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)

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 michaelpalmerbooks.com)

(Creative Commons image by cdrummbks via Flickr)

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)

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!"

Varoooooooooooom! 

(Photo copyright 2013 by the author)

Doc Bugs and Me

One of my favorite places to shop is anywhere Christmas decorations are sold. When I was growing up, my mother instilled in me a real love for rare, unusual, or antique ornaments. Thanks to her, the drawers of my ornament cabinet contain bells and glass bobbles that date from her childhood before the War (as World War II was known in our house). Over time I've added my own preferences for traditional wooden soldiers, dogs, moose, and cartoon characters, notably Snoopy and Woodstock.

One ornament has special meaning for me -- the one in the photo. I picked up Doc Bugs, as I call him, in a little out of the way place called The Spruce House, in Estes Park, Colorado. It must have been late fall, during my first year of premedical studies, when I found him hanging on a rack all by himself. Lone ornaments are hard to resist, especially if they stir up an emotional connection and you realize leaving the store without them is a mistake. 

Well, Bugs Bunny and I go way back. Tall, wise-cracking, with big feet, like me, he was my favorite cartoon character when I was a kid. Only this time, instead of his trademark carrot, he was holding a stethoscope and smiling as though he knew a secret I didn't. Right off I was certain he'd been "waiting for me" and took it as a sign that someday I'd be in his shoes, or paws, as the case may be. The next year, I came upon another version of the medical bunny, a ceramic Bugs looking rather distinguished in a long white coat holding a hospital record, another portent (except for the "distinguished" part). 

It's funny how, when pursuing a dream, you latch onto things that symbolize its fulfillment to give you hope. I'm not superstitious, but I definitely believe in the power of images to fuel our ambitions and sustain us spiritually. When such things hang on a Christmas tree, itself a very rich symbol of life and new birth, they take on deeper significance. It's as though they participate in all the tree represents and pass it along when we're most in need.

Doc Bugs has done that for me the past fifteen Christmases. Each year, taking him out of his box and hanging him in plain view has been an act of faith and each year I promised myself my time was coming. Last night, bringing Doc Bugs out once more, I said to my long-eared alter ego, "Well, Bugs, this is your first Christmas as a real doctor." It just so happens, it's mine, too.

May you have the most wonderful and joyous of Christmases and the happiest of Holiday Seasons.

(Photo copyright 2013 by the author)
   

Medical School Without a Doubt

"Regrets, Eric, that you're not down there with them?"

"Yeah...no doubts, though."

These words pass between coach Sandy McGrath and runner Eric Liddell in the film Chariots of Fire (1981).  Sitting in the stands, they're watching the 1924 Olympics event in which Liddel refused to participate because it was held on Sunday. 

As you may recall, Liddell was firm in his religious convictions, including keeping Sunday as the Lord's day. Adherence to his beliefs brought him into conflict with the Olympic Committee whose members found it incredible anyone would place God above King and Country. Seeing his teammates run without him, he wishes he was among them -- even with strong convictions, he's still human -- but it's a wish unaccompanied by doubt. In his final race, a competitor says of him, "He has something to prove. Something personal. Something guys like (our) coach would never understand in a million years."

Probably the second most common question I get about attending medical school at my age relates to whether I have any regrets about my decision. "Now that you're here, has medical school lived up to your expectations? Would you do it again, knowing what you know now? Is the pursuit and presumed attainment of a dream everything it's cracked up to be?"

Truthfully, it depends on the dreamer. For me, it certainly has been, and continues to be, as fulfilling as I hoped it would be, and in ways I couldn't have imagined what seems like a lifetime ago. In part, this is because I haven't been aiming at achieving a distant goal nearly as much as I've been engaged in a daily process of achievement. 

Life is a terminal illness for everyone and waiting to live is folly. Sure, like the rest of my classmates, I can hardly wait for the day I get my first paycheck as an attending physician, but delaying enjoyment of what I'm doing until then is like carrying a dream around in a bucket that has a hole in it. You wake up one morning to find your dream has dribbled away when you weren't looking.

