step-father frequently reminds him his presence here is for a reason. Although Superman ultimately learns the meaning of his potential from a holographic representation of Jor-El, his becoming a man of integrity results from the influence of his step-parents.

Kirk needs an experience like that of Superman, but it doesn't materialize until his early twenties. He's grown up a "genius-level repeat offender," with little concern for his future until he encounters Christopher Pike, an officer in Starfleet, following a bar fight. Pike offers Kirk what he's always lacked: a strong male role model who sees his potential and challenges him to develop it. 

In Star Trek: Into Darkness (2013), we witness Pike reprimanding Kirk for violating the Prime Directive on a recent mission. More importantly, he's angry and clearly disappointed because Kirk lied on his mission report rather than accept responsibility for his actions. Pike has expectations for Kirk that exceed those he might have for any other officer; they're the expectations a father has for his son. Nevertheless, when Kirk is relieved of command of the Enterprise, Pike goes out on a limb and argues he's worthy of a second chance. It reminds me of something I learned from my own father: dads never give up on their children.

Pike does, in essence, what no one has done before, in Kirk's experience. He requires him to live up to higher standards of integrity and behavior. He has confidence in Kirk but he knows his greatest weakness is his ego-centric immaturity. As a father figure, Pike also knows Kirk has yet to realize that mature masculinity must be rooted in something greater than himself. Pike's death is meaningful, not only because it entails losing the only functional father figure Kirk has ever known, but because it represents losing his closest connection with his biological father. His tears aren't for Pike alone, they're for the father he never knew and the life he never had.
Superman, in a similar manner, has to come to the place where his life is rooted in something transcendent. His earliest efforts to use his abilities are sporadic and situational. He rescues a crew from a burning oil drilling platform, then finds a job in a bar. He's still bound by his step-father's fears he will be rejected by the people of Earth. Superman's encounter with Jor-El helps him begin integrating who he is as Cal-El, with the life he's been given by his step-parents. In this way he is enabled to create his own vision of himself as one pledged to help humankind.

Death is a key player in the myths of Superman and Captain Kirk. Superman has to risk his life to prevent the destruction of planet Earth. Kirk literally does give his life to save the Enterprise and her crew. Both must also "die" to an immature understanding of themselves in order to become the person they were meant to be. Each received instruction in dying from a father who gave himself for those he loved. They received instruction in living from men who chose to be fathers for their sake. I'm not sure anything we do possesses greater significance than how we raise our children. Kirk and Superman show us why.  

(Creative Commons image of Man of Steel billboard by Victoria Pickering via Flickr)
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Saturday, March 29, 2014

Like Walking on Water

Walking on water is easy; it's when the waves turn into giants that things get sticky. ~ Beggar

I don't usually quote myself but since there was no one else to blame for my opening line, I figured I'd best come clean. Walking on water, metaphorically speaking, isn't hard, as long as the water's quiet and glassy smooth like the surface of a Colorado mountain lake on a summer evening. The storms that come from out of nowhere in late afternoon, however, before the evening calm, those are what separate the men from the boys.

That image has been running through my mind almost daily, the past few weeks. Walking on water, trying to "keep the faith" when all around the waves are lapping and a glance at my feet tells me I'm going under. Walking on water is precisely what seeking a residency position has felt like, walking on water without a life-jacket.

On March 9, 2010, I wrote a blog post entitled, "Medical School Through the Back Door," describing my experiences as a psychotherapy intern in the company of a group of  psychiatric residents. Back then, I was a street urchin off the pages of A Christmas Carol or Oliver Twist, my face pressed against a restaurant window, gazing hungrily while patrons dined sumptuously. The memory of that internship kept me going through medical school. I knew residency was out there, or at least I believed it was, it was just a matter of reaching it. That was in 2010.

2011 was different, or it looked to be, when I began clinical rotations. The basic sciences were behind me and board exams and I had battled it out, sword on shield, sometimes tooth and nail. Starting rotations in mid-cycle meant I wouldn't have a predictable schedule, resulting in graduation being pushed back a year. 2012 brought an unexpected gap between rotations and once again, I watched graduation skip away with the alacrity of a child playing hopscotch.

In 2013 I received my degree at long last and applied for residency. The Match came and went, leaving me without  "a date for the prom." I'm not sure there's much worse news for a fourth year medical student or recent graduate than, "We're sorry, you did not match with a program." As with any loss, your first reaction is shock and disbelief, followed by anger and frustration, and then despair sets in and you start wondering how you'll ever pay student loans. Hopefully, acceptance comes along soon, enabling you to regroup and get busy chasing available positions and contemplating Plan B or C.

The truth is, I was up and down. One day I felt optimistic, based on nothing more substantial than a phone call with a polite departmental secretary, and the next felt certain I was totally screwed. All the years I'd spent loving and learning psychiatry were circling the drain and there wasn't a single thing I could do to stop them. My Plan B involved a family medicine residency for a year and then reapplying for psychiatry. It had been done before, successfully, by others, why not me? If that failed, I'd go to Plan C: finish family medicine and see psychiatric patients. It was a good strategy, it was workable, but it really did feel lousy. It was like giving up and that's what hurt most of all.

Still, I had to face reality, painful or not, and so I began contacting family medicine programs about openings. Then a call came from the Midwest. I tried to sound casual and friendly, but I could scarcely contain myself as the voice on the other end said, "I'd like to offer you a position in our psychiatric residency program." Talk about the cavalry riding to the rescue. I even think I heard bugles blowing. Until that point, my "best day" was a Saturday morning in January, 2005, when I learned I'd been accepted to medical school. Now it had a contender.

I'm not sure what it's like to "walk on water" that's calm and placid. I'd like to find out. The past few years, though, it seems there's always been a storm brewing, either because of my own frailty or stupidity or because that's what storms do. I'm not complaining; it's better to have to negotiate a storm than sit on the bank, watching others make their way to the other side. That I've managed to come this far is a testimony to good people who stepped onto the water alongside me when the sky was at its darkest. Thanks in no small measure to them, when someone finally opened the door to a psychiatric residency, I was standing on dry land, free to walk through.

(Creative Commons image of Trout Lake, near Telluride, Colorado by Mountain Belle via Flickr)

Monday, March 3, 2014

Students With A Past (The Mythology of Medical School)

The things I remember. My childhood address, phone numbers for my dad's saddle shop, my aunt's for emergencies, the digits on my first driver's license. Considering my conflicted relationship with math, beginning with elementary school arithmetic and culminating in high school algebra, it's hilarious that I remember numbers so easily. Maybe it wasn't the numbers themselves, but their use that was a problem -- no pun intended.

I also remember a little sing-song ditty I made up during high school biology for the elements of taxonomy: Kingdom, Phylum, Class, Order, Family, Genus, Spee-sees (species). For someone who's mental hard drive has always seemed a few megabytes short of RAM, it's intriguing how bits and pieces of this and that are dredged up with ease.

It's encouraging, too, because I've never had a talent for memorizing. Spelling Bees were fun because I'd been taught the lost art of Phonics as an elementary student. Sounding out a word was as natural for me as mentally associating guitar chords with a song on the radio. It irritated other students because I spelled slowly and deliberately, rather than fire off the words from memory, but I frequently won. So, there. 

While memorization sometimes seems like my "Voldemort," learning has proven my magic wand. I'm mentioning this today because occasionally, someone who's contemplating medical school contacts me with concerns about their personal calender. Since it's turned over more often than other applicants', they're wondering how it might affect them or their performance. The doubts and fears that race through your imagination at times like this are so prolific it feels like you're possessed. The solution to possession is exorcism, but we don't need Richard Burton (The Exorcist, 1973) to banish our tormentors, instead, we need to re-tune our reality-testing skills to gain a different perspective.

There's a mythology associated with medical school, composed of assumptions, perceptions, and beliefs, some which are true, others partly true, and some downright false. Take, for instance, the notion of the "typical medical student." It's more accurate to say there is no such thing; there's only those who obtain admission and among them, you'll find so much variety you need a taxonomy to categorize it. Though still a minority "species," for several years nontraditional students have been the fastest growing one in the medical student populace. Women used to be the nontraditional applicant, now it's the student with a past.

Another assumption is medical students must be capable of memorizing vast quantities of material. I believed this once. There was also a time when I believed Viet Nam was a just war, so what does that tell you? It's true medical school does expose us to a great deal of information. That it all must be memorized is not true. Thanks to the demythologizing efforts of Dr. Francis, founder of the PASS Program in Champaign, Illinois, I came to realize how incorrect my beliefs about memorization had been. They were sincere, yes, but they were mistaken -- as mistaken as Linus, spending Halloween night in the pumpkin patch. Memorizing is important but it's not all-important. It's a useful tool but there are others that may be better.