This is why I try to take every day as another chance to work at being a doctor, even one in training, though may I forget, as we all do. Distracted by a mistake or worried about my performance, I stumble over my own frailty, and then a nurse asks me what she should do next or a patient smiles after we've discussed her upcoming procedure and I remember. Doctor is who we are on the inside, long before our names are punctuated by the initials D.O. or M.D. on our white coats.

Would I do it over again, knowing what I know now? I've probably answered that one already, but let's just say a person can arrive at the point where living authentically is more important than playing it safe. You bet I'd do it again, though, with the virtue of hindsight, there are a few things I'd do differently along the way. For instance, I'd make the acquaintance of Francis Ihejirika, MD, much sooner. Francis is the founder of the PASS Program in Champaign, Ill., and even more than successfully preparing me for board exams, he taught me how to think as a medical clinician. Eight weeks of being challenged, encouraged, patted on the back and kicked in the pants were life changing. "Thank you" is scarcely enough.

I'd also be less afraid, if that's possible and maybe it isn't when you're trying to swim against fifty-foot waves that drown the biggest ships as though they were the tiniest toys. But that's what medical school can seem like. We start out feeling vulnerable -- much like we do in those crazy dreams where we're naked and everyone else isn't. You've had those, too, huh? Funny how I never manage to have Daniel Craig's physique (Casino Royale, 2006), despite what Freud said about dreams representing wish fulfillment. Anyway, we end up finding out the individuals we thought were the smartest, the most gifted, and presumably, the most invulnerable, have have been battered by the waves, too. 

Medical school is a huge undertaking; it's the hugest thing most of us have ever attempted. I can't stress this enough. Honesty forbids me from coloring this truth in anything but black and white. Nothing I know of can adequately prepare a person for the volume of material they're going to face, the hurricane force at which it strikes, or the feelings of aloneness that surface in the wee hours before exams. It's something you have to experience to know. But looking back, I can see how I've grown in the confidence surviving brings and without a doubt, I'm braver because of it.

(Creative Commons image of Eric Liddell via Wikipedia)

Medical School at My Age

 
A week ago, a few days before graduation, I was asked the question I hear more frequently than any other: "Why did you choose to attend medical school at this time in your life?" My questioner went on to say he’d graduated in the late 1970s and couldn't imagine doing it "at my age." 

You'd think after six years I'd have gotten enough practice that answering questions like his wouldn't require much reflection. To a certain extent, that's true, except over time my understanding of why I undertook this process has grown, and along with it, the way I respond to questions related to age. 

Now, to be fair, some of it does have to do with how I read the the other person. What do they really want to know and how much time have they got? Is it polite cocktail party curiosity or are they contemplating a course correction in their own career? In this case, the question was posed by an attending anesthesiologist I'd just met and we scarcely had any time at all, so I talked briefly about pursuing a dream. As I walked to my car a bit later, it occurred to me how impossible it is to imagine myself not  being a medical student at this point in my life and how very little age has had anything to do with it.

Admittedly, that isn't entirely true. Before I undertook medical school, I argued vociferously against it, considering age my most salient point. I wanted to become a doctor and, particularly a psychiatrist. I always had, but the circumstances of life took me in other directions and it seemed ridiculous to suppose anyone would take me seriously now. Obviously, I eventually lost that argument and what I've realized over time is I never had a chance of winning in the first place. Something was afoot in my life that neither reason nor common sense nor anything else had the power to effectively counter, as I hope the following story reveals.

It was a Sunday night and my shift as a substance abuse therapist at a Boston hospital was 30 minutes away from being history when I was paged to the nursing station to handle an admission. My patient was an older, intoxicated gentleman, accompanied by his adult son. They were pleasant, intelligent, lived out on the Cape (Cod), and despite grumbling to myself about having a new admission so close to sign-out, I immediately took a liking to them both. A few moments later, while meeting with the father to sign his paperwork, he said to me, "Doctor, I want to tell you how all of this began..."  I ought to have told him I was only his therapist, but hearing the title, "doctor," honestly it felt so good, I just couldn't. 