The trouble with memorization is, it relies on short-term memory, which I called RAM (random access memory) earlier. Some students' short-term memory capabilities resemble the biological predisposition necessary for a runner to be a good sprinter. Distance runners don't sprint well because their muscles are built for endurance, not the short burst of speed. Many of us, particularly liberal arts majors, are "distance" rather than "sprint" learners. Our minds are more efficient at encoding material into long-term memory than an overloaded short-term memory. Dr. Francis taught me how to decipher the conceptual framework underlying medicine and use it to facilitate long-term memory storage. Learning 10, memorization zip. So, there.

A third popular false belief is medical students rarely sleep, nor do they have to, since they worship regularly at the Church of Starbucks. If you can't keep up with your bleary-eyed, robotic, hyper-active lab partner who gets perfect exam scores, you may as well forget it, or so goes this urban myth. Medical school is demanding, that's true, and sleep gets short-shrift now and then, but guess what? Who sleeps when they have babies waking them up every two hours? You get up, change and feed junior, then go to work. Students with a past are no strangers to the routine. 

The belief that medical students must be able to go on and on like the Energizer Bunny is a twist on a partial truth. Medical school is physically, as well as mentally, challenging. What the "bunny belief" doesn't tell you is how challenging it is for all students. By the end of each term and even before, everyone is weary. Younger, older, and those in-between. Those who graduate with their health intact generally eat (fairly) well, exercise (fairly) often, and do their best to get at least six hours a night -- the minimum for a full REM cycle, the key ingredient for effective learning. Energy is no more a gift than a silver spoon. It results from the desire to achieve and is maintained by common sense self-care. Students with a past can do this as well as anyone else.

Lastly, there is the assumption about flexibility. By this, I don't mean the fellow who crawls into a milk crate on Saturday afternoons on the Downtown Boulder Mall for dollar bills tossed into his tip jar. He's the only person I know who can do this and whatever he does the rest of the week, I'm sure it's not studying medicine. Flexibility as an urban myth concerns being set in one's ways and hints the less we've experienced, the more adaptable we are. Of course, that runs directly counter to nature's insistence that exposure is essential to adaptability. Exposure is how we develop an immune system. Exposure drives adaptation. Exposure motivates us to evolve.

Persons acclimate to rigid patterns of thinking and behaving in response to fear and uncertainty. Those who are resistant to new information are less likely to step outside their comfort zone and pursue medical school than those open to new ideas. Becoming entrenched is like psychopathology, it can happen to anybody under the right conditions. It's like falling back on memorization in a crunch. Students with a past may have to unlearn a few things, but that too, is part of being adaptable. Because you have a past doesn't mean you can't let it go.

There's more to medical school than its mythology in the same way there's more to us than appearances. Demythologizing is critical for evaluating one's potential realistically. Viewing yourself as capable is as important as envisioning the outcome as obtainable. Students with a past are as capable as their fellows. They just have to believe it. I'm living proof. 

(Creative Commons image by bfi Office Furniture via Flickr)
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Monday, February 24, 2014

Now You See Me -- Or Do You?

I am easily delighted. I'm also easily entertained, though when I was little, hearing the words, "I'm bored," exit my mouth was my mother's cue to reach for the Bayer (aspirin). My attention could be as difficult to hold as a kid's hand in an amusement park. I loved the films Houdini (1953) and The Great Imposter (1961), starring Tony Curtis, and still do. Both were about illusion, magic, "now you see it -- now you don't." The impossible becoming possible with the blink of an eye.

I remember seeing my first and only, sword-swallower in a traveling circus when I was five or six. We lived in the country, as I've mentioned before, and a circus, with three rings under the bigtop, arrived at our local fair grounds. They had all the acts you associate with larger operations like Ringling Brothers or the Shrine Circus, including a fellow who had himself shot out of a canon. A young, pretty, blond-haired girl astride a dappled Welsh pony, stole my heart and galloped through my fantasies for weeks afterward (sigh). 

I saw my first "Punch and Judy" puppets the same night, in the side-show. I remember how a devilish puppet, clad in black, crept onto the stage to scare Punch. With a menacing voice, he said, "I am the Devil." Punch responded, sarcastically, "Well, you look like the devil!" I'd heard my mother use that phrase often enough to get the hint. When Punch and Judy appear in The Santa Clause (1994) each Christmas, my mind replays that evening.