I told myself I'd explain the next day and I did. I wasn't trying to mislead him, but it felt like unfaithfulness to something I didn't quite understand, to correct him. You might say he was under the influence and simply mistook me for his physician because I was an older male. I say in vino veritas. Unknowingly, and probably unconsciously, he saw into a deep and private place and called me by the name nobody, not my parents, my friends, or anyone else, had ever spoken. For the first time in my life it seemed as though someone knew who I was. How could I deny that?

Back then I wasn't so much thinking as feeling. Drawing near the end of this leg of the journey, I've done a great deal of thinking and I've begun to realize how very much it's been like growing into a father's shoes. When we're young, we slip into them and they're huge, so huge we can't walk without stepping out of them. One day, they've grown smaller and then smaller still until they fit us as well as dad. Why attend medical school at my age? I guess you could say, that's when the shoes finally fit.

In another life, to borrow from Katy Perry, whom I love, I might have gone to medical school "on time." The tricky thing about other lives is they don't come into being unless we find a way to make them. I didn't have the keys to a Delorean (Back to the Future) in my pocket, so reversing the time-space continuum wasn't an option. All I could do was be like the proverbial turtle, who never gets anywhere unless he sticks his neck out. Yes, I was older and by definition, that meant attending medical school as an older, rather than younger, adult. Age was a piece of my puzzle. But it was only a single piece and nowhere near my biggest one. Had I been born someone else, it might have been gender, race, or national origin. We all have something we can't change.  

George Eliot (pen name of Mary Anne Evans), author of Silas Marner, said, "It's never too late to be who you might have been," to which I'd add, until it's too late for everything but that final breath.  What has become clearer and clearer to me is how much medical school and now, residency, have come to mean immeasurably more than simply fulfilling a long cherished dream. They mean being true to what I've learned about myself as this process has unfolded and there really are very few things quite as important. They mean acting on the freedom to make choices of my own rather than making up excuses for denying them and then, trying to live with the consequences. They also mean, considering everything that lies behind and whatever lies ahead of me, there isn't anything to make me regret coming this way.


(Photo copyright 2013 by the author)

Paying Your Dues or to Paraphrase Charlie Brown...

"Doesn't anyone know what surgery is all about?"

I've been wrestling with this question for the past four weeks and it hasn't been an easy match. I thought I had it pinned a couple of times and then it squirmed out from under me. Think about those occasions when you've watched Olympic wrestling and you'll get an idea what I mean. Both shoulders have to touch the floor at the same time for a winner to be called and close isn't close enough.

For my friends who are surgeons-in-residency or our preceptors, the answer is probably straightforward, surgery is about cutting. Suggesting there is a deeper philosophical significance for what they do is likely to trigger a smile, a good natured nudge in the ribs, and, "There Beggar goes again." Sorry, guys (a non-gender specific term for me, inclusive of gals, guys, and a dog or two thrown in for good measure). I can't help it. Finding meaning is what I do.

That said, I'm really not referring to surgery as such, but to basic surgical training, i.e. third-year surgical rotations. The former is way out of my league, but regarding the latter, to borrow from Country singer/songwriter Garth Brooks, I'll "choose to chance the rapids and dare to dance the tide." But as anyone knows who's rafted the Colorado or any other big river, you've got to have a guide who knows the water, and on this chilly November morning, it's my father's turn to take the tiller.

What does a saddlemaker have to do with surgery? Aside from the fact that he was well-acquainted with sharp knives and slicing through flesh? He knew what it was like to be an apprentice. You see, at the end of World War II, when he was discharged from the Army, the way someone pursued a career in saddle making was by apprenticing themselves to masters of the art. These were men, predominantly, who began honing their craft well before my father was born. They started out precisely as he was expected to, by sweeping the shop floor, watching and listening, doing a lot of what we call in medicine, "scut work," and waiting his turn.

It was frustrating, he told me years later, because he wanted to learn and surely, that was best done by doing. Being told he wasn't ready to "do," that he'd be told when he was, tried every ounce of patience he could muster. Slowly, over time, he was allowed to take carving tools and scrap leather home to practice and eventually, one thing led to another. It was very much like a third-year surgical rotation, I've decided.