Anyway, like I said, that's also where I saw my first sword-swallower. He stood next to Punch and Judy's stage, and with great flourish, proceeded to swallow a decorative sword which he said was "only a toy," and then what he insisted was a "real" blade. He even stepped behind a flouroscope so the audience could see the instrument of death inserted vertically through his mouth with the tip resting benignly in the curve of his stomach. When medical school and gross anatomy entered my life a few centuries later, I realized there was no way on earth that sword could have done what the flouroscope displayed. It was a "trick," an illusion, but one that delighted me as a child and continues to do so when I think of it.

I'm certain this is why I love the film Now You See Me (2013) with an ensemble cast including Jessie Eisenberg, one of my favorite new actors. It just delights me. The story revolves around four magicians who have been mysteriously contacted about membership in a secret society called The Eye, which is dedicated to preserving pure magic, righting wrongs, and overcoming injustice. As the plot moves forward, it includes tricks worthy of David Copperfield, slight of hand, hypnosis, and has the lead characters pursued by the FBI. Honestly, I could scarcely contain my inner child the first time "we" saw it.

Some have described Now You See Me as evidence The Illuminati have taken over Hollywood in an attempt to pull the wool over our eyes, deceive our better judgment, and secretly promote a "New World Order." Critics proclaimed the film's illusions were unrealistic and its ending unsatisfying. Personally, I wonder if we were watching the same film. I was captivated from the outset and couldn't wait for the credits to roll before hitting the restart button. Once was not enough and the second, third, and fourth viewings triggered my sense of delight as readily as the first.

Now You See Me isn't merely a story -- it's a yarn, a rambling and implausible tale, according to the Concise Oxford, though the film doesn't ramble and any implausibility lies in the eye of the beholder. There is no moral, such as you'd expect from a fable, but it does make a point, i.e. the ego can be so wrapped up in its own perceptions that it prevents us from realizing we're one, two, three steps behind what's taking place right in front of our us. I've been there, haven't you?

It also reminds us that to be captivated by wonder, we need to have a little faith, to suspend our natural disbelief, and be willing to trust. Not everything needs to be explained, as the film urges, and some things are best left unexplained. I'd agree, particularly when they make us feel like children, fascinated by what defies reason and once again, believing that anything and everything is possible.

(Creative Commons Image by ictusoculi via Flickr)

Saturday, February 22, 2014

Michael Palmer. Any Age is Far Too Young

For years I'd entertained the fantasy of crossing the Colorado state line from wherever I happened to be, with the windows rolled all the way down and Rocky Mountain High blasting on the stereo. It was going to be my fanfare, like the opening bars of the Star Wars theme or Superman, announcing to the world I was home at last. 

On a warm Indian Summer day in October, 1997, I did that very thing, driving my Ford pickup truck across the invisible boundary between Wyoming and Colorado, leaving the East Coast behind, little knowing in a few years I'd find myself on the same highway, retracing the miles back. Also little knowing that in forty eight hours, I'd be awakened by a story on NPR's Morning Edition with news I never wanted to hear. John Denver had been killed in a plane crash. I felt like I'd crashed with him. 

It was the same autumn I met author Michael Palmer in print. Michael and I never met in the same way John and I had, but we corresponded briefly, discovering how our experiences dovetailed by email. He'd been involved in the Massachusetts Physician's Health Program, working with physicians, like himself, whose lives had been affected by psychiatric illness and/or substance abuse. As a psychotherapist, prior to medical school, I also worked with doctors enrolled in the Colorado Physician's Health Program. Michael was in recovery, as he revealed years earlier, and I was attempting to recover a life I'd never known. Michael was a writer, I was trying to become one, and he offered me generous encouragement.

I found his books while prowling the Boulder Public Library, looking to feed a growing interest in medical fiction. At the time, I wasn't convinced it was even remotely possible to include medical school in my future, though I wanted to, quite badly. Reading about medicine was becoming a kind of therapy, much as writing had been for Michael, and his books helped overcome my fear that, not only had I missed the bus marked "medical school," it was gone for good. I had yet to learn there is no optimal time for going after what matters most to us, there's only now and what we do with it.

Michael was my companion during the months preceding premed coursework, when I hung onto to the ridiculous fantasy that a doctorate in clinical psychology would be enough. He helped me face the inevitable truth that nothing would ever substitute for my becoming a psychiatrist and I'd best get on with it. I learned from him how recovering a life is just as grueling and just as rewarding as what he'd gone through himself.

I'm glad I shared some of these things with him, especially now. We never know how tenuous life is, not really. We go through the daily grind with the unconscious assumption time is on our side. We do this a lot when we're younger or at least I did. We think only older people die, whatever "older" means, and if it happens to a peer, unless we know them personally, we conveniently overlook the obvious fact it could easily have been us, had the cosmic tumblers turned up our numbers instead of theirs.

The reason I'm glad I shared those things with Michael is this afternoon I learned he passed away, quite suddenly, a few months ago. He'd been in Africa, on safari, and had barely gotten back to the States when he experienced a heart attack. I can't help but think how appropriate it was for him to have been on safari; for reasons I don't quite fathom, I've always associated him with Hemingway. Michael was 71 and far too young. I feel certain he would agree, any age is far too young.

(Obituaries for Michael Palmer, MD, may be found here: New York Times and Boston Globe. Michael's final novel, Resistant, can be accessed via

(Creative Commons image by cdrummbks via Flickr)

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Wednesday, February 5, 2014

Mission Impossible

It started out a typical morning -- Oh, you'd rather it was a dark and stormy night? Good idea. I like that; here goes...

It was a dark and stormy night. The wind was howling, trees swayed like hula girls (hula girls? In Maine? Maybe on a fuzzy dashboard.) and rain lashed my windshield as I pulled out of the parking lot. Eager to get home, I didn't notice the cassette lying on the seat next to me until I reached over for my gloves. It couldn’t have been mine; I hadn't listened to a cassette recording in years. Who's been in my car, I wondered, when, and why?

I pulled onto the shoulder and gave my discovery the once over. There was no label, it didn't smell like gasoline, gunpowder, or anything obviously lethal. I hadn't dallied with anyone's girlfriend, wife, or ex, and besides, the local boys wouldn't use a tape; they'd run me down with a really big truck and then shoot me for good measure. Thinking I was fairly safe, I inserted it into the player -- with my hand on the door latch, just in case. 

A dispassionate male voice I might have accused of belonging to Lawrence Fishburne under other circumstances, said, "Good Evening, Mr. Beggar. Your mission, should you choose to accept it, is to answer the question, 'What is a D.O.?' in 140 typed characters or less. Whether you include spaces is entirely up to you. For what it’s worth, your team suggested we do something physiologically impossible with this, so you're on your own. This message will self-destruct in 5, 4, 3, 2...hiss, whirrrr, click."

Acrid grey-black smoke billowed from the CD/cassette player and I swung the door wide, leaning out into the rain and coughing like Doc Holiday in Tombstone (1993) or Wyatt Earp (1994). Somebody from the AOA with a taste for cloak and dagger, I thought, who else? Talk about Mission Impossible. Wait a minute, isn't there supposed to be theme music playing? Where's the thump-thump, thumptha thump-thump signaling I'm about to do something really cool? Mmph. Budget cuts.

What made my task resemble Tom Cruise leaping from a speeding train was the subject matter. It's hard enough to express meaningfully when you've got all night. My "assignment" -- in reality, a sort of contest, but it's more fun this way -- was going to present a challenge. How can we explain the "DO essentials" to the average person for whom "doctor," often as not, refers to an MD? It's like trying to fit an elephant comfortably into a box designed for an engagement ring and expecting it to be recognizable as an elephant when the box is opened. At this point, 140 characters started to resemble the penance given a petulant soul doing time in Purgatory. And then it got worse.

Pretty much everyone agrees, the care and feeding of both types of medical doctor is virtually identical, with the exception that DOs are also trained in the delivery of Osteopathic Manipulative Medicine. On that basis, the question might be raised, why not have the same degree? By itself, is OMM sufficient reason to warrant separate licensing, specialty boards, and so forth? In other words, why not just make all physicians DOs and be done with it? I have a sneaking suspicion the American Medical Association might have something to say about that. Not to mention my best friend who is an MD and one of the most osteopathic of physicians I've ever known. Yet, even he will admit that he and I, MD and DO, are better together than we are separately, and that is due to the differences in our training, not the similarities.