For my part, I spend a great deal of time watching and keeping my hands to myself. Students have two primary tasks in a rotation like this. The first is learning how to refrain from contaminating yourself or anything and anyone else in the operating room, no small feat in itself. One false move and you've touched something you shouldn't or bumped into someone you wish you hadn't. Mikhail Baryshnikov would cringe at the choreography.

The second task is harder, perhaps hardest of all. It entails practicing knot tying and suturing at home, standing next to the surgeon for what feels like forever, waiting to be invited to participate at the most rudimentary of levels, i.e. holding a retractor, snipping sutures, or if you're lucky, stapling an incision closed. If you're really lucky, like I was the other day, you get to guide a laproscopic camera, which has been inserted through a plastic tube called a trochanter, into a patient's abdomen, while your preceptor removes an inflamed gall bladder. It felt like I was moving up in the world.

Seriously, you want very badly, as a student, to do something that matters. It's one of the primary reasons we attend medical school in the first place. In a specialty like surgery, however, and truthfully, in all medical specialties, we have to learn the value of humility. We're students, after all, and the only proficiency we possess at this point in our education is that of memorizing large quantities of material, a skill which, our preceptors inform us, has limited applicability in the world of real medicine. It's all about learning how to wait your turn and appreciate every opportunity to do more.

Horace Mann wrote, "More will sometimes be demanded of you than is reasonable. Bear it meekly, and exhaust your time and strength in performing your duties, rather than vindicating your rights." Eventually, your time will come and those who've witnessed your commitment and devotion, will remember you as one who worked your heart out and didn't complain. As my father would say, it's called paying your dues.

(Creative Commons image of Charlie Brown shopping for a Christmas tree by KIT via Flickr; The River lyrics copyright by Garth Brooks)

Missing Megan Fox

I really like Megan Fox, but not necessarily for the reasons you might think, me being a guy and all. Sure, she's drop-dead gorgeous -- I'd have to be blind as a bat not to have noticed and trust me, I've noticed. But what I like about her so much is her role in the first two Transformer films. No, I'm not talking about the cutoff jean shorts she wears in both, though I noticed them as well. I mean her character.

Megan (if she's reading this, I hope she doesn't mind the familiarity) plays Mikaela Banes, a pretty young woman with a past. Her father has a prison record for grand theft auto and she, a juvenile record for having been his presumed accomplice. She has another liability, however, and that's her beauty and sex appeal. Like far too many women, she has a history of being regarded as a trophy.

In the first film, her boyfriend is a muscular, good-looking, football player who treats her like a possession once too often. She knows there's something wrong with the guys she's chosen to date, she doesn't like the pattern, and she has sufficient inner strength to do something about it. As she's walking home, along comes the film's hero, Sam Witwicky. Sam is everything the other guys could never be: overtly insecure, honest, and down deep, utterly courageous.

In the first installment of the trilogy, Mikaela is not only a match for Sam, in some ways she is even more heroic. For instance, when they're attacked by a mini-decepticon, she grabs a power saw and goes to work, rescuing him. During the final battle against Megatron, she is determined to save Bumble Bee by hooking him up to a tow truck and then drives it backwards down a wreckage-strewn street while he shoots at the bad guys. I love that scene.

In Revenge of the Fallen, her character is a little more traditional and her biggest challenge seems to involve convincing Sam to tell her that he loves her. Sam, how crazy do you have to be to have someone like her around and dither about saying, "I love you?" Get a clue, buddy. Anyway, that bothered me, the fact that she wasn't permitted to be the totally gutsy chick she was in Transformers. Her character wasn't just beautiful, she was admirable.

Now we come to Dark of the Moon and there's no Megan Fox. Instead, we've got a blond babe whom Sam has decided is the love of his life. She flirts with other guys and then minimizes her behavior, she's essentially focused on the accumulation of expensive toys, and perhaps, worst of all, she has absolutely no idea what makes Sam tick. You tell me what's wrong with this picture.