Our training is the overall critical factor and if the training received by DO and MD physicians were truly mirror images, an identical designation would make lexicographic sense. Despite appearances, they are not, however, and not merely because of OMM. Osteopathic medicine is oriented differently and this takes us to the heart of the matter.

Hippocrates said, "It's more important to know what sort of person has a disease than which disease a person has." He could have been speaking as a DO because osteopathic medicine focuses on persons, both as individuals and as members of a community. It conceives of them as complex entities who experience themselves and their environment in ways inclusive of cognition, emotion, and physical embodiment. Their behavior is goal-directed and they are prone to regard the search for meaning as a sublime pursuit. Their bodies are a model of integration in which the part affects the whole and nothing affects the whole without also affecting the person whom it visually represents. Ultimately, the person is everything.

Person-centered care has become a hot topic lately, especially at medical conferences. For osteopathic physicians, however, person-centered is far more than a hot topic, it is a pervasive and all-inclusive, soul-deep conviction that conditions every aspect of the doctor-patient relationship. It isn't a practice emphasis, it is our defining feature. It isn't something we do, it is who we are.

I'm way beyond 140 characters and we haven't even hinted at the role played by OMM or the osteopathic preference for finding and treating the cause of disease rather than symptoms alone, whenever possible. See what I mean? The elephant is so big and the box so very small.

Still, I did accept this mission, so I'd better get cracking. You'll forgive me if I keep one hand on the door latch. Maybe the tape wasn't a "bomb," but that doesn't guarantee my solution won't be. A D.O. is a medical doctor, dedicated to the care and treatment of persons, in sickness and health, of all that they are and wish to become, and a great deal more, besides. 140 characters without spaces. You know, I think I'm starting to hear music.

Thump thump, thumptha, thump thump...

(Creative Commons Image by Baptigrou via Flickr) 

Thursday, January 30, 2014

Nowhere Else But Here

In recent months, I've been preparing for residency interviews, thinking about questions I'd likely be asked and those I should ask of programs. One question sure to come up is, Why do you want to be a psychiatrist rather than some other kind of doctor? I've thought a lot about this, especially in light of third and fourth year rotations, the medical school version of a Baskin-Robbins ice cream shop (or any other, since I've discovered we don't have B-R in Maine) where you get to sample the flavors before deciding to buy.

Prior to rotations, my heart was set on psychiatry. I'd worked and trained in the field, coauthored a book related to a psychiatric sub-field, and truly loved every minute of it. My background set the stage to do well in residency; why do anything else? 

The trouble was, it was like being raised on chocolate ice cream (not a bad thing, by the way) and considering it my favorite. Never having tried any other flavor, how could I be so sure? Maybe it was just familiarity. Medical students often find their plans for residency change after third and fourth year rotations for that very reason. 

In order to deal with the matter fairly, I decided to approach rotations with the intent of evaluating them on their individual merits. If I still loved psychiatry best, by keeping an open mind I'd learn more and be better able to make an informed choice, come Match time. 

The outcome was surprising. I liked surgery, as do many psychiatrists, and I encountered nearly as many surgeons who'd seriously considered entering psychiatry. Why this was true and whether there's a connection between surgery and psychiatry, is unclear. Maybe that would be a good topic for a psychiatric residency research project? 

So, that was surgery. Being involved in delivering babies was wonderful and pediatrics was every bit as enjoyable as I expected it to be. Rural family practice was a warm, nurturing experience and emergency medicine was hard work and a ton of fun. A fourth year sub-internship in internal medicine showed me how much I had yet to learn and at the same time, gave me a boost of confidence about beginning residency. They were all great in their own ways, but eventually you have to make a decision. You can only sample so many flavors before the person behind the counter gets impatient.

What do you want to spend the rest of your life doing? I asked myself. This is not a casual question. No one knows how long "the rest of your life" is going to last. Could and hopefully will be a long, long, long, long time, but none of us is born with a warranty. For me, the various considerations boiled down to a second, more important question, Where have you been the happiest?

Coming up with an answer wasn't as easy as you might think. Never having had children, obstetrics and pediatrics teetered close to the front burner. But obstetrics entailed short-term relationships with patients and my interest in pediatrics was mainly directed toward child/adolescent psychiatry. Reflecting on my experiences, there was only one rotation where it was impossible to contain my enthusiasm about getting to the hospital every morning. It was the same one that made it ridiculously easy to ignore the clock at the end of my shift and the only one I had no reservations building a life around. Turns out, "chocolate" really was my favorite flavor, after all.