If we wanted to get psychological, we'd have to ask why Sam hooked up with her in the first place. According to the story line, he and Mikaela had a fight, broke up, and rather than do what any man with a lick of sense would do, i.e. turn himself inside out to get Mikaela back, he lets her go. Sam clearly has far too much pride for his own good. It's what kept him from declaring his feelings in Revenge of the Fallen and it comes back to haunt him in Dark of the Moon. We could be Freudian and say the new girl is more like his mother, but we really don't have enough character development to go that route. We do know, however, that Mikaela and his mother are two very different kinds of women and that could explain a lot.

For whatever reasons the producers decided Megan's character wasn't meant to be a part of the last film, I miss her. I liked Mikaela's resourcefulness and willingness to take a risk. Her response to Sam's question, "Fifty years from now, when you're looking back on your life, don't you want to be able to say you had the guts to get into that car?" is one with which I, as an older medical student, can well identify. I also liked the fact that she wasn't squeaky clean. She had a past she was ashamed of but she refused to let that prevent her from something better. Her wounds made her human and more interesting. Best of all, I think, she didn't allow herself to be paralyzed by fear. She could be counted on in the clinches and was capable enough to be a participant in the action rather than a hand-wringing damsel-in-distress. Definitely the right kind of gal and why I'm missing Megan Fox.


(Image of Transformers: Revenge of the Fallen via RottenTomatoes.com)

Looking Forward to Monday

I've thought about writing all week and while it's been a good week, my best in recent memory, it's also been a long one and I'm glad today is Saturday. Admittedly, my weariness can be traced, in part, to the distance I'm driving, nearly fifty miles from farm to hospital parking lot. In itself, that's really not a big deal. The landscape is pretty, the traffic minimal, and there are zero speed traps, but it's another couple of hours tacked onto an already busy schedule. There's student housing on site -- taking advantage of it, however, means not coming home in the evenings to find the dogs and cat waiting at the door. I'll take the drive.

The days themselves are fast and furious. My attending is known for the rate at which his long legs propel him down the hallways; I find that refreshing since mine do similarly. We go from patient to unit, upstairs, down and back, crisscrossing St. Mary's as though Guinness is timing our attempt to set a land speed record. With luck, I'll arrive at mid-July having shed those five stubborn pounds I've been working on the past few months.

The very best part of this rotation is waking up every morning, even if it's been a short night, with the anticipation of being scarcely able to wait until I get to the hospital. Walking onto the psych unit on Monday was everything I'd hoped it would be. The staff was cheerful and friendly and the routine as comfortable as a well-worn and obviously well-loved pair of Sketcher Shape-Ups (the best all-round footwear for the hospital, in my humble opinion). By the time my cohort, another medical student whom I've known from school, and I finished our tour of the premises, I was so charged if they'd plugged me into a light socket I could have powered the unit for a week.

One thing I've discovered in previous rotations, was how much I actually enjoy physical medicine. I think I may have mentioned how concerned I was when beginning medical school, that things might not turn out that way. Based on experience I knew I loved psychiatry but had nothing comparable when it came to listening to hearts, lungs, or palpating prostate glands. In particular, my rotation in pediatrics had me wondering if I hadn't misread my calling. My first morning in psychiatry, the clouds parted, the sun was shining through, and I swear I heard a heavenly choir under the direction of John Denver singing, "Hey, it's good to be back home again..."

It wasn't just the familiarity, though, it was the atmosphere, the sense that this was the here where I'd always belonged. A dear friend of mine struggling with choosing between psychiatry and internal medicine for residency, got it right when she said, she wasn't ready to hang up her stethoscope, like Gary Cooper hanging up his guns and riding off into the sunset with Grace Kelly in High Noon (1952). Physical medicine is where her heart lies and once a person finds that place, it's time to stake their claim. For me, nowhere else have I been even as remotely happy as I've been the past week. I am so looking forward to Monday.

Yesterday, while chatting with an internist on the chemical dependency unit, I used the phrase, "our patients," referring to the ones my preceptor and I have been working with. On strictly medical rotations, I've always tended to think of patients as under the care of my attending while I tag along, wearing shoes too big for me to fill. Yesterday, rounding on my own, I knew I had something of my own to offer, something I'd made my own by hours and days, weeks and months of hard work, and my shoes were a perfect fit. That, I can tell you, is an incredibly good feeling, indeed.