A few years ago, after a long day at the hospital in Denver, I took the dogs out and looked up at the stars. It was a chilly fall evening and after finishing their business, I'm sure they were both wondering why we didn't rush back inside to get warm. It had been a good day and at the moment I was caught up in the sudden awareness I was better at psychiatry than I'd ever been at anything else. What I mean is, I worked harder, felt like a better person, was more fulfilled, and more effective. More than anything, I was happy, truly and deeply happy, from the top of my head all the way down to the holes in the heals of my socks. That feeling has never gone away, it's just gotten stronger.

There are a lot of reasons to love something and I don't fault anyone for not loving psychiatry, though I freely admit when someone says they don't like chocolate ice cream, that does give me pause. Continuing to love it, after third and fourth year rotations, probably makes me a hopeless case, which is okay because I'm a happy one. And for me, happy like this is found nowhere else but here.  

 (Creative Commons image "Happy" by Rickydavid via Flickr)

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Wednesday, January 29, 2014

More Than Just a Piece of Paper

That's what we say, sometimes, when we're tired, when burning the candle at both ends seems to have done little to bring the end of a long academic journey into view. "___ more months, ___ more rotations," we say, "I'm going to get my piece of paper and I -- am -- gone."

I've said it. After slamming into another obstacle that meant I'd graduate another year later than my entering classmates, I've said it. On good days, I tried to act a reasonable approximation of my age and call such things "character-building." On bad days, they were miserable. The truth is, the good ones really did outnumber the bad by several factors of ten, no whitewash -- except on bad days and then they seemed to multiply as fast as zits on a teenager's face.

Medical education is a group effort and a personal one. We begin in community, like runners in the Boston Marathon, and we string out along the way. I lived off Beacon Street in Boston for a while and stood within inches of the Marathon as it passed by. First came elite runners, like the Kenyans I got to know in Boulder while walking my dogs, some in training for Boston. Long after they were out of sight, came local runners, wheelchair athletes, and those for whom a personal best was the point.

Every year there are runners who, for reasons of their own, cross the line at Boylston Street, where the bombing occurred, way late, maybe after midnight. A father, pushing his wheelchair-bound son, someone else who was injured and refused to quit. It could be anyone. There have been times in this process, when I felt like that, hell-bent on crossing the line whether anyone was there or not, and not really expecting anyone to be, certainly not at that late hour. The virtual presence of more than a hundred cheering friends on Facebook showed me how wrong a guy can be and how amazingly good it feels to discover them waiting for you.

But that's how things can go. All the potential in the world can't ensure the medical education master plan is carried out without a hitch. Something happens, then another, and before you know it, you've had to stop and regroup. Most students make it by the clock (four years), some say they made it by the grace of God and maybe they did. Maybe that's how all of us make it, even when it seems like sheer, dumb luck.

Anyway, yes, I called it a "piece of paper," especially when circumstances and/or my own frailty conspired to raise the bar -- and right when I was starting to get good at reaching it! One of my favorite Robert Browning lines goes, "A man's (person's) reach should exceed his (their) grasp." Well, gee, thanks, Bob, bet you never went to medical school, huh?!

Eons ago, when I was a kid watching classic movies about doctors and psychiatrists on our black and white TV, medical school was something other people did. To me it was as far away as growing up. Eventually, however, I did grow up or at least got taller, and found my way to medical school. When my diploma finally came in yesterday's mail, I can tell you, it was much more than just a piece of paper.

A friend, on his graduation day in 2010, waved his diploma in its protective cardboard mailer and shouted to me, "Don't forget, Beggar, there's one of these with your name on it!" I thought about him as I walked back to the house, carrying mine the same way he had. I thought about him again, opening the package and seeing my name. He was right; there was no mistake.

How does it feel, having finally crossed the elusive finishing line with my diploma in hand to prove it?  It feels empowering. Better than all those other times the bar was raised and I cursed and swore and stretched and strained and reached with all my heart and realized I could reach higher and farther still. It feels right. Residency is fast approaching (Please, God, let it be psychiatry) and it feels like I'm in the starting grid at Indy, waiting for that cute little country singer to finish the National Anthem so I can hear the words I've waited a lifetime to hear: "Ladies and Gentlemen, Start Your Engines!"


(Photo copyright 2013 by the author)
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