(Creative Commons image "Line Study at St. Mary's (Lewiston ME)" by Jody Roberts via Flikr)

My First Baby

Today I delivered my first baby -- sort of. I had the guiding hands of a resident on mine and for good reason. I've read enough about damage to the brachial plexus (a web of nerve roots between the neck and shoulder that enable feeling and movement in the hand and arm) to know that the last thing I wanted was for this sweet little gal's arm to be twisted round with fingers bent as though she was a waiter expecting a tip -- because of anything I'd done. The tension distracted me from the elation I felt, but that doesn't change the fact that the hands that caught her were mine.
 
Ordinarily, fathers are offered the opportunity to cut the umbilical cord as we place the baby on mom's belly and witness the miracle of mother-child bonding take place before our very eyes. My baby, though, was a premie -- born a little too early and a little too small for her own good -- and destined right off for an appointment with the neonatologist, followed by a few weeks in the neonatal intensive care unit. Since dad was busy assisting his wife and timing was critical, I cut the cord and then we proceeded to deliver the placenta. My first time at bat and I have to swing at another pitch, but I'm not complaining, not one bit. I've been looking forward to this for a long, long time.

My imagination had this entire experience enshrouded in a mystical light accompanied, almost, by the voices of a heavenly choir. The reality was more sobering and it took me all day to put it together. 

Delivering babies is something doctors do. I know, midwives do it, taxi drivers do it, policemen and sometimes fathers who can't get to the hospital soon enough, do it., too. Even though the division of medical labor results in many doctors only delivering babies during an OB/GYN rotation, as did I this morning, in my mind, being a doctor is still characterized by certain key tasks and delivering babies is one of them.

Whether I ever have the privilege of delivering another, I'll never forget this one nor will I ever cease to be grateful for the chief resident who stood behind me and said, "Go ahead, you can do this."




(GNU Free Documentation image via Wikipedia)

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)

What Makes It So Good

Morning "Number Two" time has the potential to be pretty significant around here. Mother Nature beckons to my dog, usually within 30 minutes of breakfast, and he firmly passes the word along to me in no uncertain terms, "You'll take me out now, if you know what's good for you." At that point, we bundle up, walk down the lane a dozen yards or so and on the way back, voila!

For him, this little outing is an aperitif, the main course being his walk in the afternoon. For me, it's an opportunity to let my brain unravel in the cool air. With this morning's unraveling, I think I may have finally figured out what makes the PASS Program work so well.

When I was a college student, immediately following high school, a friend told me, Christianity is not a religion, it's a relationship. This describes the PASS Program perfectly. It's not a method of board preparation that can be circulated in manual form and purchased at your local bookstore, though they do employ various techniques as I've stated in other posts. Nor is it an approach that can be packaged and franchised like a businesses concept. The heart of the PASS Program is reflected in the quality of relationships that develop between students and faculty and have the capability of taking us to the next level in our training. The word mentoring comes to mind.

But it's mentoring with a therapeutic twist. In psychotherapy, one may absorb a patient's experience and in the process, detoxify it so that a patient learns to live with their history without being overcome by it. Shame and discouragement have a nasty habit of accumulating, and in the life of a medical student, previously failed attempts at passing boards can result in one getting a heavy dose of both. Establishing relationships with physicians who are unashamed to admit their own frailties, and doing so while learning and thinking about medical science at the same time, is both empowering and liberating.

I suspect one of the reasons why I keep coming back to my experiences in Champaign in this blog is the enduring sense that I've been among some very special people. I admire those who are dedicated to building others up because there's so much in this world that endeavors to tear them down. When you've been in the presence of such persons, you come away feeling not only revitalized but more yourself. Had I attended the PASS Program a year ago, my life would be very different than it is now. Still, I'm not sure it would have been as meaningful to me as it has become after having been hammered twice by boards, and there's a great deal to be said for that. Some things only come along when we're ready and being ready is what makes it so good when they do.


(Photo copyright 2010 by the author)